Fibroblast is in the news! Check out this article by John Pletz of Crain’s Chicago Business.
The Shift (Part 1) – Dispelling the Shroud of Complexity: HHS’s Plan to Shift Medicare Payments from Volume to Value
By Miranda Crowell
Every so often, an industry will undergo a core-shaking and fundamental transformation; an absolute overhaul. The transformation can permeate throughout the industry. As you know, the healthcare industry has been riding a roller-coaster since the announcement of the Affordable Care Act. But the ride is far from over, and the Department of Health and Human Services (HHS) has built yet another addition to the coaster’s track.
Before the healthcare market was pulled kicking and screaming into compliance with massive Affordable Care Act (ACA) legislation, it was generally accepted that the United States had one of the most expensive health care systems in the world. And this lofty price tag did not exactly correlate with health outcomes: consumers paid more for healthcare that was arguably inferior to the services that could be obtained in other countries for less cost. (For a 2014 study on the matter, check out The Commonwealth Fund’s Study here.) This problem needed to be addressed. Boiling down the hundreds of pages of the Affordable Care Act, there are three goals at the heart of the ACA: (1) Coverage: to expand access to health insurance, (2) Costs: to protect consumers from the arbitrary actions of insurance providers, and (3) Care: to reduce costs of care and to protect the autonomy of consumer choices. In early 2015, HHS announced goals and timelines to change payment models for Medicare from quantity-based to quality-based payments. This announcement fits nicely within the goals of the Affordable Care Act. As Secretary of HHS Sylvia Burwell said in a press release on the matter, “it is in our common interest to build a health care system that delivers better care, spends health care dollars more wisely and results in healthier people.” Value-based payments strive to provide healthcare providers with a financial incentive to coordinate care for their patients and to move away from delivering care in chunks of tests and waives of treatments.
According to the HHS announcement, this shift is the first time that “HHS has set explicit goals for alternative payment models and value-based payments” in the history of the Medicare program. By the end of 2016, HHS intends to tie 30% of Medicare payments to quality or value through alternative payment models, such as Affordable Care Organizations or bundled payment arrangements, and plans to increase this number to 50% by the end of 2018. Additionally, HHS intends to tie 85% of all traditional Medicare payments to quality or value by 2016, and 90% by 2018, through programs such as the Hospital Readmissions Reductions Programs and Hospital Value Based Purchasing.
“What does all that mean,” you ask?
Don’t worry, we will walk you through it.
Many of the value-based payment puzzle pieces were envisioned in the ACA, and this announcement promulgates a timeline for implementation. As mentioned, an important piece of the HHS announcement is the healthcare provider’s participation in an Accountable Care Organization (ACO). According to the Centers for Medicare and Medicaid Services, ACOs are “groups of doctors, hospitals, and other health care providers, who come together voluntarily and give coordinated high quality care to their Medicare patients.” The main perk of participating in an ACO is that the participants share in the savings achieved for the Medicare program when the ACO is successful in lowering costs and giving high-quality care simultaneously. There are a few types of ACO programs. First, the Medicare Shared Savings Program helps Fee-for-Service providers become an ACO. Second, the Advance Payment ACO Model is an additional incentive program for select participants participating in the Shared Savings Program. Lastly, there is the Pioneer ACO Model; however, if you are not already enrolled in this model, you have missed the boat, as this program was designed for early adopters and is no longer accepting applications.
The Hospital Readmissions Reductions Program is, at the very least, well-named. In short, parts of the ACA amended the Social Security Act to establish this program. It requires CMS to reduce payments to certain hospitals that have excess readmission. Those certain hospitals use what is called an inpatient prospective payment system; a system whereby hospitals treating inpatient Medicare Part A patients are paid based on the weight assigned to a specific diagnosis-related group. It sounds complicated, but the short of it is, certain hospitals will be receiving reduced payments from CMS when excessive readmissions occur. Additionally, Congress authorized Hospital Value-Based Purchasing via the ACA. Hospitals participating in hospital value-based purchasing are paid for the inpatient acute-care services they provide based on the quality, not the quantity, of the services they provide. This program takes advantage of the hospital quality data-reporting infrastructure developed for the Hospital Inpatient Quality Reporting Program.
The HHS announcement specifically set measurable goals pertaining to the Medicare program, but HHS does not intend to limit the shift to just Medicare payments. In order to encourage and assist the entire market to jump on the value-based-payment bandwagon, Secretary Burwell also announced the creation of the Health Care Payment Learning and Action Network. This network was “established to provide a forum for public-private partnerships to help the U.S. health care payment system meet or exceed recently established Medicare goals for value-based payments and alternative payment models.” (For more information on the network, click here.) This network is an open-invite style party for all “payers, providers, employers, purchasers, states, consumer groups, individual consumers, and others.” Other tools are also available. For example, Health Care Transformation Task Force is an industry consortium that brings together private and public sector efforts to align with HHS’s value-based payment goals. This task force has many players ranging from patients to payers and strives to achieve 75% of their businesses operating under value-based payment arrangements by 2020.
