Facilitators of and Barriers to Medicaid Investment in Electronic Consultation Services

ABSTRACT

Objective: Electronic consultation, or e-consult, programs have enhanced access to specialty care for primary care providers and their patients, reducing unnecessary in-person visits and maintaining cost-effectiveness. In California, there is great variability in access to e-consult programs for low-income patients who rely on Medicaid managed care plans (MCPs) for covered benefits. This study aimed to understand MCP facilitators of and barriers to e-consult investment in California.

Study Design: Interviews conducted with California Medicaid MCPs’ leaders to learn about the facilitators of and barriers to investment in e-consult programs.

Methods: Interviews were analyzed using content analysis with multistage coding. The Exploration, Preparation, Implementation, and Sustainment framework was used to organize facilitator and barrier themes into 4 contexts: outer context (landscape of health care delivery in California), inner context (components within the medical neighborhood), innovation factors (characteristics of e-consult programs), and bridging factors (MCP actions).

Results: Twelve themes emerged from 16 interviews. Outer context themes were regulatory policies and financial policies (barriers), limited specialty care (facilitator), and patient perceptions (both). Inner context themes were workforce characteristics (both), clinical leadership (facilitator), and clinical workflows (both). Innovation factor themes were adjunct e-consult vendor services (both) and software integration (facilitator). Bridging factor themes included collaboration with other plans (facilitator), financial risk delegation (barrier), and quality improvement considerations (facilitator).

Conclusions: Medicaid regulatory and reimbursement policies posed the most significant barriers to e-consult investment by Medicaid MCPs in California. Recognition of e-consult as a mode of specialty care delivery and reimbursement for clinicians could help future e-consult programs succeed in enhancing access to specialty expertise for low-income patients.

Am J Manag Care. 2025;31(3):In Press

Takeaway Points

Electronic consultation, or e-consult, is a mode of specialty health care delivery that can improve access to specialty care. There are various facilitators of and barriers to e-consult investment from the perspective of the Medicaid managed health plan.

• Medicaid policy and reimbursement were the most important barriers to e-consult adoption.
• Common facilitators of e-consult investment were related to limited specialty care access, engaged clinical leaders in primary care practices, and collaboration among health plans.
• Understanding the facilitators and barriers may lead to changes in Medicaid policy and guide resource utilization for e-consult implementation by health plans to enhance specialty care access.

Although Medicaid expansion in the US has increased potential access to routine primary care, it has also led to new challenges and health care disparities, chief among them access to high-quality specialty care.¹ Reasons for this include low reimbursement rates for treating patients with Medicaid and limited availability of specialists. To address the supply-demand mismatch, electronic consultation (e-consult) systems have been developed.² E-consults allow referring primary care providers (PCPs) to obtain specialty expertise without the patient communicating directly with the specialist, whether through an in-person or a telehealth (phone or video) appointment. In an e-consult, a PCP sends an asynchronous message to a specialist who responds with recommendations. The PCP can share these recommendations with the patient at a future appointment or through other modes of communication, such as a phone call or electronic messaging via a patient portal. E-consult has demonstrated benefits consistent with the Quadruple Aim³: improving equitable patient access to specialty care, increasing PCP and specialist satisfaction, enhancing communication among providers who work within institutions, and introducing cost reductions through more efficient care delivery.⁴

To date, most US e-consult efforts have been within individual delivery systems,⁵ countywide and publicly funded systems,⁶ academic medical centers,⁷ and organizations at financial risk for specialty care delivery.⁸ At this time in California, where many e-consult systems have flourished, Medi-Cal (Medicaid in California) provides reimbursement to specialists who provide e-consults with dedicated Current Procedural Terminology codes; referring clinicians (most often PCPs) do not receive reimbursement. PCPs and specialists who render care in federally qualified health centers (FQHCs) and rural health centers (RHCs) are also excluded from this benefit. In the FQHC payment model, the FQHC receives a capitated payment, which is higher than the fee-for-service payment for primary care services. The higher capitated FQHC payment is intended to cover all care, including care coordination activities. However, these rates were set prior to e-consult development and thus do not reimburse the additional provider time and effort required by e-consult. Furthermore, for FQHCs and RHCs that are not part of organized delivery systems, e-consult adoption requires collaborations with health plans that can provide the e-consult infrastructure. In California, Medicaid managed care plans (MCPs) play a crucial role in determining services available for patients, and many are regulated by the Department of Health Care Services and the Department of Managed Health Care. There is great variability in whether MCPs offer e-consults to their members who receive care in FQHCs and RHCs, even though it is established that e-consult promotes specialty care access and thus health equity. The facilitators of and barriers to e-consult implementation from the health plan perspective were an existing gap in our knowledge. We sought to bridge this gap by interviewing leaders from California MCPs that were in different stages of e-consult implementation.

