Expanding Comprehensive Coverage for Tobacco

Cessation to Ensure Access to Evidence-Based Treatment in North Carolina

Ruth Petersen MD MPH; Chief, Chronic Disease and Injury Section

NC Division of Public Health

Welcome and Greetings!

Meeting purposeGoals for todayContext to help inform our discussions• Scope of the Problem• Current tobacco treatment services in NC• Quitline reach and funding available• Gallery Walk for further illustrations

Meeting Purpose

PURPOSE: In order to bolster access to existing tobacco cessation treatment options and leverage current opportunities resulting from healthcare reform, the Tobacco Prevention and Control Branch of the Division of Public Health will convene representatives from diverse systems that play a role in ensuring the health and wellbeing of North Carolinians to explore strategies for incrementally reaching 8% or 123,200 of current NC tobacco users with evidence-based treatment.

For the first time, this collaborative summit will bring together the public health, insurance, healthcare delivery and business sectors to create a shared vision for expanding and sustaining comprehensive coverage for tobacco cessation treatment.

Our Challenge for Today• Given that 62% of NC tobacco users make a serious but failed

attempt to quit smoking each year; and • Given that we are currently reaching a little over 1% of NC

tobacco users who want to quit with the current funding available;

• Given that CDC Best Practices now recommends that state Quitlines work to reach 8 % of tobacco users who want to quit;

• What do we need to set in motion today?• Can we work together to assure that 4-6% of current tobacco

users who want to quit have access to QuitlineNC through public-private partnerships?

PENNY SLADE-SAWYERDirector, NC Division of Public Health

Paradigm for Tobacco Control

Evidenced Based Interventions change social norms:

Quitlines and FDA approved medications covered for allPrice/Economic Incentives Smoke-free workplaces and public places laws Regulation/Liability

Making tobacco addiction easy and accessible:

Tobacco Advertising Low price New tobacco products

Society

TobaccoAddictionIndividual

More Diseases, More Deaths caused by SmokingNew Evidence from the Surgeon General

is in red - 2014

Smoking Causes…• 12 kinds of cancer including 87% of

lung cancers the new findings of colon and liver cancers.

• Chronic Diseases, including coronary artery disease, COPD, stroke, diabetes, TB, asthma, atherosclerosis

• Immune function disorders, macular degeneration, blindness, cataracts, hip fractures, rheumatoid arthritis

• Reproductive effects in women and men, including LBW, ectopic pregnancy, erectile dysfunction, reduced fertility.

• Overall diminished health.

Secondhand Smoke causes…In Adults:• Stroke• Lung Cancer• Coronary heart disease• Reproductive effects – LBWIn Children:• SIDS• Lower respiratory illness• Impaired lung function• Middle ear disease

NC Smoking Rates in Disparate Populations

NC BRFSS 2011

$15,000 - $24,999

<$15,000

HS Diploma/GED

<HS Education

Native American

Heavy Drinker

Uninsured

Medicaid

Overall NC Smoking Rate

0% 5% 10% 15% 20% 25% 30% 35% 40% 45%

28%

39%

26%

33%

27%

41%

36%

41%

22%

What does smoking cost NC?

• $3.8 billion per year in excess medical care costs (CDC Best Practices 2014)

– Of that, at least $769 million per year in excess health care costs for Medicaid (2006).

• $3.3 billion per year in productivity costs (2006).

We Know What WorksResearch indicates the most effective tobacco treatment is a combination of:

evidence-based coaching and

FDA approved medications.

NC Tobacco Users Want to Quit (and need help)

62% of NC tobacco users made a serious but failed attempt to quit smoking in 2011.

An evidence-based telephone tobacco treatment service

Consists of four treatment sessions Special 10 treatment sessions and

protocol for pregnant women Highly trained, professional Quit Coaches Available to all North Carolina residents

Accessible 24 hours a day, 7 days a week

Integrated with an interactive web based tobacco treatment program

Online registration

Web only treatment program

Two week starter nicotine patches to uninsured, Medicaid and Medicare recipients

Eight weeks of patches, gum or combination therapy to State Health Plan members

WHO USES QUITLINENC?

