An estimated 19 million new cases of sexually transmitted diseases (STDs) occur in the United States each year.1 Local and state health departments play a vital role in STD control and prevention by providing free clinical services to their communities.2 Rapid diagnosis and treatment prevent the spread and sequelae of STDs, which include neurological problems, cardiovascular disease, sterility, cancer, and HIV/AIDS.1,3 Young people (15–24 years of age) are disproportionately affected by STDs, accounting for half of all new infections each year.4 Free STD clinics have been particularly important for individuals without the resources to seek testing and treatment from private sector providers.2,5 The New York City (NYC) Department of Health and Mental Hygiene (DOHMH) operates 9 free and confidential STD clinics in NYC, serving persons 12 years and older without parental notification and regardless of insurance or immigration status. Services at the clinics include testing and treatment for patients presenting with symptoms of or exposure to STDs, HIV testing and counseling, vaccinations for hepatitis A and B, and emergency contraception. In 2012, these clinics had more than 94,000 patient-visits.
Because of decreases in funding for public health services, there is increased pressure for free clinics to bill for services rendered (including STD services).3,6 There is also an expectation that with the implementation of the Affordable Care Act, more patients attending STD clinics will be insured, which increases the potential revenue that can be recouped through billing. Previously, New York State Public Health Law prohibited New York local health districts (including DOHMH) from billing for STD-related services.7 In April 2013, the law was amended, removing the requirement that health districts provide STD services for free and adding that health districts “shall seek third party reimbursement for these services to the greatest extent practicable.” The regulation also specifies that patients will be diagnosed and treated, even if they lack insurance.
MATERIALS AND METHODS
Based on prior published figures, there was an expectation that instituting charges at the NYC STD clinics would result in a decrease in patient visits of 28%.5,6 We incorporated this estimate and the census of 23,885 patient-visits in April to June 2012 in our sample size calculation and found that completion of surveys among a 21% sample of NYC clinic attendees was necessary to detect the potential for such a 28% decrease in patient-visits. Between September and December 2012, a 10-question paper survey was prospectively collected at 8 of the 9 STD clinics via distribution to all patients at registration until the target 21% sample from each clinic was obtained, which yielded clinic-specific sample sizes ranging from 225 to 1143 patients. During the survey collection period, a total of 25,618 visits were made by 21,576 unique patients to the 8 clinics. A total of 5017 surveys were collected, which reflected attainment of the target sample size and a response rate of 20% (5017 surveys/25,618 patient-visits).
Surveys were anonymous and available in English and Spanish, and completion was voluntary. The survey asked respondents about what type of health insurance they had (if any), willingness to share insurance information with the clinics or receive an explanation-of-benefits letter (EOB), concerns over sharing insurance information, willingness to continue to access the clinic if charged directly for services, and what price range in self-pay fees they would be willing to pay. In anticipation of some respondents not knowing what an EOB is, it was described in the survey as “a letter [sent] to your home describing services provided at the clinic.” The survey was conducted as a needs assessment and as such was not subject to review by the NYC DOHMH institutional review board.
Frequency of responses for each variable was examined, and the difference between those distributions was calculated after excluding surveys with a missing response to the question of interest. Percentages for each response were calculated with χ2 P values for differences among men and women regarding key survey variables. Odds ratios with 95% confidence intervals were calculated. Responses to questions related to willingness to pay and amount of payment were used to project potential annual per capita visit revenues, based on respondents who were both insured and willing to share their insurance information with the clinics.
Of the 5017 STD patients surveyed, respondent ages ranged from 13 to 80 years, with approximately half aged 13 to 26 years (51.1%). More than half of respondents were male (57.7%); male respondents were older than female respondents (Table 1). Of respondents older than 35 years, most were male (70.2%). Among adolescents (respondents 13–18 years old), most were female (76.7%). Of male and female adolescents, 75.0% reported being in school and 57.4% were unemployed. Overall, 42.3% of the surveyed population was unemployed (Table 1). Of respondents with known employment status, more men (900/2508; 35.9%) than women (418/1685; 24.8%) reported being employed full time. When compared with the entire STD clinic patient population during the survey collection period, respondents were comparable by sex (57.7% male compared with 58.6% of the entire clinic population) and age (51.1% young adult [13–26 years of age] compared with 48.5% of the entire clinic population).
Of respondents reporting their willingness to pay a sliding-scale fee, men were slightly more likely to report willingness to pay compared with women (67.6% vs. 63.1%; Table 2). Women were slightly more likely than men to be concerned about receiving an EOB (38.3% vs. 34.3%). Regarding the sharing of insurance information with the clinics, there was no significant difference between sexes.
