Healthcare Consumerism’s IDD: Intentional Deficit Disorder

The salesman walked into the doctor’s office dressed in a rumpled overcoat, worn tan brogues, a hat too small for his head, and carrying a briefcase that looked more like a suitcase from the 1930’s.  I thought to myself, ‘well now Willy Lowman, are you auditioning for Death of a Salesman?’

In the waiting room, I occupied my time browsing the requisite magazines that were laying on the requisite coffee table.  People Magazine – 164 pages.  Time Magazine —56 pages – a Cliff Notes version of People.  Fifty-five pages slamming President Trump – aliens from Area 51 spearheaded the hacking of the U.S. election.  There was a one-page article about the decreasing price of gasoline.  The author of the article about gas prices was fired for not writing about real news.

`Inattention Deficit Disorder (IDD). Is IDD is a deliberate collaboration between providers and payers to not meet the customer service needs of patients, members, and consumers?  Its premise is simple—if we do not acknowledge that a problem exists, how then can we be expected to solve it?

Last week I was speaking with an executive vice president of a large payer. As a courtesy, he asked me not to mention his name because he was trying to protect the guilty party, namely his firm.

The situation is the following. His wife had been treated at a large health system. The names of the system, and the name of the payer, are not important. They are not important because you can substitute different providers and payers and it would not change the discussion.

She received a letter from her provider stating that her reimbursement claims for several thousand dollars had been denied. Two sentences. One dollar amount. Zero explanation. She started calling.

Dialing for dollars.

She called the provider. She called the payer. She asked for an itemization of the denied amount. Eleven total calls. “You have to request an itemized copy of your bill.”

“That is exactly what I am doing,” she told the person. (It does not matter whether she told a provider’s employee or a payer’s employee; knowing which it was would not affect the outcome.)

“I can’t give you that information. You must send us a letter; something with a stamp on it. And you have to prove you are you.”

“But, I am me. I am the person to whom you are speaking.  Why don’t you call me at this number?  Won’t that prove I’m me?”  “We’re not allowed to make calls,” she was told.

So, back to my conversation with the EVP about this flawed process. “Is there anything you’ve seen that can make this process better?” He asked.

“There are two possible solutions,” I said. “One of them requires that your wife enjoys singing.”

“She’s in the church choir,” he replied.

“Well then, since it looks like she will be spending way more time than she wants on hold as she tries to solve her problem, it can be helpful to find an activity that she enjoys occupying those extended periods of inactivity. If she likes musicals, I would recommend that she use all her time on hold to learn each of the roles of Les Misérables. That is what I do.” (In case you are interested, I will be presenting a one-man performance of Les Misérables this summer at the National Theater in Washington, D.C.)

The EVP did not sound too keen on my first idea. “Well,” I said. “There is another way to solve the problem, and this way works one hundred percent of the time. Tell her to stop calling. Tell her not to reply to any of their emails, and if she receives any letters from either firm, just tell her to throw them away.”

“But we probably owe them money,” he said.

“I’m not suggesting that you do not pay the bill. I am only suggesting that you quit working hard trying to figure out how to pay it and how much you owe. After a few months, she won’t have to call anymore. They will call her. And when they call, they will be very helpful. The whole idea is for you to put the monkey on their back. Get things to the point where their whole focus is on convincing you to send them money. You’ll be surprised by how helpful they will be when they initiate the call.  And before you send them a check, tell them to send you a letter with a stamp on it to prove who they are.”

Dialing for Dollars: Part Deux.

The CEO of a large health system calls to schedule an appointment at his own health system and fails.

Pshaw, you are thinking. (Apparently, pshaw is really a word.)

Many of you are probably thinking that his health system is an anomaly. Once again, my response is pshaw. When you finish reading, call your health system and pretend that you want to schedule an appointment. By the thirty-minute mark of your call, you will be screaming epitaphs into your phone—Sic (intentional error).

IDD—Inattention Deficit Disorder. It could also stand for Intentional Deficit Disorder.

