Universal Access to What?Universal Access to What?

Making primary careMaking primary carework for patientswork for patients

Tom Bodenheimer MDTom Bodenheimer MDDepartment of Family and Community MedicineDepartment of Family and Community Medicine

University of California at San FranciscoUniversity of California at San Francisco

Financial Access isFinancial Access is Step 1Step 1•• We need itWe need it…….NOW.NOW•• But it isnBut it isn’’t enought enough•• If you have health insurance, you may If you have health insurance, you may

not be able to find a primary care not be able to find a primary care physician who takes new patientsphysician who takes new patients

•• You often canYou often can’’t get a timely appointmentt get a timely appointment•• YourYour visit may be rushed; you may notvisit may be rushed; you may not

get yourget your questions answered or yourquestions answered or yourhealth issueshealth issues taken care oftaken care of

How do we guarantee How do we guarantee ---- for for all patients all patients ---- prompt access prompt access to a primary care visit that to a primary care visit that

meetsmeets all their needs?all their needs?

We need to transformWe need to transformprimary careprimary care

WhatWhat’’s the problem?s the problem?

““Primary care, the backbone of Primary care, the backbone of the nationthe nation’’s health care s health care system, is at grave risk of system, is at grave risk of collapsecollapse…”…” American College of American College of Physicians, 2006Physicians, 2006

Dwindling NumbersDwindling Numbers

# US# US med students entering med students entering Family Medicine residencyFamily Medicine residency

19971997 23402340

20052005 11321132

PugnoPugno, , Fam Fam Med 2005;37:555Med 2005;37:555

Dwindling NumbersDwindling Numbers•• Formerly, half of internal medicine Formerly, half of internal medicine

residents chose primary care internal residents chose primary care internal medicinemedicine

•• Now, 80% choose Now, 80% choose subspecialist subspecialist or or hospitalist hospitalist careerscareers

Garibaldi et al. Garibaldi et al. Acad Acad Med 2005;80:507Med 2005;80:507

Dwindling NumbersDwindling Numbers

•• Primary care internists who started Primary care internists who started practice in 1990:practice in 1990:

•• 21% had left practice entirely by 21% had left practice entirely by 20052005

ACP congressional testimony, March 1, 2006ACP congressional testimony, March 1, 2006

Primary care physician Primary care physician satisfactionsatisfaction

•• 22% of PCPs nationally do not feel they can 22% of PCPs nationally do not feel they can provide high quality care to all their patients. provide high quality care to all their patients. Center for Studying Health System Change, 2000Center for Studying Health System Change, 2000--2001 Physician 2001 Physician SurveySurvey

•• 24% of PCPs feel that the scope of care they are 24% of PCPs feel that the scope of care they are expected to provide is greater than what is expected to provide is greater than what is reasonable reasonable St. Peter et al. NEJM 1999;341:1980St. Peter et al. NEJM 1999;341:1980

PatientsPatients’’ timely access to caretimely access to care•• From 1997 to 2001, % of people unable to From 1997 to 2001, % of people unable to

obtain timely appointment rose from 23% to obtain timely appointment rose from 23% to 33%.33%.

•• 40% of emergency department visits are not 40% of emergency department visits are not urgent and are chiefly due to lack of prompt urgent and are chiefly due to lack of prompt access to primary careaccess to primary care

Strunk Strunk and Cunningham, Center for Studying Health System and Cunningham, Center for Studying Health System Change, 2002Change, 2002

Inadequate chronic care qualityInadequate chronic care qualityHalf of discharged CHF patients are Half of discharged CHF patients are

readmitted within 90 days readmitted within 90 days [Ni et al. Arch [Ni et al. Arch Int Int Med 1998;158:1231]Med 1998;158:1231]

Less than half of eligible Less than half of eligible atrial atrial fibrillation fibrillation patients receive patients receive warfarinwarfarin [[Samsa Samsa et al. Arch et al. Arch Int Int Med Med 2000;160:967]2000;160:967]

66% of people with hypertension are 66% of people with hypertension are inadequately treated inadequately treated [JNC 7, JAMA 2003; 289:2560.][JNC 7, JAMA 2003; 289:2560.]

