In our annual HealthLeaders 20, we profile individuals who are changing healthcare for the better. Some are longtime industry fixtures; others would clearly be considered outsiders. Some are revered; others would not win many popularity contests. All of them are playing a crucial role in making the healthcare industry better. This is the story of Kermit Crawford.
This profile was published in the December, 2013 issue of HealthLeaders magazine.
"Our real purpose is not putting pills in a bottle. It's the outcome that you get from adherence to your medication."
As a child, Kermit Crawford knew he wanted to be a pharmacist. He says he looked up to the man who ran the corner drugstore and knew Kermit and his family by name.
"He knew I was Harry Crawford's son, and I grew up saying, 'That's who I want to be,' " says Crawford, adding that his dream was to run his own drugstore someday.
Mission accomplished. As president of Walgreens' pharmacy, health, and wellness division, Crawford runs more than 8,000 drugstores, with sales last fiscal year of more than $72 billion. And they're not just drugstores—there are nearly 400 walk-in clinics integrated into the stores, which can administer healthcare services, such as vaccines, minor acute care, and back-to-school physicals.
Crawford's rise to be a top executive at one of the country's largest companies by revenue started in 1983, as a pharmacy intern at a Walgreens store in Houston. His subsequent roles as pharmacist, store manager, vice president of store operations, as well as his leadership as executive vice president of the company's pharmacy benefit management services gave him a broad view of a pharmacy during a fundamental shift in healthcare. The experience positioned him to transform Walgreens from prescription filler to now filling a void for medically underserved communities.
"There's clearly a shortage of physicians," says Crawford. "In the communities where we have our healthcare clinics, approximately 40% of the people who come in don't have a primary care physician. Our objective is to support and complement the traditional healthcare system. We believe we're well positioned to serve as an entry point."
Crawford's earliest attempt to modify Walgreens' value position to consumers and patients was in 2006 when the pharmacy chain started offering flu shots at its stores. His confidence was initially shaky.
"When we first began to think about really transforming the role of community pharmacists, our question was, 'Will the American consumer allow pharmacists do more than put pills in a bottle?' "
The other unanswered question Crawford faced at the time was getting pharmacists on board because they needed additional training to become certified immunizers.
"You don't graduate from pharmacy school as a certified immunizer," he says.
Crawford says the additional training appealed only to the early adopters, but two things happened that turned doubters into believers: No.1, consumers responded overwhelmingly to the convenience of getting a flu shot at a store they trusted and shopped; No. 2, the appearance of the H1N1 virus in the United States in 2009.
When the World Health Organization declared H1N1 a pandemic, the need for that vaccine spiked and production was rushed into high gear. Crawford says Walgreens' previous internal buildup to offer more flu shots and the immediate need for the H1N1 vaccine was "luck" that he leveraged into opportunity after the virus threat lessened.
In 2009, Walgreens had 17,000 certified immunizers, a retail footprint big enough to reach a signification portion of the population, and an electronic and logistics system that gave up-to-minute information on H1N1 vaccine inventory. The pandemic that scared consumers and health officials led Crawford to believe Walgreens could successfully expand its reach into healthcare even further, and today, all Walgreens pharmacists (27,000) are certified immunizers and they offer all 17 CDC-approved immunizations in approximately 40 states.
Walgreens also helped change the business side of flu shots with health insurers that didn't always include the flu vaccine as a covered benefit.
"When we first started, about 90% of all flu shots were paid for by cash," says Crawford. "Today, almost 90% are paid for by third-party payers. It's providing access to care that people didn't have before."
Crawford has also helped build a bridge with physicians, hospitals, and health systems so that the pharmacy chain would be viewed as a partner and not a threat. Among its clinical affiliations, Walgreens has collaborative care relations with Orlando Health, a nonprofit system of physician practices and hospitals that serves 1.6 million area residents; Community Health Network, another nonprofit system in central Indiana, and most notably Johns Hopkins Medicine in Baltimore.
Those collaborations build on Crawford's vision for Walgreens' newest strategy, which is managing chronic conditions, such as diabetes, hypertension, high cholesterol, and asthma. As a partner in those systems, Crawford says the objective is population health management and the role is to increase medication adherence, provide testing, and share information with patients' primary care physicians. To him, including chronic care in the business strategy is a "natural extension" of Walgreens' ever-expanding move beyond the pharmacy counter.
"Those patients are coming into our stores significantly more than they are seeing their physicians," says Crawford. "We don't see ourselves as owning that particular patient. We see it as enhancing the experience with a physician. We're helping manage it consistently, versus a patient who has diabetes and goes to their doctor every six months."
Crawford's goal of owning a single community pharmacy in a neighborhood where he can greet patients by name seems quaint and simple now, but he believes that Walgreens' strategy is returning pharmacists back to being the face of what he sees as a front door to healthcare.
"Our real purpose is not putting pills in a bottle. It's the outcome that you get from adherence to your medication," he says. "We've freed up our pharmacists to be out front interacting with patients, and they love it. Pharmacists are at the intersection of all healthcare relationships, and now with more than 70,000 healthcare professionals between our pharmacists and nurse practitioners, we are in a real sweet spot when it comes to healthcare reform and having convenient access to quality, affordable care."
In our annual HealthLeaders 20, we profile individuals who are changing healthcare for the better. Some are longtime industry fixtures; others would clearly be considered outsiders. Some are revered; others would not win many popularity contests. All of them are playing a crucial role in making the healthcare industry better. This is the story of James Merlino, MD, FACS, FASCRS.
This profile was published in the December, 2013 issue of HealthLeaders magazine.
"We spend hours and hours and lots of money on how to be at the top of our game in healthcare—nurses and physicians are doing continuing education, learning how medicine is evolving—but we spend nearly zero time on how we deliver that care."
