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The State Health Plan Comprehensive Wellness Ini6a6ve: Can a health insurance plan requiring higher out of pocket expenses for tobacco users increase utilization of tobacco cessation services?
Leah M. Ranney, PhD
Associate Director for Tobacco Prevention and Evaluation Program University of North Carolina At Chapel Hill
This work was funded by the North Carolina Health and Wellness Trust Fund Commission.
Any opinions, >indings, conclusions, or recommendations expressed in this presentation are those of the authors and do not necessarily re>lect the views and policies of the North Carolina Health and Wellness Trust Fund
Commission.
There are no :inancial or commercial interests to disclose
Agenda • Background • Process Evaluation • Logic Model • Methods • Data Analysis • Findings • Recommendations • Follow-‐up
Tobacco Use • Approximately 20% of US adults smoke
• Only 5-‐7% of US smokers successfully quit without assistance1
• Evidence-‐based behavioral and pharmacologic treatments can double unassisted quit rates across a range of populations1
1Treating Tobacco Use and Dependence: 2008 Update
Healthcare Cost
• Total annual public and private health care expenditures caused by smoking: – $96 Billion in the US2 – $2.46 Billion in North Carolina2
2Campaign for Tobacco Free Kids, May 9, 2012
North Carolina General Assembly • Passed Session Law in April 2009
• Required State Health Plan for Teachers and State Employees (SHP) to contain costs
• Implement premium increases, bene]it changes, and healthy lifestyle programs that reduce costs and improve member health
Comprehensive Wellness Ini=a=ve • July 1, 2010 all health plan members were moved to 70/30 bene]it plan
• To enroll in 80/20 bene]it plan, members needed to attest that themselves and their dependents were not tobacco users
• Current tobacco users could enroll in 80/20 if enrolled in approved cessation program
Funding Organiza=on
• NC Health and Wellness Trust Fund in conjunction with SHP issued an independent evaluation
• Tobacco Prevention and Evaluation Program received approximately $50,000 to conduct the evaluation
Process Evalua=on
• Utilization-‐Focused Evaluation – Intended users need to understand and participate in the process
– Situational responsiveness guides the collaborative process between evaluator and intended users
Stakeholders Ques=ons • Did SHP members’ understand the CWI communication materials?
• Are the SHP members aware of the SHP tobacco cessation bene]its and resources?
• What is the SHP members’ level of satisfaction with QuitlineNC services and free nicotine patches?
..
State Health Plan Tobacco Cessation Wellness Initiative Process Evaluation Logic Model
RESOURCES ACTIVITIES OUTPUTS OUTCOMES
TPEP
HWTF funding
State Health Plan (SHP)
Alere, Inc
State Health Plan
Members
Recruitment • SHP members
(70/30 plan smokers)
• SHP members - QuitlineNC callers
Focus Groups • # Groups • # Participants
Online SHP Survey • # of completed online
surveys
Focus Group Qualitative Data:
• Participants’ awareness, perception, and receptiveness of the CWI
• Participants’ awareness and usage of SHP tobacco benefits and resources
SHORT TERM LONG TERM
Increased knowledge about type of services
provided by SHP and QuitlineNC for members who use
tobacco
Increased quit rate among SHP
members
INTERMEDIATE
Increased utilization of SHP tobacco
cessation benefits and
resources
Material Development • Recruitment
Screener • Focus Group
Guide • Debrief script • QuitlineNC
Survey
Online Survey Data • Motivation for
contacting QuitlineNC • Service requested • NRT Received • Level of Satisfaction
Increased use of QuitlineNC
services by SHP members
Decreased tobacco related morbidity and
mortality for SHP menbers
Data Collection • Focus groups • Online survey
Data Analysis • Qualitative • Quantitative
Evaluation Findings • Report • Manuscript
SHP implementation of strategies that
increase awareness among members
about tobacco cessation benefits
and resources
= Process Evaluation
Evalua=on Methods • Conduct focus groups with SHP tobacco users – Assess awareness of CWI, understanding of SHP materials, and knowledge of SHP tobacco cessation bene]its and resources
• Conduct online survey with QuitlineNC SHP callers – Assess SHP members’ level of satisfaction with QuitlineNC services
UNC Public Health-‐Nursing Institutional Review Board reviewed the research plan and determined participant risk involved was minimal (10-‐1888).
