[Senate Hearing 110-829]
[From the U.S. Government Publishing Office]


                                                        S. Hrg. 110-829
 
                1-800-MEDICARE: IT'S TIME FOR A CHECK-UP 

=======================================================================

                                HEARING

                               before the

                       SPECIAL COMMITTEE ON AGING
                          UNITED STATES SENATE

                       ONE HUNDRED TENTH CONGRESS

                             SECOND SESSION

                               __________

                             WASHINGTON, DC

                               __________

                           SEPTEMBER 11, 2008

                               __________

                           Serial No. 110-35

         Printed for the use of the Special Committee on Aging



  Available via the World Wide Web: http://www.gpoaccess.gov/congress/
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                       SPECIAL COMMITTEE ON AGING

                     HERB KOHL, Wisconsin, Chairman
RON WYDEN, Oregon                    GORDON H. SMITH, Oregon
BLANCHE L. LINCOLN, Arkansas         RICHARD SHELBY, Alabama
EVAN BAYH, Indiana                   SUSAN COLLINS, Maine
THOMAS R. CARPER, Delaware           MEL MARTINEZ, Florida
BILL NELSON, Florida                 LARRY E. CRAIG, Idaho
HILLARY RODHAM CLINTON, New York     ELIZABETH DOLE, North Carolina
KEN SALAZAR, Colorado                NORM COLEMAN, Minnesota
ROBERT P. CASEY, Jr., Pennsylvania   DAVID VITTER, Louisiana
CLAIRE McCASKILL, Missouri           BOB CORKER, Tennessee
SHELDON WHITEHOUSE, Rhode Island     ARLEN SPECTER, Pennsylvania
                 Debra Whitman, Majority Staff Director
            Catherine Finley, Ranking Member Staff Director

                                  (ii)

  

























                            C O N T E N T S

                              ----------                              
                                                                   Page
Opening Statement of Senator Gordon H. Smith.....................     1
Opening Statement of Senator Herb Kohl...........................     4

                                Panel I

Statement of Kerry Weems, Acting Administrator, Center for 
  Medicare and Medicaid Services, U.S. Department of Health and 
  Human Services.................................................     5

                                Panel II

Statement of Naomi Sullivan, Medicare Beneficiary, Chico, CA.....    24
Statement of Michealle Carpenter, Deputy Policy Director and 
  Counsel, Medical Rights Center.................................    29
Statement of Tatiana Fassieux, Board of Directors Chair, 
  California Health Advocates, Sacramento, CA....................    37
Statement of John Hendrick, Project Attorney, Elder Financial 
  Empowerment Project, Coalition of Wisconsin Aging Groups, 
  Madison, WI....................................................    49

                               Panel III

Statement of John M. Curtis, President and Chief Executive 
  Officer, Vangent, Inc., Arlington, VA..........................    55

                                APPENDIX

Prepared Statement of Senator Robert P. Casey, Jr................    59
Kerry Weems Responses to Senator Smith's Questions...............    59
Michealle Carpenter's Responses to Senator Smith's Questions.....    62
Tatiana Fassieux's Responses to Senator Smith's Questions........    63
John Curtis's Responses to Senator Smith's Questions.............    63
Statement by the Health Assistance Partnership...................    65
Testimony of Jettie Turner, Medicare Beneficiary, Tupelo, MS.....    67
Testimony of Colter McLellan, Medicare Beneficiary, Picayune, MS.    77
Testimony of Dawn V. Crouse, full-time volunteer SMP Counselor, 
  Mississippi Senior Medicare Patrol, Columbus, MS...............    86
Testimony of Frankie F. Ferguson, Medicare Beneficiary, Oxford, 
  MS.............................................................    92

                                 (iii)

  


                1-800-MEDICARE: IT'S TIME FOR A CHECK-UP

                              ----------                               


                      THURSDAY, SEPTEMBER 11, 2008

                                        U.S. Senate
                                 Special Committee on Aging
                                                    Washington, DC.
    The committee met, pursuant to notice, at 10:08 a.m., in 
room SR-325, Dirksen Senate Office Building (Hon. Gordon H. 
Smith) presiding.
    Present: Senators Smith [presiding] and Kohl.

          OPENING STATEMENT OF SENATOR GORDON H. SMITH

    Senator Smith. Good morning, ladies and gentlemen. We 
welcome you all to this very important hearing, 1-800-MEDICARE: 
It's Time for a Check-Up. We're met in this historic room of 
the Senate Russell Caucus Room. I don't know that Administrator 
Weems will regard this as anything like the Watergate hearings. 
We don't intend it to be. But a lot of historic things have 
happened here.
    Certainly one of the more historic things that Congress has 
done in the last several years is the Medicaid reform, the 
update that includes Medicare Part D. Medicare Part D is a 
massive program to provide seniors with prescription drug care 
as part of their Medicare benefit.
    When we began to put this legislation together to provide 
this reform and this new benefit, we recognized that it was a 
monumental task. CMS, through Health and Human Services, has 
certainly had an enormous job to do. Our focus here today is on 
how we can do that job even better. This is not designed to 
call into question anyone's motive or in any way to question 
their sincerity, and Kerry Weems, who is the Administrator of 
CMS, has been many times to my office. I appreciate that, 
Kerry, and I appreciate your attention to this issue, and we 
are grateful for your service to our country. You've spent a 
lot of time in the Federal Government trying to get these 
programs right, and that is the spirit in which we gather here 
this morning.
    When we began to put 1-800-MEDICARE together as part of it, 
we did this because we heard predicted lots of problems that 
may emerge in terms of customer service as seniors try to 
navigate this very difficult path of getting enrolled and 
getting the benefit that comes with Medicare.
    So today's hearing is the product of a 3\1/2\ year ongoing 
investigation into the performance of 1-800-MEDICARE. Since I 
will be spending quite a bit of time during today's hearing 
talking about findings from my investigation, I'm going to take 
a moment to provide an overview of the committee's work on this 
subject. To ensure operational readiness for the first Part D 
open enrollment season, we commenced an inquiry into the 
performance of call centers in early 2005. This investigation 
has entailed the following: 500 test calls to 1-800-MEDICARE; 
annual inspections of 1-800-MEDICARE call centers across the 
country; interviews with 150 consumer service representatives 
and management staff who work at the 1-800-MEDICARE call 
centers; monitoring 200 hours of inbound calls; correcting 
error-ridden scripts related to premium withholding errors; 
reviewing call center performance data; exchanging hundreds of 
phone calls and emails with CMS, its contractors, 
beneficiaries, and advocates, subpoena of call center records 
from the administration and Part D plans; exchanging hundreds 
of--meetings with three separate CMS administrators, including 
Administrator Weems who is here today, and we appreciate his 
presence, as well as a former Social Security Commissioner.
    I also raised call center performance failures and resource 
issues at prior hearings of this committee and in the Finance 
Committee where I serve. I've convened today's hearing with the 
indulgence of the chairman. I appreciate Senator Kohl very 
much, whom I thank for his support in the committee's ongoing 
efforts to improve services at 1-800-MEDICARE.
    To start the hearing on a positive note, I'll first comment 
on what seems to be working well with 1-800-MEDICARE. See, 
there's good to report as well, Kerry. My staff have 
consistently had the highest praise for the professionalism and 
courtesy of the customer service representatives and management 
who work in the 1-800-MEDICARE call centers. The reports that I 
have received reflect that on the whole the staff at 1-800-
MEDICARE are earnest, professional, and courteous and care a 
great deal about providing the best service possible to 
beneficiaries.
    I'll be discussing this in more detail during the hearing, 
but my conclusion is that the problems at 1-800-MEDICARE lie 
more with the training and resources provided to call center 
staff rather than with the staff themselves.
    I have also been quite pleased with CMS's timely resolution 
of individual beneficiary cases that my office has referred to 
the agency. A further note. CMS recently implemented a 
dedicated access number for the State Health Insurance and 
Assistance Program, or SHIP, as it's known, and they did this 
to streamline SHIP's access to 1-800 services. CMS also 
recently hired an outside vendor to revise the training 
curriculum and call scripts used by 1-800-MEDICARE service 
representatives.
    However, as you might conclude, if all were well we 
wouldn't be here today. So let's delve into what needs to be 
improved and what we're going to spend most of this morning 
discussing. My investigation has revealed persistent problems 
at call centers and they include:
    One, confusing interactive voice response menu options, or 
IVR, as it's called.
    Another is unacceptably long waiting times, up to one hour 
during peak call periods. I know that when you spread it, 
Kerry, over a 24-hour period it takes the average down. But if 
you look at the 8 hours of business calls, that period of time, 
that's where it gets really, really long, and that's when 
people are most likely to call.
    Other problems are disconnected calls, technical and 
infrastructure failures, inappropriate referrals to SHIP and 
other entities, jargon-filled and error-ridden scripts that are 
used by customer service representatives to respond to caller 
inquiries, oversight inadequacies, training deficiencies, and 
incorrect information routinely being dispensed by customer 
service representatives.
    Many of today's witnesses will share their firsthand 
experience in trying unsuccessfully to utilize 1-800-MEDICARE. 
These stories reveal much work remains to improve call center 
services. As we'll hear in testimony today, the problems at 1-
800-MEDICARE are not mere inconveniences to beneficiaries. When 
1-800-MEDICARE provides incorrect information, the result can 
be devastating to beneficiaries.
    An Oregon transplant patient in California nearly died 
because 1-800-MEDICARE provided incorrect information about 
coverage of anti-rejection medications. A senior in Florida 
ended up in the emergency room after foregoing necessary oxygen 
treatments because 1-800-MEDICARE provided her with incorrect 
information about the durable medical equipment program.
    Earlier this year I assisted beneficiaries who received 
incorrect information about the Part D enrollment process. 
These beneficiaries had been turned over to collection agencies 
for past due premiums for a plan in which they were no longer 
supposed to be enrolled. A cancer patient nearly died because 
he could not receive assistance in locating a facility for 
chemotherapy.
    Hundreds of stories like these have been shared with my 
office by tearful beneficiaries and advocates who are 
completely exasperated by their experiences with 1-800-
MEDICARE. I've previously related to Administrator Weems my 
belief that there are failures in the system that we need to 
fix. That conclusion is informed by these test calls that we 
have made and also by the Government Accounting Office and the 
Department's own Office of Inspector General, as well as 
information provided by the agency itself regarding call center 
performance.
    The population served by 1-800-MEDICARE is comprised of our 
country's most vulnerable citizens. It is unacceptable to 
subject the sick, frail, and elderly to long waits, hour-long 
waits, disconnected calls, endless loops of referrals and call 
transfers, and erroneous information about benefits and 
services. It's imperative that we deliver this in a timely and 
accurate way.
    I want to just say as an aside that I was contacted by Good 
Morning America on this hearing today and I basically told them 
what I just said in this statement, Kerry. You didn't say it, 
but I understand someone at CMS said that our investigations 
were outdated. I don't believe they're outdated. My staff 
placed 50 test calls over the past 4 weeks. On August 28 of 
this year I received call center performance data current 
through July 2008.
    In June of this year my staff traveled with yours to the 
Richmond Call Center. At that time your staff and mine made 
test calls collaboratively onsite. During every single one of 
these test calls--let me repeat that during every single one of 
those test calls, CRS provided incorrect information. When 
asked to assign a letter grade to those test calls, the call 
center management assigned grades ranging from B-minus to F.
    During that site visit my staff also conducted side by side 
monitoring of live inbound calls. The service was less than 
stellar. My staff raised several concerns to yours onsite that 
day regarding what had transpired during those calls. After 
that site visit and after you'd been informed about what 
transpired during the June visit, I'm informed you made an 
emergency site visit of your own to a Phoenix call center to 
investigate, and I appreciate that.
    Further, throughout this week of investigation my staff 
have interviewed Vangent, Briljent, and other contractors as 
well as 53 advocates and beneficiaries.
    In any event, I very much hope that this will be a positive 
hearing. Part of our responsibility is to bring light and heat 
to issues and problems as we see them, not to denigrate but to 
build. So in that spirit, I thank you for being here, 
Administrator Weems, and I turn the mike over to my colleague 
Senator Kohl, the chairman of the committee.