Today, James Merlino, MD, FACS, FASCRS, is a go-to leader for hospitals and health systems looking for advice on how to improve their patients' experiences. In addition to his position as chief experience officer for the Cleveland Clinic, he also serves as president and founder of the board for the Association for Patient Experience, an independent nonprofit organization that grew out of discussions at the first Patient Experience Summit sponsored by Cleveland Clinic in 2010 and was established to support healthcare professionals, patients, and their families by improving the patient experience.
He has been at the helm of rethinking and redefining patient experience for the nonprofit academic medical center since 2009. But, initially, it was a job he didn't want, in a hospital he never wanted to step foot in again.
In the summer of 2005, Merlino walked out of the Cleveland Clinic after finishing his fellowship believing the world-renowned hospital was "the worst place in the world for patients." Six months earlier, Merlino's father had died there after a five-day stay related to an ambulatory procedure for bladder cancer. Merlino vowed never to return. Not because of the clinical care—complications that arose with his father's surgery were "nobody's fault," he says; rather, he was upset with the way his father was treated.
"The nurses didn't consistently round on him. His doctor didn't round on him. The communication with the family was terrible," says Merlino, who struggled with the decision to leave because he trained for his specialty in colorectal surgery at the hospital and considered it an honor to be there.
The experience on the other side of healthcare opened his eyes wide. Those five days, he says, redefined how he thought about taking care of patients.
"What I recognized pretty quickly was that we ignored the human side. We ignored the patient. We ignored the family," he says. "We spend hours and hours and lots of money on how to be at the top of our game in healthcare—nurses and physicians are doing continuing education, learning how medicine is evolving—but we spend nearly zero time on how we deliver that care."
Merlino says he returned to the Cleveland Clinic after a five-year hiatus because CEO Delos "Toby" Cosgrove, MD, assumed his title in 2005 and put a renewed focus on patient experience. Merlino says he and Cosgrove were unsure what patient experience meant, but they were both dedicated to making it a priority, something Merlino says is a must to move the needle at any hospital.
"There has to be passion around it," Cosgrove says of improving patient experience. "It's got to be a strategic priority. You have to put it front and center of everything you do in the organization. In terms of who leads it, it's got to come from the top person. It's not a nursing problem; it's not an operations problem. Anything you're doing to develop the culture has to be led by the top people otherwise it won't get the billing it deserves."
Leadership may be in charge of driving home the point that patient experience is core to the strategy at Cleveland Clinic, but Merlino is also quick to point out that it is a shared responsibility among every employee. He says he learned early on in Cleveland Clinic's patient experience journey that aligning staff was central to carrying out his vision of putting patients first. When a 43-year old patient, who was getting ready to leave after an uncomplicated surgery, showed Merlino the journal she'd kept while at the hospital, he was shocked to see how many different people had helped care for her during the five days since when was admitted.
"At the end of this hospital stay, eight physicians had signed the journal, 60 nurses, and so many other people … and she forgot to have three people sign the journal," he says. "What it said to me, in a very, critical stage of this career, was that it's not just the doctor or the nurse, it's everybody. If everybody's not aligned in thinking what we're doing and how they're interfacing with that human being, then we're not going to be successful at delivering what we're supposed to be doing, which is high-quality care."
Merlino believes communication is the fundamental building block of a patient experience that, if it is positive, will have a ripple effect in hospital safety, quality, experience, and value. The multipronged approach defines the Cleveland Clinic's "Patients First" initiative, a personal mission for Merlino, who says helping patients have a good experience is beyond "more smiling" by physicians or gimmicks that attempt to make a patient happier. To Merlino, high quality and safety flow from solid communication with everyone involved in the healthcare of a patient.
"When nurses communicate better at the bedside, medication errors are reduced, falls are reduced, pressure ulcers are reduced," he says. "Those are safety issues. When physicians communicate better with patients and nurses, compliance with treatment goes up and coordination of care improves. That's quality."
Intuitively, hospital leaders know that better communication will lead to better results, but Merlino says staff, including leadership, is tasked so heavily that it is easy to lose perspective, especially in a hospital with a lot of patients. He's not endorsing smaller hospitals, but rather a different approach to who is working in healthcare.
"I think that 90% of people who work in healthcare are there for the right reasons," he says. "I think there's probably a percentage who want to do the right thing, but don't know how to do it, and there's a small percentage of people who don't belong here."
Cutting out the small group of healthcare workers who hinder healthcare efforts is no small task, but identifying deficiencies through training and development around service excellence can help he says.
The other component of patient experience Merlino emphasizes is empathy and compassion for the caregivers, not just the patients. That idea is expressed in an emotional four-minute video Cleveland Clinic produced for its 2012 State of the Clinic Address. With only background music playing, patients, doctors, nurses, and family members are shown moving throughout a hospital setting with just a few words describing them and their situation. For example, the words, "He has been dreading this appointment. Fears he waited too long," appear next to an elderly man in wheelchair. In another scene, a physician leans against an elevator wall with the words, "Recently Divorced." The video is effective at illustrating the humanity that can get lost between caregivers and patients. It's been downloaded nearly a million times.
"It just reminds me of why this is important," says Merlino. "You have to pay attention to little things because at the end of the day, they're human beings. They come to us at their most vulnerable, terrifying time in their life. We need to deliver care in a much more compassionate way."
Fresh from an overseas trip focusing on health insurance markets and consumer empowerment, the chief marketing officer of a Massachusetts payer observes that in Australia, consumers are trained in healthcare financial literacy.
Debbie Gordon, Chief Marketing Officer, Network Health
Deborah Gordon, vice president of business development and chief marketing officer for Medford, MA-based Network Health, fast tracked her plans for a retail strategy after an eye-opening trip to Australia, New Zealand, and Singapore. Network Health's first retail space opened this week in Worcester, MA, and Gordon says the company will soon have a presence in some CVS pharmacy locations.
