Introduction
The Resolve 34 directive was established due to concerns that low-income smokers face significant obstacles in accessing support to quit smoking Despite recent advancements, many residents in the state continue to suffer from the adverse health effects of tobacco addiction, leading to substantial health-related costs for the entire state This study report, mandated by the Resolve, aims to address the identified gaps in access to effective counseling and nicotine replacement therapies for Maine smokers seeking to quit, with a particular focus on supporting low-income individuals.
The Partnership for a Tobacco-Free Maine (PTM), part of the Department of Health and Human Services and the Maine Center for Disease Control and Prevention (ME CDC), conducted the study, with the findings detailed in the attached Appendix A.
A workgroup comprised of members from PTM and its partner organizations was assembled to discuss the process for addressing the Resolve The members of the workgroup can be found in Appendix B, while Appendix C lists the stakeholders who received the preliminary proposals from the workgroup.
Study
The focus of this preliminary report, its study results, its model tobacco dependence 1 treatment program and preliminary proposals related to that program concern treatment in the public sector
“Public sector” support in Maine includes:
1 Federal support through Medicare (briefly described below);
2 State reimbursement for pharmacotherapy and counseling through the Medicaid
3 Payment for over the counter nicotine replacement therapy and counseling by the tobacco control program in Maine—PTM
PTM utilizes funds from the tobacco settlement to support various training and education initiatives aimed at promoting tobacco cessation and preventing tobacco initiation Key efforts include training healthcare providers, such as staff at Riverview Psychiatric Center, through the Center for Tobacco Independence, which also operates the Helpline Additionally, the Healthy Maine Partnerships contribute to educational outreach across the state PTM is currently engaged in a strategic planning process, set to conclude in March 2008, which aims to address the disproportionate effects of tobacco addiction on specific populations.
This study emphasizes the term "tobacco dependence" instead of "tobacco cessation," as it is more commonly referenced in related literature Both terms refer to various nicotine replacement therapies (NRT) and non-nicotine medications, collectively known as pharmacotherapies, which are essential in supporting individuals seeking to overcome tobacco addiction Additionally, treatment encompasses counseling services aimed at assisting tobacco users in their journey to quit The report specifically focuses on the financial and systemic support available for tobacco users in Maine, particularly through face-to-face counseling and pharmacotherapy funded by both private and public payers, aligning with the goals of the U.S Public Health Service.
Guidelines and U.S Centers for Disease Control and Prevention’s (U.S CDC) Best Practices for Tobacco Cessation
Tobacco dependence treatment is not a conventional medical treatment for a disease; rather, it serves as a preventive strategy aimed at overcoming an addiction often referred to as a 'chronic disease' due to its significant health consequences.
The upcoming report in December 2008 will provide conclusive recommendations on the proposals presented, while also addressing tobacco dependence treatment in the private sector and exploring potential collaboration opportunities between public and private sectors.
Overview of Problem and Costs
Commercially produced tobacco is primarily consumed as cigarettes, cigars, and pipes, with about 95% of tobacco sales in the U.S being cigarettes Smoking is a major risk factor for various cancers, particularly lung cancer, and is responsible for over 80% of lung cancer cases It is the leading cause of preventable illness and death in the United States Additionally, smokeless tobacco and traditional pipe or cigar smoking can lead to oral cancers and other serious health issues, despite not being directly linked to respiratory diseases.
Secondhand tobacco smoke is linked to serious health issues in both adults and children, including asthma, sudden infant death syndrome (SIDS), respiratory infections, and lung cancer The U.S Surgeon General has stated that any level of exposure to secondhand smoke carries some risk Consequently, decreasing tobacco consumption not only benefits smokers but also significantly lowers health risks for non-smokers.
Commercial tobacco is highly addictive, making it challenging for smokers to quit Despite approximately 75% of smokers expressing a desire to stop, only around 5% succeed in quitting without assistance However, utilizing treatment options such as counseling and pharmacotherapy significantly increases a smoker's chances of successfully quitting.
2 Traditional use of tobacco leaf for spiritual, religious or other purposes by Native Americans or others is not the subject of this report.
3 U.S Surgeon General’s Report, (SG) 2004, “The Health Consequences of Smoking”.
5 American Cancer Society Questions about Tobacco: accessed January 8, 2008 at http://www.cancer.org/docroot/PED/content/PED_10_2x_Questions_About_Smoking_Tobacco_and_Health.asp
Quitting smoking significantly boosts health, with the likelihood of success increasing by up to six times However, it often requires an average of six to seven attempts before individuals can successfully quit.
Nationally, about 21% or 45 million of all adults smoke 7 Smoking prevalence has dropped significantly since 1965 when the adult smoking rate peaked at more than 42%.
As of today, the number of former smokers has surpassed that of current smokers However, adult smoking rates remain significantly above the targeted 12% benchmark set for 2010 by the U.S CDC report "Healthy People," with the exception of Utah and two U.S territories.
