September 19, 2023

Removing the gatekeepers: Direct Specialty Care Redefines the Healthcare Landscape

The blog highlights direct specialty care's rise, enabling patients to reach specialists without referrals or insurance hurdles. It improves access, doctor-patient bonds, diagnoses, and simplifies healthcare, impacting both individuals and self-insured employers.
Removing the gatekeepers: Direct Specialty Care Redefines the Healthcare Landscape

The landscape of healthcare is evolving, and a groundbreaking approach is gaining momentum: direct specialty care. In this transformative model, patients gain direct access to specialists without the roadblocks of referrals, prior authorizations, or insurance intermediaries. The impact is significant, and its benefits are reshaping the healthcare experience for both patients and clinicians.

Direct specialty care refers to a healthcare model in which patients have direct access to specialists without the need for referrals, authorization, or gatekeeping by commercial payers.  Key to success in bypassing the gatekeepers is the development and adoption of a strategy to bundle and price a comprehensive course of care and deploy that into the market.  Facing an increasingly competitive market with declining reimbursements, this post reveals the benefits to both patients and leaders of independent specialty practices.

Putting Patients in the Driver’s Seat

From a patient perspective, the benefits are clear.  Patients can eliminate unreasonable delays in care while removing the bureaucratic barriers that push the care process further and further away from the doctor/patient relationship.  By bypassing the traditional referral process, patients can select and access their specialists more quickly. This speed can be crucial for conditions that may require more urgent attention or early intervention.  A 2022 report from the American Hospital Association concluded that: “many health plans apply prior authorization requirements in ways that can create dangerous delays in care, contribute to clinician burnout and drive up health system costs.”  

Strengthening the Doctor-Patient Bond

Direct specialty care helps to assure that patient care is doctor directed, not dictated by an insurance company.  With the rapid rise of direct pay patients including those on high-deductible health plans—coupled with the growth of the self-insured employer ecosystem—more and more patients are seeking this approach.

From a physician perspective, direct specialty care has several potential benefits for doctors. A clear example is the potential for increased patient satisfaction as it allows patients to engage with their preferred physician or practice to receive specialized care more quickly and efficiently.  For practices seeking to make the process more convenient and consumer-centric, patients will appreciate direct access to the expertise of specialists without additional barriers. This intimacy nurtures a deeper bond between patients and physicians, leading to well-informed decisions and higher patient compliance to treatment plans.

Timely Diagnoses and Better Outcomes

Timeliness is often pivotal in healthcare outcomes. Direct access to specialists expedites diagnoses and interventions, potentially leading to better health outcomes.  In their “2021 AMA Prior Authorization (PA) Physician Survey,” the American Medical Association reported that “more than 1,000 physicians found that more than 90% of respondents said prior authorization “had a significant or somewhat negative clinical impact, with 34% reporting that prior authorization had led to a serious adverse event such as a death, hospitalization, disability or permanent bodily damage, or other life-threatening event for a patient in their care.”  

Additionally, it’s likely that patients may feel more connected and engaged in their course of treatment and post-procedure instructions.  This can foster stronger doctor-patient relationships and better communication, leading to more informed decision-making.

Simplifying the Healthcare Ecosystem

Direct specialty care can streamline the healthcare system by reducing unnecessary referrals, insurance company approvals, and duplicative tests. Patients can get the right treatment from the appropriate specialist, avoiding redundancies and unnecessary paperwork.  Additionally, should the practice automate the process of providing transparently priced procedures and bundles, direct payers of all types can transact payments in an online, commerce enabled marketplace.

Empowering Practices and Boosting Satisfaction

Direct specialty care can help enable doctors to practice more fully within their specialty and avoid insurance company hassles.  It allows the practice to set fair prices for their services and devote additional time to focus on their expertise and the provision of quality care. By eliminating certain referral and authorization requirements, doctors may have the option to explore and enhance their practice models, which could be beneficial to the financial health of the practice.

Direct-Contracting: A New Avenue

Direct specialty care is not only revolutionizing patient care but also transforming how self-insured employers approach healthcare. By directly contracting with specialist providers, employers can offer their employees streamlined access to high-quality care and create longitudinal relationships with their providers. This approach eliminates intermediaries, removes unnecessary costs, and employees of self-insured employers receive the care they need promptly.

Envisioning the Future with HealthMe

However, it's important to note that along with the benefits listed above, there are potential challenges that require careful planning to remove the complexity and barriers to care.  At HealthMe, we partner with our specialty practice clients to make the complex simple by connecting patients and payers directly with doctors by transforming medical practices into eCommerce storefronts with clear, bundled pricing. This enables patients and other direct payers to shop for healthcare digitally: view transparent pricing, select a service, and checkout.

To advance this process, HealthMe condensed tens of thousands of disparate CPT/ICD codes into a functional library of 400 hundred transparently priced healthcare bundles covering the entire patient care cycle into easy- to-understand consumer centric offerings. Our growing, proprietary database of pricing information makes it easy for doctors to accurately and consistently price these bundles based on regional and national data. Our pricing data is unique in that it reflects what a consumer actually pays for a specific healthcare bundle, not what someone charges, or an insurance company pays, to a specific provider for a stand-alone CPT or HCPCS code. When the burden of needless complexity is lifted and practices offer transparent prices that inform patients and payers, then healthcare becomes shoppable like everything else—removing the gate keepers, improving access to care, and lowering costs.

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