Colorado’s Unmet
Demand for
Specialty Care
And the System We Need to Meet It
JUNE 2019
2 Colorado Health Institute
Colorado’s Unmet Demand for Specialty Care
Colorado’s Unmet
Demand for Specialty Care
And the System We Need to Meet It
4 Colorado’s Work So Far
5 Our Questions and What We Found
6 Answering the Research Questions
Question One: What is the unmet demand for specialty care by specialty area?
Question Two: What tools should Colorado’s leaders use to address the gaps?
Question Three: What would it cost to close the gaps in specialty care access in Colorado?
8 The Specialty Care Stewardship Council and Other Innovations
9 How We Did It
10 Imagining a Statewide Specialty Care System – And How to Finance It
11 Policy Implications and Remaining Questions
11 Conclusion
Acknowledgements
CHI staff members
contributing to this report:
• Alexandra Caldwell, lead author
• Jeff Bontrager
• Spencer Budd
• Brian Clark
• Cliff Foster
• Beck Furniss
• Joe Hanel
• Emily Johnson
• Michele Lueck
This work was made possible by the Telligen Community Initiative.
Special thanks to the members of Colorado’s Specialty Care Stewardship
Council and the Access to Specialty Care Engagement Network
(ASCENT) cohort. We also thank Kaiser Permanente Colorado for
supporting those important initiatives.
About the Colorado Health Institute
About the Colorado Health Institute: The Colorado Health Institute is a
nonprofit and independent health policy research organization that is a
trusted source of objective health policy information, data, and analysis
for the state’s health care leaders.
Colorado Health Institute 3
JUNE 2019
And the System We Need to Meet It
While playing with her toddler, 31-year-old Mya
*
fell on her shoulder.
She thought she strained a muscle and that it would heal on its own.
When the pain worsened, Mya went to her primary care provider who found
she had a fractured clavicle. She would need to see an orthopedic surgeon.
Despite the best efforts of her primary care provider to get her an appointment,
two offices turned down her insurance. She’s a member of Health First
Colorado, the state’s Medicaid program, and the surgeons said they had
reached their budgeted number of Medicaid patients for the year.
Now, Mya is on a waiting list to see an orthopedic surgeon at the local
community hospital.
Mya is a real patient waiting for care in Boulder as of
April 2019, and her experience is shared by hundreds of
thousands of Coloradans annually who use Medicaid
or have no coverage. These specialty care gaps persist
despite Colorado’s increasing insurance rates and
commitment to primary care access.
The Colorado Health Institute (CHI) estimates that
634,000 visits go unmet annually in Colorado because
of gaps in insurance coverage, lack of specialist
capacity, and other barriers such as reluctance of
some providers to accept patients who use Medicaid
or who have no insurance. This report explains how
CHI came up with that estimate and suggests several
approaches to addressing the gap.
Colorado has employed many of the policy options
available to states under the Affordable Care Act, from
expanding Medicaid eligibility to building a state-
based insurance exchange. Hundreds of thousands
of Coloradans have benefited. Colorado has held
on to its record-setting uninsured rate of 6.5 percent,
according to the 2017 Colorado Health Access Survey
(CHAS).
1
Colorado also has built strong primary care
capacity — nearly 85 percent of Coloradans report that
they have a usual source of care.
The story, however, is much different for specialty
care, especially for low-income Coloradans. The
median time that Coloradans wait for a general doctor
appointment is two days, but it’s more than nine days
for specialist care. Some Coloradans report waiting
up to a year. And Medicaid enrollees report waiting
1.4 times longer than commercially insured patients to
get specialty care. Medicaid enrollees are nearly three
times more likely than commercially insured patients
to report they didn’t get specialty care because they
couldn’t find a provider who took their insurance.
2
NOTE: This report uses the term “specialist” to include any licensed provider of specialty care — including MD-trained providers as well
as advanced practice professionals such as nurse practitioners, physician assistants, and others.
* Name changed to protect patient privacy.
Three Takeaways
• In Colorado, Medicaid enrollees and people
without insurance use specialty care at far
lower rates than Coloradans with commercial
insurance — illustrating a gap in access to care.
