What Is Healthcare’s Missing Link?

All things being equal. We use the phrase a lot. It occurred to me that the only reason to use the phrase is that more often than not, all things are not equal.

In healthcare, experiences never equal expectations. The last best experience that anyone has anywhere becomes the minimum expectation for the experience they want with their healthcare organization–I borrowed that phrase from a colleague.

If you look at which U.S. firms were market leaders ten years ago, and compare that list to today, you will find many of those firms are no longer on the list—go digital or go home. What is it that the best consumer-focused firms in the country do that others don’t? They created a value-experience that gets consumers to visit them daily.

And how did they do that; were they just lucky? The easy answer would be to say that they put much of their business online. But that cannot be the whole answer. Providers and payers are online and none of them are listed as the best firms to work with. Being online does not get their customers, or patients if you prefer, to visit them daily. Heck, many customers and patients never visit their provider or payer online. And why not? Let me toss the question back at you; why would they? Can you think of a single reason why one of your customers or patients would visit your organization online every day?

Simply being digital is not the solution. Your EMR did not create a bold, new way of healthcare; it simply digitized the old way.

The statement about inequality at the start of this piece becomes relevant in this discussion because your organization likely created the inequality. It all comes down to expectations. Fact 1: If you do not know the expectations of a customer or patient you will never meet or exceed those expectations. The user experience continues to be less than the user’s expectations of what that experience should be.

Fact 2: Nobody’s user experience on the phone with their provider or payer will exceed their expectations. That is because given the choice most people would rather interact with you online. You don’t want to call your payer or provider anymore than they do, so why make them?

Terry Orlick published “Pursuit of Excellence” decades ago. The book was an instant hit; everyone read it. And the reason everyone read it is because people were astonished to learn that simply being average was the new excellence. The rule of thumb for delivering a customer experience became, “We may not be great, but we are at least as good as they are.”

Imagine a world where every single interaction you had with your payer or provider could be done online and done while providing a remarkable user experience. Now imagine a world where the user experience was so good that your customers came to you every day—I know, that sounds absurd.

Providers who are saying, “There is no way we could get people to visit us daily, we cannot even get them to visit us once a year,” are not imagining a world. To get people to come you must give them a reason to come.

“Why would a healthy person want to visit us every day?” How about because they want to stay healthy? Try this exercise. Put your most creative people in a room and tell them not to come out of the room until they have imagined a compelling reason to get people in your community to visit your health system online every day.

Here’s a hint. I visit my phone every day, going to two different health-related applications—tracking my exercise and my diet. These applications don’t share information with each other. They do not assess my health, and they do not warn me when my health data should raise an alarm. They simply store data—just like your hundred million dollar EMR.

Other than a lack of imagination, there is no reason your health system cannot offer your customers, members of the population whose health you are supposed to be managing, a web-based super-app that creates a super experience. One that causes them to reach out to you.

What if that super-app let consumers do the following?

  • Enter a range of health-related data; exercise, diet, vital signs, track use of prescription medications
  • Share data among the apps
  • Review the data
  • Assess someone’s health based on that information
  • Warn the person if something seems amiss
  • Let them chat with you
  • Let them ask you to call them

People who are not even your patients might sign up for that. Sally did. Sally is forty-one, married, and has two children. Sally and her family just moved to your service area.

Now imagine that from that same super-app Sally could:

  • Select a primary care provider
  • Schedule an appointment online, using a mobile device, or by phone
  • Choose between an office, tele-health, and in-home visit
  • Be provided with the different prices for each appointment type
  • Be told what her out-of-pocket cost would be for the appointment
  • Receive payment confirmation
  • Be notified that her payer information was submitted
  • Update her health profile online and create profiles for her children
  • Track her health-points
  • Chat with a nurse
  • Review her labs
  • Request an authorization
  • Be notified her doctor is running 20 minutes late
  • Set up a payment plan
  • Be notified to schedule their children for school physicals
  • Have her families prescriptions refilled automatically…and so forth

That is what we have been talking about. That is a customer portal. Sally thinks you did this all for her. But you know that once Sally has entered all of her information into your health system she is no more likely to change health systems than she is to change banks.

