Center of Excellence for Health Systems Improvement for a Tobacco-Free New York: Statewide Stakeholder Workgroup Meeting Minutes February 25, 2015 9:00am 11:45am Empire State Plaza, CR 125, Albany, NY Attendees - Peggy Bonneau, Director of Health Initiatives, Office of the Medical Director, New York State Office of Alcoholism and Substance Abuse Services - Anthony Fiori (call in), Managing Director, Manatt Health Solutions / Coalition of New York State Public Health Plans - Susan Kansagra (call in), Assistant Vice President, Population Health, Medical, and Professional Affairs, New York City Health and Hospitals Corporation - Gregory Miller, Medical Director, Adult Services, New York State Office of Mental Health - Mark Moss, Public Health Dentist, Interlakes Dental - Wade Norwood (call in), Chief Program Officer, Finger Lakes Health System Authority - Michael Seserman, Director, Strategic Health Alliances, American Cancer Society - Donna Shelley (call in), Associate Professor of Population Health, Co-Chair Section on Tobacco, Alcohol and Drug Use, Department of Population Health, New York University School of Medicine - Sayone Thihalolipavan (call in), Medical Director, Clinical and Scientific Affairs, Bureau of Chronic Disease Prevention and Tobacco Control, New York City Department of Health and Mental Hygiene - Haven Battles, Assistant Director, Bureau of Chronic Disease Evaluation and Research, New York State Department of Health Bureau of Tobacco Control - Harlan Juster, Director, Bureau of Tobacco Control, New York State Department of Health - Stephanie Sheehan, Assistant Director, Bureau of Tobacco Control, New York State Department of Health - Julie Wright, Program Manager, Health Systems, Bureau of Tobacco Control, New York State Department of Health CAI - Michelle Gerka, Vice President, Family and Community Education, CAI - Elizabeth Jones, Director, Health Systems Improvement, CAI - Francesca Sherman, Deputy Director, Health Systems Improvement, CAI
2 Members Not Present - Elizabeth Misa, Deputy Medicaid Director, Office of Health Insurance Programs, New York State Department of Health - Michael Seilback, Vice President, Public Policy and Communications, American Lung Association of the Northeast - Cynthia Sutliff, Director of Policy, New York ehealth Collaborative - Jill Marie Williams, Associate Professor of Psychiatry & Director, Division of Addictions Psychiatry, UMDNJ-Robert Wood Johnson Medical School Meeting Minutes Purpose: To introduce Statewide Stakeholder Workgroup members to the Health Systems for a Tobacco-Free New York program and the Center of Excellence for Health Systems Improvement (COE for HSI), as well as initiate dialogue about policy issues that Workgroup membership can tackle using their connections and positions within their respective organizations. In addressing pertinent policy issues, the Statewide Stakeholder Workgroup can promote a policy environment that facilitates the work of the 10 regional contractors to promote access to evidence-based tobacco dependence treatment among populations for which tobacco use rates have not declined in recent years, specifically individuals with low-incomes, less than high school diploma, and/or serious mental illness. On February 25, members of the Statewide Stakeholder Workgroup engaged in a rich discussion that identified several strengths and weaknesses that stand to influence the Health Systems for a Tobacco-Free New York program, as well as external opportunities and threats to the success of the program stemming from the current policy environment. The COE for HSI used a SWOT - (strengths, weaknesses, opportunities, and threats) - analysis format to assess these factors and support the Workgroup with the task of prioritizing activities. I. Strengths: Where are the "internal" strengths? - The New York State Smokers Quitline is a valuable resource, with an effective quit rate of 25-35% and referral rates among the highest in the nation o The Quitline can be utilized as an added resource to complement on-site tobacco dependence treatment - The Bureau of Tobacco Control (BTC) can provide tracking and monitoring to evaluate tobacco dependence treatment efforts across New York State