METHODS

Design and Sampling

We contacted leaders of all MCPs regulated by the Department of Managed Health Care in California. Programs that were special initiatives, senior-only, dental-only, or nontraditional MCPs were excluded. Twenty-three plan leaders were invited via email to participate in semistructured interviews to learn about each organization’s investment in e-consults. Organizations were located across California and were at different stages of investment in e-consult programs, including no investment, pilot projects/early investment, or full robust implementation. Interviewees included MCP chief quality officers, chief medical officers, and CEOs.

Data Sources

Semistructured interviews were conducted by 1 investigator (D.S.T.) via Zoom between March 2022 and June 2023. Interviews consisted of 7 questions that inquired about drivers for investment, lessons learned, and facilitators of and barriers to e-consult use (eAppendix 1 [eAppendices available at ajmc.com]). Conversations lasted 30 to 60 minutes and were audio-recorded and professionally transcribed. Verbal informed consent was obtained from all participants. The study protocol was approved by a University of California Institutional Review Board (study 22-37482).

Analysis

Interview transcripts were entered into Dedoose 9.0.90, a cloud application for managing and analyzing qualitative data (SocioCultural Research Consultants, LLC). Two investigators (J.E.K. and D.S.T.) coded transcripts using direct content analysis to identify facilitators of and barriers to e-consult investment from the Medicaid plan perspective.⁹ They coded the first 3 transcripts independently and then met to share analysis and resolve discrepancies. The remaining transcripts were analyzed primarily by 1 investigator (J.E.K.), which were then confirmed by another (D.S.T.). Both coders continued to meet to discuss interpretations of the codes. Thematic saturation was reached after the 11th transcript. To maintain organization and generalizability, themes were mapped to the Exploration, Preparation, Implementation, and Sustainment (EPIS) implementation science framework, which identifies factors that influence implementation of evidence-based practice in publicly funded settings and organizes those factors into 4 constructs: outer context, inner context, innovation factors, and bridging factors.^10,11

RESULTS

Participating Plans

Of 23 organization leaders contacted, 16 (69.6%) agreed to participate (Table 1) (participants’ plans are identified throughout the article with letters A through P). Organizational size varied considerably, as did geographic representation. Five plans delegated financial risk to other entities, whereas 11 plans maintained full financial risk for their Medicaid members. The large majority of MCPs had implemented e-consult programs. Seven organizations did not participate in the study. One organization no longer planned to continue its Medicaid business and declined participation. Two plans that declined to participate did not offer e-consults. The other 4 organizations did not respond to inquiries, and their e-consult program status was unknown.

Twelve themes regarding e-consult program implementation within Medicaid health plans were identified across the EPIS constructs (Figure). A summary of the themes is presented as follows, with select representative quotes in Table 2 (full set of quotes available in eAppendix 2).

Outer Context

We defined the outer context as the health care landscape external to the medical neighborhood (the network of providers, including PCP and specialists, and other services collaborating to care for a patient) and the health plan. These themes included limited access to specialty care, regulatory recognition of e-consult, financial barriers, and patient perception.

Limited access to specialty care. An overarching theme throughout the interviews with MCP leaders was that limited access to specialty care was a facilitator of e-consult investment. E-consults often alleviate the demand for in-person specialty appointments by resolving low-complexity specialty care concerns within the primary care home via provider-to-provider consultation or by allowing the PCP to initiate the “appropriate workup in advance” (plan A) of the specialty appointment. Access to specialty care services was a challenge for plans operating in all environments, whether rural, suburban, or urban. Interviewees from rural areas cited the additional access limitation due to distances that patients must travel for in-person specialty care visits. Plan leaders in suburban and urban areas identified additional limitations caused by a paucity of specialists accepting Medicaid patients in those areas.

