'Something needs to change': ACP plans to streamline specialty referrals

The ACP has proposed a new process to streamline specialty referrals — a step that experts have called critical to fixing a massive issue in health care — but questions remain about the plan’s feasibility.

The paper “lays out how a lack of care coordination when care is provided by more than one clinician can cause fragmented care, increase risks for errors, and cause patient and clinician frustration,” and outlines recommendations for improving collaboration between primary care providers and specialists, according to a press release from ACP.

“The foundation of what I would call general internal medicine and primary care is critical in the health care system,” Shari Erickson, chief advocacy officer and senior vice president of governmental affairs and public policy at ACP, told Healio. “It’s clear that ... the more robust primary care basis there is, the better the outcomes there are for patients. But it has to go beyond that too. They don’t exist in a vacuum. And it’s really important that, in addition to building that base, that we have clear ways of operationalizing care coordination of primary care with their subspecialty colleagues.”

Along with the position paper and its recommendations, ACP also issued a playbook, which outlines the critical elements of a referral request and response, and “defines what is needed for each specific role or working relationship when more than one clinician is involved in the care of a patient,” according to the release.

Christopher V. DeSimone, MD, PhD, a cardiac electrophysiologist at Mayo Clinic, told Healio that the plan will help close the loop of communication — something he called a “glaring flaw” in the current referral process.

“I think there are a lot of benefits [to the plan] because they’ve gone over in detail and in depth to this big problem,” he said.

Issues with the current referral process

As it stands, DeSimone said the referral process is complex. Patients can ask for a referral from their provider, patients in the hospital can be referred upon discharge, or — the most common way — primary care providers can put in referrals for patients to see a specialist.

This could be done in “a number of ways,” he said. “That’s why there’s so much room for improvement.”

Most referrals are done via fax or sending over a patient’s records. The problem with these methods, DeSimone explained, is that important details like the core question the primary care provider seeks to have answered can be lost in an overload of information.

In an ideal world, he said, a primary care provider would call a specialist, describe the issue and ask about further steps, and the specialist would talk to the patient and then call the primary care provider back to discuss the best care plan.

However, he said this is currently impossible, partly due to scheduling, the backlog of patients who need to be seen and a lack of time and resources.

“There's so much overcapacity in the primary care setting as well as the sheer volume that we, as specialists, are seeing, so everyone has so much on their plate,” DeSimone said. “The biggest flaw, I would say, is there's a lack of one-to-one communication.”

ACP’s plan

Most adult patients, Erickson said, have one or more chronic conditions that need to be managed by more than one physician.

“One of our key intentions here and laying out this paper was to get at that structure. How can we better inform how that can be done in a really practical sense, so that it can be implemented?” she said. “So that really was our intent behind pulling this together: to really build on that primary care basis — it’s so important — but show that, beyond that, we need more. We need, really, a structure like this to ensure that patients get the best possible care.”

In 2010, ACP released a paper called “The Patient Centered Medical Home Neighbor,” which is “what really established the groundwork for a lot of our work in this space,” Erickson said, including what they developed later: a high-value care coordination toolkit “that really spoke to the need for high-value referrals themselves.”

The new paper builds on that work, “looking to take it to the next level, beyond the referral,” she said.

The plan lists four principles that should be at the core of collaborations between primary care providers and specialists:

• patient and family partnering;
• defined clinical roles and responsibilities;
• timely, productive communication; and
• effective data sharing.

Patient and family partnering

Broken down more specifically, the ACP recommends care team collaboration with patients and their families to encourage them to be involved in all aspects of care.

Clinicians engaging with one another, the patient and their family in shared decision-making is “critical to achieving positive care outcomes,” according to the position paper.

As a critical element of this principle, the ACP recommends that patients and their families receive an individualized referral plan that they design together, as well as copies of any relevant information. When condition management transitions from specialist to primary care, the specialty practice should also offer a transition report to the care team and the patient or their family.

The ACP also notes that care teams should give patients and their families educational materials with information about their condition management.

Defined clinical roles and responsibilities

The patient, family and care team should have a clear understanding of the roles, responsibilities and expectations of any care team members, according to ACP.

Because “ambiguity and disagreement in the respective roles and responsibilities” of specialty and primary care practices can lead to “inefficiencies, duplicated testing and patient confusion,” the ACP clarified in the position paper that the primary care team should serve as a “hub or central organizer of a patient’s overall care” with specialists serving as an extension of that hub.

