Dr. Vishnukamal Golla is the medical director for value transformation at Evolent, a specialty and primary care enablement company, where he leads the implementation of innovative value-based care models in specialty care. He spoke with Urban Health Today about ways to improve specialist engagement with primary care physicians so patients can receive seamless, high-quality, whole-person care.
Urban Health Today: Dr. Golla, please tell us about your background and your work with Evolent.
Dr. Kamal Golla: Clinically, I’m a practicing urologist, and at Evolent, I’m the senior medical director for value transformation, where I lead the implementation of value-based care models in specialty care—for example, oncology, cardiology, and musculoskeletal care. The goal here is to improve how healthcare is delivered for patients receiving specialty and primary care.
UHT: How did a urologist become interested in working with integrating primary care physicians?
DKG: My interest in collaborating with primary care physicians stems from seeing firsthand the critical role this partnership plays, particularly for patients in health-disparate populations. I vividly recall a patient with unmanaged diabetes who needed to be medically optimized prior to surgery for prostate cancer. Through close collaboration with the patient’s primary care physician (PCP), we successfully stabilized his diabetes, not only improving his surgical outcomes but also enabling the PCP to manage his overall health more effectively.
This experience highlighted the immense value of coordinated care between specialists and primary care. It became clear to me how essential seamless communication and shared decision-making are in achieving the best outcomes for patients. However, I also saw the challenges our fragmented healthcare system poses, which often makes such coordination unnecessarily difficult.
I’m passionate about creating systems where primary care and specialists work together more seamlessly. I realized that developing a better construct or model that considered these issues was really important. I wanted to dedicate my career to finding ways to support the broader population of patients and to build models that would support them regardless of their background. `
UHT: How have you seen the landscape of caring for marginalized patient populations evolve over your career?
DKG: During my residency training, the stark health disparities were very evident, especially following COVID-19. I had patients newly diagnosed with prostate cancer who were unable to get surgery because of housing, education, or income issues, and it was clear to me that certain public health initiatives needed to be incorporated into clinical interventions.
There is a growing emphasis now on understanding and addressing the root causes of health disparities. The evolution has been promising, but there’s still a lot of work left to be done.
UHT: Why is there a shortage of primary care physicians, and how does this impact patient care, especially among marginalized patients?
DKG: There has been a perfect storm of events that contributed to the PCP shortages.
One major factor is the workload that physicians, and particularly primary care physicians, are expected to carry. PCPs have to manage an overwhelming number of patients, leading to burnout or even leaving the field altogether.
We’re also seeing financial changes. One of the most recent market changes has been the introduction of the V28 modifier, which essentially changes how patients are risk-stratified. This affects reimbursement for physicians, and specifically for PCPs. This modifier has significantly impacted revenue for primary care practices, resulting in many being unable to cover their expenses for visits.
Another consideration is that we are not investing in primary care physicians. The number of residency spots has generally decreased, but populations have grown.
These shortages disproportionally affect marginalized communities because these populations often have higher disease burdens combined with less access to preventive care. These factors are exacerbated when we also have a shortage of physicians.
UHT: Is the increased demand for specialty care due to the shortage of PCPs, or are there other contributing factors?
DKG: Let’s start with some historical context. Accountable care organizations have been created in the past 10 to 15 years and these entities are made up of a group of healthcare providers with the goal of addressing the full range of a patient’s needs. This includes primary care needs, as well as specialty needs such as cardiology, oncology, and musculoskeletal care.
The trends that we’re seeing in specialty care support the need to integrate primary and specialty care. However, within the U.S. healthcare system, we see an emphasis on specialist, diagnostic, and treatment approaches to patient care. In fact, a little more than 30% of patients are referred by their PCPs to specialist providers, and over 50% of all outpatient appointments take place with specialists, showcasing that there has been a profound spike in the utilization of specialty care needs.
And when we talk about marginalized communities, these are the individuals that are disproportionately affected. These patients already have higher rates of chronic conditions and less access to primary care, which means that they’re even more likely to end up needing specialty care.
UHT: Fragmentation of care is a recurring issue in the healthcare system, especially when patients transition between primary care and specialists. What are the biggest challenges PCPs face in ensuring smooth coordination with specialists?
DKG: Ensuring smooth coordination between primary care physicians and specialists is crucial to patient care, but it comes with a few challenges.
The first is the lack of interoperability. There is no common platform where primary care doctors and specialists can communicate about a particular patient, making it difficult for physicians to relay complex patient treatment plans. This fragmented communication loop can lead to incomplete or delayed patient information sharing, ultimately impacting the patient’s care.
Another challenge is clarity. There can be confusion about the roles and responsibilities of each physician during a patient’s care journey, such as when a specialist is expected to manage the condition long-term or provide consultation versus what aspects a primary care doctor should manage.
Even knowing which specialist a patient should be referred to, or identifying a high-value specialist, can be difficult for primary care physicians. There simply are not a lot of tools readily available that can help physicians understand the quality of the specialist they are referring their patients to.
UHT: What strategies do you think could help alleviate the burden on PCPs and improve care coordination in light of this lack of clarity into whether a particular specialist provides high-quality care?
DKG: At Evolent, we recognize the importance of primary care physicians across the care journey. We find as many ways as we can to arm the PCPs with tools to successfully manage a patient holistically.
One tool is our high-value scorecards. These scorecards help the primary care physician identify a specialist based on clinical and quality outcomes.
Another tool we offer helps guide PCPs with specialist referrals. For example, a question that’s hard for a PCP to answer is if their patient should go to a community or academic oncologist. We provide the PCP with resources to help them understand what treatment may be required for their patient’s cancer type, giving them better insight into what particular practice or specialist they might recommend for their patients.
UHT: Can you recommend any improvements to facilitate timely access to specialty care?
DKG: Timely access varies based on patient needs, but I can offer a few general recommendations. First, consider a telehealth service. Sometimes, a virtual consultation is suitable for an initial patient visit. This can reduce wait times and increase access for those who might not live near a specialist.
Second, rework internal processes. For example, changing workflows so that patients are referred to the right type of specialist from the start can ensure you make the most of every available appointment. Using a system to track and prioritize referrals can also facilitate faster access, especially for those with more urgent needs.
Finally, patient navigation is an important element and one that we focus on a lot at Evolent. We help with collecting all the pieces that need to be included before a patient sees a specialist. These may include lab results, imaging tests, family history, known barriers to care, current medications, and so forth. This helps reduce inefficiencies and back and forth between PCPs and specialists.
UHT: What advice would you give the patients navigating a healthcare system in which PCPs and specialists are increasingly scarce?
DKG: The main thing is establishing a strong relationship with your PCP. They’re your advocates and the ones that will help you get referred to a specialist.
The next step is to focus on preventive care so that you don’t need to undergo complex treatments down the line. Sometimes, the best way to manage the healthcare system is to reduce the risks of needing to see a specialist, so prioritizing preventive care is critical.
I also recommend utilizing community resources. Many community health centers and clinics offer comprehensive care services based on a sliding scale. If you don’t have a PCP or a specialist, these clinics can be great resources to help you find one.
Lastly is advice that I always remind loved ones to take: advocate for yourself. Being proactive as a patient will help you navigate the healthcare system more effectively.
UHT: Thank you for your time, Dr. Golla
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