Insurance Coverage of QuitlineNC Enrollees (FY 2012)

22%

11%

41%

1%

21%

4%

Insurance Coverage

MedicaidMedicareUninsuredOtherPrivate InsuranceState Health Plan

85%

15%

15% of Private Insured callers are paid by Insurance Plan - SHP

Private insur-ance

Number of Quitline Enrollees by Commercial Health Plans – FY 2012

Aetna; 177; 3%

BCBS of NC; 1653; 31%

Cigna; 294; 5%FirstCarolina Care; 15; 0%

HealthChoice 11, 0%Other; 1710; 32%

State Health Plan; 820; 15%

UHS Medical Plan - MedCost; 126; 2%

United Health Care; 497; 9%

WellPath; 111; 2%

Demographics FY 2013

GENDER• 16,507 enrollees

AGE

Male 36.9%

Female 63.1%

0.3%

7.1%

8.1%

15.6%

25.7%

28.8%

11.8%

2.3% 0.3%

17 years old and under18 to 2425 to 3031 to 4041 to 5051 to 6061 to 7071 to 80Over 80

Education

5.0%

19.0%

7.2%

26.8%

25.4%

12.6%

1.4% 2.5%

Less than grade 9

Grade 9-11, no degree

GED

High School Degree

Some College or University

College or University Degree

Some Technical/Trade School

Technical/Trade School Degree

16,507 enrollees

NC Current QuitlineNC Enrollment by Race/Ethnicity

White Black or African American

American Indian Hispanic Other0%

10%

20%

30%

40%

50%

60%

70%

63%

31%

3% 3% 3%

Mental Health Conditions Collected from QuitlineNC Enrollees : FY 2013

51% of QuitlineNC enrollees reported one or more mental health conditions

4%

15%

9%22%

4%

7%

3%

ADHDAnxietyBi-PolarDepressionDrug or Alcohol AbusePTSDSchizophrenia

Most Quitline Enrollees Have One or More Chronic Health Conditions FY 2013

84% of QuitlineNC enrollees reported one or more chronic health condition

14%

9%

5%

3%

11%

8%

20%

14%

16%

Arthritis

Asthma

CAD

Cancer

COPD

Diabetes

High Blood Pressure

High Cholesterol

None

84% of QuitlineNC enrollees reported one or more chronic health condition

Chronic Disease Referrals

QuitlineNC EnrollmentsJanuary 2011 – June 2013

Free NRT|- --Jan 1 – May 21------|

Statewide Media CampaignApril 23 – June 30

SHP funding only

QuitlineNC state funding reinstated

Jan-11

Jan-11

Feb-11

Mar-11

Apr-11

Apr-11

May-11

May-11

Jun-11Jul-1

1Jul-1

1

Aug-11Sep

-11Sep

-11Oct-

11

Nov-11

Nov-11Dec-

11Jan

-12Jan

-12Feb

-12

Mar-12

Mar-12

Apr-12

May-12

May-12

Jun-12Jul-1

2Jul-1

2

Aug-12Sep

-12Sep

-12Oct-

12

Nov-12

Nov-12Dec-

12Dec-

12Jan

-13Feb

-13

Mar-13

Mar-13

Apr-13

Apr-13

May-13

0

500

1000

1500

2000

2500

3000

3500

4000

719

806

1294

1219946

962 527

792

587

624

715

542

3397

2381

2945

33813735

2102

43

921 957

1679

699776

1443

1244

1732

2950

22682159

NRT provided to all

CDC TIPS

State Campaign

SHP only

NRT to uninsured only

NRT to all

CDC TIPS I

CDC TIPS 2

WHAT IS GOING WELL? QuitlineNC

QuitlineNC Annual Enrollments

FY 2007 FY 2008 FY 2009 FY2010 FY2011 FY2012 FY20130

5000

10000

15000

20000

25000

40965980 6537

7624

9835

20588

16814

QuitlineNC Services for Physician Network

• Quitline Fax Referral Program

• Physician training on incorporating QuitlineNC into tobacco treatment services

• Physician resources on integrating tobacco treatment

• HIPAA compliant

• Physician support line for assistance in tobacco treatment questions

• Physicians support for quitlines as a referral source

QuitlineNC meets a critical need of

service providers

Health Professionals Are the Number One Referral Source to QuitlineNC in FY2013

NC Division of Public Health Tobacco Prevention and Control Branch -QuitlineNC Monthly Data Reports 2013

Health Pro

fessio

nal

TV/Commerc

ial

Family/

Frien

dRad

io

Brochure/

Newsle

tter/Fly

er

Health Dep

artmen

t

Newspap

er/Mag

azine

Employer

/Works

ite

Websit

e

Community O

rganiza

tion

TV/N

ews

Health In

surance

Outdoor Ad

School/C

ollege

even

t

Basketb

all/sp

orting even

t

College W

ebsite

/Email

Studen

t Heal

th Servi

ces

Cigarett

e Pack

Text M

essage

SHP Ben

efit C

hange

0

1000

2000

3000

4000

5000

6000

QuitlineNC meets a critical need of

service providers

98% satisfaction rate by SHP members with over 2/3 being very satisfied.

