THE SPECIALTY CARE REFERRAL DILEMMA: The Desperate Need for Clinical Navigation to Improve Value-Based Healthcare

Transcription

1 THE SPECIALTY CARE REFERRAL DILEMMA: The Desperate Need for Clinical Navigation to Improve Value-Based Healthcare

2 The Specialty Care Referral Dilemma AUTHORED BY ARMADAHEALTH'S MEDICAL ADVISORY BOARD Benjamin Safirstein, MD, FACP, FACC Clinical Associate Professor of Medicine, Icahn School of Medicine at Mount Sinai, New York, USA Mary Thomas, MD Pediatrician, Pedimedica, Rochelle Park, USA Scott Swanson, MD Co-Director, Minimally Invasive Surgery, Brigham and Women s Hospital, Boston, USA Iain Kalfas, MD Head, Section of Spinal Surgery, Dept. of Neurosurgery, Cleveland Clinic, Cleveland, USA Louis Aledort, MD Professor of Medicine, Hematology and Medical Oncology, Icahn School of Medicine at Mount Sinai, New York, USA Asher Kimchi, MD Co-Medical Director, Preventive and Consultative Heart Center of Excellence, Cedars-Sinai, Los Angeles, USA Sinai, New York, USA Andrew Tucker, MD Medical Director, MedStar Union Memorial Hospital Sports Medicine, MedStar Union Memorial Hospital, Lutherville, USASinai, New York, USA David Helfet, MD Chief of Combined Orthopaedic Trauma, Hospital for Special Surgery, New York, USA Acknowledgements The authors of this white paper wish to acknowledge the collaboration of Editor, Henry Mortimer, and Research Analyst, Annika Schaefer.

3 TABLE OF CONTENTS EXECUTIVE SUMMARY 2 INTRODUCTION 2 REFERRALS TO SPECIALISTS ARE INCREASING 2 SPECIALTY CARE HAS BECOME COMPLEX 3 INACCURATE DIAGNOSES ARE HARMFUL 4 THE LANDSCAPE HAS CHANGED 4 A SOLUTION IS NEEDED 5 FACTORS FOR SUCCESS 6 IN CONCLUSION 7 SOURCES 8

4 EXECUTIVE SUMMARY As employers know firsthand, the cost of providing healthcare benefits to employees continues to rise. As this white paper illustrates, a large portion of those costs are a direct result of a broken referral process between primary and specialty care. This white paper suggests that, by using the Patient Centered Medical Home as a model, specialty care navigation programs can help employers offer employees better access to the specialty care they need. This, in turn, will help employees achieve better health outcomes and allow employers to better control costs and support employee productivity. INTRODUCTION Healthcare costs continue to rise at an alarming rate and consumers are experiencing great difficulty navigating healthcare systems on their own. Moreover, the practice of medicine is becoming increasingly complex and specialized. The primarycare landscape has also changed dramatically, and the referral process from primary care providers has not sufficiently evolved or adapted to these shifting dynamics. A relatively small number of patients consume a vastly disproportionate amount of healthcare spend on specialty care. In fact, only 5% of healthcare consumers account for almost 50% of total healthcare expenses. 1 Though only 10% of the population requires referral to specialty care services each year, they account for more than 65% of the total volume of annual claims cost. 2 The 15 most expensive health conditions account for 44% of total healthcare expenses. 1 5% 50% 5% OF HEALTHCARE CONSUMERS ACCOUNT FOR ALMOST 50% OF HEALTHCARE EXPENSES All of this data makes it clear that, although specialty referral may be needed by a small percentage of the population in a given year, it is important that it be managed judiciously as it accounts for a very large portion of the total healthcare dollars spent. REFERRALS TO SPECIALISTS ARE INCREASING According to a 2011 report, one-third of all US patients are referred to a specialist each year, yet specialist visits constitute more than half of all outpatient visits. 3 This implies that patients are visiting specialists even more than they are visiting their primary care physicians (PCP). One reason for this increase is that more patients are receiving diagnoses and referrals from providers other than their own primary MDs. Physicians in the emergency room and at various urgent care facilities are often the referring physicians. Many patients (73%) are opting to use urgent care and redimed services for their medical needs rather than their PCP due to difficulty making timely appointments, getting phone advice or receiving after-hour care without having to visit the emergency room. 4 Doctors in urgent care settings seldom have longstanding relationships with patients. Therefore they do not often have access to their full medical record and have limited or no ability to follow up on a referral once it is made. Referrals become too frequent and are very often inappropriate. A study by Barnett found that from 1999 to 2009, ambulatory visits accounted for more than 100 million referrals. 5 In a report published by the Commonwealth Fund Commission, they stated that nearly three out of four patients seek out what should be primary care by going to an ER. 4 When continuity of care is lost, effective referral and effective care are jeopardized. 2

