To reduce the fragmentation of care for complex conditions, we need to take on the fee-for-service models that contribute to it, says Evolent's Dr. Vishnukamal Golla.
Seamless coordination between primary and specialty providers is vital to achieving better health outcomes, yet fragmentation and lack of visibility into patients' care are too often the reality. One reason is the sheer number of specialists involved in care: Nearly 1 in 3 Medicare beneficiaries sees five or more physicians annually, and primary care providers (PCPs) have nearly twice as many specialists seeing the Medicare beneficiaries on their patient panel than they did 20 years ago.
We spoke with Evolent Senior Medical Director for Value Transformation Vishnukamal Golla, MD, MPH, whose work focuses on innovative value-based models for specialty care. Dr. Golla also previously helped develop the components of CMS' new Making Care Primary Model that encourage better connections between specialty and primary care. Dr. Golla discusses the lack of coordination between primary and specialty care and how alternative payment models can help solve these challenges.
When you reflect on your time as a physician, can you recall a patient story that demonstrates the challenges of coordinating primary and specialty care?
Yes, I had a patient who was diagnosed with advanced cancer. His primary care provider had been managing his hypertension for years, so when he was diagnosed with cancer and I took over his care, there was initially limited communication between myself and his PCP. The PCP lacked insight into the cancer treatment plan and the patient was unsure about which doctor was managing his overall health. The patient developed fatigue, nausea and a mild decline in his renal function. His blood pressure medication needed to be adjusted, but his PCP didn't want to move forward without my input. We worked together to develop a shared care plan that allowed us to keep the lines of communication open, outlined our responsibilities, enabled data sharing, and provided patient education. This collaboration allowed us to coordinate care and empowered the patient to take control of his care journey.
What challenges do health plans face with coordination of primary and specialty care?
Integration has always been difficult, but health plans currently face some of the largest hurdles they've had in a long time. The demand for specialty care, in particular, is reaching record levels. Medicare beneficiaries are seeing 50% more specialists, on average, compared to a couple of decades ago, yet there hasn't been thoughtfulness about how to coordinate the increased demand between PCPs and specialists. As a result, we're seeing an exacerbation of fragmented care.
Of course, care access is a persistent challenge, driven by physician shortages. PCPs are one of the most under-resourced specialties in the U.S. and as their patient loads continue to grow, the ability to coordinate referrals with specialists becomes more challenging. The lack of interoperability between primary and specialty care has also made sharing data and coordinating care difficult — we're still relying on faxes to share consult information despite the many other technologies available.
What are the results of this lack of care coordination?
PCPs often lack insight into whether or not a particular specialist is the right specialist or someone who is providing high-quality care. There aren't ways to determine if providers are using guideline-concordant care, what their outcomes are, and how they're supporting patients with shared decision-making.
What we're also seeing is that many patients are waiting more than a month to see a specialist, and in that time they're vulnerable to disease progression, ED visits and hospitalizations. Patients who have comorbidities also find coordinating care with their providers difficult since they often don't have a support network in place. And while we may think that lack of care coordination is only a problem for disparate providers, these issues also occur within the same health system.
The industry has been slow to adopt value-based care, but why is the shift an imperative?
We must break free from the fee-for-service mentality that drives fragmentation. Value-based payment models create a new foundation in which PCPs and specialists can work together with an incentive model that supports their collaboration.
These models need to focus on more meaningful specialty-specific quality metrics. We should prioritize system-based or outcome-oriented measures while reducing the number of process-based measures that only increase provider burden. Most of the quality measures in the current system focus on primary care because the focus for the last decade was accountable care organizations and, in some ways, trying to support that discipline.
Can you give an example of a more meaningful measure?
With musculoskeletal conditions, functional status matters to the patient, but rarely is that measure included in a fee-for-service model. Yet value-based care can include a measure like that, and it can drive value for the patient and the provider. The provider isn't only thinking about surgery, but also about physical therapy, pain medicine, and behavioral therapy. When we're able to align the right metrics and the right clinical care pathways, that directly translates into better overall care for a patient.
Since value-based care also focuses on whole-person care, providers are incentivized to address unmet social determinants of health needs, which improve outcomes and the member experience. We're seeing many different ways that CMS and specialty care companies are trying to change the ecosystem to cultivate this transformation, and we're excited about what's to come.
How is Evolent helping to solve for the lack of care coordination?
Our solutions target distinct phases of the patient journey. When the PCP has a patient who they think needs a referral, we spend a lot of time educating the practice and providing resources such as tip sheets or guides to help them understand when the patient should be referred and what the most appropriate site of care is. We provide PCPs with a scorecard to identify specialists in the local geographical area who provide high-quality care based on a list of evidence-based criteria.
We're also actively working on a pilot for a new oncology navigation solution that will support patients from diagnosis to survivorship or end of life. The goal of the pilot is to help offload some of the administrative burden for both PCPs and specialists to ensure patients have everything they need, such as pathology and imaging reports, to prevent delays and gaps in care.
We also spend a lot of time prepping patients with questions they should ask during their first visits with the specialists, preparing for treatment, and understanding the side effects of treatment. Once they undergo treatment, we can connect them to the practice with help managing side effects or medication adherence. We have recently launched a partnership with Careology to provide a patient facing digital application which further supports the patient journey.
For patients whose cancer has progressed to an advanced stage, we provide advance care planning, as well as help with palliative care and hospice referrals when appropriate. In this way, we're supporting patients, and specialists, and ensuring PCPs are in the loop.