Smoking and tobacco use are prevalent among individuals with low socioeconomic status in Maine, with higher rates observed in uninsured adults (40%), those on MaineCare (43%), low-income individuals (31%), and those with less than a high school education (35%) Additionally, high-stress occupations, including military service and outdoor jobs like construction, farming, and logging, are linked to increased smoking rates Notably, pregnant women enrolled in MaineCare smoke at significantly higher rates (33%) compared to the general population (18%).
Individuals with major depression and serious behavioral health issues, such as schizophrenia, exhibit significantly high smoking rates, with a recent survey indicating that 30% of Maine's non-institutionalized adults with behavioral health problems smoke A demonstration project, "Project Baby Steps," led by Dr Jan Blalock at the University of Texas, is exploring the effectiveness of non-drug intensive depression therapy to assist pregnant smokers in quitting, as pharmacotherapy is generally not advisable for most pregnant women due to fetal health concerns The study participants are predominantly low-income and many have experienced abuse Additionally, research by Dr Renee Goodwin from Columbia University revealed that in a 2002 study of over 1,500 pregnant women, 22% smoked during pregnancy, with 12% classified as nicotine-dependent Notably, 30% of these smokers had a mental health disorder, and more than 50% of those who were nicotine-addicted suffered from depression.
Finally, smoking is associated with racial, ethnic and sexual preference based minorities, including lesbians, gays and transgender persons, Native Americans and certain segments
7 National Center for Health Statistics: Health, United States, 2006.
9 U.S CDC: Cigarette smoking among adults –U.S., 2004 MMWR 2005, 54:509-513.
12 Health Care provider smoking cessation advice among U.S worker groups, Lee, David J et al, Tobacco Control 2007;16:325-328, Accessed on January 8, 2008 at http://tobaccocontrol.bmj.com/cgi/content/abstract/16/5/325
A recent survey highlighted that low-income outdoor workers, who exhibit high smoking rates, receive significantly less cessation advice from healthcare providers compared to their counterparts in white-collar jobs, as reported by the CDC in September 2007.
13 Pregnancy Risk Assessment Monitoring System (PRAMS) 2005
In a 2006 message, Superintendent David Profitt of the Riverview Psychiatric Center, Maine's inpatient psychiatric facility, reported that the smoking rate among its patients was a staggering 68% For more information, visit the official Maine DHHS website.
The article by Armour et al (2007) examines the prevalence of cigarette smoking and the treatment advice offered, specifically focusing on individuals with disabilities in the United States during 2004 It highlights significant disparities in smoking rates and access to cessation resources for disabled populations The findings underscore the need for targeted public health interventions to address these inequalities and improve smoking cessation support for individuals with disabilities.
16 Medical Health, September 17, 2007; last accessed January 8, 2008 at http://google-sina.com/2007/09/17/does-smoking-make-pregnant-women-depressed/
Recent data indicates significant variations in adult prevalence rates of certain conditions among Asian and African immigrants In Maine, these rates differ markedly by region, with the affluent urban district of Cumberland reporting the lowest prevalence at 16%, while the rural Aroostook region experiences the highest rate at 28.4%.
As of now, 218,585 adults in Maine smoke, accounting for 20.9% of the adult population This smoking rate is slightly above the national median of 20.1% Over the years, Maine's adult smoking rate has shown a gradual decline from a peak of approximately 27% in 1990 Additionally, per capita cigarette pack consumption in the state has reached an all-time low.
2006 (64.8 million) and more smokers now state that they are ‘sometime’ rather than
Recent data indicates that while the overall smoking prevalence may not have decreased, many daily smokers are reducing their cigarette consumption In 2001, Maine reported the highest smoking-related mortality rate in New England, with 304 deaths per 100,000 individuals, as per the CDC's SAMMEC software Notably, over 80% of lung cancer fatalities in the state were linked to smoking.
Maine has achieved a significant decline in youth smoking rates, with only 14% of high school students and 7% of middle schoolers currently smoking, a stark decrease from 39% in 1996 This notable reduction reflects a 64% drop in smoking rates among this age group over the past decade, showcasing the effectiveness of Maine's tobacco control program As a result, the state now boasts one of the lowest smoking rates in the country and in New England, despite being ranked 34th for median income.
While Maine exhibits promising trends in teen smoking cessation, these improvements are not reflected across all demographics The state's socio-demographic factors may play a significant role in the higher smoking rates among young adults A notable disparity in smoking prevalence persists between college-bound and non-college-bound high school seniors, with non-college-bound seniors in 2003 reporting smoking half a pack or more per day at a rate of 17.2%, compared to just 5.5% among their college-bound counterparts.
Tobacco Dependence Treatment, its Benefits and Efficacy
Nicotine Replacement Therapies (NRT) have been widely available for over a decade, offering various options to help individuals quit smoking These include over-the-counter products like nicotine patches, which deliver controlled doses of nicotine through the skin, and nicotine gum, which releases nicotine when chewed For those who cannot use patches due to skin issues or cannot chew gum because of dentures, prescription options such as nicotine spray and inhalers provide alternative solutions Additionally, nicotine lozenges, available as "Commit" or in generic forms, can serve similar purposes Bupropion, marketed as "Zyban," is another effective prescription treatment that aids in smoking cessation by functioning as an anti-depressant.