Focus Group Methods • Recruited SHP members with 70/30 bene]it plan who use tobacco via letter
• Screened potential focus group participant via website or telephone questionnaire
• Offered $50 incentive • Three locations (Greensboro, Greenville, and Asheville)
Focus Group Analysis
• Focus group (N=12) -‐ Greensboro (n=4), Greenville (n=6), and Asheville (n=2)
• Supplemental Phone Interviews (N=4) • Transcriptions independently coded by two researchers using MAXQDA software
• Combination of deductive and inductive coding
Focus Group Findings
Confusing Communica=on Material
“There’s a lot of names. That’s really just hard for me to interpret where they’re coming from and why they’re important on here… I don’t know who those people are or where they come from. So it seems just like a lot of big words but there’s no background behind it.”
Complex Communica=on Materials
“It looks like another memo that comes across your desk every single day.” “And when they send the little packets out to us like they sent all of this out, it’s like reading a letter from a lawyer or something.”
Inconsistent Dissemina=on of Informa=on
“And then they really don’t tell you. They have a bulletin board where they put the sheets up and you just glance at it or then you hear another staff talking about it or whatever. But them actually coming to you and telling you about it, no.”
Eye-‐catching Communica=on Material
“… color, eye-‐catching things. Like I said you are going to need something that is going to stand out and say something that is going to bring me in and this thing right here [postcard] says “you can quit smoking tobacco”
Informa=ve Communica=on Material
“I think this is informative, especially the 1-‐800 number which I’ve never seen. This is my >irst time seeing it and that it’s providing eight weeks of nicotine replacement therapy, which I knew nothing about until tonight. So this is something I can certainly try.”
Lack of Communica=on
“….the main thing is that …..this information is not getting to them. They haven’t gotten it ... so they didn’t know it was available. I didn’t know it was available.”
Misunderstanding the CWI
“…because of my decision [to smoke] you want to drop my health insurance – now most companies and most insurance agencies don’t do that. They make you have a higher premium or things of that [nature], but they don’t drop your coverage. The State went way out there.”
Nega=ve Percep=on of SHP “I am going to tell you, this is exactly how we felt. They didn’t want smokers and big people working for the state.”
“So I mean when this came out – it was negative to start with.”
SHP Tobacco Use Verifica=on Plan “I think about a month later after we >illed that form out and turned it in, then they said they weren’t going to take and go back and check people to make sure they were being honest about everything and so most people I work with, they continued smoking and whatever and they’re still on 80/20 and I am on 70/30 and I was trying to be honest.“
“Truthfully and honestly talking about those people who did not sign the form, if I would have known that they weren’t going to come around and ask if I smoke, I probably wouldn’t have >illed it out either.” “And I told the truth and then they still didn’t get everybody. Man, that made me mad.”
