New York: Increasing Access and Promotion of Tobacco Cessation Treatment
State Spotlight | November 2022
The Centers for Disease Control and Prevention’s (CDC) 6|18 Initiative highlights CDC and partners targeting six common and costly health conditions with 18 proven interventions. The following example from Alaska showcases some of the strategies used to address one condition under the 6|18 Initiative. These profiles are stories reported by the state officials based on their work within the 6|18 Initiative.
New York Key Facts
- State population: 19.4 million
- Medicaid population: 6.8 million
- Medicaid enrollees in managed care: 76 percent
- Medicaid MCO enrollees who use tobacco: 20 percent
While participating in the Centers for Disease Control and Prevention’s (CDC) 6|18 Initiative, New York’s Medicaid program (Medicaid) and the Office of Public Health (public health) — both located within New York State’s Department of Health — partnered to increase coverage for tobacco cessation treatment for all individuals enrolled in Medicaid and remove barriers that impede access to covered treatments.
New York used the technical assistance, strategies, and collaborative opportunities made available through its participation in the 6|18 Initiative to facilitate availability of uniform tobacco cessation benefits for Medicaid enrollees. New York also developed comprehensive provider and public awareness campaigns to promote covered benefits and services to members.
New York’s 6|18 Accomplishments
- Increased coverage of tobacco cessation treatment by ensuring all people enrolled in Medicaid can obtain medically necessary counseling services and all Food and Drug Administration (FDA)-approved tobacco cessation medications. The median smoking prevalence across NY Medicaid Managed Care organizations declined in 2017 to 18.9%, from 25.4% in 2015/16. The median utilization of tobacco cessation services (i.e., counseling and pharmacotherapy) increased from an average of 27.9% in 2015 to 33.9% of all NY MMC enrollees in 2017.
- Removed barriers to treatment that limited access to effective treatments or restricted which treatments were available, such as prior authorization, step therapy, and restrictions on the number of cessation attempts.
- Developed provider and public media campaigns to increase awareness about benefits and services available to both Medicaid enrollees and health care providers.
6|18 Project Activities
New York’s Medicaid and public health agencies partnered to implement the following activities to increase access to and promote use of tobacco cessation treatments:
- Increase access and remove barriers to tobacco cessation medication and services; and
- Create provider and public awareness campaigns.
Specific activities undertaken by the New York 6|18 team included:
New York took an incremental approach to achieving comprehensive and inclusive cessation coverage, building on previous efforts to expand cessation treatment for people with behavioral health needs. Prior to participation in 6|18, New York increased access to the full range of FDA-approved cessation medications as well as to counseling services to beneficiaries with behavioral health needs. As part of its 6|18 Initiative efforts, the NY team worked to further increase coverage of cessation services by providing Medicaid enrollees with coverage for comprehensive smoking cessation treatments, including counseling services and FDA-approved medications. The New York 6|18 team also determined it was important to the state’s cessation efforts to remove common barriers to treatment including prior authorization requirements, restrictions on the number of annual cessation attempts, and restrictions on smoking cessation product formularies within Medicaid.
Medicaid first began covering some smoking cessation medications in 1999. By 2002, Medicaid issued further policies and guidelines for medication coverage accompanied by utilization management strategies.
While participating in 6|18, benefits available to individuals enrolled in Medicaid were broadened. These changes included removing the two-course annual limit for smoking cessation treatments; removing prior authorization of smoking cessation agents (exceptions would apply for brand name medications with generic equivalents available), including formulary coverage of all FDA-approved smoking cessation medications (exceptions would apply for brand name medications with generic equivalents available); and allowing concomitant utilization of two cessation medications.
Even after formal 6|18 technical assistance participation concluded, tobacco cessation efforts continued and additional barriers were removed. For example, as of April 2021, the counseling benefit was modified to include as many sessions “as medically necessary,” and additional provider types were added to the list of professionals who could provide those services.