Gordon studied consumer empowerment in healthcare in other countries as one of nine 2013 U.S. Eisenhower Fellows. In part two of our discussion, Gordon told me that consumers in both Australia and Singapore have more control over their healthcare spending than Americans currently do, and with the ramping up of health insurance exchanges, U.S. insurers need to start planning for a similar trend. Part I of our conversation is here.
HLM: Singapore was where you thought you would find examples of consumerism, but it sounds like you learned a lot more about retail healthcare in Australia.
Gordon: There's much more of a private insurance market in Australia. The other thing is that Australia has years of pricing individual products. Because they have more history, they have more assurance that the population buying insurance will look like a balanced risk pool.
As an industry, we haven't been particularly focused on pricing the individual market, and the rules are changing with community ratings. I think carriers are rightly anxious about who is going to start shopping, the risk profile, and will we lose our shirts or make money. [Also] what' the appropriate balance of pricing a product attractively to draw customers without being so low that we lose money and it's not sustainable?
One of the key challenges on the exchanges will be pricing. It's a different set of circumstances in Australia, but we may want to look over there for what they have learned about the methodology and approach to pricing products for individuals. We'll have to work it out through trial and error here.
HLM: How does Australia approach pricing in a consumer-driven healthcare market?
Gordon: A leading consumer advocacy organization in Australia surveyed their consumers, and found that people were really surprised when they got a bill for certain services. As a result, they worked on implementing a framework called "informed financial consent."
In the U.S., we are familiar with informed consent. They have that, too. But, in Australia, it's almost like when you take your car to the mechanic; the mechanic gives you an estimate.
One of the things we think in healthcare is that it's too hard to predict the cost. You don't know until you get in there what procedures are going to be needed. I would say that it's just like your car. They don't really know until they get under the hood what things they're going to need to fix, but they can at least give you an estimate.
So, in Australia, when patients go to the hospital, they [are given] an estimate of what the bill might be at the end, and it is signed just like informed consent. When we talk about consumer empowerment, to me this is a great example. You could do this on a small scale or a big scale, but the idea is right.
They also involve the Australian Medical Association, and put out communication for consumers, such as checklists for what a patient might ask the doctor or the insurance company. They're training consumers as patients in healthcare financial literacy.
In the U.S. we have been somewhat reluctant to engage in [that] until relatively recently. Now that so many more Americans are in high deductible plans or paying out of pocket before insurance kicks in, we need to catch up with some basic framework [for] how to talk about it. You don't buy a car or a house without asking questions. That was one example that I thought we could learn from, and that it tactical and tangible for our industry.
HLM: Some organizations are pushing that idea through revenue cycle strategies. What is the resistance?
Gordon: For a thousand reasons, it's hard. It's hard to estimate cost. The prices differ depending on the deal the provider has with insurance company.
If consumers start to push, if health plans and providers start to encourage that push and prepare to respond, we will figure it out. We'll only figure out the hard things if we have to. We've got a lot of challenges, but we may not willingly take on the next big challenge without a push or a without a model that shows it can be effective.
In the U.S., I think we're going to have a push from consumers who are financially exposed and want to shop. What I'm saying is we could borrow some tools from Australia, and that's the value of a trip like this.
HLM: Did Australian officials indicate that other health plan executives from the U.S. were also interested in some of the components of a foreign healthcare system for potential adoption in the U.S.?
No. What I heard was the complete opposite. Australia is very far away. I know that sounds very basic, but it is far, and that could be a barrier. Practically speaking, we've got our hands full in the U.S. There are plenty of working examples. In Australia they do not, so they have to look inward. But, by not looking overseas we miss opportunities to broaden our thinking
HLM: Was the retail component of healthcare in Singapore similar to Australia's?
Gordon: No. It was quite different. In Singapore, there is not a very mature health insurance system. Their system is a layered and thoughtful, sort of a complex mix of government and private sector interplay. What I didn't see is a really robust private insurance market.
The most compelling thing about Singapore was that they mandate health savings. It's called the Central Providence Fund, and they save for retirement, generically, and for healthcare. We, in the U.S., pay into Social Security and Medicare, but those funds we pay are pooled, so a 20-something American is not paying for himself, he is paying for his mother or his grandmother, so to speak.
In Singapore, all wage earners pay a portion of their income into their health savings account, which is called Medisave, and those accounts are like our 401k accounts. They (Medisave accounts) are individual assets, and there are rules about when you can use them, for what, how much you can use, and how much you can take out. So people are in command of their own healthcare dollars.
Singapore also only spends about 4% of their GDP on healthcare, and of that only one-and-a-half percent comes from the government. The balance comes from out-of-pocket spending and their Medisave accounts.
What you have is a predominantly privately-funded, high-performing healthcare system where people essentially buy their own services. The government sets limits on what Medisave will pay for, but the doctor can charge whatever he or she wants, and the consumer can decide what to buy. The government does not set prices. They'll determine what you can use Medisave for, but if you want to go to a certain doctor, that's fine, you'll just pay the balance out-of-pocket, or you can use private insurance.
While I didn't see the physical manifestation of healthcare retail, what I did see was a very important feature of retail healthcare, which is consumer control over spending.
After a trip to Singapore, New Zealand, and Australia, the chief marketing officer of a Massachusetts payer discusses success factors for the direct-to-consumer markets she observed in her travels.
Debbie Gordon, Chief Marketing Officer, Network Health
Back in July, Deborah Gordon, vice president of business development and chief marketing officer for Medford, MA-based Network Health, a nonprofit health plan covering 215,000 state residents, set out for Singapore to find what she could learn from their experience with consumerism in the health insurance market.
As the recipient of one of nine 2013 U.S. Eisenhower Fellowships, Gordon also traveled to two other countries, Australia and New Zealand, to continue studying her chosen topic, consumer empowerment in healthcare, over the five-week fellowship period.
