The  State  Health  Plan    Comprehensive  Wellness  Ini6a6ve:  Can  a  health  insurance  plan  requiring  higher  out  of  pocket  expenses  for  tobacco  users  increase  utilization  of  tobacco  cessation  services?  

 

 Leah  M.  Ranney,  PhD  

Associate  Director  for  Tobacco  Prevention  and  Evaluation  Program  University  of  North  Carolina  At  Chapel  Hill  

   

This  work  was  funded  by  the  North  Carolina  Health  and  Wellness  Trust  Fund  Commission.    

   

Any  opinions,  >indings,  conclusions,  or  recommendations  expressed  in  this  presentation  are  those  of  the  authors  and  do  not  necessarily  re>lect  the  views  and  policies  of  the  North  Carolina  Health  and  Wellness  Trust  Fund  

Commission.    

There  are  no  :inancial  or  commercial  interests  to  disclose  

Agenda  •  Background  •  Process  Evaluation  •  Logic  Model  •  Methods  •  Data  Analysis  •  Findings  •  Recommendations  •  Follow-­‐up    

Tobacco  Use  •  Approximately  20%  of  US  adults  smoke  

•  Only  5-­‐7%  of  US  smokers  successfully  quit  without  assistance1  

•  Evidence-­‐based  behavioral  and  pharmacologic  treatments  can  double  unassisted  quit  rates  across  a  range  of  populations1  

1Treating  Tobacco  Use  and  Dependence:  2008  Update  

Healthcare  Cost  

•  Total  annual  public  and  private  health  care  expenditures  caused  by  smoking:  – $96  Billion  in  the  US2  – $2.46  Billion  in  North  Carolina2  

2Campaign  for  Tobacco  Free  Kids,  May  9,  2012  

North  Carolina  General  Assembly  •  Passed  Session  Law  in  April  2009    

•  Required  State  Health  Plan  for  Teachers  and  State  Employees  (SHP)  to  contain  costs  

•  Implement  premium  increases,  bene]it  changes,  and  healthy  lifestyle  programs  that  reduce  costs  and  improve  member  health  

Comprehensive  Wellness  Ini=a=ve  •  July  1,  2010  all  health  plan  members  were  moved  to  70/30  bene]it  plan  

•  To  enroll  in  80/20  bene]it  plan,  members  needed  to  attest  that  themselves  and  their  dependents  were  not  tobacco  users  

•  Current  tobacco  users  could  enroll  in  80/20  if  enrolled  in  approved  cessation  program  

Funding  Organiza=on  

•  NC  Health  and  Wellness  Trust  Fund  in  conjunction  with  SHP  issued  an  independent  evaluation  

•  Tobacco  Prevention  and  Evaluation  Program  received  approximately  $50,000  to  conduct  the  evaluation    

Process  Evalua=on  

•  Utilization-­‐Focused  Evaluation  –  Intended  users  need  to  understand  and  participate  in  the  process    

– Situational  responsiveness  guides  the  collaborative  process  between  evaluator  and  intended  users  

Stakeholders  Ques=ons  •  Did  SHP  members’  understand  the  CWI  communication  materials?  

•  Are  the  SHP  members  aware  of  the  SHP  tobacco  cessation  bene]its  and  resources?    

•  What  is  the  SHP  members’  level  of  satisfaction  with  QuitlineNC  services  and  free  nicotine  patches?  

..

State Health Plan Tobacco Cessation Wellness Initiative Process Evaluation Logic Model

RESOURCES ACTIVITIES OUTPUTS OUTCOMES

TPEP

HWTF funding

State Health Plan (SHP)

Alere, Inc

State Health Plan

Members

Recruitment • SHP members

(70/30 plan smokers)

• SHP members - QuitlineNC callers

Focus Groups • # Groups • # Participants

Online SHP Survey • # of completed online

surveys

Focus Group Qualitative Data:

• Participants’ awareness, perception, and receptiveness of the CWI

• Participants’ awareness and usage of SHP tobacco benefits and resources

SHORT TERM LONG TERM

Increased knowledge about type of services

provided by SHP and QuitlineNC for members who use

tobacco

Increased quit rate among SHP

members

INTERMEDIATE

Increased utilization of SHP tobacco

cessation benefits and

resources

Material Development • Recruitment

Screener • Focus Group

Guide • Debrief script • QuitlineNC

Survey

Online Survey Data • Motivation for

contacting QuitlineNC • Service requested • NRT Received • Level of Satisfaction

Increased use of QuitlineNC

services by SHP members

Decreased tobacco related morbidity and

mortality for SHP menbers

Data Collection • Focus groups • Online survey

Data Analysis • Qualitative • Quantitative

Evaluation Findings • Report • Manuscript

SHP implementation of strategies that

increase awareness among members

about tobacco cessation benefits

and resources

= Process Evaluation

Evalua=on  Methods    •  Conduct  focus  groups  with  SHP  tobacco  users  – Assess  awareness  of  CWI,  understanding  of  SHP  materials,  and  knowledge  of  SHP  tobacco  cessation  bene]its  and  resources    

•  Conduct  online  survey  with  QuitlineNC  SHP  callers  – Assess  SHP  members’  level  of  satisfaction  with  QuitlineNC  services  

UNC  Public  Health-­‐Nursing  Institutional  Review  Board  reviewed  the  research  plan  and  determined  participant  risk  involved  was  minimal  (10-­‐1888).  

Focus  Group  Methods  •  Recruited  SHP  members  with  70/30  bene]it  plan  who  use  tobacco  via  letter    

•  Screened  potential  focus  group  participant  via  website  or  telephone  questionnaire  

•  Offered  $50  incentive  •  Three  locations  (Greensboro,  Greenville,  and  Asheville)  

Focus  Group  Analysis  

•  Focus  group  (N=12)  -­‐  Greensboro  (n=4),  Greenville  (n=6),  and  Asheville  (n=2)  

•  Supplemental  Phone  Interviews  (N=4)  •  Transcriptions  independently  coded  by  two  researchers  using  MAXQDA  software  

•  Combination  of  deductive  and  inductive  coding  

Focus  Group  Findings  

Confusing  Communica=on  Material  

“There’s  a  lot  of  names.  That’s  really  just  hard  for  me  to  interpret  where  they’re  coming  from  and  why  they’re  important  on  here…  I  don’t  know  who  those  people  are  or  where  they  come  from.    So  it  seems  just  like  a  lot  of  big  words  but  there’s  no  background  behind  it.”      

Complex  Communica=on  Materials  

“It  looks  like  another  memo  that  comes  across  your  desk  every  single  day.”    “And  when  they  send  the  little  packets  out  to  us  like  they  sent  all  of  this  out,  it’s  like  reading  a  letter  from  a  lawyer  or  something.”      

Inconsistent  Dissemina=on  of  Informa=on  

“And  then  they  really  don’t  tell  you.    They  have  a  bulletin  board  where  they  put  the  sheets  up  and  you  just  glance  at  it  or  then  you  hear  another  staff  talking  about  it  or  whatever.  But  them  actually  coming  to  you  and  telling  you  about  it,  no.”    

Eye-­‐catching  Communica=on  Material  

“…  color,  eye-­‐catching  things.    Like  I  said  you  are  going  to  need  something  that  is  going  to  stand  out  and  say  something  that  is  going  to  bring  me  in  and  this  thing  right  here  [postcard]  says  “you  can  quit  smoking  tobacco”  

Informa=ve  Communica=on  Material  

“I  think  this  is  informative,  especially  the  1-­‐800  number  which  I’ve  never  seen.  This  is  my  >irst  time  seeing  it  and  that  it’s  providing  eight  weeks  of  nicotine  replacement  therapy,  which  I  knew  nothing  about  until  tonight.  So  this  is  something  I  can  certainly  try.”    

Lack  of  Communica=on  

“….the  main  thing  is  that  …..this  information  is  not  getting  to  them.    They  haven’t  gotten  it  ...  so  they  didn’t  know  it  was  available.    I  didn’t  know  it  was  available.”      

Misunderstanding  the  CWI  

 “…because  of  my  decision  [to  smoke]  you  want  to  drop  my  health  insurance  –  now  most  companies  and  most  insurance  agencies  don’t  do  that.    They  make  you  have  a  higher  premium  or  things  of  that  [nature],  but  they  don’t  drop  your  coverage.    The  State  went  way  out  there.”      