Varenicline, marketed as Chantix, is a prescription non-nicotine medication that acts as a partial agonist to help reduce cravings and diminish the pleasurable effects of smoking Approved by the U.S Food and Drug Administration (FDA) in May 2006, Varenicline has been recognized in clinical trials as generally more effective than nicotine replacement therapies (NRT) for smoking cessation.
2007, the FDA announced it had received reports that patients using Chantix for smoking cessation had experienced suicidal ideation and occasional suicidal behavior The FDA is currently reviewing reports 35
The monthly cost of nicotine patches and gum ranges from $60 to $120, which is similar to the expense of a pack-a-day cigarette habit However, for lighter smokers, those who roll their own cigarettes, or users of pipes and machine-made cigars, these alternatives may prove to be significantly more costly For additional cost estimates of pharmacotherapies, refer to Appendix D for MaineCare Other options include lozenges, sprays, inhalers, and varenicline.
34 Lightwood JM, Phibbs CS, Glantz SA: short term health and economic benefits of smoking cessation: low birth weight, Pediatrics 1999, 104:1312- 1320
The relationship between psychiatric symptoms and smoking cessation drugs, particularly varenicline, remains unclear, as some patients continue to smoke A notable case in 2007 involved singer Carter Albrecht, who was shot by a neighbor after exhibiting delirium, allegedly linked to the combination of varenicline and high alcohol consumption Additionally, smoking cessation products like sprays and inhalers can be quite costly, ranging from $100 to $250, posing a financial burden for uninsured smokers or those with limited pharmacy coverage, especially with long-term use.
Counseling, whether through face-to-face individual or group sessions, as well as phone-based support, has proven effective in helping smokers quit In Maine, a certification program for tobacco treatment specialists ensures that all counselors at the Maine Tobacco Helpline, who provide free assistance, are certified Thirty healthcare professionals across the state have successfully completed an intensive certification program offered by the Tobacco Treatment Specialist Certification Commission, a voluntary organization coordinated by the American Lung Association of Maine.
The Center for Tobacco Independence offers training in tobacco treatment for healthcare professionals, with counseling options ranging from brief to intensive However, state reimbursement for tobacco-related counseling is limited to certain disciplines and facilities, as per MaineCare rules MaineCare has provided $20 reimbursement for brief counseling by private providers, while outpatient clinics and rural health centers, including federally qualified health centers (FQHCs), follow different cost-related rates Additionally, OMS cannot reimburse counseling rates exceeding Medicare rates Currently, tobacco dependence counseling reimbursement is under review by OMS, with potential new reimbursement codes being discussed in the upcoming year.
There is a widespread agreement among the workgroup that financial incentives for private provider practices to identify and assist tobacco users through brief interventions are lacking This absence of financial motivation contributes to the low number of certified tobacco treatment specialists, as many healthcare providers do not pursue certification for more intensive counseling Additionally, clinical practices often lack the financial support to enable their trained staff to dedicate time away from other responsibilities to provide counseling for tobacco users.
The MaineCare Primary Care Physician Incentive Program may evolve to include tobacco identification and intervention as part of its quality indicators, as suggested in this report Currently, MaineCare offers incentive payments to primary care physicians who rank above the 20th percentile on specific performance measures, which do not encompass tobacco cessation activities but do cover lead screening and mammogram rates Further details will be provided in the final report, while Appendix F outlines the existing coverage for tobacco dependence pharmacotherapy and counseling in Maine.
Quitting smoking offers significant health advantages for individuals of all ages, with cardiovascular disease mortality rates cut in half within 1-2 years of cessation Additionally, the risk of lung cancer death decreases by 50-70% within five years after quitting Ultimately, former smokers can anticipate a life expectancy similar to that of non-smokers after 10-15 years of abstaining from tobacco.
Only 5% of smokers who try to quit without assistance succeed, while up to 33% of those who receive ongoing support, such as counseling and medication, manage to quit successfully For instance, Maine's Tobacco Helpline reported a quit rate of approximately 35% among callers who received counseling and nicotine replacement therapy (NRT) after six months in 2006.
C U.S Public Health Service Clinical Practice Guidelines (“ Guidelines”) and Best
The U.S Public Health Service and the U.S Centers for Disease Control and Prevention have published guidelines, with the initial guideline released in 1996 and a second in 2000 An updated draft is set to be finalized in March 2008 and is currently available in hard copy; however, as it is still a draft, the comments regarding the update may change.
The Guidelines provide essential advice for clinicians on treating tobacco dependence at the individual practice level, focusing on prescribing standards and physician practices The initial chapters recommend effective methods for identifying tobacco use and implementing interventions and counseling Key first-line treatments suggested for smokers aiming to quit include seven pharmacotherapies: nicotine patch, gum, spray, inhaler, Bupropion, lozenges, and varenicline (Chantix), which physicians should recommend when clinically appropriate.
