Daren Anderson MD
SPEAKERS
Fred Goldstein, Daren Anderson, Gregg Masters
Gregg Masters 00:05 You’re listening to PopHealth Week on healthcare now radio. I’m Gregg Masters Managing Director of Health Innovation Media co founder and producer of this show in the studio today is Fred Goldstein, President of Accountable Health LLC, a Jacksonville, Florida based consulting firm. Fred is co founder and principal host of PopHealth Week on today’s broadcast. We’re delighted to introduce you to Daren Anderson MD, who serves as chief quality officer for Community Health Center, Incorporated. Dr. Daren Anderson is a general internist and has worked in safety net practices for his entire career. Community Health Center Incorporated is a large multi-site Community Health Center providing primary care to over 145,000 medically underserved patients across Connecticut. In addition, Dr. Anderson is the Director of Community Health Centers, Weitzman Institute, a Research and Innovation Center dedicated to improving primary care for underserved populations. The Weitzman Institute leads a range of initiatives focused on practice transformation and workforce development, and has created an econsult process that is now being used across Connecticut and in 10 additional states. In addition, Weitzman researchers are engaged in a range of research projects focused on health disparities, telehealth and pain and opioid abuse treatment in primary care. And with that introduction, Fred help us get to know Dr. Anderson and his work at both Community Health Center, as well as the Weitzman Institute.
Fred Goldstein 01:52 Thank you so much, Greg. And Daren, welcome to PopHealth Week.
Daren Anderson 01:55 Thank you so much. Glad to be here.
Fred Goldstein 01:57 Yeah, it’s a pleasure to have you on it’s really interesting work you’re doing so why don’t we first start out, give us a little bit of your background and what you’re doing at community health centers inc.
Daren Anderson 02:05 Great. Yeah, so so my background is internal medicine. You know, I went into health care wanting to be a primary care provider. And right after residency, I immediately started working in a federally qualified health center here in Connecticut, really with a focus of taking care of the medically underserved in the state. And I spent several years as a full time provider, but I think pretty early on started to become even more compelled and interested in finding ways to make the system work better. There’s so many examples of things in the healthcare system that are inefficient and ineffective, even more so when it comes to care for the medically underserved and those without insurance, and so kind of took a career path change and started taking on more administrative roles and getting more involved in in quality improvement. And then, most recently, in 2010, assumed the new role as director of the Weitzman Institute, which is our research and innovation center that we created here in Middletown, Connecticut, focused on finding better solutions to providing better care to patients in primary care with again, with a particular focus on the on the medically underserved.
Fred Goldstein 03:04 Yeah, it’s really a unique community. And a lot of times people don’t focus a lot on that, although, obviously, if you can make a difference there, it’s pretty amazing. So what are some of the unique things you’ve seen, obviously, working within a Federally Qualified Health Center? And what sort of approaches do they have that might perhaps be different from other providers or the same?
Daren Anderson 03:23 Well, the federally qualified health centers have been around for decades, and there’s, there’s over about 1200 of them across the country. Each of them is an independent organization, nonprofit, but what’s unique about them is there Board of, among other things, their board of directors is comprised at least majority of end users. And so I think, really, from the beginning of the federally qualified health center movement, the focus of those health centers has been on meeting the needs of the community and meeting the needs of the medically underserved population. And I think although each FQHC is independent, we meet on a regular basis and have common, you know, platforms to communicate and share ideas. So I think in many ways, it’s it’s one of if not the largest sort of organized group of health systems and health centers in the country focusing on meeting the needs of a specific population. And that’s allowed us to do a lot of things that in the for profit world haven’t really or necessarily been possible, at least in the past.
Fred Goldstein 04:18 Mm hmm. And part of this, you mentioned also is your the Weitzman Institute. What exactly is that? And how does that relate to the clinics? And also, what additional services are you working on through that?
