Featured in Patient Safety & Quality Healthcare, October 2018
By Brooke LeVasseur, CEO of AristaMD
The importance of primary care
Our healthcare system is predicated on a model of primary care providers as the hub of care coordination. Primary care physicians (PCPs) provide health promotion, disease prevention, health maintenance, counseling, patient education, diagnosis, and treatment of acute and chronic illnesses. Through routine check-ups, primary care can identify and treat conditions early. As a result, adults in the U.S. who have a PCP are 19% less likely to die prematurely than those who only see specialists for their care.[i] Moreover, people who receive primary care spend 33% less on healthcare than people who only see specialists – in particular, by reducing the need for emergency room care, where costs at least four times as much other outpatient settings.[ii] The role of primary care is becoming increasingly important to achieve cost and population health metrics within the shift to value-based care models.
The challenge ahead
PCPs are challenged to ensure that patients get the right care, in the right setting, by the most appropriate provider, and in a manner consistent with the patient’s desires and values. Complicating this already difficult task, an estimated 209,000[iii] PCPs are caring for a population that is fast approaching 325 million.[iv]
Not surprisingly, PCPs have gradually increased the volume of cases referred to specialist care. The number of specialist referrals has more than doubled in the United States since 1999.[v] This increase in referrals has not come without increasing challenges for both the PCP and specialists. Common issues arise for PCPs in the specialty referral process that can decrease effectiveness of care and drive up healthcare costs. These include referrals that lack complete medical workups, are sent to the wrong specialist, or are inappropriate for escalation to a specialist. Furthermore, long delays for PCPs to receive the results from specialist referrals greatly decrease the chances that the PCP can optimize the patients’ care or gain knowledge from each referral to treat similar cases in the future. The average wait time within 5 specialty areas within top 15 major metropolitan areas was over 3 weeks. Within several specialties, wait times for appointments reached up to a year.[vi] Most importantly, these referral issues may delay necessary care for patients and decrease their satisfaction with the care process.
Lastly, over-stressed PCPs and systemic issues with referrals aside, a looming shortage of specialist physicians promises to further encumber patient care. At a time when the US is faced with a highly co-morbid and aging population, the country is also projecting a deficit of 95,000 specialty physicians by 2025.[vii]
Creating the “super PCP” with telehealth resources
To overcome the issues plaguing PCP-specialist care coordination, PCPs must embrace tools and resources that extend their clinical domain without delegating patient care. “Super PCP” capability is enabled by evolving telehealth solutions including eConsult platforms, also known as “eReferrals” and “virtual consults”, that create a previously non-existent peer-to-peer communication channel between a PCP and specialist, by which the providers can confer, share the patient’s medical history, and collaborate on a care plan. The patient remains in the capable hands of the PCP while benefiting from specialized medical expertise.
An e-consult is a simple process for primary care physicians and patients. (See figure 1) During a typical office visit, the PCP documents the encounter within the EHR, logs the assessment and treatment plan, and cites the need for a specialist consult. The system extracts the necessary patient data to send to the relevant specialist who provides the consult within a matter of hours. The PCP is notified that the consult has been completed. The patient then returns to the PCP for follow-up or visits the specialist, as needed.
Sharing the experience of Dr. Christopher Dodd, Chief Care Transformation Officer at ConcertoHealth, “When embraced, eConsults became a tool for providers to help them become a ‘Super PCP’ to serve as the sole provider to the patient.” Indeed, supported by technology seamlessly integrated into the organization’s workflow and electronic health record, a PCP can manage specialty-related care with the expert guidance of board-certified specialists on clinical questions, diagnostics, work-up and treatment recommendations for patient cases that might not require a face-to-face visit with a specialist.
Dr. Dara Richards, Chief Medical Officer of Southwest Community Health Center, championed the implementation of eConsults within her organization and noted both immediate and long-term advantages. “It was very eye-opening for our organization that we could receive such a rapid and thorough response back from a specialist on a question or referral, usually within hours.” In addition, Dr. Richards noted that each consult has lasting benefits, “With the education provided from specialist recommendations, providers were realizing that if presented with the same problem in the future, a referral would not be necessary.”
The benefits of ‘super PCP’ care
eConsults benefit patients, payers, physicians, and health systems. Enhanced care coordination stems from keeping the patient within primary care where there is less opportunity for care coordination to breakdown. There are fewer appointments, less transfer of medical information, shorter time from diagnosis to treatment, and patients benefit from consistent follow-up from the provider with whom they have a longstanding relationship and trust. Additionally, patients who could not otherwise access or afford to see a specialist can benefit from specialist consultation. For instances where a specialist visit is appropriate, appointments will be available sooner because unnecessary appointments are not filling the specialist’s schedule.
eConsults benefit health insurers by keeping a higher percentage of patients within the primary care setting and thus, significantly reducing unnecessary costs. In addition to eliminating spend on unnecessary specialist visits, ensuring timely access to care can reduce unnecessary ED visits and the need for hospitalization.
For physicians, eConsults are a clinically valuable resource to expand care capabilities and increase their own knowledgebase. Fewer inappropriate referrals and more complete information sharing translate to higher patient satisfaction and retention. Physicians also benefit financially from additional revenue from expanding their scope of care. Finally, health systems benefit from eConsults’ potential to improve access to specialty care within the primary care setting, better manage population health initiatives and care coordination, as well as support quality metric initiatives.
[i] Starfield B, Shi L and Macinko J. Contribution of Primary Care to Health Systems and Health. Milbank Quarterly. Volume 83, Issue 3 2005
[ii] Cox E. Why Do We Continue Using the ER for Care? US News. Dec. 14, 2015. https://health.usnews.com/health-news/patient-advice/articles/2015-12-14/why-do-we-continue-using-the-er-for-care
[iii] AHRQ. The Number of Practicing Primary Care Physicians in the United States: Primary Care Workforce Facts and Stats No. 1. https://www.ahrq.gov/research/findings/factsheets/primary/pcwork1/index.html
[iv] US Census Bureau. https://www.census.gov/popclock/
[v] Barnett ML, Song Z, Landon BE. Trends in Physician Referrals in the United States, 1999-2009. Arch Intern Med. 2012;172(2):163–170.
[vi] Merritt Hawkins. “Survey Of Physician Appointment Wait Times And Medicare and Medicaid Acceptance Rates”. 2017.
[vii] The Complexities of Physician Supply and Demand: Projections from 2013 to 2025. Association of American Medical Colleges. 2015.