             OPENING STATEMENT OF SENATOR HERB KOHL

    The Chairman. Thank you very much and good morning to all.
    I thank Senator Smith for holding this hearing. Senator 
Smith, you and your staff launched an investigation into 1-800-
MEDICARE nearly 4 years ago. Considering all your hard work and 
due diligence, I am confident that today's hearing will lead to 
improvements in the government's ability to help seniors get 
the health care they need.
    Consumer service is a critical component of navigating the 
Medicare system. CMS currently estimates that 1-800-MEDICARE 
will receive 34.5 million phone calls in 2009. Older Americans 
use the help line to differentiate and decipher the 
overwhelming number of plan options available, to ask questions 
about coverage, to switch plans, and to file complaints.
    Senator Smith's investigation shows that, in addition to 
lengthy wait times and a failure to call participants back when 
promised, much of the information disseminated by Medicare 
customer service representatives is incorrect and inconsistent. 
These can be grave errors. Misinforming Americans about their 
Medicare coverage can cause them to pay much more out of pocket 
than they should have to or, worse, leave them without the 
treatment or medications that they require.
    This committee worked side by side with CMS on many issues 
and I appreciate the working relationships that we have. I hope 
that we can all learn lessons from today's hearing and continue 
to improve Medicare for older Americans.
    I would like to particularly thank the Coalition of 
Wisconsin Aging Groups for offering their expertise this 
morning.
    Once again I thank you, Senator Smith, for your leadership 
on this very important issue.
    Senator Smith. Thank you, Chairman Kohl.
    Kerry Weems is the Acting Administrator of the Center for 
Medicare and Medicaid Services, which administers and oversees 
1-800-MEDICARE. He's here to discuss CMS's efforts to ensure 
the overall success of the program and its working relationship 
with Vangent, the company it contracts with to accept incoming 
beneficiary calls. Kerry, take it away.

  STATEMENT OF KERRY WEEMS, ACTING ADMINISTRATOR, CENTERS FOR 
 MEDICARE AND MEDICAID SERVICES, U.S. DEPARTMENT OF HEALTH AND 
                         HUMAN SERVICES

    Mr. Weems. Thank you, Senator Smith. Good morning, Chairman 
Kohl. I'm happy to be here to discuss 1-800-MEDICARE and how it 
serves our 45 million Medicare beneficiaries.
    Just stepping back for a moment, the Medicare program has 
changed significantly since when I began my career in HHS in 
1983. At that time the total number of Medicare claims 
processed was about 325 million and most of that was on paper. 
I'd just say parenthetically, at that time we didn't have PCs 
on our desks; we had ashtrays. A lot has changed since then. 
The total number of contractors that we had processing those 
claims was 104.
    So if a beneficiary had a question about a claim or a bill 
or if they had questions about whether nursing home care or 
home health services were covered, they might have to make up 
to six phone calls, six different phone calls, to get answers 
to those questions. For example, for hospital or nursing home 
stay questions the beneficiary would have to make at least two 
phone calls to fiscal intermediaries to find answers, depending 
on what State they lived in. For physician questions, the 
beneficiary would have to make at least one call to a carrier. 
Some States, however, had two carriers, which would have 
required an additional call depending on the service. For a 
home health question, the beneficiaries would have to call the 
regional home health intermediary, and if there are questions 
about primary or secondary insurance they'd have to call the 
coordination of benefits contractor. This was not only time-
consuming, it was frustrating and probably a poor business 
model.
    So fast forward to today. Today Medicare processes nearly 
1.1 billion bills, over 99 percent of which are electronic. We 
have about 49 contractors handling those bills now. That number 
continues to decline. Most important to note is that 
beneficiaries can call one number today to get the answer to 
any Medicare-related question, and that number is 1-800-
MEDICARE.
    By calling 1-800-MEDICARE, beneficiaries can check on claim 
status, find a provider or supplier in their area, and find out 
about primary or secondary coverage. So with few exceptions, a 
beneficiary can have almost all their Medicare-related 
questions answered by calling 1-800-MEDICARE, which also refers 
beneficiaries to plans and to SHIPs for more personalized 
service.
    But the consolidation to 1-800-MEDICARE didn't occur 
overnight. It was an evolution of a vision to simplify Medicare 
processes under one roof, and it took hard work to get the 
operation that exists today.
    The 1-800-MEDICARE arm of our outreach strategy is a toll-
free number that beneficiaries can use to get help on all 
aspects of the Medicare program. Services are available around 
the clock 24 hours a day, 7 days a week. In fewer than 10 years 
we've increased the operational capacity of 1-800-MEDICARE 
almost eightfold. The phenomenal growth has been the result of 
significant changes in the Medicare program and extensive 
outreach to beneficiaries to teach them to call 1-800-MEDICARE 
for their inquiries.
    As it's matured, the number of calls handled by 1-800-
MEDICARE has grown dramatically. From 1999 to 2003, yearly 
calls averaged 5 million or less. However, the enactment of the 
Medicare Modernization Act of 2003, which included the creation 
of a prescription drug benefit, changed forever the way that 
CMS interacts with its beneficiaries. The expansion of choices 
brought about by the drug benefit and by Medicare Advantage 
meant that CMS and our partners would have to respond to many 
more inquiries about a much greater range of topics.
    As you can see from this chart on my left, with the 
implementation of the Part D program the call volume to 1-800-
MEDICARE skyrocketed. In 2004 and 2005, call volumes were 20.2 
million and 28.2 respectively. In 2004 the call volume was due 
to the issuance of the Medicare approved drug discount card. In 
2005 the annual election period for the Part D prescription 
drug program significantly increased call volumes.
    In 2006, the Part D program resulted in a dramatic spike in 
call volume, all the way to 37.5 million calls. In 2007 call 
volumes reached 30 million and we're on track to receive about 
29 million calls in 2008.
    As Medicare expanded and changed, so did our 1-800-MEDICARE 
operations. In September 2007 all beneficiary call services 
were consolidated into the beneficiary contact center, which 
encompasses all of 1-800-MEDICARE operations. 1-800-MEDICARE 
has existed in its current form for only one year.
    Senator Smith, your review of the 1-800-MEDICARE operations 
has led to changes in the system that will enhance callers' 
experiences and ensure that callers receive accurate and up to 
date information. CMS is committed to decreasing caller wait 
times. Due to recent procedural and technological changes, the 
average monthly speed of answer for this coming year, the 
remainder of the year, will be 5 minutes or less.
    As you can see from the next chart, we had contracted using 
the old technology at about 8 minutes of average speed of 
answer time. The implementation of that technology and those 
procedural changes, at your urging, has made a significant 
difference in our average speed of answer already. That will 
continue throughout the year. In addition, your concerns on the 
quality of answers callers receive have accelerated our review 
of call scripts and customer service representative training.
    As we get ready for the upcoming annual election period for 
2009, we're reviewing and updating call scripts with the help 
of a third party validator. As a result of this review so far, 
some of the scripts were deactivated and others were 
consolidated into a new Smart Script format. We've also made 
changes to the content and the flow of the scripts. Make no 
mistake, the Medicare program, the fee-for-service program, is 
a complex program and many times difficult to explain. The 
content and the flow are very important.
    We've also given our customer service representative 
training a closer look, thanks to your feedback. We're in the 
process of expediting changes to the new hire training program 
to ensure that our new customer service representatives are 
better prepared to assist callers.
    In response to feedback from the committee and others, CMS 
has worked hard to improve all aspects of the caller's 
experience. By employing new technologies, callers are able to 
self-serve using the interactive voice response, or IVR, 
system. As with virtually all call centers, callers to 1-800-
MEDICARE are greeted by an IVR. The new IVR provides callers 
the ability to access certain prerecorded information to answer 
basic questions, and it also routes callers who need specific 
information to the right customer service representative.
    The IVR allows beneficiaries to look up claims information 
and hear their current deductible status, as well as last 
year's deductible status. In addition, beneficiaries can hear 
messages about a description of the various preventive programs 
Medicare provides, how to enroll in a Part D program, how to 
switch Part D plans, and how to apply for financial assistance.
    Customer service representatives are charged with 
understanding and explaining the Medicare program to 
beneficiaries. We use a scripted content approach to provide 
beneficiaries with consistent and accurate information. This 
process assists customer service representatives to quickly and 
efficiently find information on a vast array of topics, from 
claims payment status to Medicare policies and procedures.
    Like virtually all of our work, CMS uses contractor staff 
to answer calls and manage the infrastructure of 1-800-
MEDICARE. You will hear from our contractor later. This 
strategy allows CMS to be highly responsive to call spikes that 
often accompany the annual election periods, various Medicare 
campaigns that require rapid shifts of resources or other 
special circumstances. We have the ability to reroute calls 
from less busy call centers as well as shift customer service 
representatives to phone duty who would otherwise be answering 
the mail.
    Our 1-800 number has planned and announced closing dates on 
some Federal holidays. But, given contractor flexibility, three 
call centers were open this Labor Day in anticipation of 
greater call volumes due to the impending Hurricane Gustav. In 
addition, CMS had call centers open on July 4 of this year due 
to the expanded increase in call volume from the newly 
implemented durable medical equipment program.
    Overall quality assurance and monitoring activities help 
ensure quality interactions occur between beneficiaries and 
their families across multiple channels. Our activities focus 
critical attention on customer service representative 
performance across all channels, including telephone, written 
correspondence, email, web chat. Calls are closely monitored 
and the quality monitoring that is performed is then used by 
the contractor to coach and teach and provide feedback to 
individual customer service reps.
    In our effort to continue to improve 1-800, CMS is working 
to implement several enhancements to the system in order to 
better serve callers. These will come on line through this year 
and next. We're simplifying the prescription drug plan 
enrollment algorithms to better identify beneficiary 
eligibility during special election periods. A new virtual 
callback option is being deployed which will allow callers to 
call in to our system; if they have to wait, they can hang up 
and the system will call them back while holding their place in 
the queue. That way they can talk to a customer service 
representative and not just hang on the phone.
    An improved learning management system is being implemented 
which will help us to identify the training needs of customer 
service reps and disseminate information to those CSRs in call 
centers.
    Finally, as we begin our next release of the IVR we'll 
begin playing proactive messages tailored to the beneficiary's 
particular plan and enrollment, also attuned to the time of the 
year that the beneficiary is calling.
    We acknowledge that 1-800-MEDICARE is not perfect, but we 
feel that it's successful in meeting the needs of our 
beneficiaries and with continued attention on the part of CMS 
and of this committee it will continue to improve. I'm happy to 
answer any questions you have. Thank you for giving me the 
opportunity to appear today.
    [The prepared statement of Mr. Weems follows:]