63% of people with diabetes have HbA1c levels 63% of people with diabetes have HbA1c levels greater than 7.0% greater than 7.0% [[Saydah Saydah et al. JAMA 2004;291:335]et al. JAMA 2004;291:335]

Preventive care qualityPreventive care quality

•• Over 4000 patient visits by 138 family Over 4000 patient visits by 138 family physiciansphysicians

•• Patients were up to date on Patients were up to date on –– 55% of routine screening tests55% of routine screening tests–– 24% of immunizations24% of immunizations–– 9% of health behavior counseling9% of health behavior counseling

Stange Stange et al. et al. Prev Prev Med 2000;31:167Med 2000;31:167

The reality of the 15The reality of the 15--minute visitminute visit

•• Only 37% of patients in one study were adequately Only 37% of patients in one study were adequately informed about medications they were takinginformed about medications they were taking

•• 50% of patients leave office visit not understanding 50% of patients leave office visit not understanding what the doctor saidwhat the doctor said

•• Study of 1000 physician visits, the patient did not Study of 1000 physician visits, the patient did not participate in decisions 91% of the time.participate in decisions 91% of the time.

Roter Roter and Hall. Ann Rev Public Health 1989;10:163. Braddock et al. and Hall. Ann Rev Public Health 1989;10:163. Braddock et al. JAMA 1999;282;2313. JAMA 1999;282;2313.

The reality of the 15The reality of the 15--minute visitminute visit•• A study of 264 visits to PCPs using audiotapesA study of 264 visits to PCPs using audiotapes

•• Patients making an initial statement of their Patients making an initial statement of their problem were interrupted by the physician after an problem were interrupted by the physician after an average of 23 secondsaverage of 23 seconds

•• In 25% of visits the physician never asked the In 25% of visits the physician never asked the patient for his/her concerns at allpatient for his/her concerns at all

Marvel et al. JAMA 1999;281:283Marvel et al. JAMA 1999;281:283

It cannot be doneIt cannot be done•• A primary care physician with an panel of A primary care physician with an panel of

2500 average patients will spend 7.4 hours 2500 average patients will spend 7.4 hours per day doing recommended preventive per day doing recommended preventive care [care [Yarnall Yarnall et al. Am J Public Health et al. Am J Public Health 2003;93:635]2003;93:635]

•• A primary care physician with an panel of A primary care physician with an panel of 2500 average patients will spend 10.6 2500 average patients will spend 10.6 hours per day doing recommended hours per day doing recommended chronic care chronic care [[Ostbye Ostbye et al. Annals of et al. Annals of Fam Fam Med 2005;3:209]Med 2005;3:209]

What do these data What do these data demonstrate?demonstrate?

•• Primary care is brokenPrimary care is broken

•• It needs a transformation (minor It needs a transformation (minor redesign wonredesign won’’t do)t do)

How do we fix primary care? How do we fix primary care?

Example: SF Department of Public HealthExample: SF Department of Public HealthCommunity HealthCommunity Health NetworkNetwork

getting ready to care forgetting ready to care forSan FranciscoSan Francisco’’s uninsured populations uninsured population

This may have relevance toThis may have relevance toSF Community Clinic Consortium clinicsSF Community Clinic Consortium clinics

GoalsGoals

–– To improve the patient experience To improve the patient experience ---- including quality including quality and access and access ---- while narrowing the disparities gapwhile narrowing the disparities gap

–– To make To make worklife worklife more tolerable for primary care more tolerable for primary care clinicians clinicians

–– To allow and encourage every person working in To allow and encourage every person working in primary care to fully utilize their skills and potential primary care to fully utilize their skills and potential

–– To reduce total health care costs of highTo reduce total health care costs of high--cost patientscost patients

