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Extending the 5Cs: The Health Plan Tobacco Cessation Index
Victor Olaolu Kolade, MD
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Extending the 5Cs: The Health Plan Tobacco Cessation Index

Victor Olaolu Kolade, MD
The Health Plan Tobacco Cessation Index-based on the 5C paradigm of Foldes & Manley-is introduced through a survey of New York plans.

To describe the smoking cessation services covered by licensed health plans in New York, and to evaluate plan characteristics that could account for variation in services.

Study Design
Prospective cross-sectional survey.

All 44 unique plans in the 2005 Managed Care Plan Directory of the New York State Department of Health were invited to participate. The Health Plan Tobacco Cessation Index was introduced to score each plan based on covered services, provision of counseling, capitalization of support for tobacco cessation, collaboration with the state quitline, and counting of tobacco users. Index scores ranged from 0 to 15, with higher scores indicating higher levels of cessation services. Descriptive statistics, analysis of variance, c2, and Fisher exact tests were computed.

Of 35 respondent plans, 21 (60%) scored 10—the same as the Minnesota plan that recommended 5Cs for all health plans: Cover, Counsel, Capitalize, Collaborate and Count—or higher. Smaller plans had lower scores (P = .003). Seventeen plans promoted the state quitline.

New York plans compared favorably to a plan that features a model tobacco control program, but significant variation existed. There was room for improvement in collaboration with the local quitline.

Am J Manag Care. 2014;20(10):e453-e460
The Health Plan Tobacco Cessation Index is a new metric that measures health plan tobacco control activity directly without relying on cessation activities carried out by clinical providers.
  • Deficiencies in plan offerings can be identified and addressed in order to increase plan scores.
  • Providing full coverage for all cessation medications as well as counseling should not only increase plan scores but increase quit rates.
  • The Health Plan Tobacco Cessation Index can replace the Health Plan Employer Data and Information Set Medical Assistance for Smoking Cessation measure.
Annual direct medical care expenses for treatment of tobacco-attributable illnesses have been estimated at $75 billion in the United States.1 To improve treatment outcomes, the Public Health Service (PHS) Guideline recommends that tobacco dependence be considered a chronic condition that requires repeated intervention. 2 Hence, all smokers should receive practical cessation counseling combined with appropriate pharmacotherapy; this combination produces quit rates 5 times higher than quitting without assistance.3 Unfortunately, populationbased research shows that most smokers who report making quit attempts do so without the benefit of recommended counseling and pharmacotherapy.4

Health insurance coverage for pharmacotherapy that is marketed to beneficiaries can lead to a drop in smoking prevalence.5 Appropriately, a Healthy People 2010 objective was to have 100% managed care coverage of evidence-based cessation interventions.6 BlueCross BlueShield of Minnesota (BCBSM) has suggested a 5C approach to cessation practices: Cover, Counsel, Capitalize, Collaborate, and Count.7,8 The 5C model complements the 5A approach to clinical treatment of smokers (Ask, Advise, Assess, Assist, and Arrange) and was designed to address gaps between recommended and actual cessation practices of health plans.7

In the 5C approach, Cover includes full coverage of first-line therapies for smoking cessation. Full coverage enhances the use of cessation services by smokers, compared with lesser coverage.9 Cover also assesses the adoption of written guidelines, reimbursement of healthcare providers for cessation services, and the presence or absence of barriers to use of pharmacotherapy (eg, mandatory attendance of group classes). Counsel fosters the provision of cessation counseling via telephone and by clinicians. Capitalize calls for investment of dedicated staff and resources into tobacco control. Collaboration entreats health plans to liaise with of cessation programs within the health plan, including monitoring smoking rates among members.

New York is notable because of its aggressive attempts to reduce tobacco-attributable disease and death for many years; for instance, its tobacco tax rate was the highest nationwide in 2011.11 However, its 20% smoking prevalence in 2004 far exceeded the Healthy People 2010 goal of 12% or less.12 The purpose of this study was 2-fold: to describe the smoking cessation practices adopted by health plans in New York, using the 5C framework, and to evaluate characteristics of health plans that could account for variation in practices (eg, size, type, coverage of Medicaid clients, profit status, plan affiliation).


A 20-item questionnaire was used to gather information about medications covered (with or without member co-payments), existence of prerequisites for medication coverage (eg, attendance at a cessation program), use of clinical guidelines, provider reimbursement, telephone counseling, maintenance of records of member tobacco use, and marketing of plan cessation practices and quitline services. A combination of Addressing Tobacco in Managed Care (ATMC)13 survey items and unique questions was used to achieve survey goals. The questionnaire was reviewed by local tobacco control experts before use.

The Managed Care Plan Directory offered by the New York State Department of Health in February 2005 was the sampling frame for this study. Of the 50 plans listed, 6 could not be separated from other plans listed due to commonality of contact information; therefore, 44 unique plans were considered. For each plan, website information and/or telephone consultation with plan staff were

used to identify a person likely to be knowledgeable about the survey items. He or she was then contacted by phone to introduce the survey. The survey recipients varied by plan but included such designees as director of quality management, vice president for health services, and health education manager. The identified respondents were offered the option of receiving (and completing) the survey via e-mail or facsimile. E-mail reminders were sent to persons who did not respond to e-mailed surveys at 14 and 30 days. Telephone reminders were also employed. Data collection occurred between February and August 2005. Reported data were compared with information provided on plan websites (when available) for verification purposes. State government and New York Health Plan Association (NYHPA) reports were used to standardize collection of plan demographic information.

