Providing primary care to those in the safety net is no easy task – and it just gets more difficult when it comes to specialty care.
Dr. Mitchell Katz, the director of the Los Angeles Department of Health Services, says there are 2 million uninsured within county lines, and many of them "rely on the public sector system."
"There is really no capacity for that level of uninsured people to receive specialty care," said Katz, referring to fields of medicine like neurology, cardiology, endocrinology – the list goes on. "There's better capacity in primary care because the federal government has supported federally-qualified health centers, [which] are able to provide primary care but not specialty care."
And, added Katz, because specialists in general earn two to three times the salary of a primary care physician, the same amount of money provides quantifiably less specialty care.
A recent study which looked to pinpoint the best way for clinics to provide specialty care to underserved populations found that most safety net systems rely on the "tin cup" method, in which specialists donate their services. But researchers found that an "integrated system" in which clinics integrate with local government health systems or safety net hospitals – is the most efficient way to provide this kind of care to this particular demographic.
That's precisely the kind of system Katz is moving toward with eConsult, an electronic interface which allows primary- and specialty-care doctors working with the same patient to not only see a common set of information about that patient, but to add to it whenever necessary.
What this accomplishes, says Katz, is a drastic reduction in the number of visits to a provider's office.
"There simply are not enough specialists," he said, noting again that even if there were, they'd be far more expensive than a primary care doctor. "If you start with the idea that I'm going to get everybody who needs a consultation a visit in a timely manner, you'll lose. There's just no way one could provide that many visits."
But that's OK – because not everyone needs a visit, says Katz. He gave an example:
Suppose a patient goes to a community health clinic and is referred to a liver specialist for a consultation. If the patient shows up at the liver clinic, the first thing the specialist there will need is a CT scan or a blood test. If the patient doesn't have that – and they rarely, if ever, will – then the specialist will let the patient know that's the first step, and that the patient should come back in a couple weeks after that's been taken care of.
"So that's a wasted visit," said Katz. In about a third of folks who are referred to specialists, "there's some critical lab test or piece of information" that the specialist will need for the visit to be worth everyone's time. If that's not there, both the patient's and doctor's time are wasted.
The eConsult system cuts out that extra visit by letting providers know what kind of care and tests a patient has already received or undergone.
Katz added that eConsult expedites the process for another third of patients who are referred to a specialist – even though they don't actually need to go and see a specialist. Instead, the specialist can take a look at a patient's file via eConsult, and use that information to make a recommendation to the patient's primary care provider about medications she or he should try prescribing – without a visit ever occurring. It's essentially telemedicine.
L.A. County's eConsult system is about one month old and is currently being used in communications between providers at three of the county's specialty clinics and four of its primary care clinics, in the areas of dermatology and adult and pediatric neurology.
But this system isn't widely used, and Katz says that's because something like eConsult doesn't work in a fee-for-service, visit-centered system – "which is what most of the American health care system is today," he said.
"Let's say you have insurance," he said. "The insurance pays for the visit to the dermatologist – it doesn't pay for the dermatologist to look at an email from the primary care doctor."
But within the safety net patient population, it works. And as director of the county's health services department, Katz' goal is to eventually cover all the county's clinics in more than 20 specialty areas. Next up: cardiology and women's health.
"This is an instance where the public sector can lead the way in showing others which is the more efficient model," he said.
Photo by Alex Proimos via Flickr Creative Commons.