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Pilot Study Suggests Ways Primary Providers Can Deliver Specialty Care

By Rebecca Adams, CQ HealthBeat Associate Editor

June 7, 2013 -- Using telemedicine or physician assistants and primary care providers to deliver specialty care instead of specialists seems to give patients broader access to the services without compromising quality, according to an evaluation of initiatives in six states that are still in the early stages.

The 24-page study by the Center for Studying Health System Change for the Commonwealth Fund evaluated efforts to increase access to specialty care among patients, including those enrolled in Medicaid, in Connecticut, Illinois, Minnesota, New Mexico, Oregon and Tennessee. Each model, the study said, showed the potential to be used in other states.

"Some respondents found quality of care and patient outcomes to be the same, if not better" than when patients were treated by specialty providers. The programs have not been fully analyzed to determine cost savings but the study said that comprehensive evaluations by other groups are planned for the projects in New Mexico, Connecticut, and Minnesota. Each initiative had different ways of expanding access to specialty services.

Some of the early results included, for example, an increase in the Connecticut project in the percentage of diabetic patients that got retinopathy screening. The percentage grew from 10 percent to 40 percent. In that project, the program created a telehealth program in 2009 to look for early signs of blindness in people with diabetes. Medical assistants were taught to use retinal cameras to take images of patients. The images were then sent to ophthalmologists for diagnosis. Using telehealth for diabetic retinopathy saved about $28 a patient, or about 35 percent of the cost per patient when compared to an exam by a specialist, according to the report. The project is run by Community Health Centers Inc., the Yale Medical Group and the University of Connecticut. The community health centers care for about 130,000 patients.

In New Mexico, waits for rheumatology appointments at the University of New Mexico fell from six months to one month after a videoconference-based project was created. In that program—known as Project ECHO (an acronym for Extension for Community Healthcare Outcomes)—primary care providers were trained to act as quasi-specialists. Primary care doctors and other primary care providers ask specialists for advice on how to treat patients with specific conditions, and, over time, the primary care providers learn enough to treat many common concerns without having to refer the patients to specialists. One primary care provider in the project sent all patients with rheumatology needs to specialists before the training, but after the project was implemented, that rate of referral fell to about 10 percent of cases.

The quality of care seemed "to be the same, if not better," said the study. The authors noted that patients treated for hepatitis C through Project ECHO had about the same outcomes as patients treated by specialists.

The report also said that in Oregon, the use of physician assistants helped orthopedic patients who didn't need surgery to get therapy in a quicker way than waiting for specialty care. The physician assistants also were able to replace temporary splints for patients with routine broken bones with less of a wait than the patients would have had to endure to see an orthopedist. The use of casts early on helps to heal the bones.

Some advocates of the projects hope to expand them. But the study concluded that this could be tough to do, particularly without changes to current Medicaid payment policies.

The study said potential changes might include: paying providers to consult with specialists or treat patients remotely, allowing federally qualified health centers to provide more specialty care, funding the training of primary care providers in specialty care and changing, for example, the way coordinating patient care is paid for in managed care contracts.

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