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Physician and enrollee knowledge of Medicaid coverage for tobacco dependence treatments

      Abstract

      Background

      The 2000 Public Health Service Clinical Practice Guideline, Treating Tobacco Use and Dependence, recommends health insurance coverage for tobacco-dependence treatments proven effective in helping smokers to quit. Two states with comprehensive coverage for tobacco-dependence treatments in their Medicaid programs were selected to document awareness of coverage for tobacco-dependence treatments among primary care physicians who treat Medicaid enrollees and Medicaid-enrolled smokers.

      Methods

      In 2000, surveys were conducted among Medicaid smokers (n =400) and physicians (n =160) to document knowledge of covered tobacco-dependence treatments under state Medicaid programs in two states with comprehensive coverage.

      Results

      Only 36% of Medicaid-enrolled smokers and 60% of Medicaid physicians knew that their state Medicaid program offered any coverage for tobacco-dependence treatments. Physicians were more than twice as likely to know that pharmacotherapies were covered compared to counseling.

      Conclusions

      Greater effort is needed to make Medicaid smokers and physicians aware that effective pharmacotherapies and counseling services are available to assist in treating tobacco dependence. Additionally, future research should explore the methods that are most effective in informing patients and providers regarding covered benefits.

      Background

      Treating tobacco-related illness is a major challenge in the Medicaid program where more than one in three, or 11.5 million enrollees, are smokers.

      Kaiser Family Foundation. Medicaid enrollment: Kaiser Commission on Medicaid and the Uninsured. Washington DC: Kaiser Family Foundation, 2000

      ,
      • Mathews T.J.
      Smoking during pregnancy in the 1990s.
      With considerably higher smoking rates compared to the general adult population (36% v 22%), and higher rates of smoking among pregnant women (25% v 12%), the Medicaid program bears a disproportionate share of the burden for treating tobacco-related illness.
      • Mathews T.J.
      Smoking during pregnancy in the 1990s.
      ,
      • Curry S.J.
      • Grothaus L.C.
      • McAfee T.
      • Pabiniak C.
      Use and cost effectiveness of smoking-cessation services under four insurance plans in a health maintenance organization.
      There is strong evidence that providing coverage for specific tobacco-dependence treatments is an effective means to reducing tobacco use.
      • Schauffler H.H.
      • McMenamin S.
      • Olson K.
      • Boyce-Smith G.
      • Rideout J.A.
      • Kamil J.
      Variations in treatment benefits influence smoking cessation results of a randomised controlled trial.
      ,

      Fiore MC, Bailey WC, Cohen SJ, et al. Treating tobacco use and dependence. clinical practice guideline. Rockville MD: U.S. Department of Health and Human Services, Public Health Service, June 2000

      Based on this evidence, the U.S. Public Health Service (PHS) Clinical Practice Guideline on Treating Tobacco Use and Dependence for 2000
      • Halpin H.A.
      • Ibrahim J.
      • Orleans C.T.
      • Rosenthal A.C.
      • Husten C.G.
      • Pechacek T.
      State Medicaid coverage for tobacco-dependence treatments—United States, 1994–2001.
      recommends full health insurance coverage for those treatments that have been demonstrated to be most effective in helping smokers quit. These recommended treatments include nicotine replacement therapy (NRT) in the form of gum, patch, nasal spray, and the inhaler/puffer; bupropion SR in the form of Zyban® or Wellbutrin®; and counseling services, including individual, group, and proactive telephone counseling.
      Despite the publication and dissemination of these guidelines, coverage for tobacco-dependence treatments is offered at the discretion of each state's Medicaid program, resulting in a large variation in the level of coverage for tobacco-dependence treatments across state Medicaid programs. In 2001, 36 of the 51 state Medicaid programs covered some form of tobacco-dependence treatment.
      • Schauffler H.H.
      • Barker D.C.
      • Orleans C.T.
      Medicaid coverage for tobacco-dependence treatments.
      This represents a significant increase in coverage in the 3 years since 1998 when only 24 states covered any tobacco-dependence treatments.
      • Schauffler H.H.
      • Barker D.C.
      • Orleans C.T.
      Medicaid coverage for tobacco-dependence treatments.
      ,

