October 1997 - Number Four
Julianna Gonen, PhD
Managed care has consistently emphasized its commitment to preventive health as both "the right thing to do" and the economically rational approach to providing and financing health care. This emphasis has been considered one of the values added to the U.S. health care system by managed care. Managed care is even described by supporters as a privatized form of public health, because it takes a population- and prevention-based approach to care. In rapidly evolving markets however, the incentive for health plans to make significant efforts in prevention is not always strong, particularly when enrollee turnover is high, as is especially the case with the Medicaid population. As managed care moves beyond commercial markets into Medicaid, its ability to provide traditional public health services will become imperative. Prevention and treatment of sexually transmitted diseases (STDs) has been a priority of public health clinics serving at-risk populations, while less emphasis has been placed on screening and treatment among private sector providers. As private sector managed care organizations (MCOs) move into public programs, they will be challenged to assume even more of a public health philosophy, along with the public health problems that come with the territory. Given the disproportionate impact of STDs on women, it is critical to assess the impact that the growth of managed care will have on the incidence and treatment of STDs.
The Scope of the Problem
Epidemiology and Trends. The term "STD" encompasses the diseases caused by more than 25 infectiousorganisms that are transmitted through sexual activity. Of the top 10 most frequently reported diseases in 1995 in the United States, five were STDs;1 the rates of occurrence of curable STDs in this country are the highest in the developed world. In 1993, the Alan Guttmacher Institute reported, "In stark contrast to the successes [in conquering other infectious diseases], the country has been unable to stem the spread of [STDs]. . . . At current rates, it is estimated that at least one in four--and perhaps as many as one in two--Americans will contract an STD at some point in their lives."2 Despite the great health and economic burden imposed by STDs, the scope of the problem is largely absent from public discourse and public awareness is dangerously low. This is due to the asymptomatic nature of many STDs, the fact that many adverse health consequences occur years after the initial infection, a reticence to discuss sexuality (particularly in teens), and the stigma associated with having an STD which prevents public discussion and education as well as education of patients by clinicians.3
STDs are classified as either bacterial or viral; the latter are incurable. Bacterial STDs include chlamydia, gonorrhea, syphilis, and chancroid and can be cured if detected and treated, although damage caused by the organism is not always reversible. The frequently asymptomatic nature of these diseases can delay diagnosis and treatment, increasing the likelihood of subsequent adverse health outcomes. Viral STDs include genital herpes, human papillomavirus (HPV), human immunodeficiency virus (HIV), and hepatitis B, and their consequences include recurrent painful outbreaks, liver disease, cancer, and death. Infection with common STDs, including gonorrhea, chlamydia, herpes, and chancroid, significantly increases susceptibility to HIV, the virus which causes acquired immunodeficiency syndrome (AIDS).2
STDs have largely been perceived as affecting only certain marginalized groups such as prostitutes, immigrants, the urban poor, drug addicts, and homosexuals; as a result, most individuals probably do not perceive themselves to be at risk. This is a dangerous misperception, however, as it has been estimated that each year 12-17 million women aged 15-44 may be at increased risk of contracting an STD through exposure to multiple sexual partners; the number of men exposed to multiple partners is as high or higher.2 This age group is, of course, not the only group at risk. STDs are transmitted among all sexually active groups -- heterosexual men and women, men who have sex with men, and women who have sex with women; while less is known about this last group, women who have sex only with women are generally at substantially lower risk for contracting STDs than are either men who have sex with men or heterosexuals.4 But although everyone is at risk, STDs have a disproportionate impact on women that has not been widely recognized. Although they are less prevalent among women, their complications are more severe and occur more frequently, because many STDs are transmitted more easily from men to women than the reverse, and because STDs are more likely to remain undetected in women, leading to delayed diagnosis and treatment.5
Certain STDs are of particular concern to women. Chlamydia is the most prevalent STD in the United States (4 million infections each year). It often goes untreated in women because they may remain asymptomatic and because until recently tests have been expensive.6 Pelvic inflammatory disease (PID), a preventable complication of certain STDs including chlamydia and gonorrhea, poses one of the most serious threats to women's reproductive capability. It is one of the most prevalent debilitating diseases affecting women.6 Each year more than 1 million American women experience an episode of PID, and at least one-quarter of women with acute PID experience long-term sequelae, including chronic pelvic pain, ectopic pregnancy, tubal-factor infertility, an increased likelihood of needing reproductive tract surgery, and recurrence of PID itself.
