Increasing Screening in the Private Sector Task Force

1
Increasing Screening in the Private Sector Task
Force

• Gale R Burstein, MD, MPH, FAAP Medical Director
  Epidemiology and Surveillance and STD TB
  Control Erie County Department of Health
• Buffalo, New York
• November 1, 2006

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Adolescent STI Services Challenges and
Opportunities

• Health systems level
• Provider level
• Patient (adolescent) level

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Adolescent STI Services Challenges and
Opportunities

• Systems Level

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Systems Level Opportunities

• New opportunities for routine non-invasive STI
  testing
• Urine nucleic acid amplification tests (NAATs)
  for STIs
• New Pap smear guidelines 1st Pap at 3 years
  after start sex or at 21 years old
• Chlamydia testing sexually active 16-25 year old
  females is HEDIS measure

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Systems Level Opportunities

• All 50 states and D.C. have laws allowing minors
  right to consent for STI testing and treatment
• 30 states include HIV testing and treatment in
  STI services to which minors may consent
• Federal funding for STI testing and care

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New York State Minors Reproductive Rights Law

• A minor (person lt18 yrs), may be counseled,
  tested and treated for STIs without a parent or
  guardian's consent, as long as the minor
  understands the risks and benefits of the
  proposed and alternative treatments.
• Information about STIs cannot be released to
  parents or guardians without the patients
  permission.

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Systems Level Challenges NYS Insurance Law
Section 3234

• Mandates that health insurance companies provide
  to their members/subscribers an explanation of
  benefits (EOB) statement following a filed claim
  under any policy providing hospital or medical
  expense benefits (Circular Letter No. 7, March
  24, 2005).
• EOB must contain information about the date, cost
  and scope of health care services received.
• no exception relating to the age of the member
  receiving the service or the nature of that
  service.

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Systems Level Challenges

• Adolescent age group most likely to be uninsured
• Copayments may be barrier for youth receiving
  care
• How to bill for confidential health care
  services?
• Explanation of Benefits may result in disclosure
  to parent
• Difficult to bill for sexual health services
• More time in visit not reimbursed
• Cannot bill for first pelvic exam

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Systems Level ChallengesAccess/Availability

• Health plans may not offer urine STI NAAT tests
• Many providers do not offer STI services
• Limited time available for health care visit
• Limited provider office hours
• Adolescent access to transportation

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Adolescent STI Services Challenges and
Opportunities

• Provider Level

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Provider Level Knowledge

• Not aware of non-invasive STI test options
• new urine chlamydia NAATs
• New Pap test guidelines
• Unfamiliar with minors rights to consent for STI
  care
• Lack of STI clinical training
• Unclear how to bill for confidential STI services

12
Provider Level Skill

• Many not skilled or comfortable offering
  confidential sexual health services to
  adolescents
• Performing an atraumatic parentectomy
• Discussing sexual health, including sexual
  activity information

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Provider Level Beliefs

• Assume that chlamydia is not a health problem in
  their adolescent patient population
• Low priority and lack of time
• Perceive inadequate reimbursement and financial
  disincentives for providing sexual health
  services

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Adolescent STI Services Challenges and
Opportunities

• Adolescent Patient Level

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Patient Level Knowledge

• Teens unaware of need for preventive health care
  services
• Lack of knowledge regarding STIs
• Most have no symptoms
• Usually need a test to identify infection

16
Patient Level Beliefs

• Falsely perceive low STI-risk
• stigma
• Perceive primary care provider does not want to
  address sexual health needs
• Health care is a low priority
• Believe cannot receive confidential services

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Is this hopeless????
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Providing Confidential Care for Adolescent
Healthcare in Primary Care Settings

• A Region II Infertility Prevention Project
  Demonstration Project
• Partnership with the Foundation for Healthy Living

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The Foundation For Health Living (FHL), Albany,
NY

• Non-profit, 501(c)3 health services and research
  foundation
• Mission to increase and disseminate knowledge
  about health care and improve health of NYS
  residents.
• Affiliated with HealthNow New York, Inc.
• Blue Cross Blue Shield subsidiary
• A leading NYS health plan
• Serves members from over 53 counties in Upstate NY

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Providing Confidentiality for Adolescent Health
Care A Demonstration Project

• Develop a consensus statement on adolescent
  confidentiality in health care in private
  practice settings
• Develop a set of recommendations for the NYSDOH
  and NYS Insurance Department to address gaps in
  adolescent confidentiality in the provision of
  STI-related care for commercially insured clients
  in private practice settings.

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Providing Confidentiality for Adolescent Health
CareAdvisory Work Group

• Comprised of adolescent health care stakeholders
• NYSDOH
• New York State Insurance Department
• health plans
• prominent pediatricians
• adolescent health physicians

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PCAHC Demonstration Project Objectives

• To better understand the need for confidential
  adolescent health care
• Identify barriers to confidential adolescent
  health care
• Review the current legal and regulatory state as
  it pertains to confidential adolescent health
  care
• Propose a series of recommendations for short and
  long term solutions to remove barriers
• Collate and disseminate findings from
  proceedings.
• Wherever possible, facilitate translation of
  outcomes and products for use throughout the
  nation.

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PCAHC Demonstration Project Activities

• Create an advisory work group of medical, health
  and policy experts
• Identify national experts who will help inform
  workgroup activities
• Convene 2 PCAHC meetings
• Stakeholders will convene meetings with local
  stakeholders to vet recommendations
• Review the NYS Reproductive Minors Rights Law
• Review reproductive health recommendations from
  professional medical societies, adolescent health
  providers and advocacy organizations
• Consider the unique barriers related to the
  provision of confidential reproductive health
  services for commercially insured adolescents
• Assess model provider-patient confidentiality
  tools across the country
• Consider educational interventions and materials
  tailored to health care providers, parents and
  adolescents

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PCAHC Demonstration Project Outcomes

• Develop consensus statement on adolescent
  confidentiality in health care
• Provide recommendations to NYSDOH and Insurance
  Department to address gaps in adolescent
  confidentiality
• Publish and disseminate findings, lessons learned
  and recommendations, emphasizing both local and
  national implications.
• Conduct assessment among identified health plans
  to determine if they made or plan to make any
  changes related to the provision of confidential
  STD-related care as a result of demonstration
  project recommendations.