标题：Meeting the Tobacco Cessation Coverage Requirement of the Patient Protection and Affordable Care Act: State Smoking Cessation Quitlines and Cost Sharing
摘要：Objectives. We explored whether various key stakeholders considered cost sharing with state telephone-based tobacco cessation quitlines, because including tobacco cessation services as part of the required essential health benefits is a new requirement of the Patient Protection and Affordable Care Act (ACA). Methods. We analyzed qualitative data collected from interviews conducted in April and May of 2014 with representatives of state health departments, quitline service providers, health plans, and insurance brokers in 4 US states. Results. State health departments varied in the strategies they considered the role their state quitline would play in meeting the ACA requirements. Health plans and insurance brokers referred to state quitlines because they were perceived as effective and free, but in 3 of the 4 states, the private stakeholder groups did not consider cost sharing. Conclusions. If state health departments are going to initiate cost-sharing agreements with private insurance providers, then they will need to engage a broad array of stakeholders and will need to overcome the perception that state quitline services are free. The most recent Surgeon General’s report The Health Consequences of Smoking–50 Years of Progress documents that nearly 42 million adults continue to smoke cigarettes, and the report estimates the current annual smoking-attributable mortality in the United States to be 480 000. 1 These mortality rates are preventable, and tobacco cessation treatment has been rated as one of the most effective preventive health services by the US Preventive Services Task Force. 2 Therefore, it is not surprising that tobacco cessation services were included as a tenet of the Patient Protection and Affordable Care Act (ACA; Pub L No. 111–148). One requirement of the ACA is that health insurance cover essential health benefits such as preventive services, wellness services, and chronic disease management. Under the ACA, tobacco cessation is included as a required preventive service with no copay. The new law places the financial responsibility for providing tobacco cessation treatment on the insurer or health plan, at no cost to the patient, beginning in 2014. For the past decade and before the ACA, state health departments, service provider organizations, and other national organizations have collaborated to establish a network of state-based quitlines across the United States. 3 Tobacco cessation quitlines are telephone-based programs considered to be an effective approach to cessation. 4–6 The state quitlines offer telephone counseling, medications, information, and other support to help tobacco users quit and to comply with standards set by the US Public Health Services clinical guideline. Currently, state quitlines exist in all 50 states, the District of Columbia, Guam, and Puerto Rico. The median total quitline spending for fiscal year 2013 was $1.7 million. 7 Although the majority of financial support in 2012 was provided by state governments (77%), approximately 18% was provided by the Centers for Disease Control and Prevention (CDC), and 2% came from noteworthy new sources and cost-sharing agreements with third parties such as health plans, employers, and Medicaid. 8 As implementation of the ACA moves forward, there are a number of potential implications on tobacco cessation services in general 9 and of state quitlines in particular. Because private health plans are now required to include cessations services and because state quitlines have already been offering evidence-based cessation services for a decade, whether there will be cost sharing between state health departments and private health plans is an open question. We refer to cost sharing as the option for a health plan or employer to pay the costs (or some portion of the costs) of providing the state quitline service to their population of quitline users. Cost sharing can take many forms. For example, currently there is at least 1 agreement between a quitline and a health plan for the health plan to cover 100% of quitline costs for plan enrollees. Examples of 50/50 agreements between a quitline and employer groups also currently exist, in which each covers 50% of counseling and therapy costs. However, cost sharing is not the only option for health plans or employers. Both could bypass states by contracting directly with quitline service providers or they could bypass existing quitlines altogether and find an alternative way to meet the ACA requirement. However, cost sharing may be a more attractive option to a health plan or employer because the cost of state quitline services would be at a reduced rate compared with what they would pay in a direct contract. This is especially true if the state is willing to pay for the administrative costs of the quitline service or for the promotion of the quitline to tobacco users in the state. Therefore, our aim in this study was to explore the ways various key stakeholders involved in providing coverage for tobacco cessation services are grappling with how to meet the new requirements of the ACA. Specifically, we were interested in whether and to what extent private health plans are considering cost sharing with the state quitline.
