Earlier this week the federal government clarified that insurers can’t charge people for anesthesia administered during a free colonoscopy to screen for colorectal cancer. That’s good news for consumers, some of whom have been charged hundreds of dollars for anesthesia after undergoing what they thought would be a free test. But the government guidance leaves important questions unanswered.

Under the health law, most health plans have to provide care that’s recommended by the U.S. Preventive Services Task Force without charging members anything out of pocket. The only exception is for plans that have grandfathered status under the law.

That task force, a nonpartisan group of medical experts, recommends that starting at age 50 people periodically receive either a colonoscopy, sigmoidoscopy or fecal occult blood test to screen for colorectal cancer.

Most people are anesthetized during a colonoscopy, in which a flexible tube with a camera at the end is inserted into the rectum and snaked through the large intestine to look for polyps and other abnormalities.

Although the health law made it clear that the colonoscopy itself must be free for patients, it didn’t spell out how anesthesia or other charges should be handled.

That lack of clarity allowed insurers to argue at first that if polyps were identified and removed during the colonoscopy, the procedure was no longer a screening test and patients could be billed. In 2013, regulators clarified that patients couldn’t be charged for polyps removed during a screening colonoscopy because it was an integral part of the procedure.

With this week’s guidance, the government has made it clear that consumers don’t have to pick up the tab for anesthesia during a colonoscopy either.

But other questions remain. Consumers may still find themselves on the hook for facility or pathology charges related to a screening colonoscopy, according to an email from Anna Howard, a policy principal at the American Cancer Society Cancer Action Network, and Mary Doroshenk, director of the National Colorectal Cancer Roundtable.

In addition, cost sharing rules are unclear for consumers who get a positive result on a blood stool test and need to follow up with a colonoscopy. The federal government hasn’t clarified whether that procedure is considered part of the free screening process or whether insurers can charge for it as a diagnostic procedure, Howard and Doroshenk say.

In a 2012 study, researchers found that four insurers imposed patient cost sharing for colonoscopies after a positive blood stool test and three did not.

As for consumers who paid for anesthesia and now learn that they shouldn’t have been charged, it’s unclear if they can get their money back.

“Our expectation is that those who have received a bill for anesthesia this plan year may be able to appeal, but not for previous years,” Howard and Doroshenk said.

The Department of Health and Human Services didn’t respond to a request for clarification.

Please contact Kaiser Health News to send comments or ideas for future topics for the Insuring Your Health column.

Kaiser Health News (KHN) is a national health policy news service. It is an editorially independent program of the Henry J. Kaiser Family Foundation.

LOCKHART, Texas — The call from the nursing home came just before dawn, jolting Martha Sherwood awake.

During the night, fire ants had swarmed over her 85-year-old mother, injecting their stinging venom into Natalie Sealy’s face, arms, hands and chest.

“She was just lying there being eaten alive,” said daughter Billie Pender, who said she and her sister had repeatedly complained about a broken windowsill in their mother’s room at Parkview Nursing and Rehabilitation Center. The Sept. 2 attack devastated Sealy, a retired bank teller with dementia. “She went steadily downhill,” dying in late March, said Sherwood, who brought a lawsuit against the home.

Their mother had chosen the for-profit facility two years earlier because it was near her adult children. The family didn’t know that Parkview scored poorly on staffing and other quality measures.  This year, Medicare rates it one star out of a possible five stars — the lowest rating possible — on Nursing Home Compare, which was designed by the federal government to help consumers choose a long-term care facility.

The problem for Sealy’s family and residents of many parts of the country is they have few, if any, higher-rated options if they want their loved ones close by.  Texas has the highest percentage of one-and two-star homes in the country: 51 percent of its nursing homes are rated “below average,” or “much below average,” on Nursing Home Compare, according to an analysis by the Kaiser Family Foundation. (KHN is an editorially independent program of the foundation.)

Louisiana is close behind at 49 percent, with Oklahoma, Georgia and West Virginia tying for third at 46 percent.
States with at least 40 percent of homes ranked at the bottom two rungs include North Carolina, Tennessee, Kentucky, Ohio, Pennsylvania and New York.

Stars are awarded based on government inspection reports, staffing levels and self-reported quality measures, including the percentage of residents who develop bed sores or who are injured in falls. Earlier this year, the government added quality criteria and as a result, many nursing homes dropped a star or more.

