The search for healthcare intervention sometimes begins in the middle of the night--with the call of a small child who's not feeling well or maybe the wince of a would-be skier whose knee is throbbing.
The traditional remedy to a nighttime medical emergency is the on-call physician, but now many healthcare consumers have another option: HMO-run call centers, 24-hour "hotlines" staffed by clinical nurses.
Los Angeles-based Foundation Health Systems, which has 5.5 million enrollees in 17 states, has organized its care management plan around its relatively new call center.
The basic premise of the call center, according to Philip Katz, FHS vice president and chief information officer, is that "members are never left alone to deal with a medical problem."
When someone calls into the center with a medical problem, a triage nurse on the other end of the line is able to do the following:
The call-center initiative began in July 1996 as a collaboration between Health Systems International, one of two predecessors of Foundation Health Systems, and Philadelphia Health Associates, a 26,000-enrollee independent practice association in central Philadelphia. PHA at the time was owned by Health Systems International, which merged in April with Foundation Health Corp. to form FHS.
The call center, FHS top executives say, is an ambitious attempt to live up to the literal meaning of "managed care," which has become synonymous with cost containment among its critics.
The center has a total staff of 30 nurses, each with an average of 10 years of clinical experience. Two to 18 nurses are on duty at any one time depending on expected call volume.
Total research and development costs of the project to date are estimated to be $300 million to $400 million, including spending by FHS, its technology partners and other experts. Annual costs, including continuing revision of the algorithms--the structured line of questions and discovery--software licensing fees and operation of the center, add up to about $15 million to $20 million, Katz says.
By combining computer power with medical knowledge and authorizing call center nurses to make treatment decisions, FHS aims to eliminate the referral maze that characterizes many HMOs' dealings with their members. In other words, it aims to provide truly "managed care," Katz says.
The call center, called HealthLine and based in Philadelphia, has expanded during 1997 to Colorado, Connecticut, Idaho, New Jersey, New Mexico, Oregon, Pittsburgh and Washington. The company has a total enrollment of 915,000 people in these states.
The Philadelphia-area operation, which has been in full swing since September 1996, has provided FHS with a microcosm of the grand plan and a vehicle with which it can test the acceptance of patients and providers alike.
Two independent studies conducted by Fullerton, Calif.-based Strategy Research Institute and paid for by FHS have demonstrated the call center's impact on member satisfaction and retention.
Surveys in November 1996 and February 1997 showed high and rising satisfaction with the nurses who answer the phones. For example, 96% of respondents in February were satisfied with the courtesy of nurses, and 91% were satisfied with their responsiveness, personal interest and thoroughness. Nurses' knowledge drew 87% satisfaction.
Overall, satisfaction with the outcome of calls rose to 94% in February from a respectable 81% in November.
Appraisals like those are money in the bank. A majority of respondents said such a center would be a deciding factor in their choice of a health plan, Katz says.
In November, 55% said their HealthLine experience would affect their decision to stay with FHS. In the follow-up February poll, 53% said it would affect such a decision, indicating the November numbers were not a statistical fluke.
In addition, overall satisfaction with the HMO climbed in the three months between surveys. In November, 65% of respondents said they plan to keep FHS as their health plan. By February that percentage had jumped to 84%. The survey was taken from the population of the PHA IPA in Philadelphia.
After an initial period during which some patients worried that the call system would be a barrier to seeing physicians, many patients "are enthusiastic in their praise," says James Reynolds, M.D., who was medical director of Philadelphia Health Associates when it piloted the program.
Instead, what patients found was streamlined access to medical practitioners, Reynolds says. In less critical cases, the call center serves as a 24-hour source of medical advice. It also provides an 800 number that offers callers a choice of 400 recordings about different medical subjects.
Generally, the call center approach is part of what has been coined "demand management," an attempt to curb patients' tendencies to go to specialists and emergency rooms for ills that could be taken care of in less expensive settings.
Critics say health plans that set up call centers are setting up barriers to care and are trying to practice medicine by telephone.
Yet, the results of FHS phone encounters through June 30 show that referrals to primary-care physicians or higher-intensity care dominate the outcome of the top 10 medical situations.
What's more, the call centers' algorithms lead to a direct referral to a specialist in more serious cases, says John Danaher, M.D., FHS medical director. And recent revisions to those algorithms have had the effect of increasing the number of specialty referrals, he says.
"Initially our referrals to specialists were in the 1% to 3% range," he says. "Over the past couple of months, they've been in the 5% range."
For physicians, the call-center procedure has had a clear effect on medical practice, Reynolds says. After less than a year with the call center, "physicians are adamant that they cannot live without the service and they don't want it taken away," he says.
