No Soup for You! A journey into health care ambivalence.

soupIf you don’t remember Seinfeld episode 116, season 7, you are probably confused right now. In it, a guy nicknamed “Soup Nazi” refuses to serve Jerry and his girlfriend (Sheila). Their PDA in line annoys the restaurateur, and he refuses to serve them, shouting “No soup for you!’. What could this possibly have to do with my blog? Wait and see. 

Dear Diary,

I have lofty aspirations, each night I drift off to sleep. The problem is, when I wake up, I feel exhausted. It doesn’t matter how much I’ve slept or how much caffeine I drink. Sleepiness follows me, and I find myself doing very little on my mental to-do list.

I was relieved when my doctor prescribed a medication, one he said would reduce my daytime fatigue. After gradually increasing my dose, I found myself awake more than I’d been in months. I still find myself sleepy sometimes, but having any measure of improvement is a gift.

Last month, I requested a refill of my medication online. Unlike my previous refill, this prescription was billed under a new insurance policy. I was with the same insurance carrier and used the same pharmacy; but this time, the plan insuring me was different. Under this plan, I have to use express scripts when ordering re-occurring prescriptions.

Express Scripts name is ironic, because there was nothing express about my order. When things are routine, express scripts is fine. You tell your doctor to fax his script and the medication is sent to you, without any shipping cost. You can also set up your account, so that refills are automatically sent.

If you need something outside the normal process, good luck. Since my medication won’t be covered at a retail pharmacy, I just have to take it. I am express scripts’ bitch. Competition would normally push express scripts to get their act together, but since so many of us are their bitch, express scripts can pretend they are giving the superior service their messaging claims.  As you can tell, I plagiarized some of this wording from a 1950’s text book. Keep it between us.

If you work in client service, Innovation, simplification, and quality improvements have to be an everyday part of your day. Unfortunately, many in the field are just trying to get through the day. Some focus on the clock, others on the number of people “served” and some on the amount they’ve earned. You even have those that take pride in finding ways to do less work! Regardless of your role, there are opportunities to make things better. When you deal with companies like express scripts, you can’t help but wonder if anyone is focused on improvement. It’s especially hard to do this, when your team is struggling with obstacles, such as depleted resources or Commodore 64 level technology.

You never want to leave the impression you are one of those places. You know, the kind that is perpetually unstaffed, it’s frazzled team using computer systems resembling a 1985 Atari game. If you’ve shopped at Michael’s or Macy’s, you know what I mean. Neither store has many sales associates walking the floor. I won’t subject myself to the frustration, unless there’s a particularly good deal there or I need something quickly.

When shopping at these stores, there’s nothing about my experience that says they are focused on it. But, I don’t feel obsessed enough to write about past shopping excursions. I know I can go elsewhere. With express scripts, I feel trapped. Like I am just a number, a number they see as a dollar sign rather than a patient. It’s that feeling of powerlessness that ups the ante, and makes the problems I experience more frustrating than they’d otherwise be.

In business, as in life, someone is always going to be nipping at your heels. I think of my friend’s Yorkie, Cocoa, when I say this. Cocoa is a boy dog, in case you thought otherwise. If you become complacent, your status as a client service leader won’t last. When you don’t have competition, as is the case with express scripts, goals easily slide downward. You may just focus on being good enough to hit numbers set by someone else. This is what I believe is the problem with express scripts. Being the best isn’t what they are striving for; they are instead striving to be good enough. I argue they haven’t done that either; but, if their expectations are low enough, they may feel they are exceeding client expectations. Whose I don’t know. Maybe the guy whose bonus is tied to express script profits.

I am sure express scripts would say my experience is an anomaly. Even if it is, alienating a sub-set of your customer base so badly is never “okay”. Particularly when you think of the business they are in. I’m not having issues with my strawberry & banana pancake order. We’re talking about medication that a specialist determined was best for my wellbeing. The very stuff that keeps me awake for TMZ live and my son coming home from school. Although people can lose their shit over pancakes, it’s exponentially worse when it’s medication in dispute.

My adventure with express scripts started innocently on 9/19 (Monday), when I placed a refill order online. On the surface, my experience was like every other order. However, what I didn’t know was that pre-authorization was required before my prescription could be filled.

