REDUCTION OF COMPLAINTS ABOUT MEMBER INFORMATION

Empowering Staff with Tools and Training

Like many organizations concentrating on member loyalty and satisfaction, this plan realized the importance of communication. It had explicitly made accurate, timely and simple-to-understand information a health plan priority. But a change in the plan's pharmacy benefit brought a high volume of complaints from members about the information they had received. The plan began to seriously look at how it communicated simple but important issues, such as administrative changes.

Health plans deliver information to their members in two very basic ways. Members are given written materials on benefits, how to use plan services and other educational messages.

Written materials are sent at open enrollment, and periodically as needed. Members may also call a customer service representative to answer a question or to help them understand plan procedures or benefits.

A review of the most common types of complaints showed "information given to members" to be in the top 10 categories for both commercial and Medicare members. The plan had poor telephone responsiveness rates, with a high degree of employee turnover. The sales force complained about poor customer service. The grievance and appeals committee was increasing its number of meetings. Many of these meetings involved cases in which incorrect information had been conveyed to members.

Feeling that a quality initiative could address all of these problems, senior staff directed the plan to focus its quality improvement efforts on the written and telephone information it was providing its members.

The plan used its complaints database to target potentially 100 percent of its population. This database could produce reports by category and subcategory upon request. (A sample report is included in QP Tool .)

DATA COLLECTION As customer service representatives handled complaints on the phone, they inputted free text into an electronic form. These forms were transmitted daily for analysis. Analysts assigned a category for each complaint and entered it into the database. Constant review by a supervisor, and detailed written definitions helped keep category assignments consistent among analysts.

As its quantitative measures, the plan chose complaints about member information per 1,000 members, in three subcategories:

• Delivery of written information: a complaint concerning how information was communicated to a member in writing
• Correctness of information: a complaint that the plan furnished incorrect written materials or that a plan representative gave incorrect information
• Timeliness of information: a complaint concerning delayed or late delivery of information

Baseline measurement, using 1997 data, showed an overall complaint rate of 1.26 per 1,000 members for the three subcategories combined.

The plan's Quality Improvement Committee set a goal of a 10 percent reduction in complaints in these three subcategories by 1999.

A subcommittee dedicated to member service issues carried out most of the analysis. It included representatives from customer service, provider relations, QI, sales, government programs and claims. This team used brain-storming and fishbone diagrams (included in QP Tool ) to identify critical issues leading to complaints in these three subcategories.

The plan conducted focus groups of Medicare and Medicaid members. On the commercial side, it held focus groups of brokers and group administrators. These groups confirmed that the plan had identified the correct issues.

A number of barriers to good communication seemed to be most important:

• Customer service representatives giving out wrong information
• Inadequate training for customer service representatives
• High staff turnover in customer service
• Representatives unfamiliar with new benefits and new plans
• Increased call volume from new products and rapid growth
• Late ID cards
• Poor member understanding of benefits and plan procedures
• Members discard written materials
• Members didn't receive new handbooks on re-enrollment

The plan devoted most of its effort to overcoming barriers that it felt it could impact.

The plan identified several opportunities for improvement. It needed:

• Improved training for customer service representatives
• Member materials that were more easily understood, and constantly updated
• More customer service representatives
• An improved mailing process for ID cards
• Practitioner offices that were better able to answer member questions

VICIOUS CYCLES Membership growth was leading to greatly increased phone volume. This, in turn, was leading to higher call abandonment rates and longer wait times until a call was answered. In addition to recognizing the need for resources, the plan furnished representatives with tools to deal with difficult requests. They let customer service personnel know about the efforts being made to reduce call volume by improving information given directly to members. These efforts helped cure some of the frustration being felt by customer service representatives.

The plan made outbound welcome calls to all new Medicare and Medicaid members. Interviewers waited while the members retrieved materials, so that they could be verified as received. (Sample scripts for these calls are included in QP Tool .)

A new ID card mailing process cut a week from the cycle time. The card itself was improved; it now carried specific co-pay information (included in QP Tool ).

The pharmacy department developed new information about the three-tier drug benefit. Members received a mailing with a cover letter, a list of preferred drugs and questions and answers about the benefit.

The plan revised certificate of coverage documents. New documents featured an added index, an improved look and a sixth-grade reading level.

The customer services department hired a dedicated trainer. Previously, training had been carried out by supervisors or experienced representatives pulled from telephone duty. Besides monitoring existing operations and enhancing efficiency through redesign, the trainer gathered information from other departments such as sales and health services. The trainer developed directories, guides and scripts for the representatives, and trained them in their use.

By requiring all departments that sent information to members to include customer service in their distribution, representatives were better equipped to accurately answer questions. A number of departments were affected, such as QI claims, provider relations and sales. Newsletters, health promotions, special benefit mailings and all sorts of educational materials were now provided up front to customer service representatives.

Revised member enrollment materials, including a complete handbook, were sent out to all new and re-enrolling members.

The first remeasurement was based on 1998 data (Table 1):

The plan performed no statistical analysis, but did note that it had met all its goals. Overall, less than one member in a thousand now complained about the information disseminated by the plan.

A second trainer was hired for the customer service department. This individual focused exclusively on the needs of Medicare and Medicaid members.

Realizing that members receive a great deal of plan information at their doctors' offices, the provider relations department developed an orientation program for providers' offices. The plan provided educational pamphlets, newsletters and in-service programs for practitioners and their staffs. The aim of the program was to help practitioners and office staff answer member questions. Also stressed-easy access to customer service.

The second remeasurement used data from 1999 (Table 2):

Complaints dropped again, by nearly a third, with the largest decrease coming in the area of incorrect information.

The plan has sustained the impact of this activity, despite transitioning customer service to a centralized call center. It feels that the experience gained in working together, examining procedures, moving from paper to electronic processes, and getting input from front-line staff has eased this transition.

Repeat measurement in 2000 showed continued improvement; the overall complaint rate about information was 0.22 per 1,000. Every single subcategory was reduced: delivery of written information resulted in only 0.11 complaints per 1,000 members; correctness of information in 0.07 per 1,000, and timeliness in 0.05 complaints per 1,000 members.

The plan intends to continue training efforts at the centralized call center, and is currently in the midst of providing all materials to its customer service representatives in an electronic format, further improving consistency in answering complaints, and categorizing concerns.