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RESEARCH AND PRACTICE |
William E. Lafferty is with the Department of Health Services, University of Washington, Seattle. Lois Downey is with Harborview Medical Center, University of Washington. Christine M. Holan is with the Oregon Medical Professional Review Organization, Portland, Ore. Alice Lind is with the Washington State Medical Assistance Administration, Olympia, Wash. William Kassler is with the New Hampshire Department of Health and Human Services, Concord. Guoyu Tao and Kathleen L. Irwin are with the Centers for Disease Control and Prevention, Atlanta, Ga.
Correspondence: Requests for reprints should be sent to William E. Lafferty, MD, Department of Health Services, Box 357660, University of Washington, Seattle, WA 98195-7660 (e-mail: billlaf{at}u.washington.edu).
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ABSTRACT |
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 TOP ABSTRACT INTRODUCTIONMETHODSRESULTSDISCUSSIONReferences |
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Objectives. This Seattle project measured sexual health services provided to 1112 Medicaid managed care enrollees aged 14 to 18 years.
Methods. Three health maintenance organizations (HMOs) that provide Medicaid services for a capitated rate agreed to participate. These included a non-profit staff-model HMO, a for-profit independent practice association (IPA), and a non-profit alliance of community clinics. Analyses used health maintenance organizations’ administrative data, chart reviews, and Medicaid encounter data.
Results. Health maintenance organizations provided primary care to 54% and well care to 20% of Medicaid enrollees. Girls were more likely than boys to have their sexual history taken or to be given condom counseling. Only 27% of sexually active girls were tested for chlamydia, with significantly lower rates of testing among those who spoke English as a second language. The nonprofit staff-model plan outperformed the for-profit independent practice association on most measures.
Conclusions. Substantial room for improvement exists in sexual health services delivery to adolescent Medicaid managed care enrollees.
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INTRODUCTION |
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TOPABSTRACTINTRODUCTIONMETHODSRESULTSDISCUSSIONReferences |
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Providing comprehensive primary care is critical to the prevention and control of STD. However, sexual history taking is not a usual feature of primary care.5,6 Despite national recommendations for periodic assessment of sexual activity in adolescents,7,8 only 40% of primary care physicians report that they consistently screen adolescents for sexual activity during routine visits.9 The frequency of sexual history taking and STD screening has not yet been reported for Medicaid managed care plans. This evaluation measured a range of sexual health services provided to adolescents in Medicaid managed care. It includes 3 health services contractors, representing varying organizational structures and profit statuses, that served adolescent Medicaid enrollees in Washington State in 1998.
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METHODS |
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TOPABSTRACTINTRODUCTIONMETHODSRESULTSDISCUSSIONReferences |
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A total of 4798 adolescents aged 14 through 18 years who lived in King County, Wash, were enrolled in the 3 Medicaid products for at least 11 months during 1998. Six sequentially numbered sex-specific population lists of enrollees were created: 1284 boys and 1359 girls from the IPA; 612 boys and 646 girls from the clinic alliance; and 443 boys and 454 girls from the staff-model HMO. A computerized random-number generator reordered the lists, and chart review proceeded in that order until 100 patients from each list qualified for review. To qualify for chart review, patients had to have outpatient care documented in a medical chart retained by their plan-specified primary outpatient provider. A group of 1112 enrollees (16% of the boys and 14% of the girls from the IPA; 33% of the boys and 31% of the girls from the clinic alliance; and 37% of the boys and 33% of the girls from the staff-model HMO) were required to identify 600 persons with chart-documented outpatient care. Hereafter, we refer to the sample of 1112 as the "total sample" and to the sample of 600 as the "chart-review sample."
Data Collection
We used 2 data sources to assess health service delivery. First, the Oregon Medical Professional Review Organization (OMPRO) reviewed enrollee charts at 118 sites for the IPA, 39 sites for the clinic alliance, and 1 site for the staff-model HMO. OMPRO then matched chart-review patients to encounter data that the health services contractors submitted directly to the state Medicaid agency. When encounter data showed services that were not captured through chart review, these additional findings were added to the dichotomous service-delivery measures.
Measures
Demographics.
Data on product of enrollment, sex, date of birth, race/ethnicity, and primary language came from state Medicaid eligibility files.
Definition of primary care and well care. We defined primary care as outpatient care documented in a chart retained by an enrollee’s assigned primary outpatient provider. The 600 enrollees in the chart-review sample were coded as primary care recipients, and the remaining 512 persons in the total sample were coded as primary care nonrecipients. Information from chart and encounter data were used, as described by the National Committee for Quality Assurance,10 to categorize persons in the chart-review sample according to whether they received well care during 1998.
Sexual history taking and counseling. Using chart documentation, we coded sexual history taking dichotomously, depending on whether number of sex partners, sex of sex partners, or past STD or other sexual history had been documented for any 1998 visit. The dichotomous contraceptive history taking/counseling and condom counseling measures reflected whether a patient’s chart documented any reference at all to these services during 1998.
