Why is price important? Others on the panel will provide cogent arguments about the importance of price. Suffice to say that price is one of our major levers in reducing tobacco use. And we know that reducing tobacco use in Massachusetts is critical to our governor’s ability to implement cost containment strategies in this era of health care reform.. Massachusetts spends $4.3 billion on healthcare costs every year. 10% of all healthcare costs in the Commonwealth are attributable to smoking. In Massachusetts, 8,000 people die prematurely every year from smoking-related illnesses. The data on health care costs are from SAMMEC we know that these figures do not include costs of second hand smoke, smokeless tobacco use, or health costs associated with childhood illnesses.
Adult smoking prevalence in Massachusetts is declining steadily at an average rate of 2.2%.
Cigarette smoking is declining among youth.
- These subgroups highlight the complicated role of socioeconomic status in smoking prevalence
- The areas of higher prevalence may correspond with higher usage of Mass Health as well as lower socioeconomic status
This slide shows the abrupt drop in smoking prevalence following the benefit’s implementation. Blue line is MassHealth Red line shows no insurance (low SES) – no benefit Note: Point estimates are based on six-month intervals and vary due to a small sample size. The point estimates provide a sufficient number of data points to conduct a trend analysis using Joinpoint analysis software from the CDC. The trend analysis shows the linear trend and the time period (joinpoint) in which the linear trend changes. For this analysis, the joinpoint coincides with implementation of the MassHealth tobacco cessation benefit.
Dramatic, measurable near-term health impacts when benefit was accessed 46% drop in heart attack hospitalizations among cessation benefit users Measured the first year after individual access of the benefit 49% drop in hospitalization for coronary atherosclerosis among cessation benefit users Measured the first year after individual access of the benefit No significant changes occurred in rates of hospital admissions for other diagnoses, including four respiratory conditions (pneumonia, asthma, COPD, and respiratory failure) and in seven additional diagnostic groups have not previously associated with smoking or with short-term health improvements following smoking cessation. General analytic model Study parameters for heart attack and asthma categories: Includes claims for Fee For Service (FFS), Primary Care Clinician (PCC), and Managed Care Organizations (MCO). Primary diagnoses only. Counseling only benefit users excluded from analysis. First use of medication prior to 11/17/2007. Subscribers must have at least 321 days of FFS and PCC eligibility in year prior to first use date and year after first use date. Total number of Pharmacotherapy Benefit Users: 74,454. After excluding all clients with less than 321 days of FFS and PCC eligibility in the year before and after first use of medication, excluding all counseling-only clients, and excluding all claims after 6/27/2008, the resulting sample was 21,656 .
The utilization was much higher than we had originally projected, but it didn’t exceed the allotted budget. Utilization was nearly all for medication; only 1% used counseling. Chantix was a brand-new drug at the time the benefit was first implemented. After the initial flurry of people trying the new drug, use of Chantix declined, and costs also declined.
Conventional wisdom had held that the economic benefit of quitting was primarily long-term. We now have studies that show that return on investment happening much more quickly -- within one year after a person uses the benefit. Recent studies on the MassHealth cessation benefit show that when a comprehensive tobacco cessation benefit is made available and publicized, smokers will use it. Further study has revealed the health and cost advantages of providing such a benefit. Use of the tobacco cessation pharmacotherapy benefit was associated with a 46% annual decrease in hospitalizations for acute myocardial infarction (heart attacks) and a 49% annual decrease in hospitalizations for coronary atherosclerosis. Based on these findings, a short-term return on investment analysis conducted by George Washington University found that a net savings of $2.21 for each $1 invested. For each $1 invested, savings were $3.21, yielding a net savings of $2.21. This study will be published in the journal Public Library of Science (PLoS One) (online) in the next month or two. This aligns with DPH’s own internal estimates.
We are taking what we’ve learned from MassHealth to inform our next steps. Part of health care reform was to require everyone in Massachusetts to have health insurance. Currently, nearly everyone in the Commonwealth has complied. This means that if every health plan offered a comprehensive, low-barrier smoking cessation benefit to its members, then nearly every smoker would have access to evidence-based methods to help them quit. We’ve learned from the MassHealth experience that all FDA approved medications should be covered, with low co-pays or no co-pays at all. Likewise, behavioral counseling should be offered with low or no co-pays. Because it takes most smokers several tries before they are able to quit for good, it’s important to make sure that the benefit allows for repeated tries. We have also learned that a barrier to access – even when a benefit is offered – is when people are not sure what smoking cessation benefit they are entitled to. A comprehensive smoking cessation that is consistent across all health plans reduces that confusion. All MassHealth members are entitled to exactly the same benefit. Also, promotion of an available benefit is important, and outreach should be done to providers as well as to consumers. Our goal is that someday soon, ALL smokers in Massachusetts will be able to make an evidence-based quit attempt as often as they need to. When we can ensure that, we will be well on our way to making smoking history.
