Utilization of Smoking Cessation Benefits in Medicaid Managed Care,

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1 Utiliztion of Smoking Cesstion Benefits in Medicid Mnged Cre, Office of Qulity nd Ptient Sfety New York Stte Deprtment of Helth Jnury 2015

2 Introduction According to the New York Stte Tocco Control Progrm, smoking kills 23,600 dults every yer in New York Stte (NYS), mking it the numer one cuse of preventle disese nd deth in NYS. 1 Despite hving the fifth lowest smoking rte in the United Sttes, pproximtely 2.4 million dult New Yorkers still smoke. While the 2013 sttewide smoking rte ws 17% 2 mong dults, it rnged from 12% in New Yorkers with income more thn $50,000 to 27% in those with income less thn $15, This is comprle to the 2013 estimted minstrem Medicid mnged cre (MMC) smoking prevlence rte of 22%. In totl, New Yorkers spend $10.4 illion on tocco-relted helth cre costs nnully, of which, Medicid covers $3.3 illion. 4 Due to the ddictive properties of nicotine, quitting is difficult; therefore, oth counseling nd phrmceuticl services re recommended to improve stinence rtes. 5 In 1999, the New York Stte Medicid progrm egn providing reimursement for prescription smoking cesstion products. In 2000, coverge ws expnded to include over-the-counter (OTC) smoking cesstion products. Smoking cesstion counseling services were dded to the Medicid enefit pckge in 2009, ut reimursement ws restricted to pregnnt nd postprtum women, children nd dolescents ges 10 to 21. In 2011, coverge of smoking cesstion counseling ws extended to ll Medicid eneficiries. In Octoer 2011, memers enrolled in Medicid mnged cre plns egn to receive their phrmcy enefits directly through their plns. 6 The purpose of this report is to inform plns out the prevlence of smoking nd the use of tocco cesstion services mong their enrollees. As dministrtors of helth nd phrmcy enefits, MMC plns re in unique position to work with oth clinicins nd memers to impct the utiliztion of smoking cesstion services through messging, outrech, nd cse mngement. Qulity improvement efforts should focus on incresing the use of evidence-sed tocco cesstion services nd ultimtely decresing the prevlence of smokers. 1 New York Stte Deprtment of Helth Sttistics. 2 Centers for Disese Control nd Prevention (CDC). Behviorl Risk Fctor Surveillnce System Survey Dt. Atlnt, Georgi: U.S. Deprtment of Helth nd Humn Services, Centers for Disese Control nd Prevention, 2013, 3 Centers for Disese Control nd Prevention (CDC). Behviorl Risk Fctor Surveillnce System Survey Dt. Atlnt, Georgi: U.S. Deprtment of Helth nd Humn Services, Centers for Disese Control nd Prevention, 2013, 4 New York Stte Deprtment of Helth Sttistics. 5 Fiore, MC, et l., Treting Tocco Use nd Dependence: 2008 Updte Clinicl Prctice Guideline, U.S. Deprtment of Helth nd Humn Services. Pulic Helth Service, My 2008, 6 For more informtion on wht tocco cesstion products MMC plns cover, plese visit New York Stte Medicid Mnged Cre nd Fmily Helth Plus Phrmcy Benefit Informtion Center t 1

