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Addressing Tobacco in Managed Care: Results of the 2002 Survey

Addressing Tobacco in Managed Care: Results of the 2002 Survey shown improvement in their ability to identify at least some members who smoke. Similarly, a greater percent- Introduction age of plans are employing strategies to address smoking In the United States, tobacco use is the leading pre- cessation during the postpartum period to prevent smok- ventable cause of death and disease. The health and ing relapse and during pediatric visits to reduce or elimi- cost consequences of tobacco dependence have made nate children’s exposure to environmental tobacco smoke. treatment and prevention of tobacco use a key priority among multiple stakeholders, including health plans, Conclusion insurers, providers, employers, and policymakers. In The results of the 2002 ATMC survey reflect both 2002, the third survey of tobacco control practices and tremendous accomplishments and important opportuni- policies in health plans was conducted by America’s ties for health plans to collaborate in tobacco control Health Insurance Plans’ technical assistance office as efforts. With appropriate support, analytical tools, and part of the Addressing Tobacco in Managed Care resources, it is likely that health plans, clinicians, (ATMC) program. providers, and consumers will continue to evolve in their efforts to reduce the negative consequences of tobacco use. Methods The ATMC survey was conducted in the spring of 2002 Introduction via mail, e-mail, and fax. A 19-item survey instrument was developed and pilot-tested. Of the 19 items, 12 were the same as in previous years, four were modified to col- In the United States, tobacco use is the leading prevent- lect more detailed data on areas of key interest, and able cause of death and disease. Smoking kills more than three were added to gain information about strategies to 440,000 people in the United States each year, with most promote smoking cessation. The sample for the survey deaths occurring from lung cancer, ischemic heart disease, was drawn from the 687 plans listed in the national and chronic airway obstruction (1). Yet approximately 23% directory of member and nonmember health plans in of American adults continue to smoke cigarettes (2). In America’s Health Insurance Plans. 2000, it was estimated that approximately 8.6 million per- The opinions expressed by authors contributing to this journal do not necessarily reflect the opinions of the U.S. Department of Health and Human Services, the Public Health Service, the Centers for Disease Control and Prevention, or the authors’ affiliated institutions. Use of trade names is for identification only and does not imply endorsement by any of the groups named above. www.cdc.gov/pcd/issues/2004/oct/04_0021.htm • Centers for Disease Control and Prevention 1 VOLUME 1: NO. 4 OCTOBER 2004 sons in the United States were living with at least one con- results of the 2002 ATMC survey; highlight changes from dition attributed to smoking (3). 1997 to 2002; cross-reference the findings with national guidelines and recommendations; and explore these find- The health consequences of tobacco use are accompanied ings and trends in light of the changing environment in by a staggering economic burden. Smoking caused more which health plans operate and the public’s attitude than $157 billion in annual health-related economic losses toward tobacco use. between 1995 and 1999, including $81.9 billion in smok- ing-related productivity losses and $75.5 billion in excess Methods medical expenditures (1). Smoking-attributable neonatal expenditures were estimated at $366 million in 1996, or $704 per maternal smoker (1). Together, the consequences A 19-item survey instrument was developed and pilot- and costs of tobacco dependence have made treatment and tested in the fall of 2001. The instrument was designed to prevention of tobacco use a key priority among multiple assess new trends, barriers, and opportunities related to stakeholders, including health plans, insurers, providers, addressing tobacco control in health plans, identify new employers, and policymakers. models or frameworks of care, and assess changes in health-plan–based tobacco control activities between 1997 In 1997, The Robert Wood Johnson Foundation estab- and 2002. The sample for the survey was drawn from the lished a collaborative program, Addressing Tobacco in 687 plans listed in AHIP’s national directory of member Managed Care (ATMC). This program is based on the and nonmember health plans. The directory was stratified understanding that health plans’ comprehensive benefits, based on health plan enrollment size, and a random sam- sophisticated information systems, and defined popula- ple of 246 health plans was selected. The sample size tions, as well as their ongoing partnerships with health enables the detection of a 5% difference between propor- care providers, are well suited to implement, evaluate, and tions at a = .05 and ß = .80. sustain tobacco control interventions. ATMC includes a National Program Office based at the University of The ATMC survey was conducted in the spring of 2002. Wisconsin Medical School’s Center for Tobacco Research As in 1997 and 2000, the 2002 survey was conducted via and Intervention, and a national technical assistance mail, e-mail, and fax, with telephone follow-up with non- office (NTAO) managed by America’s Health Insurance respondents at two, four, and six weeks after initial con- Plans (AHIP), formerly known as the American tact. The sample included large national plans that have Association of Health Plans (AAHP). The mission of the local plans in multiple states. As in previous years, the cor- NTAO is to advance the integration of tobacco cessation porate office of each national plan was asked to review the and prevention programs into routine health care by questionnaire and determine whether they would respond increasing the number and quality of tobacco control ini- on behalf of their local plans or ask local plans to complete tiatives within health plans. the questionnaires individually. Three of four national plans opted to respond on behalf of their local plans and The NTAO provides resources to health plans and insur- their responses reflect 64% (97/152) of the responses. ers striving to develop tobacco control programs; conducts a benchmarking awards program to highlight exemplary The 2002 survey questionnaire was similar to the 2000 health plan tobacco control initiatives; promotes best prac- survey. Of the 19 items in the 2002 questionnaire, 12 were tices and partnerships through national conferences; and the same as in previous years, four were modified to collect oversees the development of a business case model for more detailed data on areas of key interest (i.e., pharma- smoking cessation. The NTAO has also conducted three ceutical coverage and system-level interventions), and surveys of health plans over the past six years to assess three were added to gain information about strategies to practices and policies related to tobacco control. promote smoking cessation. Based on feedback provided during pretesting, the majority of survey questions focused The ATMC baseline survey was conducted in 1997, fol- on smoking cessation despite recognition that tobacco ces- lowed by a similar survey in 2000. The results of both sur- sation or tobacco control is a more encompassing term. veys were published in peer-reviewed journals in 1998 and Although we recognize that the preferred provider organi- 2002 (4,5). The purpose of this paper is to present the zation (PPO) product has grown in popularity, the 2002 The opinions expressed by authors contributing to this journal do not necessarily reflect the opinions of the U.S. Department of Health and Human Services, the Public Health Service, the Centers for Disease Control and Prevention, or the authors’ affiliated institutions. Use of trade names is for identification only and does not imply endorsement by any of the groups named above. 2 Centers for Disease Control and Prevention • www.cdc.gov/pcd/issues/2004/oct/04_0021.htm VOLUME 1: NO. 4 OCTOBER 2004 ATMC survey asked respondents to answer all questions one type of pharmacotherapy used for tobacco cessation based on their best-selling commercial health mainte- (Table 1). Bupropion, in the form of Wellbutrin, was the nance organization (HMO) product to preserve the ability most commonly covered pharmacotherapy. Only 11% of to make comparisons with previous years. plans reported that provision of full coverage for tobacco cessation pharmacotherapies is dependent on enrollment All analyses were performed with SPSS software (SPSS, in a counseling or cessation program. Inc, Chicago, Ill). Chi-square tests and t-tests were used for comparisons, and results of these tests were considered Full coverage for at least one type of behavioral inter- statistically significant when the corresponding P value vention used for tobacco cessation was reported by the vast was # .05. Consistent with previous years, the data are majority of health plans (Table 1). Telephone counseling unweighted to best describe the policies and practices of was the most commonly covered behavioral intervention, health plans. followed by face-to-face counseling and self-help materials. Health plans reported having a variety of strategies to Results encourage members to stop smoking during times that might be considered important teachable moments. The Of the 246 plans in the sample, 152 (62%) completed and majority of health plans reported having a specific strate- returned the survey. Collectively, the 152 plans represent gy to address smoking cessation during pregnancy and more than 43.5 million HMO members. Respondent plans during treatment for chronic illnesses (Table 1). were predominantly independent practice association, net- work, and mixed models. Fifty-one percent were for-profit Plans reported that a variety of strategies are used with and publicly held; 24% were for-profit and privately held; providers and their office staff to promote smoking cessa- 23% were not-for-profit; and 2% were mutual companies. tion among plan members. The majority of plans reported A comparative analysis of respondents and