Daren Anderson 04:29 Yeah, so Weitzman Institute was our unique creation, Research and Education Center that we built really with it with a unique mission of collaborating and communicating closely with other health centers like us around the country to conduct formal research and develop education programs and interventions that would improve the quality of care specifically for the types of patients cared for in the safety net. I think there’s a there’s a pretty significant gap in the sort of the academic literature and in most of the research studies that are done when there’s really under representation of minority populations, underserved populations, they don’t tend to be as well represented in research. And so that was one of the main gaps that we were trying to fill is to really conduct research specifically in those settings in really pragmatic research, not research about whether drug A is better than drug B, but rather research that would explore certain types of delivery system innovations and whether they worked, you know, does it help patients with diabetes to call up and talk with them on the phone more frequently, help give them advice about self management goals and things like that, does that intervention work, we started focusing pretty early on on looking for solutions to help address the lack of access to specialty care and found that electronic transmission of consults and electronic communication could go a long way towards bridging that gap. And so these were some of the types of problems that our research teams started focusing on. And that’s a big part of what we do at Weitzman is really try to find innovative solutions and foster and promote technology and innovation in the primary care space.
Fred Goldstein 06:02 And having worked with FQHCs in the past, when I was running a Medicaid HMO, you know, obviously, it’s a unique group of practices and how they work in their communities. And we contracted with a large number of them here in Northeast Florida back in the day, and they really were taking a slightly different approach. And I felt that if you can make the systems work in these disadvantaged populations, then those types of practices are the kinds of things that can work anywhere. Have you found that sort of in your research, you talked about these ideas of building out some of the needs for those types of patients?
Daren Anderson 06:34 Yep, absolutely. I think we take pride in what I we often think of as providing, you know, quality of care and access to innovation here in our community health center that I don’t necessarily have in the private practice that I go to. So and I think partly because of our community focus, partly because of the emphasis of integration of services in the collaboration that we have across multiple health centers, it’s enabled us to do a lot of things that are particularly innovative, the community health centers were among the earliest adopters of electronic health record technology. And you know, in that I was talking a little bit about he consults and this the research that we’ve done on on connecting electronically specialists in primary care that started in Connecticut anyway, with the Medicaid population, and we’re finding pretty rapidly that the work that we’re doing and the innovations have brought application outside of the community health centers, and in the in the more of the commercial environments as well. And I think in large part, the financial model that has, you know, in the past, up until recently, really emphasized fee for service has not, is not made it possible or not not made it advantageous for many of these types of innovative innovations to take root. But as we see a lot happening in the area of payment reform, you know, both within and outside the FQHC world, a lot more of these types of innovations are, are more advantageous. And so we’re seeing interest well beyond just the FQHCs now as we expand our work around the country.
Fred Goldstein 07:56 So let’s dig in a little bit into the e-consult system that you folks who have developed getting to specialists in the in the disadvantaged populations has always been a problem, whether that’s having enough specialists in an area to actually be seen or actually getting to the specialists. So talk about the ConferMED system and what it is and how it works.
