In today’s healthcare environment, specialists often have to treat every patient visit like they are working in the emergency room, according to Tim Johnson, Senior Vice President of the Greater New York Hospital Association. Without good information from a primary care provider, specialists are merely left to guess why a patient has been referred to their office.
“Are they being asked to take over care in its entirety, for an opinion, or to give a test and offer an opinion on that?” he said. “They need to know what level of engagement they should have with patients, and that often doesn’t come with a referral. Their default is to do everything.”
One way to avoid “doing everything,” which often means unnecessarily duplicating services like tests and X-rays, is by improving care coordination. Not only is this something all physicians may want to do, but with healthcare reform, will likely be required to do.
The lynchpin for care coordination is learning to work better with primary care providers, Johnson said. With patient-centered medical homes and accountable care organizations becoming more popular, primary care physicians will likely be the link between specialists, patients, and payers.
One way to improve care coordination is by tracking referrals to improve the information that is received. Referrals need to be clear as to why the patient is being sent there, what tests are needed, and what is expected to be reported back to the primary care provider. Specialists may have to take it upon themselves, prior to treating someone, to check with a primary care provider to find out what they need to know about the patient.
Electronic medical records can help improve referrals, but Johnson said it would be just as simple to have a primary care provider send a piece of paper with the information noted.
“I don’t think we are anywhere near this right now,” Johnson said. “But this kind of communication and coordination is where payers are going and that is going to get built into payment systems.”
Instead of being paid separately for each visit, payment models are moving toward incentive models with payments linked to outcomes, according to Johnson. Specialists will really need to prove their worth to the primary care physicians with whom they work.
“If I can demonstrate to a payer that I am meeting their goals in a more effective way, they will send more people to me and that will make difference in long run,” Johnson said. “They will be holding primary care providers accountable for the total health of patients and there will be incentive for referrals to certain places that are better partners.”
Team approach needed
Doctors are also going to have to adopt a team approach and learn to communicate with other providers like pharmacists, nurse practitioners, and case managers, said Allen R. Nissenson, MD, Chief Medical Officer at DaVita Healthcare Partners, Inc.
“Most practices don’t have readily available team components of care to focus on keeping patients healthy and out of the hospital,” Dr. Nissenson said. “Doctors will have to embrace non-physician team members.”
Doctors will also have to be more comfortable collaborating with other specialists as well, Dr. Nissenson said. Complicated patients often receive care from cardiologists, endocrinologists, and vascular surgeons.
“If you can’t get some common vision and understanding of patient care goal and manage patients collaboratively, great clinical outcomes will not be seen,” he said. “Getting the common vision and understanding is something that not everyone does well currently.”
A final partner in care coordination will be the patient. Because they are the common denominator between all of their physicians, patients will have to understand why tests are performed, why medications are given, and how to keep themselves healthier, Dr. Nissenson said.
Other than improving care and reducing costs, specialists need to be involved with care coordination because it will likely have an impact on their bottom line. Specialists are going to either act as consultants for primary care providers or take on the role of principle provider, particularly with complex patients like those on dialysis, Dr. Nissenson said. Specialists will have to embrace the new paradigm—value, not volume.
In their role as consultants, specialists must be able to demonstrate accountability and an awareness of costs, he said. Primary care providers do not want to work with specialists who do invasive studies on every patient, Dr. Nissenson said. “They will pick physicians who get outstanding clinical outcomes and are sensitive to resource use,” he said.