The “Broken” Referral Process
A successful referral process between primary care and specialty care has three major components: referral accuracy, appointment scheduling, and information exchange. However, these components are often “broken,” particularly in organizations that provide care to Medicaid patients. Broken processes prevent patients from getting access to the right care, at the right time, in the right way.
- Referral accuracy: The ideal referral involves minimal wait time and efficient use of resources. It is medically necessary, directed to the correct specialty, and complete with relevant history and workup. Up to 40% of referrals lack one or more of these key elements.
- Appointment scheduling: Ideally, patients see a specialist within a few days of receiving a referral. Shortages in certain specialties, either overall or within a given network, can lead to significant delays. According to a recent survey, the average wait time for a new patient to see a dermatologist is 32.3 days.
- Information exchange: In a successful referral environment, the primary care provider (PCP) and the specialist would communicate directly, both before and after the patient sees the specialist, and any information relevant to that patient’s care would be transferred between them. However, patients in many cases are the primary conduit of information between PCPs and specialists. Relevant information and background is often lost, resulting in delayed care plans and duplicative or unnecessary tests or procedures. Despite the availability of electronic health records and health information exchanges, relevant health information is often missing and referral loops cannot be closed.
When processes and referral pathways are broken, the impact on Medicaid patients is magnified, as patients with Medicaid are less likely to be able to access timely specialty care. Nationally, more than 30% of physicians do not accept Medicaid at all. In addition, Medicaid patients are often sicker and have higher rates of disability than commercially insured patients. They also have significantly fewer economic resources, less access to transportation, and potentially more to lose when they must miss work for health care. A broken referral process deters Medicaid patients from getting the care they need when they need it.
How eConsults Can Help
eConsults, or electronic consultations, forge better communication pathways between primary care and specialty care clinicians by connecting them electronically and enabling bidirectional exchange and consultation. They enable prompt electronic consultation between the PCP and a specialist. Through the eConsult, the PCP can share relevant clinical and diagnostic information with the specialist, resolve outstanding questions, and ask further questions as needed.
Often, the PCP and the specialist can develop a care plan without the patient having to see the specialist in person. The eConsult and related documentation ultimately become part of the patient’s record, closing the information exchange loop. When a patient requires in-person specialty care, the specialty visit is more efficient and streamlined. eConsults address both the referral accuracy and the information exchange components of successful referral processes.
Medicaid Specialist Referrals in a California Health Network
To determine how eConsults could best address problems with Medicaid referrals, the Community Health Center Network (CHCN), a network of eight federally qualified health center organizations with more than 40 primary care sites in the East Bay area of California, collaborated with eConsult provider RubiconMD to improve and streamline referrals.
CHCN provides primary and specialty care under a financial risk contract for 140,000 Medicaid managed care patients, which gives CHCN a strong incentive to make specialty referrals as efficient and effective as possible. CHCN health centers also care for an additional 150,000 patients under a variety of arrangements with other payers, including Alameda County’s health insurance for low-income residents. This particular analysis focused on the Medicaid population.
CHCN serves a predominantly underserved population, including Latino, Asian, and African American patients, with a significant portion of non-English speakers and more than 70% of patients living below the federal poverty line.
CHCN faced many referral-related challenges in 2015 — a strained specialty network, many newly graduated providers, and patients with transportation and socioeconomic challenges that impeded access to specialty care. In response, CHCN engaged RubiconMD to help analyze where its specialist referral process was broken, and to give PCPs access to its eConsult platform and its national network of specialists trained to interact with PCPs. To strengthen local partnerships with the specialists used by CHCN’s network of PCPs, RubiconMD also enabled specialists from the local public hospital system at Highland Hospital to respond to eConsults for patients in the CHCN network through the RubiconMD platform.
To make the eConsult service “insurance agnostic” — an essential feature for building it into the referral workflow of CHCN’s primary care providers — CHCN made it available on an unlimited basis for all patients seen in CHCN health centers. The eConsult service was pilot-tested starting in December 2015, and it is now available in all CHCN sites.
We interviewed primary care providers, referral coordinators, specialists, medical assistants, medical directors, and patients across multiple organizations to better understand the processes, pitfalls, and gaps in the current referral system. Our analysis revealed a referral process involving up to 20 steps.
