California Medi-Cal Incentives to Quit Smoking

Problem

Smoking is the leading preventable cause of mortality and morbidity in the United States (U.S. Department of Health and Human Services [HHS], 2014). Cigarette smoking is a risk factor for cancer and chronic diseases and it is associated with approximately 90% of lung cancer deaths (CDC 2018; HHS, 2014; HHS, 2010). The smoking prevalence in 2014 among U.S. adults covered by Medicaid was higher (29.1%) than that of individuals with private insurance (12.9%) (Jamal et al., 2015). Similarly, in California, the smoking prevalence in 2016 for beneficiaries covered by Medi-Cal, the state’s version of Medicaid, was 17.4% compared to 9.2% among those with private insurance (Zhu, Anderson, Wong, & Kohatsu, 2018). In addition, compared to those with private insurance, adult smokers enrolled in Medi-Cal were more likely to have a chronic disease, have made five or more doctors’ visits in the past year, and be in severe psychological stress (Zhu et al., 2018).

In 2016, California’s expansion of Medi-Cal under the Affordable Care Act increased the proportion of California adults in Medi-Cal from 14.2% to 28.3% (Zhu et al., 2018). Consequently, the proportion of California smokers covered by Medi-Cal insurance increased from 19.3% (738,113 individuals) in 2011-2012 to 41.5% (1,447,945 individuals) in 2016 (Zhu et al., 2018). Accordingly, advancing tobacco cessation services for the Medi-Cal population was and remains a priority for the state (California Department of Health Care Services [DHCS], 2018). Given the effect of smoking on cancer morbidity, the California Comprehensive Cancer Control plan (2011-2015) includes a number of objectives to address tobacco use. Specifically, the plan includes a strategy to “promote the California Smokers’ Helpline to Californians seeking tobacco cessation treatment.”

PSE Solution

Research conducted on employer and private insurance-based populations demonstrated the effectiveness of economic incentives for short-term preventive health care and behavior change goals (Kane, Johnson, Town, & Butler, 2004). These findings were the basis for the 2011 Center for Medicare and Medicaid Innovation (CMMI) Medicaid Incentives for the Prevention of Chronic Disease grant program, from which DHCS was awarded a 5-year, $10 million grant to examine the impact of a comprehensive incentive-based smoking cessation program within the Medi-Cal population. The Medi-Cal Incentives to Quit Smoking (MIQS) study was designed to accelerate successful quitting by: (1) increasing use of a well-established and effective phone counseling service provided by the California Smokers’ Helpline (CSH), (2) decreasing barriers to obtaining nicotine replacement patches, and (3) offering economic incentives to encourage quitting (Tong, et al., 2018). Led by DHCS, collaborators included the University of California San Diego (where CSH was developed and is currently housed), University of California Davis, University of California San Francisco, and the California Department of Public Health (CDPH) (Step 1: Engage).

Except as otherwise noted, the following information is based on “The Medi-Cal Incentives to Quit Smoking Project: Impact of Statewide Outreach Through Health Channels” study by Tong et al., published in the American Journal of Preventive Medicine in 2018. Access the journal article here. Companion articles from this special supplement also were cited in this PSE change example. Access the full supplement here.

Project Design

The project period during which incentives were promoted was from March 2012 to July 2015. MIQS analysis also included the five months after the initiative ended, from August to December 2015. In the MIQS study, Medi-Cal callers were randomized into one of three groups: 1) Usual Care (telephone cessation counseling); 2) Nicotine Patch (telephone counseling plus a one-month supply of nicotine patches direct mailed to the home); and, 3) Nicotine Patch plus Financial Incentive of up to $60 ($20 for completing the first counseling call and $10 for each subsequent call, up to a maximum of $40) (Anderson, Cummins, Kohatsu, Gamst, & Zhu, 2018). Additionally, the study examined outreach strategies to increase calls to the California Smokers’ Helpline by persons with Medi-Cal insurance. Outreach methods included direct outreach to health care providers, incentivizing calls to the Helpline, and direct member outreach through an all-household mailing.