Summary of Focus Group Findings
• SHP members did not read and/or understand SHP materials about the changes in enrollment
• SHP members did not recall receiving SHP materials or information about additional tobacco cessation bene]its and resources
Summary of Focus Group Findings
• Lack of understanding of the CWI and minimal knowledge of SHP’s additional tobacco cessation resources led to negative perceptions of the CWI
Summary of Focus Group Findings
• Developed negative perception of the SHP – With the implementation of the CWI, many SHP tobacco users felt punished
– SHP members who attested to using tobacco were disgruntled when the SHP decided not to verify tobacco use among a random sample of SHP members on the 80/20 bene]it plan
Focus Group Limita=ons
• Low number of participants – Not generalizable
• Typically focus groups are formative rather than hypothesis testing – Interpret themes and results with some caution
SHP Recommenda=ons • Develop appealing materials with appropriate literacy level
• Dissemination plan needs to include multiple methods for circulating information
• Use formative and summative evaluation data to tailor health insurance information to target audiences
• “Build a brand” around SHP tobacco cessation bene]its
Survey Methods • AlereTM, North Carolina’s tobacco cessation vendor, provided TPEP with email addresses of SHP members who used the QuitlineNC
• Random selection of 600 email addresses were pulled from the AlereTM dataset
Survey Methods
• 32 multiple choice questions • Validated questions from the Center for Disease Control (CDC)and Behavioral Risk Factor Surveillance System (BRFSS)
• Four weekly reminders • $10 gift card incentive
Survey Analysis
• 571 SHP QuitlineNC callers successfully received an email requesting participation
• Response Rate = 32% (N=185) • Descriptive statistics (SPSS)
Survey Demographics
Characteristics Percentage
Female 60%
White 79%
Mean age (Years) 50.4
Bachelors’ Degree > 26%
Professional State Employee Position
49%
Online Survey Findings
Mo=va=ons to Call
5%
8%
8%
11%
26%
67%
71%
74%
0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%
Other
Family Member
Doctor/Nurse
Friend
QuitlineNC Advertisement
Addition of cessation bene:its to SHP
Ready to quit using tobacco
Maintain enrollment in 80/20
% of Participants
0
20
40
60
80
100
120
140
Multi-‐caller options with NRT patch
One-‐time call with no coaching
Multi-‐Caller option without
NRT
One-‐time quit coach call
Self-‐ help materials only
# of participants
QuitlineNC Service Options
QuitlineNC Services
Level of Sa=sfac=on Level of Satisfaction with QuitlineNC Service Percent of
participants that were very satisfied or
satisfied Please indicate your level of satisfaction with the registration process.
97% (177 of 182)
How would you rate your satisfaction with receiving the nicotine patch from QuitlineNC?*
88% (110 of 125)
Overall, how satisfied were you with the service you received from QuitlineNC?
92% (162 of 182)
*Not all participates opted for the free nicotine patch
Addi=onal Survey Findings • Experience with QuitlineNC increased respondents’ reported con]idence in quitting tobacco (63.6%)
• Only 21% of respondents reported their experience with QuitlineNC increased their ability to quit tobacco
• Over half the respondents noted a lack of awareness of other tobacco cessation bene]its and resources available through the SHP
Summary of Survey Findings • SHP tobacco users participated in QuitlineNC both because they were interested in quitting and because they wanted to maintain enrollment in the 80/20 plan.
• Those participants who called QuitlineNC primarily chose the multi-‐caller option with eight weeks of free nicotine patch
Summary of Survey Findings
• Satisfaction with service delivery for QuitlineNC remains very high, including the delivery of nicotine patches to participants
• Awareness and utilization of tobacco cessation bene]its, other than QuitlineNC, by SHP tobacco users remains relatively low
Limita=ons
• Self-‐reported tobacco use data – Data not valid due to participants’ concerns that reporting current tobacco use would jeopardize their health bene]it status
• Response bias – Disproportionate number of moderate to high income callers
Survey Recommenda=ons • Review whether the 80/20 choice plan is having the intended effect on tobacco cessation
• Expand tobacco cessation services options available through QuitlineNC, allowing for treatment options such as nicotine gum and lozenge
• Review methods of marketing SHP tobacco cessation bene]its and resources to increase tobacco users’ awareness of free and low cost tobacco treatments
U=liza=on of QuitlineNC • Caller volume spiked dramatically during SHP annual enrollment (March/April 2010)
• 36% of QuitlineNC callers were SHP members, compared to only 5.9% in 2009
• SHP QuitlineNC caller rates remain high at 19.3% with the offer of eight weeks of free nicotine patch
SHP Evalua=on Follow-‐up
• Change format of all educational materials for all health areas (i.e., grid)
• Materials include larger text, color, and pictures
• Testing materials with lower literacy levels (Brown Creek Correctional Institution)
SHP Uses Evalua=on Findings
• Training 101 Toolkit: Standardized information for Health Bene]it Representatives and Wellness Leaders
• AlereTM is branding tobacco cessation materials with SHP
• To view other SHP materials visit: http://www.shpnc.org/ncHealthSmart/default.aspx
• For additional information on TPEP visit: http://www.tpep.unc.edu/index.htm
Questions?