Michigan PPO asks frequent ED users to phone plan first

The Blues plan says its nurse line can help prevent unnecessary emergency visits. But doctors say that's their call.

By Robert Kazel — Posted Jan. 12, 2004

Print  |   Email  |   Respond  |   Reprints  |   Like Facebook  |   Share Twitter  |   Tweet Linkedin

Blue Cross Blue Shield of Michigan recently sent postcards to 40,000 of its PPO members. The note on the cards read:

"Where you receive medical treatment can sometimes be just as important as the treatment itself. The simple truth is, not all medical 'emergencies' require a visit to a hospital emergency room." The card then asked patients to call BlueHealthConnection, the disease-management program of which the nurse line is a part. The line is staffed around-the-clock by registered nurses trained to give out a variety of information.

The plan's idea is to reduce so-called unnecessary emergency department visits. Many of the 40,000 members who received the cards were identified by the plan as frequent ED users, defined as having visited "three or four times," said Tom Simmer, MD, vice president and medical director of the Michigan Blues. PPO members don't have to call the plan before going to the emergency department, and the plan cannot bar them from going. "This is a voluntary program and is not a prior-authorization program," Dr. Simmer said.

However, some Michigan physicians wonder how pure the Blues plan's motives are. Some doctors say call lines interfere with the physician-patient relationship and run the risk of giving patients faulty advice. They wonder if Blues-employed nurses could make an objective decision, knowing that sending a patient to the ED could increase plan expenses.

"There may be a conflict of interest," said Hassan Amirikia, MD, an ob-gyn in Detroit and president of the Michigan State Medical Society. "If they direct the patient to the ER, who gets the bill?"

Getting a handle on ED use

There has been pressure by employers and other payers for plans, physicians and patients to find alternatives to the ED, considered the most expensive place to treat a patient. In the six-year period preceding 2001, there was a 16% increase in visits to hospital emergency departments, according to a study by the Washington, D.C.-based Center for Studying Health System Change.

And nurse help lines are not new.

Bloomfield, Conn.-based CIGNA HealthCare also has a toll-free line that patients nationwide may call for advice on potential emergencies or otherwise. "We do provide advice, but never binding advice," said Allen Woolf, MD, plan national medical director. "We make it clear to the people that they're speaking to a nurse, not a doctor. The nurse will state, 'I cannot supply you with a diagnosis.' "

Echoing the Michigan Blues' policy, Dr. Woolf added that for certain symptoms, nurses refer callers to the ED without hesitation. "By definition, if someone calls with chest pain we tell them to go to the emergency room," he said. "There's no attempt to walk through any algorithm if it's potentially life-threatening."

Still, some doctors say nurse lines may do patients a disservice.

Nurses on call lines typically "don't have primary care information and they may miss information [given by the patient]," Dr. Amirikia said.

Patients would be better off calling their own doctor's office to decide about emergency care, Dr. Amirikia said. Nurses there not only have access to patients' records but can consult doctors at the practice if they feel unable to handle the situation.

"Some of the symptoms are very difficult even for physicians," he said.

Nurse hotlines, when used to direct patients to or away from emergency departments, are fraught with problems, said Greg Walker, MD, an emergency physician at Sparrow Hospital in Lansing, Mich. Doctors need to be able to check patients' vital signs, and look at them to judge how ill they appear, he said.

"Those two things -- obtaining vital signs and being able to visualize the patient to ascertain how sick they look -- make telephone triage sort of a dangerous entity," Dr. Walker said. "You're not doing the patients any good if you make a mistake and steer them away from the care they need."

Although the AMA hasn't specifically adopted a policy on health plans' nurse lines, AMA guidelines call for medical advice to be given only by doctors who have a relationship with the patient and knowledge of the patient's history. It also has taken the position that plans must be accountable for medical advice they give out.

Sensing a need

The Michigan Blues say it's not its intention to interfere with the patient-physician relationship. "We don't recommend that patients not call their doctors," Dr. Simmer said, but he added that frequent past use of the ED can mean a patient lacks a relationship with a personal physician. The nurses use "structured, scripted software support" that directs and constrains their advice to the patient. "They know their position is not to diagnose," Dr. Simmer said.

A study done by the Blues plan on calls made to the nurse line during the past year -- before the postcard push -- showed that about 75% of a sample of 600 patients who called wound up not going to the ED. Forty-two percent contacted a physician for assistance instead, while 33% opted to treat themselves. The remaining 25% of the callers did go to an ED. The survey did not track the patients' outcomes.

The Blues plan does not, in general, call members' physicians to tell them about the patients' call or relay what transpired. By contrast, CIGNA's Dr. Woolf said his plan often sends a fax to the member's primary care physician as a notification of the call.

Either way, physicians say it's not the plan's place to make the assessment on emergency care, nor to encourage patients to turn to it for assistance in that decision.

"You run the risk of delaying someone when seconds count," such as in cases of heart attacks or strokes, said Nancy Auer, MD, past president of the American College of Emergency Physicians and vice president of medical affairs at Swedish Medical Center in Seattle. "You may compromise that patient's ability to recover."

For the most part, patients who come to the ED have a good reason, she said. "In my experience, patients don't abuse the emergency department very much."

Back to top



Read story

Confronting bias against obese patients

Medical educators are starting to raise awareness about how weight-related stigma can impair patient-physician communication and the treatment of obesity. Read story

Read story


American Medical News is ceasing publication after 55 years of serving physicians by keeping them informed of their rapidly changing profession. Read story

Read story

Policing medical practice employees after work

Doctors can try to regulate staff actions outside the office, but they must watch what they try to stamp out and how they do it. Read story

Read story

Diabetes prevention: Set on a course for lifestyle change

The YMCA's evidence-based program is helping prediabetic patients eat right, get active and lose weight. Read story

Read story

Medicaid's muddled preventive care picture

The health system reform law promises no-cost coverage of a lengthy list of screenings and other prevention services, but some beneficiaries still might miss out. Read story

Read story

How to get tax breaks for your medical practice

Federal, state and local governments offer doctors incentives because practices are recognized as economic engines. But physicians must know how and where to find them. Read story

Read story

Advance pay ACOs: A down payment on Medicare's future

Accountable care organizations that pay doctors up-front bring practice improvements, but it's unclear yet if program actuaries will see a return on investment. Read story

Read story

Physician liability: Your team, your legal risk

When health care team members drop the ball, it's often doctors who end up in court. How can physicians improve such care and avoid risks? Read story

  • Stay informed
  • Twitter
  • Facebook
  • RSS
  • LinkedIn