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experience of most MCOs in providing public health services, including STD-related services such as partner notification and outreach, even some of the best-organized MCOs may not have the technical expertise to take on full responsibility for STD prevention.
Training of providers. Most health care providers, including those in MCOs, are not adequately trained to deliver the range of STD services offered by public STD clinics. This is particularly true for STD-related services that require specialized skills or experience, such as counseling for high-risk sexual behavior. For example, a survey conducted by the Pacific Business Group on Health showed that approximately 56 percent of enrollees in contracted staff-model MCOs reported that their physician or other health professional had not discussed STDs with them in the last three years (Pacific Business Group on Health, unpublished data, 1994). In addition, if we accept that STD-related care is specialty care that requires extensive training and experience, then it may not be cost-effective for MCOs to replicate the technical competency found in public STD clinics.
Disincentives for MCOs. Cost-saving is a major incentive for MCOs to provide specific services to enrollees. Treating STDs is cost-saving because it averts more expensive treatment associated with treating complications of STDs. However, unless providing a specific benefit is shown to be cost-saving, MCOs may be reluctant to provide services that have not been rigorously evaluated, such as some behavioral change interventions. In addition, capitated payments for services may increase the risk of cost-shifting by MCOs. For example, MCOs may refer persons in need of STD-related services to public STD clinics to avoid assuming the costs of their care.
Patient preferences. A recent multisite survey of STD clinic patients showed that most persons surveyed chose a public STD clinic over other providers because of the convenience of obtaining care without an appointment, lower costs, and other reasons (Celum et al., 1995). Irrespective of these issues, persons who currently receive episodic care at public STD clinics may not feel comfortable in receiving care through MCOs, where a longer-term relationship with a primary care provider would need to be established.
Services involving nonenrolled persons. Many aspects of STD prevention, such as partner notification and referral, screening and case finding, and community education, may involve persons who are not members of the MCO. MCOs may not be able to provide services for nonmembers because of economic, legal, or other reasons.
Copayments. The copayment required by most MCOs is usually assessed on a per-visit basis. These copayments, although nominal for most people, may be a substantial burden for some and a barrier to seeking appropriate STD-related care, especially for preventive services.