    [GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]
    
    Senator Smith. Thank you very much, Kerry. What I heard you 
describe was an acknowledgment that we're making progress, but 
we've got a way to go, and that you and CMS take responsibility 
for that.
    Mr. Weems. That's correct.
    Senator Smith. I appreciate that, and that's the point of 
this hearing, is just so the relationship we have between the 
Legislative and Executive Branch is we're on the same page and 
we're going the same direction.
    Kerry, as I related in my opening statement, there are some 
of the problems I'd like to get your response to. For example, 
you've spoken to it a bit, but I'm worried that the scripts are 
too technical and they presuppose programmatic expertise that a 
caller won't have. I'm aware that this is contracted out and I 
want to relate to you information that one of the new 
contractors is providing.
    The beneficiary in this scenario calls 1-800-MEDICARE with 
a question. A tier one representative answers the call and 
requests the beneficiary's Medicare number. The beneficiary 
tells the first representative that he has lost his card and 
all his paperwork and does not have his Medicare number 
available. The beneficiary is then transferred to a tier two 
representative, to whom he once again has to explain his issue. 
The beneficiary also states numerous times throughout the 
exercise that he has lost his paperwork and doesn't have his 
Medicare number.
    The tier two representative continues to tell the gentleman 
that he needs to locate other documents that might contain his 
Medicare number, even though he has already stated he does not 
have these documents.
    At the end of the call, the beneficiary never gets his 
original question answered due to the fact that he does not 
have his Medicare number available. Remarkably, throughout the 
50-plus pages of this interactive training exercise, not once 
during the mock call does the representative provide the 
beneficiary with instructions on how to obtain a new Medicare 
card. Instead, the beneficiary is sent on a scavenger hunt 
throughout his house trying to locate documents that he has 
already told the representative he does not have.
    That scenario to me doesn't sound like the best response.
    Mr. Weems. No, clearly it's not. Under the circumstances 
where a beneficiary may not have access to their Medicare 
number, one of the things that we are extraordinarily careful 
about and I think you'll appreciate is disclosure of 
information to people who are not the beneficiary. In fact, 
that's one of the primary checks on a customer service 
representative: Are they in fact talking to a beneficiary? Are 
they talking to their representative? Has their representative 
been designated?
    Obviously, the situation that you describe is not ideal. 
There are other ways that a beneficiary can show who they are 
and receive the information that they need. Obviously, an area 
where we need to improve.
    Senator Smith. Kerry, are you persuaded that there's a 
sufficiently robust training program for those on the consumer 
service end?
    Mr. Weems. Sufficiency is always in the eye of the 
beholder, and in this case in the eye of the experiencer.
    I think we can do better. Part of the third party 
validation contract we have is to look at the training program 
and provide additional training--provide targeted training to 
customer service representatives.
    One of the things that we've discovered with customer 
service representatives, they come in and they get 3 weeks of 
classroom training. Classroom training only works so well for 
adults. Classroom training works well for other age groups, but 
for adults you need to get them on the phone, you need to get 
them to where they're starting to handle calls. That is our 
training model, 3 weeks of classroom training, demonstrate 
competency, move to the phones, but be closely monitored and 
closely supervised until they're able to work on their own.
    Senator Smith. Kerry, you and I have talked privately about 
whether or not there is sufficient funding for 1-800-MEDICARE. 
I have urged the agency to make the requests to the 
administration to get whatever funding is sufficient to get 
this job done, because my concern is that if seniors aren't 
given prompt, decipherable, accurate information it may cost 
them a lot in terms of late enrollment penalties that stay with 
them for the rest of their lives. It may cost them, more 
importantly, in terms of their health. We've seen many 
instances where people were given wrong information or no 
information and they suffered sometimes catastrophic health 
consequences.
    Yet you related to me something I think is important to get 
on the record. You said to me that if we just give you blanket 
more money, this wouldn't be the first priority.
    Mr. Weems. No.
    Senator Smith. I believe you said the fraud program would 
be first.
    Mr. Weems. Yes.
    Senator Smith. What was the other one?
    Mr. Weems. Survey and certification. Senator Kohl every 
year works very closely with us to try and get the survey and 
certification budget and the nursing home budget to where it 
should be. Over the last 4 years, that budget has fallen $40 
million short of our request.
    Our total budget for the past 4 years has fallen about 
900--this is our operational budget--about $928 million short 
of the dollars that we requested, and over half--
    Senator Smith. Is this because OMB is not asking for it or 
because we're cutting it?
    Mr. Weems. This is the difference between the President's 
budget and what the Congress actually appropriates.
    Senator Smith. So the President is requesting it?
    Mr. Weems. Yes.
    Senator Smith. But we have not been granting it?
    Mr. Weems. That's correct.
    Senator Smith. That's a very important thing. But what I 
want to do, because I'm focused on 1-800-MEDICARE, is to say 
that this shouldn't be the third priority. What I'm saying is 
that all of those are important and what we need to make sure 
is that you ask for what you need to do the job in a superior 
way. Then we've got to get the job done and get the money to 
you, because again this can be literally life and death issues 
for seniors.
    Mr. Weems. Yes.
    Senator Smith. I appreciate you sharing that publicly for 
the record because I think it's very, very important.
    Chairman Kohl.
    The Chairman. Thank you, Senator Smith.
    Mr. Weems, as you know, I have long fought to improve the 
safety of nursing home residents by requiring criminal 
background checks of the workers who care for them. I was 
pleased by the success of a recent CMS-sponsored pilot program 
that enabled States to expand their screening programs, which 
has kept thousands of known criminal offenders away from our 
most vulnerable citizens.
    However, I was disappointed to discover that the findings 
of the report by CMS soon to be issued describing the success 
of the pilot program have been fundamentally altered by your 
agency. The report's estimates of the total costs of requiring 
background checks for all current and prospective long-term 
care workers was inflated by a factor of ten. How do you 
explain such an extreme revision of the first report, one that 
is at odds with the initial views of the report's authors?
    Mr. Weems. Thank you for the question. CMS received this 
draft report in May of this year. As is common for reports of 
this nature and of this magnitude, the report is peer reviewed 
by CMS among senior career officials within CMS. One of our 
components noted that the report itself did not fully address 
the potential costs of the background survey, and other 
components looking at that peer review information agreed and 
asked the contractor to take another look.
    Importantly, CMS did not specify what that other cost 
algorithm should look like. Instead, they said: We think you've 
missed some things; take another look. The contractor took 
another look, provided a methodology that they worked on 
themselves--it was their own original methodology--brought that 
back to CMS.
    That methodology was again peer reviewed by the same career 
CMS staff in CMS, and agreed to. The contractor then completed 
the estimate using both methods, and both of those methods are 
in the report. I'm satisfied that this is the work of senior 
career employees using their best intellectual resources and 
judgment available to them.
    The Chairman. Well, the version of my background check 
legislation was passed unanimously out of the Finance 
Committee, as you know, yesterday. It does fall in line with 
all of the points of consideration made in the soon-to-be-
released CMS report. Based on this, do you support the bill 
that was passed yesterday out of the Finance Committee?
    Mr. Weems. We certainly support the intent of the bill. We 
have not taken a formal stance on it. The thing that we're 
going to have to look closely at is how the costs of the 
background checks would be allocated between the Federal 
Government, State government, Medicare, and Medicaid.
    The Chairman. Mr. Weems, as you're aware, I have a 
continuing concern about the information conveyed to Medicare 
recipients by Medicare Advantage sales agents. Yesterday in my 
home State of Wisconsin a company was fined for selling 
products with unlicensed agents. What measures have been taken 
to specifically address questions about Medicare Advantage 
marketing practices at the call centers?
    Mr. Weems. At the call centers, a couple of things 
happened. First of all, we have revised our scripts for the 
enrollment-disenrollment process. Previously they had suggested 
that enrollment would only be prospective. Now we ask a 
question about, do you think that you'd like this to be--I'm 
not quoting directly from the script--do you think you would 
like this to be retroactive? So now a beneficiary has that 
choice of actually being able to begin their disenrollment 
retroactively.
    Our customer service representatives are also trained to 
ask questions about, did you know what you were getting into, 
did you actually sign the paperwork--anything that might 
suggest any kind of marketing misrepresentation. If they get 
those answers, then the beneficiary can disenroll and enroll in 
a plan that they wish. Further, that complaint is forwarded to 
our complaints tracking module for follow-up by our regional 
office. That's exactly what happened in that case.
    I completely share your concern, Senator. As you know, 
earlier in this year CMS proposed a new set of tough 
regulations to deal with fraudulent marketing practices. The 
Congress took those regulations, put them into law, and I will 
tell you in the next couple of days, not weeks, those laws will 
be ensconced in a new set of regulations that will make it 
clear that that law and those regulations apply to the coming 
marketing period.
    Mr. Weems. Thank you.
    Thank you, Senator Smith.
    Senator Smith. Thank you, Senator Kohl.
    Kerry, a couple follow-ups. To the timing on call waits, 
you indicated CMS is going to reduce wait times to 5 minutes 
for the remainder of the year.
    Mr. Weems. Yes, or better.
    Senator Smith. Is that 5 minutes calculated on a 24-hour 
period or on the basis of an 8-hour work day?
    Mr. Weems. It's calculated on a 24-hour period.
    Senator Smith. So if you calculate it on an 8-hour work 
day, what does it mean if somebody's calling during a work day?
    Mr. Weems. I can give you an approximation of that, but one 
of the reasons that you see this reduction here is actually 
better management of calls during the peak periods. In the 
June-July period we implemented a command center enrichment, 
which I believe your staff had the opportunity to see, and 
actually I've made a visit to Richmond subsequently. It's 
really quite impressive and it's able to route calls from busy 
call centers to less busy call centers. It's able to move 
customer service reps who are doing other things, who might be 
in training, to quickly move them from training to a tier one 
line to start answering that phone call.
    The contractor--and they can talk to you more about this 
also--implemented a real-time compliance with the employees. So 
we know, they know, what employees are doing at any given 
moment.
    Interesting: One of the things you can see in the command 
center--and you've written me inviting us to go and you and the 
chairman are welcome at any time and I'd love to do that. You 
can see if a customer service rep has been on the phone for an 
extended period of time, so you can go to them: Do you need 
help? Why is this call--and either move the call to somebody 
that can handle it, give them the help they need so that they 
can shorten that call volume, give them the right answer, and 
move on to another call.
    Those are the kind of technological changes we've 
implemented. Also a new smarter interactive voice unit, so that 
it does ask you to put in your Medicare number, but it will 
also ask you if it's a doctor claim or a hospital claim. So 
when you get to the customer service rep--and I saw this in 
Richmond--their name comes up, the name of the beneficiary 
comes up on the screen, even before the call begins in the 
CSR's ear. They can see the claim and they can begin working 
with them the instant the call begins.
    Senator Smith. We obviously want to get that wait time as 
low as we can during that 8 hours of the regular work time.
    Mr. Weems. Yes.
    Senator Smith. If you can calculate what I think that would 
be for us, I'd sure appreciate receiving that.
    [The information referred to follows:]

    Mr. Weems. The daily average speed of answer (ASA) is 
calculated by adding up the wait times for each individual call 
and dividing it by the total number of calls. When calculating 
ASA on any timeframe, we county the total wait time spent in 
queue for the time period over the total calls answered by 
agents for the time period.
    The ASA during the 8-hour workday for the month of August 
2008 was 3 minutes, 58 seconds and for September 2008 was 1 
minute, 20 seconds. (We defined the 8-hour workday as Monday - 
Friday, 9:00am ET to 5:00 pm PT.) The overall ASA for the month 
of August 2008 was 3 minutes, 44 seconds and for September 2008 
it was 1 minute 16 seconds.

