Helen Halpin Schauffler

Variations in treatment benefits influence smoking cessation: results of a randomised controlled trial

OBJECTIVE To assess the impact and costs of coverage for tobacco dependence treatment benefits with no patient cost sharing for smokers with employer sponsored coverage in two large independent practice association (IPA) model health maintenance organisations (HMOs) in California, USA. METHODS A randomised experimental design was used. 1204 eligible smokers were randomly assigned either to the control group, which received a self-help kit (video and pamphlet), or to the treatment group, which received the self-help kit and fully covered benefits for over the counter (OTC) nicotine replacement therapy (NRT) gum and patch, and participation in a group behavioural cessation programme with no patient cost sharing. RESULTS The quit rates after one year of follow up were 18% in the treatment group and 13% in the control group (adjusted odd ratio (OR) 1.6, 95% confidence interval (CI) 1.1 to 2.4), controlling for health plan, sociodemographics, baseline smoking characteristics, and use of bupropion. Rates of quit attempts (adjusted OR 1.4, 95% CI 1.1 to 1.8) and use of nicotine gum or patch (adjusted OR 2.3, 95% CI 1.6 to 3.2) were also higher in the treatment group. The annual cost of the benefit per user who quit ranged from

Cost-sharing and the utilization of clinical preventive services

1495 to

Health Promotion for Older Americans in the 21st Century

965 or from

Availability and utilization of health promotion programs and satisfaction with health plan.

0.73 to

Support for smoking cessation interventions in physician organizations: results from a national study.

0.47 per HMO member per month. CONCLUSIONS Full coverage of a tobacco dependence treatment benefit implemented in two IPA model HMOs in California has been shown to be an effective and relatively low cost strategy for significantly increasing quit rates, quit attempts, and use of nicotine gum and patch in adult smokers.

HEALTH PROMOTION AND MANAGED CARE : SURVEYS OF CALIFORNIA'S HEALTH PLANS AND POPULATION

BACKGROUND Little is known about the effect of different forms of patient cost-sharing on the utilization of clinical preventive services or if the effect varies by type of health plan. OBJECTIVES To assess empirically the relationships between the utilization of recommended preventive services and different forms of patient cost-sharing and how the effect is mediated by type of preventive service (counseling, blood pressure, Pap smear, mammogram), type of cost-sharing (deductibles/coinsurance, copayments), and type of health plan (HMO, PPO/indemnity plan). RESEARCH DESIGN Sixteen logit models were estimated to assess variation in receiving recommended preventive care as a function of cost-sharing within plan type. SUBJECTS A sample of 10,872 employees, aged 18 to 64 years, of seven large companies served by 52 health plans with diverse cost-sharing arrangements who responded to the Pacific Business Group on Health, Health Plan Value Check Survey (response rate, 50.3%). MEASURES Receipt of recommended preventive care was based on the U.S. Preventive Services Task Force Guidelines. The effect of cost-sharing was measured as the percentage change in the probability of receiving recommended preventive care in the cost-sharing group compared to the non cost-sharing group. RESULTS The negative effect of patient cost-sharing was greatest on preventive counseling in PPO/indemnity plans (-15%) and on mammograms in all health plan types (-9%-10%). The effect on Pap smears was negative (-8%-10%) for deductibles/coinsurance in PPO/indemnity plans and copayments in HMOs. The effect of cost-sharing on blood pressure was mixed. Deductibles/coinsurance had a greater negative effect than copayments. CONCLUSIONS Eliminating patient cost-sharing for selected preventive services may be a relatively easy and effective means of increasing utilization of recommended clinical preventive care.

Differential access and utilization of health services by immigrant and native-born children in working poor families in California.

Objectives. To provide a broad overview of the role of the individual, the physical environment, and the social environment on health and functioning in older adults (65 and older), and to highlight interventions and recommendations for action on each of these levels. Data Sources. Published studies and government reports on health and functioning in older Americans and on the individual, social, and physical environmental contributors to health were identified through journal and government documents review and computer library searches of medical and social science data bases for 1980–1999. Study Selection. Preference was given to published studies and government reports that focused specifically on behavioral and environmental contributors and barriers to health promotion in Americans 65 and older and/or that highlighted creative interventions with relevance to this population. Both review articles and presentations of original research were included, with the latter selected based on soundness of design and execution and/or creativity of intervention described. Data Extraction. Studies were examined and their findings organized under three major headings: (1) behavioral risk factors and risk reduction, including current government standards for prevention and screening; (2) the role of the physical environment; and (3) the role of the social environment in relation to health promotion of older adults. Data Synthesis. Although most attention has been paid to the role of behavioral factors in health promotion for older adults, a substantial body of evidence suggests that physical and social environmental factors also play a key role. Similarly, interventions that promote individual behavioral risk reduction and interventions targeting the broader social or physical environment all may contribute to health in the later years. Conclusions. With the rapid aging of Americas population, increased attention must be focused on health promotion for those who are or will soon be older adults. Promising intervention strategies addressing the individual, the physical environment, and the social environment should be identified and tested, and their potential for replication explored, as we work toward a more comprehensive approach to improving the health of older Americans in the 21st century.

