Implementing Prayer-Agnostic Programs For Specialty Services
Historically, cost containment by commercial payers focused on limiting access to specialist services. However, since costs are concentrated in a small portion of the population with complex chronic illnesses, considering the problems caused by gatekeeping in the 1990s, limiting access to specialists for the entire population may not be an appropriate lever for lowering TME trend. In addition, enhanced access to specialty services has the potential to reduce costs and improve quality through more efficient testing and treatment regimens. We have approached specialist services with the philosophy that early and coordinated access, through the application of tools such as bi-directional referral management systems and virtual visit capabilities, will have a greater ability to lower costs. The challenge for deploying these tools is that ACOs are built off of an aligned population of patients attributed to primary care physicians. Typically, specialists in ACOs are providing care to both a fee-for-service population as well as the ACO population. The costs of providing a nonbillable service such as virtual visits is not sustainable if a large portion of the patients are not in a risk contract. We have found that integrating virtual visits and e-referrals for a limited set of a specialist’s patients poses workflow and ethical challenges. As a system with 2 prominent academic medical centers, we have therefore focused our efforts on deploying these tools to specialists who have a high proportion of patients from our primary care physicians, and continue to work through these significant challenges.
Our specialist engagement tools are focused primarily on improving access and coordination or ensuring appropriateness and optimal outcomes. First, virtual visits (asynchronous and synchronous) between patients and providers or between providers help improve access and coordination. Second, referral management systems that allow for pre-consultative communications and review with key clinical data and messages allow for more thoughtful specialist consultations. This active management of referrals allows specialists to provide accelerated “curbside” consults without a formal consult for minor issues, appropriate pre-appointment testing for improved initial in-person consultation, or accelerated scheduling for initial consultation for urgent issues. Third, we are implementing technology and workflows to capture patient-reported outcomes in our specialty practices. We are collecting and reporting this data internally and externally to ensure we are monitoring the metrics that are most important to our patients. Monitoring patient-reported outcomes is especially important when a provider is concurrently implementing cost-containment measures. Fourth, we have developed technology to assess the appropriateness of surgical procedures. This technology combines analytics of both structured and unstructured data in an electronic platform and provide feedback to providers and patients regarding relative risks and benefits of certain procedures [17]. Lastly, we are implementing clinical bundles around select surgical procedures.
As an ACO that includes academic medical centers, we have a particular challenge of balancing the mission of fostering innovative and experimental technologies that may help advance human health and medical science, while ensuring we are stewards of limited financial resources. Academic medical center–led ACOs will need to thoughtfully balance these objectives [4].