It was estimated that by the March 31st deadline for enrollment in new health care options under the Affordable Care Act, more than 7,100,000 previously uninsured people were enrolled in a health care payer source secured through the Federal or one of many state exchanges. In our home state of Colorado alone, more than 270,000 people who were previously uninsured now have private insurance or Medicaid to cover their health care expenses. Although many of these persons surely went without health care for extended periods of time, we know that many sought needed care at safety-net service sites such as in emergency departments, urgent care centers, or, for their sexual health needs, at public health family planning/sexually transmitted disease (STD) clinics like the one that we oversee in urban Denver.
In 2013, we estimated that approximately 50% of our overall STD clinic patient population would be eligible for Medicaid under planned expansions in Colorado, with at least 10% additionally eligible for coverage through the exchange (C. Mettenbrink, personal communication, 2014). Although we enthusiastically began to plan for enrolling our patient population, questions arose about just whom we might be serving through our public safety-net clinic in 2014 and beyond. Would our STD clinic patients choose to seek care in primary care settings and whom would clinics like ours serve moving into the future?
With the early adoption of expanded health care coverage, Massachusetts serves as a model for what alterations might occur in the provision of sexual health services under the Affordable Care Act (ACA). In their article in this issue of Sexually Transmitted Diseases, Drainoni and colleagues1 describe shifts and, interestingly, lack of shifts of patients from publicly funded STD settings to primary care after the expansion of health care coverage that occurred in Massachusetts in 2007. The authors depict 3 periods, precoverage mandate, after the insurance mandate was enacted, and a period after public funding for STD clinical services was eliminated and fees had to be introduced in the STD clinics. What was noted was a 20% drop in STD clinic visits and a compensatory 107% increase in primary care visits for sexual health services. The authors point out, however, that expansions in primary care sexual health visits were predominately seen in women, whereas men made up most of STD clinic patients. Thus, more people were being served in the later period, but likely not the same population that had been served before the changes.
A finding that was contrary to conventional wisdom, but not so surprising to our colleagues who run STD clinics in other jurisdictions, was that many persons continued to seek care in the STD clinics despite options for health care elsewhere. Stephens et al.2 describe that in San Francisco, 38% of patients seeking care in the health department’s public City Clinic have insurance. This is not dissimilar to our own experience in which 33% of patients seen in the Denver Metro Health STD Clinic are already insured and thus have opportunities to seek their sexual health care elsewhere, but choose to come to our clinic (C. Mettenbrink, personal communication, 2014). Our own survey data suggest that they continue to come to us out of convenience, confidentiality, and because they perceive that we will better understand and care for their problem.
Four important conclusions can be drawn from the article of Drainoni et al. First, a blanket fee is a blunt tool. After the implementation of the STD clinic US$75 fee, visits dropped 46%. We learned this the hard way in our own clinic when we saw visits drop 28.5% after establishing an across the board, but much lower fee (US$15) for all patients in 2003.3 More concerning, chlamydia diagnoses decreased 28% and gonorrhea 38% while the fee was in place; an analysis not reported by Drainoni et al. Our blanket fee was eventually eliminated. Learning from that experience, we more recently implemented a gradated fee-for-service that exempts all youth and those living in households at the lower end of the poverty scale. By exempting many from the fee while billing third-party payers, we are both assuring our public health mandate while diversifying our revenue, allowing us to continue to serve as a safety-net clinic.
Second, STD clinics will remain necessary even in an era of expanded health care coverage. Although this clearly needs to be studied further, many people will continue to seek specialized STD services out of convenience because of assumed heightened confidentiality, or perhaps because of higher-quality services that might result from seeing an expert in STDs. Clients seem willing to forego insurance coverage (underscoring the benefit that could potentially arise to STD clinics who begin billing for services4) or even pay a fee to continue to be seen in specialized STD clinical settings. When those needing ongoing safety-net services—youth, persons who have not enrolled for health care coverage, and persons not eligible for coverage—are additionally considered, it is clear that after the roll out of the ACA, specialized STD clinics will remain necessary in many jurisdictions.5,6
Third, and perhaps more importantly, this article underscores the importance of developing data collection tools that can monitor the provision of quality STD services in all primary care settings. Already, most of chlamydia and gonorrhea cases are diagnosed in primary care.7 Assuming that many persons with newfound coverage under the ACA do shift their sexual health care from specialty clinics to primary care settings, the need for infrastructure development that will allow for the determination of the quality of sexual health screening and treatment provision is paramount.8 Local—clinic or even provider-specific—data are a great motivator for provider behavior change. Providers must be informed as to how they are performing relative to national guidelines on STD, HIV, and hepatitis screening if we are to expect rates to improve. So must they be aware of the timeliness and quality of the treatment and services they provide. By prioritizing sexual health, building the IT infrastructure to monitor the provision of sexual health services and committing to the ongoing review of that data, primary care organizations will go far toward assuring timely and quality provisional sexual health clinical services.