3 o Access to this level of data will assist regional contractors in monitoring their progress toward reaching program goals and will assist the COE for HSI with tailoring efforts to reach target populations - The BTC evaluation team has the capacity to conduct an analysis on the return on investment (ROI) for Medicaid Managed Care (MMC) and private health insurance plans of investing in tobacco dependence treatment for their enrollees without limits for quit attempts, specific brands, etc., now that, following the implementation of the Affordable Care Act (ACA), fewer individuals are transitioning between different sources of health insurance coverage and all enrollees have a baseline level of coverage for tobacco dependence coverage in light of the ACA s preventive care benefits II. III. Weaknesses: Where are the "internal" weaknesses? - Although it has a high quit rate among its users, the New York State Smokers Quitline reaches 4% of all smokers, limiting its ability to have a populationlevel impact o The Quitine was intended to complement on-site tobacco dependence interventions, but often replaces them due to the handful of systems-level barriers associated with providing on-site cessation interventions, including barriers related to reimbursement, staffing, and work flow - MMC plans currently are not required to cover all FDA-approved tobacco dependence treatment medications, and benefits are limited in terms of medication brand, number of quit attempts, and counseling coverage o Patients may not receive adequate tobacco dependence treatment services to quit smoking without an unlimited Medicaid benefit Opportunities: What are the "external" opportunities? - Since 80% of tobacco users saw a health care provider in the last 12 months (this includes in behavioral health settings), in working with health systems to integrate guideline-concordant care systems-wide, regional contractors have the opportunity to touch a majority of this program's target populations - Health and Recovery Plans (HARP) include enhanced cessation services in their benefit packages, such as pharmacology and follow-up and support services, which will assist patients in maintaining their quit attempt o In the first year HARPs have been fully operational, health care/mental health settings serving those with serious mental illness will need guidance with implementation; regional contractors can provide this support as a way to garner buy-in from leadership around implementing tobacco dependence treatment policies - Initiatives stemming from New York State's Quality Strategy and Prevention Agenda (2013-2017), including the Population Health Improvement Program (PHIP), Community Health Improvement Plan (CHIP), and the Performance
Improvement Project (PIP), have been established to reduce care fragmentation and increase receipt of guideline-concordant care among populations most impacted by health disparities--aims that coincide with those of the Health Systems for a Tobacco-Free New York program o Partnerships between these contracts/programs and regional contractors have the potential to be mutually beneficial and advance program goals for all - New York State contracts with MMCs to administer benefits to enrollees o Although each change to the State's Medicaid Model Contract requires a thorough analysis of the fiscal implications tied to potential changes in service utilization, the Statewide Stakeholder Workgroup may want to consider advocating for amendments to the Medicaid Model Contract to enhance tobacco cessation benefits for MMC enrollees o Opportunities for improved Medicaid reimbursement include increasing who can be reimbursed for smoking cessation counseling and unlimiting tobacco dependence treatment benefits for all populations - There currently is not a Quality Assurance Reporting Requirements (QARR) measure for screening for tobacco use, but the introduction of one certainly would prompt MMC plans and health care providers alike to pay more attention to provision of this evidence-based practice, as QARR data are used by insurance purchasers and consumers, as well as regulatory and accreditation agencies, to gauge the quality of MMC plans o Though the addition of a QARR measure would have fiscal impact - it would require cost annual chart reviews by MMC plans - it could be a worthwhile venture for the Statewide Stakeholder Workgroup to take on in order to promote standardized tobacco dependence screening - Managing provider intervention quality is crucial to the success of the Health Systems for a Tobacco-Free New York program, assuring patients have all the tools they need for a successful quit attempt o The patient populations for which smoking rates have not declined in recent years require top-rate, evidence-based interventions o Incentivizing providers using a clinical quality metric (e.g., a QARR measure) could enhance the quality of provider intervention (and not just the incidence of interventions) - In New York State, 11 of 25 Performance Provider Systems (PPSs) chose the 4.b.i Project (Promote tobacco use cessation, especially among low SES populations and those with poor mental health) as part of their Delivery System Reform Incentive Payment (DSRIP) Projects o Several members on the Statewide Stakeholder Workgroup are involved in DSRIP processes, providing opportunity to keep tobacco use cessation on the agenda within PPSs 4
