What to Do about the $29 Billion in Specialty Care Waste

September 18, 2017

September 18, 2017

 

 

On today’s episode of Healthcare Simplified, Geb Buchness is here to talk about Specialty Care Connect. Buchness is the Senior Vice President of Business Development at Armada Health, and he’s here to say that overlooking referrals specialists is a huge mistake.

 

Because who doesn’t want to save money and improve benefits? Everybody wins when you use advice to achieve quality outcomes and to find good specialty care.

 

“One of the biggest pain points in healthcare is the breakdown between primary care and specialty care—when a member gets a diagnosis and needs a specialist,” Buchness said.

 

Good thing that Specialty Care Connect was developed to simplify the specialty referral process. It actually uses online dating logic to make the perfect match between a member with a diagnosis and a uniquely qualified specialist.

 

Twelve years ago, a team of world-renowned physicians created Specialty Care Connect to enhance the specialty referral process. “The solution was originally embedded in an executive supplemental insurance benefit, which currently covers executives and key employees in over 1,600 businesses nationwide,” Buchness explained.

 

It was so popular it became its own business. “And today we’re thriving. We have over 600,000 lives covered across many different market segments,” Buchness said.

 

When You Need a Second Opinion

 

There’s a huge gap in the current market landscape of physician referrals.

 

For one, your primary care physician (PCP) doesn’t have time to do all that investigation. “Fundamentally, primary care physicians are so overburdened,” Buchness said. There’s a shortage of them, which means a panel of PCPs should have about 2,000 patients, but a lot have more than twice that number.

 

“The bottom line is, they really don’t have the time or the information to make proper specialty referrals,” Buchness said. So they’ll refer you to a med school friend, or just the sub-specialty group they refer everyone to.

 

And for another, your neighbors, friends, and family aren’t doctors (probably). But even if they were, just because your cousin liked this one doctor doesn’t mean she’ll be perfect for you.

 

“Often times people seek referrals just based on referrals they get from their friends and family, which is about as unscientific as it can get,” Buchness said.

 

So how does Specialty Care Connect get the patient to the right specialist, for the right treatment plan, in the shortest amount of time? Research, research, research.

 

When the “Now What?” Feeling Hits

 

If you’ve ever received a diagnosis, you know that blindsided feeling. It’s a very frightening experience. People often ask, “Is my diagnosis correct? What type of specialist should I see? Which one is best for my condition?”

 

Then you go through all the practical issues. “Will they take my insurance? When can I get an appointment?”

 

So, Specialty Care Connect solves all these issues on behalf of the members. “We’re there, we’re going to make the right matches based on the diagnosis, and then we’re going to help with verifying that the physician does take the member’s health plan and finding the next available appointment,” Buchness said.

 

Plus, especially for self-funded health plans, Specialty Care Connect is a huge cost savings. It can improve employee productivity, increase the effectiveness of your basic overall health program, and reduce claims.

 

Take employee productivity. “When somebody receives a diagnosis, it’s a huge distraction,” Buchness said. “Let’s be real, a lot of people are going to be trying to deal with that during the workday.”

 

When Specialty Care Connect gets the patient to the right specialist, they’re going to get improved health and recover a lot faster than they otherwise would. If they can get back to work sooner, and they’re able to work at 100% productivity, then that’s a real benefit to their employer.

 

Or take effectiveness. Specialty Care Connect works in conjunction with any health plan. “It’s like a valuable compliment, which enhances the effectiveness of the health plan by solving that great pain point, the perilous journey from primary to specialist care,” Buchness explained.

 

And the claims cost thing? Most people just don’t really understand how much waste occurs in the specialty area.

 

Are you ready for this?

 

The annual cost of preventable medical errors is $29 billion a year.

 

Healthcare Numbers That Scare

 

Most of the $29 billion occurs in the specialty area.

 

So, guiding the patient to the right specialist to treat their specific condition eliminates duplication of effort, wrong treatment plans, unnecessary surgeries, treatments, and prescriptions.

 

“All of that waste and inappropriate effort has a profound impact upon claims cost,” Buchness said.

 

Gear up for more frightening numbers.

 

According to the American Journal of Medicine, 33% of patients will receive the wrong diagnosis.

 

50% of them will receive incorrect treatment plans.

 

45% of patients do not receive recommended standards of care.

 

The annual cost of preventable medical errors is 98,000 deaths and over a million injuries.

 

So it’s an incredibly huge issue that gets overlooked. Incredibly. Huge.

 

Which is why Specialty Care Connect leverages an incredibly huge effort to correct this problem by cutting waste with good matches.

 

How? By having a completely objective process.

 

“We have no legal or financial relationship with the specialists that we credential. In fact, they don’t even know that we’re evaluating them,” Buchness said.

 

They put basic screening criteria into an algorithm, plus affiliations, board certification, specific education and training, and so on.

 

Then they add big data analysis to figure in exactly what procedures the specialists do a lot of. If—and that’s a big if—they get past the initial screening, they get reviewed by one of 30 world renowned Sub-specialist Chiefs. After that, they’re forwarded to the Medical Advisory Board for final approval.

 

“To date, we have 35,000 specialists nationwide that have been approved and that are residing in our database,” Buchness said.

 

That’s out of the 900,000 board certified specialists in the country. “The process does weed out a lot of them,” he added.

 

 

The Logic of…Online Dating?

 

You’re a member. You have a diagnosis. You need an eHarmony-style platform to find you a great match. Here’s how it works. “We sort through the entire database to achieve the three most perfect specialty matches to treat the member’s specific condition,” Buchness said.

 

Once the matches are completed, the navigators will confirm that the offices are accepting new patients, participate in the member’s health plan, and have appointments available.

 

“Often times, we can expedite that, because we’re referring patients into the specialists’ sweet spot—the kind of patients who have already been pre-screened,” Buchness said.

 

Then they contact the member with a detailed biography—a whole write-up on the three matches, all the way down to interactive directions to the office.

 

P.S. It’s nice for members to let their PCP weigh in on the choice. Because, communication.

 

And this is what Geb Buchness says these waste-cutting measures look like in real life:

 

One particular case I can think of is one of our members had a fractured spine. She went to her local back surgeon, who recommended surgery, of course. The procedure was extremely risky and had a lengthy, arduous recovery without a high probability of success.

 

Luckily, she contacted us, and our medical team reviewed her case and recommended three end network choices of orthopedic spine surgeons who were trained to treat her specific condition.

The expert she chose recommended physical therapy instead of surgery. After the physical therapy, she was able to resume her normal activities.

 

The bottom line is that Specialty Care Connect helped this particular member avoid a risky and costly surgery with a horrendous recovery period—and saved about $150,000 in claims.

 

That’s a pretty good example of what we’re able to achieve.

 

This type of specialist referral service is an overlooked add-on that’s such an important service. If you could save yourself from paying $150,000 (and having surgery), wouldn’t you?

 

“We’ve really been able to help people out, and that’s one of the great things about what we do,” Buchness said.

Contact him by email at gbuchness@ArmadaHealth.com or by phone at his direct number: (443) 900-1809.

 

Never miss an episode by subscribing to Healthcare Simplified on iTunes or your favorite podcast player. Until next time!

 

To hear this episode, and many more like it, you can subscribe to Healthcare Simplified. If you don’t use iTunes, you can listen to every episode by clicking here.

 

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