Thomas R. Eng¹

The IOM Committee on Prevention and Control of STDs invited a small number of representatives² from managed care organizations (MCOs); local, state, and federal health agencies; and an employer-purchasing coalition to a workshop on November 8, 1995, to advise the committee on the likely impact of managed care on STD-related services. The Los Angeles area was selected as the site of the workshop because of the substantial penetration of managed care and the high rates of STDs in California. The MCOs that participated in the workshop included a nonprofit group-model MCO (Kaiser Permanente Medical Group of Southern California), a for-profit primarily IPA (independent practice association) model MCO (CIGNA Healthcare of Southern California), and two publicly owned MCOs (Contra Costa Health Plan and Los Angeles County Community Health Plan). The workshop consisted of presentations by several participants followed by an open discussion of issues related to the role of managed care in STD prevention.

Major questions and issues addressed by workshop participants included:

• STD-Related Activities of MCOs: What types of curative and preventive

• services related to STD prevention are being provided by MCOs? How do MCOs handle confidentiality issues related to STDs, and who has access to this information? What are the experiences of MCOs that are serving populations at higher risk for STDs or participating in Medicaid managed care contracts?
• Public/Private Partnerships: What types of public/private partnerships related to STD prevention exist? What are the major barriers to successful public/private partnerships? How will MCOs that rely on publicly funded STD programs deliver STD-related services if public funding for these programs decreases or is eliminated?
• Roles and Responsibilities: What should be the roles and responsibilities of the public versus private sectors regarding STD prevention? How will decreased public funding and government oversight affect these various roles and responsibilities? How can MCOs coordinate their efforts with public agencies to improve the combined effectiveness of programs and to reduce duplication of efforts? What are the responsibilities of MCOs for the health of persons who are not plan beneficiaries? What incentives exist or need to be developed, and what barriers need to be addressed in order for MCOs to make STDs a priority?
• Monitoring and Accountability: How should MCOs, public health officials, purchasers, and accrediting organizations ensure quality and accountability and monitor performance of STD-related services? What is the role of purchasers in establishing STD prevention activities as priorities in MCOs?

The following is a summary of the major issues that were discussed during the workshop. The perspectives reflected in this document do not necessarily represent the consensus of workshop participants or the committee.

CIGNA Healthcare of Southern California, a for-profit MCO that serves several southern California counties, is primarily comprised of a network of IPAs, medical groups, and individually contracted physicians (the staff-model component was sold in 1996). CIGNA serves a mostly commercial population of approximately 500,000 members but also has 108,000 Medical members. Anecdotally, rates of STDs among the commercial population have not increased in the last few years, but STD rates among Medical members have increased approximately two- to threefold. All STD-related services, including education, are triggered by and centered around patient visits to primary care providers. There is a system for automatic tracking and reporting of STDs, with nurses conducting patient follow-up for appointments. Although printed literature on STD-related topics is disseminated to providers, there has not been any STD-related

provider training in the last few years. The MCO does not have specific guidelines to ensure confidentiality of STD-related care.

Kaiser Permanente of Southern California is a nonprofit, primarily group-model MCO serving several southern California counties. It is comprised of a medical group of 2,700 physicians and has an enrollment of approximately 2,200,000. Almost all beneficiaries are commercial members since Kaiser has only recently begun to accept Medical patients. Because of its centralized laboratory, Kaiser is able to closely monitor STD diagnoses and screening test results. To ensure that clinicians are aware of the latest trends in diagnoses and to further general information exchange, there are monthly teleconferences between physicians and laboratory personnel. Although Kaiser does not directly provide services to nonmembers, Kaiser has an unwritten policy to give prescriptions to nonmember partners of STD patients. In addition to sponsoring a clinic for teenagers, the MCO has an STD prevention program called "Secrets" (Appendix H) that is targeted towards adolescents. This program was largely initiated by pediatricians at Kaiser who had a strong interest in STD education for women and adolescents.

