The movement toward health reform has led to multiple changes in the way health services are both delivered and paid for. In 2006, Massachusetts became the first state to pass health reform legislation mandating insurance coverage for all its citizens. In addition to Medicaid expansion for low-income residents, the legislation required uninsured residents to purchase a policy providing sliding scale tax credits to offset the cost, thereby ensuring affordability; a tax penalty was enforced if insurance was not purchased by the end of 2007. The legislation has resulted in near-universal coverage; data from the Massachusetts Division of Healthcare Finance and Policy in 2010 indicated that 98.1% of its citizens were insured.1
Although the high rate of coverage means that almost all individuals in Massachusetts should be able to access health care more easily, it may also influence public health service delivery and reimbursement by directly or indirectly diverting funds from public health programs. Like most states, Massachusetts has supported public health programs that ensured prompt care to anyone who had or might have a sexually transmitted infection (STI), free of charge, through the Massachusetts Department of Public Health Division of STD Prevention’s STI clinics. In 2008, major fiscal challenges during the economic recession resulted in the decision to discontinue state STI clinic funding. In response, the state’s largest urban safety net medical center initiated a new program in its STI clinic. Although patients were encouraged to use insurance to pay for treatment, a US$75 per visit fee was implemented if patients did not have or wish to use insurance. Direct state funding for the STI clinic ended on June 30, 2009; on July 1, 2009, the flat fee was implemented.
The goal of this study was to understand the impact of state funding discontinuation and subsequent institution of a flat fee on STI care in a large urban safety net medical center, in an environment of mandatory health insurance coverage. Preliminary assessment indicated an initial drop in STI clinic volume after institution of this fee (J. Hall, Director of Clinic Operations, personal communication), similar to findings noted in Denver following institution of copayments for STI clinical services.2 Our primary aim was to evaluate the impact of charging a flat fee for STI clinic services previously provided free of charge, on STI visit volume in 4 locations of care within the urban medical center: the STI clinic, primary care (PC), emergency department (ED), and obstetrics and gynecology (OB/GYN) clinics. We hypothesized that there would be a shift in STI care away from the STI clinic toward the other sites. Second, we examined shifts in payer mix (private, public, and self-pay) over time in these locations of care.
MATERIALS AND METHODS
This study involved a retrospective analysis of patients 18 years or older with International Classification of Diseases, Ninth Revision (ICD-9)–coded STI visits to 4 locations within a large urban safety net medical center: the STI clinic, PC (internal medicine), ED, and OB/GYN. We examined three 1-year periods: (1) postenactment and early implementation of health reform (July 1, 2007–June 30, 2008, T1); (2) health reform fully implemented, but before termination of state funding for STI services (July 1, 2008–June 30, 2009; T2); (3) posttermination of state STI clinic funding (July 1, 2009–June 30, 2010; T3). To identify STI visits, we created a list of ICD-9 codes for frequently encountered STI-related conditions for which patients might seek care. These included the following: contact/exposure to STI, screening for STIs, counseling on STIs/HIV, gonococcal infections, chlamydia, genital herpes, human papilloma virus, syphilis, trichomoniasis, pelvic inflammatory disease, nongonococcal urethritis, and unspecified venereal disease (see “Appendix A” [http://links.lww.com/OLQ/A84] for complete list of codes used). Data on all STI visits for the 3 periods were extracted from the medical center’s Clinical Data Warehouse. These data included total number of visits, sex, race/ethnicity, ICD-9-CM codes, and insurance type. Using aggregate electronic medical record data linked to outpatient billing records, we examined STI visit volumes and primary payer at the 4 locations over time. Payer types included private insurance, public insurance (Medicaid and Medicare), and uninsured/other (including the STI clinic fixed-fee payment). In the STI clinic, no fee/state STI clinic funding was an additional option for T1 and T2. The research was approved by the Boston University Medical Center Institutional Review Board.
Sexually transmitted infection visits were categorized by period (T1, T2, T3), location of care, patient demographics (age, sex, race/ethnicity), and payer type. χ2 Tests were used to compare distributions for categorical variables. Analysis of variance was used to compare distributions of continuous variables across periods and locations of care. Number and proportion of STI visits were obtained for all periods for each location. Analyses were conducted in SAS version 9.1.3 (SAS Institute Inc, Cary, NC). A significance level of 0.05 was used for interpretation of results.
Visits by Location
Annual visit volume for STI diagnosis–coded visits varied over time in the STI clinic and increased notably in PC. Over the 3 periods, there were 20,458 STI visits to the 4 locations of care, with a total of between 6224 and 7902 per period across the sites. Figure 1 shows the changes in overall volume of STI visits to the 4 locations over the 3 periods.