Undoubtedly, the shift in Medicare payment styles will set the tone for the rest of the industry. This brief explanation of HHS’s plan to convert Medicare payments to a value-based system is Part 1 of a three-part series aimed at dispelling (or at the very least, diluting) the shroud of complexity surrounding the HHS announcement. In Part 2, we will explore various opinions about the shift in Medicare payment styles, and outline the obstacles that must be overcome in order to comply with HHS’s plan. And finally, Part 3 will discuss how the announcement will impact persons working with, but not necessarily within, the healthcare industry. Be sure to check out https://fibroblast.com/blog/ for the series as it is released.
Bread, Milk, Eggs, and . . . Healthcare? The Advantages and Limitations of Retail-Based Health Care Clinics
By Miranda Crowell
It’s not groundbreaking news that retailers such as Walgreens, CVS Health, and Walmart offer medical care to consumers “on the go.” But in the words of Emeril Lagasse, some of the retail clinic providers have really “kicked it up a notch.” From an expanded scope of services to a heavy use of technology, retail clinic providers continue to shake up and successfully compete in the healthcare market.
Here are just a few examples:
CVS Health removed all tobacco products from its shelves in September 2014, a month ahead of schedule, added the word “Health” to its corporate name, and racked up over 900 locations of Minute Clinic across 31 states and the District of Columbia. CVS Health’s website touts that the Minute Clinics have clocked over 24 million patient visits with a 95% satisfaction rating. Even more interesting is the fact that CVS/Minute Clinic has received accreditations from the The Joint Commission (the national evaluation and certifying agency for health-care organizations and programs in the United States) on more than one occasion.
Walgreens has formed partnerships with WebMD to give Walgreens customers access to “virtual wellness-coaching programs.” Furthermore, Walgreens uses the Balance Rewards program to reward their customers for exercising, for tracking their blood glucose levels, and for accomplishing fitness goals. For instance, a customer can get 20 points for jogging a mile. The Walgreens Healthcare Clinics are integrated into Walgreens stores, and a customer can schedule an appointment online. I downloaded the Walgreens app and checked out a few of the clinic’s features online. Some of the features I found most impressive were the complete cash price list for customers who will not be using insurance for their visit and the ability to securely chat with a member of a pharmacy team through the app. Additionally, scheduling an appointment was a breeze on the company’s app, and I could easily see if Walgreens accepted my insurance on their website.
Walmart has taken their services a step further. While most retail clinic providers offer medical care for non-urgent matters such as sore throats, physicals, and basic testing for things like blood glucose and strep throat, Walmart claims to be different. And to prove it, Walmart states that its “expanded scope of services enables [it] to be [the customer’s] primary medical provider.” (emphasis added).
For purposes of this discussion, if one defines the healthcare consumer as a person in need of basic medical care, then the benefits of choosing a retail clinic over other medical providers are clear: scheduling convenience (including convenient locations, extended hours, and online scheduling tools), price transparency, and timeliness. In 2014, The Advisory Board Company asked almost 4,000 consumers what they preferred in a health care clinic treating low acuity illnesses like sore throats. With little surprise, convenience holds the key: walking into a clinic without an appointment and being seen within half an hour was ranked first out of 56 variables. Traditional primary care delivery models are not ignoring the shift either. For example, Novant Health has partnered with Target in select locations to open walk-in clinics, and Temple University Health Systems operates ReadyCare clinics in Philadelphia. But what happens when what the customer thinks is a simple sore throat turns out to be something more troublesome?
While transparency through websites, apps, press releases, etc., of retail clinics is seemingly high, one area is lacking: information on patient referrals. Retail clinics are positioned to refer patients should their case become complex, but with many retail clinics offering chronic disease management, some cases that would usually be involved in referral process can be kept within the clinic doors. As Ronald L. Hammerle, President of Health Resources, stated, “The sophisticated player recognizes that whoever controls point of entry [to health services] manages the downstream revenue.” In other words, clinics with broad services, such as chronic disease management, can grow their business (leading to increased revenue) and partner with surrounding hospitals and doctor’s groups to gain new customers. But if a referral is needed, it is unclear from the retail clinics’ websites and apps how the referral will take place. Walmart’s website at least acknowledges that they can and “will be glad to” refer out a patient should the need arise. So, I took to the street to find out.
