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Daily Archives: January 5, 2016

Gaps Remain Among States’ Medicaid Efforts To Help People Kick Smoking Habit

The 2010 federal health law has a provision that was supposed to make it easier for people on Medicaid to quit smoking. But in a number of states, it’s not, so far, having widespread success.

That’s the main takeaway from a study published Tuesday in the journal Health Affairs. The law says all state Medicaid programs have to cover tobacco cessation drugs — meaning they have to pay for things like nicotine patches, Chantix, nicotine gum or Wellbutrin, when patients are using them to try to quit smoking. But it leaves states relative freedom in how they go about doing so and what conditions they place on how the benefit is applied.

That flexibility has consequences, according to the study’s authors. They examined Medicaid data and found that very few enrollees — about 10 percent nationwide in 2013 — got medicine that might help them stop smoking, even though Medicaid recipients are around twice as likely as average Americans to be smokers.

This KHN story also ran on PBS Newshour. It can be republished for free (details).

Both from a public health standpoint and an economic one, that’s a problem, said Leighton Ku, director of the Center for Health Policy Research at George Washington University and the study’s lead author. Figures from the U.S. surgeon general indicate about 15 percent of Medicaid’s expenses — $40 billion in 2010 — are caused by smoking. The authors estimated that number will reach $75 billion this year. By contrast, Medicaid spent $103 million in 2013 on smoking cessation drugs.

“This is something where you can improve health, you can save you money,” he said. “And we’re just not very effective at it.”

In 2013, the study found, about 1.7 million prescriptions were filled or refilled for drugs to help Medicaid patients quit smoking. That’s estimated to be enough to treat about 830,0Ǡ people — out of about 8.3 million Medicaid patients whom the researchers estimated were smokers in 2013.

Some states have done a markedly better job than others. In Minnesota, for example, almost 27 percent of smokers on Medicaid were using medications to help them quit smoking, the researchers found. In Texas, only 1 percent did.

Ideally, Ku said, 100 percent of smokers on Medicaid would get help quitting. But even the Minnesota experience — which has the highest proportion of Medicaid smokers getting those prescriptions — indicates the extent to which other states currently fall short, he said.

It’s not entirely clear why, according to the researchers. But there are a number of factors that could be at play. In some states, patients have to make co-payments toward the medication, or get prior authorization from the Medicaid program before getting the drug. Those are more or less “functional barriers” that keep Medicaid beneficiaries from getting the medicine that could help them quit, said Michael Fiore, a professor of medicine and director of the University of Wisconsin Medical School’s Center for Tobacco Research and Intervention. Fiore wasn’t involved in the study.

Smoking GraphicAnd often, the study notes, people don’t realize Medicaid covers smoking cessation drugs.

“This is still a new thing,” Ku said. “It’s underappreciated, under-recognized.” The federal government hasn’t placed much emphasis on the regulation, he added, though he thinks more state Medicaid agencies are starting to prioritize it.

The study also notes another wrinkle. When it comes to states where smokers on Medicaid have less frequently gotten cessation drugs, most declined to expand Medicaid to cover a larger number of childless adults, a component of the health law the Supreme Court made optional in 2012.

That connection, Fiore said, is probably because the same states that declined the expansion are often ones that haven’t emphasized preventive care — though that isn’t always the case. He also pointed out that Wisconsin has actively publicized the smoking cessation benefit, despite choosing not to expand the low-income health insurance program.

When states don’t help people quit smoking, Ku said, they will ultimately face greater health care costs, since smoking helps cause diseases such as lung cancer and chronic obstructive pulmonary disease.

“If [those states] would expand Medicaid, more people would have access to Medicaid that would cover tobacco cessations,” he said.

For Medicaid programs that do emphasize the benefit there’s a major opportunity to recoup that spending, Fiore said, citing evidence that for each Medicaid dollar states put toward quitting smoking, they recover three times that, in as little as two years.

And that doesn’t even account for the savings in terms of how helping people quit smoking can bolster the economy, or improve a family’s health, Fiore said. When parents stop smoking, children aren’t exposed to second-hand smoke – which affects poor children more than those from higher income families — and are less likely to develop asthma. Smoking can damage someone’s health enough that he or she can’t hold a steady job, he added, a drag on the economy for which these figures don’t account.

