Medicaid coverage for tobacco-dependence treatments

This paper presents an update on the availability of tobacco-dependence treatments in Medicaid benefit packages from 1998 to 2003 and discusses variation in states' approaches for addressing tobacco cessation. In 2003 thirty-seven states had coverage for at least one evidence-based treatment. Since 1998, thirteen Medicaid programs have added coverage for at least one, while five programs have expanded coverage of these treatments. Overall, the coverage increases indicate a growing awareness of the treatments' importance for the health of Medicaid recipients, although further expansions are still needed.     

Leadership for motivation in health care

For primary health care to achieve its potential the providers have to be strongly motivated. Supportive leadership can play a significant part in bringing this about. A study in Finnish health centres showed that leadership functions, such as the encouragement of doctors and nurses, were particularly important in helping staff to feel that they were doing worthwhile jobs.     

Health care administration in the year 2000: practitioners' views of future issues and job requirements

This research identifies the most important domains in health care administration (HCA) from now to the year 2000 and differentiates job skill, knowledge, and ability requirements necessary for successful management. Fellows of the American College of Healthcare Executives from about half of the United States responded to two iterations of a Delphi mail inquiry. Fellows identified 102 issues that were content-analyzed into nine domains by an HCA expert panel. Domains, in order of ranked importance, were cost/finance, leadership, professional staff interactions, health care delivery concepts, accessibility, ethics, quality/risk management, technology, and marketing. In the second Delphi iteration, Fellows reviewed domain results and rated job requirements on required job importance. Results indicated that while a business orientation is needed for organizational survival, an equal emphasis on person-oriented skills, knowledge, and abilities is required.     

Synchronizing clinician engagement and client motivation in telephone counseling

Health care increasingly incorporates telephone counseling, but the interactions supporting its delivery are not well understood. The authors' clinical trial of a tailored, nurse-administered smoking cessation intervention for surgical patients included a telephone counseling component and provided an opportunity to describe the interaction dynamics of proactive telephone counseling over the course of 4 months. Tape-recorded telephone counseling calls for 56 consecutively enrolled individuals randomized to the intervention group resulted in a data set of 368 calls, which were transcribed and analyzed using constant comparative methods. The findings revealed varying interaction dynamics depending on the nurse's level of engagement with participants and participants' motivation to stop smoking. The authors identified four interaction dynamics: affirming/working, chasing/skirting, controlling/withdrawing, and avoiding commitment. Shifts in interaction dynamics were common and influenced the provision of support both positively and negatively. The findings challenge many assumptions underlying telephone counseling and suggest strategies to improve its delivery.     

State Medicaid coverage for tobacco-dependence treatments--United States, 2005

In 2005, approximately 41 million persons in the United States had health insurance coverage through Medicaid, a federally and state-funded health-care program, managed at the state level, for persons with limited incomes. An estimated 29% of adult Medicaid recipients were current smokers in 2004. The 2000 Public Health Service (PHS) clinical practice guideline recommends that insurance coverage be provided for tobacco-dependence treatments, including both medication (i.e., bupropion hydrochloride or nicotine patch, gum, inhaler, or nasal spray) and counseling (i.e., individual, group, or telephone). A national health objective for 2010 is to increase insurance coverage of evidence-based treatments for tobacco dependence among all 51 Medicaid programs (objective 27-8). The type of coverage for tobacco-dependence treatments offered by Medicaid has been reported since 1998, and most recently for 2003, from state surveys conducted by the Center for Health and Public Policy Studies at the University of California, Berkeley. All states and the District of Columbia (collectively referred to as states in this report) were resurveyed in 2005 regarding types of coverage and limitations in coverage since 1994. This report summarizes the results of that survey, which indicated that as of December 31, 2005, 1) 38 state Medicaid programs covered some tobacco-dependence treatment (i.e., counseling or medication) for all Medicaid recipients; 2) four states offered coverage only for pregnant women; 3) one state (Oregon) offered coverage for all medication and counseling treatments recommended by the 2000 PHS guideline; and 4) seven states (including Oregon) covered all recommended medications and at least one form of counseling. If the 2010 national health objective is to be achieved, states should offer or increase Medicaid coverage for treatment of tobacco dependence.     

