You gotta grab ’em with your “lede.” Every journalist knows that, and Medica, a not-for-profit health plan in Minneapolis, found it out too. That’s why, in revising a letter it had been mailing to members, it decided to junk the snooze-inducing first few words.
Under the headline “HEALTH BENEFIT PLAN CERTIFICATION OF COVERAGE,” the letter had greeted envelope-opening recipients with the words “The Health Insurance Portability and Accountability Act of 1996 (‘HIPAA’) requires health plans to provide former participants. . . .”
By then, of course, many of the letters had likely hit the wastebasket or recycling bin. Which was too bad, because one of the main things about this “certification,” as the letter went on to say quite a bit later, was that the plan member was supposed to hang on to it.
“The most important point was highlighted two-thirds of the way through the letter,” marvels Larry Bussey, Medica’s director of corporate communications.
But happily, Medica has given that missive a makeover. The new version greets the member by name under the headline “Important: Keep this Certificate of ‘Creditable Coverage’ or Proof of Coverage.” And the boldfaced opening sentence is clear and plain spoken: “This letter is proof that you had health insurance from Medica.”
The letter’s about-face was part of a concerted effort at Medica to improve written and oral communication with its members. Called Speaking Medica, the program’s goal is to make the health plan’s communication as clear, friendly, and jargon-free as possible. Two years on, Medica is still learning, but it has started on a path that other health plans may wish to travel.
“As health care becomes more commoditized, service becomes the differentiator,” says Lynn Altmann, Medica’s vice president of talent management, whose role in the company’s plain-language initiative began in her previous post as vice president of operations and commercial member experience. “Members have a hard time understanding the ins and outs of how to manage and use their health plan,” she says. “It’s up to us to help make sure they know how to do that effectively.”
Medica began its plain-language initiative by doing a needs assessment to figure out what consumers wanted in their relationship with a health plan. It retained a Minneapolis research firm called Experience Engineering to help with what are called “metaphor elicitation interviews.” Medica members were called at random from a demographically balanced cross section of the health plan’s membership.
Those who agreed to come in for an hour-and-a-half interview in exchange for a $100 stipend were asked to bring pictures clipped from magazines or other sources that illustrated how they wished to feel about their health plan. Participants brought, for example, images of safety nets and sports teammates to suggest the notions of support and partnership.
“One woman brought in a picture of chocolate chip cookies to symbolize the feelings of security and familiarity that her mom’s chocolate chip cookie recipe evoked for her,” Bussey recalls.
Then, in the summer of 2013, Experience Engineering, a Minneapolis company that advises businesses on ways to improve customer service, helped the health plan assess the performance of its call center reps by analyzing hundreds of calls. The challenge of improving call center communications seemed to pull Medica in opposite directions—toward more control of what the reps said on the phone (to make sure they conveyed an appropriate message and attitude) but also toward less (so reps would come off as warm and responsive helpers rather than script-reading automatons).
Another difficulty: Some reps had long-established patterns of how they interacted with members. The company had to find creative ways to change their behavior.
The takeaway from the research by Experience Engineering and the health plan was that members wanted to feel “understood, assured, and unconcerned.”
One of these innovations was the monthly buzz phrase. Group leaders choose a new phrase or statement that typifies the empathy and clarity they seek. Throughout the month, reps are encouraged to work those magic words into their phone conversations—one statement, for example, was “I want to make this simple for you.” When a rep is overheard using the phrase of the month, his or her name is put into a hat for a weekly drawing for a small reward, such as a store gift card.
“You want to be ‘caught’ using the phrase,” says Altmann. “You know you won’t be caught every time, but you get rewarded when you are.”
The leaders also tapped the call center reps for ideas. The centers began having thrice-weekly “huddles” in which reps shared the strategies they’d created for developing a connection with callers and making complex information clear to them. On the theory that the best way to convey knowledge is to draw on one’s own genuine understanding, Medica gave reps the go-ahead to leave the acronyms and lingo behind and use their own words.
Jargon can be hard to part with. To the person using it, complicated language can seem more precise.
“We empowered them to explain things to the consumer based on their own personal understanding instead of using legalese or jargon—whether that meant using an analogy, breaking a concept down into parts, or whatever,” says Altmann.
Call center reps began, for example, to describe the base benefit as “a pot of money the employer gives us” and to liken preventive care to regularly changing the rotors and brake pads in your car. “Deductibles and premiums are like a seesaw,” they’d say, coaching a member on how to compare one coverage option with another. “When one goes up, the other goes down.”
A benefit of the call center initiative, Bussey explains, was to help the health plan “identify where members were experiencing the most confusion or frustration.” Such areas—referrals, preventive care, and out-of-network benefits, for instance—could then be given special attention.
It helped that the call center effort had a natural ally in the executive suite: Dannette Coleman, the company’s senior vice president of individual and family business, had started her Medica career more than two decades ago as a call center rep.
