May 2000

Grant Results

National Program

Tobacco Policy Research and Evaluation Program

SUMMARY

From 1993 to 1996, researchers at the Group Health Cooperative of Puget Sound, Seattle, assessed the impact of different insurance coverage structures on the utilization and cost effectiveness of smoking-cessation services in a health maintenance organization.

The demand for stop-smoking programs as well as patients' incentives to quit were measured and compared under four different coverage structures, each of which paid for different portions of two categories of smoking treatment: behavioral programs and nicotine replacement therapy.

The project was part of the Robert Wood Johnson Foundation's (RWJF) national program Tobacco Policy Research and Evaluation Program.

Key Findings

  • The study found that smokers with full coverage had the highest use rates of smoking-cessation services.

    The summary of the researchers' article in The New England Journal of Medicine states, "After adjusting for differences in rates of use during the first year of coverage, we estimated that 10 percent of smokers per year would use smoking-cessation services under full coverage, as compared with 2.4 percent under reduced coverage.

    Even with a slightly lower smoking-cessation rate under full coverage, we estimated that at least one and a half times as many smokers would quit per year under full coverage as under any of the other three coverage plans."

    Average cost to the health plan per user who quit ranged from $797 in the standard plan to $1,171 in the full coverage plan.

Funding
RWJF supported the project with a grant of $169,737 between September 1993 and March 1996.

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THE PROBLEM

Although cigarette smoking is a leading cause of premature morbidity and mortality, insurance coverage for smoking-cessation services is uncommon. Several factors are converging to support the provision of coverage for smoking cessation, including:

  1. An increased focus on managed care health plans that emphasize preventive services.
  2. Advances in smoking-cessation interventions, including protocols for identifying smokers and encouraging smoking cessation in primary care practice, effective multi-component behavioral programs, and the availability of new pharmacotherapeutic agents (transdermal nicotine patches).
  3. Evidence that smoking cessation is at least as cost-effective as other medical practices.

However, the lack of information about the effect of insurance coverage on the demand for and use of clinically effective smoking-cessation interventions is a potential barrier to wide-scale adoption of insurance coverage for smoking-cessation services.

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THE PROJECT

This grant supported a longitudinal study of a defined population of a large HMO to examine the effect of different insurance coverage structures on the utilization and cost effectiveness of smoking-cessation services. Four coverage options, each with different cost-sharing structures for smoking-cessation services, were offered to a selected employer group with at least 10,000 adult enrollees. A random sample of 200 adult enrollees covered under each of the four benefit options was identified and surveyed at baseline to estimate smoking rates and the characteristics of smokers. Utilization of services, cost data, and quit and satisfaction rates were tracked for a 12-month period. The four coverage options and their selected employer groups were as follows:

  • Full coverage for behavioral programs (BP) and nicotine replacement therapy (NRT) was studied in four employer groups combined: Group Health, Metro, King County, and Pierce County, all located in Washington state.
  • Standard coverage (50 percent copayment for BP and full coverage for NRT) was studied in the federal government employer group.
  • Flipped coverage (full coverage of BP and 50 percent copayment for NRT) was studied in the Boeing employer group.
  • Reduced coverage (50 percent copayment for both BP and NRT) was studied in the State of Washington employer group.

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FINDINGS

  • Use of smoking-cessation services varied according to the extent of coverage, with the highest rates of use among smokers with full coverage.
  • Changes in the standard benefit one year after introduction did result in changes in rates of cessation service use. Removing the BP program copayment (full and flipped coverages) resulted in increased use of the BP program alone. Adding an NRT copayment along with removal of the BP copayment (flipped coverage) did not result in lower overall use of cessation services, but did marginally reduce the percentage of BP users who obtained NRT prescriptions. Removing the NRT copayment and the BP copayment (full) resulted in increased use of the BP and NRT, although it did not impact the proportion of BP users who obtained NRT.
  • The summary of the researchers' article in The New England Journal of Medicine states, "After adjusting for differences in rates of use during the first year of coverage, we estimated that 10 percent of smokers per year would use smoking-cessation services under full coverage, as compared with 2.4 percent under reduced coverage. Even with a slightly lower smoking-cessation rate under full coverage, we estimated that at least one and a half times as many smokers would quit per year under full coverage as under any of the other three coverage plans." This is because more than three times as many smokers use the smoking-cessation benefit in the full coverage plans as in the other plans.
  • Average cost to the health plan per user who quit ranged across the four benefit coverage categories: $797 (standard coverage), $801 (reduced coverage), $870 (flipped coverage), $1,171 (full coverage). Annual cost to the health plan per enrollee ranged from $.89 (reduced) to $4.92 (full).
  • Satisfaction with the cessation services did vary as a function of the level and type of coverage. Enrollees who used the smoking-cessation service with reduced coverage expressed significantly lower satisfaction with the overall quality of service, overall cost of service, and the cost of BP and NRT.

Communications

An overall outcome paper was published in the New England Journal of Medicine in September 1998. A paper with preliminary results was presented at the 9th World Conference on Tobacco and Health in Paris in October 1994. See the Bibliography for details.

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GRANT DETAILS & CONTACT INFORMATION

Project

Impact of Co-payments on Use of Smoking Cessation Services in an HMO

Grantee

Group Health Cooperative of Puget Sound (Seattle,  WA)

  • Amount: $ 169,737
    Dates: September 1993 to March 1996
    ID#:  022927

Contact

Susan J. Curry, Ph.D.
(206) 287-2873

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BIBLIOGRAPHY

(Current as of date of this report; as provided by grantee organization; not verified by RWJF; items not available from RWJF.)

Articles

Curry SJ, Grothaus LC, McAfee T, and Pabiniak C. "Use and Cost Effectiveness of Smoking-Cessation Services Under Four Insurance Plans in a Health Maintenance Organization." New England Journal of Medicine, 339(10): 673–679, 1998. Abstract available online.

Presentations and Testimony

Susan Curry, "Insurance Coverage and Use of Smoking Cessation Services," at the 9th World Conference on Tobacco and Health, October 10–14, 1994, Paris, France.

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Report prepared by: Beth Brainard
Reviewed by: Janet Heroux
Reviewed by: Marian Bass
Reviewed by: Molly McKaughan
Program Officer: Robert Hughes
Evaluation Officer: Marjorie Gutman

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