Nursing Home Compare is not the only guide to long-term care facilities. In fact, Medicare urges consumers not to rely solely on the website, but to gather information from a variety of sources, including visits to the facility. That’s because the star ratings, which launched in 2008, cannot consider all the factors important to a particular family, such as the availability of specialty care or the home’s distance from family members – a key issue because frequent visits correlate with better outcomes.
The nursing home industry criticizes the variability of state inspections, which it says make cross-region comparisons difficult. Advocates raise concerns about Medicare’s reliance on self-reported quality data.

Nonetheless, consumer groups say the stars offer a good starting point. “I’d stay away from anything that had one or two stars,” said Brian Lee, executive director of Families for Better Care, a Florida-based advocacy group for nursing home residents.
Sealy’s family didn’t have that option, however, if she was going to stay by her daughters in Lockhart, a small town about 30 miles south of Austin.

Nine of the 10 nursing homes within a 25-mile radius get only one or two stars. Only one home – about 20 miles away in San Marcos – garners three stars.  Not a single home in that radius earns four or five stars – the highest Medicare rating, although nearly half of nursing homes nationally get those scores.
Moving farther away would have made it “impossible to go visit her every day,” Sherwood said.

Sherwood’s lawsuit, filed in Caldwell County district court, alleges Parkview failed to provide a safe environment, pest control or adequate staffing. In court papers, the home’s owners deny the allegations.

‘Why Are We Allowing These Providers To Continue?’

Despite decades of scrutiny, the large percentage of low-ranked homes in Texas and across a broad swath of the country from the Deep South, through the Ohio Valley and into the Northeast shows that quality in the nation’s nearly 15,500 nursing homes remains highly variable.

“Conditions are not changing rapidly enough,” said Robyn Grant, director of public policy at the National Consumer Voice for Quality Long-Term Care. “We hear frequently about poor nursing homes and usually they’ve been poor for a long, long time. Why are we allowing these providers to continue?”

Consumer advocates cite several culprits for poor care:  Not enough staff and weak state and federal staffing rules, low pay for workers resulting in high turnover, feeble financial penalties and reluctance by state officials to close problem homes for fear of displacing residents.

States that set higher staffing standards tend to score better on quality measures, said Charlene Harrington, a University of California, San Francisco, researcher who has spent her career studying nursing home quality.

Ideally, she said, homes should provide about four hours of direct care to each resident every day, with some of that delivered by registered nurses.  But no state requires that.

Federal law requires that a registered nurse be on duty at least eight hours a day, and that a licensed vocational nurse always be on hand. About 26 states have additional standards, which are generally a ratio of residents to staff, or hours of care per day. Texas does not set specific staffing ratios for nurses’ aides and other non-licensed staff, except in specialized Alzheimer’s units.

“The nursing home industry has been able to block [stronger] federal staffing standards and in many cases state staffing standards,” said Harrington.

For-profit nursing homes also tend to get lower quality scores than nonprofits, according to several studies. In Texas, 86 percent of homes are for-profit, compared with 70 percent nationally, according to the Kaiser Foundation report. States with more low-income seniors also tend to score lower.

Nursing Homes Blame Underfunding

Nursing home industry officials say they are improving quality, citing reduced use of antipsychotic drugs and new efforts to address employee turnover.

In their view, the chief problem is insufficient Medicaid payments, which make it harder to hire and keep staff.

“We’ve been chronically underfunded for 20 years,” said George Linial, president and CEO of LeadingAge, an advocacy group whose members include nonprofit nursing homes in Texas.

While it varies by home, Linial and others said about 70 percent of Texas nursing home residents are on Medicaid.

“How can a nursing home that’s getting paid $135 a day per resident afford to pay someone a decent wage?” he asked.

Medicaid payments by the state of Texas for nursing home care are among the lowest in the country, averaging $133 a day per resident in 2014, according to a report prepared for the American Health Care Association, a federation of nursing homes, assisted living centers and other long-term care providers.

Based on 2014 cost estimates, homes in Texas faced an average shortfall of $13.81 a day per Medicaid resident, the report says.  All 34 states and the District of Columbia listed in the report — except North Dakota – had shortfalls, according to the estimates, with New York’s the largest, at $40.54 a day. Those larger shortfalls do not necessarily correlate with states with the highest percentage of low-ranked homes.