Stopping by a Chicago location of a Walgreens Healthcare Clinic, I asked the nurse practitioner how she refers patients to other doctors and specialists should the need arise. A little hesitant, she referred me with a smile to their national patient support center. (I also tweeted Walgreens the questions; I was referred to the same number). While listening to the automated voice serving to filter my call, I was informed that Walgreens Healthcare Clinics can send a summary of the visit to the patient’s primary doctor, although it does not specify how this sharing will occur. Once speaking with a representative, I was told the referral process all depends on the nurse practitioner on duty at a particular clinic and on the patient’s specific needs. In short, it is up to the nurse practitioner’s discretion as to how a patient referral is made.
The referral process from healthcare clinics to primary care doctors or specialists raises some eyebrows. On a previous Fibroblast Blog post, I posited that there are ways to mitigate medical malpractice in the patient referral process. The same concerns apply when the referring clinic is a retailer. Those medical malpractice concerns can be addressed by, inter alia, (1) referring a patient in certain situations, (2) clearly communicating patient education points, (3) securely transmitting patient health information, (4) utilizing a patient referral coordinator, and (5) clearly severing the patient/doctor (or in this instance, nurse practitioner) relationship. But when little is known about the referral process, a nurse practitioner may remain exposed to liability because it is unclear who is actually responsible for the particular patient’s care. Without more specifics on the procedure of a patient referral from a retail health clinic to a traditional doctor’s office, it seems that patient referrals may be the one limitation to retail health clinics. Moving forward, communication of a clear referral process could assist the patient in making an educated decision as to whether or not they should visit a particular health clinic. But in the present, your next health visit could be just a few clicks away.
By Miranda Crowell
In what some legal scholars are calling a “sleeper” case, the next challenge to the Affordable Care Act (ACA) was argued before the Supreme Court on March 4, 2015. King v. Burwell has likely been flying under the radar because of its über technical questions of standing, administrative law, and statutory interpretation, leaving the non-lawyer (and even most lawyers) scratching their heads.
Here is the skinny on this not so small case. In short, Petitioners, financed by the Competitive Enterprise Institute, are Virginia residents who did not want to purchase comprehensive health insurance. The Petitioners brought an action to challenge the Internal Revenue Service’s final rule which implemented a premium tax credit provision of the ACA. This final rule interprets the ACA as authorizing the IRS to grant tax credits to persons who buy health insurance on both federally- and state- facilitated “exchanges.” The Petitioners, making a textual argument, insist that tax credits can only be authorized for individuals who purchase insurance on state-ran exchanges. On the other hand, the government’s position is that tax credits can be authorized for persons who purchased insurance in both federally- and state- facilitated exchanges. Thirty-four states have federally-ran exchanges; thirteen states and the District of Columbia operate their own exchanges. Three states operate as a federal-state hybrid. As complex as the issues are in this case, the Justices will be asked to interpret and provide a final ruling on these four words: Exchange established by the State. But as we all know, a plain reading of the words in isolation is not the end of the road; even the capital letter “E” provides clues that will help the Justices make this gargantuan decision.
It is important to know that predicting the outcome of a case based on oral argument outcomes is a dangerous rabbit hole, but oral arguments can be helpful in convincing any Justices sitting on the fence of an issue. Without sending our readers into a never-ending saga on whether or not §1311 is properly deemed a “definition” or that misnomer is more properly characterized as a requirement, we do know a few things after oral argument. First, the theme of King v Burwell is undoubtedly federalism, and the Solicitor General did lean in on this theme. Second, while the Court did raise some questions on the issue of standing, it does not seem that standing or mootness will impede the Court in reaching the merits of the case. Third, Mr. Carvin, arguing for the Petitioners, raises a reasonable and fair argument (through the slightly comical overuse of the word “scintilla”) that a plain language reading of the statute will operate in favor of petitioners. And for anyone who follows the highest Court, you already know that Justice Scalia consistently supports a textual interpretation. Lastly, Justice Kagan received a host of laughter with an analogy about a memo assigned to her clerks, and she noted that, surely, Congress did not intend what she classified as a “Draconian choice” for the states. (And as an aside, Twitter user @SCOTUSHUMOR tallies Kagan as the true winner of SCOTUS laughs in Burwell.)
According to Reuters, 7.5 million people in at least the 34 states operating federally-ran insurance exchanges will lose subsidies if the Petitioners prevail. These subsidies assist low- and moderate-income people in affording insurance. If the Petitioners prevail, it is safe to say that the individual insurance market will be disrupted in a big way. But on the other hand a Government win will set precedent for great levels of deference to agencies. President Obama thinks this is a pretty straightforward case in favor of the Respondents (the Government), but legal scholars such as Jonathan Adler side in favor of the Petitioners. No matter which side of the issue you fall on, King v. Burwell will play a key role in the ACA moving forward.
