Longmont’s Hopelight Medical Clinic handles all the usual primary care ailments that low-income and uninsured patients bring to a safety net health practice: strep throat, stitches, dental cavities, anxiety.
Hopelight also regularly sees an urgent need to address much bigger problems, including one patient’s schizophrenia. But referrals and appointments for specialty care such as cardiology or geriatrics can be nearly impossible to line up for low-income patients. The specialists often don’t sign up to take Medicaid. Spots for charity care are extremely limited and far between, if offered at all.
A systemic solution would be nice. Pending that, Hopelight has benefited from a clinic 100 miles away, whose leaders said during a networking meeting, “We know a guy.”
Summit Community Care Clinic in Frisco, another safety net provider, had found a nurse practitioner specializing in psychiatric care to handle its cases involving mental health prescriptions and treatment. Try him, Summit told Hopelight.
They did. The psychiatric nurse practitioner now splits clinical time between Summit County and Hopelight’s offices in Longmont and is available for telehealth and consulting through a patient’s electronic medical record whenever needed. The patient with schizophrenia not only has regular treatment and medication, but also a home and a job.
Having specialized psychiatric care on site has been transformational for some Hopelight patients who were typically seeing “two to three months’ wait to make it into an appointment,” said Carey Kercher, a licensed social worker and Hopelight’s clinical and social services director. People can now get them within days.
“So sometimes that makes all the difference, when people are really struggling with depression, anxiety,” Kercher said.
The challenge for lower-income patients in Colorado is that sharing a psychiatric specialist with a friendly clinic three counties away is probably not a scalable solution. The Colorado Health Institute reported in a 2019 study that “specialty care remains unattainable for many.”
That year, CHI said, 634,000 necessary specialty care appointments never happened, primarily because many underinsured patients couldn’t afford a visit, or too many specialists didn’t accept Health First Colorado’s Medicaid insurance.
Medicaid patients were nearly three times as likely as commercial insurance patients to be shut out of specialty care for lack of a provider willing to take their payment.
Kaiser Permanente Colorado offered grant money and organized a group of low-income clinics and primary care providers in 2018, to network and experiment with possible solutions to the specialty care problem.
Kaiser family physician Dr. Chris Fellenz, a co-organizer of the group, had previously worked in low-income clinics in Colorado and Vermont that couldn’t find specialty appointments for their primary care patients.
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“So I would have to send these patients to the emergency room, hoping that they would get specialty care by that route,” Fellenz said. “Which often is not successful, and it’s just the wrong way to provide that type of care.”
The three-year Kaiser-sponsored study brought the clinics together to establish a baseline of their specialty referral challenges, then collaborate on potential solutions. The clinics worked together on everything from finding a software contractor for new “e-consult” sessions with willing specialty providers, to communicating with state health finance officials on what policy changes would boost specialty networks for low-income patients.
The Colorado Health Institute director Alex Caldwell, who is evaluating the work of the cohort, praised study members who find creative solutions, like sharing a psychiatric specialist. But the extraordinariness of their effort spotlights how hard it is to multiply those kinds of solutions for hundreds of thousands of patients at hundreds of locations across Colorado, she said.
“Is that sustainable? No,” Caldwell said. “It’s sustainable in the sense that this person is paid. But is that sort of a sustainable option for addressing the broader psychiatry needs in the state? No.”
E-consult is one of the more promising potential solutions. Under that concept, the local primary care provider at a low-income clinic uses a shared electronic medical record to ask an outside specialty provider to review the case. In many cases, the specialist is able to offer ideas for the primary care provider to use without making a formal, in-person specialty care appointment. In other cases, the e-consult will result in a more focused specialty appointment for the patient, that everyone in the system knows is actually necessary.
But Colorado’s Medicaid system does not yet have a refined mechanism to pay the specialty provider for those e-consult services, Caldwell said.
“The best-case scenario would be that these specialty care providers are incentivized and have a clear set of payment mechanisms and a sustainable way of making this type of care for Medicaid enrollees part of their business model,” Caldwell said. “Right now it’s just not a sustainable business model for them.”
Medicaid will also likely have to consider increasing payment rates to specialists to attract more into the system, and also convince prospects that the state has improved how quickly it pays bills and reduced the paperwork involved for those in the Medicaid network, cohort members said.
At the Summit County clinic, some patients can use Medicaid. But others may be working and making too much money to qualify for Medicaid, while not enough to afford good private insurance or stable housing, clinic CEO Helen Royal said. When those patients need specialty care for psychiatry or orthopedics or oncology, she said, “there’s just a dearth of specialists, everywhere.”
“And so some of the things we’ve done is pull on some of the heartstrings with specialists, and have them either come into our clinic for a few days or allow a certain number of patients to see them at a reduced rate,” Royal said. “But that just can’t cover the needs.”
Each of the clinics involved in the study received some Kaiser Permanente grant money to work on local solutions. Summit used some of its grant to help pay for a dedicated referral coordinator who would fight for a patient once they’d had a specialty appointment recommended.
“That’s been one intervention is making sure we really have someone who can navigate and handhold through the process,” Royal said. “And I don’t mean that in a demeaning way to our patients. I mean, I struggle with navigating health care myself, trying to figure out specialists and where they are and when you can see them.”
The cohort study did note limited success. Completed referrals increased just under 20% from the baseline period to the final report in January. And 82% of e-consults were completed within five days, up from 74% when the study began; 62% of face-to-face visits were completed within a month, up from 56%.
Over a longer period, though, the cohort’s work did not have as big an impact. Only about half of needed specialty care appointments were actually made and completed by the patient, both before and after the study. The main problem was lack of specialty appointments available — causing 65% of the incomplete referrals.
“Significant policy barriers to creating a comprehensive specialty care safety net remain,” the CHI study concludes.
Hopelight’s Kercher confirms that while the cohort was helpful, and encouraging to clinic directors used to working out problems in isolation, each medical specialty poses its own problems. Hopelight has made progress on psychiatry, but is now looking for a good rheumatologist.
And, she added, “dermatology is a real area of need. We may have some connections there now that are starting, but that’s been a difficult specialty.”