State Medicaid coverage for tobacco-dependence treatments--United States, 2006

Approximately one third of adult Medicaid recipients smoke. The Public Health Service, the Task Force on Community Preventive Services, and the Institute of Medicine recommend that health-insurance coverage be provided for tobacco-dependence treatments. In addition, a Healthy People 2010 national health objective calls for total health-insurance coverage for evidence-based tobacco-dependence treatments in all 51 Medicaid programs (objective 27-8b). The types of tobacco-dependence treatments covered by Medicaid have been reported periodically from surveys conducted by the Center for Health and Public Policy Studies at the University of California, Berkeley. This report summarizes results of the 2006 survey, which determined that 39 state Medicaid programs (including the District of Columbia) covered some form of tobacco-dependence treatment (i.e., medication or counseling) for all Medicaid recipients and one state program provided coverage for all recommended treatments. Two states that previously provided no coverage for tobacco-dependence treatment began coverage in 2006. In addition, 32 states added coverage for a new medication, varenicline (Chantix [Pfizer, Mission, Kansas]), one state expanded its coverage to include the nicotine lozenge, and one state expanded coverage to include individual counseling. If the 2010 objective is to be achieved, Medicaid coverage for tobacco-dependence treatment must increase substantially.     

Smoking cessation counseling by primary care women physicians: Women Physicians' Health Study

OBJECTIVES: The Women Physicians' Health Study (WPHS) offers a unique opportunity to examine the counseling and screening practices of women physicians. The objectives of this study were to: describe the prevalence of self-reported smoking cessation counseling among primary care women physicians and determine the association between physician demographic, professional, and personal characteristics and smoking cessation counseling. METHODS: Conducted in 1993-1994, WPHS is a nationally representative cross-sectional mailed survey of U.S. women physicians and included 4,501 respondents representing all major specialties. Primary care physicians included 5 specialty areas and were grouped into 3 categories: (1) general primary care; (2) obstetrics/gynecology (ob/gyn); and (3) pediatrics. Frequent counseling was defined as having counseled patients who were known smokers at every visit or at least once a year. RESULTS: Women physicians in general primary care (84%) and ob/gyn (83%) were more likely to frequently counsel their patients about cessation than were pediatricians (41%). Perceived relevance of counseling to a physician's practice was significantly associated with frequent counseling. Personal characteristics (current smoking status, personal or family history of a smoking-related disease, or living with a smoker as an adult or child) were not significantly correlated with counseling. CONCLUSION: The majority (71%) of physicians reported frequently counseling their patients. However, there was significant variation by physician specialty. In addition, perceived relevance of counseling was strongly associated with counseling behavior. Physician counseling on cessation can reduce tobacco-related morbidity and mortality. Increasing perceived relevance, implementing system changes, and creating accountability can facilitate cessation counseling by physicians.     

Health care and disease prevention through genetic counseling: a regional approach.

The Colorado-Wyoming Regional Genetic Counseling Program has demonstrated the feasibility and utility of providing genetic counseling services over a very large area of the Rocky Mountain Region. A basis for preventing genetic and congenital disorders has been established and the patient care provided has been as comprehensive, sophisticated and effective as for any genetic counseling clinic operating in a medical center, with the added advantage of being accessible to a much larger and less financially able patient population. Utilization data and consumer assessment of the values of this service confirm these impressions.     

Non-primary care physicians and smoking cessation counseling: Women Physicians' Health Study.

OBJECTIVES: The Women Physicians' Health Study (WPHS) offers a unique opportunity to examine the counseling and screening practices of women physicians in various specialties. In this study we describe the prevalence of self-reported counseling on smoking cessation among non-primary care women physicians and examine the association between their demographic, professional, and personal characteristics and such counseling on smoking cessation. METHODS: Conducted in 1993-1994, WPHS is a nationally representative cross-sectional mailed survey of U.S. women physicians with 4,501 respondents representing all major specialties. Physicians in 9 specialty areas were grouped in 6 categories: (1) anesthesiology; (2) general surgery and surgical subspecialties; (3) emergency medicine; (4) medical subspecialties; (5) psychiatry; and (6) other. Frequent counseling was defined as having counseled patients who were known smokers at every visit or at least once a year. RESULTS: Overall, 45% of the physicians frequently counseled smokers to quit. Medical subspecialists (80%) were most likely and psychiatrists (29%) least likely to counsel frequently. Specialty, perceived relevance of counseling to the physician's practice, and self-confidence in counseling about smoking cessation were associated with frequent counseling. CONCLUSION: Cessation counseling by non-primary care physicians can reduce tobacco-related morbidity and mortality. Increasing perceived relevance and self-confidence among this group of physicians, combined with implementation of system changes and the creation of physician accountability can facilitate the provision of such counseling.     