My doctor received a fax from express scripts on 9/21. It was faxed back that same day. Yet, I didn’t receive my medication until 10/18. I only received it then, because of persistence and the help of my husband’s employer.

At first, I did what a normal person does. I dealt with express scripts directly. After that didn’t work, I made a call to my insurance carrier, Blue Cross. Surprise! They had no idea what was going on and gave me inaccurate information. Regardless of how pleasant everyone was, no one could tell me why my medication was delayed. Every time I, or my doctor’s office called, we were told something different. When I told express script that, the reps simply repeated themselves, certain that they were right.

At one point, I insisted that I be transferred to a manager. I give this manager (Lynne) credit for coming up with the most inaccurate story of the bunch. It takes skill to be that confused and then sleep night after night, knowing you completed fucked up. * Since I asked for Lynne’s extension, I had the opportunity to leave a follow-up message. I stated that her own pre-authorization department’s information conflicted with her own. I wasn’t warm and bubbly, but I also wasn’t threatening. I simply asked Lynne to call me back. I wanted answers; an apology. A sign that Lynne respected me as a client and wanted to help. I never got that sign because 2 weeks later, she still hasn’t called me back. *Gasp, I cussed and wrote the WHOLE word out. There is really no other word for my conversation with Lynne.

Lynne, if you are reading this, I have something to share with you. Ignoring my call was infinitely worse than giving the wrong information. People are forgiving. If you apologize and let them know what you can do, they will welcome your call. It would have shown you care, you are human, and you truly wanted to solve my problem. Unfortunately, 2 of these 3 things clearly do not apply to you. I am not even sure you are human; zombie robot outsourcing would explain a lot. So next time you are lamenting you aren’t paid enough, you aren’t appreciated or that you should be promoted, remember this. If you don’t take pride in your work, and welcome the responsibility of caring for your clients, you will find yourself constantly behind. Behind where you want to be, behind in your work and behind in market share. It may seem like we don’t have a choice now, but if you make enough people mad, our voice will be heard.

Express scripts’ online experience wasn’t any better. Hardly any statuses caused the site to update. I wasn’t told when they got my doctor’s fax, when it was initially reviewed or when my order was in queue for a final determination. Instead, I was instructed to call client service, who didn’t know anything more. They were good at pretending though.

A clear, continually updated web site, can do the work of hundreds of men and women. I much rather go online and see where I’m at than be put on hold, asked scripted question, and verify my birthdate for the 10th in a week. What a wonderful tool it would be to pull screen shots of what I saw on various days, just to figure out how communication can improve. I haven’t seen anything at express scripts that suggests they’d actually do this.

Here’s my advice express scripts. Bring your team members into a room and play the phone calls I’ve had with them. Ask how they would feel if they had to worry about receiving medication on-time. Go through the automated calls and online messaging that were part of my voyage. Have technology, marketing and senior leadership in the room, ready to make changes. Get people to feel what it’s like being your client. It seems like they’ve forgotten.

I am not suggesting that there’s no one who cares at express scripts. I am suggesting instead there is a culture that inhibits caring. One that is tied to performance expectations, leadership communication, and a lack of technology and escalation alternatives.

De-sensitization is a common occurrence among those in the client service field. If you keep hearing the same complaint every day, it seems normal to you. For example, say you work at a carpet company and you constantly hear “I haven’t gotten my estimate yet, and the install is scheduled next week!” After a while, it seems reasonable to provide this information late in the game. You may even roll your eyes when someone says this, telling your cube neighbor, “This bitch has no idea! Yesterday, we told that lady how much her carpet install would be, after we put her carpet in!”

I call this phenomenon “lost perception syndrome”, and it’s rampant. Over time, client service simply forgets what it’s like to be the people they serve. It can happen to any of us, even top tier team members that lead reports, receive compliments, and boast years of seniority. It takes effort on everyone’s part, from the front line up to the CEO, to prevent this syndrome from taking hold.