Daren Anderson 08:15 Yeah, so we were really set up set out initially to solve an access problem, as you alluded to primary care can be provided and FQHCs provide a really high level of quality in primary care, but at the point at which we need advice, input guidance from a specialist, all of that quality care comes to a screeching halt. Because you know, as you alluded to specialists, depending on where you’re located are often few and far between if you’re in a rural location. And if you’re taking care of an uninsured or Medicaid patients, even if you have many specialists in the area, there’s very limited access for Medicaid and uninsured patients to those and so we set out to develop, test and really do some rigorous research on whether or not connecting with specialists electronically, would be able to help reduce that access inequality, because we knew that lack of access to specialty was one of the main drivers of healthcare inequality that we were seeing in the outcomes that our patients were experiencing. So it’s, you know, it’s less of a technology. And it’s more of really a workflow and a rethinking of the way we communicate back and forth. So the platform that we developed, and the process we put together really was simply that when a primary care provider had had a specialty related question whether they thought they needed to send a patient to a specialist, we would transmit the information about the patient in the question that the primary care provider had to a specialist. And they would be able to review that information and then confer back and forth with the PCP about what they thought and what they recommended. And, you know, our hope was that by setting up a system like that, the specialist would be able to determine, you know, how quickly the patient needed to be seen and what we ought to do in the meantime, and we found that that certainly was true. But what we found that was even more, I think, striking to us was that a significant percentage of the consults that we were sending this way didn’t need to be seen face to face at all. They the question that the PCP had the advice that they were seeking, the recommendations for next steps could be provided safely and effectively, electronically in no more than two business days. And so that’s really what e-consults are the primary care provider sends their question and the background information about the case to the specialist, and the specialist sends back some advice. Sometimes they say, here’s what I think you need to do. And I don’t need to see them in person. Other times, they will say, this person needs a face to face visit. But in the meantime, here’s some of the things that you should do to maximize the value of that visit when the patient gets to see me. And we did that on a very small scale. Starting just with one specialty cardiology did a lot of tests, which I can research to really understand how that worked. And as we were able to prove its value and its impact, we have now scaled it up to pretty much all specialties and have really built a nonprofit company around this whole concept and doing it at scale around the country.
Fred Goldstein 09:09 So in this case, it sounds like as you said, the primary care physician has a question of a specialist regarding a patient. And you’re actually in many cases not having to have the visits. So it’s become more efficient, as well as cost savings, I guess, associated with not having to do that.
Daren Anderson 11:15 Yeah, so it’s really, you know, like I said, we started off trying to solve the access problem. And our hypothesis was many of these problems could probably be answered electronically. That way, we can focus on getting patients in for face to face only for those that really need it and reduce, you know the number of patients who need access. But as you as you kind of picked up on it, as our study showed, we were really hitting the triple aim with this, because in addition to being you know, an efficient way of exchanging information, we were improving patient experience, many patients could continue to get their care in their Patient Centered Medical Home primary care in their community didn’t need to take another day off and go see a specialist. And the subsequent research we did when we were looking more at the financial side of this show that there was a significant savings to the entire healthcare system as well, because being able to provide an answer to a primary care provider in two days, and having them implement that in primary care saves significant amount of money from the alternative, which was sending patients for a specialty visit, often multiple subsequent visit. And we there’s quite a bit of evidence that you know, when patients are engaged in the specialty system, a lot of tests and procedures and things tend to get ordered. And sometimes those weren’t necessary. The the cost savings that we saw when we analyzed the claims data was significant. And I think that’s what’s now provided the driver to really build and grow systems like this within Medicaid, but also in the ACO markets, and really anywhere where cost savings is an important part of the equation.
Fred Goldstein 12:37 Yeah, particularly as we’re trying to move to value based care, I guess it’s become a little more center into the center of our thinking here. In terms of this. You mentioned that some of the federal government changes in reimbursement. Was that part of what hindered this early on? And how do providers say specialists get reimbursed?