Patient advocates are skeptical of arguments about inadequate financing, saying staffing can be good in some homes and poor in others when they operate in the same state and receive similar Medicaid payments.

“Many of these nursing homes are making profits, but they put profits over staffing,” said Harrington of the University of California.

The debate over profits is complicated because it’s difficult to track profits and revenue, since many nursing homes are owned by private corporations or limited partnerships with complex ownership structures.

“There’s plenty of profit being made by these facilities, but they’re shoveling it out through management contracts to themselves,” said Charles Brown, a partner in the law firm Brown, Wharton & Brothers, which is representing Sealy’s family in their lawsuit against Parkview.

Parkview Has ‘A Lot Of Good People’

A casual visitor to Parkview Nursing and Rehabilitation Center might have no clue about its low ratings on Nursing Home Compare. It’s a pleasant-looking facility, with colorful paper decorations made by local schoolchildren adorning its lobby and awards proclaiming it the winner of the local newspaper’s survey for “Best Nursing Home in Caldwell County.”

Administrator Lane Allen is clearly proud of the facility and his staff: “There are a lot of good people [working] in a very tough environment.”

Nursing Home Compare gives Parkview one star for staffing, saying it provides about one hour and ten minutes of licensed nursing care per resident a day, compared with a Texas average of about one-and-a-half hours. It provides one hour and 56 minutes of care per day by certified aides, compared with a Texas average of two hours and 18 minutes. The national average is nearly two and a half hours.

Allen said that one of his biggest problems is getting and keeping workers, noting that a local Dairy Queen pays $10 an hour, the same rate an entry level aide would make. He employs about 80 staffers, about three quarters of whom are nurse’s aides.

Like many nursing homes, Parkview gets mixed inspection reports: In 2011, state regulators said it provided a “substandard quality of care.” In 2012, it was “in substantial compliance” with regulations.  In 2013, problems causing “actual harm or immediate jeopardy” for residents were noted.

Following a complaint by Sealy’s daughters, the state inspected Parkview in September, finding “rules or laws were violated,” according to an Oct. 15 letter to the family. The state “intends to issue citations and may impose other sanctions,” the letter said.

But state spokeswoman Cecilia Cavuto said no citations were  issued because the enforcement division determined there was not enough evidence should the facility dispute them. Also, she said, the broken windowsill had been fixed. The October letter to the sisters should have reflected that no citations would be issued, she said. Under Texas law, homes can avoid fines if they state how they plan to fix the problem.

Asked about the ant attack, Allen said, “there are two sides to every story,” but declined to elaborate.  He referred questions to corporate officials, who declined to comment citing the pending lawsuit.
Since 2010, the home has been owned by Pinnacle Health Facilities XIX, with Plano businessman Thomas D. Scott as the majority owner, according to state records. Spokeswoman Rebecca Reid said Parkview is a leased facility operated by and managed by Preferred Care Partners Management Group, which operates in several states.

‘Enough Is Enough’

Lawmakers in several states, including Washington and Connecticut, are debating proposals to raise staffing standards to boost care.  Washington’s would require almost three and a half hours of direct care staffing per resident starting in July and large urban nursing homes would need an RN on duty 24 hours a day. Connecticut’s proposal calls for 2.3 hours of staff time per resident each day, up from 1.9 hours.

In Texas, lawmakers are deliberating on a bill that would allow the state to yank the license of any home that gets three citations for problems causing “immediate jeopardy” to residents — the most serious category — within a two-year period. The so-called “three-strikes” measure has passed the Senate and has been referred to the House Committee on Human Services.  Another bill would close a loophole that allows homes to avoid paying fines on certain serious violations if they “fix” the problems.

“We’re at a point where we say enough is enough,” said Republican state Sen. Charles Schwertner, during a February hearing on the three-strikes bill, which  he sponsored.

The bill was prompted in part by a state commission report last summer that sharply criticized the Texas agency charged with overseeing nursing homes. In fiscal 2013, state regulators took enforcement action against less than one percent of almost 38,000 violations, the commission found.  Regulators collected only $400,000 in fines against nursing homes that made an estimated $5.4 billion that year.

The industry argues that three-strikes laws are unfair because government inspectors vary in what they consider “immediate jeopardy.” It succeeded in getting lawmakers to modify the proposal so that affected homes would have the opportunity to seek a waiver if they can prove problems won’t harm residents.

