Medicare coverage of varenicline and combination nicotine replacement therapy (CNRT), the most effective smoking cessation medications, is significantly worse than Medicaid or private insurance coverage, according to a study published in Public Health in Practice.
Based on public health research, reducing out-of-pocket costs for smoking cessation promotes more quit attempts and higher overall quit rates. The researchers explained that the Affordable Care Act (ACA) required most private insurers to have no cost-sharing for US Preventive Services Task Force “Grade A” preventive services, which include all 7 FDA-approved smoking cessation medications.
The ACA also required Medicaid to cover smoking cessation medications, but there are no cost-sharing restrictions. Because Medicaid is administered by state governments, policies vary from state to state, but most provide smoking cessation medications with a low copayment of $5 or less.
On the other hand, Medicare Part D does not cover over-the-counter (OTC) products, including smoking cessation products. Similarly, Medicare Part C does not usually cover OTC medicines. Although varenicline is covered by both parts of Medicare because it is a prescription drug, patients face copayments of up to $469 per month.
Despite the differences in coverage, there is little to no data comparing the differences in access to varenicline and CNRT faced by patients with Medicare, Medicaid, or private insurance. Therefore, the researchers aimed to “characterise patients’ ability to obtain prescribed varenicline or CNRT across 3 general categories – Medicare, Medicaid and private insurance”.
The researchers conducted their study using only patients from the Duke Smoking Cessation Program to minimise differences in state policies, provider prescribing practices, and demographic variability between treatment populations. They created their population using electronic records between 26 May 2016 and 21 July 2021 of smokers 18 years or older with Medicare, Medicaid, or private insurance.
“For each patient, all smoking cessation program notes were manually reviewed and systematically coded to indicate whether the patient faced financial barriers to medication, including unaffordable copayments, unaffordable OTC costs, or the need for patient assistance programs,” the authors write. “A patient was defined as having a ‘financial barrier’ if they were unable to purchase the prescribed medication with insurance coverage or personal funds.”
To assess treatment response, the researchers also assessed which patients successfully took their medication; only patients who attempted to pick up their prescribed medication were included. They also conducted secondary analyses to see if exposure to varenicline or CNRT was associated with abstinence.
The study population consisted of 1223 smokers, of whom 607 had Medicare, 457 had private insurance, and 157 had Medicaid. Medicare patients had a mean (SD) age of 63.7 (9.27) years, which was significantly higher than both Medicaid (49.2 [11.18]; P < .001) and private insurance (50.9 (10.89); P < .001) patients.
The researchers found that 88.9% of patients overall, 89.3% of patients with Medicare, 92.3% of patients with private insurance, and 84.3% of patients with Medicaid were prescribed varenicline or CNRT. Of those who were prescribed, 1000 patients (92%) filled their prescription, including 83.2% of Medicare patients, 90.8% of privately insured patients, and 93.3% of Medicaid patients.
In addition, 784 (78.4%) of those who picked up their medication used it for at least 2 weeks; 78.6% of Medicare patients did so, as did 87.2% of both privately insured and Medicaid patients. The researchers found that patients taking varenicline or CNRT were more likely to achieve abstinence, as the abstinence rate for those exposed to these medications was 26.3%, compared with 16.7% for those taking other treatments. As a result, those who took the medications were 1.58 times more likely to quit smoking than those who did not (P < .001; 95% CI, 1.14-2.17).
From these data, the researchers determined that 45.1% of patients with Medicare had financial barriers to varenicline or CNRT. They were also 5.08 times more likely than privately insured patients (8.9%) (95% CI, 3.62-7.13; P < .001) and 2.82 times more likely than patients with Medicaid (16.0%) (95% CI, 1.86-4.27; P < .001) to have a financial barrier.
The researchers also acknowledged the limitations of their study, including that some patients had longer follow-up periods, making the assessment dependent on each patient’s engagement in care. Also, because the study was conducted in North Carolina, the results may not be generalisable to patients with Medicaid, as policies vary from state to state.
Therefore, to build on their findings, the researchers suggested analysing CMS prescription and cost data, which may better characterise national trends and help to further assess these differences. Based on their findings alone, they suggested that ACA requirements be extended to Medicare Parts D and C.
“To address this Medicare coverage gap, ACA requirements that apply to private insurers could be implemented for Medicare Parts D and C (which are administered by private companies) with explicit coverage of OTC nicotine replacement products,” the authors wrote.