Daren Anderson 12:56 So I think that the research that we did showed really significant savings to Medicaid, when we did e-consult, and reduce the number of people who needed to go face to face Connecticut Medicaid saved. I mean, it’s just in one study, for cardiology, the difference in cost per patient was over $600 per patient, if they did an e-consult was in a randomized control trial, it cost over $600 less for that patient than it did for a similar patient who was sent for face to face. And so in Connecticut, we are a fee for service, non managed care state, Medicaid picked up on that and actually used our literature to justify our study to justify adding e-consult reimbursement as a reimbursable benefit. So now specialists in the state of Connecticut can submit and get reimbursed directly for doing an e-consult. And so that initially wasn’t not having that before was a barrier, there was really no mechanism to get reimbursed for the for the work that it took to do the e-consult. And recently, CMS picked up on this same movement and the evidence around it. And as of January of this year, included e-consult as a covered benefit under Medicare as well. And so that really opens up the potential to build directly for fee for service for you know, a grow a significant and growing number of patients in the country. But I think that that’s important. And I don’t want to minimize that. But I think more important is the move, as you mentioned to towards value based care, risk based arrangements, shared savings and such because at least from a primary care perspective, when I look at what I do as a primary care provider and my colleagues day in and day out, if I’m enrolled in some sort of a shared savings plan, and the incentives are for my health center to be as efficient and low cost as possible. There aren’t that many things that I’m not already doing that generate cost savings, we’re already working really hard to reduce ER admissions to be open and available nights and weekends. We’re already working really hard on transition management to get patients in to be seen immediately when they get discharged from the hospital so they don’t bounce back. So we’ve squeezed a lot of juice out of that, that lemon if you will already. But the most expensive thing that we do every single day is send patients in for tests and procedures and to see specialists and so the e-consult intervention is really something that That allows us to make a dent in that and send those patients that needed to be seen with a specialist but keep the ones that don’t in primary care where we’re at our cost of delivering care is significantly cheaper.
Fred Goldstein 15:11 And you you mentioned the reimbursement for this. This is an econsole. And how is that potentially different from telehealth and telemedicine? Are they looked at the same by CMS?
Daren Anderson 15:23 Yeah, so telehealth is kind of a broad umbrella that encompasses a lot of different types of intervention. This is definitely not what most people think of as typical telehealth where there’s a doctor and a patient on using Skype or something to communicate back and forth, and maybe some equipment that’s taking vitals and transmitting them. So it’s not that but it is a form of telehealth and what we call it what is classified as is what’s known as asynchronous telehealth. That’s one of the key things the the information is captured and transmitted to the specialist and they don’t respond in live time they, in our case, our specialist respond in no more than two business days and get an answer back. The other thing that’s different is, this is really peer to peer communication clinician to clinician. So the primary care provider is submitting the information, the specialist is giving them some advice, similar to what we used to call a Curbside Consult. But the primary care provider is acting on that advice and deciding what to do with prescribing the meds or anything like that. So really, the specialist in this case is providing curbside guidance and advice for the PCP to apply as they see fit. And that has important implications for licensing and malpractice and things like that. And it makes this type of telehealth infinitely scalable, because nobody has to be live, you don’t need to have the patient and the specialist and the primary care office all sort of live on camera doing the consult, you can batch them and do them at different times. And many of our specialists who work for us do this, you know, in between cases or at lunch or in the evenings, some of them who have a lot of volume will actually take time out of their clinic day and build in this kind of telehealth time. So there’s a lot of benefits to it. And it’s it’s much more scalable.
Fred Goldstein 16:53 Excellent, that was really a nice description of some of those differences. What has been obviously for the primary care doctor, this kind of a unique thing to be able to do and get this kind of information in for the patient, it’s got some benefits, what’s been the response from the specialist,
Daren Anderson 17:08 I think it depends. Some specialists may see this as a threat. And in particular, if you’re in if you’re in an environment where you’re looking to get as many patients in as possible and build your revenue base and your patient base. Because you know, in truth, we are reducing the number of cases that need to go see you as a specialist. But I think the larger experience we have had though, in engaging with specialists is I think most of the specialists that I talk with and work with find this to be you know, exciting and important, because they know as well as we do that a large number of patients we send to see them probably didn’t need to come to be seen. And I don’t think anybody feels good about that you feel like you’re wasting your time, you’re wasting the patient’s time. And you know, there’s a better way of doing it. So all of the specialists who work for us at ConferMED, I think have signed on because they like being able to deliver this type of really efficient care, they’d like to engage with PCPs. And it in many ways, what they’re doing is educating primary care providers and helping with that. And a lot of people also like the idea of being able to do this work on their own time and side of the office without all the overhead and infrastructure. So there’s a lot of appeal. And the other specialty groups that I think find this very appealing are hospital clinics that are trying to meet social need, like if you are a public hospital that takes all comers and you’re seeing large numbers of uncompensated care. This allows you to really focus those resources on the patients who really needed to come in. And it allows you to keep the patients in primary care who can be treated in primary care and make access more available to those who really need it. So mixed but largely positive response.
