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Medicaid Managed Care And STDs: Missed Opportunities To Control The Epidemic
We examined the extent to which selected Medicaid managed care organizations (MCOs) promoted certain prevention and control services for sexually transmitted diseases (STDs) and the potential influence of health plans and medical groups on the delivery of STD care by primary care providers (PCPs) in seven large U.S. cities. Low-cost clinical services were routinely performed by PCPs, but higher-cost services were less often provided. Lack of organizational priority to promote STD prevention and control is a major barrier even for those MCOs that serve this high-risk, low-income population. Stronger incentives and legally binding provisions in Medicaid contracts are needed to promote adherence to standards of STD care.
The high rate of sexually transmitted diseases (STDs) in the United States and the higher prevalence of bacterial STDs among the populations that include large numbers of Medicaid beneficiaries suggest that STDs should be an important focus of disease prevention for Medicaid managed care organizations (MCOs). The high number and proportion of Medicaid beneficiaries who are enrolled in MCOs underscore the importance of Medicaid MCOs’ adopting and implementing effective policies and services to diagnose, treat, and prevent STDs. In this paper we examine the STD policies of Medicaid MCOs and their contracted medical groups (CMGs) in seven cities with a high prevalence of chlamydia, gonorrhea, and syphilis and explore whether primary care providers’ (PCPs’) STD practices may be influenced by the presence of STD policies in the managed care plans and medical groups.
STD prevalence. STDs are among the most common infectious diseases in the United States, although most Americans do not realize the extent of the epidemic.1 An estimated fifteen million new STD cases occur in the United States each year, with approximately one-quarter of these new infections affecting teenagers.2 The burden of illness from STDs is exacerbated by infertility, pregnancy complications, cancer, and a greater susceptibility to HIV infection.3 The risk of certain STDs is higher for adolescents, women, infants, some minority racial and ethnic groups, and the poor—in short, a large proportion of the Medicaid population.4 STD services should be an important component of Medicaid programs because for low-income women, adolescents, and children, Medicaid is the primary payer of periodic health screening, prenatal care, and family planning services.5 Medicaid MCO enrollment. Many states have enrolled Medicaid beneficiaries in MCOs to control Medicaid program costs and improve access; 56.7 percent of all Medicaid beneficiaries were enrolled in MCOs in 2000.6 This enrollment was expected to encourage a public health approach to disease prevention and health promotion.7 MCOs could use their provider networks, contractual relationships, and client-tracking technologies to improve coordination, promote continuity of patient care, and improve its quality. Some analysts have argued that MCOs have incentives to adopt and implement STD prevention strategies because by reducing infectious diseases, they could control their costs more effectively.8 In addition, state contracts provide opportunities to hold MCOs accountable for specific performance standards. The number of MCOs serving Medicaid beneficiaries rose from 166 in 1993 to 556 in 2000, including 208 commercial plans that served 8.4 million beneficiaries in 2000.9 The rapid entry of MCOs into the Medicaid market has generated concerns about the relative inexperience of these organizations in serving the Medicaid population, which differs from commercial enrollees. Medicaid beneficiaries experience more fluctuations in coverage.10 They also experience an apparently higher risk of STDs compared with typical managed care enrollees and thus may require more effective diagnostic techniques and treatment regimens.11 However, the variation in contractual relationships and multiple plan contracts per provider limits plans’ ability to enforce effective STD practice policies among these providers.12 Existing research. Despite the importance of this topic, existing research is limited. A comprehensive study of state Medicaid MCO contracts has identified the extent of STD-specific elements in such contracts for a number of states.13 However, we have found no other studies that have assessed whether MCOs are promoting recommended STD practice guidelines actively or that have examined the extent to which there is congruence among formal plan or group policies and PCPs’ actual practices. The crucial first step in developing effective programs to address this persistent epidemic is to gain a better understanding of MCOs’ level of involvement in promoting STD prevention and treatment.
Selection of STD practice guidelines. We addressed the absence of a single "gold standard" for evaluating STD practices by developing a list of selected guidelines and practice protocols. Most were based on recommendations of the U.S. Preventive Services Task Force or the Centers for Disease Control and Prevention (CDC); one guideline was from the Institute of Medicine and one from the Ameri-can Medical Association Guidelines for Adolescent Preventive Services (GAPS). Independent experts have recommended similar protocols.14 These practice guidelines were selected if there was a clear and strong recommendation that had been published by at least one authoritative body. An advisory panel of STD experts from Medicaid and commercial MCOs, a local health department, a state health department, a federal agency, and an advocacy organization reviewed a draft of the guidelines. The final list of guidelines appears in Exhibit 1  .
