Providers don’t just operate in silos defined by their professions, their delivery systems, or their theoretical paradigms. They operate in silos of information. There is simply so much information out there, it’s hard to track, let alone digest. By 1900, it had taken 150 years to double all human knowledge. In 2011, it was taking only 1-2 years to double, and it’s estimated that by 2020 all human knowledge will double every 72 days. So even trying to keep up with a small area of professional information is a daunting task. An information silo can create an important specialty area of expertise, but it also turns the provider into a very specialized kind of tool.
One area we’re not trained to track, but that has a significant impact on our profession, our practices, and in many ways our basic survival, has to do with the consumer side of health revolution. The word ‘revolution’ is apt, because forces are coalescing that will dramatically impact health care, and they have little to do with the Affordable Care Act or anything any of us tries to put together. They have to do with what consumers are beginning to have available to them in health care. And once consumers are truly in charge, our roles as providers will never be the same. What is going on, and what can we do about it?
From my observations of the emerging retail healthcare marketplace, there are three areas of information DCs need to track, know and to use as a basis for changing how we practice: Normalizing Supply and Demand, Patients as Consumers, and New Roles. First some background, then some solutions.
Normalizing Supply and Demand
The dynamic created between those who supply something and those who consume that something (‘demand’) is a basic economic reality. When demand outstrips supply, prices go up; when supply exceeds demand, prices go down. When there is marketplace hunger for something that isn’t available, creativity and innovation can deliver it. There is a notable kind of transparency in all this: suppliers and consumers operate in markets and marketplaces where it’s generally clear what everyone is doing.
This dynamic is familiar in any retail or service environment–with the notable exception of health care. In American health care, the supply side (providers, insurers) has controlled what the demand side had available to it, and the kind of transparency we expect in retail markets has not existed. Patients have never had any leverage, because they (we) have been held captive by others’ ability to control or manage what we could even purchase or use. Further, patients have not been able to aggregate into any kind of independent purchasing force or group, so we have not had any purchasing leverage to push down prices of services or drugs (exceptions on behalf of patients–employers and the government–have had some impact, but not on the overall dynamic).
Chiropractic has been subject to these forces in notable ways. Because demand is down (low market penetration) and supply is up (lots of DCs to serve the current perceived need), providers have trouble achieving fair compensation; in fact, our earnings ability has significantly eroded since the high point of the early 1980’s.
Patients as Consumers
Perhaps the single biggest change is in the role of consumers in health care. It wasn’t too long ago that the word consumer wasn’t ever used in relation to being a patient. Provider/patient relationships were almost normally paternalistic/maternalistic in nature, in that patients came to us to be taken care of. Providers were the source of information and the source of solutions to problems and conditions. But the Internet has democratized information in a way few could have foreseen, and there can’t be many health providers who have not had someone walk in with a sheaf of papers they just printed off the ‘net about their question or condition. It’s pretty likely that they may have more current information than the provider they’re consulting.
The ability to access this information–whether they know what to do about it or not–means that they are not as dependent on providers for information and guidance. And because of that decreasing dependency they are at least in a position to make more informed decisions. Providers still are the source of services, therapies and interventions patients cannot get on their own, but there are often so many options for these services that patients can make choices about where, from whom, at what price, and how they use—consume–them. I’ve engaged a long-time MD friend over the issue of this language for a number of years. His assertion is that the word patient has suited the historical role of ‘one who bears the burden’, and that this role transcends market forces. I disagree, in that patients are making more and more choices using the metrics and considerations retail consumers do, and that they may ‘bear the burden’ of illness, problems or disease, but they are managing that burden in entirely new ways that are not necessarily dependent on providers. And that change in role and consideration has deeply and permanently changed the basis for the patient/provider relationship. The locus of control has shifted dramatically. It’s important we understand how much more that is shared now; it requires a whole new social contract between those providing and those receiving services and information.
If information is power, consumer/patients are able to enjoy a degree of power they have not known before. What is probably important to understand as providers is that we really don’t know what consumers are thinking. We think we do. But no one has really asked the question: are patients (consumers) telling us the truth? We’ve acted as a profession as if we had a special (better) relationship with patients than medical doctors. But do we really?
A decade ago when I was in charge of developing a consumer-facing health and wellness web product for a major health plan, we set up focus groups in several major cities coast to coast. What we heard from people–men and women, younger to older–was consistent and startling. They told us several things. First, they told us that they very clearly understood they were making their own decisions about what kinds of care to ‘consume.’ Second, they told us very clearly that they were very aware that they were managing what, and how much, information to tell their providers….all of them. Coming from a provider training culture that emphasized the content, ethics, and implications of a relationship where the locus of control was firmly in providers’ hands, this was an arresting development for me. I realized at the time that patients were in charge in ways we providers had not even begun to imagine. I also realized that how we approached this new (and at the time, mostly hidden) dynamic was going to be critical for us to survive.
