Edward Anselm, MD

Medical Director

Public Health Perspectives of Accountable Care: Opportunities for Alignment

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Program Outline

• Causes of death as markers for health care cost

• Opportunities for alignment• Variation in the prevalence of tobacco

use• Variation in tobacco use taxes• Variation in tobacco cessation services• Health System Performance• The opportunities in Texas• Conclusions

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Top ten causes of death in the USA

Align with the National Tobacco Control Strategy: An evidence based approach

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Opportunities for alignment

• States that have the strongest policy interventions have shown the greatest improvements

• Population Health Levers• Taxes• Regulations• State Funding of Tobacco Control

Programs• Public Relations• Reimbursement• Heath System Performance

Tobacco Tax varies from $0.17 to $4.35

Medicaid Coverage of Smoking Cessation Treatments 2014

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Reducing Tobacco Use: Interventions to Increase the Unit Price for Tobacco Products

• Prevalence of Tobacco Use

A 20% increase in tobacco unit price would be associated with:

•3.6% median reduction in the proportion of adults who use tobacco (26 studies, median elasticity of -0.18; IQI:-0.31 to -0.11)

•7.2% median reduction in the proportion of young adults who use tobacco (22 studies, median elasticity of -0.36; IQI: -0.73 to -0.24)

• Cessation of Tobacco Use

A 20% increase in tobacco unit price would be associated with:

•6.5% increase in cessation among adults (1 study, elasticity=0.375)

•18.6% median increase in cessation among young people (5 studies, median elasticity of 0.93; IQI: 0.37 to 1.00)

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Estimation of the impact of interventionon a state-specific basis

• http://www.communityhealthadvisor.org/drupal/cha/SmokingInterventionsCosts

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Reducing Tobacco Use and Secondhand Smoke Exposure: Smoke-Free Policies

• Prevalence of tobacco use: median absolute reduction of 2.7 percentage points

• •Cessation of tobacco use: median absolute increase of 3.8 percentage points

• •Cardiovascular events: median relative reduction in hospital admissions of 5.1% (IQI: -11.6% to -2.2%; 9 studies)

State Funding for Tobacco Control

• In Fiscal Year 2014, the states will collect $25 billion in revenue from the tobacco settlement and tobacco taxes, but will spend only 1.9 percent of it – $481.2 million – on programs to prevent kids from smoking and help smokers quit.  This means the states are spending less than two cents of every dollar in tobacco revenue to fight tobacco use.

• https://www.tobaccofreekids.org/content/what_we_do/state_local_issues/settlement/FY2014/2014_02_updates/FY2014%20Funding%20for%20State%20Tobacco%20Prevention%20Programs.pdf

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Health System Performance

• Benefit design meets or exceeds ALA recommendations

• Align with inpatient smoking cessation

• Optimal use of State Quitlines

• Measurement of physician performance on counseling and use of medication enhanced by incentives

• Member engagement through HRA, DM and CM, enhanced by incentives

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Opportunities in Texas

• Adult Prevalence of Tobacco Use 15.9%, ranked 27th in the USA, 3,000,000 smokers

• Annual health care cost attributed to tobacco $8.85B

• Annual Medicaid cost attributed to tobacco $1.6B

• Tobacco attributed death in Texas 28,000

• Tobacco Tax $1.51 ranked 25th in USA

• State Spending on Tobacco Control $11.2M

• Tobacco-generated revenue (Master settlement agreement plus taxes) $1.9B

• Percent of CDC Recommended Spending-4.2%. Ranked 34th in USA

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Tobacco Control in Texas

• The mission of DSHS Tobacco Prevention and Control is to reduce the health effects and economic toll tobacco has placed on the citizens of Texas. Major goals are:

• 1.Prevent tobacco use among young people.

• 2.Promote compliance and support adequate enforcement of federal, state and local tobacco laws.

• 3.Increase cessation among young people and adults.

• 4.Eliminate exposure to secondhand smoke.

• 5.Reduce tobacco use among populations with the highest burden of tobacco-related health disparities.

• 6.Develop and maintain statewide capacity for comprehensive tobacco prevention and control

• http://www.dshs.state.tx.us/tobacco/

Conclusion

• Align with the National Tobacco Control Strategy

• Maximize state specific interventions• Taxes• Regulations• State Funding of Tobacco Control

Programs

• Optimize Heath System Performance• Smoking Cessation Benefit Design• Intervention strategies

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Sources I

• Causes of Death

• http://www.cdc.gov/nchs/data/dvs/LCWK9_2012.pdf

• Detailed state by state coverage

• http://www.lung.org/assets/documents/publications/smoking-cessation/helping-smokers-quit-2014.pdf

• Campaign for Tobacco-free kids: Detailed state tax and tobacco control policy data

• http://www.tobaccofreekids.org/

• State Specific Value Calculations

• http://www.communityhealthadvisor.org/drupal/cha/SmokingInterventionsCosts

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Sources II

• http://www.thecommunityguide.org/tobacco/increasingunitprice.html

• CDC: Detailed Sate by State data

• http://apps.nccd.cdc.gov/statesystem/Default/Default.aspx

• Health System Performance

• http://www.edwardanselmmd.com/

• Community-based interventions

• http://www.thecommunityguide.org/tobacco/comprehensive.html