Sexually Transmitted Infections Adopting a Sexual Health Paradigm (2021) / Chapter Skim
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10 Paying for and Structuring STI Services
10 Paying for and Structuring STI Services
Pages 497-546
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From page 497... ...
10 Paying for and Structuring STI Services Chapter Contents Introduction Paying for STI Prevention and Treatment Services Health Insurance Coverage Requirements • Federal Requirements for Coverage of STIs and Related Services • STI Testing and Treatment Guidelines Issued by Health Professional Organizations Assessing Systems of Care and Accountability • Performance Measures on STIs Clinical STI Services • Sexual Health Assessment • Behavioral Interventions • Immunizations • Testing and Screening • Treatment • Partner Services and Expedited Partner Therapy • Telehealth 497
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PAYING FOR STI PREVENTION AND TREATMENT SERVICES Health care and clinical preventive care in the United States are paid for by a patchwork of private insurance plans and government-supported programs, which finance STI services for the vast majority of, but not all,
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. The following sections discuss the role of publicly and privately funded coverage programs in providing access to and coverage of STI services for U.S.
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. According to data from the National Survey of Family Growth, more than 12 percent of sexually experienced adolescents aged 15–25 who were on a parent's health insurance plan reported that they would not seek reproductive and sexual health services because of concerns that a parent would find out (Leichliter et al., 2017)
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. Other barriers to confidential care for adolescents include health care providers and institutions' lack of knowledge of practices and policies regarding adolescents' rights to confidential health services, including providers not allowing opportunities for adolescents to have a private health care visit without parents being present (McKee et al., 2011)
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502 FIGURE 10-2 Health insurance coverage among individuals aged 15–49, by selected characteristics, 2019. NOTES: The Census Bureau federal poverty level (FPL)
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Many states have used a waiver mechanism to establish a Medicaid financed limitedscope family planning program that typically includes STI services along with contraceptive services and supplies (Ranji et al., 2019)
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504 FIGURE 10-3 Share of uninsured adults aged 15–49, by state, 2019. SOURCE: Kaiser Family Foundation, unpublished analysis of 2019 Census Bureau's American Community Survey; data file available upon request from PARO@nas.edu.
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Uninsured individuals, particularly those who are low income, have fewer STI screening and treatment options and typically depend on a network of safety net providers, including STI clinics and health departments, federally qualified health centers (FQHCs) , and family planning providers, for free or low-cost screening and treatment services.
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Table 10-1 shows a breakdown of which recommended preventive STI services must be covered by most private insurance plans, Medicare, ACA Medicaid expansion programs, and traditional Medicaid plans. Only preventive services recommended by USPSTF, ACIP, HRSA's Bright Futures Project, and HRSA's Women's Preventive Services Guidelines are covered without cost sharing (KFF, 2020b)
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who are at pregnancy Covered increased risk at state option for adults Bright Futures: Χ √ √ Required Screen all sexually for active adolescents children for STIs (11–21 under years old) EPSDT Covered at state option for adults Gonorrhea USPSTF: Screen Women ≤24 √ √ Covered screening all sexually active annually; at state women age 24 women >24 if option for and younger, all at increased adults sexually active risk; up to 2 women (aged screenings in 25+)
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required) Medicaid Syphilis USPSTF: Screen all Pregnant women √ √ Covered screening pregnant women at start of at state and persons at risk pregnancy and option for third trimester, adults at delivery if high risk; all men and other women annually if at risk Bright Futures: Χ √ √ Required Screen all sexually for active adolescents children for STIs (11–21 under years old)
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From page 509... ...
required) Medicaid HPV testing Women's Covers screening √ √ Covered Preventive Services once every at state Guidelines: For 5 years if option for women aged asymptomatic adults 21–29, screen with for ages 30–65 cytology every 3 years; for women aged 30–65, screen with cytology and HPV testing every 5 years or cytology alone every 3 years USPSTF: Screen √ √ Covered women aged 21–65 at state with cytology option for every 3 years or, adults for women aged 30–65 who want to lengthen screening interval, screen with cytology and HPV testing every 5 years HPV ACIP: Routine vac- Χ √ √ Required vaccine cination for men for and women aged children 11–12; also vacci- under nate the following EPSDT groups if they have not been vacci- Covered nated previously at state or have not com- option for pleted the three- adults dose series: women aged 13–26, men aged 13–21, and men who have sex with men and im munocompromised persons through age 26 continued
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required) Medicaid STI and USPSTF: Provide Up to two √ √ Required HIV intensive 20–30-minute for prevention behavioral behavioral children counseling counseling to counseling under prevent STIs to sessions annually EPSDT all sexually active for those at high adolescents and for risk Covered adults at increased at state risk for STIs option for adults Women's Χ √ √ Covered Preventive Services at state Guidelines: Annual option for counseling on STIs, adults including HIV, for all sexually active women NOTE: ACIP = Advisory Committee on Immunization Practices; EPSDT = Early and Periodic Screening, Diagnostic and Treatment; HPV = human papillomavirus; PPX = prophylaxis; USPSTF = United States Preventive Services Task Force.
