As most employers know first-hand, the costs of providing health and wellness benefits to employees continues to spiral upward. What many employers do not realize is a large portion of these costs are a direct result of the broken link between primary and specialty care.
We need to bridge this gap; we need a solution to help employees access the specialist who has the expertise to treat their conditions as quickly and efficiently as possible. This will help employees down the path to better health and lets employers control costs and strengthen their investment in employee health and productivity.
Providing health and wellness benefits to employees is becoming more and more challenging for America's employers. Health care costs continue to rise for a number of reasons like the need to comply with regulations set forth in the Affordable Care Act (ACA), an aging population base, an increase in chronic diseases, and rising health insurance rates.
But, the single largest factor contributing to rising costs may come as a surprise to you-today's fractured specialty referral system.
Any employer who takes a close look at the types of claims driving up their costs will quickly see that most come from specialty care in one way or another. In fact, though only 10 percent of the population requires referrals to specialty care services each year, they make up over 65 percent of annual claims costs.1
The Landscape Has Changed
There are three major factors leading to this shift toward specialty care.
First, the primary care landscape has changed. Gone are the days when a doctor could take as much time as needed to examine his or her patients, make a diagnosis and write a referral for specialty care based on the patient's needs. These days primary care physicians are overwhelmed by "the noise that surrounds the business of medicine" including the administrative burdens required to manage a practice and adapt to the changes brought about by health care reform.
As a result, they are forced to spend less time with patients than they want or need to, according to a recent medical economics physician survey.2 In fact, one study found that internists spend an average of only eight minutes per patient-an inadequate amount of time to do an evaluation, offer a diagnosis, and make the right referral.3
Additionally, an increasing number of patients are receiving diagnoses and referrals from providers beside their primary care physician or with whom they have no longstanding relationship such as physicians in the ER or urgent care facilities. Even patients themselves are making diagnoses and researching specialists online. Without the resources for making a qualified decision about specialty care factors like personal bias and price often become the basis for referrals.
Second, the specialty care arena has become increasingly complex. According to the American Board of Medical Specialties, there are now more than 900,000 board-certified physicians, practicing in about 200 specialties and sub-specialties, treating 30,000 disease types - many of which have more than one treatment option.
Such a broad array of options makes it very difficult for anyone without the proper guidance to find the right specialist on the first try. So, when diagnosed with an injury or illness requiring secondary or tertiary care, employees are often forced to play a game of chance, getting multiple referrals, hoping to gain timely appointments, visiting different specialists, until the right one is found if one is found at all.
This leads to the third contributing factor, a breakdown in the continuum of care that can result in any number of costly and potentially avoidable problems like revisits to the physician's office, poor patient follow-up during recovery, possible repeat admissions to the hospital, or development of co-morbid conditions.
In other words, the broken link between primary and specialty care causes poor quality care, sub-optimal outcomes, and higher costs. According to the New England Journal of Medicine, one-third of employees suffer from misdiagnosis, more than half receive incorrect treatment, and 45 percent of employees don't even receive the recommended standards of care.4
A Significant Cost to Employers
Such errors and poor outcomes cost employers upwards of $29 billion a year by some estimates.5 Though employers are aware of absenteeism, there is increasing evidence that the presence of ill or medically impaired employees may decrease productivity while at work in a phenomenon known as presenteeism.6
In other words, when employees do not get the care they need and spend time searching for adequate treatment options, they invariably miss work, and are often not fully functional or productive when they return to the office.
The bottom line is that we need a new pathway to improved health and wellness. Particularly, we need an innovative care model to redefine and improve how we access specialty healthcare, with quality and objectivity at the forefront.
Telemedicine is Not Enough
Getting a second opinion can play a role in helping repair the broken link, and there are a number of program choices available on the market. Telemedicine offers the convenience of communicating with a physician online, but it lacks the necessary clinical interaction between physician and patient, creating confusion and errors.
In fact, the American Medical Association, which doesn't oppose online second opinions, nonetheless says an in-person, face-to-face examination offer greater benefit.7 Moreover, telemedicine rarely provides direct patient access to a specialty care provider to develop and deliver the right treatment.
