Medicaid Coverage for Smoking-Cessation Drugs Reduces MI and ACS Claims in Massachusetts

Reed Miller

December 08, 2010

December 8, 2010 (Boston, Massachusetts) Massachusetts' effort to provide smoking-cessation medication to low-income individuals appears to be paying off [1].

Massachusetts' Medicaid program, MassHealth, began comprehensive coverage of tobacco-cessation medications in July 2006 as part of the state's healthcare overhaul, which made Massachusetts the first state to require that everyone have health insurance.

About 75 000 people, or 40% of smokers eligible, took advantage of the MassHealth smoking-cessation benefit in the first two and a half years after its implementation. Surveys show smoking prevalence declined among MassHealth subscribers by 10% during this period.

No other state has reported anywhere close to the same level of adoption for their Medicaid smoking-cessation benefits, according to Dr Thomas Land (Massachusetts Tobacco Cessation and Prevention Program, Boston), who told heartwire that the high adoption rate among Massachusetts smokers on MassHealth may also be attributed to a "unique environment here in Massachusetts." The Bay State was one of the earliest to have a smoke-free-workplace law and has one of the highest medical-provider-to-population ratios in the US, so "there's a 'culture of quitting' here that may not be available in other states. You can't quantify some of these things, but it's probably part of the story [of] why it worked as well as it did," he said.

MassHealth subscribers can get FDA-approved smoking-cessation pharmacotherapies, including nicotine-replacement drugs or varenicline (Chantix/Champix, Pfizer), for $1 to $3 per month. In-person or telephone smoking-cessation counseling services are also covered, but MassHealth does not require subscribers to use the counseling services to get pharmacotherapy.

Fewer than half of state Medicaid programs cover tobacco-cessation treatment that includes both pharmacotherapy and counseling, only 12% cover behavioral counseling plus all of the medications approved for tobacco-cessation treatment by the FDA, and some programs further impede access to the therapy by requiring copays or counseling sessions, Land said. MassHealth's benefit does not have any of these requirements because "this was a benefit they wanted people to use, so the barriers were dropped, and we think that's why there was high utilization," Land said. "And it's not coincidental that Massachusetts health reform went into effect on the same day. There was a lot of [media] coverage of health issues at the same time and that may have increased the awareness that this benefit was available to them."

Land and colleagues used generalized estimating equations to analyze MassHealth hospital claims data for 21 656 MassHealth subscribers who were eligible for the benefit for at least 321 days in both the year before and the year after they began the therapy. The researchers focused their analysis on the pharmacotherapy benefit, because very few MassHealth subscribers took advantage of the counseling option--97% of all claims were pharmacotherapy, and of all subscribers who used the tobacco benefit, 98% had at least one claim for a tobacco-cessation medication. Their results are published online December 7, 2010 in PLoS Medicine.

After adjustment for demographics, comorbidities, seasonality, influenza cases, and the implementation of the statewide smoke-free-air law, Land et al's analysis shows that in-patient hospital admissions for acute MI declined 46% (p=0.049) and hospitalization for other acute coronary heart disease diagnoses declined 49% (p=0.04205) between the period prior to when the patients began tobacco-cessation pharmacotherapy supplied by MassHealth and the period after beginning the therapy.

However, there were no significant decreases in hospitalization rates for respiratory diagnoses or seven other diagnostic groups evaluated. Land pointed out that previous studies have shown that enactment of smoke-free laws precipitate significant declines in ACS and MI with little short-term change in respiratory problems.

This study analyzed only in-patient hospital claims data, but Land says his group is planning further studies of the MassHealth data to measure how the smoking-cessation program reduces emergency-department or regular doctor's office visits as well as a study of the impact on pregnancy complication rates. They are also planning a cost/benefit analysis.

Unfortunately, no other state is collecting data with the same level of detail on how many people are quitting smoking and how many are taking advantage of Medicaid smoking-cessation programs. He hopes the publication of this data may inspire other states to track these data to understand the impact of publicly funded smoking-cessation programs in their states.

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