# Presentation: 688181

## 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

**Notes:**
Today I’ll review the utilization and quality of STD services in managed care organizations. I’ll synthesize recent research sponsored by CDC conducted by investigators and institutions listed here.  

## 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.

**Notes:**
READ BULLETS
Viral STDs such as HSV and genital warts due to HPV 

## 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

**Notes:**
I’ll review data from Medicaid and commercial MCOs on the utilization and quality of 

	READ BULLETS

## Slide 4

| Study | MCO/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 |

**Notes:**
I’ll cover 8 different studies that used various data sources.   These include 
A study of 21 Medicaid MCOs in the 7 US cities with high rates of reportable STDs and substantial Medicaid managed care penetration.  This study surveyed policies of MCOs and their contract medical groups, and the practices of their affiliated physicians.  
Another study of 3 Medicaid MCOs in Washington State involved review of medical records and administrative data, specifically,  electronic encounter, claims and lab data.
The 1994 National Health Interview Survey involved interviews of a representative sample of more than 3000 adults. 
The study at HealthPartners in MN and Kaiser in Colorado, two large staff model HMOs, involved a survey of  more than 700 clinicians and reviews of medical records and administrative data. 
The study at Harvard Vanguard, another large HMO in Boston,  also involved a review of medical records and administrative data. 
The study at Kaiser Northwest in Portland involved interviews with clinicians, health department staff, and patients. 
And finally, the Marketscan database was analyzed  to assess claims for STD  services to privately insured women enrolled by MCOs throughout the US.   

## Slide 5

**Notes:**
This review will largely explore the paths of  Medicaid MCOs and large HMOs because these are the settings where STD care has been evaluated so far.  We will not explore the paths of the numerous network MCOs known as IPAs PPOs and so on that now dominate the managed care  market in the US – 
So keep in mind that today you will be seeing only a small part of the managed care landscape.   If any of you in the audience are affiliated with network managed care plans and are interested in evaluating STD care, please stop by after my talk.    

## The Good News:Diagnostic Testing and Treatment

**Notes:**
First, let me address the good news about STD care in MCOs 

Diagnostic testing and treatment

## 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

**Notes:**
The one study that addressed diagnostic testing of symptomatic patients evaluated testing in 196 men at their initial visit for symmptomatic urethritis at Harvard Vanguard in the mid ’90s.  They evaluated electronic lab data and medical records and found that 

 the majority of men were tested for the most common pathogens.

## 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

**Notes:**
Now let’s see how MCOs are doing with STD treatment. First, I’ll address chlamydia.  
In this study at HealthPartners and Kaiser, more than 1000 enrolles with lab-confirmed chlamydai were evaluated. 

READ BULLETS
Altho Azithro is recommended by CDC, the safety and efficacy of this drug during pregnancy is less well established than alternative regimens. 

In a mail survey of 743 primary care clinicians at these MCOs – a survey with a  82% response rate  -- they found that when the clinicians were presented with various clinical scenarios
	READ FIRST BULLET
HOWEVER, ONLY
	READ SECOND BULLET 
So while  adherence to CDC recommmended therapy is good overall,  use of single dose therapy for patients in whom compliance may be questioned is lower than might be expected, even tho Azitro was on the formulary in  both plans. 

## 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.

**Notes:**
Now lets look at chlamydia treatment policies and practices in 21 Medicaid MCOs in high morbidity cities. 

Altho the minority of  MCOs explicitly recommended following two CDC recommended treatment approaches 
	READ COLUMNS

Most of the contracted medical groups recommended these two approached,  and most of the affliliated physicians said they would follow these practices

## 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.

**Notes:**
Now lets look at treatment of  urethrisits  

Investigators at Harvard Vanguard evaluated records for symptomatic men with positive gonorrhea or chlamydia tests

READ BULLETS

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

**Notes:**
Now for the bad news – in the areas of risk assessment, screening of asymptomatic persons, counseling, and partner services, the ball is often being dropped. 

## 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

**Notes:**
In the 1994 National Health Interview Survey,  more than 3300 adults who reported were asked if their provided addressed risk of STDs during their last  routine checkup or prenatal visit. 
Only 28% reported being asked about STDs,  substantially less than the percent being asked about  smoking – 58%, physical exercise 52%, alcohol 49%, diet 43%, contraception 36% or even illegal drugs 31%
DON’T READ
Persons who were less than age 45, male, single, at poverty level,or insured by HMO (compared to no insurance or FFS) were more likely to say they had been asked about STDs
In the study of 3 Medicaid MCOs in Washington, records of more than 1000 teens were reviewed. They found that STD and pregnancy were not uncommon. They also found that only about half received any primary care where STD risks might be routinely assessed. Of the teens who got primary care, only 45% of the girls and 15% of the boys had a sexual history taken.  
The staff model HMO was more likely than the loose network model – an IPA – to provide primary care and sexual history. The HMO had more native English speakers and provision of sexual history was most  common for teens whose primary language was  English. Different organizational structures may have also explained these differences.  The HMO was more likely to stress clinical  protocols, standardized charting, and  preventive care than the IPA which used a looser,  less systematic approach to delivering care.      

## 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

**Notes:**
Why aren’t MCO clinicians doing risk assessment? The survey of primary care clinicians  at HealthPartners and Kaiser gives us some clues. 

These Clinicians identified several barriers to sexual risk assessment. 

More than 25% rated these top three issues as problematic or highly problematic – including limited staff – a barrier at the system-level, and limited time – a barrier at the clinician level. 

See poster XXX for more information about this study. 

## 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

**Notes:**
First, let me address policies and practices in Medicaid MCOs about screening for chlamydia and syphilis. These screening services have been recommended by CDC and several clinical organizations for several years.  

