Enhancing Private Sector STI Screening: Challenges and Solutions in Adolescent Health

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

2. Adolescent STI Services:Challenges and Opportunities • Health systems level • Provider level • Patient (adolescent) level

3. Adolescent STI Services:Challenges and Opportunities Systems Level

4. 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

5. 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

6. New York State Minors Reproductive Rights Law • A minor (person <18 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 patient’s permission.”

7. 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.

8. 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

9. 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

10. Adolescent STI Services: Challenges and Opportunities Provider Level

11. 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

13. 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

14. Adolescent STI Services: Challenges and Opportunities Adolescent Patient Level

15. 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

17. Is this hopeless????

18. 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

19. 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

20. 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.

21. 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

22. 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.

23. 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 Minor’s Right’s 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

24. 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.