Specialty Care Access in the Safety Net—the Role of Public Hospitals and Health Systems
Access to specialty care in the United States safety net, already strained, is fac-ing increasing pressure with an influx of patients following the passage of the Affordable Care Act (ACA). We surveyed 18 public hospitals and health systems across the country to describe the current state of specialty care delivery in safety-net systems. We elicited information regarding challenges, provider models, metrics of access and productivity, and strategies for improving access. Based on our findings, we propose a framework for assessing and improving specialty care access with a focus on population health planning.
Specialty care, access to care, safety net, health care reform
The United States’ safety-net health care system is facing a major crisis in its ability to provide specialty care for patients. A December 2014 U.S. Department of Health and Human Services’ Office of Inspector General (OIG) report revealed that nearly half of specialist providers participating in Medicaid managed care plans did not offer appointments to enrollees; furthermore, of those who did offer appointments, wait times varied widely, with 34% having wait times of longer than one month.1 A sister report released in September 2014 showed that states commonly fail to identify when access standards are not being met.2 These challenges are not unique to the safety net. [End Page 566] In February 2014, allegations that delays in care at the Phoenix Veterans Affairs (VA) health care system led to wrongful deaths prompted a detailed investigation that culminated in VA Secretary Shinseki’s resignation and national focus on long wait times for veterans seeking care.3
Problems with access to care have been longstanding in America’s safety net. As described by the Institute of Medicine, safety-net providers “organize and deliver a significant level of health care and other related services to uninsured, Medicaid, and other vulnerable patients.”4[p. 3] Over the past 50 years, investments in community health centers (CHCs) have resulted in improved access for Medicaid and uninsured patients to primary and preventive care.5 However, as access to primary care expands, so does demand for specialty care. In one study, 25% of primary care visits at CHCs led to specialty referrals.6 Unfortunately, there has been no commensurate investment in ensuring access to specialty care for safety-net patients. It is therefore unsurprising that studies have repeatedly documented challenges in specialty care access for these patients.5-8 Indeed, a recent national survey of CHCs revealed 91% and 71% respectively reported difficulty in accessing specialty care for uninsured and Medicaid patients.9 In some areas of the country, wait times for specialty care visits of six to 12 months have been reported.5
With the 2010 passage of the Affordable Care Act (ACA), wait times for specialty care visits are expected to grow. Since the implementation of the ACA, 15 million of the previously 48 million uninsured Americans have gained health care insurance.10-11 Medicaid is expected to provide coverage to as many as 18 million additional people by 2018,12 and many of these are likely to seek care in the safety net. This influx of newly insured patients, in addition to the still considerable number of uninsured, makes the access problem increasingly urgent.
Integrated delivery systems, with a public hospital or health system as the foundation, have shown promise for improving specialty care access in the safety net.13 Prior studies of specialty access, however, have primarily examined the issue from the perspective of community health centers. There is a dearth of information on how public hospitals and health systems are grappling with the challenges of providing accessible specialty care within the safety net.
We conducted a survey of public hospitals and health systems to better understand how they are providing, assessing, and improving ambulatory specialty care delivery. We propose a framework for improving specialty care access in the safety net based on study findings.
We developed and administered a telephone survey tool to elicit information in five specific categories related to specialty care: 1) access challenges, 2) provider models, 3) metrics of adequate access, 4) metrics of productivity and efficiency, and 5) strategies for improving access. The survey featured primarily open-ended questions, and was administered using semi-structured interviews.
We chose safety-net health systems based on the following inclusion criteria: 1) be listed as a member of America’s Essential Hospitals (AEH, formerly the National Association [End Page 567] of Public Hospitals), 2) serve one of the top 20 largest metropolitan areas as measured by primary statistical areas according to the U.S. 2010 census data, and 3) offer three or more specialty ambulatory services. According to AEH, essential hospitals provide comprehensive, coordinated care for the most vulnerable patients, regardless of ability to pay.14 In metropolitan areas with more than one eligible public hospital, one system was selected at random for inclusion. California safety-net hospitals were oversampled due to our interest in statewide efforts in improving access to ambulatory specialty care. To be included in the survey, California health care systems had to meet the following criteria: 1) be a member of the California Association of Public Hospitals (CAPH) and 2) offer three or more specialty ambulatory services. In total, 31 health care systems were contacted for inclusion in this study, of which 15 were in California.
