Improving Insurance and Health Care Systems to Ensure Better Access to Sexually Transmitted Disease Testing and Prevention.

Abstract

Despite ongoing national efforts and advances in testing and treatment, sexually transmitted diseases (STDs) including human immunodeficiency virus (HIV), chlamydia, gonorrhea, and syphilis remain a significant public health challenge in the United States.1 Approximately 20 million cases of STDs and 40,000 cases of HIV are diagnosed annually,2,3 contributing an estimated $15.6 billion in total direct healthcare costs each year.4 As of 2015, new cases of syphilis, gonorrhea, and chlamydia are at the highest peak in the past decade.1 STDs and HIV infections continue to disproportionately impact historically marginalized individuals, including African American/Black, Hispanic/Latino, and sexual minority groups.1,5 Improved efforts are needed to address HIV/STD prevention, including facilitating testing and treatment approaches while minimizing barriers. There are a number of barriers to HIV/STD testing and prevention, including pre-exposure prophylaxis (PrEP) for reducing risk of HIV infection,6–9 that may be effectively addressed through reduced costs, elimination of unnecessary prior authorization requirements, and enhanced privacy in electronic medical records (EMRs). Cost and privacy barriers to STD care have historically been addressed by public STD clinics that, unlike traditional primary care or private sector settings, have provided anonymous services at no or minimal costs.10 However, declining public health funds, rising healthcare costs, and increased numbers of insured individuals following Medicaid expansion have pushed many settings to implement payment structures, including billing insurance for services.7,10–12 Thus, clinics previously providing services free of charge regardless of insurance status have adopted insurance use requirements that, while offsetting the burden of decreasing public health dollars, present a new set of challenges to patients. Paramount among these barriers is the out-of-pocket cost of services in the form of insurance copayments, coinsurance, and deductibles. Studies on patient willingness to use insurance at publicly funded STD clinics found that patients consistently report out-of-pocket costs as a major impediment to using insurance for STD services.7,13 Furthermore, patients with insurance may not want to use their insurance due to confidentiality concerns.7,13 In this commentary, we describe how insurance policies and currently employed EMRs deter patients, especially those from disadvantaged groups, from engaging in HIV/STD testing and prevention. We conclude with potential solutions that can aid healthcare practices, health information technology experts, and policymakers in improving access to these services.