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The California Department of Health Care Services (DHCS) administers the nation's largest Medicaid program. In 2012, DHCS developed a Quality Strategy modeled after the National Quality Strategy to guide the Department's activities aimed at advancing the Triple Aim. The Triple Aim seeks to improve the patient experience of care and the health of populations as well as reduce the per capita cost of health care. An academic team was contracted to assist DHCS in developing the strategy, which also was informed by extensive stakeholder input, an advisory committee, and a comprehensive inventory of DHCS quality improvement (QI) activities. From 2012 to 2018, the strategy included 129 unique QI activities. Most activities were intended to deliver more effective, efficient, affordable care or to advance disease prevention. This qualitative assessment of the DHCS Quality Strategy provides insights that may inform other Medicaid programs or large health systems as they develop quality strategies.

Introduction: This study examined survey data from before and after California expanded its Medicaid program under the Affordable Care Act. It assessed changes in the insurance status of smokers, the proportion of smokers in Medicaid, and the health and well-being of those smokers relative to their counterparts in other insurance groups., Methods: The study compared two data sets from the California Health Interview Study, the 2011-2012 (N=42,935) and 2016 (N=21,055) surveys. Measures include health insurance status, smoking status, chronic health conditions, frequency of doctors' visits, and psychological distress. Data were analyzed in 2018., Results: From 2011-2012 to 2016, the estimated number of California smokers in Medicaid nearly doubled from 738,113 to 1,447,945, and the proportion of smokers covered by Medicaid increased from 19.3% to 41.5%. Compared with those with private insurance, smokers in Medicaid were more likely to have chronic disease, have made five or more doctors' visits in the past year, and be in severe psychological distress. In 2016, a total of 51.4% of all adult smokers with chronic disease conditions and 57.8% of those in severe psychological distress were covered by Medicaid., Conclusions: With Medicaid covering a much higher proportion of smokers, especially of those smokers with chronic disease and in psychological distress, state Medicaid programs and plans must make tobacco cessation a top priority. They should encourage clinicians to ask, advise, and assist all smokers, track progress in reducing smoking prevalence, employ mass communication strategies to drive quit attempts, improve access to medications, and develop or expand programs to help smokers quit., Supplement Information: This article is part of a supplement entitled Advancing Smoking Cessation in California's Medicaid Population, which is sponsored by the California Department of Public Health., (Copyright © 2018 Elsevier Ltd. All rights reserved.)

Introduction: Innovative methods are needed to promote tobacco cessation services. The Medi-Cal Incentives to Quit Smoking project (2012-2015) promoted modest financial and medication incentives to encourage Medi-Cal smokers to utilize the California Smokers' Helpline (Helpline). This article describes the implementation and impact of two different direct-to-member mailing approaches., Methods: Medi-Cal Incentives to Quit Smoking promotional materials were mailed directly to members using two approaches: (1) household mailings: households identified through centralized membership divisions and (2) individually targeted mailings: smokers identified by medical codes from Medi-Cal managed care plans. Mailings included messaging on incentives, such as gift cards or nicotine patches. Number of calls per month, calls per unit mailed, and associated printing costs per call were compared during and 1 month after mailings. Activated caller response was based on reporting a household mailing promotional code or based on requesting financial incentives for individually targeted mailings. Analyses were conducted in 2018., Results: Direct-to-member mailings, particularly with incentive messaging, demonstrated an increase in call volumes during and 1 month after mailing, and increased Medi-Cal calls to the Helpline per unit mailed. Mailings with only counseling messages had the lowest percentage of activated calls per unit mailed, whereas the incentive messaging mailings were consistently higher. Although household mailings demonstrated lower printing costs per call, individually targeted mailings had a higher percentage of activated calls per unit mailed., Conclusions: Household and individually targeted mailings are feasible approaches to increase Medi-Cal calls to the Helpline, particularly with incentive messaging. Choosing an approach and messaging depends on available resources, timing, and purpose., Supplement Information: This article is part of a supplement entitled Advancing Smoking Cessation in California's Medicaid Population, which is sponsored by the California Department of Public Health., (Copyright © 2018. Published by Elsevier Inc.)