nonrespon- offering provider education and offering prompts and dents to the 2002 survey indicated that there were no sig- reminders to providers (Table 1). Provider prompts and nificant differences in size, tax status, or predominant reminders were coupled with provider education by 44% of model type between respondents and nonrespondents. plans. Few plans reported offering incentives to providers and their staff to promote smoking cessation. Among plans that responded to the 2002 ATMC survey, 71% reported having written clinical guidelines for smok- Health plans reported that they require providers to ing cessation. The majority of plans reported having guide- carry out a variety of assessments and activities related to lines that had been internally developed by the plan; few smoking that are in accordance with the clinical model of plans reported using the 2000 U.S. Public Health Service the 5 As: Ask, Advise, Assess, Assist, and Arrange (6). Clinical Practice Guideline on Tobacco Use and (The 2002 ATMC survey was fielded before the develop- Dependence or the 1996 Agency for Health Care Policy and ment of Assess willingness to quit.) The majority of plans Research (now the Agency for Healthcare Research and require providers to ask new patients about smoking sta- Quality [AHRQ]) Practice Guideline on Tobacco Cessation tus and include smoking status as a vital sign (ask about (Table 1). smoking status at every visit) (Table 1). Fewer plans reported requiring providers to carry out activities aimed Nearly three quarters of all plans indicated that they at advising, assisting, and following up with patients try- could identify at least some individual plan members who ing to quit smoking. smoke (Table 1). Among those plans that reported being able to identify individual smokers, the most common data Although health plans reported a variety of barriers that sources are health risk appraisals and telephone inter- limit their ability to effectively address tobacco control, the views. Only 6% of plans use enrollment data to identify most common barriers relate to resources (e.g., inadequate individual smokers. staff, funding, competing priorities) and system issues (e.g., poor data collection, reporting, record maintenance). Other The vast majority of health plans that responded to the barriers included lack of patient demand, lack of purchaser survey reported that they provide full coverage for at least demand, and delayed economic return on investment. The opinions expressed by authors contributing to this journal do not necessarily reflect the opinions of the U.S. Department of Health and Human Services, the Public Health Service, the Centers for Disease Control and Prevention, or the authors’ affiliated institutions. Use of trade names is for identification only and does not imply endorsement by any of the groups named above. www.cdc.gov/pcd/issues/2004/oct/04_0021.htm • Centers for Disease Control and Prevention 3 VOLUME 1: NO. 4 OCTOBER 2004 Tobacco control activities used by larger health plans are Discussion different from those used by smaller plans (Table 2). Based on the enrollment distribution of health plans in our sam- The results of the 2002 ATMC survey indicate that ple, we defined larger plans as those with more than health plans are using evidence-based programs and clin- 250,000 members and smaller plans as those with less ical guidelines to address tobacco use. Clinical guidelines than or equal to 250,000 members. Larger plans were detail the most effective options for helping patients to more likely than smaller plans to have written clinical quit smoking, and using strategies recommended in clini- guidelines for smoking cessation (P < .001) and to have a cal guidelines is associated with greater success in help- specific strategy to address smoking cessation during spe- ing smokers to quit (6,7). Although a large percentage of cific times, such as adolescence, pregnancy, postpartum health plans reported having written clinical guidelines visits, and hospitalization (P ranged from < .001 to .02). for tobacco cessation, it is possible that even more plans Smaller plans, more likely to be staff and group-model address tobacco cessation within other clinical guidelines plans, were more likely to be able to identify individual used for managing or treating conditions in which tobac- plan members who smoke (P < .001) and provide full cov- co use is identified as a comorbidity or risk factor (e.g., erage for some prescription pharmacotherapies used for heart disease, diabetes, asthma). It is also noteworthy smoking cessation (P ranged from <.001 to .02). that more than half of the plans reported adopting inter- nally developed guidelines, as opposed to guidelines Although the ATMC survey instruments used in 1997, developed by federal agencies and expert panels such as 2000, and 2002 were not identical, the majority of core the U.S. Public Health Service (USPHS) and AHRQ. questions on pharmacotherapies, behavioral health, and However, it is possible that plans reviewed such guide- smoking cessation strategies remained unchanged. The lines and integrated many or all of the key components percentage of plans that provide full coverage for any type into their own guidelines. of pharmacotherapy used for smoking cessation more than tripled from 1997 to 2002 (P < .001) (Table 3). The Plans showed remarkable improvement in 2002, com- percentage of plans able to identify individual smokers pared with previous years, in identifying individual plan also increased (P < .001). More plans reported providing members who smoke. The ability to identify smokers is an full coverage for telephone counseling (P = .04) and face- important indicator of a plan’s ability to remind or prompt to-face counseling (P = .011) in 2002 compared with both providers to discuss and/or advise patients about smoking previous surveys. cessation. Such provider reminders are considered an effective strategy for supporting smoking cessation and From 1997 to 2002, there were large increases in the are recommended by the Task Force on Community percentage of plans with strategies to address relapse pre- Preventive Services (7). The survey question, however, vention during the postpartum period (P = .02) and smok- assesses the percentage of plans that can identify any ing cessation during treatment for chronic illness (P = members who smoke (rather than all members who .002) and following a heart attack (P = .004) (Table 3). smoke), and the methods that plans report using to identi- fy smokers are most likely to identify subgroups of smok- Health plan performance on measures related to requir- ers (i.e., those that respond to health risk appraisals or ing providers to adhere to four of the 5 As varied in both surveys). Indeed, the ability of health plans to identify directions between 2000 and 2002 (Table 3). Although smokers is contingent upon members actively providing comparable data on these variables were not collected in information about their smoking status during some inter- 1997, the percentage of plans that require providers to ask action with the health plan, whether during enrollment, new patients about smoking status (P = .02) and strongly through a survey, or via some other point of contact. advise all smokers to quit (P = .02) decreased from 2000 to 2002, and the percentage of plans that require providers to The number of health plans providing full coverage for include smoking as a vital sign (i.e., ask about it at every any type of pharmacotherapy for tobacco cessation more visit) (P = .28) and assist smokers by referring them into than tripled in 2002, compared with previous years. In the appropriate treatment (P = .33) increased modestly. 2002 ATMC survey, nearly nine out of 10 plans reported providing full coverage for at least one type of pharma- cotherapy for tobacco cessation. Consistent with recom- The opinions expressed by authors contributing to this journal do not necessarily reflect the opinions of the U.S. Department of Health and Human Services, the Public Health Service, the Centers for Disease Control and Prevention, or the authors’ affiliated institutions. Use of trade names is for identification only and does not imply endorsement by any of the groups named above. 4 Centers for Disease Control and Prevention • www.cdc.gov/pcd/issues/2004/oct/04_0021.htm VOLUME 1: NO. 4 OCTOBER 2004 mendations based on the effectiveness of various prescrip- are leading barriers to adequately addressing tobacco con- tion and over-the-counter tobacco cessation first-line phar- trol. Health plans may benefit from developing a business macotherapies (6), the majority of plans reported provid- case model that stresses the importance of tobacco cessa- ing full coverage for bupropion. The significant increase in tion to purchasers and advocates for resources to imple- the number of plans that provide full coverage for at least ment and maintain evidence-based tobacco cessation pro- one type of pharmacotherapy related to tobacco cessation grams. Research supported by the NTAO is underway to is well aligned with the growing body of literature indicat- provide an estimated return on investment for smoking ing that reduced out-of-pocket cost is associated with cessation interventions, based primarily on smoking- greater use of tobacco cessation programs and services (8- attributable costs for health plans. 