A great example of “lost perception syndrome” occurred when I was assigned a point of contact at express scripts. This lucky guy, Dan, came to me after my husband’s employer got involved.   Even then, express scripts still took 2-days to call. When Dan did, he had as much information as the zombie robots I spoke to earlier. However, Dave didn’t pretend to know what was going on, which was a welcome relief.

I asked Dan how long it normally takes to complete a medication review. He said “2-weeks”, without the slightest hint he was unsettled by it. Dan agreed my 3-week wait was too long and apologized, but I couldn’t help but stop him. Dan, I told him in my radio-ready voice, you’ve probably been at express scripts a long time, right? He acknowledged he’d been there a while. “You’ve lost your perception. You think 2-weeks is reasonable, but it’s ridiculous.” Dan didn’t know what to say, so I bored him with the fact I used to lead a large client service team. How I couldn’t imagine giving that kind of service. Five apologies later I gave up on the topic and focused instead on how much longer the approval was going to take. A couple days, Dan hoped, but he assured me he’d watch my account along the way.

Before my express script days, I had my choice of retail pharmacies. I preferred Walgreens, which handled the occasional pre-approval with ease. I don’t recall waiting more than a day, which is exactly what any of us expect. However, Dan doesn’t have the same expectations we do. He isn’t complaining to senior leadership, when he sees delays like I experienced. He isn’t coming up with ways the process can be automated. He is simply getting through the day. This may be for a variety of reasons. Even if he agrees my experience is unacceptable, he may feel any suggestions he makes will fall on deaf ears. He may not have time to breathe, let alone make flow charts of the process.

You may picture a doctor reviewing my medical history, carefully determining if the prescribed medication should be approved. Think again. Based on the limited information Dan shared, a client service employee initially denied my order. I don’t know who the actual person was, but rumor has it her last job was folding sweaters at Old Navy.  Let’s pretend her name is Audrey, she’s the daughter of a good friend of mine who always reads my blog. Holla to Molly, what up gurl?

Audrey made her determination after considering my diagnosis and what was being treated (fatigue). Since my medication prescribed wasn’t on their approved list, Audrey hit the denial button and cropped her ex out of another Facebook photo. Then, my request was routed to a queue that has an uncanny resemblance to a black hole. There it sat, for over 2 weeks.

When Audrey made her decision, there was no communication from express scripts. It was only through repeat calls I learned that “my plan” wanted me to try ADHD medication first. Researching these medications, I read such things as “habit forming”, and “prone to abuse”. I already knew my doctor didn’t recommend taking these drugs, since most fibromyalgia patients can’t tolerate the side effects. Never mind the fact, I lay on the couch for hours watching “Say Yes to the Dress”. If that isn’t focus, I don’t know what is. Although Dan couldn’t tell me why the plan preferred I try ADHD medications, the price seemed like a likely culprit.

Once a customer service rep denies an order, it is sent to a queue that (supposedly) a pharmacist reviews. Like Audrey, this person doesn’t have my full medical history. All he/she knows is what I have and what symptoms I am trying to control. This is where (I think) my order languished, in a line full of other patients, just wanting to get their prescribed medication.

At one point, I was told my doctor needed to call the pre-authorization line, because his fax was sent to the wrong place. When the office called, we heard about this second queue and that they were sorry, but they are “a little behind”. It should just be another day or two, we were assured.  Yet, those days came and went with no word. I was lucky though, my medication only helps keep me from sleeping. What about people who need their medication to live? It sounds dramatic, but when you deal with people’s health, it’s a lot different than saying your out of chicken noodle soup.  People tend to want to know these things, hours, not weeks, after they’ve placed their order.

When the final denial came through, I got an automated message. I was told my doctor ordered a quantity above my plan limit. Huh? It seems the robot is as confused as my mother, trying to use “the google”.

With this in mind, I’ve penned a love letter to express scripts. I use the term love loosely in this context. I don’t love them at all.

Dear Express Scripts:

Well, you finally got around to breaking-up with me, after 3 weeks. I am not giving up though! We were meant to be together; sort of like cheese and tortillas. However, in this case I am not cheese and you are a stale tortilla, being shipped to a dollar store.

You must not spend much time on automated messages. The robot that called was completely confused. I guess you use the same message for all denials, because quantity is the most frequent issue you see. Good for you! I am sure it felt great getting out of your meeting early, knowing your message makes sense some of the time. You can’t bat a 1,000, am I right? LOL.