    Mr. Weems. We can estimate it, and then I would be happy to 
report it as our experience continues.
    Senator Smith. You have the budget sufficient to get it 
down to an average of 5 minutes in a 24-hour period?
    Mr. Weems. Yes.
    Senator Smith. OK. Obviously, you're dealing with Vangent 
as the prime contractor on this. My understanding is that below 
them there are a myriad of subcontractors.
    Vangent subcontracts to a company named Sensure, and it in 
turn subcontracts to Palmetto. I don't know how much more 
complicated it gets beyond that.
    But my question to you is, what are you doing to ensure 
oversight not just of Vangent, but their subcontractors? Are 
they looped into this and do you have confidence that this 
isn't so distantly removed in relationships that you're losing 
control of it?
    Mr. Weems. They are looped into it, and in fact some of 
those arrangements that you mention have been concluded as a 
matter of consolidation. The staff that exerts oversight over 
this program I have not only considerable confidence in, but 
considerable respect for. They speak to the contractor--they 
will validate this--not just daily, but I think hourly. It is 
an extraordinarily closely supervised contract.
    Senator Smith. Kerry Weems, thank you so much for your time 
and your public service. I do appreciate your acknowledgment, 
the acknowledgment of CMS, that there are real problems. The 
agency understands they need to come forward with real 
solutions, and we're just here to encourage that, because we're 
accountable as well.
    I think I've heard your commitment today that you'll work 
with us, with me, my staff, Senator Kohl and his, the entire 
Aging Committee. We want to work with you, not at you, and 
that's the spirit in which we need to get this right if we're 
going to get it done for America's seniors.
    So thank you very much.
    Mr. Weems. Thank you for the opportunity to appear, sir. 
Thank you, Senator. Good to see you.
    Senator Smith. We'll now call up our second panel. We 
welcome Naomi Sullivan, a dual-eligible Medicare beneficiary 
from Chico, CA, who will offer her on-the-ground perspective 
and experiences calling 1-800-MEDICARE. Then we'll have 
Michealle Carpenter, the Deputy Policy Director and Counsel of 
the Medicare Rights Center, who will discuss her experience 
offering information and assistance with health care rights to 
Medicare beneficiaries. Then Tatiana Fassieux, who will testify 
in her capacity as the Board Chair for California Health 
Advocates, also a program manager for the California Health 
Insurance Counseling and Advocacy Program. Tatiana will share 
with us her experiences in helping beneficiaries to navigate 1-
800-MEDICARE.
    Would you like to introduce your Wisconsin witness?
    The Chairman. John Hendrick is a Staff Attorney at the 
Coalition of Wisconsin Aging Groups, where he directs the Elder 
Financial Empowerment Project and also works with the Wisconsin 
Prescription Drug Help Line in the Elderly Benefits Specialist 
Program.
    Prior to joining the coalition, he was a managing attorney 
for 16 years of a statewide legal education agency, teaching 
thousands of non-lawyers about their legal rights. He has given 
numerous presentations throughout Wisconsin relating to elder 
rights and Medicare and presented at the 2004 and 2006 National 
Aging and Law Conference.
    We're very happy to have you with us this morning, Mr.
    Hendrick.
    Senator Smith. Well, thank you. Why don't we start with 
Naomi and we'll just go in that order. We'll be informal. We 
may even break in and ask a question or two. But you've all 
obviously heard Administrator Weems discuss recent changes at 
the call centers and I'm hoping to hear if you've actually seen 
those improvements and what you think of the testimony you've 
heard.
    Take it away, Naomi.

  STATEMENT OF NAOMI SULLIVAN, MEDICARE BENEFICIARY, CHICO, CA

    Ms. Sullivan. I'd like to thank you, Senator Smith and 
Senator Kohl, for allowing me to come before the Senate and 
explain my experience with Medicare. My name is Naomi Sullivan. 
I'm 57 years old. I live in Chico, CA. I'm on disability and am 
what is called a dual-eligible beneficiary. I am here today to 
share my story, to give voice to those who don't know how to 
speak for themselves. My hope is that the government will 
understand that there are beneficiaries like me all over the 
country who lack resources, are in dire straits, have turned to 
1-800-MEDICARE for help, and aren't getting the assistance they 
so desperately need.
    A few years ago I was making over $60,000 per year salary. 
I now live on less than $700 per month social security 
disability and have had to make choices whether to eat or pay 
my premiums and medications. A while back I went on what I call 
a refugee diet because I couldn't afford to buy groceries and 
pay all of my bills.
    I am here today because in 2007 I decided to switch my 
Medicare D plan from Humana to Blue Cross. I received an 
information card in the mail from Blue Cross, returned it, and 
shortly after received an application in the mail. I filled out 
the paperwork to enroll in a Part D plan and thought I was good 
to go. Little did I know what I was in store for.
    It turns out that somewhere along the way I was 
inappropriately enrolled in a PPO--you call it a Medicare 
Advantage plan--instead of a Part D plan. I found out about 
that the hard way when my doctor started to ask me for copays. 
I never had to pay copays because I also had MediCal. Then I 
started to get premium notices and billings, and throughout the 
year I also got many bills from my doctors. I couldn't 
understand why Medicare and MediCal weren't paying my medical 
expenses the way they used to. But I knew I had to get this 
straightened out as quickly as possible.
    So I called 1-800-MEDICARE to get some answers and to try 
to get out of the PPO, into a Part D plan I had enrolled with 
in the first place. I called 1-800-MEDICARE over a dozen times. 
I can't afford both a home phone and cell phone, so I have just 
a cell phone. When I would call 1-800-MEDICARE, I was sometimes 
on hold for up to 45 minutes at a time, and then I'd get 
transferred and disconnected and have to start all over again.
    Meanwhile, I was going over my cell phone plan minutes and 
having to pay for minutes that I couldn't afford. Eventually it 
got to the point where I simply could not afford to make one 
more call to 1-800-MEDICARE.
    All I can say is thank goodness I found Tatiana at HICAP 
because honestly I do not know what I would have done. I just 
wanted to give up. I felt like less than nothing. I felt like 
the people at 1-800-MEDICARE did not have any interest in 
helping me. I told them my story, that I was on disability and 
barely making it on less than $700 per month and could not 
afford the premiums for the plan that I had been 
inappropriately enrolled it. One Medicare representative 
suggested that I get a part-time job to help pay the premiums, 
but they didn't offer any help. They didn't tell me about any 
resources and they didn't tell me because of my situation I can 
switch plans at any time. They just kept telling me to call my 
plan and work it out.
    I just needed a little help and some direction on how to 
get things sorted out. I didn't get that from Medicare. So many 
bills got turned over to collections, I subsisted on my refugee 
diet and I couldn't get anyone to help me.
    At last I went to my local Social Security office. They 
referred me to Tatiana. She's helping me to get things 
straightened out. I'm now enrolled in a Part D plan. I don't 
have a clue how I'm going to pay for all the bills that mounted 
up while I was on the wrong plan. I know that Tatiana is 
working on that. But at least hopefully now I won't have to 
worry about going to my doctor or getting my medications.
    I feel that 1-800-MEDICARE should have an easier way for 
people to live--I'm sorry. I feel that 1-800-MEDICARE should 
have an easier way for people to get a live person, that they 
should have proper training so that they can provide accurate 
information, or at least refer callers to their local HICAP, 
because I know they have the ability to help.
    [The prepared statement of Ms. Sullivan follows:]

    [GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]
    
    Senator Smith. Thank you very much, Naomi. That's firsthand 
experience why we're having this hearing today, to try to get 
better response.
    Ms. Sullivan. Thank you.
    Senator Smith. Michealle.

 STATEMENT OF MICHEALLE CARPENTER, DEPUTY POLICY DIRECTOR AND 
                COUNSEL, MEDICARE RIGHTS CENTER

    Ms. Carpenter. Good morning, Chairman Kohl and Senator 
Smith.
    Senator Smith. You want to hit your button there.
    There you go.
    Ms. Carpenter. Good morning, Chairman Kohl and Senator 
Smith. I thank you for your longstanding and bipartisan 
commitment to the common good and welfare of people with 
Medicare.
    The persistent failures of the Medicare consumer hotline, 
1-800-MEDICARE, cause daily harm to the health and wellbeing of 
older Americans across the Nation. The volunteers and staff of 
the Medicare Rights Center confront the human hardship caused 
by these breakdowns daily. We appreciate your efforts to shine 
light on the hotline's failures as a necessary step toward 
correcting them.
    In recent years Medicare has become a daunting challenge 
for consumers to navigate. Since enactment in 2003 of the 
Medicare Modernization Act, a Wild West marketplace for 
Medicare coverage was launched and a system rich with 
opportunities to exploit people with Medicare has been 
established. To no surprise, the older, frailer, and most 
impoverished people with Medicare are most vulnerable to 
exploitation. Without safety nets, they are the most harmed by 
this exploitation.
    Regrettably, the Centers for Medicare and Medicaid Services 
has failed to provide the most basic tools to protect people 
from the danger of this marketplace. Even as the market became 
significantly more complex, repeated reorganizations of CMS's 
bureaucracy have left CMS with neither a centralized consumer 
education office nor a coordinated approach to consumer 
education. At times CMS has mixed consumer education with 
ideological propaganda. Consumers are harmed by information 
that is colored by a preference for Medicare Advantage plans 
and a political imperative to paint the prescription drug 
program in the best light regardless of reality.
    In addition to long hold times, callers often spend well 
over an hour while a poorly trained operator tries to find an 
answer to a simple question or resolve a problem. CMS's 
customer service representatives lack proper training to answer 
callers' questions or assist in resolving problems. The scripts 
from which representatives read often lack meaningful 
information. Even accurate information is often delivered in a 
way that few people can understand. Representatives provide 
false, misleading, and inaccurate information. While callers 
often call with complex problems that require the 
representative to have technical knowledge, representatives are 
unable to answer even basic questions.
    One area where 1-800-MEDICARE customer service 
representatives consistently fail to provide accurate 
information and assistance is when a beneficiary has been a 
victim of fraudulent or misleading marketing by a private 
Medicare Advantage plan. Because this problem is so widespread, 
CMS has assured us that all customer service representatives 
are well trained to handle these kinds of cases. This is not 
the case.
    In discussions with CMS last year, we were assured that 
every caller who has been fraudulently enrolled in a private 
Medicare plan will be assessed for retroactive disenrollment. 
The importance of this cannot be overstated as thousands of 
dollars may be at stake for a client who's left with unpaid 
medical bills because they were enrolled fraudulently in a 
plan.
    In our experience, representatives are aware of the 
exceptional circumstances special enrollment period which 
allows people with Medicare to disenroll from a plan any time 
during the year under certain circumstances. Unfortunately, 
representatives appear only to understand how to help people 
disenroll from the plan prospectively. On most occasions, 
callers are not assessed for retroactive disenrollment. Even 
more concerning, a representative recently told one of our 
caseworkers that Medicare does not provide retroactive 
disenrollment even for marketing fraud cases.
    When our caseworkers attempt to help clients request a 
retroactive disenrollment through an exceptional circumstances 
SEP, we are transferred from one representative to another and 
often stay on the phone for more than an hour awaiting a 
resolution. In the end we are usually told this issue will be 
transferred to the regional office for a decision and that the 
client will receive a call within a week. More often than not, 
that call never comes.
    So what should be done? For starters, CMS must increase 
oversight of the 1-800-MEDICARE contractor. CMS must 
reestablish an independent office focused on communication with 
people with Medicare that reports directly to the CMS 
Administrator. This office should have direct oversight over 1-
800-MEDICARE and should be responsible for developing training 
materials and scripts for 1-800-MEDICARE operators.
    It is our understanding that representatives are not 
trained on Medicare policy, but rather on how to search a 
database for the proper script to read to a caller. Customer 
service representatives must have at a minimum a basic 
understanding of Medicare. All representatives should have 
regular training on topics callers most frequently call about. 
This is how we train our volunteers and staff that answer our 
hotlines. This training must be reinforced with more frequent 
testing to ensure continued understanding and ability to answer 
questions accurately.
    In addition to providing better training and scripts to 1-
800-MEDICARE customer service representatives, CMS needs to 
make a concerted effort to fix the data exchange systems 
problems that plague the privatized sectors of Medicare. 
Admittedly, these data exchange systems are complicated and the 
solution is not an easy one. But it's been 3 years since 
Medicare Part D began and 5 years since the expansion of 
Medicare Advantage.
    Simplifying and standardizing Medicare choices is 
absolutely necessary. But 1-800-MEDICARE cannot wait for that 
day to come. People with Medicare must be allowed the helping 
hand that we pay 1-800-MEDICARE to offer.
    Thank you.
    [The prepared statement of Ms. Carpenter follows:]