By Miranda Crowell
The only real valuable thing is intuition. – Albert Einstein
Painting the Scene
Picture this: a patient comes to your general practice doctor’s office. Your staff has already completed the appropriate patient intake procedures, and the patient is waiting for you in room number three. You walk in with a smile, and after two minutes of small talk and a brief review of the patient’s medical history, you get down to brass tacks. The tests do not look great and you have your eye on some alarming signs of early stage cancer. Recognizing that the patient’s symptoms may be a little out of your normal scope of practice, you send your patient off to a specialist. However, the patient fails to make an appointment with the specialist, and a few follow up phone calls to check in on your patient turn out to be fruitless. Even though caring for that patient was always your priority, you unfortunately find yourself being sued for malpractice one year later.
The scenario described above may seem like a reel from every doctor’s nightmares, but the truth is that this situation can too easily become a reality. At first blush, it seems as though the general practice doctor did everything correct. All the boxes were checked…right? Let’s take a look, step by step.
First, a general practitioner doesn’t just refer a patient to a specialist because he or she thinks it is a good idea; a general practitioner actually has a “duty” to refer in certain instances. In a medical malpractice case out of Minnesota, a general practitioner chose to treat a patient’s wrist fracture instead of sending the patient out for a referral. The Minnesota Supreme Court stated that a general practitioner has an obligation to refer a patient to a specialist if “a practitioner discovers, or should know or discover, that the patient’s ailment is beyond his knowledge or technical skill.” Larsen v. Yelle, 246 N.W.2d 841, 845 (Minn. S.C. 1976). Each state may describe this duty somewhat differently, but each variance is rooted in the same fundamental concept: referring a patient is the right choice if the doctor feels that the problem is beyond the scope of his practice. Furthermore, a doctor cannot make a referral on a leisurely timeline; one court found that a doctor breached the standard of care for waiting just two-and-a-half days to refer out a paintball injury! Erickson v. Waller, 569 P.2d 1372 (Ariz. App. Div. 1 1977).
Once the referral is made, the referring doctor’s job is not over. Susan Shepard, director of safety education for The Doctors Company, says that the number one malpractice allegation in small- to medium-sized practices is failure to diagnose or delayed diagnosis. Of course, there are a million different circumstances that can lead to this tort allegation, but the scenario described above may apply if the patient can show a failure to properly track or follow up on a medical test, or a failure to follow up regarding missed appointments. As Jeff Brunker, president and chairman of the board of The MGIS Companies, Inc. stated in Avoiding Common Malpractice Pitfalls, it is not uncommon for a patient to fail to adhere to follow up recommendations, whether it be a referral or otherwise. Thus, Bunker recommends a “very bulletproof process for follow up and . . . [making] every effort to follow up with the patient, order the correct test, and basically chase down the patient.” A doctor’s intuition really pays off in this area: a doctor should be encouraged to reach out to the patient in the manner which he/she anticipates the best response. For instance, if a patient has a reputation for missing appointments, then that patient may need a few extra reminders to make it to the referred doctor’s office. Some patient management technologies have implemented automated reminders that can be helpful, but there is always a risk that an automated message will be ignored. Other options include phone calls, text messages, etc. And most importantly, do not forget to document your efforts.
Of course, no mitigation strategy is foolproof. However, taking some minor precautions in the areas of patient management can help ensure the efficacy of any particular strategy. For starters, the referring office can schedule follow-up appointments or referrals at the point of care. Second, a physician should ensure that the patient knows the importance of the follow-up advice; such serious business should not be taken lightly!
In the case where an actual referral is made, the relationship between the referring doctor and the consulting doctor can also play a role in guiding the actions of the referring doctor. In most instances, a doctor who simply advises a patient to see a specialist is not liable for negligence committed by the recommended physician. However, this is not necessarily true where there is a showing of a partnership or employment relationship between the physicians. (The specifics of this relationship are beyond the scope of this post.)
Another likely circumstance is that the patient does attend a referral appointment. Then what? Someone, often the referring physician, must assume a care-coordination role. Proper care coordination can decrease the risk of negligence and, not to mention, ensure that the patient’s condition has the best chance of success. HealthIT.gov notes that one way to assist in the coordination role is the use of electronic medical records. Electronic referral software is another. (For more on HeathIT.gov’s advice on health information exchange, click here.)
Poor patient-management can lead to allegations of medical malpractice, and a responsible, well-organized doctor’s office should create systems to mitigate its susceptibility to such claims. As noted, some ways to avoid problems down the road could include patient education, persistent follow-ups, and proper documentation of physician follow-up and coordinated-care efforts. Process improvement and risk management are just a few strategies to assist in the patient referral process.
