The Case Studies:

ACCESS TO BEHAVIORAL HEALTH SERVICES - Using an Established Model to Generate Positive Results
Description: This plan decided that urgent care services needed to be integrated into the services provided by outpatient health care teams. The plan then held a two-day conference on best practices, where it adopted a care delivery model (single-call access to triage) that had seen success in another state. The one-call model was the driving force in the reduction of waiting time for all appointments.

DECREASING COMPLAINTS AND APPEALS REGARDING REFERRALS - Addressing Opportunities for Improvement
Description: This plan addressed a major source of member complaints by simplifying its referral process, then training claims staff and practitioners on the new process.

IMPROVING THE REFERRAL PROCESS - Changing the System to Boost Satisfaction
Description: Referrals ranked among the top three reasons for complaints at this health plan, prompting the plan to redesign its referral process by allowing primary care providers to provide patients paper referrals without prior authorization, and by permitting specialists to provide referrals for routine diagnostic services.

MEMBER SATISFACTION - Improving Practices and Processes Related to Nonformulary Medications
Description: In the wake of an increase in member and employer complaints about the formulary, this plan developed a "secondary formulary" list driven by physician preference. To communicate the expanded formulary, the plan used newsletters, direct letters to physicians and meetings.

MEMBER SATISFACTION - Reducing Complaints Through Improved Communication
Description: Based on the success of two pilot programs designed to improve communication and sensitivity toward seniors, this plan developed two new training programs for its providers: a half-day session on telephone skills and a basic program on managed care for new primary care providers and their staffs.

MEMBER SATISFACTION - Systematically Analyzing Operations to Improve Overall Satisfaction
Description: The growth of this plan motivated it to restructure its customer service department, moving customer service from the operational control of the CFO and establishing a director-level position. In addition, the department's priorities were changed to emphasize quality service, rather than speed of answer. The plan also conducted inter-departmental training sessions to improve the department's knowledge base.

MEMBER SATISFACTION - Working With Provider Groups to Improve Service
Description: Through survey data and member calls, this plan found that nearly one-third of total complaints resulted from dissatisfaction with a specific medical group (which provided primary care services for 11.5 percent of the total plan population). To reduce complaints, the plan subcontracted referral management, provided customer service training for clinic staff and installed an appointment system (replacing the previous walk-in system) and an automated patient check-in system.

PHARMACY WAITING TIME - Reengineering and Automating Pharmacy Systems
Description: After member satisfaction reached an all-time low in some of this plan's pharmacies, the plan attacked the issue of pharmacy waiting time through plan-wide and targeted interventions. At the plan level, the plan implemented an automated refill process and enhanced its information systems to enable transfer of prescriptions across pharmacies. The two affected pharmacies made more efficient use of staff and physical space, introduced a voice mail refill request system and expanded pharmacy hours.

PRIMARY CARE APPOINTMENT ACCESS - Reengineering the Appointment Process
Description: The plan's triage system-actually designed to be a barrier-was reorganized to improve access, and each clinic site was made responsible for ensuring that sufficient staff was on hand to meet demand for appointments. In addition, the plan put into use appointment management software that alerted users when demand exceeded supply.

REDUCTION OF COMPLAINTS ABOUT MEMBER INFORMATION - Empowering Staff with Tools and Training
Description: This plan's initiatives were aimed at improving internal and external communication of member information. The plan called new members to confirm receipt of materials, revised and mailed information about the drug benefit, hired a dedicated trainer for its customer service staff and broadened internal distribution of member information.

REFERRAL REDESIGN - Partnering with Vendors
Description: This plan set out to increase member satisfaction with the referral process by easing the use of emergency services, streamlining the specialist referral process and implementing outreach and education programs aimed at members and providers.

RESOLUTION TIME FOR MEMBER GRIEVANCES - Meeting State Requirements With a Plan-Wide Effort
Description: Compliance with state regulations was the driving force behind this plan breaking out grievances into three levels of appeals; the plan handled grievances at the first and second levels, and it reallocated and added staff to improve turnaround time. The initiative led to the rate of grievance resolution (within 30 days) increasing from 33 percent to 99.3 percent, placing the plan in substantial compliance with the state Department of Health.

SELECTING A PRIMARY CARE PROVIDER - Making Choosing a Physician Easier
Description: This plan found that selecting and changing a primary care provider ranked consistently among the top five categories of requests handled by customer service; in addition, less than half of members rated the process of choosing a doctor as "very good" or "excellent." As a result, the plan implemented a new process for members to select a primary care provider, which called for the plan to verify providers' "patient acceptable status" three times per year.

SELECTING A PRIMARY CARE PROVIDER - More Choices; More Ways to Choose
Description: This plan built on existing initiatives by expanding its base of primary care providers, communicating the importance of selecting a primary care provider through the member newsletter, introducing an Internet tool for choosing a primary care provider and eliminating auto-assignment of a primary care provider.

THE REFERRAL PROCESS - Reengineering Referrals to Improve Satisfaction
Description: Semiannual telephone surveys revealed that this plan's existing referral process-which required that all primary care physicians contact the plan's utilization management department to request a referral-was a major source of member dissatisfaction. As a result, the plan first introduced a Referral Bypass Program that allowed some primary care physicians to make referrals without prior authorization, then a Rapid Referral Program, which allowed all primary care physicians to fax referral requests, which are entered into the system within 24 hours of receipt.