Nearly 20 million new sexually transmitted diseases (STDs) are estimated to occur in the United States each year,1 resulting in an array of potential health consequences and at a direct cost of nearly sixteen billion dollars.2 The actual total could be considerably higher as the cost of STD prevention and screening efforts, vaccination, and indirect cost are not included in this calculation.2 North Carolina contributes to these numbers with 49,904 chlamydia cases, 14,952 gonorrhea cases, 1351 new human immunodeficiency virus (HIV) cases, and 1792 new syphilis (any stage) cases reported in 2014. Of these cases, providers in eastern North Carolina specifically reported 10,472 chlamydia cases, 2884 gonorrhea cases, 236 new HIV cases, and 274 new syphilis (any stage) cases.3,4
Local health departments/districts (LHDs) are integral in the screening, treatment, and prevention of STDs within their communities and often fill a critical service gap, especially in rural locations.5 Although LHD's role and responsibilities are unique, the public health system has been habitually underfunded for decades which affect their core functions and programs including disease prevention. Statistics indicate significant variances from state to state in federal funding spent to prevent disease and improve health. North Carolina ranked 41st and in the lower 25% with US $18.32 per capita spent.6 In addition to shrinking funding sources, North Carolina LHDs are mandated by law to provide STD services at no cost to the patient. North Carolina Administrative Code 10A Chapter 41A .0204(a) states “local health departments shall provide diagnosis, testing, treatment, follow-up, and preventive services for syphilis, gonorrhea, chlamydia, These services shall be provided upon request and at no charge to the patient.”7 Although LHDs may bill governmental or nongovernmental insurance providers for STD services within this statute, there have been no studies to date to ascertain what is currently being done regarding billing these providers at the local level in North Carolina.
In addition to the incidence, cost, and funding of STD services, the comprehensive health insurance reforms initiated through The Patient Protection and Affordable Care Act of 2010, better known as the Affordable Care Act (ACA) has improved access, affordability, and quality of health care for uninsured and underinsured Americans.8 The ACA has contributed to changes in health care and expansion of the public health landscape by increasing access to care in North Carolina.9 In 2015, the number of North Carolinians enrolled in affordable, quality health insurance through the Marketplace was reported to be 560,357.10 Organizations usually dependent on discretionary grant funding for provision of STD services may face difficulties adjusting to the new financial model, but can benefit from opportunities to generate new revenue sources through subsidized private insurance plans.11 As more North Carolina residents apply for and acquire health insurance, billing for STD services and receiving reimbursement for these services appears more likely.
This descriptive study was a part of a mixed method study and was performed to better understand LHD's ability to adapt to the changing financial climate as a result of the ACA. The assessment of staff knowledge and attitudes toward billing and seeking third-party reimbursement for STD services as well as current practices were explored. This was the first study conducted and thus provided baseline knowledge. The eastern region of North Carolina was selected for the survey area due to its high STD morbidity.12
MATERIALS AND METHODS
The research protocol was approved by East Carolina University's Institutional Review Board.
The North Carolina Communicable Disease Branch granted permission for the research team to survey staff used by the 25 LHDs and/or districts that represented the 33 counties in eastern North Carolina. Each health director was given specific instructions via email on how to distribute within the agency to insure a minimum of 5 staff members from a variety of backgrounds complete the survey (i.e., clinicians, nursing staff, financial managers, front desk staff, and so on). All 25 agencies met the minimum inclusion criteria. Data collection via this electronic survey was conducted September 30, 2015, to November 1, 2015.
Using a 42-item Qualtrics survey developed by the primary author to measure staff attitudes as well as knowledge, and current billing practices, this instrument was first piloted in 2 counties for readability and comprehension. The survey was then sent electronically to the health directors in the remaining counties in the sample. Snowball sampling was used to allow for greater inclusion of staff.13 The inclusion of a variety of backgrounds in staff responding provided more robust findings than having a singular voice of the health director only.
Knowledge of Reimbursement for STD Services
There was a question on the survey, “Prior to the survey, were you aware of the possibility of coding, billing and seeking reimbursement from third-party payer commercial insurance carriers for STD services?” Respondents had the option of answering “yes” or “no.”
Attitudes toward Seeking Reimbursement for these Services
There were 2 questions on the survey regarding the respondent's attitude toward the practice of billing a client’s third-party payer/commercial insurance carrier for allowable STD services. The first question was, “Do you feel it is an acceptable practice to bill a client’s third-party payer/commercial insurance carrier for allowable STD services?” Responses were “not acceptable,” “acceptable,” or “very acceptable.” The second question was, “Do you feel STD services should always remain a “free” service in local health departments?” Responses were “strongly disagree,” “disagree,” “agree,” “strongly agree” with those responding “strongly disagree or disagree” being in support of billing for these services.
