THE ROLE OF HEALTH PLANS IN TOBACCO CONTROL

Annu. Rev. Public Health 2003. 24:247 66 doi: 10.1146/annurev.publhealth.24.100901.140838 Copyright c 2003 by Annual Reviews. All rights reserved First published online as a Review in Advance on December 2, 2002 THE ROLE OF HEALTH PLANS IN TOBACCO CONTROL Marc W. Manley, 1 Tom Griffin, 2 Steven S. Foldes, 1 Carolyn C. Link, 1 and Rebecca A.J. Sechrist 2 1 Blue Cross and Blue Shield of Minnesota, Center for Tobacco Reduction and Health Improvement, Eagan, Minnesota 55121; 2 Minnesota Institute of Public Health, 2720 Highway 10 Mounds View, Minnesota 55112; email: marc manley@bluecrossmn.com, tgriffin@miph.org, steven s foldes@bluecrossmn.com, carolyn l carlson@bluecrossmn.com, bsechrist@miph.org Key Words coverage smoking, managed care, health improvement, tobacco use, insurance Abstract Health plans play an important role in tobacco control. In this chapter we present an overview of the scientific research on health plan involvement in clinical and community interventions regarding tobacco use. Also included are interventions that have been undertaken by health plans to lower smoking rates among their members and the general population. We conclude with a new model that can be used to engage health plans in tobacco control efforts and a case study that outlines how one health plan has implemented this new model. INTRODUCTION Tobacco use is the leading cause of preventable death and disease in the United States. More than 440,000 deaths each year in this country are attributable to tobacco use (9). Approximately one third of all tobacco users in the United States will die prematurely because of tobacco dependence, and others will experience disability and pain. Because of the addictive nature of nicotine, millions of tobacco users are unable to overcome their nicotine dependence, despite their awareness of the clear connection between tobacco use and negative health consequences. Clinical interventions are effective in treating nicotine dependence. In 1996, the Agency for Health Care Policy and Research (AHCPR) [now the Agency for Healthcare Research and Quality (AHRQ)] released a clinical practice guideline for smoking cessation that described a range of strategies that health care providers can implement to institutionalize nicotine addiction treatment. Updated in 2000, the Guideline provides direction for improving cessation efforts. It describes the growing knowledge of the effectiveness of various treatment approaches and an increased understanding of the value of offering a range of services to motivate and 0163-7525/03/0505-0247$14.00 247

248 MANLEY ET AL. assist smokers to quit. Evidence also exists documenting the cost-effectiveness of smoking-cessation treatment (29). In addition to clinical interventions, there is strong evidence that sustained and substantial community interventions can decrease smoking rates in large populations. States such as California, Massachusetts, and Arizona have demonstrated that sustained commitment to aggressive and comprehensive tobacco control can decrease the prevalence of smoking, and in the case of California, can decrease the lung cancer death rate (10, 27). The Role of Health Plans Guidelines and best practices exist for clinicians and state public health agencies, but the health plan model for effective tobacco reduction is still being designed. Health plans can play a key role in implementing policies and programs that can reduce the negative impact of tobacco use on individuals and society. Health plans have the opportunity to provide coverage for nicotine addiction services, encourage health care providers to address tobacco use following accepted practice guidelines, and monitor progress toward the goal of decreasing tobacco use (20). In addition, health plans can support tobacco control efforts that are focused on the entire population by participating in campaigns to create smoke-free environments, increasing the cost of tobacco products, and limiting access to tobacco products. Many health plans have only begun to add tobacco control to their agendas. Initially, health plans simply paid claims for tobacco-related diseases without attempting to address the root cause of these conditions. As awareness grew over the past decade of tobacco as the leading preventable cause of disease and death in the United States, many health plans began limited, frequently disconnected activities designed to reduce tobacco use among their members. More recently, a small number of health plans launched more fully funded, comprehensive, population-based tobacco control programs. Health plans vary substantially in their approaches to managing health care, their organizational capacities, and their interest in and strategies related to tobacco control. Even defining health plan is a challenge. Health plans have evolved substantially since the rapid growth of managed care began in the 1970s. For the purpose of this article, a health plan is defined as an organization that insures the health care for a defined population and employs managed care techniques. These techniques are designed to improve the health of this population, improve health care quality, coordinate medical care, and control costs. The techniques may include benefit design, prevention and early treatment programs, provider credentialing and network design, health care quality improvements, coordination of care across multiple providers, disease management programs, utilization review, and restricted formularies and generic drug substitution programs. Health plans operate within different limits from those of the state health departments that pioneered tobacco control. Even a superficial review of the health plan context indicates both constraints and opportunities for tobacco control that differ from other contexts, such as state health departments. Table 1 compares

