Increasing Institutional Consumer Demand:

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Increasing Institutional Consumer Demand
Healthplans, Employers ( Government)

• Tim McAfee, MD, MPH
• 206-876-2551
• Tim.mcafee_at_
• freeclear.com

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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

3
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

4
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

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Tobacco Treatment
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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.

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Union Trust Fund Western WA Carpenters 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 42367-377 (2002)
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Results Western WA Carpenters Fund

• 944 smokers enrolled (13)
• 2/3 smoked gt20 years
• 2/3 smoked gt 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 42367-377 (2002)
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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 Govt (is a healthcare purchaser)
• Cost-effectiveness, not ROI
• Potential impact
• How it plays in Albany, Sacramento, Olympia, etc

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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

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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
  

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Employer Coverage Estimates

• Mercer national survey of employer-sponsored
  health plans 2001
• Limits
• 21response 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

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Barriers

• Lack of perceived need benefit
• Risk is buried
• Opportunity is uncertain
• Inertia
• Complexity
• Institutional biases
• The Frog Phenomenon

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HIGH PARTICIPATION RATES

• Full coverage of counseling and medication
• Integration
• Ongoing promotions
• Incentives to enroll engage

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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.
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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

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THE COST OF TOBACCO
TOBACCO COST EXPOSURE PER YEAR 350,000,000
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NET SAVINGS OPPORTUNITY
NET SAVINGS OVER 3 YEARS 13,212,787
LINK TO ROI ANALYSIS TOOL
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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

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Impact health system state

• WA state QL
• popn 5,800,000
• adult smoking 23
• 9,500/year use WA QL (0.9 of smokers)
• 3000 receive proactive follow-up
• 6,500 receive single intervention
• 685 quits (12 5)

• Group Health
• popn 580,000
• adult smoking 15
• 4,500/year use GH QL (7.5 of smokers)
• All receive proactive follow-up
• 70 with pharmacotherapy
• 540 quits (12 AIQR)

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Its a complex world

• ABC campaign increased demand, right?
• Maybe/Maybe not
• Multiple states cut back on state promotional
  campaigns

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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

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Program Participation Group Health Enrollees
One-year quit rate 25-30 (30-day abstinence
Intent-to-Treat)
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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
• MDs trained and tracked on referrals

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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