Current Clinic Practices Regarding Billing for STD Services to Third-Party Payers
There were 5 questions on the survey that were added as a means of initial assessment as to where the LHDs were in regard to their current practice of billing these STD services to third-party payers/commercial insurance carriers which also included Medicaid. The first 2 questions were a simple “yes,” “no,” “not sure” response to the question of whether the agency does bill (1) Medicaid and (2) other third-party payers for these services. If they answered “yes” to the second question, a built-in skip logic pattern asked them, “Which third-party payers/commercial insurance carriers are you currently contracted” and a free text box was provided for them to write in the names. A follow-up question was then asked “How long have you been contracted with these third-party payers/commercial insurance carriers?” Responses were “more than 2 years,” “1 to 2 years,” “6 to 11 months,” “less than 6 months,” and “not sure.” The last 2 questions asked were (1) “Who in the agency advocated making the initial change to contracting with third-party payers” and responses were: “Health director, County Commissioners, Board of Health, Financial Manager, Medical Director, Nursing Director, Other-free text box, Not sure” and 2) “Who in the agency is directly responsible for management of the contracts” and responses were: “Financial manager, Nursing Director, Other—free text box, Not sure”.
Responses were verified through Qualtrics to capture only those who had completed the entire survey. The consent form was included at the beginning of the survey, and respondents could choose not to complete the survey and exit. Because there were no identifying variables to compare those who completed with those who did not complete, we were not able to evaluate the extent of missing data.13 Descriptive statistics (frequencies and percent) were computed for selected questions in the survey. Analysis of data was performed either at the individual level (N = 183) or agency level (N = 25) based on the question.
All 25 of the health departments/districts included in the study had a response from at least 5 staff members for a total response of 210. The data presented in this study represent the 183 staff responses that had completed the survey (87%) and agency response (100%). Due to multiple responses from staff members from each of the 25 agencies, an operational decision was made before analysis to use a majority response as a positive/negative response from the agency level (i.e., if 3 reported “yes” and 2 reported “no” to a question such as “does your agency bill third-party payers/commercial insurance carriers for STD services,” this would be counted as a “yes” response for this agency). In addition, current billing practices with Medicaid were reported separately from other third-party payers/commercial insurance carriers for this study.
Characteristics of Health Departments/Districts
Of the 25 health departments/districts surveyed, all reported being a health department/district and 1 reported also being a federally qualified health center (FQHC). This agency is a health department but is receiving FQHC funding to support primary care services (see Table 1). When asked what is their current role in the agency, 23.5% reported nursing management, 23.0% reported nursing staff, 10.9% billing management, 7.7% billing staff and 35.0% reported “other” with 11 health directors being the highest reported. All 25 agencies provide STD testing and treatment on site for chlamydia, gonorrhea, HIV (testing only), and syphilis. Acute hepatitis C testing had the lowest reported with 3 agencies, reporting they did not provide this service. In regard to the type of providers the agencies use to evaluate STD patients, 24 reported using mid-level providers (nurse practitioners or physician’s assistants), and 1 agency reported the use of both the mid-level and MD provider. Twenty-two agencies reported the use of STD enhanced role registered nurses (ERRN) in their STD clinics. These nurses have received additional training and education to provide STD screening and treatment in the STD clinic by following written standing orders by the medical provider. A final characteristic of staff asked in the survey was the number of years worked in the LHD system with a range of 1 year (5.5%) to 38 years (2.2%) with the highest frequency being 15 years (8.2%).
Knowledge of Reimbursement for STD Services
Because turnover in staff, especially at the billing and clerical services level, can be substantial in many health department/district settings, understanding the level of knowledge among current staff may be helpful in assessing an agency's ability to effectively bill for these STD services through third-party payers. The respondents in the survey were asked if prior to this survey, they were aware of the possibility of coding, billing, and seeking reimbursement from third-party payers/commercial insurance carriers for STD services. An overwhelming majority of the staff respondents (87.4%) reported they had been aware of this possibility.
Attitudes Toward Seeking Reimbursement for Services
Because coding, billing, and seeking reimbursement from third-party payers/commercial insurance carriers for STD services is a relatively new practice among health departments, the attitudes of the staff are important to consider. The first question asked the staff if they felt it was an acceptable practice to bill a client's third-party payer for these services and a majority responded either it was acceptable or very acceptable to bill (92%). However, when asked about their feelings toward STD services always remaining a “free” service in health departments, 54.6% (100/183) reported either they strongly disagree or disagree (indicating they supported the practice of billing responsible sources for services) and 45.4% (83/183) reported either they strongly agree or agree (indicating their support for keeping these services free and not billing).