Introduction: In California, half of pregnant women and children are on California's Medicaid (Medi-Cal). The Medi-Cal Incentives to Quit Smoking program provided incentives to adults on Medi-Cal to call the California Smokers Helpline (Helpline) from March 2012 to July 2015. This analysis examined reach of the Medi-Cal Incentives to Quit Smoking program among pregnant and parenting women., Methods: This study examined caller data from the Helpline from 2010 to 2015 among women of reproductive age (18-45 years) enrolled in Medi-Cal (n=32,691; analyzed in 2017/2018). The authors calculated the annual percentage of the target population reached who called the Helpline by pregnancy status and used adjusted prevalence ratios to examine the associations between Medi-Cal Incentives to Quit Smoking incentive period, pregnancy/parenting status, Medi-Cal Incentives to Quit Smoking incentives ($20 gift card and nicotine patch), and counseling., Results: Over the study period, the percentage of the target population reached increased for women of reproductive age (2.1% in 2011 to 3.0% in 2014) and pregnant women (2.1% in 2011 to 3.3% in 2014). The percentage of women who asked for the $20 gift card (13.6%) was not substantially different by pregnancy status, and WIC and nonprofits were important referral sources. Pregnant women were less likely to receive nicotine patches, but there was a 3- to 4-fold increase during the Medi-Cal Incentives to Quit Smoking incentive period for both pregnant and nonpregnant women. Among nonpregnant women, counseling decreased 14% during the Medi-Cal Incentives to Quit Smoking incentive period., Conclusions: Results suggest that the nicotine patch incentives motivated women to call the Helpline, even pregnant women who needed a physician's approval consistent with current American College of Obstetricians and Gynecologists cautions about the appropriateness of the patch during pregnancy., Supplement Information: This article is part of a supplement entitled Advancing Smoking Cessation in California's Medicaid Population, which is sponsored by the California Department of Public Health., (Copyright © 2018 Elsevier Ltd. All rights reserved.)

Introduction: Certain racial and ethnic minorities have lower utilization of tobacco cessation services, such as Helpline counseling and cessation medications. The goal of the California Medicaid (Medi-Cal) Incentives to Quit Smoking Program was to facilitate successful cessation by promoting modest financial and cessation medication-related incentives to increase engagement with the California Smokers' Helpline counseling services. Differences in the response to incentives and outreach on engagement with Helpline services among racial/ethnic groups within the Medi-Cal population were examined., Study Design: Analysis of Helpline caller data., Setting/participants: African American (n=18,656); English-speaking Latinx (n=12,792); Spanish-speaking Latinx (n=3,254); and white (n=45,907) Medi-Cal callers., Intervention: The Medi-Cal Incentives to Quit Smoking team conducted statewide and community-based outreach and facilitated direct-to-member all-household mailings about the Medi-Cal Incentives to Quit Smoking program to engage with Medi-Cal callers and promote Helpline services between March 2012 and July 2015 (analyzed 2017/2018). Medi-Cal callers could ask for a $20 gift card incentive after having completed a counseling session; in September 2013, callers were offered free nicotine replacement therapy., Main Outcome Measures: Three behavioral outcomes are reported that reflect activated callers and callers who engaged in treatment that is proven to improve chances of quitting smoking: receipt of the $20 incentive, receipt of nicotine replacement therapy, and receipt of counseling., Results: African Americans and English-speaking Latinx had higher engagement with the financial incentive than whites (African American APR=1.66, 95% CI=1.59, 1.73, English-speaking Latinx APR=1.29, 95% CI=1.22, 1.36). Spanish-speaking Latinx had lower initial engagement with the financial incentive (APR=0.75, 95% CI=0.66, 0.85), but higher engagement with Medi-Cal's all-household mailing (Spanish-speaking Latinx 30.6% vs whites 18.2%, p<0.001). Although African Americans and English-speaking Latinx had similar rates of completing counseling and receiving nicotine replacement therapy as whites, Spanish-speaking Latinx had higher rates than whites., Conclusions: The promotion of modest financial and cessation medication incentives through multiple outreach channels increased callers' engagement with the Helpline and appeared to promote ethnic and linguistic equity with respect to the receipt of counseling and nicotine replacement therapy. Targeted community-based outreach may resonate particularly for African Americans, and language-concordant Medi-Cal insurance plan mailings may have reached newly covered Spanish-speaking Latinx., Supplement Information: This article is part of a supplement entitled Advancing Smoking Cessation in California's Medicaid Population, which is sponsored by the California Department of Public Health., (Copyright © 2018 Elsevier Ltd. All rights reserved.)