Nothing in this post should be construed as legal advice.
By Miranda Crowell
For some people, going to the doctor is a daunting endeavor. The immediate questions can seem just as stressful as the health problem itself: What day can I take off work? How long will this appointment take? Will my insurance cover this visit? Referrals can multiply these problems for patients because it is human nature to attach the act of referring to a bona fide health problem.
So what happens when a patient referral is made? The referral process is different from one doctor’s office to the next, but in a tech-driven economy, patients are puzzled when they are given a prescription pad with scribbles that instruct them to go see a second doctor. The patient then must keep track of the one-fourth sized sheet of paper, call the second doctor to schedule an appointment, and pray to the health gods that the appropriate information is securely transferred from the referring physician to the specialist. Giuliana Martinez is a prime example. Following an unfortunate night-time cleaning incident, Giuliana was certain that her arm was broken. After “yelping” her way to a 24-hour emergency room, Giuliana’s fears were confirmed: her arm was indeed broken and required a visit to an orthopedist. Giuliana was one of the lucky ones, in that the referral was made to the orthopedist that was on call that night, so the doctor had some background knowledge going into the next visit. But, having a background in healthcare, she was uncomfortable with the lack of autonomy she had in choosing her orthopedist.
Referral woes are not just a patient problem; at the core, this is a physician issue. Once the primary care doctor makes the referral, they lose some control and risk management becomes a real concern. (More on medical malpractice risk management in a future blog post!) As James Merlino, M.D., President and Founder of the Association for Patient Experience puts it, “It’s not about making patients happy over quality. It’s about safe care first, high quality care, and then satisfaction.” Quality, safe care can include a pleasant and enjoyable patient experience, even in the referral process. This may require what some people fear the most: change. Changing the referral process does not have to be high stress endeavor, and a technology-based referral process can have a big payoff. Forbes considers this a balance of “systems and smiles,” stating that “Done right, the work you do on patient satisfaction, on improving the patient experience, will also contribute to improving your medical outcomes.” Micah Solomon implies that there is a link between health systems and positive patient experience, noting that improving systems, such as patient referrals, will improve “smiles.”
For this perfect intersection of quality care and a positive patient experience to occur, the process must be at least on par with customer expectations. At a minimum, the patient experience is kindness and efficiency. In a world of calling for a car with a phone application, having groceries delivered to your home, and booking doctor appointments on websites like ZocDoc, its no wonder that technology has found its way to the healthcare industry. This begs the question: why has the referral process been left behind? By incorporating new technology into the referral process, customers will not be sent back to the Stone Age to schedule their next doctor’s appointment. Patient benefits include, but are certainly not limited to, booking the referral appointment at the point of care, ensuring that insurance concerns are eliminated, and receiving reminders about the future appointment. Giuliana would have been empowered with choices in her own treatment and booking the appointment right from the ER could have been a breeze, all with an electronic referral system in place that is right for the particular organization. From the physician’s perspective, increased in-network referrals, increased downstream revenue, and increased patient expectations make the change worthwhile. In short, booking a referral can be made as quickly as the patient can reference their iPhone calendar. While the kindness expectation is up to the staff, the efficiency component can certainly by shifting to a technology-based referral process. It is possible for the referral process to be on par with the rest of our tech-driven society, and when considering how to make this happen, consider Fibroblast.
By Dr. Andrew Albert, CMO
Almost 20,000,000 times a year, patients are sent to their provider and found to be in the wrong place. This essentially means that the provider they are seeing is not the correct provider for their ailment. Ultimately this can lead to poor health outcomes, ineffective use of time and exorbitant patient and health care cost. Seventy-five percent of specialists receive one to two clinically inappropriate referrals every month. Overall, 7.8% of referrals are clinically inappropriate and 87% of physicians believe this happens on a routine basis. There is nothing they can do about it. The system is broken.
Imagine a clinic schedule of 30 patients a day. The ability for a clinic to troubleshoot each and every referral that comes through the door is an arduous process. Imagine the awkward encounter in the exam room: The specialist: “Mr. Jones, how can I help you?” The patient: “Ummm, my doctor sent me.” When this happens, the specialist’s office frantically calls the referring primary care physicians office to find out the reason for the visit. Most of the time, getting through to the office to obtain clinical information in a timely manner is almost impossible. A message is left at the referring primary care office and panic ensues. The specialist’s office spends a significant amount of time trying to determine the extent of the referral patient’s illness as well as the rationale for the referral.
