1. Utilization and Quality of STD Services in Managed Care Organizations: A Synthesis of Recent Research K Irwin 1, W Lafferty 2, ER Brown 3, N Pourat 3, M Stiffman 4, D Magid 5, S Ratelle 6, R Platt 7, G Tao 1, L Anderson 1, J St Lawrence 1, E Patterson 1, J Maher 8, J Mullooly 8 1 Centers for Disease Control, Atlanta; 2 University of Washington, Seattle; 3 University of California, Los Angeles; 4 HealthPartners, Minneapolis; 5 Kaiser Permanente, Denver; 6 Massachusetts Department of Public Health, Boston; 7 Harvard Vanguard, Boston; 8 Kaiser 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

4. StudyMCO/provider surveys Patient surveys Medical Records Administrative Data Medicaid MCOs High rate cities X Medicaid MCOs Washington X X National Health Interview Survey X HealthPartners/ Kaiser Colorado X X X Harvard Vanguard X X National Physician Survey X Kaiser Northwest X X MarketScan Claims Data X

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 Policy or Practice MCO recommends (%) N=21 Medical group recommends (%) N=31 Physicians practice (%) N=50 Presumptively treat CT in presence of GC 14 79 94 Use Azithromycin for CT infection 40 68 78 N Pourat, Health Affairs, In Press.

10. Urethritis Treatment Evaluated at Harvard Vanguard, 1995-1997 Reviewed records of symptomatic men with positive gonorrhea or chlamydia tests In 196 men with positive laboratory tests, CDC-recommended therapy prescribed to: –100% with gonorrhea –88% with chlamydia In 56 men with CDC-defined signs and symptoms: –98% given CDC-recommended chlamydia treatment –77% given CDC-recommended gonorrhea treatment S Ratelle et al, Sex Transm Dis. 2001.

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

12. 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

13. 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

14. STD Screening Policies and Practices in 21 Medicaid MCOs Policy or Practice MCO recommends (%) N=21 Medical group recommends (%) N=31 Physicians practice (%) N=50 Screen sexually active teenaged girls for CT 15 45 55 Screen sexually active women 20-24 yrs for CT 10 50 47 Conduct prenatal syphilis screening 71 93 94 N Pourat, Health Affairs, In Press

15. STD Screening Nationally representative survey of physicians, 1998-1999 –Report routine CT screening of nonpregnant women all primary care physicians40% 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

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

17. Counseling Policies and Practices in Medicaid MCOs 21 MCOs: survey of counseling during sexual history MCO recommends57% Contracted medical group recommends81% Affiliated clinicians practice98% 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.

18. Barriers to STD Counseling among Primary Care Providers: HealthPartners and Kaiser Issue % who believe problematic Managing high risk patients31-35 Limited time to counsel patients27-26 No/limited counseling staff20-34 Knowing how to effectively counsel 5 - 8 Patients don’t adhere to advice to: –Abstain or use condoms during treatment25 -34 –Take full course of antibiotics 6 -13 K Irwin et al, National STD Prevention Conference, 2002

19. Partner Services Policies and Practices at 21 Medicaid MCOs Policy or Practice MCO recommends (%) N=21 Medical group recommends (%) N=31 Physicians practice (%) N=50 Advise patients to notify partners and urge testing 33 94 98 Request health department to notify partners 57 79 65 Test and treat partners even if not members or reimbursed 10 61 62 N Pourat, Health Affairs, In Press

20. Partner Services Practices Reported by 4226 Primary Care Physicians Practice for index patients % who practice with chlamydia Advise patients to notify partner to seek care79 Report patient name to health department38 Advise patient to notify health department and 23 provide them with partner information Send partner information to health department 9 Give patient medication for partners 6 Collect partner info; have office contact partner 4 J St. Lawrence, Am J Public Health, in press.

21. Partner Services of Primary Care Clinicians:HealthPartners and Kaiser Issue % who believe problematic Limited staff to manage sex partners36-45 Plan lacks policies about notifying and 28-33 treating sex partners K Irwin et al, National STD Prevention Conference, 2002

22. 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

23. 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

24. 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