Finally, the assurance that STD clinics will be needed in the future should not be taken as an excuse to be laissez faire about our role. To assure that appropriate screening is taking place and treatment is provided in a quality manner throughout health care systems, STD clinics must stop thinking of themselves as only clinics, passively serving patients who happen to come to them. Rather they must think of themselves as STD programs—local and regional centers of excellence. We must expand our capacity to better meet the current and future need of our primary care colleagues. We must assist in monitoring of screening and treatment by developing data sharing agreements, perhaps in coordination with local and state health departments, with clinical providers in our jurisdictions. Specialized STD programs, which have the experience and history in implementing screening and treatment guidelines, can and should help primary care providers routinize these guidelines within their own care settings. The technical assistance, training, and case-by-case clinical guidance experienced STD providers or funded training centers can deliver to primary care clinicians will be enormously helpful in meeting national screening standards.9,10
And it is we—the STD programs—that must take the lead in reaching out to establish closer relationships with our primary care colleagues. Most community health centers provide excellent care already, but at times, sexual health services are an afterthought in these settings. We must make the case for sexual health services with our primary care partners. We must use local surveillance data, blended with clinical data when available, to drive which clinical partners and settings should be prioritized for training and technical assistance. We must educate them on what we can bring to the table to help in their provisional sexual health work, and we must assure them that we will be there to help when challenging clinical, or social, cases arise. Treatment for STDs can occasionally be confusing for those who do not do it every day. We will improve sexual health care in the future, not only by providing it ourselves within the walls of our clinics but also by assuring that primary care settings have their own sexual health training and clinical provisional needs met.
Thus, if you run an STD clinic, do not start hanging the crepe just yet. The ACA is not our death knell. Rather it is an opportunity to expand our reach and improve community and population-level outcomes. These data from Massachusetts help assure us that we still have a role to play as both a safety-net provider and a clinical expert. We will continue to serve those without insurance or youth unfamiliar or unwilling to use third-party payers. In addition, many with insurance will continue to seek our services for our confidentiality, our convenience, and our clinical expertise.
As many patients will undoubtedly shift their sexual health care to primary care providers, we must help health care organizations prioritize and monitor the provision of sexual health services. So, too, must we assure that at-risk populations, most commonly men disproportionately served in STD settings and less likely to seek primary care, are still provided the screening services they need. Finally, we must build relationships with primary care providers. We should not look at a shift to primary care as a problem, but rather an opportunity to expand our impact, screen more people for STDs, and promote a holistic sexual health framework in our communities.
1. Drainoni M, Sullivan M, Sequeria S, et al. Health reform and shifts in funding for sexually transmitted infection services. Sex Transm Dis 2014; 41: 455–460.
2. Stephens S, Cohen S, Philip S, et al. Insurance among patients seeking care at a municipal sexually transmitted disease clinic: Implications for health care reform in the United States. Sex Transm Dis 2014; 41: 227–232.
3. Rietmeijer C, Alfonsi G, Douglas J, et al. Trends in clinic visits and diagnosed Chlamydia trachomatis
and Neisseria gonorrhoeae
infections after the introduction of a copayment in a sexually transmitted infection clinic. Sex Transm Dis 2005; 32: 243–246.
4. Downey L, Lafferty W, Krekeler B. The impact of Medicaid-linked reimbursements on revenues of public sexually transmitted diseases clinics. Sex Transm Dis 2002; 29: 100–105.
5. Golden M, Kerndt P. Improving clinical operations: Can we and should we save our STD clinics? Sex Transm Dis 2010; 37: 264–265.
6. Rietmeijer C, Mettenbrink C. Why we should save our STD clinics. Sex Transm Dis 2010; 37: 591.
7. Centers for Disease Control and Prevention. Sexually Transmitted Diseases Surveillance 2012. Atlanta, GA: U.S. Department of Health and Human Services, 2013.
8. Chow J. Measuring the uptake and impact of chlamydia screening programs—Easier said than done. Sex Transm Dis 2012; 39: 89–91.
9. Driesbach S, Devine S, Fitch J, et al. Can experiential-didactic training improve clinical STD practices? Sex Transm Dis 2011; 38: 516–521.
10. Dreisbach S, Burnside H, Hsu K, et al. Improving HIV/STD prevention in the care of persons living with HIV through a national training program. AIDS Patient Care STDs 2014; 28: 15–21.