Reimbursement for Smoking Cessation Therapy a Healthcare Practitioner’S Guide

Reimbursement for Smoking Cessation Therapy A Healthcare Practitioner’s Guide

PACT gratefully acknowledges the contributions of the following individuals who have graciously shared their time and expertise for the creation of this publication.

PACT Members Serving on the Ad Hoc Committee for Reimbursement for Smoking Cessation Therapy: A Healthcare Practitioner’s Guide

Dianne Barker, MHS Nancy A. Rigotti, MD Principal, Barker Bi-Coastal Health Consultants Associate Professor of Medicine and Preventive Medicine Calabasas, CA Harvard Medical School Director, Tobacco Research & Treatment Center Charles J. Bentz, MD Massachusetts General Hospital Boston, MA Medical Director, Tobacco Cessation and Prevention Providence Health System: Oregon Portland, OR Susan Swartz,MD Medical Director, Center for Tobacco Independence Wendy Bjornson, MPH Maine Medical Center Portland, ME Director of Tobacco Cessation Projects Tobacco-Free Coalition of Oregon Portland, OR

Anne Joseph, MD, MPH Associate Professor of Medicine University of Minnesota Medical School Minneapolis, MN

Other Contributors

Abby C. Rosenthal, MPH Susan J. Curry, PhD Office on Smoking and Health Professor, Health Policy and Administration Centers for Disease Control and Prevention Director, Health Research and Policy Centers Atlanta, GA University of Illinois at Chicago Chicago, IL Matthew P. Bars, MS Director, Smoking Consultation Service Catherine O. Maule Fort Lee, NJ Manager, Canadian Tobacco Control Research Initiative Toronto, Ontario, Canada

About PACT

Reimbursement for Smoking Cessation Therapy: A Healthcare Practitioner’s Guide was developed by PACT (Professional Assisted Cessation Therapy), whose members collaborate in the creation and dissemination of educational materials with the aim of motivating healthcare professionals in all disciplinary areas to promote smoking cessation and empower patients to quit. This guide addresses one of PACT’s critical long-term objectives, which is to make tobacco counseling and treatment fully reimbursable. PACT is supported by an unrestricted educational grant from GlaxoSmithKline Consumer Healthcare, and is administered by Amicia Inc., Hackensack, NJ 07601. 201-343-6999.

1 PACT Steering Committee

Linda A. Bailey, JD, MHS Anne Joseph, MD, MPH Director, Center for Tobacco Cessation Associate Professor of Medicine Washington, DC University of Minnesota Medical School Minneapolis, MN William C. Bailey, MD Professor of Medicine Myra L. Muramoto, MD, MPH Director, Lung Health Center Assistant Professor Eminent Scholar Chair in Pulmonary Diseases Family and Community Medicine, College of Medicine University of Alabama at Birmingham Epidemiology and Biostatistics, College of Public Health Birmingham, AL University of Arizona Health Sciences Center Tucson, AZ Wendy Bjornson, MPH Director of Tobacco Cessation Projects Judith K. Ockene, PhD, MEd Tobacco-Free Coalition of Oregon Professor of Medicine Portland, OR Director, Division of Preventive & Behavioral Medicine University of Massachusetts Medical School Worcester, MA Thomas J. Glynn, PhD Director, Cancer Science and Trends American Cancer Society Theodore V. Parran, Jr., MD Washington, DC Associate Clinical Professor of Medicine and Family Medicine Case Western Reserve University Medical School Cleveland, OH Dorothy K. Hatsukami, PhD Professor of Psychiatry Director, Tobacco Use Research Center Nancy A. Rigotti, MD University of Minnesota Associate Professor of Medicine and Preventive Medicine Minneapolis, MN Harvard Medical School Director, Tobacco Research & Treatment Center Massachusetts General Hospital Boston, MA

For more information about PACT, visit the PACT Web site at www.endsmoking.org or contact Amicia Inc., 433 Hackensack Avenue, 4th floor, Hackensack, NJ 07601; 201-343-6999.

2 Reimbursement for Smoking Cessation Therapy — A Healthcare Practitioner’s Guide

CONTENTS

Introduction and Preview 5 Introduction 5 The Status of Smoking Cessation Treatment Reimbursement in the United States 6

The Lexicon of Smoking Cessation Treatment and Health Benefit Coverage Options 7 Treatment Options and the Role of Primary Providers 8 Available Resources 11 Health Insurance Reimbursement and Other Financial Incentive Options 12

Who Is Doing What: Public and Private Sector Initiatives 13 Medicaid Coverage 14 State-Mandated Coverage 15 Employers’- and Employer -Purchasing Coalitions 16 Managed Care Organizations 17 Medicare 20 Tobacco Settlement Initiatives 21 Pharmaceutical Company Programs 22

How to Obtain Reimbursement 23 How to Code for Smoking Cessation Reimbursement 23 Learning What Smoking Cessation Treatment Is Covered: The Proactive Office Manager 26

Providers as Change Agents for Improved Reimbursement 27

Proactive Strategies for Improved Reimbursement 28

3 Appendices 29 A. Resources for Healthcare Providers and Policymakers 29 B. Resources for Consumers 31 C. Coding Information From Clinical Practice Guidelines 33 D. Smoking Cessation Coverage Worksheet 37 E. Clinical Practice Guidelines: Strategies 5 and 6 38 F. How to Derive the Cost Benefit Analysis for a Tobacco Control Initiative 39 G. Costing Out a Tobacco Control Initiative 40 H. Cost of Smoking Cessation Interventions 42 I. Sample Tobacco Control Benefit Language 42 J. State Medicaid Program Coverage of Tobacco-Dependence Treatments by Area, Type of Coverage, and Year Coverage Began—United States, 1994–2001

4 INTRODUCTION AND PREVIEW

Introduction

Reimbursement for Smoking Cessation Therapy: A Healthcare Practitioner’s Guide provides information to healthcare providers and their administrative staffs on how to obtain reimbursement for smoking cessation treatment and counseling. It contains advice for providers who wish to maximize benefits for smoking cessation, find their way around coverage deficiencies, and advocate effectively for adequate coverage.

The guide focuses on reimbursement, and is neither a review of the efficacy of various treatment types nor a compendium of all the ways to integrate smoking cessation treatment into a medical practice.

5 The Status of Smoking Cessation Treatment Reimbursement in the United States

In its June, 2000 report, Clinical Practice Guidelines: Treating Tobacco Use and Dependence, the U.S. Public Health Service urged healthcare insurers and group purchasers to provide PREVIEW benefit coverage for effective counseling and pharmacotherapy. The report also urged

AND insurers and purchasers to pay clinicians for providing tobacco dependence treatment, just as they do for treating other chronic conditions. Advances in pharmacological and behavioral treatment for tobacco dependence, combined with evidence of the economic impact of successful smoking cessation treatment, offer more hope than ever that we will continue to reduce our nation’s greatest preventable public health problem. New tools such as the INTRODUCTION Internet and telephone quitlines now provide low-cost and barrier-free access to information and counseling, adding to optimism that this health problem can be solved. This optimism is tempered, however, by missed opportunities to involve healthcare providers fully in smoking cessation treatment. Patients look to their healthcare providers for smoking cessation advice, and those attempting to quit cigarette smoking are most successful when their doctors and other healthcare providers support them. Yet, only half of smokers who see a doctor have even been urged to quit. Doctors report time pressures, paperwork, lack of training, and lack of incentives as obstacles to providing counseling. Medical assistants are busy, forget to mention it, and are frustrated by the lack of provider interest. Adequate health insurance coverage, including reimbursement for both patients and providers, increases quit rates and is thus one of the key pieces in an effective, comprehensive smoking cessation strategy. However, this piece has not yet fallen into place. Smoking cessation counseling and pharmacotherapy are not consistently provided as paid services for health insurance subscribers. Only 36 states provide coverage to Medicaid patients for smoking cessation treatment; only 10 of these cover counseling. Medicare does not provide coverage, and a minority of states mandate coverage by private health insurers and managed care organizations (MCOs). While most MCOs cover services for smoking cessation treatment, this often consists of self-help materials, which have been shown to be less effective than counseling and drug therapies. Even when there is adequate coverage, consumers may not know that benefits exist. Providers and MCOs can do more to inform consumers of existing benefits. The smoking cessation reimbursement scenario is changing rapidly, however, and there is a trend toward reimbursing smoking cessation efforts. Growing numbers of states are providing or planning to provide Medicaid coverage, and Medicare has started a pilot program in 7 states to explore the expansion of smoking cessation benefits to the elderly, the group that is hardest hit by the negative health effects of smoking. Health plans, some in public/private partnerships, are developing innovative smoking cessation strategies that include counseling and drug benefits. Tobacco settlement money is providing another alternative for funding improved services and covered benefits. As smoking becomes "the sixth vital sign," and as the majority of healthcare providers advise and help smokers to quit during office visits—and are reimbursed for providing these services—patients and providers are sure to see greater success in smoking cessation efforts. We hope this guide helps in accomplishing these important goals by giving providers a useful roadmap for smoking cessation therapy reimbursement. We welcome your feedback for future editions of this guide.