    [GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]
    
    Senator Smith. Michealle, did you take much comfort in what 
you heard the Administrator say this morning?
    Ms. Carpenter. I think a lot of the changes that are to 
come will be beneficial. They seem to be mostly about the 
technology and less about the training, which is where most of 
our concern lies.
    Senator Smith. So yours is technology, not the training?
    Ms. Carpenter. No, ours--we believe the training.
    Senator Smith. The training, not the technology.
    Ms. Carpenter. We are heartened by the technological 
improvements that will be made and we think they will be 
helpful to people with Medicare.
    Senator Smith. Very good.
    Tatiana.

   STATEMENT OF TATIANA FASSIEUX, BOARD OF DIRECTORS CHAIR, 
          CALIFORNIA HEALTH ADVOCATES, SACRAMENTO, CA

    Ms. Fassieux. Good morning. Good morning, Chairman Kohl, 
Senator Smith, and other distinguished members of the 
committee. My name is Tatiana Fassieux and I am the Board Chair 
of California Health Advocates and also a Program Manager. I 
represent the boots on the ground of Medicare beneficiaries in 
California.
    California Health Advocates is a nonprofit organization 
dedicated to education and advocacy on behalf of California 
Medicare beneficiaries. I've been in that role for about 4\1/2\ 
years. But I also represent the 24 HICAPs, the SHIPs, in 
California serving more than 4 million Medicare beneficiaries. 
In my neck of the woods, northern California, I serve five 
counties, rural counties, with about 45,000 Medicare 
beneficiaries under our program.
    But I do want to thank the committee for inviting me for 
the opportunity to speak. I do want to focus on some of the 
topics discussed, the 1-800-MEDICARE, of course, the myriad of 
problems with the call centers' performance, the resulting 
impact on the SHIPs, and of course in California in particular, 
and above all the impact on Medicare beneficiaries, and I'll 
suggest some recommendations.
    We believe that 1-800-MEDICARE reflects the credibility of 
the agency it represents, that is CMS, and the regulatory 
process that established it. So that credibility must be upheld 
quite at a very high standard.
    The SHIP network has come to rely frequently on the help of 
1-800-MEDICARE and we have the expectation that our Medicare 
beneficiaries will have accurate and timely information. In 
many instances both clients and SHIP counselors have had good 
successful contacts. We must agree to that.
    We are also pleased by the recent implementation of the 
special SHIP direct, or I should say back door, number into 1-
800-MEDICARE. We still have to go through the protocols and the 
IVR system, but we have a pseudo-back door way, and California 
has just now implemented that.
    However, as I will illustrate, credibility has been shaken 
frequently. Medicare beneficiaries and SHIPs have had 
unreasonable wait times, frequent disconnects, misinformation, 
and what troubles us is the difficulty in resolving hard cases. 
That lack of faith in prompt resolution is what concerns us.
    Beneficiaries continue to complain about the IVR system. 
They say: I wish I could get a live person, because they're 
very frustrated by that technological feature. We're still 
dealing with 1930's, 1940's seniors, who technology is just 
frightening to them. On a good day, it takes us about 10 to 15 
minutes to get to the first level of CSRs.
    The disconnects are particularly egregious, especially when 
we as SHIP counselors are trying to assist clients with the 
assistance of 1-800-MEDICARE. Where that first level cannot 
help, we get transferred to the second level, and during that 
transition we get cutoff.
    Misinformation of course can do tremendous harm. Clients 
have told us that, I wish Medicare had told us that I could 
change plans any time, when they discovered that they were in a 
plan that they should not have belonged in. They were locked 
in, according to the Medicare representative, but in reality 
they were not.
    In an instance where you mentioned, a southern California 
transplant patient was incorrectly told by a CSR that nobody 
gets lifetime anti-rejection medication, and it was because of 
our persistence we escalated and we were able to assist the 
client.
    As you heard with Naomi, her case--I am personally handling 
her case--the reason she is on such low income is because she 
felt she had to get a job and Social Security reduced her 
income, which was sort of a double whammy.
    Another counselor had reported that when we were trying to 
file a complaint we were actively discouraged, saying that a 
complaint is serious.
    Now that 1-800-MEDICARE is the single point of entry for 
all issues dealing with Medicare, including our efforts in 
dealing with very complex issues, we may have to contact a 
subcontractor. It just particularly gives us a little more 
problems in getting to the right people.
    So we appreciate that we have been given additional 
funding, but of course in California with the budget that 
funding hasn't come through yet, and in my neck of the woods 
it'll just be a few thousand dollars. $15 million globally 
sounds like a lot of money, but when you break it down to the 
individual HICAPs it's just a little bit of money.
    So we would like to propose the following actions. 
Definitely additional training, better scripts. It has been 
inferred also that they get State-specific information. 
Absolutely better CMS oversight. Who knows, a better friendly 
system in responding.
    It was good to hear from Mr. Weems about that new response 
system. The California CALPERS instituted that and it's working 
quite well.
    But one more thing I would like to suggest is that we form 
a task force that includes SHIPs, beneficiaries, CMS, and any 
other advocacy organizations to review those scripts, to review 
the training, because sometimes I think that the SHIP 
counselors definitely know more than the CSRs.
    Thank you for letting me speak.
    [The prepared statement of Ms. Fassieux follows:]

    [GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]
    
    Senator Smith. Thank you very much. That's excellent.
    John Hendrick.

 STATEMENT OF JOHN HENDRICK, PROJECT ATTORNEY, ELDER FINANCIAL 
   EMPOWERMENT PROJECT, COALITION OF WISCONSIN AGING GROUPS, 
                          MADISON, WI

    Mr. Hendrick. Thank you, Senator Smith, Chairman Kohl. My 
name is John Hendrick. I'm a staff attorney with the Coalition 
of Wisconsin Aging Groups and it's my privilege to speak to the 
committee on behalf of the coalition and share our experiences 
with Medicare's toll-free consumer service. We supervise a 
network of over 100 trained staff throughout the State of 
Wisconsin and as part of their duties they help older adults 
with the Medicare program through the State Health Insurance 
Assistance Program. For some reason that's abbreviated 
``SHIP.'' So we have a lot of experience with 1-800-MEDICARE.
    Based on our experience, we have found that 1-800-MEDICARE 
service has improved since 2006 and we appreciate that. Wait 
times outside the busy annual enrollment period can be as 
little as 5 to 10 minutes and there are many knowledgeable and 
experienced customer service representatives who are able to 
resolve most beneficiary problems in a timely and accurate 
manner. Many are doing a good job. Some are not. Also, in our 
experience we've had a high level of success with what I guess 
they call the tier two representatives that are able to deal 
with the more complex problems, and so we appreciate that 
success.
    We do have some serious continuing concerns. I would say 
our greatest concern is representatives providing consistently 
accurate information, and we have found that that is not always 
the case. There are a couple recurring problems with specific 
issues, but our biggest concern is that the bad information 
doesn't seem to relate to the complexity of the issue. It's 
just which representative you get. So if you get the wrong 
person you get the wrong answer. That makes it hard to predict 
and it's very hard for us to deal with.
    The second area of concern would be technological problems. 
For example, at busy times the average waits are over 30 
minutes. There's occasional buzzing on the line, which makes it 
difficult for beneficiaries to hear the representative. As has 
been mentioned repeatedly, senior beneficiaries have difficulty 
dealing with the telephone prompt system.
    Lastly, the area of programmatic problems, which appear to 
result either from management decisions or from training. For 
example, the customer service representatives do not leave a 
phone number when they return a call. They don't leave any 
information. They just say they're returning a call. Unless the 
beneficiary happens to pick up the call at that moment and get 
that call directly, they have to start all over again and go 
through the wait time and explain their situation all over 
again.
    At times we find as many as one-fourth of the cases have to 
be forwarded to the tier two representatives because the 
customer service representatives can't resolve the issues. That 
seems like a high percentage to us. Beneficiaries when they 
file a complaint about Part D enrollment or Medicare Advantage 
enrollment are told that they will be called back within 5 
days, and that is not the case. In our experience those calls 
never come.
    Senator Smith. Not later than 5? They just never come?
    Mr. Hendrick. Never.
    Finally, the customer service representatives frequently 
don't know that they can talk to the SHIP representative. As 
everyone here has mentioned, a way of resolving problems is for 
a well-informed SHIP representative to get on the phone with 1-
800-MEDICARE and sometimes that's what works it out. But 
unfortunately the tier one representatives sometimes will 
refuse to talk to the person unless the beneficiary is actually 
present, and that's not what the rules are. So that's an 
important mistake.
    I'd just like to mention a couple of our suggestions for 
improvement. I think you could increase the number of customer 
service representatives. The increased training which has been 
mentioned would improve the quality of the information. You 
should continue the SHIP-dedicated phone number. That has 
helped a lot to allow the SHIP representatives to get through 
and to resolve some of these problems.
    I believe the General Accounting Office secret shopper 
program was mentioned earlier. That should be continued. That 
is helping to evaluate the quality of the service and the 
accuracy of the information.
    Our final point, which isn't actually about 1-800-MEDICARE: 
We believe that all prescription drug and Medicare Advantage 
plans should be required to have their own SHIP-dedicated 
contacts. With the plans that have a separate contact for SHIP 
counselors to contact, those plans are resolving problems with 
their own plans in a much more effective way and taking the 
burden off 1-800-MEDICARE.
    In conclusion, we'd like to thank you for this opportunity. 
We hope for further improvements in 1-800-MEDICARE, and I'd be 
happy to answer any questions.
    [The prepared statement of Mr. Hendrick follows:]

    [GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]
    
