An ongoing dialogue on HIV/AIDS, infectious diseases,
December 8th, 2023
Clinician-to-Clinician Advice Is Great for Everyone but Still Horribly Undervalued
One of the best things about being an ID doctor is that you get to interact with all the medical and surgical specialties. This is one of the most common answers to the question, “Why did you choose to specialize in ID?” and it certainly resonates with me.
As a result, we’re frequently in the position of providing clinician-to-clinician advice — which, when done without seeing the patient, was historically called a “curbside” consult. Informally asked, often prefaced with “Can I ask you a quick question,?” these curbsides have pros and cons that I’ve written about on this site numerous times.
It’s a topic near and dear to my heart, so much so that I have an entire talk on this subject that starts with several slides outlining both the benefits and the risks of this practice. And for the hard-liners (see photo above on the right) who never do clinician-to-clinician advice without seeing the patient, trust me there are benefits, some of which I’ve summarized on this slide from my talk:
In a similar theme, around 10 years ago, our hospital system started offering “eConsults,” adapting similar programs from elsewhere. Instead of referring a patient for in-person consultation to a specialist, clinicians could place an order in the medical record, and a specialist would review the question, the data from the patient’s chart, and write a note.
This form of consultation occupies an intermediate place between actually seeing, interviewing, and examining a patient, and the informal “curbside” consults where you give just general advice, undocumented anywhere. Completing the note is expected within 24 hours. Because eConsults are asynchronous, meaning we specialists don’t need to respond immediately, they are far less disruptive than getting paged or called directly.
A huge advantage of this approach over curbsides is that we can review the primary data. In addition, the consulting clinician now has specific advice documented in the chart on how to proceed, which may include ordering additional tests or modifying treatment. In a small proportion of eConsults, we advise that the clinical scenario is too complex to resolve without a formal visit. After all, we can’t put a limit on the complexity of the case — that’s at the discretion of the consulting clinician. When that happens, fortunately, we’ve still been able to weigh in on tests to order ahead of time that will make an in-person visit with us or another specialist more valuable.
How has the program done?
To say eConsults have caught on vastly understates it — they are a huge hit. Imagine if a miraculous Beatles reunion became the opening act for Taylor Swift. To quote one primary care doctor who previously had a solo practice, “It’s by far the best thing about working here.”
You can easily see why they’re so popular. Not only do clinicians get access to nearly the full range of medical and surgical expertise at our academic medical center, often an eConsult can spare their patients the inconvenience and cost of an extra doctor visit. Indeed, published data on our program strongly show that eConsults decrease the volume of formal referrals, while increasing their appropriateness. Evaluations from different centers (here and here) had similar findings. Implied in these data is that care efficiency improves and the total cost to the healthcare system declines (fewer visits = lower costs).
Sounds like these eConsults are a real advance, for patients, clinicians, and payers, a rare win-win-win trifecta — so much so that we proposed expanding the eConsult service to inpatients to deal with the never-ending deluge of curbsides that arise in hospitalized patients.
So far, all sunshine and warm tropical breezes. So, what’s the problem?
No one has figured out how to pay for these things.
In a healthcare system where procedures dominate the payment landscape — the more, the better! — an advance in efficient patient care just can’t get the attention of the payers or the administrators holding the purse strings. Yes, there are billing codes for clinician advice activities without seeing the patient, but the net pay is poor (average 0.5-1 RVU, latest conversion factor $33.06/RVU), and the technical hurdles of getting reimbursement can be tricky to implement. Plus there’s this requirement:
THESE REQUIRE INFORMED PATIENT CONSENT! Since the consulting physician is not seeing the patient, the requesting physician must obtain and document informed consent.
And guess what? If you or another ID doctor ends up having to see the patient and do a consult on the case within a week, that “formal” consult can’t be billed! As a result, hardly anyone uses these codes, at least based on my emailing a variety of ID doctors in academic medical centers, and by the lukewarm responses to an online query.
So if we’re not billing insurance, how do eConsults get supported? Note I’ve used the common euphemism for money — support.
Here, our hospital system pays us for eConsults out of the Physicians’ Organization budget, a finite resource; they set the reimbursement at $50/eConsult when we started, an amount that hasn’t budged despite a substantial increase in the cost of living over the last decade. In addition, they declined our offer to expand eConsults for inpatients, even though we offered to expedite these to make discharges more efficient.
I queried a bunch of other ID doctors in a variety of practice settings about their payment models, and their responses were diverse (and fascinating). Some get paid a set amount, like our program. One does use the “interprofessional consults code” and makes do (unhappily) with the meager payments. Another uses these codes, but augments them to what seem to me to be much more reasonable rates:
(For the record, in my experience, most eConsults would be in the third or fourth category, occasionally fifth if they involve contacting the consulting clinician or a reference laboratory.)
The ID director at a “closed” healthcare system says they have no specific payment for eConsults, but that they are tied directly to the ID doctor’s job responsibility. He estimated that “all clinician-to-clinician advice for the on-call ID doctor, without direct patient contact, accounts for 3–5 hours/day” — a substantial time commitment! Finally, Dr. Allison Nazinitzky, who does ID locums work, shared with me that one of her telehealth contracts pays her $125 for an “interprofessional consult with note — a flat fee no matter how long.”
(Check out my interview with Dr. Nazinitzky. Her experience finding the true value of ID clinical care is dynamite.)
The medicolegal aspects of eConsults should be factored into any estimation of the value of the program. eConsults may reduce medicolegal risk for the referring clinician, but they substantially increase it for the specialist taking it on. Why? As noted in an excellent review of the legal risks of curbside consults, this is because we are now explicitly reviewing the patient’s chart and providing specific advice:
The closer a physician gets to providing very specific information—what dose to start with, when to draw labs and what other kinds of studies to get, and what to do specifically with a particular patient—the closer that physician is coming to being part of the care team, as opposed to just providing general information.
Despite the boilerplate language we insert at the end of each note indicating the limitations of eConsults, this will serve as little protection if a suit is filed. As part of the care team, our names can be included in any filed suit. And even if we are later dropped because we never saw the patient, the process itself can be long and painful.
So what’s the solution? I say include these advice services as part of what constitutes the job of a clinical ID doctor — give us appropriate RVU credit and/or payment for it — and make it commensurate with the time, value, and medicolegal risk associated with the service.
And if that doesn’t happen, let’s do what Dr. Andrew Pavia recommends, in my response to the query about whether he uses the interprofessional consults codes:
In other words, stop doing eConsults until they’re properly supported. Seems like a good plan!