12) and may lead to increased rates of cessation (10,11). The ATMC survey and its findings have limitations. The Consistent with literature citing the effectiveness of response rate of approximately 60% is respectable, but telephone counseling and that smokers are more likely leaves open the possibility of selection bias. Even though to use telephone counseling than to participate in indi- no significant differences were detected between respon- vidual or group counseling sessions (13,14), approxi- dents and nonrespondents on three key characteristics mately half of plans surveyed provide full coverage for (size, tax status, predominant model type), respondents telephone counseling. It is possible that even more possibly differed from nonrespondents in ways that were smokers have access to telephone counseling through not measured. Another limitation to the ATMC survey is the availability of state-sponsored quit lines. Less than that the psychometric properties of the questionnaire were 25% of plans impose an annual or lifetime limit on cov- not tested to assess reliability or validity. However, the erage for tobacco cessation treatments, indicating wide- survey design process did include substantial pretesting to spread acceptance of the USPHS guideline recommend- increase the probability of including questions that were ing coverage for repeated, intensive tobacco dependence reliable and likely to yield valid responses. Additionally, counseling and pharmacotherapy (6). we identified a potential limitation of the 1997 survey — it did not include a frame of reference for product type (e.g., The results of the 2002 ATMC survey also suggest that HMO, PPO). When the survey does not specify product plans are paying close attention to pregnancy and the type, respondents tend to answer for the HMO product. postpartum period to assist women to quit smoking. The Respondents were explicitly asked to answer for the HMO large percentage of plans reporting strategies to address product in 2000 and 2002. However, the possibility smoking cessation during and after pregnancy to pre- remains that the change in frame of reference contributes vent relapse may reflect greater health plan awareness to some differences in survey findings from 1997 to 2000 or of research that has demonstrated the cost-effectiveness 2002 (but not from 2000 to 2002). of offering smoking cessation programs to pregnant women (15). Aside from the ATMC surveys, few surveys have assessed tobacco control practices and policies of health Overall, our results indicate the greatest improvement plans. Some surveys have focused on plans operating in a in tobacco control activities is at the health plan level as single state (9,16), some have included a narrow subset of opposed to the physician level. For example, more plans plans (i.e., well-established nonprofit plans with a history report providing full coverage for pharmacotherapies than of offering tobacco cessation programs) (17), and others report requiring providers to carry out activities in support have collected information about subsets of smokers with- of the 5 As. This may be because most health plans (espe- in a plan (i.e., pregnant women) (18,19). Nevertheless, a cially those that are not staff-model HMOs) find changing 1999 survey of California health plans reported results physician behavior to be a challenge. Although more plans comparable to our results: 85% of HMOs in the California are beginning to experiment with performance feedback as survey covered at least one form of pharmacotherapy; 77% a way to change physician behavior, prompts, reminders, covered bupropion; 46% covered telephone counseling; and and provider training are more common strategies. 54% covered individual counseling (16). However, the lim- ited availability of comparable data prohibits comparisons Health plans continue to report that resource limita- of our findings with other surveys and underscores the tions, including insufficient staff and inadequate funding, importance of ATMC data for an adequate understanding The opinions expressed by authors contributing to this journal do not necessarily reflect the opinions of the U.S. Department of Health and Human Services, the Public Health Service, the Centers for Disease Control and Prevention, or the authors’ affiliated institutions. Use of trade names is for identification only and does not imply endorsement by any of the groups named above. www.cdc.gov/pcd/issues/2004/oct/04_0021.htm • Centers for Disease Control and Prevention 5 VOLUME 1: NO. 4 OCTOBER 2004 of health plan tobacco control practices and policies at the Author Information national level. Corresponding author: Carol McPhillips-Tangum, The results of the 2002 ATMC survey indicate that an MPH, CMT Consulting, 106 Geneva Street, increasing number of health plans are using evidence- Decatur, GA 30030. Telephone: 404-377-4061. E-mail: based approaches and strategies to address tobacco use. ctangum@mindspring.com. However, in light of competing priorities for limited resources, health plans may be challenged to sustain the Author affiliations: Carmella Bocchino, MBA, RN, Rita improvements they have made from 1997 to 2002. Cost Carreon, Caroline Erceg, MJ, Bob Rehm, MBA, America’s modeling and the development of a business case model for Health Insurance Plans (AHIP), Washington, DC. smoking cessation may hold promise by assisting some plans to leverage the body of literature that supports the References cost-effectiveness of tobacco cessation treatment (6,20-23). Just as challenges lay ahead, so do many important and 1. Annual smoking attributable mortality, years of potentially exciting opportunities. Health plans are in a potential life lost, and economic costs – United States, key position to implement operational policies and pro- 1995-1999. MMWR Morb Mortal Wkly Rep grams that can reduce the prevalence of tobacco use and 2002;51(14):300-3. positively impact the health of millions of individuals. 2. Centers for Disease Control and Prevention. State- Health plans have the opportunity to sustain and expand specific prevalence of current cigarette smoking access to tobacco cessation treatments and services such as among adults—United States, 2002. MMWR Morb pharmacotherapies and counseling services. As new evi- Mortal Wkly Rep 2004;52(53):1277-80.. dence emerges, health plans have the flexibility to model 3. Centers for Disease Control and Prevention. Cigarette new tobacco cessation benefits and promote them widely to smoking – attributable morbidity, United States, their membership. They also have the opportunity to influ- 2000. MMWR Morb Mortal Wkly Rep 2003; ence large purchasers of health care services by communi- 52(35):842-3. cating the value of tobacco cessation services and expand- 4. McPhillips-Tangum C. Results from the first annual ing their field of influence from the clinical and provider survey on addressing tobacco in managed care. Tob setting to the broader community. By participating in com- Control 1998;7(suppl):S11-13. munity-wide campaigns and policy initiatives that support 5. McPhillips-Tangum C, Cahill A, Bocchino C, Cutler C. tobacco cessation and prevention, stakeholders can influ- Addressing tobacco in managed care: results of the ence and help control tobacco use. 2000 Survey. Preventive Medicine in Managed Care 2002;3(3):85-94. Available from: URL: http://www.chp- In summary, the results of the 2002 ATMC survey care.com/downloads/ATMC-2000SurveyResults.pdf. reflect both tremendous accomplishments and important 6. Fiore MC, Bailey WC, Cohen SJ, Dorfman SF, opportunities for health plans to collaborate in tobacco Goldstein MG, Gritz ER, et al. Treating tobacco use control efforts. With appropriate support, analytical tools, and dependence: clinical practice guideline. Rockville and resources it is likely that health plans, clinicians, (MD): U.S. Department of Health and Human providers, and consumers will continue to evolve in their Services, Public Health Service; 2000 Jun. efforts to reduce the negative consequences of tobacco use. 7. Task Force on Community Preventive Services. Recommendations regarding interventions to reduce tobacco use and exposure to environmental tobacco Acknowledgments smoke. Am J Prev Med 2001;20(2Suppl):10-5. 8. Curry SJ, Grothaus LC, McAfee T, Pabiniak C. Use The authors thank The Robert Wood Johnson and cost-effectiveness of smoking cessation services Foundation for the unrestricted educational grant that under four insurance plans in a health maintenance made this survey possible. organization. N Engl J Med 1998;339(10):673-9. 9. Schauffler HH, McMenamin S, Olson K, Boyce-Smith G, Rideout JA, Kamil J. Variations in treatment ben- The opinions expressed by authors contributing to this journal do not necessarily reflect the opinions of the U.S. Department of Health and Human Services, the Public Health Service, the Centers for Disease Control and Prevention, or the authors’ affiliated institutions. Use of trade names is for identification only and does not imply endorsement by any of the groups named above. 6 Centers for Disease Control and Prevention • www.cdc.gov/pcd/issues/2004/oct/04_0021.htm VOLUME 1: NO. 4 OCTOBER 2004 efits influence smoking cessation: results of a random- 17. Rigotti NA, Quinn VP, Stevens VJ, Solberg LI, ized controlled trial. Tob Control 2001;10:175-80. Rosenthal AC, et al. Tobacco control policies in 11 10. Cox JL, McKenna JP. Nicotine gum: does providing it leading managed care organizations: progress and free in a smoking cessation program alter success challenges. Eff Clin Pract 2002;May-June:130-6. rates? J Fam Pract 1990;31(3):278-80. 18. Pickett KE, Abrams B, Schauffler HH, Savage J, 11. Hughes JR, Wadland WC, Fenwick JW, Lewis J, Brandt P, Kalkbrenner A, et al. Coverage of tobacco Bickel WK. Effect of cost on the self-administration dependence treatments for pregnant smokers in and efficacy of nicotine gum: a preliminary study. Prev health maintenance organizations. Am J Public Med 1991;20:486-96. Health 2001;91(9):1393-4. 12. Johnson RE, Hollis JF, Stevens VJ, Woodson GT. 19. Barker DC, Robinson LA, Rosenthal AC. A survey of Patterns of nicotine gum use in a health maintenance managed care strategies for pregnant smokers. Tob organization. DICP 1991;25:730-5. Control 2000;9(Suppl. III):iii46-50. 13. McAfee T, Sofian N, Wilson J, Hindmarsh M. The role 20. Elixhauser A. The costs of smoking and the cost effec- of tobacco intervention in population-based health tiveness of smoking cessation programs. J Public care. Am J Prev Med 1998;14:46-52. Health Policy 1990;11(2):218-37. 14. McAfee T. Increasing the population impact of quit- 21. Pronk N, Goodman MJ, O’Connor PJ, Martinson BC. lines. Paper presented at: The North American Relationship between modifiable health risks and Quitline Conference; 2002; Phoenix, AZ. short-term health care changes. JAMA 1999; 15. Marks JS, Koplan JP, Hogue CJ, Dalmat ME. A cost- 282(23):2235-9. benefit/cost-effectiveness analysis of smoking cessa- 22. Tsevat J. Impact and cost-effectiveness of smoking tion for pregnant women. Am J Prev Med interventions. Am J Med 1992;93(1A):43S-47S. 1990;6(5):282-9. 