STDs are also associated with multiple acute complications for pregnant women and their infants. STDs are associated with several types of cancer, other chronic conditions, and death. In the past 20 years there has been a dramatic increase in the incidence of HPV--the cause of genital warts--which is one of the most common STDs in the United States. Certain types of HPV are associated with cervical cancer.6 Adolescent girls are at increased risk, because they are likely to have both fewer protective antibodies to STDs and a biologically immature cervix, which may increase the risk of cervical infection, and because they are more likely to have multiple partners and less likely to use barrier contraception.2
Costs of STDs. Although few comprehensive cost data exist, it is clear that the economic burden imposed is high and that an increasing proportion of the costs is being borne by public payment sources.2 The Institute of Medicine (IOM) Committee on Prevention and Control of STDs estimated conservatively that the total costs for a selected group of STDs (excluding HIV) in 1994 were approximately $10 billion. If HIV was included the cost rose to nearly $17 billion.3
The outlook is not, however, all negative. According to the American Social Health Association, a national nongovernmental organization dedicated to the prevention and control of STDs, "recent advances in research and technology make STD control even more feasible than ever before." These advances include rapid diagnostic testing using new collection systems and single-dose treatments, reductions in the prevalence of chlamydia in several regions due to screening and treatment in multiple clinical settings, and more fully documented links between HPV and cervical cancer and between STDs and HIV.7 Opportunities thus seem to exist for managed care to help ameliorate this significant public health problem.
Prevention and Screening
The rate of spread of STDs within a population is affected by the rate of exposure of susceptible persons to infected individuals; the probability that an exposed, susceptible person will acquire the infection; and the length of time that newly infected persons remain able to spread infection to others. Recent studies have documented the effectiveness of behavioral interventions in reducing the risk of contracting STDs; these studies support a strong role for such interventions as part of a comprehensive approach to STD prevention.3 In its ideal form, managed care should be well equipped to conduct such interventions through its organized provider networks and patient education programs.
National Recommendations. The U.S. Preventive Services Task Force's Guide to Clinical Preventive Services contains many recommendations relating to STDs.8 It recommends that primary care clinicians counsel all adolescent and adult patients about measures to prevent STDs, and that such counseling be tailored to the risk factors, needs, and abilities of each patient. The recommendations specifically address women, noting that although STDs have a disproportionate impact on women, most women demonstrate limited knowledge about common STDs. The Task Force notes that many physician organizations, including the American Medical Association (AMA), the American College of Physicians, the American Academy of Pediatrics, the American Academy of Family Physicians, and the American College of Obstetricians and Gynecologists (ACOG) have issued recommendations on counseling for STD prevention. In addition to counseling about prevention, screening programs to detect disease already present can be cost-effective and even cost-saving.
Many MCOs use the national Healthy People 2000 goals to drive their internal quality improvement efforts, and the National Committee for Quality Assurance (NCQA) also uses them in creating performance measures for MCOs.9 These goals thus provide one important leverage point in attempting to influence managed care plans to increase their efforts in STD-related services. Healthy People 2000 includes goals related to STDs and to HIV infection. The health status objectives in the STD section include reductions in the rates of gonorrhea, chlamydia, primary and secondary syphilis, congenital syphilis, genital herpes and warts, PID, hepatitis B, and repeat gonorrhea. The risk reduction objectives include reducing the proportion of adolescents engaging in sexual intercourse and increasing the proportion of sexually active people who use condoms. And finally, the services and protection objectives include increasing screening, diagnosis, treatment, counseling, and partner notification in a range of specialized clinics, providing STD prevention education in school curricula, improving counseling and management of STDs by individual providers, and increasing provider referral services. Many of the goals are cross-referenced in the section on family planning objectives.
