Get 20M+ Full-Text Papers For Less Than $1.50/day. Start a 14-Day Trial for You or Your Team.

Learn More →

Addressing Tobacco in Managed Care: Results of the 2003 Survey

Addressing Tobacco in Managed Care: Results of the 2003 Survey sons learned to other health problems. Introduction Introduction Although tobacco control activity in the United States during the past several years has increased dramatically, tobacco use continues to have devastating consequences The scope and pace of tobacco control activity in the among all age cohorts. United States during the past several years has increased dramatically. Beginning with the 1998 multi- Methods state tobacco settlement, there has been heightened In November 2003, a survey of tobacco control practices attention on tobacco use and an emergence of effective and policies in health insurance plans was conducted by tobacco control strategies. Still, tobacco use continues to America’s Health Insurance Plans’ national technical have devastating consequences among all age cohorts in assistance office. The survey was the fourth and final sur- the United States. New estimates from the Centers for vey conducted as part of the Addressing Tobacco in Disease Control and Prevention (CDC) indicate that Managed Care program. Of the 215 plans in the sample, from 1997 to 2001, approximately 438,000 people in the 160 (74%) completed the survey. Collectively, these plans United States died prematurely each year as a result of represent more than 60 million members of health main- smoking or exposure to secondhand smoke (1). The most tenance organizations. recent report from the U.S. surgeon general confirms that smoking harms almost every organ in the body, Results causing numerous diseases and reducing overall quality From 1997 to 2003, health insurance plans have demon- of life and life expectancy (2). Despite these grim facts, strated increasing use of evidence-based programs and approximately 23% of American adults continue to clinical guidelines to address tobacco use. The number of smoke cigarettes (3). plans providing full coverage for any type of pharma- cotherapy for tobacco cessation has more than tripled since In addition to the health consequences of tobacco use, 1997. Plans have also shown substantial improvement in it has enormous financial consequences. In 1998, 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/2006/jul/05_0173.htm • Centers for Disease Control and Prevention 1 VOLUME 3: NO. 3 JULY 2006 Methods smoking-attributable health care expenditures were estimated at $75.5 billion (4). More recent data from 1997 to 2001 indicate that smoking costs the United A 32-item survey instrument was developed and pilot States approximately $92 billion annually in lost pro- tested in fall 2003. The instrument was designed to assess ductivity (1). Together, the health and financial conse- new trends, barriers, and opportunities related to address- quences of tobacco dependence continue to make treat- ing tobacco control in health insurance plans, identify new ment and prevention of tobacco use a priority among models or frameworks of care, and assess changes in multiple stakeholders, including health plans, insurers, health-plan based tobacco control activities between 1997 providers, employers, and policymakers. and 2003. The sample for the survey was drawn from the 687 health insurance plans listed in AHIP’s national data- In 1997, the Robert Wood Johnson Foundation (RWJF) base of member and nonmember plans. The database was established a collaborative program, Addressing Tobacco stratified based on plan enrollment size, and a random in Managed Care (ATMC). The program was based on sample of 247 plans was selected. The sample size enables the understanding that health insurance plans’ compre- the detection of a 5% difference between proportions at α = hensive benefits, sophisticated information systems, .05 and β = .80. defined populations, and partnerships with health care providers are well suited to implement, evaluate, and The ATMC survey was conducted in winter 2003. As in sustain tobacco control interventions. The initiative con- 1997, 2000, and 2002, the 2003 ATMC survey was con- sisted of a national program office (NPO) located at the ducted through mail, e-mail, and fax, with telephone fol- University of Wisconsin and the University of Illinois at low-up with nonrespondents at 2 weeks, 4 weeks, and 6 Chicago and a national technical assistance office weeks after initial contact. The sample included large (NTAO) managed by America’s Health Insurance Plans national plans that have local plans represented in multi- (AHIP). The mission of the NTAO was to advance the ple states. As in previous years, the corporate office of each integration of tobacco cessation and prevention strate- national plan was asked to review the questionnaire and gies into routine health care by increasing the number determine whether they would respond on behalf of their and quality of tobacco control initiatives within health local plans or ask their local plans to complete the ques- insurance plans. tionnaires individually. Three of four national plans opted to respond on behalf of their local plans, and their respons- As part of the program, the NTAO provided resources to es reflect 49% (78/160) of the responses. (The three nation- health insurers who were striving to develop tobacco con- al plans did not necessarily provide identical responses to trol programs, conducted a benchmarking awards program all the survey questions for all their local plans.) to highlight exemplary health plan tobacco control initia- tives, promoted best practices and partnerships through The 2003 survey questionnaire was longer but similar to national conferences, and oversaw the development of a the one used in 2002. Of the 32 items in the 2003 ques- business case model for smoking cessation. The NTAO also tionnaire, 17 were the same as in previous years; seven conducted four surveys of health plans to assess practices were added to collect more detailed data on areas of inter- and policies related to tobacco control. ATMC concluded its est (e.g., pharmaceutical coverage, attributes of cessation work in fall 2005. interventions, strategies for notifying members about ces- sation benefits, member incentives); two were added to col- The ATMC baseline survey was conducted in 1997, lect data on plans’ use of return-on-investment (ROI) followed by similar surveys in 2000 and 2002. The analysis and interest in ROI analysis tools; two were added results of the surveys were published in 1998, 2002, to gain additional insight into key areas (e.g., methods and 2004 (5-7). The fourth ATMC survey was con- used to require providers to carry out tobacco control activ- ducted in 2003. This paper presents the results of the ities, barriers plans face in addressing tobacco control); 2003 ATMC survey, highlights changes from 1997 to and four were added to enhance understanding of plan 2003, and explores findings and trends in light of characteristics (e.g., accreditation status, use of Health tobacco control activities in the United States during Plan Employer Data and Information Set [HEDIS] data). the same period. Because of feedback provided during pretesting, most sur- vey questions focused on smoking cessation despite recog- 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/2006/jul/05_0173.htm VOLUME 3: NO. 3 JULY 2006 nition that tobacco cessation and tobacco control are more that their guideline was based on either the PHS or encompassing terms. The 2003 ATMC survey was origi- AHCPR guideline (data not shown). In addition, more than nally designed to capture data about both preferred one third of plans with a guideline reported that their provider organizations (PPOs) and health maintenance guideline came from another source (e.g., disease-manage- organizations (HMOs). However, feedback received during ment vendors, state coalitions, collaborations). the initial review of the survey instrument suggested that the high degree of variability in the PPO industry (risk and Almost all plans indicated that they could identify some nonrisk bearing) made it difficult for plans to reliably or all individual plan members who smoke (Table 1). respond to survey questions. As a result, the 2003 ATMC Although only 3% of plans indicated that they could iden- survey remained focused on the HMO product (as it had tify all members who smoke, 89% reported that they could been for the previous surveys) and asked respondents to identify at least some of their members who smoke (data answer all questions based on their best-selling commer- not shown). Among the plans that reported being able to cial HMO product. identify smokers, the most common data sources were health-risk appraisals and telephone surveys. A relatively All analyses were performed with SPSS software (SPSS, small percentage of plans (12%) reported using enrollment Inc, Chicago, Ill). Chi-square tests and t tests were used for data to identify smokers. The same percentage of plans comparisons, and results of these tests were considered reported being able to identify smokers through registries statistically significant when the corresponding P value that documented smoking status. was .05 or less. Consistent with previous years, the data were unweighted to best describe the policies and practices The vast majority (88%) of respondent plans indicated of health insurance plans. that they provided full coverage (defined as no additional charge for the member outside of the member’s normal copayment for office visits) for at least one type of phar- Results macotherapy used for tobacco cessation (data not shown). Bupropion in the form of Wellbutrin was the most com- Of the 247 health plans in the sample, 32 were excluded monly covered pharmacotherapy (83%) (Table 1). because they were no longer in business or did not offer a commercial HMO product. Of the 215 valid plans, 160 Full coverage for at least one type of behavioral inter- (74%) completed and returned the survey. Collectively, the vention used for tobacco cessation was reported by most 160 plans represented more than 60 million HMO mem- (72%) health plans (data not shown). Self-directed online bers. Respondent plans were predominantly network resources were the