5 Patients themselves may be contributing to the rise in specialty care referrals by using the internet as a self-diagnosis tool and/or bypassing their PCP for a specialty referral. According to one study on managed-care organizations that permit direct patient access to specialists, a large proportion of new referrals for dermatology, OB/GYN, ophthalmology, and psychiatry were patient self-referrals without a diagnosis. 6 Patientinitiated referrals are at even greater risk of being inappropriate as some insurance plans allow patients to see a specialist without a diagnosis or referral from a PCP. The growing number of self-referrals has been associated with dissatisfaction and poor continuity of care. 7 This data suggests what is intuitive; that a lack of a stable primary care relationship often leads to inappropriate specialist use and related costs. THE CURRENT REFERRAL PROCESS IS FRUSTRATING Oftentimes, patients that are referred to specialists are unable to access the specialty care that their PCPs recommend. This may be because the patient has difficulty finding a specialist in their community, insurance coverage is not accepted, there is a lack of timely appointment availability and/or the patient just becomes frustrated and gives up. The difficulty of getting an appointment for specialist care has been cited as a growing problem, especially in underserved populations. 8 Such a breakdown in the continuum of care for patients can have wide-ranging consequences. Despite the growth and frequency of specialty care referrals, the absence of collaboration between primary care doctors and specialists has been a long-standing problem. As with any complex and multistep task, the specialty referral process is prone to breakdowns and inefficiencies. Consider, for example, that patients with chronic illnesses such as diabetes must receive care from multiple providers, in multiple settings, and require complex coordination of their care. THE DIFFICULTY OF GETTING AN APPOINTMENT FOR SPECIALIST CARE HAS BEEN CITED AS A GROWING PROBLEM... The burden of this time-consuming and complicated care coordination falls on the shoulders of the already over-burdened PCP. 9 The primary care doctor must decide who the best specialist is for his patients, make sure the patient completes that referral, solicit information back from specialists about their opinions and then implement those changes as part of a medical plan. Complicating matters, nearly half of referring physicians do not know whether their patients actually see the specialists to which they are referred. 10 SPECIALTY CARE HAS BECOME COMPLEX Another problematic factor is that specialty care has become increasingly more complex and compartmentalized. In the United States, there are now more than 840,000 boardcertified specialists in approximately 200 areas of specialization treating 30,000 different diagnoses. Complicating it further is the levels of sub-specialization. 11 This broad array of options makes it virtually impossible for anyone without the proper guidance to find not only the right type of specialist, but also one that is the most experienced in treating that patient s particular disease or condition. 3