    Senator Smith. When you heard the Administrator, do you 
have more reason to hope?
    Mr. Hendrick. Certainly some of the things that he 
described sounded promising, and I'm always amazed by what 
computers can do today. The training I think would still be a 
concern to us. The customer service representatives that are 
taking those calls, if they are not correctly trained, are not 
able to give out the correct information, and I don't think 
that what we heard today is going to fix that.
    Senator Smith. Senator Kohl.
    The Chairman. Thank you, Mr. Hendrick, and we appreciate 
all that you've done with the Coalition of Wisconsin Aging 
Group for the people of our State.
    Would you offer the observation if you were asked that, if 
1-800-MEDICARE were in competition with another organization 
providing the kind of service that we find in competition in 
the private sector of our country, they'd be out of business?
    Mr. Hendrick. Well, Senator, I often say in regard to many 
government programs and people who are complying with 
regulatory requirements: What would you do if you really wanted 
this to work? If your intention was to run a business and to 
provide good customer service so that people would come back, I 
think you would get these problems solved.
    The Chairman. Mr. Hendrick, your testimony identified a 
number of problems with Medicare call centers. If you could 
name one, which is the single worst and most persistent 
problem, and what is the most important improvement that CMS 
could implement to enhance the service of the call center for 
the recipients?
    Mr. Hendrick. I think our biggest concern is the apparently 
random provision of incorrect information. This happens with 
the tier one customer service representatives. I don't know the 
exact solution, but it seems to me that if people knew that 
they didn't know the answer and they could refer it to someone 
who could and then that call got through without being 
disconnected during the transfer, I think that would solve a 
lot of the problems that we see.
    The Chairman. Thank you so much.
    Senator Smith. Very good suggestion.
    Thank you all very much. I think that concludes our 
questions. You've added human context, put a human face on this 
problem, faceless problem of 1-800-MEDICARE. Naomi, your story 
will be remembered. So thank you all.
    Our third panel and our only panelist is John M. Curtis. He 
goes by ``Mac'' and Mac is the President and CEO of Vangent, 
the company contracted by CMS to accept incoming beneficiary 
calls. He'll discuss his company's efforts to ensure Medicare 
recipients are receiving accurate and timely information when 
calling 1-800-MEDICARE.
    Mr. Curtis, thank you for coming.

  STATEMENT OF JOHN M. CURTIS, PRESIDENT AND CHIEF EXECUTIVE 
             OFFICER, VANGENT, INC., ARLINGTON, VA

    Mr. Curtis. Thank you, Senator, Mr. Chairman. Good morning. 
My name is Mac Curtis and I am President and CEO of Vangent. 
For over 30 years we've been a provider of mission-driven 
systems and strategic business process outsourcing services for 
the Federal Government in the U.S., and around the world, 
Fortune 500 companies, health care organizations, and 
educational institutions. Our company is headquartered in 
Arlington, VA.
    I was invited here today to talk about Vangent's role in 
the 1-800-MEDICARE program. I'm not here to say that problems 
never occur or to refute the experiences described here today. 
But I can tell you about our steadfast commitment to quality 
service for all Medicare beneficiaries and offer some context 
for the issues described by the previous panel. Of the 30 
million calls received each year, the vast majority work fine. 
But we're focused on the small minority of calls that don't.
    First let me explain how the system works. Our job is to 
manage the call center facilities and the workforce that 
answers the calls that come in to 1-800-MEDICARE. Vangent has 
been working with CMS on this program for over 6 years and 
we're proud of the work we do.
    Callers into the system are prompted by the interactive 
voice response unit to provide their Medicare number and to 
select the issue they're calling about. If a customer service 
representative is not immediately available, a call is routed 
to the queue where, depending on when they call, they may have 
to wait a few minutes, sometimes longer, for the next available 
CSR qualified to answer their question. The caller is then 
connected to the CSR, who works with them to answer their 
question.
    Our contract with CMS provides that we maintain an average 
speed to answer at or less than 8\1/2\ minutes, which we 
consistently meet. Our average speed to answer during the month 
of August was 3 minutes and 40 seconds. Do we always hit the 
mark? With 30 million calls a year into the system, not every 
call is perfect. But the hard work to continuously improve and 
make the system and experience better is what we're dedicated 
to.
    Our workforce is well trained, closely monitored, and 
highly motivated to help people. CSRs undergo continuous and 
rigorous training based on industry standards and best 
practices. Vangent, in partnership with CMS, has successfully 
trained thousands of CSRs, who answer millions of beneficiary 
inquiries using this training program. Instructor-led classroom 
training is combined with multiple forms of recurring on-the-
job training to ensure continuous improvement. Every CSR is 
regularly monitored to identify trends and to measure 
individual performance. Responses are evaluated by multiple 
checkpoints for quality and accuracy, which again are based on 
industry standards and best practices.
    We also survey our callers to measure their satisfaction 
with the service they receive. What are the results of the 
monitoring and the surveys? Of the thousands of calls evaluated 
each month, over 90 percent meet the requirements of our 
rigorous quality reviews for accurate responses and customer 
interaction. In the customer satisfaction survey, the results 
we receive show that 85 percent of the callers are satisfied 
with the service, a score that's above the industry average of 
about 70 percent for contact centers.
    We're continuously working to improve the people, the 
process, and the technology that drives the 1-800-MEDICARE 
program.
    Today we've heard from the SHIPs and other advocates about 
concerns they have with the 1-800-MEDICARE system. We 
appreciate the difficult job the SHIPs have. They assist the 
neediest beneficiaries with very complex problems. We've worked 
with CMS to provide the SHIPs with tools such as--and we've 
heard about it this morning--a customized IVR and a dedicated 
800 number to make their jobs a little easier. We want to 
continue working with CMS to find additional ways we can 
improve our service to the SHIPs and their clients.
    We spent a lot of time with your staff in our call centers 
discussing how the system works and how it can be improved. We 
applaud the dedication and the zeal, Senator, they have shown 
toward improving 1-800-MEDICARE. There's no question about it.
    In summary, the vast majority of the 30 million calls 
received by 1-800-MEDICARE are handled well and correctly. But 
the issues identified here today are very important to us. 
Continuous improvement is a hallmark of this program and we 
strive to provide Medicare beneficiaries the quality of service 
they deserve.
    Thank you, Senator. I'm happy to answer your questions.
    Senator Smith. Mac, your surveys show that 85 percent like 
the service they got?
    Mr. Curtis. Yes, sir.
    Senator Smith. Eighty-five percent. So we're really dealing 
with 15 percent. Can you tell when you get a call whether it's 
a person without any agenda just needing help or one of my 
staff calling and testing you?
    Mr. Curtis. Well, normally--let me answer your question 
this way, Senator. With regard to someone calling with a 
specific question of the 30 million inquiries that come in a 
year, 98 percent--
    Senator Smith. Are we the 15 percent?
    Mr. Curtis. We're working on that, Senator. [Laughter.]
    That's good because we're trying to improve. There's no 
question about the value that your staff has provided.
    But back to my answer, Senator, of the 30 million inquiries 
we receive a year that come in to the IVR, 98 percent of those 
inquiries come with their Medicare number. So as we've talked 
about, one of the improvements that CMS has made is the 
beneficiary gets on the line, reaches the IVR, and they're 
asked their Medicare number. They put their Medicare number in 
and the record shows up on the screen for the CSR. The CSR goes 
through and they validate the beneficiaries birthday, their 
Medicare number, and then deals with the callers specific 
issue.
    So that's really where the balance of the calls come from 
with regards to a specific issue associated with the Medicare 
number. So what we are dealing with here today is the 
percentage that have very complex calls. I think your staff 
will attest to this, that the typical call is with a Medicare 
number, and it's also maybe one issue or one question. The 
reason why we know this, Senator, is that when we look at, on 
an annual basis, the number of scripts the CSRs actually go to 
to provide the scripted response, on an average call it's 1.2 
scripts per call.
    So what we're really focused on are the multiple question 
calls, where sometimes we're going to 4 to 12 times the number 
of scripts or the number of questions, and also those calls 
that don't have the Medicare number.
    Senator Smith. It is possible that someone has called in 
not from my office without a Medicare number?
    Mr. Curtis. That happens. Yes, sir, it does happen. That's 
about--from our record, that's about 2 percent that call 
without a Medicare number, that's correct.
    Senator Smith. So the other 13 percent are my staff?
    Mr. Curtis. The other 13. Well, one of that percent is 
probably my mother.
    Senator Smith. But what you're telling me is if my staff 
calls with a Medicare number they're going to be completely 
satisfied?
    Mr. Curtis. You know, Senator, I'm not going to tell you 
that out of 30 million transactions every one of them is 
perfect. I'm certainly not going to tell you that. But what I 
will tell you in all sincerity is we want all of those 30 
million transactions to go well. But no, I'm not going to say 
every one is perfect. I'm not going to say every CSR always 
gives the right answer. We've heard situations today that, a) 
are heartbreaking and, b) that's the percentage that we've got 
to get right. Every one of these calls has got to be right.
    But I think what we do focus on is the quality monitoring. 
When we're at spike we're talking about close to a little under 
4,000 customer service reps, and the quality monitoring we do 
on a monthly basis--we record calls. They're evaluated in three 
areas: Are they dealing with Privacy Act data correctly, what 
was the completeness and the accuracy of the answer on their 
call, and what are their customer soft skills?
    So it's thousands of calls a month that are recorded. The 
calls are evaluated and there's a side by side discussion with 
each CSR. We go through how well they performed.
    Now, the independent TQC contractor that Administrator 
Weems is talking about is also now evaluating additional calls. 
So we're trying, like the CSRs, to make sure that there's 
quality there and that they're answering accurately and 
completely.
    Not everyone's perfect and clearly from what we've heard 
today there are some issues. We like to get the feedback. By 
the way, I agree, establishing an organization with the SHIPs 
and the beneficiaries and CMS to support the content review I 
think is a very good idea.
    Senator Smith. The timing of this hearing, Mac, is 
intentional because we're coming up to a new enrollment period. 
That new enrollment period, for any seniors watching that want 
to enroll, starts in November. Are you representing to us that 
you're ready for this enrollment period? Because if a senior 
gets trumped up in the enrollment period and they have to 
start--they start assessing about a 1 percent penalty a month, 
and that could be a 12 percent penalty, and that 12 percent 
penalty stays with them. It's not a 1-year penalty. It's just 
they made a mistake and they live with it the rest of their 
lives.
    Even more important than the money is obviously if they're 
given the wrong information and that may have a health 
consequence to them that I know you don't intend. But we've got 
to get it right.
    So you're representing to us that you're ready for this 
next enrollment period?
    Mr. Curtis. We are getting ready, absolutely, Senator. As 
you know, the enrollment period is November 15 through December 
31. Your staff has been to our centers. One of the things I do 
want to represent is, in all of our the facilities our CSRs 
have other opportunities and other places to work. We have a 
workforce that is passionate about helping people. So I think 
the attitude is certainly one we should all be proud of and 
reassured by.
    I think you've heard about improvements in the training. 
One of the things I think that CMS has indoctrinated into the 
training curriculum is the whole notion of Medicare Advantage 
and how to deal with that. I think we're always looking at ways 
to improve that training to make sure we have the right 
answers.
    So we are getting ready, Senator. We're doing the 
recruiting, we're doing the training, and we've begun and we'll 
be ready for the spike.
    Senator Smith. Well, it's very important. Obviously, 
Naomi's case is an example that it isn't just my staff that's 
calling. Those are the people who are the focus of this hearing 
and Naomi puts a human face on it. So I want to in the 
strongest but friendliest terms as possible emphasize just how 
important it is to get systemically right all these things, get 
the training, get the processes worked out in the system, so 
that those even who are technically or high tech challenged--
I'd include myself in that number--can manage this system. I 
think that it's a huge challenge, but you took the contract.
    Mr. Curtis. Yes, sir, we did. Yes, sir, we did.
    Senator Smith. My admonition is do it, get it right.
    We want to be your cheerleaders, not your critics.
    Mr. Curtis. We're committed to doing that, Senator.
    Senator Smith. Well, thank you all very much. This has been 
a most informative hearing. We hope it helps. We're not here to 
pick a fight. We're here to find a solution.
    Thank you, Mac, for your presence, and I hope that you got 
a handle on all your subcontractors, too.
    Mr. Curtis. One comment. We are the prime contractor we 
would only use the subcontractors if we had to in a spike.
    Senator Smith. But you feel like you've got control of it?
    Mr. Curtis. Absolutely, there's no question about it. It's 
simpler now than it was before CMS consolidated the contract 
center operations.
    Senator Smith. So you're managing them, too? You're 
accountable for that?
    Mr. Curtis. Absolutely, if we use them.
    Senator Smith. Ladies and gentlemen, thank you.
    We're adjourned.
    [Whereupon, at 11:35 a.m., the hearing was adjourned.]
                            A P P E N D I X

                              ----------                              


           Prepared Statement of Senator Robert P. Casey, Jr.