Among the 4682 patients who answered the question regarding insurance coverage, 2387 (51.0%) reported having no insurance or were unaware of their insurance status (Table 1). There were 2295 respondents who reported having insurance (private or Medicaid), and of those, 2012 also responded to the question about whether they would be willing to share their insurance information at the STD clinic. Of the 2012 respondents, almost half (48.4%) reported that they would be unwilling to share insurance information with the STD clinic. Willingness to share insurance information was 4-fold higher among respondents with Medicaid-based insurance than those with private insurance (odds ratio, 4.1; 95% confidence interval, 3.4–4.9).
When presented with the prospect of being billed on a sliding scale for clinic services, 928 (20.2%) respondents reported that they would stop seeking care at the STD clinics. The remaining respondents (79.8%) reported that they would access STD clinics less or as frequently as before. Among these, nearly a quarter (24.0%) reported unwillingness to pay visit-associated fees. There was no significant difference between insured and uninsured patients regarding whether they would stop coming if a fee were instituted.
Compared with adults, adolescents were most likely to self-report that they would stop accessing NYC DOHMH services if a fee were charged and were the least willing to pay that fee, with 52.1% of adolescents reporting they would refuse. Collectively, 47.4% of all privately insured respondents had concerns over having an EOB sent to their homes, whereas among the 49 privately insured adolescents, 67.3% expressed concern. Among privately insured young adults (19–26 years old), only 47.7% expressed concern about EOBs.
Based on the survey findings, 25.4% of respondents reported having insurance and a willingness to share their insurance information. In 2012, there were 94,191 total visits to the STD clinics. Thus, by applying the survey findings to 94,191 total visits (67,492 unique patients) in 2012, we estimated approximately 23,931 potentially billable STD encounters. For those with billable insurance, we calculated the charges potentially recouped if billing had occurred in a range of US$50 to US$100 per visit. As such, these encounters could generate revenue between US$1,196,500 and US$2,393,100. In addition, given that 41.9% of survey respondents indicated that they were uninsured but still likely to access services at the STD clinic and pay a sliding scale fee, we applied the same method to the 2012 annual visits and calculated a total of 39,493 potential visits that would have been eligible to receive the sliding scale fee letter. Using the currently proposed sliding scale fee model for the STD clinics in NYC, self-pay fees between US$0 and US$50 could be recouped per visit. Thus, these encounters could generate additional revenue between US$0 and US$1,974,650.
Using STD clinic waiting room survey data, we have projected the possible impact of billing on NYC DOHMH STD services. Our findings indicate that the NYC STD clinics could recoup a substantial amount of funds through billing and collection of self-pay fees, but that a large number of patients might forgo care at the STD clinic when faced with confidentiality or financial concerns. These are the first published data examining the potential impact of billing conducted before the actual implementation of billing for STD services and will be used to guide next steps. As changes driving free STD clinics toward billing models are implemented nationwide, the information from this survey may be useful to other health departments anticipating similar shifts. It would be helpful for other health departments and organizations to conduct and report their own relevant research in order to corroborate and compare data to best serve our communities. Postimplementation evaluation will also be useful to determine what billing and self-pay models best preserve the intention of having accessible and confidential STD clinics that encourage prompt diagnosis, treatment, comprehensive screening, and partner services.
The intent of operating free services is to provide a safety net for those who cannot readily access STD evaluation and treatment through primary care or other fee-for-service providers. Because untreated STDs cause serious sequelae including infertility, poor pregnancy outcome, and increased susceptibility to contracting or spreading HIV,1 timely intervention and treatment is an important public health function. Without the safety net of free clinics, those with limited resources have fewer options, and over time, this situation may negatively impact public health.
However, with the adoption of the Affordable Care Act and ongoing budget cuts, there is increased pressure for STD clinics to bill for services rendered. There are 3 main avenues through which DOHMH can charge for services: (1) billing private insurance, (2) billing Medicaid or other public insurance, and (3) collecting fees directly from the patient. The survey findings indicate that for some patients, the barriers presented by the expectation of being billed could result in not getting tested for HIV or not seeking care for an infectious STD.
The survey findings also indicated that confidentiality is a real concern for STD clinic patients, considering that more than half of all respondents did not want to share their insurance information with the clinics (1,056/1,938; 54.5%), and a third were concerned about receiving an EOB (672/1,959; 34.3%; Table 2). The possibility of losing confidentiality due to the billing process was particularly problematic among younger respondents and those who were unemployed and worked part-time. Half of all insured respondents reported that they would refuse to share insurance information. In the comment sections of the survey, respondents expressed worry primarily about their insurance company or families knowing about an STD clinic visit. Medicaid recipients were much more likely to accept billing for services than those privately insured, perhaps because Medicaid does not send home an EOB and is state funded rather than provided by an employer.
