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Tobacco use is the leading preventable cause of death in the United States; it accounts for at least $97 billion in lost productivity annually (Centers for Disease Control and Prevention, 2008). The Public Health Service and Healthy People initiative recommend multiple evidence-based approaches to tobacco control (2008 PHS Guideline Update Panel, Liaisons, and Staff, 2008; Office of Disease Prevention and Health Promotion, 2013). Sixty-eight percent of smokers want to quit (Quinn et al., 2005); but fewer succeed unaided than with assistance, which includes the use of pharmacotherapy and counseling (Zhu, Melcer, Sun, Rosbrook, & Pierce, 2000). Costs are a significant barrier to the use of smoking-cessation treatment, and the Patient Protection and Affordable Care Act (ACA) calls for expansion of smoking cessation coverage in Medicaid and private health plans (Centers for Disease Control and Prevention, 2010).
Tennessee ranks fifth in the nation in smoking-attributable mortality (Centers for Disease Control and Prevention, 2009), first among men (Ho & Elo, 2013), and tenth in overall smoking prevalence (King, Dube, & Tynan, 2012). In 2009, TennCare (i.e., Tennessee Medicaid) did not cover smoking cessation treatment (Centers for Disease Control and Prevention, 2010). Tennessee does not require private insurance plans to cover cessation treatment, and the lack of regulation allows a wide variation in health plan offerings for tobacco dependence treatment. In addition, in 2010, Tennessee spent only 2% of the amount deemed to represent best practices for tobacco control; this was the lowest percentage in the nation (Centers for Disease Control and Prevention (2012). There have not been any published studies of smoking cessation coverage by health plans in Tennessee to date.
The Clinical Practice Guideline for Treating Tobacco Use and Dependence, published by the Public Health Service in the US Department of Health and Human Services (2008 PHS Guideline Update Panel, Liaisons, and Staff, 2008), posits that tobacco dependence is a chronic condition that requires repeated intervention until permanent cessation occurs. Therefore, all smokers should receive repeated practical cessation counseling combined with appropriate pharmacotherapy (2008 PHS Guideline Update Panel, Liaisons, and Staff, 2008). One Healthy People 2010 objective was to have 100% total managed care coverage of counseling and pharmacotherapy; a 2020 objective is to increase the number of Medicaid programs nationwide that provide comprehensive cessation coverage (Healthy People 2010, 2000; Office of Disease Prevention and Health Promotion, 2013).
First-line pharmacotherapy for smoking cessation comprises varenicline, bupropion, and nicotine replacement therapy (NRT) in the form of patches, gum, lozenges, inhalers, and nasal spray. Varenicline is the most effective agent for smoking cessation, with an odds ratio for continuous abstinence of 2.48 relative to placebo at 12 months (Mills et al., 2012). The odds ratio (OR) predictive of abstinence with NRT compared with control is 1.58; 95% confidence interval (CI) 1.50–1.66 (Stead, Perera, Bullen, Mant, & Lancaster, 2008). All of the commercially available forms of NRT (gum, transdermal patch, nasal spray, inhaler, and sublingual tablets/lozenges) increase the odds of quitting by approximately 50–70%, regardless of setting, and are effective as part of a strategy to continuously promote smoking cessation in primary care settings.
A randomized trial with smokers enrolled in two large managed care organizations in California demonstrated a beneficial effect of full coverage of smoking cessation services (Schauffler et al., 2001). Eligible smokers (N = 1,204) were randomly assigned to either the control group or a treatment group. The control group received a self-help kit (video and pamphlet), and the treatment group received the self-help kit and fully covered benefits for over the counter (OTC) NRT gum and patch, and participation in a group behavioral cessation program (BP) with no patient cost-sharing (Schauffler et al., 2001). Controlling for health plan, socio-demographics, baseline smoking characteristics, and use of bupropion, quit rates after 1 year of follow-up were 18% in the treatment group and 13% in the control group with adjusted odds ratio (aOR) of 1.6% and 95% CI: 1.1–2.4. Rates of quit attempts (aOR: 1.4; 95% CI: 1.1–1.8) and use of nicotine gum or patch (aOR: 2.3, 95% CI: 1.6–3.2) were also higher in the treatment group. The annual cost of the benefit per user who quit ranged from $965 to $1,495, or from $0.47 to $0.73 per member per month. Thus, full coverage of a tobacco dependence treatment benefit is an effective and relatively low-cost strategy for significantly increasing quit rates, quit attempts, and use of nicotine gum and patch in adult smokers. Smokers who received full coverage for NRT or participation in a group BP were significantly more likely to quit smoking than those in a control group who received a self-help cessation kit with no enhanced coverage. Most of the effect was due to higher rates of use of NRT.
