Why Should Healthcare Consumerism be 99% Invisible?

The woman walking from the hospital should have been watching where she was walking rather than speaking on her phone.  She did not see the sinkhole until she fell into it, at which point see could see it in detail.  The doctor, upon seeing her in the hole asked if she was okay.  Learning that she was in pain, he wrote her a prescription and dropped it and a pen into the hole.

A few minutes later the hospital’s director of revenue assurance walked past the hole.  She too inquired about her health.  He opened his briefcase and dropped an insurance claim form into the hole.  You should complete the form, but I don’t think having fallen into a sinkhole is covered under your plan.

The chief patient experience officer happened upon the woman and wanted to know what had happened.  Speaking with her for a few minutes, he asked the woman: how was your experience with us prior to falling in the hole?  “Would you mind filling out this patient experience survey?” He asked.  He tossed the survey and a pen into the hole and left.

The woman considered her predicament.  She thought, at least I can occupy my time by filling out the forms until I am recused.

A consultant looked in the hole.  He went by the moniker, the Voice of Reason.  (You can buy Voice of Reason t-shirts during the intermission.)  He assessed the situation and jumped into the hole.

“Now we’re both stuck,” she said.

“That’s okay,” I told her.  “I’ve been in this hole before and I know the way out.”

If you try to recast consumerism and access and engagement and experience on your own, you may find yourself in the same position as the woman.  A lot of meaningless assistance.

My experience tells me that most efforts to improve it do so without any knowledge of what their efforts should look like when they are done.

Here’s a big hint. If you design it correctly, and you must design it, it should not look like anything.  Consumerism, access, engagement, and experience should be ninety-nine percent invisible to your patients and consumers.

That ninety-nine percent should all be behind the scene.  It should be built into your consumerism architecture and platform.  The one percent seen by the patients and consumers is the hands-on user experience.

It helps if you think of it this way. Consider your tablet or phone and the underlying operating system—iOS, Android, and Windows.  Your devices are easy to use.  Their use is intuitive. What you see is the one percent.  Far more than ninety-nine percent of what makes them easy to use is invisible.  The hardware, the architecture, the processes, and the applications were designed.

And users were involved in every step of the design. It is called human-centered-design. Users knew the design would meet their needs and be simple to use before a single line of code was written.

The good news for healthcare consumerism is that a lot of the difficult work has been done for you.  The devices and the operating systems already exist.  The only remaining task is for healthcare to define what it wants to do with those tools.

Healthcare can design an experience for patients and consumers on those devices that can do everything they want, and it can be designed in a way to give them the experience they want.

Healthcare has almost everything it needs to recast consumerism.  The only thing missing is defining what it should look like when it’s done and someone with the will to do it.

Healthcare Consumerism: Only One Of Us Was Male

There were four of us in the car and we were driving to the Dallas-Fort Worth airport.

Of the three, one of us was a male. The other three were not. The math is simple; the ride was not. The three non-male members of the group were each holding their smart phones and each of them was using Google Maps.

I asked, “How much further?”

‘Seven miles,’ one of them replied. Who replied neither adds to nor detracts from the telling of the story. Seven miles turned out to be a key data point. It was key because within ten more minutes we were thirteen miles from the airport.

I used to live in Dallas, and I knew we were now headed rapidly towards Waco. I thought briefly about adding my two cents, but as I already stated, one of us was male. Male and married.  I knew from personal experience that one-on-one was not a fair fight. Three on one was just plain silly.

And so while the three Amerigo Vespucci’s in the car continued to drive south—we were now sixteen miles from the airport—I played binary Sudoku on my phone–I lost. From an elevated ramp on the interstate, I asked, “Is that the Gulf of Mexico?” Fortunately for me, my remark fell upon deaf ears.

We don’t know where we are going, but we are making very good time. Or not.

Like people, businesses try to use tools to help them meet their needs. Sometimes they use the tools advantageously, sometimes they do not.

People call us; let’s build a big room and put a lot of phones in it.

People like to use the Internet; let’s build a website, and get someone to write an app.

Get a bunch of people to ‘like’ us on Facebook.

Your patients see what is going on, and they are each asking, “Is that the Gulf of Mexico?”

The Top 15 Ways To Improve Access & Engagement

I have developed a certain affection for the television shows Survivor, Naked and Afraid, and Life Below Zero.  If you are not familiar with the shows, their premise is to determine who among the contestants has the inventiveness and mental toughness to exist on a diet of insects or to live when the average temperature is forty below zero.

