When Should a Primary Care Doctor Refer to a Specialist? Should Kidney (and Other) Specialists be Consulted Earlier or Later?

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michaelaaronson

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I'm promoting our newest kidney specialty outreach clinic at Alegent Health Immanuel Medical Center. During a recent tour, I had an interesting conversation with an Alegent Health Clinic primary care physician regarding the "right" time to involve a specialist in a patient's care.

I have blogged about this topic is the past (read more: When Should I See a Kidney Specialist?). There is good data to suggest that patients should have a nephrologist on board when the GFR is 60 or less. In other words, when the kidneys are functioning at around 60%, the primary provider should consider referring to nephrology. Is this approach a waste of money? Absolutely not! The money saved by prevention of the need for kidney dialysis far outweighs the cost of the renal consultation.

Consider the following cost effectiveness analysis: which is cheaper, the cost of a follow up visit using CPT code 99213, 99214, or 99215, or the yearly cost of performing peritoneal dialysis or hemodialysis.

* The cost of hemodialysis based on data from the United States Renal Data System (USRDS) in Minneapolis queried in 2008 is $72,000 per year per patient. (See figure top left, and note that kidney dialysis is usually 3 times a week for 3-4 hours in order to complete the 24/7 work the kidneys usually perform.)
+ By the way, note the location of the USRDS. Guess what! I trained under these brilliant minds in Minneapolis, Minnesota! In fact, that's where I get my moniker -- not America's Medical Blogger, but simple country nephrologist.
* The cost of peritoneal dialysis based on data from the USRDS queried in 2008 is $53,000 per year per patient.

$72,000 dollars a year is a lot of money per patient. Given the increased prevalence of diabetes, obesity, and high blood pressure in America, the rate of chronic kidney disease is sky-rocketing. Do the math (from The Journal of the American Medical Association):

* 1994 data: CKD Stage 1-4 = 13.1% of the U.S. population
o Stage 2: 3.20% of the U.S. population
o Stage 3: 5.40% of the U.S. population
o Stage 4: 0.21% of the U.S. population

Patients should be considered for an evaluation by a kidney doctor once they hit Stage 3-5 chronic kidney disease. Another way to say this is that patients should be considered for an evaluation by a kidney doctor once they hit 60% kidney function or worse. The key is to pick the specialist who will work as a team player with both the patient and the primary care provider -- the navigator of the patient's care -- to provide high value care while keeping costs down. One of my mentors at Hennepin County Medical Center, in Minneapolis, MN (the institution where I learned nephrology), used to say: "patients can see us now, or they can see us later. We will take great care of them either way. But they would be much better off seeing us sooner." How provocative! How profound! Thank you, Dr. Davidman. Thank you, Dr. Smith.


The twist here comes when primary care providers get "dinged" for consulting too much. I've been wanting to opine on this topic for some time now, because both in the hospital and in the clinic, there is a presumption that less is always more. In other words, some think the fewer specialists involved in a patient's care, the better the primary care physician or the hospitalist. But is that thinking correct?

I am unaware of data that suggests that involving more specialists ends up costing more when you think outside the box and look at the total cost of care as opposed to individual buckets. Most experts suggest that the quality of care is improved. As accountable care organizations come to fruition, we will know more, because the entire patient experience both in and out of the hospital can be tracked over time.

Consider the current possible scenario: your primary clinic is located at Dr. McMinn's office at the Alegent Florence Clinic:
Dr. Charles E. McMinn

Your kidney specialist Dr. Aaronson is located at the Immanuel One Professional Center, 6829 N 72nd Street, Suite 4400 (located in the Alegent Cardiology Immuanel Clinic) -- that's good.


But your hospital of choice is a competing hospital because your cardiologist prefers that place. How is your care consolidated and tracked so that the insurance companies, the accountable care organization, and you know that you are getting the best possible care? Without shared responsibility, the above approach can be problematic.