Thomas J. Glynn, PhD Dorothy K. Hatsukami, PhD PACT Co-Chair PACT Co-Chair

6 THE LEXICON OF SMOKING CESSATION TREATMENT AND HEALTH BENEFIT COVERAGE OPTIONS

Healthcare providers interested in receiving reimbursement for smoking cessation counseling should first acquaint themselves with available options for smoking cessation treatment and health insurance reimbursement. Simply stated, providers cannot expect reimbursement for treating unless they have a solid understanding of the services for which they can seek reimbursement. An understanding of available therapeutic and health benefit coverage options and resources will help providers and their administrative staffs to:

1. Know what questions to ask regarding available coverage and the limits of coverage in order to maximize both their reimbursement and their patients’ current benefits 2. Increase their awareness of referral resources 3. Effectively advocate for enhanced insurance coverage

7 Treatment Options and the Role of Primary Providers

Effective treatment for smoking cessation can consist of over-the-counter (OTC) and prescription pharmacotherapies, as well as counseling/behavioral interventions:

• Pharmacotherapies. First-line drugs include bupropion (Zyban®), nicotine gum, nicotine inhaler, nicotine nasal spray, and nicotine patch. Two second-line therapies are clonidine and nortriptyline. • Counseling/behavioral interventions. These generally consist of problem-solving, social support, and helping "quitters" obtain social support.

Primary providers can help their patients who wish to quit smoking by using both drugs and counseling, though a provider’s efforts will vary according to his or her specific practice situation. Counseling/behavioral interventions can be minimal (less than 3 minutes), low intensity (3 to10 minutes), or more intensive (longer than 10 minutes). As counseling intensity (i.e., session length and the number of sessions) increases, so does the quit rate. More intensive interventions, typically provided by smoking cessation specialists, are most effective at 4 or more sessions. TMENT

OPTIONS Smoking cessation specialists are not defined by their professional affiliation nor by the field TREA in which they are trained. Rather, the specialist views smoking cessation as a critical

TION professional role, has the requisite smoking cessation skills, and is often affiliated with 1

COVERAGE programs offering intensive cessation interventions or services. Many different types of CESSA providers—physicians, nurses, dentists, hygienists, psychologists, pharmacists, and others— are effective in helping patients to quit. Involving multiple types of providers in delivering BENEFIT

SMOKING antismoking messages appears to enhance cessation rates, according to newly updated TH

OF Clinical Practice Guidelines published by the U.S. Public Health Service (developed by the HEAL Agency for Healthcare Research and Quality [AHRQ]).2 AND LEXICON Self-help, as opposed to help that is provider-assisted, is also an option, though a less effective one on its own. Table 1 contains a summary of the types/variables of smoking cessation counseling.

8 Reimbursement for Smoking Cessation Therapy — A Healthcare Practitioner’s Guide

Table 1. Types of Smoking Cessation Counseling Services 2

Service or Service Variable Options – From Least to Most Service Provided

Screening for tobacco use • No screening provided and no screening system in place • Sporadic (i.e., individual providers may screen, but no formal system in place) • Screening system in place and screening occurs

Advice to quit • No advice to quit • Sporadic (i.e., individual providers may advise, but no formal system in place) • Provider advises quitting

Intensity of person-to-person • No intervention counseling by provider • Minimal intervention (sessions of <3 minutes) LEXICON • Low intensity (sessions of >3 but <10 minutes) AND HEAL

• Higher intensity (sessions of >10 minutes; multiple sessions) OF TH SMOKING BENEFIT Type of provider contact • No clinician/intervention

• Self-help materials only CESSA COVERAGE

• Non-physician healthcare clinician TION

• Physician TREA OPTIONS

Counseling/psychosocial • No contact TMENT intervention formats • Self-help/self-administered (e.g., pamphlet, audiotape, videotape, mailing, computer program, Internet/intranet, automated telephone line) • Individual counseling (face-to-face, proactive quitline/telephone counseling, Internet/intranet counseling) • Group counseling

Self-help interventions • Individual (e.g., books, computer programs) • Group support (in person, online)

9 The Clinical Practice Guidelines suggest that all healthcare providers give brief interventions at every visit, minimally to determine whether each patient they encounter smokes, and to provide encouragement, information, and resources necessary for quitting for those who do smoke. This is summarized as the Five A’s (Table 2).

Table 2. The Five A’s 2

Ask about tobacco use Identify and document tobacco use status for every patient at every visit

Advise to quit In a clear, strong, and personalized manner, urge every tobacco user to quit

Assess willingness Determine if the tobacco user is willing to make a quit attempt to make a quit attempt at this time

Assist in quit attempt For the patient willing to make a quit attempt, use counseling and pharmacotherapy to help him or her quit

TMENT Arrange follow-up Schedule follow-up contact, preferably within the first week OPTIONS TREA after the quit date TION COVERAGE

CESSA Consistently asking about and charting tobacco use allows providers to ensure that smoking status (perhaps determined by history or physical signs) becomes "the sixth vital sign." When

BENEFIT advising to quit, providers can give personal motivational information based on the patient’s SMOKING TH medical feedback tests,3 in order to capitalize on a "teachable moment." Sources include: OF HEAL • Smoking history and symptomatology (cough, wheeze, dyspnea, hemoptysis); AND LEXICON • Specialized assessments/medical feedback: pulmonary function testing (viewed increasingly as "the sixth vital sign"), arterial blood gases, quantitative pulmonary sputum cytology, in-office nicotine metabolite assays.

10 Reimbursement for Smoking Cessation Therapy — A Healthcare Practitioner’s Guide

The Pacific Business Group on Health (PBGH) breaks this process into more specific steps, recommending that doctors help patients quit by:

• Asking patients at every visit whether they smoke • Asking how much they want to quit • Motivating reluctant patients to try to quit • Helping motivated smokers set a quit date • Prescribing pharmacotherapies, such as nicotine gum and nicotine patch • Helping patients resolve problems that result from smoking • Counseling patients, which increases their chances of success • Encouraging relapsed smokers to try to quit again • Letting patients know about smoking cessation programs that may be offered by health plans, community organizations, or Web sites (See Appendices A and B to find resources for both providers and patients) LEXICON AND

AvAvailableailable ResourResourcesces HEAL OF TH SMOKING BENEFIT While some healthcare providers develop smoking cessation expertise and provide intensive

counseling/behavioral interventions in their practices, most depend upon community and CESSA other referral resources for which patients receive financial coverage to varying degrees. COVERAGE These services generally include self-help materials, telephone counseling (i.e., quitlines), TION

group or individual counseling, or some combination of these, which is usually more TREA effective. The Internet is fast becoming a source for information, individual counseling, and OPTIONS group support. The growth in telephone quitlines and Internet counseling is rapidly TMENT increasing access to low-cost smoking cessation services, providing an incentive to providers and patients to actively engage in smoking cessation. (See Appendices A and B)

Community-based classes and social support may be available through managed care plans, growing numbers of which now reimburse for classes. Staff model health maintenance organizations are most likely to offer classes, though other plans increasingly provide them as well. A variety of other community organizations such as the American Cancer Society and the American Lung Association also provide classes and counseling. Materials can also be obtained from the National Cancer Institute and AHRQ. In addition, some pharmaceutical companies offer counseling, targeted information, and follow-up monitoring plus other support.

11 Health Insurance Reimbursement and Other Financial Incentive Options

Healthcare providers who wish to obtain reimbursement for smoking cessation counseling in their practices have several options. These range from no reimbursement for tobacco dependency as a discrete, chronic condition to full reimbursement (and associated coding) for tobacco dependency as a chronic condition on a par with other chronic conditions (Table 3).

Table 3. The Smoking Cessation Reimbursement Spectrum

Part of job description Counseling is part of the basic job requirements Providers do not receive reimbursement for tobacco dependency as a discrete condition

Reimbursement for related conditions Providers counsel patients on quitting smoking within the content of an office visit for

TMENT related conditions (e.g., chronic obstructive pulmonary disease) OPTIONS TREA Office visit not coded separately for smoking

TION Represents a more proactive stance by physicians working within benefit constraints COVERAGE

CESSA Reimbursement for smoking cessation counseling

BENEFIT Providers code for and receive reimbursement for smoking cessation/tobacco SMOKING TH dependency counseling, even in the absence of a related condition; sources include: OF

HEAL - Health plans (e.g., Blue Cross Blue Shield of Minnesota, Group Health Cooperative

AND of Puget Sound) LEXICON - Tobacco settlement funding grants

Growing numbers of health plans award financial incentives or bonuses to providers who give their patients smoking cessation counseling. While providers do not receive specific reimbursement for smoking cessation counseling, they may receive a quality bonus for providing such counseling.4 However, there is currently no consensus as to whether primary providers should be reimbursed for providing low-intensity counseling or whether they should receive incentives for so doing.