Thirteen licensed health maintenance organizations (HMOs) and 21 Medicaid managed care plans operating in California in 1999 responded to a survey on cessation practices (Halpin Schauffler, Mordavsky, & McMenamin, 2001). Eighty-five percent of HMOs covered at least one cessation medication. While only 23% of California HMOs covered the nicotine patch or gum, 69% covered at least one form of pharmacotherapy and one type of counseling to treat tobacco dependence.
A 19-item survey of tobacco control practices and policies in health plans was conducted by America's Health Insurance Plans as part of the Addressing Tobacco in Managed Care (ATMC) program (McPhillips-Tangum, Bocchino, Carreon, Erceg, & Rehm, 2004). Of 152 HMOs nationwide, 71% of plans had written cessation guidelines, 89% fully covered at least one cessation medication, 72% identified individual members who smoked, and 11% required program attendance for NRT coverage. Fifty-two percent provided telephone counseling.
Kofman and colleagues evaluated coverage, limitations, and exclusions among 39 HMOs and Preferred Provider Organizations (PPOs) in Oregon, Kentucky, New Jersey, Florida, South Dakota and Nevada (Kofman, Dunton, & Senkewicz, 2012). Although 36 of 39 plans indicated that they covered tobacco cessation, 26 included language entirely or partially excluding tobacco cessation from coverage. Twenty-three contracts included coverage for prescription drugs for tobacco cessation, and 15 contracts did not cover prescription drugs; one contract was not clear on whether prescription drugs were covered. Twelve contracts specifically covered OTC for tobacco cessation, and 24 contracts excluded OTCs; three contracts were silent on whether OTCs were covered. Of the 12 contracts covering OTC benefits, eight required a prescription for OTC medication. None of the 39 plans studied provided tobacco cessation treatments by in-network providers without cost sharing; all the plans required prior authorization and/or proof of medical necessity.
A number of barriers to use of pharmacotherapy by smokers may be inherent to their health plan coverage. Such barriers may include requirement of co-payments and/or prior authorization, quantity limits or annual limits on coverage, and requirement of counseling before patients can receive the medications (American Lung Association, 2008).
One of the main ways smokers may access proven tobacco dependence treatments is through their health insurance coverage. Assessing the reach of cessation programs in Tennessee is thus critical to increasing quit rates and attaining the Healthy People 2020 goal of 12% smoking prevalence. The purpose of this study is therefore to assess smoking cessation services available from public and private Tennessee health care plans, with a view to recommending changes in insurance regulation if indicated.
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Web-based data were retrieved for all nine health plans. One plan provided an electronic manual and another provided a web link to its smoking cessation information.
All plans offered general health insurance coverage in at least one state other than Tennessee. Two of the nine plans (22%) reported nonprofit status. Two of the plans participated in TennCare and Medicare; Table 1 shows additional demographic data.