Having slept on the glacial face of a volcano at seventeen thousand feet, I fancy the notion of competing on those shows.  Give me a piece of twine and a pull-tab from a can of soda and I will build the iPhone 12.

So, last summer our power was out for four days because of a thunderstorm.  Instead of having to hunt narwhals while wearing nothing other than my skivvies—don’t try to picture that in your mind, I was ensconced in my home; no air conditioning, no television, and having to fight my way around obstacles at night with nothing to guide me other than my wits and the light from me cell phone.  The showers were cold, my soft drinks were warm.  I survived the first two days with nary a scratch.

By day three the lettuce was wilting and so was I.  I reflected on my not too distant halcyon days, days when I could sit in my air conditioned home and watch television shows about people trying to survive in a Brazilian rainforest eating grubs.  It was then I decided that were I able to survive my own odyssey I would put aside my dreams of living a wilderness adventure and make due with mowing my lawn.

I have no segue for this post, so here we go.

Chances are your health system’s website is a clunky old thing designed by the elderly (people over the age of thirty.)  The time to rethink what you want out of your website has come and gone; that train already left the station.  The only way to play catch-up is to dump the sclerotic vision that defines your online presence, and figure out what your stakeholders expect from it.

People who visit your website have an experience, they just have a good one.

The best way to not have to measure patient experience is to design such a good, interactive online experience that measuring it would be redundant. Design these things into your website and you will have the most progressive health system on the planet.

  • If half of your callers would rather have their needs met online, figure out how to let them do that. If you don’t know what they want to do online, ask them.
  • If half of your patients will seek a second opinion, give them a link telling them why they should stick with you
  • If half of your competitors’ patients are seeking a second opinion, give them a link telling them why they should pick you
  • If twenty percent of your callers have questions about their bills, use co-browsing and online videos to explain your bills
  • You know your patients are going to dispute their reimbursement, show them how to do that on your website; make videos explaining payer by payer how to do it
  • If a percentage of your patients want to speak with a clinician, make sure they can. Heck, make sure they can do it at a time convenient to them, which probably will not fit the hours of your call center.
  • If every single person who visits your website is either a patient or a potential patient, tailor all of its functionality to them—get rid of the other eighty links; links about the gift shop and posting baby photos online
  • If you have a scheduling center instead of a real call center—80% of your calls are not about scheduling—create a real call center.
  • Put a chat function on your website—how may I help you—and delete that silly contact us box that promises a response before the next full solar eclipse
  • Let callers on hold enter their phone numbers instead of having to wait, and have the next available agent call them back
  • Let call center agents email callers
  • If someone contacts you through your website, respond to them within an hour
  • Let people schedule appointments online
  • Since a lot of people who are considering buying healthcare from your system visit your website, give them something to do when they get their—how about a customer portal where nonpatients can store and track their health data like they do with apps on their smartphone, a portal whose data you can monitor.
  • Since only a fraction of your callers and website visitors are in your EMR, make sure you can meet the needs of everyone who isn’t—those people are called customers.

Prevent people from leaking at the start of their experience.  Design an experience focused on keepage, not leakage.  None of these features are difficult to accomplish using current technology.

If you do all of these things you will never have to worry about measuring patient experience.  You will already know it is great.  And maybe then we can ask why everyone in Washington is so concerned about building a wall to keep out the Canadians.

Healthcare Consumerism: Ask Betty

I was awoken by a strobe of orange light flashing through my bedroom windows.  I peeked outside and saw a human caravan making their way to my backyard.  By the time I had dressed and made my way out the door one my deck, I saw two men hammering wood stakes into the wet ground, and a woman stringing what looked like crime-scene tape around those stakes.  A half-dozen other people were clustered on my property, talking on cell phones, and writing on clipboards.  A lone woman was collecting water samples in test tubes.

My yard was sodden from the recent rains. As I approached the group, a guy built like a Navy Seal approached me and asked, “Where do you think you are going, Skippy?”

“Why is everyone in my backyard and standing around my puddle?” I asked.

“It was your puddle, now it’s a wetland.  Go back inside voluntarily,” he said as he reached for what looked like a Taser.

To my left was another puddle, one they had yet to rope-off.  I flopped onto my back and started moving my arms and legs.  His Taser was now pointed at my head.  “What are you doing? He screamed.

“Making wetland angels,” I replied.  “Bu the way, I think I may have just been bitten by a rare, yellow-bellied newt.”

Our world is changing faster than I can yell tree-sloth, and I didn’t even get the email.

Several of you wrote asking me to give an example of the differences between a well-functioning call center and the scheduling centers found in most health systems.  This may help.