Depending upon their health insurance coverage, patients may or may not be reimbursed for prescription or OTC drugs. While this does not pertain to provider reimbursement, it does influence providers’ willingness to counsel smokers to quit. Providers are more willing to view counseling as part of their jobs if the appropriate drug therapies are available to their patients.

12 WHO IS DOING WHAT: PUBLIC AND PRIVATE SECTOR INITIATIVES

Many smokers who wish to quit do not have insurance coverage for appropriate drugs and counseling. This problem is diminishing rapidly for growing numbers of Americans in a variety of public and private sector health insurance plans. This section contains a synopsis of these plans and other treatment funding sources, including: • Medicaid coverage • State-mandated coverage • Employers and employer purchasing coalitions • Managed care organizations • Medicare • Tobacco settlement initiatives • Pharmaceutical company programs

It is not possible to cover all initiatives within the context of this document. Appendices A and B list online resources. The hard copy version of this guide will be updated periodically, and the online version will be updated at frequent intervals.

13 Medicaid Coverage

Approximately 36% (11.5 million) of the 32 million persons covered by Federal/State Medicaid programs in 2000 were smokers.5 While state Medicaid programs are not required to provide coverage for smoking cessation treatment, they are required to provide such therapy to Medicaid recipients under the age of 21, as well as to provide services for the health and well-being of pregnant women and their fetuses. Further, they are required to screen for tobacco use and provide counseling for smoking cessation in the case of children and adolescents.

In 1998, researchers associated with and funded by the Robert Wood Johnson Foundation conducted a survey that assessed the extent of Medicaid tobacco-cessation coverage.6 The survey was mailed to 51 Medicaid program directors by the staff of the Health Policy Tracking Service of the National Conference of State Legislatures. Results showed 24 states and the District of Columbia covered some type of tobacco-dependence treatments in 1998 (Table 4). Moreover, fully half of all Medicaid recipients at that time were not covered for any smoking cessation interventions.

A subsequent survey conducted by the Center for Health and Public Policy Studies at University of California at Berkeley during 1999-2000 showed that by 2000, 31 states covered some pharmacotherapy (a 35% increase from 1998) and 13 states offered special cessation programs for pregnant women.5

When the states and District of Columbia were again surveyed in 2001,7 this upward trend had leveled off: only 36 states provided some counseling or medication, prompting researchers to conclude that "if the 2010 National Health Objective is to be achieved, Medicaid coverage for treatment of tobacco cessation should be increased dramatically." (See Table 4 and Appendix J.)

Table 4. States’ * Medicaid Smoking Cessation Coverage Results of Two Surveys: 1998 6 and 1994–2001 7

1998 2001 Coverage Number % Number %

Some type of cessation services 25 49 36 71 Selected pharmacotherapies Bupropion/Zyban® 23 45 35 69 Nicotine patch 22 43 25 49 TIVES Gum 20 39 24 47 PUBLIC

INITIA Nasal spray 17 33 26 51 T: All FDA-approved pharmacotherapy 10 20 19† 37 WHA Counseling services 10 20 10† 20 SECTOR

TE Comprehensive (all forms of NRT, bupropion, group & DOING A †

IS individual counseling) 6 12 2 4 PRIV WHO AND * Including the District of Columbia. † Includes Utah, which provides this service for pregnant women only.

14 Reimbursement for Smoking Cessation Therapy — A Healthcare Practitioner’s Guide

In January 2001, the Health Care Financing Administration (now, the Center for Medicare and Medicaid Service [CMS]) sent a letter to state Medicaid directors urging them to heed the evidence about effective smoking cessation documented in the Public Health Service Clinical Practice Guideline, Treating Tobacco Use and Dependence (June 27, 2000).8 They strongly recommended that Medicaid programs provide coverage for smoking cessation drug therapy and counseling.

State-Mandated Coverage

The 1998 Survey of State Policy on Nicotine Addiction Treatment also assessed the extent to which states mandated private health insurers or managed care providers to provide a smoking cessation benefit. Only 4 states—California, Colorado, New Jersey and North Dakota—reported any mandate for health insurers to cover smoking cessation treatment (Table 5).

Table 5. Smoking Cessation Treatment Mandates for Health Insurers

California • Group disability policies covering hospital, medical, or surgical expenses must offer substance abuse treatment, including nicotine use; policies allowed to require separate deductibles, co-payments, and overall cost limitations for this benefit • California residents may also apply for health insurance coverage for perinatal and infant care through the Access for Infants and Mothers Program, whose primary care services include health education for tobacco use

Colorado • All members of large health plans are entitled to one smoking cessation benefit • Basic plan pays for one smoking cessation program under a physician’s supervision or one authorized by the plan, limited to one treatment per lifetime and a $150 patient payment limit

New Jersey • Small groups are required to cover smoking cessation treatment under a preventive healthcare benefit

• $300 per member per year maximum AND AND WHO WHO

• If the annual preventive benefit is exhausted, annual medical check-ups PRIV

are not reimbursed IS A DOING DOING TE TE

North Dakota • Guaranteed issue statute—small and large employers are required to include SECTOR smoking cessation as a benefit WHA T: INITIA

• $150 per member per lifetime PUBLIC TIVES • Must be supervised by a physician • If certified by physician, $150 of cost will be reimbursed to member

15 Employers’-and Employer-PurcPurchasing Coalitions

The majority of employers are not required to provide health insurance benefits for smoking cessation drugs or therapy. As noted, only 4 states mandate private health insurers or MCOs to provide a smoking cessation benefit (Table 5) and, even in those states, employers who are self-insured are not required to provide coverage. In general, employers advocate against coverage mandates that they believe do not meet the particular health and business needs of their organizations.

That being said, employers—whose health benefits currently cover 62.6% of Americans9 and who have a stake in keeping employees healthy and on the job—have been a driving force in institutionalizing smoking cessation counseling into the national healthcare delivery system by:

• Selecting health plans based on quality indices such as National Committee on Quality Assurance (NCQA) accreditation and Health Employer Data Information Set 3.0 (HEDIS 3.0), a quality scorecard developed by NCQA (both NCQA accreditation and HEDIS 3.0 address smoking cessation programs and benefits in their rating systems; employees in many of these organizations [e.g., GTE Corporation] receive higher benefit contributions from their employers when they elect health plans with higher quality scores); • Instituting provisions in benefit plans through "insurance risk rating" that reward nonsmokers and providing flexible benefit credits that smokers can use for smoking cessation classes; • Enacting other internal initiatives that seek to reduce the incidence and negative cost impact of smoking, including: health promotion/wellness initiatives and health risk appraisals; on-site medical departments/primary care clinics; integrated disability management programs; smoking policies; and employee assistance and managed behavioral healthcare programs.

Providers have little opportunity to interact with employers and to advocate directly for smoking cessation treatment (unless they form their own MCOs). Nonetheless, they can still benefit from understanding the role of employers and the resources employers provide to help employees and their families (and sometimes retirees) to quit smoking. It is very important to involve group purchasers in the discussion of smoking cessation health benefit coverage. TIVES A 1988 unpublished study by the Maine Medical Assessment Foundation on employer PUBLIC

INITIA T: tobacco policy surveyed the 30 members of the Maine Health Management Coalition 10

WHA (MHMC) found: SECTOR TE DOING

A • All MHMC employers have a work site smoking policy IS

PRIV • The majority of employers offer designated outdoor smoking areas; only 10% have an

WHO entirely smoke-free work site AND • 10% require smokers to pay higher insurance premiums • Among 30 employers and a total of 44 insurance "products" - 33% provide cessation counseling at the work site - 47% provide counseling through health plans

16 Reimbursement for Smoking Cessation Therapy — A Healthcare Practitioner’s Guide

- Only 18% have full access to plan-level counseling resources - Of managed care products, 68% offer counseling compared to 40% of indemnity products - 77% of insurance products provide some coverage for the nicotine patch and bupropion (82% for managed care and 70% for indemnity plans) - Fully covered access to antismoking medications occurs in 50% of employer plans

Employer purchasing coalitions have also been drivers of growth in quality-based "value" purchasing and quality scorecards, which usually include counseling smokers on quitting. These organizations magnify the purchasing power of employers in their communities and play an important role in extending benefits coverage for smoking cessation. In a 2000 National Business Coalition on Health survey, approximately 60% of the responding coalitions reported that they use the HEDIS scorecard (up from 50% in 1998)11. Several purchasing coalitions, including the Pacific Business Group on Health in the Greater San Francisco area, the Buyers Healthcare Action Group in Minneapolis, and the Gateway Purchasers for Health in St. Louis have provided smoking cessation benefits coverage or incentives. Some have required participating HMOs to rebate a percentage of premiums if performance for each of 5 clinical measures—including smoking cessation—is unsatisfactory.