      Solberg L, Davidson G, Alesci N, Boyle R, Magnan S. Physician smoking-cessation actions. Are they dependent on insurance coverage or on patients? Am J Prev Med 2002;23:160–5

      Although there has been a significant increase in the number of state Medicaid programs offering coverage for tobacco-dependence treatments, the potential impact of this coverage is dependent on physicians and enrollees being aware of and using these covered benefits. Therefore, it is important to assess physician and enrollee awareness or knowledge of the availability of tobacco-dependence treatments through their state Medicaid program to understand the potential impact of coverage of these services on quitting behaviors and reducing tobacco use.
      The purpose of this study was to document the level of knowledge of coverage for tobacco-dependence treatments in state Medicaid programs among primary care physicians who treat Medicaid enrollees as well as among Medicaid-enrolled smokers. In addition, this study explored the factors that explain varying levels of knowledge among physicians and smokers enrolled in the Medicaid program.

      Methods

      Two surveys were conducted to answer these research questions. The first survey documented Medicaid smokers' knowledge of covered tobacco-dependence treatments under their state Medicaid program. The second survey documented knowledge of Medicaid-covered tobacco-dependence treatments among primary care physicians treating Medicaid enrollees. Based on a national survey of 51 state Medicaid programs conducted in the fall of 2000, four state Medicaid programs were identified as offering relatively comprehensive coverage for tobacco-dependence treatments (defined as coverage for over-the-counter and prescription pharmacotherapy as well as counseling services) (Center for Health and Public Policy Studies Survey of State Medicaid Programs, University of California, Berkeley, Berkeley CA, unpublished data, 2000). Medicaid programs in these four states were contacted by the Center for Health and Public Policy Studies (CHPPS) at the University of California, Berkeley, and asked to supply a list of the physicians providing medical care to Medicaid patients in their state. Only two states were able to fulfill this request. Both the Medicaid enrollee and physician surveys were conducted in these two states (State A and State B). These two states are not identified in this manuscript because confidentiality was promised to the state Medicaid departments.

      Survey 1: medicaid enrollees

      Between November 12 and 22, 2000, Lake, Snell, Perry, and Associates, under the direction of CHPPS, surveyed 400 Medicaid-enrolled smokers aged 18 to 64 years regarding their knowledge of covered tobacco-dependence treatments under their state Medicaid program. Individuals were contacted using a random-digit-dial telephone interview technique in census tracks known to have high rates of Medicaid enrollees. To determine eligibility for the survey, respondents were first asked if they were “currently enrolled in Medicaid—the program that helps lower-income people get and pay for health care.” In each state, the specific name of the state Medicaid program was also included in the question.
      Once it was established that the respondent was a Medicaid enrollee, a second set of questions was asked regarding smoking behaviors. To be eligible for the survey, respondents must have indicated that they currently smoke cigarettes some days or every day, had smoked ≥100 cigarettes in their lifetime, and had smoked cigarettes in the past 30 days. Only those individuals aged 18 to 64 years who met the above eligibility criteria were recruited to participate in the survey. The final sample included 200 Medicaid-enrolled smokers in each state for a total sample size of 400.
      The survey instrument included 40 questions addressing the respondent's smoking history, current smoking practices, knowledge of covered tobacco-dependence treatments under the Medicaid program in their state, health status, and demographic characteristics. Questions regarding knowledge of Medicaid coverage for tobacco-dependence treatments were developed based on recommendations for health insurance coverage of tobacco-dependence treatments in the 2000 PHS Clinical Practice Guideline on Treating Tobacco Use and Dependence.

      Fiore MC, Bailey WC, Cohen SJ, et al. Treating tobacco use and dependence. clinical practice guideline. Rockville MD: U.S. Department of Health and Human Services, Public Health Service, June 2000

      All of these recommended treatments were covered in both State A and State B Medicaid programs in 2000. Medicaid enrollee knowledge of coverage for tobacco-dependence treatments was assessed by the following questions: “As far as you know, does Medicaid cover medications or treatments to help people stop smoking? Specifically, does Medicaid pay for: (1) nicotine patches, (2) nicotine gum, (3) nicotine nasal spray, (4) nicotine inhaler or puffer, (5) Zyban or bupropion, which are drugs that help people quit smoking, (6) classes for people trying to quit, and (7) counseling with a health professional?” Response categories for each of these seven questions were “yes,” “no,” and “don't know.”

