ESTIMATING the COST of PREVENTIVE SERVICES
in Mental Health and Substance Abuse Under Managed Care
Model Two: Smoking Cessation Targeted at Pregnant Women
This cost model was designed on the basis of an amalgamation of three publications-Marks, Koplan, Hogue, and Dalmat (1990); Windsor, Lowe, Perkins, Smith-Yoder, Artz, Crawford, Amburgy, and Boyd (1993); and Cummings, Rubin, and Oster (1989)-and reviewed by Dorfman (2000) in references respectively numbered 1, 3, and 26.
The intervention that was most extensive (Windsor et al., 1993), targeted toward pregnant women receiving prenatal care in a public health clinic, consisted of the following components:
- A brief (15-minute) counseling session, supplemented by the use of written materials
- Medical chart reminders during prenatal visits
- Followup phone calls and letters
- A "buddy contact"
- A 2-minute no-smoking reminder embedded within a 20-minute prenatal education class
Marks et al. (1990) reported using only a single 15-minute counseling session, simple instructional materials, and two followup phone calls. Cummings et al. (1989) reported on the cost-effectiveness of a 4-minute counseling session by a physician, a 1-year followup, and a self-help booklet administered to a "hypothetical" group of adult male and female patients.
Once again, in order to make the cost model as generic as possible, it was designed to include the various components across all three studies.
Results
PMPM Cost
The Least Expensive Scenario had a median PMPM cost of $0.02, and the Most Expensive Scenario had a median cost of $0.04, with a midpoint of $0.03. Again, as in the Prenatal and Infancy Home Visits model, variability increased as the average cost increased. Across all four scenarios, 90 percent of the estimated PMPM values were within the range of $0.02 to $0.06.
Design and Input Values Used in the Model
Number of Lives Covered by the Managed Care Plan
This model, like all other models, assumed there are 100,000 enrolled lives (members) in the MCO.
Number of Intervention Cohorts Served Within a 12-Month Operational Cycle
This intervention was assumed to be one that could be offered on an ongoing basis to patients as they came in for their routine medical visits (i.e., prenatal visits in the case of pregnant women).
Number of Likely Participants Completing the Intervention
This model also used estimates of the number of members who would be women in their childbearing years. U.S. Census Bureau data from 1998 were used to determine the percentages of the general population represented by females of each age group who were potentially able to bear children (i.e., teens = ages 14 to 19, adults = ages 20 to 44) and separate tables on the birth rates of these age groups.
It was estimated that an average of 21 percent of the likely pregnant patients in a year would be smokers, as reported by Marks et al. (1990) based on a "1985-1986 Behavioral Risk Factor Surveillance System. . . of American women from 25 states and the District of Columbia" (Dorfman, 2000, p. 31).
Having established the percentage of members who were pregnant and smokers, the model estimated the number of such members who would be willing to participate in the study. Based on a figure of 93.7 percent, reported by Windsor et al. (1993), the model used a range of estimates of the percentage of the pregnant smokers who would agree to start participation. The model also estimated the percentage of pregnant smokers who would complete the program. These selected values were as low as 68 percent in the Least Expensive Scenario and as high as 78 percent in the Most Expensive Scenario.
The values were selected based on attrition rates reported by Windsor et al. (1993). Women left Windsor's planned intervention for such reasons as losing benefit eligibility, having abortions, or having miscarriages.
Materials, Staff Time, and Related Services
For each of the three studies, the model assumed that all participants would undergo one-on-one counseling with a nurse, lasting an average of 15 minutes.
The model assumed each patient received two pamphlets and a "smoking cessation guidebook" or "self-help book." Items were assumed to cost $4. Cummings et al. (1989) reported an estimate of $2 for a self-help booklet, and Windsor et al. (1993) estimated $6 per patient for the cost of materials, reproduction, and labor.
The value of nurses' time was the same as that used in the first model, based on a salary of $50,000 incrementing in each scenario by $1,000, an average productivity of 70 percent of payroll hours, and a 29 percent fringe-benefit rate.
Windsor et al. (1993) reported that each patient received a "medical letter" emphasizing the importance of smoking cessation, and a reminder was placed in the patient's medical chart so the doctor could ask questions at subsequent prenatal visits. The clerical time required for these activities was estimated at a mean of 10 minutes. Clerical salaries were estimated to start at $20,000 (with $1,000 increments for each successive scenario), with a productivity rate of 80 percent and a fringe-benefit rate of 29 percent. The letter and postage costs were estimated at $0.41 per patient.
Windsor et al. (1993) also reported on "social supports," which consisted of the following activities:
- Sending a "buddy letter," including two pamphlets, to each patient
- Sending a quarterly newsletter to each patient
These five mailings were assumed to require an average of 10 minutes of clerical time (standard deviation [SD] = 3 minutes) and $0.45 for reproduction and postage per patient.
The model also builds in the cost for the 2-minute reminder delivered by a nurse as part of a 20-minute prenatal class.
The model assumed that there were no other variable or one-time startup costs beyond the smoking cessation guides/self-help booklets and pamphlets. The final variable that had to be valued is the percentage of total expenses required to cover G&A expenses plus any profit margin. A fairly generous amount of 10 percent was used.
Discussion
This intervention entails very little in the way of initial startup costs or other fixed costs, nor does it require any extensive, specialized training for staff. Marks et al. (1990) estimated a savings of $3.31 for every dollar invested, primarily through the prevention of low-birthweight babies and averted perinatal deaths. Windsor et al. (1993) estimated a range of medical savings realized through fewer adverse birth effects from $6.72 to $17.18 for every dollar invested.
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