To rate and compare plans in terms of the level of stopsmoking services and policies, the Health Plan Tobacco Cessation Index was developed. It is based on the 5C criteria described by Manley et al.7,8 The Index allocates a maximum of 7 points to Cover, 1 to Counsel, 4 to Capitalize, 2 to Collaborate, and 1 to Count. Information about the allocation of points within categories can be found in Table 1. Analyses of Index scores were conducted using SPSS version 21.0 (Armonk, New York). Descriptive statistics, analysis of variance, χ2, and Fisher exact tests were computed. Statistical significance was at P <.05. Significance tests were 2-tailed except where otherwise stated.


Thirty-five of 44 insurers responded to the survey, representing 80% of intended health plan respondents and 77% of covered members. Membership of the respondent plans ranged from 189 to 873,794. These plans included 16 health maintenance organizations (HMOs), 14 prepaid health service plans (PHSPs), 4 partially capitated plans (PCAPs), and 1 special-needs plan. Eight were for-profit, 23 were nonprofit, and 4 were of unknown profit status based on the Directory listing. Nonprofit plans were more likely to respond than forprofit plans (P <.05). Twenty-five of the 44 plans were identified as voluntary members of the NYHPA in its directory, 20 of which completed the survey. Twenty-eight of the 35 respondents offered a Medicaid product. Plans offering Medicaid products were more likely to respond to the survey than plans without any Medicaid offerings (P <.05).


Seven plans (25%) earned 7 of 7 points for Cover (Table 2), representing maximal coverage. Plans with Medicaid other organizations that aim to reduce tobacco use.10 Count requires obtaining data necessary for measuring the success offerings were more likely to score high marks in this category than plans with no Medicaid offerings (P = .006). The 28 plans with Medicaid offerings provided full coverage of nicotine replacement therapy (NRT) (excluding lozenges) and Zyban. Of the 7 plans with no Medicaid products, only 1 reported full coverage of any cessation medication. Thus, 29 plans (83%) provided full coverage for at least 1 cessation medication. Nicotine lozenges, which were not covered by Medicaid, were covered by only 9 plans. Only 1 plan that had cessation benefits required program attendance beyond New York State Smokers’ Quitline (Quitline) participation.

Twenty-four plans (69%) had written guidelines for smoking cessation. The majority of these were based on the 2000 PHS guidelines. Guideline use was not predicted by plan size, type, profit status, or plan membership in the NYHPA. Only 13 plans (37%) reported reimbursing providers for performing any cessation services.


Fifteen plans did not provide telephone-based counseling (although 3 of these referred clients to the Quitline). Of the 20 with telephonic programs, 12 provided counseling in-house and 8 used external counselors. Telephone counseling was more likely to be offered by small plans (ie, those in the first tertile; P = .004), HMOs (P = .022), and NYHPA members (P = .017). Offering of telephone counseling was not predicted by plan profit status or Medicaid offering.


Of the 30 plans with websites, 23 had information urging members to quit or explaining how. Use of websites to disseminate information relevant to smoking cessation became more likely as plan size increased (P = .04). Whereas 91% of nonprofit plans with websites disseminated cessation information, only 50% of for-profit plans with websites did (P = .03). No relationship was seen between plan type or NYHPA membership and the provision of Web-based cessation information. Ten websites included links to the Quitline.

Thirty plans had at least 1 non-Internet tool for informing members of cessation benefits. Tools included newsletters (most common), mailers, handbooks/new member packets, telephone information lines, health fairs, advertisements for health education classes or disease management programs, and media advertisements. Newsletters distributed to members and providers from 25 plans between 2002 and 2005 were available for review as Web postings and/or hard copies. Twenty-three plans provided information related to smoking cessation at least once. The use of non-Internet tools was not associated with plan size, type, profit status, or affiliation. Five plans asked providers to inform members of their cessation benefits; however, in 2 instances, the provider manuals were the only way the health plans apprised providers of these benefits.


Seventeen plans (49%) promoted the Quitline in newsletters, websites, or both. Promotion of the Quitline was not predicted by any plan characteristic. Ten plans reported referring members to the Quitline.


Twenty-six plans (74%) had tobacco use status indicated in their member records. The ability of a health plan to identify members who smoked was not predicted by size, type, profit status, Medicaid offering, or affiliation. Table 3 summarizes the effect of individual plan characteristics on the 5C metrics.

Total Score

Total scores on the Health Plan Tobacco Cessation Index ranged from 0 to 15 out of 15 (Figure). Median and mean scores were 10, similar to the score obtained by BCBSM. Twenty-one plans (60%)—representing 4,664,048 covered lives—achieved an optimal score of 10 to 15. The 14 plans that scored 9 or less represented more than 923,451 covered lives. Plans in the first tertile (fewest members) were most likely to have low Index scores (P = .003; Table 4). Total scores were not predicted by plan type, profit status, Medicaid offering, or NYHPA membership.


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