Stratifying the patient populationStratifying the patient population•• People who need samePeople who need same--day care for acuteday care for acute

problemsproblems•• Healthy people who need preventive careHealthy people who need preventive care•• Women who need pregnancy and infant careWomen who need pregnancy and infant care•• People with a chronic conditionPeople with a chronic condition•• People withPeople with multiple complex chronic multiple complex chronic

conditionsconditions•• People with mental health/substancePeople with mental health/substance use use

problemsproblems•• People who need care at the end of lifePeople who need care at the end of life

Adapting primary care to the different Adapting primary care to the different strata of the patient populationstrata of the patient population

•• We always believed that primary care was the We always believed that primary care was the physicianphysician caring for all the problems of all those caring for all the problems of all those categories of patientscategories of patients

•• No longer possible No longer possible •• Remember: 18 hours/day to care for all chronicRemember: 18 hours/day to care for all chronic

& preventive needs of& preventive needs of the average patient panelthe average patient panel•• We need different components of primary care We need different components of primary care

to serve the different categories of patientsto serve the different categories of patients

Stratifying the patient populationStratifying the patient population

People who need samePeople who need same--day care for acuteday care for acuteproblemsproblems

•• Healthy people who need preventive careHealthy people who need preventive care•• Women who need pregnancy and infant careWomen who need pregnancy and infant care

People with a chronic conditionPeople with a chronic condition•• People withPeople with multiple complex chronic multiple complex chronic

conditionsconditions•• People with mental health/substancePeople with mental health/substance use use

problemsproblems•• People who need care at the end of lifePeople who need care at the end of life

People who need care for acute problemsPeople who need care for acute problems•• They need sameThey need same--day access. Continuity of care day access. Continuity of care

with the same physician is best, but not always with the same physician is best, but not always possible. Access > continuitypossible. Access > continuity–– Advanced accessAdvanced access–– DropDrop--in clinic/urgent care clinicin clinic/urgent care clinic–– Telephone careTelephone care–– ““Minute clinicsMinute clinics”” in the community or in pharmaciesin the community or in pharmacies–– EE--mail caremail care

•• The first task of the CHN is to gear up for sameThe first task of the CHN is to gear up for same--day access for patients with acute problemsday access for patients with acute problems

People who need care for acute problemsPeople who need care for acute problems

•• Many of the people who need sameMany of the people who need same--day day care for acute problemscare for acute problems also have also have undiagnosed/untreated chronic undiagnosed/untreated chronic conditions: hypertension, cholesterol, conditions: hypertension, cholesterol, diabetes, overweightdiabetes, overweight

•• When they getWhen they get care for their acute care for their acute condition, theycondition, they should be offered should be offered screening for common chronic conditions screening for common chronic conditions and referral to a primary care teamand referral to a primary care team

People with chronic conditionsPeople with chronic conditions•• Prompt access is important, but Prompt access is important, but

continuity of care continuity of care ---- always seeing always seeing the same primary care team the same primary care team ---- is even is even more important more important

•• Many studies show that continuity of Many studies show that continuity of care is associated with better care is associated with better outcomes and lower costsoutcomes and lower costs

•• Continuity > accessContinuity > access

People with chronic conditionsPeople with chronic conditions

•• But inBut in some CHN clinics, the next some CHN clinics, the next appointment for a new patient is 3 appointment for a new patient is 3 months from now. Thatmonths from now. That is not is not acceptableacceptable

•• How can patients with chronic How can patients with chronic conditions establish care with a conditions establish care with a primary care team in a reasonable primary care team in a reasonable period of time and continue to period of time and continue to receive care from that team?receive care from that team?

People with chronic conditionsPeople with chronic conditions•• Hire a bunch of new doctors. Not a great Hire a bunch of new doctors. Not a great

solution becausesolution because–– 1) they are expensive and1) they are expensive and–– 2) remember that the number of2) remember that the number of US medical students US medical students

going into primary care is dropping fastgoing into primary care is dropping fast•• Increase productivity of the doctors (seeIncrease productivity of the doctors (see more more

patients per day)patients per day)–– This would work if they have better support from the This would work if they have better support from the

rest of their teamrest of their team•• Hire nurse practitioners/physician assistants Hire nurse practitioners/physician assistants

and increase their productivityand increase their productivity•• Make the primary care team really workMake the primary care team really work

