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Mirrored here from: http://www.sacbee.com/273/story/1560796.html
for historical purposes.
January 21, 2009
State investigators will visit Kaiser Permanente's call center in Sacramento later this week as part of a probe into whether the health plan allows unlicensed staffers to make medical decisions.
The state won't disclose the exact date of the visit because it's worried angry Kaiser members might confront investigators with questions they can't answer yet, said Lynne Randolph, spokeswoman for the California Department of Managed Health Care.
Since The Bee reported the call center probe on Jan. 11, readers have contacted the paper to praise or condemn Kaiser's system. Some have complained to the state, alleging misdiagnoses, delays and even deaths.
In addition, call center employees said on The Bee's Web site, and in interviews, that they were coached to hold down the number of calls they transfer to nurses. One faxed The Bee a coaching form with the words "aim for 30 percent" written next to the statistics on how many calls that worker had transferred to nurses recently.
Those recounting troubles to The Bee include:
• Randy Agee of Auburn, who said he was told his wife, Gena, was having normal post-surgical pain and didn't need to see a doctor immediately after she'd been discharged from the hospital following heart surgery.
Agee said he had to fight to get appointments, and his wife died a few days later, at age 52.
Agee, who had a mediation session with Kaiser on Tuesday, said the health plan has refused to give him audio records or transcripts of his phone calls, contending they are not part of his wife's medical record. In preliminary correspondence with Agee, Kaiser told him it takes the matter seriously and that it is investigating. He has contacted the state Department of Managed Health Care about his wife's death.
• Colette Benson of Elk Grove, who said her 21-year-old daughter was told she didn't need to see a doctor for nausea and other problems following a tonsillectomy.
Her daughter, Jennifer Lynn Kilpatric, collapsed in her mother's kitchen two days later. According to a coroner's report, Jennifer bled to death due to complications of a tonsillectomy. Benson also said she has contacted the state.
• Bob Woodward, 60, who lives in Magalia east of Chico, said he was told to wait a week before seeing a doctor after a half-inch-long shard of metal broke off a sledgehammer and lodged in his arm. A Kaiser radiology report describes a 9 mm fragment of metal in his arm.
Kaiser will not comment on complaints its members have brought to The Bee, "out of respect for privacy laws," according to spokeswoman Gerri Ginsburg. She confirmed that call center audio recordings, which are kept for seven years, are not considered part of a patient's medical record and are surrendered only during legal proceedings.
The state investigation is likely to take several more months and could encompass new complaints, including allegations that phone staffers are urged to limit how many calls they transfer to nurses, Randolph said.
In 2007, the state got more complaints – 3.01 per 10,000 members – from Kaiser customers than from customers of any other large health plan in California, according to the state department's latest report.
The giant HMO dominates health care in the Sacramento region, treating nearly one-third of all residents in El Dorado, Sacramento, Placer and Yolo counties.
While Kaiser members can go online to make appointments or ask their doctors questions, most use the telephone, according to Kaiser, generating 14 million calls annually in Northern California. All are initially answered by unlicensed staffers at three call centers, including one in Sacramento.
The frontline phone crews, whom Kaiser calls telephone service representatives, ask questions from a series of scripts written by doctors.
Depending on the answers, some callers get an appointment that day or the next, others are told they will have to wait two days or more for an appointment, and others are transferred to an advice nurse.
The state is looking into whether Kaiser's approach violates a 2003 law that prohibits unlicensed workers from deciding how quickly someone gets medical care.
It has asked Kaiser for copies of its hundreds of scripts, and so far Kaiser has refused, saying they are proprietary.
Kaiser fought the 2003 law before it was passed, trying unsuccessfully to get the measure amended or vetoed. It argued at the time that the law could be interpreted to prohibit its style of scripted calls.
After the measure became law, Kaiser continued to use scripts, saying it's legal because unlicensed phone clerks don't make any decisions – they just follow written instructions from doctors.
The state has not said whether it agrees with that interpretation.
The top enforcement lawyer in the Department of Managed Health Care said making appointments is a "gray area." One of the key legislative staffers involved in drafting the 2003 law contends Kaiser is clearly ignoring it now.
The Bee's coverage of the investigation also has prompted phone calls and e-mails from those delighted with Kaiser's call center.
"I love it," said Cynthia Pell, a retired nurse who never worked for Kaiser, but whose daughter briefly staffed a call center before going to college. "You get in right away, if you know the buttons to push."
Scripted questions are "always helpful, because they're looking for problems," said Sharon Lynes, a Kaiser patient who lives in Elk Grove.
Kaiser has said its call centers have high satisfaction rates.
Most people probably are satisfied with the call center, but it can be dangerous for those with serious health problems, said Dr. C. Gresham Bayne, a San Diego physician whose practice provides house calls, often to Kaiser patients.
On some calls, when people haven't been able to get to a Kaiser doctor quickly, "what we find is terrifying," Bayne said, including "life-threatening conditions that would have warranted critical care."
Bayne said he worries Kaiser's system can put patients in a no-win situation of choosing between delayed care or potentially costly emergency room visits.
Three call center employees, who asked not to be named because they fear retaliation, said Kaiser's frontline telephone workers are coached monthly about duration of calls and how many they transfer to nurses.
They reported being told to hold down transfers to nurses to between 28 and 30 percent of calls and to keep average call time to around three minutes and 30 seconds. One said phone workers were told how much it costs, per minute, for a nurse to take a call.
Yet several also reported being told that if they have any doubt about a call, they should transfer it to a nurse.
Kaiser acknowledges that it gives regular feedback, but said in an e-mail that it would be "just as likely" to coach employees about transferring too few calls to nurses as too many.
Call The Bee's Carrie Peyton Dahlberg, (916) 321-1086.
kaiserpapers.com/californianews