Effect of Shifts in Funding for STI Services During Health Reform Changes in Massachusetts

Background: In 2006, Massachusetts passed legislation mandating health insurance coverage.  During the implementation period, the state also discontinued funding for STI Clinics due to its ongoing fiscal crisis. In response, a large urban safety net hospital initiated a flat fee ($75) per STI clinic visit for patients not using insurance, beginning July 1, 2009.

Objectives: To understand the impact of a flat fee on site of STI care, costs, and hospital charges reimbursed, in an environment mandating health insurance coverage.

Methods: Total ICD-9 coded STI visits to 4 locations (STI Clinic, Emergency/Urgent Care, OB/GYN, Primary Care) and proportion of hospital charges reimbursed, analyzed retrospectively across 3 periods:  7/1/07–6/30/08 (post-reform enactment and early implementation ), 7/1/08–6/30/09 (reform fully implemented but before termination of state STI Clinic funding), and 7/1/09–6/30/10 (post-termination of state STI Clinic funding).

Results: ICD-9 coded visits to STI Clinic increased from period 1 to period 2 then decreased in period 3 (1733 vs. 3125 vs. 1576, p < 0.0001).  Total STI visits decreased in Emergency/Urgent Care (975 vs. 768 vs. 615, p < 0.0001); increased in Primary Care (955 vs. 1184 vs. 1713, p < 0.0001); and did not vary significantly in OB/GYN.  Proportion of hospital fees reimbursed in STI Clinic increased from 0.3% to 37% from period 2 to period 3, while remaining relatively constant in other sites. 

Conclusions: When the flat fee was instituted, STI visits decreased in the STI Clinic and Emergency/Urgent Care and increased in Primary Care.  Proportion of hospital charges reimbursed increased significantly in the STI Clinic. 

Implications for Programs, Policy, and Research: In a mandatory health insurance environment, discontinuing state funding for STI Clinics was associated with increased STI visits to Primary Care.  Subsequent research will control for total visit volume in these settings and consider role of payer type (including self-pay) in costs reimbursed.