The New York team, with support from an independent evaluator, conducted a survey of individuals enrolled in fee-for-service and Medicaid managed care who smoke. The goals of the survey were to understand: (1) whether Medicaid enrollees in New York were aware of Medicaid coverage of tobacco cessation treatments; (2) whether Medicaid enrollees used tobacco cessation pharmacotherapy and counseling services to assist with a quit attempt; (3) what the real or perceived barriers associated with tobacco cessation services were among Medicaid enrollees; and (4) other Medicaid enrollees’ beliefs about quitting. This was a mail-to-web survey, meaning that individuals were mailed a letter and asked to go to a website to complete the questionnaire. The results from the survey were used to inform the state’s messaging in promotion and public awareness communications and campaign efforts geared toward sharing information about available tobacco cessation supports and services for people enrolled in Medicaid.
In addition to increasing coverage of Medicaid cessation benefits and removing barriers to treatment, the New York Medicaid and public health team focused on increasing Medicaid beneficiaries’ awareness of available benefits and services. Using what was learned from the survey, in 2016 public health used television and digital advertising to publicize Medicaid coverage of tobacco cessation treatments. The following links are examples of these targeted ads: Cigarettes Are Eating You Alive – Mask and Medicaid Can Help You Quit Smoking. An evaluation of this campaign approach showed that awareness of these messages was strongly associated with a higher likelihood of using evidence-based quitting methods at the most recent quit attempt.
A separate media campaign was directed at providers likely to treat people enrolled in Medicaid to inform and encourage them to promote cessation benefits to their patients who use tobacco. The campaign ran from March through July of 2016 with a second round implemented in from January through May of 2018. New York documented its efforts to increase the delivery of tobacco dependence treatment by health care professionals using a targeted media campaign in the following report, Reaching Providers with Cessation Messaging, New York’s Health Care Provider Media Campaign. An evaluation of the 2016 campaign was also published.
The combined approach of increasing benefits, removing barriers, and raising awareness correlated with improved utilization and decreasing prevalence. Between 2015 and 2017, the median smoking prevalence in New York’s 18 Medicaid managed care programs declined from 25.4 percent to 18.9 percent, corresponding with an increase in the overall utilizations of smoking cessation services for 14 out of 15 mainstream managed care plans. More information about the use of tobacco cessation services among enrollees in New York can be found here.
New York’s work through 6|18 is an example of how the complementary capacities of Medicaid in providing health care benefits and of public health in analysis and promotion can address a long-standing problem like tobacco use.
Public health conducted outreach efforts, specifically focusing on people enrolled in Medicaid and providers likely to have a high proportion of people enrolled in Medicaid in their practice, to raise awareness about available cessation benefits. Meanwhile, the Medicaid office led the ongoing effort to enhance cessation benefits for individuals enrolled in Medicaid managed care. Medicaid also invited a public health analyst to explain trends in cessation utilization at a meeting of MCO medical directors. This helped convince some plans to take action by utilizing public health messaging to increase benefit awareness among their members.
Public health and Medicaid in New York capitalized on the strategies, processes, and meetings made available by their participation in the 6|18 Initiative to advance their work in enhancing and promoting the use of cessation benefits. The team achieved concrete improvements in cessation benefits, and the state has seen an improvement in cessation treatment utilization within the Medicaid population. The strengthened collaboration continues, with the two departments continuing to communicate through standing meetings and email check-ins on a regular basis. Looking ahead, New York intends to continue to collaborate around cessation and other population health priorities to reduce health disparities and inequities related to tobacco use.
This publication was supported by the Centers for Disease Control and Prevention (CDC) contract #47QRAA20D001M, awarded to the National Opinion Research Center (NORC) in partnership with the Center for Health Care Strategies (CHCS). The findings and conclusions in this report are those of the authors and do not necessarily represent the official position of the Centers for Disease Control and Prevention.
CDC would like to thank Jennifer Lee, PhD, MPH, Director, Bureau of Tobacco Control, New York State Department of Health, Douglas G. Fish, MD, Medical Director, Division of Medical and Dental Directors, NORC and CHCS for their significant contributions to the 6|18 series of profiles with public health innovators across the United States. Please contact 618@chcs.org with any questions.