• Medicaid patients forgo an estimated 486,000
specialty care visits annually; for uninsured
patients it’s 148,000 visits. On average, that’s
about 87 extra visits annually for each of the
state’s medical specialists.
• Addressing these gaps will require short-term
and long-term solutions in the care safety net —
from increased use of e-consults and telehealth
to initiatives such as increased use of advanced
practice providers and more primary care
provider education to address specialty care
needs without a visit to a specialist.
4 Colorado Health Institute
Colorado’s Unmet Demand for Specialty Care
Many low-income Coloradans do not see a specialist
at all because it costs too much. This includes about
13 percent of Medicaid and Child Health Plan Plus
(CHP+) enrollees and nearly 30 percent of uninsured
Coloradans. That’s compared with only 9 percent of
commercially insured Coloradans.
The trend is the same when we compare the
experiences of people of color versus their white
counterparts. According to the CHAS, 13.6 percent
of people of color skipped specialist care due to cost
in 2017, compared with 10.3 percent of white, non-
Hispanic/Latinx Coloradans.
We also know that specialty care access varies greatly
by geography. Median wait times for specialty care
range from 6.5 days in Douglas County to 13.2 days in
some rural and frontier counties.
Colorado’s Work So Far
Efforts are underway in Colorado to address these
inequities.
For example, health care professionals are getting
around long wait times, cost barriers, and workforce
shortages using e-consults — digital communication
between a general health care professional and a
specialist to get specialty care advice without a face-
to-face patient encounter. In other words, e-consults
are generalist-to-specialist email systems.
E-consults are critical tools for addressing specialty
care needs because they do not require a patient
to schedule, get to, or pay for a face-to-face visit
with a specialist. That’s why this analysis focuses on
e-consults as a potential solution to address Colorado’s
specialty care access gaps.
Other health care providers are using telehealth
to connect patients with specialists over live video.
Patients can use telehealth services to get care when a
local specialist is unavailable. That said, patients who
use telehealth still need to get time with a specialist
and pay for the services.
Many primary care providers are also partnering
formally and informally with specialists to offer patients
in-person services when needed.
To connect these efforts at a high level of leadership,
CHI convened the Specialty Care Stewardship Council
(SCSC), a group of C-suite health care leaders
developing a statewide specialty care safety net. Read
more about the SCSC on page 8.
But these efforts have not closed the gaps, and each
solution has limitations. For example, e-consults are
not reimbursed by insurers. Telehealth services are, but
broadband internet access is a barrier. And specialists
earn more for treating commercially insured patients
than Medicaid members or uninsured patients. In
so doing, they avoid low Medicaid reimbursement
and billing challenges and socioeconomic factors
that make it harder for some patients to keep
appointments and adhere to their care plan, such
as lack of transportation and comorbidities such as
substance use and mental illness.
With support from the Telligen Community Initiative,
CHI set out to quantify the problem and find ways to
solve it.
How We Did It
CHI conducted this research for a first-ever
quantification of the unmet demand for specialty
care in Colorado.
We used a complex analysis overlaying several
data sources in our research process:
1. Identify the amount of specialty care
Coloradans receive. We used 2016 Medical
Expenditure Panel Survey (MEPS) data to
estimate specialty care utilization rates by
insurance type.
2. Identify how much specialty care
Coloradans should receive. We assumed
that commercially insured rates of specialist
visits — adjusted for different population
health needs — were the “right” amount of
specialty care patients should receive. We set
these rates of use as the target to be met by
Medicaid members and uninsured patients.
3. Compare these two amounts to find gaps
in services. We compared the Medicaid and
uninsured population specialty care utilization
rates to the commercially insured utilization
rates to identify gaps in care by specialty and
insurance group.
4. Identify tools and financing options that
can address the gaps. We reviewed the
literature to find the number of specialty care
visits that could be addressed using e-consults.
