DESIGN THINKING
Health Statement — an experience improvement
An overview of the Design Process along the project execution
During the ongoing pandemic, the market for health insurance companies in Brazil has escalated at a rapid pace. According to the National Supplementary Health Agency (Agência Nacional de Saúde Suplementar, ANS) data, the number of beneficiaries has surpassed the mark of 49 million in March of 2022, the largest number since January of 2016.
This growth doesn’t come without pain: frauds cost health plan operators in Brazil nearly R$20 billion and increase the cost of medical procedures for patients by about a third, according to data from the Institute for Supplementary Health Studies (Instituto de Estudos de Saúde Suplementar, IESS).
Among several shams, one stands out as the omission of preexistent health conditions. What may seem like a harmless casual lie early at the hiring process can actually have serious consequences for both beneficiary and health insurance company.
Discovering
When hiring a health insurance provider, one of the documents one needs to submit is the Health Statement Form. It contains several questions to assess the overall health status of the client at the moment of hiring the health insurance and also inform pre-existing illnesses or injuries (Doenças ou Lesões Preexistentes, DLPs).
DLPs refer to chronic illnesses that lead people to seek continuous treatment through health insurance, and also drives costs up with consultations, exams and procedures. Therefore, ANS created a specific type of waiting period to restrict access to high complexity exams and procedures related to it for up to 24 months. This period is called Temporary Partial Coverage (Cobertura Parcial Temporária, CPT).
— To whom is this form of interest?
Certainly, the insurance company is the most hurt party in case of poor completion of the Health Statement. Financial losses are aggravated with lawsuits that take years to settle. But even the beneficiary can find setbacks, in case fraud is proven. This person can be entitled to pay for the treatment then covered by the insurance plus penalties and due contract termination.
Context
For this study, we will take Sami Saude’s current Health Statement form (June/2022) as a model to understand the possibilities of improvements that exist and how to achieve them. First of all, is important to outline a Persona — or at least a set of behaviors to highlights her needs and the way she acts in certain circumstances. The following persona was created based on previous company research, adapted to current context of this project.
Upon finishing college at the age of 24, she was unenrolled from her parent’s health insurance due to a policy regarding adult dependents. Despite having Diabetes type I, Juliana has always been able to manage it well by adopting a healthy lifestyle and paying regular visits to her local clinic through the Unified Health System (Sistema Único de Saúde, SUS).
Lately however, Juliana has been having regular blood sugar spikes due to stressful situations at work. Getting appointments and supplies at the speed needed is becoming a challenge, and she feels the urge to get private insurance in order to keep her body in good health. After comparing some health insurance plans, she decided to go for Sami Saúde’s new plan Orion, that offers a good coverage in the area she lives.
Framing it as a big picture, Juliana’s journey inside of Sami during the hiring process as a customer would look a bit like this:
Sami and it’s competitors
Thinking about the Health Statement form itself, there is not a set way of doing it. As seen previously, there is a basic structure to it, but details are at each insurance discretion, specially the section about the health conditions.
The most common setting of a Health Statement is a compilation of health conditions grouped using the human body systems criteria. Some common disorders are listed in each question, and the client should answer it with either YES or NO. For each answered YES, the client should itemize these questions in the section bellow and provide clarification regarding which health conditions are they subject to at the moment of hiring the insurance. This type of form is usually mailed as a PDF, which the client should edit using proper computer software or print it and fill it with a pen.
Some other healthtechs in the other hand, were born with the premisse of eliminate bureaucracy and paperwork along processes, and that includes it’s hiring path as well. It’s reasonably usual to come across an electronic form when the health insurance is provided by a startup. The formats may vary, but them all seek to lessen the amount of text typed by the user, in favor or clicks. In case of need for clarification, a text field should appear from inside of the question itself.
Sami Saude though is a hybrid — although it is definitely a digital format sent via link, the general setting of the Health Statement resembles the PDF format. Which means that, specially on mobile devices, a certain amount of scrolling may be required in case of need to clarify two or more preexistent health conditions.
Defining
Based on the improvements that can be done over the Health Statement form from the data collected so far, it’s possible to formulate the following hypothesis:
- While some people don’t declare preexistent conditions on bad faith, others might not read the form throughly and omit conditions by mistake;
- PDF forms are read differently compared to interactive forms (reading patterns);
- Users get tired of reading large blocks of text and opt for the easiest way out of the form;
- Since the primary contact with the sales rep is via WhatsApp, mobile should be the most used platform;
- Current Health Statement isn’t compliant with the Design System used on Website and Mobile App;
— Is it time to interview users already?