Some critical elements here are that primary care and specialty practices “have some form of care coordination agreement that establishes an understanding” of care coordination processes and what specialists do, and that care teams establish a plan internally and “define team members for all clinical and care coordination tasks.”

Timely, productive communication

ACP also recommends engaging in informative, focused and timely communication between all parties to highlight any issues that need attention.

More than half the time, specialists report not receiving all of the information they need with a referral request, and between 25% and 50% of the time, referring clinicians report not receiving timely communication from the specialist, according to the position paper.

“Poor communication is a common pitfall of the current referral system and a major root cause of ineffective transitions between primary care and specialty times and adverse patient events,” according to the position paper.

To combat this, the ACP recommends consistent methods for care team communication that is documented in a care coordination agreement, “based on level of urgency,” and “an agreed-on communication system that alerts members of another clinical care team when urgent action is needed.” The position paper also calls for care teams to “leverage any trained support staff to help facilitate timely communication across settings.”

Effective data sharing

Since referral requests often lack important data for the specialist, the ACP recommends establishing data-sharing protocols in a care coordination agreement, noting that transfer documents should be well-organized with the most relevant data being easy to spot.

Strengths and potential setbacks

DeSimone called the new ACP plan “very comprehensive.”

“The ACP has done a good thing by getting primary care physicians and specialists involved and say, ‘here’s what’s wrong,’ and they’ve laid that out beautifully, ‘here’s how we can improve it,’ and they’ve given examples,” he said. “The beauty of it is they have a lot of great suggestions on how to improve [the referral process]. Lots of these things are involving not just the patient but the patient's family members. That will be good because then there are more eyes and more brains for each clinical scenario ... I think that’s a great idea.”

One of the biggest strengths to the plan, DeSimone said, was more effective communication.

“They also highlight, which is very important, how to close the loop of communication. So, the specialists converse back, ‘here's my findings, here's my recommendations, and here's what I've done for the patient’,” he said. “I applaud what the ACP’s doing because there's certainly fragmentation in care and patients deserve our very best. Something needs to change. This is a step toward significant improvement.”

One hindrance in rolling out this plan, DeSimone said, is that there is generally not enough time carved out in the day to review consultations “with a warm handoff or phone call to the referring primary provider.”

“Especially with a full day of patients for both primary provider and specialists, and the different schedules each have, it makes it quite difficult to have that much-needed conversation,” he said. “For the physicians who add the clerical work to their plate, their hours could extend and contribute to burnout.”

Another major limitation, which ACP acknowledges, is that the referral plan will require additional resources, DeSimone said.

“This may not be feasible given the current financial climate ... and this will likely take more federal funding or something else to help better these referral processes,” he said. “Perhaps a uniform one-page referral note from the primary provider with all of the pertinent information can be sent to the referring specialist. Then the specialist can respond with a one-page summary of the assessment and plan for the patient. This will keep everyone on the same page.”

DeSimone said the feasibility of the plan “is going to be tough.” In fact, he said, “you’re going to need a separate part of your practice to include personnel who can do this every day and aren’t seeing patients.”

“It has to be feasible because the current process isn't going to be sustainable. As patients age, more patients will have more comorbidities and more complex diseases,” he said. “There has to be something that changes for the betterment of the patients. Otherwise, care is going to be more fragmented, and things are going to be missed through the cracks in these handoffs. Will this work? Only time will tell.”

Proposed payment model

To support a more coordinated referral process, the ACP partnered with the National Committee for Quality Assurance (NCQA) to develop a new payment model centered around care coordination called the Medical Neighborhood Payment Model, Erickson said.

This model, according to ACP, would offer prospective payments to specialty care practices that incorporate advanced clinical care and coordinate with primary care partners “to fund the necessary infrastructure changes.”

In 2020, a federal advisory committee known as the Physician-Focused Payment Model Technical Advisory Committee (PTAC) voted unanimously to recommend the medical neighborhood model (MNM) to the secretary of HHS for further testing through the CMS’s Center for Medicare and Medicaid Innovation (CMMI), also known as the Innovation Center.

“In brief, the model is structured so that all MNM specialty practices receive a monthly per beneficiary per month care coordination fee to support enhanced care coordination and care delivery innovations,” Erickson said. “All model participants are also subject to a retrospective positive or negative payment adjustment based on how actual spending compares with a financial benchmark, adjusted for performance on quality and utilization metrics.”