Each referral involved up to eight different people and multiple record-keeping systems that included paper, fax, electronic health records, and other electronic platforms. Failure at even one step dramatically decreased the chance that the patient would ever see a specialist: For every five referrals ordered, only two were ultimately scheduled. The process has many possible “break” points. For example, a patient’s phone number may not be copied correctly among all the record-keeping systems, or a referral coordinator may forget to note that the patient needs a Spanish translator.
For specialist visits that were actually scheduled, it took an average of 5 weeks to process the referral and make the appointment, which in turn entailed another wait of up to several months. The time between the original referral and the specialist appointment averaged 3 to 5 months. With such a lag, 40% of the appointments resulted in either no-shows or cancellations.
Between failure to schedule appointments and failure to attend the appointments that were scheduled, only 16% of CHCN’s Medicaid patients referred to a specialist ended up seeing one.
CHCN and RubiconMD began an eConsult pilot in December 2015 with two health center organizations and 40 PCPs at six sites. PCPs were given unlimited access to the service’s network of specialists. When the service was introduced, PCPs were trained in using the platform and supported by local champions — in many cases, clinician leaders who also used the eConsult platform.
PCPs who submitted eConsults on the RubiconMD platform during the pilot period reported that up to 75% of the eConsults improved their care plan. Submitting an eConsult allowed them to avoid unnecessary labs, tests, or procedures in about 45% of cases. PCPs also reported that more than 50% of the eConsults were educational and provided value for future patient encounters.
One provider who participated in the pilot said, “It has been pivotal for me. I can’t imagine practicing without it.” Another said, “I am grateful to have access to such a fast, accurate, and current consultation service.” Patients also appreciated knowing that their PCP was being advised on their case by a nationally respected specialist.
Based on the successful results of the pilot, CHCN expanded the eConsult service to all 500 PCPs in the network. RubiconMD charges CHCN a per-patient rate based on all the patients assigned to receive care at CHCN clinics, and PCPs may use the service as often as they wish. (The cost of the service represents less than 0.5% of CHCN’s budget for specialty services.)
Currently, CHCN providers submit an average of 100 to 125 eConsult requests per week, with dermatology being the most-requested specialty. Adoption varies widely among PCPs, and CHCN is currently focusing on accelerating adoption through a deeper integration of RubiconMD into its electronic health record system.
The high impact of the eConsult program makes it an essential tool for CHCN providers to improve outcomes and the patient experience. Providers who use the service say they appreciate the quick turnaround times (often within an hour or two of contact) and the opportunity to be educated by the eConsult specialists. PCPs are aware that specialist appointments are a scarce resource, and those who use the eConsult service see it as an opportunity to allocate resources appropriately, avoid unnecessary referrals, and triage patients more effectively. The specialists appreciate having more thorough workups on the patients referred to them, and eConsults help clarify the specific clinical questions to be answered.
CHCN has not done a formal study of cost savings stemming from the use of eConsults, but small-scale studies from other RubiconMD partners suggest a savings of $300 to $800 per eConsult, from such factors as avoiding unnecessary specialist referrals and duplicative testing.
An Improved Referral Process
The eConsult service has significantly improved all key elements of the referral process for CHCN in the following ways:
- Referral accuracy: By immediately being able to leverage the consultant’s input on their case, PCPs can confirm whether the patient’s condition needs in-person specialist care or requires another specialist. If not, the patient can be spared from the arduous process of getting a specialist appointment, and can instead pursue treatment as recommended by the PCP and the eConsult specialist.
- Appointment scheduling: More accurate triage and direction of specialty consults reduce the volume of in-person specialist appointments that require scheduling, reducing administrative burden on referral staff. The shorter queue for care reduces wait time for patients to access specialty care.
- Information exchange: The eConsult exchange allows for the documentation of the exchange between the PCP and the eConsult specialist, including decisions and treatment plans, and incorporates it into the patient’s medical record. Additionally, the inclusion of diagnostic tests, relevant clinical information, and a specific clinical question allow for clarity for the specialist. Specialist opinions are documented in this process and referral loops can be effectively closed with eConsults. If the patient requires in-person specialty care, the specialist can review information from the eConsult, and the PCP can order tests or assessments as directed by the eConsult specialist so that they are completed and results are available during the patient’s visit.
We believe our program demonstrates that eConsults can help save Medicaid from its complex referral challenge, and they could be an important piece of the puzzle for organizations seeking to repair their broken or fragmented referral processes and create a robust referral ecosystem.