Making Chlamydia Screening a Priority in Medical Groups: Lessons Learned from HIV


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Presented by Michael Horberg, MD, MAS, FACP, FIDSA,
Executive Director Research, Mid-Atlantic Permanente Medical Group, Director, HIV/AIDS Kaiser Permanente, at the 2012 National Chlamydia Coalition meeting.

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  • Use graphic to demonstrate that uninsured (RW funded) % will shrink after 2014 implementation.
  • Making Chlamydia Screening a Priority in Medical Groups: Lessons Learned from HIV

    1. 1. HIVI HIV Initiative of Kaiser Permanente and Care Management Institute Making Chlamydia Screening a Priority in Medical Groups: Lessons Learned from HIVMichael Horberg, MD MAS FACP FIDSAExecutive Director Research, Mid-Atlantic PermanenteMedical GroupDirector, HIV/AIDS Kaiser PermanenteClinical Lead HIV/AIDS, Care Management InstituteChair-Elect, HIV Medicine Association
    2. 2. Speaker Disclosures• Financial • Employee of Mid-Atlantic Permanente Medical Group, PC • Research grants from Merck, Inc. and Pfizer Pharmaceuticals• Organizational • Chair-Elect, HIV Medicine Association • Member and committee chair, Presidential Advisory Council on HIV/AIDSPlease note that the opinions expressed in this presentation represent those of the presenter and do not necessarily reflect the view of Mid-Atlantic Permanente Medical Group or Kaiser Permanente.
    3. 3. First, the Private Healthcare World• Mainly smaller medical groups or individuals in practice • Many with a hospital affiliation but not all • Usually multiple contracts with multiple insurance plans • Can be through a hospital, IPA, or as an individual• Each insurance plan has its own rules, reimbursement policies, and emphases • Many say emphasis on “prevention” but that can be highly variable• Few doctors have a national focus • Or need to…
    4. 4. Private Healthcare World• More correctly, few doctors can reasonably have a focus beyond their immediate patients • Hard enough to manage your own panel of patients • But deal with others?• Most insurance plans are not worried about people outside of their covered patients • No incentive to do so; likely dis-incentives to do so.• Same applies to hospital (systems) and larger group practices. • Exceptions are usually non-profit health systems**--Examples are Health Partners, Group Health
    5. 5. Kaiser Permanente (KP)•Integrated delivery system(hospitals, clinicians, pharmacies, laband x-ray, etc.) and financing scheme•Operates like a mini-“national health Permanentesystem” Medical  Single funding stream with global budget Groups  Accountable for total health of a population Health Plan•Compete in the market for employergroups, members, physicians Members—Our Patients•KP defines the integrated model of Kaiserhealth care financing and delivery Kaiser Foundationthrough its unique partnership among Foundation Health Planthree entities – contractual and Hospitalsexclusive
    6. 6. Kaiser Permanente - Where We Are
    7. 7. HIV Demographics Vary: Comparison between US, VA, and KP—For Context Kaiser Permanente (KP) United States VA + Group HealthYear 2006 2008 2010Number HIV+ 1,100,000 (est.) 23,463 20,180% Female 25% 3% *16%% Black 50% 50% *18%% Latino 20% 7% *15-25%% >50 years of age 27% 64% 42% *--Varies significantly by state KP and GHC operate in 9 states plus DC. KP HIV population rising annually; VA remains steady. Sources: CDC, KFF, VA, KP Slide 7
    8. 8. National HIV/AIDS Strategy (NHAS)First domestic HIV strategic plan  Akin to PEPFAR and US Global AIDS StrategyGoals based on the President’s principles for HIV care in USImplementation will be key  Coordination of federal agencies (including VA)  Coordination of Public and Private  PACHA will have role (citizens’ representation)  Establishment of national metrics to gauge success Slide 8
    9. 9. National HIV/AIDS Strategy Goals…By 2015Reduce New Infections  ↓New Infections by 25%  ↑to 90% Americans who know their HIV Status  ↓Transmission by 30%Improve Access and Outcomes  ↑to 85% HIV+ in care within 3 months of Diagnosis  Seamless system of testing and linkage to care  Increase HIV providers  Set quality standards and monitorReduce HIV-Related Health Disparities  ↑ by 20% HIV+ MSM*, Blacks, Latinos with HIV RNA BLQ**--MSM: Men having sex with men; BLQ: Below limits of quantification
    10. 10. Health Care Coverage HIV+--NationalThis shoulddecreasewith HCRSOURCE: Kaiser Family Foundation based on Fleishman JA et al., “Hospital and Outpatient Health Services Utilization Among HIV-InfectedAdults in Care 2000-2002, Medical Care, Vol 43 No 9, Supplement, September 2005.; Fleishman JA, Personal Communication, July 2006 Slide 10
    11. 11. Issue 1: Identify Undiagnosed and Prevent New InfectionsThese two points cannot be separated  Similar issue for chlamydiaTest patients for HIV  Remove testing barriers  Routinize testing“Sexual health as a vital sign”?Can’t treat HIV (or chlamydia) if you haven’t diagnosed it  Repeat regularly if risk behavior present CDC, MMWR, September 22, 2006 / 55(RR14);1-17 Slide 11