Colorado Health Institute 5
JUNE 2019
And the System We Need to Meet It
Our Questions and What We Found:
Uninsured
148,000
visits
E-Consult
34,000 visits
E-Consult
133,000 visits
Face-to-Face
114,000 visits
Face-to-Face
353,000 visits
Medicaid
486,000
visits
23%
23%
27%
73%
77%
77%
Figure 1. Unmet Demand for Specialty Care among Adults (19-64) Without Insurance
and Those Enrolled in Medicaid, Colorado
634,000
Total Unmet
Specialty
Care Visits
What is the unmet demand for specialty care in Colorado?
It would take 167,000 e-consults and 467,000 patient-provider visits to meet the unmet
specialty care demand among Medicaid enrollees and uninsured Coloradans.
What tools should Colorado’s leaders use to address the gaps?
Addressing the gaps will require multiple specialty care safety net solutions, including
e-consults, in-person visits, and telehealth capabilities.
What would it cost to address the need?
It would cost about $93 million annually — or $47 million if we account for Medicaid
reimbursement — to cover all of Colorado’s unmet specialty care visits.
1.
2.
3.
6 Colorado Health Institute
Colorado’s Unmet Demand for Specialty Care
Answering the
Research Questions
This section provides answers to three questions that
motivated this work.
1. What is the unmet demand for specialty care by
specialty area?
2. What tools should Colorado’s leaders use to address
the gaps?
3. What would it cost to close the gaps in specialty
care access in Colorado?
Question One:
What is the unmet demand for
specialty care by specialty area?
About 486,000 specialty care visits for Medicaid
patients and 148,000 visits for uninsured Coloradans
go unmet annually. That’s about 83 extra visits
annually for each of the state’s more than 7,000
medical specialists (see Appendix 1).
Among specialties, the greatest disparity shared
by Medicaid and uninsured Coloradans is in
ophthalmology. Compared with their commercially
insured counterparts, Medicaid enrollees are missing
out on 99,000 ophthalmology visits, and uninsured
Coloradans are forgoing 57,000 visits. Other recent
analyses have identified ophthalmology as a growing
area of specialty care demand.
3
Otherwise, the gaps in care types differ for Medicaid
and uninsured Coloradans, according to CHI’s analysis.
For example, Medicaid members are missing 91,000
visits with dermatology service providers and 29,000
visits with general surgeons. Uninsured Coloradans are
getting significantly fewer visits for psychiatry (43,000
visits), geriatrics (18,000 visits), and endocrinology
(12,000 visits).
Considerations
Gap size versus urgency. While some of these gaps are
large — such as over 150,000 missing ophthalmology
visits — others are important due to their apparent
urgency or acuity. For example, uninsured Coloradans
are missing almost 9,000 visits with oncology service
providers.
Data capture. The MEPS data could make some
gaps appear larger or smaller than they really are.
Ophthalmology provides an example. Patients may
report having an eye exam with an ophthalmologist
— and the ophthalmologist confirms the visit — but
those services were actually delivered by optometrists
working under the supervision of the ophthalmologist.
In the MEPS data, it might appear that commercially
insured people are getting very high levels of specialty
ophthalmologist care when really they are getting
standard eye exams delivered by optometrists.
Local system data mismatch. We were unable to use
local hospital referral rates to check how our analysis
stacked up in the “real world.” That’s because hospital
system data are not collected with the purpose of
estimating unmet demand for specialty care. For
example, we were unable to use hospital referral rates
to estimate the demand for certain specialty care
types. That’s because a provider might not make a
referral for a cardiologist, for example, every time that
patient needs cardiology care. The provider might
only make that referral in certain cases, like when a
specialist is available, or if the patient specifically wants
to receive that care. This approach underestimates
the demand for specialty care. Policymakers should
consider this limitation when it comes to structuring
data systems to answer critical questions.