most commonly covered behavioral (48%) and mixed models (33%). Sixty-eight percent were interventions, followed by other self-help materials, indi- for-profit and publicly held, 8% were for-profit and pri- vidual counseling during pregnancy, and telephone coun- vately held, 23% were not-for-profit, and 1% were mutual seling (Table 1). companies. A comparative analysis of respondents and nonrespondents indicated that there were no significant Health plans reported having various strategies to differences in size, tax status, or predominant model type encourage members to stop smoking during times that between respondents and nonrespondents. might be considered important teachable moments (Table 1). Almost all plans (91%) reported having a strategy for Among respondent plans, 67% reported having a written addressing smoking cessation while a member was partic- clinical guideline for smoking cessation (Table 1). Among ipating in one of the plan’s disease-management programs. these plans, approximately one third reported using either Most health plans also reported having a strategy for the 2000 U.S. Public Health Service (PHS) Guideline on addressing smoking cessation during pregnancy (69%), Tobacco Use and Dependence (8) or the 1996 Agency for during treatment for chronic illnesses (65%), and following Health Care Policy and Research (AHCPR) Practice a myocardial infarction (56%). Guideline on Tobacco Cessation (9). More than one fourth of plans reported having a guideline that had been inter- Plans reported using several types of strategies with nally developed. Among plans that reported having an providers and their office staff to encourage smoking cessa- internally developed guideline, almost all (92%) reported tion among plan members. Approximately half of plans 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/2006/jul/05_0173.htm • Centers for Disease Control and Prevention 3 VOLUME 3: NO. 3 JULY 2006 reported offering provider education, and almost one fourth and smoking cessation strategies remained unchanged of plans reported using provider prompts and reminders (Table 3). The percentage of plans that provided full cover- (Table 1). Provider prompts and reminders were coupled age for any type of pharmacotherapy used for smoking ces- with provider education by 21% of plans (data not shown). sation increased from 25% to 88% from 1997 to 2003 (P < .001). A large increase was also noted in the percentage of Although health plans reported various health system plans able to identify individual smokers: from 15% in barriers to their ability to effectively address tobacco con- 1997 to 91% in 2003 (P < .001). trol, the most common barriers were related to resources (e.g., inadequate staff, funding, competing priorities) and Full coverage of behavioral interventions, such as coun- system issues (e.g., poor data collection, reporting, record seling and self-help materials, fluctuated from 1997 to maintenance). Other important barriers reported by more 2003 (Table 3). For example, more than half of the plans in than half of plans included lack of provider compliance, the 1997 and 2000 surveys reported full coverage for self- lack of purchaser demand, and delayed economic return on help materials, but only one fourth of plans reported simi- investment (Table 1). lar coverage in 2002, and the percentage of plans reporting full coverage for self-help materials increased to nearly Approximately 39% of plans reported that they current- 50% in 2003. Similarly, the 2002 survey indicated a statis- ly perform some type of ROI analysis on at least some of tically significant increase in the number of plans provid- their tobacco cessation activities (data not shown). Almost ing full coverage for telephone counseling, but the results all plans (94%) indicated that they would be interested in of the 2003 survey showed a decrease in coverage using an ROI analysis tool designed for tobacco cessation if (although the changes were not statistically significant one were available. across all 4 years of the survey). Several tobacco control activities seem to be more likely From 1997 to 2003, the percentage of plans with strate- to occur in larger plans than in smaller plans (Table 2). gies to address smoking cessation after a myocardial Based on the enrollment distribution of health plans in our infarction increased from 22% to 56% (P < .001) and from sample, we defined larger plans as those with more than 23% to 65% during treatment for other chronic diseases (P 250,000 members and smaller plans as those with 250,000 < .001) (Table 3). Increases in the percentage of plans with members or fewer. Larger plans were more likely than a strategy to address smoking cessation during postpar- smaller plans to have a written clinical guideline for smok- tum visits (to prevent relapse) were found from 1997 to ing cessation (P < .001) and to have a strategy for address- 2002 and sustained in 2003 (P = .03). ing smoking cessation during specific times, such as during adolescence, pregnancy, and postpartum visits and pedi- Discussion atric visits, after a myocardial infarction, and during treat- ment for other chronic illness (P ranged from < .001 to .04). We found no differences in the extent to which small- From 1997 to 2003, health plans demonstrated increas- er and larger plans provided full coverage for pharma- ing use of evidence-based programs and clinical guidelines cotherapies used for smoking cessation. Although smaller to address tobacco use. Clinical guidelines detail the most plans were more likely to report providing full coverage for effective options for helping patients to quit smoking, and some types of behavioral interventions, such as telephone use of strategies recommended in clinical guidelines is counseling and face-to-face counseling (P < .001), larger associated with greater success in helping smokers to quit plans were more likely to report providing full coverage for (9,10). Although most health plans reported having a writ- self-help materials (P = .01) and individual counseling of ten clinical guideline for tobacco cessation, it is possible pregnant women (P = .02). Smaller plans were also more that even more plans address tobacco cessation within likely to report having annual or lifetime limits on cover- other clinical guidelines used for managing or treating con- age for smoking cessation interventions (P < .001). ditions in which tobacco use is identified as a comorbidity or risk factor (i.e., asthma, heart disease, and diabetes). Although the survey instruments used in the 1997, 2000, 2002, and 2003 ATMC surveys were not identical, a core Slightly more than one fourth of the plans with a clinical set of questions on pharmacotherapies, behavioral health, guideline for tobacco cessation reported using the PHS 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/2006/jul/05_0173.htm VOLUME 3: NO. 3 JULY 2006 guideline. Among plans that indicated that they use an age for at least one type of pharmacotherapy for tobacco internally developed guideline, almost all (92%) reported cessation. Consistent with recommendations based on the that their guideline was based on either the PHS or effectiveness of various prescription and over-the-counter AHCPR guideline. Interestingly, nearly two thirds of plans tobacco cessation first-line pharmacotherapies (9), most reported that their written clinical guideline was based on plans reported providing full coverage for at least one form or developed from a source other than the PHS or AHCPR. of bupropion (Wellbutrin). The significant increase in the A review of the qualitative data provided by plans in number of plans that provide full coverage for at least one response to this question indicated that many of the plans type of pharmacotherapy for tobacco cessation is well are using guidelines developed by disease-management aligned with the growing body of literature indicating that vendors and various state coalitions and collaborations. reduced out-of-pocket cost is associated with greater use of This finding lends further support to the idea that health tobacco cessation programs and services (11,12) and may plans may be increasingly incorporating their tobacco ces- lead to increased rates of cessation (13). sation activities into the broader set of activities and guide- lines that they use for the management of diseases related Given the literature citing the effectiveness of telephone to tobacco use (i.e., asthma, heart disease, and diabetes). counseling and indicating that smokers are more likely to use telephone counseling than to participate in individual Plans have shown tremendous improvement since 1997 or group counseling sessions (14,15), it is not surprising in identifying individual plan members who smoke. The that more plans in 2002 reported offering full coverage for ability to identify smokers is an important indicator of a telephone counseling than in 1997. However, the results of plan’s ability to remind or prompt providers to discuss or the 2003 ATMC survey indicate that fewer plans in 2003 advise patients about smoking cessation and also commu- are providing full coverage for telephone counseling than nicate with members about their health plan’s cessation in 2002. Although the survey did not assess reasons for programs and benefits. Provider reminders are considered offering or not offering specific types of interventions, it is to be an effective strategy for supporting smoking cessa- possible that increased availability of local or state-spon- tion and are recommended by the Task Force on sored quit lines has resulted in less need for health plans Community Preventive Services (10). to provide coverage for telephone counseling. In the 2003 ATMC survey, the response choices to the The fact that 91% of plans reported having a strategy for question “Can your plan identify individual members who addressing tobacco cessation with patients already partic- smoke?” were revised slightly to allow plans to indicate ipating in disease-management programs underscores the whether they could identify all members who smoke or importance of promoting disease-management programs some members who smoke. The results of the 2003 survey as a vehicle for addressing tobacco cessation. In environ- indicate that although almost all