23. Warner KE. Cost effectiveness of smoking cessation 16. Halpin Schauffler HH, Mordavsky JK, McMenamin S. therapies. Pharmacoeconomics 1997;11(6):538-49. Adoption of the AHCPR Clinical Practice Guideline for Smoking Cessation: a survey of California’s HMOs. Am J Prev Med 2001;21(3):153-61. Tables Table 1. Results from the 2002 Addressing Tobacco in Managed Care Survey (N = 152), United States % Yes Plan has written clinical guidelines for smoking cessation 71.1 Plan uses internally developed clinical guidelines for smoking cessation 56.6 Plan uses the 2000 U.S. Public Health Service Clinical Practice Guideline 5.3 Plan uses the 1996 Agency for Health Care Policy and Research Guideline 3.3 Plan uses guidelines from some other source 5.9 Plan is able to identify individual members who smoke 71.7 Data sources used by plans to identify individual members who smoke (among plans that can identify smokers): Health risk appraisal 89.9 Telephone survey 74.1 Sample of medical records 60.6 Administrative data review 53.2 (Continued on next page) The opinions expressed by authors contributing to this journal do not necessarily reflect the opinions of the U.S. Department of Health and Human Services, the Public Health Service, the Centers for Disease Control and Prevention, or the authors’ affiliated institutions. Use of trade names is for identification only and does not imply endorsement by any of the groups named above. www.cdc.gov/pcd/issues/2004/oct/04_0021.htm • Centers for Disease Control and Prevention 7 VOLUME 1: NO. 4 OCTOBER 2004 Table 1. (continued) Results from the 2002 Addressing Tobacco in Managed Care Survey (N = 152), United States % Yes Mail-based survey 48.6 Electronic medical record 48.6 Enrollment information 6.4 Plan provides full coverage for: Bupropion (as Wellbutrin) 79.2 Bupropion (as Zyban) 41.1 Prescription NRT nasal spray 35.8 Prescription NRT inhaler 35.8 NRT over-the-counter patches 8.6 NRT over-the-counter gum 4.6 Plan provides full coverage for: Telephone counseling 51.7 Face-to-face counseling 41.1 Self-help materials (e.g., booklets, videos, audiotapes, tailored mailings) 25.8 Individual counseling of pregnant women 19.2 Group counseling or classes 15.9 Plan has annual or lifetime limits on coverage for smoking cessation interventions 15.1 Plan allows patients to self-refer to smoking cessation services 59.3 Plan requires providers to: Ask new patients about their smoking status 61.2 Include smoking status as a vital sign (i.e., ask about and document status at every visit) 54.3 Strongly advise all patients who smoke to quit 44.1 Refer smokers to intensive treatment as appropriate 33.6 Arrange for follow-up with patients trying to quit smoking 30.3 Plan has specific strategy to address smoking cessation during: Pregnancy 56.6 Treatment for other chronic illness 52.0 Post-myocardial infarction 46.7 Postpartum visits (relapse prevention) 46.7 Adolescence 28.9 Pediatric visits (secondhand smoke) 28.3 Hospitalization 7.2 Plan has guidelines, protocols, or pathways to address smoking cessation during: Pregnancy 65.1 Treatment for other chronic illness 61.8 Post-myocardial infarction 57.2 Adolescence 57.2 (Continued on next page) The opinions expressed by authors contributing to this journal do not necessarily reflect the opinions of the U.S. Department of Health and Human Services, the Public Health Service, the Centers for Disease Control and Prevention, or the authors’ affiliated institutions. Use of trade names is for identification only and does not imply endorsement by any of the groups named above. 8 Centers for Disease Control and Prevention • www.cdc.gov/pcd/issues/2004/oct/04_0021.htm VOLUME 1: NO. 4 OCTOBER 2004 Table 1. (continued) Results from the 2002 Addressing Tobacco in Managed Care Survey (N = 152), United States % Yes Pediatric visits (secondhand smoke) 55.3 Postpartum visits (relapse prevention) 53.3 Hospitalization 36.2 Plan funds a full- or part-time tobacco control program staff position 19.1 Plan used the following strategies with providers and/or their office staff in the past year to promote smoking cessation: Provider education 69.8 Providing prompts and reminders to encourage providers to address tobacco control 53.2 Elimination of pre-authorization requirements for smoking cessation interventions 40.1 Increased reimbursement for smoking cessation counseling/assistance 34.2 Incentives for providers and their staff to effectively address tobacco 4.6 Increased amount of time that providers can spend with patients 2.0 Barriers limiting plan’s ability to address tobacco control: Resource barriers (e.g., staff, funding, competing priorities) 73.5 System barriers (e.g., poor data collection, reporting, record maintenance) 40.7 Lack of patient demand 39.7 Lack of purchaser demand 38.4 Delayed economic return on investment 33.1 NRT indicates nicotine replacement therapy. Table 2. Tobacco Control Activities by Size of Health Plan: 2002 Addressing Tobacco in Managed Care Survey (N = 152), United States < > 250,000 Members 250,000 Members (N = 102) (N = 50) % Yes % Yes P Plan has a written clinical guideline for smoking cessation 62.4 90.0 <.001 Plan provides full coverage for: NRT over-the-counter gum 3.0 8.0 .17 NRT over-the-counter patches 7.9 10.0 .67 NRT inhaler 42.6 22.0 .01 NRT nasal spray 42.6 22.0 .01 Bupropion (as Zyban) 47.5 28.0 .02 Bupropion (as Wellbutrin) 80.0 77.6 .73 Plan provides full coverage for: Telephone counseling 62.4 30.0 <.001 Face-to-face counseling 52.5 18.0 <.001 Group counseling or classes 14.9 18.0 .62 (Continued on next page) The opinions expressed by authors contributing to this journal do not necessarily reflect the opinions of the U.S. Department of Health and Human Services, the Public Health Service, the Centers for Disease Control and Prevention, or the authors’ affiliated institutions. Use of trade names is for identification only and does not imply endorsement by any of the groups named above. www.cdc.gov/pcd/issues/2004/oct/04_0021.htm • Centers for Disease Control and Prevention 9 VOLUME 1: NO. 4 OCTOBER 2004 Table 2. (continued) Tobacco Control Activities by Size of Health Plan: 2002 Addressing Tobacco in Managed Care Survey (N = 152), United States < > 250,000 Members 250,000 Members (N = 102) (N = 50) % Yes % Yes P 14.9 28.0 .054 Individual counseling of pregnant women 20.8 36.0 .04 Self-help materials 17.0 28.6 .10 Plan has annual or lifetime limits on coverage for smoking cessation interventions 68.3 40.8 .001 Plan allows patients to self-refer to smoking cessation services Plan requires providers to: 48.0 88.0 <.001 Ask new patients about smoking status 39.2 85.7 <.001 Include smoking status as a vital sign (i.e., ask about and document status at every visit) 46.1 83.3 .001 Strongly advise all patients who smoke to quit 37.3 26.0 .17 Refer smokers to intensive treatment as appropriate 35.3 20.0 .054 Arrange for follow-up with patients trying to quit smoking 90.2 34.0 <.001 Plan able to identify individual members who smoke Plan has a specific strategy to address smoking cessation during: 5.9 76.0 <.001 Adolescence 42.2 86.0 <.001 Pregnancy 33.3 74.0 <.001 Postpartum visits (relapse prevention) 5.9 74.0 <.001 Pediatric visits (secondhand smoke) 33.3 74.0 <.001 Post-myocardial infarction 39.2 78.0 <.001 Treatment for other chronic illness 3.9 14.0 .02 Hospitalization Plan has guidelines, protocols, or pathways to address smoking cessation during: 52.0 68.0 .06 Adolescence 56.9 82.0 .002 Pregnancy 46.1 68.0 .01 Postpartum visits (relapse prevention) 48.0 70.0 .01 Pediatric visits (secondhand smoke) 50.0 72.0 .01 Post-myocardial infarction 53.9 78.0 .004 Treatment for other chronic illness 48.0 12.0 <.001 Hospitalization 14.7 28.0 .05 Plan funds a tobacco control program staff position Boldface indicates a significant difference. NRT indicates nicotine replacement therapy. The opinions expressed by authors contributing to this journal do not necessarily reflect the opinions of the U.S. Department of Health and Human Services, the Public Health Service, the Centers for Disease Control and Prevention, or the authors’ affiliated institutions. Use of trade names is for identification only and does not imply endorsement by any of the groups named above. 10 Centers for Disease Control and Prevention • www.cdc.gov/pcd/issues/2004/oct/04_0021.htm VOLUME 1: NO. 4 OCTOBER 2004 Table 3. Comparison of Data from the 1997, 2000, and 2002 Addressing Tobacco in Managed Care Surveys, United States 1997 2000 2002 (N = 323) (N = 85) (N = 152) (% Yes) (% Yes) (% Yes) P Plan provides full coverage for: Any pharmacotherapy for smoking cessation 25.0 59.2 88.8 <.001 Zyban 17.6 37.2 41.1 .57 Any over-the-counter NRT 6.6 14.9 8.6 .004 NRT only with program enrollment 25.0 26.0 10.8 .004 Plan provides full coverage for: Telephone counseling 32.8 36.8 51.7 .04 Face-to-face counseling 26.6 23.6 41.1 .01 Group counseling or classes 35.7 37.0 15.9 <.001 Self-help materials 54.1 56.6 25.8 <.001 Plan provides full coverage for any behavioral or pharmacotherapy 75.0 94.4 98.0 .28 Plan requires providers to: Ask new patients about smoking status NA 74.1 61.2 .02 Include smoking status as a vital sign (i.e., ask about and NA 43.5 54.3 .28 document status at every visit) Strongly advise all patients who smoke to quit NA 68.3 44.1 .02 Refer smokers to intensive treatment as appropriate NA 24.7 33.6 .33 Arrange for follow-up with patients trying to quit smoking NA 36.5 30.3 .15 Plan able to identify individual members who smoke 14.9 27.1 71.7 <.001 Plan has a specific strategy to address smoking cessation during: Adolescence 17.6 24.2 28.9 .46 Pregnancy 45.0 59.0 56.6 .72 Postpartum visits (relapse prevention) 13.6 30.5 46.7 .02 Pediatric visits (secondhand smoke) 15.8 17.3 28.3 .06 Post-myocardial infarction 21.7 27.2 46.7 .004 Treatment for chronic illness 22.6 31.3 52.0 .002 Plan funds a full- or part-time tobacco control program staff 7.7 23.5 19.1 .15 position Boldface indicates a significant difference. NRT indicates nicotine replacement therapy. NA indicates data not available because question was not included in 1997 ATMC survey. The opinions expressed by authors contributing to this journal do not necessarily reflect the opinions of the U.S. Department of Health and Human Services, the Public Health Service, the Centers for Disease Control and Prevention, or the authors’ affiliated institutions. Use of trade names is for identification only and does not imply endorsement by any of the groups named above. www.cdc.gov/pcd/issues/2004/oct/04_0021.htm • Centers for Disease Control and Prevention 11 http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png Preventing Chronic Disease Pubmed Central

