The shortage of specialist physicians in the United States continues to receive a great deal of attention as an area of concern. However, a lesser-known compounding factor is the increase in referral rates. In a 2012 study, the National Ambulatory Medical Care Surveys found that between 1999 and 2009, the probability of receiving a specialist referral during an ambulatory patient visit increased from 4.8% to 9.3%, a 92% increase, nearly double. While this study is now several years old, we can surmise that this trend has continued due to the persistence of several factors contributing to the overall disparity between specialist referrals and the number of available specialist physicians.
The clear impact of these compounded problems is substantially increased wait times among patients with a physician referral for specialist appointment. In 15 major metro areas, a recent Merritt Hawkins study covering the medical specialties of cardiology, dermatology, orthopedic surgery, and obstetrics and gynecology, found appointment wait times increased 25% from 2014 to 2017. Wait times averaged 24.1 days across the study, with some extreme cases waiting 165 days for an appointment.
Long wait times impact patient outcomes and healthcare operations
On top of the anguish and emotional impact of waiting for care, diseases and illnesses can progress as patients sit in appointment queues for weeks or even months on end. As NEJM describes, “long waits before appointments, particularly specialist appointments, often contribute to the development of avoidable complications,” which cause more difficult health cases both for the patient and for the physicians caring for them.
There are notable effects on healthcare operations that add to the case for reducing patient wait times as a crucial avenue for improving healthcare overall. For example, long wait times for appointments increase the prevalence of no-shows, indicating that patients are either frustrated enough to not follow through on scheduled appointments or forget appointments altogether because of the long interim period. Sometimes appointments can even be moved around by specialist physicians at the last minute, leaving patients in limbo for even longer.
Additionally, long wait times frequently lead to patients receiving inefficient care. Firstly, extended waits often deter patients from seeking initial care. This shifts the healthcare industry away from proactive to reactive care, which is less effective and more costly for all parties involved. Secondly, the inability to access the care they need and when they need it, leads to patients seeking care within inappropriate settings. These patients are more likely to be admitted to EDs, as the 30-day rate of ED and inpatient usage was 8.7 times higher for patients awaiting a specialist appointment. A study by Truven Health Analytics noted that 71% emergency room visits are unnecessary and avoidable. Each of these issues alone make strong cases for reducing patient wait times; these issues combined suggest reducing patient wait times is a crucial goal that must be prioritized when it comes to streamlining healthcare delivery and improving quality of care.
In light of these concerning figures and effects, healthcare organization operations are turning their focus toward reducing wait times and improving patient outcomes. This fits well as part of an overall strategy to increase quality and efficiency of healthcare delivery. Below, we will focus on how telehealth platforms, specifically eConsults, combat multiple factors driving specialist appointment wait times, streamlining the physician referral process and thereby reducing patient wait times for happier and healthier patients.
Positive impacts of reducing patient wait times by accessing specialty care from within primary care
Increasingly, healthcare providers are entering into value-based payment arrangements. Telehealth solutions, and specifically eConsults, can support the drive toward more efficient care by increasing access to specialists while better optimizing time and place of care.
eConsults are is an electronic form of peer-to-peer collaboration, providing PCPs with a platform to consult with specialists on specific patient cases. eConsult interaction occurs using a secure, HIPAA-compliant messaging platform, where specialist guidance is received within 24 hours, drastically reducing the interim time between referral and treatment. eConsults can replace more than 70% of routine referrals with immediate, specialist-guided treatment from the PCP, without the wait and additional cost. Keeping lower acuity patients out of the specialist referral queue means faster access to face-to-face visits for the higher acuity patients, expediting care and improving outcomes for all.
One provider (and frequent user of AristaMD eConsults) at a Federally Qualified Healthcare Center describes the challenges of securing specialty care for the patients at her clinic: “Especially with MediCal patients, it usually takes at least four or five months for a patient to complete a referral. Very often, patients end up waiting three to five months, then receive notification their appointment has changed, the specialist has moved, or even that the specialist is no longer taking that patient’s insurance. Some of these patients are then in limbo for more than six to nine months. This is where the benefit of AristaMD’s eConsult platform comes in. AristaMD specialists provide guidance on patient care plans, for example diagnostic or medication recommendations, within 24 hours.”
