ACOsSpecialty PhysiciansSpecialty ServicesValue-Based Health Care

How Physicians Can Navigate to Get Better Value from Specialty Services

By October 9, 2019 No Comments

In recent articles, we’ve discussed how Value-Based Health Care must help consumers make good decisions. Equally as important, CMS is now emphasizing how physicians should serve as navigators for their patients, providing information and guidance.

Let’s take a closer look at how the triad of primary care physician, specialist consultant, and patient can effectively engage in a process that improves Value through better outcomes and lower cost. To focus on the shifting role of primary care physicians (PCPs), we use “physician navigation” to describe PCP actions to coordinate care for their patients. To emphasize continuity of care at stake for the patient, we describe specialty physician involvement as “consultation” rather than “referral.”

Improvement of the Consultation Process Drives Value for Providers Under Risk

More than a third of patients are referred to a specialist each year in the U.S., and specialist visits constitute more than half of outpatient visits. Given breakdowns in all components of the specialty-consultation process, this is an area ripe for improvement.

Most Medicare Risk models, such as ACOs and Direct Contracting, hold primary care physicians responsible for cost. To avoid revenue loss, PCPs must scrutinize the sources of cost and ensure that they are participating in the consultation process. Organizations must recognize that the vast majority of costs do not stem from direct primary care services, but, rather, from those ordered or performed by consulting specialists. Pinpointing where the consultation process has successfully delivered cost savings and quality—and why—is essential to the process of developing future interventions to improve quality and efficiency.

Primary Care Physicians Lack Critical Information About Their Patients’ Consultations

This takes more than just reviewing EHR data, which typically does not provide PCPs with enough clinical context to support their understanding of whether their patients have received services of value. Our experience at Roji Health Intelligence in data aggregation and analytics teaches that information that is explicitly evaluative (particularly in a negative sense) will most often not be found in the EHR. Poor results may only be inferred from some data, such as laboratory results (e. g., elevated Hemoglobin A1Cs), readmissions, or high volume of ER visits.

In some cases, this is not anyone’s ”fault,” but, rather, a consequence of a patient’s advanced disease state or some factors beyond the physician’s or patient’s capacity to address. There’s also the human nature factor: When things go wrong, clinicians are reluctant to highlight a bad outcome. When things go right, the reasons are often not clear, and successful outcomes are often taken for granted.

Use of passive data collection, directly pulled from claims and/or the EHR, has been touted as a benefit to clinicians because it reduces paperwork. However, this removes the potential for PCPs’ scrutiny and oversight. When this data is used to evaluate clinicians and patients without any clinical context, it fosters blame games and resentment.

Capturing meaningful data requires direct input from the primary care physician, specialist consultant, and patient. This process should serve to engage and motivate physicians and patients. The crux of improving the consultation process is how to manage this process effectively for both primary care physicians and specialists.

Three Key Elements for a Better Consultation Process

As organizations move into Risk contracting, they need to maintain a healthy balance on how they scrutinize consultations. Over-referring creates cost issues for the organization, while under-referring risks patient harm, physician dissatisfaction, and increased liability.

The following three elements should be part of an effort to focus on the efficacy and effectiveness of patient outcomes involving consultations with specialists. As with every good improvement process, building a positive foundation for physician engagement requires education, innovation, and valid measurement of results.

1. The consultation process should be viewed as an educational opportunity for collaborating and improving patient results. Communication among the parties is essential.

  • Education should involve all participants in the consultation triad: the primary care physician, specialist, and patient.
  • The specialist should use the consultation as an opportunity to update and inform the referring clinician of the patient’s condition or any planned procedure. Creating a personal link encourages future consultations and can improve the long-term care of the patient. The specialist should, of course, educate the patient and make sure he or she understands the diagnosis and recommended plan of care.
  • The PCP should give the specialist feedback from the patient’s perspective of what went well in the consultation, as well as ongoing information on the patient’s status. In turn, the primary care physician should also inform the patient about prior patients’ favorable experiences with the consultant.
  • The patient should provide feedback on the experience of the consultation process, highlighting the learning opportunities for both the PCP and specialist.

2. Innovation, not cookie-cutter processes, will succeed in improving patient outcomes.

  • Positive and innovative approaches have more success with physicians. But there are no shortcuts to improvement, and feedback from diverse sources as well as physician involvement is necessary. Organizations must dig into the consultation process to see what techniques are worthwhile and successful, with both PCPs and specialists involved in a positive, results-focused effort.
  • Each organization and practice has its own idiosyncrasies that either enhance or cripple results. These are worth understanding and addressing through positive feedback.

3. Physician engagement in consultation improvement must be measured to get better buy-in and results.

  • ACOs can measure clinician and patient engagement in the consultation process as follows:
    • For the primary care clinician, has appropriate coding been used to indicate that a request for consultation occurred?
    • Have the PCP, specialist, and patient completed a post-consultation assessment? This information should be part of the PCP review of the consultation.
  • Rewarding creative interventions derived from positive outcomes assessments, particularly for challenging cases, can encourage clinician involvement in the process and provide new material for intra-network education and collaboration.

Just getting clinicians to look at the consultation results is a big step. Having clinicians respond on selected consultations that have had a favorable impact is essential. Determining causes of success affords a non-defensive approach more likely to be championed by the clinicians, and lowers the barrier to getting patient feedback.

Primary Care Physician Role as Patient Navigator

This focus on the consultation processes is a key step toward fostering patients as informed health care consumers and physicians as navigators. Even when the patient may decide as a consumer not to follow through on the consultation, the referring clinician should be aware of this decision in order to appropriately modify the treatment plan.

In short, the physician navigator needs to track the consultation in order to make sure nothing falls through the cracks, or to determine reasons for patient hesitancy.

It’s worth noting that any efforts that involve PCPs should be gradually integrated into practices. The pushback against added requirements can be extreme, with some calling the current system a “human rights violation.”

Rewarding clinicians for volume of patients versus improvement in care must change. Combined with other incentives, measuring and rewarding engagement is at the core of changing the system. Finding and exploring success creates an environment favoring improved results.

ACOs and Risk-Bearing Organizations Should Resist Network Steerage of Patients

Increasingly, the choice of specialist consultants is driven by factors beyond patient decisions and PCP preferences. Choice of consultants is often limited by the patient’s enrollment in a health plan with a narrow network of specialists. Who is included in the network and how specialists are selected are both critical factors in the patient’s choice of health plan; but the need for a specialist cannot always be anticipated at the time when a patient enrolls. If consultation beyond some organizations is discouraged, the patient’s and PCP’s options are significantly curtailed.

Some large employers are now steering the consultation process. Walmart Centers of Excellence, which uses nationally recognized centers for highly specialized care, is one example of this emerging trend. Volume as a surrogate for quality for uncommon procedures and conditions has been resurrected.

The great majority of consultations, however, are not for such rare situations. A program to improve the efficacy of office-based consultations should prove valuable for ACOs and payers. For this effort to succeed, the primary care physician, patient, and specialist consultant must each contribute, listen to one another, and collaborate. Maintaining a focus on continuity of care and long-term outcomes is essential.

Founded as ICLOPS in 2002, Roji Health Intelligence guides health care systems, providers and patients on the path to better health through Solutions that help providers improve their value and succeed in Risk. Roji Health Intelligence is a CMS Qualified Clinical Data Registry.

Image:  John Thomas