We completed telephone interviews with representatives from 18 different public hospitals in eight different states. Participating health systems were advised that answers would be kept anonymous for analysis to encourage candid responses. For each participating health care system we abstracted data regarding county population size, race/ethnicity, insurance, and social characteristics using analyses from the Health Resources and Services Administration Bureau of Primary Health Care Uniform Data System, 2014 (Table 1). When possible, interviews were conducted with the ambulatory care director of each system. If an ambulatory care director was not available, alternative interviewees were chosen based on familiarity with the structure and practice of ambulatory specialty care in their organization. All interviews were recorded and subsequently transcribed for use in qualitative analysis (see interview questions, Appendix 1). Interviews were conducted by one of 14 members of the research group. Interviewers were instructed to ask follow up questions not part of the interview script if they thought new themes were emerging. Data for this survey were collected between December 2013 and March 2014. This study was approved by the University of California, San Francisco Committee on Human Research.
Four members of the research group independently read all 18 transcripts, then reached consensus about the major themes within each of the five established categories. Themes were identified by comparing and contrasting responses in addition to evaluating for key words in context in relation to the five established categories. Subsequently, each of the four members independently re-reviewed all transcripts for references to specific themes. These were collated, charted and tabulated. After analysis of the first 13 interviews, no novel themes emerged.
Eighteen of 31 health care systems completed the interview for a response rate of 58%. The remaining 42% were non-responders. Ten of the responding institutions were safety-net health care systems within California. The remaining eight respondents were from the following states: Washington, Massachusetts, Georgia, Texas (two respondents), Michigan, New York and Minnesota. The safety-net institutions that participated in the survey served diverse county populations (Table 1). The county population sizes ranged from 739,000 to over 9,000,000. Based on data from the Uniform Data System, [End Page 568]
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the racial/ethnic diversity within the communities also showed significant variation with 13 out of 18 communities being predominantly white, four predominantly Hispanic/Latino and one predominantly black. On average, 17% of the population had Medic-aid coverage, while 21% was uninsured. Social characteristics, such as percentages of population with food insecurity (9% to 23%), without English proficiency (2% to 15%), or with limited access to a physician due to cost (5% to 23%), ranged widely. The specialist to population ratio also varied widely between counties, from one specialist per 308 residents to one specialist per 1,449 residents. The majority of respondents served predominantly urban counties, making the following results particularly representative of this setting. Common responses are summarized in Table 2.
Challenges in providing adequate ambulatory specialty care were reported by all respondents. The most frequently cited challenge was an inadequate pool of specialists interested in working in the safety net from which to hire. An inability to match local specialist salaries was also commonly noted. Given the difference in salary, [End Page 570] respondents noted that physicians who are less committed to the mission of caring for the underserved are unlikely to choose to practice in the safety net.
Lack of necessary ancillary staff and clinical space limited the ability of some respondents to provide adequate specialty care. A unique challenge noted by safety-net hospitals associated with medical schools was the coordination required between the medical school and the hospital for the hiring of specialists, providers other than physicians, and ancillary staff.
Difficulty in predicting the future demand for specialists was of some concern. Specifically, survey respondents expressed uncertainty regarding how the insurance expansion under the ACA would affect the demand for specialty care. After the implementation of the ACA, some have experienced an influx of insured patients with specialty care needs in the Emergency Department who do not yet have primary care providers (PCPs).
Provider models for specialty care
A significant degree of heterogeneity in how safety-net hospitals and health systems contract for specialty care was identified. Six systems contracted individually with specialists and specialty groups to provide care. Of these, two reported variation among contracts between, and even within, specialties. For example, surgical specialties may be compensated by either case rate or lump sum based on individual contracts. Of the five health care systems directly employing specialists, two reported that this allows greater flexibility in staffing, while one identified challenges with productivity. Half of the safety-net hospitals obtained specialty care via affiliation with an academic medical center. Three systems used a combination of provider models.