      Survey 2: medicaid physicians

      In the fall of 2000, lists of physicians who treat Medicaid patients were obtained from the state Medicaid programs in State A and State B. The sampling strategy for this survey included the following steps:
      • Physicians without addresses or phone numbers were removed from the sample.
      • Physicians who were not primary care physicians (family medicine, internal medicine, pediatrics, general medicine, or obstetrics/gynecology) were removed from the sample. Pediatricians were included because they have an important role to play in treating tobacco dependence in children and their parents.
      • A random sample of physicians to be screened was drawn for each state. This was accomplished by assigning each physician a number and then using the random number generator function in Excel to designate the physicians to be included in the sample.
      • A total of 1182 physicians were contacted at the phone number given by the state Medicaid office. The person answering the phone was asked to confirm that the sampled physician was currently practicing medicine, that the physician sees Medicaid patients, and that she or he is a primary care physician (as defined above). Additionally, physicians were removed from the sample if their phone number was disconnected, or if they were retired or deceased.
      A sample of 274 eligible physicians was contacted and faxed the two-page survey instrument. Follow-up with each physician was conducted by telephone and fax over an 8-week period. A total of 160 physicians responded to the survey for a response rate of 58%. This included 70 physicians in State A (50% response rate) and 90 physicians in State B (67% response rate). Table 1 details the results of the sampling strategy.
      Table 1Sampling procedure for primary care physicians participating in Medicaid programs, 2000
      State AState BTotal
      Number of physicians on lists received from state Medicaid office13,52765,53579,062
      Removed: invalid state; missing phone number or address145571438598
      Removed: non–primary care physicians6023Information not available
      The Medicaid physician list from State A identified physicians by specialty, while the physician list from State B did not. Therefore, in State B it was necessary to contact individual physician offices to screen out physicians who were not primary care physicians.
      Total eligible to be sampled604958,39264,441
      Total number of physicians randomly sampled to be contacted
      The Medicaid physician list from State A identified physicians by specialty, while the physician list from State B did not. Therefore, in State B it was necessary to contact individual physician offices to screen out physicians who were not primary care physicians.
      3538291182
      Number of physicians who were determined to be ineligible for the survey
      Physicians were determined to be ineligible for the following reasons: incorrect phone numbers, disconnected phone numbers, phone numbers that no one ever answered, the physician was not a primary care physician, the physician no longer practiced medicine at that number (they had left, moved, retired, or died), or the physician does not see Medicaid patients.
      213695908
      Number of physicians determined to be eligible for the survey and who were faxed the survey instrument140134274
      Number of completed surveys returned7090160
      Response rate50%67%58%
      a The Medicaid physician list from State A identified physicians by specialty, while the physician list from State B did not. Therefore, in State B it was necessary to contact individual physician offices to screen out physicians who were not primary care physicians.
      b Physicians were determined to be ineligible for the following reasons: incorrect phone numbers, disconnected phone numbers, phone numbers that no one ever answered, the physician was not a primary care physician, the physician no longer practiced medicine at that number (they had left, moved, retired, or died), or the physician does not see Medicaid patients.
      The survey instrument contained 15 questions designed to obtain information regarding practice and demographic characteristics of physicians as well as knowledge of coverage for tobacco-dependence treatments in their state Medicaid program. Physician knowledge of Medicaid coverage for tobacco-dependence treatments was assessed by asking physicians if their “state Medicaid program covers any of the following smoking-cessation treatments: (1) nicotine replacement patch; (2) nicotine replacement gum; (3) nicotine replacement nasal spray; (4) nicotine replacement inhalers; (5) Zyban; (6) Wellbutrin; (7) individual counseling; and (8) behavioral and/or support programs for smokers.” Response categories for each of these eight questions were “yes,” “no,” and “don't know.”

