Cutting barriers to tobacco-quit treatment helped, but not enough; Ky. has wide differences among regions, and not enough money

Photo: healthyplace.com

By Melissa Patrick
Kentucky Health News

Since Kentucky passed a law in 2017 that reduced barriers to tobacco treatment and counseling, Kentucky Medicaid providers have diagnosed more people with tobacco use and there has been a 30 percent increase in counseling, but in several parts of the state these improvements remain very modest, according to a new policy brief. 

"The good news is that the state law has increased access to counseling and medication. However, we have more to do. We need to invest in implementing this law so that more people have access to tobacco treatment.," said Ellen Hahn, a University of Kentucky nursing professor and the director of the university's BREATHE (Bridging Research Efforts and Advocacy Toward Healthy Environments) initiative. 

The 2017 law requires insurers, including Medicaid, to cover all seven tobacco-cessation medications approved by the U.S. Food and Drug Administration, and counseling services recommended by the U.S. Preventive Services Task Force. It also eliminated co-payments for medication and counseling, requirements tying medication coverage to counseling, and limits on length of treatment. 

The law is meant to reduce barriers to smoking-cessation help for the 23.4% of Kentuckians who smoke, a rate that is even higher among Medicaid participants. Nationally, the overall smoking rate is 14%.

The researchers analyzed Medicaid claims in to see how often Kentucky health-care providers diagnosed tobacco use and treatment. The analysis looked at Medicaid claims from November 2014 to December 2019, before and after the law took effect.  

The study found that there was a slight but statistically significant decline, from before the law to after the law, in the prevalence of tobacco use among Medicaid patients.

But it also found that even though health-care providers regularly used codes to indicate tobacco use by Medicaid patients, they didn't use counseling codes as often, indicating a shortage of counseling.

Regional differences

The decline in tobacco use among Medicaid patients was not consistent across the state's 15 area development districts. For example, the brief notes that tobacco use increased significantly in the Pennyrile district (Caldwell, Christian, Crittenden, Hopkins, Livingston, Lyon, Muhlenberg, Todd and Trigg counties) while it decreased significantly in the Kentucky River district (Breathitt, Knott, Lee, Leslie, Letcher, Owsley, Perry and Wolfe counties).

But the Kentucky River district showed a significant decline of 37% use of counseling services, while statewide use of those services was rising 30%.

Hahn added that there was great variability between ADDs when it came to claims for counseling services. For example, she noted that claims rose 79% in the Fivco district (Boyd, Carter, Greenup, Lawrence and Elliott counties) while the Cumberland Valley district (Bell, Clay, Harlan, Knox, Laurel, Rockcastle and Whitley counties), saw just a 5% increase. Hahn said others had "very minimal" increases.

The brief points out that benefits for evidence-based tobacco treatment are underutilized in Kentucky. Hahn said health-care providers may need a better understanding of what they can bill for. For example, she said, providers may not know that they can be reimbursed for tobacco counseling. 

The brief recommends that Medicaid providers need to receive systematic and standardized training on tobacco treatment-related diagnosis, including what billing codes to use. It also recommends increased training in evidence-based tobacco treatment, particularly in ADDs with low tobacco-cessation claims.

"Regular tracking and monitoring claims data for counseling interventions will ensure Medicaid beneficiaries receive the full scope of evidence-based treatments (i.e., medications plus behavioral support)," the brief says. 

Hahn noted that a prior policy brief found a desire for more tobacco treatment and cessation training, but only about one-third of health-care practices report that their providers have received continuing education about tobacco treatment in the past two years. 

"Tobacco is such an important risk factor and the cause of so many chronic diseases; it affects literally every organ in the body; it really needs to be a priority for all providers," Hahn said. "And so they need that kind of ongoing training, to make sure they're using evidence-based practice and that they understand the medications as well as the treatment for behavioral-health modalities."

State's tobacco-control efforts relatively weak

Hahn said the state needs stronger tobacco-control policies to decrease its smoking rate. She noted that the state regularly gets failing grades from the American Lung Association in its "State of Tobacco Control" report. 

"If you go to states where the excise tax for tobacco products is high, where they spend closer to what the CDC recommends for tobacco prevention and treatment, and places that have restrictions on smoking, smoke free laws, and also have access to tobacco treatment -- those states do better and they have, therefore, lower smoking rates," Hahn said.

Kentucky offers a 1-800-QUIT-NOW hotline for free tobacco cessation services.  Hahn said this number is under-utilized mainly due to lack of funding to promote it, so Kentuckians don't know about it. She said Oklahoma spends $3 million a year on media campaigns to promote its quit line and they get 30,000 callers a year. Kentucky's quit line gets only 3,000 calls a year, she said. 

"We've had a 43% cut in tobacco funding since fiscal year '21," she said. "So that doesn't help." 

The brief was issued by the University of Kentucky College of Nursing, with support from the Cabinet for Health and Family Services on behalf of the Department for Medicaid Services.  

It is the third in a series of four. The other ones address tobacco dependence treatment, increasing treatment capacity and practice recommendations for managed care organizations, which provide care for Kentuckians on Medicaid.