3 Methods These nlyses descrie trends in smoking prevlence nd tocco cesstion service utiliztion in minstrem MMC from 2009 to Anlyses were restricted to MMC enrollees ges due to limited dt vilility regrding smoking prevlence mong the FFS Medicid popultion. Those individuls dully eligile for Medicid nd Medicre were excluded, s were those enrolled in HIV Specil Needs Plns (SNPs). Pln enrollment ws ssigned sed on enrollment t the end of the yer nd using n 11-month continuous enrollment criteri for ech mesurement yer. 7 Utiliztion events were identified using Medicid clims nd encounters dt. Smoking cesstion counseling services were identified using procedure codes nd 99407, corresponding to smoking cesstion counseling lsting 3 to 10 minutes, nd greter thn 10 minutes, respectively. Ntionl Drug Codes (NDC) were used to identify clims nd encounters for phrmceuticl products within therpeutic codes 72142, 72143, 72144, 72145, 72147, 72148, nd Buproprion, due to its use s oth smoking cesstion gent nd n ntidepressnt, ws excluded from nlyses, except for cses in which the drug s therpeutic code explicitly indicted its use ws for smoking cesstion. Becuse the precise numer of smokers in minstrem MMC is not directly known y helth plns or y the stte, prevlence estimtes were generted using Consumer Assessment of Helthcre Providers nd Systems (CAHPS ) 8 survey dt. The CAHPS survey is memer stisfction survey dministered to rndom smple of pln enrollees. The CAHPS survey sks enrollees if they now smoke cigrettes or use tocco every dy, some dys, or not t ll. For the purpose of this nlysis, those who nswered every dy nd some dys were considered smokers. The dult CAHPS survey is dministered every other yer to Medicid mnged cre enrollees. Thus, the percent of identified smokers in ech MMC pln ws held constnt over two yer periods, nd pplied to the yerly chnges in MMC pln enrollment to otin pln-specific prevlence estimtes nd the estimted numer of smokers. Estimtes were further djusted to ccount for regionl vrition in smoking prevlence. This ws chieved y clculting estimted regionl (rest of stte nd New York City) smoking prevlence rtes for ech pln, when pplicle. Sttewide prevlence rtes were then the verge of regionl prevlence rtes weighted y regionl enrollment. Utiliztion rtes were clculted s the proportion of unique smokers who utilized smoking cesstion enefit during ech yer divided y the estimted numer of smokers within given MMC pln. 7 Enrolled in pln for t lest 11 of the 12 clendr months 8 CAHPS is registered trdemrk of the Agency for Helthcre Reserch nd Qulity (AHRQ) 2

4 Results Trended pln-specific smoking prevlence rtes from re displyed in Tle 1. Prevlence rtes re sed on CAHPS dt nd re only ville every other yer. High prevlence rtes re noted mong ll MMC plns over the five-yer period. In 2013, the prevlence rnged from 14 to 41 percent. Tle 1: Smoking Prevlence Trends y Medicid Mnged Cre Helth Pln, Helth Pln 2009/2010* 2011/2012* 2013 Affinity Helth Pln, Inc AMERIGROUP New York, LLC Cpitl District Physicins' Helth Pln, Inc Excellus BlueCross BlueShield Fidelis Cre New York HIP (Emlem Helth) HelthPlus HelthNow New York Inc HelthFirst PHSP, Inc Hudson Helth Pln, Inc Independent Helth's MediSource MVP Helth Pln, Inc MetroPlus Helth Pln, Inc Neighorhood Helth Providers, Inc Totl Cre UnitedHelthcre of New York, Inc Univer Community Helth, Inc WellCre of New York, Inc *The percent of identified smokers in ech pln ws held constnt over two yer periods since CAHPS dult survey dt is only ville every other yer. HelthPlus ws cquired y Amerigroup New York, LLC in My, Neighorhood Helth Providers, Inc ws cquired y HelthFirst PHSP, Inc in Jnury,