The primary care teamThe primary care team•• The entire team includes physicians,The entire team includes physicians,

PA/NPs, RNs, pharmacists, health PA/NPs, RNs, pharmacists, health educators, physical therapists, social educators, physical therapists, social workers, receptionists,workers, receptionists, medical medical assistants, community health workersassistants, community health workers

•• TheThe crucial subunit of this team iscrucial subunit of this team istraditionally the physician and the traditionally the physician and the medical assistantmedical assistant

The The newnew primary care teamprimary care team

•• Same people as the traditional teamSame people as the traditional team•• Major changes in the crucial physician/ Major changes in the crucial physician/

medical assistant subunitmedical assistant subunit•• Transforms the medical assistant into a Transforms the medical assistant into a

health coach, provides lots of training, health coach, provides lots of training, and gives her more responsibilityand gives her more responsibility

•• This new subunit is called the This new subunit is called the ““teamletteamlet””

New Primary Care TeamNew Primary Care Team

Teamlet Teamlet 11 ClinicianClinician 2 Health 2 Health coachescoaches

Teamlet Teamlet 22 ClinicianClinician 2 Health 2 Health coachescoaches

Teamlet Teamlet 33 ClinicianClinician 2 Health 2 Health coachescoaches

The New Primary Care TeamThe New Primary Care Team•• WhatWhat functions do functions do clinicians clinicians need to perform?need to perform?

–– Most acuteMost acute–– Uncontrolled chronicUncontrolled chronic–– Complex multiComplex multi--comorbid comorbid chronicchronic–– Acute on top of chronicAcute on top of chronic–– Building relationships with patientsBuilding relationships with patients

•• WhatWhat functions dofunctions do cliniciansclinicians notnot need to perform?need to perform?–– Routine preventive servicesRoutine preventive services–– Chronic patients who need selfChronic patients who need self--management supportmanagement support–– Controlled chronic patientsControlled chronic patients

Clinician = physician, Clinician = physician, nurse practitioner,nurse practitioner, physician assistantphysician assistant

Remember the reality of theRemember the reality of the1515--minute visit?minute visit?

•• Only 37% of patients are adequately informed about Only 37% of patients are adequately informed about medications they were takingmedications they were taking

•• 50% of patients leave office visit not understanding 50% of patients leave office visit not understanding what the doctor saidwhat the doctor said

•• Patients do not participate in decisions 91% of the Patients do not participate in decisions 91% of the time.time.

•• Patients making an initial statement of their problem Patients making an initial statement of their problem are interrupted by the physician after an average of 23 are interrupted by the physician after an average of 23 secondsseconds

Roter Roter and Hall. Ann Rev Public Health 1989;10:163. Braddock et and Hall. Ann Rev Public Health 1989;10:163. Braddock et al. JAMA 1999;282;2313. al. JAMA 1999;282;2313. Marvel et al. JAMA 1999;281:283Marvel et al. JAMA 1999;281:283

We need to replace the 15We need to replace the 15--minute visitminute visit

•• In the In the teamlet teamlet concept, the 15concept, the 15--minute minute visit is extended tovisit is extended to–– PrePre--visit by health coachvisit by health coach–– Visit by physician (perhaps with coach)Visit by physician (perhaps with coach)–– PostPost--visit by health coachvisit by health coach–– BetweenBetween--visit by health coachvisit by health coach

PrePre--visit by health coachvisit by health coach

Agenda setting (average patient interruptedAgenda setting (average patient interrupted in 23 in 23 seconds)seconds)Vital signs including BMI, smoking status, takes Vital signs including BMI, smoking status, takes major portions of the historymajor portions of the historyOrders health maintenance/chronic disease services Orders health maintenance/chronic disease services that are duethat are due (based on(based on physicianphysician--written protocols)written protocols)Gives standard immunizations (from protocols)Gives standard immunizations (from protocols)Medication reconciliation (often takes clinician 5 Medication reconciliation (often takes clinician 5 minutes to figure out which meds patient is actually minutes to figure out which meds patient is actually taking, and which meds from another physician or taking, and which meds from another physician or healer patient is additionally taking)healer patient is additionally taking)Informs clinician of negotiated agendaInforms clinician of negotiated agenda

