Medi-Cal Proposes to Aid Sex Partners
State health officials are seeking to squelch a dramatic rise in chlamydia infections by expanding the role of public health insurance and altering the doctor-patient relationship.
The Medi-Cal program is proposing to pay for drugs to treat the sexual partners of beneficiaries infected with chlamydia, one of the most common sexually transmitted diseases. Medi-Cal, which serves California’s poor and disabled, has never before paid for any treatment of non-beneficiaries.
The move follows passage of a state law allowing doctors to prescribe medication to the sexual partners of chlamydia patients, even if physicians have never met the partners and do not know their identities. Normally, doctors must conduct a good-faith examination of patients before prescribing medications.
Experts say the state’s actions are necessary because current public health measures have proved inadequate to contain chlamydia.
Preliminary data for 2001 suggest that reported infections topped 100,000 for the first time, up by nearly two-thirds in five years. Some of the recent increase may result from more screening, although one expert said the estimates are too low.
Chlamydia patients often display no symptoms, and the actual toll of new infections in the state probably reaches 300,000 to 600,000 each year, said Dr. Gail Bolan, chief of the sexually transmitted disease control branch at the California Department of Health Services.
Women Face Worse Health Consequences
The new approach is aimed primarily at preventing reinfection in women, since they face worse health consequences from chlamydia, including possible infertility, scarring and ectopic pregnancies. Also, the disease is most common in girls 15 to 19 years old, followed by women ages 20 to 24, and Medi-Cal covers far more women than men.
If doctors treat only an infected woman--and not her sexual partners--she has a 15% to 30% chance of becoming reinfected with the disease within six months.
“It’s a big deal,” said Dr. George Rutherford, a professor of preventive medicine and epidemiology at UC San Francisco. Treating partners “is an absolutely necessary piece of the armamentarium in this disease control program.”
Bolan agreed: “If you don’t take care of the partner, then you haven’t taken care of your patient.”
Before the state law took effect, doctors could have been penalized by the state medical board if they prescribed a drug to a patient without a good-faith examination.
While some doctors quietly risked sanction, most simply advised infected patients to have their sexual partners seek testing and treatment. Even now, many officials prefer that to giving drugs to patients for their partners. Treatment usually consists of a single dose of Azithromycin, a common antibiotic.
The partner treatment law, which took effect last year, had widespread support from the medical community, in part because a single dose of antibiotics is not considered risky and is difficult to abuse.
But some local health officials say they are not rushing to give prescriptions to sexual partners they haven’t examined. The Los Angeles County Department of Health Services, for instance, wants to study the program in a couple of clinics before it implements it in all county facilities.
One trial headed by the federal Centers for Disease Control and Prevention found that reinfection rates appeared to be lower among women who gave medications to their partners, compared to women who advised their partners to visit a physician.
But the researchers said that the study wasn’t conclusive.
$75,000 Grant Allows Broader Evaluation
Dr. Peter Kerndt, who heads Los Angeles County’s sexually transmitted disease control program, said his office has received a $75,000 grant to study the approach further.
“If we can show that it will be cost-effective in public clinics, it will be a lot easier for it to be made policy,” Kerndt said. “This is the time to do evaluation if you’re going to do it at all.”
The San Francisco Department of Public Health began providing medication for sexual partners in December 1998, well before the state law was discussed. By declaring a local health emergency, officials were allowed to provide drugs for a range of sexually transmitted diseases without a patient exam.
Since then, city STD clinics have given out 517 doses to partners of chlamydia patients, or about 15 doses a month, and 964 for gonorrhea, said Dr. Jeffrey Klausner, San Francisco’s STD control officer. A city survey found that 70% of patients gave the medicine to their partners.
The state spent the past year researching whether it could use Medi-Cal funds to pay for partner treatments. Because Medi-Cal is jointly funded by the state and federal governments, its decision is subject to approval by the U.S. Department of Health and Human Services.
A federal health official said the state’s request, the first of its kind in the nation, is under review. Historically, the federal Medicaid program--of which Medi-Cal is a part--allows services to be provided to eligible members only.
Federal officials could require the state to submit a formal application, which could result in delays. If the request is denied, the state would have to seek alternative funding.
In the private sector, health maintenance organizations have adopted various stances on paying for treatment of nonmembers.
The San Francisco Health Plan, whose 40,000 clients have low incomes, began paying for drugs for members’ sexual partners last year, said medical director Dr. Karen Smith.
For Doctors, New Law Was ‘a Wake-Up Call’
Until now, doctors “really weren’t listening about this epidemic,” Smith said. But once the law passed, “a lot of doctors’ heads turned. It was a wake-up call.”
But Health Net of California, among others, has no plans to pay for drugs for nonmembers, said senior medical director Dr. Mark Finch. The HMO did, however, support the law and has sent educational materials about chlamydia to doctors and patients.
“We certainly do not discourage the issuing of a prescription for a partner of a Health Net member by the physician,” Finch said. “On the other hand, we don’t reimburse the partner for that.”
Lawmakers in some other states are watching California’s efforts closely. In Wisconsin, state Rep. Sheldon Wasserman hopes to revive the issue there after a similar treatment bill that he introduced died two years ago.
“Unfortunately, some of my colleagues in the Legislature are not as forward-thinking,” said Wasserman, a Democrat and obstetrician-gynecologist. “Just to say that California has passed it looks good, because we’re not the first in the nation to do this. Having you guys pass it is helping my cause.... “
(BEGIN TEXT OF INFOBOX)
Chlamydia is the most frequently reported sexually transmitted disease in the state and nation.
Up to 40% of women with untreated chlamydia can develop pelvic inflammatory disease, which can cause infertility, chronic pelvic pain and ectopic pregnancies.
Three-quarters of women and 50% of men have no symptoms.
Symptoms in women can include vaginal discharge, lower abdominal pain and a burning sensation during urination. In men, they include urethral discharge, painful urination, and irritation around the opening of the penis.
The chart below shows reported cases of chlamydia in recent years. Experts believe the actual number of new infections is much higher than those reported--up to 600,000 per year in California and 4 million nationally.
1998 1999 2000 2002
(provisional) United States
Cases 607,752 659,441 702,093 NA
Rate* 234.2 254.1 257.5 NA
California
Cases 76,401 85,022 95,458 101,113
Rate* 228.8 250.6 276.8 293.2
Los Angeles**
Cases 24,148 27,585 31,078 32,182
Rate* 273.0 307.5 341.2 348.4
* Rates are per 100,000 population
** Los Angeles County figures do not include Long Beach or Pasadena, which file their numbers separately.
Sources: California Department of Health Services,
Centers for Disease Control and Prevention
Compiled by MALOY MOORE/Los Angeles Times
