Conflicting Laws and Innovative Approaches

1. Can Providers Assure Commercially-Insured Adolescents Confidentiality for STI Screening and Treatment? Conflicting Laws and Innovative Approaches Gale R Burstein, MD, MPH, FAAP Erie County Department of Health Buffalo, NY

2. Provider Strategies to Assure Confidentiality with Billing Individual-Level Systems-Level

3. Individual Provider Strategies What are they doing? • Survey of providers caring for adolescents • Posted on provider listserves • Society for Adolescent Medicine (SAM) • American Academy of Pediatrics Section on Adolescent Health (AAP/SOAH) • ~40 responses

4. Individual Provider Strategies • “This is a perpetual problem…… Right now, I basically tell patients that their parents can get an EOB and that they should go to Planned Parenthood, their school-based clinic, give the hospital lab an alternative address for the bill or pay cash for laboratory testing to bypass their parent's managed care plan.” • “Guaranteeing confidentiality can be a trap, because there is no little in our control.”

5. Individual Provider Strategies • “Creative coding” for office visit • Encourage teens to disclose to parents • Teen can pay out of pocket • Flexible spending health accounts and high-deductable plans create new challenges

6. Systems-level Provider Strategies • Work with health plans to change EOB text • Example: 3 Western NY health plans • “Laboratory” • “Laboratory Services” • “LAB/Clia Test” • STD services/test codes in “confidential” class • EOB reads as “medical service”

7. Public Health Strategy Local Health Department-Level

8. Partner with Provider Groups • State medical and nursing societies • State medical professional organization chapters • i.e., AAP, AAFP, ACOG, SAM • Local medical professional societies • AAP Pediatric Councils

9. Erie County Department of Health Strategy Example of Local Health Department-Level Strategy

10. Adolescent Reproductive Health Care Tool Kit • Tools to overcome barriers to office-based confidential sexual health care service delivery • Billing • Private time with teen • Gaining parental acceptance for confidential services • Referral resources

11. Adolescent Reproductive Health Care Tool Kit: Contents • Billing/coding fact sheet • ICD9 and CPT Codes • Vignettes as models for use • Parent brochure • Office can personalize with name and logo • Download state YRBS risk behavior data • Table of all CT and GC tests

12. Adolescent Reproductive Health Care Tool Kit: Contents • Tips for office • Maximizing office confidentiality • Making office teen friendly • How to perform “atraumatic parentectomy” • Available at: • AAP/SOAH web site @ www.aap.org/sections/adol/ • NACCHO tool box web site @ http://naccho.org/toolbox/index.cfm

13. Public Health Reaching Providers: Tool Kit Dissemination via Academic Detailing

14. Academic Detailing • Office-based educational intervention with food • Based on Pharma model • Successful in changing providers behaviors

15. Promoting Adolescent Reproductive Health Project (PARHP) • Goals: • Improve confidential adolescent sexual health care access • Increase CT screening for sexually active teen ♀ • Partners • Foundation for Healthy Living • NYSDOH Bureau of STD Control • 3 local health plans

16. PARHP Methods • Work with health plan (BCBS of WNY) to develop list of 50 primary care and 25 OBGYN offices with highest teen patient volume • Academic detailing to offices with tool kit and lunch

17. PARHP Tool Kit Content: Additional Erie County Content • PRCH Minor Access Cards • Summarize laws surrounding the provision of sexual health services to minors in 11 states • Available @ www.prch.org/resources • AAP Teen Health Care Bill of Rights • List of local low- or no-cost clinics for sexual health care services • Reporting information

18. PARHP Evaluation • Chlamydia Screening HEDIS data • Pre- and post-intervention • By office • By provider • Provider pre- and post-test KAP survey

19. Questions