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Kicking the Habit Saves Members' Lives as Minnesota Blues, Group Health Show
This article was published in News and Strategies for Managed Medicare & Medicaid July 3, 2000
Smoking is the most preventable cause of death in the U.S., with tobacco-related health care expenditures running more than $50 billion annually. Smoking also is tied to more than 430,000 deaths per year. However, managed care organizations have been slow to encourage members to kick the habit. That could soon change, however.
An updated clinical guideline on treating tobacco addiction released last week by the U.S. Public Health Service could spur more Medicare and Medicaid HMO operators to incorporate smoking cessation efforts or benefits, according to experts on insurance, public health and smoking cessation programs.
Traditionally, health plans have been reticent to cover smoking cessation efforts because of a lack of data on a program's likely return on investment, the propensity of HMO executives not to invest in programs that may not pay off until years later, and the failure by so many plans to treat smoking as a disease, says Susan Curry, director of Group Health Cooperative of Puget Sound's Center for Health Studies.
But the new guideline challenges those beliefs.
"First, we need to call tobacco dependence what it is - a chronic disease, not unlike high blood pressure or diabetes," said Michael Fiore, M.D., chairman of the panel that released the tobacco cessation guideline. The guide updates a 1996 guideline. Over the last four years, Fiore says, a tremendous amount of research has shown the effectiveness of these programs.
In fact, Fiore told MMM recent research has shown that even six to eight weeks of treatment has proved to boost successful smoking quit rates. Furthermore, it costs between $200 and $400 per smoker to offer "an off-the-shelf" smoking cessation program. In fact, the guideline even notes that just three minutes of a physician's time devoted to smoking cessation per smoker is important in helping patients kick the habit.
Only 5% of "self-quitters" successfully stop smoking. But research has shown that 30% of smokers successfully stop when helped professionally. "What other disease can we treat for six to eight weeks and have [such an impact]?" Fiore rhetorically asks.
The guideline will "substantially increase" success rates, Fiore says. "In fact, if every doctor, nurse, dentist or other health care provider and health plan uses this tool in practice across America, we can more than double quit rates from one to at least 2 million new quitters a year." Three Medicare/Medicaid managed care programs have shown that these programs work and are cost effective.
Minnesota Blues' Effort to Reduce Smoking
Blue Cross and Blue Shield of Minnesota, the first health plan in the nation to sue the tobacco companies and the only private-sector health plan to have recovered damages, was among the first health plans in the nation to offer a discount premium to non-smokers, beginning in the early 1980s.
The plan has intensified its efforts to encourage and assist members to quit smoking in recent years. The Blues, which got out of the Medicare HMO business this year, counts nearly 100,000 Medicaid members in its Medicaid HMO, and offers smoking cessation efforts to this population. Typically, Medicare and Medicaid populations have a higher percentage of smokers than the general population, according to Rachel Grossman, who heads up Group Health Plan's smoking cessation program in Seattle.
"For a health plan, investing in tobacco reduction is a no-brainer," according to Mark Banks, M.D., president and CEO of Minnesota's Blue Cross plan. "It saves money, it improves health and it saves money."
The insurer, in fact, has set up a combination program that offers all members counseling and access to medication for tobacco dependence. Blue Cross' smoking cessation effort follows closely to the updated guideline released last week. "We cover both the behavioral side and the pharmaceutical side," says Marc Manley, executive director of the Blues' Center for Tobacco Reduction and Health Improvement.
In fact, many changes have occurred since the original smoking cessation guideline was published in 1996. New information on cost savings, more available drugs to treat nicotine addiction and proven strategies to treat tobacco dependence have become available in the last couple of years.
On the pharmaceutical side, five medications are now available to treat tobacco dependence, whereas only two existed in 1996. The Blues began covering the new drugs, including the nicotine patch, gum and Zyban, beginning in late 1998. On the behavioral side, the company began paying physicians this year for their time spent on educating and assisting patients to quit.
Blue Cross recognizes tobacco use and/or dependence as a medical illness, Manley says, just as it views hypertension or diabetes. As a result, it pays physicians for the number of visits it requires them to treat patients who are smokers to quit. MDs are paid on length of visit and not on diagnoses, he says. Manley says the insurer's costs for the smoking cessation effort are so small that "we can't calculate" them.