“Thank you so much! I have been quit for almost 3 months. I can taste foods now. I can breathe again! I have COPD and my doctor was so happy when she listened to my lungs that she cut down on my other medications. My home smells good again and I am so happy. It’s affected my whole family as well. My daughter also quit for her new baby and she has been quit for 3 months now too!” Caller from Wayne County

“I couldn’t have done this without your help. I have not smoked in exactly one year and just having someone to talk to throughout my quit has really helped.” A.P., Harnett County

 “This program works! You all have made my life better. It feels so good to live life again and not give up. I really appreciate what you have done.” Caller from Forsyth County

Participants are satisfied with

QuitlineNC services

QuitlineNC Has Worked for the State Health Plan for Teachers and State Employees

Responder Quit Rate Intent to Treat Quit Rate

SHP Member 41.8% 21.1%

Non-SHP Members 36.9% 15.0%

30 day point prevalence at 7 months from initial call

QuitlineNC is high quality and

effective

6 Month Quit Rates Comparison

51%****

****NC State Health Plan Quit Rates from members who completed four or more counseling calls plus used all 8 weeks Nicotine Patches

*Fiore, Treating Tobacco Use and Dependence, Clinical Practice Guidelines 2008 Update** Alere Wellbeing, QuitlineNC Comprehensive Evaluation Report, 2011***State Health Plan for Teachers & State Employees, Evaluation Report, 2010-2011Responder rates at 30 days point prevalence

10% Physician Advice Alone*

30% QuitlineNC Counseling**

42% QuitlineNC*** Counseling & NRT

QuitlineNC is high quality ad effective

Six Months Quit Rates and Number of Successful Quits (30 day point prevalence1)- 5,109 Total Quitline Enrollment

SHP Allocation Intent-to-Treat Quit Rate2

Respondent Quit Rate3

Median Number of

Quitters

$1,080,972 21.1% (1078) 41.8% (2136) 1607

1. Respondents being tobacco free for the last 30 days or more at the time of the 7-month survey. 2. This measure regards non-respondents and those who responded “don’t know” or “refused” as continued tobacco users, and thus

provides a more conservative quit rate. 3. This measure includes only those respondents reached reporting successful tobacco cessation and thus provides a higher quit rate

QuitlineNC is very cost effective

State Health Plan Costs vs. Benefits

SHP Allocation Cost Avoidance "Benefit"$0

$500,000

$1,000,000

$1,500,000

$2,000,000

$2,500,000

$3,000,000

$3,500,000

$4,000,000

$4,500,000

$1,080,972

$4,274,620

Annual per Capita Medical Costs of Tobacco Use $2,660Number of individuals presumed to quit due to Quitline NC x 1,607

Estimated cost avoidance “benefit” $4,274,620

QuitlineNC is very cost effective

Annual Health Care Costs per Tobacco User and QuitlineNC Services

Medical Costs Cost per Enrollment Cost per Quit $-

$500.00

$1,000.00

$1,500.00

$2,000.00

$2,500.00

$3,000.00 $2,660.00

$212.00

$673.00

QuitlineNC is very cost effective

Cost Benefit Analysis

Benefit $4,274,620 $3.95---------- = --------------- = -------- = ~ 4:1 ROICost $1,080,972 $1.00 For every dollar SHP spent on QuitlineNC services, SHP saved $3.95.

QuitlineNC is very cost effective

RESOURCES Helping NC tobacco users who want to quit

Total QuitlineNC Funding and Enrollment

FY09 FY10 FY11 FY12 FY13 FY14 $-

$500,000.00

$1,000,000.00

$1,500,000.00

$2,000,000.00

$2,500,000.00

$3,000,000.00

$3,500,000.00

0

5000

10000

15000

20000

25000

6616

8321

9739

21728

16871

FundingEnrollment

Most Current QuitlineNC Year (2013) Compared to Goals for QuitlineNC Reach

Current R

each

in 2013

Public-Priv

ate Part

nerships G

oal

CDC Best Prac

tices Goal

Number of T

obacco User

s in North

Carolin

a0

200000

400000

600000

800000

1000000

1200000

1400000

1600000

22025 92400 123200

1540000

1.4%6%

8%

Partnering with QuitlineNC Makes Good Sense

Helps meet ACA criteria

QuitlineNC is high quality and

effective

Participants are satisfied with

QuitlineNC services

QuitlineNC meets a critical need of service providers

QuitlineNC is very cost effective

It is easy to partner with QuitlineNC

Coming soon - QuitlineNC – New Resources for Public Private Partnerships

Fiscal AgentNC Public Health Foundation

• Chuck Bridger – Key ContactOperations ManagerPhone: (919) 707-5237chuck.bridger@ncphf.org

• Elizabeth MacLachlanExecutive DirectorPhone: (919) 707-5237elizabeth.maclachlan@ncphf.org

Expert Advice and Technical Assistance

Tobacco Prevention and Control Branch

• Joyce Swetlick – Key ContactDirector, Tobacco CessationPhone: 919-707-5402Joyce.Swetlick@dhhs.nc.gov

• Sally Herndon Branch HeadPhone: 919-707-5401Sally.herndon@dhhs.nc.gov