“My doctor sent me” is all you have as a clinician. These patients are often without symptoms. Herein lie two problems: (i) the patient is potentially in the wrong office and (ii) the reason for the referral can extrapolate to any ailment. Both parties look at one another expecting to better understand the issue at hand. After a thorough history and physical of the patient, the patient leaves with scripts in hand; scripts for tests she likely don’t need 75% of the time. Imagine the patient’s surprise when she finds out she was sent to the wrong physician and underwent tests she didn’t need. If only the communication could have been better.
Referrals can be wasteful. Proactive doctors’ offices will ask patients why they’re coming in. Unfortunately not all doctor have the staff time to dedicate to this process. Administrators are buried in paperwork at baseline.
As a clinician I do my best to avoid wasteful referrals. Ultimately an erroneous referral leads to significant waste in the healthcare system. This leads to unnecessary expense for the insurance company and hospital system. The doctor’s job is to determine if something is terribly wrong. Therefore a referral is not as simple as the patient showing up the wrong physician; doctor and patient shrugging their shoulders and the patient leaving. There are tremendous legal ramifications. If something is truly wrong, i.e. a concerning EKG result or arrhythmia, the physician is responsible.
A streamlined process is absolutely necessary. A process that facilitates the handoff from one doctor’s office to the other, with the appropriate clinical information. If the referring physician is truly dedicated, the clinical information must be conveyed in a seamless fashion. Fibroblast offers a comprehensive and efficient system to facilitate an appropriate and safe referral.
It is important to consider a setting of multiple referrals. A primary care doctor can evaluate a diabetic patient and generate up to three or four referrals for that patient. Often times the diabetic will need to see a nutritionist, a cardiologist, an endocrinologist, an ophthalmologist and a podiatrist. How can we minimize errors and facilitate a safe “hand off?” Who is going to oversee this process?
If the referral process is broken and unnecessary referrals are made to the wrong physicians in the setting of a system where referrals are necessary to improve health outcomes, a very thoughtful and careful system needs to be in place. EMR’s are not dedicated to this process. There is a high level of complexity to an EMR and if we are going to fix the referral process, the technology needs to match the need. Fibroblast can reconcile these disparities in a careful, easy and efficient manner.
Ultimately, when a patient states that his or her doctor sent them, the appropriate information will be at hand and hospitals and healthcare systems can ensure patient safety and provide better care for their community.
By Dr. Andrew Albert, CMO
One in 20 people will get colon cancer. It’s the second most common cause of death in men and third most common cause of death in women.
Colon cancer arises from small polyps that generally take up to 10 years go grow. Ten years, that’s quite a long time. Some patients have few polyps and others have many. Unfortunately, colon cancer requires just one polyp to rear cancer’s ugly head. I would venture a guess that most of my patients–90% or more–have one polyp after the age of 50. Guidelines by the American Gastroenterology Association suggest Colonoscopy for all patients over 50 (some before then). There are multiple options provided patients to prevent colon cancer; none as effective as Colonoscopy. A Colonoscopy takes 30 minutes of procedure time. Unfortunately, studies have shown (over the past 5 to 10 years) that 30-40% of patients proceed with Colonoscopy. The remainder fails to comply—the one in 20 to get colon cancer.
Why Aren’t More Patients Following Up and Getting Colonoscopies?
Why is this case? What causes such a discrepancy? Polyps and lack of treatment equals colon cancer. Isn’t this intuitive? Fear, apprehension, and angst about the procedure affect compliance with recommendations for screening. At times, patient may exhibit denial. “There is nothing wrong with my health, I feel perfectly fine”. As a physician, these words send waves of anxiety through me. Aside from walking the patient to the gastroenterology suite, there are few options in addressing these barriers. These barriers know no socioeconomic or cultural boundary.
The Patient Referral Process is Broken
What about physicians? With the development of shared risk, there is greater attention paid to the referral process; more significant focus on “measures” and “outcomes.” Referrals to gastroenterologists have increased significantly. Approximately 69% of primary care physicians (PCPs) report they send specialists patients’ medical history and reason for consultation at time of referral, though only 35% of specialists report that they receive such information. Moreover, nearly 81% of specialists claim to send notifications about test results back to referring PCPs, though only 62% of PCPs report receiving such information. Ultimately, only 50% of referrals actually lead to a completed appointment and most referring physicians have no idea whether their patient was seen in the first place.
Unfortunately, it’s because of ineffective scheduling. The referral process is broken. Hospital systems across the nation describe an “abyss,” a chasm between the referring and receiving physicians’ offices. The boundaries of this abyss can often be measured in feet not necessarily miles. The issue is so simple and clear. Walking across the hall or driving the few blocks from one office to another can present a challenge. Patients get lost and it’s out job to help them find their way.