Regulatory requirements not recognizing e-consult as a mode of health care delivery. The barrier most frequently discussed by plan leaders regarding e-consult uptake was related to policies and regulations. Participants highlighted that e-consults are not currently recognized as a mode of health care delivery by Medi-Cal, which then prevents e-consult access from contributing to health plans’ specialty network adequacy and timely specialty access requirements. One participant stated, “It comes down to whether [e-consult] is a covered benefit or not” (plan B). A few participants mentioned that the regulations are out of date, with one saying that it would be better to “give us credit for care delivered through e-consult as opposed to requiring it to kind of conform to an old version of what it means to get care” (plan C). One plan leader did mention that although e-consult does not count for specialty access, providing e-consult for its members still would decrease the demand for in-person referrals, thus positively impacting the plan’s timely access requirements.

Financial barriers. Another overarching barrier was related to absence of PCP remuneration for e-consult activities from Medi-Cal. One participant described, “From the [PCP’s perspective], there’s no extra benefit to me. I’m not getting compensated, and it’s more work for me to take on” (plan D). A few plan leaders also discussed that in a fee-for-service compensation context, even though e-consult is a lower-cost delivery model, it makes more financial sense for specialists to complete a telehealth visit or in-person visit, which are fully reimbursed and require minimal effort from the PCP’s perspective compared with e-consult.

Several MCP leaders said it was important for changes in compensation to originate from state policy. One plan even attempted to pass state legislation to provide compensation to PCPs in FQHCs, although it ultimately was vetoed. Given this lack of remuneration for the e-consult service, a few participants described alternative funding sources beyond Medicaid to initiate and maintain their e-consult program. This funding often came from the health plan itself or outside grants. Funding from the health plan had the benefit of being potentially sustainable, as the health plan could continue to include e-consult support in its budget if it deemed that there was a higher benefit from providing e-consult services than from supporting other initiatives. Because plans receive a per-member, per-month rate to deliver care, there is a financial return on investment on e-consults because they decrease unnecessary specialty care visits.

Patient perception. Patient perception of e-consult services was described as both a barrier to and facilitator of e-consult investment. Interviewees worried that patients may be less satisfied with their care via e-consult because, as one participant stated, “Sometimes I’m not confident that our members who are benefiting or using the services necessarily know that they are getting the high-quality specialist service that they’re looking for.… Members may also believe that their access to in-person specialist care is delayed by this process” (plan E). Similarly, another plan leader stated that the “advent of telehealth…and the adequate reimbursement for [synchronous telehealth have] made e-consult a little less compelling for us” (plan F) because patients can speak directly with the specialist, which may lead to increased patient satisfaction compared with care received via e-consult. On the other hand, a potential facilitator was that when patients were aware of the dialogue between their PCP and a specialist, they were pleased that they would not need to take time off work to see a specialist in person.

Inner Context

We defined the inner context for e-consult implementation as the components within the medical neighborhood, which included the themes of workforce characteristics, clinical leadership, and clinical workflows.

Workforce characteristics. Plan leaders enumerated ways in which the clinical workforce characteristics acted as facilitators of and barriers to e-consult implementation. E-consults provided learning opportunities to PCPs, allowing them to expand their capabilities and scope of practice. As one plan leader stated, “They’re gaining knowledge; they’re making more appropriate, comprehensive referrals when they do need to make them” (plan G). Another plan leader identified clinician characteristics that could influence uptake, stating, “When you have a smaller practice that has older physicians, and it’s yet another change that you’re expecting of them, you’re less likely to have a large-scale uptake. But with the younger physicians who are used to having integrated medical records and so on, you’re more likely to have a higher level of uptake” (plan A). In addition, a high turnover rate in PCPs leads to a lack of “institutional memory” (plan H), thus requiring repeated outreach to PCPs on how to use e-consults.

Interviewees discussed the importance of ensuring that in-network specialists participating in e-consults are reimbursed and have time allotted to manage e-consults. One participant asked, “Are they setting themselves up realistically where they have a provider who does e-consults and telehealth all day and it’s protected? Or does this become more of an afterthought, where it’s added onto their day and it’s just an impossibility?” (plan A). Additionally, the capacity of primary care clinics’ frontline staff to serve as e-consult referral coordinators while also having other responsibilities was identified as a factor in implementation: “[The staff are] wearing all these different hats, and so asking them to do one more thing, they’re just like, ‘Love to do it, sounds great, but we don’t have the resources.’ So it’s 100% an uphill battle all the time” (plan I).

