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Reimbursement for Tobacco Dependence Counseling:

Employer, Managed Care, Medicaid

Reimbursement for Tobacco Dependence Counseling:

Employer, Managed Care, Medicaid

ABBY C. ROSENTHAL, MPHOffice on Smoking and Health

National Conference on Tobacco or HealthNovember 2002

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Purpose• Describe Tobacco Dependence Treatment Guideline

guidance about counseling

• Provide a framework for population based cessation initiatives

• Review Community Guide Recommendations about reimbursement

• Describe reimbursement strategies for cessation

• Provide an overview of existing state initiatives

• Identify Medicaid implementation strategies

• Discuss State based employer initiatives

• Describe Tobacco Dependence Treatment Guideline guidance about counseling

• Provide a framework for population based cessation initiatives

• Review Community Guide Recommendations about reimbursement

• Describe reimbursement strategies for cessation

• Provide an overview of existing state initiatives

• Identify Medicaid implementation strategies

• Discuss State based employer initiatives

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Efficacy of Different Counseling Formats (n=58 studies)

Number Odds Ratio Cessation RateType of Provider of Arms (95% C.I.) (95% C.I.)

No format 20 1.0 8.2

Proactive 26 1.2 (1.1-1.4) 13.1 (11.4-14.8)Telephone counseling

Group counseling 52 1.3 (1.-1.6 13.9 (11.6-16.1)

Individual counseling 67 1.7 (1.4-2.0) 16.8 (14.7-19.1)

Number Odds Ratio Cessation RateType of Provider of Arms (95% C.I.) (95% C.I.)

No format 20 1.0 8.2

Proactive 26 1.2 (1.1-1.4) 13.1 (11.4-14.8)Telephone counseling

Group counseling 52 1.3 (1.-1.6 13.9 (11.6-16.1)

Individual counseling 67 1.7 (1.4-2.0) 16.8 (14.7-19.1)

Estimated Estimated

Source: Fiore et al. Treating Tobacco Use and Dependence:Clinical Practice Guideline, USDHHS, 2000

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Efficacy of Different Levels of Person-to-Person Contact (n=43 studies)

Number Odds Ratio Cessation RateLevels of Contact of Arms (95% C.I.) (95% C.I.)

No contact(reference group) 30 1.0 8.8

Minimal contact(5 min.) 19 1.3 (1.0-1.6) 13.4 (10.9-16.1)

Brief counseling(>3 to ???Min) 16 1.6 (1.2-2.0) 16.0 (12.8-19.2)

Individual counseling(>10 min.) 55 2.3 (2.0-2.7) 22.1 (19.4-24.7)

Number Odds Ratio Cessation RateLevels of Contact of Arms (95% C.I.) (95% C.I.)

No contact(reference group) 30 1.0 8.8

Minimal contact(5 min.) 19 1.3 (1.0-1.6) 13.4 (10.9-16.1)

Brief counseling(>3 to ???Min) 16 1.6 (1.2-2.0) 16.0 (12.8-19.2)

Individual counseling(>10 min.) 55 2.3 (2.0-2.7) 22.1 (19.4-24.7)

Estimated Estimated

Source: Fiore et al. Treating Tobacco Use and Dependence:Clinical Practice Guideline, USDHHS, 2000

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Cost of Counseling

Group program $70(Seven 1-hour sessions over 6 weeks)

Proactive telephone counseling $185+(Five phone calls over 1 year)

Individual, face-to-face counseling $200+(Four 10-minute sessions with a physician)

Group program $70(Seven 1-hour sessions over 6 weeks)

Proactive telephone counseling $185+(Five phone calls over 1 year)

Individual, face-to-face counseling $200+(Four 10-minute sessions with a physician)

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Three Levels of Cessation Interventions

• Individuals

• System changes

• Populations

• Individuals

• System changes

• Populations

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Impact = Efficacy x Reach

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Methods Used on Last Attempt to Quit

• 68% tried to quit without using any assistance

– 7% used other methods (chewed regular gum, hypnosis)

• 21% used NRT

• 2% used a prescription medication

• 1% used self-help materials

• 1% used counseling

• 68% tried to quit without using any assistance

– 7% used other methods (chewed regular gum, hypnosis)

• 21% used NRT

• 2% used a prescription medication

• 1% used self-help materials

• 1% used counseling

Yankelovich Partners Inc. Smoking cessation study. American Lung Association, 1998.