Advocates strongly support the bill.

“This says … nursing homes that have a license from the state must live up to that license,”says Amanda Fredriksen, AARP’s associate director for state policy in Texas.

The three-strikes bill would not have affected Parkview.  Sealy’s daughters are hoping the legal system will keep someone else’s mother from suffering as their mother did.

“Things happen, I understand,” says Sherwood. “But when they happen from being negligent, or not doing proper maintenance, [people] should be held accountable.”

Kaiser Health News (KHN) is a national health policy news service. It is an editorially independent program of the Henry J. Kaiser Family Foundation.

The insurance program was called “Believe Me”  — but Kairis Chiaji had her doubts.

She and her husband Arthur were skeptical that the new health plan they purchased for 2015 would actually work out. That’s because their experience in 2014 had been a disaster, she said.

The Sacramento, Calif., couple had been thrilled to learn last year about the prospect of subsidized coverage under the nation’s health law, she recalled. Each of them had been uninsured for years when they signed up for coverage through the state exchange, Covered California.

“I just thought about how many people who are like me,” explained Kairis, 43, a self-employed natural hairstylist and doula. “If you have a lot of money, you’re covered. If you don’t have any money, you’re covered. When you’re in the middle, working hard every day, that’s when it’s really tough.”

When her children were little she worried about paying for their care if they were injured.

“I just simply told my children, listen, all I’ve got is a ruler and duct tape, so you’re not allowed to break any bones. Literally you can’t get hurt,” she said.

Arthur, an immigrant from Kenya who worked in food preparation, hadn’t had coverage since he left his home country,  which has a national health insurance program. “Everybody can afford insurance,” said Arthur, 39, who married Kairis in 2013. “And so that’s how I thought it was gonna be [in America]. That was not the case.”

At a health fair in February 2014, the Chiajis signed up for a plan with Anthem Blue Cross at a cost of $138 a month for the two of them. Her two oldest children, who are 18 and 22, were able to get insurance through Medicaid, the state and federal program for the poor, and her younger son has private insurance through his father, Kairis’ ex-husband.

Kairis and Arthur went home and waited to receive their insurance cards and first bill. Nothing arrived.

At the end of June, they finally received their cards and a bill for May, June and July, Kairis said.

They sent in one month’s payment, which they assumed would be for July since they hadn’t even known they were eligible for coverage in May and June. But Anthem told them  their payment only covered May, Kairis said.

When Kairis called Anthem to ask whether there had been a mistake, “they said you’re not covered [now] because you have to pay the months before now,” she said.

As she tried to resolve the problem, Anthem told her to hold off paying another bill until the insurer was able to process a change in their  income, which would lead to a slightly lower premium. So she waited, but didn’t get another bill.

Around that time, the couple brought two more children into their home, whom they are in the process of adopting from the foster system.  Arthur tried to go to the doctor for a physical exam to complete the adoption but was told by the medical office he wasn’t covered.

Kairis tried to clear things up on the phone with Anthem. “You wait on line for an hour, you get disconnected, they say no one can talk to you and hang up on you,” she said. “It was really frustrating.” When she called Covered California, she said, she got a message explaining operators were busy and she was disconnected.

Kairis estimated that she spent about 20 hours in all trying to figure out their insurance situation.  Each time she called, she said, she was told something different.

“At some point, [Anthem] said the month that you paid for basically amounted to nothing. There was never a month when we had insurance we could use, and you have to back pay four months worth of coverage in order  to get covered right now — $138 times four, they wanted that payment.”

That would have been $552 for insurance the Chiajis said they never actually had.

Kaiser Health News contacted both Anthem and Covered California to get their take on the problem. Both said that according to their records, the Chiajis had coverage consistently through May. The Anthem spokesman added that the confusion was probably caused by some early communication issues between Covered California and the insurer.

No one  has tracked how many people had problems like the Chiajis in the first year of enrollment, but many customers reported initial computer and communication glitches. For example, consumers and insurance agents in California  said that when they tried to tell Covered California about a change in their income, their insurance plans were cancelled and they had to be re-enrolled, according to  the Center on Health Reporting.

Anthony Wright, executive director of Health Access, an advocacy group in California, said the percentage of people who experienced problems enrolling in Covered California  was  likely  small.

