A Scorecard for Tobacco
Dependence-Treatments in
State Medicaid Programs
Sara McMenamin, PhD
Helen Halpin, PhD
Matthew Ingram
UC Berkeley
June 27, 2010
Background
g
• Tobacco use accounts for nearly half a
million deaths each year
year.
• Smoking rates are 50% higher among
Medicaid enrollees
• Tobacco dependence is treatable, yet access
to comprehensi
comprehensive
e therapies is ins
insufficient
fficient
Research Goals
• To document coverage for tobaccodependence
p
treatments in Medicaid
programs
• To document barriers to covered tobaccodependence treatments
p a scorecard comparing
p
g coverage
g
• To develop
and access to tobacco-dependence
treatments
2008 PHS Guideline
Medication Recommendations
• M
Medications
di ti
th
thatt are effective
ff ti smoking
ki
cessation treatments:
 Ni
Nicotine
ti replacement
l
t th
therapy ((gum, patch,
t h iinhaler,
h l
lozenge, spray)
 Bupropion (brand name Zyban)
 Varenicline (brand name Chantix)
• Combination therapies:




Nicotine patch + nicotine gum
Nicotine patch + nicotine spray
Nicotine patch + nicotine inhaler
patch + bupropion
p p
SR
Nicotine p
2008 PHS Guideline
Counseling Recommendations
• Effective counseling formats that should
b used
be
d iin smoking
ki cessation
ti
interventions:
 Proactive telephone counseling
 Group counseling
 Individual face-to-face counseling
• Both counseling
o n eling and
nd medi
medication
tion should
ho ld be
provided to patients trying to quit smoking.
2008 PHS Guideline
Benefit Design Recommendations
• Remove barriers to tobacco dependence
treatment benefits:
 No copayments
 No limitations on utilization





Duration
Number of courses
P i authorization
Prior
th i ti requirements
i
t
Making medication conditional on counseling
Dollar caps
p
Methods
• Collecting data since 1998
• Internet ssurvey
r e of all 51 Medicaid
programs
• Developed 2 scores:
 Coverage
g
 Access
• Created an overall score
Methods: Coverage
g Score
• Components of the Coverage Score
 NRT Coverage
Co erage
 Chantix/Varenicline coverage
 Bupropion/Zyban coverage
 Individual and Group counseling
coverage
 Combination therapies coverage
• Score ranges from 0 to 5
Methods: Access Score
• Components of the Access Score:
 No requirement for copayments for TDTs
 Unrestricted duration of use
 No p
prior authorization requirements
q
 No stepped-care requirements
 No counseling requirements for pharmacotherapy
coverage
• Score ranges from 0 to 5
Results: Coverage
g Score
• Mean Coverage Score = 3.0
 28 co
cover
er ffullll NRT
 43 cover Chantix/Varenicline
 39 cover Bupropion/Zyban
 10 cover Individual and Group
counseling
 33 cover combination therapy
Results: Access Score
• Mean Access Score = 2.1
 34 require copayments for TDTs
 32 restrict duration of use
 27 have
h
prior
i authorization
th i ti requirements
i
t
 8 use stepped-care requirements
 16 require counseling to access
pharmacotherapy coverage
Distribution of Coverage and
Access Scores
16
16
14
16
13
12
10
10
9
9
8
8
6
6
6
4
4
3
2
2
0



Score
Coverage Score
Access Score


Distribution of Total Score
10
9
9
8
8
8
7
6
6
6
5
5
4
4
3
2
2
1
1
1
1
2
1
0
0
3
4
5
6
7
Total Score (Coverage + Access)
8
9
10
Medicaid Programs with the
Highest and Lowest
Lo est Scores
• Highest Scorers







New Mexico (10)
New Jersey (9)
P
Pennsylvania
l
i (9)
Minnesota (8)
N
New
H
Hampshire
hi (8)
Oregon (8)
W hi t DC (8)
Washington
• Lowest Scorers






Alabama (0)
Connecticut (0)
G
Georgia
i (0)
Kentucky (0)
Mi
Missouri
i (0)
Tennessee (0)
Summary of Findings
• Coverage for counseling continues to lag behind
coverage for pharmacotherapy
• Barriers to treatment persist even where
progress
p
g
has been made on coverage
g
• Requiring co-payments is the most common
barrier used byy Medicaid p
programs
g
to limit
access to TDTs
program
g
scored 10 stars,, while
• Onlyy 1 Medicaid p
6 offer no coverage for TDTs.
Policy Implications of
H l h Care
Health
C
Reform
R f
• All USPSTF A and B level recommended TDTs must be
covered by all Medicaid programs as of Jan 1, 2013
• Additional provision for pregnant Medicaid smokers
• Reforms do not address use of access barriers
• Monitoring of implementation of health care reform by
state Medicaid programs will be crucial to assess:
 Compliance with coverage
 Continued use of access barriers