Conflicting Laws and Innovative Approaches Can Providers Assure Commercially-Insured Adolescents Confidentiality for STI Screening and Treatment? Conflicting Laws and Innovative Approaches Gale R Burstein, MD, MPH, FAAP Erie County Department of Health Buffalo, NY

Provider Strategies to Assure Confidentiality with Billing Individual-Level Systems-Level

Individual Provider Strategies What are they doing? Survey of providers caring for adolescents Posted on provider listserves Society for Adolescent Medicine (SAM) American Academy of Pediatrics Section on Adolescent Health (AAP/SOAH) ~40 responses 1430 Physicians:  1089 or 78% All Other Adolescent Health Providers:  313 or 22% SAM-L is open to members and non-members (as long as the non-members "register" with the national office): 1065 AAP: 60,000 pediatricians SOAH: 675 members

Individual Provider Strategies “This is a perpetual problem…… Right now, I basically tell patients that their parents can get an EOB and that they should go to Planned Parenthood, their school-based clinic, give the hospital lab an alternative address for the bill or pay cash for laboratory testing to bypass their parent's managed care plan.” “Guaranteeing confidentiality can be a trap, because there is no little in our control.”

Individual Provider Strategies “Creative coding” for office visit Encourage teens to disclose to parents Teen can pay out of pocket Flexible spending health accounts and high-deductable plans create new challenges

Systems-level Provider Strategies Work with health plans to change EOB text Example: 3 Western NY health plans “Laboratory” “Laboratory Services” “LAB/Clia Test” STD services/test codes in “confidential” class EOB reads as “medical service”

Public Health Strategy Local Health Department-Level

Partner with Provider Groups State medical and nursing societies State medical professional organization chapters i.e., AAP, AAFP, ACOG, SAM Local medical professional societies AAP Pediatric Councils

Erie County Department of Health Strategy Example of Local Health Department-Level Strategy

Adolescent Reproductive Health Care Tool Kit Tools to overcome barriers to office-based confidential sexual health care service delivery Billing Private time with teen Gaining parental acceptance for confidential services Referral resources

Adolescent Reproductive Health Care Tool Kit: Contents Billing/coding fact sheet ICD9 and CPT Codes Vignettes as models for use Parent brochure Office can personalize with name and logo Download state YRBS risk behavior data Table of all CT and GC tests

Adolescent Reproductive Health Care Tool Kit: Contents Tips for office Maximizing office confidentiality Making office teen friendly How to perform “atraumatic parentectomy” Available at: AAP/SOAH web site @ www.aap.org/sections/adol/ NACCHO tool box web site @ http://naccho.org/toolbox/index.cfm

Public Health Reaching Providers: Tool Kit Dissemination via Academic Detailing

Academic Detailing Office-based educational intervention with food Based on Pharma model Successful in changing providers behaviors

Promoting Adolescent Reproductive Health Project (PARHP) Goals: Improve confidential adolescent sexual health care access Increase CT screening for sexually active teen ♀ Partners Foundation for Healthy Living NYSDOH Bureau of STD Control 3 local health plans

PARHP Methods Work with health plan (BCBS of WNY) to develop list of 50 primary care and 25 OBGYN offices with highest teen patient volume Academic detailing to offices with tool kit and lunch

PARHP Tool Kit Content: Additional Erie County Content PRCH Minor Access Cards Summarize laws surrounding the provision of sexual health services to minors in 11 states Available @ www.prch.org/resources AAP Teen Health Care Bill of Rights List of local low- or no-cost clinics for sexual health care services Reporting information

PARHP Evaluation Chlamydia Screening HEDIS data Pre- and post-intervention By office By provider Provider pre- and post-test KAP survey

Questions