Chapter 5 of the Guidelines focuses on system change and benefit design, emphasizing their importance for state purchasers in creating effective model state programs Meanwhile, Chapter 6 updates the evidence with new meta-analyses that support the intervention recommendations from Chapter 5, offering a comparative analysis of the success rates for various treatment methods.
The Update emphasizes the necessity for innovative counseling strategies tailored for adolescents, American Indians, and individuals with low educational attainment It advocates for real-world research over clinical trials and highlights the importance of generating consumer demand for effective treatments Additionally, it provides a comprehensive analysis of proactive quitlines and cessation interventions specifically designed for low socioeconomic status individuals, adolescent smokers, pregnant smokers, and those with psychiatric conditions.
36 U.S DHHS The health benefits of smoking cessation: A report of the SG U.S.DHHS, PHS, CDC, Office on Smoking and Health Rockville, MD 1990
37 U.S Public Health Service Clinical Practice Guidelines, 2000.
The System Interventions (Strategies) for system administrators and purchasers (briefly) are :
1 Implement a tobacco user identification system in every clinic
2 Provide education, resources and feedback to promote provider intervention
3 Dedicate staff to provide tobacco dependence treatment and assess the delivery of this treatment in evaluations
4 [Hospital based care intervention omitted as non-applicable.]
5 Include tobacco dependence treatments (counseling and pharmacotherapy) identified as effective in the guideline as paid or covered services for all subscribers or members of health insurance packages
6 Reimburse clinicians and specialists for delivery of effective tobacco dependence treatments and include these interventions among the defined duties of clinicians
By 2003, 90% of private insurance plans provided coverage for at least one tobacco treatment, a significant increase from 25% in 1997 Additionally, by 2005, 72% of Medicaid programs offered at least one treatment recommended by guidelines, up from 42% in 2000.
The Update also notes that studies have demonstrated the superior effectiveness of particular combinations of counseling and medications (33%) vs just counseling (22%) or just medication alone (12%)
Model Tobacco Dependence Treatment Program…
Based on the recommendations outlined in the Guidelines and Best Practices, along with findings from a preliminary study, the workgroup has concluded that an effective tobacco dependence treatment benefit for employees and beneficiaries covered by state or privately funded health plans should include comprehensive support and resources.
1 Screening and counseling for tobacco use treatment
• All benefit elements are consistent with the recommendations and conclusions of major evidence based Guidelines*, including the U.S Public Health Services’ Treating Tobacco
Use and Dependence: A Clinical Practice Guideline, 2000 (as updated)
• Tobacco use by the patient must be identified, documented, assessed and addressed by all clinicians in every clinical setting and at every visit (i.e., not just the annual physical).
• There is ready access to evidence-based counseling services, including individual (at brief and more intensive levels), group and telephone based counseling services, ensuring multiple opportunities for treatment.
2 Evidence based pharmacotherapy is readily available
All FDA-approved tobacco use treatment medications, including both prescription and over-the-counter options, are readily accessible Current first-line treatments encompass nicotine replacement therapies such as patches, gum, lozenges, sprays, and inhalers, along with the antidepressants bupropion and varenicline (Chantix) Additionally, coverage is available for the simultaneous use of multiple pharmacotherapies when clinically warranted.
• While strongly recommended, there is no requirement of participation in a formal counseling program as a precondition for gaining access to a medication benefit
Medication and counseling are most effective when combined but medication or counseling, alone, are more effective than self-help only.
4 Cost sharing and deductibles minimal; duration of treatment reflects successful quit patterns
• Patient out-of-pocket treatment costs are minimal; there are no significant co-payments, deductibles, step, prior authorization or lifetime or annual limits on coverage provided.
Tobacco treatment services offer multiple treatment episodes annually, allowing for four or more sessions per year, with coverage for at least two 90-day treatment courses per beneficiary Each session must exceed 10 minutes to address the frequent relapse patterns associated with tobacco dependence, ensuring effective support for individuals seeking to quit.
5 Targeting benefits to those most in need
Targeted smoking cessation programs are essential for special populations, such as pregnant smokers, who require tailored support that includes more intensive and proactive counseling, while avoiding Nicotine Replacement Therapy Other groups that would benefit from these specialized treatments include individuals with behavioral health and substance abuse issues, low-income individuals, teens, and members of the LGBTQ+ community, as well as racial and ethnic minorities like Hispanic/Latinos, Asians, and Native Americans.
6 Adequate reimbursement to appropriate providers
•A variety of trained clinicians, including certified tobacco treatment specialists, not just physicians, are eligible for reimbursement for providing tobacco cessation treatment.
• Reimbursement to providers for tobacco use treatment services is adequate to cover reasonable costs of delivering the service.
7 Education offered and Evaluation conducted
• A sustained education/promotional campaign is offered to raise awareness of the benefits and to encourage utilization (among health systems, providers and consumers).
The program establishes a framework for gathering essential data to track treatment and benefit utilization, aligning with the Health Plan Employer Data and Information Set (HEDIS) and National Committee for Quality Assurance (NCQA) standards related to tobacco use This data collection aims to assess both population-level and individual-level effects of the benefit.
This initial model program serves as a foundational overview, which will be enhanced and updated in the final report through further research and collaboration with private sector representatives, including service providers, major employers, and private insurers.
