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The Role of Reimbursement and Third Party Financial Support in Sustaining Quitlines Michele Patarino Claire Brockbank Collaborative Health Solutions January.

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Presentation on theme: "The Role of Reimbursement and Third Party Financial Support in Sustaining Quitlines Michele Patarino Claire Brockbank Collaborative Health Solutions January."— Presentation transcript:

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2 The Role of Reimbursement and Third Party Financial Support in Sustaining Quitlines Michele Patarino Claire Brockbank Collaborative Health Solutions January 7 and 9, 2009 NAQC Issue Paper

3 Introduction Purpose of project: –Assess the current practices of quitlines with regard to third party reimbursement and other forms of financial support, –Provide an overview of the opportunity for obtaining third party support, and –Set out next steps for garnering third party financial support for quitlines.

4 Introduction Collaborative Health Solutions partners have been involved in Colorado tobacco control for 8 years: –Assessment of Native American tobacco control needs –Assessment of State Tobacco Education and Prevention Program –Program Director for Health Systems Change work including promotion of Quitline/fax referral –Consultant to Hospital System/Health Promotion grant –Consultant to Colorado Department of Public Health & Environment on Strategy to Engage Health Plans in Tobacco Cessation –Tobacco Rapid Improvement Activity facilitation for primary care, pediatric, and other types of practices

5 Introduction Also extensive health plan and purchaser experience over 25 years –Worked in private plans, Medicaid, Medicare –Led strategic planning –Worked in product development including wellness programs and disease management –Ran a small group purchasing pool –Consulted with National Business Coalition on Health and state business groups on health –Involved in health policy work (covering the uninsured) in Wyoming and Colorado

6 Process Reviewed literature on tobacco control efforts to engage health plans and/or employers Reviewed NAQC 2006 survey results Developed survey and fielded via survey monkey (2008) Followed up via phone/ Compiled results

7 Environment Recognition of value of quitlines Current funding of quitlines Future of Tobacco Control Funding

8 Opportunity for Reimbursement Prevention and chronic disease management typically provided by health care providers and reimbursed by third party payers Tobacco is the exception and still sits largely in the public health domain –Reimbursement will require building a bridge between public health and private payers

9 Barrier for Public Health Professionals Understanding the Health Insurance Market –Fully Insured employer groups –Self-Insured employer groups –Government programs –Pressure on costs Preventive Services Disease Management (DM)

10 Fully Insured Approximately one-quarter of the insured population Employer pays flat premium, insurance company bears all the risk Regulated at the state level Typically small employers

11 Self-Insured Also one-quarter of the population Self-insured company bears all the risk by agreeing to pay for all services used by its employees Avoids paying insurance company profit margin, marketing costs, premium taxes etc. Generally requires 250+ employees Exempt from state regulation

12 Government Government acts as purchaser of benefits on behalf of: –government employees –Medicaid program As purchaser, government generally self-insures and therefore is immune to state regulation Government acts as regulator at the state level

13 Mandates Requires insurance company coverage of specific health care providers, benefits or patient populations –Council for Affordable Health Insurance estimates that mandates increase cost of basic coverage from 20% – 50% –Supported by advocates, opposed by purchasers, insurers and providers –Occurs at state level only and impacts only the fully insured population

14 Influencing Purchasers/Payers (sources: Kaiser Family Foundation and Employee Benefits Research Institute) Market Sector Approximate Market Share Leverage Fully Insured 23%Sales and benefit negotiations Quitline & Rx benefit DM coverage Self-Insured23%Must perceive ROI Government28%a.As purchaser – ROI b.As regulator – Mandates Mandates strongly opposed by most natural partners – employers, providers, health plans Individual7% Uninsured19%

15 Quitline Practices – August 2008 survey 25 respondents 24 respondents gather insurance status or employer information Five states have financial arrangements with insurers, institutions, or employers Only two responding states have mandated benefits

16 Quitline Practices – (Literature and Interviews) Very limited 3 rd party-Quitline collaboration –Insurers subsidizing quitline –Transfer callers from state quitline to private insurer quitline –Health plans, businesses and other partners contribute funding for NRT for callers

17 Barriers Cited by Quitlines NRT to all citizens makes insurers rely on state quitline coverage State budget crunches makes ongoing support difficult Lack of understanding by public health officials of how to interact with 3 rd party payers National decision-making

18 What Quitlines Recommended – Interviews NAQC could help articulate ROI and other compelling arguments for working with insurers and employers NAQC could use national leverage to build case for coverage and support

19 Recommendations 1.Spectrum of options 2.Circumstance-specific feasibility 3.Leverage points for expanding access to and use of quitlines 4.National support and leverage 5.State and local tools

20 Next Steps 1.Develop value messages for key constituents a)Employers b)Health Plans c)Disease Management Vendors d)Medicaid 2.National convener and clearinghouse 3.Tool kit

