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Increasing Institutional
Consumer Demand:
Healthplans, Employers (& Government)
Tim McAfee, MD,
MPH
206-876-2551
Tim.mcafee@
freeclear.com
Why bother with institutions?
• Strong evidence that
– removal of access barriers
– aggressive institutional promotion
markedly increases individual consumer
use of evidence-based services
BUT:
• There is only fair to middling institutional
demand for tobacco treatment services
Populations
• 80% of population has health insurance
• 70% of smoking population works
• 100% live in a state
• Special institutional populations:
– Those who hold the risk long-term
• Union Trusts
• VA
• Medicare
Financing as a social justice issue:
• 99% of MSA and tax dollars are
being spent on things other than
helping smokers quit
• Tobacco taxes are an involuntary
tax on an addiction
• Smokers are disproportionately
represented in the poor
• Treating tobacco dependence
should be a core, evidence-based
component of healthcare
Tobacco Treatment
On Wisconsin
• Medical Assistants invited 4,174 adult smokers
– Free patches with or without CQ or counseling
– In urban Milwaukee clinics
• 68% of those invited accepted
• 1/2 re-contacted, screened & agreed
• Half self-selected Rx:
– 25% patch-only
– 33% patch + CQ
– 42% patch + CQ + Counseling
“We made it incredibly easy to use with barrier and
hassle-free access at time of contact”
– Michael Fiore
Fiore MC et al. Integrating smoking cessation treatment into primary care: an effectiveness
study. Preventive Medicine 38 (2004) 412-420.
Union Trust Fund:
Western WA Carpenter’s Fund
• Population: 23K – 7,400 smokers
• Intervention:
– Coverage for nicotine patches, gum &
bupropion
– Coverage for proactive phone counseling
– Publicity via mailing and union meeting
announcements
Ringen et al. Am J Ind Med 42:367-377 (2002)
Results
Western WA Carpenter’s Fund
• 944 smokers enrolled (13%)
– 2/3 smoked >20 years
– 2/3 smoked > a pack a day
• Program usage
– 60% chose 5-call program
– 75% used a medication
• Outcomes
– 22-27% quit rate at 12 or more months
Ringen et al. Am J Ind Med 42:367-377 (2002)
Understanding their lawn…
• Healthplans
–
–
–
–
Purchaser & user (providers & enrollees) pressure
Regulatory requirements
Evidence of rapid ROI or cost-effectiveness
Complex and variable other factors (KISS)
• Employers
– ROI
• Healthcare costs & productivity
– KISS
– Why not just fire them?
• State Gov’t (is a healthcare purchaser)
– Cost-effectiveness, not ROI
– Potential impact
– How it plays in Albany, Sacramento, Olympia, etc
Product/services
• Healthplans:
– Interested in disease mgmt models
• Stratification
• Manage population
• Recruitment & effectiveness competency
– Interested in integrated offerings
• Employers:
– Show me the productivity savings!
– Carve out or insist healthplans provide
Healthplan Coverage Estimates
• ATMC 2002 survey - Coverage
–
–
–
–
for patches: 8.6%
For Bupropion; 40-80%
For phone counseling: 52%
For individual counseling: 41%
• Limitations
–
–
–
–
Only best-selling commercial HMO product included
No ASO vs fully-insured distinction
Based on survey response – 2/3 from 3 national plans
Some answers do not jibe with experience
• #s improved from previous surveys
McPhillips-Tangum C, et at. Addressing tobacco in managed care: results of the
2002 survey. Prev Chronic Dis (serial online) 2004 Oct: URL:
http://www.cdc.gov/pcd/issues/2004/oct/04_0021.htm
•Employer Coverage Estimates
• Mercer national survey of employersponsored health plans 2001
• Limits:
– 21%response rate
• Results:
– 90% note increased productivity & decreased healthcare
costs as reasons to cover preventive services
– Biggest discrepancy between calculated impact/value and
provision is tobacco treatment:
• Any type of treatment: 20% (29% in HMO)
• Prescriptions:
15% (24% in HMO)
• Counseling:
10% (17% in HMO)
Bondi MA et al. Employer Coverage of Clinical Preventive Services in the United States.
American Journal of Health Promotion January 2006
Barriers:
• Lack of perceived
need & benefit
– Risk is buried
– Opportunity is
uncertain
•
•
•
•
Inertia
Complexity
Institutional biases
The Frog
Phenomenon
HIGH PARTICIPATION RATES
1. Full coverage
of counseling
and medication
2. Integration
3. Ongoing
promotions
4. Incentives to
enroll &
engage
STRONG SUPPORT FOR
INCENTIVES
2005 Wall Street Journal online poll* reveals:
– 71% of adults think employers should
provide financial incentives to employees
who join a stop smoking program
– 63% of adults favor different levels of
insurance premiums for smokers
*Based on sample of 2,007 U.S adults. Survey conducted by
Harris Interactive Health-Care in December 2005.
What drives institutional demand?
• 1) Guaranteed and predictable impact
(participation + outcomes) from known
strategies
• 2) Comparison against other programs
that are embraced with much lower
proof of ROI/effectiveness (statins,
mammograms, holiday parties)
• 3) Comparison against what happens if
you do nothing: Spiraling cost and
sickness
THE COST OF TOBACCO
Client Population
Adult Covered Lives
Adult Smokers
Excess cost/smoker
1,000,000
670,000
140,000
$2,284
TOBACCO COST EXPOSURE PER YEAR:
$350,000,000
NET SAVINGS OPPORTUNITY
NET SAVINGS OVER 3 YEARS:
$13,212,787
LINK TO ROI ANALYSIS
TOOL
Public-private partnerships
Minnesota/Oregon examples:
• Healthplans/employers cover meds &
phone
• State & Healthplan mass media
• Quitline or phone center triage functions
• Integration of pharmacotherapy into
treatment AND promotion
• Help with advocacy
Impact: health system & state
Group Health:
WA state QL:
• pop’n: 580,000
– adult smoking 15%
• 4,500/year use GH QL
(~7.5% of smokers)
• pop’n: 5,800,000
– adult smoking 23%
• 9,500/year use WA QL
(~0.9% of smokers)
– All receive proactive followup
– 70% with pharmacotherapy
=540 quits (12% AIQR)
– 3000 receive proactive
follow-up
– 6,500 receive single
intervention
=685 quits (12% & 5%)
It’s a complex world
• ABC campaign – increased demand,
right?
• Maybe/Maybe not:
• Multiple states cut back on state
promotional campaigns
Novel Healthplan approaches
• HIP NY
– DM vendors provided known smokers
– FC called
– 50% of those contacted signed up
• Lumenos
– Consumer-directed Healthplan
– Provided counseling/meds as first-dollar
coverage + HSA incentive
– Strong education
– Above-average participation rate
Program Participation
Group Health Enrollees
4500
4000
3500
Group
Phone
Total
3000
2500
2000
1500
1000
500
0
1992
1993
1995
1997
1998
1999
One-year quit rate: 25-30%
(30-day abstinence ~ Intent-to-Treat)
2000
WHAT WORKS
• National retail employer: 21% participation
– $10 monthly premium differential
– Continuous communication
• Southwest employer: 18% participation
– Pre-launch web-cast to all managers
– CEO launch and follow up letters
• Large western health plan: 8%
participation
– Brochures in all clinics
– Frequent member communications
– MD’s trained and tracked on referrals
What we need…
• Better ROI data & packaging
– Chronic condition REAL ROI examination
– Productivity data
• Better institutional trend data
• Bully pulpit pressure from public health
• Products that speak more directly to
institutional needs