Coverage of Tobacco Dependence Treatments for Pregnant Smokers in Health Maintenance Organizations
American Journal of Public Health
September, 2001
by Kate E. Pickett, PhD, et al
"Approximately 13% of pregnant women in the United States smoke, with serious health consequences for themselves and their infants."
"We surveyed coverage of prenatal tobacco dependence treatments in health maintenance organizations (HMOs) in California to assess the availability, accessibility, use, and effectiveness of services offered to pregnant smokers."
"MediCal managed care plans were more likely to provide coverage for face-to-face services (individual and group counseling) compared with commercial HMOs. In California, members of MediCal managed care plans may have better access to the most effective, clinically intensive tobacco dependence treatment services, because providers of MediCal managed care are mandated to identify and intervene on risk conditions identified during pregnancy."
"Our findings suggest that in 1997, most California HMOs were not covering the extended or augmented psychosocial interventions that have been recommended for all pregnant smokers by the US Public Health Service. Although managed care offers the potential for increasing the availability and accessibility of such services for plan members, this survey suggests that that potential is not being realized. In addition, many California HMOs are unable to judge the use or effectiveness of these services and can neither track the costs and benefits of existing programs nor determine the need for additional services."
<http://www.ajph.org/cgi/content/full/91/9/1393>http://www.ajph.org/cgi/content/full/91/9/1393
Comment: Because of the purported "success" of managed care health plans in controlling costs, the California state administration decided to utilize managed care organizations for MediCal, California's Medicaid program. MediCal has been somewhat of a challenge for managed care organizations, both because of federal mandates for coverage ("bureaucratic government interference") and because of chronic underfunding of the Medicaid program. The private managed care plans have had fewer controls on benefits and greater funding, allowing them to "excel" in managing care partly by putting in place preventive programs that will improve outcomes of their patient-beneficiaries. Smoking cessation programs during pregnancy represent an optimal use of health care resources, and provide an opportunity for managed care plans to prove that they deliver on their promise of higher quality care and more preventive services.
Although both utilize managed care, the underfunded MediCal program, with "excess government interference," significantly outperformed the private managed care plans in this crucial preventive program. This was at a time (1997) when the private plans were fully developed and operational and were still flush with cash. If less funding and more government oversight produces a better outcome, isn't it time to take a closer look at the overall structure of our health care system? How about a publicly administered, universal health insurance program? Any takers?