Table 1. Tennessee Health Plan Demographic Data
|Health plan||Enrollment in Tennessee||Profit status||Participation in TennCare||Participation in Medicare||Plan type studied|
|Plan A||185,593||For profit||No||No||PPO|
|Plan B||1,820,898||Not for profit||Yes||Yes||PPO|
|Plan C||NA||For profit||No||No||PPO|
|Plan D||574,952||For profit||No||Yes||PPO|
|Plan E||NA||Not for profit||No||No||PPO|
|Plan G||308,605||For profit||Yes||Yes||PPO|
|Plan H||34,000||For profit||No||Yes||PPO|
|Plan F||NA||For profit||No||No||PPO|
|Plan I||NA||For profit||No||Yes||PPO|
Table 2 summarizes the coverage of first-line therapies for smoking cessation. There was wide variation in coverage of prescription and over-the counter medications. Six of nine (67%) plans covered any form of smoking cessation medications; only two (22%) covered all medications. Four insurance carriers (44%) included coverage for the oral drugs bupropion and varenicline, but only with prior authorization. One required purchase from a specific partner pharmacy for coverage. Two insurance carriers covered bupropion alone with prior authorization. Two insurance carriers covered all five forms of NRT, one plan (11%) required program attendance and participation for gum and patch coverage, and the other six (67%) did not cover NRT. TennCare covered all smoking cessation medications but required prior authorization for bupropion or varenicline. Figure 1 shows that bupropion was the drug most often covered, followed by varenicline, NRT patches and gum, then other forms of NRT.
Table 2. Health Plan Coverage of Smoking Cessation Treatment
| ||Nicotine replacement therapy (NRT)||Non-NRT drugs||Counseling|
|Item covered, yes versus no||Item covered, yes versus no||Item covered, yes versus no|
|Health plan||Gum||Patch||Nasal spray||Lozenge||Inhaler||Varenicline||Bupropion||Group||Individual||Telephone|
|Total (excluding TennCare)||3||3||2||2||2||4||6||3||5||2|
Based on ALA criteria, only one plan (plan A) provided comprehensive coverage in 2012. Two plans (22%) provided moderate coverage, three plans (33%) offered inadequate coverage, and three plans offered no coverage. Review of available plan enrollment data suggests that 2,581,443 people had access to comprehensive or moderate coverage. In contrast, TennCare provided inadequate coverage.
Although there are three types of guideline-recommended counseling (individual, group, and telephone), only three of the nine plans (33%) studied specifically included both individual and group counseling as a covered benefit. Two (22%) covered individual counseling alone, up to 12 times per year, while four excluded it. Two of the plans (22%) covered telephone counseling. There was Tennessee Tobacco Quitline information on four plan websites.
TennCare covered group and individual counseling, but only for pregnant women. Telephone counseling was not covered, although the Tennessee Tobacco Quitline is hyperlinked on the TennCare website.
Table 3 describes potential barriers to coverage for smoking cessation. These barriers to tobacco cessation treatment include medical necessity or prior authorization requirements, as well as requirements to participate in a formal program. Most health plans providing coverage for oral medications required prior authorization (Table 2). Health insurance plans studied also had different approaches to cost sharing for tobacco cessation medication and counseling. Four of the nine (44%) health plans that covered prescription drugs applied co-pay requirements for these drugs. One plan did not require co-pays, while another would waive co-pays for counseling by in-network providers and medication filled at partner pharmacies. All plans providing medication coverage allowed only one or two quit attempts per year.
Table 3. Coverage: Strength and Barriers
|Plan||Strength of coverage||Quantity limit||Prior authorization required||Co-payment required||Limit on quit attempts|
|Plan E||None||No coverage||No coverage||No coverage||No coverage|
|Plan F||None||No coverage||No coverage||No coverage||No coverage|
|Plan I||None||No coverage||No coverage||No coverage||No coverage|
TennCare had quantity limits on all first-line cessation medications, but required no co-pay for medications or counseling.
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In 2012, health plans in Tennessee provided suboptimal coverage for smoking cessation. Of the nine plans available, 67% covered at least one cessation medication. This is lower than the 89% found in a nationwide study (McPhillips-Tangum et al., 2004) and 85% in California (Halpin Schauffler et al., 2001). NRT gum and patch coverage required program attendance and participation in 11% of plans; this is the same proportion reported by McPhillips-Tangum et al. (2004). Coverage of NRT patch and gum in Tennessee (22%) was similar to the 23% among California HMOs (Halpin Schauffler et al., 2001). The reason for low coverage of NRT by Tennessee health plans is unclear; there was no obvious difference in coverage between the patch and gum (available OTC) and the inhaler, lozenge and nasal spray (requiring prescription). The Tennessee Quitline did not provide free NRT to any residents in the period under review.