6 200 SUBSPECIALTIES 30,000 DISEASES 840,000 SPECIALISTS Delay to referral is another known flaw in the referral process. Late referrals have been associated with worse health outcomes. In a study of long-standing renal disease, patients who did not see a nephrologist at least 90 days before initiation of dialysis had a 37% higher likelihood of death in the first year of treatment. 12 Nearly one-fifth of patients with stage III or IV colorectal cancer were not referred to medical oncologists for adjuvant chemotherapy. 13 Such delays in treatment have resulted in poor outcomes. Patients in need of specialty care often spend months and sometimes years searching for the right specialist, accumulating unnecessary tests and procedures along the way; or worse, they never make it to see a specialist at all. INACCURATE DIAGNOSES ARE HARMFUL Possibly the most concerning aspect of the referral process is the frequency of inaccurate diagnosis. According to Improving Diagnosis in Health Care, a report from the Institute of Medicine, inaccurate diagnoses continue to harm an unacceptable number of patients. 14 In fact, it is likely that most people will experience at least one diagnostic error in their lifetime, sometimes with devastating consequences. 14 Researchers at Johns Hopkins University examined more than 350,000 malpractice claims over 25 years and found that diagnostic errors defined as missed, wrong or delayed diagnoses accounted for nearly 29% of claims. 15 This study also found that diagnostic errors made up the biggest share of claims payments from 1986 to 2010 and resulted in death in more than 40% of claims. 15 A recent article in the BMJ shows that inpatient medical errors are extremely common and may now be the third-leading cause of death in the United States claiming 251,000 lives every year, more than respiratory disease, suicide, fire arms and motor vehicle accidents. 16 Medical errors are clearly too frequent, but the majority of these errors do not result from individual recklessness or the actions of a particular group. In a landmark paper, To Err is Human, researchers concluded that errors are caused by faulty systems, processes and conditions that lead people to make mistakes or fail to prevent them. 17 While this is a cumulative problem in which no one group is to blame, it reveals that a better system is needed. THE LANDSCAPE HAS CHANGED The healthcare landscape has shifted and the primary care model remains in a relative state of crisis. According to a study examining family and internal medicine physician referral decisions, the reorganization of healthcare over the past few decades has increased the number of referrals made outside of office visits with the PCP. More and more referrals come from telephone conversations with a provider or from recommendations given by non-physician office staff. 18 Gone are the days when a physician could take as much time as needed to examine his or her patients to make a diagnosis and a referral for specialty care based on the patient s needs. According to a study published in Medical Economics, primary care physicians are overwhelmed and as a result, they are forced to 4

7 spend less time with patients than they want or need to. 19 Patients are acutely aware that access to and the amount of time spent with their physicians has decreased. These statistics tell us that the role of a primary care doctor is changing. PCPs no longer play the part of healthcare quarterback, synthesizing a patient s medical record and acting as a gatekeeper to connect patients with specialists once a diagnosis is made and a more complicated level of care is needed. Patients are in growing need of support for specialist referrals because their primary doctor, if one exists, has limited time and resources dedicated to this important aspect of care. A SOLUTION IS NEEDED The impending mandates of value-based care, which will require PCP s to improve the specialty referral process, recognizes the importance of the quality of the referral and its impact on cost. Streamlined collaboration helps providers provide better care. A 2002 study published in the New England Journal of Medicine demonstrated that concurrent care by both a PCP and a cardiologist in the post-mi period was associated with a further reduction in mortality than care by a PCP alone. 20 Further supporting this concept, studies have shown that patients treated by an endocrinologist and a primary care physician were more likely to receive optimal care than those seeking endocrinologists alone % WASTE IN TOTAL US HEALTHCARE EXPENDETURES We know that excellent specialist care is necessary to streamline diagnosis and correctly manage illness. In the landmark article "The Quality of Health Care Delivered to Adults in the United States," researchers reported that only 52-58% percent of patients receive recommended follow-up care. 22 The result of this lack of follow-up is extremely costly. Failure of care coordination and failures of care execution contribute to a 20% waste in total US healthcare expenditures. 17 One growing solution is the Patient Centered Medical Home (PCMH) model. This is an approach to organizing and delivering primary care that emphasizes teamwork and coordination of effort by providers. The PCMH model is designed to cut overall costs and spending by reducing inpatient visits, emergency department use and hospital readmissions. It is based on the idea that better communication leads to better and more cost-effective care. The Guided Care PCMH model, developed by an interdisciplinary team at the Johns Hopkins Bloomberg School of Public Health, features nurse coordinators and multidisciplinary physician teams working in community-based practices. 23 Studies published by RTI International, a health services research journal, suggest that accredited PCMHs deliver lower costs and improve healthcare. 24 A large part of the lower costs and more effective care experienced in the PCMH setting stems from the investment in resources for specialty referral. Emphasis is placed on the quality of the specialist and how he or she matches the patient s specific needs. Another factor in reducing healthcare cost relates to referral tracking, which has been shown to be an important task for the referring provider to assure that the patient is actually seen by the specialist. 5