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vaccination, and cervical cancer screening. NQF also collects data on the share of persons with HIV being screened for STIs and vaccination rates for hepatitis A and B, although these are not typically the focus of STI prevention efforts.
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Similarly, HEDIS reports that only half of sexually active women aged 16–24 who were enrolled in an HMO or PPO and had a health care encounter had a chlamydia screening during the measurement year; the rates were slightly higher for those in a Medicaid HMO (58 percent)
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Chlamydia screening in women • Assess the share of sexually active women (NCQA, n.d.-b) aged 16–24 who had at least one test for chlamydia during the measurement year (2018: HMO 51%, PPO 48%, Medicaid HMO 58%)
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: Proportion of female admittees juvenile detention facilities tested in large juvenile detention facilities diagnosed with chlamydia Timely treatment of women • Among clients of IPP family planning clinics, with chlamydia at family proportion of women with positive CT tests who planning sites are treated within 14 and 30 days of the date of specimen collection Timely treatment of women • Among clients of IPP family planning clinics, with gonorrhea at family proportion of women with positive GC tests who planning sites are treated within 14 and 30 days of the date of specimen collection Timely treatment of women • Among clients of STD clinics, proportion of with chlamydia at STD women with positive CT tests who are treated clinics within 14 and 30 days of the date of specimen collection Timely treatment of women • Among clients of STD clinics, proportion of with gonorrhea at STD women with positive GC tests who are treated clinics within 14 and 30 days of the date of specimen collection Timely treatment of P&S • Proportion of P&S syphilis cases treated within 14 syphilis cases and 30 days of the date of specimen collection Syphilis testing of women at • Proportion of female admittees entering selected select adult jails project area adult city and county jails who were tested for syphilis New syphilis cases • Proportion of women tested who are newly diagnosed in select adult diagnosed with syphilis (any stage) in select adult jails jails Timely syphilis treatment in • Proportion of women newly diagnosed with select adult jails syphilis (any stage)
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From page 515... ...
also pose a barrier to the future development of a sexual and reproductive health reimbursement bundle that could potentially include payment for the recommended screening and treatment services for STIs, counseling, and other services. CLINICAL STI SERVICES In 2020, CDC released recommendations on improving quality of STI clinical services, including sexual history and physical examination,
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From a pragmatic and strategic point of view, it is important to examine each of these settings in detail to determine their optimal role in STI care and prevention. The next sections discuss different components of STI clinical care, followed by a detailed review of STI services in the spectrum of care settings that identifies the relative strengths and weaknesses and how they may fit together in a continuum of services rather than a fragmented system.
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Thus, STI screening programs, such as opt-out chlamydia screening for high-prevalence groups (e.g., those under 25) regardless of sexual health assessment and even bypassing the provider, could be developed.
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to increase behavioral assessment, improve patient education, and establish behavior change goals to increase positive sexual health practices and decrease STI risk. To stay relevant and fresh, however, these interventions need regular updates.
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Screening is universal or age-based testing for populations considered to be at specific risk for a certain pathogen and may include opportunistic testing (i.e., offering a test, typically in a health care setting, to a person who makes a visit unrelated to the test, such as chlamydia testing for a sexually active woman visiting her primary care provider for an upper respiratory tract infection and who has no STI symptoms or concerns)
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As a result, STI testing is now conducted in a variety of settings, which has effectively broadened the available venues beyond the traditional STI specialty clinic, and extragenital (i.e., pharyngeal and anal) testing should now be the standard of care for all providers of basic STI services per CDC guidelines (Barrow et al., 2020)
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"Express" Visits for STI Testing NAATs have obviated the need for invasive anogenital sampling, so some STI clinics have explored the possibility of testing-only visits (i.e., not including physical examination of asymptomatic patients) with the
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Future availability and implementation of POC testing will be particularly important in the evolution of the express visit option to decrease the time to treatment for clients who otherwise do not present with an immediate reason to treat. Treatment At the provider level, STI treatment either follows a positive STI test (etiologic treatment)
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. Unfortunately, neither POC testing nor treatment are available in many clinic settings, and implementation studies are necessary to better understand how and with what means the quality of STI care in these settings may be improved (Gaydos et al., 2019)
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. EPT has become more common among publicly funded family planning clinics; a study found that 79 percent provided EPT at the same visit (Zola and Frost, 2016)
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Some pre-COVID-19 policies have limited the extent to which patients can have an STI visit remotely through strict requirements as to the type of provider and sometimes patient location and communication medium. The COVID-19 pandemic, however, has transformed the role of telemedicine in the future of health care, including STI care (Nagendra et al., 2020)
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clinical specialists who are experts in sexual health and STI care and treatment, telemedicine will likely hold appeal beyond the COVID-19 era. Rural areas may benefit the most, as these have many fewer specialized providers available (AIDS United and MAO of Alabama, 2017)
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, leaving substantial room for improvement that may be accomplished by educating the general public to expect their primary care provider to offer a basic set of sexual health services. As discussed in Chapter 6, the widespread implementation of EHRs in primary care settings is a promising tool in completing sexual health assessments and expanding STI screening, including opt-out testing for selected persons.