An RCT designed to increase Medicaid smokers' quitting success was conducted in California during 2012-2013. In the trial, alternative cessation treatment strategies were embedded in the state's ongoing quitline services. It found that modest financial incentives of up to $60 per participant and sending nicotine patches induced significantly higher cessation rates compared with usual care alone and usual care plus nicotine patches. Building upon that study, this study assessed potential population-level costs and benefits of integrating financial incentives and nicotine patches in a quitline setting for Medicaid smokers. A cost-benefit analysis was undertaken from the Medicaid program's perspective. The Cardiovascular Disease Policy Model was used to simulate future healthcare expenditures over a 10-year horizon for each treatment strategy for a study cohort of California Medicaid enrollees who were aged 35-64 years in 2014 (n=2,452,000). To simulate potential population-level benefits under each treatment strategy, each treatment was applied to all active smokers in the study cohort (n=478,300). Sensitivity analyses were conducted by varying key parameters, such as cessation costs, discount rate, relapse rates, and time horizon. Adding both financial incentives and nicotine patches to usual quitline care would result in $15 million net savings over 10 years, with a benefit-cost ratio of 1.30 compared with the usual care plus nicotine patches strategy. It would yield $44 million net savings, with a benefit-cost ratio of 1.90 compared with usual care alone. The strategy of providing financial incentives and mailing nicotine patches directly to Medicaid smokers who call the quitline is cost saving. SUPPLEMENT INFORMATION: This article is part of a supplement entitled Advancing Smoking Cessation in California's Medicaid Population, which is sponsored by the California Department of Public Health., (Copyright © 2018 Elsevier Ltd. All rights reserved.)

Introduction: Asian male immigrants have high smoking rates. This article describes outreach approaches in the Medi-Cal Incentives to Quit Smoking project to incentivize California Medicaid (Medi-Cal) calls to the California Smokers' Helpline (Helpline) Asian-language lines., Methods: Outreach efforts adapted Medi-Cal Incentives to Quit Smoking materials for the Asian-language lines. Community-based efforts included outreach at ethnic supermarkets and distribution through community networks. Leveraging the Helpline's Asian print media campaign, three press releases promoted Medi-Cal Incentives to Quit Smoking with Lunar New Year or community physician messaging. Medi-Cal all-household mailings with tracking codes also included the Asian-language lines. Helpline caller characteristics and trends were examined for project period 2012-2015. Analyses were conducted in 2018., Results: Among 4,306 Asian American Pacific Islander Medi-Cal callers, there were 37% Asian-speaking Asian Americans (9.5% Chinese, 17.2% Vietnamese, and 10.5% Korean); 44% English-speaking Asian Americans; 9% Pacific Islanders; and 10% Asian American Pacific Islander not otherwise specified. Almost 10% of Asian-speaking Asian Americans were activated by the financial incentive and this was similar for all-household mailings, although this was lower than the other groups. Medi-Cal calls to the Asian-language lines increased, from an average of 18 calls/month to 47 calls/month (162% increase) in the first and last 12 project months respectively. Community outreach was limited by timing and sustainability. The 3-month call totals before and after the Asian-language press releases were significantly greater for Asian-speaking calls than for English-speaking calls (Cochran-Mantel-Haenszel p<0.001, OR=1.70, 95% CI=1.45, 1.99)., Conclusions: Whereas community outreach is challenging, promising population-based methods for in-language, culturally tailored outreach can include press releases with ethnic media and direct-to-member mailings., Supplement Information: This article is part of a supplement entitled Advancing Smoking Cessation in California's Medicaid Population, which is sponsored by the California Department of Public Health., (Copyright © 2018 Elsevier Ltd. All rights reserved.)