Zero-cost patient acquisition and retention–the missing link. Imagine a world.

2017’s De Novo Healthcare Strategy: Shift Happens

Everyone is interested in changing healthcare, but at some point, one must ask the question, just how serious is their interest.

Because of what happened on November 8, hopefully everyone who wrote their strategy about how to approach population health and accountable care had the foresight to write their strategy on a Etch-A-Sketch. The military has a saying about battle plans; once the first shot is fired, all plans go our the window. 
Did I just hear a shot across the bow of the USS Healthcare?

Healthcare organizations that were giddy with the anticipation of filling their coffers with the passage of Obama Care can now be heard weeping and gnashing their collective teeth.

The best way to handle the fertilizer that is about to hit their air circulation system should do two things; grab your Etch-A-Sketch with both hands and shake it vigorously and, write a new strategy. Shift Happens.

The time has come to throw out everything you thought you knew about what to do in the next five years and give careful consideration to what you should do now.

Friday I met with a senior executive of one of the most venerated health systems in the country. Part of our discussion focused on how healthcare needed to change in order to manage care and to drive wellness.

His idea, which I liked much better than mine, was that healthcare needed to take its current model and multiply it by negative one. What if, he suggested, instead of people paying to see the doctor, the doctor paid us when we needed to see him or her? On the flip side, on the days we did not need to see the doctor—because we are healthy—we pay the doctor.

Although it would be difficult to make the numbers work, if the healthcare’s goal is to make people healthy, intellectually the model makes sense.

Healthcare Innovation: I Want To Buy A Vowel

The valet took my car.  The Walmart greeter, turned his head sideways kike a swimmer and welcomed me. I asked him if the hospital was running any sales today on procedures or illnesses.  That always confuses them.  Then  I sashayed over to the coffee emporium.  

After taking out a small loan to pay the barista, I sat in the most ornate hospital lobby I had ever seen.  There was a large atrium in the middle of the lobby extending to the twelfth floor.  I squinted to see if there were frescos painted on the ceiling.  A man wearing a black three-piece suit was playing music-to make-you-forget-you-were-sick on a grand piano–I’m not kidding.  The only missing embellishments were free pony rides and a killer whale leaping in a water park.

It was like being at the Ritz.  Healthcare consumerism personified; valet parking, a greeter, a great lounge, and gourmet coffee.  Your innovation dollars at work.

Consumerism is not a cultural revolution underway involving a sudden new enthusiasm for taking care of customers.  In fact it lacks both the revolution and the enthusiasm.

The biggest problem in innovating consumerism is that institutions are looking for easy solutions, and they have developed plans and approved budgets to ensure they get easy solutions–check the box and move on to the next big problem whose leaders are seeking an easy solution.  No one likes to work harder than he or she needs to.

Many healthcare executives are betting that if they wait long enough, consumerism will simply fix itself.  Waiting is  essentially long slow periods of nothing much interspersed with ocassional bursts of something.  Bursts of something never fixed anything.

The first something they will do is call a meeting. They’ll give the meeting a fancy name, and email everyone a detailed agenda.  Someone will bring a PowerPoint presentation and distribute printed copies of the deck.  And after everyone grabs a cup of coffee or a lotus flower tea, they’ll vote on whether to fund a consumerism initiative. They’ll make speeches for and against.  The behavioral psychology subcommittee will analyze who voted for what. By which time it won’t matter anymore.

“Do you have everything you need to improve consumerism?”  The CIO asked his committee; out-of-date people doing out-of-date things.  Apparently he was concerned the committee had exceeded its brief by thinking on its own.  The CIO ignored the fact that his question was way too existential and his powers of motivation had been diminished since waterboarding was out of fashion at the moment.  Fortunately for him, ignorance about how to solve the consumerism problem was not yet considered a capital crime.