If we do not know there is a problem, how can we be expected to fix it?

Well, now you know. Payers and providers make it very difficult for patients and members and consumers to meet their needs. Either they do not know that the problem exists. Or they know it exists, and they just don’t care.

Either way, it is a poor reason to have a call center.  If a patient calls the call center and nobody answers the call, did the patient make a noise?

Healthcare Consumerism: You Cannot Predict The Past

You cannot predict the past; unless you are looking at healthcare.

Healthcare is very predictable when it comes to customer experience.  At least from the perspective of healthcare’s customers.  The problem is not that there are bad experiences.  The problem is that there are good ones elsewhere and patients and consumers compare those good experiences to the bad ones they have in healthcare.

If you’re in a horror movie, you make poor decisions. It’s what you do. A group of kids is running from a murderer in the middle of the woods when they stumble upon a dark, old cabin. “Let’s hide in the attic,” exclaimed the teenage boy.  “No, in the basement,” shouts his girlfriend.  A hysterical girl is crying and asks, “Why can’t we just get in the running car?!” the others dismiss her as crazy “Are you crazy?! Let’s hide behind the guy wearing the hockey mask.” They run towards the sound of the chainsaw. The guy wearing the hockey mask gives them a look as if he can’t believe how stupid the kids are. “Head for the cemetery!” shouts the oldest teenager.

Poor decisions. Head for the cemetery. Whether you are in the provider, payer, or pharma community, we’ve all been in one of those meetings where someone asks, why can’t we head for the cemetery?  The rest of the people in the meeting dismiss him and run toward the sound of the chainsaw.

Suppose the cemetery suggestion is, “We need to create daily habituation with our patients and consumers.”  Stated more simply, we need to get them to interact with us daily, not just once every two to three years. If a patient or consumer only contacted us once a year, creating daily habituation means getting people to increase their rate of contact by 36,500 percent!

So, how does healthcare achieve daily habituation, and what would it look like?

There is a great deal of activity in healthcare around cloud computing. Almost every health organization is doing something with a cloud, but only with their own cloud. But few if any health systems share their cloud any more than they share their cafeteria. Not only do they not share it with other providers, they don’t share it with payers, they don’t share it with pharmacies, and they do not share it with their patients and consumers.

For example, Philadelphia has several very good health systems. Imagine looking out from the top of one of the city’s highest buildings — what would you see? You would see a cloud hovering above the Hospital of the University of Pennsylvania. Across the street, another cloud would be floating above CHOP. One above Thomas Jefferson; one above Einstein, Hahnemann, a Cancer Treatment Center of America, and the Philadelphia VA.

A few dozen single clouds. Partly cloudy.

You continue looking, and you see that the sun is shining on all the people entering and leaving the various health systems. That is because the clouds only cover the health systems. The clouds do not cover the patients or the visitors or the family members.

If you are asking yourself, what is the answer for achieving daily habituation?  People —patients and consumers — are missing the two things they need the most to drive any kind of habituation:

  1. They have no effortless way to communicate anything about their health with you — your call center is not a communication tool; calling your organization is the last act of a desperate person.
  2. Your organization has not given them a compelling reason to communicate with you.

What healthcare needs is Healthcare Relationship Management to interconnect:

  • Patients and providers
  • Consumers — prospective patients — and providers
  • Consumers and payers
  • Consumers and pharmacies
  • Providers to payers to pharmacies to consumers

Healthcare needs a Healthcare Relationship Management Cloud,. An interactive, interconnected way of communicating whatever one party wants the other party to know.

And what do patients and consumers want you to know about them? Nobody knows. And the reason nobody knows is that nobody ever asked them. Heck, if we are being honest, most providers do not even track why people call.

Last week, I met with a senior executive of a very large payer. During our meeting, I drew a large, oblong shape to represent his customers. Way over by one end, I portioned off a small bit of the shape to represent the fraction of his customers that interacted with them on a regular basis. Our discussion focused not on the tiny portion of people that communicated with his organization, but rather on the much larger group of members who never communicated with them.

