MANAGED CARE PROGRAMSMOKING CESSATION

Polly C. Tamayo

MHA 628

Professor Ona Johnson

November 28, 2011

Smoking Cessation ProgramChronic diseases are the leading cause of

death in the United StatesHeart disease, stroke, cancer, diabetes, and

arthritis are costly and preventable (CDC, 2010)

Tobacco use, physical inactivity, poor nutrition, and excessive consumption of alcohol are risk factors that lead to chronic disease

The Role of Preventing DiseaseMany studies show that prevention can

decrease chronic disease by eliminating risk factors (Kongstvedt, 2007)

Rising health care costs are affecting the Americans’ access to health care and the economy

Interventions for chronic diseases are costly (Russell, 2009)

Disease management (DM) as defined by DMAA is a “system of coordinated health care interventions and communications for populations with conditions in which patient self-care efforts are significant (Kongstvedt, 2007)

Managed care organizations (MCOs) implemented DM to their members to lower the costs of care, improve access, and improve quality health care

DM programs (DMP) should have six components to be considered a full service DM program (Kongstvedt, 2007)

Patient IncentivesSmoking is “among the leading causes of premature mortality and

preventable death in the U. S.” as reported by CDC (Patel, Larson, Hong, Brown & Hargreaves, 2009, p. 933)

Research showed that there was a decrease of smoking rates from 41.2 percent in 1965 to 20.8 per cent in 2004 (Terry, Seaverson, Staufacker, & Tanaka, 2010)

Counseling, pharmacotherapy, and telephone-based counseling improved success of quitting smoking (Terry et al, 2010)

Cash or gift certificates are given for participants and additional award to complete the program

Patient satisfaction since expenses incurred will be reimbursed by the health plan

Discounts on fitness centers and weight management programs.

Physician IncentivesMCOs reward physicians or clinics who implemented quality

improvement and preventive programs (Kongstvedt, 2007)Performance feedback from claims data helps physicians to be

informed of their patients’ preventive servicesImplementation of electronic health records (EMR/EHR) can

improve communications between MCOs , providers, and patients.

MCO’s pay-for-performance programs give incentives to provide the best quality health care and document patient outcomes (Kongstvedt, 2007)

Physician IncentivesThe Ambulatory Care Quality Alliance (AQA, 2007)

released 26 health care quality indicators for clinicians to use in improvement efforts which include measures relating to smoking cessation.

Reimbursement adjustments and bonus payments are MCO’s incentives for physicians meeting quality health care

Case ManagementDefined as a “collaborative process that assesses, plans,

implements, coordinates, monitors, and evaluates the options and services required to meet an individual’s health needs, using communication and available resources to promote quality, cost effective outcomes” (Kongstvedt, 2007)

Case manager works to communicate to the different healthcare professionals, health plans, and should have strong clinical expertise.

In smoking cessation program, the case manager should focus on the patient’s overall management from the start to the time that patient quit smoking.

Case ManagementThe community case management program is to provide

patients “access to medical, social, financial, educational, and other services to meet the basic needs of living day to day” (Kongstvedt, 2007, p. 263).

In prevention and wellness program, the case manager is responsible to review patient records and progress, review quality issues, visit and follow up, and talk to patient and family members about the plan of care.

FacilitiesHospitals, medical groups, and physician offices should

be given incentives if their employees participate in the smoking cessation program

Counseling visits, coverage for nicotine cessation medications , preventive services, immunizations and screening should be part of member benefits to increase access to these facilities (Kongstvedt, 2007).

Behavioral health care services should be included in the smoking cessation program to counsel participants to change their lifestyle.

Quality of CareThere are three criteria used for assessment of

quality: structure, process, and outcome by Donabedian (Kongstvedt, 2007).

Structure are the qualifications of physicians. and personnel, licensure of facilities, compliance of safety codes, record keeping, and physician network appointments (Kongstvedt, 2007).

Process criteria is the way care is provided such as preventive health screening, and follow up of critical lab results

Quality of CareOutcome criteria are the overall result of the treatment or

service such as infection rates, morbidity, and mortality (Kongstvedt, 2007).

Continuous improvement process model is the modern quality program based on “fundamentals of quality assurance, incorporates the improvement aims of the Institute of Medicine (IOM), and is responsive to the changing marketplace”(Kongstvedt, 2007, p.340).

Prevention such as smoking cessation program should have a quality assurance program in place to provide quality of care to participants.

Prescription Benefits Prescription drug program are part of MCO’s member

benefits including Medicaid programs and Medicare Part D (Kongstvedt, 2007).

Employers should look and study into their prescription drug benefit to be able to obtain the most effective pharmacy benefit program (PBP) (Kopenski, 2008).

The PBP design should include three factors:” multiple delivery channels, complex provider contracting, and a vast range of drug products “(Kopenski, 2008, p.7)

Prescription BenefitsMedCo has services besides mail-order such as giving

information if the different prescription medications do not react with each other.

Employers should choose a PBP best suited to all employees which has low copayments, and provide extra services to members such as drug information

“Aligning all aspects of pharmacy benefit is the best and only way to help control drug benefit costs and at the same time promote greater employee satisfaction” (Kopenski, 2008, p.11).

The Future of Data Use and InformaticsThe use of information technology will enhance data

collection, research, and development in managed careClaims data will be used in the future for further research

and development to study and improve quality health care.The implementation of EMR not only in hospitals but also

physician offices, MCOs will be able to monitor utilization trends and costs of health care (Kongstvedt, 2007).

For smoking cessation program, access to health plans educational materials will be easy through the internet.

Conclusion Chronic disease is the leading cause of death which is

costly and considered to be preventable. Managed care organizations are implementing disease

management programs to prevent chronic disease. Risk factors such as tobacco use, inactivity, poor nutrition

and excessive alcohol consumption should be resolved.Smoking cessation programs will be successful with the

support of family, providers, health plans, other health care professionals, and the state and federal government

References

AIM. (2007). Practice improvement, Annals of Internal Medicine, 146(3), Retrieved from http://www.ebscohost.com.

Centers for Disease Control and Prevention. (2010). Chronic diseases and health promotion, Atlanta, GA, Retrieved from http://www.cdc.gov.

Kongstvedt, P. (2007). Essentials of Managed Health Care 5th edition, Sudbury, MA. Jones and Bartlett.

Kopenski, F. (2008). Prescription drug benefit design: the building blocks and their impact on cost, Benefits Quarterly, 24(4), p. 7-11, Retrieved from http://www.ebscohost.com.

References Patel, K., Schlundt, D., Larson, C., Hong, W., Brown, A., & Hrgreaves, M.

(2009). Chronic illness and smoking cessation, Nicotine and Tobacco Research, 11(8), p. 933-939, Retrieved from http://www.ebscohost.com.

Russell, L. (2009). Preventing chronic disease: an important investment, but don’t count on cost savings, Health Affairs, 28(1), p. 42-45, Retrieved from http://www.ebscohost.com

Terry, P., Seaverson, E., Staufacker, M., & Tanaka, A. (2011). The effectiveness of telephone-based tobacco cessation program offered as part of a worksite health promotion program, Population Health management, 14(3), p.117-125, Retrieved from http://www. ebscohost.com.