HEALTH PLANS AND TOBACCO CONTROL 249 TABLE 1 Selected characteristics of state health departments and health plans affecting tobacco control activities State health department Health plans Motivation Save lives; reduce morbidity Save lives; reduce morbidity; save money; demonstrate health plan value to purchasers Population Entire state Enrolled membership Approach Population-based May be clinic-based or populationbased, but for a population with greater turnover Special Local health departments; Physicians, employers, members relationships Center for Disease Control and Prevention (CDC) Data sources Behavioral Risk Factor Surveillance Claims records, special surveys; System (BRFSS); death records, HEDIS indicators special surveys; cancer registry Unique concerns Legislatures Short-term return on investment these contexts in several areas. A state health department s basic motivation to implement tobacco control is to save lives and reduce morbidity. While these motivations exist in a health plan, there are other salient forces at work. These include the need to control health care costs and to demonstrate the health plan s value to its purchasers. The pervasive emphasis on providing health care within a specified budget presents a major challenge to implementing tobacco control programs as well as all the other health improvement programs that require long-term investment. State health departments and health plans take population-based approaches to prevention, but the higher annual turnover in health plan populations means that the return on the investment in health improvement may not accrue to the company that makes the initial investment. When compared to other organizations, health plans have some advantages for tobacco control. Health plans have ongoing contractual relationships with health care providers, employers, and their members. These relationships offer avenues for communication, options for incentives, or requirements for performance to achieve specific objectives. Health plans also have administrative claims and other individual level data to determine health status, health care utilization, and costs. These may be linked to information about the status of tobacco use. Finally, health plans are often large and influential companies, with the ability to influence health policy through legislators and other decision-makers. The purpose of this paper is to describe the role of health plans in tobacco control. It includes a review of scientific literature on this topic and reviews clinical and community interventions that have been conducted by health plans to reduce tobacco use. Excluded are studies that have been conducted in a health maintenance organization (HMO) setting where the primary purpose was to test a specific clinical intervention, such as nicotine replacement. Instead, we focus on interventions

250 MANLEY ET AL. undertaken by health plans for the specific purpose of lowering smoking rates among their members and the general population. This review is not intended to summarize the tobacco control activities of all health plans. It includes recommendations for health plans to consider when implementing a comprehensive tobacco control program and a brief case study of such a program. ECONOMIC BENEFITS OF TOBACCO CONTROL TO HEALTH PLANS Tobacco use costs the United States more than $150 billion each year. Included in this figure is over $75 billion in health care costs (9). The case has been extensively and repeatedly made that tobacco cessation and prevention are among the most cost-effective measures available to society. One analyst referred to smoking cessation as the gold standard of health care cost effectiveness (22). A large and growing literature examines the cost-effectiveness of smokingcessation programs (23, 65, 68). Whether measured in cost per life-year saved (LYS), cost per quality-adjusted life years (QALY), or cost per quitter, the costeffectiveness of smoking cessation compares favorably with other widely accepted preventive services. The cost-effectiveness of tobacco control programs has been extensively examined in the clinical setting (16, 17, 18, 30), with pharmacotherapy (50, 67), for pregnant women (25, 37) and other high-risk groups, and in the work setting (4, 28, 34, 69). These findings are helpful in building and sustaining support for tobacco control among plan administrators and medical staffs (49). One study (56) examined the relationship between modifiable health risks and short-term health care charges in a health plan population aged 40 and older. Examining health plan charges prospectively over 18 months, they found that tobacco use was related to 18% higher charges. These results provide evidence that reducing these health risks may offer health plans relatively short-term returns on investments for persons in this age group. Reassuring as these analyses are about the ultimate value to society of tobacco control, only a few focus specifically on the issues that concern health plan managers. For health plans, the benefits of prevention tend to be abstract and distant, whereas the costs are tangible and immediate. Key questions from the health plan perspective include the potential repercussions of cessation benefits on utilization and costs of services, the implication of member turnover for return on investment, and the length of time until returns may be realized. One analysis suggests that for the health plan the return on investment in a workplace cessation program becomes positive within ten years based exclusively on savings in health care costs, even with a 10% annual turnover rate common to many health plans (70). Health plans, however, are keenly aware of the needs of employers. From an employer s point of view, the return on investment from funding a cessation program may be much