Taking a short cut to solve consumerism is right up there as one of the worst ideas of all time.  Consumerism just hasn’t risen to its proper level of importance to earn the attention it requires. It’s almost as though payers and providers decided to hand the problem over to a couple of skinny-pants-wearing interns, with IQs in the shallow end of the gene pool, and told them to write a white paper on consumerism and publish it through an organic bookstore. 

Solving consumerism deserves your best effort.  Unless you don’t mind being negligent.  Negligent about accountable care, population health, and Star ratings.  Negligent about access and engagement, and negligent about your approach to patient acquisition and retention.  Otherwise, you can continue to check the box, build a new atrium for your hospital, and change the color scheme of your website.

None of your patients are turning cartwheels about how effective your consumerism strategy is. Au contrare.  Patients who’ve had bad customer experiences are likely to fold up their tents and go somewhere else.  

But, what would happen if your consumerism strategy took into account that the value of each new patient was $200,000 and the value of each retained patient was $100,000?

Customer experience is not a Zen thing.  Bad customer experience is like chaos theory. A butterfly flaps its wings in Omaha, and two hundred patients in New York can’t schedule their appointments.  On the other hand, good customer experience should have everything the customer needs, and nothing he or she doesn’t.  Need an example?  The link to your gift shop on the homepage of your website.

Thanks for playing.

Healthcare’s Favorite Meaningless Numbers For Managing Its Business

I was a mathematician for six months.  That long enough for me to discover that real mathematicians were a lot smarter than me.  I had no more chance of being successful  than a Detroit auto worker who did not speak Spansih.

One of the things I remember is that it’s pretty easy to convince yourself that you can get the numbers to tell you whatever you wanted them to say. I learned how to prove that one plus one did not equal two, a fact that led me not to trust numbers.

That fact was especially true with statistics.

Last night we attended the ice hockey game at the Rochester Institute of Technology.  The scoreboard overhead displayed to sets of numbers; the score, and the number of shots on goal–the SOG.  The game ended in a 1–1 tie.  I told my son that hockey would be more fun if they doubled the size of the net and used two pucks simultaneously.  Americans don’t like ties.

The SOG showed that RIT had thirty-six shots on goal.  U-Conn had twenty-one SOGs.  As you can see, the SOG is a meaningless stat; lipstick on a pig.  It is meaningless because the only stat that matters is the score.  RIT was not awarded an extra goal simply because they had missed fifteen more shots than their opponent.  But the total lack of value of the stat does not stop them from tabulating it.

As I’ve written previously, the business of healthcare–how it’s managed–is mired in a 0.2 business model.  While all other industries have taken flight with business models that employ design-thinking, interactive, cognitive, and mobile-first technologies, healthcare–providers and payers–continue to debate the color of the carpeting to install in their call centers.  And they manage their business based on meaningless data they collect to measure access and engagement.

Healthcare could fill a book with its meaningless stats.  It’s even likely that many healthcare organizations paid someone a lot of money to create a dashboard so that their management could get up-to-the-minute updates on those stats.  “Joe-Bob, come over here and take a look at these numbers!  I’m showing that we have a .2% improvement on stat 7 from the same quarter last year.”

“What does that mean in terms of patient engagement?”  Asked Joe-Bob.

“I don’t’ know.  But I do know that better is always a good thing.  Isn’t it?”

Below are but a few of the most meaningless statistics that are collected and reviewed by executives whose jobs are to improve patient and member access and engagement.  Access and engagement, if they are measured at all, are measured using data collected online and from call centers.