Introduction: Previous studies found that offering free nicotine patches significantly increases calls to quitlines, although most used pre-post designs and did not directly compare the effects of patches and other incentives. The current study with California Medicaid members used a 2 × 2 design to directly assess the effects of offering free patches and incentives on calls to a quitline. The hypotheses were that offering either would make members more likely to call, and that offering both would increase demand even further., Methods: Flyers were inserted into a mailing sent to 4,268,696 Medicaid households, with one of four offers: (1) free counseling; (2) counseling plus patches; (3) counseling plus a $20 gift card; and (4) counseling plus patches and gift card. Ninety percent received the first offer and 10% received one of the other three offers, in equal proportions. The mailers shipped late 2013 to early 2014. Data were collected 2013-2015 and analyzed 2018., Results: Response rates were 0.029% for counseling, 0.115% for counseling plus patches, 0.122% for counseling plus gift card, and 0.200% for counseling, patches, and gift card. Both patches and gift cards had statistically significant effects (both p<0.001). Promotional costs were 59%-75% lower with an incentive. Non-whites responded more strongly than whites to a gift card offer., Conclusions: Offering either free patches or a $20 gift card quadrupled the likelihood of Medicaid smokers calling a quitline; offering both had a nearly additive effect. Incentive offers dramatically increased the cost-effectiveness of promotions. Piggybacking on existing Medicaid communications to promote cessation proved very successful., Supplement Information: This article is part of a supplement entitled Advancing Smoking Cessation in California's Medicaid Population, which is sponsored by the California Department of Public Health., (Copyright © 2018 Elsevier Ltd. All rights reserved.)

Introduction: Most successful trials of financial incentives for smoking cessation have offered large rewards contingent on outcomes. This study examines whether more modest incentives to encourage engagement, non-contingent on outcomes, also increase cessation; whether sending medications directly to participants boosts quitting; and whether these strategies are effective in Medicaid., Study Design: Three-group RCT of usual care (UC); nicotine patch (NP); and NP and financial incentive (NP+FI)., Setting/participants: Medicaid beneficiaries calling the California Smokers' Helpline, 2012-2013 (N=3,816). Data were analyzed in 2017., Intervention: All participants enrolled in evidence-based, multisession telephone counseling. All received proof of enrollment with which they could obtain free quitting aids at their pharmacy. NP and NP+FI also received nicotine patches sent to their homes. NP+FI received up to $60 for completing counseling calls., Main Outcome Measures: Quit attempt rate, 7-day and 30-day abstinence at 2 and 7 months, and 6-month prolonged abstinence (primary outcome)., Results: In both complete-case and intention-to-treat analyses, outcomes trended upward from UC to NP to NP+FI. Differences between NP and UC were generally nonsignificant. By contrast, the NP+FI group significantly outperformed the other groups on all measures. In intention-to-treat analysis, compared with UC, NP+FI was more likely to make a quit attempt (68.4% vs 54.3%, p<0.001); be abstinent for 7 days at 2 months (36.1% vs 25.5%, p<0.001) and 7 months (21.2% vs 16.1%, p=0.002); be abstinent for 30 days at 2 months (30.0% vs 18.9%, p<0.001) and 7 months (21.5% vs 16.7%, p=0.004); and achieve 6-month prolonged abstinence (13.2% vs 9.0%, p=0.001)., Conclusions: Financial incentives increased treatment engagement and short- and long-term smoking cessation, despite being modest and non-contingent on outcomes. The study found that incentives can be effective in a Medicaid population, and can feasibly be integrated into existing quitline services., Trial Registration: The trial is registered at www.clinicaltrials.gov NCT01502306., Supplement Information: This article is part of a supplement entitled Advancing Smoking Cessation in California's Medicaid Population, which is sponsored by the California Department of Public Health., (Copyright © 2018 Elsevier Ltd. All rights reserved.)

