In the Affordable Care Act era, no-cost-to-patient publicly funded sexually transmitted infection (STI) clinics have been challenged as the standard STI care delivery model. This study examined the impact of removing public funding and instituting a flat fee within an STI clinic under state-mandated insurance coverage.
Cross-sectional database analysis examined changes in visit volumes, demographics, and payer mix for 4 locations in Massachusetts’ largest safety net hospital (STI clinic, primary care [PC], emergency department [ED], obstetrics/gynecology [OB/GYN] for 3 periods: early health reform implementation, reform fully implemented but public STI clinic funding retained, termination of public funding and institution of a US$75 fee in STI clinic for those not using insurance).
Sexually transmitted infection visits decreased 20% in STI clinic (P < 0.001), increased 107% in PC (P < 0.001), slightly decreased in ED, and did not change in OB/GYN. The only large demographic shift observed was in the sex of PC patients—women comprised 51% of PC patients seen for STI care in the first time period, but rose sharply to 70% in the third time period (P < 0.0001). After termination of public funding, 50% of STI clinic patients paid flat fee, 35% used public insurance, and 15% used private insurance.
Mandatory insurance, public funding loss, and institution of a flat STI clinic fee were associated with overall decreases in STI visit volume, with significant STI clinic visit decreases and PC STI visit increases. This may indicate partial shifting of STI services into PC. Half of STI clinic patients chose to pay the flat fee even after reform was fully implemented.
Health insurance reform and imposition of a flat fee in a sexually transmitted infection (STI) clinic for those unwilling or unable to use health insurance were associated with significant STI clinic visit decreases and primary care STI visit increases in a Massachusetts safety net hospital. Half of remaining STI clinic patients elected to pay the fixed fee.
From the *Department of Health Policy and Management, Boston University School of Public Health, Boston, MA; †Section of Infectious Diseases, Boston University School of Medicine, Boston, MA; ‡Center for Health Quality, Outcomes & Economic Research, ENRM Veterans Administration Hospital, Bedford, MA; §Section of General Internal Medicine, Boston University School of Medicine, Boston, MA; ¶Division of STD Prevention & HIV/AIDS Surveillance, Massachusetts Department of Public Health, Jamaica Plain, MA; and ∥Section of Pediatric Infectious Diseases, Boston University School of Medicine, Boston, MA
Acknowledgments: The authors thank the following individuals for their contributions: Mahada Maya McDoom, PhD; Jake Morgan, MS; Natasha Neal, MPH; Gina Lee, MPH; and Breighl Mobley (Boston University School of Public Health) for assistance with development of figures and preparation of the manuscript for submission; Linda Rosen, MSEE (Boston Medical Center) for supplying the data; David Rosenbloom, PhD (Boston University School of Public Health) and Noelle Cocoros, DSc, MPH; Kevin Cranston, MDiv; and Alfred DeMaria, Jr, MD (all from the Massachusetts Department of Public Health), for review of the manuscript; and Thomas Gift, PhD, and Gail Janes, PhD (Centers for Disease Control and Prevention), for invaluable assistance, consultation, and review throughout the project. None of these individuals received any financial compensation for their involvement with this article.
Conflicts of interest and source of funding: No conflicts of interest were reported. This work was supported by the Massachusetts Department of Public Health through CDC-RFA-PS09-902. The Massachusetts Department of Public Health reviewed and approved this report before submission for publication.
Correspondence: Mari-Lynn Drainoni, PhD, Department of Health Policy and Management, Boston University School of Public Health, 715 Albany St, Boston, MA 02118. E-mail: firstname.lastname@example.org.
Received for publication December 6, 2013, and accepted March 31, 2014.
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