The Labyrinth of Care
excerpted from the book
how health care in America became
big business - and bad medicine
by Donald L. Bartlett and James
Broadway Books, 2006, paper
Nearly one of every three dollars now spent on health care goes
for administration, from processing the voluminous paperwork of
billing to enforcing the length-of-stay guidelines that brought
grief to Musette Batas. A generation after introducing business
practices to health care, the United States spends a higher percentage
of its health care dollars to administer the system than any other
country. A study published in the New England Journal of Medicine
in 2003 comparing administrative costs in the United States and
Canada concluded that U.S. costs are three times higher: $1,059
per capita in the United States in 1999; $307 per capita in Canada.
A generation ago, your personal health
care decisions-a medical appointment, a prescription, a test,
a recommendation for a specialist-flowed through your doctor's
office. Your physician decided whether you would have a procedure,
whether you would be admitted to a hospital, and how long you
would stay. To cut costs, the insurers took much of that power
away from doctors and gave it to the health care call center.
Here, in their lexicon, was a way to "manage" care,
which really meant to restrict and deny care. The length-of-stay
guidelines and coding schemes were but tools to achieve that end.
The call center became the command post to carry it all out.
Since then, hundreds of call centers have
popped up across the country, employing thousands of workers.
A few are located in or near big cities, but most are in medium-sized
communities or small towns. Often they are in areas where jobs
are hard to come by, thereby enabling owners to hold down wages
and still attract grateful workers. Bismarck, North Dakota, hosts
some of the health care industry's largest centers. In towns like
Visalia in central California, the call center is the largest
For many Americans, the centers are perhaps
the most infuriating symbol of U.S. health care. The chief function
of the faceless people who answer the phones seems to be to see
how long callers can be kept on hold or how many times they can
be compelled to call again and again before securing a satisfactory
answer to a question. Housed in warehouse-like buildings, the
centers sit anonymously alongside interstate highways or sequestered
in featureless office parks. The interiors of these places don't
look like they have anything to do with medicine, and the workforce
could just as easily be filling orders for L.L.Bean.
Imagine an empty Wal-Mart, lined with
row after row of cubicles, each separated by a low partition,
stretching in every direction as far as you can see. Inside each
pod is a compact workspace with a computer terminal and an operator,
usually a woman, wearing a telephone headset. Rising above this
vast grid of squares is the constant sound of phones ringing,
people talking, and computer keys clicking. In some centers, the
sound goes on twenty-four hours a day. As calls stream in, they
are randomly routed to operators. If a caller complains of a medical
problem, the operator asks a series of questions: Where is the
pain or discomfort? 'When did it start? How intense is it? Have
you had it before? 'Who is your primary-care physician? The questions
may give callers the impression that they are speaking with someone
who is well versed in medicine. But most operators are simply
reading questions that appear on their computer screens and keying
in the answers.
The operators rely on software programs
called scripts that offer up standardized queries about various
ailments and injuries, allowing people with no medical training
to diagnose conditions that were once solely the responsibility
of medical professionals. In theory, a caller who has a serious
problem will be turned over to a nurse or physician. But that
decision rests largely with the operator, often a low-paid worker
who is new to the job.
For many call-center employees, their
only training is mechanical and rudimentary-how to answer the
phone, how to use the computer, how to access the scripts, how
to input the caller's answers, and how to make a referral. A good
telephone manner is a plus, but it's not essential. What the industry
requires most is bodies to answer an evergrowing tidal wave of
calls. Although these workers have become crucial cogs in the
health care bureaucracy, they rank at the bottom of the industry's
hierarchy. When insurers cut their budgets, they are among the
first to go. People hired one month are often laid off a few months
later, and sometimes long-standing employees are terminated only
to see their jobs filled by new hires at lower pay.
The call centers are essentially factories,
today's equivalent of yesterday's assembly lines. Tethered to
telephones all day and fielding an endless stream of inquiries,
appeals for help, billing questions, and requests for referrals,
prescription refills, and doctors' appointments-all the while
under pressure to move on quickly to a waiting callworkers are
much like their predecessors in textile mills at the dawn of industrialization.
The surroundings may be cleaner, better lighted, and less noisy,
but they are every bit as regimented and stressful.
The work is intense. On any given day,
an operator handles dozens of calls from worried and angry patients
and physicians asking why a referral didn't come through, or why
a patient had to pay such a large percentage of a medical bill,
or why a physician wasn't reimbursed in full for a procedure.
Doctors become livid when they talk about the amount of time they
waste on the phone with clerks who, after consulting their computer
screens, refuse to grant a referral or authorize a test because
they deem the physician's request to be medically unnecessary.