Context: Medicaid populations have low rates of advance care planning (ACP). Potential policy interventions include financial incentives., Objective: To test the effectiveness of patient plus provider financial incentive compared with provider financial incentive alone for increasing ACP discussions among Medicaid patients., Methods: Between April 2014 and July 2015, we conducted two sequential assessor-blinded pragmatic randomized trials in a health plan that pays primary care providers (PCPs) $100 to discuss ACP: 1) a parallel cluster trial (provider-delivered patient incentive) and 2) an individual-level trial (mail-delivered patient incentive). Control and intervention arms included encouragement to complete ACP, instructions for using an online ACP tool, and (in the intervention arm) $50 for completing the online ACP tool and a small probability of $1000 (i.e., lottery) for discussing ACP with their PCP. The primary outcome was provider-reported ACP discussion within three months., Results: In the provider-delivered patient incentive study, 38 PCPs were randomized to the intervention (n = 18) or control (n = 20) and given 10 patient packets each to distribute. Using an intention-to-treat analysis, there were 27 of 180 ACP discussions (15%) in the intervention group and 5 of 200 (2.5%) in the control group (P = .0391). In the mail-delivered patient incentive study, there were 5 of 187 ACP discussions (2.7%) in the intervention group and 5 of 189 (2.6%) in the control group (P = .99)., Conclusion: ACP rates were low despite an existing provider financial incentive. Adding a provider-delivered patient financial incentive, but not a mail-delivered patient incentive, modestly increased ACP discussions. PCP encouragement combined with a patient incentive may be more powerful than either encouragement or incentive alone., (Copyright © 2017 American Academy of Hospice and Palliative Medicine. Published by Elsevier Inc. All rights reserved.)

Background: In recent decades the overall smoking prevalence in the US has fallen steadily. This study examines whether the same trend is seen in the Medicaid population., Methods and Findings: National Health Interview Survey (NHIS) data from 17 consecutive annual surveys from 1997 to 2013 (combined N = 514,043) were used to compare smoking trends for 4 insurance groups: Medicaid, the Uninsured, Private Insurance, and Other Coverage. Rates of chronic disease and psychological distress were also compared., Results: Adjusted smoking prevalence showed no detectable decline in the Medicaid population (from 33.8% in 1997 to 31.8% in 2013, trend test P = 0.13), while prevalence in the other insurance groups showed significant declines (38.6%-34.7% for the Uninsured, 21.3%-15.8% for Private Insurance, and 22.6%-16.8% for Other Coverage; all P's<0.005). Among individuals who have ever smoked, Medicaid recipients were less likely to have quit (38.8%) than those in Private Insurance (62.3%) or Other Coverage (69.8%; both P's<0.001). Smokers in Medicaid were more likely than those in Private Insurance and the Uninsured to have chronic disease (55.0% vs 37.3% and 32.4%, respectively; both P's<0.01). Smokers in Medicaid were also more likely to experience severe psychological distress (16.2% for Medicaid vs 3.2% for Private Insurance and 7.6% for the Uninsured; both P's<0.001)., Conclusions: The high and relatively unchanging smoking prevalence in the Medicaid population, low quit ratio, and high rates of chronic disease and severe psychological distress highlight the need to focus on this population. A targeted and sustained campaign to help Medicaid recipients quit smoking is urgently needed.

Introduction: Prevention is the most cost-effective approach to promote population health, yet little is known about the delivery of health promotion interventions in the nation's largest Medicaid program, Medi-Cal. The purpose of this study was to inventory health promotion interventions delivered through Medi-Cal Managed Care Plans; identify attributes of the interventions that plans judged to have the greatest impact on their members; and determine the extent to which the plans refer members to community assistance programs and sponsor health-promoting community activities., Methods: The lead health educator from each managed care plan was asked to complete a 190-item online survey in January 2013; 20 of 21 managed care plans responded. Survey data on the health promotion interventions with the greatest impact were grouped according to intervention attributes and measures of effectiveness; quantitative data were analyzed using descriptive statistics., Results: Health promotion interventions judged to have the greatest impact on Medi-Cal members were delivered in various ways; educational materials, one-on-one education, and group classes were delivered most frequently. Behavior change, knowledge gain, and improved disease management were cited most often as measures of effectiveness. Across all interventions, median educational hours were limited (2.4 h), and median Medi-Cal member participation was low (265 members per intervention). Most interventions with greatest impact (120 of 137 [88%]) focused on tertiary prevention. There were mixed results in referring members to community assistance programs and investing in community activities., Conclusion: Managed care plans have many opportunities to more effectively deliver health promotion interventions. Establishing measurable, evidence-based, consensus standards for such programs could facilitate improved delivery of these services.