There are numerous additional issues with completing colonoscopy. A multivariate analysis from the Journal of General Internal Medicine identifies barriers including those of female sex, younger age, and insurance type. Patients also perceive colonoscopies as being painful and have concerns about modesty and bowel preparation. As a result, adherence to colonoscopy is low. Ultimately, better communication with patients and resolution of barriers will increase compliance. Making the process of scheduling easier will decrease the impact of such barriers.
This past year, I had the unfortunate experience of diagnosing three colon cancers on the same day. Three women presented to the gastroenterology lab. These lovely and relatively young women were 60, 62, 65 years of age. All three came in for screening colonoscopy. None of them had symptoms. All were found to have colon cancer; a situation that could have been avoided.
Colon cancer is preventable beatable and treatable. Imagine looking at the warm, kind, anticipatory faces of those patients. Then imagine your patient’s smile disappear as you inform them they have cancer. Continue to imagine that pit in your stomach when you realize that if they presented sooner, these conversations would never have taken place.
Thinking about the situation, everyone is affected by this outcome. Aside from the obvious consideration of the patient, one also needs to consider the family, the primary care provider, and the insurance carrier. How could we let this happen!? Colon cancer is “preventable” and all I can think about is how we could have done better for our patient. With all our knowledge, what could we have done differently?
Let’s Start Fixing the Referral Process by Automating it
The referral process is broken and we can no longer rely on patients to make the right decisions with their care, even if informed. We, as providers, need to take responsibility for safety and outcomes. We need to do better for our patients. It’s time to focus on processes at hand and improve healthcare with each attributed life. We need to address these barriers head-on.
An automated referral management platform eliminates patients “falling through the cracks.” The referring doctor or the doctor’s staff would be able to refer at the point of care and schedule the referral, increasing the likelihood that patients will follow through with the procedure. We have seen this with plastic surgery and weight loss referrals in particular. An automated referral management platform would help ensure timely diagnosis and treatment for patients, decreasing the subjectivity of the process overall. Does one really choose to have a colonoscopy? No. Will patients follow through if their physician facilitates the process? Absolutely.
Since the referring doctor schedules the required appointment before the patient leaves the office, the referring doctor can ensure that the specialist within the appropriate time frame will see the patient. Manually tracking referrals is not only difficult and time-consuming, but it also draws health care staff away from other critical tasks. An automated referral management platform takes care of this problem by allowing providers in the referral chain to see whether patients attended their appointments. The coordination of care would no longer be an issue. Such technology would further advance the referral process by sending automated appointment reminders via email or text messages, further promoting patient attendance.
Fibroblast facilitates patient care, improves outcomes, improve safety and quality for healthcare systems. The benefit is clear. It’s time to take the next step!
How Improving the Radiology Referral Process Can Improve Patient Care, Patient Experience, and Reduce Health Care Costs in the Long Run.
This following is a guest post by Dr. Sanket Shah, a Resident Physician in Diagnostic Radiology.
Imaging is an integral part of a patients care. Radiology is a key diagnostic tool for many diseases while also playing an important role in monitoring treatment and predicting outcome. Despite the rapid technological advancement in diagnostic imaging, access to this valuable tool often falls through the cracks related to poor imaging referral management. When choosing a specialist or procedure (including imaging centers), patients rely heavily on their doctor to make the referral that is in the patient’s best interest as outlined in this survey carried out by the Center for Studying Health System Change. However, it seems that more can be done at the point of care to improve this process.
Often, patients go to see their primary care doctor in the ambulatory setting with an ailment, for which an imaging test is ordered. For example, a family member recently fell during the Chicago Marathon due to the large crowds at the beginning of the race and injured his elbow. A day after the race he went to see his primary care doctor. When I asked him what his doctor said about his elbow, he told me he received a prescription for an elbow X-ray. As a resident physician in radiology, I was excited to review his radiograph with him only to be disappointed to find out he had not yet gotten his x-ray (almost 2 weeks later). On top of that, it took him about an hour to find his prescription (see below), which was buried in other important household paperwork, when I asked to see it.
The puzzled look on his face when asked where he was going to get the elbow x-ray taken only made my frustrations with the process grow even more. I spent a few minutes that night looking on the health organization’s website his doctor is affiliated with, where there is a list of preferred in-network imaging centers. He was essentially expected to set up his own appointment and bring his paper referral with him to the appointment in order for the appointment to be accepted. As his elbow was still visibly swollen 2 weeks later, I urged him to get the X-ray taken as soon as possible. If he indeed has a fracture (which I suspect he may), the process has already delayed his care.
