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Lack of cessation program knowledge may keep smokers from quitting
The extent of Medicaid coverage for smoking-cessation medications may be a major barrier in getting low-income people to stop smoking, according to research published in Preventing Chronic Disease.
“Many … organizations encourage coverage of all FDA-approved cessation medications and counseling and elimination of barriers that might limit access,” Leighton Ku, PhD, MPH, Milken Institute School of Public Health, Washington, D.C., and colleagues wrote. “However, these benefits may go unused if patients and physicians are unaware that they are available or are not sufficiently engaged to attempt quitting. Fewer than half of smokers in Medicaid-managed care plans reported that their physicians offered assistance, such as medications or counseling, to quit.”
Ku and colleagues evaluated factors that could affect the use of smoking-cessation medication among Medicaid beneficiaries from 2010 to 2014. They analyzed the effects of Medicaid smoking cessation coverage; Medicaid limitations, such as prior authorizations and copayments; state tobacco policies, such as taxes and smoke-free zones; smoking prevalence and norms; and other public health programs, such as quitlines.
They used the ratio of the number of prescription fills or refills paid by Medicaid for FDA-approved cessation medications divided by the estimated number of adult Medicaid smokers for each state and year as the outcome variable. Researchers noted that since one medication, bupropion, may be prescribed for depression, quitting smoking or both, they created two versions of the variable with that drug. There were 255 state-year observations for the 50 states and Washington, D.C., in the period studied.
They found that average use of Medicaid tobacco cessation medication fluctuated widely across state levels but only changed slightly nationwide. They also found that broader Medicaid coverage of FDA-approved medications was slightly connected to increased use of medications, but smoke-free laws or cigarette taxes had little effect (even though average cigarette taxes rose). There were modest increases in the percentage of states that either had quitlines that offered cheap or no-cost medications to callers or provided coverage for all types of smoking-cessation medications. Only two individual policy variables — a state’s decision to cover all medications increased use and mandating counseling to get medications had a negative effect on use — had a significant effect on use of smoking-cessation medication.
“Many organizations recommend against Medicaid policies such as copayments, prior authorization, and limits of duration of benefits that could restrict access to cessation medications,” Ku and colleagues wrote. “Although the analyses did not result in significant effects of these policies, common sense suggests that they could limit access for some, and there is no compelling reason for states to adopt or retain restrictive policies, given the low cost of tobacco cessation therapy.”
Researchers wrote smoking cessation treatment costs are “minute” when compared with covering the treatment costs associated with smoking-related diseases through Medicaid.
“The long-term challenge will be for Medicaid to collaborate with public health agencies, managed care plans, health systems, and clinicians to develop and implement more effective strategies to help smokers to quit and to monitor the effectiveness of these efforts,” they wrote. – by Janel Miller
Disclosure: Healio Family Medicine was unable to confirm the authors’ relevant financial disclosures prior to publication.
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When our patients smoke, they are in fact exhibiting behavior that is the cardinal sign of a complex, biosocial compulsive disorder of the brain. Far from a trivial matter, neuroplastic changes in brain biology induced by repeated exposure to nicotine reliably result in ambivalence, a dual-mindedness wherein patients are both desperate for change and desperate not to change. The continuation of maladaptive behaviors in the face of a rational desire to stop, is the hallmark of nicotine dependence, and is frequently resolved by adopting compromise positions, including the use of “light” or filtered cigarettes, a reduction in the number of cigarettes smoked per day, or more recently, use of electronic cigarettes. As a result, the global tobacco epidemic continues to claim nearly 6 million lives annually, despite a near-universal appreciation of the catastrophic health consequences of continued use among both patients and clinicians. Because this illness is concentrated within the lowest socioeconomic cohorts, it makes sense for Medicaid plans to offer generous coverage for cessation pharmacotherapies. What doesn't make sense is for plans to put up unnecessary barriers to access when the illness is characterized by fleeting motivation and a reluctance to make a change. What makes even less sense is when clinicians don't take advantage of the benefits their patients are offered. Plans won't change if demand remains limited. Is there another problem that "the system" watches kill so many, yet treats so few?