Optimizing Your Practice Through Service Values

Jonathan W. Berlin MD, MBA

ARRS 108th Annual MeetingBusiness & Practice Management Seminar

April 13, 2008

Disclosure of CommercialInterest

Neither I nor my immediate family members have a financial relationship with a commercial organization that may have a direct or indirect interest in the content of this presentation.

Presentation Overview

• Changing Landscape: Increasing Patient Consumerism, Quality as A Prerequisite

• Quality and Service Differing Perceptions of Patients & Providers

• Quality Versus Loyalty Their differences & Importance of Loyalty

• What Does This Mean for Radiology?

Changing Healthcare Landscape

• The healthcare landscape is changing

• Gradual shift from employee based healthcare insurance to greater individual choice, and expense. Greater co-pays and deductibles More non-covered healthcare services.

Shift in Healthcare

• “Traditionally, employers selected health care products for their workers and paid for most of the services.

• Increasingly…those costs are being passed on to individuals, who now decide what products to buy, as well as where, when, and how to buy them.”

http://www.mckinseyquarterly.com/article_page.aspx?ar=1951&L2=12&L3=63&srid=17&gp=0 Accessed 3/15/07

Increased Expenses Are Driving the Change

• “The underlying force propelling (the movement toward increasing individual responsibility) is medical inflation, which is rising two to three times faster than general inflation, so companies are increasingly reluctant to bear the full cost of health care.”

http://www.mckinseyquarterly.com/article_page.aspx?ar=1951&L2=12&L3=63&srid=17&gp=0 Accessed 3/15/07

Increasing Healthcare Costs for Corporations

• General Motors now spends about $1,525 on health care for every car it produces - or roughly $6 billion in 2005.

• Ford spends more on health care than on steel

• Starbucks spent more on health insurance for its employees in 2005 than on raw materials needed to brew coffee.

http://www.rightreality.com/articles/health_care_neither_you_nor_your_company_can_afford_it.htmlAccessed 4.9.07

Increased Utilization of Imaging

• On average, between 1998 and 2001, utilization per Medicare enrollee increased 16% per year for MR imaging and 7%–15% per year for CT, US, interventional radiology, and nuclear medicine, while that for radiography increased 1% per year.

• Which radiology procedures cost more?

Radiology 2005;234:824-832.

Utilization of Radiology Services is Increasing

• Diagnostic imaging services paid under Medicare’s physician fee schedule grew more rapidly than any other type of physician service between 1999-2003.

• Evaluated another way, the average growth of physician services during this period was 22% -- for imaging it was 45%.

http://www.medpac.gov/publications/congressional_testimony/031705_TestimonyImaging-Hou.pdf, Accessed 12.4.07

Percent Growth in Medicare Spending Per Beneficiary Controlled for Price, 1999-2003

0

5

10

15

20

25

30

35

40

45

Major Proc. E & M Minor Proc. Tests Imaging

% Increase,1999-2003

http://www.medpac.gov/publications/congressional_testimony/031705_ TestimonyImaging-Hou.pdf, Accessed 12.4.07

Increasing Co-Payments and Out of Pocket Expenses

• Increasing corporate expenditures can be addressed by increasing out of pocket expenses for healthcare.

• People who have to pay for their healthcare use less and are more discerning.

Percentage of Healthcare Expenses in Individual Hands

• “By 2011 the fate of $550 billion to $600 billion of premiums will be in the hands of individual decision makers, not employers or the government.” McKinzie Quarterly, March 2007

Trends To Individual Spending Producing Greater Transparency

• This is leading to trends to facilitate decision making for healthcare consumers

• These changes include: a greater emphasis on healthcare quality transparency of health care quality &

outcomes data Transparency of price data

Mission of the US Dept. HHS Value Driven Website

• Health care transparency provides consumers with the information and the incentive, to choose health care providers based on value.

• Consumer choice…motivates the entire system to provide better care for less money.

http://www.hhs.gov/transparency/ Accessed 3/7/06

Is This Change Irreversible? Don’t Rely on Government

• “It is highly unlikely that the health care system will ever return to a more wholesale environment.

• The biggest impediment is the under-funded Medicare liability of $30 trillion—more than 2.5 times the US gross domestic product.

• This liability makes it extremely difficult for any government to assume responsibility for rising health care costs.”

http://www.mckinseyquarterly.com/article_page.aspx?ar=1951&L2=12&L3=63&srid=17&gp=0 Accessed 3.15.07

Where Does Radiology Fit In?

• Radiology co-pays are increasing at the same time that consumers are becoming more conscious of quality and service.

• Our insurance: outpatient radiology services only covered at 90% in 2008, 95% in 2007, and 100% in 2006

• How is radiology responding?