CIGNA and Kaiser represent two different types of MCO structures and missions. MCO structures range from relatively loosely organized networks of health care providers in IPAs to group- and staff-model organizations where the providers' practices are closely monitored. Missions of MCOs vary between the publicly operated, nonprofit organizations and the investor-owned, for-profit corporations. Many workshop participants believe that strong staff-model MCOs, such as Kaiser, may be more likely than IPAs to have the oversight structure and organization necessary to implement effective STD preventive services. Group-and staff-model MCOs also tend to have more centralized information systems that allow for better surveillance of health conditions and performance monitoring.

The Los Angeles County Community Health Plan is one of only two publicly owned and operated MCOs in California. The MCO has an enrollment of approximately 115,000 persons, all of whom are medically or economically indigent. Because the MCO considers the enrolled population to be at high risk for STDs, the MCO conducts routine screening for gonorrhea and chlamydial as part of every pelvic exam and provides STD-related risk-reduction education with each health maintenance examination. One of the major problems that the MCO has encountered is the large turnover in eligibility for plan coverage, since eligibility is income-dependent. This problem hinders the establishment of longer-term relationships between providers and patients.

The Contra Costa Health Plan is the other county-sponsored and operated staff-model MCO in California. It has an enrollment of approximately 24,000

persons, 65 percent of whom are Medicaid beneficiaries or other medically needy populations, including homeless persons. The Contra Costa Health Plan has a close collaborative relationship with the Contra Costa County Health Department. In a memorandum of understanding, the MCO and the county health department have outlined their specific roles and responsibilities for various health services, including STD-related care. The agreement covers STD-related education, reporting, contact investigation, and treatment. For example, when surveillance data indicate a specific problem within the catchment area of the MCO, the MCO will develop and implement a plan to provide STD-related risk-reduction information to all members in consultation with the county health department. One issue that the MCO has been dealing with is the conflict between the need for medical providers to know the treatment history of the individual and the patient's wish for confidentiality.

Because the Los Angeles County Community Health Plan and the Contra Costa Health Plan are both operated by local governments, they have built-in linkages with county health department activities and priorities. These linkages have allowed the MCOs and local health department programs to ensure that specific components of STD-related services are available. These MCOs, like other MCOs that serve large numbers of medically and economically needy persons, have found that the general package of managed care services developed for employer-sponsored or commercial populations may not be appropriate for indigent populations. There is a growing recognition that persons in publicly funded programs, such as Medicaid, have health care needs different from those of the commercial or general population.

Both opportunities and concerns were identified by workshop participants regarding the potential impact of managed care on STD prevention activities. The major potential strengths of MCOs in providing STD-related services include the following:

• Coordination and integration of care. STD-related services should be coordinated and integrated with primary care. Because MCOs provide all primary care for enrollees, they will be better able to coordinate and integrate STD-related care into primary care compared to specialized public STD clinics or fee-for-service providers.
• Screening for STDs. If MCOs adopt public health recommendations for screening of sexually transmitted infections as standard policy, the numbers of patients who will be screened will increase substantially compared to patients outside of the managed care environment, where screening decisions are up to individual health care providers and are not centralized.
• STD-related data and information systems. Given the potential of centralized

