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 3million 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.