Helping smokers quit — opportunities created by the affordable care act

The NEW ENGL A ND JOUR NA L of MEDICI NE Helping Smokers Quit — Opportunities Created
by the Affordable Care Act
Tim McAfee, M.D., M.P.H., Stephen Babb, M.P.H., Simon McNabb, B.A., and Michael C. Fiore, M.D., M.P.H., M.B.A.
In its review of tobacco-dependence treatments, thereby increase rates of cessa- the 2008 clinical practice guideline of the U.S. tion. Though these provisions have received little publicity, they could Public Health Service concluded, "Indeed, it is dif- contribute greatly to improving the ficult to identify any other condition that presents quality of health care and achiev- ing better health outcomes while such a mix of lethality, prevalence, cians and patients, making it reducing health care costs.
and neglect, despite effective and harder for physicians to help pa- One major provision of the readily available interventions."1 tients quit smoking.2 ACA requires nongrandfathered The low utilization of clinical ces- Improved coverage of cessa- private health plans to cover, with- sation interventions by smokers tion treatments increases at- out patient cost sharing, preven- and physicians alike is partly at- tempts to quit, treatment use, and tive services that have received an tributable to inadequate insurance rates of successful quitting.1 In A or B grade from the U.S. Preven- coverage1,2: many health insurers particular, coverage that reim- tive Services Task Force. These ser- still fail to cover the evidence- burses cessation interventions vices include tobacco-cessation in- based counseling and medication may increase the chances that terventions.
treatments recommended in the physicians will intervene with On May 2, 2014, the Depart- 2008 guideline.2 Even when these smokers. Methods that rapidly and ments of Health and Human Ser- treatments are covered, barriers to easily connect smokers with ces- vices, Labor, and the Treasury utilization such as copayments sation-treatment resources also in- jointly issued guidance on cessa- and prior-authorization require- crease treatment utilization and tion coverage for insurers (www ments make obtaining them cessation rates.1 costly and inconvenient.2 Further- Several provisions of the Af- This guidance, which is based on more, complex, unclear, and varia- fordable Care Act (ACA) are de- the 2008 guideline,1 stated that in- ble tobacco-cessation coverage signed to address the long-stand- surers would be in compliance if can be confusing for both physi- ing gap in cessation coverage and they covered, without cost shar- n engl j med nejm.org The New England Journal of Medicine Downloaded from nejm.org by GIUSEPPE FRANCESCO SFERRAZZA PAPA on November 19, 2014. For personal use only. No other uses without permission. Copyright 2014 Massachusetts Medical Society. All rights reserved. Helping Smokers Quit if state Medicaid programs re- Affordable Care Act Guidance on Coverage of Tobacco-Cessation Treatment.*
moved barriers to obtaining cessa- A group health plan or health insurance issuer will be considered to be in com- tion medications such as copay- pliance with the ACA's requirement to cover tobacco-use counseling and interven- ments and prior authorization, tions if it covers the following, without cost sharing or prior authorization: placed these medications on pre- 1. screening of all patients for tobacco use; and ferred drug lists, and covered ces- 2. for enrollees who use tobacco products, at least two tobacco-cessation at- sation counseling. Another provi- tempts per year, with coverage of each quit attempt including sion requires traditional state •▪ four tobacco-cessation counseling sessions, each at least 10 minutes Medicaid coverage to include a long (including telephone, group, and individual counseling), and •▪ any FDA-approved tobacco-cessation medications (whether prescription comprehensive cessation benefit or over-the-counter) for a 90-day treatment regimen when prescribed by for pregnant women; this provi- a health care provider.
sion has increased state Medicaid coverage of cessation counseling * To date, the FDA has approved seven smoking-cessation medications: five nicotine medications (patch, gum, lozenge, nasal spray, and inhaler) and two non-nicotine and medications for this popula- pills (bupropion and varenicline). Information is adapted from www.dol.gov/ebsa/ tion.4 The ACA also eliminates faqs/faq-aca19.html; additional information is available at www.ctri.wisc.edu/ cost sharing for the cessation treatments covered by Medicare — individual counseling and ing or prior authorization, two people quit smoking, even when prescription medications — for quit attempts per year, including those people switch insurers.
asymptomatic Medicare benefi- individual, group, and telephone The ACA also includes impor- ciaries.
counseling and all medications tant provisions regarding cessation Finally, another ACA provision approved by the Food and Drug coverage for Medicaid and Medi- allows some health insurers to Administration (FDA) for tobacco care beneficiaries who smoke. A charge tobacco users premiums up cessation (see box). Requiring cov- high percentage of Medicaid en- to 50% higher than those charged erage for this full range of proven rollees are smokers, and smok- to nonusers. The ACA requires cessation treatments allows smok- ing-related disease is a major fac- insurers in the small-group mar- ers and their physicians to select tor driving increases in Medicaid ket to waive the increased pre- the treatment that best suits costs. Research suggests that more mium if smokers participate in a their needs and will most likely comprehensive state Medicaid cov- cessation program. Although im- increase utilization of these treat- erage for cessation treatments is posing higher premiums on to- ments. Before this guidance was associated with higher quit rates bacco users might motivate them issued, the specifics of how insur- among Medicaid enrollees,3 but to quit, it could also cause them ers were expected to implement such coverage varies widely. The to conceal their tobacco use, avoid the ACA's preventive-services pro- ACA's requirement that insurers seeking cessation assistance, or visions mandating tobacco-cessa- cover certain specific preventive forgo health insurance altogether. tion coverage had not been de- services with no cost sharing ap- Such unintended consequences fined, and coverage had varied plies to newly eligible Medicaid may be more likely to occur in beneficiaries in states that opt to the absence of comprehensive ces- If fully implemented in insur- expand Medicaid but not to ben- sation coverage. It will be impor- ance coverage, this guidance eficiaries with traditional, preex- tant for health insurers, employers, should substantially increase to- pansion Medicaid coverage.