So far, only 300 to 400 members out of 2 million insured have exercised the benefit, but Manley expects that to grow as the current program, which began early this year, ages. Manley says out of the 2 million members the Blues count in Minnesota, 150,000 are smokers. The company expects that it can match smokers' quit rates of other successful programs, which range from 15% to 30% of smokers going through such programs.
In another effort to get higher quit rates among its smokers, the company recently started offering a telephone counseling program, called Blue Print for Health, and advertising it on television throughout the state, Manley says. "This can help move people to quit, even if they don't want to," he says.
The ads simply tell those smokers who are insured by Blue Cross to call a certain number for the program. The telephone counseling program first assesses where people are in terms of their smoking habits and their desire to quit. A program is then individually designed for each person. Follow-up consultations are done periodically over the following year.
"Telephone counseling, problem solving and skills training, and help in securing social support both inside and outside of the standard treatment settings are also very effective," according to Fiore.
Group Health Finds Kicking the Habit Is Cheap
Group Health Cooperative researchers have done some of the most important work in proving that smoking cessation saves money, in addition to lives. In a study conducted among the Seattle-based HMO membership, researcher Curry and associates found that smoking cessation efforts are successful in getting smokers to quit, and that smokers who are given full coverage to such programs are more likely to use the benefit.
About 10% of smokers would use smoking-cessation services when fully covered, versus 2.4% under reduced coverage. Although 28% of smokers taking advantage of full coverage quit smoking, 38% of those with partial coverage entering the program kicked the habit "The effect on the overall prevalence of smoking was greater with full coverage than with the cost-sharing plans," Curry and colleagues wrote in a study published two years ago in The New England Journal of Medicine.
"The average total cost per benefit user who stopped smoking ranged from $928 for the standard benefit to $1,192 for the full benefit," Curry wrote.
Group Heath, which began offering some smoking cessation benefits in 1992, increased partial coverage of a smoking cessation benefit to full coverage in May 1997. By the spring of 1998, enrollment in the HMO's Free and Clear program jumped from 1,300 to 3,500, says Grossman, coordinator of Group Health's Tobacco Clinical Roadmap.
As of the end of last year, Group Health had a success rate of 30% of smokers who would quit for at least 30 days. The HMO's cost for each enrollee entering the program - whether they succeed or not - runs between $100 and $150.
The HMO's smoking cessation benefit includes 100% coverage for the behavioral aspect of the program, which members can access once a year. With that, members can access a pharmatherapy benefit, which includes nicotine-replacement therapy and bupropion, with enrollees paying their normal Rx drug copay. The behavioral part of the program is offered as an individual or group program, which includes counseling with health professionals and access to counselors via an 800 number call-in line. The plan is in the process of targeting programs for smokers who have chronic medical conditions and for pregnant women.
Getting Pregnant Women to Quit Smoking
Since 1993, New Hampshire Medicaid has offered smoking cessation benefits to pregnant women seeking routine health care at four of the state's 14 clinics contracted to care for pregnant women eligible for Medicaid under an extended services program. Initially a two-year demo, the state continues to cover smoking cessation education-related services performed by nurses and other trained health professionals in group and individual sessions.
"It does make a difference," according to Cecelia Gaffney, advisor to the state's Medicaid program. "The quit rate is four times higher at clinics that provide routine counseling and are reimbursed by Medicaid."
Of the 1,517 women seen at the state's clinics providing prenatal care for Medicaid-eligible and indigent women, quit rates at the four centers offering the counseling coverage was 18.8%, based on 1998 data. In comparison, the quit rate at the other clinics was just 4.2%, Gaffney says.
Why is it so difficult for low-income pregnant women to stop smoking? Gaffney says they live in a world of smokers. "Not smoking makes a woman different from her partner, her best friend and her family," according to Gaffney. "We learned that many women use cigarettes to manage their relationships and their lives. They may smoke to relax with a friend, end an argument with a partner or take a break from their children. They tell us quitting is like losing their best friend."
Oddly, the state has not expanded the program into the other clinics. "The other sites didn't pick up on it," Gaffney says, adding that no one was trained in the other clinics to help people stop smoking. "Just having a mechanism to reimburse isn't enough, although it is necessary.having a strong training program for clinicians is a linchpin."
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