By Ruth Carol, contributing writer, May 01, 2013
As the number of patient-centered medical homes (PCMHs) and accountable care organizations (ACOs) increases rapidly and moves outside of the federal government’s realm into the world of private insurers, dermatologists are looking for ways to meet the expectations of these entities, which emphasize primary care. To accomplish that, some dermatologists are aligning themselves with the driving tenets of these care delivery models and systems: improving coordination of care, increasing patient satisfaction, and improving quality while controlling costs.
Although the Centers for Medicare and Medicaid Services continues to tout PCMHs and ACOs as a cure for the failing health system, it is no longer the only one forming them. Major health plans are now embracing the PCMH model, rolling them out from Connecticut to California. Likewise, provider organizations, health systems, and commercial payers are building ACO models. As many as 428 ACOs are operating in 49 states, according to health care consulting firm Leavitt Partners.
Dermatologists can foster coordination of care with primary care physicians (PCPs) in several ways, starting with communication. While it may sound like a simple enough activity, communication between PCPs and specialists is clearly lacking. A recent study published by the Commonwealth Fund (Issue Brief. 2011 Oct 19;23:1-14) showed that nearly 70 percent of PCPs report always or almost always sending patient information to the specialist, but only approximately 35 percent of specialists report receiving such information. Conversely, approximately 80 percent of specialists say they always or nearly always send consultation results back to the referring PCP, but only approximately 62 percent of PCPs said that they received such information. [pagebreak]
“The bottom line is that communication has not been seamless,” said Alexa Boer Kimball, MD, MPH, vice chair of dermatology at Massachusetts General Hospital and senior vice president of the Mass General Physicians Organization. Some dermatologists are great at this; they always send a letter back to the referring physician, she noted. For others, it has not been a high priority, perhaps because dermatologists are in such high demand.
Standardizing communication can help. As an example, the physician referral forms at Massachusetts General Hospital, which receives numerous referrals, are starting to include questions about the referring physician’s communication preferences. That way, the practices can know whether to write, email, or call the referring physician. This can be done in a small practice as well. “You may not be able to tailor communications for every referring physician,” she said, “but certainly for your most frequent referring physicians.” Know the communication preferences for top referring physicians and make sure the front desk staff also knows them, she advised.
Specialists should always acknowledge a referral and communicate the diagnosis and treatment recommendations back to the referring physician, said Marc Halley, MBA, president and CEO of Westerville, Ohio-based Halley Consulting Group. However, some PCPs want a call prior to the consult to discuss the patient’s situation, he said. “Primary care physicians want to be engaged in the care of their patients and treated as a member of the care team.” [pagebreak]
Furthermore, communication shouldn’t be confined to patient referrals. Halley recommended tracking referrals on a monthly basis for each physician. Dermatologists should periodically call or sit down with the PCPs to ask how they can help better serve the PCPs’ patients. This should be done especially if there is a change in referral patterns during a 60-day period. “Find out how to meet their patients’ needs and each other’s,” he said. Find out what their areas of frustration are. Finding the time to do this can be a challenge because physicians have such busy schedules, but Halley believes it is worth the time as he always hears from physicians, “I tend to refer to people I know and trust.”
Coordinating care may mean educating PCPs in how to treat common, uncomplicated dermatologic conditions. Randall Roenigk, MD, the Robert H. Kieckhefer Professor in the department of dermatology at Mayo Clinic, has helped develop care models for PCPs treating acne and warts. At Mayo Clinic, patients first see the PCP for these conditions. If typical treatments fail, then they are referred to a dermatologist. “The family practitioners were appreciative that we provided these guidelines and they’re happy to follow them because it’s not their area of expertise,” he said. Dr. Roenigk views this as a form of triage for a patient-centric practice whereby the PCPs manage the simple cases and refer the more complicated ones. “I’m happy not to see patients more appropriately treated in the primary care physicians’ office,” said Dr. Roenigk, who has not seen a drop in demand for his services during the 10 years that these care models have been in place.
He understands that some dermatologists, especially those in solo practices who are not part of a larger group such as an ACO, may feel threatened when such top-down decisions are made. However, Dr. Roenigk has a different viewpoint. “You can have more influence if you participate in the process,” he said. So instead of insisting that PCPs should never treat any basal cell carcinomas (BCCs), show them how to effectively treat superficial BCCs, he said. Instead of insisting that PCPs should never perform biopsies, suggest that they send them to a trained dermatopathologist to read them. [pagebreak]
Dr. Roenigk also coordinates care with PCPs using e-consults. According to a recent Commonwealth Fund report, e-consultation can improve care coordination and increase patient access to specialists. Other entities, such as the Specialty Care Initiative in San Diego, use e-consults along with round tables, lectures, and webinar series to help improve care coordination between providers.