      Results

      Sample characteristics

      Table 2 presents the demographic characteristics of the adult, nonelderly Medicaid smokers in the sample. Approximately half were male (49%). In the sample, 22% were aged 18 to 29; 24%, 30 to 39; 20%, 40 to 49; and 34%, 50 to 64. There was not much diversity in terms of racial and ethnic make-up. Eighty-five percent of the respondents in the sample identified themselves as being white, 5% reported being black, and 10% reported being Asian, American Indian, or another race/ethnicity. Similarly, only 5% of the sample reported that they are of Hispanic ethnicity. Forty-four percent worked full-time, 14% worked part time, 9% were unemployed and 33% were out of the workforce. Approximately half were married or living as married and 46% were educated past high school. Eighteen percent described themselves as being in fair or poor health.
      Table 2Demographic characteristics of adult, non-elderly Medicaid smokers and Medicaid primary care physicians, 2000
      Medicaid-enrolled smokersTotal (n=388)
      Twelve pregnant women were removed from this analysis.
      Gender
      Male49%
      Female51%
      Age
      18–29 years22%
      30–39 years24%
      40–49 years20%
      50–64 years34%
      Race/ethnicity
      White85%
      Black5%
      Asian/American Indian/Other10%
      Marital status
      Married and living as married49%
      Single30%
      Other21%
      Education level
      <High school graduate20%
      High school graduate34%
      >High school graduate46%
      Health status
      Excellent/very good41%
      Good41%
      Fair/poor18%
      Medicaid primary care physiciansTotal (n=160)
      Primary care specialty
      Family and general practice50%
      Internal medicine28%
      Pediatrics12%
      OB/Gyn10%
      Main practice setting
      Partnership or group practice73%
      Staff or group model HMO9%
      Solo practice8%
      Community health center/other10%
      Gender
      Female39%
      Male61%
      Age
      28–40 years41%
      41–50 years34%
      ≥51 years25%
      Percent of practice revenue from Medicaid
      ≤20%75%
      >20%25%
      Awareness of clinical practice guidelines
      2000 PHS Guideline27%
      Sources: University of California, Berkeley Survey of Medicaid Primary Care Physicians, 2000; University of California, Berkeley Survey of Medicaid Smokers, 2000.
      HMO, health maintenance organization; Ob/Gyn, obstetrics/gynecology; PHS, U.S. Public Health Service.
      a Twelve pregnant women were removed from this analysis.
      Demographic and practice characteristics are also presented for physicians in Table 2. Half of the physicians in this sample were family or general practitioners. An additional 28% practiced internal medicine, 12% were pediatricians, and 10% practiced obstetrics/gynecology. Physicians were most likely to be in a partnership or group practice (73%), 9% practiced in staff or group model HMOs, 8% were in solo practice, and 10% practiced in either community health centers or another practice setting. Almost two thirds of the physician sample were male (61%). Additionally, 41% were aged 28 to 40 years; 34%, 41 to 50; and 25%, >50. Twenty-five percent of physicians in this sample reported that >20% of their practice revenue derived from Medicaid patients. Additionally, when asked about their knowledge of clinical practice guidelines for smoking cessation, 27% reported that they were aware of the 2000 PHS guideline.