In the STI clinic, STI visits increased 49% from T1 (3242) to T2 (4830). After state funding ended, in T3, STI visits decreased to 2596, a 46% decrease from T2. Overall, there was a 20% decrease in STI visits in the STI clinic between T1 and T3 (P < 0.001). In PC, STI visits increased 32% between T1 (811) and T2 (1069), with an overall 107% increase from T1 to T3 to 1680 (P < 0.001). Although there was a statistically significant change in STI visits in the ED over time (1297 in T1, 1127 in T2, 1160 in T3; P = 0.001), this is likely due to large numbers for data analysis and may not be clinically significant. There were no statistically significant changes seen in STI visit volume in OB/GYN (874 in T1, 876 in T2, 896 in T3; P = 0.39). We also found that although STI visits comprised a consistent proportion of total visits in both the ED (1.3%–1.5%) and OB/GYN (2.7%–2.8%) over the 3 periods, in PC, STI visits accounted for 0.8% of total visits in T1, 1.0% of total visits in T2, and 1.4% of total visits in T3 (P < 0.001), again illustrating the increase in STI-related care in PC.
There were statistically significant differences in the demographics of the patients seen across locations of care. In terms of race/ethnicity, black patients comprised most of patients seen for STI care in the ED (69%), PC (55%), and OB/GYN (55%), whereas less than half of STI clinic patients were black. The STI clinic had the greatest proportion of white patients (35%). Hispanic patients were least likely to be represented for STI visits in PC (11%; P < 0.001). Men accounted for more than 75% of visits to the STI clinic, whereas in the ED and PC, visits by male patients comprised 56% and 40% of visits, respectively (P < 0.001). Finally, the youngest patients tended to have their STI visits in the ED, whereas the oldest patients tended to be seen in PC (P < 0.001).
Table 1 shows the demographic information of the study sample within each location of care over time. Within the STI clinic, there were statistically significant differences by period by race/ethnicity, sex, and age. Statistically significant differences were found in the ED by race/ethnicity (P = 0.01) and age (P = 0.0002). In OB/GYN, there were statistically significant differences over time by sex (P < 0.0001). In PC, there were statistically significant differences over time in race/ethnicity and sex of patients seen for STI care. In particular, women comprised 51% of PC patients seen for STI care in T1 and 52% in T2, but rose sharply to 70% in T3 (P < 0.0001). However, the STI clinic consistently had the greatest proportion of white patients and male patients, and the STI clinic and ED consistently saw the youngest patients no matter what period examined. In summary, except for the steep increase in the proportion of patients with STI who were female in PC in T3, no specific large demographic shifts were noted across time in each clinical setting. Although statistically significant differences over periods were detected, most of these differences seem to be due to large numbers for data analysis and were not clinically relevant.
Payer Mix for STI Care
Figure 2 illustrates primary payer for STI visits over time. Because of the state funding for the STI clinic in T1 and T2, even if patients were insured, they were unlikely to use insurance. During T3, half of STI clinic patients paid the fixed fee for care, whereas 35% used public insurance and 15% used private insurance. In the ED, approximately 80% of visits were covered by public insurers during all periods, private insurance covered 10% of these visits, and the remaining 10% of STI visits were by uninsured patients. In OB/GYN, approximately 70% of visits were covered by public insurers during all periods; private insurance covered approximately 25% of visits and less than 5% of visits were by uninsured patients. Although payment patterns for STI care over time in the ED and OB/GYN did not change (P = 0.68 and P = 0.10, respectively), there were changes over time in payment for STI visits in PC (P < 0.0001). During T1 and T2, 65% of visits were covered by public insurance, with 29% (T1) and 28% (T2) covered by private insurance. In T3, the public insurance payments decreased to 55% and private insurance increased to 34%. The percentage of uninsured visits increased slightly but steadily going from 6% in T1 to 11% in T3.
As health reform implementation progressed in Massachusetts, direct state STI clinic funding was eliminated, a flat fee was established in the STI clinic of an urban medical center for those not billing care to insurance, and notable changes in patient volume and payer mix were observed across this institution. Sexually transmitted infection clinic patient volume rose between T1 and T2, likely driven by the expansion aims and strong focus on STI care from a new clinic medical director who was in place between September 2008 and July 2009 (T2). However, there was an overall 20% decrease in STI clinic patient volume from T1 to T3 where the only discernible difference was the institution of a flat fee, consistent with observations by Rietmeijer et al.2 This coincided with an approximate doubling in volume of STI visits in PC but no increase in STI visit volume in the ED or OB/GYN. It may be that once insured, patients had the option of seeking STI care in a general, PC setting rather than in a designated STI clinic, although it remains unclear why there was an increase in uninsured visits in PC after implementation of health reform given that there was no change in PC clinic policy. The slight decrease seen in STI visits to the ED contrasts with preliminary data from New Hampshire, which saw a sharp increase in STI visits reported from EDs when state funding for STI clinics ceased in 2011.3 Perhaps there was no observed increase in STI visits to this ED because most Massachusetts patients are insured and have other options.
Of note, during the period of study, STI surveillance case report volume from this institution mirrored overall state case report volume trends,4 which is to say that chlamydia case reports increased, gonorrhea case reports decreased, and infectious syphilis case reports increased, from T1 to T3 (Y. Tang, Director of STD Surveillance, MDPH, personal communication). However, STI surveillance data are unlikely to reflect rapid shifts in health services.