Managed Care Organizations

MCOs have a history of covering preventive services and thus have the opportunity to effect healthy lifestyle changes in their member populations. Their influence is growing, as 90% of insured Americans now receive their health benefits through some type of MCO.12 According to the Kaiser Family Foundation and Health Research and Educational Trust, fully 96% of those covered by employer health insurance were MCOs in 2002.13 Since MCOs comprise the nation’s major healthcare delivery mechanism, healthcare providers who wish to ensure coverage for their patients and reimbursement for themselves should educate themselves regarding MCOs’ smoking cessation reimbursement policies.

While few states mandate that MCOs cover smoking cessation services, growing numbers of health insurers and MCOs are offering some level of treatment for smoking cessation. AND AND

The Robert Wood Johnson Foundation, in partnership with the AHRQ, the Centers for WHO Disease Control and Prevention, and the National Cancer Institute, conducted surveys of all PRIV IS IS A DOING DOING

managed healthcare plans each year from 1997 to 2000 as part of their "Addressing Tobacco TE 14 in Managed Care" initiative. These surveys had the overall objective of assessing the SECTOR degree to which MCOs addressed smoking cessation through application and awareness of WHA T: the Clinical Practice Guidelines, and whether they had integrated smoking cessation into INITIA their routine care policies, their governmental advocacy efforts, and their attempts to PUBLIC overcome barriers to addressing smoking cessation. Tables 6 through 8 summarize results TIVES from the 2000 survey.

17 WHO IS DOING WHAT: PUBLIC

18 AND PRIVATE SECTOR INITIATIVES Re Phar Benefit * Self Groups/classes F T Zyban NR NR NR Benefit Ensure Ha Arrange Encourage Include Strongly A Document Requir Beha T T T elephone ace sk A million able able able ve f w at T T T er tot - ne aiting macother help -to- (O (prescription) only

home vior literat al smok w ement TC) people. support of smoking F T Groups/classes Counseling Self-help Allo Some Zyban W Zyban NR NR NR NR Some

f 7. 8. 6. advise f elephone ollo ace-to-f al patients ace materials with 85 ellbutrin rooms counseling T T T T smoking ure patients ers and w int out w (O (prescription) only (prescription Of Co A A A counseling Requir ® self-ref -up t t and erv program ap about to TC) ype ype ddr of ddr ddr all st in fe ace verage st materials y and 1 af with intensiv about ention ® with day 36 patients r W counseling at f of of ing during who essing essing st essing us counseling ellbutrin are erral health smoking care e at smoking antismoking ing program xam patients as us smoking MCOs trained smok F e + to

ull plans set pregnancy a in of who treatment rooms Pr O vit programs medical T T T tings TC) e cessation Ke obacco Co o al obacco obacco (62.5%) Of cessation tr to to smok viders sign st ying feri y verage maint counsel beha at Antismoking us ng e record when completed to to vioral ain F and quit in pharmacotherap in in ull to quit patients f smok appropriate

the Manag Coverage Manag Manag smoking Assess/Int or inter and risks Smoking e-free v ret ention about urned of ed ed ed

Benefits, (% en smoking y the quit av ) vironment Car Car Car av erv ailable sur ailable ting Cessation e e: e ve ene y, 20 in 20

Compar representing 1 00 00 997 for 1 997 17 54.1 35.7 26.6 3 25.0 25.0

Surv 6.6 Surv 2.8 T .6 vs. obacco 15 Int ison ser ey ey 20 vice erv : : 00 to of MCOs* MCOs* MCOs entions MCOs more Us 14 20 F 23.6 36.8 37 46.6 56.6 69.4 86.2 25.3 44.0 37 26.0 20.0 1 1 59.2 56.6 37 23.6 36.8 37 26.0 20.0 14.9 23.8 24.7 36.5 43.5 68.8 7 81 41 13.8 ull 4.9 3.3 00 4.1 e 2 . .0 than .2 .2 .3 .0 (%) 14 (% * 14 26 ) 14 Reimbursement for Smoking Cessation Therapy — A Healthcare Practitioner’s Guide

A growing number of health plans have assumed proactive roles in developing tobacco treatment systems at the patient level, the practice level, and the health plan/MCO level (Table 9). Humana Inc.—one of the nation's largest providers of health insurance—launched “RxAllowance” in July of 2003, a prescription drug benefit that provides reimbursement for preventive medicines, including smoking cessation therapy. This is the industry's first such prescription drug coverage plan in which drugs are grouped according to their ability to prevent a serious medical episode or the need for further medical care. Smoking cessation therapies fall into the plan's Group D, "drugs that meet cosmetic and other lifestyle needs." Humana pays an allowance to a participating pharmacy for each prescription or refill and the consumer pays the balance, if any.

Table 9. Notable Public and Private Sector Antismoking Initiatives

Managed Care Organization Smoking Cessation Benefits or Provider Incentives

Allina Health Performance expectations/incentives with central tobacco user registry and telephone counseling

Blue Cross and Blue Shield of Minnesota NRT benefits; counseling, chronic disease office visit

Blue Cross Blue Shield of Maine Follows Clinical Practice Guidelines 2 (Appendix E); (South Portland, Maine) covering tobacco control as a chronic disease office visit

Group Health Cooperative of Puget Sound One individual or group program per calendar year; educational materials; one course of NRT per calendar year, provided individual is participating in the Group Health "Free and Clear" program

Health Alliance Plan Counseling by HAP-affiliated primary care physicians, telephone counseling, and smoking control classes; nicotine replacement therapy (prescription and OTC) with a prescription drug rider

HealthPartners (Minnesota) NRT benefits; counseling AND AND

Humana Inc. "RXAllowance" prescription plan for preventive WHO

medicines, including antismoking medications PRIV IS IS A DOING DOING TE TE Network Health Plan (Menasha, Wisconsin) 24-hour health advice line offers members a SECTOR SECTOR multifaceted smoking cessation program; WHA the "Call It Quits" program T: INITIA

PUBLIC Oregon Statewide Tobacco 16 health and 9 dental plans implemented an adapted Cessation Project version of the 1996 AHCPR (now AHRQ), especially TIVES for the Medicaid population; led to the statewide integration of the Oregon Quitline

Tufts Health Plan (Waltham, Massachusetts) Smoking cessation program for pregnant women using telephone counseling

19 WHO IS DOING WHAT: PUBLIC

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Tobacco Settlement Initiatives

Legislatures across the country are deciding how to spend the hundreds of billions of tobacco settlement dollars that will flow into states for the next 25 years. Experts give states mixed reviews as to their stewardship of these resources. According to Show Us the Money: A Report on the States' Allocation of the Tobacco Settlement Dollars published in January 2003 by The Campaign for Tobacco-Free Kids (in association with the American Lung Association, American Cancer Society, American Heart Association, and SmokeLess States National Tobacco Policy Initiative), the states will receive $8.7 billion in tobacco-settlement money in Fiscal Year (FY) 2003.18 Unfortunately, despite collecting more money than ever before between tobacco-settlement and cigarette tax revenues, funding for the same period declined by 11.2% ($86.2 million). The deepest cuts occurred in states that had made great headway in cessation and prevention, including California (with a cut of 34.3%) and Massachusetts (with a 90% cut and complete elimination of a successful program; Table 10).

There were some positive developments in utilization of these funds for FY 2003, as 20 states increased funding for tobacco prevention, while 13 cut funding during this period. Indiana, Maine, Maryland, Minnesota, Mississippi, and New Jersey have become leaders in tobacco prevention and cessation. There was also strong public support in Arizona, Montana, and Oregon for initiatives that restored or increased funding for tobacco prevention and cessation initiatives.

Table 10. Show Us the Money: A Report on the States' Allocation of the Tobacco Settlement Dollars—Key Findings18

Only 4 states—Maine, Maryland, Minnesota, and Mississippi—are funding tobacco prevention and cessation programs at the minimum levels recommended by the CDC. This is down from 5 years ago, with Maryland being added and Arizona and Massachusetts dropping from the list (in FY 2004, Arizona and Montana will fund tobacco prevention programs at the CDC minimum if their elected leaders abide by ballot initiatives approved by voters in November 2002).

Only 19 states (including the 4 above) have committed even 50% of the minimum funding level recommended by the CDC. This is the same number as in 2002.

Sixteen states have committed only modest amounts to tobacco prevention and cessation (25 to 50% of the CDC minimum). AND AND

Twelve states have committed minimal amounts to tobacco prevention and cessation (less WHO than 25% of the CDC minimum). PRIV IS IS A DOING DOING TE TE

Three states—Michigan, Missouri, and Tennessee—and the District of Columbia currently SECTOR

spend none of their tobacco settlement tax revenue on tobacco prevention. This is the same WHA number as in 2002, with Missouri joining the zero list and North Carolina, which now funds T: INITIA

tobacco prevention at $6.2 million a year, leaving the list. PUBLIC TIVES In FY 2003, the states will spend $682.3 million on tobacco prevention and cessation, a cut of 11.2% from FY 2002. This is the first budget year since the 1998 tobacco settlement in which states cumulatively cut such funding.