The Role of Health Care Providers. Individual health care providers, particularly primary care providers, are the most direct avenue through which to both convey information about STD prevention and to screen for and treat infections already present. Healthy People 2000 calls for increases in the proportion of primary care providers correctly managing their patients with STDs and the proportion of both primary care and mental health providers who provide STD and HIV prevention counseling. New data from the Kaiser Family Foundation reveals that only 12% of women aged 18-44 who had had a first visit with a health provider in the past year reported that their provider had raised the issue of STDs as part of their routine reproductive health care. Many women were not even asked routine questions about their sexual activity.10
The IOM's Committee on STDs convened a workshop in November 1995 to explore the impact that the advent of managed care would have on STD-related services. Participants identified provider training as among the possible barriers to effective STD-related services in managed care. They stated that most providers are not trained to deliver the range of services found in public STD clinics, and that health plans might not consider it cost-effective to replicate the technical competency of these clinics within their provider networks.11 Concern was also expressed that capitated providers might be less willing to conduct diagnostic and screening tests and to spend the time needed to provide counseling and education on STDs. Among the working group's recommendations were increased provider training and the integration of STD-related services into primary care. In a more recent IOM workshop, participants reiterated the concerns about inadequate training and time constraints; recommendations that emerged from this group included collaborative development of clinical practice guidelines for STD-related care.12
One of the advantages of managed care is the ability of health plans to provide continuing education and guidance to their panels of physicians and other providers.13 Managed care thus affords a unique opportunity to improve the prevention, surveillance, and treatment of STDs in the private sector thro ugh the dissemination of practice guidelines and the monitoring of provider performance. While STDs are a common component of outpatient medical practice, fewer than 20 percent of medical education programs provide adequate training in taking sexual histories and in STD evaluation and treatment. MCOs could harness their market power by insisting on hiring staff with such training who must be periodically recertified or obtain relevant CME credits.14 The extent to which MCOs have fulfilled their potential for physician education in STDs is not well known, however, and barriers to the realization of this goal do exist.
Public Health, Managed Care, and STDs
Some critics of managed care doubt whether private--and particularly for-profit--health plans possess the requisite commitment to caring for the needy and underserved, while others view managed care plans as potential partners in combating public health problems. The roles and responsibilities of public versus private health care professionals in the prevention of STDs have not been clarified as the health care delivery system has changed.3 Some, however, see potential for managed care to assist in alleviating the "hidden epidemic" of STDs in the United States.
Efforts at the Federal Level. The Centers for Disease Control and Prevention (CDC) is the national agency charged with combating the spread of STDs, chiefly through its Division of STD/HIV Prevention. In 1992, the CDC established the STD Prevention Partnership, a coalition of national organizations "that share concern about the continuing spread of STDs, including HIV." Its mission is "to support and encourage partnerships among the private, voluntary, and public sectors in developing and implementing plans to reduce the incidence and impact of STDs."15 In addition to professional organizations like the ama and ACOG and numerous health advocacy groups, the Partnership's membership includes the American Association of Health Plans (AAHP), the national trade association for managed health care plans. The Partnership endorsed a set of critical components of STD prevention and control in 1996 which emphasized the need for public and private sector providers to work together in their implementation.16
The Partnership also adopted a separate document focusing on women and STDs, which identified several opportunities: the female condom, vaginal microbicides, and new non-invasive diagnostic tests; increasing recognition of the links between STD prevention and other factors such as domestic violence, communication skills, self-esteem, and self-efficacy; increased condom use among high-risk populations; and a nationwide focus on infertility prevention. Challenges include the greater transmissibility of STDs to women, women's limited ability to protect themselves from STDs, the asymptomatic nature of many STDs in women, the difficulty of diagnosing STDs in women, and the greater severity of consequences of STDs in women. The Partnership's recommends incorporating STD prevention into family planning and prenatal care services, increasing research on STD microbicides, and providing women-specific STD-related training to providers of health care to women, "especially managed care providers."17
CDC has generally taken an approach of working constructively with MCOs in addressing various public health issues in such areas as childhood and adolescent immunization, and continues to do so in STD-related services. CDC's STD/HIV Prevention Division released a request for applications this year for "Health Services Research on STD Prevention Within Managed Care Settings."18 The research must be conducted as a collaborative effort between an MCO and either an academic institution or a state or local health department (or both). The four areas for which funds were made available (and the grantees) are: an STD-managed care prevention services survey (UCLA); quality of service studies (University of Washington, the Seattle-King County Department of Public Health, OMPRO and three MCOs, in coordination with the National Committee for Quality Assurance); notifiable disease reporting and information systems studies (Massachusetts Department of Public Health and Harvard Pilgrim health Care); and population-level STD prevention studies (PruCare, Emory University, and the Georgia State Health Department). Stating that "managed care . . . has and will continue to have an impact on the way in which STD prevention is conducted in both the private and public sectors," the division created the grant in order to "develop a knowledge base through published research in scientific literature which will improve delivery of STD prevention services within managed care settings." Another expected outcome is the establishment of new partnerships and relationships between managed care plans and public health agencies to address STD prevention and treatment collaboratively.
