"My 20-month-old daughter has had a cold for a week that hasn't gotten better, and today she started wheezing. What should I do?"
"Does she have any allergies?"
"Is she short of breath?"
"Does she have a fever? Earache? Abdominal pain? A rash?
"Generally, simple colds don't require a visit to the doctor, but since there hasn't been improvement and you've noticed wheezing, you should call the doctor."
This conversation took place last month between a parent and a nurse. The nurse was not sitting in a pediatrician's office and did not know the child's doctor or, for that matter, the child or the parent. The nurse was talking from an 800-number telephone line in Windsor, Conn., set up by Aetna Health Plans to answer questions from policyholders around the country about their health.
Phone calls like this one have become increasingly common in the last two years as health maintenance organizations and other managed care health insurers have given patients access to toll-free telephone lines staffed by registered nurses, most operating 24 hours a day, seven days a week.
More than 13 million people can now call these phone lines, double the total a year ago. The goal is to reduce unnecessary doctor visits by having the nurses conduct what amounts to telephone triage, determining whether callers need medical care or whether they can get by with self-care.
Insurance companies are by far the largest users of these phone services, and Aetna and a few others have started their own telephone counseling subsidiaries. But several large corporations, like Kodak and Texas Instruments, have also contracted with phone counseling services to reduce their health care costs.
And a handful of doctors use them for after-hours coverage to cut down on the number of calls they get at home.
Insurance company executives see these phone lines as the next wave of medical cost-cutting. Having reined in doctors and hospitals by negotiating lower fees, managed care insurers are now trying to rein in patients by giving them an alternative to scheduling appointments with doctors or showing up in the emergency room when they feel sick.
"Aetna believed that we had to move beyond the supply side and reduce demand for physician services," said David Feffer, an assistant vice president who started Aetna's phone counseling service, called Informed Health.
Studies by actuarial and benefits consulting concerns show that the phone lines pay off. Insurers spend 50 cents to $1.20 per member each month, depending on the service, and save $46 to $184 per member each year.
Most of the people who use these phone lines have questions about particular symptoms, mainly fever, sore throats, cough, vomiting, earaches and abdominal pain. Nurses do not make diagnoses, but rather assess how serious a person's condition is by asking detailed questions.
"If a parent calls because a child has a bee sting, the first question the nurse will ask is whether the child is having trouble breathing or other systemic reactions," said Dr. Edward Bergmark, president of Optum, the nurse telephone line operated by United Health Care, an insurance company in Minnetonka, Minn. "The nurse punches the responses into a computer and then the computer tells the nurse what to tell the caller."
Bonnie Morcomb, a registered nurse who directs Optum, said, "If the child is having trouble breathing, the parent would be told to call 911." But if there are no systemic reactions, she said, the nurse would recommend acetaminophen as well as a few home remedies to relieve the pain, like applying ice or meat tenderizer to the sting.
Callers can get much more detailed information, too. Someone
who has a serious illness and is trying to decide among several treatments can request a search of the literature on each one that explains its effectiveness and its drawbacks.
"No physician has the time or the inclination to help patients understand the benefits and risk of various treatments," said Dr. Donald M. Vickery, chairman and medical director of HealthDecisions International, a phone counseling company in Golden,Colo. "We help the patient come to a decision."
Callers are happy with the services, according to follow-up surveys done by the phone counseling companies themselves. Optum boasts that patient satisfaction is 99 percent.
There have been no malpractice suits against any of the companies, nor have there been any out-of-court settlements for recommendations that had disastrous consequences.
But some doctors are critical. "More than anything else, 800 numbers are a way of saving money," said Dr. James Todd, executive vice president of the American Medical Association. He questioned the usefulness and the quality of the information given.
"Nurses' education does not qualify them to give advice over the telephone without making a diagnosis," he said. "If someone has abdominal pain, it can be anything from gas to appendicitis. How is a nurse at the other end of an 800 line going to advise someone about this, and what is the advice based on?"
Dr. Isadore Rosenfeld, a clinical professor of medicine at Cornell University Medical College in New York who is the author of several popular medical books, including "Symptoms" (Bantam Books), said: "If the 800 numbers provide general health information, they're fine, but if they're used to interpret symptoms, I deplore them. The motivation of the insurance companies is to save on the cost of office visits, not to increase patient welfare."
But the companies stand by the integrity of their services, arguing that the information they give patients comes from databases of hundreds of symptoms that are compiled or at least reviewed by doctors and updated a few times a year.
Each company uses a different database, however, so the potential exists for nurses on different 800 lines to give different recommendations to callers with the same symptoms.
But that did not happen when a reporter, the mother of the wheezing 20-month-old, called two services. The nurses from Aetna and Optum both suggested calling the child's doctor. And both wanted to check back a few days later to find out how the child was feeling.