plans can identify indi- ments where numerous health improvement programs vidual members who smoke, only 3% reported being able must compete for limited resources, the ability to effective- to identify all members who smoke, and 89% reported ly address tobacco cessation within the context of other being able to identify some members who smoke. programs may be strategically and clinically important. Information provided by plans on the methods they use to Indeed, most plans have strategies for addressing tobacco identify smokers also indicates that they are most likely to cessation during pregnancy, when a patient is being treat- identify subgroups of smokers (i.e., people who respond to ed for a chronic illness, and after acute events such as health-risk appraisals or surveys). Although it would be myocardial infarction, suggesting that plans are moving in ideal for plans to identify all smokers and intervene with this direction. each individually, identifying all members of any subgroup engaging in a health behavior would be a challenge for any Health plans continue to report that resource limita- organization. tions, including too few staff and inadequate funding, are leading barriers to adequately addressing tobacco control. The number of health plans providing full coverage for Although just over one third of plans reported conducting any type of pharmacotherapy for tobacco cessation has any type of ROI analysis on their tobacco cessation activi- more than tripled since 1997. In the 2003 ATMC survey, ties in 2003, there was widespread interest in identifying almost nine out of 10 plans reported providing full cover- and using ROI analysis tools for tobacco cessation. 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/2006/jul/05_0173.htm • Centers for Disease Control and Prevention 5 VOLUME 3: NO. 3 JULY 2006 Fortunately, research supported by the NTAO has Conclusion recently resulted in the development of a Web-based ROI analysis tool for smoking cessation interventions based The results of the 2003 ATMC survey indicate that an primarily on smoking-attributable costs to health plans increasing number of health plans are using evidence- (16). The ROI tool should be especially useful to health based approaches and strategies to address tobacco use plans that need to rationalize their investments in smok- among members. Although almost all plans reported that ing cessation interventions or convince purchasers of the their tobacco control activities were limited by resource value of such interventions. and systems barriers, they have been able to sustain the improvements made since 1997. Even so, many plans may Limitations benefit from taking advantage of the recently developed ROI analysis tool to leverage the body of literature that The ATMC survey and its findings have limitations. The supports the cost-effectiveness of tobacco cessation treat- response rate of approximately 74% is respectable but still ment and advocate for the resources necessary to sustain leaves open the possibility of selection bias. Although no their tobacco control activities (8,21-23). significant differences were detected between respondents and nonrespondents on three key characteristics (size, tax As others have previously noted, health plans play an status, and predominant model type), respondents may important role in tobacco control (24). In particular, plans possibly differ from nonrespondents in ways that were not continue to be in a unique position to implement opera- measured (e.g., level of interest, commitment to tobacco tional policies and programs that can reduce the preva- control). Another limitation to the ATMC survey is that lence of tobacco use and improve the health of millions of the psychometric properties of the questionnaire were not people. In addition to their role in sustaining and expand- tested to assess reliability or validity. However, the survey ing access to tobacco cessation treatments and services, design process did include pretesting to increase the prob- health plans should continue to model new tobacco cessa- ability of including questions that were reliable and likely tion benefits, promote them widely to their membership, to yield valid responses. Additionally, we identified a and influence large purchasers of health care services by potential limitation of the 1997 survey — it did not include communicating the value of tobacco cessation services. a frame of reference for product type — and corrected all New opportunities to participate in policy initiatives that subsequent ATMC surveys accordingly. Based on inquiries support tobacco control and promote public health are made to plans following the 1997 survey, we learned that essential next steps to maintain the availability of these when a frame of reference is not provided, the tendency is services over the long term. to base answers on the best-selling HMO product, and this is what respondents were explicitly asked to do in 2000, It is unclear whether the findings fom the 2003 ATMC 2002, and 2003. However, there is still a possibility that survey apply to other forms of health insurance, such as the change in frame of reference contributed to some of the PPOs. Unlike HMOs, which have traditionally empha- differences in survey findings between the 1997 survey sized preventive health care and wellness activities such and more recent surveys (but not between the 2000, 2002, as smoking cessation, PPOs have emphasized network or 2003 surveys). size, expertise, and discounted access to network providers for members. Although some health insurance Few surveys other than the ATMC surveys have been companies are likely to offer the same tobacco control designed to assess tobacco control practices and policies of programs in both their PPO and HMO products, others health plans. Of those that have been conducted and pub- may vary their tobacco control programs and policies by lished, some have focused on plans that operated only in a product or purchaser. single state (12,17); some have included only a narrow sub- set of plans (i.e., well-established, nonprofit plans with a Nevertheless, the lessons learned in tobacco control history of offering tobacco cessation programs) (18); and should be applied to other areas where behavioral health others have collected information only about subsets of modification is a core component in the treatment of the smokers within a plan (i.e., pregnant women) (19,20). illness or condition. We agree with others who have stat- Despite their more limited scope, these surveys have yield- ed that one of the most important lessons to be learned ed data comparable to the data from the ATMC surveys. from tobacco control is that tackling similar conditions 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/2006/jul/05_0173.htm VOLUME 3: NO. 3 JULY 2006 (e.g., obesity) will require a sustained, thoughtful, well- 2. Centers for Disease Control and Prevention. The resourced, multidimensional effort (25). Additional les- health consequences of smoking: a report of the sur- sons may include recognition of the importance of being geon general. Atlanta (GA): U.S. Department of able to identify individuals in need of services, offering Health and Human Services, Centers for Disease coverage for effective pharmacotherapies and treatments, Control and Prevention; 2004. and incorporating programs (such as those for tobacco ces- 3. Centers for Disease Control and Prevention. State- sation and obesity) into existing disease-management pro- specific prevalence of current cigarette smoking grams for which tobacco use and obesity are risk factors or among adults United States, 2002. MMWR Morb common comorbidities. Mortal Wkly Rep 2004;52(53):1277-80. 4. Centers for Disease Control and Prevention. Smoking The period from 1997 to 2003 was an active and signifi- attributable mortality, morbidity, and economic costs cant time for tobacco control at the local, state, and nation- (SAMMEC): adult and maternal and child health soft- al levels. During these 7 years, health plans accomplished ware. Atlanta (GA): U.S. Department of Health and a great deal and demonstrated a strong commitment to Human Services, Centers for Disease Control and smoking cessation with proven results. Yet there are still Prevention; 2004. many important opportunities for health plans to advance 5. McPhillips-Tangum C. Results from the first annual their tobacco control activities and to transfer the lessons survey on addressing tobacco in managed care. Tob learned in tobacco control to other important public health Control 1998;7(suppl):S11-S13. priorities. Health plans and other stakeholders should look 6. McPhillips-Tangum C, Cahill A, Bocchino C, Cutler C. ahead to the coming years for opportunities to continue Addressing tobacco in managed care: results of the their collaborative efforts to improve the health of individ- 2000 survey. Preventive Medicine in Managed Care uals and populations. 2002;3(3):85-94. 7. McPhillips-Tangum C, Bocchino C, Carreon R, Erceg C, Rehm B. Addressing tobacco in managed care: Acknowledgments results of the 2002 survey. Prev Chronic Dis [serial online] 2004 Oct. The authors thank the Robert Wood Johnson 8. Fiore MC, Bailey WC, Cohen SJ, Dorfman SF, Foundation for the unrestricted educational grant that Goldstein MG, Gritz ER, et al. Treating tobacco use made this survey possible. and dependence: clinical practice guideline. Rockville (MD): U.S. Department of Health and Human Services, Public Health Service; 2000. Author Information 9. U.S. Department of Health and Human Services. 1996 smoking cessation, clinical practice guideline No. 18. Corresponding Author: Carol McPhillips-Tangum, Agency for Health Care Policy and Research publica- Experion Healthcare Group, 106 Geneva St, Decatur, tion no. 96-0692. Washington (DC): U.S. Department GA 30030. Telephone: 404-377-4061. E-mail: of Health and Human Services, Agency for Health ctangum@experion.com. Care Policy and Research; 1996. 10. Task Force on Community Preventive Services. Author Affiliations: Bob Rehm, Rita Carreon, Caroline Recommendations regarding interventions to reduce M. Erceg, Carmella Bocchino, America’s Health Insurance tobacco use and exposure to environmental tobacco Plans, Washington, DC. smoke. Am J Prev Med 2001;20(2S):10-5. 