Providers have a portion of the population they serve who do not interact with them. And so, do pharmacies. Not interacting, and not needing to interact are two different things. Not interacting results from:

  • No compelling reason to interact
  • No effortless way to interact

Now suppose consumers had an easy way to interact with your organization on a regular basis. And suppose they had a compelling reason to interact with your organization on a regular basis. Why would that be a good thing for both parties? These are a few things that spring to mind:

  • Healthier people
  • Improved care coordination
  • Reduced admissions and readmissions
  • Population health management
  • Patient acquisition and retention

And that is how healthcare demonstrates that it cannot predict the past.  People cannot interact with their healthcare services.  And they never could.  If you want to play lumberjack you should learn to carry your end of the log.


Scoring Customer Experience: Ask The East German Judge

The lettering on the lawn sign read, ‘do not walk on the grass.’  If the sign was a business euphemism for not upsetting the apple cart, most people’s shoes would be free from grass stains.  My shoes would be dripping chlorophyll.

Not too long ago the Olympic Games weren’t so much a global sporting competition as they were a global competition between good governments and evil governments.  Although over a hundred countries participated, the only three that mattered to Americans were us, the Soviet Union, and East Germany.

It was a given that the Soviets would win the ice hockey gold medal and the U.S. would win the basketball gold medal, and the East German men would win gold medals in women’s swimming.

Like in today’s Olympics, judges scored events like gymnastics and boxing.  Subjective scores left up to the whims, biases, or fears of the judges.  The American judges probably had some built-in bias against the Soviet and East German competitors, and the Soviet and East German judges were biased against the American athletes.  In an attempt to prevent those biases from skewing the athlete’s performance, the highest and lowest scores were not counted.

When a U.S. judge gave a high score to a communist athlete’s performance, the worst that would happen is that fans of the U.S. athlete would boo the judge. If an East German judge scored an American athlete’ performance too high, that judge ran the risk of being shot.  If the judge’s score was way too high, that judge ran the risk of having to live in the Soviet Union.

Scoring is subjective. “Your call may be recorded for quality purposes.”  In other words, the people with whom you speak at a call center will be scored based on how well they performed on the phone.

An employee, or perhaps a panel of employees, listens to the call center agent’s performance and scores that performance.  Fortunately for the call center agents, it is considered bad form to shoot poor performing agents.

This approach is like focusing on the quality of the match that started a forest fire.  We know a lot about the agent’s performance.  We know nothing about the experience of the caller.  We don’t know how many times the person called about the issue.  We don’t know if the caller’s issue was resolved.  We don’t know if the reason the person called was that they could not do what they needed to do online.

Companies are experts at improving the performances of their call center agents—scoring matches.  They have less much expertise when it comes to understanding how their patients and customers would have scored those same agents.

Maybe they should have asked the East German judge.

What Happens when Wonder Bread Meets Healthcare?

The woman I passed during my run today wore purple tights, a purple top, and a green hat—she looked like an eggplant on two feet.

Did you know that Wonder Bread has been around for ninety-six years?  It’s been an American staple for school lunches for most of those years.  One slice of bread, a slice of bologna, and a second slice of bread.  The basic sandwich for sixth-graders.  If you are not a fan of bologna, use something else; cheese, ham, or PB&J.  The bread part stays the same.

A piece of Wonder Bread in 1921 would look identical to a 2017 piece of the same bread.

Tang, the drink of choice for astronauts, was invented in 1957—four years before we invented astronauts.  The recipe has not changed in 60 years.  For lunch, kids can eat the Same Wonder Bread and drink the same Tang as their grandparents.

Some things don’t change.  Sometimes that is a good thing.

During their lunch breaks, the people who answered the phones in the call centers of hospitals in 1957 would eat their Wonder Bread sandwiches and drink their Tang.  Today, call center agents can eat the same lunch.  And when they are finished eating their lunches, they answer the same kinds of calls, using essentially the same technology that was used in 1957—from 8 a.m. until 5 p.m., Monday through Friday.