To help explain it, I met with James and Betty.  James works for your scheduling center; you’ve probably seen him in the cafeteria—tall, lanky…parts his hair on the left.  Betty works for Nordstrom.  I asked both of them to tell us what their job is like and what they do during their shift.

James began. “My job reminds me of one of those people I’ve seen at a driving range,” he said.  “If you’ve ever hit balls at a driving range, you may have seen a person driving around the range in what looks like a metal birdcage.  It looks like a wheeled metal box wrapped in wire, and it is pulling a long, rubber-grooved cylinder.  The grooves pick up the driving range balls, and they are dropped into a collection basket.”

“I’ve seen those when I golf,” I said.  “Everyone tries to hit the cart with their shots.”

“Exactly.  That is what it feels like answering calls at the scheduling center.  Everyone is shooting at me and I just must sit there and take it.  I bet you didn’t know that only about twenty percent of the calls I answer are from someone trying to schedule an appointment.”

“What do you do with the rest of the calls?”

“Sometimes I try to answer them, but I don’t have any of the tools or information I need.  So, I either tell them to call another number—that may or may not be the right number—or I transfer the caller to someone who may or may not be able to answer their call correctly.  Sometimes I find myself giving basic medical advice.”

“Don’t you have a nurse who can help them?”

“You’re kidding, right?  Heck, we don’t even have a decent enough scheduling system to help me to do my job.  I am only able to schedule sixty percent of the people who need an appointment.”

That was James. Betty’s response was just as interesting.

“Have you ever been to a big city park where they have dozens of chessboards set up?” I nodded affirmatively.  “Well, sometimes a master chess player will play dozens of games simultaneously, the master against all of the others.  That is what my job at Nordstrom’s call center feels like.  No two questions are the same, and I am expected to give the right answer to every caller the first time, every time.  But I have a CRM system that lets me provide the answer to every question.”

“So, let’s say I call you about a problem I had with a suit I purchased and had tailored at one of your Seattle stores.  Could you help me with that even though I live in Philly?”  I heard her enter my phone number into her system.

“The one you bought June 3rd, the Ted Baker pinstriped?  I see you called once before.  It looks like the alterations to the pants were incorrect, and they applied a credit to your account.  You shipped it back to be re-altered on the 11th.  The alterations were finished on the 23rd.”

“I still have not received it.”  More keyboard clicks.  “It shipped yesterday, overnight, along with a tie picked out by your personal shopper; no charge for the tie.  May I help you with anything else?”

There is a world of difference between what a health system’s call center can do and what a real call center can do.

After speaking with Betty I remembered that I was supposed to have scheduled my MRI yesterday.

What should I do?  What would you do?  I placed a call.  “Betty, there is one more thing you can help me with…”

 

“Your Insurance Policy Does Not Cover Ponies”

During my run, today I started thinking about the call I had with my healthcare insurance provider. It was not a pleasant experience.  The more I thought about the call, the more confused I became.

The payer, having no idea who was calling, asked me for my member number.  The term ‘member’, I think, is used to make us feel like we are being fawned over.  I thought about other organizations of which I was a member.  I was a member of the boy scouts. I belong to a gym; I am one of their members.  Being a member implies being a part of something bigger than myself.  It implies a sense of belonging, a sense of clubbiness, a sense of intimacy.

Sometimes it requires a payment—dues.  Having health insurance requires paying dues, but that is the only common thread of membership.  There is no clubbiness.  You become a member of an organization, you pay dues to that organization because you get something in return for those dues.  You get what you pay for.  Not only that, you get what you think you paid for.  There are no surprises.

At my gym, the attendant never tells me that my membership only entitles me to use the treadmill for thirty minutes.  I have never been told that page 37, paragraph 4, of my member agreement clearly states that I am not allowed to use the sauna.

The problem between me and my payer, and you and yours, comes down to a single point.  I want to accomplish one thing, and my payer wants to accomplish something totally different.  Even if my payer wanted to meet my needs, their customer experience strategy was not designed to meet them.

Their entire customer experience strategy is designed to do two, and only two things:

  • Maximize receivables
  • Minimize payables

Customer experience via their call center allows you to:

  • Buy a policy (a membership)
  • Make a payment
  • Add a family member
  • Update your personal information
  • File a claim
  • Try to dispute a claim—you can dispute it all you want, but this is a zero-sum game
  • Try to cancel your policy—the system is designed to make this very difficult

Online, your number of options are fewer.  Those options are designed to bring cash in, not to let it out.

