Accessing specialty healthcare can be difficult for many individuals in the United States due to several factors. One of the main barriers is the high cost of healthcare services, particularly for those without health insurance or limited coverage. Many specialty care services, such as surgeries or advanced diagnostic testing, can be prohibitively expensive, making them unattainable for those who need help to afford them. Even those with health insurance come across many barriers to accessing specialty care. A shortage of specialists in certain areas, particularly in rural or underserved communities, can lead to long appointment wait times or difficulty finding a specialist who accepts a patient’s insurance. Navigating the complex healthcare system can be challenging, particularly for those who need to speak English or are unfamiliar with obtaining referrals and authorizations.
These additional factors can make accessing specialty healthcare a significant challenge for many individuals:
1. Insurance Limitations
Many health insurance plans have limitations on which specialists are covered or require higher out-of-pocket costs for specialist care. This can make it difficult for some individuals to access the specialty care they need. In addition, if the patient has an HMO, a visit to your primary care practitioner is often required before seeing a specialist. If the patient arrives for a specialist’s appointment with no referral, they may be asked to:
- Contact the primary care physician to obtain the referral.
- Reschedule the appointment.
- Pay the estimated cost of the service before seeing the physician.
By having to take these additional steps, patient care is delayed.
2. Geographic Barriers
Some areas of the US need more specialists, particularly in rural or remote regions. This can make it difficult for some patients to access the necessary care. Geographic challenges can be as simple as the distance to and from the specialist’s office to receive care, or the challenges can be more complicated like not having a neurosurgeon in any surrounding cities and creating long-distance travel plans accommodations to access care. These issues are often referred to as social determinants of health (SDoH). Some patients in urban areas also face geographic barriers due to a lack of transportation or long travel times using public transit.
3. Wait Times
Long wait times can lead to delays in diagnosis and treatment, resulting in disease progression or complications. This can lead to poor health outcomes, reduced quality of life, and increased healthcare costs. Wait times can also disproportionately affect specific populations, such as those with low income, limited access to transportation, or who live in rural areas with fewer healthcare resources. Long wait times can cause significant stress and anxiety, further impacting an individual’s physical and mental health. Wait times for healthcare services can play an essential role in determining an individual’s overall health and well-being, making access to specialty care advice a critical social determinant of health.
Wait time data for Endocrinology and Gastroenterology:
- Endocrinology has an average wait period of 67 days, which surpasses the overall survey average by 19 days.
- Gastroenterology generally has more providers per clinic, yet still averages a 64-day wait time per provider and a 16-day increase from the overall average.
How Does Referral Management Aid in Specialist Accessibility?
Referral management can play a significant role in making healthcare more accessible by streamlining the process of obtaining specialist care.
1. Verify Insurance and Identify In-Network Specialist
AristaMD enables primary care practices to perform an insurance eligibility verification in real-time before referring the patient to a specialist. The platform also gives referral coordinators the ability to identify in-network specialists. In many primary care clinics, referral coordinators have a list or cheat sheet of local specialists. This list contains physicians familiar to the primary care provider and is used to refer patients. Lists like this have limitations.
As the number of health plans proliferate, it’s unlikely that the specialists on the PCPs list will accept all of the possible insurance and plan combinations. AristaMD helps practices avoid sending the patient out of network by confirming the insurance information is correct and valid but also by supplying the practice with a list of in-network providers. It is well documented that patients sent to out-of-network specialists are much less likely to schedule the appointment, resulting in incomplete referrals and patients that never receive specialty care.
2. Geographic Barriers
Specialty healthcare doesn’t have to be limited because of the patient’s location. AristaMD offers two solutions that address the needs of patients who cannot access specialty care due to a limited number of specialists in the area and travel constraints. First, the referral management portion of the platform provides a list of specialists sorted by their in-network insurance status and the distance from the patient’s location. Second, AristaMD offers an eConsult solution that enables the primary care provider (PCP) to connect with a specialist through our secure platform. The specialist typically provides advice back to the PCP within 4-6 hours. The PCP is able to develop a treatment plan and provide care to the patient more than 70% of the time – eliminating the need for a face-to-face visit.
3. Wait Times
AristaMD also helps reduce wait times. Answer a few simple questions to determine if the patient is eligible for an eConsult to eliminate face-to-face referrals when the patient’s condition is emergent and non-procedural. The application also allows the referring provider to indicate if the patient’s need should be expedited. Ensure that patients are referred to the appropriate specialists based on their needs to reduce delays and improve the accuracy of diagnosis and treatment. By coordinating referrals and eConsults, referral management systems can help patients avoid unnecessary appointments or testing and ensure that they receive the care they need in a timely and efficient manner.
The AristaMD platform can do so much more. Access our referral management service to help improve communication between primary care providers and specialists, ensuring patients receive the best possible care. By sharing patient information and test results, primary care providers and specialists can collaborate more effectively to develop treatment plans and provide continuity of care. Referral management can also help reduce the administrative burden on providers, freeing up time and resources to focus on patient care.