State Support
Under federal Medicaid regulations, smoking cessation benefits, including counseling and drug therapy, are optional, with the exception of children enrolled in the EPSDT program MaineCare covers preferred medications for smoking cessation, such as Bupropion, which is also used to treat depression, nicotine replacement therapies like patches and gum, and, since January 1, 2008, the non-nicotine medication varenicline.
MaineCare covers various nicotine delivery methods, including sprays, inhalers, and lozenges, with prior authorization under specific conditions All pharmacotherapy options require a $3.00 co-pay and are limited to a three-month annual supply, except for Chantix, which may be covered for up to six months once in a lifetime Brief counseling services are also available.
$20 per episode in most clinical settings, 3 times per year, is also reimbursed for a physician or physician supervised staff member See Appendix F for comparative chart summarizing these MaineCare benefits
Since August 2001, the Partnership for a Tobacco-Free Maine has managed and funded the operation of the Maine Tobacco Helpline, utilizing resources from the Master Settlement Agreement with tobacco manufacturers.
The Helpline offers evidence-based treatment for tobacco dependence in accordance with U.S Public Health Service Clinical Practice Guidelines Key components include the Maine Tobacco HelpLine and the provision of nicotine replacement therapies.
Medication Voucher program, and (3) Tobacco Treatment Training to educate health professionals about tobacco dependence and train Tobacco Specialists.
Since August 2002, the program has offered a telephony-based counseling service and a medication voucher program that provides free nicotine patches and gum Additionally, trained tobacco treatment specialists are available to offer complimentary counseling to Maine residents who are smokers and seeking to quit.
It serves on an annual basis an average of 4-6% (about 8-13,000 callers) of the current smokers in Maine This is a high utilization rate, compared to other quitlines around the country
Within 24 hours, trained certified tobacco cessation counselors provide assistance to callers, conducting evaluations under medical supervision If deemed clinically appropriate, callers may receive a voucher for complimentary cessation medications such as patches, gum, or lozenges, subject to certain exceptions.
Vouchers for cessation treatment are not available to callers with alternative coverage, including those with private insurance or public programs like MaineCare and Medicare, as counselors do not verify actual coverage status Callers with these insurances are directed to their providers for prescriptions Many insured callers report lack of coverage or exhausted limits, leading to potential delays in accessing medication due to lengthy appointment wait times with primary care doctors Approximately 25% of callers are uninsured, 21% are on MaineCare, and 54% have private insurance.
The Helpline facilitates fax referrals from healthcare providers, offering specific forms to federally qualified health centers, rural health centers, and hospitals Its callers largely reflect Maine's adult smoking demographic, with a higher representation of uninsured adults and a lower proportion of young adults Additionally, the Helpline provides support to a limited number of callers facing behavioral health challenges and assists teen and pregnant smokers exclusively through counseling.
The Helpline may not be the ideal solution for every smoker, as it primarily provides free over-the-counter medications like patches, lozenges, and gum to select callers However, it offers the most accessible option for adult smokers in the state to obtain medication and counseling, particularly when compared to other resources, including some large employer-sponsored programs.
State Master Settlement Agreement Funding for tobacco dependence treatment
Maine stands out as one of the few states that invests more than the minimum required funds from tobacco company settlements into tobacco control and health programs In FY08, approximately $17 million was allocated to these initiatives, overseen by PTM 39, including over $3 million designated for new programs and counseling vouchers distributed through the Tobacco Helpline and community providers However, this funding remains modest compared to the best practice standards set by the U.S CDC Notably, the Helpline estimates that for several years, around half of the medication voucher budget has been utilized for vouchers given to callers with private insurance that either has been exhausted or does not cover tobacco dependence medications.
From FY 2005 to 2007, MaineCare allocated between $1.3 million and $1.5 million for pharmacotherapy and counseling services aimed at assisting smokers enrolled in its programs to quit Notably, counseling expenses accounted for just 3% of the total costs incurred In FY 2007, the state's contribution amounted to 36.73%, equating to approximately $515,300 For a detailed overview of all MaineCare claims paid, refer to Appendix H.
In April 2007, a survey report evaluated the adoption of system strategies by state Medicaid programs, focusing on four key strategies: identification systems, education and feedback, coverage of treatment, and clinician reimbursement The report revealed that MaineCare had implemented elements of three out of the four strategies, while the first strategy, which pertains to a systematic identification system for tobacco users, was not addressed For more details, refer to the Adoption of System Strategies for Tobacco Cessation by State Medicaid.
Programs, Bellows, Nicole M et al, Medical Care, Vol 45, Number 4, April, 2007 and
Appendix G Three states -Oregon, Pennsylvania and West Virginia—had adopted some part of all four system strategies for cessation
Medicare's coverage for tobacco dependence treatment has seen improvements, yet it remains limited The program typically covers two types of counseling sessions: intermediate (3-10 minutes) and intensive (over 10 minutes) Beneficiaries are eligible for two quit attempts annually, with each attempt allowing for up to four counseling sessions, totaling a maximum of eight sessions within a 12-month period To qualify, a Medicare beneficiary must have a condition negatively impacted by tobacco use or experience issues with medication metabolism due to tobacco Additionally, tobacco cessation medications may be included under a Medicare "Part D" prescription plan.