Service Delivery: Public and Private. STD screening and treatment services for underserved groups have traditionally been provided in dedicated public STD clinics run by local health departments, as well as in community-based health clinics and in private care settings. Public STD clinics often face a situation similar to family planning clinics,19 in that clients who have private health insurance may still seek services at these public clinics in order to ensure confidentiality or because they are more comfortable receiving these services in these settings. Thus, public clinics often provide services to patients who have insurance and could access private sector providers, and the clinics are not reimbursed.
Despite the existence of these dedicated STD clinics, most STDs are in fact diagnosed by private sector providers. Little is known about the prevalence or spectrum of STDs encountered in private settings relative to public STD clinics. And studies of STD-related services in private sector settings indicate the need for improvements. The advent of managed care has generated new attention to how STD-related services may be delivered effectively in private health plans, as well as in plans that serve beneficiaries of publicly funded programs such as Medicaid. According to the IOM, managed care plans may improve STD-related services through the coordination and integration of STD care with primary and preventive care, which are emphases of managed care; their population-based approach to health care; their use of information systems to monitor STD-related trends; the adoption of public health screening recommendations as standard policy; the improvement of the quality of STD-related care; their accountability to both purchasers and beneficiaries; and the ability of plans to retain culturally appropriate providers.
Despite these promises, there are also concerns about managed care's role in STD prevention. STDs have not been a high priority for most MCOs, perhaps due to the widespread misperception that risk is confined to small sectors of the population and that STDs are not a problem of white, middle-class, middle-aged and older women. Plans also vary widely in their technical ability to deliver services and may be reluctant to provide services for which they do not see demonstrated cost savings. Persons with STDs may prefer to receive care out of plan for confidentiality reasons, plans may not adequately notify and treat sexual partners if they are not plan members, the eligibility of Medicaid managed care enrollees is usually short term, and there is a lack of standard definitions for essential STD-related services, including counseling. Some of the limitations of MCOs are in fact the flip side of some of their advantages, such as the potential for compromised confidentiality through the use of centralized information systems and team-based care, and the risk that capitated primary care providers will forego screening and education. Other concerns include the limited experience of most MCOs in providing public health services, the possible reluctance of MCOs to replicate the expertise of public STD clinics through training their own providers, copayments that may pose a barrier to care for low-income enrollees, and potential cost-shifting generated by capitated providers referring patients to public clinics.20 As with other preventive services, there is some doubt as to whether MCOs truly have enough incentive to provide STD counseling and screening, when volatile markets and high enrollee turnover may not make investment in prevention cost-effective for a given health plan in the short run.
Many of the opportunities and challenges involved in providing STD-related services in managed care that were outlined above were stated in terms of managed care's potential; in fact not a great deal is known about managed care and STDs. A 1994 survey of HMOs conducted by the Henry J. Kaiser Family Foundation and the Group Health Association of America (now the American Association of Health Plans) that focused on reproductive and HIV/AIDS care asked whether plans had special confidentiality protections for certain categories of services.21 Of responding plans, 13.2 percent indicated that they had such protections for the diagnosis and treatment of STDs; fewer than 2 percent had separate billing procedures for STD services. Plans were also asked whether parental consent or notification was required when providing certain services to minors. For the diagnosis and treatment of STDs, nearly 88 percent did not require such consent; 3.3 percent required consent, and 7 percent indicated that they abide by pertinent state law.