• automated information systems, there is a great potential for better information and data on STDs and STD-related services in managed care populations. The larger, more structured MCOs (such as groupand staff-model MCOs) are likely to have particularly useful patient population data. This assumption may not hold true for less-structured MCOs, such as some IPAs that lack centralized data systems. The information systems of publicly sponsored health insurance programs (e.g., Medicaid and Medicare) have been traditionally structured around the delivery of curative services on a fee-for-service basis and have not been particularly useful in evaluating public-health-related or preventive services.
• Quality of STD-related care. As a result of automated information systems, most MCOs have systems for monitoring quality of care and measuring performance. Standardized performance measures, such as the Health Plan Employer Data and Information Set (HEDIS) system coordinated by the National Committee on Quality Assurance, have the potential to greatly improve STD-related care in MCOs.
• Accountability for services. MCOs, by virtue of being organized systems of care, facilitate increased accountability of providers to purchasers and, ultimately, to beneficiaries. Purchasers are able to hold MCOs accountable by ensuring that specific services are available and delivered within the specifications of negotiated contracts and agreements. Through contract obligations, it may be possible to hold MCOs accountable for all aspects of STD-related care.
• Preventive health. Compared to traditional fee-for-service insurance companies, MCOs have emphasized preventive health services because many preventive health measures are cost-saving. Since MCOs are responsible for covering health conditions occurring within the enrollment period, they are more likely to emphasize health promotion and disease prevention and to encourage healthy behaviors among their enrolled populations compared to noncapitated providers.
• Access to care. Because the mission of MCOs and government regulations require that beneficiaries have convenient access to primary care services, MCOs are more likely to have greater access to care than dedicated public STD clinics. In addition, some communities that are currently at high risk for STDs do not have access to local public STD clinics.
• Cultural barriers to care. MCOs that serve populations at high risk for STDs are more likely to have providers of different cultural backgrounds and language capabilities than many public STD clinics or health plans that serve only commercial populations. These MCOs may be better able to provide culturally sensitive STD-related services to diverse populations than public STD clinics and health plans that do not serve high-risk populations.

The major potential limitations of MCOs in providing STD-related services include the following:

• Confidentiality of services. One of the major concerns regarding the ability of MCOs to deliver STD-related services is related to safeguarding the confidentiality of such services. Automated information systems and the team-oriented approach to care associated with most MCOs increase provider, employer, and potential public access to medically sensitive information. Ensuring confidentiality for STD-related services is especially critical for adolescents. It is important to allow adolescents to receive care without parental consent and to ensure that their parents are not notified of STD-related treatment through billing or other means.
• Uninsured persons. Inadequate access to health care for uninsured persons is a major barrier to STD prevention. Increasing competition resulting from the move towards managed care and reductions in publicly financed health care may reduce access. This may result from public hospitals and clinics shutting down or curtailing services and from decreasing eligibility thresholds for publicly financed programs such as Medicaid. Therefore, even if MCOs assume full responsibility for STD prevention and provide the same spectrum of services as public programs, public STD clinics may still be needed to provide services to persons who neither have private insurance nor qualify for Medicaid or other public assistance.
• Quality of care. Capitated payments for services encourage MCOs to limit costs. It is possible that MCOs, compared to providers who are reimbursed for their rendered services, may be less willing to conduct diagnostic and screening tests, thereby potentially compromising the quality of care. In addition, the short amount of time available for routine appointments may be a disincentive for MCO providers to become involved in patient education and prevention activities, since these activities require an investment of time.
• Interest and mission. STDs are not a priority for most MCOs, especially those that do not serve populations at high risk for STDs. It is logical to expect that MCOs serving high-risk populations, such as Medicaid participants, will be more interested in STD prevention than health plans serving lower-risk populations, such as employer-sponsored groups. An MCO's interest in STD prevention may also be dependent on its mission. The mission of the MCO is often closely aligned with the MCO's status as a nonprofit or for-profit organization. For example, nonprofit MCOs are more likely to reinvest their excess revenue in the organization, whereas for-profit MCOs are obligated to funnel a substantial portion of their profits to their stockholders or owners. The mission of for-profit MCOs, therefore, may be in conflict with providing services, such as preventive services, that are not cost-saving to the organization.
• Variability of MCOs. There is a wide spectrum of MCOs, and consequently there is a wide range of technical ability among MCOs in providing STD-related services. In general, MCOs that have greater service coordination and oversight (e.g., staff- and group-model MCOs) are likely to be more effective in STD prevention than MCOs with less infrastructure (e.g., IPAs). Given the limited

