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Improving Access to Specialty Care for Medicaid Patients: A Conversation With Laurie E. Felland, MS, Director of Qualitative Research at the Center for Studying Health System Change | AHRQ Innovations Exchange

Improving Access to Specialty Care for Medicaid Patients: A Conversation With Laurie E. Felland, MS, Director of Qualitative Research at the Center for Studying Health System Change | AHRQ Innovations Exchange
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Improving Access to Specialty Care for Medicaid Patients
A Conversation With Laurie E. Felland, MS, Director of Qualitative Research at the Center for Studying Health System Change

Improving Access to Specialty Care for Medicaid Patients: A Conversation With Laurie E. Felland, MS, Director of Qualitative Research at the Center for Studying Health System Change

By the Innovations Exchange Team 


Community health centers provide primary health care services to medically underserved communities and vulnerable populations. Health centers that meet certain criteria—including providing comprehensive, culturally competent, and high-quality care—are designated as federally qualified health centers (FQHCs) and receive Federal funding. Primary care providers at community health centers have long struggled with obtaining and coordinating access to specialty care for low-income patients. A June 2013 Commonwealth Fund report1, coauthored by Laurie E. Felland, MS, examined six innovative models for improving access to specialty care for Medicaid patients.

Innovations Exchange: What barriers do low-income patients face in gaining access to specialty care?

Ms. Felland: Medicaid pays less in general for specialist services than do Medicare and commercial health insurers. Few specialists accept Medicaid patients, and those who do often limit the number they treat. As a result, patients often face long wait times, which can have adverse health consequences.2 Low-income patients also may have difficulty arranging transportation and childcare, which are barriers to keeping appointments with specialists. Many small specialty practices lack the resources to address these barriers, whereas FQHCs are better equipped to offer social and support services.

What is the role of FQHCs in improving access to specialty care for low-income patients?

In some states and communities, FQHCs, Medicaid programs, health plans, and providers are collaborating to improve timely access to medical and surgical specialty services for Medicaid enrollees. My colleagues and I examined six models for improving such access—in Connecticut, Illinois, Minnesota, New Mexico, Oregon, and Tennessee—that included FQHCs as partners.

What were the main goals and strategies of the six models?

The models supported innovative ways to deliver specialty care and ensure that specialty-care referrals for Medicaid patients were appropriate and efficient.

The main strategies they used were:

  • Increasing the availability of specialty care by bringing specialists to primary care sites remotely through telemedicine or in person, and by using physician assistants to deliver specialty care
  • Expanding the role of primary care physicians and nurse practitioners in managing certain specialty needs, supported by training and electronic consultations
  • Enhancing communication and coordination among primary care providers and specialists through the medical home approach, including the use of dedicated staff (access coordinators) to arrange specialty care

How did these model programs ensure that specialty referrals were necessary?

Many of the models aim to reduce the need for inperson specialty referrals by providing the needed specialty service within the primary care setting, or using information technology for consultations with specialists. Patients with complex medical needs were referred to specialists for further evaluation or procedures. For example, CareOregon reserved the use of orthopedic specialists for procedures and surgeries, and for handling emergencies. Physician assistants, specializing in orthopedics, screened and triaged patients to identify those who did not need surgery or were not good candidates for surgery. The physician assistants provided patients with basic orthopedic services and assisted them with other options, such as weight loss, diabetes self-management, or physical therapy.

In addition, some models used Web-based communication tools, such as eReferral or eConsults, to help primary care providers obtain an expert consultation and avoid inappropriate or premature referrals.

How is technology increasing access to specialists for low-income patients?

Telemedicine enables specialists to communicate remotely with primary care providers, and to diagnose and treat patients. Nashville-based specialists used telemedicine to treat patients at primary care sites throughout the state. University-based specialists in New Mexico used videoconferencing to consult remotely with primary care providers and trained them to treat straightforward specialty conditions. Cardiologists at the University of Connecticut used eConsults to respond to questions from primary care providers and provided guidance about patient management.

What improvements resulted from improved access to and efficient use of specialists?