Some things don’t change.  That’s a good thing if you happen to like Wonder Bread and Tang.

It’s a bad thing if you happen to be a person who needs to access their health system. It can feel like an internecine relationship; the proletariat versus the hospitalists.

Health system executives are absent when it comes to improving access and engagement.  A lot of patients are calling.  A lot of people are having to call more than once.  And a lot of people aren’t calling back.

A Cynical Muse On Consumerism

Taxi rides in Chicago last month were 42% lower than they were in May 2016.

Uber and Lyft.  A one-hundred-year-old industry, an industry embedded in every city in America is disappearing in less than a decade.  It is disappearing because people found an alternative solution that took them from A to B and provided a better user experience for less money.

Until healthcare decides to reinvent its business model to one that is more closely aligned with Uber, it is destined to suffer the same fate as Sears.  Patients will seek an easier solution.  They will fly to it like moths to a patio light.

A recent trend on provider websites has gone from ‘find a doctor’ to ‘request an appointment.’  To boldly go where no man has gone before.  Patients are still left chasing unicorns, the elusive online scheduling.  Had the group which designed your health system’s website taken the time to ‘open the doors, and see all the people,’ people who wanted to schedule an appointment instead of requesting one, your health system would have more new patients.

Some health systems view consumerism as though they were walking through their house in pitch darkness, confident they knew where all the furniture was, only to have someone flip the lights on and show them that nothing was where they thought.  By the way, I’m the guy at the light switch.

Novice consumerismalists want to put ‘two and two put together,’ and argue that the answer is four, as in if consumerism were any simpler we would be diagraming the issue with crayons. From my perspective, I try to appreciate their keen sense of advanced mathematics and to suggest that simply focusing on two and two does not get them where their patients and customers need them.

I ask, “have you ever heard of cognitive dissonance?  It’s when you hold on to a belief that all of the facts attest to your belief when they attest to the opposite.”  Novices study consumerism like an anthropologist on Easter Island.

If your health system’s call center is the control room in Oz, healthcare consumerism is the issue behind the curtain.  Those who feel comfortable positing a solution are the same people who misunderstood the problem.  When we meet to discuss consumerism, some hospitalists try to sit at the big people’s table.  While your system is focused on finding the needle in the consumerism haystack, your consumers are trying to tell you that they own those haystacks.

Many health systems treat consumerism as a ‘theory,’ like climate change or evolution.  They assess my intentions like they had a fifth of a second to identify me as friend or foe before they start shooting.  They look at me as though I am an unhinged refugee from a boy band. (Was I supposed to be hinged?)  We sit there mute, as if we were in a no-talking competition and serious about winning.  They like to pretend I am not there, like I am a hole in the air.  The last time they listened to a consultant, Abraham Lincoln was in short pants.

Health systems form consumerism committees. They meet.  They buy bagels and muffins and a fruit tray and yogurts served in cute parfait glasses and cardboard boxes of coffee.  Because your health system has gone-green, biodegradable cups woven out of recycled hemp fibers are positioned next to the coffee.

I bite the head off a muffin.

Yellow legal pads are placed on the table, made from recycled paper from a defunct organic bookstore, directly in front of each chair.  Pens inscribed with the hospital’s name lay parallel to the pad of paper.  Post-meeting, the committee members will email their notes around like birds spread seeds from berries.  They should have hired a bunch of interns to write a term paper.

The purpose of the meeting is to suss out consumerism. Long slow periods of nothing much, with occasional bursts of something.  Like cutting the arms off an octopus; dealing with seven arms is better than dealing with eight.  Like chaos theory.  A butterfly flaps its wings in Ontario, and two hundred prospective patients wonder why they can’t schedule an appointment online.

Fortunately, slothfulness is not a capital crime.  It’s like getting a task force trying to figure out how to turn the Titanic.  While the task force may eventually succeed in turning it, they won’t accomplish it until they hit an iceberg.

