Archives For care management

Looks like it should taste good.

A red, ripe tomato sitting on a kitchen counter

Supermarket tomatoes look amazing and taste like cardboard. Why? Decades ago farmers began tweaking the tomato’s DNA to look more appealing on the shelf and last longer. However, the same genetic mutation that makes for great color – prevents the production of sugars and carotenoids that make a tomato taste like a tomato. It also, ironically, kills off most of the health benefits.

I think care management has gone the way of the tomato.

Most health insurers have care management programs that look good enough (we provide high-quality low-cost care!). But bite into one and you find that there’s not a lot of care there at all. In fact personal communication and interaction, the hallmarks of care management, have all but disappeared. (Notice how I didn’t use the phrase “customer engagement” which I think has been wildly overused and part of the problem. That’s another blog.)

So let’s take a closer look.

Walk the halls (cube farms?) of any insurer and you might be impressed by the titles on the nameplates: Customer Care Specialist, Senior Care Coordinator, Integrated Care Manager and Provider Relations Specialist. Looks impressive – yes? You might actually think the majority of these folks can solve some problems – right?

Upon closer inspection you’ll find the cubes are filled with the least expensive, least experienced people  – and this is the team that makes the first impression on a customer.  In fairness, the majority of these folks do the best they can with what they’ve got. Sadly, what they have is poorly integrated systems and policy & procedure overkill. The result? Most front line staff would love to help you but they can’t.

This is most evident by the excruciatingly frustrating experience we all have when we call 1-800 Health Plan. If you can successfully make it past the efficient teleprompt menu of 30 dialing options (“Before selecting an option, listen carefully as our menu has changed – and connect with a live person in less than two minutes, you are off to a good start.

Initial hurdle cleared, Joe Member Service Rep welcomes you by stammering through his “Thanks for Calling” script – the delivery of which has all the warmth and authenticity of “Have a nice day!” at the check out line at the grocery store.

You spend the next few minutes spelling your name (at least twice) and reciting you Member ID (all 27 alpha/numeric characters of it). These preliminaries dispensed with, Joe assures you that “your call is important,” before placing you in Muzak on hold while his screen updates. (BTW if you are a glutton for punishment, I dare you to click on the Muzak link – if only to study the option for “Sonic Branding.” I’m not kidding.)

A minute or two of NuJazz is all it takes for Joe to click his way through an online decision grid to see if he’s allowed/authorized to help you. Odds are stacked heavily against Joe.  Okay, he can’t help you, but the good news is Tina the Care Coordinator can. It’s another minute for the “warm” transfer. Don’t assume that means the facts of your call will magically appear on Tina’s screen. Hard to believe given all the tech we have at our disposal, but for whatever reason, healthcare organizations lag far behind everyone else when it comes to integrated customer support systems – but I digress.

Tina introduces herself to you and after dutifully repeating all the information you just gave Joe, you will be asked a new series of Q&A driven by her desktop software. For whatever reason this software/system/computer is always buggy. “I’m sorry. My computer keeps freezing up. Can you repeat that again? You need a referral for…what?” And so it goes.

With any luck, after 15 to 20 minutes into this care management “excellence ” you might get your question answered.  Might. However, if your issue requires the intervention of a licensed professional, the chances of you connecting to one during that first call are slim to none. Unlike the first two levels of care management, RNs and Medical Directors are few and far between. Because they are some of the highest salaried staff, they are saddled with the responsibilities of three people. In fact, most nurse managers and medical directors today spend less time practicing at the top of their license than they ever have. What does this mean to us?

Instead of providing peer-to-peer guidance to our physician (comparing treatment options, evaluating the latest research, getting that authorization for surgery fast-tracked), they are bogged down managing staff, managing casework, managing committees and managing “management.” So consider it a victory if you get a call back from these ultimate decision makers within 48 hours. This whole process is incredibly frustrating for everyone and instead of getting better; it seems to be getting worse.

Back to tomatoes…

Breeding the genetic mutation out of tomatoes, according to researchers, could take years. Once corrected, the tomato might look less appealing, but the taste and nutrition will be back. I think we need to look at care management through the same lens. Time to excise the overly aggressive cost containment gene and reintroduce genuine, hassle-free communication. It could take a while, but once we engineer the care back into care management, I’m willing to bet the cost savings will be there. One might say improvements might show up organically.

More posts on re-designing care management are on the way.