About half of health plans studied (52%) provided telephone counseling nationwide and in California (Halpin Schauffler et al., 2001; McPhillips-Tangum et al., 2004); however, only two Tennessee plans covered telephone counseling. These findings highlight an inadequacy in smoking cessation coverage in Tennessee.
The one plan with a comprehensive cessation benefit unfortunately includes a prior authorization for prescription drugs. Indeed, the plans that provided moderate and inadequate coverage also presented two or more barriers to the use of such coverage, similar to the findings of Kofman et al. (2012).
Over 1,112,000 people were TennCare enrollees in 2010–2011 (Kaiser Family Foundation, 2011). Nationwide, 32.6% of Medicaid enrollees were smokers in 2007 (American Lung Association, 2008); if this remained true in Tennessee, then 362,805 smokers had inadequate insurance-based access to cessation treatments. Even though TennCare covered all first-line medications with no co-pays, barriers to successful cessation utilizing this coverage included quantity limits and prior authorization. Pregnant women were the only TennCare-insured people eligible for group and individual counseling. Expansion of Medicaid benefits for smoking cessation can lead to reductions in smoking prevalence (Land et al., 2010) and hospitalization claims for acute myocardial infarction and coronary artery disease, known smoking-attributable conditions (Land et al., 2010).
At the same time, 3,277,900 Tennessee residents had private insurance, of which 696,457 had enrolled in plans with inadequate or no coverage for smoking cessation. The estimated percentage of smokers with private insurance across the United States is 17.1% (American Lung Association, 2008). If this holds true in Tennessee, then 119,094 smokers had private insurance that provided inadequate or no cessation coverage in 2012.
The foregoing suggests that about 481,900 smokers in Tennessee have insurance benefits for smoking cessation that are suboptimal. If 68 percent of these smokers want to quit (Quinn et al., 2005), providing full cessation coverage to these 327,691 persons has the potential to reduce smoking and its attributable morbidity and mortality in Tennessee significantly.
All plans that met study criteria were included, leading to a 100% capture rate. Comparisons were made to other states when possible. To date, this study is the first assessment of smoking cessation coverage provided by health plans in Tennessee.
While there are a small number of health plans in this study, all the available plans in Tennessee are included. Multiple attempts to verify information gleaned from the internet via direct surveys of staff of each health plan proved futile. Health plan dissemination of cessation benefits to enrollees could not be ascertained; likewise, availability of case managers or cessation coaches to smokers could not be assessed.
To meet or exceed treatment recommendations of Healthy People 2020 and other national guidelines, the State of Tennessee should require all health plans to cover evidence-based recommended cessation treatments. Tennessee should also fund provision of free NRT to motivated callers to the Quitline.
Insurance companies, program administrators, and employers should ensure that they cover comprehensive tobacco cessation treatments that include all Food and Drug Administration-approved medications and both individual and group counseling. Health plans should offer premium discounts to enrollees who purchase OTC NRT.
Employers negotiating benefits for employees and their dependents should seek to reduce barriers in smoking cessation coverage. The public health community in Tennessee should advocate for evidence-based strategies known to reduce smoking prevalence.
As of 2012, Tennessee had not achieved the 2010 Healthy People objective of total managed care coverage for smoking cessation. Citizens continued to experience barriers to smoking cessation treatment in Tennessee, due in part to limitations in insurance coverage. These barriers needlessly increase morbidity and mortality, as well as costs related to health care in Tennessee. If Tennessee implements the above policy recommendations, over 481,000 current smokers will have enhanced access to comprehensive cessation treatment; this will improve quality of life, save lives, and reduce health care costs.