increasing institutional consumer demand: tim mcafee, md, mph 206-876-2551 tim.mcafee@ freeclear.com...
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Increasing Increasing InstitutionalInstitutional Consumer Demand:Consumer Demand:
Tim McAfee, MD, MPH
206-876-2551
Tim.mcafee@freeclear.com
Healthplans, Employers (& Government)
Why bother with institutions?
• Strong evidence that – removal of access barriers – aggressive institutional promotion
markedly increases individual consumer use of evidence-based services
BUT:
• There is only fair to middling institutional demand for tobacco treatment services
Populations
• 80% of population has health insurance
• 70% of smoking population works
• 100% live in a state
• Special institutional populations:– Those who hold the risk long-term
• Union Trusts• VA• Medicare
Financing as a social justice issue:
• 99% of MSA and tax dollars are being spent on things other than helping smokers quit
• Tobacco taxes are an involuntary tax on an addiction
• Smokers are disproportionately represented in the poor
• Treating tobacco dependence should be a core, evidence-based component of healthcare
Tobacco Treatment
On Wisconsin
• Medical Assistants invited 4,174 adult smokers– Free patches with or without CQ or counseling– In urban Milwaukee clinics
• 68% of those invited accepted• 1/2 re-contacted, screened & agreed• Half self-selected Rx:
– 25% patch-only– 33% patch + CQ– 42% patch + CQ + Counseling
“We made it incredibly easy to use with barrier and hassle-free access at time of contact”
– Michael Fiore
Fiore MC et al. Integrating smoking cessation treatment into primary care: an effectiveness study. Preventive Medicine 38 (2004) 412-420.
• Population: 23K – 7,400 smokers
• Intervention:– Coverage for nicotine patches, gum &
bupropion– Coverage for proactive phone counseling– Publicity via mailing and union meeting
announcements
Ringen et al. Am J Ind Med 42:367-377 (2002)
Union Trust Fund: Western WA Carpenter’s Fund
Results Western WA Carpenter’s Fund
• 944 smokers enrolled (13%)– 2/3 smoked >20 years– 2/3 smoked > a pack a day
• Program usage– 60% chose 5-call program– 75% used a medication
• Outcomes– 22-27% quit rate at 12 or more months
Ringen et al. Am J Ind Med 42:367-377 (2002)
Understanding their lawn…
• Healthplans – Purchaser & user (providers & enrollees) pressure– Regulatory requirements– Evidence of rapid ROI or cost-effectiveness– Complex and variable other factors (KISS)
• Employers– ROI
• Healthcare costs & productivity– KISS– Why not just fire them?
• State Gov’t (is a healthcare purchaser)– Cost-effectiveness, not ROI– Potential impact– How it plays in Albany, Sacramento, Olympia, etc
Product/services
• Healthplans:– Interested in disease mgmt models
• Stratification• Manage population• Recruitment & effectiveness competency
– Interested in integrated offerings
• Employers:– Show me the productivity savings!– Carve out or insist healthplans provide
Healthplan Coverage Estimates
• ATMC 2002 survey - Coverage– for patches: 8.6% – For Bupropion; 40-80%– For phone counseling: 52%– For individual counseling: 41%
• Limitations– Only best-selling commercial HMO product included– No ASO vs fully-insured distinction– Based on survey response – 2/3 from 3 national plans– Some answers do not jibe with experience
• #s improved from previous surveys
McPhillips-Tangum C, et at. Addressing tobacco in managed care: results of the 2002 survey. Prev Chronic Dis (serial online) 2004 Oct: URL: http://www.cdc.gov/pcd/issues/2004/oct/04_0021.htm
•Employer Coverage Estimates
• Mercer national survey of employer-sponsored health plans 2001
• Limits:– 21%response rate
• Results:– 90% note increased productivity & decreased healthcare
costs as reasons to cover preventive services– Biggest discrepancy between calculated impact/value and
provision is tobacco treatment:• Any type of treatment: 20% (29% in HMO)• Prescriptions: 15% (24% in HMO)• Counseling: 10% (17% in HMO)
Bondi MA et al. Employer Coverage of Clinical Preventive Services in the United States. American Journal of Health Promotion January 2006
Barriers:
• Lack of perceived need & benefit– Risk is buried– Opportunity is uncertain
• Inertia• Complexity• Institutional biases• The Frog Phenomenon
HIGH PARTICIPATION RATES
1. Full coverage of
counseling and
medication
2. Integration
3. Ongoing
promotions
4. Incentives to
enroll & engage
STRONG SUPPORT FOR INCENTIVES
2005 Wall Street Journal online poll* reveals:
– 71% of adults think employers should provide financial incentives to employees who join a stop smoking program
– 63% of adults favor different levels of insurance premiums for smokers
*Based on sample of 2,007 U.S adults. Survey conducted by Harris Interactive Health-Care in December 2005.
What drives institutional demand?
• 1) Guaranteed and predictable impact (participation + outcomes) from known strategies
• 2) Comparison against other programs that are embraced with much lower proof of ROI/effectiveness (statins, mammograms, holiday parties)
• 3) Comparison against what happens if you do nothing: Spiraling cost and sickness
TOBACCO COST EXPOSURE PER YEAR:$350,000,000
TOBACCO COST EXPOSURE PER YEAR:$350,000,000
THE COST OF TOBACCO
Client Population 1,000,000
Adult Covered Lives 670,000
Adult Smokers 140,000
Excess cost/smoker $2,284
NET SAVINGS OPPORTUNITY
LINK TO ROI ANALYSIS TOOLLINK TO ROI ANALYSIS TOOL
NET SAVINGS OVER 3 YEARS: $13,212,787
NET SAVINGS OVER 3 YEARS: $13,212,787
Public-private partnerships
Minnesota/Oregon examples:
• Healthplans/employers cover meds & phone
• State & Healthplan mass media
• Quitline or phone center triage functions
• Integration of pharmacotherapy into treatment AND promotion
• Help with advocacy
Impact: health system & state
Group Health:• pop’n: 580,000
– adult smoking 15%• 4,500/year use GH QL
(~7.5% of smokers)– All receive proactive follow-
up– 70% with pharmacotherapy
=540 quits (12% AIQR)
WA state QL:• pop’n: 5,800,000
– adult smoking 23%• 9,500/year use WA QL
(~0.9% of smokers)– 3000 receive proactive
follow-up– 6,500 receive single
intervention
=685 quits (12% & 5%)
It’s a complex world
• ABC campaign – increased demand, right?
• Maybe/Maybe not:
• Multiple states cut back on state promotional campaigns
Novel Healthplan approaches
• HIP NY– DM vendors provided known smokers– FC called– 50% of those contacted signed up
• Lumenos– Consumer-directed Healthplan– Provided counseling/meds as first-dollar
coverage + HSA incentive – Strong education– Above-average participation rate
Program ParticipationGroup Health Enrollees
0
500
1000
1500
2000
2500
3000
3500
4000
4500
1992 1993 1995 1997 1998 1999 2000
GroupPhoneTotal
One-year quit rate: 25-30% (30-day abstinence ~ Intent-to-Treat)
• National retail employer: 21% participation– $10 monthly premium differential– Continuous communication
• Southwest employer: 18% participation– Pre-launch web-cast to all managers– CEO launch and follow up letters
• Large western health plan: 8% participation– Brochures in all clinics– Frequent member communications– MD’s trained and tracked on referrals
WHAT WORKS
What we need…
• Better ROI data & packaging– Chronic condition REAL ROI examination– Productivity data
• Better institutional trend data
• Bully pulpit pressure from public health
• Products that speak more directly to institutional needs
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