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A HUSKY Health Plan Initiative

Presenter:Michael Hebert, MSW, MBA

Rewards to Quit Coordinator, CHNCT

September 11, 2013

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The Challenge

Medical care for smoking related health issues costs $96 billion/year

People living with mental illness or substance use disorders consume 40% of all tobacco products (SAMHSA, 2013)

38% of adults with mental illness or substance use disorders smoke; only 19.7% of adults without these conditions smoke (SAMHSA, 2013)

60% of Medicaid members with serious mental illness smoke (SAMHSA, 2013)

30% of CT’s Medicaid members smoke

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Health Risk Factors

There are 363,900 (13.2%) adult tobacco users in Connecticut Approximately 4,700 die of smoking related causes each year, which is

about 13 deaths each day 18.9% of all adult smokers are over the age of 45 In 2010, 14.6% of women in Connecticut of child-bearing age (18-44

years) smoked cigarettes 90% of chronic obstructive pulmonary disease deaths (COPD, or

emphysema and chronic bronchitis) is caused by smoking. COPD prevalence rates are highest among those 65 years of age and older.

Approximately 80 to 90 percent of lung cancer deaths in women and men are because of smoking

Smoking is the major risk factor for heart disease, stroke and lower respiratory tract infections, which are all leading causes of death in people over the age of 50.

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Source: CT Department of Public Health

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Participant Benefits Many smokers want to quit and need assistance achieving their

own goals: As many as 70% of current smokers want to quit, with success rates as

low as 2%-3%. Barriers to quitting include access to smoking cessation programs,

nicotine replacement therapies and an inability to fully weigh the long term risks of smoking.

Financial incentives may provide the additional support and motivation needed to make a quit attempt. Become aware of the full risks and associated costs of smoking (personal

and family members’ health, financial costs) Smokers are present biased and often delay quitting today for the

temporary relief of tobacco, and the future quit attempt never comes. Financial incentives can help reinforce the decision to quit and reinforce

the habit of not smoking.

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Many smokers want to quit and need assistance achieving their own goals:

70 percent of current smokers want to quit 52 percent of adult smokers stopped smoking for one day in an

attempt to quit Smoking cessation success rates are low (as low as three percent) Too few seek professional services and medications

Low-income individuals are: more likely to smoke and be in poor health, but less likely to quit on their own (poor access to cessation programs,

lack of support and/or coaching)

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Incentives and Behavior Change

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New Connecticut Medicaid Smoking Cessation Coverage

New Connecticut Medicaid Smoking Cessation Coverage

Smoking Cessation Counseling

Smoking Cessation Counseling

Nicotine Replacement Therapies

Nicotine Replacement Therapies

24 -hour Telephone Quitline

24 -hour Telephone Quitline

Prescription Medications for

Cessation

Prescription Medications for

Cessation

Expanded Services Expanded Therapies

Peer Counselors (phase 2, June 2014)

Peer Counselors (phase 2, June 2014)

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Project Overview

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CT Department of Social Services (DSS) was awarded a five-year grant from the Centers for Medicare and Medicaid Services (CMS) under the Medicaid Incentives for Prevention of Chronic Disease (MIPCD) grant program

Grant awarded to test impact of incentives on smoking behavior change among HUSKY A, C and D members ages 18 and over

The goals of the Rewards to Quit program are to: Study the impact of financial incentives on quitting smoking with a special

focus on: Members with Severe and Persistent Mental Illness (SPMI) Pregnant and Postpartum Women

Reduce rates of CT Medicaid members who smoke by 25 to 30 percent

Program builds on recent expansion of HUSKY coverage for smoking cessation services (effective January 1, 2012)

Program participation and outcomes will inform future decisions regarding Medicaid smoking cessation programs and future funding

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Program oversight is provided by: CMS: Federal grantor agency CT DSS: Grantee, Lead Agency (state Medicaid agency) CHNCT: Medical ASO for HUSKY Health Yale University: State program evaluator

Other key project partners: Department of Public Health: CT Quitline Department of Mental Health & Addiction Services: LMHAs Hispanic Health Council: Peer Coaching & Focus Groups Local Mental Health Authorities (LMHAs), (6) privately-operated Person-Centered Medical Home Participants

Rewards to Quit Project Partners

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Medicaid SmokersMedicaid Smokers