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holds great promise for the improvement of etiologic treatment in primary care settings. Finally, primary care providers need to have easy access to resources that offer technical assistance in implementing appropriate STI services, clinical consultation, and referral.
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Family Planning Women accessing family planning services are typically young and sexually active and are therefore an important target for opportunistic STI screening, especially for chlamydia, gonorrhea, and syphilis. Nearly all publicly supported family planning clinics offered testing for chlamydia and gonorrhea (98 percent)
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The large network of clinics employs a sizable cadre of providers who are well trained in providing confidential and sensitive services, including STI care, which could be an important foundation to expand the availability of STI services to not only traditional family planning populations but also broader communities who are disproportionately affected by STIs. Many of these clinics are already invested in serving socially and financially marginalized communities and could be used to address the current dearth of services available to individuals who are at high risk for exposure to STIs but lack access and coverage.
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In addition, these clinics are increasingly branded as "sexual health" clinics that are fully integrated to address not only STIs and HIV treatment but also family planning, sexual dysfunction, and other related services, such as gender-affirming care for transgender and non-binary community members. Such clinics tend to be early adopters of newer approaches to testing, results notification, and wrap-around services that are key to enabling them to be as client centered as possible.
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As detailed in Chapters 8 and 12, parents' and educators' involvement is critical to develop a comprehensive sexual health discourse in educational settings and create and implement school-based STI prevention programs, including regular STI screening and HPV vaccination. Correctional Facilities Based on the evidence that chlamydia and gonorrhea rates are generally higher among persons in correctional facilities, especially juvenile detention centers, than among demographically similar individuals in the general community, CDC recommends that women and men up to ages 35 or 30, respectively, in correctional facilities be screened for both diseases at entry, if symptomatic/following exposure, and at discharge (CDC, 2015b)
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These care systems, as discussed in greater detail in Chapter 3, present an important opportunity for screening and periodic sexual health assessment, including of sexual safety. Thus, while continuing sexual health discourse is a priority for the entire military community, military health care providers need to be a driving force in initiating and supporting this discourse and, through proactive STI screening, can significantly impact personnel's STI epidemiology.
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Their center of gravity will vary depending on local resources and STI leadership. Collaboratives could form around an STI specialty clinic with strong ties to the community or evolve from HIV care centers, family planning clinics, or community clinics that have expanded into STI specialty care.
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The addition of these new measures could pro vide incentives for the development of payment bundles that could improve the scope and quality of sexual health services offered by plans and programs. Conclusion 10-4: The ongoing transition of local STI clinics to comprehen sive sexual health clinics taking place in some jurisdictions in the United States is an important trend that needs to be supported and accelerated.
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Conclusion 10-6: Targeted initiatives for creating new, improved, and easier care access points for sexual health care are needed. Promising initiatives include readily accessed STI screening and treatment services venues, such as urgent care centers and pharmacies.
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Emerging opportunities, including online testing and increased involvement of nontraditional providers, hold promise in further strengthening the STI care system. There are many missed opportunities for sexual health assessment and STI evaluation in many settings, however, and better coordination of private and public STI services at the local level would move the field from fragmentation to integration, with better overall outcomes for STI prevention and control.
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2017. A new resource for STD clinical providers: The Sexually Transmitted Diseases Clinical Consultation Network.
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2017. 340B drug pricing program fre quently asked questions for Title X family planning agencies.
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2019b. Minors' access to STI services.
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2019. Improving women's health and combat ting sexually transmitted infections through expedited partner therapy.
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2013. Effect of risk-reduction counseling with rapid HIV testing on risk of acquiring sexually transmitted infections: The AWARE randomized clinical trial.
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2020. Title X family planning annual report: 2019 national summary.
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2021. Medicaid ex pansion and rates of reportable sexually transmitted infections in the United States -- A county-level analysis.
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2005. Concurrent sexually transmitted infections (STIs)
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2016. Publicly funded family planning clinics in 2015: Patterns and trends in service delivery practices and protocol.
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