Clinical leadership. Strong primary care clinic leadership was consistently identified as an essential facilitator of the successful implementation and adoption of e-consults. One plan leader summarized this by saying, “If a clinic does not want to implement e-consults, they will not do it. I can tell you with 90% certainty that it was at the clinic leadership level that the priority of e-consult was made” (plan G). Another participant’s comments echoed the importance of leadership: “I think it takes a lot of leadership.… There’s a gazillion different reasons why they [PCPs] didn’t want to. But over time, there was fairly good uptake, and it was driven by the clinical leadership at the organization” (plan A).

Clinical workflows. Plan leaders frequently identified cumbersome clinical workflows as barriers to high adoption of e-consult programs, including the need to log into a separate software system to submit an e-consult. Another barrier is when e-consult services are available for certain specialties but not others, requiring primary care clinicians to confirm the availability of the service prior to submitting an e-consult. The inclusion of referral coordinators was seen by some plan leaders as a facilitator to help offload the logistical effort from the PCPs, yet it could also act as a barrier by adding another layer of complexity and delay to the process. One plan leader described the calculation a PCP makes: “As a provider, I’m probably going to [ask,] ‘How complex is this case and which [method of obtaining specialty expertise] is going to cause me the least amount of abrasion, filling out this prior authorization request for [an in-person specialty care visit] or going in and entering clinical data for an e-consult?’ ” (plan A).

MCP leaders also discussed the tension between making e-consults mandatory and giving providers the option to refer directly to the specialist first. There was a concern that making e-consults mandatory could lead to providers placing a consult for the sake of complying with the requirement with limited or no value added from the e-consult dialogue. On the other hand, participants discussed that a mandatory e-consult could allow for “more of the care [to be completed] prior to the actual in-person specialty visit” (plan J).

Innovation Factors

We defined innovation factor themes as unique e-consult program characteristics that affected health plans’ e-consult strategies. These included adjunctive services from the e-consult vendor and software integration.

Adjunct e-consult vendor services. Some e-consult vendors offer adjunctive services that facilitate the investment in e-consult by health plans. For example, one vendor provided an implementation team to help troubleshoot cumbersome clinical workflows. Whereas some e-consult vendors provided only the essential software, other vendors also provided their own specialty consultants. A few plan leaders mentioned that the ideal e-consult vendor was one that also provided telehealth services, potentially providing continuity of care: “In the best of worlds, the provider who’s doing the e-consult is also a provider who could do a telehealth [visit], is also the provider who could do a face-to-face [visit]” (plan A).

In addition, plan leaders discussed the importance of accessing data from the e-consult program to monitor the appropriate use of e-consults and ensure that they did not result in delays in care delivery. Many interviewees discussed barriers in obtaining the required encounter-level claims data for specialist payment from the e-consult vendors. For example, one said, “Some of the challenges we have had with some of the e-consult providers have been their abilities to…work with a managed care plan. The basics like the submission of encounter data, the submission of big claims data—the payment methodology hasn’t necessarily worked similar to what it’s been like with an individual provider” (plan K).

Software integration. Plan leaders frequently discussed the importance of software integration to facilitate e-consult implementation. Consistent with the aforementioned clinical workflow theme, plan leaders described resistance from PCPs if they were told to log into a separate system outside of their usual electronic health record (EHR) to submit an e-consult and to follow up on responses. A clear facilitator of e-consult investment was the ability of an e-consult vendor to integrate their software with different EHRs, as evidenced by this quote: “EHR integration [is] the billion-dollar driver” (plan I).

Bridging Factors

We defined bridging factors themes as those related to actions or considerations of the health plans, acting as the intermediary between the inner context (medical neighborhood) and the outer context (the broader health care landscape).