Table 1. Top Five Specialties by Most Unmet Visits,
Medicaid and Uninsured, 2017
Medicaid
Specialty
Unmet
Visits
Percentage Met
by E-consults
1. Ophthalmology 99,000 18%
2. Dermatology 91,000 40%
3. Other Specialty 62,000 28%
4. Gynecology/Obstetrics -
Pregnancy-Related
54,000 33%
5. General Surgery 29,000 18%
Uninsured
Specialty
Unmet
Visits
Percentage Met
by E-consults
1. Ophthalmology 57,000 18%
2. Psychiatry 43,000 18%
3. Geriatrics 18,000 30%
4. Endocrinology 12,000 41%
5. Oncology 9,000 48%
Colorado Health Institute 7
JUNE 2019
And the System We Need to Meet It
Next Steps
The Specialty Care Stewardship Council
recommended conducting a “deep dive” into the
largest gaps, such as unmet ophthalmology visits.
Questions could include:
• How many of these visits require services from
ophthalmologists — such as cataract surgery or
medical care for issues like glaucoma?
• How many of these visits could be addressed by
optometrists — such as eye exams?
• How many of these visits — if any — could be
handled through telehealth?
Question Two:
What tools should Colorado’s leaders
use to address the gaps?
CHI estimates that about 26 percent of Colorado’s
unmet demand for specialty care could be addressed
using an e-consult, though this varies by specialty
(see Appendix 1).
Some specialty areas lend themselves to e-consults
better than others. For example, the literature
suggests that almost half of neurology visits can
be addressed with an online or phone consultation
between primary care provider and specialist.
Considerations
The literature varies. We reviewed the literature
to identify 15 studies that demonstrate “avoided
specialty care visits” as a result of an e-consult. For
example, this analysis includes information captured
in the Los Angeles Safety Net eConsult program
and the Rubicon MD eConsult pilot with Colorado’s
Doctors Care. The literature varies in how “avoided
specialty care” is defined and analyzed. In looking
at gastroenterology, for example, three different
studies found that anywhere between 20 and 52
percent of face-to-face visits could be avoided with
an e-consult between a primary care provider and a
gastroenterologist.
Question Three:
What would it cost to close the
gaps in specialty care access in
Colorado?
CHI estimates it would cost about $93 million
annually to pay for all the unmet specialty care
visits in Colorado at the average rate of private
insurance reimbursement. That’s about $150 per
visit.
This estimate assumes a new funder such as
a foundation — as opposed to an increase in
reimbursement from the state Medicaid program,
for example — would pay the full cost of all
unmet specialty care visits, including visits that
otherwise would be covered by Medicaid at a lower
reimbursement rate than private insurance.
This estimate also assumes that the average use of
specialty care and reimbursement rates in private
coverage is appropriate. In fact, the literature
shows an over-use of specialty care in private
settings. Those additional services, tests, and
procedures may inflate the cost unnecessarily.
The price tag drops to $47 million annually to cover
all unmet specialty care visits when we account for
Medicaid reimbursement of some of these missing
visits and potential overutilization of care in the
commercially insured population.
Specialty Unmet Visits
Portion of Visits Potentially
Avoided by E-Consults
Number of Visits Potentially
Avoided by E-Consults
Dermatology 91,000 40% 37,000
Ophthalmology 156,000 18% 28,000
Gynecology/Obstetrics - Pregnancy-Related
54,000 33% 17,000
Other Specialty
62,000 28% 17,000
Geriatrics 37,000 30% 11,000
Table 2. Which Specialties Would Have the Biggest Reduction in Unmet Demand If E-Consults Are Used?
8 Colorado Health Institute
Colorado’s Unmet Demand for Specialty Care
Since 2016, CHI has convened the Specialty Care
Stewardship Council (SCSC), a group of C-suite
health care leaders developing a statewide
specialty care safety net.
It includes stakeholders from the governor’s office,
delivery systems, Medicaid, insurers, providers,
public health agencies, and medical schools. The
SCSC’s achievements to date include informing
CHI’s estimates of specialty care demand and
generating potential statewide solutions to
address the demand.
CHI has also convened a cohort of five programs
increasing access to specialty care as part of the
Kaiser Permanente Colorado-funded effort known
as ASCENT (Access to Specialty Care Engagement
Network).
Colorado’s health care leaders take access
to specialty care seriously. Innovative work is
happening to increase access to specialty care
across safety net clinics, large health care systems,
Medicaid, health alliances, and other groups.