I would not mind paying my dues if I knew that in doing so my payer would meet my expectations.  Like you, I have learned that the best a payer will do is meet a portion of our expectations. Your membership does not allow you to use the sauna.

There is no opportunity to use my membership to proactively manage my health and to drive my wellness.  In addition to maximizing receivables and minimizing payables, the entire payer business is designed to focus on what was—a treatment or a procedure.  It is all about cash flow.  Payers know nothing about the efficacy of your treatment or procedure.  They know nothing about your current health and the health you want to achieve.

Payers spend millions on big data.  They spend millions more analyzing that data.  Those millions tell them who and what to exclude.  They have a zillion data points about broad groups of people and zero data points about the current health of an individual.

People, members, want to be healthy and to stay healthy.  They want to be connected.

People want payers to know who they are and how they are.  It’s no more effective than a five-year-old wanting a pony.  Page 37, paragraph 4, of your insurance policy states, “your membership does not include ponies”.

Why Is Healthcare Trying To Sell Socks?

There are 1,541,335 people in the US named Paul.  Four thousand and thirty-five people are surnamed Roemer.  And there are twenty-one people named Paul Roemer.  Among those are a PhD economist, a basketball player, a few doctors, and a male model—and no, I am not the model.

All the Pauls are different, as are the Roemers, and the Paul Roemers.

What could someone who had something to sell market and sell specifically to the Pauls and the Roemers and the Paul Roemers?  They could sell a keychain with the name Paul attached to the fob.  And a nameplate for a desk to the twenty-one Paul Roemers.  And a headstone to the same twenty-one people.

There is nothing else they could market and sell if their intent was to sell a product or service targeting those specific groups of individuals.  The Wall Street Journal would not create a marketing campaign targeting the unique characteristics of the Pauls.  Ralph Lauren would not create a clothing line specific to the type of casual wear favored by the group referred to as the Pauls.

And I had a think.  I thought about marketing and selling and healthcare.

But if you think about the marketing campaigns of providers and payers and big pharma, their whole approach to marketing and selling is to sell to the Pauls–not to Paul.

Healthcare markets in one of two ways.  It markets to everyone, or it markets to specific groups of individuals.  It markets to prospective patients as though they were all gathered in a stadium.

A healthcare provider tells everyone listening to NPR about its unique cardiology treatment.  A payer runs a thirty-second ad about its coverage for cardiac patients.  And the pharmaceutical firm places an ad in People magazine extolling the wonders of its new Beta-blocker.

These campaigns fail first because they approach millions of cardiology patients, or any other group of patients, as a ubiquitous group—the Pauls.

The second reason it fails is because their entire approach is to purchase patients’ attention.  Healthcare’s approach is to market information.  Their strategy is outbound marketing—marketing information.  Outbound telemarketing is one example.

Patients and members want value, not information.  They want connected marketing and connected interactions.

While your organization is marketing to the masses, or even to a specific subset of individuals, patients, and members want you to connect with them—a specific Paul, not all the Pauls.  Elderly people are not all the same.  Nor are cancer patients or children.

While you are marketing to a stadium of people, the people in that stadium are interacting with you as individuals. There is only one caller on each call.  There is only one person at their computer or smart device looking at your website.  The same holds true for patient portals.  One patient portal does not fit everyone.

I want you to know me.  Healthcare does not know me.

The world has gone digital.  Healthcare has not.  In the digital world, individual patients go find what they need.  This requires healthcare to change how it approaches and interacts with people.  It requires inbound marketing.

Provider and payer call centers approach callers as though every caller is the same.

Payer and provider websites do the same thing.  One size fits all.  While that may work it you are selling socks, it does not work if you are trying to acquire patients and members, retain them, and manage their health.

Healthcare must change its strategy to be effective at consumerism and access and engagement.  Otherwise, you are just selling socks.

Healthcare Payer Business Model–The Grinch Who Stole Christmas

Karen, a good friend, dropped by this weekend.  She brought croissants and her Scottish terrier, I guess thinking we would eat one of the two.  The dog bared its teeth and growled at me, which made me divert my gaze to the croissant.  Fortunately for me, on the danger scale, terriers fall somewhere between guppies and sunflower seeds.  Karen has the fashion sense of an accordionist in a polka band.  One might argue, as she did, that I didn’t have the right to criticize her sartorial spender as I was dressed in bellbottom pants and was sporting a Puka shell necklace.

