title: Health reform and shifts in funding for sexually transmitted infection services.
abstract: BACKGROUND
  In the Affordable Care Act era, no-cost-to-patient publicly funded sexually transmitted infection (STI) clinics have been challenged as the standard STI care delivery model. This study examined the impact of removing public funding and instituting a flat fee within an STI clinic under state-mandated insurance coverage.
  
  
  METHODS
  Cross-sectional database analysis examined changes in visit volumes, demographics, and payer mix for 4 locations in Massachusetts' largest safety net hospital (STI clinic, primary care [PC], emergency department [ED], obstetrics/gynecology [OB/GYN] for 3 periods: early health reform implementation, reform fully implemented but public STI clinic funding retained, termination of public funding and institution of a US$75 fee in STI clinic for those not using insurance).
  
  
  RESULTS
  Sexually transmitted infection visits decreased 20% in STI clinic (P < 0.001), increased 107% in PC (P < 0.001), slightly decreased in ED, and did not change in OB/GYN. The only large demographic shift observed was in the sex of PC patients--women comprised 51% of PC patients seen for STI care in the first time period, but rose sharply to 70% in the third time period (P < 0.0001). After termination of public funding, 50% of STI clinic patients paid flat fee, 35% used public insurance, and 15% used private insurance.
  
  
  CONCLUSIONS
  Mandatory insurance, public funding loss, and institution of a flat STI clinic fee were associated with overall decreases in STI visit volume, with significant STI clinic visit decreases and PC STI visit increases. This may indicate partial shifting of STI services into PC. Half of STI clinic patients chose to pay the flat fee even after reform was fully implemented.
authors.affiliation: From the *Department of Health Policy and Management, Boston University School of Public Health, Boston, MA; †Section of Infectious Diseases, Boston University School of Medicine, Boston, MA; ‡Center for Health Quality, Outcomes & Economic Research, ENRM Veterans Administration Hospital, Bedford, MA; §Section of General Internal Medicine, Boston University School of Medicine, Boston, MA; ¶Division of STD Prevention & HIV/AIDS Surveillance, Massachusetts Department of Public Health, Jamaica Plain, MA; and ∥Section of Pediatric Infectious Diseases, Boston University School of Medicine, Boston, MA.
authors.forename: Mari-Lynn
authors.initials: ML
authors.lastname: Drainoni
authors.forename: Meg
authors.initials: M
authors.lastname: Sullivan
authors.forename: Shwetha
authors.initials: S
authors.lastname: Sequeira
authors.forename: Janine
authors.initials: J
authors.lastname: Bacic
authors.forename: Katherine
authors.initials: K
authors.lastname: Hsu
mesh_terms: D003430:Cross-Sectional Studies; D018166:Health Care Reform / Q000191:economics; D006297:Health Services Accessibility / Q000191:economics / Q000458:organization & administration*; D006801:Humans; D019458:Insurance Coverage; D007348:Insurance, Health; D058991:Patient Protection and Affordable Care Act / Q000191:economics; D012725:Sexual Behavior; D012749:Sexually Transmitted Diseases / Q000191:economics / Q000453:epidemiology; D014481:United States