Covering the underserved beyond the medical home

Friday, November 01, 2013 12:24 PM
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Collective action problem facing Colorado specialists

Amy Beeson and Chris Haas

Despite persistent endocrine dysfunction after the removal of a pituitary adenoma, a young uninsured woman fails to present for follow-up, fearing another bill she can’t afford. . . . A child with Medicaid misses four weeks of school while waiting to be seen by a dermatologist for an autoimmune rash that his parents fear is contagious. . . . A 55 year-old man presents to his primary care physician with personality changes and new-onset seizures, but area neurologists aren’t accepting new Medicaid patients. . . .

Regardless of practice environment, any Colorado physician who encounters underserved patients – here defined as those without insurance in addition to Medicaid enrollees – is apt to have stories in which gaps in access to specialty care have played a deleterious role in quality of care and long-term health outcomes.

In the recent tide of health care legislation and national, state and local initiatives, much attention has been given to expanding access to primary care services; for example, $11 billion in the Affordable Care Act are aimed at expanding the federally-qualified health center program to meet the increase in demand. There is no such plan, however, to meet the increased number of referrals to specialists that will follow the expansion.

We cannot deny that despite the best efforts of these health centers and other primary care providers to manage and treat disease early on, patients will still require the services of a specialist when a disease progresses beyond the scope of our first-line preventative measures and treatment regimens. Underserved patients have no less need for specialty care than those who are insured outside of Medicaid. It follows that no revision of health care in our communities is complete without taking a hard look at how we can improve the interface between primary care and specialty care services, particularly in the realm of the safety net.

Minding the gaps
The Colorado Health Institute’s 2010 Colorado Safety Net Specialty Care Assessment report states that securing specialty care referrals for Medicaid enrollees and the uninsured is “difficult, inconsistent, and often futile.” One need not look far to understand why the specialty safety net is lacking. The provision of specialty care is resource intensive. Gaps in reimbursement between safety net and insured patients are wider for most specialty visits than those in primary care, and reimbursement may be delayed. Additionally, higher rates of missed appointments among the uninsured and Medicaid patients are missed opportunities both to provide care and to be reimbursed.

Beyond reimbursement, patients in the safety net are more likely to have complex needs, such as language barriers, negative social determinants of health, and co-morbid mental illness. Arranging referrals for uninsured and Medicaid patients is an additive challenge; for example, a neurologist may be willing to see the man with seizures but the patient may eventually require imaging studies that are unaffordable or inaccessible as part of that patient’s workup.

Finally, in some practice environments, specialists may be combating a perception of those who see underserved patients as being less competitive in the private insurance market; thus some doctors or institutions may fear that the very presence of uninsured or Medicaid-enrolled individuals in their waiting rooms could be a deterrent to privately-insured patients.

Overcoming the collective action problem
A collective action problem describes the situation in which Colorado specialty providers find themselves. Such a problem occurs when an entire group would benefit from a particular action, but the action is costly to any one individual to attempt alone, such that coordinated action of the group allows for a collective benefit that would not be possible from individuals acting independently.

Most Colorado specialists have a real desire to be inclusive in their practices and to care for those who are in need regardless of insurance status. Take Doctors Care: south metro Denver physicians in 80 different specialties comprise a volunteer network that serves thousands of patients each year. Specialists around the state provide volunteer services, whether onsite or offsite, and collaborate with primary care physicians who work with the underserved when needs arise. Some physician leaders seek to innovate by providing electronic consults or pioneering new, interdisciplinary models of care (such as one modeled after the University of New Mexico’s Project ECHO) to meet the needs of their communities.

But many also find themselves constrained in their practice environments by institutional and financial factors. Some choose to place caps on the number of Medicaid patients they will see; others worry that they will have to do so soon or they won’t withstand the floodgates of newly-eligible patients who are referred. Though they may feel called to be inclusive, they are unwilling to “carry the burden” of caring for the underserved alone.

Specialty care is naturally fragmented. There are numerous barriers to developing consensus within such a diverse group. Indeed, there are few occasions when it is necessary that physicians of all specialties come to the table to figure out how they will meet a need, not individually in a patchwork manner, but deliberately in a coordinated manner.

In times of change, however, the health of communities and the stability of the health system depends on this coordinated action. Through physician leadership, collaboration, and participation in organized medicine, we have the potential to create solutions that will allow practices to thrive while covering the gaps in our safety net. We need to come together as a network of providers and hospitals in Colorado to envision a way forward that can be implemented broadly and distribute the time, effort, and cost that is required to ensure that no patient or group of patients is felt to be a burden too heavy to bear.

Amy and Chris are second- and fourth-year students, respectively, at the University of Colorado School of Medicine. We are grateful to the all the Specialty Care Access focus group members from the CMS annual meeting for their insights, as well as Chet Seward, Meredith Niess, and Allegra Melillo for their contributions.

This is part of an ongoing project. We are interested in interviewing specialists about their experiences with underserved patients in their practices. Please contact us if you would like to share your experience or any innovative ideas!

Posted in: Colorado Medicine | Cover Story


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