39 PL 2007, c 240 depending upon the plan (each plan may vary), however, over the counter treatments such as the nicotine patch or gum are not covered by the Medicare plan
Approximately 34% of U.S military personnel currently smoke, with rates remaining stable since 2002 and an increase in smoking among younger members Maine has a significant population of veterans and active-duty military The Army, Navy, Marine Corps, Air Force, and Coast Guard provide group tobacco cessation classes for active duty, National Guard, reserve, and retired service members and their families However, Tricare, the health program for veterans and their families, typically does not cover pharmacotherapy or counseling for tobacco dependence In May 2006, Tricare launched a pilot program called “Healthy Choices for Life” in four states (excluding Maine), offering free one-on-one counseling through a quitline and complimentary nicotine replacement therapy via a mail-order pharmacy for those seeking to quit smoking.
Privately Funded Tobacco Dependence Treatment Insurers and Employers
Maine’s private health insurance market will be discussed in greater detail in the final report It generally consists of:
• the small group and individual insurance market (regulated by the Maine Bureau of Insurance) with insurers Anthem, Cigna, Aetna and Harvard Pilgrim comprising most of those markets;
The large group market in Maine operates without state regulation and encompasses ASO (Administrative Services Only) plans, where employers take on financial risk and manage their own health plans Notable examples include the Maine State Employees Health Plan, the Municipal Employees Health Trust, and the health plans offered by Hannaford Brothers and Bowdoin College.
• “Dirigo Choice”, the state sponsored health program with subsidized premiums for low income persons, with coverage through Harvard Pilgrim Health , effective January 1, 2008
Innovative Treatment Partnerships
Proposals
Proposals are grouped according to Guidelines’ system strategy addressed and state agency primarily responsible (or jointly responsible) for proposal is noted by acronyms PTM or MC.
(1) Implement systematic tobacco use identification and intervention in every clinical practice
MaineCare is introducing an incentive payment for participating physicians who systematically identify, record, and track tobacco use among patients, as well as provide interventions This initiative will be supported by training from the Center for Tobacco Independence, ensuring that physicians are equipped to effectively address tobacco use in their practice.
(2) Provide education, resources and feedback to promote provider intervention
Implement a statewide patient fax referral system through primary care providers to the Maine Tobacco Helpline, ensuring comprehensive feedback on patient outcomes Additionally, assess the cost-benefit analysis of the fax referral system to enhance its effectiveness and sustainability.
• Provide feedback to primary care providers on utilization of tobacco counseling services by MaineCare members within their practice by developing a quarterly report of counseling code utilization MC
• Educate identified MaineCare members who smoke about pharmacotherapies and about tobacco cessation options through tracking of their claims and through partnership with manufacturers’ pharmacy representatives MC
(3) Dedicate staff to provide tobacco dependence treatment and assess that treatment
This project aims to implement and assess a community-based tobacco treatment counseling program that focuses on intensive support for pregnant women, youth, and individuals with co-morbid mental health issues The initiative will be delivered through Rural Health Centers located in underserved areas of Maine, ensuring that vulnerable populations receive the necessary resources and care to combat tobacco use effectively.
Implement a pilot project that assesses the effectiveness of a stepped care approach, integrating HelpLine counseling with personalized face-to-face treatment for young tobacco users This initiative specifically targets pregnant individuals and those with co-morbidities or mental health challenges, providing the necessary professional support to facilitate their quitting journey.
(4) Include tobacco dependence treatments (counseling and pharmacotherapy) as paid services for all subscribers/members of health plans
• MC will explore increasing rate of reimbursement for more intensive tobacco counseling and for professionals including certified tobacco cessation specialists who provide this service (fiscal impact) MC/PTM
• MC will explore waiving co-pays for pharmacotherapies and eliminating current requirements of step therapy (fiscal impact) MC
(5) Reimburse clinicians and specialists for effective tobacco dependence treatment
• MC will explore reimbursable counseling reimbursement to additional provider disciplines, including certified tobacco cessation specialists (fiscal impact) MC
Conclusions
The workgroup aims for this report, along with the model tobacco dependence treatment program and preliminary proposals, to serve as a basis for informed discussions about enhancing public and private sector support for tobacco treatment It seeks to foster collaboration among policymakers, stakeholders, and others dedicated to improving the tobacco dependence treatment system in Maine.
Research shows that tobacco dependence treatment is highly effective in achieving abstinence and is the top preventive health care measure, offering significant cost-effectiveness However, it is often inadequately addressed by most insurers, employers when designing health benefits, and primary care physicians, leading to its underutilization among tobacco users.
Despite improvements in smoking cessation efforts across the country and in Maine, significant barriers still hinder smokers from accessing affordable treatment Key issues include the low rates of healthcare providers systematically identifying smoker status and referring patients for intensive treatment, high out-of-pocket costs for nicotine replacement therapy (NRT) and other medications, inconsistent insurance coverage for counseling services, and lengthy wait times to see primary care doctors for prescriptions.