Plan selection. We selected MCOs in seven large U.S. cities that had very high rates of reported syphilis, gonorrhea, and chlamydia cases and also had more than half of their Medicaid population enrolled in managed care. These cities included Baltimore, MD; Charlotte, NC; Dayton, OH; Louisville, KY; Memphis, TN; Norfolk, VA; and Oklahoma City, OK. In each city we selected MCOs that served the largest proportions of Medicaid beneficiaries, if more than one plan was serving this population. We randomly selected up to five CMGs associated with those MCOs. We then selected PCPs associated with those CMGs, enabling us to relate information and responses across three associated tiers: MCO, CMG, and PCP. Our samples of these three tiers were systematically selected to reflect diversity among Medicaid-serving MCOs and their providers and not to be representative of all Medicaid plans, groups, and providers.
Interview protocol.
We conducted telephone interviews with the medical directors, or their designated respondents, of the MCOs and CMGs, and we interviewed practitioners who were PCPs. Twenty-one MCOs participated out of twenty-four contacted (88 percent response rate). Fourteen of the twenty-one plan respondents (67 percent) were medical directors, while the rest were utilization/ quality managers and Medicaid program managers. Nearly two-thirds of the plans we studied reported that 75 percent or more of their enrollees were Medicaid beneficiaries, while 29 percent reported that fewer than one-fourth of their enrollees were Medicaid patients (Exhibit 2
We aimed to interview three CMGs for each MCO, selecting those that were significant Medicaid providers. However, six plans declined to supply their provider directories for further CMG and PCP interviews. We compensated for lower participation rates among groups in some MCOs by including additional groups in other MCOs. Thus, instead of three groups per MCO, we interviewed one to five groups in each MCO that agreed to identify its medical groups. We interviewed the medical director or designated alternate in thirty-one CMGs (55 percent response rate). Three-fourths of group respondents were medical directors. Among the medical groups, 66 percent reported that Medicaid recipients accounted for 50 percent or less of their enrolled patients. Two-thirds of CMGs had ten or more PCPs in their groups. From each CMG, we randomly selected three PCPs who were contracted or employed by these groups, using provider directories supplied by the MCOs. PCPs in some groups refused to participate; they were replaced with providers in other groups, resulting in a range of from one to nine PCPs per group. A total of fifty PCPs were interviewed (45 percent response rate), of whom 70 percent were physicians and 26 percent were nurse practitioners or physician assistants. Almost half (48 percent) had been practicing for fewer than ten years, and 20 percent had twenty or more years of postdegree experience. One in four providers reported that Medicaid recipients constituted more than half of their practice, while 42 percent said that they accounted for 25 percent or less of their practice. More than half of the providers in the sample were working in clinics or hospitals, and two-thirds were paid on a capitation basis for their Medicaid patients. The high refusal rate among the targeted sample populations led to findings that cannot be generalized to the entire Medicaid managed care system. Thus, the findings are considered to be qualitative and mainly used to illustrate and raise issues rather than to draw firm policy conclusions. Data collection occurred between October 1998 and June 1999.
Medicaid MCOs and STD policies. Sampled Medicaid MCOs were asked whether they recommend STD practice guidelines directly to their PCPs. Plans did not do so consistently, despite the high prevalence of STDs in the cities they served and in the populations from which they drew their enrollees. Slightly more than half of the surveyed plans recommended that PCPs provide preventive counseling while taking a sexual history (Exhibit 1  ). Of the other STD practice guidelines, three or fewer plans recommended presumptively treating chlamydia in the presence of gon-orrhea, annually screening sexually active adolescents and women ages twenty to twenty-four for chlamydia, or testing and treating sexual partners regardless of plan membership or reimbursement. Recommendations of other practices that could prevent the spread of STDs or enhance patient compliance, such as using single-dose therapies for chlamydia and advising infected patients to notify partners and urge them to get tested, were limited to only 40 percent and 33 percent of the MCOs, respectively.
Medicaid CMGs and STD policies.