Several studies have already noted demonstrable decreases in wait times once eConsults were introduced in large health systems. The San Francisco Department of Public Health saw dramatic improvements following the introduction of their eConsult program. The median wait time for a non-urgent appointment with a rheumatology specialist was drastically reduced from 126 days to 29 days. Additionally, patients visiting specialists needed fewer follow-up appointments as a result of a more extensive pre-visit workup made possible by this telehealth platform. Other similar successes have been observed in Los Angeles and the NYC Health + Hospitals System, with the latter finding that median wait times for high-urgency specialist visits decreased from 30 days to 16 days as a result of eConsult implementation.
Conclusion
eConsults are ideal for addressing the growing problem of lengthy patient wait times. They empower PCPs to deliver specialist-guided care to lower acuity patients in a timely manner while freeing up the capacity for in-person specialist visits for the more complex, higher acuity patients who need them most.
Over the past few years, there have been encouraging improvements in the realm of mental health care in the United States. Initiatives to improve mental health outcomes, such as the Affordable Care Act (2010), have been primarily aimed at requiring increased insurance coverage to encompass mental health services at levels comparable with physical medical care.
Despite these improvements, such policies do not address issues caused by access challenges within the referral system, and many of the one in five adults suffering from mental illness in the United States still are not accessing the mental health care they require and need. In particular, there exists a shortage of mental health providers across the country, and these health professionals are likely to be out-of-network for many patients. Further barriers preventing patients from obtaining care include travel, missed work time associated with appointments, and the social stigma of seeking mental health care.
Faced with these challenges, patients with mental health issues are resorting to emergency departments in search of mental health services. Hospital emergency departments lack access to psychiatric services and mental health resources. Further, as patients are improperly treated in urgent care settings, this can lead to reduced access to care for those with acute medical issues, which then results in poorer overall outcomes at the highest cost of care.
To address these multi-faceted challenges, value-based care models have placed particular importance on the role of primary care, as these organizations are uniquely positioned to promote innovation and efficiency through proactive and coordinated care. When it comes to mental health services, primary care providers (PCPs) serve at the front line of care and are positioned to be an excellent means of providing access to mental health care to a patient population in need. However, many PCPs lack adequate resources to treat these often complex and specialized issues.
Telehealth technologies, such as telepsychiatry and eConsults, can support primary care practices by creating networks to provide timely, documented, and standardized access to mental health professionals. This equips PCPs to more effectively manage patients with mental health concerns, reducing wait times and improving mental health outcomes.
AristaMD’s eConsult platform connects PCPs with adult and pediatric psychiatry, addiction medicine, and behavioral health specialists to provide care planning support and treatment recommendations. Ninety-one percent of AristaMD’s mental and behavioral health eConsults have been shown to include medication regimen guidance including initiation of treatments, diagnostic recommendations, and medication dosage adjustment, all of which can be managed within the primary care setting with the support of specialty insight.
As primary care providers (PCPs), we’re increasingly trying to manage total patient care for more patients and facing worsening challenges in ensuring our patients can access the care they need.
In 2009, a short ten years ago, there were an estimated 209,000 PCPs providing services for a patient population that has now already exceeded 325 million individuals. The number of specialist referrals has doubled since 1999, increasing wait times and potentially diminishing overall healthcare quality for patients. Even more worrisome and adding to the challenge of access to specialty care is the projected shortage of up to 104,900 physicians in the United States by 2030—61,800 of whom will be specialists.
This worsening shortage in specialty care physicians adds to other factors challenging access, including Medicaid and Medicare acceptance rates, geographic barriers, and financial burden. eConsults can provide a solution for this growing problem. eConsults help mitigate access challenges by providing rapid specialist insights to PCPs who allow us to provide more comprehensive care, improving patient outcomes and satisfaction, all while reducing healthcare costs for patients and paying entities.
From my experience, there are three main benefits that eConsults contribute to delivering timely access to high-quality care:
At community health center practices, a routine referral can take 1 to 2 months before patients are able to be seen face-to-face by a specialist. For our patients, barriers to specialty care access are multi-faceted including limited regional specialist availability, patient transportation to and from visits, as well as a multitude of cost factors such as missed work, childcare, and out-of-pocket expenses. The use of eConsults provides a method of collaborating with specialists via an online portal to quickly provide access to specialty care for many patients—some of whom may otherwise go without.
Leveraging eConsults allows us to identify whether a face-to-face specialist referral is necessary for a patient, or if they can be treated within primary care with specialist guidance. eConsults are capable of replacing a large percentage of face-to-face referrals, but even in cases where the eConsult specialist does recommend a face-to-face visit, PCPs gain insight prior to the appointment on any workup that can be done in advance of the patient’s specialist visit. This saves time for both patients and overworked specialists. AristaMD’s eConsult platform is a guide to help PCPs provide patients with comprehensive, efficient, and effective care. It gives us the ability to provide “double the care for the patient” as they are being cared for by their primary physician and the consulting specialist.