HEALTH PLANS AND TOBACCO CONTROL 251 more rapid. One analysis suggests a break-even point of just over three years (69). CLINICAL INTERVENTIONS What Constitutes Effective Treatment? Certain clinical interventions have demonstrated effectiveness in helping individuals stop smoking. Seventy percent of smokers in the United States report that they would like to quit smoking (64). Only 6% of smokers will stop smoking on their own (11). The United States Public Health Service (USPHS) Guideline emphasizes that dependence on tobacco is a chronic condition that often requires repeated efforts to quit. The Guideline states that every patient who uses tobacco should be offered at least one of these options: (a) Patients willing to try to quit using tobacco should be provided with treatments identified as effective in the Guideline; (b) Patients unwilling to try to quit using tobacco should be provided with a brief intervention designed to increase their motivation to quit. Clinical interventions include brief messages delivered to smokers during encounters with a health care provider. Because 80% of Americans over age 18 visit a health care provider at least once each year, this strategy could reach large numbers of smokers (5). Clinicians can use the five As approach to provide a brief clinical intervention in less than five minutes. The five As approach suggests that clinicians Ask patients about smoking, Advise all smokers to quit, Assess each smoker s willingness to attempt to quit, Assist those who want to quit, and Arrange follow-up visits with those who are trying to quit (33). These minimal clinical interventions have increased successful quit attempts and increased smokers motivation to quit. It is essential that clinicians and health care delivery systems (including administrators, insurers, and purchasers) institutionalize the consistent identification, documentation, and treatment of every tobacco user who is seen in a health care setting (29). Intensive clinical interventions involve extensive interaction between a smoker and a health care provider. These interventions often include multisession counseling and therefore reach only a small number of smokers. Increasing the intensity, frequency, and duration of the intervention is associated with greater success (66). The Guideline suggests that three types of counseling and behavioral therapies were especially effective and should be used with all patients who are attempting tobacco cessation: (a) provision of practical counseling (problem solving/skills training), (b) provision of social support as part of treatment (intra-treatment social support), and (c) help in securing social support outside of treatment (extra-treatment social support) (66). Pharmacologic interventions include both nicotine-replacement therapies (nicotine gum, nicotine patch, nicotine inhaler, and nicotine spray) and buproprion. Both have been demonstrated to be effective aids to quitting smoking in randomized,

252 MANLEY ET AL. controlled trials. Except in the presence of contraindications, these should be used with all patients who are attempting to quit smoking (29). Impact of Coverage for Behavioral and Pharmocological Interventions The USPHS Guideline made two recommendations regarding insurance coverage for the treatment of nicotine addiction: 1. Include tobacco dependence treatments (both counseling and pharmacotherapy) identified as effective in this Guideline, as paid or covered services for all subscribers or members of health insurance packages. 2. Reimburse clinicians and specialists for delivery of effective tobacco dependence treatments and include these interventions among the defined duties of clinicians (29). A federal Task Force on Community Preventive Services recommended reducing patient out-of-pocket costs for effective cessation therapies. Sufficient scientific evidence demonstrates that reducing out-of-pocket costs for effective cessation therapies increases both use of the effective therapy and patient tobacco use cessation (36). Other authors have recommended that Medicaid cover tobacco treatment services (2). Insurance coverage may refer to payments that reduce or eliminate out-ofpocket costs to patients receiving services or to the reimbursement of health care providers for a particular service. A small number of studies have examined the effect of reduced out-of-pocket costs on patients use of tobacco treatment services and their smoking behavior. In general, reductions in patients out-of-pocket expenses have resulted in increased utilization of services. This is particularly true for pharmacotherapy (15, 21, 38, 40, 59). Utilization of behavioral therapy (group counseling and telephone counseling) has also increased when patients costs are reduced or eliminated (21, 59). It is less clear that reductions in patients costs lead to reductions in smoking. Two randomized, controlled trials did find increased smoking-cessation rates among patients who were provided treatment services at reduced or no cost (38, 59). Among two nonrandomized trials, one did and one did not find significant differences in cessation rates among patients who had lower costs for their services (15, 21). One observational study of the effect of insurance coverage for pharmacotherapy for smoking cessation found higher knowledge of the coverage in smokers but no change in the use of pharmacotherapy and no higher rates of quitting, as implemented by two health plans (7). Few studies have directly examined the impact of insurance coverage for tobacco treatments on the practicing behavior of clinicians. A recent pilot study in the United Kingdom examined the effect of paying clinics 15 pounds (approximately $23.00 US) for each patient who successfully quit smoking. However, the number of patients who received effective treatment did not increase (14). In a U.S. pilot study, obstetrical practices were offered $150 for each smoker they counseled.

HEALTH PLANS AND TOBACCO CONTROL 253 Training in effective tobacco cessation techniques was provided to these clinics. However, advice to patients decreased and smoking prevalence increased during the study period (42). One health insurance company recently changed its policy to routinely pay clinicians for outpatient treatment of tobacco dependence. In spite of repeated efforts to communicate this policy to providers, there has not been a significant increase in claims for this service (44). Tobacco-dependence treatments are safe, effective, and cost-effective relative to other medical and disease-prevention interventions. There is no evidence that they increase health care costs; there is no rationale for excluding these treatments from routine reimbursement. In addition, smoking patients report greater satisfaction with their care when tobacco-dependence treatment is offered (61). Current Clinical Practices and Policies of Health Plans A number of studies have examined the current tobacco control policies and practices of health plans. These studies have gathered information about insurance coverage for the treatment of tobacco use, health education programs for health plan members, and education and incentives for health care providers. Some of these studies have surveyed a broad range of health plans; others have focused on specific groups of health plans, or on those health plans that provide services for Medicare or Medicaid populations. The American Association of Health Plans (AAHP) conducted national surveys of health plans in 1997 and 2000 using a random sample of U.S. health plans (51, 52). These surveys provide information about national trends and current practices. Like all the other surveys reviewed in this section, the AAHP surveys are based on the self-reports of a single health plan employee. INSURANCE BENEFITS FOR TOBACCO USE There is a wide range of insurance benefits offered by U.S. health plans. In 2000, 59% of plans reported provision of full coverage for at least one type of pharmacotherapy [buproprion or nicotine replacement therapy (NRT)]. Buproprion was covered by 37%, over-the-counter (OTC) NRT by 15%, and prescription NRT by 20%. Coverage for OTC NRT and buproprion increased significantly between 1997 and 2000. Behavioral treatments were also covered by some health plans. In 2000, 37% of plans covered telephone counseling, 24% covered face-to-face counseling, and 37% covered group counseling. Coverage for these behavioral treatments did not increase significantly between 1997 and 2000 (51). A survey of 13 California HMOs in 1999 produced similar findings. Eighty-five percent of these HMOs covered at least one form of pharmacotherapy. Forty-six percent covered at least one form of NRT. Seventy-seven percent covered buproprion. California HMOs covered somewhat more behavioral interventions than the nation as a whole. Forty-six percent covered telephone counseling, and 54% covered individual counseling (58).

