In a collection of cubicles overlooking Market Street in Philadelphia, a multimillion-enrollee HMO is attending to the task of living up to the original meaning of managed care.
At any moment of the day or night, triage nurses may be connected through their telephone headsets to an enrollee in one of eight states where an 800 number feeds into the "comprehensive member support center."
A keystroke away, on a personal computer in each cubicle, are computer programs dealing with four dozen general medical complaints, allowing nurses to judge the seriousness of a problem and talk through what to do about it.
In an era when managed care has become synonymous with cost containment, Foundation Health Systems is betting $15 million to $20 million annually that it can differentiate itself to patients and payers. It will do this by encouraging enrollees to call a central number for advice, action and expedited referrals to the right provider.
The basic premise is that "our members are never left alone to deal with a medical problem," says Philip Katz, vice president and chief information officer of Woodland Hills, Calif.-based FHS, a 5.1 million-enrollee HMO operating in 17 states.
The HMO plans to collect its reward in the form of high retention of enrollment. This will be fostered partly by streamlined dispatching of authorized referrals and capitalizing on information to keep health problems from getting worse for the patient-not to mention more costly for the health plan to fix.
The engine of the operation is a clinical information system that combines medical-triage expertise and patient-specific information with the raw power of computer processing to cover a lot of ground in a short time.
Service lineup.About 20% of FHS' total enrollment now has access to the call center, and that percentage is expected to double by the end of the year.
The rollout of all service features may take years and vary by market, but here's what the triage nurses are being mobilized to do when a person dials in:
Pull up the electronic clinical history of the patient, including notes of previous medical visits, recurring conditions, and medications with possible side effects.
Use a computer program to quickly identify or rule out serious problems, then narrow down the problem by posing a series of questions that lead to more questions, just like doctors do.
Depending on the problem, conclude what to do and where to send the patient next, ranging from emergency treatment to basic tips on handling the problem at home.
Schedule a pre-approved visit within hours of the call to a primary-care physician.
Get the patient straight to a specialist if the situation warrants, without having to endure the delays inherent in the usual gatekeeper routine.
In lesser medical events, call up standing orders from specific physicians, giving counsel tailored to a physician's practice preferences.
Call back every couple of hours to see if the situation is getting better or worse for the patient.
From theory to practice.The idea of combining nurses' healthcare instincts with highly computerized knowledge about appropriate avenues of treatment was announced with fanfare 18 months ago (March 4, 1996, p. 60).
The initiative is a joint venture between Foundation Health Systems and Health Data Sciences Corp. Health Data is a San Bernardino, Calif.-based healthcare software developer that markets a system under the name Ulticare for computerizing the collection, reporting and analysis of medical data.
That unveiling included many promises about how the approach could shave costs while providing higher-quality care and producing happy managed-care enrollees.
Since then, HMOs nationwide have popularized the use of call centers formed to serve the patient-management niche, some operated by publicly traded companies such as Phoenix-based National Health Enhancement Systems and Rancho Cordova, Calif.-based Access Health (Sept. 9, 1996, p. 20).
FHS and Health Data now have a year of operation and more than 41,000 calls under their belt, and a sense of how the effort is faring in patient and physician acceptance, referral patterns and the ability of nurses to handle new duties.
Begun as a pilot project in Philadelphia, about 40% of the call volume has come from the HMO's 60,000 enrollees in the greater Philadelphia area, Katz says. The remainder have come from a phased-in base of 900,000 enrollees elsewhere in Pennsylvania and in Colorado, Connecticut, Idaho, New Jersey, New Mexico, Oregon and Washington state. The center now fields 2,500 calls a week.
In the first year of operation, "we've learned an awful lot about the triage process," Katz says, adding that significant changes already are in the works to revise computer-calculated decisions and dispositions of calls.
An outgrowth of that experience is a basic benefit that all HMOs hope for: Patients are reporting not only high satisfaction with the service but also an inclination to stay with the health plan because of it.
If the satisfaction figures translate into retention, the call center could be central to the HMO's ability to retain market share while it does battle in open-enrollment periods.
Katz says it takes about $200 to land a new commercial HMO enrollee and $800 to attract a Medicare enrollee, including expenses for marketing, advertising, telemarketing and presenting to employee groups. The cost of retaining enrollees is a little harder to quantify, but he says it's only a fraction of new-enrollee efforts-perhaps $50 a year, mainly to keep them informed about services.
The call center is one service that could help FHS hang onto its enrollees at that low carrying cost. The upcoming fall open-enrollment period-the first since the call center debuted-will put those high hopes to the test, Katz notes.