What’s happened in the years since has only affirmed and reinforced this awareness. As information on health has proliferated, and as barriers to access it have lowered, we now have a population of consumers (potential patients) who are informed, reaching out to non-providers for guidance (social networking), using new financial models to pay for services (high deductible health plans, health savings accounts, debit cards, etc.), and managing relationships with multiple providers for their contribution to clinical needs. Consumers have, in fact, become their own case managers. The professional silos we operate in (where we don’t share information with other providers and have no way to compare our contribution to good outcomes with others) put consumers in this position. And they are taking advantage of it, for all the reasons that retail consumers understand their purchasing decisions drive behaviors and innovation on the supply side. The game is changing–permanently. Innovation in the ‘mHealth‘ (mobile health) industry is breathtaking, and web-based decision support tools for consumers that will only reinforce and strengthen their position make this an unalterable change. It’s a new world out there. What are we to do?
Seizing the Opportunity
These three aspects of operating in today’s health care system marketplace offer substantial challenges. Move effectively to prepare yourself for these and the rewards will be great; move poorly and you staying in business will be increasingly difficult. What can we do? There are some very practical and productive steps you can take.
Align your services with the demand–and build. Consumers normally have at least a sense of what they want–even if they can’t describe it. Steve Jobs famously said ‘consumers don’t know what they want,’ but if there is no hunger for something, products and services don’t catch on. Consumers want help living healthy lives, and they want effective help dealing with health problems and challenges. The biggest lesson chiropractors can take from how the retail marketplace function operates is to describe your services in ways consumers recognize. We often worry about being technically correct when we describe our services, but our language isn’t how consumers think. We’ve acted as if the only problem was having enough of an opportunity to educate people about subluxation, neck and back problems. But millions of dollars have been spent on patient and consumer education, and we’ve got 7% of the market. It’s time we do some basic consumer research.
Step 1: Ask your patients how they think of you and your services. Hold a simple focus group and invite people to come in who represent the breadth of your patient types and demographics. Pay them (often focus groups pay participants $100 cash) or feed them. Ask them their words for your services. Ask them what they tell others about you and/or your office.
Step 2: Write up a draft advertisement using your patients’ words–and ONLY their words. See how it reads to your patients. You don’t have to like it. It’s not for you.
Step 3: Use the advertising copy in an ad, flyer, postcard, or social media channel. Track new patient responses. Once they are in your office, you can add any educational components you think may work to broaden your patients’ knowledge, understanding and awareness of chiropractic. But do so carefully. If specific language creates a response, be ready to have that expectation rewarded when they do show up.
Treat your patients as consumers–and as customers. Consumers expect choices, information, and decision-making support. They expect transparency about pricing, and they expect to see their friends doing the same thing or shopping at the same places.
Step 1: Think through how you can add choices to the treatments and case management plans you propose. Especially when people are paying more out of their own pockets, examine whether or not you can have an à la carte list of services, with bundles of services at discounted price points. Too ‘retail’ for you? Walmart, Target and Macys differentiate themselves from each other by price, service and quality. Take that to heart.
Step 2: Make information available about health care issues–not just conditions. Health care is confusing. Get information about HSAs, high deductible plans, other financial aspects of health care, and put it out to your customers and on your website. Establish yourself as a source of this type of information, and people will look to you for services when they need them.
Step 3: Make customer service an explicit aspect of the experience of being your patient/customer. Patients expect long waits, disinterested desk staff, and a harried doctor. Customers expect good service and a climate of responsiveness to their needs and problems, and attentiveness. Build those qualities into the experience of coming into your office, and your customers will reward you by telling others.
Prepare yourself for a new role as advisor. Most patients will show up now well-educated about any problems or conditions they have–or think they have. Many will be essentially testing you to see if you’re as up to date as information on the Internet is. Most of the time, we’re going to fail that test. But what we can do is to be solicitous of what they already know and to ask them what they know of their choices.
Step 1: Ask your customer what they already know about their choices. Use that awareness as a way of building a bridge of understanding. It’s entirely possible that they may not really want what you have to offer as a first choice; help them understand their choices first, and present yourself as a solution second. We are trained to lecture people about their choices. Let’s learn to ask them first. Everyone’s life is unique and complex.
Step 2: Separate your role as ‘solution’ from your role as guide. Trust can’t be advertised; trust can’t be presumed; trust has to be earned. Establish yourself as a trusted source of accurate information that isn’t linked to self-interest. Don’t ever use the word ‘trust’ in any advertising. People will stay away in droves.
Step 3: Make information free, and charge for services. Create ways people can ask you questions and make your answers available in a way that others can access, even without knowing you. Blog about health care. Put chat on your website with advertised chat times. Do podcasts on being a consumer in today’s confusing health care world. Give people simple, direct and relevant answers to the problems they’re handling every day.
The rest of 2013 and the year of 2014 are going to be significant in America as the rest of the Affordable Care Act becomes operational. State health exchanges will become established. Insurers will be offering more and more choices for individual sales. Employers will be abdicating more and more responsibility for vetting options for their health benefits and giving employees allowances to make their own choices. Many aspects of our system today are going to change. I believe it is for the better; many argue just the opposite. We will have to see, but we won’t have to wait long now.
For doctors of chiropractic, it’s my view that it’s going to be critical that we see the trends developing I’ve highlighted above, and take meaningful steps to respond. None are very complicated. But these all require very new behaviors and very new thinking on our part. Mobilize successfully, and the rewards will be great. Wait, or react poorly, and staying in business will become more and more difficult.