A Nebraska program called NeHii is a phenomenal program that shares information, with your consent, among health care organizations. However, it doesn't address or fix the issues solved by an accountable care organization. Please don't misunderstand: NeHii is great, but it does not take responsibility for patients care, nor is it willing to risk share like an accountable care organization.

With respect to the hospital, most people do not appreciate that the majority of the expense occurs at day 1 -- excluding the outliers who remain in hospital for weeks. Decreasing length of stay from 3 days to 2 days appears at first glance to result in a 1/3 reduction of cost, but the math doesn't work out that way. Be careful when you interpret studies that suggest theoretical as opposed to actual savings. When specialists are consulted appropriately, it makes sense there would be money saved because tests can be ordered earlier, and patients can get healthier sooner.

So when should a primary care doctor refer to a specialist? Consider the following consultation criteria:

* The primary care doctor feels uncomfortable and can use the help of a specialist.
* Another specialist needs help co-managing a problem and needs another specialist's input.
* The patient and/or family requests a "expert" opinion.
* The situation based on objective criteria suggests a specialty consult is appropriate.
o For example, if a patient is intubated, there should be a pulmonologist on board to help manage the ventilator.

Did you know that an aggressive palliative care approach not only improves patient and family satisfaction but also saves money? Many opine that earlier consultation to a palliative care specialist is extremely beneficial. Some doctors prefer to wait to get these docs involved. Let me give you an example of how the early use of palliative care medicine improves patient care and saves the system money. (Read more: my interview with Dr. Pierre Lavedan, MD, Palliative Care Physician.)

Dr. Morgan, Palliative Care Doctor

A patient has incurable cancer and is admitted to the intensive care unit for mental status changes associated with metastases to the brain. The patient has received standard of care therapy to no avail and doesn't want to be included in any research trials. The patient has a living will that states he wants to be kept comfortable. There is a concern that the patient cannot protect his airway and will need to be intubated. However, the patient's wife who is the power of attorney, wants everything done and is not ready to "let the patient go."

Ethical issues here include patient autonomy, justice for all, and the concept of "do no harm."

* Autonomy: the right of the individual to make his or her own decisions regarding care. We should respect the wishes of the patient. Some patients want everything done; some want minimal interventions and be made comfortable.
* First, do no harm: in Latin the term is "Primum non nocere." Some ethicists argue that keeping someone alive when care has become futile is inappropriate, despite the patient's wishes.
* Justice: given the limited resources we have to spend on health care, we should be fair to all citizens. If large sums of money are spent on one patient, then there may not be enough funding available to take care of other patients.

If a patient wishes to be kept comfortable and avoid having aggressive therapy, and a family member rejects the patient's wishes, physicians need to respect the autonomy of the patient. When this situation occurs, a family conference can be quite helpful. A palliative care physician is a doctor who joins the discussion. I like to think of these folks as a "fresh pair of eyes" to help mediate a resolution acceptable to all parties.

In addition, from the perspective of "justice for all," if the health care a doctor provides becomes futile, some ethicists argue that the millions of dollars might be better spent, such as immunizing children against disease. The thinking here is that the patient is not going to make it regardless of the money spent, and therefore the approach should change to actively working to keep the patient comfortable and addressing any pain and suffering the patient might have.

Learn more: when I was in medical school at the University of Connecticut, we learned ethics while we dissected cadavers. How fitting. While I don't remember most of the structures of the palm and the wrist:
I do remember the lessons learned during my ethics classes. Many critics of health care education opine that ethics is placed in medical school curriculum as "filler." Although "the superficial palmar branch of radial artery and recurrent branch of median nerve to thenar muscles" may help a hand surgeon, that information is rarely needed for most practices. However, the knowledge of ethics is extremely important to be a good doctor, especially in our current climate. I hope today's students have real time to focus on ethics, outside of having to memorize thousands of Latin and Greek names to pass a test.

For those of you who have interest in the ethics of medicine, consider reading Beauchamp's Principles of Biomedical Ethics. Although a tough read, the book puts it all together in a way that applies to today's ethical challenges that physicians face daily. Patients can benefit as well because letting a loved one go is a tough process. Understanding the points in this book can help you make decisions.



