Health Plan Uses Secret Healthcare Shoppers in Emergency Room Management

Friday, November 30th, 2007
This post was written by Melanie Matthews

Many healthcare organizations monitor patient satisfaction as part of their overall quality improvement initiatives. As part of an initiative to divert non-essential ER cases to primary care, Wellpoint utilized secret shoppers to evaluate consumers’ experience at its network physician offices and identify ways to improve access. In a recent audio conference on redirecting non-urgent ER cases to more appropriate healthcare settings, Dr. Karen Amstutz, Wellpoint’s regional vice president and medical director of state-sponsored business, described how it went:

We wanted to look at what our members experience when they try to access care appropriately through our physician offices. We began with a secret shopper program to physician offices, which revealed that one of our offices were dropping phone calls and patients were unable to complete a call successfully through to the office. The staff was also directing patients to the ER when the primary care doctor was not available or the clinic was too busy to offer an appointment. Finally, we identified that often the staff didn’t triage our members and ask them questions about what was going on to help them decide how urgent the visit was — whether it was the same day or could be handled the next day.

Based on these findings, we made recommendations to our providers about scheduling appointments and about walk-in hours. … Part of the reason that our providers were willing to accept our interventions is that there’s a very close relationship between our network education representatives and our provider offices. So when we went back to them with secret-shopper information, we already had a very good longstanding relationship on which to say, “Here’s what we’re seeing. Can we talk about how we might work together and help you solve these problems which will help us and our members?”

This was just part of Wellpoint’s approach, which reaped some great reductions in ER visits and hospital admissions per member. It also focused a lot of attention on educating its members about self-care—knowing when to head to the ER and when a visit to the primary doctor should suffice. Extended hours (with special reimbursement codes), nurse triage lines and hospital-health plan collaborations helped, too.

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