Regular check-ups

For the past 18 months, the Employee Benefits Division of the CIGNA Corporation, a Connecticut-based insurance and financial services firm, has conducted an ongoing national survey of patients who belong to its network of health maintenance organizations. The network encompasses 43 HMOs in 24 states, staffed by 14,000 primary care physicians and 33,000 specialty care physicians in 1,000 hospitals.

The goal of the survey is to assess the members' satisfaction with their primary care physician, says Sali Bonazelli, assistant director, customer satisfaction monitoring, CIGNA Employee Benefits Division. "The results are primarily for the health plans and also for the individual doctors. The doctors really like getting feedback on how their patients perceive them."

In a three to five minute phone interview, the patients give their impressions of several areas of their interaction with the doctor and his or her staff, including: staff courtesy, doctor attentiveness to patient questions and needs, and how clearly the doctor explains treatment options to the patient. The patients also express an overall satisfaction rating and indicate if they would recommend the service to a friend. The study interviews twelve patients per quarter for each doctor whose patient load meets the sample criteria.

While mail is generally considered the most cost effective methodology for such a study, Bonazelli says that telephone was chosen because it offers a high response rate and a low self-response bias-two things that mail can't easily provide.

"There have been other satisfaction efforts that we've done in the past and in those cases we've used more of a qualitative approach. We've looked at in-depth interviewing, either in person or by telephone, we've done meetings and focus groups. I think that those really serve a good purpose for establishing baselines of information or getting indications of where we should look next. But because of the way we want to use the results of the satisfaction survey, we think that the telephone methodology gives us the best results."

Tangible ways to improve

Bonazelli says the patient satisfaction survey has been valuable because it provides CIGNA with tangible ways to improve service. "In one of the health plans we found out that the members really wanted to be able to contact the health plan for help with administrative issues in the evening. We didn't have evening hours, so we put them in. In another case, we found out that both the patients and even our providers found the explanation of benefits that accompanies reimbursement payments confusing. That led to a work group that revised the explanation of benefits.''

Because the survey is national and it encompasses all of the CIGNA health plans, it assists the company in gearing service levels in the various regions of the country. "When you first organize a health plan network, you put in the same service standards across the board. But different regions have different expectations. You might find out, for instance, the people in the Midwest don't mind waiting 20 minutes to see the doctor, whereas someone in New York thinks waiting five minutes is horrendous. The research helps us see trends and patterns and that allows us to tailor service.

"The results are also helpful in designing communications programs for the various providers or employers. We can find out what's understood and what isn't and we can mold expectations a lot better as a result of the information we get from the satisfaction survey."

In addition to improving service, contacting patients for their opinions can create a feeling of goodwill towards the company, Bonazelli says. "With a survey like this, you very often reach people who wouldn't normally tell you what they think, or who feel that they're dealing with a big company that really doesn't care about what they think. A three or five minute phone call asking for an opinion makes a big difference.

"Corporations, especially those the size of ours, can tend to get internally focused. We become so enmeshed in operations that reality-what the customer wants and needs-can get misplaced. We can get into a mode of thinking where we're determining what our customers need based on what we think. The satisfaction monitoring serves as a reality check and it allows us to be responsive to the customers and the market as a whole. That's critical in today's business climate."

Uncover problems

Bonazelli says that because the patient satisfaction study is ongoing, it functions as a diagnostic tool to uncover problems, and, if problems are uncovered, the study also helps monitor changes made to remedy them.

"One of the things that we do with all of our telephone surveys, regardless of the objective, is to include a question that asks the respondent if they want to hear from or talk to a representative from CIGNA regarding the service. This goes for health plan members as well as those in whatever employer groups we might be serving. And we always provide a CIGNA phone number at the end of the survey because we think that respondents might want to verify with the company sponsoring the survey rather than the vendor. Depending on the survey subject, between 25% and 60% of respondents will do that."

When designing the survey instrument, one of CIGNA's primary concerns was to avoid including questions that might mislead respondents about service capabilities. "We want to make sure that we only ask about things that we can change or that we're willing to change. That way we feel we get the most usable data and it also doesn't raise respondent expectations in areas that we really can't or won't do anything."

Changes have been made to the questionnaire over time as the health mans and doctors have received the survey results. "We very frequently find going into a project that we're sure we know what information we need, and then you get two or three or nine months into the project and you find more uses for the data, which means that the reporting format or the statistical base has to change. There are a lot of last minute changes, simply because the information you obtain from the research turns out to be a lot more important than you think it will going in."

Reported monthly

CIGNA sends written reports and tabulated results of the survey findings monthly to each of the health plans around the country, outlining how each plan scored on its own and in relation to others. After seeing early results, the physicians and HMOs came up with more service areas that they wanted the research to explore, Bonazelli says, citing an example of questions about appointment waiting time. "Initially, we asked the patients how satisfied they were with the amount of time spent

waiting to see the doctor. That gave us a good gauge. But we weren't finding out how long the wait time is, so we added a question to do that."

Within CIGNA, presentations of research results are made and reports and memos are sent as needed to various departmental and managerial levels. Because research is conducted in all of the many divisions within CIGNA, including property and casualty insurance, and employee retirement and savings benefits, the corporation publishes a quarterly market research update that summarizes the results of the work of all of the research departments within CIGNA.

"It not only communicates results, it keeps us from duplicating work," Bonazelli says, "because even though we have varied lines of business within the company there is the tendency to duplicate if we're not careful. The updates also give us new ideas for approaching a research project and help us make fewer mistakes. You inevitably make mistakes in research, but you make fewer mistakes when you know what disasters struck somebody else."

Strong communication

Bonazelli says that a key to the effectiveness of the patient satisfaction research study thus far has been strong communication between CIGNA and the Gallup Organization, the Princeton, New Jersey-based research firm assisting CIGNA with the study. It has allowed the two sides to cope with the many information processing tasks the survey requires.

For example, CIGNA recently acquired EQUICOR, a group insurance and managed health care organization, and absorbing that company's information on patients and health care providers into the survey process has been time-consuming. "It's a challenge because we're dealing with all kinds of information and data processing systems. We can't hit one mainframe to get all of our doctors or all of our members so we're feeding Gallup information from nine or ten different sources.' Bonazelli says.

"The information processing capabilities at the various HMOs seem to be at different levels. You have state of the art and you have primitive, and we all seem to be somewhere in between. The biggest challenge for Gallup and for us is making sure that we're gathering the sample we want and making sure that the proper sample information gets to Gallup. Working with that wide range of capabilities has been a big challenge and Gallup has been a major help with that. All of our vendors have bent over backwards to keep our data good."

Local study

Currently in development is a local monitoring study designed to track patient satisfaction with other services offered by the health plans. "Along with the relationship with the primary care physician that our members might have, they also avail themselves of other services within the health plan, and the local study will gauge the member satisfaction levels with the various services available through the health plan."

As with the patient satisfaction study, the results will be returned on a site by site basis, but the scope is national, to allow the individual health plans to compare their satisfaction levels to a national average. Gallup will also serve as the research vendor, Bonazelli says, to avoid duplicating respondents. "We want to make sure that we're not calling the same households. And it's much easier to deal with that huge amount of sample data through one vendor rather than spreading it around."