Actions/Results

Actions

Outreach took place on five different fronts: 1) Statewide outreach via state and county health department networks; 2) County outreach, both in-person in eight counties with higher Medi-Cal smoking rates as well as to tobacco cessation agencies; 3) Direct-to-Medi-Cal provider mailings in targeted counties, including safety-net clinics, tribal health clinics, facilities providing alcohol and drug treatment to American Indians/Alaskan Natives, all federally recognized tribes in the state, rural health clinics and small rural hospitals, and school-based health centers; 4) Direct-to-member mailings to all Medi-Cal households, including a mailing code for tracking purposes; and, 5) Community-based outreach, through events such as health fairs, intended for racial and ethnic minorities and lesbian, gay, bisexual and transgender members (Step 6: Implement). A paid media campaign was not implemented due to budget constraints. Outreach materials included postcards and flyers that promoted the Helpline’s English, Spanish and three Asian-language lines. Materials were available for download through a unique MIQS website, as well as the DHCS and CDPH websites.

Results

The study assessed quit attempt rates, and 7-day, 30-day and 6-month abstinence (quitting) (Anderson et al., 2018a). The Nicotine Patch + Financial Incentive intervention significantly outperformed the other two interventions (Anderson et al., 2018a). In comparing Usual Care to the Nicotine Patch + Financial Incentive groups, the following were found:

The quit attempt rate for Nicotine Patch + Financial Incentive was 68.4% vs. 54.3% for Usual Care.

Six-month prolonged abstinence measured 7 months after enrollment for Nicotine Patch + Financial Incentive was 13.2% vs. 9.0% for Usual Care. (Anderson et al., 2018a).

The direct-to-member all household mailing was particularly cost effective. Flyers advertising the services of the California Smokers’ Helpline in English and Spanish were mailed to over 4.2 million Medicaid households and contained one of four messages in a randomized design: 1) offer of free cessation counseling; 2) offer of free cessation counseling + free nicotine patches; 3) offer of free counseling + a $20 gift card; and 4) offer of free cessation counseling + nicotine patches and the gift card (Anderson, Kirby, Tong, Kohatsu & Zhu, 2018b). Offering either free nicotine patches or a $20 gift card quadrupled the likelihood of Medicaid smokers calling the quitline and offering both had an additive effect. (Anderson et al., 2018b). Piggybacking on existing Medi-Cal communications to members was a very effective way to promote the California Smokers’ Helpline. (Anderson et al., 2018b). Promotional costs per caller were $130.56 for counseling-only offer; $32.48 for counseling + nicotine patches; and $41.58 for counseling + nicotine patches + gift card and were much more cost-effective than the national Tips from Former Smokers® campaign, which cost approximately $260 per call (Anderson et al., 2018b).

The total number of Medi-Cal callers seeking Helpline services during the study period was 92,900, reflecting a 70% increase from prior annual averages, with 12.4% asking for the financial incentive, 17.3% reporting the mailing code, and 73.3% receiving nicotine patches. After incentivized mailings to Medi-Cal members began, call trends increased 23% above the expected for the Medi-Cal population growth.

Regarding outreach strategies, the study revealed that outreach promoted through health channels that incentivized Medi-Cal members to call the Helpline increased the use and reach of the Helpline’s services. The annual reach of Medi-Cal smokers calling the Helpline increased (2.3% in 2011 to 4.5% in 2014). Some subgroups with higher reach rates also had higher rates of asking for the financial incentive (African American and American Indian Californians), reporting the all-household mailing code (white Californians), or did both (Californians aged 45-64 years).

Success Factors and Key Questions Addressed

What difference(s) did the PSE change make in the short-term?

Over approximately 3.5 years, 92,900 Medi-Cal smokers called the Helpline. This figure represents a 70% increase from previous annual averages. Nineteen months after the MIQS outreach began, the number of Medi-Cal callers exceeded non-Medi-Cal calls. Medi-Cal members made the majority of calls to the Helpline during the MIQS initiative. Once MIQS incentives ended, the number of Medi-Cal calls decreased by 47%, but remained higher than non-Medi-Cal calls.

One of the big successes from the study was to find out how cost effective the all household mailings are at generating calls to the quitline. The California Tobacco Control Program continues quarterly mailings to Medi-Cal beneficiaries to promote the quitline services.

The study also demonstrated that incentives used in employer-based plans to promote health are also very effective in a Medicaid population and that incentivizing quitting is a cost benefit. Sung et al. (2018) concluded that providing modest financial incentives and mailing nicotine replacement products directly to Medicaid smokers who call the quitline not only increases cessation rates, but is also cost saving within five years.

What difference(s) did the PSE change make in the long-term?

As the Helpline’s reach was doubled to maximum levels during the MIQS initiative, MIQS demonstrated the efficacy of using health care channels to incentivize Medicaid recipients to quit smoking. In a related randomized controlled trial that included a subset of Medi-Cal callers from this study in its sample, both quit attempts and cessation, at two and six months, increased among Helpline callers who received nicotine patches and financial incentives (Anderson et al., 2018a).