254 MANLEY ET AL. A survey of health plans actively involved in tobacco control found somewhat better results (57). All 11 covered at least one form of pharmacotherapy. Eight plans had multisession telephone counseling programs provided at reduced or no cost. Only four covered individual counseling that lasted 30 min or more. MEDICAID BENEFITS State governments make insurance-coverage decisions for Medicaid populations. In 2001, 37 million low-income Americans received their health insurance through Medicaid. More than 58% of Medicaid beneficiaries are enrolled in managed care plans (13). In 1998, 25 states did not cover any treatments for tobacco dependence. Only ten states covered any form of behavioral treatment, and only six (Delaware, Maine, Maryland, Minnesota, New Mexico, and Oregon) had comprehensive benefits that covered both behavioral and pharmacologic treatments. In 2000, nine more states began covering at least some treatments. But only one state provided coverage for all the counseling and pharmacotherapy recommended by the USPHS (12). Health plans face many challenges in providing Medicaid patients with effective treatment for nicotine dependence. One of the most daunting is the length of enrollment in a health plan. One plan reported a median length of enrollment of 1.9 months (31). This was probably a unique situation, but high turnover rates present a formidable challenge. BEYOND INSURANCE BENEFITS In addition to providing insurance coverage for effective treatments, some health plans are taking other steps to help reduce tobacco use. The AAHP survey found that 74% of plans require health care providers to ask new patients about smoking. Forty-three percent of plans require providers to ask about smoking at every visit and to record this information as part of the patient s vital signs. Several health plans have used provider performance data to encourage improvements in the treatment of smokers (8, 19, 32, 35). Among HMOs in California, 54% assess the degree to which providers deliver these treatments, primarily through the Health Plan Employer Data and Information Set [HEDIS (tm) ] reporting and chart audits (58). HEDIS (tm) is used by the National Committee for Quality Assurance (NCQA) to assess health plans. HEDIS (tm) includes a survey that asks health plan members who smoke if they ve been advised by a physician to stop. In 2000, 66% of adult smokers in health plans said they had been so advised (53). Targeting services for nicotine-dependence treatment for pregnant women who smoke has significant potential to reduce the health consequences of smoking and produce health care cost savings (43). However, the potential for managed care to increase availability and accessibility of these services has not been fully actualized. A survey of California HMOs found that in 1997, only 8% covered a comprehensive array of services including individual counseling, group counseling, telephone counseling, and self-help kits for pregnant women. Ninety-two percent covered at least one service modality; only 8% covered no tobacco-dependence treatment (55). Forty-five percent of U.S. managed care organizations surveyed in 1997 reported a specific smoking-cessation strategy targeting pregnant women. Lack of patient interest, competing clinic priorities, and lack of a system to identify smokers were the most common barriers. While authors note limitations