      Knowledge of coverage for tobacco-dependence treatments

      Table 3 presents the findings on enrollee and physician knowledge of Medicaid coverage for specific tobacco-dependence treatments. While all seven tobacco-dependence treatments included on the survey are covered under the two state Medicaid programs, only a minority of Medicaid smokers knew that these treatments were covered. Overall, only 36% knew that any of the seven tobacco-dependence treatments were covered benefits under their state Medicaid program. Additionally, 29% had knowledge of any type of pharmacotherapy benefits, and only 22% knew of any type of counseling benefits. Twenty-one percent of Medicaid smokers reported knowing that NRTs were covered by Medicaid (15% inhaler, 13% patch, 13% gum, 11% spray). Twenty percent knew that Zyban/bupropion was covered. Knowledge of covered counseling benefits was also quite low with 19% of Medicaid-enrolled smokers aware of coverage for individual smoking-cessation counseling and 21% aware of coverage for smoking-cessation classes.
      Table 3Medicaid enrollees' and physicians' knowledge of coverage for tobacco-dependence treatments, 2000
      TreatmentMedicaid smokers (%) (n=388)Medicaid PCPs (%) (n=160)
      Knowledge of any benefits3660
      Knowledge of any pharmacotherapy2958
      Knowledge of any NRT2146
      Patch1344
      Gum1322
      Spray1111
      Inhaler1510
      Zyban®/Wellbutrin2052
      Knowledge of any counseling2223
      Smoking cessation individual counseling1914
      Smoking-cessation group counseling2119
      Sources: University of California–Berkeley Survey of Medicaid Smokers, 2000; University of California–Berkeley Survey of Medicaid Primary Care Physicians, 2000.
      aAll are covered in both states.
      NRT, nicotine replacement therapy; PCP, primary care providers.
      Primary care physician knowledge of Medicaid benefits for treating tobacco dependence is also limited (Table 3). Physicians were asked if their state Medicaid program covered five drugs for the treatment of tobacco dependence and two types of smoking-cessation counseling services. Again, although all seven tobacco-dependence treatments included on the survey were covered in both states, only 60% of the primary care physicians surveyed knew that Medicaid covered any of them. Physicians were most likely to know that Zyban/Wellbutrin (52%) and the nicotine patch (44%) were covered under their state Medicaid program. Fewer than one fourth of physicians surveyed knew that nicotine gum (22%), group counseling (19%), individual counseling (14%), nicotine nasal spray (11%), or the nicotine inhaler (10%) were covered under their state Medicaid program.
      Overall, primary care physicians treating Medicaid enrollees had higher rates of knowledge of covered benefits for treating tobacco dependence compared to Medicaid-enrolled smokers. Physicians had higher rates of knowledge for coverage of any benefits (60% v 36%), knowledge of any pharmacotherapy (58% v 29%), and knowledge of any NRT (46% v 21%). Differences in knowledge of pharmacotherapy and counseling benefits were more pronounced among physicians than among enrolled smokers, with more than twice as many physicians aware of any pharmacotherapy benefit (58%) than were aware of any counseling benefit (23%).
      Logistic regression models were estimated to explain variation in knowledge of coverage for tobacco-dependence treatments in state Medicaid programs (Table 4). Controlling for demographic and smoking characteristics, Medicaid enrollees who started smoking before age 16 had lower adjusted odds of knowing that their state Medicaid program covers NRT in the form of gum, nasal spray, or inhaler, or counseling, whether individual or group. Additionally, respondents in very good or excellent health had lower adjusted odds of knowing that their state Medicaid program covered nicotine inhalers, individual counseling, and group counseling compared to respondents in good, fair, or poor health status.
      Table 4Adjusted ORs and 95% CIs of Medicaid enrollees and physicians knowing that Medicaid covers specific tobacco-dependence treatments, 2000
      Medicaid smoker knowledge
      Controlling for age, gender, race, stage of readiness, educational level, marital status, number of cigarettes smoked per day, and doctor advice to quit smoking.
      PatchGumSprayInhalerZyban®/WellbutrinIndividual counselingGroup counseling
      Started smoking before age 160.6(0.3–1.3)0.4
      OR significant at p<0.1 level.
      (0.2–0.9)
      0.4
      *OR significant at p<0.05 level.
      (0.2–0.9)
      0.5
      OR significant at p<0.1 level.
      (0.2–1.0)
      0.9 (0.5–1.6)0.3
      OR significant at p<0.1 level.
      (0.1–0.6)
      0.4
      OR significant at p<0.1 level.
      (0.2–0.7)
      Health status is excellent or very good1.4 (0.7–2.6)0.8 (0.4–1.6)0.9 (0.5–1.9)0.6
      OR significant at p<0.1 level.
      (0.3–1.1)
      1.0 (0.6–1.7)0.6
      OR significant at p<0.1 level.
      (0.3–1.0)
      0.6
      *OR significant at p<0.05 level.
      (0.3–0.9)
      State B1.2 (0.6–2.2)0.6 (0.3–1.2)0.9 (0.4–1.7)0.7 (0.4–1.3)1.3 (0.8–2.3)1.0 (0.6–1.6)0.9 (0.5–1.6)
      Physician knowledge
      Controlling for physician practice setting, primary care specialty, gender, and age.
      Aware of 2000 PHS guidelines2.0 (0.9–4.5)2.6
      OR significant at p<0.1 level.
      (1.1–6.0)
      1.2 (0.4–3.9)1.7 (0.5–5.7)1.7 (0.8–3.7)6.0
      OR significant at p<0.1 level.
      (2.1–17)
      2.9
      OR significant at p<0.1 level.
      (1.2–7.1)
      Percent practice revenue from Medicaid patients is >20%2.8
      OR significant at p<0.1 level.
      (1.2–6.3)
      2.1 (0.8–5.2)1.4 (0.4–4.8)1.8 (0.5–6.3)2.3
      OR significant at p<0.1 level.
      (1.1–5.2)
      3.9
      OR significant at p<0.1 level.
      (1.3–12)
      2.4 (0.9–6.2)
      State B1.4 (0.7–2.9)1.4 (0.6–3.2)0.5 (0.2–1.5)0.3
      OR significant at p<0.1 level.
      (0.1–1.1)
      0.7 (0.3–1.3)0.4
      OR significant at p<0.1 level.
      (0.1–1.1)
      1.4 (0.6–3.4)
      CI, confidence interval; OR, odds ratio.
      * OR significant at p<0.1 level.
      ** *OR significant at p<0.05 level.
      a Controlling for age, gender, race, stage of readiness, educational level, marital status, number of cigarettes smoked per day, and doctor advice to quit smoking.
      b Controlling for physician practice setting, primary care specialty, gender, and age.
      After controlling for physician characteristics and practice setting, primary care physicians who were familiar with the 2000 PHS guideline had higher adjusted odds of knowing that their state Medicaid program covered nicotine patch, nicotine gum, individual counseling, and group counseling compared to physicians who were not aware of the PHS guideline. Additionally, primary care physicians who reported that >20% of their total practice revenue came from Medicaid payments had significantly higher adjusted odds of knowing that the nicotine patch, Zyban/Wellbutrin, individual counseling and group counseling are covered under their state Medicaid program compared to physicians reporting that ≤20% of their practice revenues are Medicaid payments.