8 EMPHASIS IS PLACED ON THE QUALITY OF THE SPECIALIST AND HOW HE OR SHE MATCHES THE PATIENT S SPECIFIC NEEDS. PCMH models are beginning to provide insight on the value of navigating patients to the most appropriate specialty care resources, but they reach a limited number of patients and are only scratching the surface of what could be done. We suggest that supplemental clinical navigation programs can fill that need and can be made available broadly to the population. We propose that ensuring patients are objectively matched to a specialist experienced in diagnosing and treating their specific condition will deliver significant improvement in patient satisfaction, cost and outcomes. Providing the missing link from PCP to specialist could be transformational to the healthcare system and of profound value to all constituents in the chain including sponsors of healthcare benefits. FACTORS FOR SUCCESS To be successful, a specialty clinical navigation program must have: A governing body of leading physicians with deep and broad knowledge, international prominence and the highest most objective clinical standards. An objective research and credentialing process with screening and quality standards to identify the best specialists, pinpoint their strengths down to the narrowest area of expertise and most advanced treatment modalities. An independent medical board to oversee the qualifications of accredited boardcertified specialists or the equivalent. An organized and personal approach to a patient medical intake, including understanding the clinical profile, coverage limitations and personal preferences. The ability to provide access to specialists on a timely basis. Verification of what is required by the specialist prior to seeing the patient. Verification of insurance coverages accepted. A follow-up mechanism to facilitate communication with primary care physicians about referral outcomes. The benefits of specialty clinical navigation programs extend to primary care and specialty physicians alike in a number of ways. The ideal partner, they improve the referral pathways in both directions by allowing primary and specialty care providers to stay in communication. Like the PCMH model, they offer an approach to improved coordination and continuity of care by ensuring the efficient delivery of excellent and timely patient care. They provide a specialist with an appropriate referral that matches their ideal patient which will come prepared with any prerequisite testing. For healthcare systems, they reinforce the highest and best use of their specialists. Finally, they reduce or eliminate resource requirements associated with facilitating referrals and the costly impact of errors. 6

9 IN CONCLUSION Due to a broken physician referral system, the economics and complexity associated with providing specialty care has become overwhelmingly burdensome for many Americans. The broken link between primary and secondary care is a shared problem that must be addressed by changes in process. By using a supplemental clinical navigation program, we have the power to transform this paradigm and increase patient satisfaction, improve outcomes and control costs. This solution will bridge the gap between primary care physicians and specialists to deliver more streamlined, affordable and effective care. Equally important is ensuring that the specialist is the right match for the needs of the patient in terms of location, insurance coverage and availability, as well as the specialist s specific skills and clinical relevance. A successful patient-physician match must take into account the patient s diagnosis as well as the physician s training, experience, volume and access to the latest diagnostic and therapeutic options pertinent to the patient s situation. It is time to recognize the value of accessing the right specialists at the right time. When patients receive the wrong care, it can increase cost, delay care and potentially jeopardize lives. Implementing a supplemental specialty clinical navigation program offers a way to solve the specialty care referral dilemma and improve value-based care. 7