HEALTH PLANS AND TOBACCO CONTROL 255 of the study that limit generalizability of these data, the findings suggest that many health plans could expand coverage and provision of treatment services to pregnant women (3). MODEL PROGRAMS There are many published reports of individual health plans that attempted to improve providers treatment of tobacco users. Health plans, and especially staff-model HMOs, have reported on specific system improvements, such as the delivery of treatment services by nurses (60) or pharmacists (1). Another HMO used a randomized controlled trial to test the effectiveness of different methods to enhance compliance with a smoking-cessation guideline. This study concluded that an intervention directed at clinic leaders resulted in more compliance than an intervention aimed at all clinic physicians (41). One health plan, Group Health Cooperative of Puget Sound (GHCPS), has been actively involved in implementing evidence-based tobacco-cessation strategies for more than a decade (19, 45, 46, 48). Their groundbreaking work led to a population-based, evidence-based, systematic effort to improve clinical treatment of tobacco use. Implementation strategies included securing organizational support for tobacco use reduction at multiple levels of the organization, providing coverage for cessation services, and developing and maintaining an infrastructure that supported brief, repetitive messages to members from providers and other sources to quit smoking. In addition, the plan provided community-wide messages through its newsletter and advertisements, and engaged in efforts to influence public policy and social norms. A second plan, Blue Cross and Blue Shield of Minnesota (Blue Cross), is described in greater detail later in this article. COMMUNITY INTERVENTIONS Health plans have also worked in communities to lower smoking rates. The Centers for Disease Control (CDC) has recommended nine components of a comprehensive tobacco control program. These elements include both clinical and communitybased activities. In its recommendations for managed care organizations (MCOs) the CDC states, Although all nine components are important, we regard community based programs to reduce tobacco use as the most essential (24). A variety of community-wide interventions, based on strong scientific evidence, have been strongly recommended by the U.S. Task Force on Community Preventive Services (see http://www.thecommunityguide.org) (63). Smoking bans and restrictions that limit smoking in public areas and workplaces help reduce exposure to secondhand tobacco smoke and contribute to a decrease in smoking prevalence. Interventions that increase the price of tobacco, including the excise tax on tobacco products, reduce smoking initiation among adolescents and increase cessation. Mass media campaigns of long duration and high intensity conducted in combination with other interventions reduce tobacco use prevalence among adolescents. Other community-wide interventions hold potential to reduce tobacco use and continue to be evaluated. However, they currently lack sufficient evidence to be recommended. These strategies include interventions to restrict youth access

256 MANLEY ET AL. to tobacco, regulations that restrict promotion and advertising of tobacco products, and tobacco product labeling (36, 66). Many health plans have undertaken community interventions to reduce tobacco use, almost always in combination with improvements in their clinical cessation services. By participating in tobacco control coalitions, health plans have supported legislation to decrease youth access to tobacco, increase tobacco excise taxes, and strengthen clean indoor air regulations (48). Health plans have lobbied for stronger tobacco control programs in state health agencies (47) and have implemented their own counter-advertising campaigns (39). RECOMMENDATIONS FOR ENHANCING THE ROLE OF HEALTH PLANS: THE FIVE Cs The full promise of health plan involvement in tobacco control has yet to be realized. Gaps between the recommended and actual practice of health plans were identified by the AAHP s survey of health plans in 1997 and 2000 (51). Although significant improvements were made in some areas, gaps and therefore opportunities exist. A new model is needed. To complement and extend the five As that guide clinical treatment of smokers, Blue Cross developed the five Cs to guide health plans to full engagement in effective tobacco reduction (see Table 2). In contrast to the five As that focus specifically within the clinical environment, the five Cs address a broad spectrum of activity that reaches from within the institution of the health plan to the clinical setting and into the broader community. Cover Effective Treatments The first C, Cover effective treatments, is clearly within the sphere of influence of the health plan and is one of the six intervention systems recommended in the USPHS Guideline (29). TABLE 2 The 5 Cs The 5 Cs for enhancing the role of health plans in tobacco control Cover effective treatments Counsel members who smoke Capitalize Collaborate Count Definition Benefit coverage for cessation medications and clinician counseling No- or low-cost access to effective behavioral counseling via phone and in clinical settings Staff and significant financial resources dedicated to tobacco control Add tobacco control to health plan policy agenda; clinical and community cooperation Data and research to monitor progress, measure return on investment, and improve quality

HEALTH PLANS AND TOBACCO CONTROL 257 The USPHS Guideline recommends five first-line therapies for full coverage: buproprion SR, nicotine gum, nicotine inhaler, nicotine nasal spray, and the nicotine patch. Health plans should provide this coverage for all members and should encourage state governments to provide full coverage for Medicaid members. These members are among the poorest insured people and have a higher smoking rate than the general population (6). Coverage should be provided with no utilization caps since smokers typically require multiple attempts before successfully quitting, and because tobacco dependence is a chronic condition that often requires repeated intervention (29). Limiting members to a single course of NRT in a 12-month period, for example, imposes an artificial barrier that ignores the likelihood of a repeat attempt and the potential need for additional pharmacological aid. Coverage of effective pharmacotherapy relieves a significant barrier for lower-income and other populations. Reimbursement processes should recognize and reimburse tobacco dependence as a chronic medical illness. Office visits for medically appropriate evidencebased treatment should be billed to the health plan with a diagnosis code of 305.1 (tobacco-use disorder). Reimbursement should follow. This change in reimbursement policy can reduce the complexity of the coding and billing system and bring administration of tobacco claims in line with the scientific understanding of tobacco use. Reimbursement changes alone will not assure that every patient is treated at every clinical encounter and has access to effective counseling. Health plans must provide clinicians with training and support the adoption of guidelines that will improve their treatment of tobacco users. Counsel Members Who Smoke The second C, Counsel members, focuses on providing effective behavioral counseling that is systematically and easily available through clinicians and directly to members. As noted above, the USPHS Guideline clearly recommends coverage of effective behavioral counseling as part of the basic benefits package for all health insurance products. But even the best clinical system will not reach all smokers. A two-pronged approach, clinician counseling and phone-based counseling, makes behavioral support accessible and affordable and respects the variety in smokers needs and preferences related to quitting. Telephone-based cessation counseling, available in California since 1992 (71) and increasingly across the nation since then, is another proven counseling option. Health plans in states with no population-wide phone counseling programs can develop such services for their members. Health plans can aggressively recruit callers through mass media and other mechanisms. Effective counseling programs include those that provide smokers with practical problem solving and skills training, provide social support as part of the treatment, and help smokers obtain social support outside of treatment (29). The advantages of telephone counseling are numerous. The fact that clients can avail themselves of services without leaving their homes

