MaineCare Tobacco Treatment Quality Matrix, 2010


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MaineCare Tobacco Treatment Quality Matrix, 2010

  1. 1. Purpose: Recommended quality improvements to MaineCare tobacco cessation coverage for inclusion in a risk-based managedcare contract for specific MaineCare populations and services.Quick Facts and Background Information:  41.4%i of Maine’s Medicaid/MaineCare recipients smoke. This is more than twice the rate of smoking of Maine’s adult population (17.2%ii), and well above the national average.iii o 76%of MaineCare smokers desire to quit smoking. iv  10.58% of Maine’s Medicaid/MaineCare expenditures, or a total of $216 million, are attributed to tobacco use.v  Best Practice Guidelines o In 2007, a legislative directive (Resolve 2007, c. 34) required the Department of Health and Human Services to “undertake a study of best practice treatment and clinical practice guidelines for tobacco cessation treatment” and to “use the most recent available clinical practice guidelines of the US Department of Health and Human Services Public Health Services” to design a model for both public and private insurance coverage of tobacco cessation treatment. Below is one result of study: an outline of a model tobacco dependence treatment program—  Screening, identification and intervention for tobacco use by every practice with referral as necessary for further counseling.  Evidence based pharmacotherapy is readily available to all.  Pharmacotherapy and counseling are not linked in a payment scheme; one can be reimbursed without the other.  Cost sharing and deductible are minimal; the duration of treatment reimbursed reflects successful quit patterns.  Benefits are targeted to those most in need of assistance with quitting such as pregnant smokers and those with behavioral health problems, such as depression.  Providers are given adequate reimbursement for counseling.  Education is conducted about benefits offered and evaluation of treatment provided is conducted on a regular basis.  Impact of Health Care Reform o As of October 2010, all Medicaid programs will be required to cover a comprehensive treatment benefit for pregnant women on Medicaid. o Tobacco treatment medications have been removed from the list of excludable medications.Ako 10/10
  2. 2. o States that cover all preventative services given a grade of ‘A’ or ‘B’ by the US Preventative Services Task force (including tobacco treatment) with no cost-sharing will begin receiving a one percentage point increase in FMAP for those services starting in 2014. Item Description Timeline Outcomes Existing Benefit  Implement mandated  Tobacco screening agreement with providers  90% of providers will be coverage provided to identify, document, addressing tobacco use when provided in a  All new and renewing assess and address with Medicaid patients physician’s office. contractors will be tobacco use with all and will be reporting to Screenings required to adhere to patients at every visit. MaineCare screening this procedure by July  Offer reimbursements to data associated with 2013. offices that submit reports tobacco use among their of compliance with this Medicaid patients. mandated item.  Continued coverage of all  NRT gum and patch  Pharmacotherapy  50% of MaineCare FDA approved limited to up to 3 barriers, including recipients who smoke pharmacotherapy months (each) prior authorization and express a desire to (prescription and OTC). duration per year. requirements and quit will utilize at least  Eliminate copays for any Maybe used in duration limits will be one form of and all FDA approved combination with removed from pharmacotherapy in their tobacco treatment Bupropion. Access to MaineCare benefits by attempt to quit tobacco pharmacotherapy, or  NRT nasal spay Pharmacotherapy July 2012. by July 2013. provide copay voucher covered with prior  Copays and cost  Of the 50% who attempt program for individuals authorization, if sharing requirements to quit using who cannot afford their gum and patch tried for tobacco treatment pharmacotherapy, 20% prescriptions. and failed or if medications will be will successfully have quit  Remove prior presence of a eliminated by July by July 2014. authorization requirement condition that 2012. for NRT nasal spray and prevents usage ofAko 10/10
  3. 3. inhaler. preferred drug or  Eliminate requirements for interaction with one treatment in order to another drug and utilize another (i.e. require preferred drug patient use patch before exist. use of inhaler).  NRT inhaler is  Remove single-time use covered with prior limit on use of Varenicline authorization, if (Chantix). gum and patch tried  Eliminate duration and failed or if limitations on presence of a pharmacotherapy and condition that support for multiple quit prevents usage of attempts. preferred drug or interaction with another drug and preferred drug exist.  NRT lozenge is covered for members not able to tolerate patch or gum. May be used in combination or with Bupropion tablets for cessation.  Varenicline is covered with prior authorization with a lifetime limit of one use.  Bupropoin SR 100 and 150mg isAko 10/10
  4. 4. available up to 3 months per year.  MaineCare requires $3 copay for all pharmacotherapy.  All tobacco cessation products require MaineCare members meet with the primary care provider before pharmacotherapy can be administered.  Provide reimbursements  Expanded  50% Medicaid patients  Individual for tobacco treatment and reimbursements for who identify themselves counseling available screening preformed by physicians and as smokers who wish to to members for up certified tobacco tobacco treatment quit will be referred to to 3 treatment specialists specialists who the Maine Tobacco sessions/appointme working under qualified provide counseling HelpLine. nts per year. provider. shall be implemented  50% of Medicaid patients  Individual  Implement fax services by July 2012. who identify themselves counseling is only a (and EMR) for providers  All contracted as smokers through the reimbursable Counseling Services and referring patients to the practices will begin initial physician screening measure on the Clinical Reimbursements Maine Tobacco HelpLine. utilizing the new will receive intermediate inventive payment  Continue to provide counseling codes for counseling (3-10 for private reimbursement for physicians and in- minutes). physicians; does not intensive (>10 minute) office tobacco  30% of Medicaid patients cover TTS-C. tobacco treatment treatment specialists who identify themselves  Group counseling is counseling conducted by by July 2013. as smokers through the not covered under physician, and add  Data related to initial physician screening MaineCare. reimbursement for utilization of quit will receive intensive certified tobacco resources will be counseling (>10 minutes).Ako 10/10
  5. 5. treatment specialists. obtained by  5% of Medicaid patients  Provide reimbursements MaineCare and who identify themselves to physicians and certified reported out by as smokers with a desire tobacco treatment December 2014. to quit through the initial specialists for providing physician screening will group therapy sessions to participate in group Medicaid patients. tobacco treatment counseling.  30% of Medicaid patients who identify themselves as smokers through the initial physician screening will utilize telephone counseling, such as that provided by the Maine Tobacco HelpLine.Communication plan of MCOs shall include:  Promotions directly related to the MaineCare tobacco treatment benefit o Paid media, such as television ads, radio ads, web banner and other applicable means to reaching target population o Consumer materials crafted for low-literacy population. o Provider education materials to increase awareness and utilization of benefit and referral.  Education should target both the primary care provider and practice management.i BRFSS, 2008.Ako 10/10
  6. 6. ii BRFSS, 2009.iii The Medicaid population (18-65) smokes at a rate of 32.6%. National Health Interview Survey, 2007.iv BRFSS, 2008.v Campaign for Tobacco-Free Kids, 2010.Ako 10/10