Current Clinic Practices Regarding Billing for STD Services to Third-party Payers (including Medicaid)
When asked about billing Medicaid and other third-party payers/commercial insurance carriers for STD services, 23 (92%) reported they did bill Medicaid, and 20 (80%) reported billing third-party payers. Blue Cross/Blue Shield is the largest provider with 20 (80%) reporting they have a current contract with this agency (see Table 2). In regard to those who do have a contract with third-party payer/commercial insurance, only 9 (45%) of the 20 reported having this for more than 2 years. When asked who advocated for making the initial change to contracting with third-party payers/commercial insurance carriers, the health director was identified by 5 (25%) of the 20 agencies, and 8 (40%) agencies were not sure. When asked who in the agency is directly responsible for the management of the third-party payer/commercial insurance contracts, 11 (55%) of the 20 agencies reported the financial manager was responsible.
There is limited literature examining LHD's evolvement since the implementation of the ACA. Our study of LHDs in eastern North Carolina found consistency among the departments/districts in the screening and treatment of STDs. Most LHDs used mid-level providers and ERRN in their STD clinics. NC Medicaid recognizes and reimburses for ERRN services in the testing and treatment of STDs; however, private insurance reimbursement for ERRN services has not yet been fully investigated. Since the use of ERRNs in LHD's STD clinics is a common practice, receiving appropriate reimbursement for their services from commercial carriers will be vital to the LHDs bottom line and will be crucial in their future contract negotiations.
Although LHDs are familiar with and commonly bill Medicaid for STD services, their experience billing these services to other third-party payers/commercial insurance carriers is not as robust. This may be due in part, to less familiarity with commercial insurance and fewer insurance provider contracts. Although most LHDs (80%) report a current contract with Blue Cross and Blue Shield, slightly less than half have had any commercial contract for more than 2 years. These findings suggest LHD's foray into the commercial insurance arena is fairly recent and offers additional room for development. North Carolina LHDs are not alone in this transition as in a recent survey LHDs in Texas were also less likely to report billing third-party payers for STD services than compared to community health centers or hospital based clinics.11 Well-defined billing processes and protocols, as part of a robust revenue cycle management program, optimizes revenue generation and likely would improve the financial health of the LHD.
The final concept assessed in this survey was the current attitudes of the staff in these LHDs and the acceptability of billing for STD services to third-party payers/commercial insurance carriers. Overwhelming positive response was reported as this being an acceptable or very acceptable practice; but was less clear in the next question of whether or not these services should remain free in health departments. Historically, many services offered by the LHD, including STD services, have been free to the client and have not been billed to third-party payers other than Medicaid if applicable. Remarkably, nearly half of the respondents felt STD services should remain free and not billed to commercial insurance. This response is somewhat understandable considering the newness of the billing practice. Prochaska and DiClemente14 describe contemplation (an early stage of change), as “sitting on the fence.” Changes at this stage can be encouraged through evaluation of the pros and cons and the identification of positive outcomes. Local health departments/districts have a responsibility to educate their communities regarding decreased funding sources and the growing need to bill to sustain current service levels. According to the proposal from the grant that supported this study, this will be a new way of thinking for many LHDs due to the fact many counties have grown accustomed to “we have always done it this way” thinking (written communication, December 2014). From a policy perspective, the impact of the ACA with billing for STD services and the mixed perceptions of the staff in these LHDs are not unique. A recent study in North Carolina with Free Clinics’ directors reported mixed feelings on the general perception of the ACA with 34% reporting no benefit to their clinics.15
Our study focused on health departments/districts in eastern North Carolina and therefore is not generalizable to other agencies. A major limitation is the fact that the survey did not ask about the quality or extent of the contract with the third-party payer. It is not possible to determine if the contracts are providing maximum payments for the services they provide. In addition, no data were collected on those who chose not to complete the survey after reading the consent compared to those who did complete. Therefore, it is not possible to determine any patterns of missing data for potential bias.13
This study has opened a dialog and presented possibilities for potential reimbursement opportunities for LHDs in providing STD services. Staff attitudes and knowledge regarding billing practices for STD services are important to consider because these individuals make up the agency and ultimately, provide the voice and direction to the policies developed. Further investigation is needed to determine barriers to billing, coding and reimbursement from third-party payers/commercial insurance carriers as well as the robustness of the contracts to identify strategies and improve processes. In addition, investigation into the mixed responses dealing with the provision of STD services being a “free” service at the LHD level and the reported high acceptability of billing a commercial insurance carrier are also warranted. There was a high degree of inconsistency in the responses on the survey by the staff as no question garnered complete agreement. The operational definition of an agency response had to be used when reporting current practices at this level. For this reason, it is unclear if the practice should remain free due to confidentiality, access to care or the collection of copays. This study will continue in the coming year with the additional 67 counties in the state being surveyed and this question will be explored further.
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