Now that she's back, Gordon says the biggest lessons she learned about how consumers bought health insurance came not from Singapore, but from Australia.
HLM: What were the big takeaways for you after visiting Singapore, New Zealand, and Australia?
Gordon: I learned so many things. One, all health systems are in transition. The premise of my trip was that the U.S. is on the precipice of a major transformation in many ways between the market forces, the ACA (Patient Protection and Affordable Care Act), and the cost pressures that we're facing in the industry.
I thought, 'I'm going to go to some of the world's best performing health systems to see what they have figured out.' And while I was there, I realized that they, too, were at points of transition. All systems are in transition, and the best ones move on purpose. They're constantly looking for ways to improve to adapt to new conditions and new challenges.
Our health system certainly is in transition, and it always will be. And we should ask how we [can] deploy continuous improvement techniques within a mindset of constant change and improvement to make our system better.
A lot of people said, 'You could never do this in the U.S. because it's so big.' People get a bit overwhelmed with our healthcare system. It's big, it's complex, it's layered, and I think that can be an obstacle to making improvements.
The countries I visited are relatively small, and I realized they could do things because they are small. Their systems have some ability to make change at a national level that we perhaps do not, as easily. What I tried to do when I was in those conversations was think about the right level of where we could making something happen. The broad lesson was we may have to start small to make change.
HLM: How does culture influence healthcare?
Gordon: Culture has so much influence on how we implement our healthcare system. In Australia, for example, they call themselves pragmatists. They are not super politically ideological. It was described to me as a fight for the middle in Australian politics, and a general nature or culture of finding solutions. They would talk about health system reform in those terms.
They also couldn't quite understand the controversy over the ACA. I would explain that it's a political dynamic that we have. In Australia, their politics are less extreme, and so what I found was a general confusion about why we couldn't get certain things done in the U.S. And maybe that's part of their success, that they put politics aside.
HLM: Where do you see opportunity for the U.S. from examples you saw in the countries you visited?
Gordon: What I saw in Australia was a working consumer market for health insurance. For example, I landed in Sydney, went to my first meeting, which was with the Director General of the Health Department of New South Wales, and then left. It was a beautiful day, and I had flown across the world and felt a sense of accomplishment, and while walking down the street in Sydney, I realized I was looking at health insurance stores.
Fifty percent of their population buys private insurance. The government really wants them to buy in to relieve the financial pressure on the public system. But then there is a whole industry that knows how to sell, service, and market to individuals. There is almost no role for employers. Employers might be a marketing channel, but virtually no one gets their health insurance through their employers, except for expats, that's what I was told.
It's very timely. Putting politics aside, we can all agree that the Healthcare.gov implementation has been sub-optimal. Where you stand on the political spectrum affects how you interpret that failure. Some people are saying, 'See? That's why we shouldn't have this legislation,' and others are not worried about it.
What I would say, based on what I saw in Australia, is it can work, it does work. I think a lot of people have dismissed that we (U.S.) could have a working market for health insurance. But, the fact is there is a country, not that dissimilar to ours… that has in its mix a thriving health insurance industry that serves individuals.
You walk down the street and you see retail locations to transact with your health insurance company. They're promotional in nature, so the signs are for mature consumer marketers. It's something the health insurance industry in the U.S. is on the cusp of, and in Australia is a working example.
HLM: For Network Health, how realistic is a retail model?
Gordon: We are actually setting up a retail presence in Worcester, Mass. We are partnering with our parent company, Tufts Health Plan, which is a large commercial and Medicare Advantage insurer.
We do believe collectively people will want to see us face-to-face, and that we can add a level of service by being on the ground in a retail presence. Will we have a storefront every few blocks in the city of Boston? No, but we are trying to be creative and resourceful. I think the point Australia makes, and shows, is that it is a complex purchase and people do want some human contact.
HLM: A key part of making the insurance exchanges affordable in the U.S. is having a large number of young people enroll to spread the risk, has Australia also figured that part out as well?
Gordon: Yes. They use a mix of carrots and sticks to encourage people over a certain income [level] to buy health insurance. It's completely optional; there's no mandate. If you do not buy in, you pay more in taxes, and if you buy in before age 31, you pay a lower premium for the rest of your life. They call it a premium load factor, and they've created a dramatic incentive.
HLM: Are health insurance exchanges in danger of losing their status as a game changer as a result of a rocky launch?
Gordon: I think if the train hasn't left the station, it's about to. I really do think the concept of a marketplace should be apolitical. We see marketplaces in every other industry, even complex ones like other kinds of insurance, banking products, and the travel industry. It's technically challenging but solvable. The marketplace for health insurance reflects the way we buy other things, and I just don't think you put that back in the bag.
Next week, in the second part of our conversation, Gordon continues to describe the health insurance business practices in Australia that she believes the U.S. could learn from, as well as the consumer health market in Singapore.
The Healthcare Association of New York State studies 10 of the most well-known report cards that attempt to quantify hospital performance—including those from the Leapfrog Group, Healthgrades, and U.S. News and World Report—and ranks them.
Healthcare likes data, so it's a safe bet it's going to love data about data. Stats lovers take notice: We now have another hospital report card. But instead of scoring hospital quality, this one scores the hospital report cards themselves.
For marketing departments that rely on those lists to state their case to the public, the results may be surprising.
The Report on Report Cards was released to the public on Monday; but HANYS membership got a peek at the nine-page document last week. "We hear from our members that all these report cards come out with the varied scores and methodology, and it's confusing," says HANYS spokeswoman Melissa Mansfield.
The annual report cards are meant, in part, to give consumers helpful information for making healthcare decisions. But these lists and grades are also an important component of hospital marketing strategy. For example, when Children's Hospital Los Angeles rebranded itself in 2011, the advertising campaign centered on the message that it was the best children's hospital in L.A.