Clinician visitClinician visit•• Health Coach may participate in visit if Health Coach may participate in visit if

translation needed, if time in schedule, if translation needed, if time in schedule, if clinician/patient comfortableclinician/patient comfortable

•• Health Coach can fill out forms, do some Health Coach can fill out forms, do some computer entry, set up for procedures, get computer entry, set up for procedures, get things not in the roomthings not in the room

•• Health Coach does tasks, giving clinician Health Coach does tasks, giving clinician more time for diagnosis, management, more time for diagnosis, management, and relationship buildingand relationship building

•• Visit ends with clinician filling out After Visit ends with clinician filling out After Visit Summary (paper or EMR)Visit Summary (paper or EMR)

PostPost-- visit by Health Coachvisit by Health Coach

•• Makes sure patients understand everything on Makes sure patients understand everything on After Visit Summary (50% donAfter Visit Summary (50% don’’t know what t know what happened in the visit)happened in the visit)

•• Makes sure patient agrees with decisions made in Makes sure patient agrees with decisions made in visitvisit (patients don(patients don’’t participate in decisions 91% t participate in decisions 91% of the time)of the time)

•• Does behaviorDoes behavior--change goal setting/action planschange goal setting/action plans•• Helps patients navigate systemHelps patients navigate system•• Sees if patient has any issues/concerns; Health Sees if patient has any issues/concerns; Health

Coach listensCoach listens•• Clinician may Clinician may ““pop inpop in”” if Health Coach has if Health Coach has

questionsquestions

BetweenBetween--visit by Health coachvisit by Health coach

•• Coach calls patients between visits to see Coach calls patients between visits to see how they are doing with taking their meds, how they are doing with taking their meds, behaviorbehavior--change action plans, how they change action plans, how they are feelingare feeling

•• For patients to call their physician is often For patients to call their physician is often difficult; they can call the coach if there is difficult; they can call the coach if there is a problem, providing betweena problem, providing between--visit easy visit easy accessaccess

•• Coach checks with physician if neededCoach checks with physician if needed

Team functioningTeam functioning•• Primary care team members also interact Primary care team members also interact

with patients by phone or ewith patients by phone or e--mail, thereby mail, thereby reducing the number of face to face visits reducing the number of face to face visits neededneeded

•• Group visits can be plannedGroup visits can be planned•• If group visits are difficult to organize, miniIf group visits are difficult to organize, mini--

group visits might work as wellgroup visits might work as well•• The health coaches offThe health coaches off--load tasks from the load tasks from the

physician thatphysician that do not require a medical do not require a medical degree; this should allow physicians to degree; this should allow physicians to increaseincrease productivity without added stressproductivity without added stress

To summarizeTo summarize•• It would be great if all patients newly coming into the It would be great if all patients newly coming into the

CHN and the SF Community Clinic Consortium could CHN and the SF Community Clinic Consortium could have prompt access and continuity of care bothhave prompt access and continuity of care both

•• That goal is almost impossible to reachThat goal is almost impossible to reach•• Better to do whatBetter to do what’’s possible:s possible:

–– SameSame--day care for acute patientsday care for acute patients–– ScreenScreen for chronic conditions and refer to a team for chronic conditions and refer to a team

which provides continuity of carewhich provides continuity of care–– The clinician/coach The clinician/coach teamlet teamlet improves the patient improves the patient

experience and increases the productivity of the experience and increases the productivity of the clinicianclinician

Stratifying the patient populationStratifying the patient population•• People who need samePeople who need same--day care for acuteday care for acute

problemsproblems•• Healthy people who need preventive careHealthy people who need preventive care•• Women who need pregnancy and infant careWomen who need pregnancy and infant care•• People with a chronic conditionPeople with a chronic condition•• People withPeople with multiple complex chronic multiple complex chronic

conditionsconditions•• People with mental health/substancePeople with mental health/substance use use

problemsproblems•• People who need care at the end of lifePeople who need care at the end of life

