1. Trends in Clinic Visits and Diagnosed C. trachomatis and N. gonorrhoeae Infections Following the Introduction of a Co-Pay in an STD Clinic C. Rietmeijer L. Lloyd G. Alfonsi Denver Public Health Department Denver, Colorado Presented at the 2004 National STD Prevention Conference March 8, 2004 Philadelphia, PA

2. Background Offering of clinical (diagnostic and treatment) services has historically been a key strategy for STD control and prevention To maximize the impact of this strategy, STD clinical services have traditionally been offered at no or low cost to the patient

3. Background - 2 To offset decreases in public funding, fee for services, usually in the form of co- payments, may be initiated or increased However, little is known about the effects of such (co-)payments on access to and utilization of services and the ability of STD control programs to diagnose and treat STDs

4. Background - 3 The Denver Metro Health Clinic (DMHC) is the largest STD clinic in the Rocky Mountain region Due to budget shortfalls, DMHC was forced to introduce co-payments to its clients in December, 2002

5. DMHC Co-Payment Structure $15 – Residents of Denver, Adams, Arapahoe, or Douglas County presenting with a new problem $65 – Residents of other counties presenting with a new problem None – Patients with a known positive test for STDs with documentation of positive results – Contacts of patients with known STDs with documentation of contacts status – Follow-up visits – HIV testing only ($10.00 optional)

6. DMHC Co-Pay Statistics 2003

7. Objective To evaluate trends in patient visits and diagnosed CT and GC infections prior to and after the introduction of the co-pay at DMHC

8. Methods - 1 Retrospective analysis of the computerized DMHC medical record database Comparing first three quarters of 2002 (prior to initiation of co-pay) to first three quarters of 2003 (after initiation of co-pay)

9. Methods - 2 Analysis of data on GC and CT cases reported for the City and County of Denver to the Colorado Department of Public Health and Environment Comparison of DMHC-reported GC and CT cases in Denver with cases reported by other providers for the first 3 quarters of 2002 and 2003

10. 20022003 Start Co-Pay Denver Metro Health Clinic Visits 2002 -2003

11. Clinic Visits DMHC 2002– 2003 by Quarter Total visits 2002 through third quarter: 11,382 Total visits 2003 through third quarter: 8,132 Difference through third quarter: 3,250 = 28.5%

12. Clinic Visits DMHC 2002 - 2003 Percent Decline by Gender % Percent decline women: 34.0 Percent decline men: 25.1

13. Clinic Visits DMHC 2002 - 2003 Percent Decline by Age % Percent decline age <20: 46.3%

14. Chlamydia Cases DMHC 2002– 2003 by Quarter Total cases 2002 through third quarter: 1519 Total cases 2003 through third quarter: 1092 Difference through third quarter: 427 cases = 28.1%

15. Gonorrhea Cases DMHC 2002 – 2003 by Quarter Total cases 2002 through third quarter: 871 Total cases 2003 through third quarter: 539 Difference through third quarter: 332 cases = 38.1%

16. Chlamydia and Gonorrhea DMHC 2002 - 2003 Percent Decline by Gender %

17. Chlamydia and Gonorrhea DMHC 2002 – 2003 Percent Decline by Race/Ethnicity %

18. Chlamydia and Gonorrhea DMHC 2002 – 2003 Percent Decline by Age Group %

19. Among those < 25 years: – Total visits were down by 38% – CT cases were down by 38.2% – GC cases were down by 33.8% This age group accounted for: – 85.6% of fewer diagnosed CT infections – 39.6% of fewer diagnosed GC infections

20. Visits and GC Infections Among MSM DMHC 2002 – 2003 Total visits by MSM declined by 229 (21.1%) GC cases among MSM declined by 82 (40.2%)

21. Chlamydia Prevalence DMHC 2002 - 2003 By Age Through third quarter %

22. Gonorrhea Prevalence DMHC 2002 - 2003 By Age Through third quarter %

23. Chlamydia Reports By Provider Denver City and County: 2002-2003 DMHC: -298 (29.9%) Other Providers: -282 (12.0%) DMHC/Other Providers Ratio: 0.42 (2002); 0.33 (2003)

24. Gonorrhea Reports By Provider Denver City and County: 2002-2003 DMHC: -252 (40.2%) Other Providers: -55 (8.2%) DMHC/Other Providers Ratio: 0.94 (2002); 0.61(2003)

25. Conclusions Findings strongly suggest a causal relationship between institution of the co- pay and declining service utilization Persons at risk for gonorrhea, women, and persons younger than 25 years appear to be disproportionally impacted by financial barriers

26. Limitations Simple before-after analysis: cannot prove causal relationship Patients may have accessed services outside of DMHC

27. Implications for Program Even the institution of a modest co-pay ($15) may result in significant declines in STD clinic service utilization and diagnosed STDs