In my experience, eConsults have been particularly successful with endocrinology cases. Typically, these cases don’t require a face-to-face visit, but instead require diagnostics that can be ordered by a PCP and reviewed by a specialist who provides a quick recommendation on the patient’s treatment plan. I’ve had cases in the past where a specialist’s treatment plan included diagnostic lab testing every 4 to 6 months for the patient. In this case, the patient was able to avoid numerous specialist visits and was able to do the routine lab regimen within primary care.
As PCPs, it’s our responsibility to do what we can to positively impact the health of our communities. As part of this duty, it’s imperative we shepherd innovative solutions, such as different types of telehealth. I’ve used eConsults as an effective tool to reduce specialist referrals, which results in low-acuity patients being treated quickly within primary care. This ensures many patients are able to access care within days, opposed to months. For many patients, this is the difference between a worsening condition and sending them to the ER, versus managing their conditions within the comfort of their PCP’s office.
By Chris Jaeger, advisor for ACO and health system strategy, AristaMD.
In April 2019, CMS announced the Primary
Cares Initiative which is expected to reduce administrative burdens and
increase patient care while decreasing healthcare costs. Learn more about the
payment models of the Primary Cares Initiatives, and how eConsults directly
support this new initiative.
While the healthcare landscape has never
been static, rarely has it seen such radical changes as within recent decades.
The United States’ population continues to age, and the prevalence of chronic
conditions such as obesity, diabetes, heart disease, and anxiety/depression contribute
to a substantially increased demand for care. These factors are pushing a shift
from a provider-centric model toward more efficient, outcomes-based models that
put the patient at the center and heavily rely on primary care as the steward
of patient care.
Primary care is a vital resource in
dealing with the many factors altering the healthcare landscape. A 2019 study
published in JAMA Internal Medicine
corroborates this, finding that for every 10 additional primary care physicians
per 100,000 people, patients saw a 51.5-day increased life expectancy—more than
2.5 times the increase associated with additional
nonprimary care physicians. For years, primary care delivery has shifted along with
changes in the healthcare landscape. Innovations in primary care and aligned
incentive models reward more continuous and comprehensive healthcare, as
opposed to care delivery and reimbursement models for discrete moments or
episodes of care highlighted by numerous appointments and separate visits to
different providers. These innovations strive to put patients at the center of
care above all else.
To promote further adoption of
primary-care based models, the U.S. Department of Health and Human Services
(HHS) and Centers for Medicare & Medicaid Services (CMS) recently announced
a set of payment models meant to further transform primary care through
value-based options under the new Primary Cares Initiative. This
voluntary initiative will test financial risk and payments for primary care
physicians (PCPs) based on performance and efficiency, including five new
payment models under two paths: Primary Care First (PCF) and Direct Contracting
(DC). These models, slated to hit 20 states in the year 2020, seek to address
the many difficulties in paying for, and incentivizing, valuable primary care
within current payment models.
Primary Cares Initiative payment models
aimed to PCPs
All five of the payment models described
in the Primary Cares Initiative are aimed at PCPs in the hopes of improving
services at these linchpins within the healthcare system. However, these models
can be grouped into two distinct categories–Primary
Care First and Direct Contracting–and there are variations within these groups.
Primary Care First
The models categorized under PCF are aimed
squarely at relieving strained hospital resources and improving health outcomes
through primary care. These models aim to more adequately reward primary care
providers through performance-based payment adjustments, in the hopes that this
will be an effective way to reduce the overuse of hospitals for healthcare
needs. These two models are:
Primary Care First
(PCF): The general PCF model will test whether
risk- and performance-based payments for primary care practitioners will reduce
Medicare expenditures while preserving or improving quality of care. Under this
option, payment will be provided to an advanced primary care site based on the
size of its patient population (on top of a flat primary care visit fee), and adjusted
based on performance within “easily understood, actionable outcomes,” according
to CMS. The performance-based adjustment represents a potential quarterly
upside of up to 50 percent of revenue as well as a potential small downside (10
percent of revenue).
Primary Care First
–High Need Populations: In
addition to the general PCF model, the Primary Cares Initiative includes a
payment model specifically geared toward practices specializing in care for
high-need patient populations. This includes patients with chronic care needs
and a group the model refers to as seriously ill populations (SIP). This
payment model creates an option for high-need patients without a primary care
physician to receive care from a participating practice if the patient
indicates interest.