This $682.3 million amounts to only 3.4% of state revenues from tobacco settlement and tobacco taxes, and only 42.6% of the minimum recommended by the CDC.

At least 18 states and the District of Columbia have sold the rights to, or securitized, all or part of their future tobacco settlement payments to investors for a much smaller up-front payment, or have passed laws authorizing such action. 21 Pharmaceutical Company Programs

Several pharmaceutical companies who manufacture smoking cessation therapies sponsor online antismoking programs to be used in conjunction with their products. Such computer- tailored behavioral treatment modalities have proven quit rates higher than those seen with nicotine replacement therapy alone.19

GlaxoSmithKline offers the "Committed Quitters® Program" (www.committedquitters.com), an 8-to-12 week, personalized antismoking behavioral support plan offered free with the purchase of Nicorette® Starter Kit or a Step 1 or Step 2 box of NicoDerm® CQ®. Enrollees receive a newsletter addressing high-risk situations and social support, coping strategies and other motivational aids. Patients can enroll via the toll-free number found inside either the Nicorette or NicoDerm CQ packaging or at the above Web site. Online enrollees obtain individualized information instantaneously, 24-hours a day, 7 days a week; those who enroll by phone receive support materials in the mail. All continue to receive personal support over the entire course of therapy.

GlaxoSmithKline also offers the Zyban Advantage Plan (ZAP) pack for patients who purchase a 7-week full course of Zyban® (bupropion SR). The ZAP pack contains a quit diary to record daily progress during the treatment, a cassette on best kept secrets on quitting, a counseling booklet, a family guide to help smokers during the quitting process, stress reliever, screen saver, and a poster.

Novartis offers the Habitrol® Support Program (www.habitrol.com), a free, interactive, personalized, 6-step series of antismoking exercises delivered online, to be used in conjunction with the Habitrol transdermal nicotine patch. A toll-free support line staffed by registered nurses (1-888-227-5777) is also available free of charge to Canadian residents only. Novartis also has an antismoking Web site in French and German (www.nicotinell.ch).

Pfizer's Nicotrol® Web site (www.nicotrol.com) offers the Nicotrol® Helping HandTM Program, a free, personalized, online support program that identifies an enrollee's smoking profile and tracks his/her progress towards quitting. TIVES PUBLIC

INITIA T: WHA SECTOR TE DOING A IS PRIV WHO AND

22 HOW TO OBTAIN REIMBURSEMENT

How to Code for Smoking Cessation Reimbursement

Healthcare providers interested in reimbursement for providing smoking cessation counseling must do so within the limitations of a system that does not yet universally reimburse for either brief or intensive interventions. Providers often work within less than ideal coverage. For example, drugs may be covered but counseling may not; patients may have to pay for their own OTC drugs while obtaining counseling from their healthcare providers. Where counseling is a covered benefit, providers can simply code for it using the ICD-9 code for tobacco dependence (305.1). In these cases, providers may deliver low-intensity counseling covering all or part of the "5 A’s" (Ask, Advise, Assess, Assist, Arrange) within the context of office visits for other diseases or conditions (e.g., COPD or cough). They may also offer this counseling as part of medical assessments for related conditions or during routine physical examinations. For example, clinical opportunities to address smoking-related diseases present themselves when healthcare professionals review the results of the following tests with their patients:

• Electrocardiography • Total leukocyte counts • Blood pressure measurements • Hematocrit • Auscultation of heart and lungs • Blood lipid studies • Blood coagulation studies • Serum alpha antiprotease measurements • Pregnancy tests • Carboxyhemoglobin determinations • Biological markers of tobacco exposure, such as carbon monoxide and cotinine; pulmonary function tests; histopathological changes

23 Many smokers have smoking-related diagnoses (e.g., bronchitis) that permit third-party insurance reimbursement through the CPT or ICD-9 codes corresponding to these diagnoses (Tables 11 and 12).3 Table 13 offers suggestions on how to handle various antismoking reimbursement scenarios. (See also the coding section of the Clinical Practice Guidelines—Appendix C.)

Table 11. Medical Procedures Table 12. ICD-9 Codes REIMBURSEMENT and CPT Codes of Smoking- AIN Related to Smoking Related OBT Co-Morbidity 3 Diseases 3 TO

HOW Consultation 99244 Metaplasia, 519.1 tracheobronchial tree Hemoglobin 85018 Carcinoma, in situ, 231.2 Spirometry 94060 bronchus and lung (pre/post with bronchodilators) Reduced vital capacity 794.2

Spirometry 94010 Chronic obstructive 491.2 pulmonary disease (COPD) Respiratory flow 94375 volume loop Emphysema, obstructive 492.8

Aerosol inhalation 94664 Infection, upper airway 465.9

Carbon monoxide 94720 Dyspnea 786.0 diffusion capacity (DLCO) Hypercholesterolemia 272.0 Pulse oximetry 94760 Cough 786.2 Carboxyhemoglobin 94250 Abnormal sputum 786.4 End tidal carbon dioxide 94770 Chest pain 786.50 Chest x-ray (PA & LL) 71020 Asthma 493.00 Electrocardiogram 93000 Chronic airway 496.00 Lipid Profile obstruction Total cholesterol 82465 Diabetes mellitus 250.0 HDL 83718 LDL 83721 Coronary atherosclerosis 414.0 VLDL 83719 Toxic effect of tobacco 989.84

24 Reimbursement for Smoking Cessation Therapy — A Healthcare Practitioner’s Guide

Table 13. Provider’s Reimbursement Troubleshooting Guide

Situation Suggestion/Options HOW

Drugs are covered, but counseling is not • Counsel patient in conjunction with treatment for TO

related conditions OBT

• Refer to low-cost community resources, telephone, AIN

or Internet counseling programs REIMBURSEMENT • In the case of employer plans, find out if an in- house wellness/health promotion program is available or if flexible benefit plans provide credits or dollars that can be used for smoking cessation • Look into online chat groups and pharmaceutical company programs online (e.g., www.quit.com)

Prescription drugs are covered, • Ask the office manager or other staff member but preauthorization is required involved with counseling to learn about the MCO’s specific requirements and develop a positive relationship with those individuals charged with preauthorization at the MCO

Brief counseling is covered, • Learn about low-cost community, telephone, or but intensive counseling Internet counseling programs (multiple sessions >10 minutes in length) • Find out if the patient’s employer provides is not on-site programs • Look into online chat groups and pharmaceutical company programs

Drug benefits are denied and the patient • Look into pharmaceutical company programs for cannot afford to pay for medications low-income patients, as well as services provided by the state

An elderly patient smokes and suffers • See the above advice regarding obtaining from COPD but does not have coverage counseling for smoking cessation treatment since it • Medicare pilot program applies in Alabama, is not covered by Medicare Florida, Missouri, Nebraska, Oklahoma, Ohio, and Wyoming

• Look into pharmaceutical company programs

In addition to understanding and maximizing existing coding systems, proactive providers can institute tracking and coding systems with which to monitor smoking and smoking cessation treatment in their practices. Refer to the section "Providers as Change Agents for Improved Reimbursement" (pages 27-28) for examples of tracking codes.

25 Learning What Smoking Cessation Treatment Is Covered: The Proactive Office Manager

Healthcare providers can take a proactive stance through their office managers or other MCO liaison personnel and thereby equip themselves with cessation treatment coverage levels for drugs and counseling in the health plans in which they participate. This information

REIMBURSEMENT will allow them to: AIN • Confidently communicate choices to their patients; OBT

TO • Help their patients maximize their benefits and thus increase their chances of

HOW successfully quitting; • Receive any allowable reimbursement for smoking cessation counseling; • More effectively advocate for health plan changes that serve their patients’ best interests and also result in provider reimbursement.

This research can also be part of the "tire-kicking" that providers should do when considering joining an MCO. Appendix D contains a worksheet that can be used for this purpose.

If this information is not readily available in the contract or in other materials the provider has received from the health plan, the office manager/MCO liaison can call the MCO’s provider relations department to assess benefits, perhaps faxing or E-mailing the worksheet prior to the conversation. In the case of Medicaid subscribers, office managers can use the worksheet in their conversations with state insurance departments to determine allowable Medicaid coverage levels in their state.

26 PROVIDERS AS CHANGE AGENTS FOR IMPROVED REIMBURSEMENT

There are a number of proactive steps that providers and their staffs can take to advocate for adequate health insurance coverage for smoking cessation treatment.