5 Pln-specific trends in smoking cesstion phrmceuticl utiliztion from re displyed in Tle 2. Declines in the rte of phrmceuticl enefit utiliztion re noted mong mny MMC plns over the five-yer period. Interestingly, rtes declined slightly fter the 2011 mnged cre crve-in of the phrmcy enefit, lthough some plns show increses or little chnge. Tle 2: Phrmceuticl Benefit Utiliztion Rte Trends y Medicid Mnged Cre Helth Pln, Helth Pln * Affinity Helth Pln, Inc. 10.9% 10.7% 12.4% 11.0% 13.8% AMERIGROUP New York, LLC 7.6% 7.9% 9.6% 9.4% 9.1% Cpitl District Physicins' Helth Pln, Inc. 21.6% 21.2% 17.5% 16.0% 17.0% Excellus BlueCross BlueShield 18.2% 16.8% 17.1% 16.9% 17.8% Fidelis Cre New York 15.3% 15.1% 14.1% 13.4% 12.6% HIP (Emlem Helth) 12.3% 10.7% 8.7% 8.7% 10.0% HelthPlus 9.0% 8.6% 11.8% - - HelthNow New York Inc. 15.6% 14.2% 14.7% 14.3% 14.2% HelthFirst PHSP, Inc. 12.7% 13.3% 10.8% 11.5% 14.6% Hudson Helth Pln, Inc. 17.6% 17.1% 17.0% 16.8% 15.0% Independent Helth's MediSource 16.6% 15.8% 15.0% 15.5% 15.5% MVP Helth Pln, Inc. 19.6% 17.4% 15.1% 10.6% 15.5% MetroPlus Helth Pln, Inc. 13.0% 14.0% 14.4% 15.6% 15.2% Neighorhood Helth Providers, Inc. 10.6% 10.4% 9.1% 9.2% - Totl Cre 17.8% 16.5% 16.6% 16.8% 16.7% UnitedHelthcre of New York, Inc. 12.8% 10.5% 14.6% 12.8% 9.9% Univer Community Helth, Inc. 15.0% 14.4% 12.8% 14.5% 7.6% WellCre of New York, Inc. 12.9% 13.1% 12.8% 8.7% 13.4% *Mnged Cre s Prescription Drug Benefit Crved-In (Octoer 1, 2011). HelthPlus ws cquired y Amerigroup New York, LLC in My, Neighorhood Helth Providers, Inc ws cquired y HelthFirst PHSP, Inc in Jnury,

6 Tle 3 descries pln-specific trends in the counseling enefit utiliztion rte. Unlike phrmceuticl enefit utiliztion, rtes of counseling enefit utiliztion demonstrte incresed use for ll plns with the lrgest increses oserved in 2011 when Medicid expnded coverge of smoking cesstion counseling to ll eneficiries. Tle 3: Counseling Benefit Utiliztion Rte Trends y Medicid Mnged Cre Helth Pln, Helth Pln * Affinity Helth Pln, Inc. 3.0% 3.8% 8.3% 14.9% 23.7 AMERIGROUP New York, LLC 4.1% 6.1% 12.5% 15.9% 16.9 Cpitl District Physicins' Helth Pln, Inc. 3.5% 5.6% 8.4% 13.4% 10.6 Excellus BlueCross BlueShield 3.9% % 10.4% 10.8 Fidelis Cre New York 5.3% 7.3% 11.0% 15.2% 16.5 HIP (Emlem Helth) 4.0% 6.3% 7.7% 11.3% 14.6 HelthPlus 2.6% 4.0% 9.2% - - HelthNow New York Inc. 5.2% 6.1% 11.3% 13.0% 15.1 HelthFirst PHSP, Inc. 2.5% 4.0% 6.7% 12.4% 19.5 Hudson Helth Pln, Inc. 6.4% 7.9% 9.1% 17.5% 19.9 Independent Helth's MediSource 3.8% 4.5% 7.9% 11.1% 14.0 MVP Helth Pln, Inc. 2.9% 4.3% 8.5% 11.0% 12.7 MetroPlus Helth Pln, Inc. 2.3% 4.4% 7.1% 15.0% 17.2 Neighorhood Helth Providers, Inc. 1.8% 4.1% 6.2% 10.5% - Totl Cre 2.8% 7.2% 12.4% 12.6% 19.3 UnitedHelthcre of New York, Inc. 5.9% 6.5% 14.9% 17.2% 14.8 Univer Community Helth, Inc. 3.1% 3.7% 7.5% 11.2% 13.0 WellCre of New York, Inc. 4.4% 6.2% 10.8% 15.9% 15.4 *Medicid expnded coverge of smoking cesstion counseling to ll Medicid eneficiries. HelthPlus ws cquired y Amerigroup New York, LLC in My, Neighorhood Helth Providers, Inc ws cquired y HelthFirst PHSP, Inc in Jnury,