Call-center workers are the health plans'
gatekeepers who restrict and ration care by saying "no"
to patients and physicians alike. Technically, they are customer-service
representatives, but usually their work is just the opposite-to
discourage care, tests, or procedures, and reduce or delay reimbursements.
Operators are under enormous pressure
to minimize the time they spend talking on the phone or processing
claims. Those who take longer than average are reprimanded and
threatened with dismissal. Says an employee at one California
operation: "They will say, 'Now what is the problem here?
You know how long you are supposed to be on the phone." In
this job, she says, the fear of spending too much time with a
patient is "always hanging over your head." The briefer
the calls, of course, the more calls that can be fielded, which
means fewer employees and more for the bottom line. One health
care consultant says, "If you measure this by the number
of calls they have to take, these are sweatshops."
In northern California, Kaiser Permanente dangled similar incentive
bonuses before clerks to keep calls brief. In a plan implemented
at three large centers in Sacramento, San Jose, and Vallejo in
2000, Kaiser promised, according to the Los Angeles Times, to
reward clerks with upward of a 10 percent salary bonus if they
accomplished three of four objectives:
o Handle regular calls in less than three
minutes and forty-five seconds.
o Schedule or request appointments for
patients in no more than 15 percent to 35 percent of cases.
o Transfer fewer than 50 percent of calls
to nurses for additional help.
o Spend an average of 75 percent or more
of the workday answering calls.
In a year's time, an aggressive clerk
could earn a bonus of $2,500 by keeping talk to a minimum and
referring fewer callers to physicians and nurses. Kaiser maintained
that the program was to promote good service, but it sparked outrage
among Kaiser's call-center nurses, who believed that it encouraged
untrained clerks to make medical decisions that might harm patients.
After two years, Kaiser abandoned the experiment, saying that
it "wasn't working." But Kaiser's long-range strategy,
like that of most HMOs and insurers, is still to shift more work
to lower-paid clerks with no specialized medical knowledge.
Online and Offshore
Today, when you phone your health care
company, you have no idea who's answering the call or where that
person is located. Not so many years ago, companies tried to place
centers in the same region as their enrollees. But that effort
gave way to pressures to consolidate into ever-larger facilities,
to cut costs, and to save money. If you place a call to your health
provider from your home in Ohio, you might just as easily wind
up talking to someone in New Jersey or North Dakota or California;
the whole process is so anonymous, so remote. Courtesy of fiber-optic
cables and satellites, it's about to get even more remote. Before
long, your call will connect you to someone so polite, so well
spoken, and so American-sounding that you won't know that you're
speaking to a person halfway around the globe-in India.
This new stage in the evolving world of
American health care got under way quietly in late 2000 when Aetna,
one of the nation's largest health insurers, embarked on a little-known
pilot project in the heart of India's Silicon Valley. Starting
with twenty-three employees, Aetna established a claims-processing
operation in the southern Indian city of Bangalore to transfer
information from personal health claims filed by Aetna subscribers
in the United States into the company's database. Previously,
such claims had been processed at an Aetna call center in Allentown,
Earlier that year, Aetna instructed its
Allentown workers to bundle up paper claims and ship them to a
company in Texas, where they were electronically scanned into
portable document files (PDF). The images were e-mailed to two
Aetna offshore sites, one in Ireland and a newer one in Bangalore.
Workers at each then input the data from the imaged claims.
Over the next two years, Aetna, lured
by wage rates that averaged 80 percent less than in the States,
shifted more of its claims processing to India. In Allentown,
where the offshore processing was reviewed, claims agents noticed
errors in the data coming back. "The only time you could
have any communication was by e-mail, and it was difficult to
explain to them what they were doing wrong," said one former
employee who asked not to be identified. "For the consumer
it is a shame. The average person has no idea this is going on."
Aetna was so pleased with its Bangalore
venture that it added more workers there and opened another claims
center in New Delhi. Aetna employees from Allentown were dispatched
to train their Indian counterparts. By the end of 2002, Aetna
had more than five hundred agents in India processing American
health claims. As the hiring continued in India, the layoffs began
Although Aetna kept a low profile about
its Indian operation, word spread rapidly among health care companies.
For years there had been talk about tapping the low-wage, English-speaking
Indian market to take over some of the administrative expenses
incurred by call centers in the States, but this was the first
sign that it might be feasible on a wide scale. "Aetna was
absolutely the groundbreaker on this," said one Indian consultant,
"the big kahuna."
Others soon followed, and still others
planned to do the same. United Healthcare, the nation's second-largest
insurer, launched plans for a 300-person call center and claims
operation in Mumbai (Bombay) and let it be known it hoped to have
as many as 4,000 agents in India in coming years. Consultants
who track the industry say that more insurers and health plans,
including Wellpoint, Coventry, Horizon Blue Cross & Blue Shield,
Humana, and Blue Cross & Blue Shield of Michigan, are actively
trying to establish Indian call centers.
