The Specialty Access Initiative in Sonoma County

 

People who are uninsured or underinsured, especially those with chronic medical problems, suffer increased morbidity and mortality when access to specialists is limited.[1] One recent case study of a small city revealed substantial gaps in access to specialty care despite the presence of a medical school, an abundance of primary care and specialty physicians, two major teaching hospitals, a large FQHC, and other safety net resources.[2]

 

The Sonoma County Medical Association (SCMA) recognizes that poor specialty access for the underserved (such as Medi-Cal patients) leads to poor quality care, poor outcomes, and financial burdens for local physicians, clinics and hospitals. In collaboration with the Redwood Community Health Coalition and other organizations, SCMA formed a task force in the spring of 2008 to improve access to specialty care in Sonoma County. The task force included 15 physicians representing a variety of specialties and modes of practice.

 

The task force heard many familiar reasons why specialists would not see Medi-Cal patients, including: “Last month Medi-Cal sent me a check for 12 cents” (local surgeon); “Fifty percent of my surgeries are never paid for. The rest we have to submit five times to get paid” (local orthopedist); and “I tried to accept Medi-Cal, and got flooded with patients; I couldn’t afford it anymore” (local specialist). 

 

As a result of these problems, Medi-Cal patients are often sent out of Sonoma County. Within the county, there are long waiting lists, delayed and suboptimal care, and progression of disease. When these patients are finally seen, there are often communication problems, such as lack of interpreters, along with a dearth of important information on consult requests. In addition, referring providers often don’t get the consultant’s report, and there is poor case management, such as prescriptions that can’t be filled and studies that can’t be done. 

 

In sum, the task force learned that specialty visits outside FQHCs present a high risk of uncoordinated care. In contrast, there was evidence that specialty visits occurring within FQHCs increase capacity, decrease cost, increase quality and educate the referring physicians. 

 

In 2004, the Alliance Medical Center (an FQHC in Healdsburg) established a dermatology clinic at the urging of its medical director, Dr. Jeff Meckler. The clinic has grown into a model for providing specialty access for the underinsured.[3] The key factors for success include:

• The dermatology clinic operates within the FQHC, allowing reasonable reimbursement for services, less hassle for the specialist, and improved access to interpreter services. The specialists either volunteer or are paid a competitive hourly rate.
• The dermatology community organized around a shared commitment to providing care for the underserved. At present, most of the county’s dermatologists participate in the clinic. 
• Patients must be referred by a medical provider using a customized one-page referral form and are triaged based on need. This procedure significantly limits inappropriate referrals. There is space at the bottom of the form for the consultant’s assessment and recommendations, which is faxed back to the referring physician the same day, improving efficiency of communication.
• A highly trained dermatology physician assistant manages the clinic and provides continuity.
• Family medicine residents rotate through the clinic, allowing local dermatologists to function in an attending role. The clinic provides an efficient learning environment for the residents, and their presence allows for increased patient volume, thereby improving access for patients needing dermatology care. 
• The presence of an on-site dermatologist facilitates communication with primary care providers in the clinic.

 

As a result, the task force sent a survey to all the county’s orthopedists to identify barriers to orthopedic access and to assess each physician’s willingness to provide access. Many orthopedists responded. We learned that the orthopedists did not want to leave their office or hospital setting to go to a community clinic but were willing to have appropriately triaged cases added to their clinic or surgery schedule. We also learned that the needs and obstacles to access for surgical and medical specialties were distinct but overlapping.

 

Based on the survey results, the task force established a modified orthopedic clinic at the Southwest Community Health Center, an FQHC in Santa Rosa. The clinic is staffed by a volunteer physiatrist (Dr. Kirk Pappas), an orthopedic physician assistant (Carlo Ferrarone), and residents from the family medicine program. Cases are effectively triaged. Those not requiring surgery are managed medically and with procedures that can be performed in the FQHC. Patients who fail medical management and need surgery are triaged for referral to an orthopedic surgeon.

 

To manage those referrals, the task force created an orthopedic roster that includes the names and preferred contact method of those orthopedists willing to participate; their preferences for handling pre-op and post-op patient flow; their OR setting; and the types of cases they prefer (see sidebar). Next we met with local hospital representatives to ensure access to operating rooms and required ancillary services. 

 

 

At present, Medi-Cal patients needing surgery are triaged to non-Kaiser orthopedists on the roster, and patients who are unfunded are triaged to Kaiser. With current participation and demand, we envision that our willing orthopedists will add 0-2 cases a month to their schedules. 

 

Endocrinologists and neurologists are also involved in the task force. Dr. Yuichiro Nakai has volunteered for many years to keep an endocrinology clinic going at the Chanate Family Practice Center. He helped the clinic improve its flows and drafted curricular improvements for residency training while presenting conferences and attending in the clinic. 

 

The demand was more than a monthly clinic could handle, however, so Dr. Nakai and clinic director Dr. Jerry Eliaser sorted out where an endocrinologist was most needed. Since two-thirds of the backlogged endocrinology referrals from the county safety net are thyroid-related, their frequency is enough for family medicine residents to gain expertise. Residency faculty member Dr. David Schneider is piloting a new thyroid clinic at Chanate FPC with internal referrals until the flows are running smoothly. When they are, the clinic will open to the rest of the safety net. Meanwhile, Chanate FPC is working with community endocrinologists to create a clinic for non-thyroid cases. 

 

A subgroup of the specialty task force, led by Dr. Allan Bernstein, is addressing access to neurology services in Sonoma County. Only two FQHCs (Petaluma and Chanate) offer these services, and their backlogs are extensive. Possible expansion of the neurology program is still in the planning stages.

 

A major issue for neurology is “headache,” a common complaint in emergency room visits that results in many wasted dollars for imaging studies and in expensive medications being used for the wrong diagnosis. Discussions are underway to extend neurology training to family medicine residents and nurse practitioners. Common neurology issues include headache, epilepsy, neuropathy, dementia and movement disorders. 

 

The task force continues to fine-tune and improve access to orthopedics, endocrinology and neurology. Our next focus is improved access to urology and otolaryngology. For surgery, Operation Access is already facilitating access for unfunded patients.[4] 

 

Partnership Health Plan has arrived in Sonoma County and has brought renewed interest in developing contracts to improve access to all specialties. In addition, the FQHCs are rapidly developing patient-centered medical homes. In this model, every safety-net patient has a continuous relationship with a primary care provider and a team of community clinic staff. This model interfaces with specialists, emergency departments and hospitals to provide efficient care to those in need. 

 

As highlighted in this article, we have already seen significant improvements in access to specialty care, but these achievements are only a start to improving health care in Sonoma County. Further changes will require smart, sensitive and specialty-specific approaches and will depend upon the goodwill and commitment of everyone involved—from the patients most in need, medical providers, and the broader community. SCMA is pleased to play an active role in stewarding the specialty access initiative and is committed to its success.