DeaAnn Marshall, chief marketing and development office for CHLA, says she felt comfortable using that as a premise because of the grades the hospital received from various report cards.
"What we use in our marketing materials and our advertising is our U.S. News & World Report Honor Roll status," says Marshall. "We are [also] ranked as the fifth best children's hospital in the country by U.S. News and World Report. We are also a Magnet hospital, which is the highest designation for high-quality nursing care; we are also a Leapfrog hospital."
But, HANYS' report card awarded both Leapfrog's Hospital Safety Score, and U.S. News and World Report's Best Hospitals List only one star out of three. Only four report card-issuing organizations received HANYS' highest ranking of three stars:
Mansfield says the report is meant to be a tool for hospital leaders to make sense out of the various report cards. It is not meant as endorsement of any one. From letters grades to check marks, the variation among the reports can be confounding, so HANYS developed nine criteria for grading the report cards:
Transparent methodology
Evidence-based measures
Measure alignment
Appropriate data source
Current data
Risk-adjusted data
Data quality
Consistent data
Hospital preview
Leapfrog and U.S. News and World Report received only one star from HANYS because both organizations fully or partially met only a few of the criteria. The transparency of each organization's methodology was included as a criterion (one that Leapfrog passed, but U.S. News and World Report failed) because HANYS believes the results should be able to be replicated.
Most of the report cards were credited with using evidence-based measures to develop their individual rankings. HANYS's report, however, criticized the America's Best Hospitals Report, issued by Healthgrades, because it doesn't "provide scientific evidence" that shows the relationship between its 28 measures of complication and mortality and a hospital's quality. U.S. News and World Report's Best Hospitals List also received criticism for relying on "subjective perception".
The report cards or rankings that HANYS had the most faith in were from governmental or accrediting organizations. Both Hospital Compare, run by CMS, and the Joint Commission's Quality Check, were praised for meeting all or most of the nine measures HANYS used.
"The transparency and evidence-based measures were the strongest parts," says Mansfield, noting the report shows the organizations that ranked low on the used questionable data whether it was from administrative claims or data that wasn't validated.
Now, are these hospital lists meant to be compared side-by-side? Not really. But, the consumer doesn't know that. And if hospital rankings are being used in your organization as a selling point, you have to put yourself in the role of a patient or caregiver. When you do, it becomes clear that these lists are confusing.
HANYS graded 10 report cards, and marketers know there are many more local lists that doctors and hospitals also pay attention to. In Dallas, for example, D Magazine issues its own "Best Doctors" list, along with the best burgers, best cocktail, and so on. The marketing director of a specialty hospital in Big D has told me that it is imperative they make D Magazine's list every year because it's important to their patient clientele. The key phrase of that sentence is the latter part, "important to their patient."
Instead of looking at lists, it's time to start listening to patients.
The second healthcare toolset Deloitte and Intermountain have launched this year applies treatment and outcomes across an entire population of patients, and is able to focus on specific therapeutic areas. Licensing the data is a revenue stream.
Deloitte Health Informatics (DHI) and Salt Lake City-based Intermountain Healthcare are expanding their population health analytics tools. The organizations announced their collaboration earlier this year to leverage Intermountain's vast healthcare data warehouse for insight into population health.
PopulationMiner, the newest analytic tool, launched in mid October. According to a statement from Peter Haug, director of Intermountain's Homer Warner Center for Informatics Research, the data generated with PopulationMiner will "provide insights into a broad range of medical conditions and clinical care."
This is the second healthcare toolset Deloitte and Intermountain have launched this year. In June, they unveiled OutcomesMiner, which analyzes the relationships between healthcare conditions and outcomes for a patient.
PopulationMiner is slightly different in that it applies treatment and outcomes across an entire population of patients, such as women over 40 years old, asthma patients, etc.
"This is a more narrow tool focused on specific therapeutic areas," says Katherina Holzhauser, assistant vice president of IS commercialization for Intermountain. "The market told us, 'Great, you have something for asthma, but we're interested in the broader population.' So we leveraged our understanding from the first tool, OutcomesMiner."
Intermountain's forward thinking (it started using computers to store healthcare information in the 1970s) has been a boon for researchers, but now has even more significance with the current focus on population health and value-based reimbursement.
"They've been collecting data and using it to improve care for so long … you can look at long-term trends," says Asif Dhar, managing director for DHI. "We found that the average, hospital systems that may have great data may not have all the tools in place for population health."
Dhar and Holzhauser both say that hospitals who sign up to use the tool will be able to better understand care patterns that lead to certain outcomes across a population of patients. The data that accompanies patient information is double-blinded to protect privacy, and includes 2.5 million records.
Intermountain's data is specific to its regional area, and there will be some variation, but Holzhauser says that shouldn't impede analysis from a provider that's hundreds or thousands of miles away.
"On one hand, some of the social variation may not reflect the nation as a whole," she says. "For example, we do have patients who have come to Intermountain for a good part of their life. But, we have a long, longitudinal view. There's value when you're wanted to look at real world information."
Holzhauser says that when other providers use the tool, in increase the richness of population health data overall.
"We're not suggesting intermingling the data," she says. "Rather, if they use the same toolset (PopulationMiner), for women over 40 with COPD, for example, then they may notice that at Intermountain, patients have a shorter length of stay, and then start to analyze why."
Another key part of developing this subscription-based population tool is based on the financial reality of increasing costs. Licensing healthcare data to other organizations to use is a new revenue stream, Holzhauser concedes.
"We are looking out into the future," she says. "We looked at accountable care and said, 'That's not enough,' so we asked ourselves, 'How can we be better, and also do we have value that others are willing to pay for?' "
Healthcare organizations that have fully committed to improving patient experience share the common belief that developing a patient-centered culture is key to their success.