But their enthusiasm has more to do with better patient management and relief from the burden of call duty than with some of the core objectives of the service, Reynolds says.
How it works
The engine of the HealthLine operation is a clinical information system that combines medical expertise, patient-specific information and raw computer-processing power.
To cover contractual limitations on where a caller 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 enrollee and all other economic relationships, Katz says.
So, for example, if a triage trail leads to a medical referral, the system won't refer a caller in a capitated physician network to care outside that network unless it's an emergency.
The call-center initiative is a joint venture between FHS and Health Data Sciences Corp., a San Bernardino, Calif.-based healthcare software developer that markets Ulticare, which computerizes the collection, reporting and analysis of clinical data.
The 179 algorithms were developed by HealthTrac, a company formed by members of the Stanford University faculty to simplify 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 complaint such as a cough, a headache or abdominal pain.
Nurses at the call center identify an algorithm based on the caller's complaint as well as any information available on the caller through on-line records detailing medication and inpatient history and other pertinent facts.
As of May 1, the records of about one-seventh of the HMO's total membership had been linked to the call center via Ulticare, according to Health Data Sciences.
The Philadelphia location had most of the necessary computerization in place before the call center was founded because the six-hospital Graduate Health System already was running the Ulticare system in its inpatient and 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, which allowed data from both to be merged into one database.
The system gives call-center nurses direct access not only to patient information but also a direct computerized route to physician and hospital locations for scheduling visits and dispatching results of call encounters in advance of a patient's arrival, Katz says.
In other locations, scheduling is done by telephone and fax. A caller's primary-care physician is notified by automatic fax of the HealthLine encounter, plus any referral to a specialist or an emergency room. Referral sites also get a fax with authorization information.
FHS has reached 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.
Impact on physicians
The load the call center has taken has helped physicians make better use of their time, says Reynolds of Philadelphia Health Associates.
Now that call-center nurses are handling the anxious patients who once set off physician pagers or triggered early morning phone calls, the volume of calls to physicians has dropped. For example, an FHS pediatrician on call during "high sickness" seasons used to receive 30 to 40 calls on a weekend night; now he or she will likely get seven to 10 calls, or 15 at the most.
Although physicians still are consulted in serious cases, such as referrals to an emergency room, "the rest of the stuff that's trivial in nature, that can be handled by the algorithms, those don't come through," Reynolds says.
The one routine call that does still come through is the request for a prescription refill, which can account for up to half of the phone volume of a physician on call, he says.
Earlier this year, the IPA and the call center began to develop a list of standard pharmacy orders for FHS patients, but the effort was delayed when FHS sold Philadelphia Health Associates to Allegheny Health, Education and Research Foundation, a Pittsburgh-based healthcare network expanding into Philadelphia.
Another advantage of triage referrals made during off-hours is significant improvement in practice management the next day. Appointments and the accompanying rationale for them are already on the schedule and more evenly distributed during the day, so "physicians come in the morning and have an idea of what kinds of acute problems they have to face," Reynolds says.
The direct route
The way things are headed, an increasing number of referrals from the call center will bypass a primary-care office in favor of preauthorized appointments with a specialist.
As the center enters its second year of operation, experts in the underlying logic and medical reasoning behind the algorithms are doing some retooling, looking for coexisting conditions and ways to more accurately pinpoint when a patient should go directly to a specialist.
It's built around "golden moments in medicine," Danaher says, "in which the prompt attention and intervention of a specialist can markedly affect the outcome of an event."
For example, the cartilage and other internal workings of an injured knee are more likely to heal if the knee is treated soon after the injury, not days or weeks later, the time it may take to go through primary-care measures and eventual referral to a specialist, Danaher says.
So, clearly, a skier with all the symptoms of an anterior cruciate ligament injury is a good candidate for direct referral to an orthopedist, he says.
Although it sounds simple, Reynolds says the concept of direct specialist referral needs some refining before generalists get comfortable with it. "There's only so much you can do about deciding on problems over the phone," he says.
In fact, doctors still are reluctant to cede patient contact to a computer even when that computer can save them a lot of work. "It will take some time for physicians to develop trust in having someone (and something) else doing their patient histories," Reynolds says.
As nurses develop more sophistication and physicians develop confidence in the system, that situation will improve, he says. "Let's face it, they're not pediatricians, they're nurses. And this is a new role for them."
The call center operates even during physician office hours, easing the caseload of practices' clinical nurses. The center's triage nurses have time to follow up on a case in a way doctors and harried staff nurses do not. Before, a clinical nurse with other duties to perform would try to follow up on a patient's treatment. Now, Reynolds says, a triage nurse can keep track of whether the patient is responding to treatment or needs to see a doctor.