January 22, 2022
  • January 22, 2022

Low-income Colorado patients can’t get specialist care

By on August 3, 2021 0

Longmont’s Hopelight Medical Clinic treats all of the usual primary care ailments that low-income, uninsured patients bring to a safety-net health practice: strep throat, stitches, tooth decay, anxiety.

Hopelight also regularly sees an urgent need to tackle much bigger issues, including a patient’s schizophrenia. But referrals and appointments for specialist care such as cardiology or geriatrics can be nearly impossible to line up for low-income patients. Often, specialists do not register to take Medicaid. Spaces for charitable care are extremely limited and spaced out, if at all.

A systemic solution would be good. In the meantime, Hopelight has benefited from a clinic 100 miles away, whose executives said at a networking meeting, “We know a guy.”

The Summit Community Care Clinic in Frisco, another provider of safety nets, had found a nurse practitioner specializing in psychiatric care to handle cases involving mental health prescriptions and treatments. Try it, Summit tells Hopelight.

They did it. The Psychiatric Nurse Practitioner now shares clinical time between the Summit County and Hopelight County offices in Longmont and is available for telehealth and consultation via a patient’s electronic medical record when needed. The schizophrenia patient not only has regular treatment and medication, but also a home and a job.

Having specialist psychiatric care on-site has been a transformation for some Hopelight patients who typically saw “a two to three month wait before making an appointment,” said Carey Kercher, a registered social worker and director of clinical and clinical services. social networks of Hopelight. People can now get them in a matter of days.

Peaks outside Frisco are pictured through the office window of Summit Community Care Clinic Patient Referral Coordinator Alejandro Baltazar on July 30, 2021 (Andy Colwell, Colorado Sun Special)

“So sometimes it makes all the difference when people are really struggling with depression, anxiety,” Kercher said.

The challenge for low-income Colorado patients 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 “specialized care remains inaccessible to many.”

That year, the CHI said, 634,000 appointments needed for specialist care never took place, mainly because many underinsured patients could not afford a visit or too many specialists failed. were not accepting Medicaid insurance from Health First Colorado.

Medicaid patients were nearly three times more likely than commercial insurance patients to be excluded from specialty care because of a lack of a provider willing to accept payment.

Kaiser Permanente Colorado provided grants and organized a group of low-income clinics and primary care providers in 2018, to network and experiment with possible solutions to the problem of specialty care.

Kaiser’s family doctor Dr Chris Fellenz, co-organizer of the group, had previously worked in low-income clinics in Colorado and Vermont that could not find specialist appointments for their primary care patients.

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“So I should send these patients to the emergency room, hoping that they would get specialist care that way,” Fellenz said. “Which often doesn’t work, and it’s just the wrong way to provide this kind of care.”

The three-year Kaiser-sponsored study brought clinics together to establish a baseline of their specialty referral challenges, and then collaborate on potential solutions. The clinics worked together on everything from finding a software vendor for new “online consultation” sessions with volunteer specialty providers, to communicating with state health finance officials on issues. policy changes that would stimulate specialized networks for low-income patients.

Colorado Health Institute director Alex Caldwell, who assesses the work of the cohort, praised study members who come up with creative solutions, like sharing a psychiatric specialist. But the extraordinary of their efforts highlights just how difficult it is to scale up these kinds of solutions for hundreds of thousands of patients in hundreds of places across Colorado, she said.

“Is it sustainable? No, ”Caldwell said. “It’s sustainable in the sense that this person is paid. But is this kind of a sustainable option to meet the broader needs of psychiatry in the state? No.”

E-consult is one of the most promising potential solutions. According to this concept, the local primary care provider of a low-income clinic uses a shared electronic medical record to request an external specialist provider to review the case. In many cases, the specialist is able to offer ideas to the primary care provider without making a formal in-person specialist care appointment. In other cases, the electronic consultation will result in a more focused specialist appointment for the patient, which everyone in the system knows is actually needed.

But Colorado’s Medicaid system does not yet have a sophisticated mechanism to pay the specialist provider for these online counseling services, Caldwell said.

“The best scenario would be if these specialist care providers are incentivized and have a clear set of payment mechanisms and a sustainable way to integrate this type of care for Medicaid registrants into their business model,” said Caldwell. “At the moment, it’s just not a sustainable business model for them. ”

Medicaid will also likely need to consider increasing specialist payment rates to attract more into the system, and also convince prospects that the state has improved the speed with which it pays bills and reduced the paperwork involved for network members. Medicaid, cohort members said.

At the Summit County Clinic, some patients can use Medicaid. But others may be working and earning too much to qualify for Medicaid, when they are not enough to afford good private insurance or stable housing, said clinic CEO Helen Royal. . When these patients need specialized psychiatric, orthopedic or oncology care, she said, “there’s just a shortage of specialists everywhere.”

“And so some of the things we have done is pull some of the sore cords with specialists, and have them come to our clinic for a few days or allow a number of patients to see them at a reduced rate.” , Royal mentioned. “But that just can’t cover the needs.”

Helen Royal, CEO of the Summit Community Care Clinic, at the Frisco Clinic, July 30, 2021 (Andy Colwell, special for the Colorado Sun)

Each of the clinics involved in the study received a Kaiser Permanente grant to work on local solutions. Summit used part of its grant to help pay for a dedicated referral coordinator who would fight for a patient once a specialist appointment was recommended.

“It was an intervention to make sure we really have someone who can navigate and hold hands throughout the process,” said Royal. “And I don’t say that in a humiliating way for our patients. I mean, I have a hard time navigating health care on my own, trying to find specialists, where they are and when you can see them. “

The cohort study noted limited success. Completed referrals increased by just under 20% between the reporting period and the final report in January. And 82% of online consultations were completed in five days, up from 74% at the start of the study; 62% of in-person visits were made within a month, compared to 56%.

Over a longer period, however, the work of the cohort did not have such a large impact. Only about half of the appointments required for specialist care were actually made and completed by the patient, both before and after the study. The main problem was the lack of available specialist appointments – causing 65% of incomplete referrals.

“Significant political obstacles to the creation of a comprehensive safety net for specialized care

remain, ”concludes the CHI study.

Kercher of Hopelight confirms that while the cohort has been helpful and encouraging for clinic directors accustomed to solving problems in isolation, each medical specialty poses its own problems. Hopelight has made progress in psychiatry, but is now looking for a good rheumatologist.

And, she added, “Dermatology is a real area of ​​need. We might have connections there starting now, but it’s been a tough specialty. ”

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