Hospitals and healthcare organizations are keeping their fingers crossed that the significant investments they've made in patient experience initiatives will have the trickle-down effect of improving market share, HCAHPS scores, and clinical outcomes.
The organizations that have fully committed to improving patient experience share the common belief that developing a patient-centered culture is key. They know cosmetic adjustments such as new paint and/or more smiles are not the answer, but those things can be the beginning of getting employees to "live the mission" of a hospital, believing that the patient is at the center of everything they do.
Increasingly, hospitals seem to be catching on to the need for a fully supportive culture. In the HealthLeaders Media Intelligence Report, Patient Experience Beyond HCAHPS: Care Coordination and Cultural Transformation Intelligence Report, nearly 40% of survey respondents said that their organizations planned to pursue a cultural transformation related to improving patient experience over the next three years.
If this describes your organization, buckle up, because it is not easy. Changing the culture of a hospital is very difficult; however, when it is done right, the results are rewarding.
Spotlight on a New Covenant
In the west Texas town of Lubbock, Covenant Health, a four-hospital system owned by Irvine, CA–based St. Joseph Health, took what some might call a touchy-feely approach to patient experience.
Called "Spotlighting," the program was developed in conjunction with design consultants at IDEO in 2010. The goal of spotlighting is to fulfill Covenant Health's objective of fostering sacred encounters with every patient.
"It's how we make people feel," says Cayce Kaufman, regional patient experience director for Covenant. "It's not just to increase our patient satisfaction. It's also to say that we believe that every encounter can be sacred, and [spotlighting] is how you help foster that."
The basis of spotlighting is finding opportunities that can become sacred encounters between a nurse and a caregiver, or doctor and a patient. The opportunities are called scenes, and they can take place anywhere, but IDEO found three main interactions that are a natural fit for fostering a sacred encounter: admitting, resting, and discharge. In spotlighting lingo, says Kaufman, it's 'warm welcome', 'sweet dreams', and 'thoughtful goodbye.'
Though the scenes sound standard, they aren't. Each department, or design team, creates its own scene during a brainstorming session that Kaufman leads. She first has the design team pick a moment that can be singled out as a potential sacred encounter, then she asks the team to pick a tone or a word that helps define how the staff want their patients to feel.
"Once you get the tone, you can decide, what does that look like? What are the gestures? It's not scripting. It's different than saying, 'You need to say this, and you need to do this.' We say, 'What types of things did your mom do?' "
To help the team define its tone, Kaufman has them go through magazines and cut out images that demonstrate the word the team picked. From there, the team develops a plan that consistently reinforces how the staff wants a patient to feel. This can be in the form of gestures, kind words, or "props," which Kaufman says are not far off from what doctors have been doing for years.
"It's a lot like a lollipop in a pediatrician's office. Was there value in that? Probably not, but how did it make the child feel?" she says.
What's important is that the communication, or encounter, be seamless and organic. Once the details have been worked out for a specific interaction, the team members try it out with a set of fresh eyes. It could be a patient, or it could be someone from a different unit. There is a lot of feedback and modifying the scene before it's rolled out to the entire department.
"It takes a long time to do this," says Kaufman, who estimates that start to finish, the process of spotlighting a single department can take as long as three months. A continuous feedback loop from patients to caregivers keeps the team informed, and is important to making sure their techniques are working.
Marketing's Role
The amount of time that Covenant spends on training its employees to accurately and compassionately communicate with patients puts it in front of other organizations that are just getting started.
Covenant's early entry into improving patient experience has paid off. The improvements that came after spotlighting began include improved employee morale, engagement from leadership, and HCAHPS scores, though tying those scores to patient experience is tricky, and not really an accurate reflection of one another.
Marketing's role in patient experience is important, says Lynne Cunningham, MPA, FACHE, Studer Group coach.
"Marketing can plan a key role in gathering data, interpreting data, and communicating data in a consistent manner," says Cunningham. "This applies to employee engagement, provider engagement, patient sat and clinical quality data."
Cunningham describes the pressure organizations are under to improve patient experience as "tremendous."
"If you're not getting better faster than the other guy, you're getting worse, and everyone is working on improving clinical and service metrics … no one is being left out of the equation."
On a mission to improve health literacy among its employees as a pathway toward improving health outcomes, Blue Cross and Blue Shield of Minnesota found a solution that not only engaged them, it turned some into "change prophets."
Blue Cross and Blue Shield of Minnesota's launch of an educational game to help its employees better understand their health insurance benefits outperformed the health plan's expectations and highlighted a new population that is instrumental in creating a successful internal messaging launch—employee champions.
Matt Marek, vice president of product and consumer experience for BCBS MN, says employee champions are a cross section of workers that have one thing in common.
"They want to make a difference; they want to be a change agent," he says. "They're almost like change prophets. It is a healthy mix of new and more tenured employees, but they're celebrating something they believe in."
The issue that stirred up BCBS MN employees' excitement was increasing health literacy. As documented by the Agency for Healthcare Research and Quality (AHRQ) and the Harvard School of Public Health, there is a significant correlation between health literacy and hospitalizations, ED use, and prescription adherence.
Essentially it boils down to this: the less a patient knows, the more expensive their healthcare is without the benefit of a better outcome.
BCBS MN's ultimate goal of improving health and health outcomes begins far earlier than when a member walks through the doors of a doctor's office or hospital. It starts, says Marek, with knowing when to utilize provider services.
"The problem is that [only] 20% of members and employees understand their benefits," he says.
Instead of sending out another round of memos explaining how insurance works or holding an employee meeting explaining insurance benefits, BCBS MN decided to give its 3,000 employees access to Healthcare University, an interactive online program that uses videos, quizzes, and games to teach employees about their benefits and how to make more cost-conscious healthcare decisions.