Addressing Tobacco in Managed Care: Results of the 2002 Survey

Preventing Chronic Disease , Volume 1 (4) – Sep 15, 2004

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Abstract

shown improvement in their ability to identify at least some members who smoke. Similarly, a greater percent- Introduction age of plans are employing strategies to address smoking In the United States, tobacco use is the leading pre- cessation during the postpartum period to prevent smok- ventable cause of death and disease. The health and ing relapse and during pediatric visits to reduce or elimi- cost consequences of tobacco dependence have made nate children’s exposure to environmental tobacco smoke. treatment and prevention of tobacco use a key priority among multiple stakeholders, including health plans, Conclusion insurers, providers, employers, and policymakers. In The results of the 2002 ATMC survey reflect both 2002, the third survey of tobacco control practices and tremendous accomplishments and important opportuni- policies in health plans was conducted by America’s ties for health plans to collaborate in tobacco control Health Insurance Plans’ technical assistance office as efforts. With appropriate support, analytical tools, and part of the Addressing Tobacco in Managed Care resources, it is likely that health plans, clinicians, (ATMC) program. providers, and consumers will continue to evolve in their efforts to reduce the negative consequences of tobacco use. Methods The ATMC survey was conducted in the spring of 2002 Introduction via mail, e-mail, and fax. A 19-item survey instrument was developed and pilot-tested. Of the 19 items, 12 were the same as in previous years, four were modified to col- In the United States, tobacco use is the leading prevent- lect more detailed data on areas of key interest, and able cause of death and disease. Smoking kills more than three were added to gain information about strategies to 440,000 people in the United States each year, with most promote smoking cessation. The sample for the survey deaths occurring from lung cancer, ischemic heart disease, was drawn from the 687 plans listed in the national and chronic airway obstruction (1). Yet approximately 23% directory of member and nonmember health plans in of American adults continue to smoke cigarettes (2). In America’s Health Insurance Plans. 2000, it was estimated that approximately 8.6 million per- The opinions expressed by authors contributing to this journal do not necessarily reflect the opinions of the U.S. Department of Health and Human Services, the Public Health Service, the Centers for Disease Control and Prevention, or the authors’ affiliated institutions. Use of trade names is for identification only and does not imply endorsement by any of the groups named above. www.cdc.gov/pcd/issues/2004/oct/04_0021.htm • Centers for Disease Control and Prevention 1 VOLUME 1: NO. 4 OCTOBER 2004 sons in the United States were living with at least one con- results of the 2002 ATMC survey; highlight changes from dition attributed to smoking (3). 1997 to 2002; cross-reference the findings with national guidelines and recommendations; and explore these find- The health consequences of tobacco use are accompanied ings and trends in light of the changing environment in by a staggering economic burden. Smoking caused more which health plans operate and the public’s attitude than $157 billion in annual health-related economic losses toward tobacco use. between 1995 and 1999, including $81.9 billion in smok- ing-related productivity losses and $75.5 billion in excess Methods medical expenditures (1). Smoking-attributable neonatal expenditures were estimated at $366 million in 1996, or $704 per maternal smoker (1). Together, the consequences A 19-item survey instrument was developed and pilot- and costs of tobacco dependence have made treatment and tested in the fall of 2001. The instrument was designed to prevention of tobacco use a key priority among multiple assess new trends, barriers, and opportunities related to stakeholders, including health plans, insurers, providers, addressing tobacco control in health plans, identify new employers, and policymakers. models or frameworks of care, and assess changes in health-plan–based tobacco control activities between 1997 In 1997, The Robert Wood Johnson Foundation estab- and 2002. The sample for the survey was drawn from the lished a collaborative program, Addressing Tobacco in 687 plans listed in AHIP’s national directory of member Managed Care (ATMC). This program is based on the and nonmember health plans. The directory was stratified understanding that health plans’ comprehensive benefits, based on health plan enrollment size, and a random sam- sophisticated information systems, and defined popula- ple of 246 health plans was selected. The sample size tions, as well as their ongoing partnerships with health enables the detection of a 5% difference between propor- care providers, are well suited to implement, evaluate, and tions at a = .05 and ß = .80. sustain tobacco control interventions. ATMC includes a National Program Office based at the University of The ATMC survey was conducted in the spring of 2002. Wisconsin Medical School’s Center for Tobacco Research As in 1997 and 2000, the 2002 survey was conducted via and Intervention, and a national technical assistance mail, e-mail, and fax, with telephone follow-up with non- office (NTAO) managed by America’s Health Insurance respondents at two, four, and six weeks after initial con- Plans (AHIP), formerly known as the American tact. The sample included large national plans that have Association of Health Plans (AAHP). The mission of the local plans in multiple states. As in previous years, the cor- NTAO is to advance the integration of tobacco cessation porate office of each national plan was asked to review the and prevention programs into routine health care by questionnaire and determine whether they would respond increasing the number and quality of tobacco control ini- on behalf of their local plans or ask local plans to complete tiatives within health plans. the questionnaires individually. Three of four national plans opted to respond on behalf of their local plans and The NTAO provides resources to health plans and insur- their responses reflect 64% (97/152) of the responses. ers striving to develop tobacco control programs; conducts a benchmarking awards program to highlight exemplary The 2002 survey questionnaire was similar to the 2000 health plan tobacco control initiatives; promotes best prac- survey. Of the 19 items in the 2002 questionnaire, 12 were tices and partnerships through national conferences; and the same as in previous years, four were modified to collect oversees the development of a business case model for more detailed data on areas of key interest (i.e., pharma- smoking cessation. The NTAO has also conducted three ceutical coverage and system-level interventions), and surveys of health plans over the past six years to assess three were added to gain information about strategies to practices and policies related to tobacco control. promote smoking cessation. Based on feedback provided during pretesting, the majority of survey questions focused The ATMC baseline survey was conducted in 1997, fol- on smoking cessation despite recognition that tobacco ces- lowed by a similar survey in 2000. The results of both sur- sation or tobacco control is a more encompassing term. veys were published in peer-reviewed journals in 1998 and Although we recognize that the preferred provider organi- 2002 (4,5). The purpose of this paper is to present the zation (PPO) product has grown in popularity, the 2002 The opinions expressed by authors contributing to this journal do not necessarily reflect the opinions of the U.S. Department of Health and Human Services, the Public Health Service, the Centers for Disease Control and Prevention, or the authors’ affiliated institutions. Use of trade names is for identification only and does not imply endorsement by any of the groups named above. 2 Centers for Disease Control and Prevention • www.cdc.gov/pcd/issues/2004/oct/04_0021.htm VOLUME 1: NO. 4 OCTOBER 2004 ATMC survey asked respondents to answer all questions one type of pharmacotherapy used for tobacco cessation based on their best-selling commercial health mainte- (Table 1). Bupropion, in the form of Wellbutrin, was the nance organization (HMO) product to preserve the ability most commonly covered pharmacotherapy. Only 11% of to make comparisons with previous years. plans reported that provision of full coverage for tobacco cessation pharmacotherapies is dependent on enrollment All analyses were performed with SPSS software (SPSS, in a counseling or cessation program. Inc, Chicago, Ill). Chi-square tests and t-tests were used for comparisons, and results of these tests were considered Full coverage for at least one type of behavioral inter- statistically significant when the corresponding P value vention used for tobacco cessation was reported by the vast was # .05. Consistent with previous years, the data are majority of health plans (Table 1). Telephone counseling unweighted to best describe the policies and practices of was the most commonly covered behavioral intervention, health plans. followed by face-to-face counseling and self-help materials. Health plans reported having a variety of strategies to Results encourage members to stop smoking during times that might be considered important teachable moments. The Of the 246 plans in the sample, 152 (62%) completed and majority of health plans reported having a specific strate- returned the survey. Collectively, the 152 plans represent gy to address smoking cessation during pregnancy and more than 43.5 million HMO members. Respondent plans during treatment for chronic illnesses (Table 1). were predominantly independent practice association, net- work, and mixed