Beyond the point of care, there are also gaps in physician communication which often cause a delay in patients care. I can share a recent example which involved a patient getting an X-ray for a sports related injury. The x-ray demonstrated a fracture in a location which also indicated ligament damage, which was correctly reported by the radiologist. The ordering physician was late to follow up on the imaging results probably assuming the radiologist or patient would inform him of any abnormality requiring follow-up. The patient assumed his doctor would have notified him if anything was wrong, and the radiologist assumed the ordering physician would have followed up with the final report or the patient. This ultimately resulted in delayed care for the patient which rendered him outside of the time window necessary to successfully repair the torn ligament. Who is at fault? Is it the individuals or the process? Many providers often do request imaging reports be faxed to their offices once the radiology report becomes available, which often do not go through for many various reasons including a high volume environment. As a result, imaging findings that are deemed “non-urgent” often fall by the wayside. With the tools available today, such a process gap should be avoidable and studies have showed that using a referral tool within an EMR can improve physician communication.
Although many larger healthcare organizations are implementing such tools to improve requests for imaging, lab tests, and specialist referrals in the era of accountable care and meaningful use, many smaller organizations and stand alone doctors’ offices still lag behind the curve. One big hurdle in the system today seems to be the lack of interoperability between large EMR vendors which often limits a physician’s ability to exchange patient information as stated in this recent New York Times article.
As imaging plays a pivotal role in a patients care, it is important for both providers and imaging centers to develop better methods to manage their patients imaging referrals. If providers were capable of processing an imaging request at the point of care before a patient leaves the primary care doctors office, it can make an immediate impact on a patients care, as it makes them much more likely to follow through with their appointment. This would also create a healthier relationship and improve communication between imaging specialists and their referring physicians, which is right in line with the American College of Radiology Imaging 3.0 Campaign. With the patient’s best interests in mind, there is much room for improvement in increasing speed to schedule (in-turn decreasing turn-around time), driving patients to centers in-network, while also improving an imaging centers referral capture rate. It’s time to utilize technologies that make it easier for patients to get the care they need and for doctors to share information and communicate with each other better to enhance patient care.
Problems with patient referral management are a major concern for healthcare providers everywhere, and if they aren’t, they should be. One of the major problems doctors have with referring patients is out-of-network patient leakage. However, there’s something worse at stake. When the referral system doesn’t work as it should, doctors and their patients are at serious risk. Doctors face the potential for malpractice suits and patients face an increased risk of health complications or even death.
The following is what too frequently happens in a referral situation: A patient shows up with a medical concern that warrants the review of a specialist or a doctor notes health matters of concern during an office visit. The doctor gives the patient a referral on a piece of paper and the patient leaves the office with instructions to call and schedule an appointment. Either the patient fails to make an appointment to see the specialist in a timely manner or the patient loses the paper altogether. Sometimes the patient does make the appointment, but he waits far too long to actually see the specialist. In all of these cases, the patient doesn’t get the timely diagnosis and follow-up care he needs.
Such issues with referrals can lead to a missed or delayed diagnosis, and in the case of serious diseases and conditions like cancer or heart disease, that may cost the patient her life. As for the doctor in question, he or she may be slapped with a malpractice lawsuit, accused of failure to diagnosis or delay in treating the patient. In such cases, handing the patient a piece of paper with a referral on it simply isn’t good enough.
BETTER REFERRAL MANAGEMENT TO REDUCE MALPRACTICE RISK
Providers and medical malpractice insurance carriers would be well advised to consider an automated referral management system designed to eliminate the risks outlined above and reduce patient leakage. Here’s how such a system can help:
Lost or Forgotten Referrals: An automated referral management platform would eliminate the chance that a patient fails to follow up with a specialist. The referring doctor or the doctor’s staff would be able view a list of in-network specialists while the patient is at the point of care and schedule the referral appointment with the specialist seamlessly and in real time. This helps increase the chance that the patient will follow through with seeing a specialist and provides documentation that the referring doctor provided the appropriate referral.
Delayed Treatment: An automated referral management platform would help ensure timely diagnosis and treatment for patients. Since the referring doctor schedules the required appointment before the patient leaves the office, the referring doctor can ensure that the specialist within the appropriate time frame will see the patient.
Poor Patient Care Follow-Up: Another major issue with patient referrals is follow-up care. How can doctors determine whether patients kept their appointments and received appropriate care? Manual tracking is not only difficult and time-consuming, but it also draws health care staff away from other critical tasks. An automated referral management platform takes care of this problem by allowing providers in the referral chain to see whether patients attended their appointments, as well as the outcome of the visit and any recommended follow-up care. This technology would further advance the referral process by sending automated appointment reminders via email or text messages, further promoting patient attendance.