The Primary Care Team SchoolThe Primary Care Team School

•• Intensive training of nonprofessional Intensive training of nonprofessional staff who wish to become Health staff who wish to become Health Coaches is critical to the success of Coaches is critical to the success of this conceptthis concept

The Primary Care Team School The Primary Care Team School would teachwould teach

•• Panel management using registriesPanel management using registries•• SelfSelf--management support skills management support skills

•• Intensive patient education Intensive patient education ---- adult learning theory adult learning theory •• Encourage and train patients to become active Encourage and train patients to become active

participants in their care participants in their care •• Intensive skills training (disease specific)Intensive skills training (disease specific)•• Teach patients problemTeach patients problem--solving skillssolving skills•• Assisting patients with psychosocial issues and the Assisting patients with psychosocial issues and the

emotional impact of having a chronic condition emotional impact of having a chronic condition

The Primary Care Team School The Primary Care Team School would teachwould teach

•• Agenda setting Agenda setting •• How to order routine chronic/preventive studiesHow to order routine chronic/preventive studies•• Medication reconciliation Medication reconciliation •• Closing the loopClosing the loop•• Shared decision makingShared decision making•• BehaviorBehavior--change goal setting/action planschange goal setting/action plans•• Navigating the system, especially pharmacy, Navigating the system, especially pharmacy,

social services, mental healthsocial services, mental health•• Listening to patientsListening to patients

Stratifying the patient populationStratifying the patient population•• Healthy people who need preventive careHealthy people who need preventive care

–– Coach orders recommended studies. Physician talks with Coach orders recommended studies. Physician talks with patients after studies are donepatients after studies are done

•• People with a chronic conditionPeople with a chronic condition–– Physician does medication management. Coach (with health Physician does medication management. Coach (with health

educator) does patient education, medication adherence, educator) does patient education, medication adherence, behaviorbehavior--change counseling, orders routine studies. Registries change counseling, orders routine studies. Registries are needed to manage the chronic conditions of the entire are needed to manage the chronic conditions of the entire population and a team member needs to be responsiblepopulation and a team member needs to be responsible

•• Red: people with multiple complex chronic conditionsRed: people with multiple complex chronic conditions–– Physician does great majority of the care. Coaches assist with Physician does great majority of the care. Coaches assist with

betweenbetween--visit phone calls, help navigating systemvisit phone calls, help navigating system•• People who need samePeople who need same--day care for acute conditionsday care for acute conditions

–– There must beThere must be phone advice capability and dropphone advice capability and drop--in services.in services.PA/NPs and RNs can provide much of the dropPA/NPs and RNs can provide much of the drop--in work.in work.

Paying for New Primary Care TeamPaying for New Primary Care Team

•• Payment reform is needed to sustain a Payment reform is needed to sustain a transformed practicetransformed practice

Payment for phone followPayment for phone follow--up, eup, e--encounters encounters Payment for population managementPayment for population managementExpanded payment for the longerExpanded payment for the longer teamlet teamlet visits visits including preincluding pre-- and postand post--visitsvisitsPayment for training in the Primary Care Team Payment for training in the Primary Care Team SchoolSchool

•• Health plansHealth plans might be convinced to pay for might be convinced to pay for these functions if they see evidence that it will these functions if they see evidence that it will save them money downstream (ED, hospital, save them money downstream (ED, hospital, specialty costs)specialty costs)

The New Primary Care TeamThe New Primary Care Teamis a work in progressis a work in progress

Comments are desired and Comments are desired and appreciatedappreciated

TBodenheimerTBodenheimer@@fcmfcm..ucsfucsf..eduedu

Addendum:Addendum:Primary carePrimary care--specialty interfacespecialty interface

•• Timely access to specialty care is often poorTimely access to specialty care is often poor•• Specialists are the Specialists are the ““invisible driver of health care invisible driver of health care

costscosts””•• Once a patient is touched by a specialist, or several Once a patient is touched by a specialist, or several

specialists, it is not uncommon for a cascade of specialists, it is not uncommon for a cascade of studies and procedures to ensurestudies and procedures to ensure