Nega=ve  Percep=on  of  SHP  “I  am  going  to  tell  you,  this  is  exactly  how  we  felt.    They  didn’t  want  smokers  and  big  people  working  for  the  state.”  

 

“So  I  mean  when  this  came  out  –  it  was  negative  to  start  with.”  

 

SHP  Tobacco  Use  Verifica=on  Plan  “I  think  about  a  month  later  after  we  >illed  that  form  out  and  turned  it  in,  then  they  said  they  weren’t  going  to  take  and  go  back  and  check  people  to  make  sure  they  were  being  honest  about  everything  and  so  most  people  I  work  with,  they  continued  smoking  and  whatever  and  they’re  still  on  80/20  and  I  am  on  70/30  and  I  was  trying  to  be  honest.“    

“Truthfully  and  honestly  talking  about  those  people  who  did  not  sign  the  form,  if  I  would  have  known  that  they  weren’t  going  to  come  around  and  ask  if  I  smoke,  I  probably  wouldn’t  have  >illed  it  out  either.”    “And  I  told  the  truth  and  then  they  still  didn’t  get  everybody.  Man,  that  made  me  mad.”      

Summary  of  Focus  Group  Findings  

•  SHP  members  did  not  read  and/or  understand  SHP  materials  about  the  changes  in  enrollment  

•  SHP  members  did  not  recall  receiving  SHP  materials  or  information  about  additional  tobacco  cessation  bene]its  and  resources  

Summary  of  Focus  Group  Findings  

•  Lack  of  understanding  of  the  CWI  and  minimal  knowledge  of  SHP’s  additional  tobacco  cessation  resources  led  to  negative  perceptions  of  the  CWI  

Summary  of  Focus  Group  Findings  

•  Developed  negative  perception  of  the  SHP  – With  the  implementation  of  the  CWI,  many  SHP  tobacco  users  felt  punished    

– SHP  members  who  attested  to  using  tobacco  were  disgruntled  when  the  SHP  decided  not  to  verify  tobacco  use  among  a  random  sample  of  SHP  members  on  the  80/20  bene]it  plan  

Focus  Group  Limita=ons  

•  Low  number  of  participants  – Not  generalizable  

•  Typically  focus  groups  are  formative  rather  than  hypothesis  testing  –  Interpret  themes  and  results  with  some  caution  

SHP  Recommenda=ons  •  Develop  appealing  materials  with  appropriate  literacy  level  

•  Dissemination  plan  needs  to  include  multiple  methods  for  circulating  information  

•  Use  formative  and  summative  evaluation  data  to  tailor  health  insurance  information  to  target  audiences  

•  “Build  a  brand”  around  SHP  tobacco  cessation  bene]its  

Survey  Methods  •  AlereTM,  North  Carolina’s  tobacco  cessation  vendor,  provided  TPEP  with  email  addresses  of  SHP  members  who  used  the  QuitlineNC  

•  Random  selection  of  600  email  addresses  were  pulled  from  the  AlereTM    dataset  

Survey  Methods  

•  32  multiple  choice  questions  •  Validated  questions  from  the  Center  for  Disease  Control  (CDC)and  Behavioral  Risk  Factor  Surveillance  System  (BRFSS)  

•  Four  weekly  reminders  •  $10  gift  card  incentive    

Survey  Analysis  

•  571  SHP  QuitlineNC  callers  successfully  received  an  email  requesting  participation    

•  Response  Rate  =  32%  (N=185)  •  Descriptive  statistics  (SPSS)  

