Telephone triage improves demand management effectiveness - Managed Care

Healthcare Financial Management, August, 1998 by Margaret Sabin

Telephone triage, or telephone advice counseling, is becoming a key managed care point-of-entry tool for patients and health plan members accessing the health system. Telephone triage functions as a logical front-end for health plans, integrated physician groups, or integrated delivery systems that want to shift their managed care efforts toward demand management.

Key components of telephone triage include patient education, patient information, and guided access to appropriate care. Telephone triage generally requires 24-hour staffing by registered nurses and a computer software package based on either clinical protocols or clinical algorithms.

Organizations can either install an in-house system or purchase this service from a vendor, health plan, or another provider. The decision to develop a telephone triage service in-house or to outsource it is determined largely by volume and the user's strategy for moving to successive levels of risk management.

Telephone triage is more pervasive than ever, thanks to the growth of managed care. About 35 million Americans now have access to telephone triage services, up from less than 2 million in 1990. Analyst Stuart Goldberg of Merrill Lynch & Co. estimates that the demand management industry, of which telephone triage is a part, is growing by more than 25 percent a year and could cover up to 100 million people by the year 2001.(a)

Customers for telephone triage services include employers, health plans, and any other risk-bearing managed care entity. Several Medicaid plans have acquired telephone triage services and sponsor individual pilot programs in areas such as Oregon and Washington, D.C. Also, self-insured companies, such as General Motors, have turned to telephone triage services for their employees. Currently, the greatest growth in its use is among health plans, followed by capitated providers.

Key arguments for implementing telephone triage are improved quality of care, access, reimbursement, and cost reduction.(b) Telephone triage is an access tool for patients that can increase patient satisfaction with their health care and health plan, as well as their compliance with telephone advice.(c) Moreover, telephone triage may become an almost required tool for capitated entities, especially for health plans, since under capitation, the ability to control demand is necessary to manage costs as well as care.

Payers and consulting organizations report average annual savings of $50 to $240 per member using telephone triage. In 1996, Blue Cross Blue Shield of Oregon and Access Health, Inc., a telephone triage vendor, conducted a study of Medicaid claims data. This study, assisted by Hewitt Associates, compared 14,000 members who had access to telephone triage services to 14,000 members who did not. The study showed savings of $184 per member per year for members with access to telephone triage.(d)

A More Versatile Product

Telephone triage, through programs such as Ask-A-Nurse, once functioned merely as a referral service to physicians and hospitals. The current generation of telephone triage products focuses on controlling demand for health services and keeping patients out of the hospital through a variety of services in various configurations:

* Advice counseling only;

* Advice and referrals (with or without a link to utilization management);

* Access to patient education, including self-care manuals and/or a prerecorded audio library;

* Disease management services; and

* After-hours telephone coverage for physicians.

The triage call center can even consolidate existing telephone services, including advice and referrals, wellness class scheduling, and cancer or other disease-specific hot lines. Moreover, an interested organization can either install an in-house system or purchase this service from a vendor, health plan, or another provider.

The clinical sophistication of telephone triage services has increased as it has evolved from the use of unstructured protocols, which are heavily reliant on the prior training and judgment of the triage professional, to the use of structured protocols, which provide written guidelines but still rely heavily on prior training and judgment, to clinical algorithms, which are essentially physician-developed, yes-no decision trees that assess specific medical complaints. Algorithms are the most highly structured approach to date.

One rule of thumb seems to be that the greater the structure of the triage system, the higher the degree of agreement with physician judgment. Some physicians argue that clinical algorithms are superior to protocols in their ability to identify complaints that can be safely triaged to lower levels of intervention. Moreover, algorithms provide superior documentation of patient encounters and also may reduce malpractice liability risk, particularly if the algorithms are based on the best available data. However, the outcome differences between protocols and algorithms are a subject of debate; only time and the accumulation of outcome data will prove whether significant differences exist between the two approaches and which, if either, is superior.