Examples include:
• The State Innovation Model (SIM) is a
governor’s office initiative helping primary
care practices integrate specialty services such
as behavioral health care into primary care.
• Aurora Health Access convenes the Specialty
Care Interest Group to better understand
barriers to specialty care access and to identify
strategies to address those barriers in Aurora.
• Mile High Health Alliance’s Specialty Care
Network connects primary and specialists
to meet needs among Medicaid patients in
Denver.
• The Boulder County Health Improvement
Collaborative is piloting a referral database
with primary and specialty care providers.
• Kaiser Permanente Colorado’s safety net
specialty care program connects uninsured
patients in Colorado safety net clinics with
e-consults and face-to-face visits delivered by
Kaiser specialists.
The Specialty Care Stewardship Council and Other Innovations
ASCENT Cohort, April 2019 in Longmont.
Colorado Health Institute 9
JUNE 2019
And the System We Need to Meet It
Considerations
Uninsured Coloradans would benefit … maybe.
The $47 million annual price tag would cover
missing specialty care visits for Colorado’s uninsured
population. Those visits make up about a fifth of the
total unmet visits but half the price tag. That’s because
no one is paying for these visits today — Medicaid or
otherwise.
The challenge is less related to the price tag and
more related to getting a payment structure in place.
For example, giving uninsured Coloradans access to
even partially subsidized specialty care services would
not make sense without providing primary care as well.
This is only one definition of cost. Pinpointing costs
is a complicated exercise that raises an important
question — whose costs? Payers? A foundation? The
state? Out of pocket patient costs? Hospitals? $47
million is a relatively small increase in the Medicaid
budget but a large annual grant from a foundation.
Future investigations should assign a potential “buyer”
to help refine this estimate.
Assumptions abound. Doctors often provide more
care than a patient needs. This is known as doctor-
induced demand. This analysis assumes that we can
reduce doctor-induced demand, even though there is
no system in place to do so.
The analysis also does not account for provider
shortages. Even if there is a way to pay for visits, it
will not matter if Colorado lacks enough providers.
Finally, the estimate does not account for the
potentially slow adoption of e-consults. Many of
the savings in this analysis come from e-consults,
and the annual price jumps to $62M if doctors
don’t use e-consults.
How We Did It
CHI used Medical Group Management
Association (MGMA) price data to estimate
specialty care visit costs. We found overutilization
in commercially insured population, and that
overutilization was attributed to the cost per visit,
not to the total number of visits. We estimated
that specialists deliver about a fifth more care
per visit than patients need, so we reduced
the price per visit by 21 percent to account
for overutilization. We did not assume that
overutilization applied to e-consults.
We also did not assume any cost difference
between commercially insured and Health First
Colorado populations for e-consults.
Figure 2. A Statewide Model For Increasing Access to Specialty Care
INTERVENTIONS
Upstream Systems to Address Demand Downstream Systems Short-term Long-term
Patient
Specialty
Care
Needs
Increased
Access to
Specialty
Care
Improved
Health
Telehealth
OUTCOMES
• Delivering specialty care using primary care.
e.g., Extension of Community Health Outcomes
(ECHO) trains primary care providers to
address specialty care needs in a primary
care environment.
• Leveraging Machine Learning.
e.g., The Human Diagnosis Project
synthesizes knowledge globally from
hundreds of volunteer specialty care providers.
• Growing the specialist workforce capacity.
e.g., Rural counties can expand access to
specialty care by hiring lower cost advanced
practice providers such as nurse practitioners
to deliver needed specialty care.
Care Coordination
Behaviors and External Factors
In-Person Visits
E-Consults
10 Colorado Health Institute
Colorado’s Unmet Demand for Specialty Care
Imagining a Statewide Specialty Care System –
And How to Finance It
Create Social Impact Bonds
Funders provide capital and the state pays
them back when program outcomes are
achieved.
Example in Colorado: Colorado’s Coalition
for the Homeless’ Social Impact Bond Initiative
Policy Questions: Who could provide
start-up funding? How do we measure the
investment’s success?