•• Specialists vary markedly in resource use. There may Specialists vary markedly in resource use. There may be a 4be a 4--fold variation in the costs of care between one fold variation in the costs of care between one specialist and another in the same community seeing specialist and another in the same community seeing the same average level of patient acuity with no the same average level of patient acuity with no difference in outcomesdifference in outcomes

Reducing faceReducing face--toto--face specialty face specialty referralsreferrals

•• For nephrology, all referrals except renal For nephrology, all referrals except renal biopsies and dialysis can be done by ebiopsies and dialysis can be done by e--mail mail ----they are information onlythey are information only

•• EE--mail the lab values (how they have changed mail the lab values (how they have changed over time) and meds and the over time) and meds and the nephrologist nephrologist will will ee--mail you the answermail you the answer

•• 85% of endocrine referrals are information 85% of endocrine referrals are information only (mostly diabetes, thyroid, calcium)only (mostly diabetes, thyroid, calcium)

Reducing faceReducing face--toto--face specialty face specialty referralsreferrals

•• GI: dyspepsia, diarrhea: many referrals GI: dyspepsia, diarrhea: many referrals can be information only; if unable to can be information only; if unable to dx dx and rx, may need formal referral for and rx, may need formal referral for endoscopyendoscopy

•• GI: hepatitis B and C: except for GI: hepatitis B and C: except for Hep Hep C C liver liver bxbx, all referrals can be information , all referrals can be information only. Provide lab studies, and get advice only. Provide lab studies, and get advice on managementon management

Reducing faceReducing face--toto--face specialty face specialty referralsreferrals

•• Cardiology: sending history, EKG, echo, Cardiology: sending history, EKG, echo, and noninvasive coronary artery studies, and noninvasive coronary artery studies, many referrals can be information only for many referrals can be information only for stable CHD, CHF, A Fibstable CHD, CHF, A Fib

•• For acute coronary syndrome, some For acute coronary syndrome, some arrythmiasarrythmias, need formal referral, need formal referral

•• For question of conservative rx vs. For question of conservative rx vs. intervention, information only, together intervention, information only, together with shared decision making with patient with shared decision making with patient (best done with PCP and health dialog)(best done with PCP and health dialog)

Reducing faceReducing face--toto--face specialty face specialty referralsreferrals

•• Surgical referrals for elective/patient Surgical referrals for elective/patient preference surgery, best is for PCP to do preference surgery, best is for PCP to do shared decision making with patient using shared decision making with patient using health dialog, and send to surgeon if patient health dialog, and send to surgeon if patient preference (BPH with low PSA, asymptomatic preference (BPH with low PSA, asymptomatic gallstones or hernia)gallstones or hernia)

•• If surgery not patient preference (e.g. AAA If surgery not patient preference (e.g. AAA over 5 cm or TIA with significant carotid over 5 cm or TIA with significant carotid stenosisstenosis), need formal referral), need formal referral

Reducing faceReducing face--toto--face specialty face specialty referralsreferrals

•• A substantial % of referrals are information A substantial % of referrals are information only and should be done by eonly and should be done by e--mailmail

•• ? Will patients object? If they see the e? Will patients object? If they see the e--mail mail referral and specialty answer, they may referral and specialty answer, they may think it is OK. We arenthink it is OK. We aren’’t suret sure

•• For some problems (orthopedics) in which For some problems (orthopedics) in which the physical exam is crucial, best to have the physical exam is crucial, best to have specialist come to primary care practicespecialist come to primary care practice

Reforming the primary careReforming the primary care--specialty interface can reduce specialty interface can reduce

health care costshealth care costs

•• Because specialty care isBecause specialty care is a major a major driver of high and rising costs, driver of high and rising costs, reducing facereducing face--toto--face specialty visits face specialty visits has major potential to reduce health has major potential to reduce health care costs, which is a precare costs, which is a pre--requisite to requisite to health plans paying for transformed health plans paying for transformed primary careprimary care