11. Curry SJ, Grothaus LC, McAfee T, Pabiniak C. Use and cost-effectiveness of smoking cessation services References under four insurance plans in a health maintenance organization. N Engl J Med 1998;339(10):673-9. 1. Centers for Disease Control and Prevention. Annual 12. Schauffler HH, McMenamin S, Olson K, Boyce-Smith smoking attributable mortality, years of potential life G, Rideout JA, Kamil J. Variations in treatment bene- lost, and productivity losses United States, 1997-2001. fits influence smoking cessation: results of a random- MMWR Morb Mortal Wkly Rep 2005;54(25):625-8. ized controlled trial. Tob Control 2001;10:175-80. 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/2006/jul/05_0173.htm • Centers for Disease Control and Prevention 7 VOLUME 3: NO. 3 JULY 2006 13. Kaper J, Wagena EJ, Willemsen MC, van Schayck CP. Reimbursement for smoking cessation treatment may double the abstinence rate: results of a randomized trial. Addiction 2005;100(7):1012-20. 14. McAfee T, Sofian N, Wilson J, Hindmarsh M. The role of tobacco intervention in population-based health care. Am J Prev Med 1998;14:46-52. 15. McAfee T. Increasing the population impact of quit- lines [conference paper]. Phoenix (AZ): North American Quitline Conference; 2002. 16. Fellows JF, Rehm B, Hornbrook M, Hollis J, Haswell TC, Dickerson J, et al. Making the business case for smoking cessation and ROI calculator. Washington (DC): America s Health Insurance Plans; 2004. Available from: URL: http://www.businesscaseroi.org*. 17. Halpin Schauffler H, Mordavsky JK, McMenamin S. 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. 18. Rigotti NA, Quinn VP, Stevens VJ, Solberg LI, Rosenthal AC, Zapka JG, et al. Tobacco-control policies in 11 leading managed care organizations: progress and challenges. Eff Clin Pract 2002;5(3):130-6. 19. Pickett KE, Abrams B, Schauffler HH, Savage J, Brandt P, Kalkbrenner A, et al. Coverage of tobacco dependence treatments for pregnant smokers in health maintenance organizations. Am J Public Health 2001;91(9):1393-4. 20. Barker DC, Robinson LA, Rosenthal AC. A survey of managed care strategies for pregnant smokers. Tob Control 2000;9(Suppl 3):46-50. 21. Warner KE, Mendez D, Smith DG. The financial impli- cations of coverage of smoking cessation treatment by managed care organizations. Inquiry 2004;41(1):57-69. 22. Pronk N, Goodman MJ, O’Connor PJ, Martinson BC. Relationship between modifiable health risks and short-term health care changes. JAMA 1999;282(23):2235-9. 23. Warner KE. Cost effectiveness of smoking cessation therapies. Interpretation of the evidence and implica- tions for coverage. Pharmacoeconomics 1997;11(6):538-49. 24. Manley MW, Griffin T, Foldes SS, Link CC, Sechrist RA. The role of health plans in tobacco control. Annu Rev Public Health 2003;24:247-66. 25. Warner KE. Tobacco policy in the United States: les- sons for the obesity epidemic. Policy Challenges in Modern Health Care 2005;7:99-114. 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/2006/jul/05_0173.htm VOLUME 3: NO. 3 JULY 2006 Tables Table 1. Results from the 2003 Addressing Tobacco in Managed Care Survey (N = 160) Activity % Yes Activity % Yes Plan has a written clinical guideline for smoking cessation 66.6 Plan has a strategy to address smoking cessation Among plans with a written clinical guideline for smoking cessation During participation in disease-management programs 91.0 Plan uses the 2000 U.S. Public Health Service Guideline (8) 28.3 During pregnancy 68.6 Plan uses an internally developed clinical guideline 27.4 During treatment for other chronic illness 64.7 Plan uses the 1996 Agency for Health Care Policy and Research 7.5 After myocardial infarction 56.4 Guideline (9) During postpartum visits (relapse prevention) 46.8 Plan uses a guideline from some other source 36.8 During adolescence 32.1 Plan is able to identify some or all members who smoke 91.1 During pediatric visits (secondhand smoke) 29.5 Among plans that can identify smokers, data sources used by plans to During hospitalizations 11.5 identify individual members who smoke Plan funds a full- or part-time tobacco control program 16.1 Health-risk appraisal 64.7 staff position Telephone survey 59.3 Plan used the following strategies with members in the past year to Mail-based survey 34.1 inform them about cessation benefits or encourage them to take advan- tage of covered treatments Medical record review (random sample) 18.7 General member education (e.g., newsletters, Web site, 60.0 Administrative data review 16.5 announcements) Electronic medical record 15.4 Customized member education (e.g., mailings directed at 31.0 members meeting criteria or conditions) Enrollment information 12.1 Increased availability of smoking cessation programs and 22.6 Registry containing smoking status 12.1 interventions Plan provides full coverage for Discounts or reimbursements for NRT 21.3 Bupropion (as Wellbutrin) 83.3 Discounts or reimbursements for community resources 14.8 Bupropion (as Zyban) 29.5 Plan used the following strategies with providers, office staff, or both in the past year to promote smoking cessation Prescription NRT nasal spray 19.2 Provider education 51.9 Prescription NRT inhaler 19.2 Prompts and reminders to encourage providers to address Prescription NRT patches 18.6 tobacco control 22.4 Over-the-counter NRT patches 9.6 Elimination of preauthorization requirements for smoking Over-the-counter NRT gum 7.7 cessation interventions 9.1 Over-the-counter NRT lozenges 6.4 Incentives for providers and their staff to effectively address 7.7 tobacco Plan provides full coverage for Increased reimbursement for smoking cessation counseling 3.9 Self-directed, online resources (interactive and noninteractive) 56.4 and assistance Self-help materials (booklets, videos, audiotapes, customized 45.5 Increased amount of time that providers spend with patients 0.6 mailings) Barriers to addressing tobacco control among plans Individual counseling of pregnant women 44.2 Resource barriers (e.g., staff, funding, competing priorities) 92.9 Telephone counseling 42.3 System barriers (e.g., data collection, data reporting, record 87.7 Individual face-to-face counseling 35.9 maintenance) Group counseling or classes 21.2 Delayed economic return on investment 61.3 Plan has annual or lifetime limits on coverage for smoking 19.3 Lack of purchaser demand 54.5 cessation interventions Lack of provider compliance 54.2 Plan allows patients to self-refer to smoking cessation 48.8 services Lack of patient demand 42.6 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. www.cdc.gov/pcd/issues/2006/jul/05_0173.htm • Centers for Disease Control and Prevention 9 VOLUME 3: NO. 3 JULY 2006 Table 2. Tobacco Control Activities by Size of Health Plan, 2003 Addressing Tobacco in Managed Care Survey (N = 160) <250,000 >250,000 Plan Members Plan Members Activity (N = 63), % Yes (N = 97), % Yes P Value Plan has a written clinical guideline for smoking cessation 25.4 61.5 <.001 Plan provides full coverage for NRT over-the-counter gum 5.1 9.3 .34 NRT over-the-counter patches 8.5 10.3 .71 NRT inhalers 20.3 18.6 .78 NRT nasal spray 20.3 18.6 .78 Bupropion (as Zyban) 37.3 24.7 .10 Bupropion (as Wellbutrin) 83.1 83.5 .94 Plan provides full coverage for Telephone counseling 74.6 22.7 <.001 Face-to-face counseling 69.5 15.5 <.001 Group counseling or classes 28.8 16.5 .07 Individual counseling of pregnant women 32.2 51.5 .02 Self-help materials 32.2 53.6 .01 Plan has annual or lifetime limits on coverage for smoking cessation 25.8 15.5 <.001 interventions Plan allows patients to self-refer to smoking cessation services 50.9 47.0 .67 Plan is able to identify individual members who smoke 88.4 92.8 .56 Plan has a strategy to address smoking cessation During adolescence 22.0 38.1 .04 During pregnancy 40.7 85.6 <.001 During postpartum visits (relapse prevention) 11.9 68.0 <.001 During pediatric visits (second hand smoke) 13.6 39.2 .001 After myocardial infarction 25.4 75.3 <.001 During treatment for other chronic illness 37.3 81.4 <.001 During hospitalizations 15.3 9.3 .26 Plan funds a tobacco control program staff position 22.4 12.4 .14 NRT indicates nicotine replacement therapy. Proportions were compared using the chi-square test; results were considered statistically significant at P <.05. 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/2006/jul/05_0173.htm VOLUME 3: NO. 3 JULY 2006 Table 3. Comparison of Data from the 1997, 2000, 2002, and 2003 Addressing Tobacco in Managed Care Surveys 1997 Respondents 2000 Respondents 2002 Respondents 2003 Respondents Activity (N = 323), % Yes (N = 85), % Yes (N = 152), % Yes (N = 160), % Yes P Value Plan provides full coverage for Any pharmacotherapy for smoking cessation 25.0 20.0 88.8 87.8 <.001 Bupropion (as Zyban) 17.6 37.2 41.1 29.5 .10 Any over-the-counter NRT 6.6 14.9 8.6 9.6 <.001 NRT only with program enrollment 25.0 26.0 10.8 19.3 .01 Plan provides full coverage for Telephone counseling 32.8 36.8 51.7 42.3 .07 Face-to-face counseling 26.6 23.6 41.1 35.9 .04 Group counseling or classes 35.7 37.0 15.9 21.2 .002 Self-help materials 54.1 56.6 25.8 45.5 <.001 Any behavioral therapy or pharmacotherapy 75.0 94.4 98.0 96.2 <.001 Plan is able to identify individual 14.9 27.1 71.7 91.1 <.001 members (some or all) who smoke Plan has a specific strategy to address smoking cessation During adolescence 17.6 24.2 28.9 32.1 .46 During pregnancy 45.0 59.0 56.6 68.6 .08 During postpartum visits 13.6 30.5 46.7 46.8 .03 During pediatric visits 15.8 17.3 28.3 29.5 .10 After myocardial infarction 21.7 27.2 46.7 56.4 <.001 During treatment for chronic illness 22.6 31.3 52.0 64.7 <.001 Plan funds a full- or part-time tobacco 7.7 23.5 19.1 16.1 <.001 control program staff position NRT indicates nicotine replacement therapy. Although the survey instruments used in the 1997, 2000, 2002, and 2003 Addressing Tobacco in Managed Care surveys were not identical, a core set of questions on pharmacotherapies, behavioral health, and smoking cessation strategies remained unchanged. Proportions were compared for 1997 and 2003 surveys using the chi-square test; results were considered statistically significant at P < .05. 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/2006/jul/05_0173.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 2003 Survey