• experience of most MCOs in providing public health services, including STD-related services such as partner notification and outreach, even some of the best-organized MCOs may not have the technical expertise to take on full responsibility for STD prevention.
• Training of providers. Most health care providers, including those in MCOs, are not adequately trained to deliver the range of STD services offered by public STD clinics. This is particularly true for STD-related services that require specialized skills or experience, such as counseling for high-risk sexual behavior. For example, a survey conducted by the Pacific Business Group on Health showed that approximately 56 percent of enrollees in contracted staff-model MCOs reported that their physician or other health professional had not discussed STDs with them in the last three years (Pacific Business Group on Health, unpublished data, 1994). In addition, if we accept that STD-related care is specialty care that requires extensive training and experience, then it may not be cost-effective for MCOs to replicate the technical competency found in public STD clinics.
• Disincentives for MCOs. Cost-saving is a major incentive for MCOs to provide specific services to enrollees. Treating STDs is cost-saving because it averts more expensive treatment associated with treating complications of STDs. However, unless providing a specific benefit is shown to be cost-saving, MCOs may be reluctant to provide services that have not been rigorously evaluated, such as some behavioral change interventions. In addition, capitated payments for services may increase the risk of cost-shifting by MCOs. For example, MCOs may refer persons in need of STD-related services to public STD clinics to avoid assuming the costs of their care.
• Patient preferences. A recent multisite survey of STD clinic patients showed that most persons surveyed chose a public STD clinic over other providers because of the convenience of obtaining care without an appointment, lower costs, and other reasons (Celum et al., 1995). Irrespective of these issues, persons who currently receive episodic care at public STD clinics may not feel comfortable in receiving care through MCOs, where a longer-term relationship with a primary care provider would need to be established.
• Services involving nonenrolled persons. Many aspects of STD prevention, such as partner notification and referral, screening and case finding, and community education, may involve persons who are not members of the MCO. MCOs may not be able to provide services for nonmembers because of economic, legal, or other reasons.
• Copayments. The copayment required by most MCOs is usually assessed on a per-visit basis. These copayments, although nominal for most people, may be a substantial burden for some and a barrier to seeking appropriate STD-related care, especially for preventive services.

Most MCOs are currently not focused on STDs for various reasons. With some exceptions, there is generally insufficient awareness of STDs and their consequences among MCOs and other private sector health care providers. Some MCOs serving mainly commercial populations may not consider STDs to be a major problem because infection rates are perceived to be low. For MCOs to recognize STD prevention as a priority, workshop participants felt that an organized effort to educate MCOs regarding the broad consequences of STDs, such as infertility and cancer, and the potential cost savings associated with STD prevention is necessary. The most likely leaders in this effort are employer-purchaser groups, community-based organizations, and local health departments and other government agencies.

The role and impact of purchasers of health services (e.g., employer groups and other coalitions) are likely to be significant in encouraging MCOs to provide STD-related services. Regardless of the type of MCO, all MCOs will be responsive to the needs of purchasers. MCOs seem willing to provide specific services as contract obligations if they consider the contract as desirable.

The Pacific Business Group on Health is a nonprofit employer-purchaser coalition of 29 large public and private employers in the San Francisco Bay Area. The organization represents more than three million employees, dependents, and retirees and negotiates terms and premiums for health plan contracts on behalf of approximately 15 member companies. The Pacific Business Group on Health has integrated the recommendations of the U.S. Preventive Services Task Force regarding clinical preventive services into their negotiated benefits packages and has implemented performance measures for many of these services. To ensure that MCOs are accountable for meeting performance goals, the Pacific Business Group on Health holds 2 percent of premium payments ''at risk," pending a review of health plan performance.

Workshop participants suggested that the public health community encourage purchasers to consider STD prevention as a priority. Employers are interested in including preventive health services in their negotiated benefits packages, especially if the services are shown to be cost-saving for the company. However, some STD-related services may not be cost-saving, and these services will still need to be supported. Employers may be increasingly interested in the health of the general community, recognizing that employers within a region are essentially drawing from the same employee pool.

Many local and state health departments have been preparing themselves for the likely impact of managed care on the delivery of primary and public health services. The Los Angeles County Department of Health Services and the California Department of Health Services have both developed strategies to ensure that STD-related services will continue to be provided as more people are enrolled into managed care.

