Involving specialists in value-based care is hard. Not only is specialty care a more diverse space, but it's also more tied to traditional fee-for-service reimbursement and episodic care delivery. We’ve previously discussed how engaging specialists in accurate HCC capture is a ‘no-regrets’ opportunity in this hybrid financial incentive state—but what ambitious, yet feasible behavior changes remain for specialists? In this series, we discuss the three you should start with.
E-consults are another way to reduce low-value referrals. In fact, multiple executives told us e-consults are a top opportunity when transitioning to value-based care—calling them a “bridge to value.” Short-term, they quicken PCP-specialist interactions on patient care plans, upskills PCPs to manage low-acuity specialty cases, and improve patient access by freeing up specialist capacity for patients who need their care most. Long-term, e-consults help educate referring providers, improving their referral patterns and reducing costs.
What we mean: Electronic consultations (e-consults) are asynchronous messages sent between providers within a shared EHR or web-based platform. PCPs primarily use e-consults to ask a clinical question, determine necessity of a formal referral, and facilitate diagnostic evaluation.
What we don’t mean: We do not mean one-off emails or informal conversations between PCPs and specialists that aren’t tracked. E-consult programs should operate systematically.
Start by training a small number of physician champions within each specialty to serve as designated e-consultants. Limiting the number of initial participants ensures consistency in the timeliness and quality of e-consult responses for PCPs. Participating specialists will also get to practice with the tool and help iterate on the process. Then, as volumes dictate, offer peer trainings to grow this pool of physicians and increase capacity.
Many organizations implement e-consults by making them part of on-call coverage. This approach works but risks further disengaging physicians. It adds an extra obligation to an already dissatisfying aspect of their job. Instead, reserve time for the dedicated e-consultants to respond to e-consults. This will ultimately translate to healthier attitudes about e-consults and a higher quality of care.
E-consults take up valuable physician time. It’s important to recognize that for both the consulting specialist and referring physician.
For the consulting specialist: E-consult programs generally reimburse specialists for each respective e-consult. These reimbursement rates vary by organization, payer, and time required. Mayo Clinic’s consulting specialists earn the same amount of RVUs (1.74) as they would for an in-person visit. This is a win for specialists since responding to an e-consult takes about one-third the time of an in-person visit. It’s a win for Mayo Clinic since e-consults are 1.4 times more likely to generate return visits to primary care over referrals to specialists. Given only Medicare and some other payers compensate physicians for e-consults, some organizations may choose to establish a lower RVU range determined by time spent. For example, one health system reimburses e-consults that take <10 minutes at 0.5 RVUs, and those that take 11-20 minutes to answer at 1 RVU.
For the referring physician: Many organizations already tie PCP compensation to quality and costs. In addition, organizations can incentivize referring physicians to use e-consults by reducing their workload. For example, L.A. Care Health Plan implemented an e-consult program to encourage PCPs to manage patients in primary care as much as possible. As an incentive, L.A. Care removes pre-authorizations for any referrals that go through this process. Given health plans’ interest in decreasing inappropriate referrals, consider partnering on e-consult implementation as a step on the bridge to value. This way, PCPs are making care escalation decisions solely with fellow providers’ opinions rather than a plan’s.
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This expert insight series is sponsored by Episource, an Advisory Board member organization. Representatives of Episource helped select the topics and issues addressed. Advisory Board experts wrote the post, maintained final editorial approval, and conducted the underlying research independently and objectively. Advisory Board does not endorse any company, organization, product or brand mentioned herein.
Sandberg SF, Shipman SA, and Erikson CE. “Innovations at the Interface of Primary and Specialty Care,” American Association of Medical Colleges, (2016).
Bhavsar I, et al., “Electronic Consultations to Hepatologists Reduce Wait Time for Visits,” Hepatology Communications, 3, no. 9 (2019): 1177-1182.
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