"We've tried to educate our members," says Marek, echoing the sentiment of other employers who've attempted to increase the health literacy of their own workforce.
The tool, developed by Change Healthcare, a Brentwood, TN–based company that works with health plans to increase member engagement and reduce costs, awards points and badges to users who master a course on healthcare education.
"We were testing the theory, 'Can gamification change behavior?' " What they learned was that "Gamification is a great way to educate," says Marek.
For BCBS MN, the pilot curriculum included ten courses. Each begins with a 2–3 minute animated video. Users then answer a five-question quiz, which unlocks a game and leads to more subject areas, as well as points and badges that are made public on a leader board visible to BCBS MN members.
The program launched in February, so it is too early to tell if the games led to the ultimate goal of a behavior change, but Marek was encouraged to see employees beat every goal BCBS MN set for participation.
Out of 3,000 employees, 1,343 registered for Healthcare University. The 38% participation rate exceeded the health plan's goal of 20% registration. "We were absolutely thrilled," says Marek. "I wasn't sure where we would land."
The communications strategy to launch the program was relatively simple – emails were sent, icons pushed out to employee desktops and a takeover of the company's intranet for several days.
The real key to getting employees registered was not in catchy graphics and slogans. It was all about people. BCBS MN's CEO Michael Guyette set the tone for participation by registering and using the tool himself. Other leadership followed, as did employees, and this is where Marek says he saw the excitement for health literacy come alive. Some employees then "took it upon themselves to champion" the education portal. Marek says the internal encouragement was no surprise because he says the culture of BCBS MN is supportive.
"We didn't create employee champion groups before the pilot," he says. "Identifying employee champions is part of our culture. We've taken an active role in attempting to be more transparent with projects and encouraging people to be more involved."
In addition to blowing past its registration goal, BCBS MN also saw its users surpass the company's 30% completion rate of at least one subject buy double digits. Initial results saw 53% of users finish one subject, and 62% of users who completed one course went on to finish all of them.
Another key to its internal marketing campaign was timing. The pilot launched in February.
"We tied it into a time of year we thought would draw more attention," says Marek. "It is part of the reason, I think, healthcare is broken— open enrollment, benefit changes … it is all crammed together in the fall."
It's not clear if the animation, games, and creative content will eventually lead to consumers making better, more informed decisions about their healthcare. But the successful launch of the tool points to the importance of having a culture that supports the mission of an organization.
When employees see leadership "living the mission," pushing out a marketing message to employees can take on a life of its own, doing a lot of the legwork of posters and elevator wraps.
"The employee champions are important to the process," says Marek. "We got more bang for our buck."
BCBS MN is now reviewing how to reward behavior change, and considering whether to extend the healthcare education portal beyond its employees to its members in 2014.
Instead of announcing its rebranding campaign all at once, Mercy Health rolled out its new look and tagline one service line at a time. Investing in market research upfront has been key to its success.
Catholic Health East's Mercy Health System, a four-hospital system with senior and long-term care services based in Philadelphia, serves the Delaware Valley, which includes counties in Pennsylvania, New Jersey, Delaware, and Maryland. Patients who live in this area have access to some of the most highly acclaimed hospitals and health systems.
To compete for patients in a crowded and high-profile market, Mercy Health officials decided to do things a little differently to revamp the system's image. The organization developed a marketing strategy that rolled out its revitalized brand one service line at a time.
"We have very limited resources," says Gabrielle DeTora, principal of DeTora Consulting, who acted as interim chief marketing officer for Mercy Health during the development of the campaign, which kicked off in 2012. "Mercy probably has a marketing budget for all four hospitals equal to one competing hospital. In order to get the reach we needed, we took a pulse approach."
The "pulse approach" tactic began in February with Mercy Health promoting its cardiovascular service line followed by its orthopedic, cancer, and bariatric services. DeTora says that in addition to being financially limited, there was also not enough time to do a separate rebranding campaign for each business sector, which is why the health system decided to essentially find one message that would resonate with patients and use it for each service line throughout the year.
"To optimize our minimal marketing budget, we developed an overarching brand campaign creative structure, but launched only service line campaigns all falling under the master brand umbrella," says DeTora. "This was to build brand consistency and frequency of messaging to drive overall consumer preference, while still delivering patients to very specific service lines."
Customer Survey
The first step was finding out consumers' perception of Mercy Health. DeTora partnered with Swanson Russell, a full-service marketing and advertising agency, to help carry out quantitative and qualitative brand research. A consumer telephone survey of 800 participants showed that preference for the hospital had decreased since 2010, the last time the hospital system had surveyed consumers.
Knowing that competition had increased, DeTora wanted to find out how Mercy Health could stand out from the crowd. Five focus groups, made up of 15–20 people each, informed DeTora that patients preferred a doctor who would spend time with them.
"They defined top doctors as someone who is going to take the time to listen to them, to understand their medical issue, which was totally different than how the administration defined a top doctor," she says. "That changed the language associated with the campaign."
Leadership believed consumers defined top doctors as those who worked at competing academic medical centers. DeTora says when the focus group results showed otherwise, hospital leaders were surprised.
"We got a lot of lightbulbs going off," says DeTora. "They realized they had tunnel vision. We really needed to be clear about our target audience, and we needed to do something that was more appealing to them."
Message Development Members of the ad agency DeTora used also spent nearly a week at Mercy Health hospitals to interview staff, including physicians and nurses. The agency team found out that what made Mercy Health unique was also what consumers wanted—extra time spent talking and understanding individual medical issues.
The information led the agency to develop four messaging concepts, but the one that scored highest in an online survey of Mercy Health users and nonusers was the one that promoted the system as high quality, and more, which was incorporated into the tag line, "But you deserve more."
"When you look at what Mercy can offer—they can do all of the same things as other community hospitals and then some—so we tried to level the playing field," says DeTora. "What's the difference? We really take the time."