Patient -Centered

Medical Homes

Patient -Centered

Medical Homes

First providers begin

recruitment on March 27, 2013

First providers begin

recruitment on March 27, 2013

Pregnant and Postpartum

Medicaid Smokers

Pregnant and Postpartum

Medicaid Smokers

Federally Qualified

Health Centers

Federally Qualified

Health Centers

Target Populations Available Locations Time Period Studied

Recruitment ends Fall 2015

Recruitment ends Fall 2015

Medicaid Smokers with

Severe & Persistent

Mental Illness

Medicaid Smokers with

Severe & Persistent

Mental Illness

Local Mental Health

Authorities

Local Mental Health

Authorities

Participating OBGYN &

Pediatrician Practices

Participating OBGYN &

Pediatrician Practices

Evaluation complete Fall

2016

Evaluation complete Fall

2016

Rewards to Quit Timeline

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Current Uses of Financial Incentives

Health-related financial incentives are used to improve the following:

Health outcomes Improve compliance Lower medical spending Improve worker productivity

Examples of targeted behaviors (MIPCD): Weight loss Smoking cessation Diabetes and Cardiovascular Disease Primary Care (Screening)

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Role of the Participating Clinics

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Responsibility Randomized In (Intervention)

Randomized Out (Control)

Connecticut Quitline

Screen for tobacco use X X

Complete screening, and smoking status and habit assessment forms

X X

Complete intake form for program enrollment

X X

Provide smoking cessation services/products

X X

Tobacco cessation counseling X X X*

NRT X X X*

Prescribe medications X X

Provide referrals if necessary X X

Administer CO test, if requested by member

X X

Track and report activities for purposes of incentives

X X

* Existing Quitline protocols

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Randomization Strategy

Randomized trials conducted by Yale University:Compares those with incentives (“Intervention”) to

those without (“Control”) All patients have new access to cessation services Only those participants enrolled in the

“Intervention” receive financial incentivesRandomize to show causality: Does the program

work?Test the effectiveness of process (peer coaching) and

cost (utilization) outcomesCMS requires randomization

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R2Q Measures

Assess effectiveness of financial incentives over standard care in the areas of:

Cessation Program enrollment Use of counseling services (individual and telephonic) Program dropout rates Cessation success rates at three months and twelve months Study will test various incentive levels: No Incentive Low ($) Incentive Peer Coaching (June 2014)

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Participant Enrollment Process

Participant enrollment completed via clinicians within PCMHs, FQHCs, LMHAs, OB-GYN and Pediatrician offices

365-day program cycle begins the day smokers agree to participate in the program.

Can enroll for up to two enrollment cycles

Each enrollment cycle = 12 months from date of enrollment

Enrollment cycle for pregnant women = 12 months or ([months of enrollment prior to delivery]+[6 months post-partum]), whichever is longer

Program EnrollmentProgram Enrollment

1. Clinicians screen for smoking status 2. Patient eligible for study if:

a. Smoked within last 30 daysb. At least 18 years oldc. Enrolled in HUSKY A, C or D

3. Clinicians provide information about study and ask to participate.

4. If patient agrees to participate, initial screening questionnaire and enrollment forms required

5. If patient declines to participate, they will be asked again at all future visits.

6. Service Visit forms submitted for each treatment encounter

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Rewards to Quit Incentives The maximum incentive payments per member per activity

(Treatment Groups only): Counseling Sessions:

$5/each session with maximum of 10 sessions (total incentive payment of $50) Two bonus payments of $15 each can be earned, each one for completing a series

of five sessions Tobacco-free CO breathalyzer tests:

$15 per negative test with a maximum of 12 tests per member Four bonus payments of $10 can be earned, each one for having three consecutive

negative tests

The maximum potential Rewards to Quit incentive payment per member: $350 per 12-month enrollment period (max two enrollment periods per person), and $600 per calendar year

NOTE: No financial incentives are provided for NRT or prescription medications

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Rewards to Quit Participation Status

115 Rewards to Quit Participants 70 Women Enrolled 45 Men Enrolled 172 Counseling visits received 126 CO Breathalyzer Tests received 7 NRT’s prescribed

7 Rewards to Quit Active Clinics 5 Control Clinics 2 Intervention Clinics 5 LMHAs 2 FQHCs

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This data reflects current information as of September 9, 2013

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R2Q Support Services

Members can receive support with tobacco cessation questions by calling Member Services at 1-800-859-9889

Members can receive free transportation to smoking cessation counseling visits and CO breathalyzer testing arranged by the participating provide by calling Logisticare at 1-888-248-9895

Providers can receive support with enrollment applications and resources by calling Provider Services at 1-800-440-5071

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Questions

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