258 MANLEY ET AL. is particularly helpful for those whose mobility is limited or who live in rural or remote areas. This aspect also appeals to many that are reluctant to seek face-toface help, especially in group settings. Moreover, the increased accessibility of the telephone format may help to redress the longstanding underrepresentation of the non-white population among those who seek assistance (71). Capitalize The third C, Capitalize, is the dedication of significant staff and financial resources to tobacco control. Investments in programs to reduce tobacco use yield significant returns to health plans. But there is no return if there is no investment. In 2000, tobacco companies spent more than nine billion dollars to promote their products (26). Health plans must acknowledge the scale of this opposition to the public s health and fund tobacco control efforts accordingly. Although no single organization can match the tobacco companies dollar for dollar, a significant investment that demonstrates an understanding of the eventual return-on-investment must be made. Between 1997 and 2000 the percentage of plans that reported funding either a full- or part-time staff person dedicated to tobacco control activities rose from 7.7% to 23.5% (51). Collaborate The fourth C, Collaborate, recognizes the need for health plans to work with other organizations who share the goal of reducing tobacco use. Health plans exist in a highly competitive environment, but tobacco control offers the opportunity to collaborate with competitors as well as with allies such as public health departments and voluntary health organizations. As an internal Philip Morris document outlines, the greatest threat to tobacco companies is organized opposition....our biggest challenge has not been the anti-smoking advertising...rather it has been the creation of an anti-smoking infrastructure, right down to the local level... It has the potential to peel away from the industry its many historic allies (54). In public policy, tobacco companies can likely beat small groups, but they have a more difficult time prevailing over large, diverse, well-organized coalitions. Health plans must join, and at times lead, coalitions of health and community organizations in advocating for effective tobacco control. In collaboration with allies, health plans can influence policies that promote health and reduce problems caused by tobacco use. As business and health leaders, health plans can bring key messages to legislators and other decision-makers. Major tobacco control policies include increasing the tobacco tax (a proven method for decreasing tobacco use among youth) and protecting people from exposure to secondhand smoke through local ordinances or state legislation. Additional policies include protecting state tobacco settlement funds dedicated to tobacco prevention and treatment and avoiding tobacco industry sponsored legislation that seeks to preempt local units of government from passing strong clean indoor air ordinances. By adding these issues to the health plan s legislative agenda, health

HEALTH PLANS AND TOBACCO CONTROL 259 plans change the dynamics at the state capitol in favor of policies that protect and promote health. Count The fifth C, Count, points health plans toward data systems and measurement. Counting is critical for health plans to foster effective tobacco-control programs and to demonstrate their value to both external and internal health plan audiences. Health plans possess vast quantities of data from administrative claims on the diseases, services, and costs incurred by their members. However, these administrative data sets are not always useful for measuring the impact of tobacco control programs. Health plans have not routinely collected information on tobacco use or other preventable conditions on their claims data. As a result, very few health plans have the capacity to determine the smoking status of all or even most of their members. This presents a major barrier to employing disease management and other tools of managed care, which all require identification of individual cases to prevent disease progression and escalating costs (51). With better systems to identify tobacco users, providers and health plan staff may target and tailor interventions to smokers (49). Health plans should Count to demonstrate their progress in providing effective treatment to tobacco users. Increasingly, accreditation groups, employer coalitions, government regulators, and consumers are holding health plans accountable for their services. Pressure is growing to demonstrate the added value that the health plan provides. Tobacco control programs can demonstrate this added value by documenting their successes. Measurement is an essential component of virtually all plans for quality improvement, and this is also true for tobacco control. Data feedback helps drive behavioral change among health care providers and has increased chart identification of smokers and documentation of provider advice (49). Measurement to improve differs in important ways from measurement for accountability (62). At minimum, it must be simple, comparative, rapid, and confidential in order to alter behavior. Although strategies exist to help smokers quit, many questions can be answered only through experimental research. Only through planned research programs can the scientific base for tobacco control interventions in the health plan setting be expanded and strengthened. CASE STUDY OF BLUE CROSS AND BLUE SHIELD OF MINNESOTA Blue Cross has more than 2 million members in Minnesota and throughout the country in multiple provider networks. Its open-access network includes 96% of all providers in Minnesota. Blue Cross provides a variety of products and services, including health plans for businesses and individuals, pharmacy benefits