    I would like to thank Senator Smith for organizing this 
important hearing on the 1-800-Medicare number and the service 
it offers Medicare beneficiaries and their families. This 
hearing is the product of an extensive investigation that 
Senator Smith and his staff began in 2005 into 1-800-Medicare 
and the concern that our older citizens and other Medicare 
beneficiaries are not receiving accurate information from the 
customer service representatives who answer these calls.
    1-800-Medicare, the general customer service number all 
Medicare beneficiaries call with questions or problems, is 
often both the first and last resort for many Medicare 
beneficiaries. Sometimes these calls involve life and death 
issues. Accordingly, we must ensure that beneficiaries and 
their families receive accurate and timely information.
    There are currently almost 45 million Medicare 
beneficiaries in this country, including almost 2.2 million in 
Pennsylvania. Millions more are on Medicaid. Many of these 
individuals are easily confused by the choices Medicare offers 
and the multiple choices and decisions they must navigate to 
enroll in various plans and programs. As result, they call 1-
800-Medicare looking for simple answers to often complex 
questions. The results can be far from helpful.
    While 1-800-Medicare is available 24 hours a day, seven 
days a week, callers can experience lengthy wait times before 
speaking to a customer service representative. Once they speak 
to a person, beneficiaries have reported representatives can be 
difficult to understand because they are too technical or 
presume knowledge about the Medicare program the caller does 
not have. At times callers are simply given wrong information.
    Hubert Humphrey used to say that one of the things we and 
society should be judged on is how we treat our older citizens. 
Are we providing them with appropriate help in their time of 
need? From the evidence before us at this hearing, it seems we 
are not.
    Bottom line, Mr. Chairman, our older citizens, and all 
Medicare and Medicaid beneficiaries who utilize the 1-800-
Medicare number need timely answers to their questions and they 
need accurate answers. It is estimated that 1-800-Medicare will 
field 34.5 million calls in 2009. CMS and Congress should 
strive to make this process better, shorten wait times and 
provide customer service representatives with the tools they 
need to give accurate and complete information to callers.
    We all know Medicare is a complex program. Our older 
citizens call this number with the expectation that the 
customer service representative on the other end will be able 
to provide them with correct and helpful information be it 
explaining the difference between traditional Medicare and 
Medicare Advantage or helping them choose which prescription 
drug plan best meets their needs. It is our job to ensure they 
find the answers they are looking for and that those answers 
are correct. I look forward to hearing the testimony of 
Administrator Weems and our other witness. Thank you, Mr. 
Chairman.
                                ------                                


           Kerry Weems Responses to Senator Smith's Questions

    Question 1. The New 5 Minute ASA
    It was encouraging to hear the plans that CMS has for 
reducing wait times at the call centers. Will CMS be formally 
revising the call center contract to require a 5 minute average 
speed of answer (ASA)?
    Answer: CMS modified the contract with Vangent effective 
October 1, 2008 to lower the ASA from 8 minutes down to 5 
minutes through the current option year which ends May 31, 
2009.
    Question 2. Hiring of Briljent
    In December 2007, CMS contracted with Briljent to revise 
the training curriculum and call scripts. Why did CMS remove 
these responsibilities from Vangent and reassign them to a new 
contractor?
    Answer: We conducted a full and open competition for the 1-
800-MEDICARE contract and its support services as the prior 
contracting vehicle was expiring. As part of the competitive 
bid process, we set aside certain activities for small 
businesses. The training, quality, and content support services 
were determined to be appropriate for a small business set 
aside. Therefore, Vangent was not eligible to compete for those 
activities. Briljent, as a small business contractor, was 
successful in its bid for this work.
    Question 3. Taskforce
    I have serious concerns that CMS and its contractors are 
unable to assess call center performance from a beneficiary's 
perspective and do not understand the challenges confronting 
beneficiaries when they try to use 1-800-Medicare. Though I was 
initially encouraged to hear that CMS had contracted with 
Briljent to revise CSR training and scripts, I remain concerned 
that this contractor's work product thus far does not 
adequately address the problems identified by my investigation. 
Therefore, to provide better feedback to CMS and its 
contractors in developing call center training curricula and 
scripts, is CMS willing to implement the advisory taskforce 
recommended by witnesses at the September 11, 2008 hearing? If 
no, why not? If yes, by what date can we expect to have that 
taskforce in place?
    Answer: CMS does not believe an advisory taskforce is 
necessary for 1-800-MEDICARE training materials and scripts. 
The quality, scripting and training development contractor 
works very closely with CMS staff and subject matter experts to 
ensure materials are relevant and up-to-date. We also obtain 
feedback from our CSRs to ensure scripts and training materials 
provide CSRs with subject matter knowledge and address the 
caller's need. CMS has consistently made available 1-800-
MEDICARE Part D scripts to CMS Partners via the www.cms.gov 
website.
    Additionally, CMS already has two committees that provide 
feedback on beneficiary education, including 1-800-MEDICARE. 
The Advisory Panel on Medical Education (AMPE) is governed by 
the Federal Advisory Committee Act and exists for the broader 
purpose of advising CMS on beneficiary education matters. In 
the past the APME has given general suggestions and comments 
about 1-800-MEDICARE, which have included topics such as wait 
times and non-English language issues. The National Medicare 
Education Program (NMEP) Coordinating Committee has also 
addressed partner questions and comments regarding 1-800-
MEDICARE at its meetings.
    We believe that these combined efforts provide sufficient 
opportunity for feedback and forming an advisory taskforce 
would duplicate our existing efforts.
    Question 4. Other Items that Need to Be Improved at 1-800-
Medicare
    Despite CMS' plans to reduce the ASA from eight minutes to 
five, I did not hear much at the hearing by way of planned 
improvement that would address other technological issues and 
adequately address problems with respect to the accuracy of 
responses provided to callers. Can you please explain CMS' 
plans for improving the following:
    The interactive voice response system, or IVR as it is 
called, is challenging for seniors to navigate.
    I would ask that CMS revise the IVR to provide an option to 
go directly to an agent.
    Answer: We do not currently offer a prompt that sends a 
caller directly to an agent and have no plans to implement such 
a change. As it is currently set-up the IVR technology improves 
the efficiency of our operations and enables some callers to 
``self-serve'' and receive the information they need without 
having to speak with a CSR. In situations where we cannot serve 
the caller via the IVR, the caller is seamlessly routed to the 
CSR who is best able to handle the specific topic.
    It also should be easier to reach an agent and obtain 
service for beneficiaries who do not have their Medicare number 
at hand.
    Further, the IVR should provide choices that better align 
with callers inquiries.
    Answer: While a Medicare beneficiary does not need to have 
a Medicare number at hand in order to obtain information from 
1-800-MEDICARE, having this number allows both the IVR and CSRs 
to quickly access the beneficiary's specific information and 
more efficiently serve the caller. Less than 2% of calls coming 
into 1-800-MEDICARE are from callers without a Medicare number.
    The new 5 minute ASA is encouraging. But I still feel 
strongly that CMS should contract for wait times specific to 
peak call periods.
    By what date can we look for CMS to revise the call center 
contract to reflect an ASA specific to peak call periods?
    What resources will it take (including additional funding) 
to accomplish this?
    Answer: No, CMS will not be revising the call center 
contract to mandate an ASA specific to peak call periods.
    Scripts still are too technical and presuppose program 
expertise that most beneficiaries likely do not possess. 
Scripts also tend to be siloed by issue and do not provide 
common-sense responses for questions that cut across multiple 
issues.
    What steps does CMS and its contractors undertake to ensure 
content is comprehensible by beneficiaries?
    Further, is CMS willing to implement focus group testing on 
scripts?
    Answer: We recently completed an extensive review and 
update of all the 1-800-MEDICARE Part D scripts. As a result of 
our review, we have reduced the number of Part D scripts from 
53 to 25. Notably, we have updated the overview script that 
CSRs use to help triage caller issues and quickly access the 
most appropriate Part D script. We expanded the questions/
linkages on that script and incorporated examples to help CSRs 
assist callers. We have completed a similar review of all of 
the MA scripts and have reduced the number of MA scripts from 
28 to 2. In addition, we have reduced the previous 10 Low-
Income Subsidy (LIS) scripts into one consolidated script to 
make it easier for CSRs to respond to various LIS questions. 
All 1-800-MEDICARE scripts are scheduled to be reviewed and 
updated by the end of January 2009.
    We have implemented a process by which 1-800-MEDICARE 
scripts are reviewed and focus tested by CSRs before being 
fully implemented.
    1-800-Medicare customer service representatives (CSRs) have 
complained to my staff that their three week general training 
does not adequately equip them for the scenarios that they 
encounter on the phone during live calls. What specific 
improvements can we look for in CSR training and oversight over 
the next six months? Specifically:
    CMS might consider incorporating a more robust program of 
test calls in to its quality assurance program.
    Answer: As part of the 1-800-MEDICARE quality assurance 
program, our contractors will continue to conduct test calls to 
examine readability, content flow and logical placement of 
content. Vangent regularly conducts test calls by topic with 
its CSRs for implementing comprehensive script updates. In 
addition, both Vangent and Briljent perform calls for new or 
key initiatives such as the Prescription Drug program to 
determine whether the script addresses the caller's need and 
provides a consistent answer. When making test calls, Briljent 
and Vangent test callers are provided specific call 
instructions and use pre-written scenarios. As before, CMS 
staff members will continue to listen to actual recorded calls, 
but will not make test calls.
    On the topic of training, customer service representatives 
currently have four calls per month reviewed. Call center 
management have referred to this review process as ``a routine 
mechanical checklist that lacks common sense and does not 
provide adequate insight in to whether a representative has 
appropriately identified a caller's issues, answered those 
questions and closed the loop for a caller.'' CMS must do a 
better job ensuring that representatives are appropriately 
identifying and resolving callers' issues.
    Answer: Each fall as we near the Annual Enrollment Period, 
a Readiness Plan is developed and implemented. As part of this 
Readiness Plan, all drug plan scripts are reviewed and updated 
and specific Readiness training is provided to the CSRs. We 
model our scripts and Readiness Plan on how Medicare 
beneficiaries and their caregivers ask questions. Based on 
prior years experience, we use a combination of instructor-led 
and self-paced refresher training. The complexity of the 
subject determines whether CSRs receive instructor led or self-
paced training.
    As part of our script review, we updated several scripts, 
which improved the CSRs' ability to navigate within the script. 
We also updated terminology in the script to match the 2009 
Medicare & You handbook language.
    CMS also must drastically improve the process by which 
information is captured and recorded by the 1-800 Medicare 
system. Each time a beneficiary is transferred to a new 
representative, and each time a beneficiary calls to follow up 
on a prior call, they are forced to recount their entire story 
over and over again to each person with whom they speak. 
Further, customer service representatives rarely seem to be 
able to provide any useful information on the status of 
complaints and other inquiries. What improvements can we look 
for regarding the foregoing?
    Answer: CSRs have access to caller activity and history 
through the CSR desktop application. CSRs can also determine 
what scripts were used during the call. Where applicable, CSRs 
provide additional insight through the use of the CSR comment 
field in the CSR desktop application.
    Additionally, effective September 19, 2008, CMS implemented 
a more streamlined approach for the retro-disenrollment 
process, minimizing the number of CSR transfers.
    Currently, 1-800-MEDICARE CSRs have the ability to 
determine whether a Part D complaint has been filed, and 
whether the complaint has been resolved or is pending. We are 
trying to obtain more information on the status of complaints 
and have made a formal request for additional data. The request 
is currently being reviewed within CMS.
    What additional levels of funding will CMS require to 
accomplish the foregoing improvements?
    Answer: Given CMS's competing priorities, such as claims 
payments, program oversight, and quality improvement, the FY 
2009 requested funding level for 1-800-MEDICARE is appropriate 
within that context. In fact, we've ensured that 1-800-MEDICARE 
spending has remained steady despite budget cuts in other 
areas. In addition, we have identified efficiencies in call 
center operations that have achieved savings in the past year. 
These savings are allowing us to bring down our caller wait 
times.
                                ------                                