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1995

1993

1991

1995

1993

1991

Few Doctors Counsel Patients about Smoking Cessation

Source: Substance Abuse: The Nation’s Number One Health Problem from Thorndike An et al. “National Patterns in the Treatment of Smokers by Physicians.” JAMA, 1998;279(8):604-8.

1995

1993

1991

30% 60%

Asked by Doctors if Patient Smokes, Percent of All Patient Visits

Doctor Provides Smoking Counseling, Percent of Smoker Visits

Doctor Prescribes Nicotine Replacement Therapy, Percent of Smoker Visits

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• Measurements (4 studies):

– Use of treatment (median impact + 7 pct pts)

– Patient cessation (median impact + 7.8 pct pts)

• Measurements (4 studies):

– Use of treatment (median impact + 7 pct pts)

– Patient cessation (median impact + 7.8 pct pts)

Reducing Out-of-Pocket Costs

Source: Hopkins D, Briss P, Ricard C, Husten C, et al. Am J Prev Med 2001;20(2S):16-66.

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State Medicaid Coverage of Tobacco Dependence Treatment, 1998-2000

State Medicaid Coverage of Tobacco Dependence Treatment, 1998-2000

Comprehensive coverage

Partial coverage

No coverageSource: MMWR, November 9, 2001.

TX

ARAZ

AK

OK

ND

WY

ORID

LA

KS

IANE

MT

UT

SD

NV

CO

WA

NM

MO

MN

CA

GA

TN

AL

KY

OH

MS

FL

PA

WI

IN

NY

WVVA

NC

SC

NH

CT

DE

RIMA

NJ

MD

MN

IL

MI

HI

VT

DC

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Medicaid Coverage for Treatmentof Nicotine Dependence

• Counseling– 11 states reimburse for individual counseling

– 10 states cover group counseling

• Prescription tobacco-treatment medications– 31 states cover some prescription medications

– 22 states cover all products

• OTC tobacco-treatment medications– 23 states cover OTC medications

• There are often restrictions on use of services or products

• Counseling– 11 states reimburse for individual counseling

– 10 states cover group counseling

• Prescription tobacco-treatment medications– 31 states cover some prescription medications

– 22 states cover all products

• OTC tobacco-treatment medications– 23 states cover OTC medications

• There are often restrictions on use of services or products

MMWR, November 9, 2001

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BackgroundBackground

• High smoking prevalence among Medicaid enrollees

• % of low birthweight births higher in Medicaid populations

• Tobacco related disease is a major expense for Medicaid

• High smoking prevalence among Medicaid enrollees

• % of low birthweight births higher in Medicaid populations

• Tobacco related disease is a major expense for Medicaid

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Cost BenefitCost Benefit

• For every $ 1 dollar spent on smoking cessation for pregnant women $ 3 saved (Marks, et al. 1990)

• An annual percentage point decline in smoking prevalence would prevent 1,300 low birth weight babies and save $21 million in 1995 U.S. dollars (Lightwood et al. 1999)

• For every $ 1 dollar spent on smoking cessation for pregnant women $ 3 saved (Marks, et al. 1990)

• An annual percentage point decline in smoking prevalence would prevent 1,300 low birth weight babies and save $21 million in 1995 U.S. dollars (Lightwood et al. 1999)

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Medicaid Purchasing Specifications

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Treatment Recommendations

• 5 A’s

• 5 R’s

• Two 90 day courses of FDA-approved medications

• Two 90 day courses of counseling (individual, group or telephone)

• 5 A’s

• 5 R’s

• Two 90 day courses of FDA-approved medications

• Two 90 day courses of counseling (individual, group or telephone)

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RecommendationsRecommendations

• Know your current Medicaid Coverage

• Compare coverage to Medicaid Model Language

• Coordinate with state Medicaid Agency to make the case for evidence-based treatment