21 Acknowledgments and Contributors We thank the following individuals for their assistance: Linda Bailey, NAQCRandi Lachter, NAQC Debbie Montgomery, COJulie Hare, AL Irene Centers, KYAnn Wendling, MN Dena Pope, MSAmanda McCartney, OH Melanie Tidwell, OHTodd Hill, VT Cynthia J. Goto, HI Linda Wright Eakers, OK Shirley Deethardt, NEMajel Arnold, CA Katy L. Wynne, SCLaura Saddler, OR Kathy Danberry, WVKate Kobinsky, WI Sara Wolfe, MDIdalis Mercado, PR Katie Shuttleworth, CTMichelle Walker, ND Karen Goodson, FLNancy Jane Heilman, NM Ann Wendland, NYHeather Beck, MT Tasha Bergeron, LA Donna Warner, MA

22 For Additional Information or to Provide Feedback on Next Steps Contact Randi Lachter at: Or Michele Patarino at:

23 Health Systems Change Collaborative Insurance and Reimbursement Task Group

24 Define Scope, Assess Feasibility, Make Recommendation Gather information on current state of insurance coverage and reimbursement for tobacco cessation Explore the interest of various stakeholders to promote and/or implement change Consider and recommend feasible objectives that the Collaborative and its member states should pursue

25 Insurance and Reimbursement Feasibility Report Wendy Bjornson, Oregon Health and Science Sally Carter, Oklahoma Todd Hill, Vermont Randi Lachter, NAQC Elena List, U of Massachusetts Medical School Deb Montgomery, CO Dept of Public Health & Environment Michele Patarino, Colorado Clinical Guidelines Collaborative/Collaborative Health Solutions Michael Renner, Ohio Pamela Studwell, ALA of Maine Ann Wendling, ClearWay Minnesota SM, Task Leader

26 Lack of access to cessation treatment and underutilization of available services Few tobacco users have comprehensive tobacco cessation benefits Diagnostic and procedural coding are inconsistently used and reimbursed; and poorly understood Among factors cited most often by physicians as significant barriers to counseling patients, 52% identified limited reimbursement for a physician’s time* All three contribute to lack of provider consistency in addressing tobacco cessation and barriers for patients in accessing effective cessation services. Impetus for Selecting this Topic

27 27 Background 2007 National Business Group on Health survey of 506 companies: On average, employers cover two of five CDC recommended components of cessation benefit Only 2% cover all five components recommended by CDC 34% of employers state that they have not considered offering smoking cessation benefits Employers are unsure of the impact smokers have on their business

28 Issues Different types of third party payers –Public - medical assistance coverage varies significantly among states –Private - fully and self insured (subject to ERISA) –Lack of awareness by insurers of adequate and effective cessation benefits and resulting return on investment Inconsistent reimbursement for like coded services, dependent on: –Level of provider –Negotiated purchaser (public and private) and health plan contracts/discounts

29 Objective 1 Through collaboration with other stakeholders, influence public and private insurers to offer comprehensive cessation benefits to all members/ employees

30 Feasible Strategies Emphasize productivity and health care cost ROI Position tobacco cessation as an integral component of physical and behavioral disease prevention and management Encourage enhancement of accreditation and service quality standards for tobacco cessation with feedback to insurers

31 Feasible Strategy: Stakeholder Collaboration Potential National Partners: AMA, APA ALA CDC PHS (Clinical Practice Guidelines) National Working Group for ACTTION/Partnership for Prevention National Business Group on Health National health plan endorsement e.g. BCBS National Association of Health Plans

32 Objective 2 Facilitate selection by states of “best fit” effective evidence based cessation programming through: Reporting successful case studies (e.g. ME, MA, MN, CO, OK) Creating models of stakeholder collaboration and coordination across systems

33 Feasible Strategy: Standard Setting Standard setting and model development: Include consideration of various acceptable state-wide service delivery and program designs Use best practices to guide designs of evidence-based programming

34 Feasible Strategies Considering state health care funding environment: Discuss merits of or balance between quitline and individual counseling Consider unique programs such as ‘wellness’ onsite cessation classes or sessions Consider ‘best way’ to increase access to pharmaceuticals

35 Feasible Strategy: Stakeholder Collaboration Quitlines State tobacco control programs Private insurers Purchaser groups Medicaid programs

36 Objective 3 Improve reimbursement for tobacco cessation services provided through all evidence- based programs by qualified providers

37 Feasible Strategy: Background Paper Current state of coding is variable and reimbursement depends on payer. Begin with: Descriptive – white paper (1) Current codes and utilization (public and private) / levels of reimbursement (2) Medicare codes and utilization data (3) State Medicaid coverage survey/analysis (4) Available private health plan data

38 Feasible Strategy: Advocacy Develop a small task group to monitor status and maintain contacts with strategic partners to explore opportunities for: Improving reimbursement within current systems, face-to-face and quitline, for tobacco treatment specialists e.g. through use of ATTUD articulated standard Coding changes: e.g. bundling of screening and brief intervention with referral for more intensive counseling in one code

39 Feasible Strategy: Stakeholder Collaboration Recruit and collaborate with potential national partners: AMA, APA, NASW ATTUD NAQC CMS Partnership for Prevention ICD 11 Work Group

40 Anticipated Challenges Competing priorities Cost of health care and state of economy Disputed attribution of responsibility (e.g. state vs. private insurer)

41 Possible Evaluation Measures Periodic surveys e.g. National Business Group on Health Employer Survey HEDIS ® CAHPS ® Evalue8 TM National Medical Assistance Survey JCAHO measurements ALA state cessation report card


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