Preventing Chronic Disease , Volume 3 (3) – Jun 15, 2006

Loading next page...
 
/lp/pubmed-central/addressing-tobacco-in-managed-care-results-of-the-2003-survey-NBuIIFL030

References

References for this paper are not available at this time. We will be adding them shortly, thank you for your patience.

Publisher
Pubmed Central
eISSN
1545-1151
Publisher site
See Article on Publisher Site

Abstract

sons learned to other health problems. Introduction Introduction Although tobacco control activity in the United States during the past several years has increased dramatically, tobacco use continues to have devastating consequences The scope and pace of tobacco control activity in the among all age cohorts. United States during the past several years has increased dramatically. Beginning with the 1998 multi- Methods state tobacco settlement, there has been heightened In November 2003, a survey of tobacco control practices attention on tobacco use and an emergence of effective and policies in health insurance plans was conducted by tobacco control strategies. Still, tobacco use continues to America’s Health Insurance Plans’ national technical have devastating consequences among all age cohorts in assistance office. The survey was the fourth and final sur- the United States. New estimates from the Centers for vey conducted as part of the Addressing Tobacco in Disease Control and Prevention (CDC) indicate that Managed Care program. Of the 215 plans in the sample, from 1997 to 2001, approximately 438,000 people in the 160 (74%) completed the survey. Collectively, these plans United States died prematurely each year as a result of represent more than 60 million members of health main- smoking or exposure to secondhand smoke (1). The most tenance organizations. recent report from the U.S. surgeon general confirms that smoking harms almost every organ in the body, Results causing numerous diseases and reducing overall quality From 1997 to 2003, health insurance plans have demon- of life and life expectancy (2). Despite these grim facts, strated increasing use of evidence-based programs and approximately 23% of American adults continue to clinical guidelines to address tobacco use. The number of smoke cigarettes (3). plans providing full coverage for any type of pharma- cotherapy for tobacco cessation has more than tripled since In addition to the health consequences of tobacco use, 1997. Plans have also shown substantial improvement in it has enormous financial consequences. In 1998, 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/2006/jul/05_0173.htm • Centers for Disease Control and Prevention 1 VOLUME 3: NO. 3 JULY 2006 Methods smoking-attributable health care expenditures were estimated at $75.5 billion (4). More recent data from 1997 to 2001 indicate that smoking costs the United A 32-item survey instrument was developed and pilot States approximately $92 billion annually in lost pro- tested in fall 2003. The instrument was designed to assess ductivity (1). Together, the health and financial conse- new trends, barriers, and opportunities related to address- quences of tobacco dependence continue to make treat- ing tobacco control in health insurance plans, identify new ment and prevention of tobacco use a priority among models or frameworks of care, and assess changes in multiple stakeholders, including health plans, insurers, health-plan based tobacco control activities between 1997 providers, employers, and policymakers. and 2003. The sample for the survey was drawn from the 687 health insurance plans listed in AHIP’s national data- In 1997, the Robert Wood Johnson Foundation (RWJF) base of member and nonmember plans. The database was established a collaborative program, Addressing Tobacco stratified based on plan enrollment size, and a random in Managed Care (ATMC). The program was based on sample of 247 plans was selected. The sample size enables the understanding that health insurance plans’ compre- the detection of a 5% difference between proportions at α = hensive benefits, sophisticated information systems, .05 and β = .80. defined populations, and partnerships with health care providers are well suited to implement, evaluate, and The ATMC survey was conducted in winter 2003. As in sustain tobacco control interventions. The initiative con- 1997, 2000, and 2002, the 2003 ATMC survey was con- sisted of a national program office (NPO) located at the ducted through mail, e-mail, and fax, with telephone fol- University of Wisconsin and the University of Illinois at low-up with nonrespondents at 2 weeks, 4 weeks, and 6 Chicago and a national technical assistance office weeks after initial contact. The sample included large (NTAO) managed by America’s Health Insurance Plans national plans that have local plans represented in multi- (AHIP). The mission of the NTAO was to advance the ple states. As in previous years, the corporate office of each integration of tobacco cessation and prevention strate- national plan was asked to review the questionnaire and gies into routine health care by increasing the number determine whether they would respond on behalf of their and quality of tobacco control initiatives within health local plans or ask their local plans to complete the ques- insurance plans. tionnaires individually. Three of four national plans opted to respond on behalf of their local plans, and their respons- As part of the program, the NTAO provided resources to es reflect 49% (78/160) of the responses. (The three nation- health insurers who were striving to develop tobacco con- al plans did not necessarily provide identical responses to trol programs, conducted a benchmarking awards program all the survey questions for all their local plans.) to highlight exemplary health plan tobacco control initia- tives, promoted best practices and partnerships through The 2003 survey questionnaire was longer but similar to national conferences, and oversaw the development of a the one used in 2002. Of the 32 items in the 2003 ques- business case model for smoking cessation. The NTAO also tionnaire, 17 were the same as in previous years; seven conducted four surveys of health plans to assess practices were added to collect more detailed data on areas of inter- and policies related to tobacco control. ATMC concluded its est (e.g., pharmaceutical coverage, attributes of cessation work in fall 2005. interventions, strategies for notifying members about ces- sation benefits, member incentives); two were added to col- The ATMC baseline survey was conducted in 1997, lect data on plans’ use of return-on-investment (ROI) followed by similar surveys in 2000 and 2002. The analysis and interest in ROI analysis tools; two were added results of the surveys were published in 1998, 2002, to gain additional insight into key areas (e.g., methods and 2004 (5-7). The fourth ATMC survey was con- used to require providers to carry out tobacco control activ- ducted in 2003. This paper presents the results of the ities, barriers plans face in addressing tobacco control); 2003 ATMC survey, highlights changes from 1997 to and four were added to enhance understanding of plan 2003, and explores findings and trends in light of characteristics (e.g., accreditation status, use of Health tobacco control activities in the United States during Plan Employer Data and Information Set [HEDIS] data). the same period. Because of feedback provided during pretesting, most sur- vey questions focused on smoking cessation despite recog- 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/2006/jul/05_0173.htm VOLUME 3: NO. 3 JULY 2006 nition that tobacco cessation and tobacco control are more that their guideline was based on either the PHS or encompassing terms. The 2003 ATMC survey was origi- AHCPR guideline (data not shown). In addition, more than nally designed to capture data about both preferred one third of plans with a guideline reported that their provider organizations (PPOs) and health maintenance guideline came from another source (e.g., disease-manage- organizations (HMOs). However, feedback received during ment vendors, state coalitions, collaborations). the initial review of the survey instrument suggested that the high degree of variability in the PPO industry (risk and Almost all plans indicated that they could identify some nonrisk bearing) made it difficult for plans to reliably or all individual plan members who smoke (Table 1). respond to survey questions. As a result, the 2003 ATMC Although only 3% of plans indicated that they could iden- survey remained focused on the HMO product (as it had tify all members who smoke, 89% reported that they could been for the previous surveys) and asked respondents to identify at least some of their members who smoke (data answer all questions based on their best-selling commer- not shown). Among the plans that reported being able to cial HMO product. identify smokers, the most common data sources were health-risk appraisals and telephone surveys. A relatively All analyses were performed with SPSS software (SPSS, small percentage of plans (12%) reported using enrollment Inc, Chicago, Ill). Chi-square tests and t tests were used for data to identify smokers. The same percentage of plans comparisons, and results of these tests were considered reported being able to identify smokers through registries statistically significant when the corresponding P value that documented smoking status. was .05 or less. Consistent with previous years, the data were unweighted to best describe the policies and practices The vast majority (88%) of respondent plans indicated of health insurance plans. that they provided full coverage (defined as no additional charge for the member outside of the member’s normal copayment for office visits) for at least one type of phar- Results macotherapy used for tobacco cessation (data not shown). Bupropion in the form of Wellbutrin was the most com- Of the 247 health plans in the sample, 32 were excluded monly covered pharmacotherapy (83%) (Table 1). because they were no longer in business or did not offer a commercial HMO product. Of the 215 valid plans, 160 Full coverage for at least one type of behavioral inter- (74%) completed and returned the survey. Collectively, the vention used for tobacco cessation was reported by most 160 plans represented more than 60 million HMO mem- (72%) health plans (data not shown). Self-directed online bers. Respondent plans were predominantly network resources were the most commonly covered behavioral (48%) and mixed models (33%). Sixty-eight percent were interventions, followed by other self-help materials, indi- for-profit and publicly held, 8% were for-profit and pri- vidual counseling during pregnancy, and telephone coun- vately held, 23% were not-for-profit, and 1% were mutual seling (Table 1). companies. A comparative analysis of respondents and nonrespondents indicated that there were no significant Health plans reported having various strategies to differences in size, tax status, or predominant model type encourage members to stop smoking during times that between respondents and nonrespondents. might be considered important teachable moments (Table 1). Almost all plans (91%) reported having a strategy for Among respondent plans, 67% reported having a written addressing smoking cessation while a member was partic- clinical guideline for smoking cessation (Table 1). Among ipating in one of the plan’s disease-management programs. these plans, approximately one third reported using either Most health plans also reported having a strategy for the 2000 U.S. Public Health Service (PHS) Guideline on addressing smoking cessation during pregnancy (69%), Tobacco Use and Dependence (8) or the 1996 Agency for during treatment for chronic illnesses (65%), and following Health Care Policy and Research (AHCPR) Practice a myocardial infarction (56%). Guideline on Tobacco Cessation (9). More than one fourth of plans reported having a guideline that had been inter- Plans reported using several types of strategies with nally developed. Among plans that reported having an providers and their office staff to encourage smoking cessa- internally developed guideline, almost all (92%) reported tion among plan members. Approximately half of plans 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/2006/jul/05_0173.htm • Centers for Disease Control and Prevention 3 VOLUME 3: NO. 3 JULY 2006 reported offering provider education, and almost one fourth and smoking cessation strategies remained unchanged of plans reported using provider prompts and reminders (Table 3). The percentage of plans that provided full cover- (Table 1). Provider prompts and reminders were coupled age for any type of pharmacotherapy used for smoking ces- with provider education by 21% of plans (data not shown). sation increased from 25% to 88% from 1997 to 2003 (P < .001). A large increase was also noted in the percentage of Although health plans reported various health system plans able to identify individual smokers: from 15% in barriers to their ability to effectively address tobacco con- 1997 to 91% in 2003 (P < .001). trol, the most common barriers were related to resources (e.g., inadequate staff, funding, competing priorities) and Full coverage of behavioral interventions, such as coun- system issues (e.g., poor data collection, reporting, record seling and self-help materials, fluctuated from 1997 to maintenance). Other important barriers reported by more 2003 (Table 3). For example, more than half of the plans in than half of plans included lack of provider compliance, the 1997 and 2000 surveys reported full coverage for self- lack of purchaser demand, and delayed economic return on help materials, but only one fourth of plans reported simi- investment (Table 1). lar coverage in 2002, and the percentage of plans reporting full coverage for self-help materials increased to nearly Approximately 39% of plans reported that they current- 50% in 2003. Similarly, the 2002 survey indicated a statis- ly perform some type of ROI analysis on at least some of tically significant increase in the number of plans provid- their tobacco cessation activities (data not shown). Almost ing full coverage for telephone counseling, but the results all plans (94%) indicated that they would be interested in of the 2003 survey showed a decrease in coverage using an ROI analysis tool designed for tobacco cessation if (although the changes were not statistically significant one were available. across all 4 years of the survey). Several tobacco control activities seem to be more likely From 1997 to 2003, the percentage of plans with strate- to occur in larger plans than in smaller plans (Table 2). gies to address smoking cessation after a myocardial Based on the enrollment distribution of health plans in our infarction increased from 22% to 56% (P < .001) and from sample, we defined larger plans as those with more than 23% to 65% during treatment for other chronic diseases (P 250,000 members and smaller plans as those with 250,000 < .001) (Table 3). Increases in the percentage of plans with members or fewer. Larger plans were more likely than a strategy to address smoking cessation during postpar- smaller plans to have a written clinical guideline for smok- tum visits (to prevent relapse) were found from 1997 to ing cessation (P < .001) and to have a strategy for address- 2002 and sustained in 2003 (P = .03). ing smoking cessation during specific times, such as during adolescence, pregnancy, and postpartum visits and pedi- Discussion atric visits, after a myocardial infarction, and during treat- ment for other chronic illness (P ranged from < .001 to .04). We found no differences in the extent to which small- From 1997 to 2003, health plans demonstrated increas- er and larger plans provided full coverage for pharma- ing use of evidence-based programs and clinical guidelines cotherapies used for smoking cessation. Although smaller to address tobacco use. Clinical guidelines detail the most plans were more likely to report providing full coverage for effective options for helping patients to quit smoking, and some types of behavioral interventions, such as telephone use of strategies recommended in clinical guidelines is counseling and face-to-face counseling (P < .001), larger associated with greater success in helping smokers to quit plans were more likely to report providing full coverage for (9,10). Although most health plans reported having a writ- self-help materials (P = .01) and individual counseling of ten clinical guideline for tobacco cessation, it is possible pregnant women (P = .02). Smaller plans were also more that even more plans address tobacco cessation within likely to report having annual or lifetime limits on cover- other clinical guidelines used for managing or treating con- age for smoking cessation interventions (P < .001). ditions in which tobacco use is identified as a comorbidity or risk factor (i.e., asthma, heart disease, and diabetes). Although the survey instruments used in the 1997, 2000, 2002, and 2003 ATMC surveys were not identical, a core Slightly more than one fourth of the plans with a clinical set of questions on pharmacotherapies, behavioral health, guideline for tobacco cessation reported using the PHS 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/2006/jul/05_0173.htm VOLUME 3: NO. 3 JULY 2006 guideline. Among plans that indicated that they use an age for at least one type of pharmacotherapy for tobacco internally developed guideline, almost all (92%) reported cessation. Consistent with recommendations based on the that their guideline was based on either the PHS or effectiveness of various prescription and over-the-counter AHCPR guideline. Interestingly, nearly two thirds of plans tobacco cessation first-line pharmacotherapies (9), most reported that their written clinical guideline was based on plans reported providing full coverage for at least one form or developed from a source other than the PHS or AHCPR. of bupropion (Wellbutrin). The significant increase in the A review of the qualitative data provided by plans in number of plans that provide full coverage for at least one response to this question indicated that many of the plans type of pharmacotherapy for tobacco cessation is well are using guidelines developed by disease-management aligned with the growing body of literature indicating that vendors and various state coalitions and collaborations. reduced out-of-pocket cost is associated with greater use of This finding lends further support to the idea that health tobacco cessation programs and services (11,12) and may plans may be increasingly incorporating their tobacco ces- lead to increased rates of cessation (13). sation activities into the broader set of activities and guide- lines that they use for the management of diseases related Given the literature citing the effectiveness of telephone to tobacco use (i.e., asthma, heart disease, and diabetes). counseling and indicating that smokers are more likely to use telephone counseling than to participate in individual Plans have shown tremendous improvement since 1997 or group counseling sessions (14,15), it is not surprising in identifying individual plan members who smoke. The that more plans in 2002 reported offering full coverage for ability to identify smokers is an important indicator of a telephone counseling than in 1997. However, the results of plan’s ability to remind or prompt providers to discuss or the 2003 ATMC survey indicate that fewer plans in 2003 advise patients about smoking cessation and also commu- are providing full coverage for telephone counseling than nicate with members about their health plan’s cessation in 2002. Although the survey did not assess reasons for programs and benefits. Provider reminders are considered offering or not offering specific types of interventions, it is to be an effective strategy for supporting smoking cessa- possible that increased availability of local or state-spon- tion and are recommended by the Task Force on sored quit lines has resulted in less need for health plans Community Preventive Services (10). to provide coverage for telephone counseling. In the 2003 ATMC survey, the response choices to the The fact that 91% of plans reported having a strategy for question “Can your plan identify individual members who addressing tobacco cessation with patients already partic- smoke?” were revised slightly to allow plans to indicate ipating in disease-management programs underscores the whether they could identify all members who smoke or importance of promoting disease-management programs some members who smoke. The results of the 2003 survey as a vehicle for addressing tobacco cessation. In