models. Fifty-one percent were for-profit Plans reported that a variety of strategies are used with and publicly held; 24% were for-profit and privately held; providers and their office staff to promote smoking cessa- 23% were not-for-profit; and 2% were mutual companies. tion among plan members. The majority of plans reported A comparative analysis of respondents and nonrespon- offering provider education and offering prompts and dents to the 2002 survey indicated that there were no sig- reminders to providers (Table 1). Provider prompts and nificant differences in size, tax status, or predominant reminders were coupled with provider education by 44% of model type between respondents and nonrespondents. plans. Few plans reported offering incentives to providers and their staff to promote smoking cessation. Among plans that responded to the 2002 ATMC survey, 71% reported having written clinical guidelines for smok- Health plans reported that they require providers to ing cessation. The majority of plans reported having guide- carry out a variety of assessments and activities related to lines that had been internally developed by the plan; few smoking that are in accordance with the clinical model of plans reported using the 2000 U.S. Public Health Service the 5 As: Ask, Advise, Assess, Assist, and Arrange (6). Clinical Practice Guideline on Tobacco Use and (The 2002 ATMC survey was fielded before the develop- Dependence or the 1996 Agency for Health Care Policy and ment of Assess willingness to quit.) The majority of plans Research (now the Agency for Healthcare Research and require providers to ask new patients about smoking sta- Quality [AHRQ]) Practice Guideline on Tobacco Cessation tus and include smoking status as a vital sign (ask about (Table 1). smoking status at every visit) (Table 1). Fewer plans reported requiring providers to carry out activities aimed Nearly three quarters of all plans indicated that they at advising, assisting, and following up with patients try- could identify at least some individual plan members who ing to quit smoking. smoke (Table 1). Among those plans that reported being able to identify individual smokers, the most common data Although health plans reported a variety of barriers that sources are health risk appraisals and telephone inter- limit their ability to effectively address tobacco control, the views. Only 6% of plans use enrollment data to identify most common barriers relate to resources (e.g., inadequate individual smokers. staff, funding, competing priorities) and system issues (e.g., poor data collection, reporting, record maintenance). Other The vast majority of health plans that responded to the barriers included lack of patient demand, lack of purchaser survey reported that they provide full coverage for at least demand, and delayed economic return on investment. The opinions expressed by authors contributing to this journal do not necessarily reflect the opinions of the U.S. Department of Health and Human Services, the Public Health Service, the Centers for Disease Control and Prevention, or the authors’ affiliated institutions. Use of trade names is for identification only and does not imply endorsement by any of the groups named above. www.cdc.gov/pcd/issues/2004/oct/04_0021.htm • Centers for Disease Control and Prevention 3 VOLUME 1: NO. 4 OCTOBER 2004 Tobacco control activities used by larger health plans are Discussion different from those used by smaller plans (Table 2). Based on the enrollment distribution of health plans in our sam- The results of the 2002 ATMC survey indicate that ple, we defined larger plans as those with more than health plans are using evidence-based programs and clin- 250,000 members and smaller plans as those with less ical guidelines to address tobacco use. Clinical guidelines than or equal to 250,000 members. Larger plans were detail the most effective options for helping patients to more likely than smaller plans to have written clinical quit smoking, and using strategies recommended in clini- guidelines for smoking cessation (P < .001) and to have a cal guidelines is associated with greater success in help- specific strategy to address smoking cessation during spe- ing smokers to quit (6,7). Although a large percentage of cific times, such as adolescence, pregnancy, postpartum health plans reported having written clinical guidelines visits, and hospitalization (P ranged from < .001 to .02). for tobacco cessation, it is possible that even more plans Smaller plans, more likely to be staff and group-model address tobacco cessation within other clinical guidelines plans, were more likely to be able to identify individual used for managing or treating conditions in which tobac- plan members who smoke (P < .001) and provide full cov- co use is identified as a comorbidity or risk factor (e.g., erage for some prescription pharmacotherapies used for heart disease, diabetes, asthma). It is also noteworthy smoking cessation (P ranged from <.001 to .02). that more than half of the plans reported adopting inter- nally developed guidelines, as opposed to guidelines Although the ATMC survey instruments used in 1997, developed by federal agencies and expert panels such as 2000, and 2002 were not identical, the majority of core the U.S. Public Health Service (USPHS) and AHRQ. questions on pharmacotherapies, behavioral health, and However, it is possible that plans reviewed such guide- smoking cessation strategies remained unchanged. The lines and integrated many or all of the key components percentage of plans that provide full coverage for any type into their own guidelines. of pharmacotherapy used for smoking cessation more than tripled from 1997 to 2002 (P < .001) (Table 3). The Plans showed remarkable improvement in 2002, com- percentage of plans able to identify individual smokers pared with previous years, in identifying individual plan also increased (P < .001). More plans reported providing members who smoke. The ability to identify smokers is an full coverage for telephone counseling (P = .04) and face- important indicator of a plan’s ability to remind or prompt to-face counseling (P = .011) in 2002 compared with both providers to discuss and/or advise patients about smoking previous surveys. cessation. Such provider reminders are considered an effective strategy for supporting smoking cessation and From 1997 to 2002, there were large increases in the are recommended by the Task Force on Community percentage of plans with strategies to address relapse pre- Preventive Services (7). The survey question, however, vention during the postpartum period (P = .02) and smok- assesses the percentage of plans that can identify any ing cessation during treatment for chronic illness (P = members who smoke (rather than all members who .002) and following a heart attack (P = .004) (Table 3). smoke), and the methods that plans report using to identi- fy smokers are most likely to identify subgroups of smok- Health plan performance on measures related to requir- ers (i.e., those that respond to health risk appraisals or ing providers to adhere to four of the 5 As varied in both surveys). Indeed, the ability of health plans to identify directions between 2000 and 2002 (Table 3). Although smokers is contingent upon members actively providing comparable data on these variables were not collected in information about their smoking status during some inter- 1997, the percentage of plans that require providers to ask action with the health plan, whether during enrollment, new patients about smoking status (P = .02) and strongly through a survey, or via some other point of contact. advise all smokers to quit (P = .02) decreased from 2000 to 2002, and the percentage of plans that require providers to The number of health plans providing full coverage for include smoking as a vital sign (i.e., ask about it at every any type of pharmacotherapy for tobacco cessation more visit) (P = .28) and assist smokers by referring them into than tripled in 2002, compared with previous years. In the appropriate treatment (P = .33) increased modestly. 2002 ATMC survey, nearly nine out of 10 plans reported providing full coverage for at least one type of pharma- cotherapy for tobacco cessation. Consistent with recom- The opinions expressed by authors contributing to this journal do not necessarily reflect the opinions of the U.S. Department of Health and Human Services, the Public Health Service, the Centers for Disease Control and Prevention, or the authors’ affiliated institutions. Use of trade names is for identification only and does not imply endorsement by any of the groups named above. 4 Centers for Disease Control and Prevention • www.cdc.gov/pcd/issues/2004/oct/04_0021.htm VOLUME 1: NO. 4 OCTOBER 2004 mendations based on the effectiveness of various prescrip- are leading barriers to adequately addressing tobacco con- tion and over-the-counter tobacco cessation first-line phar- trol. Health plans may benefit from developing a business macotherapies (6), the majority of plans reported provid- case model that stresses the importance of tobacco cessa- ing full coverage for bupropion. The significant increase in tion to purchasers and advocates for resources to imple- the number of plans that provide full coverage for at least ment and maintain evidence-based tobacco cessation pro- one type of pharmacotherapy related to tobacco cessation grams. Research supported by the NTAO is underway to is well aligned with the growing body of literature indicat- provide an estimated return on investment for smoking ing that reduced out-of-pocket cost is associated with cessation interventions, based primarily on smoking- greater use of tobacco cessation programs and services (8- attributable costs for health plans. 