The committee members are as focused as a kid with a magnifying glass focused on an anthill.  Consumerism kindergarten.  They want to go down the rabbit hole when the best approach would have been to cozy up to the Queen of Hearts.  They are looking for easy solutions, and they have the budget to make them happen.  They’ll vote on whether to use the committee’s funds to buy a philodendron for the call center.

Recasting consumerism involves taking a risk. But so does getting out of bed every morning, and a lot of people are not morning people.  Even though there is a degree of risk, it’s not like having Comey testify before Congress.  Most consumerism efforts fail.  Patients view those efforts as a Zen thing.  If health systems try to be more consumer-friendly, and their patients don’t know that their system tried to be more consumer-friendly, patient wonder whether the health system really tried at all?

One executive told me her system was going to address consumerism later.  “Later than what?” I asked.  “Is this one of those perpetually imminent initiatives?”  It felt like her strategy had no place to go, and all the time in the world to get there.

As a consultant, I’ve had to learn to roll with the punches.  Fortunately, waterboarding has gone out of favor.  Who knows, maybe they’ll name a bridge after me.


The Patient Experience-Deck Furniture Paradigm

This whole deal of the Parisian Accord troubles me.  It also troubles my whale.  I keep her in the bathtub right next to my email server.  I hope Director


Years ago, because of the lizard brain, our government decided that for important decisions, decisions like launching nuclear weapons, the responsibility had to be shared between two people.  (If the responsibility was shared by three people, I would have used the preposition among rather than between.)  That is why two thumbs are required on two launch buttons.  I do not know how things are in your home, but in ours, when it comes to important decisions about things like deck furniture, there is only one launch button, and I am not allowed to have a user-ID.

Twice a year, in early spring and late fall, my wife and I do the lizard brain dance, and we do it regarding our deck furniture. The spring deck furniture dance is more difficult than the fall dance because the furniture must be carried up to the deck.  Our metal deck furniture has been hibernating in our basement all winter, right next to the brown bear. (Given the ramifications of us leaving the Paris Accord, once the ice caps melt, the bear may not have to hibernate.)

When our metal furniture awakens from its hibernation, it needs to be carried by hand, by the husband, from the basement, up enough stairs to make me wish I had installed an elevator, to the deck—the deck that was just power washed by the same husband.  Fifteen minutes into this exercise I am missing the snow.  With furniture raised above my head, I plod slowly up the stairs like a pachyderm from the now-defunct Barnum and Bailey circus. (The elephants are not worried about the warmer temperatures.)

I was waiting for my neighborhood friends, guys like me, to set up lawn chairs and watch the parade, but it occurred to me they were either hiding from their spouses, or they were having their own furniture parades.

Our metal outdoor deck furniture is unlike any other deck furniture.  Unlike others in that according to my wife, our outdoor furniture was not designed to live outdoors. Not in the winter, and not in the rain.  The furniture’s seats and cushions were extruded from some unidentified man-made material whose half-life probably exceeds that of the fruitcake my grandmother made when I was twelve. My wife’s concern is that if the furniture gets wet it may have a Wicked Witch of the West event and melt.

Even so, when rain threatens I will be hauling those cushions, the same cushions I just hauled outside, back inside.

“The cushions don’t melt,” I tell her.

She counts the cushions and asks, “Are we missing a cushion?”

“No, I’ve been soaking one in the bathtub all winter—right next to the whale.  It looks good as new,” I tell her.

“That is not the same as leaving it out in the rain.  And since you raised the point, why is there a whale in the tub?” So much for me trying to make a point.

So, how do we tie my furniture problem into something that makes reading this post worthy of your time?  I think when it comes to assessing patient experience many hospitals believe that when their patients are not in the hospital they are hibernating, that they don’t need access, that they don’t need to be engaged.

That belief begs the question, what do hibernating patients do?  They call their provider.  They want access.  And how is access defined?  There are two ways to consider that question—from the perspective of the health system and from the perspective of the caller.  Nota bene.  Providers don’t collect data about access and engagement.  Patients collect that data every time they call.