Not yet — because of the fact that Health Statement isn’t a recurring form on the life of the beneficiary (or at least shouldn’t be), it was decided not to take a direct approach at this point of the project.
Instead, we sought to observe user behavior through Hotjar analysis. With this plugin installed on de current Health Statement form, it is possible to watch the user using the document by the mouse cursor movements, how long does it take them to read passages of text, interact with components etc. Is important to note that no sensitive data is captured by the plugin, and neither the name nor the health information is ever shared with the researcher. Here are some insights provided by the analysis of 50 form filling sessions:
- Low mobile adoption, despite of primary contact with sales rep via WhatsApp. By improving performance in mobile interfaces, could we also improve mobile adoptability?
- Sami’s Health Statement form doesn’t perform well in mobile interfaces due to responsivity and overall small clicking areas;
- Mobile forms are not read in full (or scanned) before they are filled out;
- Every user who checked YES to any question and needed to provide clarifications, had to scroll back from the Additional Clarifications section to the aforementioned question to read the full statement again — only to return to Additional Clarifications section to justify their answer;
- Increased session time is a possible friction along the form. By bringing an open-answer field close to the referred question, is possible to speed up the hiring process, and thus grow our client base faster and increase productivity for the sales reps;
- Regarding Desktop analysis, some people use the mouse cursor to follow the lines while they read. Could they get lost in the paragraph if they didn’t? Shouldn’t the text be shorter here?
- Qualified Medical Interview (to be more explored at the “Market and Regulation” section bellow) is an often ignored field, even to those who fill up the form more carefully. Perhaps this question would be more useful at the beginning of the form, not after answering the questions. In this case, this should also be rephrased in order to make sense in the new context;
Market and regulation
The healthcare market in Brazil is indeed subject to many regulatory authorities, such as the previously mentioned ANS and General Data Protection Regulation (Lei Geral de Proteção de Dados, LGPD). Before even start answering questions, the client is asked to read orientations regarding the Health Statement form filling.
Presenting these instructions to the client is an insurance’s obligation and fail to comply with it results in penalties which depending of the recidivism, might result in the suspension of permission for insurance commercialization.
According to the Ministry of Health’s Normative Resolution nº 162, the insurance should provide an informative Guidance Letter to the Beneficiary in which are stated general guidelines about how to fill out the Health Statement and also their rights regarding preexistent conditions and general coverage.
Besides that, when hiring insurance the client should be informed they have the option to ask for assistance of a general practitioner to fill the Health Statement out defrayed by the insurance. Most people decide to do it by themselves, and very few claim to have used help from their own doctor — at their own expense. Even when the client decides to do it alone, the insurance should make this option clear.
There are however a couple points to pay attention here:
- The Guidance Letter to the Beneficiary has a specific formatting to be followed (Times New Roman, 11pt, single spacing), subject to penalties of the law if doesn’t followed. This formatting however was conceived in a time when insurances used to mail these documents as sheets of paper or sending them as PDF files to be printed. This is not a format that works well in screens, specially in mobile interfaces. To stay compliant with the Normative Resolution then, it was decided to keep this formatting only at the final document to be signed at the end of the process (not shown in this study);
- Although offering the Qualified Medical Interview is an obligation, is not necessarily an advantage that clients request it. Although it has the potential of better form filling, for every person that requests it, it means the hiring process will be suspended for around 24h in between time to request an appointment with a general practitioner and filling out the form. A better approach in this scenario, would be making the form overall language more accessible, eliminating ambiguities and making it the most objective as possible.
“How might we make the most out of the digital format in order to deliver the best experience for both client and stakeholders along the process?”