Metrics of access
Most systems (89%) used wait times as their primary metric of access; however, wait times were measured in various ways. Half of the systems measured wait time as the next available appointment, whereas the other half used third next available appointment. The purpose of measuring third next available appointment time is to minimize the variation in available appointment time created by random occurrences such as cancellations. Four health care systems measured the backlog of patients waiting for appointments as a metric of access. To obtain a quantitative sense of supply and demand for specialty care within their system, five health systems measured the ratio of new referrals to the number of available appointments within a certain time frame.
In addition to quantitative metrics, eight health care systems periodically measured perceptions of specialty care access directly from specialty clinic leadership. Only one health system periodically assessed PCP perceptions of adequate access to specialty care for their patients. Seven engaged external consultants to provide one-time assessments of specialty care provision within their health system. Reports of the value of such assessments were variable.
Metrics of productivity and efficiency
The safety-net health care systems we surveyed used various measures of productivity and efficiency. Some used measures of patient volume such as the number of patient visits per clinic session or the number of visits per full time equivalent (FTE) provider. One concern with judging productivity by volume alone is that it may encourage providers to continue seeing established patients they know well because they can be seen quickly, leading to higher patient volume. This may decrease available slots for new patients. A commonly used measure [End Page 571] of productivity that may counterbalance this is the work relative value unit (wRVU). This measure attempts to capture and quantify the expertise, complexity, and amount of work a provider performs per encounter, and subsequently gives more weight to new patient visits than to follow-up visits. This was used by 50% of respondents. Three health systems measured the new patient to follow-up visit ratio as another metric assessing whether specialists are inflating patient volume by scheduling known patients.
Productivity and efficiency were assessed using the ratio of FTE providers to patients by four health care systems. Some health systems established goal ratios based either on internal data or data available through organizations such as the Medical Group Management Association (MGMA) or Practice Support Resources (PSR), though it was noted that these organizations do not provide information specific to safety-net health systems. Four health care systems reported measuring cycle time, a metric defined as the time a patient spends in clinic from arrival to departure. This measure takes into account both provider efficiency and clinic operational efficiency.
Strategies for improving access
Safety-net hospitals used a range of methods to improve access to specialty care (Box 1). A prior study of strategies to expand specialty care for Medicaid patients by Felland et al.15 found that strategies largely fell into one of three main approaches: 1) increasing specialist capacity, 2) expanding the role of the PCP, and 3) enhancing communication and coordination. Responses from our survey also tended to fall into one of these three broad categories. In an integrated health system, these three categories frequently overlap, but thinking of them discreetly can be helpful for organization and planning purposes.
Increasing specialist capacity
Strategies for increasing specialist capacity included increasing the number of specialty providers and clinics, deploying nurse practitioners and physician assistants in specialty clinics, engaging in asynchronous electronic consultations, and using various forms of telehealth, such as digital retinal photography and teledermatology, to increase the number of patients receiving specialty care. Respondents cited significantly increased efficiency using telehealth modalities, allowing specialists to complete many more care encounters in the same period of time than for in-person visits. Four systems actively identified patients in specialty clinics appropriate for discharge back to their PCP as a means of increasing available specialist appointment slots. Notably, effective discharge requires agreement between PCPs and specialists regarding the appropriate division of responsibilities, as well as development of anticipatory guidance for re-referral.16
Expanding the role of PCPs
Strategies to expand the role of the PCP included pro-longed immersion of the PCP in specialty care clinic (referred to by one health care system as mini-fellowships) and use of PCPs in mini-specialty clinics (e.g., chronic management of diabetes, osteoporosis, congestive heart failure) to reduce the number of specialty referrals. One rural health system used family medicine-trained physicians as PCPs while internists with concentrated experience in various subspecialties of internal medicine provided specialty care with back-up from fellowship-trained specialists. The concept of such so-called expert-generalists has already taken hold in Canada and is now becoming part of the discussion of cost-effective specialty access expansion in the U.S. One health care system respondent was strongly opposed to any expansion of PCP responsibilities, given concerns that PCPs were already overextended. [End Page 572]
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Enhancing communication and coordination
Health care systems also reported targeting PCP-specialist communication and care coordination as a strategy for improving access to specialty care. The most common method for enhancing communication was the use of electronic referral and consultation systems (eReferral/eConsult).17-19 These systems use Web-based technology to facilitate referrals and integrate PCP and specialist communication with the goals of increasing access, improving dialogue, and optimizing efficiency.19 Five systems reported use of a centralized referral office to pre-screen the referrals based on guidelines established by the specialty clinic, while two systems used an integrated electronic consultation system to provide pre-consultative guidance and virtual co-management when appropriate. Five systems reported co-locating specialists and PCPs in the same clinical care space with a goal of promoting informal consultations for low-complexity questions, thereby reducing the need for formal consultation visits. Informal consultations were generally not billed. Two systems reported that they had sponsored events that placed PCPs and specialists in the same social setting (e.g., informal dinners) in order to foster education and partnership.