and federal and state health au- bacco users' access to proven ces- A separate ACA provision pro- thorities to closely monitor the sation treatments that could help hibits states from excluding FDA- implementation and effects of this thousands of smokers quit. Physi- approved cessation medications provision. If negative effects be- cians, insurers' associations, and from traditional, preexpansion come evident, states have the state health and insurance officials Medicaid coverage. If states fully authority to prohibit insurers from can play key roles in ensuring that implement this provision, it could charging tobacco users higher health plans and insurers are substantially improve access to premiums or to reduce the max- aware of and follow this guidance. cessation treatments for Medicaid imum allowable surcharge in- If all insurers provide such cover- enrollees. The impact of this pro- crease. At least six states and age, they will all benefit when vision could be further enhanced the District of Columbia have n engl j med nejm.org The New England Journal of Medicine Downloaded from nejm.org by GIUSEPPE FRANCESCO SFERRAZZA PAPA on November 19, 2014. For personal use only. No other uses without permission. Copyright 2014 Massachusetts Medical Society. All rights reserved. Helping Smokers Quit already barred insurers from im- increases in quit attempts even From the Office on Smoking and Health, posing higher premiums on smok- among smokers not using cessa- Centers for Disease Control and Preven- tion, Atlanta (T.M., S.B., S.M.); and the Cen- ers (www.cms.gov/CCIIO/Programs tion assistance, because such ter for Tobacco Research and Intervention, -and-Initiatives/Health-Insurance messages normalize quitting and University of Wisconsin School of Medicine reassure smokers that help is avail- and Public Health, Madison (M.C.F.).
The ACA has the potential to able should they need it. Physi- This article was published on November 19, dramatically increase coverage of cians from every specialty, pub- 2014, at NEJM.org.
evidence-based cessation treat- lic health entities, insurers, and ments, making these treatments health care organizations can 1. Fiore MC, Jaen CR, Baker TB, et al. Clinical
available to millions of Americans. all play vital roles in making pa- practice guideline: treating tobacco use and dependence: 2008 update. Rockville, MD: However, these potential bene- tients who use tobacco aware of Department of Health and Human Services, fits will be realized only if both the expanded cessation-coverage Public Health Service, 2008 (http://www smokers and physicians are aware options now available to them.
of the opportunities the law af- Comprehensive, barrier-free, .html#Clinic).
fords. Promotion was essential widely promoted tobacco-cessa- 2. Kofman M, Dunton K, Senkewicz MB.
to the impressive outcomes of tion coverage makes it easier for Implementation of tobacco cessation cover- age under the Affordable Care Act: under- the 2006 Massachusetts Medicaid smokers to quit and for physicians standing how private health insurance poli- tobacco-cessation benefit. The pro- to help them do so. By covering cies cover tobacco cessation treatments. motions used ranged from exten- and publicizing the availability of Washington, DC: Georgetown University Health Policy Institute, 2012 (http://www sive outreach and materials dis- proven cessation treatments, in- .tobaccofreekids.org/pressoffice/2012/ tribution targeting physicians to surers can reduce smoking rates, georgetown/coveragereport.pdf).
radio and transit ads and mail- smoking-related disease, and 3. Greene J, Sacks RM, McMenamin SB. The
impact of tobacco dependence treatment ings targeting Medicaid enrollees. health care costs. Over time, such coverage and copayments in Medicaid. Am J Over a 3-year period, the benefit coverage could accelerate the end Prev Med 2014;46:331-6.
was used by 37% of Massachusetts of the epidemic of tobacco-relat- 4. McMenamin SB, Halpin HA, Ganiats TG.
Medicaid coverage of tobacco-dependence smokers who were covered by ed disease. If the ACA's tobacco- treatment for pregnant women: impact of Medicaid (more than 70,000 smok- cessation provisions are fully im- the Affordable Care Act. Am J Prev Med ers),5 the smoking rate among plemented, they could turn out to 2012;43:e27-9.
5. Land T, Warner D, Paskowsky M, et al.
state Medicaid enrollees fell from be one of its greatest legacies.
Medicaid coverage for tobacco dependence 38% to 28%,5 hospitalizations for treatments in Massachusetts and associated myocardial infarction fell by al- The views expressed in this article are decreases in smoking prevalence. PLoS One those of the authors and do not necessarily most half, and $3.12 in medical represent the official position of the Cen- savings were realized for every ters for Disease Control and Prevention.
dollar spent on the benefit. Pro- Disclosure forms provided by the au- Copyright 2014 Massachusetts Medical Society. thors are available with the full text of this motional activities also prompt article at NEJM.org.
n engl j med nejm.org The New England Journal of Medicine Downloaded from nejm.org by GIUSEPPE FRANCESCO SFERRAZZA PAPA on November 19, 2014. For personal use only. No other uses without permission. Copyright 2014 Massachusetts Medical Society. All rights reserved.

Source: http://www.ao-sanpaolo.it/curarsi/centro-antifumo/NEJM-smoking-cessation.pdf