Survey  Demographics  

Characteristics   Percentage  

Female   60%  

White   79%  

Mean  age  (Years)   50.4  

Bachelors’  Degree  >   26%  

Professional  State  Employee  Position  

 49%  

Online  Survey  Findings  

Mo=va=ons  to  Call  

5%  

8%  

8%  

11%  

26%  

67%  

71%  

74%  

0%   10%   20%   30%   40%   50%   60%   70%   80%   90%   100%  

Other  

Family  Member  

Doctor/Nurse  

Friend  

QuitlineNC  Advertisement  

Addition  of  cessation  bene:its  to  SHP  

Ready  to  quit  using  tobacco  

Maintain  enrollment  in  80/20  

%  of  Participants  

0  

20  

40  

60  

80  

100  

120  

140  

Multi-­‐caller  options  with  NRT  patch  

One-­‐time  call  with  no  coaching  

Multi-­‐Caller  option  without  

NRT  

One-­‐time  quit  coach  call  

Self-­‐  help  materials  only  

#  of    participants  

QuitlineNC  Service  Options  

QuitlineNC  Services  

Level  of  Sa=sfac=on  Level of Satisfaction with QuitlineNC Service Percent of

participants that were very satisfied or

satisfied Please indicate your level of satisfaction with the registration process.

97% (177 of 182)

How would you rate your satisfaction with receiving the nicotine patch from QuitlineNC?*

88% (110 of 125)

Overall, how satisfied were you with the service you received from QuitlineNC?

92% (162 of 182)

*Not  all  participates  opted  for  the  free  nicotine  patch  

Addi=onal  Survey  Findings  •  Experience  with  QuitlineNC  increased  respondents’  reported  con]idence  in  quitting  tobacco  (63.6%)    

•  Only  21%  of  respondents  reported  their  experience  with  QuitlineNC  increased  their  ability  to  quit  tobacco      

•  Over  half  the  respondents  noted  a  lack  of  awareness  of  other  tobacco  cessation  bene]its  and  resources  available  through  the  SHP  

Summary  of  Survey  Findings  •  SHP  tobacco  users  participated  in  QuitlineNC  both  because  they  were  interested  in  quitting  and  because  they  wanted  to  maintain  enrollment  in  the  80/20  plan.      

•  Those  participants  who  called  QuitlineNC  primarily  chose  the  multi-­‐caller  option  with  eight  weeks  of  free  nicotine  patch  

Summary  of  Survey  Findings  

•  Satisfaction  with  service  delivery  for  QuitlineNC  remains  very  high,  including  the  delivery  of  nicotine  patches  to  participants  

•  Awareness  and  utilization  of  tobacco  cessation  bene]its,  other  than  QuitlineNC,  by  SHP  tobacco  users  remains  relatively  low  

Limita=ons  

•  Self-­‐reported  tobacco  use  data  – Data  not  valid  due  to  participants’  concerns  that  reporting  current  tobacco  use  would  jeopardize  their  health  bene]it  status  

•  Response  bias  – Disproportionate  number  of  moderate  to  high  income  callers  

Survey  Recommenda=ons  •  Review  whether  the  80/20  choice  plan  is  having  the  intended  effect  on  tobacco  cessation  

•  Expand  tobacco  cessation  services  options  available  through  QuitlineNC,  allowing  for  treatment  options  such  as  nicotine  gum  and  lozenge  

•  Review  methods  of  marketing  SHP  tobacco  cessation  bene]its  and  resources  to  increase  tobacco  users’  awareness  of  free  and  low  cost  tobacco  treatments  

U=liza=on  of  QuitlineNC  •  Caller  volume  spiked  dramatically  during  SHP  annual  enrollment  (March/April  2010)  

•  36%  of  QuitlineNC  callers  were  SHP  members,  compared  to  only  5.9%  in  2009  

•  SHP  QuitlineNC  caller  rates  remain  high  at  19.3%  with  the  offer  of  eight  weeks  of  free  nicotine  patch  

SHP  Evalua=on  Follow-­‐up  

•  Change  format  of  all  educational  materials  for  all  health  areas  (i.e.,  grid)  

•  Materials  include  larger  text,  color,  and  pictures  

•  Testing  materials  with  lower  literacy  levels  (Brown  Creek  Correctional  Institution)  

 

SHP  Uses  Evalua=on  Findings  

•  Training  101  Toolkit:  Standardized  information  for  Health  Bene]it  Representatives  and  Wellness  Leaders  

•  AlereTM      is  branding  tobacco  cessation  materials  with  SHP  

 

•  To  view  other  SHP  materials  visit:  http://www.shpnc.org/ncHealthSmart/default.aspx  

 •  For  additional  information  on  TPEP  visit:  http://www.tpep.unc.edu/index.htm  

 

Questions?