Planning for the future
In addition to the five major areas assessed with the struc-tured interview, open-ended questions revealed novel ways in which several safety-net health systems are planning for the future. One system reported analyzing the ZIP codes of patients seen in its specialty clinics to determine the appropriateness of having specific specialists see patients in ZIP codes with a high demand for specialists. Another created a data analytics team that used Medicare data and demographic information to project evolving needs for specialty care in the coming years. Some systems were investing in telehealth as a way to provide flexibility in the face of unforeseen future demand or unanticipated obstacles. For example, during a temporary hospital closure in the aftermath of Hurricane Sandy on the East coast, various telehealth modalities helped maintain ongoing care. All health systems interviewed are grappling with how best to deal with both the predictable and the unpredictable challenges that they will face in the future.
This study investigated how public hospitals and health systems, predominantly in urban settings, are providing, assessing, and improving specialty care delivery. Across all systems surveyed, specialty care access emerged as a key challenge. There was significant variation in provider models for specialty care. Specialty care delivery was assessed using measures of capacity, specialist productivity, and clinic operations. Finally, safety-net systems reported being acutely aware of the pressing need to improve access to specialty care and they are employing a variety of innovative approaches to do so.
By necessity, when considering strategies to improve access, safety-net health systems must think creatively given resource limitations. Operating in a market-based economy, safety-net systems have a persistent challenge with funding sufficient specialists who garner higher salaries in the private sector. Under this pressure, these systems have developed innovative systems of care redefining PCP-specialist provider roles and using technology to leverage scarce specialty resources.
From the results of this study, we integrated many common practices and novel strategies into a framework for assessing and improving specialty care access (Figure 1). [End Page 574]
Safety-net hospital systems currently use several different metrics to assess their capacity to provide specialty care that meets demand in their patient population. Wait times are the most frequently used. Wait time as a metric is patient-centered, easy to measure and, importantly, is closely related to provider and patient satisfaction.20 However, there are few benchmarks regarding appropriate wait times for specialty care.21 In Canada, the Wait Time Alliance established benchmarks for wait times in five key specialty areas. These benchmarks have since been expanded to encompass a broader array of treatments and specialties.20,22 The Wait Time Alliance has assessed not only wait times, but also patient perceptions of these benchmarks,20 demonstrating that duration of wait time plays a large role in patient satisfaction. While the U.S. health care system has different patient and physician expectations, as well as different financial incentives and regulatory requirements from Canada, the creation of similar benchmarks in the U.S. would be helpful to standardizing access goals for specialty care. Other measures that systems should consider include the ratio of number of referrals to number of available appointments, patient satisfaction and both specialist and PCP provider perception of access to specialty care.