How did you measure/document the impact of the PSE change intervention?

Helpline counselors requested callers’ demographic data, including age, sex, race/ethnicity, sexual orientation and insurance plan (if any), among others; source of referral to the Helpline; chronic diseases; and behavioral health conditions. Counselors also reported if callers asked for the financial incentive, received nicotine patches, mentioned the mailing code (from the direct-to-member mailings), or called one of the non-English language Helplines. The primary outcomes measured were: (1) the proportion of Medi-Cal callers activated by the initiative’s incentive outreach and completing a counseling session; (2) monthly call count trends; (3) source of referrals to the Helpline among Medi-Cal and non-Medi-Cal callers; and (4) the percentage of the Medi-Cal population reached who called the Helpline.

Were there barriers to implementing the PSE change? If so, what were the lessons learned?

Implementation barriers included the significant restructuring of Medi-Cal necessitated by the rapid expansion of Medi-Cal managed care plans that had different capacities for outreach, and a considerable drop in state tobacco control funding that left most counties with minimal funding and staffing.

Related Resources

In December 2018, the American Journal of Preventive Medicine issued a special supplement that focused on various aspects of the Medi-Cal Incentives to Quit Smoking (MIQS) initiative. Access those articles here.

A partnership between Truth Initiative and Mayo Clinic offers the EX Program, supporting tobacco cessation for a multigenerational workforce. Learn more here.

REFERENCES

Anderson, C. M., Cummins, S. E., Kohatsu, N. D., Gamst, A. C., & Zhu, S.-H. (2018a). Incentives and patches for Medicaid smokers: An RCT. American Journal of Preventive Medicine (55)6S2, S138-S147. doi.org/10.1016/j.amepre.2018.07.015

Anderson, C. M., Kirby, C. A., Tong, E. K., Kohatsu, N. D., & Zhu, S.-H. (2018b). Effects of offering nicotine patches, incentives, or both on Quitline demand. American Journal of Preventive Medicine (55)62S, S170-S177. doi.org/10.1016/j.amepre.2018.07.007

California Department of Health Care Services. (2018). DHCS strategy for quality improvement in health care. Retrieved from https://www.dhcs.ca.gov/services/Documents/DHCS_Quality_Strategy_2018.PDF

Centers for Disease Control and Prevention. (2018). Smoking & Tobacco Use, Health Effects of Cigarette Smoking. Retrieved from https://bit.ly/2ra3YIR.

Jamal, A., Homa, D. M., O’Connor, E., Babb, S. D., Caraballo, R. S., Singh, T., . . . King, B. A. (2015). Current Cigarette Smoking Among Adults — United States, 2005–2014. Morbidity and Mortality Weekly Report, 64(44), 1233-1240. doi.org/10.15585/mmwr.mm6444a2

Kane, R. L., Johnson, P. E., Town, R. J., & Butler, M. (2004). A structured review of the effect of economic incentives on consumers’ preventive behavior. American Journal of Preventive Medicine (27)(4), 327-352. doi.org/10.1016/j.amepre.2004.07.002

Sung, H.-Y., Penko, J., Cummins, S. E., Max, W., Zhu, S.-H., Bibbins-Domingo, K., & Kohatsu, N. D. 2018. Economic impact of financial incentives and mailing nicotine patches to help Medicaid smokers quit smoking: A cost-benefit analysis. American Journal of Preventive Medicine (55)62S, S148-S158. doi.org/10.1016/j.amepre.2018.08.007

Tong, E. K., Stewart, S. L., Schillinger, D., Vijayaraghavan, M., Dove, M. S., Epperson, A. E., . . . Kohatsu, N. D. (2018). The Medi-Cal incentives to quit smoking project: Impact of statewide outreach through health channels. American Journal of Preventive Medicine (55)6S2, S159-S169. doi.org/10.1016/j.amepre.2018.07.031

U.S. Department of Health and Human Services [HHS]. (2014). The Health Consequences of Smoking—50 Years of Progress: A Report of the Surgeon General. Atlanta: U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health.

U.S. Department of Health and Human Services [HHS]. (2010). How Tobacco Smoke Causes Disease: What It Means to You. Atlanta: U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health.

Zhu, S.-H., Anderson, C. M., Wong, S., & Kohatsu, N. D. (2018). The growing proportion of smokers in Medicaid and implications for public policy. American Journal of Preventive Medicine 55(6)(sup 2), S130-S137. doi.org/10.1016/j.amepre.2018.07.017