Leverage Health System Community Benefit
Spending that promotes community
health helps health systems retain their tax
exemptions.
Example in Colorado: Kaiser Permanente
Colorado Safety Net Specialty Care Program
Policy Questions: Do community benefit rules
incentivize meaningful investments in critical
issues such as specialty care access? How will
these incentives change over time?
Change Medicaid Reimbursement Policy
Colorado’s Medicaid program would reimburse
for e-consults — specialty care consultations
delivered via electronic messaging.
Example in Colorado: Colorado’s Medicaid
2016 rheumatology e-consult pilot program
Policy Questions: How much would it cost to
reimburse primary care providers for the time
they spend on e-consults? How much would it
cost to incentivize specialists to offer e-consults?
Expand Loan Repayment Initiatives
Providers commit to practicing at a high-need
site in return for loan repayment.
Example in Colorado: Colorado Health Service
Corps Loan Repayment Program
Policy Questions: Will this option sustainably
increase the number of specialists — especially
those who serve uninsured and publicly insured
Coloradans?
SHORT-TERM
LONG-TERM
Figure 3. Statewide Specialty Care Safety Net System Financing Options
The statewide specialty care system that we envision
will include e-consults, telehealth, and in-person visits.
But the model will also invest in systems transformation
to fundamentally change the way people access care,
including:
• Provider education to promote specialty care access
in primary care and non-traditional environments;
• Increased use of advanced practice providers such
as nurse practitioners and physician assistants; and
• Emerging innovations such as machine learning
that can increase access to specialty care.
This model is illustrated in Figure 2. It was produced
through partnerships between CHI and Colorado’s
health care leaders.
Colorado will need short-term financing options
to launch this model and long-term options to
sustain it.
CHI conducted a series of key informant interviews
and literature reviews to identify four options for
policymakers to explore:
Short-term:
• Create social impact bonds
• Leverage hospital community benefit
Long-term:
• Change Medicaid reimbursement policy
• Expand loan repayment initiatives
Colorado Health Institute 11
JUNE 2019
And the System We Need to Meet It
Policy Implications and
Remaining Questions
CHI’s research reveals that addressing unmet specialty
care demand will require multiple approaches.
For example, any solution should include a mix of
improved care coordination, education for primary
care providers to address specialty care needs
without a specialist, as well as face-to-face visits with
specialists.
E-consults could provide a place to start. There is a
mountain of evidence documenting their effectiveness
increasing access to specialty care.
4, 5, 6
That said,
expanding the use of e-consults raises multiple policy
questions:
• What models exist for reimbursing e-consults?
Should payment be limited to specialists or include
primary care providers as well?
• Which types of visits, procedures, or services are
more amenable to e-consults than others? Where
could policymakers start?
• How long would it take for the state to realize a
return on its investment in e-consults?
• What are the unique needs of rural areas?
For example, to what extent are rural clinics
equipped with broadband internet to support
e-consults or telehealth? Is the specialty care
provider workforce sufficient in rural areas to
provide in-person referrals?
• What are the implications for licensure rules?
• What would it take for more providers to serve
Medicaid members?
Conclusion
Analyzing Colorado’s unmet specialty care
needs has illuminated the broad stakeholder
interest in expanding access to specialty care
for people who lack insurance or are enrolled
in Medicaid. Challenging work is ahead —
from selecting a model and implementing it,
to making sustainable changes in the way
Coloradans access specialty care via e-consult,
telehealth, advanced practice provider, and other
approaches. This analysis moves Colorado one
step closer to expanding access to specialty care
for everyone who needs it.
1
Colorado Health Institute. (2017). “2017 Colorado Health Access Survey: The New Normal.”
https://www.coloradohealthinstitute.org/research/colorado-health-access-survey-2017.
2
Colorado Health Institute. (2017). “2017 Colorado Health Access Survey: The New Normal.”
https://www.coloradohealthinstitute.org/research/colorado-health-access-survey-2017.
