Coverage of Tobacco Dependence Treatments for Pregnant Smokers in Health Maintenance Organizations

Approximately 13% of pregnant women in the United States smoke,1 with serious health consequences for themselves and their infants.2^–7 However, many women make important changes in health behavior when pregnant and approximately 30% of women smokers quit spontaneously early in their pregnancies.8 In June 2000, the US surgeon general released clinical practice guidelines for smoking cessation programs and recommended that “because of the serious risks of smoking to the pregnant smoker and fetus, whenever possible pregnant smokers should be offered extended or augmented psychosocial interventions that exceed minimal advice to quit.”9 Minimal contact interventions also have been shown to have some benefit for pregnant smokers and their offspring.10^–14

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. The survey addressed the following services: individual, group, and telephone counseling and self-help kits. The eligible sample included 39 full-service HMOs, all of which responded to the survey. For each HMO, we identified the most knowledgeable staff member to answer the survey.

Only 3 HMOs (8%) covered all 4 services. Thirty-six HMOs (92%) covered at least 1 treatment, whereas 3 (8%) covered no tobacco dependence treatments for pregnant women. Seventeen HMOs (44%) reported covering at least 1 additional smoking cessation service, such as nicotine replacement therapy, for pregnant women beyond those about which we asked. Coverage ranged from a low of 44% for self-help kits and individual counseling to a high of 56% for telephone counseling (Figure 1 ▶).

FIGURE 1—

Coverage of prenatal smoking cessation services among California health maintenance organizations (N = 39).

In many cases, HMOs delegated decisions about provision of treatments to the medical groups with which they contract. Among HMOs covering each service, prior authorization requirements for coverage were low. Specialty training requirements were highest for group counseling (57%) and lowest for staff providing self-help kits (18%). Thirteen HMOs (33%) reported having established memoranda of understanding or contractual relationships with other organizations to provide tobacco dependence treatment services to their members.

Of the HMOs covering services, only 67% monitored utilization (e.g., keeping lists of participants). Only 28% of these HMOs monitored quit rates among pregnant smokers. Thirty-two of the 39 HMOs (82%) reported that their providers screen all pregnant women for smoking, whereas 7 HMOs (18%) did not know whether screening took place.

Medi-Cal managed care plans were more likely to provide coverage for face-to-face services (individual and group counseling) compared with commercial HMOs (Figure 1 ▶). In California, members of Medi-Cal managed care plans may have better access to the most effective, clinically intensive tobacco dependence treatment services, because providers of Medi-Cal 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.9^,15 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.