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2008 Going Green Conference: Building, Technology & Practices

Thursday, October 9, 2008, 7:30-11:45 a.m., Doubletree Hotel, Rohnert Park

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Health Care: Clinics seek solutions for specialty care access issues

Like most problems in the low-income health care setting, access to specialty care has become another unfortunate casualty of budget warfare between public funders and community clinics.

The system has become increasingly complex and expensive, forcing many specialists to leave the system altogether. Now North Bay doctors on both ends are attempting to work toward a solution together.

“Specialty care access has always been an issue, but it has gotten increasingly worse, especially in Sonoma County, as the number of specialists has severely eroded,” said Patricia Talbot, Sonoma Valley Community Health Center chief executive officer.

“Imagine you are one of the few remaining specialists and all the clinics are basically fighting for referrals all the time. It’s a great financial risk to take on those patients, there is a massive amount of paperwork and for many, the only solution was to stop seeing those patients altogether.”

Dr. Kelly Pfeifer, medical director for the Redwood Community Health Coalition and the Petaluma Health Center, is the current champion of concentrated efforts to increase specialty care access in Sonoma County by exploring several models also in the works in Marin and Napa counties.

She said in the past most specialists offered some pro bono or community work, but that changed when successful managed care models like Kaiser took off and specialists started reporting losses every time they saw a Medi-Cal patient.

“Right now there is a drastically increasing number of uninsured, and when [clinics] do find a specialist that sees Medi-Cal it’s kind of like opening the flood gates. People from 100 miles around will send their patients there.”

Dr. Pfeifer said the leading possibility for change depends on decreasing demand by better educating primary care physicians, increasing supply through specialist buy-in and improving coordination so specialists do not feel bombarded by community clinic requests.

“If the physicians feel like they can participate in the community clinic without being overburdened, they are more apt to buy in to the idea,” said Kaiser Permanente specialist Dr. Kirk Pappas, who was also recently voted new president of the Sonoma County Medical Association.

Dr. Pappas has long volunteered at Southwest Community Health Center and is part of a recently formed committee in the medical association aimed at helping the clinics improve access to specialty care.

He said the medical association is currently collaborating on one model that will decrease pressure on specialty care physicians by eliminating unnecessary referrals. This is done by developing standardized protocols for primary care physicians through an electronic medical records system.

Recently, the Redwood Community Health Coalition began implementation of a region-wide community clinic electronic medical records system that has the ability to upload protocols into patient charts. When completed, any time a primary care doctor begins to process a patient that might need specialty care, they have a step-by-step process for what tests should be ordered, what to check for and what they can deal with on their own.

Kaiser has offered the clinics access to its evidence-based protocols, and the coalition is in the process of adapting and integrating the steps into its system. Recently, San Francisco General Hospital implemented a similar system and was able to cut its wait time for colonoscopies from one year to one month.

Another model that has worked successfully in several clinics and which Dr. Pfeifer is hoping to expand in the orthopedics and endocrine specialties is the development of on-site specialty clinics, or “hub clinics.”

“In order for this kind of model to work, you have to have 100 percent buy-in within a specialty. If it’s just one or two doctors volunteering their time, they will get burned out,” said Dr. Jeff Sugarman, a private practice dermatologist that leads a hub clinic at Alliance Medical Center of Healdsburg.

Dr. Sugarman started the Northern California Dermatology Referral Center within Alliance about four years ago and now has about 10 physicians that rotate through the clinic. They serve patients from as far as northern Mendocino and Yolo counties and recently started involving residents from the Santa Rosa Family Practice Center.

Also, by having the specialist work in the clinic, patients are more likely to show up for their appointment and primary care physicians can better consult with specialists if they have questions.

“The key factor in having a successful specialty model is finding ways to use the specialists you have in the most effective way, said Robert Moore, medical director for Community Health Clinic Ole in Napa. He said by just implementing the hub site model they were able to eliminate about half of their specialty referrals.

Another method that is almost to the implementation stage in Marin and developed in a similar form in Napa will create a central referral center to compile all clinic requests and streamline paperwork for participating physicians.

“As with most clinics, we have to handle specialist referrals on a case-by-base basis. … It’s really labor intensive, and a lot of times the patient still has to wait a long time,” said Marin Community Clinics Chief Executive Officer John Shen.

Last year, the organization received a $150,000 planning grant from Kaiser to develop the project that will be fully implemented next year. “This will make it so much easier to solicit more specialist participation because they know they won’t be overrun with requests,” Mr. Shen said.

Another project in the works in Sonoma and Marin is the implementation of a telemedicine system that would allow specialists in remote locations to consult patients and primary care doctors via video satellite system. Currently other Northern California clinics have successfully implemented specialists telemedicine systems.

Community clinics also save money by hiring “circuit rider” specialists who split their time between sites. By doing this, clinics, including Southwest, Petaluma Health Center and Marin Community Clinics, share the burden of paying for a full-time staff person.

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Submit items for this column to D. Ashley Verrill at 707-579-2900 ext. 215, averrill@busjrnl.com or fax 707-579-8475.