Analysis for this paper focused on MSA roles and responsibilities, training, and job satisfaction. This framing resulted in three main findings: (1) MSAs’ role assisting Veterans with obtaining needed care involves more than just scheduling; (2) MSA training may not prepare them well for assisting Veterans with obtaining needed care; and (3) low salary and lack of recognition of the important and complex tasks performed by MSAs contribute to dissatisfaction and high turnover.
MSAs’ Role Assisting Veterans with Obtaining Needed Care Involves More than Just Scheduling
Although commonly considered to be an entry-level position requiring minimal skills, we found that call center and PC MSAs reported performing a variety of tasks related to helping Veterans access needed care (see Table 1). For example, many consider call center MSAs’ main tasks to include scheduling appointments for primary care and forwarding messages to PCPs and care teams. Veterans’ phone calls to providers often result in callback loops (many VA PC clinics do not provide telephone numbers for Veterans to call their care teams directly); Veterans phone the call center repeatedly because they either never received a call back from their PC team, or missed the call when it came. Addressing these callback loops requires call center MSAs to troubleshoot the most effective means of connecting patients with PC teams and deescalate frustrated Veteran patients.
Table 1 MSAs Helping Veterans Obtain Needed Care Half of call center MSAs reported that their most difficult calls come from angry patients either requesting to speak directly to their providers or because they have not received a (timely) call back from their PC team. In addition, many call center MSAs reported devoting time to assisting Veterans with malfunctioning medication refill systems, allowing the patient to vent their frustration while trying to solve the problem. As a result, the call length sometimes exceeds the performance metric target of one minute or less.
Disgruntled patients talk on and on while calls are building up in the queue. MSA did not receive training for disgruntled calls so they let patient talk and try to take notes. There’s only so much MSA can do — Notes from CC MSA interview
Encounters with frustrated patients were not exclusive to call center MSAs. Three PC MSAs said that one of the hardest parts of coming to work was interacting with angry patients seeking resolution to healthcare system challenges. PC MSAs described tasks relating to assisting Veterans with accessing needed care by scheduling follow-up visits, showing patients how to use the check-in kiosks, communicating with other members of their PCMH team about patient needs, directing lost patients to other locations, and scheduling for non-primary care clinics (e.g., radiology, audiology).
MSAs schedule specialty too. If the doctor puts in a consult for the eye clinic then they have to schedule. MSA has two clinics on top of their own clinic now — Notes from PC MSA interview
In spite of operating procedures that discourage communication between call center and PC MSAs, the majority of PC MSAs reported that they received frequent, sometimes daily communication from call center MSAs, primarily via instant message or telephone. Call center MSAs contact PC MSAs with questions about scheduling appointments (e.g., appropriate length, 30 min or 60min) or to transfer patients returning phone calls they received from a member of their primary care team. As one PC MSA explained:
PC MSAs are not supposed to answer phone calls from them (call center) but they still call primary care. MSA gets the majority of their calls because he/she answers the phone the most. States that 90% of calls are from the call center — Notes from PC MSA interview
MSA Training May Not Prepare Them Well for Assisting Veterans with Obtaining Needed Care
Many MSAs reported that they received inadequate training to prepare them for their role in assisting Veteran patients with obtaining needed care. MSAs described three training components: (1) New Employee Orientation (NEO), a 3-day program that introduces new employees to general VA worklife, human resources, benefits information, etc.; (2) MSA Academy, an online training that teaches MSAs to operate the multiple software programs and interfaces they will use on the job; and (3) job shadowing a more experienced MSA to learn how calls are handled in real time before taking calls without assistance. While half of the MSAs said they received each of these components, we found widespread variation in the content and length of training and some differences by type of MSA.
We found less variation in training experiences of call center MSAs as compared with PC MSAs. Two-thirds of call center MSAs reported that they completed NEO for varying lengths of time (1 day–1 week). About half said they shadowed other MSAs as part of their training, again for different lengths of time (1–2 weeks). Two call center MSAs reported that they learned mainly on-the-job with little or no formal training. In contrast, PC MSAs at all but one primary care clinic reported not receiving at least one of the three training components (NEO, MSA Academy, job shadowing).
Both types of MSAs perceived a need for more training in technical and relational skills. Some MSAs felt that they could have used more instruction on working across multiple different software platforms simultaneously to schedule patients.
MSA says it would’ve been helpful to know how to use all the systems as they work together, rather than learn them independently. The way it’s presented is that it’s separate systems, but you need all of them open — Notes from PC MSA interview
MSAs, particularly in call center settings, reported a need for more training on effective communication with frustrated patients or how to decompress after a difficult call. Table 2 lists additional training needs reported by both types of MSAs.
Table 2 Training Elements Reported as Not Provided or Inadequate to Prepare MSAs for Their Role MSA Low Salary and Lack of Recognition Are Contributors to High Turnover
The MSA position is one of relatively modest salary, limited capacity for advancement, and substantial workload. These factors combined with day-to-day emotional rigors add further difficulty to an already complicated job. High turnover was reported by MSAs in both call center and primary care settings as contributing to making their jobs less desirable and/or more difficult, creating perpetually understaffed clinics and call centers:
MSAs see a lot of people come and go. When people are fully trained, they leave. The call center feels like the training hub for the whole hospital. Nobody wants to stay in the call center — Notes from CC MSA interview
Another call center MSA explained the link between being understaffed and its effect on patient perceptions at his/her clinic:
The infrastructure here isn’t big enough to handle all the Vets coming in; they see it as a decline in satisfaction, but they don’t see the call center is understaffed and overwhelmed. Vets take it personally, so MSAs have to explain to them what’s actually happening — Notes from CC MSA interview
Many MSAs expressed the desire to obtain a higher paying position, or a position with higher status and greater responsibility. When asked if they planned on being in the same position a year from now, a third of all MSAs said “no” outright. Most of those who answered “no” said they had either applied or were applying for other positions elsewhere in the healthcare system and/or wanted to “move up.” Only a handful of MSAs said definitively that they plan to work in their current role for the next year, and a few indicated that they would like to be promoted to MSA leads within that time. Another third of MSAs reported they were unsure if they would remain in the position for another year.
Call centers are looked at as the bottom of the hierarchy. But MSAs really run med renewals and we are the hub. MSAs don’t get the paygrade and don’t get recognized enough — Notes from CC MSA interview