PLEASANT PRAIRIE, Wis. - A 59-year-old Colorado man, suffering chest pains, calls his health plan's emergency number. Seconds later, he's talking with a dispatcher a thousand miles away in Wisconsin.
"I think I need an appointment with my doctor," the man says, his voice a little strained.
The dispatcher, who works for a company under contract to managed-care giant Kaiser Permanente, decides - in this case - that an ambulance is necessary. So she puts the man on hold and calls his local 911 number in Colorado.
This is the next evolution of managed care: Insurers, who already dictate what medications are covered and how long patients will stay in hospitals, now want to oversee emergency services. Whether you get an ambulance when you fall ill might soon be overseen by your insurer - if you dial your health plan instead of 911.
The change, supporters say, will help patients who call their health plans when they should have called 911. And they say similar efforts are likely to be adopted by insurers nationwide.
Critics say the program will confuse patients about what number to call in an emergency, delay care and undermine the nation's 911 system.
"It puts decision-making as to whether a situation is life-threatening into the hands of a dispatcher, and, whether they're medical professionals or not, that wastes what could be life-saving minutes," says George Burke , spokesman for the International Association of Firefighters. Opposition has come mainly from firefighters, whose departments may also offer paramedic and ambulance services.
By helping decide when to send ambulances to patients calling health plan advice lines, insurers want to reduce overuse of emergency care while still providing protection for those who need it.
"There's a finite number of ambulances. We want to reserve them for those who really need them," says Jim Cusick, emergency medical services director for Kaiser Permanente.
Local 911 systems generally send ambulances to whomever calls. Cusick says that can lead to "not having a hot 911 ambulance ready for the heart attack or stroke victim because they're off carting someone with a broken leg."
Kaiser first with plan
Kaiser is the first to oversee ambulance services, signing a five-year, $600 million deal with American Medical Response, an Aurora, Colorado-based subsidiary of Laidlaw. Under the deal, AMR will provide all medical transport for Kaiser, handle claims processing and answer calls from patients at its Wisconsin center.
AMR is touting its program, called Pathways, as a one-stop shop for everything from appointment scheduling and nurse advice to emergency rescue.
Kaiser tested and refined the program in its Colorado region during the past two years and is poised to take it nationwide this fall. Other insurers are watching closely: Humana and Foundation are testing AMR's program in south Florida.
Though the program will vary region by region, Kaiser says it will retain its own advice nurses but channel urgent calls directly to Pathways.
"Our ultimate goal is to provide a safety net to members who choose to call nurse advice rather than 911," says Jay Goldman, Kaiser's medical director for ambulance services.
Care quality vs. costs
Like other changes in health care, the Pathways program raises concerns about how to balance providing quality care with the need to keep costs down.
"Done carefully, it's a good service. Done to save money first, it's risky," says Mark Hauswald, an associate professor of emergency medicine at the University of New Mexico and author of studies on paramedic services.
Although no one is actively promoting Pathways as a 911 replacement, critics fear that insurers ultimately might.
At the very least, critics say, it heightens already established fears among patients that they must get permission from their health insurers before seeking medical care, even in an emergency.
"This puts fear into people that if they call 911, insurance won't pay for it," says Burke at the firefighters' association. His association successfully lobbied Maryland lawmakers in May to forbid insurers from creating programs that compete with 911.
Though some patients might fear that their bills won't be paid if they don't call their health plans, others call their health plans in emergencies rather than 911 because they don't think their conditions are serious, even when faced with chest pains or difficulty breathing.
On the same day the 59-year-old called, the operators at AMR's Wisconsin call center handled more than 70 other calls. Most were from Kaiser staff seeking routine transfers of patients .
About a dozen, however, were patients for whom AMR called emergency ambulances, including a woman with possible internal bleeding. One caller refused an ambulance. A few other callers were deemed not to have serious medical problems and were sent back to Kaiser's appointment system or an advice nurse.
At most other insurers' advice lines, callers with serious problems are told to hang up and call 911. Many patients can and do. But some may refuse to contact 911 or pass out first.
"Fundamentally, we are improving the level of services by providing access to someone who can get 911 to patients faster than has been done in the past," says Robert Watson , president of the Pathways program at AMR.
Kaiser is rolling out the program slowly. In some areas, patients will be directly connected to Pathways with the push of a button on the telephone. In other states, only non-emergency situations, such as transferring patients from one hospital to another, will be handled by Pathways.
In Colorado, the Pathways program initially increased ambulance use, Kaiser's Cusick says. But now, after a number of changes, ambulance use is down by 17%, he says.
There have not been a significant number of complaints about the Pathways program reported to state regulators, says Cindy Ehnes at the Department of Insurance. Nor have emergency room doctors seen problems, says Dennis Beck, medical director for CarePoint, which staffs six hospital emergency rooms in the Denver area.
"It's not like it's absolutely without flaw, but it's not a big problem today," Beck says.
Firefighters, however, say Pathways delays emergency care because patients talk first with the AMR center in Wisconsin before 911 is contacted. Sometimes an AMR ambulance is sent even when another company's ambulance is closer, firefighters say.
Also, callers' addresses and telephone numbers don't automatically pop up on AMR's computers, as they would if callers dialed the 911 system from anything but a cell phone.
"If people were programmed to call 911 instead, we wouldn't have to worry about the guy in Wisconsin knowing if this was a Littleton call or a Lakeland call or if the street was north or south," says Craig Gravitz, chief of the Denver Health Paramedic Division.
Some just doubt that telephone dispatchers, who have minimum of four weeks training, can make good decisions on who needs an ambulance.
"You cannot do telephone triage of patients," says Chief Wayne Zygowicz of the Littleton, Colo., fire department. "There will be a percentage of people, and it may be a small percentage, where you cannot tell what the symptoms are over the phone."
And some firefighters say the program will undermine the 911 system by siphoning off insured patients, potentially leaving fire departments and non-AMR ambulances to carry a greater percentage of indigent or uninsured patients.
Watson of AMR says the system will not undermine 911. "We're capturing these people who have elected not to call 911 and putting them back into the system," he says, even if that means a rival ambulance company gets the business.
As for the firefighters' concerns, AMR's Watson and Kaiser's Cusick say they welcome scrutiny.
"We're the first out of the chute and getting the criticism," Cusick
says. "It's healthy to have the dialogue and have someone watching your
every move. There's no way I'm going to do something that will hurt 911
or hurt a patient. My family is out there, too."