Measurement of specialist productivity is integral to ensuring that scarce specialist resources are used most effectively. Traditional productivity measures, [End Page 575] such as number of visits and wRVUs, are valuable and being widely employed. Maximizing visit-based productivity is crucial as well. Reducing no-show rates, particularly for safety-net populations where no-show rates are typically higher than in the private sector,23,24 can optimize visit-based productivity. Productivity generated through non-traditional patient care delivered via telehealth modalities and eReferral/eConsult also needs to be measured. The number of unique patients served and the ratio of new to follow-up appointments are useful measures on a population level. Regarding the latter, the appropriate ratio may vary by specialty, as chronic disease management may require long-term specialty clinic follow-up (and a lower ratio) while procedural specialists may be able to more rapidly discharge patients back to primary care. The establishment of appropriate ratios by specialty and for specific diseases has become increasingly pressing since the release of a recent report showing that greater than 50% of specialty clinic appointments are for established patients.25
Clinic operations can be assessed using measures of a range of clinic processes, and traditionally these are the most universally used and generalizable metrics. Overall access as perceived by the patient, reflected in the Clinician and Group Consumer Assessment of Health care Providers and Systems (CG CAHPS) survey results, deserves attention. One measure of the ease with which patients are interacting with specialty care clinics is the number and proportion of abandoned telephone calls (calls in which a patient hangs up prior to the completion of the telephone encounter). This may be an important marker of the quality of patient experience. Cycle time is also patient-centered and has the additional benefit of capturing many aspects of a clinic’s system, from clerical staff activity to nursing responsibilities to time spent with the physician. Using Lean techniques, a radiology department in California decreased mean telephone wait time from 20 minutes to less than one minute with no increase in staffing, and an otolaryngology clinic in Illinois decreased wait time for appointments by 28% without additional hires.26 The radiology department used Plan-Do-Study-Act (PDSA)27 cycles to identify problems and started a daily staff huddle to incorporate a culture of continual improvement, a core component of Lean. Many organizations have dramatically improved efficiency with such quality improvement strategies.28
Health system innovation
Given the perennial supply-demand mismatch for spe-cialty care in the safety net, it is not surprising that several care delivery innovations emanated from safety-net settings. Project ECHO, an initiative of the University of New Mexico to deliver multidisciplinary specialty care to rural underserved areas,29 and the innovative communication tools eReferrals/eConsults leverage scarce specialist resources to reach more patients through their PCPs. Other systems have expanded the specialist care pool by using specialty trained midlevel providers. For example, nurse practitioners with training can safely perform endoscopies.30 The specialty pool is also being expanded by specialty trained generalists (through mini-fellowships and dedicated generalist-experts) and efforts to increase scope of practice through continuing medical education (CME) and coordinated discharge to PCP. Group visits are also a promising method to expand access, particularly with chronic disease management where peer support and exchange are valuable. This has been used successfully in diabetes management.31
Planning for the future
While working to increase clinic capacity, improve specialist [End Page 576] productivity, and enhance clinic and system-based operations, health care systems are also anticipating and planning for future specialty care needs. For example, if access to a particular specialty is deemed adequate, the specialist FTE to patient population ratio can be used as a local benchmark. This ratio is specific to a given health care system’s current specialty care capacity, productivity and patient population. The ratio can be used to project specialist FTE needs based on demographic changes, such as an aging population or an expected increase in members. Predicting future specialty care needs can be challenging given the need for robust data sets and analytics as well as the ability to risk adjust for the higher prevalence of many diseases and conditions in the safety-net population, such as tobacco use, diabetes and obesity. Patient registries can lend useful information to this purpose.
Beyond access, planning for the future also requires attention to quality metrics, patient outcomes, patient experience, cost, and value. While the Center for Medicare and Medicaid Services (CMS) has introduced a set of quality measures for ambulatory care, quality measures for specialty care are lacking.32 Fewer than expected systems interviewed in this study reported assessing patient satisfaction or patient outcomes related to care they received in a specialty clinic. The International Consortium for Health Outcomes Measurements (ICHOM), has created quality outcome measures for certain specialty care conditions;33 none, however, are specific to a safety-net population. There remains a great need for quality specialty care benchmarks sensitive to the unique constraints and demands of safety-net systems.
The survey participants were, by design, skewed towards California public hospitals. Thus, the results may not be representative of a more nationally balanced sample. Nonetheless, nearly half of respondents (44%) were from states other than California strengthening the generalizability of our results. Given our inclusion criteria targeting large metropolitan areas, a minority of health systems interviewed served rural counties; of these, all were in California. The data revealed in this study, therefore, largely reflect challenges and practices in urban settings.