Managed care for preventive services: a review of policy options.

There has been increasing interest in using patient satisfaction as an indicator of quality of care by the purchasers of health plans, as well as the basis for marketing by competing plans. Few studies have examined if availability and utilization of health promotion programs are associated with patient satisfaction with the health plan. Data from the Bay Area Business Group on Health 1992 Employee Medical Plan Satisfaction Survey were used to examine these relationships. The findings indicate that persons enrolled in staff-model health maintenance organizations are much more likely to be offered health promotion programs by their plan or physician compared with persons enrolled in independent practice association-model health maintenance organizations and indemnity plans. However, regardless of plan type, employees who have been offered stop-smoking programs, stress management programs, weight-control programs, cholesterol screening and blood pressure screening, or any health promotion program by their plan or physician are more satisfied with their health plan than whose who have not. In addition, employees who have participated in a health promotion program also are more satisfied than employees who have not participated in such a program. The findings have important implications for designing and restructuring health plans to better meet consumer preferences.

Expanding Health Insurance Coverage for Smoking Cessation Treatments: Experience of the Pacific Business Group on Health

Objectives.To document the extent to which physician organizations, defined as medical groups and independent practice associations, are providing support for smoking cessation interventions and to identify external incentives and organizational characteristics associated with this support. Methods.This research uses data from the National Study of Physician Organizations and the Management of Chronic Illness, conducted by the University of California at Berkeley, to document the extent to which physician organizations provide support for smoking cessation interventions. Of 1587 physician organizations nationally with 20 or more physicians, 1104 participated, for a response rate of 70%. Results.Overall, 70% of physician organizations offered some support for smoking cessation interventions. Specifically, 17% require physicians to provide interventions, 15% evaluate interventions, 39% of physician organizations offer smoking health promotion programs, 25% provide nicotine replacement therapy starter kits, and materials are provided on pharmacotherapy (39%), counseling (37%), and self-help (58%). Factors positively associated with organizational support include income or public recognition for quality measures, financial incentives to promote smoking cessation interventions, requirements to report HEDIS (Health Plan Employer Data and Information Set) scores, awareness of the 1996 Clinical Practice Guideline on Smoking Cessation, being a medical group, organizational size, percentage of primary care physicians, and hospital/HMO ownership of the organization. Conclusion. Physician organizations are providing support for smoking cessation interventions, yet the level of support might be improved with more extensive use of external incentives. Financial incentives targeted specifically at promoting smoking cessation interventions need to be explored further. Additionally, emphasis on quality measures should continue, including an expansion of HEDIS smoking cessation measures.

Adoption of the AHCPR Clinical Practice Guideline for Smoking Cessation A Survey of California's HMOs

INTRODUCTION The purpose was to examine whether health-promotion programs offered by California health plans are a serious attempt to improve health status or a marketing device used in an increasingly competitive marketplace. The research examined differences in the coverage, availability, utilization, and evaluation of health-promotion programs in California health plans. METHODS A mail survey was done of the 35 HMOs (86% response) and 18 health insurance carriers (83% response) licensed to sell comprehensive health insurance in California in 1996 (some plans sell both HMO and PPO/indemnity products). The final sample included 30 commercial HMOs and 20 PPO and indemnity plans. The 1996 California Behavioral Risk Factor Survey (BRFS) of 4,000 adults was used to estimate population participation rates in health-promotion programs. RESULTS Californias HMOs in 1996 offered more comprehensive preventive benefits and health-promotion programs compared to PPO and indemnity plans. HMOs relied on a more comprehensive set of health-education methods to communicate health information to members and were more likely to open their programs to the public. HMOs are also more likely to have developed relationships with community-based and public health providers. Participation in health-promotion programs is low (2%-3%), regardless of plan type, and most health plans limit evaluations to assessment of member satisfaction and utilization. Only 35%-45% of HMOs, and no PPO/indemnity plans, assess the impact of health-promotion programs on health risks and behaviors, health status, or health care costs. CONCLUSION For the majority of Californias PPO and indemnity plans, health promotion is not an integral part of their business. For the majority of HMOs, health-promotion programs are offered primarily as a marketing vehicle. However, a substantial minority of HMOs offer health-promotion programs to achieve other organizational goals of health improvement and cost control.