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Smoking Control Policies in California Health Plans

Institution: University of California, Berkeley
Investigator(s): Helen Halpin, Ph.D.
Award Cycle: 1999 (Cycle 8) Grant #: 8RT-0097 Award: $80,542
Subject Area: Public Health, Public Policy, and Economics
Award Type: Research Project Awards

Initial Award Abstract
Objective: This study will provide important information about the adoption of tobacco control policies in health plans operating in California in 1999. By surveying both commercial and Medi-Cal HMOs, as well as Preferred Provider Organizations (PPOs), we will draw comparisons, assess conformance with federal guidelines for smoking cessation, and determine the characteristics of health plans that have adopted specific smoking control policies. The policies include coverage for smoking cessation treatments (nicotine replacement therapy, Zyban, behavioral programs), physician training in smoking cessation counseling, incentives to health care providers to increase smoking cessation counseling rates, and charting of smoking status in the patient's medical record.

Methods: A questionnaire will be mailed to all of the HMOs and PPOs and all of the Medi-Cal managed care plans operating in California in 1999 (N=50). Every effort will be made through mail and telephone follow-up to obtain a 100% response rate. For those health plans that indicate in the mail survey that they have adopted any smoking control policies, in-depth telephone interviews will be conducted to obtain additional details on policy adoption, design and implementation.

Data Analysis: Statistical analysis will be conducted to estimate the prevalence of smoking control policy adoption in health plans, to assess conformance with federal guidelines, and to examine the relationships between policy adoption and plan characteristics. We will examine differences in rates of smoking control policy adoption by different health plan characteristics.

Policy Relevance: The findings from this research will provide health plans, their enrollees, employers and other purchasers, and state policy makers with current information on health plan practices related to smoking control, identifying gaps for new public health policies, as well as best practices to share with other plans.

Final Report
The objectives of this project were to conduct the first statewide assessment of smoking control policies in health maintenance organizations (HMOs) in the United States, to estimate the prevalence of smoking control policies among the 95 HMOs licensed and operating in California under the Knox Keene Act, and to identify the structural characteristics of HMOs (staff /group model versus IPA model, size of enrollee population, years in operation, for-profit versus not-for-profit, PERS participation, insurer owned, independent HMO chain) that are associated with adoption of specific tobacco control policies.

The findings from our study suggest that a majority of the HMOs in California are not covering the tobacco dependence treatments recommended in the AHCPR Clinical Practice Guideline for Smoking Cessation. Of the plans responding to the survey, the only treatments covered by half were Zyban (58%), individual counseling for greater than 10 minutes (54%), and self-help materials (100%). Nicotine replacement therapy, including gum, patch, nasal spray, and inhalers, were covered by one-quarter of the plans or less. The health plans in our study also reported that there was not strong purchaser demand for covering these services. The only two services for which purchasers requested coverage from at least one-third of the plans was Zyban and the nicotine patch. Less than onequarter of the plans reported that purchasers had requested coverage for any counseling services or nicotine gum. Less than half of the plans assess smoking rates among their members, and fewer than half offer any incentives to medical groups or IPAs to increase provision of tobacco dependence treatments. Despite these findings, more than threequarters of the HMOs reported that they were aware of the AHCPR Guideline and a majority indicated that they had used it in the design of their benefits.

The findings from our study suggest that the majority of smokers in California HMOs are not covered for the tobacco dependence treatment services that have been demonstrated to be most effective in helping them to quit smoking. In addition, we found that few HMOs were offering the support services recommended in the AHCPR guideline, nor were purchasers requesting coverage for these benefits. A great deal more work needs to be done with purchasers, health plans, and providers to increase the provision of effective tobacco dependence treatments and reduce the leading cause of disease and premature death in the state - tobacco use.