“But even if you’re dealing with 10 percent or 1 percent, in Covered California  you’re still talking about tens of thousands of people. And for them, it’s completely frustrating, it’s a huge problem. It  undermines the entire basis of why they’re signing up for insurance, which is the security against medical costs,” Wright said.

When the exchanges first launched,  “the private insurers just didn’t have the systems in place and didn’t have the capacity to deal with this volume of customers,” Wright said.

In November, Kairis and Arthur Chiaji received a letter from Anthem Blue Cross, asking them to renew their coverage for 2015. But the couple had had enough. They enrolled instead with the Kaiser Permanente, at a slightly higher cost of $158 a month. (Kaiser Health News is not affiliated with Kaiser Permanente.)

Again, there was confusion. The family said it received a bill for January coverage, though Covered California had told Kairis her plan did not begin until Feb. 1.

But this time around, Kairis was more savvy. Right away, she arranged a conference call between Kaiser Permanente and Covered California, cleared up the error, and paid for her first month of coverage — February.

In March, Arthur injured his wrist while lifting heavy trays of food at work. The Chiajis were still waiting for their Kaiser Permanente insurance cards to arrive, but Arthur needed to see the doctor as quickly as possible.

This time, the Chiajis were in luck: Kaiser Permanente had created a special program in 2014, at the beginning of subsidized coverage under the Affordable Care Act, to ensure that any delays in enrollment would not prevent new members from receiving care.

The program, called “Believe Me,” allowed patients who believed they were Kaiser Permanente members but were not yet officially entered in the system to get care without paying at the time of service. Kaiser holds the medical bills for 90 days to give the system time to catch up.

Kairis was able to book her husband an appointment with a Kaiser doctor under a temporary ID number. It turned out he had twisted but not fractured his wrist, and he was sent home with a brace. He went back two more times for treatment of that injury and an inflamed hip, and eventually the card arrived in April.

“We’re able to get care, so I’m not worried if my husband gets hurt on the job or if I twist my finger and can’t braid. I’m comforted,” she said.

Like many people,  Kairis said her experience of the health law was more positive in the second year after the exchanges were launched. Polls show Americans recently have gone from being more opposed to the law to being just about evenly split on its merits.

Still, there is a way to go, said Kairis. “It would be really nice if Covered California and the health insurers would streamline their process a little better and if everyone had the same info,” she said.

“You know with anything new there are going to be glitches. But now that millions of people are enrolled in coverage, they have to figure out how to make it work.”

Kaiser Health News (KHN) is a national health policy news service. It is an editorially independent program of the Henry J. Kaiser Family Foundation.

About 137 million individuals with private insurance are guaranteed access to free preventive services.

In the late 1990s you could have taken what hospitals charged to administer inpatient chemotherapy and bought a Ford Escort econobox. Today average chemo charges (not even counting the price of the anti-cancer drugs) are enough to pay for a Lexus GX sport-utility vehicle, government data show.

Hospital prices have risen nearly three times as much as overall inflation since Ronald Reagan was president. Health payers have tried HMOs, accountable care organizations and other innovations to control them, with little effect.

A small benefits consulting firm called ELAP Services is causing commotion by suggesting an alternative: Refuse to pay. When hospitals send invoices with charges that seem to bear no relationship to their costs, the Pennsylvania firm tells its clients (generally medium-sized employers) just say no.

Instead, employers pay hospitals a much lower amount for their services — based on ELAP’s analysis of what is reasonable after analyzing the hospitals’ own financial filings.

For facilities on the receiving end of ELAP’s unusual strategy, this is a disruption of business as usual, to say the least. Hospitals are unhappy but have failed to make headway against it in court.

“It was a leap of faith,” when Huffines Auto Dealerships, which provides coverage to 300 employees and their families, signed on to the ELAP plan a few years ago, said Eric Hartter, chief financial officer for the Texas firm.

What he says now: “This is the best form of true health care reform that I’ve come across.”

Huffines first worked with ELAP on charges for an employee’s back surgery. The worker had spent three days in a Dallas hospital.  The bill was $600,000, Hartter said.

Like many businesses, the dealership pays worker health costs directly. At the time it was working with a claims administrator that set up a traditional, “preferred provider” network with agreed hospital discounts.

