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Kaiser Clerks Paid More for Helping Less
Health care: Bonuses were given for limiting members' calls and doctors' appointments. HMO defends program but has dropped it.
By CHARLES ORNSTEIN
Times Staff Writer

May 17 2002

Kaiser Permanente, the state's largest HMO, until recently had awarded financial bonuses to call center clerks who spent the least
amount of time on the phone with each patient and limited the number of doctors' appointments, internal documents show.

From January 2000 until last December, telephone service representatives at Kaiser's three call centers in Northern California could
earn a bonus of up to 10% of their salary if they arranged appointments for 15% to 35% of callers and if they spent less than an average
of three minutes, 45 seconds on the phone per patient.

Moreover, a recent Kaiser-commissioned survey of 505 registered nurses at those centers found they had "a serious concern" that callers
were being forced to wait too long for doctors' appointments. The call centers, which handle appointments and inquiries for Kaiser's
3 million members in Northern California, are in Sacramento, Vallejo and San Jose.

Nurses "feel unable to help patients and said they spend a lot of time dealing with frustrated members when they are not able to schedule
appointments," said the Terranova Consulting Group report, obtained by The Times.

Nurses did not participate in the clerks' bonus program.

Kaiser spokesman Jim Anderson dismissed suggestions that the bonuses were intended to make it more difficult for patients to access care.
Rather, he said, they were intended to reward good service and were based on the call centers' past performance.

"This was a pilot program, and it was discontinued because it was determined that it wasn't working" and didn't improve service to members,
he said.

"It's always difficult to balance the amount of time spent with an individual caller versus the amount of time that the next person has to wait to
talk to someone," Anderson said. "We'll always err on the side of helping the person who is on the phone who needs our assistance."

Since the nurses survey, Anderson said, Kaiser has made improvements in scheduling, training and appointment availability in Northern California.

The California Nurses Assn., the union representing Kaiser's registered nurses, contends that the main problem with the call centers is that
unlicensed telephone clerks field patient calls and make decisions about when to schedule appointments or refer a caller to a medical advice nurse.

That amounts to evaluating a patient's medical condition, a task restricted to licensed medical personnel by state law, the union contends.

State HMO regulators said Thursday that they are investigating that complaint.

"If we weren't concerned, we wouldn't be looking at it," said Daniel Zingale, director of the California Department of Managed Health Care.

Although Zingale would not discuss the inquiry in detail, he said his office has the power to order Kaiser to change its call center policies.

Kaiser knows of no state inquiry, Anderson said, adding that no regulators have visited Kaiser facilities regarding these matters.
"If there are questions, we would be happy to work with whoever is raising them and help them resolve them," he said.

One of Kaiser's own physicians found problems at the Vallejo call center. Dr. Harvey Kayman, a doctor at the pediatric call center from
December 1999 until April 2000, wrote in a report the month he left that the center needed a "complete revision of the mission, goals and
objectives ... so that it no longer functions as a barrier, but an agent of communication."

Kayman said pediatric medical providers sent him messages reflecting their "distrust, anger, disappointment and pessimism about the call center."

Patients have complained about "the impersonal nature of the service they receive" and believe that the call center "puts a barrier between
them and their clinical providers," he wrote.

Anderson said Kayman's report was unsolicited. But, "interestingly enough, many of the things listed in his report were already on the
drawing board for changes at the call center," he said.

The incentive plan for the telephone clerks was unveiled in January 2000 in company memos. The incentives were a joint pilot program
between Kaiser and Service Employees International Union Local 250, which represents the telephone clerks.

To qualify for a bonus, employees had to meet three of four criteria, according to one memo:

Handle regular calls in less than three minutes and 45 seconds and foreign language calls in under eight minutes 30 seconds.

Schedule or request appointments in 15% to 35% of cases.

Transfer fewer than 50% of calls--60% on nights and weekends--to advice nurses for additional help.

Spend an average of 75% or more of the workday answering calls.

Bonuses, from 2% to 10% of a worker's salary, were awarded if staff members met or exceeded the targets, the document says.
Other factors to be considered were attendance, tardiness and customer service. Each person could earn up to $625 in bonuses every quarter.

An internal document, titled "Talking Points for Managers," said the bonuses are a way to "reward and encourage performance
improvements."

"Kaiser Permanente is making a financial commitment to its employees for the purpose of improving our phone service to members,"
the document said.

Dr. Linda Peeno, a former health plan medical director who now testifies against HMOs in malpractice suits, said the Kaiser incentive
program was "egregious."

"It just virtually ensures that you're not going to get appropriate evaluation, and you're certainly not going to get access to anyone who
would be able to evaluate you appropriately," said Peeno, whose own experiences in HMOs is the subject of the upcoming Showtime movie
"Damaged Care."

"It's a recipe for not just minimal care, but no care."

In the recent survey, Kaiser's call-center nurses reported feeling pressure to spend little time with each patient.

"The nurses are being forced to quickly deal with these people, write it up and move on to the next one or else they're disciplined,"
said Morton Newman, one of the union's labor representatives.

Nurses get regular reports outlining their average handling time, and that criterion is factored into their annual evaluation, he said.

"There's tremendous pressure on the nurses to cut off the calls, which is a conflict with their license," Newman said.

Anderson said there is no limit to the amount of time nurses can spend with callers. The Kaiser documents, obtained by The Times,
come nine months after a top Kaiser official acknowledged past delays in meeting patients' demands. He said those problems were rectified.

According to minutes of a meeting last year, the chief executive of Kaiser's Northern California physician group described how in the past
"we chose not to provide our patients with what they desired." Kaiser documents suggested that his was done to save money and "control demand."

That strategy proved counterproductive because patients persisted until they got past the telephonic triage system, the doctor said.
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