7 Tle 4 descries pln-specific utiliztion rtes mong the suset of minstrem MMC enrollees who hd t lest one clim/encounter for oth counseling nd phrmceuticl services from Despite the incresed efficcy of using oth enefits in comintion, y 2013, helth pln rtes rnged from low of 1.8% to high of 5.9%. Overll, smll ut consistent increse is oserved for the time period. Tle 4: Rte Trends of Comined Counseling nd Phrmceuticl Tocco Cesstion Benefits y Medicid Mnged Cre Helth Pln, Helth Pln * Affinity Helth Pln, Inc. 0.8% 1.1% 2.2% 3.3% 4.5% AMERIGROUP New York, LLC 0.9% 1.1% 2.4% 2.7% 2.8% Cpitl District Physicins' Helth Pln, Inc. 1.1% 1.5% 2.3% 3.9% 3.7% Excellus BlueCross BlueShield 1.5% 2.3% 3.0% 3.3% 3.6% Fidelis Cre New York 1.6% 2.2% 2.9% 3.5% 3.6% HIP (Emlem Helth) 1.1% 1.4% 1.4% 1.9% 2.5% HelthPlus 0.6% 0.8% 1.8% - - HelthNow New York Inc. 1.6% 2.0% 3.2% 3.7% 4.0% HelthFirst PHSP, Inc. 0.6% 1.1% 1.6% 3.0% 4.0% Hudson Helth Pln, Inc. 2.2% 2.8% 2.9% 5.5% 5.9% Independent Helth's MediSource 1.3% 1.6% 2.1% 3.5% 3.8% MVP Helth Pln, Inc. 1.2% 1.7% 2.8% 2.5% 3.6% MetroPlus Helth Pln, Inc. 0.4% 1.2% 2.0% 4.1% 3.9% Neighorhood Helth Providers, Inc. 0.3% 0.8% 1.1% 2.1% - Totl Cre 1.2% 2.2% 3.2% 4.0% 5.5% UnitedHelthcre of New York, Inc. 1.5% 0.7% 3.3% 3.3% 2.6% Univer Community Helth, Inc. 1.3% 1.4% 2.3% 3.4% 3.9% WellCre of New York, Inc. 1.0% 1.8% 2.5% 2.4% 1.8% *Medicid expnded coverge of smoking cesstion counseling to ll Medicid eneficiries nd Mnged Cre s Prescription Drug Benefit Crved-In (Octoer 1, 2011). HelthPlus ws cquired y Amerigroup New York, LLC in My, Neighorhood Helth Providers, Inc ws cquired y HelthFirst PHSP, Inc in Jnury,