  • Number of people who access their website each month
  • Average minutes spent viewing each web page–this statistic should tell the webmaster that they have hundreds of pages that nobody ever views
  • Total number of Facebook ‘likes’
  • Average wait-time per caller (Some callers have enough time on their hands to buy green bananas.)
  • Average number of callers in the queue
  • Average talk-time
  • Average handle-time

There would be no negative impact on their businesses if providers and payers stopped tracking those numbers tomorrow.

If you want to measure the success of access and engagement, track these statistics:

  • Number of people who accomplish a single task by visiting your website.  Note: tracking the number of people who went to your site to learn at what hour the gift shop opened is meaningless.  Equally meaningless is those who viewed ‘Find a Doctor.’
  • Number of people who scheduled an appointment online
  • Number of visitors who used online chat
  • Number of visitors inputting information in the ‘Contact us” box who received a real-time reply
  • Number of one-time visitors (leakage)
  • Number of callers who called because they could not accomplish what they needed on your website
  • Number of callers who wanted to speak with someone helpful  on weekends and after 6 p.m.
  • Number of callers who called your scheduling center for a reason other than scheduling an appointment (this number is usually around 80%
  • Number of abandoned calls (leakage)
  • Average number of calls per person to resolve a single issue
  • Number of frustrated callers who do not call back (leakage)

If you track theses numbers and understand their impact, you should be depressed.

If you want to know what to do to improve access and engagement, develop innovation teams to figure out how to manage each of those statistics.  The targets for some of those numbers should be one hundred percent, and the targets for the others should be zero.  I will leave it to you to determine which are which.

If that option is not attractive to you, you could sign up for a match.com account and write your profile; “Fond of unicorns and long walks on the beach.”

Brand Awareness Is Worthless: Patient Awareness Is Valuable

One of the strange things about tsunamis is that the most damage is always the result of the second wave, a wave that catches survivors of the first wave by surprise.

If I was a healthcare executive I would have spotters positioned along the beaches looking for wave number two. Instead, many appear to be taking on Mad Magazine’s Alfred E. Neuman’s “What—Me Worry?” attitude.
And here’s why. Ask to see a copy of your health system’s strategic plan. That may be naiveté on my part, but let us pretend that such a document exists. In it you should find a section about where the industry is headed, how that effects your organization, and what your organization is going to do to either take advantage of it or to defend itself from it. I’ll give you a few moments to read those sections…

You couldn’t find that part of the plan, could you? If you went back five years you wouldn’t have any more luck finding that same information in your system’s 2010 strategic plan. Your 2010 strategic plan should have mentioned something about possible threats to your business, possible threats about continuing to remain relevant. And included in the discussion about threats should have been a discussion about consumerism—healthcare’s four-letter word.

I challenge you to name a single, provider-driven, impactful innovation to the business of healthcare in the last fifty years. An innovation created by providers to improve their business model. Can anyone recall leaving a strategy meeting and thinking, “Wow, that should shake things up.”

Large retailers held those meetings five years ago, and they came out of their meetings with a plan to bring three things to healthcare; disruption, efficiency, and cost management. Those companies include Wal-Mart, CVS, Whole Foods and Target. And how have providers reacted? They have not.

Now for the bad news. Those same organizations have held more meetings, and what is about to hit the streets is wave two of the tsunami. And that wave will deliver even greater disruption, more efficiency, and even better cost management.

I don’t know the figures for the number of patients seen by CVS, but I am willing to bet that their growth rate and acquisition of new patients is worthy of envy. And since more people are not getting ill, all of those patients must be coming from somewhere. Retailers are gaining share in a market of excess capacity. The Minute Clinic model has demonstrated that it’s patients are brand-agnostic unless patients are seeking specialized care.

Is there a better brand name on the planet? Minute Clinic—service in a minute. And they compete for patients against organizations that have Eight-Week Clinics—service when we have an opening.

CVS did not have to build a single new facility to take millions patients from providers and PCPs; they simply reallocated floor space. Heck, they hardly even advertise, and millions of people gladly drive one or two miles for on-demand healthcare.

