America on the line

The use of the telephone to foster primary care has long been a staple of US healthcare. Given the large number of solo practices in this country and the need to keep patients attached to practices, doctors have grown used to the telephone being the best means of maintaining contact after office hours. Patients also prefer to use the telephone to learn about non-serious medical options rather than travelling to, and waiting to see, their doctor.

The growth of managed care has led to the formalisation and expansion of this practice in recent years, although in different ways. Most health systems have been using telephone triage systems to set appointments, to direct patients to appropriate levels of care, and to screen for appropriateness of treatment. These systems have expanded and have now become a basic element of managed care in the US.

Hospitals seeking new business have created telephone-based referral systems in which a patient looking for a particular type of doctor, or a patient who reports particular symptoms, can be directed to a doctor on the hospital staff. Many group practices use a telephone triage system to determine whether patients should seek care at a hospital emergency room or wait until one of the practice doctors is available for a particular episode of care. They also use a triage system to determine if a patient should see another doctor in the network after hours rather than seek care elsewhere. In most cases it is registered nurses or nurse practitioners who serve as the triage agent.

Patients have reported finding it easier to talk to nurses because they are less intimidating and tend to give better explanations of prescription drug use and medical terms. This use of telephone systems represents an expansion of a relatively well-known and well-developed strategy.

A commonplace of US medicine has been the telephone call to the doctor to ascertain the need for a more formal visit. In fact, in what has been called 'hidden primary care', it has been the doctor's spouse who, in many cases, has been delegated responsibility for this function. As the person who answers the telephone, the doctor's wife (and it is almost always a wife) has been found to be a source of comfort and common sense for patients who are uncertain about the severity of their illness, or that of their child.

It is well known, though not well researched, that most of these telephone calls are from distraught parents wanting to know what to do about a child with earache, stomach ache or a bad feverish cold. In most cases, a simple answer can reduce the anxiety of the patient (or the parent) without generating a visit and a bill. Moreover, patients feel far less intimidated discussing symptoms with the wife of a doctor than the doctor himself.

No medical practice likes an unanticipated visit. They can disrupt routines, cause delays, or anger patients who have already arranged appointments. Problems finding medical records, delays in ascertaining insurance coverage and other similar difficulties reduce the effectiveness of medical care. It is due to this that telephone triage has grown so rapidly. Hospitals have desperately sought ways to reduce use of emergency rooms, companies have looked for ways to avoid having sick employees taking time off work, colleges have sought ways to keep their health centres from overuse during peak periods. All of these needs have led to the growth of telephone triage. Yet the factor that has increased its use more than anything else has been the need to control use by managed care systems. Having received their premiums in advance and having guaranteed comprehensive care, a health maintenance organisation which does not control its members' use will soon go out of business. It has been this financial imperative that has driven managed care companies to develop extensive telephone triage systems.

The basic premise of telephone triage, as it has been developed in the US, has been to relieve the pressure on emergency rooms by requiring potential patients to check in before actually using the facility. This accomplishes two functions at the same time: it ensures that patients get proper and necessary care when they need it, and it ensures that the HMO will not have to pay expensive hospital bills for patients who can be treated in less costly ways.

Patients who seek care without having been triaged may find themselves responsible for the cost of that care. This has been a double-edged sword for the managed care companies: it helps them to control their costs, but it also creates great resentment toward the companies among their patients.

Most HMOs require their patients to telephone a charge-free number before accessing care for any medical service except clear emergencies. Patients who do not go along with this requirement find themselves billed for the services they have received, unless they were physically unable to ring. To prevent abuse of this system, many states have passed legislation which prohibits managed care companies from billing patients for emergency room care if 'a prudent layperson' would use an emergency room in similar circumstances. What this means is that if you think you need emergency services, the HMO is responsible for paying for them. National legislation that would propose similar standards for emergency room use across the country has been introduced in Congress, but has not yet been passed because of the strong opposition from the managed care companies.

Beyond emergency room use, many HMOs want their patients to speak to a triage nurse before seeking care. Here again, the reason is both to ensure that patients receive the most appropriate care, but also to ensure that patients are not using up scarce resources if they are not needed.

A story I was told recently by one of my students gives a flavour of this practice. She had a bad sore throat and cough and wanted to see her doctor to make sure that she did not have pneumonia or need antibiotics. She had previously had fee-for-service insurance whereby she would make an appointment with her doctor and be seen that day or the next and almost certainly have had a throat swab taken. She would also probably have been given several prescriptions. Whether or not she needed these was not the point: she would have left the doctor's feeling that her problems would soon go away. Having recently been enrolled in an HMO because her employer shifted the insurance to a managed care company, her first experience of this new environment was a conversation with a triage nurse who would not arrange an appointment for her, instead telling her to drink fluids and take cough medicine. She would not be given an appointment unless she had a significant fever or her symptoms lasted more than a week. She was, as you might imagine, furious at this treatment since she felt she was paying to receive care, not to be put off.

From the perspective of the HMO, this use of triage to deny care was driven by economics and served to save the company money, resources, and staff time. From its perspective, there was an extremely good chance that my student had a bad cold or a flu that would go away by itself. If the symptoms got worse the patient would be seen by medical personnel who would know there was a need for care. This is part and parcel of the concept of managed care, yet the companies have done little to educate the public about this and therefore incur their resentment rather than their respect.

Triage is a useful device for separating those most in need of care from those who will not benefit from care, but for most people most of the time it is not a welcome development. Having paid for medical care insurance, the idea that one will be denied access to care or not be able to receive the care one wants does not inspire confidence. The poor job that managed care companies have done in educating their members about how they work, and their desire to save the healthcare system money, has come back to haunt them in patient complaints and regulatory oversight. The cynicism they have fostered through their attempts to make fast profits has left their members questioning everything that they do - including things that might even be beneficial. It will be a struggle to get consumers to understand that some procedures that may have a cost-saving impact may also be beneficial to them and are not being adopted only to increase revenues.

The next major development in the use of triage systems is related to the growth of the Internet. Some managed care companies are experimenting with e-mail: patients can provide details of their symptoms by e-mail and a triage doctor or nurse will respond. Such systems allow the triage team to have access to the medical records of the patient and thus interpret current symptoms in light of past history. A future development of this approach will be to have the triage personnel e-mail prescription orders to a local pharmacy so that the patient can get new medication or refills.