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4/23/2013

AHUSKYHealthPlanInitiative
JudithJordan, LCSW,MBA DirectorofMedicalAdministration, DSS 860.424.5860 MichaelHebert,MSW,MBA RewardstoQuitCoordinator, CHNCT 203.626.7120

Reimbursement&Incentivesfor TobaccoTreatment
April24,2013
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ProjectOverview
MedicaidIncentivesforPreventionofChronicDisease(MIPCD)grantprogram underCentersforMedicareandMedicaidServices(CMS) 5yeargranttotestimpactofincentivesonsmokingbehaviorchangeamong HUSKYA,CandDmembersages18andover. ProgrambuildsonrecentexpansionofHUSKYcoverageforsmokingcessation services(effectiveJanuary1,2012) Programparticipationandoutcomeswillinformfuturedecisionsregarding andfuturefunding Medicaidsmoking gcessationprograms p g g Goals Studytheimpactoffinancialincentivesonquittingsmokingwithaspecial focuson: o MemberswithSeriousMentalIllness(SMI) o PregnantandPostpartumWomen ReduceratesofCTMedicaidmemberswhosmokeby25to30%

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ProjectOverview
Programoversightisprovidedby: CMS:Federalgrantoragency CTDSS:Grantee,LeadAgency(stateMedicaidagency) CHNCT:MedicalASOforHUSKYHealth YaleUniversity:Stateprogramevaluator Otherkeyprojectpartners: DepartmentofPublicHealth:CTQuitline DepartmentofMentalHealth&AddictionServices:LMHAs HispanicHealthCouncil:PeerCoaching&FocusGroups LocalMentalHealthAuthorities(LMHAs),(6)privatelyoperated PersonCenteredMedicalHomes

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ProjectOverview
RewardstoQuittobeimplementedthroughselectproviders LocalMentalHealthAgencies ObstetricsProviders Pediatricians PersonCenteredMedicalHomes

Randomizationtooccurbyprovider,notbyindividual Randomizationwithineachprovidertype Randomizationbypractice,notsite

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Assesseffectiveness offinancialincentivesoverstandardcare for: Cessationprogramenrollment Useofcounselingservices(individualandtelephone) Programdropoutrates Cessationsuccessratesatthreemonthsandtwelve months Studywilltestvariousincentivelevels: Noincentive Low($)incentive High($) incentive(processandoutcomemeasures)
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ProgramOverview Objectives

ProgramOverview: ExperimentalDesign
Randomizedtrials Comparesthosewithincentives(Treatment)tothosewithout (Control) Allpatientshavenewaccesstocessationservices Onlythoserandomizedtoincentivesinitiallygetincentives Randomizetoshowcausality:Doestheprogramwork? CMSrequiresrandomization Randomization: Byprovider, notpatient Withineachprovidertype Bypractice,notsiteorindividualpractitioner

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ProjectOverview
Successoftheprogramdependsonproviders
Screenmemberfortobaccouse Educate,informandmotivate Engagememberintreatment Enrollsmokerinincentiveprogram Providesmokingcessationservices/products Trackandreportactivitiesforpurposesofincentives

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Motivationfor TobaccoCessationReform?
Costsofchronicconditionsandpoorhealth outcomes:
Coststoplansponsors(employers,government (Medicare Medicaid) (Medicare, Coststoindividual Coststosociety

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IncentivesandBehaviorChange: TheProblem
Medicalcareforsmokingrelatedhealthissuescosts$96 billion/year Peoplelivingwithmentalillnessorsubstanceusedisorders consume40%ofalltobaccoproducts(SAMHSA,2013) 38%ofadultswithmentalillnessorsubstanceusedisorders smoke; theseconditions k only l 19.7% 19 7%%of fadults d lt without ith tth diti smoke(SAMHSA,2013) 60%ofMedicaidmemberswithseriousmentalillness smoke 30%ofCTsMedicaidmemberssmoke

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IncentivesandBehaviorChange: TheProblem
Lowincomeindividualsare:
morelikelytosmokeandbeinpoorhealth lesslikelytoquitontheirown pooraccesstocessationprograms lacksupportand/orcoaching

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IncentivesandBehaviorChange: TheProblem
Manysmokerswanttoquitandneedhelp
70%ofcurrentsmokerswanttoquit 52%ofadultsmokersstoppedsmokingforonedayinan attempttoquit Smokingcessationsuccessratesarelow(aslowas3%) Toofewseekprofessionalservicesandmedications