      Limitations

      One limitation to this study was a potential nonresponse bias. Among physicians, it was expected that nonresponding physicians were even less likely to be knowledgeable about coverage, and thus that the results reported here could be an overstatement of the degree to which physicians were aware of covered benefits for treating tobacco dependence under Medicaid. Another limitation of this study was that the true distribution of demographic characteristics of Medicaid-enrolled smokers and Medicaid physicians in State A and State B are not known. The state Medicaid programs could not provide us with demographic information on their Medicaid smokers or the physicians who treat Medicaid patients. This made it impossible for us to estimate how representative the sample was of the total population of Medicaid-enrolled smokers and Medicaid physicians in these two states.

      Discussion

      Data from previous surveys of state Medicaid policies for treating tobacco dependence offer some insight into what each state Medicaid program did to try to inform physicians and patients of covered treatments. In 2000, the Medicaid program in State A reported that they did not engage in any activities to inform tobacco users of the availability of covered tobacco-dependence treatments or encourage the utilization of these benefits (Center for Health and Public Policy Studies Survey of State Medicaid Programs, University of California, Berkeley, Berkeley CA, unpublished data, 2000). In contrast, the Medicaid program in State B reported a number of activities to inform their Medicaid enrollees of the availability of covered tobacco-dependence treatments. To inform Medicaid enrollees about these benefits, State B used their website, newsletters, mailers, advertisements for health education classes, advertisements for disease management programs, an information line, new member packets, health fairs, a quit line, and state TV and radio spots. Despite the differences in the approaches taken in State A and State B, there were no differences in the rates at which Medicaid enrollees reported knowledge of covered tobacco-dependence treatments in these two states. This suggests that the techniques employed in State B were not very effective in informing Medicaid enrollees of the availability of covered treatments.
      It has been found previously that smokers who knew that they have coverage for tobacco-dependence treatments are more likely to report that their physician asked about their tobacco use status, advised them to quit smoking, assessed their interest in quitting, assisted them in quitting, and arranged a follow-up visit.