• In the context of Strategies 4 and 5 of Clinical Practice Guidelines pertaining to provider and patient reimbursement (Appendix E): - Educate oneself about guidelines - Before joining the panel of an MCO, inquire to what extent guidelines are met - Advocate with existing MCO contracts

•Regarding the specific benefits that are covered: - Ask specific questions about coverage and quality bonuses before contracting with an MCO; then use Appendix D to study and track coverage - Advocate for expanded coverage (Appendix I); since smokers often try to quit smoking 4 or more times before being successful, benefits should support several quit attempts to reduce the incidence and costs of smoking

•Learn about the cost benefit associated with providing smoking cessation benefits and share this information with patients’ MCOs; if providers are able to identify a champion within the HMO (perhaps an executive personally affected by a smoking-related tragedy or the Chief Financial Officer), they can provide this person with these financial tools (Appendix F) •Develop or adopt a system (codes, procedures, a line on forms/medical charts) of tracking codes for preventive healthcare measures, including the incidence of smoking and counseling, or encourage health plans to do so: - At the point of encounter, providers can thus easily record whether the patient smokes and what services/advice were provided; otherwise, chart reviews are required to determine the extent to which preventive services have been provided - Such a system will facilitate providers’ acceptance into the provider panel of MCOs with NCQA accreditation and/or HEDIS mechanisms and make a case for specific coverage decisions or for broader MCO coverage - A 2001 pilot study shows the feasibility of such systems, and notes that computerized charting systems are superior to paper-based systems.20 - The Providence Health System in Oregon has developed such a system based on HEDIS 3.0 quality measures and the organization’s internal quality tracking program (Table 15).4

27 PRPROAOACTIVECTIVE SSTRATRATEGIESTEGIES FORFOR IMPROIMPROVEDVED REIMBURSEMENTREIMBURSEMENT

• Educate oneself about health plans’ or MCOs’ concerns regarding coverage of behavioral counseling and formulate possible responses to these concerns (Table 14).21

Table 14. Reasons Insurers Do Not Reimburse for Behavioral Counseling

Concern Response

Concerned that additional benefits The cost-effectiveness of all evaluated smoking will force increase in premiums cessation interventions remains highly attractive; Group Health Cooperative has estimated their comprehensive program costs $0.10 to $0.40 per member per month

Not convinced that getting smokers Studies have shown cost decreases to quit will reduce other healthcare costs after 4 years; employer costs will decrease more rapidly

Unconvinced that getting their insurees Synthesized models show that 50% of program to quit will reduce their plan’s costs costs will be recouped in 6.5 years, even

AGENTS due to turnover of membership accounting for turnover; the vast majority of other MCO services do not result in reduced costs CHANGE REIMBURSEMENT AS

Learn about tobacco settlement initiatives in your state and get involved in advocacy for IMPROVED enhanced treatment resources funded by settlement money. PROVIDERS FOR Encourage health plans to participate in Robert Wood Johnson/American Association of Health Plan's "Addressing Tobacco in Managed Care" programs (awards program, grants, surveys, and annual conference) administered by the National Technical Assistance Office, which also provides day-to-day technical assistance for providers (Appendices A and B).

Adopt a coding system. One reason tobacco cessation is not systematically addressed in healthcare settings is the lack of a framework for measurement.20 The Providence Health System in Oregon has developed such a system, similar to traditional CPT and ICD-9 codes, that facilitates measurement and reimbursement for delivery of preventive health services, including addressing tobacco use (Table 15).4 Table 15. Providence Health System Tobacco Tracking Codes 4

Concern Response

TR001: Smoking TR100: Smoking cessation counseling TR002: Non-smoker/remote quitter (>6 months) TR003: Recent quitter (<6 months)

These codes are documented by the clinician when service is provided, recorded on fee slips, and submitted to MCOs for reimbursement. The system is based on HEDIS 3.0 quality measures and the 1999 Providence Health Plan quality bonus program. A project to refine and implement these codes, funded by the Robert Wood Johnson Foundation, is currently under way.

28 APPENDIX A 29 on to Guide s the center A)

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of comprehensiv comprehensiv comprehensiv comprehensiv comprehensiv a a a a a treat treat treat treat treat aluation aluation aluation aluation aluation re-ev re-ev re-ev re-ev re-ev comprehensiv comprehensiv comprehensiv comprehensiv comprehensiv the f f f f f actor actor actor actor actor the the the the the aluation aluation aluation aluation aluation Initial procedures; procedures; procedures; procedures; procedures; of of of of of and and and and and adult adult late adolescent adult risk risk risk risk risk tobacco tobacco tobacco tobacco tobacco or e e e e e management management management management management f f f f f c and and and and and actor actor actor actor actor hildhood e e e e e e e e e e (age (age (age Pe xamination, xamination, xamination, xamination, xamination, e e e e e xamination, xamination, xamination, xamination, xamination, r management management management management management iodic use use use use use 1 65 40-64 of of of of of (age est est est est est 8-39 tobacco tobacco tobacco tobacco tobacco y (age and and and and and ears ablished ablished ablished ablished ablished Compr 1 y y of of of of of 2-1 ears) ears) and and and and and the the the the the 5-1 and an an an an an 7 and and and and and use use use use use 1 ehensiv y of of of of of ordering ordering ordering ordering ordering individual, individual, individual, individual, individual, ears) patient, patient, patient, patient, patient, older) y counseling/ counseling/ counseling/ counseling/ counseling/ ears) an an an an an and and and and and individual, individual, individual, individual, individual, the the the the the e late adult adult adult of of of of of APPENDIX C 35 ’s

y and ug y. Guide the one the only s hus, dr orders, vices actor actor actor actor the actor actor T 60 f f f f of f f a patients, injur or number to ser and of at

w Reduction or headings. y. and/or during aluation hotherap risk risk risk risk anding risk risk c the y) and sician 15 or ev (ne dependence. y ations. hiatric use receiving ximately ximately ximately ximately ximately ximately v c or the the the the the the psy tobacco f tobacco ph hniques), Practitioner’ management act these conditions, illness F y and the of patient psy or underst therapeutic tec f hotherap codes, therapeutic ke combination appro appro appro appro appro appro c treat treat treat treat and treat treat obser individuals individuals hotherap modifying of y use c whether the ype Risk under patients to to to to to management t to -99404 to counseling the psy (i.e., enting an erbal treatments treatments and medical v vior or hiatric v all (psy hiatric indicated, of and f c as Healthcare Healthcare or c the hniques, with entions

and d/ pre v A aluation y, 99401 those vided of ention ention ention ention ention psy ention tec beha an tobacco psy counseling udies v v v v insight ev v v vice ould — — both using or procedure); procedure); procedure); procedure); procedure); procedure); when and f pro st inter of w he spent e of guideline: realit the T ser management comorbid inter inter inter inter basis inter inter aluation – (codes of of vides counseling of the dependence dependence

ev vices time Therapy Therapy health medical the in ve using medicine pro management), ser (separate (separate (separate (separate (separate (separate modified e date e and/or and/or and/or and/or and/or on and/or guideline ace supportiv billing Counseling Counseling modification Billing medical treatment treatment diagnostic hese elopment counseling with g be recei T of who aluation management or tobacco ectiv insight-oriented, f this entiv the vior dev f discussion el the v ev same report Cessation Cessation v ef can ug hosen in or e and/or that to code -up promoting promoting ace-to-f f ., c le of f , to the dr e pre vices. specific individual individual individual individual individual individual w Specific medical beha as the is of medication dependence counseling counseling counseling counseling to counseling counseling clinician (e.g All the of the an an an an an an ser as ollo on Counselin the used codes f ectiv billing used f others cognitiv Smoking Smoking unique and to to to to to to es/Codes ers other the r code or ef or use f Counseling y specific of fo for for are ref or or f -modifying purpose be tobacco hange. y billing aluation the c vided vided vided vided vided vided medicine medicine medicine medicine the ypically medicine medicine his oup use and initial to t or eatment eatment ev ocedur vior T xaminations), f inpatient), documented furnished e e e e the e e

or e Tr Gr determines Individual pro pro pro pro pro pro y) codes Pr or y. f hotherap F the or are therapeutic these management vs. f c are beha appropriate entiv entiv entiv entiv entiv entiv appropriate appropriate use use use use use use laborator sical psy hese responsibilities and fice that appropriate entions

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v Prev Prev Prev Prev are Prev Prev therapeutic codes phy hiatric Reimbursement Reimbursement vices or alterations), – diagnostic of apeutic hotherap (of treatment f c y.

be y hotherap c patient). 1 Medicine, 1 counseling). counseled c Medicine, ty ser minutes minutes minutes minutes minutes demonstrated inter minutes and ation e psy e tobacco tobacco tobacco tobacco tobacco tobacco noted vide encounter encounter appropriate appropriate the

Dependence Dependence of vice Ther rie (psy psy interactions, a ould codes, billing aluation (both of 60 30 99403 of 45 99404 of 60 9941 of 30 99412 9940 of 99402 of 15 h, ic be va ention pro e e w are ser ev medical of • • • • • •

