CT_Rewards_To_Quit_Program-Omnibus_CommuniCare_Conference
description
Transcript of CT_Rewards_To_Quit_Program-Omnibus_CommuniCare_Conference
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A HUSKY Health Plan Initiative
Judith Jordan, LCSW, MBADirector of Medical Administration, DSS
860.424.5860
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Michael Hebert, MSW, MBARewards to Quit Coordinator, CHNCT
203.626.7120
Reimbursement & Incentives for Tobacco Treatment
April 24, 2013
Project Overview• Medicaid Incentives for Prevention of Chronic Disease (MIPCD) grant program
under Centers for Medicare and Medicaid Services (CMS)
• 5‐year grant to test impact of incentives on smoking behavior change among HUSKY A, C and D members ages 18 and over.
• Program builds on recent expansion of HUSKY coverage for smoking cessation services (effective January 1, 2012)
• Program participation and outcomes will inform future decisions regarding Medicaid smoking cessation programs and future funding
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• Goals
– Study the impact of financial incentives on quitting smoking with a special focus on:
o Members with Serious Mental Illness (SMI)
o Pregnant and Postpartum Women
– Reduce rates of CT Medicaid members who smoke by 25 to 30 %
• Program oversight is provided by:
– CMS: Federal grantor agency
– CT DSS: Grantee, Lead Agency (state Medicaid agency)
– CHNCT: Medical ASO for HUSKY Health
– Yale University: State program evaluator
• Other key project partners:
Project Overview
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– Department of Public Health: CT Quitline
– Department of Mental Health & Addiction Services: LMHAs
– Hispanic Health Council: Peer Coaching & Focus Groups
– Local Mental Health Authorities (LMHAs), (6) privately‐operated
– Person‐Centered Medical Homes
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• Rewards to Quit to be implemented through select providers
– Local Mental Health Agencies
– Obstetrics Providers
– Pediatricians
– Person‐Centered Medical Homes
Project Overview
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• Randomization to occur by provider, not by individual
– Randomization within each provider type
– Randomization by practice, not site
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Program OverviewObjectives
• Assess effectiveness of financial incentives over standard care for:
• Cessation program enrollment
• Use of counseling services (individual and telephone)
• Program dropout rates
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• Cessation success rates at three months and twelve months
• Study will test various incentive levels:
• No incentive
• Low ($) incentive
• High ($) incentive (process and outcome measures)
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Program Overview: Experimental Design
• Randomized trials
– Compares those with incentives (“Treatment”) to those without (“Control”)
• All patients have new access to cessation services
• Only those randomized to incentives initially get incentives
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– Randomize to show causality: Does the program work?
– CMS requires randomization
• Randomization:
– By provider, not patient
– Within each provider type
– By practice, not site or individual practitioner
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Success of the program depends on providers
• Screen member for tobacco use
• Educate, inform and motivate
• Engage member in treatment
• Enroll smoker in incentive program
Project Overview
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Enroll smoker in incentive program
• Provide smoking cessation services/products
• Track and report activities for purposes of incentives
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Motivation forTobacco Cessation Reform?
Costs of chronic conditions and poor health outcomes:
• Costs to plan sponsors (employers, government (Medicare Medicaid)
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(Medicare, Medicaid)
• Costs to individual
• Costs to society
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Incentives and Behavior Change: The Problem
• Medical care for smoking related health issues costs $96 billion/year
• People living with mental illness or substance use disorders consume 40% of all tobacco products (SAMHSA, 2013)
• 38% of adults with mental illness or substance use disorders k l 19 7% % f d lt ith t th diti
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smoke; only 19.7% % of adults without these conditions smoke (SAMHSA, 2013)
• 60 % of Medicaid members with serious mental illness smoke
• 30% of CT’s Medicaid members smoke
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Incentives and Behavior Change: The Problem
Low income individuals are:
• more likely to smoke and be in poor health
• less likely to quit on their own
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• less likely to quit on their own
• poor access to cessation programs
• lack support and/or coaching
Many smokers want to quit and need help
• 70 % of current smokers want to quit
• 52 % of adult smokers stopped smoking for one day in an attempt to quit
Incentives and Behavior Change: The Problem
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• Smoking cessation success rates are low (as low as 3 %)
• Too few seek professional services and medications
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Why Should Smoking Cessation Be Incentivized?
• Many smokers want to quit and need assistance achieving their own goals:
– As many as 70% of current smokers want to quit, with success rates as low as 2%‐3%.
– Barriers to quitting include access to smoking cessation programs, nicotine replacement therapies and an inability to fully weigh the long term risks of smoking
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term risks of smoking.
• Financial incentives may provide the additional support and motivation needed to make a quit attempt.