The new brand and messaging concept was delivered in a multimedia ad campaign promoting Mercy Health's cardio care. For example, the print ad in the Philadelphia Inquirer stated, "Premiere Heart Surgeons? You Bet. But you deserve more.
The other ads are similar, with text explaining that "You deserve more" means more understanding from Mercy Health physicians and nurses.
Rebranding Tactics The campaign also included a microsite, TV, direct mail, newsletters, banner ads that were interactive, heart healthy recipes, cooking videos, and physician marketing. Unique Web traffic went up 50%, and call volume from the campaign went up 40%, year over year.
Web and call inquiries are soft measures of consumer interest, and DeTora says Mercy Health is now working toward a new customer relationship management system that will identify how many calls lead to appointments, then procedures, and so forth.
There is some evidence that the hospital system is seeing real results from its campaign. DeTora says Mercy Health's goal of increasing inpatient invasive surgery and outpatient noninvasive surgery is on target, noting that all areas of cardiology services have increased in volume by 10%. Leadership at Mercy Health is also happy with the results.
Results
"We are very pleased with the campaign," says Daniel Bair, FACHE, administrative director, cardiovascular and radiology services for Mercy Health System. "Even with our limited resources and a highly competitive market, the results have been within expectation on most fronts and exceeding expectations on many others."
DeTora says the key component in developing this branding campaign was time spent talking to and surveying consumers. It really helped the system understand what its patients wanted and valued.
"What was most interesting was the quantitative and qualitative market research that inspired the campaign," says DeTora. "We really tried to understand what was more important to the consumer first. In looking at ourselves from the inside out, we really understood spending time with patients was a big differentiator for us."
Social media channels allow a healthcare provider great reach for a fraction of the cost of traditional media such as billboards, newspapers, magazines, print, and television. But "spraying and praying" all over the Web is not a good strategy.
By now, using social media as a component of a hospital or health system's marketing strategy is a no-brainer—Facebook, Twitter, YouTube, Pinterest, etc., are platforms that are here to stay.
While it may be difficult to draw a straight line from Facebook impressions or YouTube views to patients through the door, it has become clear that if an organization is not actively using social media, it is missing an important marketing opportunity. The question is no longer, "Are you using social media?" Instead, it's, "How many social media channels are you using?"
The last question is an important one. Social media channels allow a hospital to be in front of more people for a fraction of the cost of traditional media such as billboards, newspapers, magazines, print, and television, but "spraying and praying" all over the web will not work without knowing your target audience.
Back to basics
Compass Imaging, an independent, freestanding outpatient imaging center with two locations along the Gulf Coast in Mississippi, relies heavily on its referring physicians. About three years ago two things happened, Tony Giardina, director of marketing for Compass, tells me.
"A huge percentage of our referring physicians were getting bought up by hospital systems, so we lost a big percentage of our business," he says. "So we started to think, 'Do we go to commercials? Do we do billboards?' "
At the same time, he says the practice saw the explosion of businesses using Facebook, and "we didn't want to be left behind." That enthusiasm led Compass to think it should be on every social media platform available, but Atlantic Health Solutions, a physician referral consulting firm that has worked with Compass on its marketing strategy since 2004, advised against it.
"Compass is on the Gulf Coast, and in that area, we found that referring physicians were active on Facebook, but not so much Twitter," says Sara McFarland, communications and social media specialist at Atlantic. "So we focused on increasing their presence on Facebook."
Focus on your audience
McFarland collates the monthly social media metrics reports for Compass. Since they began focusing on building its Facebook presence, website traffic has increased year-over-year. For example, from July 2012 to July 2013, unique website visitors went up by 37%. The increase extends to their Facebook impressions, as well.
"The biggest takeaway is 'Don't overdo it,' " says McFarland. "If you're just doing a little bit here, and a little bit there on every social media channel, then you're not really providing value. You're not going to see a return on investment."
Solely focusing on Facebook might seem like it is too narrow, but it's a smart move based on sound research McFarland did to make sure that Compass would capture the attention of its targeted audience.
"We're seeing a direct correlation between Facebook clickthroughs and website traffic," she says.
The singular focus on one social media platform was a strategy that Giardina says he initially didn't believe would pay off for Compass.
"I honestly didn't think anyone was going to care," he says. "We weren't crazy about it (Facebook), but we did it anyway. We've come a long way, for example, we promote health fairs we participate in and nine times out of ten people at those fairs say they found us on Facebook."
Physician referral tool
Compass also uses its Facebook page to engage with its referring physician offices, using a strategy that keeps the referrals coming in and relations on good terms with individual offices.
Each week, Giardina says, it features a local physician office on its blog, which is also posted on its Facebook page. It's a way to get content for the Compass blog, but it also builds relationships within their community.
"We try to do someone new every week," says Giardina. "If we are getting a lot of referrals from a doctor's office, we'll feature them. Or, if someone says it's slow, then I'll say, 'Hey, I'll do a write up for you on our blog,' and it helps them, and it helps us."
It's rare for a patient to come in on their own without a physician referral, though since Compass stepped up its presence on Facebook, those types of patients are on the rise. Giardina says before it focused on engaging with patients on Facebook, it may have had one person per month come in. Now, he says it's more like two or three new patients per month.
"It's hard to gauge the direct return on investment, but lets' just say we get two patients—one for an MRI, one for a CT – with not a lot (of ad spend) on Facebook… that return is phenomenal."
For independent physician offices or freestanding facilities like Compass, it is tempting to invest significant resources, whether it is time, money, staff, or all three, in social media channels. There are so many and they are simple to use, but smart marketers know that the value of social media comes from knowing if the target audience using it.
"Before Facebook we were focused on word-of-mouth referrals," says Giardina. "Social media is the new digital word of mouth, and it has helped our visibility tenfold."