12) and may lead to increased rates of cessation (10,11). The ATMC survey and its findings have limitations. The Consistent with literature citing the effectiveness of response rate of approximately 60% is respectable, but telephone counseling and that smokers are more likely leaves open the possibility of selection bias. Even though to use telephone counseling than to participate in indi- no significant differences were detected between respon- vidual or group counseling sessions (13,14), approxi- dents and nonrespondents on three key characteristics mately half of plans surveyed provide full coverage for (size, tax status, predominant model type), respondents telephone counseling. It is possible that even more possibly differed from nonrespondents in ways that were smokers have access to telephone counseling through not measured. Another limitation to the ATMC survey is the availability of state-sponsored quit lines. Less than that the psychometric properties of the questionnaire were 25% of plans impose an annual or lifetime limit on cov- not tested to assess reliability or validity. However, the erage for tobacco cessation treatments, indicating wide- survey design process did include substantial pretesting to spread acceptance of the USPHS guideline recommend- increase the probability of including questions that were ing coverage for repeated, intensive tobacco dependence reliable and likely to yield valid responses. Additionally, counseling and pharmacotherapy (6). we identified a potential limitation of the 1997 survey — it did not include a frame of reference for product type (e.g., The results of the 2002 ATMC survey also suggest that HMO, PPO). When the survey does not specify product plans are paying close attention to pregnancy and the type, respondents tend to answer for the HMO product. postpartum period to assist women to quit smoking. The Respondents were explicitly asked to answer for the HMO large percentage of plans reporting strategies to address product in 2000 and 2002. However, the possibility smoking cessation during and after pregnancy to pre- remains that the change in frame of reference contributes vent relapse may reflect greater health plan awareness to some differences in survey findings from 1997 to 2000 or of research that has demonstrated the cost-effectiveness 2002 (but not from 2000 to 2002). of offering smoking cessation programs to pregnant women (15). Aside from the ATMC surveys, few surveys have assessed tobacco control practices and policies of health Overall, our results indicate the greatest improvement plans. Some surveys have focused on plans operating in a in tobacco control activities is at the health plan level as single state (9,16), some have included a narrow subset of opposed to the physician level. For example, more plans plans (i.e., well-established nonprofit plans with a history report providing full coverage for pharmacotherapies than of offering tobacco cessation programs) (17), and others report requiring providers to carry out activities in support have collected information about subsets of smokers with- of the 5 As. This may be because most health plans (espe- in a plan (i.e., pregnant women) (18,19). Nevertheless, a cially those that are not staff-model HMOs) find changing 1999 survey of California health plans reported results physician behavior to be a challenge. Although more plans comparable to our results: 85% of HMOs in the California are beginning to experiment with performance feedback as survey covered at least one form of pharmacotherapy; 77% a way to change physician behavior, prompts, reminders, covered bupropion; 46% covered telephone counseling; and and provider training are more common strategies. 54% covered individual counseling (16). However, the lim- ited availability of comparable data prohibits comparisons Health plans continue to report that resource limita- of our findings with other surveys and underscores the tions, including insufficient staff and inadequate funding, importance of ATMC data for an adequate understanding The opinions expressed by authors contributing to this journal do not necessarily reflect the opinions of the U.S. Department of Health and Human Services, the Public Health Service, the Centers for Disease Control and Prevention, or the authors’ affiliated institutions. Use of trade names is for identification only and does not imply endorsement by any of the groups named above. www.cdc.gov/pcd/issues/2004/oct/04_0021.htm • Centers for Disease Control and Prevention 5 VOLUME 1: NO. 4 OCTOBER 2004 of health plan tobacco control practices and policies at the Author Information national level. Corresponding author: Carol McPhillips-Tangum, The results of the 2002 ATMC survey indicate that an MPH, CMT Consulting, 106 Geneva Street, increasing number of health plans are using evidence- Decatur, GA 30030. Telephone: 404-377-4061. E-mail: based approaches and strategies to address tobacco use. ctangum@mindspring.com. However, in light of competing priorities for limited resources, health plans may be challenged to sustain the Author affiliations: Carmella Bocchino, MBA, RN, Rita improvements they have made from 1997 to 2002. Cost Carreon, Caroline Erceg, MJ, Bob Rehm, MBA, America’s modeling and the development of a business case model for Health Insurance Plans (AHIP), Washington, DC. smoking cessation may hold promise by assisting some plans to leverage the body of literature that supports the References cost-effectiveness of tobacco cessation treatment (6,20-23). Just as challenges lay ahead, so do many important and 1. Annual smoking attributable mortality, years of potentially exciting opportunities. Health plans are in a potential life lost, and economic costs – United States, key position to implement operational policies and pro- 1995-1999. MMWR Morb Mortal Wkly Rep grams that can reduce the prevalence of tobacco use and 2002;51(14):300-3. positively impact the health of millions of individuals. 2. Centers for Disease Control and Prevention. State- Health plans have the opportunity to sustain and expand specific prevalence of current cigarette smoking access to tobacco cessation treatments and services such as among adults—United States, 2002. MMWR Morb pharmacotherapies and counseling services. As new evi- Mortal Wkly Rep 2004;52(53):1277-80.. dence emerges, health plans have the flexibility to model 3. Centers for Disease Control and Prevention. Cigarette new tobacco cessation benefits and promote them widely to smoking – attributable morbidity, United States, their membership. They also have the opportunity to influ- 2000. MMWR Morb Mortal Wkly Rep 2003; ence large purchasers of health care services by communi- 52(35):842-3. cating the value of tobacco cessation services and expand- 4. McPhillips-Tangum C. Results from the first annual ing their field of influence from the clinical and provider survey on addressing tobacco in managed care. Tob setting to the broader community. By participating in com- Control 1998;7(suppl):S11-13. munity-wide campaigns and policy initiatives that support 5. McPhillips-Tangum C, Cahill A, Bocchino C, Cutler C. tobacco cessation and prevention, stakeholders can influ- Addressing tobacco in managed care: results of the ence and help control tobacco use. 2000 Survey. Preventive Medicine in Managed Care 2002;3(3):85-94. Available from: URL: http://www.chp- In summary, the results of the 2002 ATMC survey care.com/downloads/ATMC-2000SurveyResults.pdf. reflect both tremendous accomplishments and important 6. 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Use The authors thank The Robert Wood Johnson and cost-effectiveness of smoking cessation services Foundation for the unrestricted educational grant that under four insurance plans in a health maintenance made this survey possible. organization. N Engl J Med 1998;339(10):673-9. 9. Schauffler HH, McMenamin S, Olson K, Boyce-Smith G, Rideout JA, Kamil J. Variations in treatment ben- The opinions expressed by authors contributing to this journal do not necessarily reflect the opinions of the U.S. Department of Health and Human Services, the Public Health Service, the Centers for Disease Control and Prevention, or the authors’ affiliated institutions. Use of trade names is for identification only and does not imply endorsement by any of the groups named above. 6 Centers for Disease Control and Prevention • www.cdc.gov/pcd/issues/2004/oct/04_0021.htm VOLUME 1: NO. 4 OCTOBER 2004 efits influence smoking cessation: results of a random- 17. Rigotti NA, Quinn VP, Stevens VJ, Solberg LI, ized controlled trial. Tob Control 2001;10:175-80. Rosenthal AC, et al. Tobacco control policies in 11 10. Cox JL, McKenna JP. Nicotine gum: does providing it leading managed care organizations: progress and free in a smoking cessation program alter success challenges. Eff Clin Pract 2002;May-June:130-6. rates? J Fam Pract 1990;31(3):278-80. 18. Pickett KE, Abrams B, Schauffler HH, Savage J, 11. Hughes JR, Wadland WC, Fenwick JW, Lewis J, Brandt P, Kalkbrenner A, et al. Coverage of tobacco Bickel WK. Effect of cost on the self-administration dependence treatments for pregnant smokers in and efficacy of nicotine gum: a preliminary study. Prev health maintenance organizations. Am J Public Med 1991;20:486-96. Health 2001;91(9):1393-4. 12. Johnson RE, Hollis JF, Stevens VJ, Woodson GT. 19. Barker DC, Robinson LA, Rosenthal AC. A survey of Patterns of nicotine gum use in a health maintenance managed care strategies for pregnant smokers. Tob organization. DICP 1991;25:730-5. Control 2000;9(Suppl. III):iii46-50. 13. McAfee T, Sofian N, Wilson J, Hindmarsh M. The role 20. Elixhauser A. The costs of smoking and the cost effec- of tobacco intervention in population-based health tiveness of smoking cessation programs. J Public care. Am J Prev Med 1998;14:46-52. Health Policy 1990;11(2):218-37. 14. McAfee T. Increasing the population impact of quit- 21. Pronk N, Goodman MJ, O’Connor PJ, Martinson BC. lines. Paper presented at: The North American Relationship between modifiable health risks and Quitline Conference; 2002; Phoenix, AZ. short-term health care changes. JAMA 1999; 15. Marks JS, Koplan JP, Hogue CJ, Dalmat ME. A cost- 282(23):2235-9. benefit/cost-effectiveness analysis of smoking cessa- 22. Tsevat J. Impact and cost-effectiveness of smoking tion for pregnant women. Am J Prev Med interventions. Am J Med 1992;93(1A):43S-47S. 1990;6(5):282-9. 