George Rodgers, MD, Assistant Professor of Internal Medicine at Dell Medical School, co-authored the following post.
More than a third of primary-care patients require additional physician expertise to address their health issues and are referred to a specialist. In fact, in 2009, about one in 10 visits to a primary-care provider resulted in referral to a specialist. But many people — including those in communities in Travis County facing the greatest challenges to health — have difficulty accessing specialty care. It’s one of the more vexing problems in the U.S. health care system and is a blatant example of the adverse impact of our fragmented delivery system.
We should start by noting that there are important distinctions between primary care and specialty care in health care. Primary-care providers have undergone comprehensive training and have diverse expertise to enable them to manage the most common medical problems and to recognize when additional expertise is required. Specialty-care providers have undergone training that is more focused on a specific area, so they have deeper expertise but do not treat all medical problems. Handing off a patient from one provider to another can pose significant challenges. Difficulties are magnified if the primary-care provider and the specialist are in different health care systems. But even when they are in the same system, there are many barriers to accessing specialty care.
Summit & Workshop
To address these barriers, on May 5, 2017, the Dell Medical School and the Community Care Collaborative co-sponsored a “Stakeholder Summit on Access to Specialty Care: Improving Access to Specialty Care for Adults Who Are Underinsured or Underinsured in Travis County.” This was followed by an “Access to Specialty Care: Post-Summit Workshop” on June 17. At the first meeting, more than 60 participants (including patients, health system representatives, primary care providers, specialists and national experts) shared their expertise and participated in breakout groups that proposed initial ideas on how to improve access to specialty care. At the second meeting, almost 30 participants engaged in extensive discussions to determine seven pilot projects to improve access to specialty care. During the subsequent months, we have been working on funding and hammering out the details of the seven pilot programs.
Getting More Patients Into Specialty Clinics
The most direct way to increase access to specialty care is to get more patients into specialists’ clinics. Of the seven pilots, three are intended to do just that. They will:
- Create improved processes to efficiently work through the referral waiting lists to get more specialty appointments made.
- Write better referral guidelines to help primary-care providers refer the right patient, at the right time, with the right preparation.
- Provide transportation to and from specialty clinics free of charge for patients in financial need, since transportation is such a problem for so many people.
Improving Access to Specialty Expertise
Even with these enhancements, there is still not enough capacity in the system to provide timely specialty care to all patients. The problem also can be addressed by replacing “access to specialists” with “access to specialty expertise.” In general, patients greatly prefer to get their care in the office of their primary-care provider instead of the office of a specialist — and four of the pilot programs aim to facilitate that. They will:
- Use “e-consults” to facilitate communication between a primary-care provider and specialist, giving primary-care providers the information they need to help the patient or decide on a regular referral.
- Align providers with a specialist in primary-care groups that are large enough to amass additional training so the primary care provider can deliver at least some of the specialty care locally, with light support from the specialist.
- Connect patients and specialists with telehealth applications (audio and video connection for convenience and efficiency) in cases that do not require physical examination of the patient by the specialist.
- Bring some of the advanced testing that is required for specialty cardiac assessment to primary-care clinics on a rotating basis using a mobile platform as an alternative to transporting the patient to a central testing location.
Advantages to these four approaches include familiarity with providers, staff and surroundings, less travel, fewer visits and reduced co-payments. In many situations, this is the best way to provide care.
We look forward to seeing these pilot projects progress and are excited about the tremendous potential that this collaboration between Dell Med and the Community Care Collaborative has for improving access to specialty care.