The Unfought War on STDs
Employers spend billions a year coping with the consequences of sexually transmitted disease but little to prevent them. Public health officials want that to change.By Lani Luciano
With private health insurance premiums up more than 8% last year and another 11% to 20% hike on the way, you might expect employers, who shoulder most of the tab, to favor any proven method for cutting health care costs. But the fact is, even flu shots are often a low priority for companies focused on this quarter's profits, not next quarter's sick list. So it's no surprise that, when it comes to a highly sensitive health issue like sexually transmitted disease, employers aren't eager to get involved. "It's hard to get companies interested in STD management, other than HIV/AIDS," observes Suzanne Mercure, a principal with Barrington and Chappell, a health care consulting firm in Falls Church, Va., "even though early intervention can save them a lot of money downstream." Indeed, a 1997 report by the Institute of Medicine estimated that the direct and indirect costs of STDs other than HIV/AIDS, including medical complications and lost productivity, add approximately $10 billion a year to the nation's health bill.
An urgent example is chlamydia, the country's most prevalent bacterial STD, according to the Centers for Disease Control and Prevention(CDC), infecting 5% to 10% of females under age 25. Identified through screening of cervical cells or urine, it's easily cured with a few dollars worth of antibiotics. However, in 75% of infected women, the infection produces no symptoms so few patients seek screening on their own. Untreated, 40% of chlamydia cases develop into pelvic inflammatory disease (PID), costing an average of $1,167 to treat, according to a recent study in the journal Obstetrics and Gynecology. As many as one in five women with untreated PID may become infertile and one in 10 may suffer an ectopic (tubal) pregnancy, catastrophes that can easily produce five- or even six-figure medical bills. Newborns of mothers with untreated chlamydia run a high risk of developing conjunctivitis or pneumonia, and the disease increases by three- to five-fold the susceptibility of both women and men to HIV infection.
Despite these potentially high stakes, just 660,000 cases of chlamydia were reported to the CDC in 1999, only a fraction of the three million new infections the agency estimates would be identified with appropriate screening. Since roughly 67% of females age 13 to 18 and 57% between 19 and 24 -- target age groups for testing -- are covered by private health insurance, the private sector is key to waging a war on STDs. Yet a 1999 survey of health plans by the National Committee for Quality Assurance (NCQA) found that only 18.5% of sexually active female members under age 20 and 16% between 21 and 26 were routinely screened for the infection. A survey that same year of 60 large companies and 100 small business health care purchasing co-ops showed just two respondents reporting any STD-management activities -- in both cases, employee newsletter reminders about condoms and safer sex.
One hurdle to private sector activism is that many employers, like most Americans, view STDs as strictly a public health problem -- mainly an affliction of the underclass. In truth, "most types of STDs are distributed across the socioeconomic spectrum," says Joan Cates, vice president of development and policy for the American Social Health Association (ASHA), which puts the total number of new infections in the U.S. each year at 15 million. In addition to young women, other at-risk groups include inconsistent users of barrier contraception and individuals with new or multiple partners within the previous 90 days.
Perhaps a greater hurdle to employer involvement is that STDS are, admittedly, a touchy subject, especially since effective screening would conceivably target the teenage children of employees. (In January, a Connecticut legislator proposed a mandate that all in-state high school seniors and college freshmen be tested for chlamydia, an idea almost certain to generate controversy.)
Employers are conflicted over the notion that they should, or even could, take the initiative on improving the reproductive health of their workers. "We haven't embraced public health concerns because we're employers," sighs Catherine Kunkle, vice president of the National Business Coalition on Health (NBCH). "It's not our job." Still, the NBCH is one of three employer groups* that, in December 1999, embarked on three-year partnerships with the CDC -- the first time the agency has formally enlisted the help of private purchasers in public health issues. CDC grants totaling $1.5 million will help the three develop proactive interventions to reduce health costs and improve productivity. (For more information on the CDC partnerships, check www.wbgh.org and click on "CDC gateway.")
What, exactly, can employers do to boost STD screening rates? While worksite education programs that encourage high-risk individuals to self-select for testing would undoubtedly be useful, public health officials realize that many companies are not comfortable in that assertive a role. "We think that employers can do a lot simply by telling providers what standard of health care they expect and making sure their insurance contracts cover the services," says Kathleen Irwin, a physician with the CDC's Division of STD Prevention.
Other CDC experts, like health scientist Lynda Anderson, are optimistic that a new quality performance measure included in NCQA's Healthplan Employer Data Information Set (HEDIS) 2000 will be a major tool for improvement. The measure, developed with a strong push from the CDC, grades health plans on the percentage of their sexually active female members age 15 to 25 who receive screening for chlamydia. Because HEDIS performance data is used by many businesses and consumers to select their health plans, the new measure can be a powerful agent of change once it's fully operational, probably within three to five years. "If health care purchasers demand the measure, providers will have to incorporate it into their care systems," notes Anderson.
Of course, that's a big "if". Depending on the testing method, chlamydia screening can cost from $5 to $15 per test, plus the cost of an office visit and another $15 or so each to treat infected patients and their partners. To date, consultants like Mercure acknowledge, rising health costs have generally inspired beleaguered companies to scramble for near-term savings rather than focus on solutions with long-term payback. Observers like ASHA's Joan Cates are not counting on a new attitude. "Companies freely admit they think it's more important to save money up front than to protect the health of women and their families later on," she sighs.
*also the Employers' Managed Health Care Association and the Washington Business Group on Health.
Lani Luciano is a freelance editor specializing in health policy and health economics. A winner of the Gerald R. Loeb Award for business journalism, she has been a commentator on public radio's "Marketplace" and her work has appeared in Barron's, Money, Business and Health and other magazines. This is part of the Morning Briefing, a summary of health policy coverage from major news organizations. Sign up for an email subscription.