About four years ago, Mona Z. Mofid, MD, a dermatologist in private practice in La Jolla, Calif., became a member of the Sharp Community Medical Group (SCMG), an independent physician association that covers 140,000 lives in the San Diego area and includes more than 225 PCPs and 530 specialists. As part of a pilot project, she traveled to two busy PCP practices to provide dermatologic care to patients and education to PCPs and physician extenders. Today, Dr. Mofid travels seven days per month to five busy primary care offices that are part of SCMG. The program was designed to increase access to members, provide better patient care, improve member satisfaction, and coordinate care at the patient’s “home base” while reducing costs, she explained. It was primarily initiated to assist elderly patients who had difficulty traveling. In addition, Dr. Mofid said, there were a lot of unnecessary biopsies being performed because PCPs sometimes had difficulty identifying benign lesions, such as traumatized seborrheic keratoses, which a dermatologist may have been able to diagnose without a biopsy, possibly through the use of dermoscopy. Rashes, for example, were often misdiagnosed as tinea, which led to a delay in diagnosis and unnecessary medications being prescribed. Basal cell carcinomas, she said, may be able to be treated with electrodessication and curettage under the pilot program, whereas the PCP alone might have biopsied the BCC and then sent the patient to a surgeon for an excision.
“You can’t expect primary care physicians to know all about the skin. We spend more time on the skin during post-graduate training than they do on the entire body,” Dr. Mofid said. “Dermatology is a respected specialty for a reason, but that doesn’t mean we can’t teach them a lot of the bread and butter because there’s so much of it.” [pagebreak]
In the beginning, she provided a lot more hands-on education to the PCPs and physician extenders who shadowed her at the various clinics as they learned the basics and became more comfortable with patient diagnoses and treatment. Nowadays, PCPs and physician extenders still see some patients with her amid their normal schedules. She may pull providers into a patient visit if there is a teaching opportunity, said Dr. Mofid, who travels with liquid nitrogen, lidocaine, a biopsy kit, a portable electrocautery machine, and a dermatoscope, among other supplies. Sometimes a provider asks her to take a quick look at a patient who is there for a non-dermatology appointment. Some PCPs won’t treat atypical moles and want her to do full body scans on patients with a history of skin cancer. Others buy their own dermatoscopes and take courses. Over time, some PCPs become comfortable, for example, treating superficial BCCs with imiquimod. “Every physician has his or her own comfort level, largely based on his or her experience and patient population,” she said.
For dermatologists who want to foster care coordination with referring PCPs, Dr. Mofid suggested taking half a day every few months to visit or shadow a referring PCP. Another option is to have the PCP schedule appointments one afternoon with complex dermatology patients to see the patients together.
This program has increased communication and collegiality between her and the PCPs in SCMG, Dr. Mofid said. “Before these physicians were names on a paper. Now they are my colleagues and we are a team taking care of these patients.” Although it requires her to be a little more flexible when she is not working in her office or with her staff, the experience is fulfilling as a physician, teacher, and colleague.
The program also resulted in reduced costs of approximately $1 million, or 25 percent of the dermatologic expenditures, in one year, Dr. Mofid added. SCMG pays her an hourly wage for her time spent in the five primary care practices; the individual offices collect and keep the copays for the visit and SCMG collects information regarding what the charges for her visits would have been had they taken place as referrals. SCMG, she said, “realizes that by decreasing referrals, increasing patient satisfaction, decreasing wait time to see the specialist, and saving on unnecessary biopsies, visits, prescriptions, and administrative paperwork generating referrals,” her role as a visiting dermatologist is extremely beneficial from the perspective of patients, PCPs, and the health plan. [pagebreak]
Improving patient satisfaction
Patients also save money because they pay a PCP co-pay and not the higher specialist co-pay to see her at their PCP’s office. Plus, they prefer seeing Dr. Mofid in a familiar setting and not having to travel further out as her office is anywhere from five to 30 miles away from the various PCP offices, and the wait time to see the dermatologist is often reduced. The primary care practices learn to manage their referrals, as they have a certain number of appointments available to them once a month; this, Dr. Mofid said, enables them to prioritize scheduling and manage the basics without overloading the system. Thus, the program improves patient access to specialty care and the patient’s overall experience, and there is still no shortage of patients to be seen in Dr. Mofid’s practice.
Creating positive experiences for referral patients is important to PCPs. Halley has often heard PCPs say about referring physicians, “If my patient has a positive experience, you will get my next referral. If you create a problem for my patient, you won’t.” Even rude front desk staff members can be damaging, he said. (For more on the role of front desk staff in setting impressions of a practice, see p. 13.) Halley recommended conducting patient satisfaction surveys and reporting the results to referring physicians.