The survey tool developed and used for this study aimed to elicit qualitative data with open-ended questions. Because of this, there was natural variation between interviews, although the structured interview script helped to limit this variability. In addition, this may have introduced a degree of recall bias, with respondents unintentionally omitting certain information. The survey was revised for clarity and completeness based on the first four interviews, introducing another potential source of variability in responses. These four systems were not resurveyed as it was felt that there were no significant gaps in information. Finally, the response rate was 58%, making our results susceptible to selection bias. However, no major new themes were elicited after 13 interviews, sug-gesting thematic saturation.
The influx of newly insured patients under the Affordable Care Act is forcing safety-net health care systems to evaluate their preparedness to meet the demand for specialty care. As new patients enter into primary care, the demand for specialty care is increasing, and will continue to do so at an accelerating rate. This wave of increasing demand is [End Page 577] making an already strained access problem more urgent. Both the ability to accurately assess current specialty care capacity and the ability to efficiently and cost-effectively expand access are crucial endeavors for all safety-net health systems in the U.S.
While prior studies of specialty care access in the safety net have focused on the experience of CHCs, our national survey of eighteen, predominantly urban, safety-net health care systems solicited the experience of public hospitals and health systems. We found that leaders in specialty care delivery are rising to meet these challenges with a number of innovative and proactive strategies. Further study of safety-net health systems in rural communities is needed to elucidate specific challenges and strategies in that setting. We have proposed a framework for assessing and improving specialty care access that integrates the best practices observed in our survey. This framework may be a useful tool for safety-net health systems to provide appropriate specialty care to their patients.
LENA K. MAKAROUN is affiliated with the University of Washington, Department of Medicine, Division of Geriatrics and the VA Puget Sound Healthcare System. CHELSEA BOWMAN is affiliated with the Palo Alto Medical Foundation. KEVIN DUAN is affiliated with the University of California, San Francisco, Department of Medicine, Division of Hospital Medicine. NATHAN HANDLEY is affiliated with the University of Pennsylvania, Department of Medicine, Division of Hematology-Oncology. DANIEL J. WHEELER is affiliated with the University of Minnesota, Department of Medicine. EDGAR PIERLUISSI is affiliated with the University of California, San Francisco, Department of Medicine, Divisions of Geriatrics and Hospital Medicine. ALICE HM CHEN is affiliated with the University of California, San Francisco, Department of Medicine, Division of General Internal Medicine.
Appendix. SURVEY QUESTIONS
1. How does your organization provide ambulatory specialty services?
2. Are trainees (medical students, residents and fellows) involved in provision of care within your medical system? If so, what unique challenges arise from their inclusion?
3. If needed, how does your organization contract for specialty services?
4. How does your organization plan for physician staffing of specialty clinics? How does your organization plan for non-physician staffing?
5. What are your priorities in specialty staffing?
6. Are there metrics you are using to determine appropriate number of specialists?
7. What are your perceived challenges in specialty staffing?
8. Who determines allocation of resources—is there a top down or bottom up approach?
9. Does your organization have a formal planning process for ambulatory specialty care?
• If yes—can you explain what that process entails?
• If no—how do you decide to increase or decrease capacity in a given specialty area?
• What parameters do you use?
• How are you planning around the Affordable Care Act?
10. How does your organization decide that ambulatory specialty care capacity is adequate?
11. Have you changed the number or composition of your ambulatory specialty services in the past 5 years? Why?
12. The California Department of Managed Care issued regulations for patients to see a specialist within 15 days of referral. How has your organization addressed mandates to ensure access to ambulatory specialty care?
13. How does the specialist referral process work in your organization? Have you made any changes to the referral process? [End Page 578]
14. 14. Has there been any thought within your organization about expanding the scope of the primary care physician?
15. Are there any other strategies your organization uses to improve access to outpatient care?
16. Are there clinics in your organization that you think exemplify best practices in improving access?
We would like to acknowledge and thank all survey participants and their affiliated institutions for their generosity of time and experience. We would also like to acknowledge the following for their contributions to this project: Marcus Dahlstrom, Manuel Diaz, Kelly Fung, Karthik Giridhar, Joseph Hippensteel, Jennifer Mandal, Jonathan Overdevest, Heidi Schmidt, Lindsey Stephens, Kevin Yee, and Josue Zapata.