Imaging Economics February 2007 p. 35

Quality as Measured by Radiologists

• Quality as Measured by Radiologists:

Appropriate Ordering by Clinicians (ACR appropriateness criteria)

Protocol Selection: Type of Protocol and Contrast Usage

Adapted from Mayo Clinic Radiology Quality Map Events and Metrics, Imaging Economics February 2007

How Radiologists Measure Quality

• Patient Examination: Complication Rate

• Interpretation of Exam: Accuracy, Standardized Report, Usefulness of Information in Report to Clinicians

• Finalization of Report: Typographical or Textual Error Rate in Report, Timeliness of Report Signings

Adapted from Mayo Clinic Radiology Quality Map Events and Metrics, Imaging Economics February 2007

Adapted Mayo Clinic Quality Map

• Is Communication to Referring Physicians Accomplished in a Timely Manner? Are Referring Physicians Satisfied with the level of Communication?

• Outcomes: Is the Health Outcome Improved for Patients?

Adapted from Mayo Clinic Radiology Quality Map Events and Metrics, Imaging Economics February 2007

The Essential Nature of Quality

• Quality Measures such as these are ESSENTIAL for any radiology practice, and they are admirable as well.

• Swenson: Three Reasons for Greater Attention to Quality: Differentiation Among Providers Quality Measures Will Increasingly Be

Required by Payers Moral Imperative: The Physician’s Role

Quality: The Differentiator in a Flat World, Imaging Economics February 2007

Quality Measures

• Quality Measures will Increasingly Become a Prerequisite for Radiology Practices

• They are essential for survival and not optional

• However…are they enough??

Lingering Questions About Quality and Health Care

• To examine this question requires asking some additional questions: Do patients and Health Care Providers have

the same means and experience to assess quality? Do they measure the health care experience the same way?

Are adapting quality measures enough, or should health care organizations also pay attention to other factors such as patient “experience”?

2006 Airline Quality Rating

2006 Airline Quality Ratinghttp://aqr.aero/aqrreports/AQR2006final.pdf Accessed 3/7/07

2006 Airline Quality Rating

• Flights On – Time

• Denied Boarding

• Mishandled Baggage

• Customers Complaints: Over sales, Fares, Refunds, Animals, Customer Service, False Advertising, Discrimination, Reservations / Ticketing / Boarding

2006 Airline Quality Ratinghttp://aqr.aero/aqrreports/AQR2006final.pdf Accessed 3/7/07

What is Missing From This Rating System?

Airline and Airplane Safety Data is Absent

• Airline Safety Data Number and Frequency of Crashes Number and Frequency of Near Misses Number of Fatalities and Injuries from

Crashes

• Airplane Safety Data Age of Airplane Fleet Maintenance Records of the Fleet

Pilot Safety Data is Missing

• Pilot Safety Data: Age and Experience of Pilots Number of Pilots in Airline with Substance

Abuse Problems Exam Scores of Pilots Age and Type of Simulator Equipment Airline

Pilots Trained On

Reasons For Airline Data To Be Missing

• Why is airline safety data missing? Because it is not really questioned by customers. As a

generalization, customers assume competency of the airline, the pilot, and the equipment.

Other Industries are Similar to This – Competency is Generally Assumed

• Auto Industry: When we rent cars do we specify those with low crash rates?

• Elevators / Escalators• Bridges / High Rises / Balconies / Porches / Fire Safety

Patients Do Not Measure Efficacy

• In the same manner, healthcare quality data is not as readily accessible by customers for clinical efficacy or outcomes.

• That doesn’t mean it’s not important – it only means that customers notice other qualities as well, and these other qualities impact on them, sometimes in a more personal and up-front manner.

Efficacy Versus Experience in The Hospital Setting

• “Hospitals spend their efforts in clinical results and process improvement (which) can be measured objectively. The patient, however, judges quality by his or her perceptions, something that … cannot be verified in the same way as outcomes. The patient is judging the overall experience of being in the hospital.”

Lee F. If Disney Ran Your Hospital, Second River Healthcare Press, 2004

Importance of Experience

• “Patients will make clinical decisions based on non-clinical information.”

• Case of the “Dead Fish” in the waiting room aquarium – the patient thinks, “If they can’t take care of a fish, how can they take care of me?”

Gabriel BA. Your Complete Guide to Patient Service, Physician’s Practice, March 2008

Is Proven Clinical Efficacy Enough?

Experience and Service Increasingly Important

• “I’ll tell you what keeps me awake at night. The quality of our clinical care is …proven and we’ve been able to attract patients from great geographical distances because of it. But…all our trend data shows that consumers are becoming more demanding and will continue to be. It’s in our best interests to offer the service levels and experience that patients are starting to seek.”

• Phyllis Marino, Associate Director of Marketing, Cleveland Clinic

http://www.interplaygroup.com/docs/Beyond_Patient_Satisfaction_An_Interplay_Whitepaper.pdf Accessed April 2007

How are We Doing?