The administrator looked at the bill and said, “‘Don’t worry. By the time we apply the discounts and everything else it’ll be down to about $300,000,’” Hartter recalled. “I said, ‘What’s the difference? That doesn’t make me feel any better.’”

Instead he had ELAP analyze the bill. The firm estimated costs for the treatment based on the hospital’s financial reports filed with Medicare. Then it added a cushion so the hospital could make a modest profit.

“We wrote a check to the hospital for $28,900 and we never heard from them again,” Hartter said.

Now Huffines and ELAP, which launched this service in 2007 and has been growing since, treat every big hospital bill the same way. The result has saved so much money that what the dealership and workers contribute for health costs stayed unchanged for six years while benefits remained the same, Hartter said.

More than 200 employers providing health coverage to about 115,000 workers and dependents have hired ELAP. Company CEO Steve Kelly said he is aware of only one other, smaller, benefits consultant with the same approach.

Normally customers who don’t pay bills get hassled or sued. This sometimes happens to ELAP clients and their workers. Hospitals send patients huge invoices for what the employer refused to pay. They hire collection agents and threaten credit scores.

ELAP fights back with lawyers and several arguments: How can hospitals justifiably charge employers and their workers so much more than they accept from Medicare, the government program for seniors? How can hospitals bill $30 for a gauze pad? How can employee-patients consent to prices they will never see until after they’ve been discharged?

The American Hospital Association and the Federation of American Hospitals did not respond to requests for comment about ELAP.

ELAP is not merely a medical-bill auditor, like many other companies, combing hospital statements for errors. It sets the reimbursement, telling hospitals what clients will pay.

Eventually, “overwhelmingly, the providers just accept the payment” and leave patients alone, Kelly said. A federal district judge in Georgia decided a 2012 case against a hospital and in favor of ELAP and its furniture chain client.

Most patients being dunned by hospitals are unlikely to meet with the same success on their own, lacking backup from ELAP and its legal firepower.

Under ELAP’s main model, neither employers nor their claims administrators sign contracts with hospitals. Employers detail the reimbursement process in documents establishing how the plan covers workers. That gives it legal weight, ELAP has argued in court. ELAP agrees to handle all hospital bills for an employer and defend workers from collections in return for a percentage fee tied to total hospital charges.

There is no hospital network. Employees may use almost any facility. Payments are made later based on ELAP’s analysis.

That may change, Kelly said. Often it makes sense even for medium-sized employers to contract directly with hospitals to treat their workers, he said. That way prices are clear.

But for now ELAP clients such as Huffines and IBT Industrial Solutions are giving hospitals a different dose of medicine.

At IBT, a Kansas distributor of bearings and motors, “runaway health costs were starting to threaten the long-term viability of our company,” said chief financial officer Greg Drown. After reading “Bitter Pill,” a critical Time magazine piece about hospitals, IBT executives decided to try something else.

They hired ELAP, which was “not a simple or risk-free move,” cautions Drown.

About one IBT worker in five using a hospital gets “balance billed” for amounts the employer won’t pay, he said. That can take months to resolve even with ELAP’s legal support. But ELAP’s program cut health costs by about a fourth, he added.

Recently managers at a big medical system in metro Kansas City “finally figured out we were doing something a little bit different,” sent “a nasty letter” and followed up with a call, he said.

The hospital executive on the phone “was very condescending and thought I was stupid and had been duped by a predatory consultant and had been sold a — quote — crappy plan,” Drown said.

Drown listened. He told the man he would consult with his colleagues and reply.

“I called him back a week or two later and left him a rather detailed voicemail that said, ‘We’re not changing anything. We’re staying where we are.’ And the guy never called me back.”

Kaiser Health News (KHN) is a national health policy news service. It is an editorially independent program of the Henry J. Kaiser Family Foundation.

Doctors called it the black hole.

If their low-income or uninsured patients needed specialty care, they put in a referral to the massive Los Angeles County health care bureaucracy and then waited — for weeks or even months. It could take eight months to see a neurologist, more than three to see a cardiologist.

To speed things up, doctors at county and community clinics urged their patients to go straight to the emergency room, the unofficial back door for specialist appointments. That way, patients could bypass the long waits and get the recommended colonoscopy or CT scan. But that route was expensive and burdensome to ERs.