8 Tle 5 descries pln-specific overll utiliztion rtes for the time period. Driven y increses in the utiliztion of counseling enefits, the overll utiliztion rte demonstrtes stedy nnul increse for the time period. Tle 5: Overll Utiliztion Rte Trends y Medicid Mnged Cre Helth Pln, * Helth Pln Affinity Helth Pln, Inc. 13.1% 13.4% 18.5% 22.7% 33.0% AMERIGROUP New York, LLC 10.8% 12.9% 19.6% 22.6% 23.2% Cpitl District Physicins' Helth Pln, Inc. 24.1% 25.4% 23.5% 25.5% 23.9% Excellus BlueCross BlueShield 20.5% 19.9% 22.3% 24.0% 24.9% Fidelis Cre New York 19.0% 20.2% 22.1% 25.1% 25.6% HIP (Emlem Helth) 15.3% 15.6% 15.0% 18.2% 22.1% HelthPlus 11.0% 11.8% 19.2% - - HelthNow New York Inc. 19.2% 18.3% 22.8% 23.6% 25.4% HelthFirst PHSP, Inc. 14.6% 16.2% 16.0% 20.9% 30.2% Hudson Helth Pln, Inc. 21.9% 22.2% 23.2% 28.7% 28.9% Independent Helth's MediSource 19.2% 18.7% 20.8% 23.2% 25.7% MVP Helth Pln, Inc. 21.4% 20.0% 20.8% 19.1% 24.6% MetroPlus Helth Pln, Inc. 14.8% 17.3% 19.5% 26.5% 28.5% Neighorhood Helth Providers, Inc. 12.2% 13.7% 14.2% 17.6% - Totl Cre 19.4% 21.5% 25.7% 25.4% 30.5% UnitedHelthcre of New York, Inc. 17.2% 17.6% 26.2% 26.7% 22.2% Univer Community Helth, Inc. 16.8% 16.8% 19.2% 22.4% 24.1% WellCre of New York, Inc. 16.2% 17.5% 21.1% 22.2% 21.2% *The utiliztion rte is clculted s the numer of unique memers, ges enrolled in given pln for t lest 11 months during the yer, who utilized smoking cesstion enefit, out of the totl numer of estimted smokers in ech pln. HelthPlus ws cquired y Amerigroup New York, LLC in My, Neighorhood Helth Providers, Inc ws cquired y HelthFirst PHSP, Inc in Jnury, In ddition to sking respondents out smoking nd tocco use, the 2013 dult CAHPS survey lso sked series of questions relted to the use of smoking nd tocco cesstion enefits. The mjority of self-identified smokers (77%) reported they hd een dvised to quit smoking/using tocco y their doctor or other helth provider in the pst six months. In ddition, 55% reported tht mediction ws recommended or discussed y doctor or helth provider to ssist with tocco cesstion. A slightly smller proportion (46%) reported tht their doctor or helth provider discussed or provided methods nd strtegies other thn mediction to ssist with tocco cesstion. While CAHPS self-report of oth phrmceuticl nd counseling 7

9 Percent service utiliztion ws higher thn the service utiliztion indicted in the nlysis of Medicid clims nd encounter dt, it is importnt to note tht the CAHPS phrmceuticl question did not inquire out filled prescriptions, just if mediction hd een recommended or discussed. Conclusion Despite efforts to control the use of tocco in New York Stte, tocco use remins highly prevlent mong enrollees in New York Stte Medicid progrm. Expnsion of the Medicid enefit pckge hs helped to increse ccess to counseling nd phrmceuticl services, yet only minority of enrollees re utilizing these services. Figure 1 descries smoking cesstion enefit utiliztion in minstrem MMC plns for the time period. From , the phrmceuticl enefit utiliztion rte remined reltively stle, with slight decline oserved fter the 2011 mnged cre crve-in of the phrmcy enefit. Conversely, counseling utiliztion rtes stedily incresed, s did the rte of enrollees receiving comintion of counseling nd phrmceuticl enefits. Incresed utiliztion of the counseling enefit lso drove increses in the overll utiliztion rte. However, despite oserved increses, nerly three qurters of smokers in minstrem MMC plns, re not utilizing smoking cesstion enefits. As such, dditionl qulity improvement efforts re wrrnted to increse the use of tocco cesstion counseling nd phrmceuticl services nd ultimtely increse the numer of Medicid mnged cre enrollees who successfully quit using tocco. For more informtion out this report, plese contct Kevin Mlloy t the Office of Qulity nd Ptient Sfety t , or send n emil to Figure 1: Smoking Cesstion Benefit Utiliztion, Minstrem Medicid Mnged Cre, Phrmceuticl Benefit Counseling Benefit Overll Benefit 5 Comined Counseling & 0 Phrmceuticl Benefit* *Includes the suset of enrollees who hd t lest one clim/encounter for oth counseling nd phrmceuticl services. 8

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