“There are very few things we do in health care that have a positive return on investment, and smoking cessation is one of those,” he added. “It doesn’t take a decade.”

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Feds Funding Effort To Tie Medical Services To Social Needs

The federal government has announced a $157 million project to help hospitals and doctors link Medicare and Medicaid patients to needed social services that sometimes have a bigger impact on their health than medical interventions.

Public health experts have known for decades that even with medical care easily available, patients are often limited in their ability to get better or maintain good health if they lack stable housing, access to healthy food, or the ability to get to and from medical appointments.

The goal of the “Accountable Health Communities” project is to find better ways to identify patients’ non-medical needs and connect them to available services in their communities. The social services to be linked include those related to housing, food, personal safety, inability to pay utility bills and transportation. The project will fund up to 44 separate experiments over five years. Applications are being accepted by the Centers for Medicare & Medicaid Services and announcement of the winning proposals is expected later this year.

This KHN story also ran on NPR. It can be republished for free (details). logo npr

The goal of combining medical and social services is not just to help patients, wrote the team in charge of the project in this week’s New England Journal of Medicine. “The test will assess whether systematically identifying and addressing health-related social needs can reduce health care costs and utilization.”

“Many community service organizations…might be able to help” patients with health-related social needs, said Dr. Patrick Conway, chief medical officer at CMS in a conference call with reporters, “but many clinics and hospitals aren’t linked well to these organizations.”

There are already small-scale examples of one-stop shopping for medical and social needs around the country that are showing positive results. For example, Hennepin Health in Minnesota, which serves low-income residents who are eligible for Medicaid, has reduced both hospital and emergency room admissions among its caseload.

The bigger challenge is “scaling up” — or figuring out how to provide such services to more people who need them.

Part of the problem is a cultural gap — not between the patients and providers, but between health care professionals and social service agencies.

Medical and social service providers “are not used to working with one another or collaborating,” said Tricia McGinnis, a vice president at the Center for Health Care Strategies, which works on projects to improve state Medicaid programs.

And more often than not, the bureaucracy involved, particularly in programs that serve the poor, can make collaboration difficult if not impossible.

For example, said CHCS Vice President Allison Hamblin, “fitting together a complicated Medicaid financing stream with a complicated housing financing scheme — it’s horrendous.”

McGinnis said that projects to connect health and social services are getting more popular as the health care moves towards a payment system that rewards medical providers for keeping patients healthy rather than simply doing things to them. Such systems provide a financial incentive to make sure social needs are met, if only to keep down their medical bills. But it’s not clear how fast those savings might materialize.

For the sickest and most expensive patients, things like helping them get to and from medical appointments and helping pay utility bills so they don’t have to choose between that and buying medication can produce savings “probably pretty fast,” she said. But for patients whose social service needs are purely preventive, “it’s hard to reap those (medical) savings quickly enough” to reimburse the social service providers.

Perhaps most critical to the program, said Ashish Jha, a professor at the Harvard School of Public Health, is that the 44 separate programs about to be funded be rigorously evaluated “so we actually learn what works and what doesn’t.”

The program is being run by the Center for Medicare and Medicaid Innovation, which was created by the Affordable Care Act to find ways to improve and pay for health care. But its record so far on providing results of its projects has been spotty, at best.

“The innovation center hasn’t been the strongest” at evaluation, Jha said.

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State Highlights: N.H. Heroin, Opioid Task Force To Take Proposals To State House; Conn. Grapples With Cost Transparency Law

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Calif. Group Fails To Get Ballot Referendum On Law Giving Terminally Ill Access To Lethal Drugs

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Missouri Lawmakers Recommend Contempt Proceedings For St. Louis Planned Parenthood Head

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Viewpoints: Quit Fighting Health Law And Fix It; The Money Trigger That Sets Hospital Stays

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LifePoint Health Buys Hospitals In Georgia, North Carolina

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States Put High Drug Prices On Agenda For 2016

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S.C. Lawmakers To Wrestle With Medicaid Costs, While Calif. Gets Waivers To Implement Reforms

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VA Won’t Help Pay For Service Dogs For Vets With PTSD

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