The same survey queried HMOs on their management of plan members with HIV. Thirty-six percent had guidelines in place for HIV antibody testing, and 31 percent had specific guidelines for managing patients with HIV. One-quarter reported having dedicated outpatient facilities that specialized in HIV care, while 16.6 percent had dedicated inpatient facilities and approximately 58 percent had arrangements with community-based organizations to provide support services to HIV/AIDS patients. Slightly more than 61 percent said they provided HIV antibody test results counseling. Fewer than 20 percent reported having special quality assurance procedures for HIV care, while 37 percent offered HIV patients expanded access to new HIV drugs. More than 28 percent offered or supported specialized HIV care training for their physicians, and close to 33 percent designated specific physicians to provide primary care to patients with HIV. Just over a quarter offered targeted HIV primary prevention; these efforts were effected through physicians, newsletters, health forums, and risk reduction groups. Some 38 percent of plans tracked the HIV census at each of their sites, for use in long-term planning, patient outreach, case reporting for public health purposes, and health forums.
The IOM Committee on STDs conducted its own survey in late 1995 of selected MCOs that would likely serve populations at high risk for STDs (Medicaid recipients, or inner city residents, for example). Over half attempted to define high-risk groups for STDs and approximately half provided STD-related services specifically targeted to adolescents. But only 26 percent provided STD-related services to persons outside the plan.3
Health Plan Models. Some MCOs have been proactive in STD-related care. For example, Group Health Cooperative of Puget Sound conducted a randomized controlled trial to determine whether selective testing for cervical chlamydial infection would prevent PID among enrollees. High-risk women were identified through a questionnaire mailed to all enrolled women aged 18-34; eligible respondents were then randomly assigned to undergo testing or to receive usual care, and both groups were followed for a year. Over 2,600 women were included in the study, and at the end 9 cases of PID were verified in the screening group, compared with 33 cases among women receiving usual care. The plan concluded that a strategy of identifying, testing, and treating women at increased risk for cervical chlamydial infection was associated with a reduced incidence of PID.22 The CDC is actively considering funding replications of this study at several other MCOs to build an evidence base to support the provision of chlamydia screening by health plans.
Part of the IOM's 1995 workshop on STDs and managed care entailed comparing several plan models and their experiences with STD care. In CIGNA's HMO in southern California, a private for-profit IPA-model plan, all STD-related services are triggered by and centered on patient visits to their primary care providers; the health plan has a system for automatic tracking and reporting of STDs. Kaiser Permanente's plan in the same region, a private non-profit group-model HMO, uses its centralized laboratory facilities to monitor STD diagnoses and screening test results closely and holds monthly teleconferences between clinicians and lab personnel. There is an unwritten policy of providing prescriptions to the sexual partners of members who are diagnosed with STDs, even if the partners are not members of the health plan. Kaiser also has a prevention program targeted to adolescents. Many at the IOM workshop concluded that group and staff-model HMOs were more likely than network and IPA-model plans to have the necessary oversight structure and organization necessary for effective STD prevention services, surveillance, and reporting.11
These private health plan experiences were contrasted with those of two publicly owned MCOs that were created to serve low-income and indigent populations, the very populations at increased risk for STDs because of their limited access to education and health care services. At the Los Angeles County Health Plan, routine gonorrhea and chlamydia screening is part of every pelvic exam, and enrollees are provided with STD-related risk reduction education with every exam. Contra Costa Health Plan, a staff-model MCO, and the County Health Department have outlined their roles and responsibilities regarding STD-related and other services in a memorandum of understanding that covers education, reporting, contact investigation, and treatment. The public nature of these plans and their built-in links to county health departments have ensured that STD-related services are available to plan enrollees. The Los Angeles County Health Department, in delineating the roles of the health department and of MCOs in serving Medi-Cal (Medicaid ) enrollees, included a provision requiring the health plans to reimburse county STD clinics for care provided to enrollees. The state of California has required Medi-Cal MCOs in 12 counties to subcontract with local health departments for several public health services, including STD-related care.11
Managed care plans have the potential to adopt not only a public health philosophy of care, but also public health models for delivering certain kinds of services like those needed for STDs. Greater collaboration between private MCOs and the public health sector has in fact been an oft-cited recommendation. But health plans also could go beyond existing models to expand their vision--for example, in focusing more efforts on evaluating and screening men for STDs. This would not only enhance the health of male enrollees but also help reduce the STD burden on women.