So, if I am an executive at CVS or Walgreens, what is the next great question they should be asking themselves? I think it is this—“How can we deliver more care to more people without requiring people to come to our stores?” That is wave number two.

The other issue overlooked by provider executives is that 75% of people are very loyal to their retailers. Their loyalty to organizations from which they purchase their medications is even higher because their healthcare insurance is tied to a specific drug retailer.

Consider this for a moment. People think of Uber as a taxi service. Uber’s valuation exceeds $40 billion dollars. And guess what?  Uber, the taxi service, does not own a single car. That same taxi service does not employ a single driver. It does not care whether gas prices go up or down because it does not pay for a single gallon of gas. It simply puts drivers and passengers together and lets them sort out the market.

Hotels.com does not own a single hotel. OpenTable does not own a single restaurant. What those organizations own are ideas, ideas that put buyers and sellers together easily and in real time.

And while firms like CVS are disrupting the traditional way of purchasing healthcare, health system executives still think of the term customer as another one of those four-letter words. Note to health system executives: do not concern yourselves with how many letters are in the word, concern yourselves with how to embrace the word.

Every health system that added valet parking did so for one reason—to attract and retain patients. Upgrading your cafeteria and adding a valet service are not examples of innovating your business model.

Beefing up your marketing department will not enable your health system to compete against the second wave. Most health systems cannot even tell you whether marketing’s efforts added a single patient to their system last year.

The time to innovate was last year, and the year before, and so on. My immediate advice to provider executives would be to do one of two things; hold an innovation retreat and do not let anyone leave until everyone in the room thinks, Wow, that should shake things up. Or, grab your Speedo and some suntan lotion, and wait for the second wave.

A Life Sciences Solution For Consumerism: Beer, Mustaches, & Tuna

Consumerism is a topic that you either get or you don’t.  Those who get it, get it right away.  I’d have more success speaking with a turnip about it than with those who don’t.

Consumerism is a catch-all phrase for a number of healthcare initiatives that more often than not are nothing more than polite country club discussion across all of the healthcare sectors.  Without recasting consumerism, population health management and accountable care will be ineffective.  Without consumerism, complying with the Affordable Care Act and boosting Star ratings will be very difficult.

I spoke recently about implementing consumerism with the president of one of the largest life sciences firms, the president of one of the national pharmacy chains, a EVP of one of the three largest payers, and with several senior provider executives.  The conversations are all the same–either they do not even know where to start, or they started without knowing what they are doing.

The two biggest questions people have of healthcare to make consumerism work are knowing, “Who am I?” And “How am I?”

If you do not know who I am and how I am you cannot offer me care that is accountable and you cannot manage my health.

Warren Beatty stared in the movie, Heaven Can Wait.  Beatty played the role of a professional football quarterback who died in a car accident and was reincarnated as the CEO of a large conglomerate.  The business was in a lot of trouble because of the shady way it conducted itself.  The business owned a tuna company.  It kept its costs low by scooping up whatever happened to be swimming past its nets.  It caught a lot of tuna, and a lot of Dolphins.  The Dolphins died just like the tuna, and the company received a lot of bad press from killing Flipper.

During a board meeting, Beatty’s character announced that the company had to find a way to catch tuna without killing any more Dolphins.  He told the board, “We are going to be the good-guy tuna company.”

Life sciences, the small molecule people, are the furthest removed from patients. That is just the nature of their business. Even so, that is no excuse for not having a consumerism program.  Currently, life sciences’s entire approach to consumerism is to run television adds entreating people to tell their doctors to prescribe a particular medication.  Ten seconds of young, smiling healthy people follow by twenty seconds of a pleasant sounding person warning viewers that the product could cause everything from the death of their dog to hair loss to suicide.  That approach doesn’t leave many people feeling warm and fuzzy.

