Call centers future focal point of health care

By Michael Eliastam, MD, Associate Partner

Ann Blocker, Manager

Andersen Consulting LLP

Wellesley, MA

Situation: Mary is the mother of 4-year-old Sally, who one night develops a high fever. An ED nurse examines Sally and classifies her as a non-urgent case. She estimates Sally’s wait time at two hours. The nurse then offers Mary another option: If she uses the health call center, Mary’s co-pay will be waived, regardless of the advice given or how Mary acts on the advice. From a special phone, Mary is automatically connected to a call center nurse who asks some simple questions and quickly rules out serious causes for Sally’s fever. She explains what can be done to care for Sally at home and gives Mary a toll-free number to use next time she or Sally needs care.

Situation: John, a severe asthmatic, has a history of hospitalization. At his last discharge, John was assigned a case manager, who discussed with him triggers for his asthma, his personal health goals, and a plan to achieve his goals. She and John agreed they would talk on the phone weekly. The nurse helped whenever John’s care did not progress as planned — when he had difficulty getting a prescription filled, or when he found that his asthma attacks were not responding to inhaler use. Each time the nurse called John, she made notes about his progress. If he deviated significantly from a plan she had developed with his doctor, the nurse reviewed the reasons with both John and his doctor. Over time, John was hospitalized less and attended work more. Most importantly, he felt as though he finally had control over his health.

In both of these stories, the telephone is used to meet health needs, resulting in lower cost, more satisfying care, and good outcomes. Twenty years of research shows that many people use hospital, emergency, and clinic services when they could stay home, follow a nurse’s advice, and still receive high-quality, convenient care. But consumers often believe that the health care system should help them with problems that are actually better resolved through self-care, counseling, and healthier lifestyle choices.

Demand management, which experienced doctors and nurses have practiced for years, tries to meet a patient’s needs while minimizing unnecessary use of health care services. We believe this practice must evolve in two ways. The first is the definition of the word "unnecessary," which in our new context refers to the consumer’s perception of need. Research demonstrates that two people with similar conditions may want and need very different health care services. This suggests that health care should address both individuals’ condition and their perceptions about their condition.

Services take on new meaning

The definition of "health care services" is also broadening. Again, the consumer drives the definition, so any service the consumer perceives as health care is included. Thus herbalists, personal trainers, and acupuncturists take their place as members of the health care team. By embracing the consumer’s definition of health care, the optimal mix of all services can be created, instead of the optimal mix of traditional services. This integration can create synergy and minimize conflicts between services.

These two definitional changes drive a powerful paradigm: A knowledgeable consumer can choose from among health care options. The typical result: lower cost to the plan, the provider, and to the consumer, who in turn feels better, and data that begin to demonstrate measurable health outcomes to all interested parties.

The telephone plays a powerful role in this new paradigm. We believe call centers, which have the people, processes, and technology necessary to use the telephone efficiently, will play a pivotal role. Current complexity makes it difficult to imagine a system where health care providers have the information they need to act together to meet an individual’s needs. A health call center can act as the hub to the many spokes in this complex system.

As demand management evolves, organizations will implement new programs more holistically, often looking beyond organizational boundaries. For example, health insurance plans often require ED visit authorizations. Yet the individual’s doctor rarely knows that the authorization or the visit has occurred. With 30% to 50% of ED visits classified as "non-urgent," the doctor, who often can influence a patient’s behavior, doesn’t have the very information he or she needs to do so.

In the new consumer-driven model, health care professionals will be organized as a virtual team that comes together when one individual requires its services, then reforms with different members to meet the needs of the next individual. Consumers will be grouped based on common needs: diagnosis, perception, social condition, etc. They will belong to a primary care center, where a team of specifically selected advisors — doctors, nurses, therapists, etc. — will work with the consumer to achieve individually defined success.

The health care network will ensure that consumers can access any type of safe care prov-ider. Acute hospitals will resemble today’s ICUs, and community sites will provide less acute clinical care as required. All will be linked by information.

The simplest way to provide this link is electronically, through an information hub like a health call center. This strategy requires a portable, universal medical record for each consumer, not to store all of their information, but to track where the relevant information is stored. Health care team members will use this information to meet a consumer’s needs, while protecting information integrity and consumer privacy.

Rewarding teams, consumers

Incentives will help all team members "do the right thing." Physician recognition and reimbursement systems will reward those who improve preventive care, consumer satisfaction, and clinical outcomes. Similar incentives will help consumers choose lower-risk behaviors, use resources effectively (including the call center) and try to be well-informed health care decision makers.

Access managers in this new model will help differentiate their organizations in two ways. As care moves out of acute settings, consumers will demand more access channels. The access department can help integrate care across channels by becoming a key data collection point, going beyond demographics to catalog a variety of consumer and provider characteristics. This information will be used to better match consumer groups to health care teams and understand how and why the health care system fails some individuals.

Access managers also can differentiate their organization through the service they provide. With consumers more empowered, health care organizations will have to differentiate themselves based on service, as well as cost and clinical quality. The result will be a more responsive system, where people have the information and expertise to make the right health care decisions for themselves.