Study citations: Foulds J. Smoking cessation services show good return on investment. BMJ. 2002;324:608–9. Javitz HS, Swan GE, Zbikowski SM. et al. Return on investment of different combinations of bupropion SR dose and behavioral treatment for smoking cessation in a health care setting: an employer's perspective. Value Health. 2004;7:535–43. [PubMed] Warner KE, Mendez D, Smith DG. The financial implications of coverage of smoking cessation treatment by managed care organizations. Inquiry. 2004;41:57–69 Halpern MT, Dirani R, Schmier JK. Impacts of a smoking cessation benefit Warner KE, Smith RJ, Smith DG. et al. Health and economic implications of a work-site smoking-cessation program: a simulation analysis. J Occup Environ Med. 1996;38:981–92. [PubMed] 401. Halpern MT, Khan ZM, Young TL, Battista C. Economic model of sustained-release bupropion hydrochloride in health plan and work site smoking-cessation programs. Am J Health Syst Pharm. 2000;57:1421–9. [PubMed] 402. Halpern MT, Shikiar R, Rentz AM. et al. Impact of smoking status on workplace absenteeism and productivity. Tob Control. 2001;10:233–8. Tobacco dependence treatment has been referred to as the “gold standard” of health care cost effectiveness.
Tobacco Cessation and Worksite Wellness
Tobacco Cessation and Worksite Wellness November 13, 2012Massachusetts Department of Public Health, Tobacco Cessation and Prevention Program
Context• Massachusetts spends $4.3 billion on healthcare costs every year.• 10% of all healthcare costs in the Commonwealth are attributable to smoking.• In Massachusetts, 8,000 people die prematurely every year from smoking- related illnesses.
Other Tobacco Product Use* Among High School Students: Massachusetts, 1999-2009• Other Tobacco Products (OTP) are beginning to surpass cigarette consumption among adolescents in MA Source: Youth Risk Behavior Survey 1993-2009 * Used one or more days during the past 30 days.
Adult Smoking Prevalence Among Subgroups:Massachusetts, 2010 More Likely to Smoke Less Likely to Smoke 30.3% 25.7% 23.1% 22.6% 19.0%14.1% 11.2% 8.7% 7.0%MA Adults MassHealth* <$25K High school Disabled LGBT* Private $75K + College household or less** health household degree** income insurance* income Source: Massachusetts BRFSS, 2010. * Adults, age 18-64 ** Adults, age 25+
Adult Smoking Prevalence By Race/Ethnicity: Massachusetts, 2008-201020% 18% 15% 15%0% White Black Hispanic Source: Behavioral Risk Factor Surveillance System
Why address tobacco use as an employer?• At least $96 billion per year in direct medical costs in US 1• Businesses pay an average of $2,189 in workers‘ compensation costs for smokers, compared with $176 for nonsmokers2• An estimated $96.8 billion per year in lost productivity due to sickness and premature death in US3• Cost analyses have shown that tobacco cessation benefits, from an employers perspective, are cost-saving.4,5 1, 3 CDC, MMWR , September 30, 2011/60(38);1305-1309 2, 4 National Business Group on Health, November 2011 5 US DHHS, Treating Tobacco Use and Dependence- 2008 Update
Comprehensive Approach• Tobacco Free Policies• Benefits/Insurance Coverage• Workplace programs that include evidence- based treatment options
Approach 1: Worksite Policies• MA state law since 2004 – Review of basic requirements of SFWL – Employers have the discretion to implement additional or stricter policies.• Common additions: – Smoke-free outdoor spaces/campuses – Buffer zones – Tobacco-Free campus (smokeless, alternative products)
Statistics on Quitting Post SFWL• A Cochrane review found evidence that community interventions using "multiple channels to provide reinforcement, support and norms for not smoking" had an effect on smoking cessation outcomes among adults, including: • Policies making workplaces1 and public places smoke-free • Estimated that "comprehensive clean indoor laws" can increase smoking cessation rates by 12%–38%2 1. Lee CW, Kahende J (2007). "Factors associated with successful smoking cessation in the United States, 2000". Am J Public Health 97 (8): 1503–9. doi:10.2105/AJPH.2005.083527 2. Lemmens V, Oenema A, Knut IK, Brug J (2008). "Effectiveness of smoking cessation interventions among adults: a systematic review of reviews". Eur J Cancer Prev 17 (6): 535–44. doi:10.1097/CEJ.0b013e3282f75e48
Approach 2: Employee Benefits• PPACA Law – Beginning in 2014, all new health plans will be required to offer smoking cessation benefits (both medications and counseling) to members free of co-pays.• MassHealth Benefit (2006)• Commonwealth Care Benefit (2012)