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insight-oriented, e as ev ev interpret use obacco ., ch ve h vices est of minutes Int separate They As T Pr olv Pr documenting should v dependence emotional/mood place interactions, treatment procedure counseling dependence pharmacotherap the ser In (e.g It in suc and abo Psy medical b) a) 2. supportiv procedure management supportiv B. APPENDIX C 36 4. 3. 2. 1. Suppor Of Other Beha Inpatient Dental fice • • • • • • • • • • • • • • vior D1320 90853 90822 appro supportiv 90821 9081 appro supportiv 9081 9081 appro supportiv 90816 90809 f supportiv 90808 90807 f supportiv 90806 90805 f supportiv 90804 or Psyc ace ace ace-to-f Coding tiv Other Modifying Hospital, e hother with with 7 9 8 ximately ximately ximately Ps W W W W W W Individual Group Individual Individual Individual Individual Individual T yc ace obacco e, e, e, e, e, e, ith ith ith ith ith ith Outpatient the the hother in in in in in in ap with medical medical medical medical medical medical Pa patient patient an an an an an an psy y 75 45 20 and/or r counseling tial inpatient inpatient inpatient of of of the ap psy psy psy psy psy psy to to to c hotherap fice fice fice y 80 50 30 c c c c c c Hospital, ev ev patient ev ev ev ev F hotherap hotherap hotherap hotherap hotherap hotherap Suppor acility or or or aluation aluation aluation aluation aluation aluation minutes minutes minutes outpatient outpatient outpatient hospit hospit hospit y f or (other – tiv y, y, y, y, y, y, or the and and and and and and Insight-or f f f

al, al, al, insight-oriented, ace-to-f ace-to-f ace-to-f insight-oriented, insight-oriented, insight-oriented, insight-oriented, insight-oriented, e Residential control Ps partial partial partial than management management management management management management f f f acilit acilit acilit yc hother ace ace ace a y, y, y, hospit hospit hospit ient and multiple-f

appro appro appro with with with ed, Car prev ap al, al, al, y the the the beha ximately ximately ximately beha beha beha beha beha ser ser e ser ser ser ser Beha ention or or or F amily acility vices vices vices vices vices vices patient patient patient residential residential residential vior vior vior vior vior vior vior group) of 20 75 45 modifying modifying modifying modifying modifying modifying – Modifying

oral Insight-or to to to 30 80 50 care care care disease minutes minutes minutes and/or and/or and/or and/or and/or and/or set set set and/or ient ting ting ting ed, , , , f f ace-to- ace-to- APPENDIX D 37 Guide s C Plan Practitioner’ B Plan Healthcare Healthcare A — — A Therapy Therapy Plan ) Cessation Cessation PA ered); , ksheet r cov y? required ered MD v viders Smoking Smoking ., Wo

vices co co-pa for for pro (e.g ser be tempts erage benefit telephone at ork to ed ug cov vide w verage xternal dr e quit pro TC net pharmacy Co or online; O preauthorization to no with specializ or f if e ed Reimbursement Reimbursement fice) medication multiple ur of regular vide s ugs

sessions or person; those f ’s dr allow as are erage eat pro in of h v F limit y required sician/other Cessation Cessation only co vider ap (i.e., patc gum inhaler same or phy ered: viders pro ork required ® ugs annual withhold/bonus cap number w cov the (in pro Design dr Bonus care or practitioner e; y prescription required y y ork Nicotine Zyban Nicotine Nicotine Design of ation or macother prescription Smoking Smoking ered w members co-pa etime TC rimar ype D. Other Utilization lif Quality Capit Is P Net Out-of-net All Plan Co-pa In-house T Intensiv Eligibility Counseling Counseling Methods O MD Phar Cov Benefit APPENDIX E 38 tr Reimburse Include pre since paid Smoking Evidence S Str smoking R A primar programs, should questions smoking f Smoking belt that duration prepaid increase pre P Evidence S Str pharmacotherap Pr A ser tobacco-use co A or or E. rimar eimburse ctio ctio TRA TRA eatments o goal v v v vice vide members at at subscribers erage Clinical entiv entiv use, reimbursing ser egies egies • • • • • • n n st y y TEGY TEGY of . pledge clinicians Include treatments Inf Include patients Educat care Ev the Co udies 22 vices or co care care of rates e e cessation cessation and cessation cessation t Health of aluat or v v at obacco discounted insurers ser medical basic er: gum erage f m organizations ee-f f f nicotine cessation or or eac pro clinicians w sho f clinicians and vices e: 6 5 Include or f of to e: Pr ee- smoking smoking eight of to of or Implementation Implementation y y h viders. benefits use, Inf phy subscribers Include w cessation assist actice -ser to P (nicotine use fo health visit with health eople orm treatments. treatments practices, should include treatments treatments that such r dependence all -ser sicians addiction loss, vice and ef these prescription frequently classes, that ev insurance subscribers f the cessation cessation vice ectiv ph

the pac insurance/managed and 20 as er and smoking clinicians Guideline as encourage y replacement y insur help ser 10 patient sician f kage ser smoking pro clinicians or e patient these other of w including , ser smoking vices in specialists ell vices (both (both the pro vision

prescriptions health Ev the f the ance subscribers inter treatment cite vices, or as counseling viding en dr insurers cessation of national when tr f who patient all use int or ug pharmacotherap pharmacotherap decreased defined cessation of eatments the that ref if insuf v insurance ention individual, the deliv cessation s erv a benefits pac smoking suc therap erral and : uses prev ava he smok the Str ficient (e.g treatment entions h health as er identify ka ilabilit f or y f care. theref rates. or entiv duties as in to against f or y tobacco or a at ., y) will ge er she treatment. of the alcohol reimbursable intensiv Health tobacco-use nicotine deliv increases cessation treatments and ef pac group, egies insurance does y as s e ef promotion be

f ore Clinicians F of job ectiv is reasons care of f kages. ectiv y y urthermore, counseling among smoking paid reimbursed of ready co ery salaried and and increase description Plan not use and e v e mild replacement 5 resulted ered e programs smoking treatment

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6 pharmacotherap disease insurance ve or an y in and trend y er el cessation defined least quit, and 2

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pre ormance ef obacco w h and v not fo pac of ypertension insurance of erage f cost-ef as ard ting ectiv education r v duties increases -ser treatments, "report ention prescribed Inf be kages a treatments consistently has decreased . to ser barrier and y e ormation vice

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initiativ pro of healthcare industr encouraged ting counseling) and deliv the to in or e all to viders clinicians and sho nicotine including as Set ex . pro and high smoking at cessation as incentiv f cessation presence

subscr pro ering or e, Clinicians ercise, tend se y wn of encourage viding [HEDIS]) paid managed is st include vided v c salaried surprising eral udy holesterol. to pro univ ef suc as gum, to ser es . f ibers seat 23 viders, ectiv other part f as ersal ask h of ound to vices the e of ,

Reimbursement for Smoking Cessation Therapy — A Healthcare Practitioner’s Guide

F. How to Derive the Cost Benefit Analysis for a Tobacco Control Initiative 24

Estimating Costs for Implementing a Tobacco Control System Some basic plan numbers inserted into the formulas in Appendix G will provide a rough cost estimate for providing a tobacco control intervention. Providers should develop a page or two with an easy-to- read summary of these cost figures before approaching organizational leadership. Curry et al., in a large, randomized control trial of 4 levels of coverage within Group Health Cooperative of Puget Sound (GHC), determined that the average cost to the health plan per smoker who quit ranged from $797 with standard coverage to $1,171 with full coverage.25 The annual cost of a comprehensive program ranged from $6 to $33 per smoker. The annual cost per plan enrollee ranged from $0.89 to $4.92 with full coverage. In 1999, Schauffler et al., conducted a study to determine the effect of instituting first-dollar coverage for tobacco cessation services during the year of the study.26 This study was conducted in collaboration with Cigna and Blue Cross of California. A total of 1200 adult smoking enrollees of these plans were randomized into control and experimental groups. Both groups were mailed a video on smoking cessation and a self-help brochure. In addition, the experimental group was offered up to 4 8-week courses of nicotine replacement therapy (NRT). To access the benefits, participants called a toll-free number and were mailed NRT and/or a referral to a cessation program. The use of NRT, quit attempts, and quit rates was significantly higher in the experimental compared to the control group. Only 2% of smokers enrolled in the trial enrolled in a smoking cessation program. With material production, operation of the telephone line, and NRT, the intervention cost approximately $0.47 per member per month.