    12. 12. Why Don’t We Test More: Barriers to HIV TestingGuidelines Conflict  CDC and USPSTF Guidelines differ CDC: Routine testing of all Americans aged 13-64 USPSTF: No recommendation for routine testing (C Level) Recommend at-risk testing and pregnant women (A Level)No nationally accepted metric on HIV testingWritten informed consent used to be a barrier  Not for other sexually transmitted infections or routine blood tests  46 states, DC, and the VA no longer require written consentOnly California, DC mandate coverage of cost of test  Medicare now covering targeted HIV testing  Preventive services included in healthcare reform— only with USPSTF A/BSTIGMA Slide 12
    13. 13. How HIV Testing Issues Relate to ChlamydiaUSPSTF Recommendations limit perceived need of testing:
    14. 14. HEDIS (NCQA) Doesn’t Help EitherHEDIS Measure: Chlamydia screening: percentage of women 16 to 24 years of age who were identified as sexually active and who had at least one test for chlamydia during the measurement year.• Most clinicians will not be concerned with others• Most health plans will not be concerned with other patients • Need to get HEDIS and USPSTF to expand definitions and recommendations• Note: CDC is “lukewarm” to more general testing also.
    15. 15. KP Performance on Chlamydia Testing• Committed to it • (KP Georgia #1 nationally—not just within KP)• US 90th Percentile performance: 53.4% (age 16-24)• KP Program wide performance: 65.8%* • All KP regions are above US 90th percentile • Also, all regions and KP nationally above US 90th percentile for ages 16-20 or 21-24 age groups• KP performance demonstrates that with commitment at multiple levels this is achievable • But even we can improve*--Commercial plans; similar results for Medicaid only patients
    16. 16. But Even Bigger Barrier…Provider discomfort about talking to their patients about sex maybe biggest barrier of all. • Especially if the patient is older than the doctor • And may be “preachy” rather than frank and open with younger patientsAlso, many doctors do not perceive their patients at risk • This is true even among doctors in adolescent clinics and other “high risk” clinics. • We see this a lot in HIV—adolescent doctors don’t think their sexually active patients are at risk
    17. 17. Issue 2: Testing is NOT TreatmentI know I’m stating the obvious and “preaching to the choir”.• Of course, you cannot treat if patients are not diagnosed• And you cannot treat if patients are not in care • Or seeking care• And there is often a disconnect between testing and treatment • Including linkage to care
    18. 18. Linking patients to HIV care (and helping patients access care)42-59% HIV+ in US are not in care  Includes undiagnosed and lost to follow-up  Greater risk of late entry for older Americans and malesTesting and then Link to Care  Critical step that has many potential and REAL gaps  Including those lost from care  Care means evaluation for ART and earlier use of ART  Requires increased ART adherence effortsUnlike integrated care systems, testing is often uncoupled with care systemsPotentially, the biggest challenge in HIV care Van Gorder, 2010; Klein,, JAIDS, 2003; Althoff,, CID, 2010; Hogg, et. al., The Lancet, 2008; 372: 293-299 Slide 18
    19. 19. KP Non-NQF HIV Quality Measures non-NQF Measures: All Sites Combined: 2007, 2008, 2009 Linkage to care KPCO and KPHI data not available for 2007 100 93.8 94.0 94.3 88.6 88.8 87.5 90 80 70 61.7 61.8 60.5 62.4 55.4 59.3Percent 60 50 40 27.1 25.7 25.6 30 20 10 0 HIV Testing CD4 Measured CD4 < 200 Adherence Median ART Among STI in 90 days of Among Newly to ART ≥90% Adherence Positives Identified HIV+ Diagnosed (3 STI) HIV+ 2007 2008 2009
    20. 20. Our NQF/NCQA HIV Quality Performance NQF Endorsed Measures--KP Performance Reflects multidisciplinary team effort 100.0 92.9 94.4 94.5 86.3 85.8 85.5 86.8 89.2 90.5 90.0 76.8 79.3 77.8 80.0Percent Success 68.0 65.6 65.9 70.0 60.0 2007 50.0 2008 40.0 2009 30.0 20.0 10.0 0.0 Retention CD4 PCP On HIV HIV RNA <75/mL In Care Measured Prophylaxis Treatment Metric
    21. 21. VA HIV Care Quality Measures (2008 data)79% with VL/CD4 in last 6 months31% met AIDS criteria at entry into registry*  14% met AIDS criteria—all HIV+86% appropriate PCP prophylaxis72% ever pneumococcal vaccination77% Hepatitis B immune or vaccinated96% Hepatitis C screened83% HIV+ on ART with maximal viral control *--Either newly diagnosed or transferred into VA Slide 21The State of Care for Veterans with HIV/AIDS, December 2009;
    22. 22. HIV Lessons for Chlamydia and Access to Care• Performance metrics are for testing and not treatment• Again, these are often disassociated • Testing may be by one department but treatment by another • Or more likely, sexual health treatment outside of system but rest of care is not • Primary care may not be the ones doing follow-up or gynecology may test but not be the ones to get test results • This is potentially less of an issue with the greater deployment of electronic health records
    23. 23. New Pap Guidelines Don’t Help Either• For women, gynecologist is often the primary care doctor • Historically, it’s why women see primary care more often than men when looking at folks <50 years old• New pap guidelines (gee thanks ACOG…) are to start 3 years after first sexual activity or 21yo and then q 3 years • Likely won’t get women in annually• Also, with increased HPV vaccination, there may be even less returns in the future.