Most of the medical groups recommended at least some STD practice guidelines to their PCPs, regardless of the presence of guidelines from their contracted MCOs. More than three-fourths of CMGs recommended preventive counseling while taking a sexual history, presumptively treating chlamydia in the presence of gonorrhea, treating minors for STDs without parental/guardian consent, conducting syphilis screening as part of prenatal care, advising infected patients to notify partners and urge testing, and alerting the public health department to notify partners and urge testing (Exhibit 1
Medicaid PCPs and STD policies.
PCPs reported that they usually followed CDC-recommended STD practices (Exhibit 1 Influence of MCO and CMG policies on PCP practices. PCPs’ provision of STD services may be influenced by a number of factors, including the policies of the plans and groups. First, we examined the extent to which PCPs’ reporting of practices was consistent with whether the plans and groups with which they were affiliated recommended the practices. We selected forty-five PCPs for whom we had complete information on their affiliated plan or group (thus including information on ten MCOs and nineteen CMGs). Although the small sample sizes and the design of the study do not allow definitive conclusions regarding the factors that influence providers’ practices, some patterns suggest tentative conclusions.
For most of the guidelines, the proportion of PCPs who reported practicing the guideline was not much different whether the plan or group recommended the guideline or not (Exhibit 3
Some recommended practices were far from universal among PCPs, regardless of whether their plan or group had a related policy. More education of PCPs seems necessary to encourage them to treat minors without parental consent and to alert the health department to notify partners of infected patients. However, the results also indicate that plan and group policies may exert a positive influence on delivery of some STD services. For example, if their MCO or CMG recommended the practice, providers were more likely to report that they annually screened adolescents for chlamydia and provided single-dose therapy for treating the condition. Annual screening of young women for chlamydia was not recommended by any of the MCOs, yet 45 percent of the PCPs performed this test. Further analysis revealed that 59 percent of the CMGs affiliated with these PCPs had recommended this practice (data not shown). However, the CMG’s recommendation seemed to be associated with PCPs’ performance of this guideline: 77 percent of PCPs affiliated with groups that recommended annually screening young women reported this practice versus 28 percent who were affiliated with groups that did not recommend it. Another counterintuitive finding was the smaller proportion of PCPs who reported testing and treating their patients’ sexual partners, regardless of expected reimbursement, in plans and groups that recommended it compared with the proportion in plans and groups that did not. Additional analysis did not reveal any plan or group characteristics that could have contributed to this finding. The most likely explanations are the legal liabilities in providing care to those not directly under a physician’s care and the prohibition of such treatment by the health plan, state, or medical boards at the time of this study. Reasons for compliance or noncompliance. We asked MCO and CMG respondents and PCPs why they did not recommend or comply with a particular guideline. Plan and group respondents cited the cost of routine screening as the reason for not recommending it. A few mentioned provider autonomy as a reason for not recommending single-dose therapy for chlamydia, and several mentioned medical liability as a reason for not recommending treatment of sex partners and the possible legal liabilities if their PCPs treated nonmembers. Some plan respondents also reported that they did not recommend STD guidelines because STD control was a low priority, because of the perception that it was inexpensive to treat STDs, the belief that the incidence of STDs was low among their patient populations, or their recent entry into the Medicaid market (which implies a lack of familiarity with the health problems of the Medicaid population or not being prepared to serve them). PCPs, however, consistently cited financial constraints as barriers to following some guidelines. The exclusion of medications such as Azithromycin from the health plan or Medicaid formulary was cited as a reason for not using it to treat chlamydia. Providers also reported that the lack of payment for some procedures that were deemed unnecessary by MCOs and the lack of funds for universal testing were reasons for not screening sexually active adolescents annually.
Impact of organizational and individual characteristics.
We also studied a number of organizational and individual characteristics that may influence STD service delivery. We found that more PCPs working in clinics or hospitals or who were female reported screening sexually active adolescents than did those who were male or in private practice (Exhibit 4
PCPs with more than 50 percent Medicaid patients reported annual screening of adolescents and young women for chlamydia more often than did PCPs with less than 50 percent Medicaid patients. Similarly, PCPs who were in groups with more than 50 percent Medicaid patients screened teens and directly observed patients taking their single-dose chlamydia medication more often than did PCPs who were in groups with less than 50 percent Medicaid patients.