Direct Contracting
The direct contracting path includes a pair of risk-sharing payment models, both voluntary, along with a third payment model for which CMS is seeking public input. Like the PCF models, these models aim to reward those providing more efficient, high-quality care. However, these models are geared toward organizations with experience serving broader patient populations rather than individual primary care practices. The three models are:
Direct Contracting
– Global Population-Based Payment (PBP): Participants
in the Global model will take on the full share of risk, but also be eligible
for 100 percent of any savings achieved on the total cost of care for aligned beneficiaries.
Direct Contracting
– Professional PBP: Under the
Professional model, participants will retain both savings and losses accrued on
the total cost of care for aligned beneficiaries, but at a rate of 50 percent.
Direct Contracting
– Geographic PBP: The Geographic
model is similar to the Global model, but with an important caveat:
Participants would accrue 100 percent of savings or losses on the total cost of
care, but only for aligned beneficiaries within a target region. The
stated aim for this model is to drive accountability to a local level so that
communities can develop strategies tailored to more individualized needs. CMS
is still seeking input on this model, however.
Additional healthcare initiatives strengthening
primary care
As mentioned above, primary care is a
crucial avenue for fostering improved health outcomes for a wide range of
patients and populations. In addition to increased life expectancy, some
motivations for focusing on improved primary care include the following:
Adults in the U.S. who have a primary care provider have 19 percent lower odds of premature death than those who only see specialists for their care.
People who have a primary care provider save 33 percent on healthcare over their peers who only see specialists.
A study in a North Carolina ER found that nearly 60 percent of the patients’ problems could have been addressed in a primary care clinic for a savings of 320 percent to 720 percent — that’s a value of a three to seven times reduction in healthcare spend.
For many, primary care serves as the entry point to the healthcare system, as individuals and families alike head first to their primary care physician for treatment. Primary care emphasizes population health and managing chronic illness. As such, primary care is an ideal means for improving our healthcare system on many fronts including access, cost of care, and quality of healthcare services.
Given the benefits listed above, it’s no surprise that so much attention has been paid to improve primary care, and the Primary Cares Initiative is not the first such effort. Programs such as the Patient-Centered Medical Home (PCMH), the Comprehensive Primary Care (CPC+) program, and Medicare Advantage Value-based Insurance Design (VBID) test model give healthcare stakeholders the means to promote triple and quadruple goals of allocating resources more efficiently, improving health outcomes, and improving the experience of all individuals involved–including both physicians and patients.
As its name implies, the PCMH is focused
on putting patients at the center of healthcare. It recognizes the value of team-based
primary care, and five core attributes are
included in this model:
Patient-centered
Comprehensive
Coordinated
Accessible
Committed to
quality and safety
Beyond PCMH is the CPC+ program, an
initiative aimed squarely at care sites that have demonstrated significant
improvement and transformation in pursuit of value-based goals. Payers are invited by CMS to participate in
the program if they provide, or aim to provide, care practices that go beyond
fee-for-service payments based solely on visits and episodic appointments. Through
this program, CMS aims to work with payers representing 5 to 7 markets and accounting
for roughly 525 practices (around 75 practices in each market). Some 330,750
patients would be reached by this initiative, which focuses on several
functions for practices to achieve greater healthcare successes including:
Access and
continuity
Care management
Comprehensiveness
and coordination
Patient and
caregiver engagement
Planned care and
population health
By their nature, Medicare Advantage (MA) plans
seek to optimize the delivery of healthcare for their members. Receiving
capitated payments to provide all Medicare-covered services to plan
participants, plan objectives are the perfect setting to test models of care
delivery that may reduce cost while being able to offer beneficiaries improved access,
options, and quality of care–versus traditional Medicare plans. MA plans have proven to be more efficient in
reducing expenditures than both Accountable Care Organizations (ACOs) and
traditional Medicare. The Medicare
Advantage Value-Based Insurance Design (VBID) model was introduced in 2017 by CMS to allow MA plans the opportunity to
offer supplemental benefits or reduced cost-sharing for enrollees with certain
chronic conditions who engage with services/providers that are of highest
clinical value to them. CMS released major changes to the VBID model in January 2019, and plans to
test new additions 2020 to 2024. The updates are intended to
lower costs while increasing the quality and coverage of care for Medicare
beneficiaries and include:
Allowing customization of cost-sharing based on chronic condition, socioeconomic status, or both, including some non-health related benefits, such as transportation.