The most frequent experience patients and consumers have with their provider are through their provider’s call center.  And guess what?  If those providers don’t meet the expectations and needs of those callers it does not matter to them how high their provider’s HCAHPS score was.  Those callers will do one of two things, neither of which are good for the provider.  They will choose a hospital which can meet their needs, they will manage their health one their own, or they will go to ED. Oh, and they will tell others of their experience.

A colleague of mine was receiving chemotherapy at one of the leading US cancer hospitals.  She spent three hours on the phone trying to schedule a follow-up appointment.  Now she spends her period of hibernation telling others not to go to that hospital.  Health systems cannot put that toothpaste back into the tube.

Why Is Healthcare Like Kittens Playing With Matches?

Obama Care, Trump Care, Who Cares?

As I dyed-in-the-wool, right-of-right conservative, I cannot believe I am writing this.

Sometimes, if it is broke, don’t fix it.  Especially when it comes to healthcare reform.  Obama Care.  People who can’t afford healthcare get healthcare.  Trump Care.  People with healthcare lose it unless they pay a lot more.  George Bernard Shaw said, “A government that robs Peter to pay Paul can always depend on the support of Paul.”  Given enough time, when this line of thinking is applied to healthcare reform either Peter or Paul dies because he no longer has insurance.

Everyone in Congress who is playing with healthcare has exceeded their level of competency.  By a lot.  A whole lot.  They are guilty of policy making without a hall pass, of trying to color outside the lines without any crayons.

On May 22, 1856, a member of the U.S. House of Representatives, entered the Senate chamber and, because he disagreed with a senator, using a cane he beat the senator into unconsciousness. Today, a beating of that degree would be deemed a bridge too far. It would be politically incorrect.  However, to borrow a line from the movie Network, people who need healthcare–all of us–need to tell Congress, “we are mad as hell and we are not going to take it anymore.”

Two rules should govern our society:

  • Kittens should not be allowed to play with matches
  • Congress should not be allowed to play with healthcare

Under the plans of both parties, the definition of patient-centric has gone from patient-centric care to patient-centric cost.  While pre-Obama healthcare was less than perfect, it sort of worked, even though it teetered on its edge.  Congress’s efforts remind me of the game, Jenga.  Jenga is the game where players take turns removing wooden blocks, one block at a time, from a tower of fifty-four blocks.  The more blocks that are removed, the weaker the tower becomes.

According to many, the old healthcare model had reached the point that when the next block was removed the tower would collapse.  Under Obama Care and Trump Care, it looks like both initiatives tried to fix a tower while it was collapsing.  We, you and me we, should have required our Congressional representatives to practice with wooden blocks before they practiced their wizardry on one-third of our economy.

The Democrats clicked their heels together three times and approved a bill that none of them read.  The Republicans borrowed the Democrats’ shoes and approved a bill that took less time to write than it takes to mow your lawn.  Patient-centric became party-centric.

So, just how screwed up is the plan my team submitted?  You only need to know two facts about the Republican plan to understand what a complete failure they’ve put forth:

  • One of every six people in the U.S. is sixty-seven or older
  • Under their plan, the annual cost of healthcare for someone sixty-seven or older, whose income is more than $27,000, will be $13,000—roughly fifty cents of every dollar
  • (The Republican plan’s underpinning unwittingly seems to stem from a line in Charles Dickens’s A Christmas Carol. “If they would rather die,” said Scrooge, “they had better do it, and decrease the surplus population.”  The Republicans were not so crass as to say let those people sixty-seven and older die, but a plan with such high costs will go a long way to decreasing the percentage of people sixty-seven or older.  Surplus population 101.)

While both political parties worked to fix what appears to be an insoluble problem, they did so without accounting for the only people who mattered: patients.  The impact of the party’s actions has landed on those who are the least capable of adapting to those actions—patients.

My idea?  Since the Russians are so tight with many of our elected officials, perhaps we should ask the Russians to fix our healthcare mess, or at least ask them to do their best to divert Congress’s focus away from healthcare.  What we had may not have been great, but like democracy .