environ- indicate that although almost all plans can identify indi- ments where numerous health improvement programs vidual members who smoke, only 3% reported being able must compete for limited resources, the ability to effective- to identify all members who smoke, and 89% reported ly address tobacco cessation within the context of other being able to identify some members who smoke. programs may be strategically and clinically important. Information provided by plans on the methods they use to Indeed, most plans have strategies for addressing tobacco identify smokers also indicates that they are most likely to cessation during pregnancy, when a patient is being treat- identify subgroups of smokers (i.e., people who respond to ed for a chronic illness, and after acute events such as health-risk appraisals or surveys). Although it would be myocardial infarction, suggesting that plans are moving in ideal for plans to identify all smokers and intervene with this direction. each individually, identifying all members of any subgroup engaging in a health behavior would be a challenge for any Health plans continue to report that resource limita- organization. tions, including too few staff and inadequate funding, are leading barriers to adequately addressing tobacco control. The number of health plans providing full coverage for Although just over one third of plans reported conducting any type of pharmacotherapy for tobacco cessation has any type of ROI analysis on their tobacco cessation activi- more than tripled since 1997. In the 2003 ATMC survey, ties in 2003, there was widespread interest in identifying almost nine out of 10 plans reported providing full cover- and using ROI analysis tools for tobacco cessation. 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/2006/jul/05_0173.htm • Centers for Disease Control and Prevention 5 VOLUME 3: NO. 3 JULY 2006 Fortunately, research supported by the NTAO has Conclusion recently resulted in the development of a Web-based ROI analysis tool for smoking cessation interventions based The results of the 2003 ATMC survey indicate that an primarily on smoking-attributable costs to health plans increasing number of health plans are using evidence- (16). The ROI tool should be especially useful to health based approaches and strategies to address tobacco use plans that need to rationalize their investments in smok- among members. Although almost all plans reported that ing cessation interventions or convince purchasers of the their tobacco control activities were limited by resource value of such interventions. and systems barriers, they have been able to sustain the improvements made since 1997. Even so, many plans may Limitations benefit from taking advantage of the recently developed ROI analysis tool to leverage the body of literature that The ATMC survey and its findings have limitations. The supports the cost-effectiveness of tobacco cessation treat- response rate of approximately 74% is respectable but still ment and advocate for the resources necessary to sustain leaves open the possibility of selection bias. Although no their tobacco control activities (8,21-23). significant differences were detected between respondents and nonrespondents on three key characteristics (size, tax As others have previously noted, health plans play an status, and predominant model type), respondents may important role in tobacco control (24). In particular, plans possibly differ from nonrespondents in ways that were not continue to be in a unique position to implement opera- measured (e.g., level of interest, commitment to tobacco tional policies and programs that can reduce the preva- control). Another limitation to the ATMC survey is that lence of tobacco use and improve the health of millions of the psychometric properties of the questionnaire were not people. In addition to their role in sustaining and expand- tested to assess reliability or validity. However, the survey ing access to tobacco cessation treatments and services, design process did include pretesting to increase the prob- health plans should continue to model new tobacco cessa- ability of including questions that were reliable and likely tion benefits, promote them widely to their membership, to yield valid responses. Additionally, we identified a and influence large purchasers of health care services by potential limitation of the 1997 survey — it did not include communicating the value of tobacco cessation services. a frame of reference for product type — and corrected all New opportunities to participate in policy initiatives that subsequent ATMC surveys accordingly. Based on inquiries support tobacco control and promote public health are made to plans following the 1997 survey, we learned that essential next steps to maintain the availability of these when a frame of reference is not provided, the tendency is services over the long term. to base answers on the best-selling HMO product, and this is what respondents were explicitly asked to do in 2000, It is unclear whether the findings fom the 2003 ATMC 2002, and 2003. However, there is still a possibility that survey apply to other forms of health insurance, such as the change in frame of reference contributed to some of the PPOs. Unlike HMOs, which have traditionally empha- differences in survey findings between the 1997 survey sized preventive health care and wellness activities such and more recent surveys (but not between the 2000, 2002, as smoking cessation, PPOs have emphasized network or 2003 surveys). size, expertise, and discounted access to network providers for members. Although some health insurance Few surveys other than the ATMC surveys have been companies are likely to offer the same tobacco control designed to assess tobacco control practices and policies of programs in both their PPO and HMO products, others health plans. Of those that have been conducted and pub- may vary their tobacco control programs and policies by lished, some have focused on plans that operated only in a product or purchaser. single state (12,17); some have included only a narrow sub- set of plans (i.e., well-established, nonprofit plans with a Nevertheless, the lessons learned in tobacco control history of offering tobacco cessation programs) (18); and should be applied to other areas where behavioral health others have collected information only about subsets of modification is a core component in the treatment of the smokers within a plan (i.e., pregnant women) (19,20). illness or condition. We agree with others who have stat- Despite their more limited scope, these surveys have yield- ed that one of the most important lessons to be learned ed data comparable to the data from the ATMC surveys. from tobacco control is that tackling similar conditions 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/2006/jul/05_0173.htm VOLUME 3: NO. 3 JULY 2006 (e.g., obesity) will require a sustained, thoughtful, well- 2. Centers for Disease Control and Prevention. The resourced, multidimensional effort (25). Additional les- health consequences of smoking: a report of the sur- sons may include recognition of the importance of being geon general. Atlanta (GA): U.S. Department of able to identify individuals in need of services, offering Health and Human Services, Centers for Disease coverage for effective pharmacotherapies and treatments, Control and Prevention; 2004. and incorporating programs (such as those for tobacco ces- 3. Centers for Disease Control and Prevention. State- sation and obesity) into existing disease-management pro- specific prevalence of current cigarette smoking grams for which tobacco use and obesity are risk factors or among adults United States, 2002. MMWR Morb common comorbidities. Mortal Wkly Rep 2004;52(53):1277-80. 4. Centers for Disease Control and Prevention. Smoking The period from 1997 to 2003 was an active and signifi- attributable mortality, morbidity, and economic costs cant time for tobacco control at the local, state, and nation- (SAMMEC): adult and maternal and child health soft- al levels. During these 7 years, health plans accomplished ware. Atlanta (GA): U.S. Department of Health and a great deal and demonstrated a strong commitment to Human Services, Centers for Disease Control and smoking cessation with proven results. Yet there are still Prevention; 2004. many important opportunities for health plans to advance 5. McPhillips-Tangum C. Results from the first annual their tobacco control activities and to transfer the lessons survey on addressing tobacco in managed care. Tob learned in tobacco control to other important public health Control 1998;7(suppl):S11-S13. priorities. Health plans and other stakeholders should look 6. McPhillips-Tangum C, Cahill A, Bocchino C, Cutler C. ahead to the coming years for opportunities to continue Addressing tobacco in managed care: results of the their collaborative efforts to improve the health of individ- 2000 survey. Preventive Medicine in Managed Care uals and populations. 2002;3(3):85-94. 7. McPhillips-Tangum C, Bocchino C, Carreon R, Erceg C, Rehm B. Addressing tobacco in managed care: Acknowledgments results of the 2002 survey. Prev Chronic Dis [serial online] 2004 Oct. The authors thank the Robert Wood Johnson 8. Fiore MC, Bailey WC, Cohen SJ, Dorfman SF, Foundation for the unrestricted educational grant that Goldstein MG, Gritz ER, et al. Treating tobacco use made this survey possible. and dependence: clinical practice guideline. Rockville (MD): U.S. Department of Health and Human Services, Public Health Service; 2000. Author Information 9. U.S. Department of Health and Human Services. 1996 smoking cessation, clinical practice guideline No. 18. Corresponding Author: Carol McPhillips-Tangum, Agency for Health Care Policy and Research publica- Experion Healthcare Group, 106 Geneva St, Decatur, tion no. 96-0692. Washington (DC): U.S. Department GA 30030. Telephone: 404-377-4061. E-mail: of Health and Human Services, Agency for Health ctangum@experion.com. Care Policy and Research; 1996. 10. Task Force on Community Preventive Services. Author Affiliations: Bob Rehm, Rita Carreon, Caroline Recommendations regarding interventions to reduce M. Erceg, Carmella Bocchino, America’s Health Insurance tobacco use and exposure to environmental tobacco Plans, Washington, DC. smoke. Am J Prev Med 2001;20(2S):10-5. 