Preliminary findings show increased availability of specialist appointments, although demand for specialists exceeded the supply. For example, Community Health Centers, Inc. (CHCI), a large FQHC that operates primary care centers in Connecticut, reported that the percentage of diabetic patients receiving retinopathy screening rose from 10 percent to 40 percent.3 After implementation of Project ECHO (an acronym for Extension for Community Healthcare Outcomes) at the University of New Mexico, wait times for rheumatology appointments declined from 6 months to 1 month.3 In addition, CHCI found that the use of telemedicine for diabetic retinopathy screening saved approximately 35 percent (roughly $28) per patient compared with a conventional examination.3 Project ECHO, which trained primary care providers how to treat hepatitis C, found that patients had outcomes comparable to those of patients treated by specialists.4

Who funded these models to improve access to specialty care?

Often, the funding came from a combination of public and private sources, with most of the funding coming from private grants, State Medicaid agencies, or Medicaid managed care plans. Some hospitals provided assistance to health centers to increase specialty services or to have hospital-based specialists provide training for primary care providers. Providers also covered some of the costs from their operating margins. For example, the University of Chicago Medical Center provided capital funds for Access Community Health Network (ACCESS), a FQHC operating approximately 40 community clinics in the Chicago area, to almost double its number of examination rooms and added specialty services, with ACCESS absorbing the operating costs of the expansion. By providing funding for some of these initiatives, Medicaid-funded programs can demonstrate their ability to provide specialty care more efficiently.

What Medicaid payment policy changes may be necessary to accommodate these models?

State Medicaid agencies may want to investigate how they can reimburse specialty care that is delivered in nontraditional ways such as consultations that use electronic messaging or telemedicine. Medicaid typically does not reimburse primary care providers for the time or costs they spend on training. States that want to achieve cost savings need to document how these new models can save money.

Community health centers that want to provide more specialty services must first obtain Federal and State approval to receive the enhanced Medicaid payment rates for those services. Also, most State Medicaid programs will not reimburse an FQHC for more than one medical visit per patient per day, which requires the FQHC to absorb the cost of the second visit or to schedule the specialty appointment for a later date. State Medicaid programs might consider paying for two medical visits per patient per day or increasing the payment rate for medical visits to FQHCs to account for the additional cost of providing a specialty service.

How generalizable are these models and strategies?

The strategies implemented in these models can be applied to patients in general, regardless of their insurance status. In public and private health care settings, providers can seek to use their resources more efficiently by adopting strategies such as using telemedicine, working with access coordinators, or getting training to help them make appropriate specialty referrals.

What direction will these models take in the future?

As health care reform continues, health centers and primary care providers can expect to see more patients who will be eligible for Medicaid health insurance or subsidized private coverage. The Affordable Care Act expands Medicaid coverage to people with incomes of up to 138 percent of the poverty level, and health insurance exchanges will provide subsidized coverage for people with incomes of up to 400 percent of the poverty level. The model programs that we identified in the report offer practical strategies for increasing access to specialty care as primary care expands through medical homes and accountable care organizations, and as more specialty needs are identified.

About Laurie E. Felland, MS:

Ms. Felland is a senior health researcher and director of qualitative research at the Center for Studying Health System Change, where she focuses on low-income people's access to medical care, including safety net providers and public insurance programs. Previously, she was a policy analyst at the Massachusetts Division of Health Care Finance and Policy and a redesign analyst at Regions Hospital in St. Paul, MN. Ms. Felland holds a bachelor's degree in economics from Carleton College and a master's degree in health policy and management from the Harvard School of Public Health.

Disclosure Statement: Ms. Felland reported that the Center for Studying Health System Change received a grant from the Commonwealth Fund to conduct research and analysis of Medicaid specialty care models and publish the findings in a report.

1 Felland L, Lechner AE, Sommers A. Improving access to quality care for Medicaid patients: policy issues and options. The Commonwealth Fund. 2013 Jun. Available at: http://www.commonwealthfund.org/Publications/Fund-Reports/2013/Jun/Improving-Access-to-Speciality-Care.aspxExternal Link.

2 Resneck J Jr, Pletcher MJ, Lozano N. Medicare, Medicaid, and access to dermatologists: the effect of patient insurance on appointment access and wait times. J Am Acad Dermatol. 2004;50(1):85-92. [PubMed]

3 Li Z, Wu C, Olayiwola JN, et al. Telemedicine-based digital retinal imaging vs. standard ophthalmologic evaluation for the assessment of diabetic retinopathy. Conn Med. 2012;76(2):85-90. [PubMed]

4 Arora S, Thornton K, Murata G, et al. Outcomes of treatment for hepatitis C virus infection by primary care providers. N Engl J Med. 2011;364(23):2199-207. [PubMed]

Last updated: July 17, 2013.

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