Recommended benefit for smoking cessation• All 7 FDA-approved medications are covered for 2 courses of treatment in a calendar year with a prescription• Brief and intensive counseling are a covered service• Four tobacco cessation counseling sessions of at least 30 minutes for at least two quit attempts per year. This includes proactive telephone counseling, group counseling and individual counseling.• No copayments or coinsurance and not subject to deductibles, annual or life time dollar limits. Federal Employees Health Benefits (FEHB) as of 2011
Promotion and Utilization 10,000 40% of all 75% MassHealth smokers Consumer Awareness 8,000 Total People Using Benefit 75,810Number of Claims 6,000 31% Consumer Awareness 4,000 2,000 MTCP MTCP Promotions Promotions Began Ended 0 Apr-06 Jul-06 Oct-06 Jan-07 Apr-07 Jul-07 Oct-07 Jan-08 Apr-08 Jul-08 Oct-08 Jan-09 Apr-09 Announcement to 20,000 providers 6/06. Announcement to all MassHealth subscribers 6/06. Additional outreach to health centers, hospitals, community agencies, and providers beginning 8/06. Articles placed in over 15 professional and MCO newsletters beginning 9/06. MTCP radio and transit campaign 12/06 – 5/07. MassHealth wellness brochures 7/07. MTCP cessation television campaign 11/07 – 1/08. Consumer awareness surveyed by MTCP in 10/06 and by University of Massachusetts in 1/08.
Declines in Smoking Prevalence Smoking Prevalence in Massachusetts Adults (18 - 64): MassHealth vs. No Insurance Over 33,000Smoking Prevalence (6-Month Annual Rolling 45.0% MassHealth smokers quit 40.0% Average) 35.0% 26% drop in 30.0% smoking prevalence 25.0% 03 04 99 00 01 02 05 06 07 08 20 20 20 20 20 20 19 20 20 20 1/ 1/ 1/ 1/ 1/ 1/ 1/ 1/ 1/ 1/ 7/ 7/ 7/ 7/ 7/ 7/ 7/ 7/ 7/ 7/ MassHealth (Point Estimates) No Insurance (Point Estimates) MassHealth (Model Estimates) No Insurance (Model Estimates) Annual percentage rate (APR) change for smoking prevalence among MassHealth uninsured adults in Massachusetts aged 18-64. Source: Massachusetts Behavioral Risk Factor Surveillance System, 1998 to 2008
Near-term health impact• Study finds health impact within one year – 46% decrease in probability of hospitalization for heart attack – 49% decrease in probability of hospitalization for acute coronary heart disease – Controlled for demographics, prior health risks, seasonality, statewide influenza rates, and the implementation date of the Massachusetts Smoke-Free Workplace Law
Actual costs of benefit• Actual costs only exceeded $7 million allocation in one fiscal year• Costs were primarily for medication; counseling had only a 1% utilization rate• FY07 $3.9 million• FY08 $7.023 million• FY09 $5.9 million• Costs decreased as use of Chantix decreasedSource: MassHealth encounter data
Return on Investment• Studies of the MassHealth benefit found that a positive return on investment happens within one year.• A study by George Washington University shows a $2.21 net gain for every $1.00 spent on the MassHealth smoking cessation benefit.
Building on the MassHealth experience• Coverage for all FDA-approved medications• Coverage for behavioral counseling• Low co-pays• Allow for repeated quit attempts• Consistency of benefit across plans• Promotion of available benefit
Supporting tobacco treatment in workplace• Develop clear and concise communications• Frame communication as goal of better health for employees, not cost saving• Create a "brand" around the cessation program• Use a variety of communication methods such as: – Employers intranet, Home mailings, Mass e-mails, Posters, Employee newsletters• Recruit employees to assist with support and encouragement for employees trying to quit• Be patient — recognize that this kind of culture change can take time http://www.businessgrouphealth.org/tobacco/cases tudies/index.cfm
Massachusetts Department of Public Health, Tobacco Cessation and Prevention Program
• At least $96 billion per year in direct medical costs in US1• Businesses pay an average of $2,189 in workers‘ compensation costs for smokers, compared with $176 for nonsmokers2• An estimated $96.8 billion per year in lost productivity due to sickness and premature death in US3• Cost analyses have shown that tobacco cessation benefits, from an employers perspective, are cost-saving.4,5 1, 3 CDC, MMWR , September 30, 2011/60(38);1305-1309 2, 4 National Business Group on Health, November 2011 5 US DHHS, Treating Tobacco Use and Dependence- 2008 Update