    24. 24. HIV Lessons for Chlamydia and Treatment• Treatment has costs • Don’t forget co-pays • For students and poorer folk this is real issue • Fortunately, azithromycin is generic • As is doxycycline, erythromycin, ofloxacin • Not levofloxacin yet• Follow-up testing for cure is rare • Not advised by CDC for initial treatment • Recommended if repeat treatments required • Especially if treatment was not in healthcare system • Example: gets tested/treated at Planned Parenthood but usual care is with private doctor
    25. 25. Issue 3: Treatment for Partners• Rarely, treatment for partner happens• Not covered by insurance usually • And no real incentive to do so • Not covered by Medicare or Medicaid• You cannot write a double dose prescription if not for the patient to take himself/herself • And no “wink wink”!• Potential medical, safety, and bacteriologic issues with empiric treatment for partners • Need to know drug allergies of partner • Could widespread use lead to resistance?
    26. 26. Issue 4: Remove Disparities— The Application to Chlamydia is ObviousStigma is rampant in HIV  Both at testing and at accessing care  And racial discriminationPatients must feel valued, at ease, and have faith in healthcare providersCommunity must support HIV+ patients and those at risk  Public-private partnerships likely of useNeed to improve outreach to youth and older Americans  Consider newer technologies (do you tweet?)  Go to where they are; not where you areRemove language barriers and health illiteracyConsider gender issuesSTOP HOMOPHOBIA AND RACISM!! Slide 26
    27. 27. Issue 4b: Adolescents and Their Parents• Minors can consent for STI screen and treatment without parental consent or notification • All 50 states plus DC• However, “explanation of benefits” (EOB) may go to parent • This is a breach of confidentiality but very grey area in the law • It’s who pays for the insurance… • Some health systems, like KP, don’t have EOB so not an issue • Potential solution: No co-pays and fees for STI care • Title X clinics are exempt
    28. 28. Making the Case in a Private Health SystemWhat will work: What will not work:1. Engage partners 1. Telling them what to do2. Be open to their ideas 2. No consideration of  Each system is VERY financial issues different.  I’d recommend  It’s not one size fits all abandoning partner3. Understand their context treatment for now  They may not want 3. No consideration of chlamydia as its own USPSTF or HEDIS issue limitations4. Work to reduce stigma on 4. Not recognizing that ACA a more public basis will have great impact
    29. 29. Potential Solutions1. Think about joining all STI under “sexual health”  KP did this with our latest HIV and STI testing and prevention guidelines  “Ask, Screen, Intervene” is applicable to all STI, even if USPSTF and NCQA don’t think so  Widen the scope of Why Screen for Chlamydia2. Work to have USPSTF expand recommendations  Insurers, Medicare, and health care reform work off of USPSTF levels A and B recommendations3. Get HEDIS criteria expanded  Health plans respond to HEDIS!!  Consider reporting results on your website
    30. 30. Potential Solutions (2)4. Recognize health systems that succeed  It becomes a matter of pride  And let’s them know someone is paying attention5. Work to fully implement ACA (Health Care Reform)  Strong emphasis on preventive medicine  More Americans in care  With (hopefully) greater “essential benefits” many states will expand sexual health and treatment for conditions
    31. 31. Potential Solutions (3)6. Find champions at medical centers and health systems  The more local the better, but respect the rules of the health systems  Probably better if they are the peers of the target audience  So, if target audience is pediatricians, make sure champion is a pediatrician  May require multiple champions at a single medical center/system  This may require grants, $$, and training  CME credit?
    32. 32. “Working together, I am confident that wecan stop the spread of HIV and ensure thatthose affected get the care and support theyneed.” --President Barack ObamaThe same applies to chlamydia.The great work continues. Thank you. Slide 32