The workgroup aims to create an actionable plan for implementing the preliminary proposals, contingent upon their fiscal feasibility, by the end of the 2008 fiscal year Additionally, they plan to engage in more in-depth discussions with physicians, tobacco treatment specialists, service providers, insurers, and employers throughout the year to finalize their recommendations.
The National Commission on Prevention Priorities emphasizes the importance of preventive care, highlighting its usage, disparities, and health benefits in a report by the Partnership for Prevention from August 2007 This initiative aims to enhance access to tobacco dependence treatment for residents of Maine through collaborative efforts.
PLEASE NOTE: The Office of the Revisor of Statutes cannot perform research, provide legal advice, or interpret Maine law For legal assistance, please contact a qualified attorney.
Resolve 123rd Legislature First Regular Session
Chapter 34 S.P 499 - L.D 1421 Resolve, Regarding Tobacco Cessation and Treatment
The Department of Health and Human Services, in collaboration with the Partnership for a Tobacco-Free Maine, Maine Center for Disease Control and Prevention, and the Office of MaineCare Services, is tasked with studying best practices and clinical guidelines for tobacco cessation treatment This study will utilize the latest clinical practice guidelines from the U.S Department of Health and Human Services Public Health Service and aim to develop a model tobacco cessation program applicable in both public and private sectors A report on the findings is expected to be submitted to the Joint Standing Committee on Health and Human Services by January.
15, 2008 The committee may submit legislation to the Second Regular Session of the 123rd Legislature related to best practice treatment and clinical practice guidelines for tobacco cessation treatment.
Department of Health and Human Services
Office of MaineCare Services (MaineCare)
Brenda McCormick Director, Division of Health Care Management
Roderick Prior, MD Medical Director, MaineCare
Steve Davis Director, Division of Policy and Performance
Nicole Rooney Comprehensive Health Planner II
Bruce McClenahan Manager, Pharmacy Unit, Division of Health Care Management Melody Martin Manager, Quality Management Unit, Div of Health Care Management
Partnership for a Tobacco Free Maine, Maine Center for Disease Control and Prevention
MaryBeth Welton Tobacco Control Program Manager, Partnership for a Tobacco- Free Maine
Coalition on Smoking or Health/Health Policy Partners of Maine
Pamela MB Studwell Senior Policy Analyst
Allesandra Kazura MD Co-Director (medical), Maine Tobacco Helpline
Kenneth Lewis Co-Director, Maine Tobacco Helpline
Tobacco Treatment Specialist Certification Commission
Alfred Wolff Center for Tobacco Independence, Prog Manager, Education and Training
Rebecca Hitchcock RN CTI, Counselor
Katherine Pelletreau Director, Maine Association of Health Plans
Katie Fullam-Harris Anthem, Director of Government Relations
Maxwell Barus, MD Co-Medical Director, Anthem
Michael Fleming HEDIS Coordinator, Anthem
Maureen Kenney Employee Benefits, Hannaford Brothers
Ellie Udeh Wellness Program Director, Hannaford Brothers
Health Policy Partners/Maine Coalition on Smoking or Health
Pam Studwell Senior Policy Analyst
John LaCasse MD Medical Care Development, (also, Maine Practice Improvement Network)
Ed Miller Executive Director, American Lung Association of Maine
Lani Graham MD Maine Health Access Foundation
Daniel Meyer PhD PTM Advisory Council (Dir of Research, ME-Dartmouth Family Practice)
Rep Lisa Miller Maine House of Representatives
Joanne Joy Healthy Communities, Capitol Area, Director, Behavioral Health Task Force
Phyllis Wolf PTM Advisory Council
Prepared by OMS on 4/07; state/federal share (FY07): 36.73% / 63.27%
The certification of trained Tobacco Treatment Specialists is a program of the American Lung Association of Maine (ALAME)
Tobacco treatment is based on the Clinical Practice Guideline: Treating
Tobacco Use and Dependence (U.S Public Health Service, June 2000) The
Guideline contains strategies and recommendations to assist tobacco treatment specialists and clinicians to deliver effective, evidence-based treatment for tobacco use and dependence
A Certified Tobacco Treatment Specialist (TTS-C) is a trained healthcare professional specializing in tobacco dependence treatment Equipped with the necessary knowledge and skills, the TTS-C offers effective strategies for managing tobacco addiction and serves as a valuable resource for other healthcare providers Additionally, the TTS-C is adept at delivering tailored treatment for special populations, including individuals with co-morbidities, chemical dependencies, or those who are pregnant.
ALAME has established a commission of experienced professionals in addiction and substance abuse, as well as counseling and intensive tobacco treatment, to supervise the certification process for individuals aspiring to become certified tobacco treatment specialists.
Provide quality assurance to clients, third party payers, employers, and referring health care providers
Ensure best practice performance standards
Graduate of the 2-day Intensive Tobacco Training provided by the
Partnership for a Tobacco Free Maine (PTM)
Minimum of a 2-year degree in a health-related field such as but not limited to health education,mental health or nursing A complete listing is on the application form.