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WhyShouldSmokingCessation BeIncentivized?
Manysmokerswanttoquitandneedassistanceachievingtheirowngoals: Asmanyas70%ofcurrentsmokerswanttoquit,withsuccessratesas lowas2%3%. Barrierstoquittingincludeaccesstosmokingcessationprograms, nicotinereplacementtherapiesandaninabilitytofullyweighthelong termrisksofsmoking. smoking Financialincentivesmayprovidetheadditionalsupportandmotivation neededtomakeaquitattempt. Becomeawareofthefullrisksandassociatedcostsofsmoking (personalandfamilymembershealth,financialcosts) Smokersarepresentbiasedandoftendelayquittingtodayforthe temporaryreliefoftobacco,andthefuturequitattemptnevercomes. Financialincentivescanhelpreinforcethedecisiontoquitand reinforcethehabitofnotsmoking.
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CurrentUsesofFinancialIncentives
Healthrelatedfinancialincentivesareusedtoimprovehealth outcomes,improvecompliance,lowermedicalspendingand improveworkerproductivity Whoutilizesfinancialincentives?Employers,health insuranceproviders,contingencymanagement Examplesoffinancialincentivesused:directpayments, bonuses,giftcards,vouchers,subsidized/freeservices, premiumadjustments Examplesoftargetedbehaviors:Weightloss,smoking cessation,healthriskassessments,primarycare/preventive carevisits
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IncentivesandBehaviorChange: WhyIncentives?
Theywork!
Increaseeffortstoquit Increasequitrate Shorttermcessationratesamongincentive groupsweretwotothreetimesthoseofthe nonincentivegroups(Cahill&Perera,2011)

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IncentivesandBehaviorChange: WhyIncentives?
Theywork! Forpregnantwomen:
Abs nenceattheendofpregnancy

(41%incentivesvs.10%noincentives) 12weekpostpartumassessment(24% vs.3%);(Heil,2008). Improvedfetaloutcomes

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IncentivesandBehaviorChange: MedicaidandSMIPopulations
Stillunknown: EffectivenessforMedicaidpopulation EffectivenessforthosewithSMI Longtermeffectiveness: g Onetrialfoundasignificant effectofincentives oncessationoveroneyear(Volpp,2009): Cessationat15/18months:9.4%incentivesvs. 3.6%noincentives RewardstoQuitisanopportunitytostudytheeffectof incentivesonthesepopulations

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IncentivesandBehaviorChange: CharacteristicsofEffectiveIncentives
Paidonobjectivecriteria Clearcessationtargetsandtimeframes Frequent Reinforcesquitdecisionandbehaviors Immediate
Instantrewardsmaintainmotivationandparticipation

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IncentivesandBehaviorChange: CharacteristicsofEffectiveIncentives
Salient
Messagingmustbeclearandtargetedtosmoker (education,language)

DoseResponse p
Largerincentivesforlongtermcessationmotivatesand reinforcesquitdecision

Complementaryservices
Incentivescombinedwithcounselingandpeercoaching mosteffective
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Providerparticipationiskeytoprogramsuccess
Responsibility
Screenfortobaccouse Complete screening,andsmokingstatus andhabitassessmentforms Complete intakeformforprogram enrollment Providesmokingcessation services/products Tobacco cessationcounseling NRT Prescribe medications Providereferralsifnecessary AdministerCOtest,ifrequestedby member Trackandreportactivitiesforpurposesof incentives
* Existing Quitline protocols

Randomized In (Treatment)
X X X X X X X X X X

RandomizedOut (Control)
X X

Connecticut Quitline

X X X X X X*

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ProgramOverview: Incentives
Designedtobemaximallyeffective:
Paidonobjectivecriteria Paidforcessationapproachesproventobeeffective CounselingServices(IndividualorGroup) NegativeCObreathalyzertest Paidfrequentlytoreducedropoutrates Paidsoonuponcompletionoftask/achievement/goal Cumulatively,paymentsarelargeforcontinued participation(doseresponse) Bonuspaymentsprovidedtoencouragecontinued engagement

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ProgramProcessandRules IncentivePayments
Incentivepaymentspaidonobjectiveandverifiedcriteria: CounselingincentivespaidonProviderreportedservicedata COtestincentivespaidonphysicianofficeconfirmation Allincentiveswillbeelectronicallydepositedonareloadabledebit cardweekly: AllparticipantsinTreatmentgroupswillreceiveareloadable debitcard Asincentivesareearned,valueisloadedontothedebitcard, whichcanbeusedforpurchases(notATMwithdrawals) Loadingandotheradministrativefeesassociatedwiththe debitcardarepaidbystate

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ProgramProcessandRules IncentiveAmounts
Themaximumincentivepaymentspermemberperactivity(Treatment Groupsonly): o CounselingSessions: o $5/eachsessionwithmaximumof10sessions(totalincentivepayment of$50) o Twobonuspaymentsof$15eachcanbeearned,eachonefor completingaseriesoffivesessions o TobaccofreeCObreathalyzertests: o $15pernegativetestwithamaximumof12testspermember o Fourbonuspaymentsof$10canbeearned,eachoneforhavingthree consecutivenegativetests ThemaximumpotentialRewardstoQuitincentivepaymentpermember:
$350per12monthenrollmentperiod(maxtwoenrollmentperiodsper person),and $600percalendar year NOTE:NofinancialincentivesareprovidedforNRTorprescriptionmedications

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ProgramProcessandRules
ProgramEnrollment Programenrollmentcompleted viaclinicianswithinPCMHs, FQHCs,LMHAs,OBGYNand Pediatricianoffices 365dayprogramcyclebeginsthe d smokers day k agreeto t participate ti i t intheprogram.
1. Cliniciansscreenforsmoking status 2. Patienteligibleforstudyif:
a. Smokedwithinlast30days b. Atleast18yearsold c. EnrolledinHUSKYA,CorD

3 Cliniciansprovideinformation 3. aboutstudyandaskto participate. 4. Ifpatientagreestoparticipate, initialscreeningquestionnaire andenrollmentformsrequired 5. Ifpatientdeclinestoparticipate, theywillbeaskedagainatall futurevisits.