11. Curry SJ, Grothaus LC, McAfee T, Pabiniak C. Use and cost-effectiveness of smoking cessation services References under four insurance plans in a health maintenance organization. N Engl J Med 1998;339(10):673-9. 1. Centers for Disease Control and Prevention. Annual 12. Schauffler HH, McMenamin S, Olson K, Boyce-Smith smoking attributable mortality, years of potential life G, Rideout JA, Kamil J. Variations in treatment bene- lost, and productivity losses United States, 1997-2001. fits influence smoking cessation: results of a random- MMWR Morb Mortal Wkly Rep 2005;54(25):625-8. ized controlled trial. Tob Control 2001;10:175-80. 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/2006/jul/05_0173.htm • Centers for Disease Control and Prevention 7 VOLUME 3: NO. 3 JULY 2006 13. Kaper J, Wagena EJ, Willemsen MC, van Schayck CP. Reimbursement for smoking cessation treatment may double the abstinence rate: results of a randomized trial. Addiction 2005;100(7):1012-20. 14. McAfee T, Sofian N, Wilson J, Hindmarsh M. The role of tobacco intervention in population-based health care. Am J Prev Med 1998;14:46-52. 15. McAfee T. Increasing the population impact of quit- lines [conference paper]. Phoenix (AZ): North American Quitline Conference; 2002. 16. Fellows JF, Rehm B, Hornbrook M, Hollis J, Haswell TC, Dickerson J, et al. Making the business case for smoking cessation and ROI calculator. Washington (DC): America s Health Insurance Plans; 2004. Available from: URL: http://www.businesscaseroi.org*. 17. Halpin Schauffler H, Mordavsky JK, McMenamin S. 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. 18. Rigotti NA, Quinn VP, Stevens VJ, Solberg LI, Rosenthal AC, Zapka JG, et al. Tobacco-control policies in 11 leading managed care organizations: progress and challenges. Eff Clin Pract 2002;5(3):130-6. 19. Pickett KE, Abrams B, Schauffler HH, Savage J, Brandt P, Kalkbrenner A, et al. Coverage of tobacco dependence treatments for pregnant smokers in health maintenance organizations. Am J Public Health 2001;91(9):1393-4. 20. Barker DC, Robinson LA, Rosenthal AC. A survey of managed care strategies for pregnant smokers. Tob Control 2000;9(Suppl 3):46-50. 21. Warner KE, Mendez D, Smith DG. The financial impli- cations of coverage of smoking cessation treatment by managed care organizations. Inquiry 2004;41(1):57-69. 22. Pronk N, Goodman MJ, O’Connor PJ, Martinson BC. Relationship between modifiable health risks and short-term health care changes. JAMA 1999;282(23):2235-9. 23. Warner KE. Cost effectiveness of smoking cessation therapies. Interpretation of the evidence and implica- tions for coverage. Pharmacoeconomics 1997;11(6):538-49. 24. Manley MW, Griffin T, Foldes SS, Link CC, Sechrist RA. The role of health plans in tobacco control. Annu Rev Public Health 2003;24:247-66. 25. Warner KE. Tobacco policy in the United States: les- sons for the obesity epidemic. Policy Challenges in Modern Health Care 2005;7:99-114. 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/2006/jul/05_0173.htm VOLUME 3: NO. 3 JULY 2006 Tables Table 1. Results from the 2003 Addressing Tobacco in Managed Care Survey (N = 160) Activity % Yes Activity % Yes Plan has a written clinical guideline for smoking cessation 66.6 Plan has a strategy to address smoking cessation Among plans with a written clinical guideline for smoking cessation During participation in disease-management programs 91.0 Plan uses the 2000 U.S. Public Health Service Guideline (8) 28.3 During pregnancy 68.6 Plan uses an internally developed clinical guideline 27.4 During treatment for other chronic illness 64.7 Plan uses the 1996 Agency for Health Care Policy and Research 7.5 After myocardial infarction 56.4 Guideline (9) During postpartum visits (relapse prevention) 46.8 Plan uses a guideline from some other source 36.8 During adolescence 32.1 Plan is able to identify some or all members who smoke 91.1 During pediatric visits (secondhand smoke) 29.5 Among plans that can identify smokers, data sources used by plans to During hospitalizations 11.5 identify individual members who smoke Plan funds a full- or part-time tobacco control program 16.1 Health-risk appraisal 64.7 staff position Telephone survey 59.3 Plan used the following strategies with members in the past year to Mail-based survey 34.1 inform them about cessation benefits or encourage them to take advan- tage of covered treatments Medical record review (random sample) 18.7 General member education (e.g., newsletters, Web site, 60.0 Administrative data review 16.5 announcements) Electronic medical record 15.4 Customized member education (e.g., mailings directed at 31.0 members meeting criteria or conditions) Enrollment information 12.1 Increased availability of smoking cessation programs and 22.6 Registry containing smoking status 12.1 interventions Plan provides full coverage for Discounts or reimbursements for NRT 21.3 Bupropion (as Wellbutrin) 83.3 Discounts or reimbursements for community resources 14.8 Bupropion (as Zyban) 29.5 Plan used the following strategies with providers, office staff, or both in the past year to promote smoking cessation Prescription NRT nasal spray 19.2 Provider education 51.9 Prescription NRT inhaler 19.2 Prompts and reminders to encourage providers to address Prescription NRT patches 18.6 tobacco control 22.4 Over-the-counter NRT patches 9.6 Elimination of preauthorization requirements for smoking Over-the-counter NRT gum 7.7 cessation interventions 9.1 Over-the-counter NRT lozenges 6.4 Incentives for providers and their staff to effectively address 7.7 tobacco Plan provides full coverage for Increased reimbursement for smoking cessation counseling 3.9 Self-directed, online resources (interactive and noninteractive) 56.4 and assistance Self-help materials (booklets, videos, audiotapes, customized 45.5 Increased amount of time that providers spend with patients 0.6 mailings) Barriers to addressing tobacco control among plans Individual counseling of pregnant women 44.2 Resource barriers (e.g., staff, funding, competing priorities) 92.9 Telephone counseling 42.3 System barriers (e.g., data collection, data reporting, record 87.7 Individual face-to-face counseling 35.9 maintenance) Group counseling or classes 21.2 Delayed economic return on investment 61.3 Plan has annual or lifetime limits on coverage for smoking 19.3 Lack of purchaser demand 54.5 cessation interventions Lack of provider compliance 54.2 Plan allows patients to self-refer to smoking cessation 48.8 services Lack of patient demand 42.6 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. www.cdc.gov/pcd/issues/2006/jul/05_0173.htm • Centers for Disease Control and Prevention 9 VOLUME 3: NO. 3 JULY 2006 Table 2. Tobacco Control Activities by Size of Health Plan, 2003 Addressing Tobacco in Managed Care Survey (N = 160) <250,000 >250,000 Plan Members Plan Members Activity (N = 63), % Yes (N = 97), % Yes P Value Plan has a written clinical guideline for smoking cessation 25.4 61.5 <.001 Plan provides full coverage for NRT over-the-counter gum 5.1 9.3 .34 NRT over-the-counter patches 8.5 10.3 .71 NRT inhalers 20.3 18.6 .78 NRT nasal spray 20.3 18.6 .78 Bupropion (as Zyban) 37.3 24.7 .10 Bupropion (as Wellbutrin) 83.1 83.5 .94 Plan provides full coverage for Telephone counseling 74.6 22.7 <.001 Face-to-face counseling 69.5 15.5 <.001 Group counseling or classes 28.8 16.5 .07 Individual counseling of pregnant women 32.2 51.5 .02 Self-help materials 32.2 53.6 .01 Plan has annual or lifetime limits on coverage for smoking cessation 25.8 15.5 <.001 interventions Plan allows patients to self-refer to smoking cessation services 50.9 47.0 .67 Plan is able to identify individual members who smoke 88.4 92.8 .56 Plan has a strategy to address smoking cessation During adolescence 22.0 38.1 .04 During pregnancy 40.7 85.6 <.001 During postpartum visits (relapse prevention) 11.9 68.0 <.001 During pediatric visits (second hand smoke) 13.6 39.2 .001 After myocardial infarction 25.4 75.3 <.001 During treatment for other chronic illness 37.3 81.4 <.001 During hospitalizations 15.3 9.3 .26 Plan funds a tobacco control program staff position 22.4 12.4 .14 NRT indicates nicotine replacement therapy. Proportions were compared using the chi-square test; results were considered statistically significant at P <.05. 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/2006/jul/05_0173.htm VOLUME 3: NO. 3 JULY 2006 Table 3. Comparison of Data from the 1997, 2000, 2002, and 2003 Addressing Tobacco in Managed Care Surveys 1997 Respondents 2000 Respondents 2002 Respondents 2003 Respondents Activity (N = 323), % Yes (N = 85), % Yes (N = 152), % Yes (N = 160), % Yes P Value Plan provides full coverage for Any pharmacotherapy for smoking cessation 25.0 20.0 88.8 87.8 <.001 Bupropion (as Zyban) 17.6 37.2 41.1 29.5 .10 Any over-the-counter NRT 6.6 14.9 8.6 9.6 <.001 NRT only with program enrollment 25.0 26.0 10.8 19.3 .01 Plan provides full coverage for Telephone counseling 32.8 36.8 51.7 42.3 .07 Face-to-face counseling 26.6 23.6 41.1 35.9 .04 Group counseling or classes 35.7 37.0 15.9 21.2 .002 Self-help materials 54.1 56.6 25.8 45.5 <.001 Any behavioral therapy or pharmacotherapy 75.0 94.4 98.0 96.2 <.001 Plan is able to identify individual 14.9 27.1 71.7 91.1 <.001 members (some or all) who smoke Plan has a specific strategy to address smoking cessation During adolescence 17.6 24.2 28.9 32.1 .46 During pregnancy 45.0 59.0 56.6 68.6 .08 During postpartum visits 13.6 30.5 46.7 46.8 .03 During pediatric visits 15.8 17.3 28.3 29.5 .10 After myocardial infarction 21.7 27.2 46.7 56.4 <.001 During treatment for chronic illness 22.6 31.3 52.0 64.7 <.001 Plan funds a full- or part-time tobacco 7.7 23.5 19.1 16.1 <.001 control program staff position NRT indicates nicotine replacement therapy. Although the survey instruments used in the 1997, 2000, 2002, and 2003 Addressing Tobacco in Managed Care surveys were not identical, a core set of questions on pharmacotherapies, behavioral health, and smoking cessation strategies remained unchanged. Proportions were compared for 1997 and 2003 surveys using the chi-square test; results were considered statistically significant at P < .05. 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/2006/jul/05_0173.htm • Centers for Disease Control and Prevention 11

Journal

Preventing Chronic DiseasePubmed Central

Published: Jun 15, 2006

References