Rising satisfaction.Most locations participating in the enrollee support center are just getting the program established, but the Philadelphia-area operation got into full swing in September 1996 as a collaboration between Health Systems International, one of two predecessors of FHS, and Philadelphia Health Associates, a 26,000-enrollee independent practice association in central Philadelphia.
PHA at the time was owned and managed by Woodland Hills, Calif.-based HSI, which merged in April with Rancho Cordova, Calif.-based Foundation Health Corp. to form FHS. PHA was sold in November 1996 to Pittsburgh-based Allegheny Health, Education and Research Foundation.
Two independent surveys conducted in November 1996 and February 1997 by Fullerton, Calif.-based Strategy Research Institute, and paid for by the HMO, show high and rising satisfaction with the call center.
In February, 96% of respondents said they were satisfied with the courtesy of the nurse, and 91% said they were satisfied with nurses' responsiveness, personal interest and thoroughness. Nurse knowledge satisfied 87% of the respondents.
Overall, satisfaction with the outcome of calls rose to 94% in February from a respectable 81% in November.
A majority of respondents agreed the center would be a deciding factor in selection of a health plan, Katz says. In November, 55% said their experience would affect their decision to stay with the HMO; in the February poll, 53% said it would.
Overall satisfaction with the HMO climbed in the three months between surveys. In November, 65% said they plan to keep FHS as their health plan. By February, the figure jumped to 84%.
The enrollees responding to the survey were from the initial Philadelphia enrollment base.
Concerns eased.Patients "are enthusiastic in their praise" after an initial period in which some feared that the call system would act as a barrier to their physicians, says James Reynolds, M.D., medical director of Philadelphia Health Associates when it piloted the program.
Instead, patients gained streamlined access to a medical practitioner when appropriate, Reynolds says. In lesser cases, they had a 24-hour voice to turn to for medical advice, as well as an 800 number to hear one of about 400 recorded messages on individual medical subjects.
The center has a staff of about 30 nurses averaging 10 years of clinical experience. From two to 18 nurses are on duty depending on expected call volume.
Generally, the approach is part of what's being coined "demand management," an attempt to curb ingrained tendencies of patients to go to specialists and emergency rooms for ills that could be taken care of in less expensive settings.
As HMOs and capitated physician practices take on more financial risk for the healthcare costs of their enrollees, the idea of demand management has taken on urgency and prompted the establishment of call centers. But that's exposed health plans to criticism that they're setting up barriers to care and trying to get by with telephone medicine.
In results of FHS phone encounters through June 30, however, referrals to primary or higher-intensity care dominate the outcome of the top 10 medical situations encountered by the clinical nurses (See chart, p. XX).
In addition, the call center's structured lines of questioning and discovery, called algorithms, lead to a direct referral to a specialist in more serious cases, says John Danaher, M.D., medical director of the overall patient-management program. And recent revisions to those algorithms increased the number of specialty referrals, he says.
"Initially our referrals to specialists were in the 1% to 3% range," he says. "Over the last couple of months they've been in the 5% range."
How it works.The 179 algorithms were developed by HealthTrac, a company formed by Stanford University faculty to apply the scientific discipline of medical practice for the general population.
Danaher says the procedure "replicates the thinking of a general practitioner" in getting to the bottom of a general complaint such as a cough, a headache or abdominal pain.
A clinical nurse calls up an algorithm based on the complaint as well as patient data available through on-line records detailing pertinent facts such as inpatient and pharmacy history.
To cover contractual limitations on where an enrollee can go for care and for what reasons, the computers also contain data on benefit plans, eligibility for care, provider networks available to a particular caller and all other economic relationships, Katz says.
So, for example, the system will recognize that if a triage trail leads to a medical referral, a plan enrollee in a capitated physician network won't be referred outside that network unless it's an emergency, he says.
As of May 1, about one-seventh of the HMO's enrollment had computerized patient records linked to the call center via Ulticare, according to Health Data Sciences. To make that piece work, providers have to be using the clinical systems that can feed patient data to the call center.
The Philadelphia location had most of that computerization in place because six-hospital Graduate Health System already was running the Ulticare system in its inpatient as well as outpatient hospital operations, says Katz, who was that system's vice president of strategic planning and technology before moving to Health Systems International.
Philadelphia Health Associates and its physicians on staff at Graduate also were using the computer system, allowing all data on their patients to be merged into one database, he says.
That's also given call-center nurses direct access to the information and a return link to physician and hospital locations for scheduling visits directly into office calendars and dispatching results of call encounters in advance of a patient's arrival, Katz adds.
In other locations, scheduling is done over the phone and by fax. An enrollee's primary-care physician is notified by automatic fax of the call-center encounter, plus any referral to a specialist or emergency room. Referral sites also get a fax of the encounter documentation as well as authorization information.