I can read my cats minds, and I think I can read yours too. I don’t think you frequently (dare I say ever) study your process from start to finish. Maybe you do when it comes to a routine order, but all those pesky other scenarios, not so much.

I say this because each step of my process was disjointed.  Is there any one person that feels responsible for the total client’s experience? Everything about my contact with express scripts tells me no. I get it, being responsible for the entire thing, start to finish, sounds overwhelming. If it doesn’t, you aren’t considering all the things that touch client experience. Even if you know what should be improved, how can you get everyone- from web design, to sales, to shipping, and so on to listen to you?  Especially you, the kid in the corner wearing ill fitted hand-me down smurf pj’s. You can’t, right? That’s why you are probably ok just knowing Dan apologized to me; if you are aware of my experience at all.

In all fairness, I appreciated the laughs we shared. Like, when your rep answered “I don’t know” 3 times in a row, and then asked “did I answer all of your questions” per script. Or how you called me, you know my voice, and we’re continuing a conversation, but you still have to verify my birthdate and zip code.

Even if you read my letter, I am not sure you are prepared to fully invest in fixing problems like mine.  I can hear a manager (not Lynne, she’d throw my letter in the shredder) saying, “We’ll have some of our people work on this, when they have time”. It just doesn’t work that way. At least not when there’s many different processes, impacting thousands of clients.   I’m not saying only expensive business consultants can make a difference. In fact, I think it’s best if people really close to the process get involved. If you don’t experience what you are solving, you can’t really get to the root of the issue. Just sitting down with the people who talk to clients and actually doing something with what they say, would be a great start. You should try it sometime.  I bet Dan has some feedback for you.

Express script could easily invest in technology that expedites the review process. With fewer humans needed, secondary reviews could happen quickly. Yet, many client service teams struggle for technology resources, competing with areas of the business that are considered profit centers. Client service is often left feeling their ideas are nothing but thoughts on paper. Getting resources assigned to work on your ideas or money to purchase technology, can be difficult. Especially if work-arounds exist and company leaders don’t value client service the way they should.

How do you put a value on happier clients? We know that happy clients refer their friends. That they keep coming back. But unless you have strong ways to track this, which again takes technology, it’s hard to know the benefit of exceptional client service. It’s nearly impossible really, and in many cases the benefit is something you won’t see until well into the future. If you service mortgages, for example, it could be 10 years before someone will even consider using your services again. Therefore, it’s hard to argue your need is more important, when you can’t measure the benefit and it may not come for some time.

Many in client service are friendly caring souls, who can hold their own with clients, but become meek when surrounded by senior leadership. This is why focusing on measuring the things happening around you and producing clear and convincing data is important. If you don’t know how many of your clients are experiencing a certain problem, you haven’t even begun understanding the problem. If all you can do is a tick sheet, to measure how many times something comes up, that’s a start.

I am nowhere close to a math savant. In fact, the closest I’ve come to that is having a son in honors math. I took statistics as a 20 year, and had no clue that it was probably one of the most important classes of my college career. I was more of a Deviant Social Behavior kind of gal. This was before the internet, so a lot of the things I read about were news. Somehow though, I remembered enough to make myself look like a genius. Not just about deviant behavior, but also statistics.  It wasn’t hard to do, because many in client service just aren’t numbers orientated.  They can talk their way out of Kim Kardashian’s Paris hotel room, but the terms control limits and independent variable gets them every time.

If you only remember one thing from my blog, remember this. Numbers without context are useless. If complaints are up 20%, but your business has doubled, you are actually doing better than before. But, if you only look at the number of complaints coming in, you’ll never know that. You always have to look at anything that may influence what you are measuring. If you find yourself responsible for reviewing data or requesting it, you should at least watch some YouTube videos or read a statistic for dummies like-book. If you don’t want to do that, at least ask yourself “how can I keep this in context”, when reviewing reports.