Trends in employer-sponsored health insurance coverage for tobacco-dependence treatments

BACKGROUND: Nearly 1.8 million smokers in California receive their health insurance benefits through their employer. The extent to which these workers have coverage for tobacco-dependence treatments (TDTs) through their employer-sponsored health care is unknown. METHODS: This research used the 2000 and 2005 data from the California Employer Health Benefits Surveys to determine coverage for TDTs by private firms. The overall response rates of firms to the survey were 41% and 36%, respectively. The samples used in this analysis are limited to private firms in California that offered employee health benefits in 2000 (n=729) or in 2005 (n=745). RESULTS: This research found that among private firms offering health insurance coverage, there was a significant increase from 2000 to 2005 in the percentage of workers covered for any TDTs (44% to 57%). Rates of coverage for all three forms of TDTs (nicotine replacement therapy, Zyban((R)), counseling) doubled from 11% to 22% over the 5-year time period. CONCLUSIONS: Although coverage levels have improved, they still fall short of the recommendations made in the U.S. Public Health Service guidelines as well as in the Healthy People 2010 objectives. Given the effectiveness, cost effectiveness, public demand for coverage, and relatively low cost of covering TDTs-estimated to be $3-$6 per member per year-it is difficult to understand why such coverage is not more widely available in California.     

Effective employee counseling for the first-line health care manager

Counseling is an important supervisory skill applied for a number of purposes. Although the need for counseling is as constant as any need facing the manager, a number of commonly encountered barriers often prevent effective counseling. In most instances, counseling is a necessary step preceding disciplinary action, and it is always an important step in improving employee performance. Although the manager may not come to the job with expertise in counseling, counseling can nevertheless be learned through practice and the conscientious application of a few simple guidelines.     

State Medicaid coverage for tobacco-dependence treatments--United States, 1994-2001

Tobacco use is the leading preventable cause of death in the United States. One of the national health objectives for 2010 is to increase insurance coverage of evidence-based treatment for nicotine dependence (i.e., total coverage of behavioral therapies and Food and Drug Administration [FDA]--approved pharmacotherapies) in Medicaid programs from 36 states to all states and the District of Columbia (DC) (objective 27.8). To increase both the use of treatment by smokers attempting to quit and the number of smokers who quit successfully, the Guide to Community Preventive Services recommends reducing the "out-of-pocket" cost of effective tobacco-dependence treatments (i.e., individual, group, and telephone counseling, and FDA--approved pharmacotherapies) for smokers. The 2000 Public Health Service (PHS) Clinical Practice Guideline supports expanded insurance coverage for tobacco-dependence treatments. In 2000, approximately 32 million low-income persons in the United States received their health insurance coverage through the federal-state Medicaid program; 11.5 million (36%) of these persons smoked (CDC, unpublished data, 2000). The amount and type of coverage for tobacco-dependence treatment offered by Medicaid has been reported for 1998 and 2000 from state surveys conducted by the Center for Health and Public Policy Studies (CHPPS) at the University of California, Berkeley. All states and DC were re-surveyed in 2001 about amount and type of coverage, and level of coverage since 1994. This report summarizes the results of the survey, which indicate that the number of Medicaid programs providing some coverage for tobacco-dependence counseling or medication increased from 34 in 2000 to 36 in 2001, but only one state offered coverage for all the counseling and pharmacotherapy treatments recommended by the 2000 PHS guideline. If the 2010 national health objective is to be achieved, Medicaid coverage for treatment of tobacco dependence should be increased dramatically.     

State medicaid coverage for tobacco-dependence treatments--United States, 1994-2002

In 2000, of approximately 32 million persons who received health insurance coverage through Medicaid programs, an estimated 11.5 million (36%) smoked. One of the national health objectives for 2010 is to provide coverage by Medicaid in the 50 states and the District of Columbia (DC) for nicotine-dependence treatment. The Guide to Community Preventive Services recommends reducing the cost of tobacco-dependence treatments to increase the number of smokers who successfully quit smoking. The 2000 Public Health Service (PHS) Clinical Practice Guideline also supports expanded insurance coverage for tobacco-dependence treatments. The amount and type of coverage for tobacco-dependence treatment offered by Medicaid has been reported previously for 1998, 2000, and 2001. In 2002, all states and DC were surveyed again about the amount and type of coverage they provided. This report summarizes the results of the survey, which indicate that as of December 31, 2002, 1) 36 Medicaid programs covered some tobacco-dependence counseling or medication for all Medicaid recipients, 2) four states offered coverage only for pregnant women, 3) two states offered coverage for all pharmacotherapy and counseling treatments recommended by the 2000 PHS guideline, and 4) seven states covered all recommended medications and at least one form of counseling. To improve the health of populations with disproportionately high rates of smoking, the 50 states and DC should provide coverage under Medicaid for all recommended tobacco-dependence treatments.