In
Copyright Since September 11,
2000
This
web site is
in no manner
affiliated with any Kaiser entity and the for profit Permanente
Permission
is granted to mirror this web site -
Please acknowledge where the material was obtained.
Link
for Translation of the Kaiser Papers
| ABOUT US |
CONTACT
|
MCRC kaiserpapers.com/californianews
Mirrored here from: http://www.sacbee.com/273/story/1560796.html
for historical purposes.
State probes whether Kaiser call centers endanger patients By Carrie Peyton Dahlberg cpeytondahlberg@sacbee.com Published: Sunday, Jan. 11, 2009 | Page 1A
Worried that Kaiser Permanente may be letting unlicensed staffers make medical decisions, the state is investigating the giant HMO's call centers and plans to demand documents that Kaiser has refused to surrender.
The probe began in response to a nurse's complaints that mishandled calls are leaving Kaiser patients vulnerable to misdiagnoses and delayed care.
The investigation is also shedding light on a 2003 state law that was intended to block just what Kaiser is still doing – using a semi-automated system to let people with no medical training determine how quickly a patient is seen.
Kaiser contends those call center employees have so little discretion they don't actually make any medical decisions – they just follow scripts written by doctors, asking questions that a doctor would ask.
"The script is what I would say if I were standing next to them as a physician," said Dr. Lesley Levine, regional clinical director for Kaiser's three call centers, including one in Sacramento.
Yet using scripts that way is exactly what the 2003 law aimed to prohibit, said Evan Goldberg, who was chief of staff for the law's author, then-Sen. Debra Bowen. Bowen is now California's secretary of state, and Goldberg is chief deputy secretary of state.
"No script can be written for every individual caller and every case," Goldberg said. He called Kaiser's stance "disheartening," adding, "They're not even winking at the law, they're just ignoring it."
Roughly one-third of the people in the Sacramento area – 652,000 in Sacramento, Yolo, El Dorado and Placer counties as of last July – get care from Kaiser, the region's dominant health care provider.
To make an appointment or ask their doctor a question, Kaiser members can go online. Most opt to make a phone call, which is routed to the three call centers now being probed.
Investigators from the state Department of Managed Health Care have been asking for copies of the scripts Kaiser trains its clerks to use. The HMO so far has refused, saying the scripts are proprietary.
Managed Health Care is "absolutely" entitled to those records, said Lynne Randolph, the department's deputy director for communications. State investigators plan to visit the Sacramento call center soon and will demand the scripts, she said, as part of the special probe into Kaiser's call procedures.
The department regularly audits health plans, but has done only 10 such special investigations in the past four years.
"We felt this was a serious enough issue that it did warrant an on-site, non-routine investigation," Randolph said.
Kaiser defends its scripts as efficient, cost-effective and so carefully tuned that Kaiser patients as a group may end up healthier than those who use other medical systems.
"Once you call us, we will guarantee you safe passage" through a thicket of potential medical problems, said Levine. "If patients were in danger, I'd be all over it."
Yet some Kaiser nurses say that when a clerk picks the wrong script, or standardized questions fail to flag a potential problem, patients' lives can be at stake.
"It's dangerous," said Christine Erickson of Granite Bay, who has been a Kaiser telephone advice nurse for nearly six years. From a rash to a sore arm to a question about a prescription, "things that seem very, very benign might be serious and life threatening."
Erickson said she believes at least one patient died of a massive infection partly because a clerk did not respond appropriately when the diabetic man's relatives said he was unable to eat or walk.
Kaiser won't comment on any specific cases, citing patient confidentiality, but said it takes all complaints about patient safety seriously and investigates them thoroughly.
Another caller with serious lung disease was told to wait a day for an appointment because a clerk used a "cold/flu/sinus" script inappropriate for an elderly person with lung problems, Erickson said.
Call The Bee's Carrie Peyton Dahlberg, (916) 321-1086.
Part 2Published: Sunday, Jan. 11, 2009 | Page 1ABy the time the patient called back and reached an advice nurse, she was fighting so desperately for breath that Erickson and a doctor told her to go to an emergency room.
Relatives of another patient, who was just out of the hospital after heart surgery, were repeatedly told they'd have to call back the next day because no one could answer their questions about when the man should start taking his post-hospital medication, Erickson said.
"The family kept pushing, pushing to get a nurse," Erickson said, and were hugely frustrated when they finally got through. She helped them connect with a doctor who said the man should start taking his medication that evening.
Kaiser contends that scripts make better medicine – as well as happier patients.
"Nurses, believe me, I love nurses, but on a telephone evaluation they tend to be very conservative," said Levine.
Nurses spend more time on the phone with callers, which can frustrate the patient, she said, and the wait to reach a nurse is also longer.
"If you have a bunion and want to see somebody, how is a nurse going to help you with that decision?" Levine asked.
Kaiser gives nonmedical people who answer phone lines a few weeks of training and pays them $15 to $16 per hour. It pays about $50 an hour to the advice nurses to whom more complicated calls are routed.
Call centers in San Jose, Vallejo and Sacramento employ 1,200 front-line phone workers, 800 nurses and a small team of doctors.
Patients who specifically ask to talk to a nurse are transferred to one, Levine said, and clerks will type in a message for patients who want to send a note to their doctor. Most of those messages are answered within 24 hours, she said.
To further ensure safety, Kaiser has a list of 15 "emergent concerns," such as chest pain, trouble breathing and other potentially dangerous conditions that will get a caller switched immediately to a special line that nurses answer quickly, usually in 10 to 15 seconds.
A committee of doctors, nurses and others reviews the hundreds of scripts regularly, looking at complaints, new research and patient outcomes, before revising dialogues.
The state's investigation so far has not turned up any "substantiated" safety complaints, Levine said, and the call center has not been the target of any state fines.
The call center did not exist in 1996, when a woman's death led to a $1 million state settlement, assessed after Kaiser was accused of several missteps, including handling her calls inappropriately.
Now, the state Department of Managed Care is trying to determine whether Kaiser is following the 2003 law, which a state attorney calls confusing.
"Booking an appointment is in a gray area," said Amy Dobberteen, the department's chief of enforcement.
Along with those who wrote the law, though, some Kaiser nurses see the rule as much more black and white.
Clerical personnel can do nonmedical tasks such as giving directions to a clinic or pharmacy, or booking appointments for physicals or other regular health checks, they say. The first-line clerks should not make appointments for people who aren't feeling well.
"In every other job I've had as an advice nurse, if a patient has a symptom, they're supposed to be transferred directly to a nurse," Erickson said.
Bowen had very specific dialogue with Kaiser while the Legislature was debating her bill, Senate Bill 969, which aimed to limit what call center personnel can do.
The HMO was so worried the bill could prevent its use of scripts that it wrote Bowen asking her to amend it. It gave her draft language that would have allowed its style of scripted conversations. She refused to amend the bill.
After the measure passed, Kaiser wrote to then-Gov. Gray Davis, asking him to veto it, saying it would create confusion over proper roles of telephone staffers. Instead, the governor signed it.
He did note that call center workers still could make appointments, but he never explained under what circumstances.
Despite the repeated concerns that Kaiser raised about the measure potentially stopping its use of scripted conversations, it has continued to rely on them.
Call The Bee's Carrie Peyton Dahlberg, (916) 321-1086.
kaiserpapers.com/californianews