An Innovative Solution
We need a more robust solution to help employers and employees address the financial burdens associated with health care programs and produce better health and wellness outcomes. With an expert, objective guide and access to the most appropriate medical specialists, employees in need can confirm their diagnoses effectively and receive timely, cost-optimized treatment. In turn, this helps employers reduce claims costs and support productive, healthy employees.
A supplemental specialty clinical navigation program meets these needs. For example, such a program can help employers protect their investment in-and bolster the effectiveness of-existing population health and wellness management programs.
By ensuring that at-risk employees get an appointment with the specialist who has the experience in diagnosing and treating their specific conditions, employers can reduce absenteeism and presenteeism at the office and improve the health and productivity of their workforce.
What is a Supplemental Specialty Clinical Navigation?
What constitutes "a supplemental specialty clinical navigation"? There are three core elements:
- A foundation of a rigorous evaluation process for identifying and screening medical experts, combined with a thoroughly detailed, researched profile on each MD and their clinical expertise (diseases, treatments).
- An objective, reliable process to match an employee's needs with the physicians who have the right skills and expertise to help drive optimal outcomes.
- Expert assistance in providing access to specialists as quickly as possible.
Factors for Success
To be successful, a specialty clinical navigation program must have the following:
- A governing body of leading physicians with a wide array of medical knowledge, international prominence, and the highest, most objective clinical standards.
- An objective credentialing process with screening and quality standards to identify the right specialists and pinpoint their areas of specialization and expertise.
- The ability to provide access to specialists on a timely basis. An independent medical board to oversee the qualification of accredited board certified specialists.
- A follow-up mechanism and reporting capabilities to connect with primary care.
The benefits to specialty clinical navigation programs extend beyond the workplace to primary care and specialty physicians alike, in a number of ways.
- They improve the referral pathways, in both directions, by allowing primary and specialty care providers to stay in communication.
- They offer an approach to improved coordination and continuity of care by ensuring the efficient delivery of timely patient care.
- They reduce or eliminate resource requirements associated with facilitating referrals and the costly impact of errors.
Right Specialist, Right Time
It is time to recognize the value of accessing "the right specialist, at the right time." The economics and complexity associated with providing health and wellness benefits to employees has become overwhelmingly burdensome for many American companies due to a broken physician referral system.
When employees receive the wrong diagnosis for specialty care, it can delay delivery of care, add to a company's costs and potentially jeopardize lives. Implementing a supplemental specialty clinical navigation program can guide employees to the right specialists for diagnosis, get proper treatment quickly, help employers reduce unnecessary claims and costs, support and enhance investment in wellness and disease management programs and return employees to better health-and work-faster.
About the Author
Dr. Benjamin Safirstein serves as Chief Medical Officer for ArmadaHealth, which is dedicated to objectively helping customers identify and access the right medical expertise for their unique need. Dr. Safirstein is currently Clinical Associate Professor of Medicine at the Mount Sinai Medical School.
He is the founder and past president of the Asthma Institute of New Jersey and Chairman of the Scientific Committee of the Arthur Ashe Institute for Urban Medicine.
- Halvorson GC. Health Care Reform Now!: A Prescription for Change. San Francisco, CA: Jossey-Bass; 2007
- The 86th annual physician report: Why administrative burdens keep physicians away from patients, Medical Economics. Accessed September 27, 2015.
- Block L, Habicht R, Wu AW, Desai SV, Wang K, Silva KN, Niessen T, Oliver N, Feldman L. In the wake of the 2003 and 2011 duty hours regulations, how do internal medicine interns spend their time? Journal of General Internal Medicine. 2013 Aug;28(8):1042-7.
- N Engl J Med 2003; 348:2635-2645 June 26, 2003 5. Kohn LT, Corrigan JM, Donaldson MS, editors. To err is human: building a safer health system. Washington, DC: National Academy Press, Institute of Medicine; 1999.
- Schultz AB, Chen CY, Edington DW. The cost and impact of health conditions on presenteeism to employers: a review of the literature. Pharmacoeconomics. 2009;27(5):365-378.
- Wilner AN. Telemedicine: The doctor is online, but at what cost? Medscape Neurology/Neuro Notes. January 12, 2015. http://www.medscape.com/viewarticle/837759. Accessed September 29, 2015