When billing commences, the STD clinics will be obligated by Medicaid to attempt to collect a fee from patients without insurance (i.e., Medicaid is intended as a last-resort payer). This is particularly important for patients choosing to withhold insurance information. When neither Medicaid nor a third-party source can be billed for a particular patient, the NYC STD clinics will apply a sliding scale fee. This comes with its own set of challenges and concerns. For example, other local health departments that implemented fees in their STD clinics experienced decreases in clinic attendance soon thereafter.5,6 Based on our survey, 20.2% of NYC clinic survey respondents reported that they would stop accessing the STD clinics if a fee were implemented. The survey findings suggest that once billing is implemented, up to 13,633 patients (accounting for 19,026 visits) per year might not come to an STD clinic, and given that approximately 56% of visits to the STD clinics from September to December 2012 resulted in at least 1 STD diagnosis, the implementation of a fee could increase the number of infections that go undiagnosed and untreated in NYC.
Privacy issues were a primary barrier to adolescents’ access to clinic services. In this survey, adolescents were the age group most reluctant to access clinics or pay a fee if billing were implemented and were also the most concerned about the mailing of EOBs. Three quarters of these adolescents were in school and more than half of them were unemployed, which affects their ability to pay fees themselves. Furthermore, adolescents may not want their parents to know that they are sexually active—or any of the other details that could come from the insurance company. Currently in New York, anyone able to give consent for STD care can receive it—irrespective of age and without permission or knowledge of their parents or guardian.7 Given that adolescents and young adults are already disproportionately at risk for STDs, the implementation of billing in the STD clinics has the potential to be especially impactful to their sexual health. Thus, the DOHMH plans to take steps to assure that billing will not be a barrier to adolescents who seek screening or treatment of diseases that significantly affect public health and also does not interfere with adolescents’ rights to confidential STD care in New York State.
To assure adolescents access to care, the DOHMH will not collect insurance information or distribute a sliding scale fee letter to any STD clinic patient who is younger than 19 years at the time of service. Those 19 years and older who do not provide third-party information for billing will be billed on a sliding scale based on income and household size. Such patients will be given a billing invoice to be remitted by mail. No funds will be collected at the time of service, and no follow-up bill will ever be sent. Patients will also be clearly told that they will not be denied service because they lack insurance or cannot pay the fee. Steps like these should help keep community trust and potentially prevent losses in attendance by patients truly requiring safety net STD services. The goal of the DOHMH is to continue to diagnose, treat, and prevent the spread of STDs while addressing the mandate to begin collecting revenue from insurance providers and patients via a sliding scale fee.
The revenue collected via billing would be paid to a NYC general fund, and any associated financial impact on STD clinic operations would be indirect. Combining the projections from insurance billing and sliding scale fees, we determined that the clinics could potentially recoup as much as US$4,367,750 in a year from STD service delivery. Note that these values are neither precise nor necessarily representative of what the clinics will charge, as actual charges have not been finalized. This is an optimistic estimate, considering that many patients will not pay the sliding scale fee and that many willing to pay will be at the lower end of the sliding scale. It is also possible that these gains will be offset in part by the increased health care costs subsequent to voluntary delay or missed diagnosis, treatment, and screening for other infections due to the billing requirement.
There are some important limitations to the application of the survey data. Most importantly, the survey is based on self-report and perception of how billing could compromise each respondent’s confidentiality and finances. The survey posed hypothetical questions and may not accurately predict how a patient will behave when faced with actual changes in clinic policy. Furthermore, the survey did not collect any information about the respondent’s STD risk or current symptoms, and thus, we cannot evaluate how the policy change might impact subpopulations of patients (symptomatic patients or men who have sex with men) differently. The actual effects of the system implemented will need careful evaluation. We also did not ask what course of action would be taken by those respondents who indicated that they would cease accessing NYC DOHMH STD clinic services. It would be helpful in future studies to ask whether they would seek care elsewhere. Finally, there is no way to know how many patients would actually mail in their STD clinic fees, but it is likely that only a small percentage of self-pay patients will remit the cost. Fee schedules have yet to be determined because DOHMH is also currently mapping insurance billing codes to services provided at the STD clinics. Despite these limitations, the data can help us anticipate how our patients might behave, what their expected insurance coverage might be, and how much we can expect to collect from insurance reimbursements and patient fees.
New York City DOHMH, as a provider of safety net care, is aware that policies and procedures must be crafted so that persons requiring services can access them in a timely fashion. Our next steps are the actual design and implementation of a billing process. After implementation, NYC DOHMH will continue to evaluate the impact these changes have on patient access to STD services and to monitor clinic volumes to ensure that we continue to meet the STD diagnostic and treatment needs at the community level.