Learn the three key lessons that policymakers, payers, and leaders in provider organizations can use to better align incentives and unlock the systemic benefits that e-Consults can offer.
E-Consults are communications between primary and specialty health care providers. They can increase access to needed specialty care for complex or acute conditions, especially in rural and underserved areas, and in safety-net settings. E-Consults can also reduce the cost of care by allocating resources more effectively, reducing unnecessary use of specialty care, and enabling specialists to deploy their expertise where it’s most needed. And, they strengthen the role of primary care, building PCPs’ knowledge and enabling them to care for their patients holistically and longitudinally.
So why, when e-Consults offer so much, has their uptake been relatively limited to date? Why do health systems that implement them often struggle with low utilization? And why does Medicaid and commercial reimbursement remain patchy?
We analyzed policy levers to scale and sustain e-Consults in four states (Massachusetts, New York, Rhode Island, and Washington State). We have also drawn on learnings from Project Arkansas e-Consultations (PARC), a pilot to generate evidence for e-Consults in a commercially-insured population, funded by the Peterson Center on Healthcare in partnership with Arkansas Blue Cross Blue Shield.
Here, we highlight three lessons from these states that policymakers, payers, and leaders in provider organizations can use to better align incentives and unlock the systemic benefits that e-Consults can offer.
1. It helps to have a state-wide focus on reducing the total cost of care.
Three of the states we looked at (Massachusetts, Rhode Island, and Washington) have mandated targets to contain the growth of health care costs. This may seem far removed from e-Consults. But state cost growth benchmarks create an environment where policymakers, payers and providers align around a need for clinical innovation to reduce spending without reducing access to care. In this context, e-Consults are an attractive tool, and in some of the states we spoke to, cost constraints may have motivated their uptake, though in others, promoting e-Consults was just seen as the right thing to do for patients.
Arkansas was selected to pilot e-Consults with a commercially-insured population partly because it was a participant in CMS models including Comprehensive Primary Care+ and Primary Care First. Over time these models created infrastructure for multi-payer alignment and a focus on care delivery transformation at a practice level. Significantly, an evaluation by Mathematica found that this focus on transformation alone, without additional incentives to reduce costs, was not enough to drive adoption.
2. Value-based reimbursement and alternative payment models drive adoption.
Pressure on health care cost growth can lead to greater, though often uneven, value-based reimbursement and alternative payment models (APMs). Though fee-for-service (FFS) reimbursement by Medicaid and other payers is an important step to signal the value of the service, e-Consult adoption at scale is often greatest in accountable care or capitated settings.
In Massachusetts, for instance, in addition to FFS reimbursement, the Medicaid MassHealth Primary Care Sub-Capitation Program aims to reduce costs and to strengthen the role of primary care by paying a per member per month (PMPM) fee to cover the cost of typical primary care services. Higher-tier capitation payments were linked to e-Consult implementation and this drove uptake significantly.
In New York there is no mechanism for Medicaid to reimburse federally-qualified health centers (FQHCs) for e-Consults. Nevertheless, some centers, including Finger Lakes Community Health, showed that e-Consults could be sustainable under value-based contracts, and used early successes to advocate for broader payer support.
In Arkansas, a small number of primary care practices were outliers and used e-Consults extensively, accounting for most of the adoption during the pilot. These practices tended to be in value-based contracts and saw e-Consults as a tool to help them succeed.
3. Multi-payer alignment is key.
For PCPs to adopt e-Consults at scale, the workflow needs to be streamlined, and they need to know that the majority of their patients are eligible. For e-Consults to gain traction in a state or region, a critical mass of payers (both Medicaid and commercial; Medicare has reimbursable codes for e-Consults) has to be on board.
In states where e-Consults have scaled more successfully, critical mass has been achieved through large payers taking the lead and through formal mechanisms to support collaboration. In New York State, Medicaid signalled strong support for e-Consults by reimbursing for both primary and secondary codes starting in April 2024.
In Rhode Island, Medicaid does not reimburse, but there is one dominant commercial payer (Blue Cross Blue Shield RI), which took the lead in reimbursing for e-Consults, driving other payers to follow suit. In Washington, leading commercial Blue Cross plans and Molina Healthcare agreed to reimburse in line with Medicaid, creating uniform access.
In some cases, formal alignment mechanisms underpinned these efforts. In Rhode Island, the Community Care Transformation Collaborative (CTC-RI) served as a vehicle for bringing together not just payers but also providers and other stakeholders around shared goals to improve and integrate primary care. Arkansas had the Arkansas Health Care Payer Improvement Initiative, creating a framework for collaboration between payers, and SHARE, a well-functioning health information exchange. When Arkansas Blue Cross Blue Shield, the original partner in the pilot, started reimbursing for e-Consults, they were quickly joined by Centene, one of the state’s major Medicaid plans.
States have a role to play in creating the conditions for e-Consults to succeed.
E-Consults are complex interventions, and to reach their full potential, they require both facilitative policy environments and a ground game of provider education and engagement.
For states, there is a growing focus on reducing the total cost of care at state and federal levels, including through new CMS models like AHEAD. As policy-makers regulate health care, design reimbursement models, facilitate health information exchanges (HIEs), and bring together a range of stakeholders, they can set the stage for e-Consults to play a role in achieving this ambition.