Fiscal impact reports (FIRs) are prepared by the Legislative Finance Committee (LFC) for standing finance

committees of the NM Legislature. The LFC does not assume responsibility for the accuracy of these reports

if they are used for other purposes.

Current FIRs (in HTML & Adobe PDF formats) are a vailable on the NM Legislative Website (legis.state.nm.us).

Adobe PDF versions include all attachments, whereas HTML versions may not. Previously issued FIRs and

attachments may be obtained from the LFC in Suite 101 of the State Capitol Building North.

F I S C A L I M P A C T R E P O R T

SPONSOR Feldman

DATE TYPED 01/21/05 HB

SHORT TITLE 24-Hour Nurse Health Advice Phone Line

SB 206

ANALYST Hanika-Ortiz

APPROPRIATION

Appropriation Contained Estimated Additional Impact Recurring

or Non-Rec

Fund

Affected

FY05

FY06

FY05

FY06

$600.

Non-Recurring

GF

SOURCES OF INFORMATION

LFC Files

Responses Received From

Department of Health (DOH)

Health Policy Commission (HPC)

Developmental Disabilities Planning Council (DDPC)

SUMMARY

Synopsis of Bill

SB 206 appropriates $600 thousand from the general fund to the DOH for start-up funding to es-

tablish phase one of a twenty-four-hour nurse health access telephone advice line and to contract

with a statewide consortium of safety net providers with a web-based system of care coordina-

tion. This advice line would coordinate services to benefit the health of New Mexicans regard-

less of insurance status.

SB 206 contains an emergency clause.

Significant Issues

Telephone triage is only a small part of the telehealth movement that is sweeping the nation. In

New Mexico, the HPC and DOH report Medicaid Salud!, managed care organizations and sev-

eral other insurance plans such as Presbyterian, Molina, Blue Cross/Blue Shield and Lovelace

Sandia, provide 24-hour telephone lines to appropriately manage care and reduce unneeded

emergency room or physician office utilization. This service is contacted with out-of-state pro-

viders. There is currently no resource available for non-members of these health plans to seek

after hours advice. The advice line has the potential to support economic development and save

resources for the state by pooling funds currently spent for several telephone advice line provid-

ers.

Senate Bill 206 -- Page 2

A nurse health and care coordination advice line could offer needed information and guidance so

patients could manage their illnesses earlier and avoid costly and overcrowded emergency room

visits. Many uninsured patients encounter economic, transportation, and cultural obstacles that

impede healthcare access. A readily available nurse triage service may reduce these barriers. Un-

insured patients often lack a primary care physician and either delay care, or utilize the emer-

gency department. The HPC report studies have shown the uninsured patient may be less likely

to defer needed care if so advised by a telephone advice-line nurse.

According to the HPC, when a call comes in the 24-hour advice line nurse assists the caller with

predetermined lines of inquiry (computer algorithms) for hundreds of common symptoms. The

nurse’s questions, prompted by the computer program, narrows the range of possible conditions,

and the nurse instructs the caller about the urgency of receiving professional care or recommends

simple home care if professional assistance is unnecessary. A database of New Mexico’s care

delivery and social services resources would need to be developed and maintained to facilitate

care coordination.

PERFORMANCE IMPLICATIONS

SB 206 supports the DOH Strategic Plan in Program Area 2: Health Care Delivery – Public

Health Division, Strategic Direction: Improve access to health services.

The HPC reports concerns SB 206 could violate Stark laws (inducement of Medicare patients to

a particular facility). An advice line nurse may develop a rapport with providers of care that may

be seen as a conflict of interest. In addition, the quality and effectiveness of a state sponsored

line might influence a health plan’s decision to continue their own nurse advice lines.

FISCAL IMPLICATIONS

The appropriation of $600 thousand contained in this bill is a non-recurring expense to the gen-

eral fund. Any unexpended or unencumbered balance remaining at the end of fiscal year 2006

shall revert to the general fund. According to the DOH, the appropriation was not part of the Ex-

ecutive Budget Recommendation submitted in 2004 and reviewed by the LFC.

The DOH reports the appropriation is for start-up costs such as infrastructure set-up, recruitment,

training, computer and software purchasing. Future funding opportunities may exist by looking

at existing Salud dollars to the Medicaid Managed Care Organizations for their advice lines, dol-

lars from commercial insurance providers, foundation and grant funds. Existing providers and

health plans would benefit from a reduction in bad debt from lowered uninsured use of their

emergency departments.

The DOH states the appropriation is non-recurring, however there is likely to be additional costs

associated with salaries, continuing education and maintenance of systems costs. The American

Institute for Preventative Medicine reports nurse advice lines cost $10 to $12 per family per year,

and only 10% of the people with access to the service will call it.

ADMINISTRATIVE IMPLICATIONS

The DOH states the provision of SB 206 could be implemented with existing staff. However, it is

likely additional nursing staff would have to be hired and trained.

Senate Bill 206 -- Page 3

SB 206 is in alignment with New Mexico’s efforts in local and state emergency management

planning and response, and public health anti-terrorism activities. Emergency preparedness is

currently hampered by lack of a statewide, accessible system to share vital medical information

with the community.