Collaboration with other plans. Collaboration among plans, particularly among those that operate within the same county, emerged as a strong facilitator of e-consult implementation. Several interviewees identified the challenge to clinicians if e-consults were a covered benefit by one Medicaid health plan but not another in the same county. In those circumstances, clinicians would need to verify individual patients’ health insurance plan information before submitting an e-consult. Explicit collaboration, assurance that each plan offered the same “menu of services” (plan L), and payment for e-consults for uninsured patients were all identified as potential facilitators. As one participant stated, “We felt strongly that, to the extent possible, we would bring [e-consult] solutions together and work with the other health plans in the county” (plan L). Reinforcing this concept of collaboration, participants from plans that were not yet offering e-consults to their members expressed a desire to learn from leaders at other organizations: “If that was sort of packaged to me, it would also make it a lot easier for me to move forward.… I feel my process is reinventing the wheel, [including] exploration and discovery other people have [already] done” (plan J). Because health plans in geographic proximity are traditionally in competition with each other for members, participant leaders identified the important role that the California Department of Health Care Services could play in facilitating collaborations.

Delegation of financial risk. Several Medicaid MCPs contract with independent practice associations (IPAs), which are groups of health care providers who manage and share the financial responsibilities of providing care to their members. Plan leaders described delegation as a barrier to implementing e-consult programs due to the extra layer of logistics and willingness to share costs. One plan leader said that “most IPAs…have prior authorization requirements for a consult, which is a whole other layer of complexity” (plan A). Another plan leader stated, “The IPAs were really pushing back and said, ‘Yeah, this sounds like a great program, and if you pay for it, we’ll do it,’ but we didn’t really have a strategy to cover those shared risk environments” (plan M).

Quality improvement planning. Health plan investment in a data monitoring plan to assess the quality and appropriate use of e-consults was identified as an important facilitator. Leaders felt it was important to capture data for internal quality improvement purposes, calculate a return on investment, and share these data with state regulatory bodies to demonstrate the value added from e-consult programs. “We have a very robust and meaningful quality oversight program that we employ just as part of our program management, and it’s important that the state knows that we don’t leave [e-consult implementation] to chance…reassuring them that there is a quality plan in place, and we watch these programs from so many different dimensions” (plan M).

DISCUSSION

In this study, we identified the key facilitators of and barriers to e-consult implementation from the perspective of MCPs in California. Previous studies have described high levels of satisfaction with e-consult programs among providers and patients^12-14 and identified facilitators and barriers to implementation from the patient and provider perspectives.¹⁵ Strong clinician and executive leadership, established funding models for clinician reimbursement, and a commitment to optimizing clinician workflows to overcome extra burden on PCPs have been highlighted as elements key to implementation. Our study expands on this body of literature to add the health plan viewpoint. Consistent with prior studies’ results, we found that suboptimal in-person specialty care access, presence of strong clinical leadership in primary care practices, and clinician remuneration were important facilitators. We also identified a novel facilitator of implementation, which focused on collaboration among health plans. Building on prior studies, we discovered that the most important barriers to e-consult implementation were related to Medicaid policy.

E-consult services were initially conceived to expand access to specialty care.² Our findings confirm this as an important facilitator of e-consult investment by MCPs. We also highlight the essential role of Medicaid policy in e-consult implementation. In contrast to Medicaid policy in some states (eg, Colorado¹⁶), Medi-Cal does not currently remunerate PCPs for the care they facilitate through e-consult. Additionally, although Medi-Cal reimburses specialists who provide e-consult services, this excludes specialists who operate in FQHCs and RHCs. This prevents providers in California who care for patients with the least access to specialty care from being compensated for their e-consult activities, which could exacerbate existing disparities in access to specialty care by insurance status. Furthermore, managed health care regulations in California do not recognize e-consults as a mode of health care delivery. Thus, specialty care expertise delivered via e-consults cannot contribute to timely access standards to which MCPs in California are held accountable. For these reasons, there is little incentive for plans that predominantly serve patients with Medicaid to invest resources in e-consult implementation.

The effect of policy can be witnessed in the adoption of telehealth services. Prior to the COVID-19 pandemic, telehealth services had limited adoption. However, during the pandemic, CMS rapidly pivoted to reimburse telehealth services, leading to significant changes in infrastructure to promote telehealth care.¹⁷ This example highlights how federal policy can drive significant changes in care delivery and serves as a model for improving e-consult implementation. A recent study noted that many Medicaid medical directors, who are responsible for the scientific and clinical appropriateness of Medicaid policies in their states, support reimbursement for telehealth professional services, including e-consults.¹⁸ Of note, although some study participants preferred investing in synchronous telehealth appointments over e-consult interactions, the delivery of care through telehealth does not fully address the current limited access to specialty care.

