A HUSKY Health Plan Initiative Presenter: Michael Hebert, MSW, MBA

1. A HUSKY Health Plan Initiative Presenter: Michael Hebert, MSW, MBA Rewards to Quit Coordinator, CHNCT September 11, 2013

2. The Challenge • 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 smoke; only 19.7% of adults without these conditions smoke (SAMHSA, 2013) • 60% of Medicaid members with serious mental illness smoke (SAMHSA, 2013) • 30% of CT’s Medicaid members smoke

3. Health Risk Factors • There are 363,900 (13.2%) adult tobacco users in Connecticut • Approximately 4,700 die of smoking related causes each year, which is about 13 deaths each day • 18.9% of all adult smokers are over the age of 45 • In 2010, 14.6% of women in Connecticut of child-bearing age (18-44 years) smoked cigarettes • 90% of chronic obstructive pulmonary disease deaths (COPD, or emphysema and chronic bronchitis) is caused by smoking. COPD prevalence rates are highest among those 65 years of age and older. • Approximately 80 to 90 percent of lung cancer deaths in women and men are because of smoking • Smoking is the major risk factor for heart disease, stroke and lower respiratory tract infections, which are all leading causes of death in people over the age of 50. Source: CT Department of Public Health

4. Participant Benefits • 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. • 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.

5. Incentives and Behavior Change • Many smokers want to quit and need assistance achieving their own goals: • 70 percent of current smokers want to quit • 52 percent of adult smokers stopped smoking for one day in an attempt to quit • Smoking cessation success rates are low (as low as three percent) • Too few seek professional services and medications • Low-income individuals are: • more likely to smoke and be in poor health, but • less likely to quit on their own (poor access to cessation programs, lack of support and/or coaching)

6. New Connecticut Medicaid Smoking Cessation Coverage Expanded Services Expanded Therapies Smoking Cessation Counseling Nicotine Replacement Therapies 24 -hour Telephone Quitline Prescription Medications for Cessation Peer Counselors (phase 2, June 2014)

7. Project Overview • CT Department of Social Services (DSS) was awarded a five-year grant from the Centers for Medicare and Medicaid Services (CMS) under the Medicaid Incentives for Prevention of Chronic Disease (MIPCD) grant program • Grant awarded to test impact of incentives on smoking behavior change among HUSKY A, C and D members ages 18 and over • The goals of the Rewards to Quit program are to: • Study the impact of financial incentives on quitting smoking with a special focus on: • Members with Severe and Persistent Mental Illness (SPMI) • Pregnant and Postpartum Women • Reduce rates of CT Medicaid members who smoke by 25 to 30 percent • 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

8. Rewards to Quit Project Partners • 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: • 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 Home Participants

9. Rewards to Quit Timeline Target Populations Available Locations Time Period Studied Medicaid Smokers Patient -Centered Medical Homes First providers begin recruitment on March 27, 2013 Pregnant and Postpartum Medicaid Smokers Federally Qualified Health Centers Recruitment ends Fall 2015 Medicaid Smokers with Severe & Persistent Mental Illness Local Mental Health Authorities Evaluation complete Fall 2016 Participating OBGYN & Pediatrician Practices

10. Current Uses of Financial Incentives • Health-related financial incentives are used to improve the following: • Health outcomes • Improve compliance • Lower medical spending • Improve worker productivity • Examples of targeted behaviors (MIPCD): • Weight loss • Smoking cessation • Diabetes and Cardiovascular Disease • Primary Care (Screening)

11. Role of the Participating Clinics * Existing Quitline protocols

12. Randomization Strategy • Randomized trials conducted by Yale University: • Compares those with incentives (“Intervention”) to those without (“Control”) • All patients have new access to cessation services • Only those participants enrolled in the “Intervention” receive financial incentives • Randomize to show causality: Does the program work? • Test the effectiveness of process (peer coaching) and cost (utilization) outcomes • CMS requires randomization

13. R2Q Measures • Assess effectiveness of financial incentives over standard care in the areas of: • Cessation Program enrollment • Use of counseling services (individual and telephonic) • Program dropout rates • Cessation success rates at three months and twelve months • Study will test various incentive levels: • No Incentive • Low ($) Incentive • Peer Coaching (June 2014)

14. Participant Enrollment Process Program Enrollment • Participant enrollment completed via clinicians within PCMHs, FQHCs, LMHAs, OB-GYN and Pediatrician offices • 365-day program cycle begins the day smokers agree to participate in the program. • Can enroll for up to two enrollment cycles • Each enrollment cycle = 12 months from date of enrollment • Enrollment cycle for pregnant women = 12 months or ([months of enrollment prior to delivery]+[6 months post-partum]), whichever is longer • Clinicians screen for smoking status • Patient eligible for study if: • Smoked within last 30 days • At least 18 years old • Enrolled in HUSKY A, C or D • Clinicians provide information about study and ask to participate. • If patient agrees to participate, initial screening questionnaire and enrollment forms required • If patient declines to participate, they will be asked again at all future visits. • Service Visit forms submitted for each treatment encounter

15. Rewards to Quit Incentives • The maximum incentive payments per member per activity (Treatment Groups only): • Counseling Sessions: • $5/each session with maximum of 10 sessions (total incentive payment of $50) • Two bonus payments of $15 each can be earned, each one for completing a series of five sessions • Tobacco-free CO breathalyzer tests: • $15 per negative test with a maximum of 12 tests per member • 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

16. Rewards to Quit Participation Status • 115 Rewards to Quit Participants • 70 Women Enrolled • 45 Men Enrolled • 172 Counseling visits received • 126 CO Breathalyzer Tests received • 7 NRT’s prescribed • 7 Rewards to Quit Active Clinics • 5 Control Clinics • 2 Intervention Clinics • 5 LMHAs • 2 FQHCs • This data reflects current information as of September 9, 2013

17. R2Q Support Services • Members can receive support with tobacco cessation questions by calling Member Services at 1-800-859-9889 • Members can receive free transportation to smoking cessation counseling visits and CO breathalyzer testing arranged by the participating provide by calling Logisticare at 1-888-248-9895 • Providers can receive support with enrollment applications and resources by calling Provider Services at 1-800-440-5071

18. ? Questions