– Become aware of the full risks and associated costs of smoking (personal and family members’ health, financial costs)
– Smokers are present biased and often delay quitting today for the temporary relief of tobacco, and the future quit attempt never comes.
– Financial incentives can help reinforce the decision to quit and reinforce the habit of not smoking.
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Current Uses of Financial Incentives
• Health‐related financial incentives are used to improve health outcomes, improve compliance, lower medical spending and improve worker productivity
• Who utilizes financial incentives? Employers, health insurance providers, contingency management
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• Examples of financial incentives used: direct payments, bonuses, gift cards, vouchers, subsidized/free services, premium adjustments
• Examples of targeted behaviors: Weight loss, smoking cessation, health risk assessments, primary care/preventive care visits
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Incentives and Behavior Change: Why Incentives?
They work!
• Increase efforts to quit
• Increase quit rate
• Short term cessation rates among incentive
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groups were two to three times those of the non‐incentive groups (Cahill & Perera, 2011)
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Incentives and Behavior Change: Why Incentives?
They work!
For pregnant women:
• ↑Abs nence at the end‐of‐pregnancy (41 % incentives vs. 10 % no incentives )
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•12‐week postpartum assessment (24 % vs. 3 %); (Heil, 2008).
• Improved fetal outcomes
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Incentives and Behavior Change: Medicaid and SMI Populations
Still unknown:
– Effectiveness for Medicaid population
– Effectiveness for those with SMI
– Long‐term effectiveness:
• One trial found a significant effect of incentives
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gon cessation over one year (Volpp, 2009): Cessation at 15/18 months: 9.4 % incentives vs. 3.6 % no incentives
Rewards to Quit is an opportunity to study the effect of incentives on these populations
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Incentives and Behavior Change:Characteristics of Effective Incentives • Paid on objective criteria
— Clear cessation targets and timeframes
• Frequent
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— Reinforces quit decision and behaviors
• Immediate
— Instant rewards maintain motivation and participation
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Incentives and Behavior Change:Characteristics of Effective Incentives • Salient
—Messaging must be clear and targeted to smoker (education, language)
• Dose Response
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—Larger incentives for long‐term cessation motivates and reinforces quit decision
• Complementary services
— Incentives combined with counseling and peer coaching most effective
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Provider participation is key to program success
Responsibility Randomized In (Treatment)
Randomized Out(Control)
Connecticut Quitline
Screen for tobacco use X X
Complete screening, and smoking status and habit assessment forms
X X
Complete intake form for program enrollment
X
Provide smoking cessation services/products
X X
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Tobacco cessation counseling X X X*
NRT X X
Prescribe medications X X
Provide referrals if necessary X X
Administer CO test, if requested by member
X
Track and report activities for purposes of incentives
X X
* Existing Quitline protocols
Program Overview:Incentives
Designed to be maximally effective:
– Paid on objective criteria
– Paid for cessation approaches proven to be effective
– Counseling Services (Individual or Group)
– Negative CO breathalyzer test
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Negative CO breathalyzer test
– Paid frequently to reduce dropout rates
– Paid soon upon completion of task/achievement/goal
– Cumulatively, payments are large for continued participation (dose response)
– Bonus payments provided to encourage continued engagement
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Program Process and RulesIncentive Payments
• Incentive payments paid on objective and verified criteria:
• Counseling incentives paid on Provider‐reported service data
• CO test incentives paid on physician office confirmation
• All incentives will be electronically deposited on a reloadable debit card weekly:
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• All participants in Treatment groups will receive a reloadable debit card
• As incentives are earned, value is loaded onto the debit card, which can be used for purchases (not ATM withdrawals)
• Loading and other administrative fees associated with the debit card are paid by state
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Program Process and RulesIncentive Amounts
• The maximum incentive payments per member per activity (Treatment Groups only):o Counseling Sessions:
o $5/each session with maximum of 10 sessions (total incentive payment of $50)
o Two bonus payments of $15 each can be earned, each one for completing a series of five sessions
o Tobacco‐free CO breathalyzer tests:
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o Tobacco free CO breathalyzer tests: o $15 per negative test with a maximum of 12 tests per membero Four bonus payments of $10 can be earned, each one for having three consecutive negative tests
• The maximum potential Rewards to Quit incentive payment per member: • $350 per 12‐month enrollment period (max two enrollment periods per
person), and • $600 per calendar year
NOTE: No financial incentives are provided for NRT or prescription medications
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Program Process and Rules
• Program enrollment completed via clinicians within PCMHs, FQHCs, LMHAs, OB‐GYN and Pediatrician offices
• 365‐day program cycle begins the d k t ti i t
Program Enrollment
1. Clinicians screen for smoking status
2. Patient eligible for study if:a. Smoked within last 30 days
b. At least 18 years old
c. Enrolled in HUSKY A, C or D
3 Clinicians provide information
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day smokers agree to participate in the program.