5 o As DSRIP processes restructure the health care delivery system within each PPS, regional contractors have an opportunity to lend their expertise and advice on how to best integrate evidence-based tobacco dependence treatment into care delivery (specifically within PPSs that have kept the tobacco measure) - OMH is implementing a new smoke-free policy in 2015, which will draw upon lessons learned from the Office of Alcoholism and Substance Abuse Services (OASAS) o Statewide Stakeholder Workgroup members can utilize their influence to engage decision-makers during the roll-out of this policy, prompting timely responses to unforeseen implementation challenges as they emerge* - Literature on implementation science, specifically implementation drivers, can serve as another resource to inform the strategies employed by the COE for HSI and regional contractors - To avoid duplication of efforts and unnecessary spending by health systems, the process of integrating the 5 A s into electronic health record (EHR) systems could be centralized through vendors' corporate/central offices o Centralized coordination with EHR vendors could assist with integration of evidence-based tobacco dependence treatment prompts into EHR systems on a statewide-level IV. Threats: What are the "external" threats? - Many health care/mental health providers cannot bill for provision of smoking cessation counseling, including social workers and registered nurses o The current reimbursement environment deters health care organizations from triaging components of care to the above skilled practitioners practitioners who may have more time to dedicate to counseling and behavioral interventions - Regional contractors and health care/mental health providers do not always have full information regarding which tobacco dependence treatments are included on each MMC plans' formularies o Providers are hesitant to prescribe and/or dispense pharmacology to patients if that medication will not be covered/reimbursed - As high-risk individuals shift from Fee-for-Service Medicaid to HARPs, they will encounter barriers to access that are inherent in any managed care environment o Although such challenges will be resolved over time, there will be a need for Statewide Stakeholder Workgroup members, regional contractors, and the COE for HSI to work together to monitor progress and identify opportunities to address implementation challenges as they arise* - MMC and private health insurance plans coverage of tobacco dependence treatment does not always results in an immediate ROI, especially
6 considering the 85% relapse rate among tobacco users and the churning of plan enrollees o Most insurance companies do not recognize the economic value in investing in tobacco dependence treatment, even when the cost of tobacco-related illness is so high - Nicotine Replacement Therapy (NRT) is not available in residential mental health facilities due to the lack of on-site prescribers and issues surrounding reimbursement o At present, these patient populations often must stop using tobacco without the aid of tobacco dependence treatment, necessitating the establishment of systems and policies to assure this population has access to NRT immediately upon entering facilities* o One policy solution to the reimbursement issue would be to add to cost of NRT to the larger Medicaid bundled payment to facilities - NYS DOH, OMH, and/or OASAS regulate many of the mental health treatment facilities that the regional contractors have prioritized working with in Year 1 of the Health Systems for a Tobacco-Free New York contract o Regional contractors require an understanding of the regulatory bodies governing agencies and the implications of these bodies on proposed work; such knowledge is critical to working with agencies to plan strategies for integrating tobacco dependence treatment into existing frameworks* V. Identified Priorities - Develop partnerships with PHIPs to create synergies, avoid duplication of efforts, and advance program goals for all - Add the cost of NRT to mental/substance abuse treatment facilities larger bundled payments from Medicaid* - Expand Medicaid reimbursement for the provision of smoking cessation counseling to include a broader group of health care providers - Create a QARR measure on screening for tobacco use *Denotes behavioral health item to be addressed with Mental Health Sub-Committee Next Steps 1. COE for HSI: Type-up and circulate meeting minutes 2. COE for HSI: Arrange second Statewide Stakeholder Workgroup Meeting 3. COE for HSI: Arrange first Mental Health Sub-Committee Meeting
4. Wade Norwood: Write-up how the work of the Statewide Stakeholder Workgroup relates to the work of PHIP, and how these two contracts can work together to advance project goals 7