But it doesn’t have to be that way.  Life sciences could be the good-guy tuna company.  All that is needed is a strong executive and a vision.  Permit me to share one such vision with you.

As many of you know, I had a heart attack thirteen years ago.  As a result, I take the usual medications for heart disease.  I don’t know which firms produce them, and none of those firms know who I am.  I visit my cardiologist once a year, and I work very hard to ensure that I do not have to visit him more often.  It seems like there could be a better way to manage that aspect of my health. Somebody makes my meds.  Blue Cross pays for my meds.  CVS dispenses my meds. And, Penn Medicine prescribes my meds.  

The circle of life.  It is a closed loop. Every organization does their part.  And none of those organizations has a clue about my health.

I watched a TED Talk yesterday about an Australian, who while drinking beer with his mates one November evening, pondered that fact that while their are many social groups to combat women’s health issues, that there were no groups combating diseases that affect men.  And so, he started a group to combat prostate cancer.  

His goal initial goal was simple.  In the first decade of this century, he got guys to grow 1970s-style mustaches to signal their of awareness of prostate cancer.  Buy the end of its first year, four hundred and fifty hirsute Aussies had grown mustaches.  In Australia, a mustache is referred to as a “Mo,” and as a result he called his group “Mo”vember which is a portmanteau of “mo” and November.

Then he decided that the group should raise money to help improve the screening and treatment of prostate cancer.  He asked the executives of the major life sciences firms to support his group, but none of them did.  Fosters, the Australian beer company was the only firm to back the group.  To date, he and his mustached friends have raised over several hundred million dollars, and Movember is global.

Guys, beer, and upper lip hair have become a powerful force for wellness.  Ideas do not have to be complicated to be effective.  After all, some guy just started a company selling untucked shirts–I am willing to bet that there was a lot of beer involved somewhere in their launch process.

Health sciences firms can do more to improve care and to drive wellness than simply running feel-good commercials.  So, knowing that millions of people want to be healthy and to stay healthy, what if a life sciences firm or a payer or CVS did the following?  What if a firm created the Facebook version of health–“Healthbook”™?

Think about it.  Facebook has been moderately successful.  Half of the world’s population already knows how to interact with a Facebook-like social media platform.  Although there are hundreds of social media sites for a variety of illnesses, they are a bunch of trees looking for a forest.  Be the forest.  Decide to be the good-guy tuna company of your industry.  Design and build Healthbook™.  Give it a remarkable user interface that delivers a remarkable user experience.  Let patients and healthy people connect with each other about what works and what doesn’t.  Make it something they want to go to to manage their care and their wellness.

Do this and all of a sudden millions of people start to think that some big pharma company is using its size and capital to do more that simply running Stepford Wives commercials.  Payers, instead of being viewed as the death-stars of healthcare, could be seen as doing something other than denying claims.

Healthcare Consumerism Lessons From Monty Python :) 

If a business problem cannot be explained by looking at something from Monty Python, in my opinion, it is not worth solving.
 My go-to film for explaining all things related to healthcare is Monty Python and the Holy Grail. Just to get the juices flowing, let’s set the stage with a few lines from the movie: 
King Arthur: I am your king.

Peasant Woman: Well, I didn’t vote for you.

King Arthur: You don’t vote for kings.

Peasant Woman: Well, how’d you become king, then?

[Angelic music plays… ]

King Arthur: The Lady of the Lake, her arm clad in the purest shimmering samite, held aloft Excalibur from the bosom of the water, signifying by divine providence that I, Arthur, was to carry Excalibur. That is why I am your king.

Dennis the Peasant: Listen. Strange women lying in ponds distributing swords is no basis for a system of government. Supreme executive power derives from a mandate from the masses, not from some farcical aquatic ceremony.

Arthur: Be quiet!

Dennis the Peasant: You can’t expect to wield supreme power just ’cause some watery tart threw a sword at you!