260 MANLEY ET AL. management, administrative services for self-insured groups, managed care services for workers compensation, behavioral health care management services, and health and wellness programs. Blue Cross and the state of Minnesota filed a lawsuit in August 1994 against cigarette manufacturers and their trade associations on grounds that the industry deceived consumers, which resulted in higher health care costs for Blue Cross and the state. After a five-month jury trial, the suit was successfully settled in May 1998. The historic settlement yielded unprecedented financial and public health gains, including a $6.1 billion settlement for the state and a more than $400 million settlement for Blue Cross. In the settlement, the tobacco industry also agreed to discontinue sales of promotional items, end billboard and transit advertising, disclose tobacco industry payments to lobbyists, end tobacco advertising in motion pictures, and cease its opposition to legislation designed to reduce youth tobacco use. In addition, the settlement established the Minnesota Tobacco Document Depository, home to more than 27 million pages of previously secret tobacco industry documents. Four days after announcing the landmark settlement, attorneys began to file class-action lawsuits claiming the Blue Cross settlement should be paid directly to members. Those suits were eventually dismissed. In 2002, Blue Cross completed a four-year regulatory and administrative process that resulted in approval by the Minnesota Department of Commerce of the A Healthier Minnesota plan, a $412 million, ten-year plan to reduce tobacco use and improve health. Unfortunately, further legal challenges have blocked the use of settlement funds to implement this plan. However, Blue Cross continues to support significant tobacco reduction and health improvement activities. Blue Cross aims to reduce tobacco use by Minnesota s adult population by 30% over the next ten years. To achieve this goal, Blue Cross is beginning a comprehensive tobacco reduction plan that includes clinical, community, public awareness, and direct-to-individual strategies. Cover Effective Treatments In 1998, Blue Cross changed its standard cessation benefit for fully insured members to include prescription and over-the-counter nicotine patches, nicotine gum, and buproprion. Two years later, the standard cessation pharmacy benefit was expanded to include nicotine inhaler and nicotine nasal spray, thereby encompassing all of the first-line therapies recommended by the USPHS Guideline. Both prescription and over-the-counter nicotine patches are covered when accompanied by a physician prescription. Members pay their standard copayment for prescription drugs. No utilization caps or pre-authorization requirements exist; rather, the patient and physician assess the patient s readiness and medical appropriateness of a first or repeat course of treatment. Blue Cross changed its medical policy in order to recognize and reimburse the treatment of tobacco dependence as a chronic medical illness and to make

HEALTH PLANS AND TOBACCO CONTROL 261 behavioral counseling available through clinical and direct-to-member methods. This policy change supports both patients and clinicians who want to discuss pharmacological treatment and make use of the expanded coverage for cessation medication. Counsel Members Who Smoke In addition to clinical counseling, members who smoke also have access to the BluePrint for Health stop-smoking program, a telephone-based counseling program available at no cost to all Blue Cross members. Since the program began in June 2000, more than 14,000 members have received counseling. All smokers, not just those who are ready to quit, receive individualized counseling, supported by a computerized expert system that analyzes participant progress and concerns and feeds back tailored support. As participants work toward a successful quit, progress along the stages-of-change continuum is mapped. Members are recruited primarily through paid television advertising, a strategy that makes information about the program available to all members. Physician and employer outreach also supplement member-direct recruitment. Communications to physicians and clinic managers promote the program as an adjunct to physician treatment, a supplement to the fifth A, arranging follow-up care for patients seeking to quit smoking. Capitalize Blue Cross has dedicated significant financial and human resources to combating tobacco use, even though the company is currently barred from spending settlement funds from its tobacco litigation. Blue Cross formed the Center for Tobacco Reduction and Health Improvement in 1998, and today the 20 members of the Center s staff implement a number of population-based programs to reduce tobacco use and prevent disease. Staff members from other parts of the company also help to implement many of these programs. Collaborate In 1984, Blue Cross was a founding member of the Minnesota Smoke-Free Coalition and has been involved in all subsequent efforts to promote effective public policies to reduce tobacco use. Blue Cross and other Minnesota health plans joined with Coalition members to support legislation designed to reduce illegal access by youth to tobacco products. The Coalition successfully defeated pre-emption, allowing local communities to retain the power to implement and enforce the law. In 1995, Blue Cross and other health plans joined the campaign to increase the tobacco excise tax. More recently, Blue Cross has worked to reduce exposure to secondhand smoke; worked to protect the Minnesota Department of Health tobacco prevention endowment funds; and provided leadership, testimony, and lobbyist attention to the current tobacco excise tax campaign.