Los Angeles County had a 1995 budget of approximately $40 million for STD programs and operated a system of 10 public STD clinics. Funding for public STD clinics had been reduced as a result of county fiscal problems; 29 public clinics were in operation during the previous year. Historically, there was limited collaboration between the health department and MCOs in STD-related issues. In response to decreased funding for public health programs and increased enrollment of the Medicaid population into managed care, the health department recently clarified the specific roles and responsibilities of the local health department and participating MCOs in several major public health areas as part of the county's Medicaid (Medical) managed care contract. In this contract, health department and MCO responsibilities for specific aspects of STD prevention, such as treatment, disease reporting, and partner follow-up, are outlined. In addition, the contract requires that MCOs reimburse the county STD clinics for services provided to MCO members.

In January 1995, the California Department of Health Services required that all Medical managed care contractors in 12 counties have subcontracts with respective county or city health departments regarding responsibilities in nine public health areas, including STDs. The contracts would have to describe the general relationship between the local health department and the MCO, the responsibilities of the health department, the responsibilities of the MCO, and areas of shared responsibility.

The California Department of Health Services has also recently initiated the California Partnership for Adolescent Chlamydial Prevention. This is a statewide partnership bringing together government agencies, MCOs, academic health centers, and professional associations to address policy issues related to STDs among adolescents. This initiative also seeks to coordinate clinical preventive services for adolescents in managed care settings with community STD prevention activities and to coordinate all categorical state STD-related programs. Other components of this initiative include a media campaign targeted towards teenagers; development of screening, counseling, and education interventions; school-based programs; and training programs for health care providers.

The Centers for Disease Control and Prevention (CDC) established a Managed

Care Working Group in January 1995 to foster partnerships between public health agencies and MCOs to improve public health. In a recent publication, the Working Group outlined its high priority areas for CDC's collaborative activities with MCOs and other health organizations, including prevention effectiveness and guidelines, Medicaid and managed care, research, and capacity development in public health agencies (CDC, 1995). The CDC recently initiated several collaborative activities with managed-care-related organizations. For example, a CDC epidemiologist is currently assigned on detail to the American Association of Health Plans (formerly Group Health Association of America) as a resource on public health issues. In addition, CDC staff have provided input regarding public health performance indicators, including STD-related indicators, to be used in the next version of HEDIS (3.0).

Given the recent and likely future reductions in public funding for public health services, many workshop participants believe that alternative funding streams for STD-related services, including public STD clinics, will need to be explored. Given that capitation encourages MCOs to keep costs down, there is a potential danger that MCOs may refer their patients with STDs to public STD clinics. In order to prevent this type of cost-shifting, local health departments will need to establish a mechanism for reimbursement of services.

The following are the major conclusions expressed by various workshop participants during the meeting. They do not necessarily represent a consensus of workshop participants or the conclusions of committee members.

• Increase emphasis of STDs among MCOs. Most MCOs are currently not focused on the problem of STDs. MCOs and other providers need to be encouraged to consider STD prevention as priorities. Changing "organizational norms" or the prioritization process of MCOs through methods similar to those used by employers and other purchasers should be considered. Additional incentives for MCOs to become more involved in STD prevention will have to be developed for many MCOs to offer comprehensive STD-related services.
• Define roles and responsibilities. The roles and responsibilities of MCOs, local public health departments, community-based organizations, and other stakeholders in STD prevention need to be clearly defined. In an era of limited resources for public health, it is important to identify what each potential provider of STD-related services does best and determine how each provider should function in an integrated system of STD-related services. Often, a formal mechanism for defining roles and responsibilities does not exist at the local level. A collaborative

