The Role of Reimbursement and Third Party Financial Support in Sustaining Quitlines

Michele PatarinoClaire Brockbank

Collaborative Health Solutions

January 7 and 9, 2009

NAQC Issue Paper

Introduction

Purpose of project:– Assess the current practices of quitlines

with regard to third party reimbursement and other forms of financial support,

– Provide an overview of the opportunity for obtaining third party support, and

– Set out next steps for garnering third party financial support for quitlines.

IntroductionCollaborative Health Solutions partners have been

involved in Colorado tobacco control for 8 years:– Assessment of Native American tobacco control needs– Assessment of State Tobacco Education and Prevention

Program– Program Director for Health Systems Change work

including promotion of Quitline/fax referral– Consultant to Hospital System/Health Promotion grant– Consultant to Colorado Department of Public Health &

Environment on Strategy to Engage Health Plans in Tobacco Cessation

– Tobacco Rapid Improvement Activity facilitation for primary care, pediatric, and other types of practices

Introduction

Also extensive health plan and purchaser experience over 25 years– Worked in private plans, Medicaid, Medicare– Led strategic planning– Worked in product development including wellness

programs and disease management– Ran a small group purchasing pool– Consulted with National Business Coalition on Health

and state business groups on health– Involved in health policy work (covering the uninsured)

in Wyoming and Colorado

Process

• Reviewed literature on tobacco control efforts to engage health plans and/or employers

• Reviewed NAQC 2006 survey results• Developed survey and fielded via

survey monkey (2008)• Followed up via phone/e-mail• Compiled results

Environment

• Recognition of value of quitlines• Current funding of quitlines• Future of Tobacco Control Funding

Opportunity for Reimbursement

• Prevention and chronic disease management typically provided by health care providers and reimbursed by third party payers

• Tobacco is the exception and still sits largely in the public health domain– Reimbursement will require building a

bridge between public health and private payers

Barrier for Public Health Professionals

• Understanding the Health Insurance Market– Fully Insured employer groups– Self-Insured employer groups– Government programs– Pressure on costs

• Preventive Services• Disease Management (DM)

Fully Insured

• Approximately one-quarter of the insured population

• Employer pays flat premium, insurance company bears all the risk

• Regulated at the state level• Typically small employers

Self-Insured

• Also one-quarter of the population• Self-insured company bears all the

risk by agreeing to pay for all services used by its employees

• Avoids paying insurance company profit margin, marketing costs, premium taxes etc.

• Generally requires 250+ employees • Exempt from state regulation

Government

• Government acts as purchaser of benefits on behalf of: – government employees– Medicaid program

• As purchaser, government generally self-insures and therefore is immune to state regulation

• Government acts as regulator at the state level

Mandates

• Requires insurance company coverage of specific health care providers, benefits or patient populations– Council for Affordable Health Insurance

estimates that mandates increase cost of basic coverage from 20% – 50%

– Supported by advocates, opposed by purchasers, insurers and providers

– Occurs at state level only and impacts only the fully insured population

Influencing Purchasers/Payers(sources: Kaiser Family Foundation and Employee Benefits Research Institute)

Market Sector

Approximate Market Share

Leverage

Fully Insured 23% Sales and benefit negotiations• Quitline & Rx benefit• DM coverage

Self-Insured 23% Must perceive ROI

Government 28% a. As purchaser – ROIb. As regulator – Mandates

Mandates strongly opposed by most natural partners – employers, providers, health plans

Individual 7%

Uninsured 19%

Quitline Practices –August 2008 survey

• 25 respondents• 24 respondents gather insurance status

or employer information• Five states have financial arrangements

with insurers, institutions, or employers • Only two responding states have

mandated benefits

Quitline Practices – (Literature and Interviews)

• Very limited 3rd party-Quitline collaboration– Insurers subsidizing quitline– Transfer callers from state quitline to

private insurer quitline– Health plans, businesses and other

partners contribute funding for NRT for callers

Barriers Cited by Quitlines

• NRT to all citizens makes insurers rely on state quitline coverage

• State budget crunches makes ongoing support difficult

• Lack of understanding by public health officials of how to interact with 3rd party payers

• National decision-making

What Quitlines Recommended – Interviews

• NAQC could help articulate ROI and other compelling arguments for working with insurers and employers

• NAQC could use national leverage to build case for coverage and support

Recommendations

1. Spectrum of options2. Circumstance-specific feasibility3. Leverage points for expanding

access to and use of quitlines4. National support and leverage5. State and local tools

Next Steps

1. Develop value messages for key constituents

a) Employersb) Health Plansc) Disease Management Vendorsd) Medicaid

2. National convener and clearinghouse3. Tool kit

Acknowledgments and ContributorsWe thank the following individuals for their assistance:

Linda Bailey, NAQC Randi Lachter, NAQCDebbie Montgomery, CO Julie Hare, ALIrene Centers, KY Ann Wendling, MNDena Pope, MS Amanda McCartney, OHMelanie Tidwell, OH Todd Hill, VTCynthia J. Goto, HI Linda Wright Eakers, OKShirley Deethardt, NE Majel Arnold, CAKaty L. Wynne, SC Laura Saddler, ORKathy Danberry, WV Kate Kobinsky, WISara Wolfe, MD Idalis Mercado, PRKatie Shuttleworth, CT Michelle Walker, NDKaren Goodson, FL Nancy Jane Heilman, NM Ann Wendland, NY Heather Beck, MTTasha Bergeron, LA Donna Warner, MA