Individual and family business became the focal point of the company’s overhaul of its numerous written communications—like that “certification” letter. Under Coleman’s leadership, Medica had introduced a new technology for enrollment and claims processing for that business segment. The changeover offered a chance to take a fresh look at communications.
“It was a unique opportunity to look all at once at every written communication the company regularly sent out—enrollment letters, explanations of benefits, claim letters, denial-of-appeal letters, newsletters, and so forth—and rewrite them all to make them more clear, direct, and understandable,” says Altmann. Medica is now doing a similar review of its communications in its commercial, Medicare, and Medicaid segments.
One thing the health plan has learned is that it was simply sending out too many letters. Of 375 letters in the individual and family business segment, 200 were eliminated.
Medica scrutinized the remaining letters—in many cases, forms to be completed and personalized with a consumer’s specific information—to be sure they were consistent with its goal of making members feel “understood, assured, and unconcerned.” To do so, it established a 10-member Communications Review Board, with members from different departments across the company. Initially, it was a fairly major time commitment; members convened for two-hour sessions twice weekly.
Altmann and Bussey both serve on this board, along with a call center director, a senior director of information technology, and the vice president of communications for the commercial segment. A lawyer is always present because regulatory requirements are frequently involved. If the communication relates to a specific clinical area, a doctor or nurse may also sit in.
“The writers who have developed a letter draft will present it, and we’ll go over it for clarity and consistency—for the use of a common glossary of terms, for example,” says Altmann. Adds Bussey: “We try to make the meetings fun. The first time people come, they perhaps feel a bit overwhelmed.”
The board meetings do double duty, Bussey explains. The text in question is improved, and the company’s writers and editors get trained in how to communicate clearly so that their future work needs less revision. The board uses a checklist approach to evaluate a document, using a series of questions: Does it clearly explain the step Medica is taking, what the member needs to do, and how to do it? Does it explain the why? Does it eliminate jargon? Is it written at an eighth-grade level? A text’s grade level is evaluated using the “Show Readability Statistics” option that comes with Microsoft Word.
The review process often requires thinking outside the terminology in which even public relations professionals spend their days. An early draft of a reminder letter aimed at members who didn’t appear to be refilling their prescriptions used the word adherence, recalls Bussey: “But that term isn’t part of most people’s everyday vocabulary. It was changed to ‘taking your medicine.’”
Letters that touch on painful topics or that give recipients bad news are a challenge. “We’ve had letters for members who have lost a baby,” says Bussey. “And recently we reviewed a letter to someone who didn’t understand that he or she had gone out of network and was therefore being charged out-of-network rates.”
“Our task in cases like that,” says Altmann, “is to make sure we always address the recipient respectfully—not in cold, transactional language. We present other options, if possible, to help the member make sure such a mistake doesn’t recur and always to keep in mind that this is a person we’re talking to.”
To test the effectiveness of its effort to make its communications member-friendly, Medica also established an informal external review process using volunteers—some with family connections to Medica employees—who were communications-savvy but didn’t work in the health care or insurance industries. These reviewers received drafts of proposed messages to members and were asked to comment—brutally if need be.
“Sometimes when we thought we’d made something as simple and clean as possible, we’d get it back and it would say, ‘Don’t understand what you’re trying to say in the first paragraph,’” Altmann remembers. “And we’d be like, ‘Really?’ But it’s because we live and breathe this stuff every day.”
One of the external reviewers, Andy Ringgold, says he often thought he was reading rough drafts—but wasn’t. Retired from a career with the National Park Service, where he says he had a reputation as the “editor from hell,” Ringgold says communications from health care companies need to be clear and should always list a contact person with a phone number. And if possible, “They shouldn’t sound like they’re from Big Brother.”
Have Medica’s efforts to clean up its communications been worth the investment of staff time and other resources? The health plan has no return on investment figure but says other indications are encouraging. Last year, the first full year of the Speaking Medica program, phone conversations with Medica’s call center reps had an average “satisfied” rate of 4.59 out of 5.0, the best in the company’s history. Through 2014, Medica’s CAHPS rating in surveys by AHRQ have risen annually for five years running. (In somewhat plainer language, that’s the Consumer Assessment of Healthcare Providers and Systems rating from the U.S. Agency for Healthcare Research and Quality.)
Anecdotes aren’t evidence, but they send a positive signal. A member who commented on the call center volunteered that the Medica rep he had spoken with had used “plain language” without even being prompted with the phrase. A public radio call-in show about people’s health insurance hassles drew a Facebook comment from someone who declared that “my [renewal] letter from Medica gave me all sorts of information, and it was great.”
Asked for their advice to other health plans interested in launching plain language initiatives, Altmann and Bussey caution that jargon and complicated language are often hard to part with. In any field, people get attached to jargon because it is efficient. To the person using it, complicated language can seem more precise.
“We didn’t get lots of resistance, but there were pockets of it,” says Altmann. “When we tried to break things down to an eighth-grade reading level, some people would complain, ‘That doesn’t sound formal enough. Why would we say it that simply?’”