3. Clinicians provide information about study and ask to participate.
4. If patient agrees to participate, initial screening questionnaire and enrollment forms required
5. If patient declines to participate, they will be asked again at all future visits.
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Program Overview: Enrollment
• All HUSKY A, C and D members ages 18 and over are eligible
• Can enroll for up to two enrollment cycles
• Each enrollment cycle = 12 months from date of enrollment
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• Enrollment cycle for pregnant women = 12 months or([months of enrollment prior to delivery]+[6 months post‐partum]), whichever is longer
• Ensures that women can receive incentives for at least six‐months postpartum
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New CT Medicaid Smoking Cessation Coverage
Smoking Cessation Counseling
Nicotine Replacement Therapies
Expanded Services Expanded Therapies
Program Details
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Counseling Therapies
24 ‐hour Telephone Quitline
Prescription Medications for
Cessation
Peer Counselors (phase 2)
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Medicaid Smokers
Patient ‐Centered
Medical Homes
First providers begin
recruitment on March 27, 2013
Pregnant and Postpartum Medicaid
Federally Qualified
Health Centers
Target Populations Available Locations Time Period Studied
Recruitment ends Fall 2015
Rewards to Quit Timeline
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SmokersHealth Centers
Medicaid Smokers with Severe Mental
Illness
Local Mental Health Authorities
Participating OBGYN & Pediatrician Practices
Evaluation complete Fall
2016
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Program Details
• Covered Medicaid services and treatment
• Group counseling sessions
• Access to telephone Quitline
Ni ti l t th i
Available Services & Treatments
All participants will have access to Medicaid
services and treatments regardless of study group assignment
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• Nicotine replacement therapies
• Prescriptions for smoking cessation
• Study specific services
• Outcome‐ and process‐based financial incentives
• Peer counseling (via Hispanic Health Council) within three cities
Access to study‐specific services will depend on study arm assignment and geographic location
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Program DetailsRewards to Quit Program (365 Days)
Program Enrollment
Available Services & Treatments
Process Incentives
Outcome Incentives
• Physician assesses smoking status
• Medicaid services: NRT, prescription, counseling
• Counseling session
• Quitline call
• Tobacco‐free CO test
• Max # incentives
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• Offers cessation treatment
• If patient accepts, enrolled in study arm
counseling, Quitline
• Additional services: peer counseling‐Phased in later
• Max # incentives
• Bonus for multiple sessions/calls
• Bonus for consecutive tobacco‐free readings
Smoking Cessation Evaluation3
mo.
12 mo.12 mo.
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CO Breathalyzer Testing
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CO Breathalyzer Testing & Incentives
To be eligible for a reward for the tobacco‐free CO breathalyzer test all must be true
• It must be 7 days since the last test (Maximum of 12 per year)
• Maximum of 12 tobacco‐free tests results per year
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To be eligible for a bonus for the tobacco‐free CO breathalyzer test
• Individual must have had 3 negative (tobacco‐free) CO tests in a row
• Maximum of 4 per year
Technical note ‐ A CO test of >=8 parts per million indicates current smoking for non‐pregnant adults, and >= 2 parts per million for pregnant women
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Reloadable Rewards to Quit Card
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Welcome Card for Members
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Counseling & CO Breathalyzer Motivational Cards
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http://www.rewardstoquit.org
Provider Portal to Access Intake Formshttp://www.huskyhealthct.org/providers/provider updates.html website
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Intake & Informed Consent Forms
• Program Instructions
– General Instructions
– Form Instructions
Rewards to Quit Intake Form(Spanish version)
Rewards to Quit Intake Form(English version)
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• Part A – Basic Information
– Provider information
– Patient information
• Part B – Smoking Status & Habits
• Part C – Patient Informed Consent
• Program Service Visit (Treatment Only)
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Policy Transmittal 2011‐35, PB 2011‐94Expansion of Smoking Cessation Coverage
Smoking cessation billing.pdf
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Provider Billing Procedures‐ PB 2011‐94
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Changes to Rewards to Quit Program• Incentives paid for CT Quitline calls will not be available to
treatment group enrollees at the start of the project on March 27, 2013
• Psychodynamic group counseling services will be billable to Medicaid at the beginning of the project with specific credentialing and curriculum requirements for tobacco
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credentialing and curriculum requirements for tobacco cessation
• Providers can receive support with enrollment applications by calling 1.800.859.9889, Ext. 1070
• Members can receive support with tobacco cessation questions by calling 1.800.859.9889, option 4 (Member Services), option 4 (Smoking Cessation)
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Questions
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