PCP workflows and clinic leadership have been cited previously as impacting the success of e-consult implementation.¹⁵ Our study confirms and further builds on this finding by identifying key ways the health plans can support e-consult adoption. These include investing in organizational resources, such as hiring staff to assist primary care clinics with implementation, as well as working closely with primary care leadership to reduce implementation burdens faced by clinicians, including paying for integration of e-consult software into EHR systems. In addition, collaboration among health plans emerged as a novel facilitator.

The data presented in this study suggest that the most impactful mechanism to facilitate e-consult adoption in California would be Medicaid policy change, allowing e-consults to contribute to specialty care timely access metrics and providing remuneration of both PCPs and specialists who facilitate care through e-consult regardless of ambulatory practice setting. Of note, in January 2023, CMS issued a letter addressed to state health officials¹⁹ stating that coverage and payment of e-consult services was permissible. Although this has not yet led to any changes in California’s Medicaid policy, it provides potential opportunities for growth in California. In addition, having leadership from the state’s Department of Health Care Services and Department of Managed Health Care promote best practices with e-consult programs would be beneficial (eg, establishing forums or conferences to share knowledge among health plan executives and clinical leaders). This could include highlights of studies that have examined quality care delivery for single specialties (eg, cardiology, dermatology) through e-consult.^20,21 Future areas of research that could promote Medi-Cal policy change include in-depth cost analysis and modeling to explore financial implications specific to the Medi-Cal context and investigating the impact of Medicaid policies on e-consult implementation other states, including its influence on downstream measures of health equity.

Limitations

This study has a few limitations. Most plans that participated in the study had implemented e-consult at least to some extent, if not robustly, despite the unfavorable remuneration context. There were 2 organizations that declined participation, stating that they did not offer e-consult; 4 other organizations did not respond at all. Further insights on the barriers to e-consult implementation from these plans would have been valuable. In addition, this study focused on MCPs in California and may not be generalizable to leaders of other insurance providers such as commercial plans, Veterans Affairs, and Medicare or Medicaid MCPs that operate in different states.

CONCLUSIONS

This study identifies key facilitators of and barriers to e-consult investment from the viewpoint of MCPs, which offer insurance to most Californians with Medicaid. Medicaid policy and restrictive reimbursement procedures were the most important barriers to e-consult adoption. Health plans can play an important role in the success of an e-consult program by providing resources for establishing and maintaining a program. These findings may help inform changes in Medi-Cal policy and guide resource utilization for e-consult implementation by health plans to enhance access to specialty expertise to broad patient populations, thus promoting health equity and improved outcomes in the Medicaid population.

Author Affiliations: University of California, San Francisco (JEK, AMD, DST), San Francisco, CA; BluePath Health Consulting (LS), Larkspur, CA; Center for Innovation in Access and Quality, Zuckerberg San Francisco General Hospital (DST), San Francisco, CA.

Source of Funding: California Health Care Foundation.

Author Disclosures: Drs Kim and Tuot report receipt of funding for this manuscript from the California Health Care Foundation. Dr DeDent reports attendance of the CHEST conference and receipt of the Pulmonary Fibrosis Foundation Scholars Award, Nina Ireland Program for Lung Health Award, and American Thoracic Society Interstitial Lung Disease Award. Dr Tuot has a pending grant submitted to the National Institutes of Health to evaluate e-consult implementation. The remaining author reports no relationship or financial interest with any entity that would pose a conflict of interest with the subject matter of this article.

Authorship Information: Concept and design (DST); acquisition of data (LS, DST); analysis and interpretation of data (JEK, AMD, DST); drafting of the manuscript (JEK, AMD, DST); critical revision of the manuscript for important intellectual content (JEK, LS, AMD, DST); provision of patients or study materials (LS); obtaining funding (DST); administrative, technical, or logistic support (JEK, LS); and supervision (DST).

Address Correspondence to: Delphine S. Tuot, MDCM, MAS, University of California, San Francisco, 1001 Potrero Ave, Building 100, Room 342, San Francisco, CA 94110. Email: Delphine.tuot@ucsf.edu.

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