This preliminary study focused on Medicaid MCOs that enrolled populations at higher risk of contracting STDs. Despite the limitations of the samples, the findings raise concerns about whether MCOs as currently configured are effective vehicles for public health approaches to controlling STDs. The results also provide some direction regarding interventions to enhance clinical approaches to controlling STDs. Overall, lack of organizational priority is a major barrier to providing STD care to Medicaid populations. STDs are perceived by some plans as inexpensively treated ailments compared with investments in prevention and control. The turnover in Medicaid eligibility and Medicaid enrollees makes it less likely that a plan will reap the benefits of prevention and early treatment in the short term. However, the costs of high STD rates and the consequences of prolonged illness are more likely to severely affect the public in the long term. Alternatively, the common element among guidelines frequently practiced by PCPs appeared to be the ease of administration or a possible consensus within the medical profession rather than the presence of a recommendation from the plan or group. Practices such as presumptive treatment of chlamydia in the presence of gonorrhea may be influenced by cost concerns, since treatment may be less costly than testing. However, counseling practices may be influenced by the provider’s training and comfort with discussion of STD practices.16 Role for state policy. Recommended STD practices targeted to Medicaid managed care patients can be promoted and improved through state policy. By 1999 most state managed care contracts in the seven states studied had STD-related content limited to services and benefits; only Tennessee’s and Oklahoma’s contracts had language that was specific to chlamydia and gonorrhea.17 State Medicaid programs can improve STD control and management by incorporating options such as developing and adopting explicit practice standards; providing adequate reimbursement for STD services such as routine screening of State Medicaid programs can improve STD control and management by incorporating options such as developing and adopting explicit practice standards; providing adequate reimbursement for STD services such as routine screening of adolescents, promoting single-dose therapy for chlamydia, and testing and treating nonplan partners; effectively promoting the use of recommended standards of STD care; and mandating standards of STD care in contractual agreements with Medicaid MCOs, including adequate financial incentives to implement recommended practices and penalties for failure to do so. Provision of adequate STD services by Medicaid MCOs can be assured by including specific language in purchasing contracts with states.18 It remains to be seen how the newly implemented Health Plan Employer Data and Information Set (HEDIS) performance measure of annual chlamydia screening of young women may encourage screening, but it is a step in the right direction and is likely to have some impact.19 Caveats and starting points. Because our findings are applicable to Medicaid managed care, no comparisons were possible with fee-for-service (FFS) Medicaid. Medicaid MCOs are likely to differ from FFS Medicaid in their delivery of STD care. The qualitative nature of this study precludes generalizing from our findings to all Medicaid MCOs. Similarly, self-reported physician practice may not truly reflect actual behavior, which is better measured through chart reviews. Nevertheless, these findings are a starting point for an important dialogue among managed care plans, state Medicaid programs, public health departments, advocacy groups, researchers, and beneficiaries. The ultimate goal of containing the STD epidemic and improving access of Medicaid managed care enrollees to appropriate STD services can be achieved only by raising awareness, increasing collaboration, and adopting and implementing effective policies.
Nadereh Pourat is a senior researcher at the University of California, Los Angeles (UCLA), Center for Health Policy Research (CHPR) and an adjunct assistant professor at the UCLA School of Public Health. Richard Brown is director of the CHPR and a professor in the UCLA School of Public Health. Natasha Razack is a project manager at the CHPR. William Kassler is state medical director, New Hampshire Department of Health and Human Services, in Concord. The research for this paper was supported by grants from the Centers for Disease Control and Prevention Division of STD Prevention (CDC Grant no. R30/CCR914853-01) and the Robert Wood Johnson Foundation (RWJF Grant no. 33564). The authors are grateful for the generous assistance and guidance of their study’s funding officers: Janelle Dixon of the CDC and Phyllis Kane of the RWJF; consultants: John Goldenring, James Kahn, and Sara Rosenbaum; volunteer advisory committee members: Gail Bolan, David Chernoff, Don L. Garcia, Robert Harmon, Lynn Kersey, Wendy J. Long, Andy Nelson, Richard Platt, Gary R. Richwald, and Gerald Zelinger; Chris Beardmore of the UCLA Office for Protection of Research Subjects; Tonya Hayes of the UCLA Institute of Social Science Research; and research and support staff from the UCLA Center for Health Policy Research. The authors are especially grateful for the in-depth comments on this paper provided by Kathleen Irwin, chief of the Health Services Research and Evaluation Branch, Division of Sexually Transmitted Disease Prevention, CDC.
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Background
Study Methods