It’s a problem across the nation: Specialists are hard to find for many patients, and even harder to afford. Sick people may grow sicker as they wait for appointments, causing them unnecessary discomfort and making treatment more costly in the long run. Diabetics may suffer with untreated foot ulcers, raising the risk of amputation; patients with abnormal chest X-rays may turn out to have cancer.

With a million patients a year depending on Los Angeles County for health care, local officials decided they had to act. Hiring scores of costly specialists wasn’t an option. So in 2012 they created a program called eConsult, modeled after a system at San Francisco General Hospital, to streamline the referral process.

The L.A. County program allows for a Web-based conversation between primary care doctors and specialists that can include the exchange of medical records and photographs. The specialist typically responds to inquiries within three days and a decision on a referral soon follows.

Much as a triage nurse clears the way for accident victims in a crowded ER, clinics would use guidelines for each specialty — created by specialists and primary care doctors working together — to determine who needs an appointment and how quickly. The primary care physicians can continue to care for the remaining patients, consulting with specialists electronically.

Three years later, it’s clear the program hasn’t been a panacea. Most patients in Los Angeles County still need face-to-face appointments with specialists, and there still aren’t enough of them to go around. But both primary care doctors and specialists say things have gotten better.

The county quickly realized its hypothesis was right — about 30 percent of patients referred by providers at county and community clinics didn’t actually need to see a specialist in person. Primary care doctors said they now have a clear way to communicate with specialists about their patients. And when patients do get to the specialist’s office, more have the necessary lab work or tests so the appointments are more efficient.

Overall, doctors agree that the electronic referral system has improved both communication and collaboration among doctors on both sides. And primary care doctors say the new system is far better than the old days, when they would have to “beg, borrow and plead” to get appointments for their patients.

Wait times for specialists in general also have dropped, although a small number of patients with nonurgent health issues still may have to wait up to six months for appointments, according to the county’s specialty care director, Dr. Paul Giboney.

COSTS COULD GO UP

In L.A. County, about 10,000 eConsult requests come in each month across more than 40 specialties. The program has the potential to become a national model: Giboney said health leaders in Illinois, Alaska, Connecticut and elsewhere have contacted him to ask about how the county’s program works.

But some primary care doctors have argued that they don’t have the skills, time or resources to manage patients who need more advanced care. In addition, the system isn’t set up to pay community physicians for the added work, tests or procedures that specialists request before seeing patients.

“Without any extra reimbursement, those costs are hitting the primary care providers,” said Dr. Richard Seidman, chief medical officer at Northeast Valley Health Corp., which runs several community clinics.

EConsult works better for some specialties than others. For example, an endocrinologist may be able to advise a doctor on how to manage the complications of diabetes or a cardiologist can suggest ways to manage a heart murmur but an ophthalmologist can’t treat cataracts through an electronic conversation. Nearly 90 percent of patients referred to ophthalmology end up with an in-person appointment.

Nevertheless, Dr. Lauren Daskivich, an ophthalmologist with L.A. County, said she no longer has to try to interpret one-line referrals and can more easily figure out what type of eye doctor a patient needs to see and how soon. “For the first time, we have actually been able to triage how urgently they need to get in,” she said.

Nationwide, the problem of access to specialists has eased somewhat due to the Affordable Care Act, which enabled more than 16 million people to get insurance. But the health law didn’t cover everyone, most notably people living here illegally, and specialists may not take the insurance that patients have.

Electronic consultation by itself can’t resolve the access problem for poor patients, said Dr. Nwando Olayiwola, associate director of UC San Francisco’s Center for Excellence in Primary Care, who studies these efforts nationally. “It solves a huge part of the problem but it doesn’t solve all of it,” she said.

For now, the Los Angeles County health care system is still overburdened. One doctor put it simply: Technology doesn’t solve the problems that were there before technology.

At the UMMA Community Clinic in South Los Angeles, more than 40 percent of patients remain uninsured and some have been in the queue for a specialist appointment for months. The clinic’s Dr. Cesar Barba says he’s grateful there is a way to talk to specialists and identify those who need to be seen more quickly.

The eConsult system helps, but it “is not the ideal,” Barba said. “The best solution is if we had more specialists. That would be ideal.”

Kaiser Health News (KHN) is a national health policy news service. It is an editorially independent program of the Henry J. Kaiser Family Foundation.