We talked politics.  When we do, it is a veritable Tennessee Williams play, akin to playing Twister on the edge of a cliff.  Our time together would have been more enjoyable had we simply agreed to listen to an eight-track tape of Abba. Ours was not a conversation for the junior varsity.  With or without the use of automatic weapons, to hold my own I had to step up my game with her.  Karen has always had a mind of her own—it’s how she uses it that keeps me awake at night.  Sometimes I feel as though our combined intellect could not solve the TV Guide crossword puzzle.

She was a Hillary acolyte and someone whose mission in life was wondering why Gilligan never left the island.  I however, was from the dark side and content to solve the world’s problems from the comfort of my Barcalounger.  I launched into defending my political position with as much trepidation as a middle school geography teacher trying to find Burma on a dated classroom map.  I would have had an easier time defending my position had I been trying to squeeze a hippo through a clarinet.

I tend to stand out even in a crowd of one.  Some people who know me think that I am the type of guy who might just walk into a Seven-Eleven and lose it just because the Slurpee machine wasn’t working.  That’s not true, unless, of course it was the blue Slurpee pump that was on the fritz.

Trump supporters.  When I speak of this, I speak in parenthesis to ensure I am not overheard.  Wondering what to do, I looked it up online. WWTDD—what would Tyler Durden Do? (The Fight Club).   The first rule of the Fight Club is that you don’t talk about the Fight Club.  The first rule of post-election politics is that you don’t tell anyone for whom you voted. I was disappointed to learn that there were no links on Google about anyone offering asylum to Trump supporters.

Being a Trump supporter is analogous to having a dirty secret.  While my friends and neighbors shared their political opinions incessantly prior to the election, everyone who had opined has gone into seclusion.  People get that way when the conservatism cat gets out of the bag; but I’m a dog person.

I grew up in Baltimore—70 miles from where I live as the crow flies; 90 miles if the crow were driving a pickup. My wife and I were supposed to be on our way to Baltimore but we were running late because one of us takes too long to put on our makeup and the other one of us gets impatient and threatens to leave.  This is when one of us decides to send the other one of us to a reeducation camp.  As someone who prides himself in knowing which way the wind is blowing, I changed out of my Brooks Brothers suit and dressed in rags and Birkenstocks.

So now you know how I spent the holiday.  I don’t have a segue, so let’s dive into this post and then you can get back to whatever it was you were doing.

The Wall Street Journal had an article about a drug that helps reduce the urge to smoke—Chantix.  The article wasn’t really about Chantix.  Rather, it focused on the fact that payers do not cover prescriptions for Chantix.

Healthcare just gets curiouser and curiouser.  If you’ve never smoked, smoke a pack a day for a month, try to quit, and then return to reading this post. Literature suggests it is easier to quit using heroin than to quit smoking.  I used to smoke.  I tried everything imaginable to quit. I even went to a hypnotist hoping that would help me quit smoking.  And the hypnosis worked.  Until I got in my car and immediately lit a cigarette.  (However, now, every time I hear my trigger word, “consumerism”, I stop whatever I’m doing and I launch into my version of Rosalind Russell singing Everything’s Coming Up Roses from the Broadway musical Gypsy.  It could have been worse. I could have been hypnotized to say the line from Silence of the Lambs, “It rubs the lotion on its skin; it does whatever it’s told.”)

I digressed.  So, I took Chantix, and I stopped smoking.

The WSJ article about why payers would not cover the cost of Chantix confused me.  After all, not smoking is a good thing.  Right?  Because not smoking would prevent several other illnesses.  A, implies B.  but that is not how payers look at the issue.  While they may be interested in preventing members from smoking, they have no financial interest in the fact that A leads to B for smokers.

When payers do the math, they know that some percentage of smokers are well on their way to B—contracting smoking-related diseases.  Smoking-related diseases that are expensive to treat.  Smoking-related diseases that do not count as pre-existing conditions.

Their logic makes financial sense to them.  We know smokers will cost us more in the long run.  So, if we cover Chantix, we are still stuck with paying for the diseases those smokers will incur once they quit smoking.  If we don’t cover smokers, we pay out less.

The payer care model for smokers seems to parallel Dickens’s line from A Christmas Carol—“Let them die and decrease the surplus population.”

Payers’ advertising buries that fact.  Their advertising continues to show healthy people picnicking and hang-gliding.  To be accurate, their commercials should depict a black and white clip of Alistair Sims explaining to the two men collecting charitable contributions, let them die and decease the surplus population.  Chantix only stops a percentage of smokers from smoking.  The let them die model is much more effective if your firm is responsible for paying smokers’ medical claims.

Once smokers die, the payers’ out-of-pocket costs are zero.