September 2000

This Ain't No Disco

by Susan Frager, LCSW

The first time I experienced the Strobe as an employee of a managed behavioral care company, I thought one of my co-workers had gone into cardiac arrest. Or that maybe I would. All of a sudden, lights flashed, and a buzzer that sounded like a dying cat went off, three times in a row.

“What’s that?”  I looked across the aisle at my neighbor. “Keep your head down and look busy!” Clinicians all over the long room were sitting down in their cubes, putting on telephone headsets. Conversations stopped abruptly as people turned to their computer monitors. No one dared look up.

The Strobe, I would later learn, was a frequent occurrence in this noisy, tense call center full of 6-foot by 6-foot cubes, neatly arranged side by side, stretching from one wall to the other without interruption. I learned that anyone whose head was visible above the cube line was in for it, when the Strobe went off. Supervisors could be seen prowling the aisles, looking for people who were not on the phone. My dreams ever since have been haunted by that sound, and the image of a Luke Skywalker-style lightsword decapitating the unlucky employee who happened to be caught standing up when the Strobe sounded and flashed.

The Strobe was the signal to the team of intake clinicians and their backups, the case managers, that there was at least one caller who had been waiting on hold longer than 20 seconds. Not just any caller, though. Only members of the employer’s health plan, because the plan had paid extra to be sure that none of its “lives” ever had to spend time on hold. Any professional not already on the phone when the fatal Strobe sounded was expected to drop whatever they were doing and answer the incoming call, whether they were a member of the intake team or not.  This was Serious Business. If we, the team, failed to meet the contract guarantee with the employer that 98% of the calls to the member line would be answered in fewer than 30 seconds, the company would lose hundreds of thousands of dollars.

There were elaborate systems in place to make sure that never happened. To start with, you couldn’t just arrive, turn on your computer, and get to work. Case managers and intake clinicians weren’t considered officially “arrived” at work until we punched a personalized login code into the phone, which would tell the automated call distribution system that we were at work. (A side benefit of the phone login requirement, at least for management, was the fact that somewhere in cyberspace, a computer recorded the time you logged in. Management denied that the phone login was a high-tech version of a time clock, but everyone knew better. This was confirmed, just before I left for good, by my short stint on the After Hours team, which covered nights and weekends. In After Hours, they gave you an “occurrence” for each late arrival. Late was defined as 3 minutes past your starting time, determined by the phone login clock. A certain specified number of occurrences meant a verbal warning, a few more meant a written warning, beyond that, you were history. They meant it too.  

Once safely logged in to the phone, you had three choices of call reception mode. “Available” meant that you were part of the “clinical referral line hunt group.” In other words, member-callers who chose the option “if you would like to access your mental health benefit, press #,” would be routed to those in “available” mode. Then there was the “unavailable” mode, and something they called “work.” “Work” blocked calls, but it was meant to be used when you were sitting at your desk entering data from calls into the computer. “Unavailable,” for intake team members, was only to be used for when you were not at your desk, because supervisors kept track of the percentages of time spent in each of the three modes. Those of us not on the intake team lived on “unavailable.” Except, of course, when it Strobed.

The Strobe was so important, in fact, that it had its own guardian, the “Strobe Operator.” This person’s entire job consisted of watching the call volume on a computer and setting off the Strobe when a call reached 20 seconds on hold. The Strobe Operator continually surveyed clinicians’ call reception modes - as did any supervisor who cared to activate the same program on their computer. The supervisors were also the arbiters of Quality. They were supposed to listen randomly to intake calls, make sure thorough clinical assessments were completed, and then tell us how we could improve in our customer service, or else how to expedite the handling of calls. Professionals’ overall performance on calls was graded on a complex point system, and kept in our personnel files. Those dropping below an 85% performance level were given detailed disciplinary goals to be met in specific time frames, at peril of job loss.

The wall monitor completed the ensemble of systems designed to make sure that we met our goal of answering all calls in under 30 seconds. Mounted high on the wall facing the intake team, the wall monitor looked like one of those stock exchange instant-readout boards. Anyone looking at it, if they knew what the symbols meant, could tell how many clinicians were on “available,” how many were currently on calls, the number of callers that were waiting, the number of people on “work,” and so on.     Behind the scenes, the computer kept statistics on the percentages of time spent in each mode, the average talk time on calls, and the percentage of referrals made to each level of care. Clinicians on the intake team were given their stats in monthly meetings, and if they hadn’t met certain pre-determined targets, they were instructed on how to get their performance in line.

Case managers, those of us clinicians who were not part of the intake team, were permanent backup. If the Strobe went off at 9:57 am, it didn’t matter if you had a telephone appointment with a provider or hospital review nurse at 10. We were monitored on the number of times each of us answered the Strobe, and those of us falling behind our peers were told in no uncertain terms that we had better hop to it.

The caller could be anyone. The Strobe was the ultimate gamble. The person on the other end of the line could be suicidal, or they might just want to know why a claim had not been paid. I’m not sure which was harder to deal with; callers who ended up hospitalized probably had a better chance of getting their problem resolved than those calling about claims or network issues. At least I could authorize care if someone was calling requesting treatment. If it was a claims or network problem, I would have to pass the caller on to the appropriate department, and I had no illusions that the caller’s situation would be solved, only hope. We all knew that other departments did not always fulfill their functions as thoroughly or as efficiently as we would have liked. How could we believe that everything was okay, when we dealt with the consequences, in the form of numerous complaints that we were powerless to fix? 

People’s claims never got responded to, or were inappropriately denied.  “Yes,” I said, “that session was authorized. No, I don’t know why the claim was denied.  Would you like me to transfer you to Claims?”

The provider network was riddled with out-of-date addresses and telephone numbers. “No, I’m sorry, I can’t update your record.” Why not? “Because you have to have special computer access codes to be able to make address and phone number changes. I’m sorry, it’s silly that they don’t allow us access. Would you like to be transferred to Provider Relations? Really, that’s all I can do.” “Yes, I understand you’ve sent a letter requesting changes five times. I even believe it, I had to send a copy of my own license update to Provider Relations four times, myself.”

The sense of utter powerlessness and futility was far more draining than working with the most clinically demanding of clients, and, like the Strobe, it assaulted me every day.

Susan Frager, LCSW, is the author of Managing Managed Care: Secrets from a Former Case Manager, published earlier this year by John Wiley & Sons.  Susan can be reached at sfrager@swbell.net.

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