Industry observers believe that it's only
a matter of time before a substantial number of American patients
who phone their health care plans will reach someone in India.
And most of them won't even know it's happened. The sophistication
and technical expertise of the Indian call-center industry is
such that connecting an American health care consumer to an Indian
worker in a call center halfway around the globe is virtually
seamless. Technology is only part of the reason. Young, college-educated
Indian call-center employees undergo training to Americanize their
voices and become familiar with contemporary American culture.
Schools have sprouted across the subcontinent
to train workers to sound like Americans when they answer phone
calls from the United States. At Call Center College in Bangalore,
students receive four weeks of intensive instruction in which
they are "immersed in the American sound," says Julian
P. Gurupatham, vice president of training. The goal, he says,
is to produce an accent "any American can understand."
Equally important is cultural immersion. Trainees watch hours
of American television shows and movies to soak up pop culture.
Friends, Ally McBeal, The Simpsons, Whose Line Is It Anyway?,
and Sabrina The Teenage Witch are popular TV serials. Among movies,
The Truman Show, Volcano, and Jurassic Park are big hits. After
this training, says Prakash Gurbaxani, former CEO of an Indian
high-tech company, "it's very rare that anyone will figure
out that their 1-800 call is actually being answered in India."
Inside the call centers, to remind workers
of their American state of mind, walls are plastered with American
flags and slogans, and each clerk's phone flashes a message indicating
the city and state of the incoming call. At the most sophisticated
centers, clerks even get up-to-the-minute information on weather
conditions and the latest sports scores in the caller's hometown.
To make American callers believe they are speaking to someone
in the States, workers in many Indian centers adopt American names
and, when asked, give their location as a city or state in the
United States. "At work I am Candy," one Mumbai call-center
employee told an Indian online journal. "Outside I am Rehka.
That's how I see it. There's nothing more to it. It is like with
actors. They play a part every time." But the deception troubles
some: "Can a company genuinely argue that they are offering
excellent . . . 'customer service' if the first thing they tell
their agents to do is lie about their name and then their geographic
location?" asked a worker in an Internet chat room.
Less than a decade ago, India's international
call-center industry got its start by setting up offshore operations
for U.S. credit-card companies.
It has since expanded into computer services,
online sales, software technical support, banking, tax returns,
travel services, and more. Everyone agrees that the American health
care market is the next big frontier, the one offering the greatest
potential of all. The vast number of administrative jobs and constant
pressure on insurers to maximize profits are expected to produce
a steady migration of call-center and other health-industry jobs
to India. Ravi Shah, a Wisconsin-based consultant who is working
to facilitate the transfer, thinks it will be huge: "Given
the right approach, successful execution, offshore [business processing]
is likely to become an integral part of [the health care] industry...
What we have seen so far is not even the tip of the iceberg, with
the best yet to come."
Shah and other consultants see a process
unfolding: Most of the health care giants will start with claims
processing, as Aetna did. Then they will move on to more direct
call-center services such as telephone inquiries. Eventually,
offshore call centers will take on most of the tasks now performed
in U.S.-based centers, including claims adjudication, membership
enrollment, and policy changes, in which India-based agents will
converse with American health care consumers. Ultimately, the
centers could provide medical advice as well. "There are
tons of doctors and nurses in India today who don't have jobs,"
observes Julian Gurupatham of Bangalore's Call Center College.
American health insurers are keeping quiet
about the move. Says one consultant: "Most of these companies
don't want to make a lot of this information public because it
creates a lot of problems for them, like a backlash from consumers,
who wouldn't be thrilled to know that somebody in India is reading
their medical records."
And for good reason. Any call-center worker
in the United States who made public a patient's medical records
could be charged with violating privacy laws and fined for divulging
confidential personal medical information. But what recourse is
there if a clerk in India, f Pakistan, or elsewhere in Asia decides
to do just that?
Despite potential hazards to patients, the offshore health care
bureaucracy will continue to grow, for the same reason that consumers
buy dresses, shirts, trousers, shoes, and other clothing made
anywhere from the northern Mariana Islands to China: cheap labor.
But don't look for the savings to show up in your health insurance
premiums. Instead, the money will flow to the insurers' bottom
line, and your premiums, co-pays, and deductibles will continue
to spiral upward.
As for the insurers, it's going to get
even better, thanks to the information technology revolution.
The next health care work expected to move offshore, notably,
again, to India: the reading of mammograms, xrays, and MRIs.