Increasing Increasing InstitutionalInstitutional Consumer Demand:Consumer Demand:

Tim McAfee, MD, MPH

206-876-2551

Tim.mcafee@freeclear.com

Healthplans, Employers (& Government)

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

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

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

Tobacco Treatment

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.

• 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 42:367-377 (2002)

Union Trust Fund: Western WA Carpenter’s Fund

Results Western WA Carpenter’s Fund

• 944 smokers enrolled (13%)– 2/3 smoked >20 years– 2/3 smoked > 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 42:367-377 (2002)

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 Gov’t (is a healthcare purchaser)– Cost-effectiveness, not ROI– Potential impact– How it plays in Albany, Sacramento, Olympia, etc

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

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

•Employer Coverage Estimates

• Mercer national survey of employer-sponsored health plans 2001

• Limits:– 21%response 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

Barriers:

• Lack of perceived need & benefit– Risk is buried– Opportunity is uncertain

• Inertia• Complexity• Institutional biases• The Frog Phenomenon

HIGH PARTICIPATION RATES

1. Full coverage of

counseling and

medication

2. Integration

3. Ongoing

promotions

4. Incentives to

enroll & engage

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.

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

TOBACCO COST EXPOSURE PER YEAR:$350,000,000

TOBACCO COST EXPOSURE PER YEAR:$350,000,000

THE COST OF TOBACCO

Client Population 1,000,000

Adult Covered Lives 670,000

Adult Smokers 140,000

Excess cost/smoker $2,284

NET SAVINGS OPPORTUNITY

LINK TO ROI ANALYSIS TOOLLINK TO ROI ANALYSIS TOOL

NET SAVINGS OVER 3 YEARS: $13,212,787

NET SAVINGS OVER 3 YEARS: $13,212,787

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

Impact: health system & state

Group Health:• pop’n: 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)

WA state QL:• pop’n: 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%)

It’s a complex world

• ABC campaign – increased demand, right?

• Maybe/Maybe not:

• Multiple states cut back on state promotional campaigns

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

Program ParticipationGroup Health Enrollees

0

500

1000

1500

2000

2500

3000

3500

4000

4500

1992 1993 1995 1997 1998 1999 2000

GroupPhoneTotal

One-year quit rate: 25-30% (30-day abstinence ~ Intent-to-Treat)

• 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– MD’s trained and tracked on referrals

WHAT WORKS

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