The survey of 21 Medicaid MCOs in cities with high STD morbidity found that few MCOs had explicit policies supported recommended chlamydai screening practices, only about half of  their medical groups did, and only about half of the physicians reported such screening. 

The picture was a bit rosier for prenatal syphilis screening – here, the majority of MCOs and medical grcups recommended screening, and nearly all physicians said they practiced it. 

## 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

**Notes:**
These findings from Medicaid MCOs are consistent with data from the  nationally representative sample of primary care physicians surveyed in 1998-1999. Jan St Lawrence presented these data at our last STD meeting in  Milwaukee.  In this study, about 80% of physicians practiced in private sector settings and many were affililiated at least one MCO.
Among physicians who had treated some STD in the past year, only 40% of primary care physicians and only 55% of ob/gyns reported routinely providing  Ct screening to nonpregnant women. 
Regarding prenatal syphilis screening in ob/gyns and family practioners who provide prenatal care, only  READ BULLET

A review of MarketScant data that includes claims for syphilis tests in pregnant women einrolled in more than 200 commercial MCOs througout the US found that only 
READ BULLET. 

Obviously, this is far less than the universal screening recommended by several clinical organizations and most state laws. 

## Chlamydia Testing in MCOs, 1998-2000

- National Committee on Quality Assurance, 2001
- W Lafferty, Am J Public Health, In Press

**Notes:**
The extent of testing for chlamydia in MCOs also looks poor.

CDC actively monitors data on the new HEDIS performance measure for CT testing – the measure is one of many that is used to track the quality of care in  MCOs.  You see that in sexually active teens and young women who are to be screened under this measure, on average, less than 20% were tested in the hundreds of MCO across the country reporting their testing rates. 

These HEDIS findings are consistent with the study of 3 Medicaid MCOs in Washington.The study  assessed screening of sexually active teenaged girls in 1998 before the HEDIS measure was introduced and found that screening rates varied by type of MCO- highest in the staff model HMO, but less than half were being screened in any plan.   They found that testing rates were significantly higher in girls who spoke English as their primary language, and the HMO enrolled more of these girls.     

## 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.

**Notes:**
Now let’s leave screening issues and looks at counseling policies and practices

Two studies addressed this in Medicaid MCOs

The study of 21 MCOs in cities with high morbidity found that 

READ BULLETS

The study in Washington reviewed charts of 600 teens who got primary care services – 
	READ BULLETS

## 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

**Notes:**
Again, the survey at HealthPartners and Kaiser gives us a hint at some of the barriers to counseling 

20% or more rated these three counseling issues were problematic or highly problematic.  In addition,  the problem of patients not adhereing to clinican advice to abstain or use condoms during treatment was commonly rated as problmeatic. 

## 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

**Notes:**
Finally, I’d like to review what we’ve learned about partner services in MCOs.  

In the survey of 21 Medicaid MCOs,  less than 2/3 of MCOs had policies about PS such as the three listed here READ BULLETS.

However, the contracted medical groups and affliated provicers were more likely to report policies or practices for various PS approaches.

## Partner Services Practices Reported by 4226 Primary Care Physicians

- Practice for index patients 	    		% who practice
-    with chlamydia
- Advise patients to notify partner to seek care	79
- Report patient name to health department		38
- 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.

**Notes:**
The national physician survey found a real diversity of approached for partner services

Most reported using methods recommended by CDC

But about a quarter reported using methods  not recommended by CDC.
 READ THIRD BULLET

 Few said they provided  patients treatment for their partners 
	POINT TO SECOND TO LAST BULLET. . 

## 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

**Notes:**
The clinician survey at HP and Kaiser raised some issues about partner services in large HMOs

  more than a quarter reported that some aspect of PS was problmeaticc – 

READ BULLETS

## 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

**Notes:**
Preliminary results from a recent evaluation of parnters services for patients with chlamydia at Kaiser Norhtwest in Portland underscores some of these same issues. This study reviewed  MCO policies interviewed  clinician,  disease  intervention specialists, and patients about their experiences. 

READ BULLETS – MCO POLICIES
CDC Guidelines that advise patient referral
Oral agreement, blanket permission

Several barriers  reported by clinicis – lack of clear plan policies, too little time to meet with patients to discuss partner issues, lack of education materials for infected members or their parnters. , lack of knowledge about role of health dept  in partner services, concerns about medical and  legal issues related to treating partners without first evaluating them, and general reluctance to talk to patients about partners. Clinicians noted they are reluctant to elicit partner  information  from teens because of concerns about reporting sexual abuse and statutory rape 

This MCO is now evaluating methods to improve partner services such as developing and disseminating more explicit policies, better coordination  with health dept , educating clinicains about  the health dept role in partner services, and use of written educational materials for patients and their parttners. 

## 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

**Notes:**
So to sum up my impression of STD care in MCCs

In the MCOs evaluated to date, services appear adequate for diagnostic tesitng and treatment 

However,substantial improvement is needed in 
READ BULLETS

## 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

**Notes:**
Based on these findings, I would recommend that
	READ BULLETS

Because of intense cost containment pressures in MCOs and that improvement of STD care is rarely a top priority in MCOs, I recommend that 
	READ BULLETS 

Most cost effective PS services such as patient referral with written support materials or phone support from advice nurses, patient delivered therapy, or selected DIS referral of patients who are less likely to notify their partners  
	READ BULLETS
CT and viral common in MCOs

Address all levels where barriers may be present and interventions may act to overcome barriers – policy and guidelines of the plan or contracted medical groups, clinicians, patients, health department  

THANK YOU