23. Warner KE. Cost effectiveness of smoking cessation 16. Halpin Schauffler HH, Mordavsky JK, McMenamin S. therapies. Pharmacoeconomics 1997;11(6):538-49. Adoption of the AHCPR Clinical Practice Guideline for Smoking Cessation: a survey of California’s HMOs. Am J Prev Med 2001;21(3):153-61. Tables Table 1. Results from the 2002 Addressing Tobacco in Managed Care Survey (N = 152), United States % Yes Plan has written clinical guidelines for smoking cessation 71.1 Plan uses internally developed clinical guidelines for smoking cessation 56.6 Plan uses the 2000 U.S. Public Health Service Clinical Practice Guideline 5.3 Plan uses the 1996 Agency for Health Care Policy and Research Guideline 3.3 Plan uses guidelines from some other source 5.9 Plan is able to identify individual members who smoke 71.7 Data sources used by plans to identify individual members who smoke (among plans that can identify smokers): Health risk appraisal 89.9 Telephone survey 74.1 Sample of medical records 60.6 Administrative data review 53.2 (Continued on next page) The opinions expressed by authors contributing to this journal do not necessarily reflect the opinions of the U.S. Department of Health and Human Services, the Public Health Service, the Centers for Disease Control and Prevention, or the authors’ affiliated institutions. Use of trade names is for identification only and does not imply endorsement by any of the groups named above. www.cdc.gov/pcd/issues/2004/oct/04_0021.htm • Centers for Disease Control and Prevention 7 VOLUME 1: NO. 4 OCTOBER 2004 Table 1. (continued) Results from the 2002 Addressing Tobacco in Managed Care Survey (N = 152), United States % Yes Mail-based survey 48.6 Electronic medical record 48.6 Enrollment information 6.4 Plan provides full coverage for: Bupropion (as Wellbutrin) 79.2 Bupropion (as Zyban) 41.1 Prescription NRT nasal spray 35.8 Prescription NRT inhaler 35.8 NRT over-the-counter patches 8.6 NRT over-the-counter gum 4.6 Plan provides full coverage for: Telephone counseling 51.7 Face-to-face counseling 41.1 Self-help materials (e.g., booklets, videos, audiotapes, tailored mailings) 25.8 Individual counseling of pregnant women 19.2 Group counseling or classes 15.9 Plan has annual or lifetime limits on coverage for smoking cessation interventions 15.1 Plan allows patients to self-refer to smoking cessation services 59.3 Plan requires providers to: Ask new patients about their smoking status 61.2 Include smoking status as a vital sign (i.e., ask about and document status at every visit) 54.3 Strongly advise all patients who smoke to quit 44.1 Refer smokers to intensive treatment as appropriate 33.6 Arrange for follow-up with patients trying to quit smoking 30.3 Plan has specific strategy to address smoking cessation during: Pregnancy 56.6 Treatment for other chronic illness 52.0 Post-myocardial infarction 46.7 Postpartum visits (relapse prevention) 46.7 Adolescence 28.9 Pediatric visits (secondhand smoke) 28.3 Hospitalization 7.2 Plan has guidelines, protocols, or pathways to address smoking cessation during: Pregnancy 65.1 Treatment for other chronic illness 61.8 Post-myocardial infarction 57.2 Adolescence 57.2 (Continued on next page) The opinions expressed by authors contributing to this journal do not necessarily reflect the opinions of the U.S. Department of Health and Human Services, the Public Health Service, the Centers for Disease Control and Prevention, or the authors’ affiliated institutions. Use of trade names is for identification only and does not imply endorsement by any of the groups named above. 8 Centers for Disease Control and Prevention • www.cdc.gov/pcd/issues/2004/oct/04_0021.htm VOLUME 1: NO. 4 OCTOBER 2004 Table 1. (continued) Results from the 2002 Addressing Tobacco in Managed Care Survey (N = 152), United States % Yes Pediatric visits (secondhand smoke) 55.3 Postpartum visits (relapse prevention) 53.3 Hospitalization 36.2 Plan funds a full- or part-time tobacco control program staff position 19.1 Plan used the following strategies with providers and/or their office staff in the past year to promote smoking cessation: Provider education 69.8 Providing prompts and reminders to encourage providers to address tobacco control 53.2 Elimination of pre-authorization requirements for smoking cessation interventions 40.1 Increased reimbursement for smoking cessation counseling/assistance 34.2 Incentives for providers and their staff to effectively address tobacco 4.6 Increased amount of time that providers can spend with patients 2.0 Barriers limiting plan’s ability to address tobacco control: Resource barriers (e.g., staff, funding, competing priorities) 73.5 System barriers (e.g., poor data collection, reporting, record maintenance) 40.7 Lack of patient demand 39.7 Lack of purchaser demand 38.4 Delayed economic return on investment 33.1 NRT indicates nicotine replacement therapy. Table 2. Tobacco Control Activities by Size of Health Plan: 2002 Addressing Tobacco in Managed Care Survey (N = 152), United States < > 250,000 Members 250,000 Members (N = 102) (N = 50) % Yes % Yes P Plan has a written clinical guideline for smoking cessation 62.4 90.0 <.001 Plan provides full coverage for: NRT over-the-counter gum 3.0 8.0 .17 NRT over-the-counter patches 7.9 10.0 .67 NRT inhaler 42.6 22.0 .01 NRT nasal spray 42.6 22.0 .01 Bupropion (as Zyban) 47.5 28.0 .02 Bupropion (as Wellbutrin) 80.0 77.6 .73 Plan provides full coverage for: Telephone counseling 62.4 30.0 <.001 Face-to-face counseling 52.5 18.0 <.001 Group counseling or classes 14.9 18.0 .62 (Continued on next page) The opinions expressed by authors contributing to this journal do not necessarily reflect the opinions of the U.S. Department of Health and Human Services, the Public Health Service, the Centers for Disease Control and Prevention, or the authors’ affiliated institutions. Use of trade names is for identification only and does not imply endorsement by any of the groups named above. www.cdc.gov/pcd/issues/2004/oct/04_0021.htm • Centers for Disease Control and Prevention 9 VOLUME 1: NO. 4 OCTOBER 2004 Table 2. (continued) Tobacco Control Activities by Size of Health Plan: 2002 Addressing Tobacco in Managed Care Survey (N = 152), United States < > 250,000 Members 250,000 Members (N = 102) (N = 50) % Yes % Yes P 14.9 28.0 .054 Individual counseling of pregnant women 20.8 36.0 .04 Self-help materials 17.0 28.6 .10 Plan has annual or lifetime limits on coverage for smoking cessation interventions 68.3 40.8 .001 Plan allows patients to self-refer to smoking cessation services Plan requires providers to: 48.0 88.0 <.001 Ask new patients about smoking status 39.2 85.7 <.001 Include smoking status as a vital sign (i.e., ask about and document status at every visit) 46.1 83.3 .001 Strongly advise all patients who smoke to quit 37.3 26.0 .17 Refer smokers to intensive treatment as appropriate 35.3 20.0 .054 Arrange for follow-up with patients trying to quit smoking 90.2 34.0 <.001 Plan able to identify individual members who smoke Plan has a specific strategy to address smoking cessation during: 5.9 76.0 <.001 Adolescence 42.2 86.0 <.001 Pregnancy 33.3 74.0 <.001 Postpartum visits (relapse prevention) 5.9 74.0 <.001 Pediatric visits (secondhand smoke) 33.3 74.0 <.001 Post-myocardial infarction 39.2 78.0 <.001 Treatment for other chronic illness 3.9 14.0 .02 Hospitalization Plan has guidelines, protocols, or pathways to address smoking cessation during: 52.0 68.0 .06 Adolescence 56.9 82.0 .002 Pregnancy 46.1 68.0 .01 Postpartum visits (relapse prevention) 48.0 70.0 .01 Pediatric visits (secondhand smoke) 50.0 72.0 .01 Post-myocardial infarction 53.9 78.0 .004 Treatment for other chronic illness 48.0 12.0 <.001 Hospitalization 14.7 28.0 .05 Plan funds a tobacco control program staff position Boldface indicates a significant difference. NRT indicates nicotine replacement therapy. The opinions expressed by authors contributing to this journal do not necessarily reflect the opinions of the U.S. Department of Health and Human Services, the Public Health Service, the Centers for Disease Control and Prevention, or the authors’ affiliated institutions. Use of trade names is for identification only and does not imply endorsement by any of the groups named above. 10 Centers for Disease Control and Prevention • www.cdc.gov/pcd/issues/2004/oct/04_0021.htm VOLUME 1: NO. 4 OCTOBER 2004 Table 3. Comparison of Data from the 1997, 2000, and 2002 Addressing Tobacco in Managed Care Surveys, United States 1997 2000 2002 (N = 323) (N = 85) (N = 152) (% Yes) (% Yes) (% Yes) P Plan provides full coverage for: Any pharmacotherapy for smoking cessation 25.0 59.2 88.8 <.001 Zyban 17.6 37.2 41.1 .57 Any over-the-counter NRT 6.6 14.9 8.6 .004 NRT only with program enrollment 25.0 26.0 10.8 .004 Plan provides full coverage for: Telephone counseling 32.8 36.8 51.7 .04 Face-to-face counseling 26.6 23.6 41.1 .01 Group counseling or classes 35.7 37.0 15.9 <.001 Self-help materials 54.1 56.6 25.8 <.001 Plan provides full coverage for any behavioral or pharmacotherapy 75.0 94.4 98.0 .28 Plan requires providers to: Ask new patients about smoking status NA 74.1 61.2 .02 Include smoking status as a vital sign (i.e., ask about and NA 43.5 54.3 .28 document status at every visit) Strongly advise all patients who smoke to quit NA 68.3 44.1 .02 Refer smokers to intensive treatment as appropriate NA 24.7 33.6 .33 Arrange for follow-up with patients trying to quit smoking NA 36.5 30.3 .15 Plan able to identify individual members who smoke 14.9 27.1 71.7 <.001 Plan has a specific strategy to address smoking cessation during: Adolescence 17.6 24.2 28.9 .46 Pregnancy 45.0 59.0 56.6 .72 Postpartum visits (relapse prevention) 13.6 30.5 46.7 .02 Pediatric visits (secondhand smoke) 15.8 17.3 28.3 .06 Post-myocardial infarction 21.7 27.2 46.7 .004 Treatment for chronic illness 22.6 31.3 52.0 .002 Plan funds a full- or part-time tobacco control program staff 7.7 23.5 19.1 .15 position Boldface indicates a significant difference. NRT indicates nicotine replacement therapy. NA indicates data not available because question was not included in 1997 ATMC survey. The opinions expressed by authors contributing to this journal do not necessarily reflect the opinions of the U.S. Department of Health and Human Services, the Public Health Service, the Centers for Disease Control and Prevention, or the authors’ affiliated institutions. Use of trade names is for identification only and does not imply endorsement by any of the groups named above. www.cdc.gov/pcd/issues/2004/oct/04_0021.htm • Centers for Disease Control and Prevention 11

Journal

Preventing Chronic DiseasePubmed Central

Published: Sep 15, 2004

References