STD and pregnancy diagnosis and testing. Chart reviewers abstracted information on testing for cervical cancer, other STD, and pregnancy. For all 3 of these measures, additional evidence was obtained from Current Procedure Terminology (CPT)11 and International Classification of Diseases, Ninth Revision, Clinical Modification (ICM-9-CM)12 codes in the encounter data. Reviewers also checked for positive test results or provider diagnoses, which were summarized for the entire 12-month period.
Estimation of sexual activity in girls. We classified girls as sexually active if in chart or encounter data there was any reference to intercourse, or if a service was noted that is usually performed only if a girl is sexually active.13 Encounter data evidence included ICD-9-CM, CPT, and the Health Care Financing Administration’s HCFA Common Procedure Coding System (HCPCS)14 codes related to reproductive health issues.
Statistical Analysis
Pearson 
2, Mann–Whitney, and Kruskal–Wallis tests were used to identify significant univariate differences between plans in enrollee characteristics and service provision. Independent predictors of the primary outcomes were identified through logistic regression models. All potential predictors and confounders of interest were entered simultaneously and retained in the final models. The probabilities associated with estimated odds ratios were based on the likelihood ratio test, and 95% confidence intervals were based on the Wald test. Statistical significance was evaluated after application of the Bonferroni adjustment within sets of analyses.
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RESULTS |
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TOPABSTRACTINTRODUCTIONMETHODSRESULTSDISCUSSIONReferences |
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summarizes the demographic characteristics of the enrollees in the 3 products. There were significant racial differences between HMOs for both the total sample of 1112 enrollees (212 = 71.685, P = .000) and the chart-review sample of 600 enrollees (212 = 75.199, P = .000), with higher percentages of Whites in the IPA and the staff-model HMO than in the clinic alliance. In both the total sample (24 = 65.537, P = .000) and the chart-review sample (24 = 54.752, P = .000), there were significant HMO differences in the proportion of enrollees speaking English as a primary language, with the staff-model HMO having a higher number of primary English speakers than the IPA and the clinic alliance.
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Of the 600 enrollees who received some primary care during 1998, 32% (35% of boys and 29% of girls) had a well care visit; just under 30% (15% of boys and 45% of girls) had a sexual history taken; 19% (5% of boys and 33% of girls) had contraceptive history taking/counseling; and 13% (7% of boys and 18% of girls) received condom counseling. There was a significant association between well care and sexual history taking; 47% of 194 enrollees with well care and 21% of 406 without well care had sexual/STD histories taken at a well care or other visit during the 12-month period (Fisher’s exact P = .000). Of the 600 patients reviewed, only 1% of boys and 6% of girls were diagnosed with an STD, and 6% of the girls were pregnant. Eleven percent of girls either were pregnant or had been diagnosed with an STD.
Between-HMO Comparisons of Sexual History Taking, Counseling, and Chlamydia Testing
Sexual health services were provided so rarely to teenage boys that no significant differences between the 3 HMOs could be detected. However, there were substantial differences in the HMOs’ provision of sexual health services to girls, with the clinic alliance and staff-model HMO always providing more services than the IPA. The HMOs differed significantly in rates of chlamydia testing for all girls (IPA = 7%, clinic alliance = 12%, staff-model HMO = 23%; 22 = 11.130, P = .004) and for sexually active girls (IPA = 15%, clinic alliance = 22%, staff-model HMO = 41%; 22 = 9.798, P = .007).
Table 2 summarizes the results of the logistic regression models of chlamydia testing of sexually active girls. In the multivariate model, primary language was a significant predictor of chlamydia testing: only 1 of the 32 girls in the non-English/unknown language group received such testing. Although provision of chlamydia testing was strongly linked to provision of pelvic examinations, only 54% of all pelvic examinations documented in charts included a chlamydia test.
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DISCUSSION |
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TOPABSTRACTINTRODUCTIONMETHODSRESULTSDISCUSSIONReferences |
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Findings from a national self-report survey of adolescent boys15 have documented low reproductive health services utilization in the adolescent male population, and rates of sexual history taking and counseling in our male sample were even lower than those reported for Medicaid-insured boys in the national sample. The suggestion is that capitated managed care is particularly unsatisfactory as a mechanism for delivering reproductive health services to a vulnerable teenage male population. The low rates of service provision to girls in the non-English language group may have reflected patient–provider language discordance or cultural differences. Other studies have documented deficits in health care provision to patients whose primary language does not match that of the predominant culture.16
HMOs differed in their rates of delivering sexual health services. For most measures, the IPA provided fewer services than the staff-model HMO. At least some of the differences in product performance may be attributable to structural differences among the 3 HMOs. Staff-model HMOs stress clinical service protocols, standardized charting tools, and centralized laboratory testing. HMOs that are managed in this fashion also have the capacity to engage in research efforts that focus on service provision, a factor that will serve to improve delivery of services. If our findings resemble patterns in other health care markets, they suggest that HMOs that manage capitated payments but lack integrated systems to improve care and promote prevention are unlikely to provide optimal sexual health services to adolescents. This finding is not encouraging, given that staff-model HMOs now cover less than 3% of people living in the United States.17
The chlamydia testing rate of 26.8% in our sample falls far short of national performance standards, which recommend annual screening of all sexually active girls under age 20,7,18 particularly because most of this testing was diagnostic testing of symptomatic girls rather than screening of asymptomatic girls (data not shown). None of the HMOs employed urine-based chlamydia tests; the need for pelvic examinations to obtain endocervical specimens is admittedly a barrier to screening, but even among sexually active girls who received pelvic examinations, 38% were not tested for chlamydia. This finding demonstrates that coupling chlamydia screening with routine pelvic examinations would improve screening rates, as suggested by another evaluation.19
A limitation of our evaluation is that it considered services provided during only 1 calendar year. Hence, we also examined encounter data documenting services delivered during 1999 to the 600 enrollees in the chart-review sample. For the composite sample of 177 girls with evidence of sexual activity in either year, the chlamydia test rate for the 2-year period increased from 27% to 39%. Only 1 additional boy had a documented chlamydia test during 1999. These data suggest that expanding the review period would likely increase our estimates of sexual health services delivery. Even so, the estimates provide a picture of very limited service.