I am healthcare’s Dennis the Peasant, and, yes, you can become a consultant by having strange women in ponds throw swords at you. At least it worked for me.

Staying with our theme of mediaeval British oppression of the working class, in the 14th century, the part of Ireland ruled by the English had various forms of demarcation. One of those forms was a castle moat that separated the castle. The separation was called the English Pale. Going to the other side of the separation, away from English Rule was referred to as going beyond the Pale. So see, if nothing else, you’ve learned something new today.

Is it beyond the pale to think that the business of healthcare can handle words of three or more syllables? Words like engagement and consumerism and innovation? Although the word innovation starts with the letter ‘i’, many times there is no ‘you’ in innovation.

Permit me the chance to try to explain what I mean by using the following example. If you’ve ever bought a pair of reading glasses, you know that you do not need to know your prescription. Al you have to do to find the right pair for you is to stand a foot away from the sign with themes sages printed in various sizes of lettering, and keep trying on different powers of glasses until you can read the text saying, “If you can read this, you have found the right pair.”

Pretty simple. Until you get your eyes examined. That is when you learn that you see differently from each eye. That tells you that the reading glasses you just bought with the same strength for each eye are no what you need.

The quick solution is not always the best solution.

And so it is with healthcare consumerism and patient and customer access. Almost every health system in the US has opted for the easy solution to deal with patient access and engagement.

• Business problem: people call us

• Business solution: build a call center

Problem solved. Not so fast Skippy. And this is why you find yourself searching your deleted emails for the one from Dennis the Peasant. Moi.

If you think having a call center is the solution to your patient access problem, stop reading this and call your health system and try to schedule an appointment. And it only gets worse from there. Access begets engagement. And engagement begets experience. And bad experiences are why patient leakage on the front end of patient journeys is a hundred times greater than it is on the back end.

Your call center does more to degrade patient acquisition, patient retention, and care management than almost any other business process in your organization. But it’s an easy solution to a complex problem, and it allows you to check the ‘problem solved’ box and it frees you up to wrestle with all of the other gnarly problems you have.

And so, to complete the circle of life analogy from Monty Python to the English Pale to healthcare, I am listening to Pink Floyd as I am writing. And the Floyd are British.

Guard: Who goes there?

King Arthur: It is I, Arthur, son of Uther Pendragon, from the castle of Camelot. King of the Britons, defeater of the Saxons, Sovereign of all England!

Guard: Pull the other one!

King Arthur: I am, and this is my trusty servant Patsy. We have ridden the length and breadth of the land in search of knights who will join me in my court at Camelot. I must speak with your lord and master.

Guard: What? Ridden on a horse?

King Arthur: Yes!

Guard: You’re using coconuts!

King Arthur: What?

Guard: You’ve got two empty halves of coconut and you’re bangin’ ’em together.

King Arthur: So? We have ridden since the snows of winter covered this land, through the kingdom of Mercia, through…

Guard: Where’d you get the coconuts?

King Arthur: We found them.

Guard: Found them? In Mercia?! The coconut’s tropical!

King Arthur: What do you mean?

Guard: Well, this is a temperate zone.

King Arthur: The swallow may fly south with the sun or the house martin or the plover may seek warmer climes in winter, yet these are not strangers to our land?

Guard: Are you suggesting that coconuts migrate?

King Arthur: Not at all. They could be carried.

1st soldier with a keen interest in birds: What? A swallow carrying a coconut?

King Arthur: It could grip it by the husk!

Guard: It’s not a question of where he grips it! It’s a simple question of weight ratios! A five ounce bird could not carry a one pound coconut.

King Arthur: Well, it doesn’t matter. Will you go and tell your master that Arthur from the Court of Camelot is here?

Guard: Listen. In order to maintain air-speed velocity, a swallow needs to beat its wings forty-three times every second, right?

It may be easier to teach a coconut how to migrate than to make it easy for your patients to access your health system.

Regards, Dennis