Although some patients may have moved to PC, the decreased number of patients seen in the STI clinic did not translate into equivalent increases in other settings. Moreover, the increase in STI volume in PC during T3 was solely among women, whereas STI clinic attendees tended to be male. This would argue against STI clinic patients shifting directly into PC, despite the fact that most of the newly insured within Massachusetts were male.5 Patients formerly seen in STI clinic may have sought care outside this medical center. For example, data from family planning clinics indicate an increase in services delivered since the advent of health reform.6 Also, patients formerly seen in the STI clinic may be delaying or forgoing care, potentially putting themselves and others at risk for disease transmission.7 This is consistent with data from studies from STI clinics and other settings indicating that even the imposition of small copayments decreases service use.2,8
It was notable that 50% of patients who came to the STI clinic paid the fixed fee. This is unlikely due to lack of insurance, given the high level of coverage in Massachusetts. We assume that most patients elected to avoid using their insurance for this service. Whether anonymity, specialty expertise, or some other factor or combination of factors9,10 motivates patients to continue to seek and pay out-of-pocket for STI care in STI specialty settings, it seems that even access to health insurance will not lead all patients to use of the medical home (PC) for STI clinical services. Moreover, if patients felt “forced” to use their insurance, some might delay or forgo care due to privacy or anonymity concerns or inability to pay the fixed fee. It is important to note that changing trends in public funding for STI care continue in other areas of the country as well. For example, after discontinuing public STI clinic funding in Santa Clara County, California, in 2007, the county recently proposed implementing a US$40 flat fee for STI care in 2013, based on previous surveys implying patient willingness to pay that amount.11 Plans to monitor whether the fee becomes a deterrent to being seen in an STI specialty clinic setting are ongoing in Santa Clara County.
Certain demographic differences existed across our clinical settings and persisted over time. Sexually transmitted infection clinic patients tended to be male and white compared with the other 3 settings. Although some of these findings are consistent with findings from other studies,9,12,13 most studies have found STI clinic patients to be predominately poor and persons of color,9,12,13 raising the question of what might happen after imposition of a fixed fee in STI clinic settings different from ours. Our finding that ED patients seen for STI care were more likely to be black compared with patients in other clinical sites within this institution does support earlier work indicating that patients who are poor and persons of color tend to rely more on the ED for care.14,15
This study has several limitations. First, it is based on data from 4 clinical settings within a single institution, limiting its generalizability. However, the single institution evaluated was of interest because it is Massachusetts’ largest urban safety net medical center. Second, use of ICD-9 coding of STI visits in PC, ED, and OB/GYN settings may have led to incorrect or incomplete ascertainment of STI visits, especially because the codes analyzed were coded at the time of the visit and changes in diagnoses may have occurred after laboratory results became available. In addition, during provision of general PC or OB/GYN care, STI services may have been provided but not coded as such, thus underestimating the amount of STI care provided. To address this concern, we did include less specific codes such as contact or exposure or counseling for STI (see “Appendix A”), but without full chart review, it is unlikely we captured all possible STI visits. Third, this analysis was of aggregate demographic and visit volume data, rather than patient-level data. Therefore, we cannot determine if individual patients had multiple STI-related visits over the study period and whether their locations of care changed over time. We also cannot assess details of clinical conditions or quality of care.
Despite these limitations, important knowledge can be gained from this study. The combination of health reform creating universal insurance coverage and challenging financial times, which led to the implementation of a flat-fee option to access STI clinic services, has changed STI service delivery and financing in this urban safety net medical center. We saw an increase in STI-related care being delivered in the PC setting but not the ED. If this indicates increased access to the PC “medical home,” then one goal of health reform may be realized. Increased use of health insurance for STI-related care in the medical home may also help remove some of the stigma associated with use of these services in segregated specialty clinic settings. However, health reform may have unintended consequences because expansion of insurance coverage is being funded in part by shifting funds from programs that supported other patient care activities, such as support for hospitals that cared for a disproportionate share of the poor and, in Massachusetts, public STI clinics.16–18 Politicians and policy analysts have argued that such shifts are appropriate because “everyone will have insurance” for necessary services. Our study calls this assumption into question for 3 reasons: (1) the decline seen in STI clinic visits was not fully compensated for by visits in other care settings; (2) the demographics of the patients being seen for STI visits in PC during the last period did not reflect the demographics of patients typically seen in our STI clinic; and (3) a significant proportion of remaining STI clinic patients elected to pay a flat fee specifically to be seen in STI clinic. Rather than conceiving of financing of STI clinical services as all-or-nothing public versus insurance-only options, the focus should be on lowering barriers to quality STI clinical care through various shared-cost mechanisms in multiple settings that allow health care consumers greater choice. Further work is needed to understand the implications of cost sharing and the cost for quality of STI clinical services rendered in different clinical settings.
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