In the past three years, I have accumulated 240 hours of documented experience in intensive tobacco treatment, which can include hours completed up until the submission of my case study for review by the TTS-C Commission.
*Refer to Practice Components of an Intensive Tobacco Treatment Intervention
Certification Process – Each step must be successfully completed before moving on
Step 1: Complete and submit application Tobacco Treatment Certification
Commission for review and acceptance
To be eligible, applicants must provide documentation of at least 240 hours of intensive tobacco treatment within the last three years Notably, these hours can continue to accrue until the case study is submitted for review, allowing for ongoing professional development and training.
Step 2: Pass the TTS-C written certification examination
Step 3: Prepare and submit a case study of an intensive tobacco treatment intervention to the Commission for review and acceptance
Step 4: Demonstrate application of the Core Competencies of a Tobacco
Treatment Specialist by successfully presenting your case study before the Commission once the case study has been accepted
The exam features a combination of multiple choice and essay questions, focusing on the Clinical Practice Guideline and essential competencies, including the Biology of Nicotine Dependence, Patient/Client Intake and Assessment, Counseling, Pharmacology of Tobacco Treatment, Treatment of Special Populations, Relapse Prevention, and Organizational Needs.
The American Lung Association of Maine (ALAME) collaborated with the Center for Tobacco Independence (CTI) and the Partnership for a Tobacco-Free Maine (PTM) to create the Maine Tobacco Treatment Specialist program This initiative aims to enhance tobacco cessation support and resources across the state, promoting healthier lifestyles and reducing tobacco-related health issues.
The Certification Program features a clear distinction between the training and certification processes, with CTI overseeing the training and ALAME managing the certification This separation is designed to align with best practices from other professional certification programs and to prevent potential conflicts that may arise if one organization were responsible for both training and certification.
Contact: The American Lung Association of Maine at 1-800-499-5864 or
Email Lee Scott at lscott@lungme.org
CURRENT TOBACCO TREATMENT COVERAGE OVERVIEW - MAINE Insurance Coverage for Nicotine Replacement Therapy, Bupropion & Counseling
Source of coverage Nicotine Patch Nicotine Gum Spray Lozenge Inhaler Zyban Chantix (varenicline) Smoking
Up to 3 months supply / year;
CO PAY (3.00); requires provider script although over the counter medication
Up to 3 months supply / year;
CO PAY (3.00); requires provider script although over the counter medication
Prior authorization is required for certain medications, particularly if previous treatments such as gum and patches have been unsuccessful This applies in cases where a medical condition prevents the use of the preferred drug or when there is a potential interaction with another medication Additionally, a copayment may be necessary, and an appointment with a healthcare provider is recommended.
Available to patients not able to tolerate patch or gum COPAY; provider apptmt
Prior authorization is required for medication use if previous attempts with gum and patches have been unsuccessful, or if there is a medical condition that prohibits the use of the preferred drug, or if there is a potential drug interaction Additionally, copayment and a provider appointment may be necessary for obtaining the preferred medications.
Bupropion SR 100 and 150mg instead, which is the generic form of Zyban
Up to 6 mos w/COPAY; effective 1/1/08, available w/o prior authorization;
Note: patch and gum prescribed with Chantix, may be paid, with prior authorization not covered
99402 - used alone or in addition to appropriate code (3/patient/cale ndar year/doctor); effective 1/1/08 new codes 99406 3-10 minutes; and 99407 10+ mins
Harvard Pilgrim plan available 1/1/08; coverage unknown
Harvard Pilgrim plan available 1/1/08; coverage unknown
Harvard Pilgrim plan available 1/1/08; coverage unknown
Harvard Pilgrim plan available 1/1/08; coverage unknown
Harvard Pilgrim plan available 1/1/08; coverage unknown
Harvard Pilgrim plan available 1/1/08; coverage unknown
Harvard Pilgrim plan available 1/1/08; coverage unknown
Harvard Pilgrim plan available 1/1/08; coverage unknown
Harvard Pilgrim plan available 1/1/08; coverage unknown
$200 / year (after deductible is met), $400 / lifetime (for all NRT and Zyban) $10 PCP co pay
$200 / year (after deductible is met), $400 / lifetime (for all NRT and Zyban) $10 PCP co pay
Covered with prescription $200 / year (after deductible is met),
$400 / lifetime (for all NRT and Zyban)
$200 / year (after deductible is met), $400 / lifetime (for all NRT and Zyban) $10 PCP co pay
LIMIT Base Coverage includes: Covered with prescription
$200 / year (after deductible is met), $400 / lifetime (for all NRT and Zyban)
Covered with prescription $200 / year (after deductible is met),
$400 / lifetime (for all NRT and Zyban)
LIMIT Base Coverage includes: Covered with prescription $200 / year (after deductible is met), $400 / lifetime (for all NRT and Zyban) $10 PCP co pay
Smoking cessation classes provided through a hospital or physician's office $35/class,
2 physician follow-up visits anually