Ideating
So we gathered the knowledge we needed so far and is time to start generating ideas focusing on users — Juliana, as a matter of fact. So do it by sectioning the Health Statement in it’s 3 main parts and discussing ideas in Design Critique sessions:
Beneficiary’s Orientation Letter
1. The most obvious way to go here would be placing the ANS’ format as it is required in the document itself.
Pros: Compliance with regulations;
Cons: Poor usability and absolute disagreement with the Design System;
2. A similar one would be placing an hyperlink to a different page with this document.
Pros: Using the exact same document provided by ANS is probably the safest option;
Cons: Taking the user out of the intended course of action is a risky move at the Sales rep point of view, this should be avoided as much as possible;
3. Since most people tend to skip anything that looks and feels like Terms and Conditions, we could present 3 main topics as a gist from the main text and leave an hyperlink opening a modal with the original text. Regarding ANS’ constraints, the original formatting could be printed at the final contract that ends up with the beneficiary upon completion of the form.
Pros: Favors the user conveying information in a more friendly way;
Cons: Grey area in regulation — wasn’t done before by any of our competitors;
Assisted Medical Interview
1. The original setting of options were the following 3: refusing assistance, claiming to have received help from their own doctor OR soliciting Sami’s doctor assistance. In the later case, a dialog modal would appear confirming this option and informing this could delay the hiring process in up to 24h;
2. Giving the client 3 long options may be overwhelming. Instead, the two options mentioning assistance can be grouped in one in the first moment. Then if assistance is requested, the client can choose how to receive it — the alerts regarding delays could be presented in info cards instead of dialog modals;
Health Statement
From what we know so far, the only forms that are automatically analysed by the system are the ones without any preexistent condition at all. The reason for this is that every time a YES question prompts an open clarifications field, a human will need to audit the form manually.
If we could lessen the need for writing along the hiring process, could we also decrease the demand for human labor in auditing these forms?
Apparently, yes! By transforming the shape of the questions, we also make it possible to automate the analysis of many other Health Statement forms, in case the common preexistent conditions.
The chips offer not only more agility at the time of filling up the form, but also could be potentially linked to ICDs (Classificação Internacional de Doenças, CID) internally to the API.
An option for ‘Others’ would still be applicable, since we can’t possible list every health condition and still keep it concise. Questions could be rewritten favoring the chip format, presenting the most common conditions, even the ones that wouldn’t prompt CPTs (ex: Diabetes), to avoid opening new text fields.
From the client’s perspective, this means less chunks of texts to deal with and a quicker task completion. From the business perspective, automating a great portion of Health Declaration analysis have the potential of relieving the pressure on the people who audit these forms (less repetitive work) and also speeding up B2C sales process, since this would be one less form to wait approval to proceed with closing deals.
Prototyping
With all these ideas in mind, is time to define who’s user that will be testing this prototype: ideally, someone who had hired Sami’s health insurance within the last couple weeks before the test.
Although we do want to focus on the functionality and flow of the product, we are able to add higher levels of detail to it quicker thanks to the Design System. By designing more interactive and believable prototypes, we’re also able to collect more realistic feedback from users when testing.
Disclaimer 1: Since this is a modified piece of study for a past employer, I’m not authorized to showcase the high-fidelity prototype, although it was built and used as base for the following phase of this project.
Testing
This stage often feeds into other stages of the Design Thinking process, allowing us to empathize and gain a better understanding of users, generate new ideas to solve the user’s problem and also improve the prototype. Since this is a heavily regulated sector that doesn’t allow much plasticity in it’s core structure, we opted to test a high-fidelity prototype with our target audience.
Before resourcing to users, we decided to perform an Heuristic Evaluation as a cost-effective way to catch usability or accessibility issues before testing with real users.
Test preparation
Along with the Research team, we prepared a script to run a moderated usability test with our users. The idea was to conduct it via Google Meets, sending an interactive Figma prototype link and asking the interviewee to share the screen so we can watch the whole interaction. A person would conduct the test with the user and a third person would take notes. With the permission of the interviewee, we get to record this whole interaction for later consulting purposes.
Before bringing the test to our real users, we decided to run a couple ‘down the hallway’ tests with people who also worked at Sami at that time, but without any ties or context about this project. The idea was to validade overall usability of the mockup. A main con about this approach was that since we weren’t testing with the right users, there was no comparison effect with previous Health Statement form filling.
The outcome of these tests was positive in the overall, which allowed up to proceed to gathering the contacts of people who fit the profile of our users at the CRM platform and recruit them via WhatsApp as the next phase.
Disclaimer 2: As I was laid off just before conducting usability tests, it wasn’t possible to validate many of the hypotheses raised throughout the project. Therefore, this is the end of this presentation.