      Michealle Carpenter's Responses to Senator Smith's Questions

    Question 1. What Is the Top Priority Fix
    Based on your experience, what is the one item that is the 
most pressing priority that you would ask CMS to first address 
to ensure seniors get reliable answers and prompt service 
during the 2009 plan enrollment period, which starts in 
November.
    Answer. 1-800-Medicare Customer Service Representatives 
(CSRs) hold great responsibility and, in this key role, they 
are affecting people's lives significantly. For this enrollment 
period, beginning November 15, 2008, CSRs must be given a 
standard operating procedure that allows them to assess how 
callers are currently receiving their coverage and whether they 
need to make a choice going forward. CSRs must be able to 
determine whether the caller had creditable coverage and 
whether the caller wishes to continue with that coverage. If 
the caller needs to choose a plan, because he or she does not 
have creditable coverage, is new to Medicare, or needs to 
evaluate whether his or her current MA-PD or PDP plan will 
continue to meet his needs, only then should the CSR begin to 
research available options. To do this, the CSRs must be able 
to use the plan finder websites to assist callers in selecting 
the most appropriate plan. This will also require the CSR to 
know how to find important information on the plan finder 
website. These websites are not often easy to use, requiring 
people with Medicare to look through pages of information 
before they locate which doctors are in a MA plan's network or 
which services are excluded from an out of pocket maximum. CSRs 
should also be cautioned against steering callers to any 
particular type of plan, such as a Medicare Advantage plan over 
original Medicare. This will require that the CSR have a basic 
understanding of Medicare, the available options, and the 
benefits and consequences of each.
    Question 2. It has been represented to the Committee that 
most calls to 1-800-Medicare are simple, single-question calls. 
In your extensive work with seniors, do you find that to be the 
case?
    Answer. The simple answer to the question is no, people 
almost never call with just one simple question. The very 
nature of the Medicare program makes a single, simple questions 
unlikely. Even if someone does call with what appears to be a 
simple question, the answer is rarely simple and often requires 
additional follow up questions. But beyond that, we have found 
that CSRs often are unable to handle what should be straight 
forward questions.
    Question 3. Complaints About 1-800-Medicare
    CMS and Vangent have represented that that they are not 
aware of significant complaints about service at 1-800-
Medicare. My office has received numerous complaints regarding 
difficulties in filing complaints at 1-800-Medicare--either 
complaints about service at 1-800-Medicare or complaints about 
plans or other issues. In your casework with seniors, have you 
experienced these problems? Further, in your experience, after 
a bad experience with 1-800-Medicare, are seniors going to take 
the time to call back in to 1-800-Medicare to file a complaint 
about their service at 1-800-Medicare?
    Answer. Generally, people with Medicare are unaware that 
they are able to make a complaint about 1-800-Medicare or about 
their plans or other issues. In our experience, by the time a 
person with Medicare comes to us, they are very frustrated with 
1-800-Medicare and do not want to call the number again if they 
do not have to. To resolve this problem, 1-800-Medicare should 
institute a quality improvement measure that allows seniors to 
automatically complete a satisfaction survey after the call or 
to have they survey sent to them via the mail to complete and 
return.
                                ------                                


       Tatiana Fassieux's Responses to Senator Smith's Questions

    Question 1. What Is the Top Priority Fix
    Based on your experience, what is the one item that is the 
most pressing priority that you would ask CMS to first address 
to ensure seniors get reliable answers and prompt service 
during the 2009 plan enrollment period, which starts in 
November.
    Answer. During the upcoming Annual Coordinated Election 
Period (AEP), many Medicare beneficiaries will be seeking 
information about their options to change Part D and Medicare 
Advantage plans. One of the most frequently requested types of 
information will be an analysis of Part D options in a given 
state based upon a beneficiary's drug needs. When a beneficiary 
calls 1-800-MEDICARE for such information, usually a response 
is mailed to the caller that includes the ``top three'' or so 
plans that best meet an individual's drug needs. Instead of 
relying upon this information, though, 1-800-MEDICARE customer 
service representatives (CSRs) must be able to explain specific 
formulary issues, such as when a prescription is shown as ``not 
on formulary.'' This type of analayis is necessary, as it could 
give beneficiaries the opportunity to choose different plan 
options. In addition, CSRs must be able to explain additional 
Medigap rights that might be available to callers from 
different states, or, alternatively, affirmatively refer 
callers to a local SHIP in order to obtain such information.
    Question 2. It has been represented to the Committee that 
most calls to 1-800-MEDICARE are simple, single-question calls. 
In your extensive work with seniors, do you find that to be the 
case?
    Answer. In our work, we find that often the question is 
simple but the answer can be complex. Many questions that we 
receive require analysis, including a rephrasing of the 
original question (e.g. ``I want to know if I can change my 
drug plans turns into ``What are my options to change plans, 
what should I look for when comparing coverage between plans, 
etc.''). Medicare beneficiaries regularly seek our assistance 
with complex issues, and presumably, also call 1-800-MEDICARE 
with similar issues. While we are unable to provide a breakdown 
of simple vs. complex calls that either we or 1-800-MEDICARE 
receive, we strongly urge CMS to give more attention to the 
calls it deems to be complex.
    Beneficiaries and SHIP counselors alike are frustrated with 
their inability to get back to the same 1-800-MEDICARE CSR, 
requiring starting the process/explanation all over again each 
time a call is transferred or dropped--with no assurances that 
all notes are being taken. CSRs do little check of callers' 
understanding, and there is still an ongoing frustration with 
the IVR; beneficiaries need to get a live person on the phone 
at the outset.
    Question 3. Complaints About 1-800-Medicare
    CMS and Vangent have represented that that they are not 
aware of significant complaints about service at 1-800-
MEDICARE. My office has received numerous complaints regarding 
difficulties in filing complaints at 1-800-MEDICARE--either 
complaints about service at 1-800-MEDICARE or complaints about 
plans or other issues. In your casework with seniors, have you 
experienced these problems? Further, in your experience, after 
a bad experience with 1-800-Medicare, are seniors going to take 
the time to call back in to 1-800-Medicare to file a complaint 
about their service at 1-800-MEDICARE?
    Answer. As discussed in our testimony, we are more prone to 
hearing about problems with 1-800-MEDICARE than successes. In 
our experience, we have certainly encountered many complaints 
about the difficulties in filing complaints at 1-800-MEDICARE--
both about the hotline itself and plan or other issues. After a 
bad experience with 1-800-MEDICARE, we have found that Medicare 
beneficiaries often do not take the time to either call them 
back or file a complaint. All too often, beneficiaries will 
reach their local SHIP program after a frustrating experience 
with 1-800-MEDICARE and a subsequent referral from Social 
Security or a non-Medicare related agency. Such contacts often 
occur after much time has elapsed following a caller's initial 
attempt to reach 1-800-MEDICARE, which can further exacerbate 
the individual's problems.
    Thank you for the opportunity to provide these follow-up 
comments.
                                ------                                


          John Curtis's Responses to Senator Smith's Questions

    Question.  What problems have you identified that need 
immediate attention, and what steps do you plan to take to 
remedy these problems and deliver drastic improvements before 
the start of the 2009 enrollment period, which starts in 
November?
    Answer. Vangent takes its responsibility to Medicare 
beneficiaries seriously, and is approaching the 2009 Annual 
Election Period with a strong emphasis on continuous 
improvement and quality service.
    Each summer, Vangent develops and implements a readiness 
plan to ensure that we are prepared to meet the increased 
demand of the Annual Election Period. This plan covers all 
aspects of the BCC operation and is a cornerstone of our 
approach to providing high quality service during the fall 
``spike'' period.
    The following are just a few examples of the steps we are 
taking to improve service:
    Lowering Wait Times and Supporting Our Infrasture
    We have implemented a number of operational technology 
improvements to minimize the time required for a beneficiary to 
reach a CSR trained to answer his or her question. In 
September, we opened an additional call center to accommodate 
the increase in call volume associated with the Annual Election 
Period.
    We have also implemented a BCC ``Command Center'' that 
monitors wait times 24 hours a day, seven days a week, and 
shifts workforce as needed to meet incoming call volumes.
    The Command Center monitors network and phone systems at 
each site to quickly identify and address any problems that may 
arise.
    As stated by Acting Administrator Weems, we are committed 
to maintaining an average monthly speed of answer of 5 minutes 
or less through the remainder of the year.
    Training and Scripting
    In preparation for the Annual Election Period, CMS works 
with Vangent and the Training, Quality and Content contractor 
to review and update all drug plan scripts, and provide 
specific training to CSRs.
    We are also taking every opportunity to review ``frequently 
asked questions'' with CSRs to ensure that they are prepared to 
respond accurately and effectively to these questions.
    Finally, CMS has implemented an improved Learning 
Management System that will allow us to better identify 
training needs of CSRs and disseminate information to those 
CSRs and call centers.
    Quality
    Throughout the Annual Election Period, we will reinforce 
our commitment to quality. We will continue to closely monitor 
calls and aggressively address any opportunities for 
improvement identified by our Independent Quality contractor.
    We recognize the important role that 1-800-MEDICARE plays 
in helping Medicare beneficiaries make informed decisions about 
their benefits. We take that responsibility seriously, and are 
committed to providing high quality service not only during the 
Annual Election Period, but throughout the year.

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