10 SOURCES Stanton MW, Rutherford MK. The high concentration of U.S. health care expenditures. Rockville (MD): Agency for Healthcare Research and Quality; Research in Action Issue 19. AHRQ Pub. No Halvorson GC. Health care reform now!: A prescription for change. San Francisco: Jossey-Bass; Mehrotra A, Forrest CB, Lin CY. Dropping the baton. Milbank Q Mar;89(1): How SKH, Shih A, Lau J, Schoen C. Public views on U.S. health system organization: A call for new directions. August Commonwealth Fund pub Vol. 11. Barnett ML, Song Z, Landon BE. Trends in physician referrals in the United States, Arch Intern Med. 2012;172(2): Balogh EP, Miller BT, Ball JR, editors; Committee on Diagnostic Error in Health Care; Board on Health Care Services; Institute of Medicine; The National Academies of Sciences, Engineering, and Medicine. Improving diagnosis in health care. Washington (DC): National Academies Press (US); 2015 Dec. 15 Saber Tehrani AS, Lee H, Mathews SC, Shore A, Makary MA, Pronovost PJ, Newman-Toker DE. 25-year summary of US malpractice claims for diagnostic errors : An analysis from the National Practitioner Data Bank. BMJ Qual Saf Aug;22(8): Makary MA, Daniel M. Medical error-the third leading cause of death in the US. BMJ May 3;353:i Berwick DM. Eliminating waste in US healthcare. JAMA. 2012; 307(14): Forrest CB, Reid RJ. Passing the baton: HMOs influence on referrals to specialty care. Health Aff (Millwood) Nov-Dec;16(6): Forrest CB, Nutting PA, Starfield B, von Schrader S. Family physicians referral decisions: Results from the ASPN referral study. J Fam Pract Mar;51(3): Forrest CB, Weiner JP, Fowles J, Vogeli C, Frick KD, Lemke KW, Starfield B. Self-referral in point-of-service health plans. JAMA May 2;285(17): Forrest CB, Shadmi E, Nutting PA, Starfield B. Specialty referral completion among primary care patients: Results from the ASPN Referral Study. Ann Fam Med Jul- Aug;5(4): Pham HH, O'Malley AS, Bach PB, Saiontz-Martinez C, Schrag D. Primary care physicians' links to other physicians through medicare patients: The scope of care coordination. Ann Intern Med Feb 17;150(4): Bourguet C, Gilchrist V, McCord G. The consultation and referral process. A report from NEON. Northeastern Ohio Network Research Group. J Fam Pract Jan;46(1): The American Board of Medical Specialties fact sheet. Available from factsheet_10_14.pdf. 12 Avorn J, Bohn RL, Levy E, Levin R, Owen WF Jr, Winkelmayer WC, Glynn RJ. Nephrologist care and mortality in patients with chronic renal insufficiency. Arch Intern Med Sep 23;162(17): Oliveria SA, Yood MU, Campbell UB, Yood SM, Stang P. Treatment and referral patterns for colorectal cancer. Med Care Sep;42(9): The 86th annual physician report: Why administrative burdens keep physicians away from patients. Med Econ. Available from com. 20 Ayanian JZ, Landrum MB, Guadagnoli E, Gaccione P. Specialty of ambulatory care physicians and mortality among elderly patients after myocardial infarction. N Engl J Med Nov 21;347(21): Lafata JE, Martin S, Morlock R, Divine G, Xi H. Provider type and the receipt of general and diabetes-related preventive health services among patients with diabetes. Med Care May;39(5): McGlynn EA, Asch SM, Adams J, Keesey J, Hicks J, DeCristofaro A, Kerr EA. The quality of health care delivered to adults in the United States. N Engl J Med Jun 26;348(26): Grumbach K, Bodenheimer T, Grundy P. The outcomes of implementing patient-centered medical home interventions: A review of the evidence on quality, access and costs from recent prospective evaluation studies. Washington, DC: Patient-Centered Primary Care Collective; Au-gust Van Hasselt M, McCall N, Keyes V, Wensky SG, Smith KW. Total cost of care lower among Medicare fee-for-service beneficiaries receiving care from patient-centered medical homes. Health Serv Res Feb;50(1):

11 This white paper is sponsored by TopDoc Connect, a trusted leader in specialty care referrals. TopDoc Connect 230 Schilling Circle, Suite 140 Hunt Valley, MD TopDoc Connect is facilitated by ArmadaHealth, LLC, an independent company that does not have any legal or financial relationship with the physicians it recommends. ArmadaHealth, LLC, is not a provider of healthcare or medical treatment or advice.