FHS is reaching into its own databases to download data on demographics, prescriptions, claims and encounters, benefit plans and provider networks for all enrollees served by the call center, Katz says.
Directing traffic.When call centers were conceived, healthcare organizations were trying to stave off unfounded visits to specialists or trips to the emergency room for routine care. Nurses or other call-takers were armed to give self-care advice, plug callers into recorded snippets of advice or refer to a primary-care doctor who would make the decision on specialist referrals, Katz says.
But by merging computer power with known wisdom about where physicians would send a patient when confronted with certain symptoms, the FHS-HDS venture committed "well over $1 million" to developing pinpoint direction for nurses on how to lead a discussion with an enrollee to an "end point," Katz says.
The initial development came up with 43 end points, or dispositions, of a call-center case. Predictably, self care topped the list in frequency during the first year of operation, but other urgent-care and specialty authorizations are near the top (See chart, p. XX).
"The fundamental basis is having very highly structured clinical-information-system knowledge bases with fast response time," Danaher says. "Because of the response time, you can make a lot of connections and you can also process a lot of questions."
Going into the second year of operation, experts in the computer logic and medical reasoning behind the algorithms are retooling many of them to look for more situations in which a patient should go directly to a specialist. The number of end points is now up to 48.
The plan is built around "golden moments in medicine," says Danaher, "in which prompt attention and intervention of a specialist can markedly affect the outcome of an event."
For example, cartilage and internal workings of an injured knee are more capable of being mended early than if they harden during the days or weeks it takes to go through primary-care measures and eventual referral to the specialist anyway, Danaher says.
So if a skier who bangs up his knee can't flex it or put weight on it, and ice and ibuprofen aren't helping the swelling, that may support a suspicion of an anterior cruciate ligament injury and justify a direct referral to an orthopedist, he says.
Because algorithms are organized around general symptoms, the investigation of complaints can end up in a referral to different types of specialists, says Dina Kraemer, FHS' manager of protocol development.
In treating a cough, for example, possible end points include an appointment with a pulmonologist, cardiologist, oncologist or infectious-disease specialist. Lower-back pain could get a patient hooked up with any of seven specialties: orthopedics, oncology, rheumatology, neurology, gastrointestinal medicine, obstetrics/gynecology or occupational health.
Overall, direct referrals to ophthalmologists (1.5% of all dispositions), obstetricians/gynecologists (1.5%) and orthopedists (1.3%) were the top end points to specialists in the period between Sept. 9, 1996 and June 30, 1997, Kraemer says.
Continuing revision of the algorithms combined with other analysis costs, software license fees and operation of the call center add up to $15 million to $20 million a year, Katz says. FHS estimates total research and development costs to date at roughly $300 million to $400 million.
"That's not all out of FHS' pocket," he says. It includes investments of technology partners and other experts in developing the call center, clinical data repository, physician practice management system and other clinical information systems, the algorithms and other analytical tools.
Doctors settle in.For physicians, the call-center procedure has had a material effect on medical practice, says Reynolds of Philadelphia Health Associates. After less than a year with the call center, "physicians are adamant that they cannot live without the service," he says.
But the reasons for that enthusiasm have more to do with improvements in patient management and relief from the burden of call duty than with some of the core objectives of the service, Reynolds says.
When it comes to computer-assisted medicine, physicians aren't being converted in droves to some of the care-automation aspects (See related story, p. XX).
"In some cases, the system will work like a charm," Reynolds says. "In other areas, it will be very iffy."
Another hurdle is the computer capacity required of physician practices participating in but not under the control of FHS.
The HMO's data generated by claims and patient encounters can be used to construct rudimentary profiles on enrollees, but the potential of the program's clinical foundation depends on enticing independent providers to install the Ulticare system for practice management, Katz acknowledges.
The HMO is talking to physician groups, especially those with a high percentage of Foundation patients, to sell them on some of the electronic reporting and administrative streamlining that could make dealings with the HMO easier and worth the investment, Katz says.
Although overhead reduction and better management are initial practical benefits, physicians and the HMO also will achieve the bonus of a fully electronic medical record, he says. "The clinical data repository, which is the core of the system, is basically a passive byproduct of the automation of the patient-care process."
Foundation also plans to market heavily to the physicians' patients. An upcoming advertising campaign will attempt to increase awareness of the call center and include incentives to use the service, Katz says.
One possible incentive, still in the discussion stage, involves waiving a copayment if a referral is gained through the call center. That would promote the aims of the triage program, he says, and generate the savings that result from getting people to the right doctor at the right time.