The results of this evaluation provide a baseline on which improvement can be measured in the future. Interventions to improve sexual health services provision to enrollees in Medicaid managed care are urgently needed.
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Acknowledgments |
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Human Participant Protection
The work was done in accordance with requirements of the institutional review board of the Centers for Disease Control and Prevention, the Human Research Review Section of the Washington State Department of Social and Health Services, and the Human Subjects Division of the University of Washington.
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Footnotes |
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Accepted for publication January 15, 2002.
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References |
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TOPABSTRACTINTRODUCTIONMETHODSRESULTSDISCUSSIONReferences |
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2. Kaiser Family Foundation. What Teens Know and Don’t (But Should) About Sexually Transmitted Diseases: A National Survey of 15 to 17 Year-Olds. Available at: http://www.kff.org/content/archive/1465/stds_t.pdf. Accessed February 9, 2001.
3. Bolan G, Ehrhardt AA, Wasserheit JN. Gender perspectives and STDs. In: Holmes KK, Mardh P-A, Sparling PF, Weisner PJ, eds. Sexually Transmitted Diseases. 3rd ed. New York, NY: McGraw-Hill; 1999:117–127.
4. Centers for Disease Control and Prevention, Division of Sexually Transmitted Disease Prevention. Sexually Transmitted Disease Surveillance—1999. Atlanta, Ga: Centers for Disease Control and Prevention; 2000.
5. Tao G, Irwin KL, Kassler WJ. Missed opportunities to assess sexually transmitted diseases in US adults during routine medical checkups. Am J Prev Med. 2000;18:109–114.[Medline]
6. Handsfield HH. STD risk assessment and chlamydia screening: what’s missing? Am J Prev Med. 2000;18:183–185.[Medline]
7. US Preventive Services Task Force. Guide to Clinical Preventive Services: Report of the US Preventive Services Task Force. 2nd ed. Washington, DC: US Dept of Health and Human Service, Office of Public Health and Science; 1996.
8. Elster AB, Kuznets NJ, eds. AMA Guidelines for Adolescent Preventive Services (GAPS): Recommendations and Rationale. Baltimore, Md: Williams & Wilkins; 1994.
9. Millstein SG, Igra V, Gans J. Delivery of STD/HIV preventive services to adolescents by primary care physicians. J Adolesc Health. 1996;19:249–257.[Medline]
10. National Committee for Quality Assurance. HEDIS 1999, Technical Specifications, vol 2. Washington, DC: National Committee for Quality Assurance; 1998.
11. American Medical Association. Current Procedural Terminology: CPT. Chicago, Ill: American Medical Association; 1998.
12. Health Care Financing Administration. International Classification of Diseases, 9th Revision, Clinical Modification. 4th ed. Los Angeles, Calif: Practice Management Information Corporation; 1994.
13. Mangione-Smith R, McGlynn EA, Hiatt L. Screening for chlamydia in adolescents and young women. Arch Pediatr Adolesc Med. 2000;154:1108–1113.
14. Health Care Financing Administration. HCFA Common Procedure Coding System (HCPCS). Washington, DC: Health Care Financing Administration; 1985.
15. Porter LE, Ku L. Use of reproductive health services among young men, 1995. J Adolesc Health. 2000;27:186–194.[Medline]
16. Woloshin S, Schwartz LM, Katz SJ, Welch HG. Is language a barrier to the use of preventive services? J Gen Intern Med. 1997;12:472–477.[Medline]
17. HMO-PPO/Medicare-Medicaid Digest, 1999. Kansas City, Mo: Hoechst Marion Roussel, 1999.
18. Centers for Disease Control and Prevention. 1998 guidelines for treatment of sexually transmitted diseases. MMWR Morb Mortal Wkly Rep. 1998;47(RR-1):53.
19. Tao G, Walsh CM, Anderson LA, Irwin KL. Avenues to combat the silent epidemic of chlamydia infection in managed care organizations: an analysis of the HEDIS measure on screening for Chlamydia trachomatis. Prev Med Manag Care. 2000;1:177–183.
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| HOME | HELP | FEEDBACK | SUBSCRIPTIONS | ARCHIVE | SEARCH | TABLE OF CONTENTS |