Access is part of the patient satisfaction equation. On average, new patients wait about 30 days to get an appointment with a dermatologist while established patients wait approximately 17 days, according to the AAD’s 2012 Dermatology Practice Profile Survey. “Our field has gained a reputation for having long delays in getting patients in unless they can pay cash for cosmetic procedures,” Dr. Roenigk said. How quickly patients are seen, given test results, and treated are all steps that can be measured on a patient survey. [pagebreak]
Steps can be taken to improve performance in those areas, according to Dr. Kimball, who was involved in designing an outpatient scheduling model to ease long waiting times at the dermatology clinic. Through a number of interventions including extending the time between follow-up appointments for a number of non-urgent issues, the clinic decreased its wait times substantially. Furthermore, this strategy may be applicable for many types of dermatology patients. A study published in a recent issue of the Journal of Clinical Oncology (2011 Dec. 10;29:(35):4641-6) showed that decreasing the number of follow-up visits for melanoma patients does not negatively impact outcomes.
Access and outcomes are what PCPs at ProvenHealth Navigator, Geisinger Health System’s PCMH, focus on when working with specialists, noted Joanne Sciandra, associate vice president for population health at Geisinger Health Plan. Geisinger employs embedded case managers to work with the most complex patients at many of its busiest community-based primary care sites. As part of its effort to build out the PCMH to specialists, Geisinger recently began using case managers in its nephrology clinics to manage patients receiving dialysis. It is possible a similar program could be established involving dermatologists who treat patients with chronic wounds. In addition, a pilot project that entails home video monitoring could involve dermatology consults for home-bound patients who have chronic wounds.
“Clinical quality is essential, but it’s a given,” Halley said. “When moving into the realm of ACOs, utilization management is important. Specialists should make sure that they provide services efficiently and effectively, and perform invasive or high-cost procedures only when necessary.” [pagebreak]
However, outcomes are a little harder to come by in dermatology because the measures tend to be more subjective. Other specialties have objective measures, for example, based on lab values or administration of a particular medication, Dr. Roenigk said. “The dermatology community needs to come to a consensus around standards to measure and begin measuring them in an objective way.” He acknowledged that both the AAD and American Board of Dermatology are working toward that goal.
Quality measures may be slow coming in dermatology, but not impossible to obtain. For example, at Massachusetts General Hospitals’s dermatology clinic, all patients with psoriasis and acne are graded in a consistent way about the severity of their condition on the day of the visit. “I now know the average severity of a patient with those conditions,” Dr. Kimball said. Additionally, she has enough aggregated data to follow a couple hundred patients through the system. “For example, I can now tell what percent of these patients were clear or almost clear in one year.” Dermatologists can also demonstrate how much skin cancer they diagnose each year by tracking patients with that diagnosis, she said.
“The dermatology community needs to publicize existing research and conduct new research to show how dermatologists increase value,” Dr. Kimball stressed. There is already substantial research showing that dermatologists perform significantly fewer biopsies to detect skin cancer or melanoma than do internists. Furthermore, dermatologists make more accurate diagnoses. “Specialists provide really outstanding care and often do it in a much more cost effective way because it’s their area of expertise. But we can’t just be protective about it, we need to engage with the rest of medicine,” Dr. Kimball said. (An AAD effort to gather such data is underway and is one of the organization’s top priorities.) [pagebreak]
Moreover, dermatologists need to stay ahead of the curve, which may mean reducing unnecessary procedures, she continued. They don’t want to see a repeat of the 1990s, when access to specialty care was restricted, nor do dermatologists want the government, payers, or others dictating appropriate use of procedures, such as in the case of Mohs micrographic surgery for skin cancer. “We want the field to make the appropriate recommendations about what we should and shouldn’t be doing,” Dr. Kimball said.
Dermatologists should also consider eliminating extra costs to the health care system, wherever possible. A recent cost comparison of ointments versus creams used at the dermatology clinic found a four-fold difference in cost in some cases, she said. “Dermatologists are going to have to re-educate themselves on costs of medications and procedures and make substitutions where it is clinically appropriate to do so,” Dr. Kimball said.
In the brave new world of PCMHs and ACOs, dermatologists need to demonstrate the value proposition. “This is an important opportunity for dermatology to define itself and the value we provide to patients,” Dr. Kimball said.
The growth of ACOs
In January, the Department of Health and Human Services unveiled 106 new ACOs, bringing the grand total to more than 250 ACOs responsible for as many as four million Medicare beneficiaries nationwide. When adding the number of ACOs formed outside of the Medicare program that number jumps to 428 ACOs in 49 states, according to Leavitt Partners.
Accountable care organizations have become so numerous that they recently established their own association. In February, organizations representing more than 60 ACOs from more than 15 states formed the National Association of ACOs. The not-for-profit organization is expected to facilitate ACOs working together to increase quality of care, lower costs, and improve the health of their communities.