Fred Goldstein 18:34 And in terms of this system, how do you how do you select the specialist? Is there some sort of quality review that goes on for those or they have to apply and submit documents?
Daren Anderson 18:46 Yeah, absolutely. So we’re we’re very particular about our specialists and really look to recruit, you know, the best and brightest specialists that we can get all of our specialists are licensed, fully licensed in their sub specialty, we credential them ourselves. But I think, you know, in addition to being great in their field, we really I think one of the most important things about an e-consult is it’s more than just answering a question what the what the what the specialist is doing is really providing education and clear guidance and advice to a PCP and they need to do that in a way that the PCP understands and react to quickly. So we actually have a fairly robust training for our specialists, we audition them essentially all of our of our specialists, when they say if they’ve passed through our credentialing and everything, we start them off with several consults. And then we review them carefully. They get feedback from from a group of reviewers that we have in the company. And then we continue to educate them on the not on their discipline, but really on on how to make their responses as as effective and educational as possible. And then we give them ongoing feedback reports and kind of report cards that show how they’re doing and really track down anytime we get a complaint or anything like that. So we hold them to a fairly high standard, really look to them to be as it to be educators as much as just answering consult questions.
Fred Goldstein 20:00 And Given that your multi state is it the whole country you can essentially serve.
Daren Anderson 20:05 So we are currently providing consults in 15 states and several more teed up for the next quarters. You know, we’ve had to do a state by state analysis with of all of the licensing, credentialing legal aspect. Because this isn’t the same as straight up telehealth, if we were providing direct to patient telehealth we simply would need to be licensed in every state. But this type of peer to peer consultation, depending on the state is does not always require an in state licensure. So there’s a lot of technicalities and a lot of things that we’ve had to understand. And so we we think really strategically about which state we want to work in so far, as I said, we’ve we’ve entered into 15. And that’s about to increase, but we’re aiming to really do this for as largest swath of the country as we can, because there’s need everywhere.
Fred Goldstein 20:48 And that’s fascinating. You know, I hadn’t, I had always thought that this would be similar to a direct consult to a patient, but obviously, it’s different. It’s back sided. So some states don’t require that state licensure cuz I know having nurses handle calls from patients a lot of times, you know, we had to make sure we had multi licensure for all of our nurses to do that. And the calls and as you build this out, if people want to potentially join this network, how do they go about doing that?
Daren Anderson 21:11 The easy answer is, you know, in our website, ConferMED.com, there’s a there’s a button, the push to to get more information. And we have a team of account managers that reach out, you know, right away to talk with each organization, we’ve been really developing on the back end, something that I’d like to call quickstart, which is almost kind of a do it yourself rapid enrollment process that allows you know, you might be a small clinic, you know, up in the mountains in Wyoming and you you may want to engage with us and do e-consults, we want to be able to make that available to you as quick as possible. So we’ve tried to make the process as streamlined as possible. Maybe one small example, we got a call just a couple of weeks ago from a city from a community health center in a city that had just seen an unexpected influx of refugees from Africa. And they had a variety of unusual tropical diseases. And the primary care providers wanted some guidance from an ID doctor. And in less than a week we had we were connected with their to their EHR, and we were exchanging information and getting consults back to them in a rapid and effective way. So we’re really trying to make that engagement process as easy as possible, because there’s, there’s really no place in the country where this sort of thing isn’t needed and wouldn’t be beneficial.