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ProgramOverview: Enrollment
AllHUSKYA,CandDmembersages18andoverareeligible Canenrollforuptotwoenrollmentcycles Eachenrollmentcycle=12monthsfromdateof enrollment Enrollmentcycleforpregnantwomen=12monthsor ([monthsofenrollmentpriortodelivery]+[6monthspost partum]),whicheverislonger Ensuresthatwomencanreceiveincentivesforatleastsix monthspostpartum

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ProgramDetails
NewCTMedicaidSmokingCessation Coverage
Expanded Services
SmokingCessation Counseling

Expanded Therapies
Nicotine Replacement Therapies Prescription Medicationsfor Cessation

24hourTelephone Quitline

PeerCounselors (phase2)

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RewardstoQuitTimeline
Target Populations
Medicaid Smokers

Available Locations
Patient Centered MedicalHomes

Time Period Studied


Firstproviders begin recruitmenton March27,2013

Pregnantand Postpartum Medicaid Smokers Medicaid Smokerswith SevereMental Illness

Federally Qualified HealthCenters

Recruitment endsFall2015

Local MentalHealth Authorities Participating OBGYN& Pediatrician Practices

Evaluation completeFall 2016

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ProgramDetails
AvailableServices&Treatments CoveredMedicaidservicesand treatment Groupcounselingsessions AccesstotelephoneQuitline Ni ti replacement Nicotine l tth therapies i Prescriptionsforsmoking cessation Studyspecificservices Outcome andprocessbased financialincentives Peercounseling(viaHispanic HealthCouncil)withinthreecities
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Allparticipants willhave accesstoMedicaid servicesandtreatments regardlessofstudy groupassignment

Accesstostudyspecific serviceswilldepend on studyarmassignment andgeographic location

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ProgramDetails
RewardstoQuitProgram(365Days) Program Enrollment
Physician assessessmoking status Offerscessation treatment Ifpatientaccepts, enrolledinstudy arm

Available Services& Treatments


Medicaid services:NRT, prescription, counseling counseling, Quitline Additional services:peer counseling Phasedinlater

Process Incentives
Counseling session Quitlinecall Max#incentives Bonusfor multiple sessions/calls

Outcome Incentives
TobaccofreeCO test Max#incentives Bonusfor consecutive tobaccofree readings

3 mo.

SmokingCessationEvaluation

12 mo.

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COBreathalyzerTesting

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COBreathalyzerTesting&Incentives
Tobeeligibleforarewardforthetobaccofree CObreathalyzertestallmustbetrue Itmustbe7dayssincethelasttest (Maximumof12peryear) Maximumof12tobaccofreetestsresults peryear Tobeeligibleforabonusforthetobaccofree CObreathalyzertest Individualmusthavehad3negative (tobaccofree)COtestsinarow Maximumof4peryear Technicalnote ACOtestof>=8partspermillion indicatescurrentsmokingfornonpregnant adults,and>=2partspermillionfor pregnantwomen
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ReloadableRewardstoQuitCard

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WelcomeCardforMembers

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Counseling&COBreathalyzer MotivationalCards

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http://www.rewardstoquit.org

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ProviderPortaltoAccessIntakeForms http://www.huskyhealthct.org/providers/providerupdates.html website

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Intake&InformedConsentForms
Rewards to Quit Intake Form (Spanish version) Rewards to Quit Intake Form (English version)

ProgramInstructions GeneralInstructions FormInstructions PartA BasicInformation Providerinformation Patientinformation PartB SmokingStatus&Habits PartC PatientInformedConsent ProgramServiceVisit(TreatmentOnly)
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PolicyTransmittal201135,PB201194 ExpansionofSmokingCessationCoverage Smokingcessationbilling.pdf

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ProviderBillingProcedures PB201194

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ChangestoRewardstoQuitProgram
IncentivespaidforCTQuitlinecallswillnotbeavailableto treatmentgroupenrolleesatthestartoftheprojecton March27,2013 Psychodynamicgroupcounselingserviceswillbebillableto Medicaidatthebeginningoftheprojectwithspecific credentialingandcurriculumrequirementsfortobacco cessation Providerscanreceivesupportwithenrollmentapplicationsby calling1.800.859.9889,Ext.1070 Memberscanreceivesupportwithtobaccocessation questionsbycalling1.800.859.9889,option4(Member Services),option4(SmokingCessation)
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Questions

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