Most people are familiar with some form of triage: When you go to an emergency room, you first sit down with a triage nurse who records your symptoms, takes your vital signs and assesses the urgency of your medical need.

As of Thursday, that’s happening over the phone for 911 callers in Washington, D.C., where triage nurses now sit alongside 911 dispatchers to help field calls.

Why are they there? D.C. has the highest rate of 911 calls in the U.S., and 1 in 4 of those calls is not an actual emergency — instead, it’s a twisted ankle, or a cough or a rash. The new triage program aims to improve those numbers by diverting needs that aren’t urgent to medical care that doesn’t involve an ambulance or an emergency room.

During a practice session, trainee Ogechi Ukachu, a registered nurse who has previously worked in an ER, clicks through a series of questions.

“Are you having any difficulty breathing or catching your breath?” she asks the training exercise’s pretend caller, who has complained of a sore throat. “Do you hear any weird sounds when you’re breathing — like whistling?” No, and no, the caller tells her.

It’s not an emergency, Ukachu determines, so instead of having the dispatcher send an ambulance, Ukachu gets to work finding the caller an appointment with a primary care provider who can see the patient that day.

On her computer, based on the information the caller has provided, Ukachu can see whether the patient already has a relationship with a doctor or clinic, or, if not, which community health clinic is closest. She can also see nearby clinics’ schedules for the day, so can make the patient an appointment.

The triage nurses can even coordinate free Lyft rides for people who are on Medicaid — including a stop at a pharmacy if needed.

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Dr. Robert Holman, medical director of the D.C. Fire and EMS Department, got the idea for the program two years ago, when he realized the city’s system was getting backlogged with nonemergency calls.

Claire Harbage/NPR

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Claire Harbage/NPR

The “ride” part of the new triage service is critical, proponents say, because that’s the real emergency for many of the inappropriate calls to 911. Some callers simply have a hard time getting to the doctor in parts of the district where clinics can be miles away, and public transportation may not be readily accessible.

It has taken two years to pull off this plan. City health agencies, 22 primary care clinics, contractors and unions were all involved, under the coordination of the D.C. Fire and EMS Department.

“We’re very excited,” says Dr. Robert Holman, the department’s medical director, “and of course we all have butterflies in our stomach.”

Holman says he hit upon the idea soon after taking his job two years ago. He was looking at the city’s emergency call data and noticed that more than a hundred calls every day were for basic medical issues.

“I simply asked a question,” he says. ” ‘Wouldn’t this be simply better evaluated using a triage nurse?’ “

Other cities across the U.S., such as Louisville, Reno and the Dallas-Fort Worth area, have tried similar initiatives, Holman says. But D.C.’s program is distinct in its broad reach, and in the way it’s embedded within the 911 dispatch system.

The hope is that the triage line will save the city and insurers money — ambulances and ERs are the most expensive way to deliver care. Wait times for ambulances should go down, as should ER overcrowding.

And the patients will benefit, too, Holman believes. One example might be someone like a patient he encountered in his previous job at a walk-in health clinic; she’d come to the clinic looking for antibiotics for an infection.

“She mentioned that she’d had a bladder infection quite recently that was treated easily in an emergency department nearby,” he recalls.

Instead of just giving her the antibiotics, Holman also checked the patient’s vital signs and talked to her. Her blood glucose levels were really high. She was depressed and had stopped taking her diabetes medication, she told him.

“We could actually offer her treatment for her behavioral health problem as well as treatment of her diabetes,” he says, “in addition to [treating] her bladder infection.”

This is part of Holman’s message to city residents: Helping callers get a primary care visit, if they need one, is a service the triage nurse can provide.

“The mapping of our low-acuity callers exactly maps to where our community health centers are in Washington,” he says.

However, D.C. has a somewhat rocky history when it comes to its emergency services. In a few high-profile cases in the past, patients have died while waiting for emergency care. Some 911 callers who are advised their case isn’t an emergency may feel they’re being denied something crucial.

To address these fears in advance, Holman and his colleagues have crisscrossed the district, going to community meetings and neighborhood associations talking to residents.

Lois Wiley, a longtime resident of the LeDroit Park neighborhood, is skeptical of the triage plan and lets Holman know that at a public meeting.

“Suppose,” she says, “I say I don’t want to talk to the nurse, I want to go to the hospital?”

Holman tells her the city’s response will be based on the severity of the problem. “If you call with a sore throat,” he says, “we are not taking you to the emergency department.”

“Oh, yes you are,” Wiley says under her breath.

In the face of that sort of skepticism, Washington officials are prepared to carefully monitor how well the pilot project is working.

According to the city’s plan, every caller who gets sent to a clinic instead of the ER will be surveyed the next day about their experience. And data analysts will be checking ambulance response time, ER use, primary care use and 911 call volume.

