Background

1. Utilization and Quality of STD Services in Managed Care Organizations: A Synthesis of Recent Research K Irwin1, W Lafferty2, ER Brown3, N Pourat3, M Stiffman4, D Magid5, S Ratelle6, R Platt7, G Tao1, L Anderson1, J St Lawrence1, E Patterson1, J Maher8, J Mullooly8 1Centers for Disease Control, Atlanta; 2University of Washington, Seattle;3University of California, Los Angeles; 4HealthPartners, Minneapolis; 5Kaiser Permanente, Denver; 6Massachusetts Department of Public Health, Boston; 7Harvard Vanguard, Boston; 8Kaiser Permanente Northwest, Portland

2. Background • By 1998, private sector clinicians were caring for ~ 70% of persons with chlamydia, ~55% of persons with gonorrhea, and high proportions of person with viral STDs. • Most private sector clinicians are affiliated with one or more managed care organizations (MCOs). • MCOs include commercial and Medicaid plans. • ~56% of Medicaid enrollees are covered by MCOs. • Today most MCOs are loosely managed network models. Tightly “managed” staff models cover ~ 3% of enrollees.

3. Objectives of this Review • To review data from Medicaid and commercial MCOs on utilization and quality of: • diagnostic testing of symptomatic persons • treatment • sexual risk assessment • screening of asymptomatic persons • counseling • partner services

6. The Good News:Diagnostic Testing and Treatment

7. Diagnostic Testing of Symptomatic Patients • Evaluated testing of 196 men at initial visit for symptomatic urethritis • Harvard Vanguard, 1995-1997 • 92% tested for chlamydia • 83% tested for gonorrhea • 98% who met CDC criteria for urethritis tested for chlamydia and gonorrhea S Ratelle et al, Sex Transm Dis, 2001

8. Chlamydia Treatment • HealthPartners/Kaiser study of 1078 enrollees with laboratory-confirmed chlamydial infection, 1998-1999 • Review of pharmacy and medical records revealed: • >97% prescribed CDC-recommended treatment • Reasons for use of different therapy usually noted • Azithromycin was prescribed to: • 25% of men and nonpregnant women • 92% of pregnant women. • Survey of 743 clinicians revealed: • 96% would prescribe CDC-recommended treatment • 65% would prescribe azithromycin for illicit drug user M Stiffman et al, National STD Prevention Conference, 2000

9. Chlamydia Treatment Policies and Practices in 21 Medicaid MCOs N Pourat, Health Affairs, In Press.

10. The Bad News:Risk Assessment, Screening, Counseling and Partner Services

11. Sexual Risk Assessment • 1994 National Health Interview Survey: • 3390 adults 18-64 years with checkup or prenatal care • 28% reported being asked about STDs G Tao et al. Am J Prev Med, 2000 • Three Medicaid MCOs, Washington State, 1998 • Medical records and encounter data of 1112 teens 14-18 yr • STD/pregnancy found in girls (11%) and boys (1%) • 54% received primary care. Of those: • 45% of girls had sexual history taken • 15% of boys had sexual history taken • Staff model HMO was more likely than IPA to provide primary care and sexual history. W Lafferty et al. Am J Public Health, 2002

12. Barriers to Sexual Risk Assessment at HealthPartners and Kaiser • Survey of 743 primary care providers, 1999-2000 • Issues reported as “problematic” or “highly problematic” • limited staff to take sexual history • providers can’t find time to address STD • providers can’t find time to elicit sexual history • provider discomfort discussing sexual matters • patient discomfort discussing sexual matters K Irwin et al, National STD Prevention Conference, 2002

13. STD Screening Policies and Practices in 21 Medicaid MCOs N Pourat, Health Affairs, In Press

14. STD Screening • Nationally representative survey of physicians, 1998-1999 • Report routine CT screening of nonpregnant women • all primary care physicians 40% • ob/gyns 55% • Report routine syphilis screening of pregnant women • ob/gyns 87% • family practitioners 40% J St Lawrence, Am J Public Health, in press • MarketScan Data: Claims for syphilis tests in pregnant women enrolled in commercial MCOs • 50% of women had test anytime during pregnancy G Tao et al, Building Bridges Managed Care Research Conference, 2002

15. Chlamydia Testing in MCOs, 1998-2000 National Committee on Quality Assurance, 2001 W Lafferty, Am J Public Health, In Press

16. Counseling Policies and Practices in Medicaid MCOs • 21 MCOs: survey of counseling during sexual history • MCO recommends 57% • Contracted medical group recommends 81% • Affiliated clinicians practice 98% N Pourat, Health Affairs, in press. • 3 MCOs: chart review of counseling practices for 600 adolescents receiving primary care • 7% of boys and 18% of girls received condom counseling W Lafferty, Am J Public Health, in press.

17. Barriers to STD Counseling among Primary Care Providers: HealthPartners and Kaiser Issue % who believe problematic • Managing high risk patients 31-35 • Limited time to counsel patients 27-26 • No/limited counseling staff 20-34 • Knowing how to effectively counsel 5 - 8 • Patients don’t adhere to advice to: • Abstain or use condoms during treatment 25 -34 • Take full course of antibiotics 6 -13 K Irwin et al, National STD Prevention Conference, 2002

18. Partner Services Policies and Practices at 21 Medicaid MCOs N Pourat, Health Affairs, In Press

19. Partner Services of Primary Care Clinicians:HealthPartners and Kaiser Issue % who believe problematic • Limited staff to manage sex partners 36-45 • Plan lacks policies about notifying and 28-33 treating sex partners K Irwin et al, National STD Prevention Conference, 2002

20. Partners Services, Kaiser Northwest • MCO policies: • No explicit policies, but refers to CDC Treatment Guidelines • Oral agreement gives DIS permission to contact members without clinician approval; 1/3 of clinicians aware, few DIS seek approval. • No policy on care for non-members; ~15% patients given 2x doses • If exposed partner seeks care at Kaiser, most empirically treated • Practices of 21 clinicians: • Nearly all advise patients to notify partner and urge to seek care. • No clinicians collected partner information or contacted partners. • ~ Half told patients discussed reporting or possible DIS contact • Experience of 7 DIS and 35 patients: • DIS estimated 10%-65% of members had been alerted by clinician • DIS estimated they interviewed ~58% of infected members • ~ Half of interviewed members were satisfied with encounter. J Maher, Personal Communication

21. Summary • In MCOs evaluated, services appear adequate for: • Diagnostic testing of symptomatic persons • Treatment of acute STDs • Substantial improvement is needed in: • Sexual risk assessment • Screening of asymptomatic persons • Counseling • Partner services

22. Recommendations • Interventions in MCOs should prioritize selected issues: • Risk assessment • Screening of asymptomatic persons • Counseling and patient education • Partner services • Interventions should minimize resources and training: • Audio-CASI risk assessment in waiting areas • Integrate STD tests with routine Paps, prenatal labs • Use non-MD staff, written/AV materials to counsel/educate • Use more cost effective partner service methods • Research in network MCOs that now dominate US market • Address chlamydia and viral STD common in MCOs • Address all levels where interventions may act