Erickson explained that the MNM “would feature two distinct tracks:” Track 1 practices would bill traditional Medicare as usual, while Track 2 practices would receive reduced Medicare payments “in exchange for prospective quarterly payments based on projected spending.”

The proposed payment model builds on ACP’s Patient-Centered Medical Home Neighbor model, “which emphasizes coordinated, team-based care,” Erickson said in a press release. In the Patient-Centered Medical Home Neighbor care model, practices work to ensure “appropriate and timely consultations and referrals,” ensure the flow of relevant information and guide “determination of responsibility in co-management situations,” according to ACP.

The new model, however, offers “a multipronged approach to evaluating and rewarding high-quality, efficient care,” the organization said.

“The model emphasizes coordination with primary care practices to co-manage patients and ensure timely exchange of information. This includes tracking referrals and follow-up, sharing summaries of care, tracking and sharing lab results — and entering this information electronically in the patient’s medical record,” Erickson said.

She also said that all participants of the MNM model need to have systematic, specified methods for identifying patients who have experienced acute incidents, “exchanging clinical information with admitting hospitals, obtaining discharge summaries and sending electronic summaries of care to other facilities following transitions.”

“This is critical in order to close gaps and eliminate fragmentation across settings. Ultimately, these interventions drive better quality and outcomes, experience of care and costs,” she said. “Additionally, every referral will be triaged to ensure that the patient is seen by the correct specialty practice. This will reduce wait times for patients to be seen and help to eliminate duplicative and unneeded test.”

In this model, practices would also need to “meet consensus-based standards to improve care coordination and advanced care delivery and incorporate a pre-screening process for all visits to ensure that patient visits are maximized,” according to ACP. The model would require practices to report quality, cost and outcomes data with certified electronic health record technology to minimize the burden on a practice “while maximizing its ability to collect and leverage data to promote accountability and drive performance improvement.”

Timeline

Erickson said the ACP is in discussions with CMMI about testing the model, but the timing has been a challenge because the PTAC recommended testing during the transition between the Trump and Biden administrations.

CMMI went through “strategic refreshing” with the administration change “and now seems to be delving more wholeheartedly [into] developing or updating or adding to the models that they have implemented so far,” Erickson said. She now feels that they are “at a good time,” which is why they are continuing discussions.

“ACP believes that the updated CMMI strategy is aligned with the goals of the MNM model and continues to have discussions with the agency staff regarding testing all or some of the model,” Erickson said.

She added that many of the details, such as which specialties will test the model, how long the testing will last and when the model could be implemented, “will be determined by CMMI and/or others that may initiate formal testing of the model.”

However, she noted that PTAC “continues to invite ACP and our partner in the development of this model, NCQA, to discuss key elements of our proposal to help inform their ongoing efforts.”

“For instance, our model is discussed in the 2021 PTAC report on the role of care coordination in optimizing value-based care and ACP will be presenting at an upcoming PTAC meeting in March 2023 that will focus on specialist integration within population-based total cost of care models,” Erickson said.

References:

• ACP lays out mechanisms for better care coordination between primary and specialty care to improve patient care. https://www.acponline.org/acp-newsroom/acp-lays-out-mechanisms-for-better-care-coordination-between-primary-and-specialty-care-to-improve. Published April 29, 2022. Accessed Nov. 3, 2022.
• ACP 'Medical Neighborhood Model' payment model pilot being recommended to HHS secretary. https://www.acponline.org/advocacy/acp-advocate/archive/september-25-2020/acp-medical-neighborhood-model-payment-model-pilot-being-recommended-to-hhs-secretary. Published Sept. 25, 2020. Accessed Nov. 3, 2022.
• Beyond the Referral: Principles of effective, ongoing primary and specialty care collaboration. https://www.acponline.org/acp_policy/policies/beyond_the_referral_position_paper_2022.pdf. Published April 2022. Accessed Nov. 3, 2022.
• The “Medical Neighborhood” advanced alternative payment model (AAPM) proposal. https://aspe.hhs.gov/sites/default/files/private/pdf/261881/ProposalACPNCQA-Resubmitted.pdf. Published November 2018. Accessed Nov. 3, 2022.
• The patient-centered medical home neighbor: the interface of patient-centered medical home with specialty/subspecialty practices. https://www.acponline.org/system/files/documents/advocacy/current_policy_papers/assets/pcmh_neighbors.pdf. Published Aug. 1, 2010. Accessed Nov. 3, 2022.