Recommendations. In its recently published report The Hidden Epidemic, the IOM Committee concluded that an effective national system for STD prevention does not exist and must be established. The Committee developed a comprehensive series of recommendations toward this end, some of which focused on managed care. The IOM recommended greater assumption of responsibility by private sector organizations and clinicians, including increased coverage of and support for comprehensive STD-related services by private health plans, and extension of these services to sex partners whether they are plan members or not. Inclusion of STD-related performance measures in HEDIS (see below) and the development of information systems to integrate preventive services performance data with community health status indicators and STD program data were also enumerated goals. Others included implementation by health plans of policies to ensure confidentiality of STD- and family planning-related services provided to adolescents and other individuals; incorporation of STD-related services into primary care (while retaining the safety net of public dedicated STD clinics); the development of collaborative agreements between managed care plans and local public health agencies to coordinate STD-related services, including payment for services provided to plan enrollees by public sector providers; the collaborative development of clinical practice guidelines; the incorporation of STD services in Medicaid required services; outreach to employer/purchaser groups; and the funding of cost-effectiveness research relevant to MCOs.20
The current iteration of the Health Plan Employer Data and Information Set (HEDIS), the predominant set of performance measures for managed care plans, contains no measures related to STDs. One measure--chlamydia screening--was submitted to NCQA by the CDC and is in the testing set. The measure as currently defined is an estimate of the percentage of sexually active women aged 15-25 who have been screened for chlamydia in the past year. Several technical specification issues are being worked out during the testing phase, particularly how to identify the measure's denominator, or relevant population, as no consistent and reliable indicators for sexual activity exist. Proxies for sexual activity such as Pap tests, other STD tests, contraceptive prescriptions, and visits for prenatal care are being considered but will fail to capture the entire population at risk. Another technical barrier has been the lack of a CPT code for non-culture chlamydia screening, the predominant method in use. The CDC has submitted a new code to the ama, which has agreed to include the code in the next CPT-4 version, to be released in January 1998. The committee that develops HEDIS measures also stated that there must be an assessment of how reliably chlamydia screening is reported before the measure can be fully incorporated.23 The chlamydia screening measure and several others from the HEDIS testing set are being pilot tested in a small sample of health plans to assess the accuracy of proxy measures of sexual activity and the overall feasibility of the measure.24
The IOM report recommended that STD-related measures be incorporated into HEDIS, but at this point no performance measures other than chlamydia screening are pending inclusion. HEDIS is by necessity a limited set of measures, not intended to assess every function performed by MCOs. One measure in an area like STDs may be all that can reasonably be expected and might be used as a proxy for how the MCO addresses STDs in general. However, it is still of value to develop other measures to assess managed care performance on STD screening and treatment, for use in quality assessment activities other than HEDIS performance measurement.
Several features of STDs and their prevention and treatment make them difficult targets for measurement. For bacterial STDs like syphilis and gonorrhea, incidence tends to be quite focused geographically, making measurement less relevant for some health plans. For viral STDs that lack a cure, measuring incidence would not necessarily relate very directly to a health plan's efforts in treatment, as those testing positive who remain within a plan would continue to be counted in subsequent incidence rates. Health plans are reluctant to report numbers that do not appear to reflect well on their performance, particularly in areas over which they feel they have little control.
The IOM has concluded that, to date, STDs have not been a high priority for MCOs, and yet managed care is continually assuming a greater role in ensuring public health. STDs are a critical component of the mission of preserving public health, and they are of particular importance to women. STD prevention, screening, and treatment need to be mainstreamed into primary and preventive health care for all, but this does not seem to be happening because of service fragmentation, inadequate provider training, and biases regarding which patients are at risk.
Based on this review, a number of issues remain for further exploration:
4. Recent studies, however, have shown lesbians to be at greater risk than previously thought for women-to-woman transmission of certain STDs. See, for example, Carroll, et al. Gynecological infections and sexual practices of Massachusetts lesbian and bisexual women. J Gay & Lesbian Med Assoc 1997;1:15-23.
9. U.S. Department of Health and Human Services, Public Health Service. Healthy People 2000--National Health Promotion and Disease Prevention Objectives. Washington, DC: U.S. Government Printing Office, 1990.
12. Eng TR, et al. The potential role of health plans in public health: ensuring services for sexually transmitted diseases. Abstract for American Public Health Association annual meeting, November 1997.
13. See Insights #2.
19. See Insights #3.