The HPC suggests pursuing contracting with existing health plans who already know the care

coordination; nursing and legal issues associated with telephone advice lines.

TECHNICAL ISSUES

The HPC would like to see “statewide consortium of safety net providers” defined in SB 206.

AMENDMENT proposed under Section 1, line 23, “…to benefit the health of all New Mexico

residents…” might address the issue of providing advice for people living outside of New Mex-

ico, a liability concern addressed by the HPC. An alternative might be a telephonic system in

place identifying callers as from within the state.

AMENDMENT proposed in description under AN ACT, to add the word “registered” to line 11,

“…TWENTY-FOUR-HOUR registered nurse …”, as Licensed Practical Nurses are typically

excluded from this form of employment.

OTHER SUBSTANTIVE ISSUES

The DOH reports:

•

New Mexico has one of the highest rates of uninsured people in the U.S. (25.6 percent of

non-elderly), and 29 of its 33 counties are designated as Medically Underserved Areas

and Health Professions Shortage Areas. These problems are exacerbated by large geo-

graphic size and sparsely populated rural counties. The Primary Care Collaboration

(PCC), a task force consisting of representatives of public-private healthcare stake-

holders, DOH and Managed Care Organizations, in addition to the Health Care Coverage

and Access Task Force, has determined the need to establish statewide access to health

advice 24 hours a day for all New Mexicans.

•

A statewide 24-hour nurse health access telephone advice line could have significant im-

pact on the health and safety of New Mexicans and reduce stresses on the current deliv-

ery systems. Health care costs would be reduced by improving access to primary care, in-

creasing assignment of uninsured to a primary care provider, and providing relief to over-

crowded Emergency Rooms. The advice line would also improve retention and recruit-

ment of physicians to rural areas by providing night-time relief for rural providers. The

toll free line would provide a system to monitor the types of calls coming in, allow epi-

demiologists to evaluate trends, and offer an additional means of providing information

to the public during state health emergencies. Data collected via a nurse advice line

could be used to detect disease outbreaks early so that spread can be limited.

•

Nurses who would answer questions, offer advice and identify local resources would

provide services in English and Spanish. Nurses would also need to receive training in

working with persons with developmental disabilities. The 24-hour nurse health access

telephone advice line would be linked with other social service and emergency lines, in-

cluding 911, 211, Consumer Hotline, Substance Abuse Referral, State Agency on Aging

Information and Referral, the NM Poison Center, and others.

Senate Bill 206 -- Page 4

The HPC reports:

•

The findings of a recent study on the effectiveness of telephone advice lines show 75%

of callers followed advice seeking emergency department care, 52% followed advice to

visit/call the physician’s office, and 91% followed stay at home advice. Researchers have

found that nearly 70% of patients changed their plans for seeking care after calling the

advice line, with nearly two-thirds of these patients changing to a lower intensity of care

(American Journal of Managed Care August 2004).

•

A budget that takes into account the size of the target population, the expected volume of

calls, and the cost and risk management implications of providing advice would be

needed. Costs could vary substantially, depending on whether the program can share ser-

vices with other telephone-based services, whether it includes any fixed costs of opera-

tions, and if it can be purchased on a per-call basis or must be created in total internally.

•

There are potentially significant legal risks to the state as financing agent for such a ser-

vice. For example, a telephone-triage nurse working for Kaiser Permanente recom-

mended that a sick infant be taken to a hospital 42 miles from home because closer medi-

cal centers were not part of the HMO’s discount plan. The baby suffered a heart attack en

route, and in 1995 a jury found Kaiser Permanente liable for bad medical advice and

awarded the child’s parents $46 million. (Medical Economics, June 1996).

•

Additional issues arise when nurses give advice to callers in different states. Health pro-

viders or plans may risk sanctions by rendering services to a patient in a state where the

health provider is not licensed. Although no reported licensure action against a national

24-hour advice line for operating without a license has been found, at least one managed

care provider has been penalized for providing services in several jurisdictions without

the appropriate licenses. (RN, March 1996). Each state has a different definition of what

constitutes the practice of medicine and practice of nursing. Even if a nurse’s advice is

within the purview of a nursing board in one state, the same advice might not be permit-

ted under the nurse’s license in another state and might instead constitute an unlawful

practice. This issue has likely been resolved with New Mexico health plans with mem-

bers who reside in other states, but work and have health insurance from a New Mexico

employer. However, this would require further research.

ALTERNATIVES

Insured persons would continue to use services under their health plans.

WHAT WILL BE THE CONSEQUENCES OF NOT ENACTING THIS BILL.

Uninsured or persons with limited resources may pursue emergency departments for non-urgent

situations, or may delay care in life threatening situations.

POSSIBLE QUESTIONS

How will TTY and similar devices be made available for use by persons with disabilities.

Senate Bill 206 -- Page 5

Will there be any recognition for people who do not have telephones.

How many other states have 24-hour health access nurse advice lines.

AHO/lg