Fred Goldstein 22:16 Yeah, that’s a fantastic example. And you talked about no place in the country, which is obviously very true. As an FQHC you work with these special populations. Is this something that can be mainstreamed into the rest of medicine, Medicare, commercial plans, etc, and prove similarly beneficial, you believe?
Daren Anderson 22:31 Yep, I do, I believe very much so, and we are working with commercial plans now. And we have implemented our solution in a variety of non Medicaid non FQHC clinics and health systems as well. And I think that’s likely where we’re going to be seeing more significant growth in the future. As you know, as we talked about a little bit before, there’s the ACO model, a lot of Value Based Payment Options coming out of the major payers and all that. And so we’re expecting to see much more of our work to have benefit and to be implemented, you know, outside of the safety net, which, which I think is every bit as important.
Fred Goldstein 23:03 This may be really a dumb question. Are there any areas of medicine where you think this might not work? For really any specialist really wouldn’t matter?
Daren Anderson 23:12 No, it’s interesting. People often kind of assume that things like orthopedics, plastic surgery, those types of specialties would just there just is no way you could do a Curbside Consult like this because you know, sort in orthopedics you kind of feel their knee, you’ve got to twist their hip and all that sort of stuff. But I think what I would say is there are certain specialties for which it’s more beneficial, and other specialties which may be less used less often. But for example, in dermatology, we found that about 90% of all the consults that gets submitted for dermatology can be completely resolved with ane-console don’t need a face to face for orthopedics the number is much less but that having been said there, I’m always surprised at how many times we send any console to orthopedist and he’s able to say yeah, this is really not a surgical problem. Here’s how we would approach it, I’d recommend physical therapy and this that and the other so there’s I wouldn’t say that there’s any areas where there’s there’s never a use free consult, but it’s just a matter of sort of how much and you know, oncology is another example where we we don’t do an awful lot of oncology consults either so there certainly are certain scenarios and certain specialties that really require that face to face presence, but but not many,
Fred Goldstein 24:16 as you built this network out are there certain areas you’re looking for more providers in that may be your growth there’s been a little higher, and you need more.
Daren Anderson 24:25 So we have our specialty network is growing really rapidly. We are recruiting specialists around the country have made almost a waitlist of specialists the areas where I will say we’re always looking for specialists though in particular are dermatology which is the highest demand e-consult dermatologist are few and far between and hard to get appointments with and so we’re always looking for dermatologists on top of that endocrinology, cardiology, gastroenterology and rheumatology are most popular. We’re always looking for more specialists. The other area that I think we’ve had the the biggest challenges and have had to really work hard to build a network is in the pediatric subspecialties. We’re doing a lot of e-consult work in rural locations, school based health centers and places really outside of the major urban centers extremely difficult to get access to pediatric subspecialties. And so we have a partnership here with the Connecticut Children’s Medical Center that provides many of our e-consult reviewers for the pediatric disciplines. But we’re always looking for more. So that’s actually right now my number one priority is is building that pediatric network further.
Fred Goldstein 25:27 Right. Well, Darren has really been fantastic having you on the show covered a lot of ground really appreciate it. So thank you so much for joining us and PopHealth Week.
Daren Anderson 25:34 Thank you very much. It was a pleasure.
Gregg Masters 25:36 And that will be the last word on today’s broadcast. I want to thank Dr. Darren Anderson, the chief quality officer of Community Health Center, Inc, and director for the Weitzman Institute. Community Health Center Inc, is a leading health care provider in Connecticut building a world class multi-state Primary Care Health Care System dedicated to caring for the underserved. Do follow their work on the web via www.chc the number one.com and on Twitter by @chcConnecticut for Fred Goldstein, Dr. Darren Anderson and HealthcareNOW radio this is Greg master saying bye now.
SUMMARY KEYWORDS
specialists, consult, patients, telehealth, primary care, community health center, primary care provider, specialty, Weitzman Institute, connecticut, research, state, care, center, providing, medicaid, federally qualified health, work, country, unique