3
HIS Markit Ltd for Association of American Medical Colleges. (2019). “The Complexities of Physician Supply and Demand: Projections
from 2017 to 2032.” https://aamc-black.global.ssl.fastly.net/production/media/filer_public/31/13/3113ee5c-a038-4c16-89af-
294a69826650/2019_update_-_the_complexities_of_physician_supply_and_demand_-_projections_from_2017-2032.pdf.
4
Barnett, M.L., et al. (2017). “Los Angeles Safety-Net Program eConsult System Was Rapidly Adopted and Decreased Wait Times
To See Specialists.” Health Affairs 36(3): 492-499.
5
Olayiwola, J.N., et al. (2016). “Electronic Consultations to Improve the Primary Care-Specialty Care Interface for Cardiology in the
Medically Underserved: A Cluster-Randomized Controlled Trial.” Annals of Family Medicine 13(2): 133-140.
6
Fort, M.P., et al. (2016). “Implementation and Evaluation of the Safety Net Specialty Care Program in the Denver Metropolitan Area.”
The Permanente Journal 21:16-022.
Endnotes
12 Colorado Health Institute
Colorado’s Unmet Demand for Specialty Care
Specialty Type Medicaid Uninsured Total Unmet Visits
Unmet Visits Per
Colorado Specialist
Allergy / Immunology Visits 20,727 711 21,438 *
Anesthesiology Visits 1,007 - 1,007 2
Cardiology Visits 2,301 - 2,301 18
Dermatology Visits 91,442 - 91,442 687
Endocrinology / Metabolism
(Diabetes, Thyroid) Visits
- 11,514 11,514 634
Gastroenterology Visits 26,503 - 26,503 590
General Surgery Visits 29,399 7,287 36,686 94
Geriatrics Visits 18,641 18,230 36,871 *
Gynecology / Obstetrics Visits
- Pregnancy-Related (Including
Prenatal Care & Delivery)
53,554 - 53,554 165
Hematology Visits 1,417 1,065 2,482
Nephrology Visits - - - -
Neurology Visits - - - -
Oncology Visits 565 8,601 9,166 111
Ophthalmology Visits 98,706 57,427 156,133 1,283
Orthopedics Visits 19,904 - 19,904 72
Other Specialty Visits 62,294 - 62,294 *
Otorhinolaryngology
(Ear, Nose, Throat) Visits
10,137 - 10,137 134
Pathology Visits - - - -
Physical Medicine / Rehab Visits 1,933 - 1,933 31
Plastic Surgery Visits 13,658 326 13,983 405
Proctology Visits - - -
Psychiatry / Psychiatrist Visits - 42,603 42,603 116
Pulmonary Visits - - - -
Radiology Visits 29,250 - 29,250 50
Rheumatology Visits - - - -
Thoracic Surgery Visits - - -
Urology Visits 4,930 - 4,930 85
Total 486,367 147,765 634,131 83
Appendix 1: Data Tables
Table 3. Total Unmet Demand for Specialty Care in Colorado, 2017.
* Licensure data are insufficient for analysis.
Colorado Health Institute 13
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And the System We Need to Meet It
Specialty Type Total Unmet Visits
Portion That Could
Potentially Be Met
by E-consult
Visits Potentially
Addressed by
E-Consult
Remaining
Unmet Visits
Allergy / Immunology Visits 21,438 18% 3,859 17,579
Anesthesiology Visits 1,007 30% 298 708
Cardiology Visits 2,301 51% 1,162 1,139
Dermatology Visits 91,442 40% 36,577 54,865
Endocrinology / Metabolism
(Diabetes, Thyroid) Visits
11,514 41% 4,721 6,793
Gastroenterology Visits 26,503 34% 9,099 17,404
General Surgery Visits 36,686 18% 6,603 30,082
Geriatrics Visits 36,871 30% 10,933 25,939
Gynecology / Obstetrics Visits
- Pregnancy-Related (Including
Prenatal Care & Delivery)
53,554 33% 17,405 36,149
Hematology Visits 2,482 33% 819 1,663
Nephrology Visits - 27% - -
Neurology Visits - 50% - -
Oncology Visits 9,166 48% 4,400 4,766
Ophthalmology Visits 156,133 18% 28,104 128,029
Orthopedics Visits 19,904 18% 3,583 16,322
Other Specialty Visits 62,294 28% 17,209 45,085
Otorhinolaryngology
(Ear, Nose, Throat) Visits
10,137 18% 1,825 8,312
Pathology Visits - 30% - -
Physical Medicine / Rehab Visits 1,933 30% 573 1,360
Plastic Surgery Visits 13,983 18% 2,517 11,466
Proctology Visits - 30% - -
Psychiatry / Psychiatrist Visits 42,603 18% 7,669 34,935
Pulmonary Visits - 18% - -
Radiology Visits 29,250 30% 8,673 20,577
Rheumatology Visits - 24% - -
Thoracic Surgery Visits - 30% - -
Urology Visits 4,930 30% 1,479 3,451
Total 634,131 26% 167,507 466,625
Table 4. Tools to Meet the Unmet Demand for Specialty Care — Potential Impact of E-Consults.