It wasn’t until the later part of my career that I focused on numbers the way I should. I learned the hard way that your biggest problems are what you aren’t measuring. For example, how many times have you been put on hold and the call “accidentally” disconnects after 15 minutes? Things like this may be happening more than you think. Your team members may not be able to make themselves available for the next call, because they are away from their desk completing steps. The time these steps take, may surprise you. All of this is discoverable with the right reporting, but first you have to ask yourself what needs to be measured. Even if you don’t work in a call center, just about every client service position has aspects to it that are quantifiable. What those things are cannot be found on a general list. It is truly unique to the type of business you are in, how you do it, and how many people make up your team.

I love food. I use butter and cheese, and eat way too many desserts. I am not as thin as I’d like, but I look decent. If I stand the right way, crossing my ankles to hide the width of my thighs and no one is behind me, I look great in a bikini. Because of my hobby (eating) I go to a lot of restaurants. I’ve never worked at one, but I can think of several things I’d measure if I did. How long does it take to turn over tables by waiter, comes to mind. Maybe one of your waiters is slow to serve clients and as a result, his tables are filled longer, increasing your wait at the door. Those patrons may be frustrated enough they change their mind about ordering dessert. Next time, they decide to go to your competitors. All of this may be hidden from your view, but it can be uncovered with careful observation and measurement.

The least express scripts can do, is make sure they are expedient in reviewing their client’s medication orders. I don’t think wanting that, is demanding too much. But if express scripts doesn’t measure the right things, and actually talks about what they see, they may not realize how bad their experience has gotten.

When the final denial came through, I was unwilling to give up. My doctor prepared a letter, explaining why the medication prescribed was preferable. Within hours of receipt, express scripts approved my medication. The order was shipped over night the next business day. I wondered why the appeal process was so fast compared to everything else. If this letter was enough to get my request approved, why didn’t express scripts ask for it earlier? With more questions than answers, I was left with little confidence in express scripts’ ability to serve me in the future. After all, there was reason to believe I’d still be waiting, if my husband didn’t complain to the right person at work.

There are many lessons to take-away from my express scripts experience. If a multi-disciplinary team reviewed my process in full, they could solve problems experienced by many clients. They could improve their messaging, determine necessary web site enhancements, and how training and technology can come together to create an exceptional client experience.

The sad thing is I don’t believe this review will take place. A company committed to making these changes is not likely to be okay taking 27 days* to ship medication. Now, I could be overly harsh in my analysis. Maybe express scripts recently had incredible pharmacist turnover. The ones they have, may be already working 18 hour days. But, seeing how flawed communication was and considering past experiences, I believe express scripts has a systemic problem. This is more than temporary resource issue.

*Based on the date my doctor faxed the requested form and the date my medication was shipped via UPS.

My husband joked express scripts should hire me, to fix their issues. Since hiring and initial training play a big part in creating a client service culture, anyone trying to fix express scripts has their work cut out for them. However, small incremental changes are not beyond express scripts limits. It’s a goal that I hope everyone, from the reception desk to the board room, will undertake. It may take an earthquake to shake express scripts up, but if employers demand multi-faceted service level agreements of them, it may just happen. Let’s just hope no one dies while we wait.

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3 thoughts on “No Soup for You! A journey into health care ambivalence.

  1. Thanks for the shout-out! Audrey will be delighted to have gotten to play a villain — and Cocoa! If I had a budget and administrative control over our customer service folks, I would hire you to come in. How do you get customer service folks to have more empathy for their customers? I have this, but I deal with fewer people than they do and people are nicer to me than they are to them. I have heard stories that make my blood run cold of people mocking the very customers who, in essence, sign their paycheck (are fellow sentient beings, etc.). So there are two issues I see — having a systematic approach to what we do substantively for our work (a good policy and procedure manual that folks know to read combined with general competence and good training) and having grace (honor, accountability, and manners) and professionalism in our outreach. Holy Christmas.

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  2. Believe me you don’t want to work at ESI – they have one of worst reputations as an employer in town. Plus you would have to move back here and live with your mom…..

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    1. That was my plan, but instead I was going to buy a house next to yours. I figured we could power walk every night together. But then I realized Nancy may not like that. So instead, you just need to become the CFO there, so my meds get approved. Jackie worked there at one point I think. Maybe she can set you up.

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