Other cities grappling with the same difficult issues will be closely watching, too.

This story is part of NPR’s reporting partnership with local member stations and Kaiser Health News.

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States are continuing to do battle with budget-busting prices of prescription drugs. But a recent federal court decision could limit the tools available to them — underscoring the challenge states face as, in the absence of federal action, they attempt on their own to take on the powerful drug industry.

The 2-to-1 ruling Friday by the U.S. Fourth Circuit Court of Appeals invalidated a Maryland law meant to limit “price-gouging” by generic drug manufacturers, inspired by cases such as that of former Turing Pharmaceutical CEO Martin Shkreli, who raised one generic drug’s price 5,000 percent after buying the company.

The law, which had been hailed as a model for other states, is one of a number of state initiatives designed to combat rapidly rising drug prices. It gave the state attorney general power to intervene if a generic or off-patent drug’s price increased by 50 percent or more in a single year.

If dissatisfied with the company’s justification, the attorney general could file suit in state court. Manufacturers could face a fine of $10,000 and potentially have to reverse the price hike. The generics industry was fiercely critical of the law.

“We are evaluating all options with regard to next steps,” Maryland Attorney General Brian Frosh said, in a written statement. His office would not elaborate further.

The state could appeal to have the case heard “en banc,” meaning by the full Fourth Circuit, as opposed to just the three judges.

Such appeals aren’t commonly granted, but this law could be a strong candidate, suggests Dr. Aaron Kesselheim, an associate professor at Harvard Medical School who researches drug-price regulation.

The Friday ruling looms large as other state legislatures grapple with ever-climbing drug prices.

Similar price-gouging legislation has been introduced in at least 13 states this year, though none of those measures became law, according to the National Conference of State Legislatures. Three other bills failed to gain passage.

The NCSL also cited the law in a March advisory for states seeking new approaches to regulating drug prices.

The appeals court’s finding could have a chilling effect on such efforts, especially as more state legislatures wrap up business for 2018.

“A negative court ruling will put a damper or a pause on state activities,” says Richard Cauchi, NCSL’s health program director. “Unless this topic is your number one priority of the year, your legislators are juggling multiple bills, multiple strategies. When bill three gets in trouble, they move to bill four.”

The appeals court held that Maryland’s law overstepped limits on how states can regulate commerce — specifically, a constitutional ban on states controlling business that takes place outside their borders. The majority ruling argues that since most manufacturers of generic drugs and medication wholesalers engage in trade outside Maryland, the state cannot control what prices they charge.

In a dissenting opinion, the panel’s third judge argued Maryland can regulate the drug prices charged within the state since it only is meant to affect medications being sold to its own residents.

Kesselheim, in an article published last month in the medical journal JAMA, argued a similar point.

Regardless, striking down a law on constitutional grounds can be particularly discouraging, says Rachel Sachs, an associate law professor at Washington University in St. Louis, who researches drug regulations.

“If it had been a rejection on vagueness grounds, that’s something you can cure with a more specific statute,” she says. “But the fact that they said this is unconstitutional poses real concern for other states.”

That’s important. While the federal government has talked a big game on bringing down drug prices, it’s done little. Instead, states have taken the lead — spurred by the budget squeeze pricey prescriptions impose on their Medicaid programs and on benefits packages for state employees.

But states have far fewer tools at their disposal than does Congress. Most state laws so far only tackle pieces of the problem — targeting a specific drug or particular practice, specialists in health law say.

“We’ll get more broad and better evolution on this issue if the federal government decides to take it seriously — which it hasn’t so far,” Kesselheim says.

In the meantime, Maryland’s law is only one of a bevy of approaches.

Other states have focused on price transparency laws. In California, drug companies must disclose in advance if a price might increase by more than a set percent, and the companies must justify that increase.

Drugmakers have sued to block the California law.

New York has limited what the state will pay for medications, establishing a process to review if expensive drugs are priced out of step with their medical value.

Since 2017, a number of states have passed laws regulating pharmaceutical benefits managers — the contractors who negotiate discounted drug coverage for insurance plans, but who rarely reveal what level of discount they actually pass on to consumers.

Health policy specialists expect that activity to continue, especially as drug prices show little sign of letting up.

“The states are going to keep trying and experimenting,” Sachs says. “This is a problem that isn’t going away.”

Even efforts such as Maryland’s — which targeted price gouging — will likely remain at the forefront.

“I don’t think this is the end of states trying to do something on price gouging,” says Ellen Albritton, a senior policy analyst at the consumer advocacy group Families USA, who consults with states on drug pricing policy. “It’s such an issue that offends people’s sensibilities. It’s crazy [that] people can do this.”

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