14 Colorado Health Institute
Colorado’s Unmet Demand for Specialty Care
This entire study is limited to people ages 19-64.
It used MEPS office-based medical provider visit data
file that includes only MDs and excludes optometrists,
psychologists, podiatrists, and chiropractors.
Specialties excluded in CHI analysis:
• Dental care
• General, non-pregnancy-related OB/GYN visits
• Pediatric visits
• Internal medicine
• General practice
• Family medicine
Measuring unmet demand
CHI used data from the 2017 CHAS to estimate the
population of Coloradans covered by commercial
insurance or Medicaid and those who are uninsured. The
CHAS is the premier source of data on health insurance for
Coloradans.
We used data from the 2016 MEPS and 2016 Behavioral
Risk Factor Surveillance System (BRFSS) to identify current
rates of utilization by payer. MEPS data have rates of
utilization by specialty and payer, but are only available
at the multistate level. BRFSS data on the overall rate of
health care utilization helped us see how Colorado differed
from surrounding states and to adjust these estimates
accordingly.
Analysis of this data provided estimates for current annual
use by payer and specialist.
We then assumed that commercially insured rates of
specialist visits were appropriate, and we set these rates
of use as the target to be met by Medicaid members and
uninsured patients.
However, we also wanted to account for the fact that acuity
levels, and therefore specialist demand, varied by payer
population. In other words, different payers may serve
populations that have very different specialty care needs.
So, we adjusted commercially insured demand by specialist
to account for these differences. The adjustment factor
was based on data from Denver Health, which provided
information on the rate of referrals by specialist — whether
or not those specialty referrals resulted in a visit.
Appendix 2: Methods
Allocating to e-consults versus
patient-provider visits
We conducted a literature review to identify the
portion of unmet visits that could be addressed by
e-consults. When no literature was available, we
used an average of the available portions of unmet
visits that could be addressed by e-consults.
Measuring costs
We used data from Medical Group Management
Association (MGMA) to identify private costs by
payer.
MGMA price data were leveraged to estimate the
total cost of paying for the specialty care safety net.
This analysis did not have data for each discrete
specialty, except for cardiology, gastroenterology,
general surgery, hematology, nephrology,
neurology, oncology, and urology. For all other
specialists, the overall average specialty care rate
was used.
We based e-consult costs on May 2017 mean
provider hourly pay as reported by the Colorado
Bureau of Labor Statistics.
We also wanted to see how costs would change if
we took into account evidence that privately insured
patients are given 21 percent too much care. So we
reduced costs by 21 percent for patient-provider
visits.
Colorado Health Institute 15
JUNE 2019
And the System We Need to Meet It
303 E. 17th Ave., Suite 930, Denver, CO 80203 • 303.831.4200
coloradohealthinstitute.org
The Colorado Health Institute is a trusted source of independent and objective health
information, data, and analysis for the state’s health care leaders. CHI’s work is made possible
by generous supporters who see the value of independent, evidence-based analysis. Those
supporters can be found on our website coloradohealthinstitute.org/about-us