      Solberg L, Davidson G, Alesci N, Boyle R, Magnan S. Physician smoking-cessation actions. Are they dependent on insurance coverage or on patients? Am J Prev Med 2002;23:160–5

      Additionally, smokers who were aware of coverage were more likely to report that their physician encouraged them to use medications and that their physician gave them a prescription for medications. This suggests that knowledge on the part of the patient can play a role in influencing physician behavior.
      There were also differences in the approaches used by State A and State B to inform primary care physicians of Medicaid benefits. In State A, the Medicaid program informs physicians about covered treatments through their website, notices sent out twice per month, bulletins sent as needed, and in provider manuals. In State B, the Medicaid program informs physicians about covered treatments through a newsletter, website, and a table detailing covered treatments. There were few differences in the rates at which physicians in both states were aware of Medicaid coverage for tobacco-dependence treatments. Medicaid physicians in State B had lower adjusted odds of knowing that NRT inhalers and individual counseling were covered benefits under their state Medicaid program compared to physicians in State A. It is not clear from this study which of the methods used to inform physicians are more or less effective in informing physicians of covered benefits. This suggests the need for future research that explores successful strategies for the dissemination of information on covered benefits to physicians.
      Primary care physicians' knowledge of Medicaid coverage for tobacco-dependence treatments is likely to influence the successful treatment of tobacco use and dependence in the Medicaid population. The results of this study suggest that physicians are not well informed about Medicaid benefits for treating tobacco dependence and that most do not know if specific pharmacotherapy or counseling services are covered for their Medicaid patients who smoke. Although physicians reported being more aware of pharmacotherapy coverage compared to coverage for counseling services (58% v 23%), the rates for both were quite low. It is possible that pharmaceutical detailing may be responsible for higher knowledge of pharmacotherapy benefits compared to counseling benefits. Physicians' more limited knowledge of counseling benefits is potentially detrimental for enrolled Medicaid smokers who are pregnant women because the current PHS guideline advises physicians to carefully consider use of medications to treat tobacco dependence—NRT and bupropion—during pregnancy since they have not been tested for safety or efficacy in pregnant women.
      • Schauffler H.H.
      • Barker D.C.
      • Orleans C.T.
      Medicaid coverage for tobacco-dependence treatments.
      While it may be unrealistic to expect physicians to keep track of all benefits that are covered by the dozens of health plans with which they contract, these results suggest that there is certainly room for improvement by state Medicaid programs in increasing primary care physicians' knowledge of coverage for tobacco-dependence treatment for their Medicaid enrolled patients. Thus, physicians are missing a key opportunity to utilize effective treatments to reduce tobacco use in the Medicaid population.
      If the goal for state Medicaid programs in covering tobacco-dependence treatments is to increase rates at which smokers try to quit and to reduce the prevalence of tobacco use in the Medicaid population, a more concerted effort is needed to make both Medicaid smokers and physicians aware that effective pharmacotherapies and counseling services are available at no cost to assist in treating tobacco dependence. It is not enough for state Medicaid programs simply to cover tobacco-dependence treatments; they must also effectively inform both enrollees and physicians of their availability. Unfortunately, there is little research or evidence of which methods of communication are most effective in informing patients and providers regarding covered benefits; therefore this is a topic that requires further study. Furthermore, the degree to which knowledge of covered benefits for treating tobacco dependence influences smoking cessation has not been explored. Future research that addresses these two issues is needed.

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        • Mathews T.J.
        Smoking during pregnancy in the 1990s.
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        • Curry S.J.
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        • Pabiniak C.
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        • Ibrahim J.
        • Orleans C.T.
        • Rosenthal A.C.
        • Husten C.G.
        • Pechacek T.
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        MMWR Morb Mortal Wkly Rep. 2003; 52: 496-500
        • Schauffler H.H.
        • Barker D.C.
        • Orleans C.T.
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      3. Solberg L, Davidson G, Alesci N, Boyle R, Magnan S. Physician smoking-cessation actions. Are they dependent on insurance coverage or on patients? Am J Prev Med 2002;23:160–5