Reduce wait times for Medi-Cal specialty care

Like many communities across the country, the greater Sacramento region has specialized health care issues that are not easily resolved.UC Davis Health 2022 Community Health Needs Assessment (PDF) found that wait times for specialist appointments were “excessively long,” regardless of payer. In settings where supplies are limited, it is those with the greatest difficulty accessing care who face the longest wait times.

In Sacramento County, 1 in 5 Medi-Cal enrollees had difficulty finding specialty care (PDF), such as cardiologists, rheumatologists, and urologists, in 2020 and 2021. JAMA network open The study also found that caregivers of children with Medicaid coverage were more frustrated finding specialty care for their children than caregivers of children with private insurance. They were also more than twice as likely to report it.

Diana Camacho, MPH, senior program officer at the California Healthcare Foundation, said health care has been looking for solutions to this problem for years. “We know that people on Medi-Cal and the uninsured are suffering because they can't get medical attention when they desperately need it. The longer treatment is delayed, the worse the patient's prognosis.'' Furthermore, the longer a patient waits to see a specialist, the more specialized care they may need.

Recognizing the need to reduce inequities in specialty care, representatives from Wellspace Health, a Federally Qualified Health Center (FQHC) with 30 clinics in Sacramento, Placer, and Amador Counties, several years ago We started brainstorming with UC Davis Health.

The team determined that inadequate Medi-Cal reimbursement was a barrier to access that could be improved. Fees were so low that even when specialists were available, reimbursements did not cover overhead costs and providers often could not financially justify accepting Medi-Cal patients. “It's not all about the money,” said Cordia Roche, MBA, Wellspace's chief strategy officer. “But like any business, sustainability is important in healthcare.”

If the team can find a way to simply break even, rather than letting professionals make a profit from providing Medi-Cal services, they might be on to something.

Reduce wait times for Medi-Cal specialty care

After much discussion, WellSpace and UC Davis came up with a partnership model called Specialty Connect. “Here in the Sacramento area, five or six individual FQHCs have asked for help providing access to specialists,” said Ann, associate chief strategy officer at the University of California, Davis School of Health. Boynton said. “We have found a solution that allows us to provide access to patients on Medi-Cal through the right structure in an economically sustainable way. became the most viable way for us to move forward.”

Here's how two organizations made Specialty Connect work. WellSpace has applied for a scope of services expansion (PDF) with the Health Resources and Services Administration to include new specialties and be able to charge for them. Wellspace then entered into an agreement with UC Davis Health to hire experts for half a day for a flat fee using a binding professional services agreement. This fee includes UC Davis Health salaries and provider benefits. The specialists then see patients at her Specialty Connect, an independent clinic run by her WellSpace. WellSpace pays for specialist certification, malpractice insurance premiums, supplies, equipment, nurses and other support staff while practicing with SpecialtyConnect.

Because WellSpace is an FQHC, the organization is eligible for funding under Section 330 of the Public Health Service Act. Importantly, WellSpace will also be eligible for enhanced reimbursement when serving Medi-Cal patients. In effect, if a provider works under the auspices of Specialty Connect/WellSpace, it will be financially profitable. No one loses, the patient wins.

Of course, what seems so simple rarely actually happens. “Believe me, this took years of discussion and planning,” Boynton said, not to mention overcoming obstacles.

Remove barriers to specialized treatment

Sacramento, like many areas of California, is a state in which Medi-Cal managed care plans provide financial responsibility for health care services for enrollees to independent practice associations (IPAs), physician groups, and, usually, the state, for a down payment amount. We use a model of delegation to other healthcare providers who receive payment. Health plans to provide services. This means that you receive a certain amount of money to cover the expected cost of medical services for a particular patient over a certain period of time. In this delegation model, an FQHC like WellSpace contracts directly with an IPA to become the patient's primary care provider, and the IPA provides the specialty network.

However, the contracted IPAs were not keeping up with the demand for specialty care. There is an awareness of the problem here. “Right now, he's the only gastroenterologist between his two largest IPAs, which account for about 400,000 Medi-Cal recipients in the county,” Roche said. “There are approximately 250,000 adults who want access to that one specialist. So, needless to say, if a patient just makes a preventive appointment with that gastroenterologist, she will be treated for six to nine months. You will have to wait.”

Another major obstacle was directly related to the way professionals worked. Doctors at the University of California, Davis use an electronic medical records system called Epic, and WellSpace uses his electronic medical records system called NextGen. “It's not reasonable to expect physicians to learn a completely new system,” Boynton says. For now, WellSpace employs medical scribes (personal assistants who accompany doctors during patient visits and enter documents into her NextGen for record-keeping and billing purposes), but experts at Epic I continue to use it. This redundancy will be resolved when WellSpace switches to Epic this year.

Despite all these challenges, Specialty Connect works.

Advancement of Specialty Connect

The number of people treated so far is modest, but patients and UC Davis doctors are satisfied, Roche said. “As a United Church, we are mission-focused,” Boynton said. “Our physicians really want to be part of the solution.”

The plan is to continue slow and steady. “We want to be realistic about growth,” Roche said. Specialty Connect began in January 2023 with Rheumatology. “As soon as we opened, three months worth of appointments filled up quickly.” While this still means long waits for some patients, it is a marked improvement over previous wait times. I am. And we expect appointment waiting lists to continue to improve as providers address patient waits.

A heart failure outpatient clinic will also open at the end of 2023. In addition to rheumatology and cardiology, Specialty Connect plans to add several other specialties in 2024, including gastroenterology and possibly urology.

Roche and Boynton acknowledge that meeting the needs of the Sacramento region may also require expertise from larger health systems outside of UC Davis. All plans must track medical outcomes to fully determine the impact of their approach on Medi-Cal patients.

“But for now, we're happy that this is off the ground and we're looking at ways to expand our services, but always in a sustainable way,” Roche said.

Camacho praised Specialty Connect as an innovative solution that can be replicated in other communities, but said it is not a panacea. “To really solve this problem, we're going to need a number of solutions,” she says. “This model is promising because partners are working to address specialty care access issues in an economically sustainable and reproducible manner that will have a major impact on the health and lives of Medi-Cal patients. Because we are united.”