Expanding eligibility to include chronic condition special needs plans (SNPs), dual eligible SNPs, institutional SNPs, and regional preferred provider organizations.
Bolstering the rewards and incentives programs that plans can offer beneficiaries to take steps to improving their health.
Increasing access to telehealth services.
Thus, the Primary Cares Initiative
represents not just a single push to improve the healthcare system as a whole
through primary care, but an overarching drive to do so via many initiatives
and programs. Bringing more practices on board with initiatives such as the
PCMH, CPC+, innovation within Medicare Advantage, and the Primary Cares
Initiative will undoubtedly solidify the success of these and future programs,
as stakeholders and policymakers come to a greater understanding of how to
incentivize and create a path toward improved healthcare outcomes.
eConsults directly support Primary Cares Initiatives
by maximizing primary care’s value in healthcare delivery
A continuing challenge in maximizing the
efficiency and effectiveness of primary care is that of managing specialist
referrals. Electronic consultations (eConsults) have gained favor in meeting
this challenge. eConsults help in reducing variations in referrals, increasing
access to specialist care and consultations among broader populations, and
reducing wait times for specialist visits.
With the new CMS Primary Cares Initiative
targeting advanced primary care practices for these payment models, eConsults
are becoming increasingly valuable. Advanced primary care practices are defined as those that
demonstrate an aim toward implementing fundamental strategies that focus on
patient needs, with primary care as the foundation for maximizing value in
healthcare delivery. These practices focus squarely on improving primary care
in terms of health outcomes and lower costs. A key component of such advanced
primary care practices is shepherding resources to improve efficiency and
effectiveness in order to achieve their goals.
eConsults — which directly support
improved health outcomes, reduced costs, and increased provider and patient
satisfaction — are one such resource. As more health systems look toward
creating PCMH models and consider adopting new value-based payment models under
the Primary Cares Initiative to better manage the health of their patient
population, eConsult systems will be instrumental in improving team-based care
coordination and communication.
If it isn’t already clear, the headlines are signaling that the era of healthcare innovation is upon us and moving swiftly. Managed Medicaid plans could be losing out on millions of contracted lives (and money) by lagging in the adoption of digital telehealth resources to improve access to care and patient outcomes. Leveraging an eConsult solution is a proven way to increase access to high-quality care while lowering system cost, ensuring innovation scoring opportunities are not missed.
Innovation is the new constant
Although the pace of innovation in healthcare has traditionally been slow, organizations are increasingly seeking new ways to innovate in order to support value-based care models. Recent partnerships formed between Amazon, Berkshire Hathaway and JPMorgan Chase, CVS and Aetna, Cigna and Express Scripts, and so on strongly indicate that innovations rooted in providing better care for lower costs are paramount to the success and growth of healthcare.
Payers whose ongoing strategies are not placing precedence upon innovation will be left in the dust. Not only will this be costly for access and quality, it can jeopardize managed Medicaid payers’ chance of re-procuring and expanding contracts.
Managed Medicaid Plans must innovate to reach objectives
Managed Medicaid plans need innovations to improve the value and efficiency of healthcare provided. To ensure they’re getting the best value, state Medicaid programs re-procure contracts with managed care payer groups on a perpetual basis — sometimes as frequently as every three years. States use these periods as an opportunity to seek updated solutions to long-standing or emerging challenges, often assigning points to questions that speak to innovations in care delivery for Medicaid recipients.
Key Medicaid challenges
Barriers to care and access within Medicaid programs are often among the most important issues states and managed care plans are attempting to address. The Kaiser Family Foundation 2017 survey of Medicaid managed care plans reported high rates of difficulty in recruitment for some specialties and listed provider supply as a leading challenge.
Timely access to care is key to healthcare goals, as delays in accessing necessary care exacerbate health conditions, in turn leading to more costly treatment and poor outcomes. This lack of care access worsens a health crisis that could have been easily avoided with more proactive (and less expensive) care.
A key takeaway from 2018’s 11th annual Medicaid Managed Care Summit was that, “Reforming healthcare in the U.S. is not about spending more money, but about moving around the dollars that we’re already spending.” Adoption of eConsult platforms allows health plans to solidify their value-based initiatives and Medicaid payers to expand access to needed specialist services, bring new physician access points to urban and rural areas and leverage the latest in technology and sophisticated referral protocols to help meet members’ care needs.
