The Maze of Specialty Healthcare

As a physician training in cardiology, it is sobering to witness the inefficiencies of our healthcare system, and the resulting barriers to high-quality specialty care faced by our patients. While patients feel the brunt of this broken system, other stakeholders including physicians, healthcare systems, and payers, don’t have it easy either. The ‘system’ seems to work against everyone.

Lets walk in the shoes of each stakeholder and understand their journey in this oversimplified healthcare maze.


Female therapist doctor examining male patient with stethoscope, medical treatment and healthcare concept vector Illustration on a white background

I had the privilege to care for a wonderful lady, 50 years of age, in my clinic recently. Her story exemplifies the complexity and the resulting fallout of our healthcare system. Mrs. X is someone who would be termed a ‘frequent flyer’ to refer to her high utilization of healthcare. Besides visits to her PMD, her healthcare journey is marked by several visits to her cancer specialist for lung cancer, and cardiologist for heart failure from clots in her lungs. At her most recent visit with me in the cardiology clinic, she happened to mention a rash in her arms and legs that is typical of a clotting phenomenon. Concerned, I ordered blood work that revealed rapid decline in her kidney and liver function and reduced blood counts. I sent her to be admitted to the hospital where her condition was rapidly deteriorating to a life-threatening one. Over the next few days, I tried to reach out to the PMD, who was not in the same network as our hospital and succeeded only after trying several times. When I was finally able to obtain the patient’s records from her PMD and other specialists, I found that she had received blood work that was positive for a rare disease called Antiphospholipid Syndrome two years ago – that the hematologist had not communicated to the PMD. What this essentially means is that not only was a life-threatening diagnosis missed, but lack of treatment led her to develop clots in her lungs causing heart failure and now in several other body organs – a condition that is called Catastrophic Antiphospholipid Syndrome (yes, that is what it is called!). Fortunately, for the patient, we were able to identify this rare condition in time and provide the recommended treatment that saved her life. But – a system that can allow for potential lives lost merely because of miscommunication between doctors – does not feel safe at all.

While this may sound like a one-off experience, it is way more common than you might think. Several physician surveys have elucidated the grim reality that there is no communication between the specialist and the referring doctor more than 50% of the times. Besides poor communication resulting in poor outcomes, patients have to wait for several weeks before they can actually see a specialist. For example, patients have to wait for 45 days, on average, before they can see a cardiologist in Boston! Once they do manage to see a cardiologist, they are often referred further for several diagnostic tests, like echocardiograms and nuclear stress tests. Not only are these tests expensive, they may also require pre-authorization by insurance providers introducing more delays in this care episode. Not infrequently, patients receive unnecessary tests because of several reasons including malpractice concerns and defensive medicine, compensation structures that incentivize more testing, direct to consumer marketing, and patient requests. Only after several weeks, a few visits, a few tests, and a lot of wasted time in the physician office waiting room, might patients actually receive the care they sought out.

Specialist physicians


I was surprised to find that I was not the only one thinking about the ‘patient-access paradox’. I can attest to the fact that my patients have to sometimes wait for up to weeks for an appointment with me, or opt for a complete stranger physician instead. I have also observed that, not uncommonly, I find myself sitting opposite a patient who was either inappropriately referred to me by the referring provider, or comes with incomplete referral information rendering the visit rather inefficient. This overutilization/underutilization of specialist visits is a very common phenomenon indeed. In a physician referral survey from 2015, ~ 20 million referrals to specialists are clinically inappropriate each year. 65% of these inappropriate referrals were either sent to the wrong specialist or did not require a referral at all. When sent a clinically inappropriate referral, 63% of the physicians will refer the patient to another, more suitable, physician (incurring an estimated $1.9 billion in lost wages and unnecessary co-pays annually), and 36% end up providing care themselves (putting quality of patient care at risk). More efficient referrals may free up specialty resources and improve access to specialty care. Better solutions for patient-physician mismatch are warranted to solve for this patient-access paradox.