262 MANLEY ET AL. Blue Cross clinical and community initiatives are also conducted in partnership with other organizations. One example is an intensive, collaborative actionresearch project. Blue Cross is working with MPAAT and Minnesota s communities of color to conduct relevant, respectful research and collaboratively design interventions to reduce tobacco use in each community. The Diverse Racial and Ethnic Groups and Nations (DREGAN) project is successfully building new relationships among the partner organizations and is training community members to manage projects and conduct field research. Count Shortly after the settlement with the tobacco companies, Blue Cross collaborated with MPAAT, the Minnesota Departments of Health and Human Services, and the University of Minnesota on a large survey of the state s and the health plan s populations in order to establish baselines prior to the launch of interventions. Blue Cross is again collaborating with the same groups and the CDC to field test the newly designed Adult Tobacco Survey in 2002 2003. In addition to the Adult Tobacco Survey, other assessments will be used to address individual components of this program. Blue Cross launched its phone counseling program in June 2000, and is conducting a follow-up study of program enrollees to determine the 12-month quit rate. This analysis will help determine if the program is achieving its goal to enroll a broader group of smokers rather than only those who are ready to quit at the time of enrollment. Blue Cross teamed with Medical Scientists, Inc. to address the problem of calculating return on investment from its various tobacco-control activities. This collaboration will produce a sophisticated software product that will permit calculation of return on investment and rapid sensitivity testing for specific populations and interventions. A large survey of physicians conducted in 2002 aims to identify practice patterns related to smoking and to explore the relationships between these patterns and physician attitudes. SUMMARY There is a wealth of evidence that supports more engagement of health plans in clinical and community tobacco control interventions. Effectiveness, cost-effectiveness, and the experience of leading health plans provide the necessary support for expanding the role of health plans. Challenges to addressing tobacco control include inadequate staffing and funding, competing priorities, and inadequate data collection (51). Although these are significant and real challenges, the overwhelming evidence supports the human and financial benefits to aggressive and sustained action. We offer a new model for expanded health plan engagement, the five Cs, that complements and extends the traditional clinical focus of the five As. By Covering effective treatment, Counseling members who smoke, Capitalizing, Collaborating,

HEALTH PLANS AND TOBACCO CONTROL 263 and Counting, health plans can implement policies and programs that reduce the negative impact of tobacco use on individuals and society. ACKNOWLEDGMENTS The authors gratefully acknowledge Nina Alesci, Dr. Neal Holton, and Dr. Sanne Magnan for their insights and contributions to earlier drafts of this paper. LITERATURE CITED 1. Barbour DM. 2001. Development and implementation of a tobacco consultation program for managed care pharmacists. Am. J. Health-Syst. Pharm. 58:211 13 2. Barker DC. 2000. Building a comprehensive, evidence based tobacco treatment system in managed care. Tob. Control 9(Suppl. I):il 3. Barker DC, Robinson LA, Rosenthal AC. 2000. A Survey of managed care strategies for pregnant smokers. Tob. Control 9(Suppl. III):iii46 50 4. Bertera RL. 1991. The effects of behavioral risks on absenteeism and health-care costs in the workplace. J. Occup. Med. 33(11):1119 23 5. Blackwell DL, Collins JG, Coles R. 2002. Summary health statistics for U.S. adults: National Health Interview Survey, 1997. National Center for Health Statistics. Vital Health Stat. 10:205 6. Blue Cross and Blue Shield of Minnesota, Minn. Dep. Health, Minn. Partnership for Action Against Tobacco. 2001. Quitting Smoking: Nicotine Addiction in Minnesota. 7. Boyle RG, Solberg LI, Magnan S, Davidson G, Alesci NL. 2002. Does insurance coverage for drug therapy affect smoking cessation? Health Aff. 21(6):162 68 8. Carlson CL, Chute P, Dacey S, McAfee, TA. 2000. Designing tobacco control systems and cessation benefits in managed care: skill building workshop. Tob. Control 9(Suppl. I):i25 29 The Annual Review of Public Health is online at http://publhealth.annualreviews.org 9. Cent. Dis. Control Prev. 2002. Annual smoking-attributable mortality, years of potential life lost, and economic costs United States, 1995 1999. MMWR 51(14):300 3 10. Cent. Dis. Control Prev. 2000. Declines in lung cancer rates California, 1988 1997. MMWR 49(47):1066 69 11. Cent. Dis. Control Prev. 1993. Physician and other health-care professional counseling of smokers to quit United States, 1991. MMWR 42(44):854 57 12. Cent. Dis. Control Prev. 2001. State Medicaid coverage for tobacco dependence treatments United States, 1998 and 2000. MMWR 50(44):979 82 13. Cent. Medicare Services. Medicaid Managed Care State Enrollment December 31, 2001. http://cms.hhs.gov/medicaid/ managedcare/mmcpr01.pdf 14. Coleman T, Wynn AT, Barrett S, Wilson A, Adams S. 2001. Intervention study to evaluate pilot health promotion payment aimed at increasing general practitioners antismoking advice to smokers. BMJ 323(7310):435 36 15. Cox JL, McKenna JP. 1990. Nicotine gum: Does providing it free in a smoking cessation program alter success rates? J. Fam. Prac. 31(3):278 80 16. Croghan IT, Offord KP, Evans RW, Schmidt S, Gomez-Dahl LC, et al. 1997. Cost-effectiveness of treating nicotine dependence: the Mayo Clinic experience. Mayo Clin. Proc. 72:917 24