Assessing the Existing Cost to the MCO of Current Tobacco Use APPENDIX APPENDIX Determining current costs of tobacco use to the plan is more difficult. If the plan has an epidemiologist or a health economist, they may be able to provide assistance. Another possibility is the state health department. Group Health Cooperative of Puget Sound (GHC) used the Washington State Tobacco Analysis, done with the CDC’s SAMMEC software (Smoking-Attributable F Morbidity, Mortality, and Economic Costs), applying their membership percentage of the state’s population and then estimating the cost for smoking in their plan’s membership. The SAMMEC software package is available through every state health department. It provides cost estimates when population-based prevalence data are entered. Like Group Health Cooperative, providers can find out the cost of smoking per capita in their state and multiply this by the number of members in their plan. If per capita cost is not available, the state health department can provide the estimated cost of smoking for the entire population of a state. If, for example, we say a state’s cost of smoking is $2.5 billion for 9 million residents, this comes to $277 per capita. If the example plan has 500,000 members, it can be guestimated that smoking costs the plan $138,500,000. Another way to examine cost is to take the cost per smoker. In the example above, if 68% of the plan members are adults and 20% of these are smokers, the cost per smoker is $2,036. If you then look at the formulas in Appendix G and assume that 5% of smokers will utilize smoking cessation services (i.e., 3,400 persons) the plan cost for smoking cessation services is 3,400, multiplied by what you have calculated for the cost of medication plus the cost of counseling. The cost of implementing a smoking cessation program will be substantially less than the cost of smoking-related illness. The socioeconomic mix of the population is an important consideration when assessing cost. The cost of tobacco use will tend to be higher in a lower income population, in part because a higher proportion of such a population smokes. If you need additional assistance in developing cost data, contact your plans actuarial department.

39 APPENDIX G 40 B. members departments utiliz but numbers abov T C. **Call f but plan-pro tobacco Cooperativ Fiv *T A. initiativ T ollo G. Satisf he he o ob Zyban e calculate COS CLA COS NUMBER most nothing viously wing: f number e Costing e—estimate percent ollo action y our pro e. cost SSES: vided T T wing control pharmacy ma vided will cost OF OF using e Sur the appro is of y of of to ve not PHARMA SMOKING more. smoking number is OF published be Out P y people ser ximately members dev and tobacco a uget can , the smaller use SMOKERS benefits f vices. ormat elop also 10y of a percent Sound an T Medicaid estimated the cessation CO be obacco y. ears cost . on control administrator

f CESSA

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at Most use local this percent this a costs the ol comprehensiv ers ant 40% a will initially pharmacy time as 1 plans Initiativ

ser = x – = x x = x x Man 0% in t to in ypically that as a age (1 vice—5% the w health a 999 a . participation Number 20%* (those Number T Expenditure a (use Cost 2% (from Number Expenditure Cost 5% (from Number y ork with multiplier; T health , otal some plans maximum to of plan here Detroit, be (people (people determine closely e smok y a of of a number f e 24 airly abo abo estimate small midpoint who presumed is plan members find approac 6 smoking in the MI of of of dat to of ers ve ve Example activ sample. with

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= = to an y component per ma A Existing in in in been from from mean h s s s vide $50 counseling counseling — — the estimate es Use") vidual had individual individual he the er er er above pro whic y T of documented documented to or or or telephone telephone or indi es s s cost range range the f f calculation) calculation) calculation) estimated 5 er plan. estimated estimated from smok smok smok . to to to score, Therapy Therapy costs obacco data that ve ve ve costs T to costs incentiv the es of of of ssessing Incentiv telephone telephone 3

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It Ph entr reported calculating 3. 1. 1. 2. Pharmacotherap Sample Pharmacotherap or $ ‡ To that F. † E. D. $ APPENDICES H & I 42 Fo related Smoking Gr in at prescription. a inhaler members prescription Nicotine HAP ser patient’ not programs (HAP). Smoking Health Group Individual F Brief Minimal Int Cost on amount advising quit the T I. H. ull he HAP r subsequent one oup erv Sample the vices of entire count counseling Cost f smoking ollo net counseling fice of ention -af , intensiv time.

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vided a y , y nicotine $1 a vices v of supply ed ear v sicians, Health Alliance co $71 $94.24 $56.48 $33.20 y aries P prescription HAP costs ention, with cessation 23.1 smoking er to HAP must v , ref an ered .83 and y e Smok the this through -af to er 9 according (patc phy (GHC), inter ma of under replacement, ral filiated be smoking the ma assuming Member at cost, screening sician y by er cessation h, v prescribed 10 y ser be outpatient ention when

be another gum, 0% ser th its depending vices pro dispensed Plan e to repeated vices control of vider the that to , the do but by . APPENDIX J 43

00 Guide 3 P — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — none 998 s 1 20 elephone ea, T rage ered v Ar treatments?” ve

co Co Y) by 01 00 P 7† W — — — — — — — — — — — — — — — — — — — — — — — — — — 10 996 998 994 999 998 999 999 20 1 1 1 1 1 1 1 20 Practitioner’ 01 and Individual A, W Counseling ered. f 6 TN, P oup — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — 996 998 994 998 999 r of tobacco-dependence 1 1 1 1 1 Guideline. 994–20 SC, 1 eatments* eatments* Healthcare Healthcare first A, Tr wing P A as ractice es, P w ollo h G f — — NE, 01 00 00 00 , P — — — — — — — — — — — 25 997 996 996 996 996 996 996 996 998 999 998 997 999 996 996 996 998 999 999 996 atc the 20 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 20 20 20 P Stat MO of Clinical y treatment ed MA, an vice Therapy Therapy , er KY 01 ered 00 00 00 Ser P v — — — — — — — — — — — — 24 997 996 996 996 996 996 996 996 998 999 998 996 999 996 996 996 998 999 996 cov Gum 20 IA, 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 20 20 20 co , ge h ID ra Health eac A, ve an—Unit Cessation Cessation G ® program , Co ublic ear 01 01 y 00 00 CT P P — obacco-Dependence obacco-Dependence 35 997 997 997 997 997 997 997 997 999 997 996 998 999 998 997 999 997 997 997 999 997 997 997 997 998 999 999 999 997 996 20 20 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 20 20 Beg T 00 Zyban the

(AL, 20 of Medicaid

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ge the Pr treatments an 15 to An ra ge 01 00 00 00 to 36 999 996 996 996 996 996 999 996 996 996 999 998 994 996 998 999 999 996 996 996 997 996 996 996 996 997 999 996 996 996 996 998 of ve ed 20 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 20 20 20 Beg ear pregnant al Y Co ask or vera tot f as a response w Co 1, 0 of erage a Medicaid Medicaid v a 20 also of y ot co ot e In a Columbia

xico basis ate tobacco-dependence Island irginia of of st Dak erse Carolina Dak are ork V 26. ana Hampshire Me J Y ype the h aii w ornia the yland ada = ona higan Stat T w w w w w w w ah isconsin xas est ea of Eac Medicaid On N ev irginia ermont ouisiana otal J. Ne Ne † § Te W W T * Rhode South Ut V V North North Ohio Oklahoma Oregon Mississippi Mont N Kansas L Maine Mar Mic Minnesot Dela Florida Ha Illinois Indiana Ariz Arkansas Calif Colorado Ne District District Ne Ar REFERENCES 44 Ref 21 23. 22. 20. 26. 25. 24. 17 6 R 16. 15 18 K 13. 12 14 0 S 10. 19 11 7. 9. 8. 6. 5. 4. 3. 2. 1. . . W ...... Sc Av Med Se Av Sc 20 McPhillips-T Accessed Survey www National www National Medical J Supplement Mills cms.hhs.go W State Af State maintenance Bentz Nashville, P Bar U AZ: T influence insurance Cur Used American Logsdon Health; US 1 monitor Bentz material Shif Campaign www Pilot Center 1 McPhillips-T survey er 998;7(Suppl 998;7(Suppl obacco une resentation eceipt aiser wa .S. arner estmoreland, fair hauf hauf 0 t ailable ailable ences tlement s ry 1;50(44):979-982. Depar fman Ariz r . Depar Will tz, MP .cms.hhs.go .nahu.org/go .nbc RJ s 30, 1 Medicaid Medicaid with SJ CJ CJ . . s fler fler 989;5(5):249-256. F . , V ona 20 Pr SH. amily . , of Mark for KE. Assessment tobacco-use , . , ol Cessation as Association Business 20 Cur Fe DN, h.org/member Help tment S, smoking at: at: Grothaus eventi Implementing Davis J TN. Association 0 plans advice HH, HH, tment permission. for uly 2: 1:20(1):298-303. Dollar v/states/let r 03. a Medicare angum angum 1 Depar , ry Smoking P rent www www 988 at: et conducted 1):S50-S54. 1):S1 org supplement aty Objecti Lazaro T F S 24, McMenamin Bark LH, obacco-F oundation TM. co co Shares The enior ve N, of in anization. of v/media/press/release.asp?Counter=21 tobacco J population s to verage verage vernment%5Cissues%5Cmanaged_care%5Cindex.htm. tment .health .ahcpr 1 A, 20 . Coalition Health P a Bayley cessation: Medicine in -S1 er A C, C. LC, Health Let roudfoot S quit ves health 03. CM, vailable Fo R s of assessment ociety & Healthcare out DC, ter Cahill R of ohay 3. ter Stop of undation. McAfee s.htm. esults Health ree Medicaid .go by tobacco of for s/smd0 smoking ypeople.go Health for for Meier cessation the and to Health and to Orleans B.

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