• process for examining systems of STD-related services will need to be established. One possibility is for local health departments to organize a forum or other mechanism for the various stakeholders to come together and discuss their perspectives, with the goal of developing a strategy for coordinating STD-related services in the community. Strong leadership at the local level is necessary for this to be successful. Roles and responsibilities can also be defined through contract negotiations between purchasers and providers when appropriate, such as in the case of Los Angeles County's Medicaid managed care contracts. Mechanisms other than contract negotiations, however, should be available in communities that do not have opportunities to enter into formal contracts with MCOs.
• Increase collaboration between public health agencies and employers and other purchasers. Employers and other purchasers have an important role in ensuring that comprehensive STD-related services are available and that MCOs are accountable for their performance in delivering services. These purchasers need to be educated regarding the benefits of such services. Public health professionals should work with them to determine the preventive services that should be provided to beneficiaries. State and local governments that have Medicaid contracts with MCOs should ensure that responsibility for specific essential public health services, including STD prevention, is addressed through contracts or other agreements.
• Increase collaboration between public and private sectors. In light of decreasing public funds for public health, private/public partnerships should be developed to ensure availability of STD-related services. However, given the limited information and experience regarding both the effectiveness of public/private partnerships and the ability of some MCOs to provide such services, these partnerships should proceed cautiously. Publicly funded activities may need to be maintained until collaborative activities are evaluated and found to be effective. For example, the impact of reductions in federal funding for public STD clinics should be evaluated before clinic services are decreased.
• Integrate services and increase effectiveness and efficiency of programs. STD-related services, both preventive and curative, should be incorporated into primary care. As public funding for public health programs decreases, governments at all levels will need to maximize the effectiveness and efficiency of current programs. In collaboration with private sector health organizations, governments will need to objectively evaluate the effectiveness of various STD-related programs and integrate and coordinate services.
• Maintain public STD-related services. Even if MCOs assume increasing responsibility for STD prevention, persons who do not have private insurance, or do not qualify for Medicaid or other public assistance, will need to rely on public STD-related services. This may be particularly important if the numbers of the uninsured increase. Therefore, services provided by public STD clinics should be maintained and delivered by public STD clinics or by other publicly funded programs in high-incidence areas. However, in communities where STD incidence

• is low, it may be appropriate for STD-related services to be delivered by alternate providers.
• Protect confidentiality of STD-related services. MCOs and other providers of STD-related services should safeguard the confidentiality of STD-related services, especially for adolescents. States that do not have laws ensuring complete confidentiality of STD-related services for adolescents should consider them.
• Train providers. Health care providers, including those in MCOs, are not adequately trained in the spectrum of STD-related services. MCOs should provide training to their staff in both curative and noncurative preventive health, especially management of high-risk behaviors.
• Tailor MCO services for high-risk groups. The general managed care packages of services developed for commercial populations may not be appropriate for indigent populations. MCOs and other providers should develop the capacity to address the unique needs of the high-risk populations that they serve. MCOs that serve indigent populations and others at high risk for STDs will need to tailor the traditional package of health services for commercial populations to the health care needs of high-risk populations.
• Educate policymakers. Local, state, and federal policymakers in private and public health agencies and organizations should be educated regarding the issues associated with managed care in STD prevention. Local health departments, in particular, should develop expertise on issues related to managed care and public health. In addition, legislators at all levels should have a good understanding of these issues.
• Conduct further research. Many policy and funding decisions regarding STD-related programs are being made in the absence of good data on program effectiveness. Additional research regarding the effectiveness of various interventions in STD prevention needs to be conducted to support data-based decision-making. A mechanism for sharing information and experiences regarding effective or innovative STD prevention programs should be developed. Information on "best practices" should be available to all stakeholders in STD prevention. Evaluation or research components should be built into public/private partnerships.
• Explore new sources of funding. New sources of funding for STD-related services should be considered. One potential source of funding for public health programs is payments assessed against publicly funded nonprofit hospitals and health plans that convert to for-profit status. Another potential source is a "tax" levied on MCOs and health insurance companies to pay for public health activities that benefit their enrolled populations.

CDC (Centers for Disease Control and Prevention). Prevention and managed care: opportunities for managed care organizations, purchasers of health care, and public health agencies. MMWR 1995;44(No. RR-14).

Celum CL, Hook EW, Bolan GA, Spauding CD, Leone P, Henry KW, et al. Where would clients seek care for STD services under health care reform? Results of a STD client survey from five clinics. Eleventh Meeting of the International Society for STD Research, August 27-30, 1995, New Orleans, LA [abstract no. 101].