Let me give you another example of the benefits associated with early nephrology consultation: many clinics do not give intravenous iron to iron deficient patients because of the cost. Instead, many doctors send their patients to infusion centers so that the infusion center can "eat the cost," and the clinic can avoid the expense. However, if the primary doctor were "responsible" for the cost of the iron infusion, there might be incentive to try an alternative approach that saves everyone money. This is the thinking behind the slogan: high value, low cost health care.

This situation demonstrates how accountable care organizations help solve problems. All care, delivered by one system, with risk sharing assumed by all: the insurance company, the doctor, the patient, and the health care system can decrease costs while providing value. This approach allows the system to manage risk, not avoid risk. For example, I give patients oral heme iron with a milligram dosage approximating the intravenous preparation. In some ways, my approach is a step forward in iron delivery because the patients don't have to use their veins to get intravenous iron (important when a patient will eventually need a fistula).

The iron pill I'm referring to contains heme iron (even though it is currently a trade (non generic medication). Milligram for milligram it saves the system money while giving better care to the patient. And it works. (Oh no! This is going to kill my generic prescription percentage numbers, but I have to do the right thing because of my belief in honesty and integrity.) Hopefully, I'll be tracked and my numbers will show how much I save the system while benefiting the patient! Otherwise, no Disney Cruise for my family next year. ;-) Say hi to Darth Boorishenzo for me!

* Read more: Treatment Options for Patients with Iron Deficiency -- Especially Chronic Kidney Disease Patients.
* Please also consider: The American Healthcare Bubble is about to Burst! Using the "5 Hog Phrases" to Explain Why.
* and The Synchronized Prescription Refill Service: A Patient Centric Model.)
* Finally, check out Picking the Right Hospital System for the Health of Your Family. This Approach May Save Your Life!

In conclusion, prior to starting Alegent Nephrology in Omaha, Nebraska, I spent a year of my life practicing Internal Medicine with help from great friends like Fredrick J. Schwartz, M.D. and Allan D. Wilsey, M.D. in Papillion, Nebraska. I appreciate the challenges of primary care because I did it while preparing for my Internal Medicine Recertification. Believe me when I say that primary care is extremely challenging. These hard working medical providers are the admirals of the ship, helping you, the patient, navigate through the medical system. It is a specialty in and of itself. And they know when you need to see a rheumatologist and not an orthopedist or a pain specialist. (Read more: Arthritis Pain Hurts! My Pain Medicine is "Killing my Kidneys." What can I do?)

Although I can take care of a patient's kidney problems, even with knowledge of general medicine, I found that specialists knew more than me when it came to Endocrinology and Diabetes, Cardiology, Pulmonary / Critical Care Medicine, etc. I'm glad these folks are around. By consulting appropriately, and early, I prevented problems, helped to save both the patient and the system money, and delivered better care.

Even though hospitals and clinics for the most part have different primary providers with different focuses, accountable care organizations combine the two buckets into one to provide a continuum of care and put the patient first. If primary care docs get "dinged" for appropriate consultations, we need a cultural paradigm change via a Thomas Kuhn Structure of Scientific Revolutions. In sum, an early, less expensive outpatient consult to a specialist may prevent disease, prevent that hospitalization in the first place, and provide world class patient care. I encourage organizations who are experimenting with a patient centered medical home or are developing an accountable care organization to test my hypothesis. I predict that when a valuable resource is used judiciously and appropriately, the patient's experience through the continuum of care will improve, everyone wins, and we may further bend the cost curve of health care. Everyone wins; nobody loses.

Please feel free to comment on www.michaelaaronsonmd.com!

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    1. Rajesh Goel Aug 31, 2021
      They have been suggested to visit nephrologists only because the problem related to kidneys are very common nowadays due to drinking polluted water. So, there is a vast increase in the number of patients dealing with such problems.