• Work with Medicaid to promote benefit

• Know your current Medicaid Coverage

• Compare coverage to Medicaid Model Language

• Coordinate with state Medicaid Agency to make the case for evidence-based treatment

• Work with Medicaid to promote benefit

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Employer/Purchaser Initiatives

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0

10

20

30

40

50

Cessation Counseling Drugs and Devices

Pe

rce

nt

Employer Coverage of Tobacco-Use Treatment

Source: Partnership for Prevention, 1998

HMO

Indemnity Plan

42%

16%

38%

25%

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The Office of Personnel Management Now Encourages Coverage of Clinical Tobacco-Use

Treatment Interventions• “We encourage plans to provide benefits for smoking cessation

that follow the Public Health Service’s treatment guidelines.

• Consistent with these guidelines, primary care visits for tobacco cessation should be covered with the standard office visit co-payment.

• Individual or group counseling for tobacco cessation should be covered with no co-payment.

• Prescriptions for all FDA-approved medications for treatment of tobacco use should be covered with the usual pharmacy co-payments.”

• “We encourage plans to provide benefits for smoking cessation that follow the Public Health Service’s treatment guidelines.

• Consistent with these guidelines, primary care visits for tobacco cessation should be covered with the standard office visit co-payment.

• Individual or group counseling for tobacco cessation should be covered with no co-payment.

• Prescriptions for all FDA-approved medications for treatment of tobacco use should be covered with the usual pharmacy co-payments.”

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Blue Cross/Blue Shield Response• We now treat smoking cessation services the same as

other medical or mental health/ substance abuse services.

• Previously, under Standard Option, smoking cessation services were limited to $100 of coverage per lifetime.

• In addition, we no longer limit smoking cessation drugs to one course of treatment per year; additional courses of treatment do require prior approval and participation in a smoking cessation program.

• We now treat smoking cessation services the same as other medical or mental health/ substance abuse services.

• Previously, under Standard Option, smoking cessation services were limited to $100 of coverage per lifetime.

• In addition, we no longer limit smoking cessation drugs to one course of treatment per year; additional courses of treatment do require prior approval and participation in a smoking cessation program.

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North Carolina

• Implemented North Carolina Prevention Partners

• Prevention Report Card

• Basic benefits

• Cost/ Return on Investment Formulas

• www.ncpreventionpartners.org

• Implemented North Carolina Prevention Partners

• Prevention Report Card

• Basic benefits

• Cost/ Return on Investment Formulas

• www.ncpreventionpartners.org

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Wisconsin• State, University, Medicaid

Partnership

• Incentive/risk initiative

• State employee coverage

• Medicaid involvement

• State, University, Medicaid Partnership

• Incentive/risk initiative

• State employee coverage

• Medicaid involvement

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Recommendations• Promote effective treatment

• Work toward public and private sector reimbursement for cessation treatment

• Develop creative working relationships with purchasers, providers, and payers

• Coordinate with managed care and other insurers to create effective system change in public and private sectors

• Develop strategies to promote effective implementation of Medicaid coverage

• Promote effective treatment

• Work toward public and private sector reimbursement for cessation treatment

• Develop creative working relationships with purchasers, providers, and payers

• Coordinate with managed care and other insurers to create effective system change in public and private sectors

• Develop strategies to promote effective implementation of Medicaid coverage

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Next Steps

• Identify coverage provided through health plans

• Promote online referral to the quitline

• Assess smoke-free worksite status in your area

• Explore Medicaid coverage and promote monitoring

• Determine cessation coverage by your own agency and work to provide if not available

• Identify coverage provided through health plans

• Promote online referral to the quitline

• Assess smoke-free worksite status in your area

• Explore Medicaid coverage and promote monitoring

• Determine cessation coverage by your own agency and work to provide if not available

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© Published in the New Yorker, 10/07/2002

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Paradigm of Tobacco-Use Treatment

Higher price for tobacco

Reducing cost of treatment

Counter-advertising

Telephone quitlinesIndividual

Society

TobaccoAddiction

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CDC Office on Smoking and Health

www.cdc.gov/tobacco

770-488-5705

www.cdc.gov/tobacco

770-488-5705