For Additional Information or toProvide Feedback on Next Steps

Contact Randi Lachter at: rlachter@NAQuitline.org

OrMichele Patarino at:

MLPatarino@msn.com

Health Systems Change Collaborative Insurance and Reimbursement Task

Group

Define Scope, Assess Feasibility, Make Recommendation

• Gather information on current state of insurance coverage and reimbursement for tobacco cessation

• Explore the interest of various stakeholders to promote and/or implement change

• Consider and recommend feasible objectives that the Collaborative and its member states should pursue

Insurance and ReimbursementFeasibility Report

Wendy Bjornson, Oregon Health and ScienceSally Carter, Oklahoma

Todd Hill, VermontRandi Lachter, NAQC

Elena List, U of Massachusetts Medical SchoolDeb Montgomery, CO Dept of Public Health &

EnvironmentMichele Patarino, Colorado Clinical Guidelines Collaborative/Collaborative Health Solutions

Michael Renner, OhioPamela Studwell, ALA of Maine

Ann Wendling, ClearWay MinnesotaSM, Task Leader

Lack of access to cessation treatment and underutilization of available services• Few tobacco users have comprehensive tobacco

cessation benefits

• Diagnostic and procedural coding are inconsistently used and reimbursed; and poorly understood

• Among factors cited most often by physicians as significant barriers to counseling patients, 52% identified limited reimbursement for a physician’s time*

All three contribute to lack of provider consistency in addressing tobacco cessation and barriers for patients in accessing effective cessation services.

Impetus for Selecting this Topic

27

Background

2007 National Business Group on Health survey of 506 companies:

• On average, employers cover two of five CDC recommended components of cessation benefit

• Only 2% cover all five components recommended by CDC• 34% of employers state that they have not considered

offering smoking cessation benefits• Employers are unsure of the impact smokers have on their

business

Issues

• Different types of third party payers– Public - medical assistance coverage varies

significantly among states – Private - fully and self insured (subject to

ERISA)– Lack of awareness by insurers of adequate

and effective cessation benefits and resulting return on investment

• Inconsistent reimbursement for like coded services, dependent on:– Level of provider– Negotiated purchaser (public and private) and

health plan contracts/discounts

Objective 1

Through collaboration with other stakeholders, influence public and private insurers to offer comprehensive cessation benefits to all members/ employees

Feasible Strategies

• Emphasize productivity and health care cost ROI

• Position tobacco cessation as an integral component of physical and behavioral disease prevention and management

• Encourage enhancement of accreditation and service quality standards for tobacco cessation with feedback to insurers

Feasible Strategy: Stakeholder Collaboration

Potential National Partners:• AMA, APA• ALA• CDC• PHS (Clinical Practice Guidelines)• National Working Group for ACTTION/Partnership for Prevention • National Business Group on Health• National health plan endorsement e.g. BCBS• National Association of Health Plans

Objective 2

Facilitate selection by states of “best fit” effective evidence based cessation programming through:

• Reporting successful case studies (e.g. ME, MA, MN, CO, OK)

• Creating models of stakeholder collaboration and coordination across systems

Feasible Strategy: Standard Setting

Standard setting and model development:

• Include consideration of various acceptable state-wide service delivery and program designs

• Use best practices to guide designs of evidence-based programming

Feasible Strategies

Considering state health care funding environment:• Discuss merits of or balance between

quitline and individual counseling • Consider unique programs such as

‘wellness’ onsite cessation classes or sessions

• Consider ‘best way’ to increase access to pharmaceuticals

Feasible Strategy: Stakeholder Collaboration

• Quitlines

• State tobacco control programs

• Private insurers

• Purchaser groups

• Medicaid programs

Objective 3

Improve reimbursement for tobacco cessation services provided through all evidence-based programs by qualified providers

Feasible Strategy: Background PaperCurrent state of coding is variable andreimbursement depends on payer.

Begin with:

Descriptive – white paper(1) Current codes and utilization (public and

private) / levels of reimbursement(2) Medicare codes and utilization data(3) State Medicaid coverage

survey/analysis(4) Available private health plan data

Feasible Strategy: AdvocacyDevelop a small task group to monitor status and maintain contacts with strategic partners to explore opportunities for:

•Improving reimbursement within current systems, face-to-face and quitline, for tobacco treatment specialists e.g. through use of ATTUD articulated standard

•Coding changes: e.g. bundling of screening and brief intervention with referral for more intensive counseling in one code

Feasible Strategy: Stakeholder Collaboration

Recruit and collaborate with potential national partners:

• AMA, APA, NASW

• ATTUD

• NAQC

• CMS

• Partnership for Prevention

• ICD 11 Work Group

Anticipated Challenges

• Competing priorities

• Cost of health care and state of economy

• Disputed attribution of responsibility (e.g. state vs. private insurer)

Possible Evaluation Measures

• Periodic surveys e.g. National Business Group on Health Employer Survey

• HEDIS®

• CAHPS®

• Evalue8TM

• National Medical Assistance Survey

• JCAHO measurements

• ALA state cessation report card