That’s not all. As a cardiologist, I am often faced with a LOT of administrative burden – the most painful of which is the prior authorization process. Prior authorization is a cost-control measure, targeted at restricting access to treatments, drugs and services. This process requires physicians to obtain approval from the patient’s health plan prior to the delivery of the prescribed treatment, test or medical service in order to qualify for payment. In a recent physician survey administered by the American Medical Association, more than nine in 10 respondents said prior authorization had a somewhat negative clinical impact, with 28 percent reporting that prior authorization had led to a serious adverse event such as a death, hospitalization, disability or permanent bodily damage, or other life-threatening event for a patient in their care. While it was originally well intended to deliver cost-effective care, prior authorization has come to pose a costly administrative obstacle to patient-centered care instead. Short of legislative reform, an ideal solution is one that might take this administrative burden off the physicians’ shoulders in a cost-effective manner.

Health systems


Healthcare organizations face multiple high-priority concerns – production pressures, declining reimbursement, shift to value-based payment models, maintenance of market share and reputation, cost control – all while also trying to improve patient experience and quality of care. The US health care system needs to address an unsustainable trajectory of high costs and middling outcomes. The US has the highest per capita health expenditures in the world but ranks last among developed nations in care quality, efficiency, and equity. Recent government health care reforms, including the Patient Protection and Affordable Care Act and the Medicare Access and Children’s Health Insurance Program Reauthorization Act (MACRA), aim to improve value. The fee-for-service (FFS) payment model contributes to escalating healthcare expenditures and inconsistent quality. Payers are moving away from the FFS payment model. The Department of Health and Human Services announced its goal to shift 50% of Medicare payments to alternative payment models by 2018, which was met in early 2016, nearly a year ahead of schedule. Commercial payers also aim to tie 75% of payment to value by 2020. More primary-care doctors work directly for hospitals, and they are being pushed to keep lucrative referrals for specialists, surgeries and imaging within their network. That can mean a smaller pool of potential doctors to see, termed narrow networks, and higher out-of-pocket costs for patients. What this essentially translates into is the surreal reality that a patient may not be referred to the best doctor for specialty care, but the most cost-effective doctor for the healthcare system within which the patient seeks care. That is a scary world to live in.

Most policymakers believe payment reform is necessary to improve care, and public and private payers are experimenting with a range of payment models that better align payments with value. While these measures are absolutely necessary in the face of mounting healthcare costs, we need efficient systems to ensure that quality of care for patients is at least preserved, if not improved, as a result.

Health Insurers


In many ways, we end up blaming the health insurance companies for all our collective health problems. If we pay low premiums, but high co-pays, we blame them. If pay low co-pays, but high premiums, we blame them. If they try to control unnecessary costs and reduce coverage, we blame them. Our basic instinct is to vilify health insurers at any chance that we can get. Because we think that they are the bad guys who become rich at the cost of our health.

Yet, they are faced with problems of their own. One of the biggest challenges facing them is the uncertainty over the Affordable Care Act. The two big headlines in the health insurance industry over the past couple years have been mergers (Aetna/CVS) and insurers dropping out of the individual health insurance marketplace (e.g. Humana, Aetna and UnitedHealth). With the individual mandate removed, a ‘death spiral’ scenario can be envisioned with increasing premiums for those who stay. Moreover, like hospitals, shifting payment models from fee-for-service to value-based reimbursement also challenges insurers. Health insurers are working with providers on figuring out ways to address social determinants of health as payments will be tied to health outcomes rather than procedures done. Another challenge for health insurers is the limited ability to control cost. Since private insurers do not have the purchasing power or policy options that the government has, they struggle with controlling spending. We have seen increased consolidation of providers as large provider groups buy up smaller hospitals in their state. This makes it even more difficult for insurers to negotiate prices with providers. Steering referrals to cost-effective physicians delivers a clear return-on-investment for payers by reducing the overall cost of care. Major insurers such as Humana and Cigna are now employing medical groups. Ultimately, what this means for patients, is higher copays and premiums, narrow networks, inability to choose their doctors, decreased coverage, and ultimately poor satisfaction and outcomes.

So, what’s the answer? Well, I will not claim to have it. But, what if we could come up with a health technology solution for managing referrals and reducing the patient-access paradox, improving physician communication, and reducing administrative burden to drive revenue growth in fee-for-service models, while also delivering margin and cost protection in the evolving fee-for-value models? What if payers were to benefit as a corollary from said reduced costs? And, what if patient satisfaction was the key metric at the center of this solution, and not a corollary? Well, I can only dream 🙂

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