An Innovative Solution for Sacramento’s Specialist Desert

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The greater Sacramento area, like so many communities across the country, has a specialist health care problem that’s not easily solved. The UC Davis Health 2022 Community Health Needs Assessment (PDF) found that, regardless of payer, wait times for appointments to see specialists are “excessively long.” In an environment where the commodity is in limited supply, it’s the people with the biggest challenges accessing care who face the longest waits.

In Sacramento County, one in five Medi-Cal enrollees had difficulty finding specialty care (PDF) from providers like cardiologists, rheumatologists, and urologists in 2020 and 2021. And a 2023 JAMA Network Open study also found that caregivers of children insured by Medicaid were more than twice as likely as caregivers of children with private insurance to report feeling frustrated trying to find specialty medical care for their children.

Health care has long looked for solutions to this problem, said Diana Camacho, MPH, a senior program officer for the California Health Care Foundation. “People with Medi-Cal or those who are uninsured are not able to see specialists even when they desperately need them, and we know they suffer for this. The more the care is delayed, the worse the outcome for the patient.” Furthermore, the longer a patient must wait for a specialist, the higher the intensity of the specialty care they may need.

Acknowledging the need to mitigate the specialist care inequity, representatives from WellSpace Health, a Federally Qualified Health Center (FQHC) with 30 clinics in Sacramento, Placer, and Amador Counties, began brainstorming several years ago with UC Davis Health.

The team determined that inadequate Medi-Cal reimbursements were a barrier to access that could be remedied. The rates were so low that even when a specialist was available, the reimbursement didn’t cover their overhead, which meant the provider often could not financially justify taking Medi-Cal patients. “Money is not everything,” said Cordia Losh, MBA, WellSpace’s chief strategy officer. “But sustainability is important in health care just like in any business.”

If the team could figure out a way for specialists to simply break even rather than make a profit from providing Medi-Cal services, they might be onto something.

Cutting Wait Times for Medi-Cal Specialty Care

After much discussion, WellSpace and UC Davis devised a partnership model called Specialty Connect. “We had five or six separate FQHCs here in the Sacramento area asking us to help provide access to specialists,” said Ann Boynton, the UC Davis Health associate chief strategy officer. “We saw a solution that allowed us in a financially sustainable manner to be able to provide access to patients who have Medi-Cal through the right structure. As we worked through that, this partnership with WellSpace became the most viable way for us to move forward.”

Here’s how the two organizations made Specialty Connect work: WellSpace applied for a Health Resources and Services Administration expansion of scope of services (PDF) to include new specialties and be allowed to bill for them. Then, using a binding professional services agreement, WellSpace contracted with UC Davis Health to hire its specialists for half days at a flat rate. The rate covers UC Davis Health’s cost of salary and benefits for the providers. The specialists then see patients at Specialty Connect, a freestanding clinic that WellSpace maintains. WellSpace pays for the specialist credentialing, malpractice insurance premiums while practicing at SpecialtyConnect, supplies, equipment, and nurses and other support staff.

Because WellSpace is an FQHC, the organization qualifies for funding under section 330 of the Public Health Service Act. Importantly, WellSpace also qualifies for enhanced reimbursement when serving Medi-Cal patients. In effect, when providers work under the auspices of Specialty Connect/WellSpace, the financials pencil out. Nobody loses and the patients win.

Of course, what seems so simple rarely is. “Believe me, this took years of discussion and planning,” said Boynton — not to mention navigating the obstacles.

Clearing Away Obstacles to Specialty Care

Sacramento, like many regions of California, uses a model in which the Medi-Cal managed care plans delegate financial responsibility for health services for enrollees to independent practice associations (IPAs), groups of physicians and other providers who generally receive a capitated payment from the health plan to deliver services. This means they receive a set amount of money to cover the predicted cost of health care services for a specific patient over a certain period. In this delegated model, FQHCs like WellSpace then directly contract with the IPA to be a primary care provider for the patient, and the IPA provides a specialty network.

But the contracted IPAs were not keeping up with the demand for specialty care. Here’s a sense of the problem: “Between the two largest IPAs, which account for about 400,000 Medi-Cal recipients in the county, there is only currently one gastroenterologist,” said Losh. “You have about 250,000 adults who might want to access that one specialist. So, needless to say, we find that patients have a six- to nine-month wait just to get a preventive appointment with that gastroenterologist.”

Another significant obstacle directly involved how the specialists do their work. UC Davis physicians use an electronic health records system called Epic, while WellSpace uses one called NextGen. “It wouldn’t be reasonable to expect the doctors to learn an entirely new system,” said Boynton. For now, WellSpace has hired medical scribes — a personal assistant who accompanies physicians during patient visits and enters documentation in NextGen for recordkeeping and billing purposes — while the specialists continue to use Epic. This redundancy will be resolved when WellSpace switches to Epic this year.

Despite all these challenges, Specialty Connect works.

Onward for Specialty Connect

Though the number of people served so far has been modest, Losh said patients and UC Davis physicians are pleased. “As a UC, we’re mission-based,” said Boynton. “Our doctors really want to be a part of this solution.”

The plan is to continue slowly and steadily. “We want to be pragmatic with the growth,” said Losh. Specialty Connect began with rheumatology in January 2023. “As soon as we opened up, the appointments were filled three months out almost immediately.” This still means a long wait time for some patients, but it’s a marked improvement over the previous wait time. And, as providers work through the patient backlog, they anticipate the waiting list for appointments will continue to improve.

At the end of 2023, the heart failure clinic opened. In addition to rheumatology and cardiology, Specialty Connect will add several other specialties in 2024, including gastroenterology and perhaps urology.

Losh and Boynton acknowledge that meeting the Sacramento area’s needs may also require specialists from large health care systems other than UC Davis. All of the plans must track health care outcomes to fully determine the approach’s impact on Medi-Cal patients.

“For now, though, we’re pleased we got this off the ground, and we’re looking for ways to expand services — but always in a sustainable way,” said Losh.

Camacho commended Specialty Connect as one innovative solution that may be replicated in other communities, but she said it is not a panacea. “To truly solve this problem, we will need many solutions,” she said. “This model is promising because partners are coming together to address specialty care access problems in financially sustainable and replicable ways that will meaningfully impact Medi-Cal patients’ health and lives.”

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