• How are health care organizations and providers doing in addressing the patient experience?

Quality and the Patient’s Perception – The Case of Gerald

• “Too often when I speak with my son’s doctors, we end up talking about him as if he’s not even there. (At one) doctor visit…his pediatrician was so clearly pressed for time that she worked on (my son) like she was part of a race-car pit crew.”

Cullen T. The Wall Street Journal. 2/22/07. Putting “Care” Back in Health Care

The Subjective Nature of The Health-Care Experience

• “It’s rare that I walk away from one my family’s doctor appointments or dental visits with a good feeling. It’s not that my family is in poor health or that we’re not receiving proper treatment. Rather, it’s feeling that our health-care providers just don’t have time to care about my family.”

Cullen T. The Wall Street Journal. 2/22/07. Putting “Care” Back in Health Care

Introducing Patient Loyalty

• Why is the patient experience important?

• Because it correlates to patient loyalty.

• Loyalty: A patient's likelihood to return to a healthcare facility (Gallup)

http://www.bartleby.com/61/44/L0274400.html Accessed 4.9.07, www.gallup.comAccessed 4.9.07

Examining Customer Loyalty Economics

• Two companies: one with customer retention rate of 95%; the other with retention rate of 90%

• Both companies acquire new customers at 10% per year

• The company with 95% customer retention increases net customers by 5% per year and can double in size in 14 years; the company with only 90% customer retention does not change its customer amount in that same time.

Reichheld FF. The Loyalty Effect 1996 Harvard Business School Press

The Loyalty Effect

• 1. Loyal customers insure steady growth• 2. Sustainable growth enables the organization

to attract and retain the best employees• 3. Loyal employees reduce costs and improve

quality• 4. Loyal customers insure steady volume so that

profits can be put back into the system

Reichheld FF. The Loyalty Effect 1996 Harvard Business School Press

The Importance of Loyal Patients

• Healthcare may be different than the car business

• However, it does stand to reason that loyal patients will seek further care, if needed, at the same facility.

• Additionally, loyal patients have the power to suggest referrals, increasing business.

Measuring Loyalty

• The question then becomes: How do we measure

loyalty?• Among our patients • Among our staff

How do we increase loyalty?

• Among our patients • Among our staff

Physician – Patient Relationship Most Important Factor

• The overwhelmingly powerful determinant of patient satisfaction and loyalty in the group practice setting…is the interaction between the patient and the physician. Our studies have shown that this factor does more to explain patient satisfaction and loyalty than all other factors combined.

The Satisfaction Monitor Jan/Feb 2001 Drivers of Patient Satisfaction in the Group Practice Setting Jerry Seibert, MA, President - Parkside Associates http://www.pressganey.com/products_services/readings_findings/satmon/article.php?article_id=186Access 3/7/07

Increasing Patient Contact in Radiology

• What does this mean for radiology?• How often do we introduce ourselves to

patients? How often do we call patients with results? How often do we go over exams with patients?

• Have we ever had experiences with patients where they were upset that we called them?

• Should we be increasing our patient contact?• Could these changes foster patient loyalty?

Patient Preferences for Test Results from Radiologists

• Over a 10 day period at University of Texas, patients in body imaging, mamms, and ultrasound were asked the following: Did they want the radiologist to tell them if the results were normal If the results were abnormal, did they prefer to hear the results from

their primary care doctor or did they feel entitled to an immediate explanation of their test results.

• 92% of patients wanted the radiologist to tell them if the results are normal.

• If the results are abnormal 87% wanted the radiologist to tell them. • CONCLUSION. Most patients prefer to hear the results of imaging

examinations from the radiologist at the time of the procedure rather than to hear them later from the referring physician, regardless of the findings.

Disclosure of imaging findings to patients directly by radiologists: survey of patients' preferences. AJR Am J Roentgenol. 1995 Aug;165(2):467-9

Patients and The Internet

• According to recent surveys, approximately 79% of patients have internet access

• Of those, 70% would like to have access to their medical test results on line.

• Are we as radiologists doing enough to communicate with patients?

Gabriel BA. Your Complete Guide to Patient Service, Physician’s Practice, March 2008

Things To Think About For Radiology?

• Does the average patient in our department: Know what a radiologist is? Know who is interpreting their study? Talked to any of the radiologists in the

department?

Prerequisites for Adequate Care

• “As with non-healthcare industries, the number one reason for patient dissatisfaction is lack of courtesy, respect, and attention...

Merys RM. The Importance of Service in the Healthcare Setting: Building a PatientFriendly Practice. Medical Group Management Association

Zagat and Wellpoint Physician Evaluation System

• Zagat Survey and Wellpoint Health Insurance launching free on-line consumer ranking of doctors available to select members in its Blue Cross and/or Blue Shield licensed subsidiaries.

• Qualities doctors will be evaluated on: Trust Communication Availability Office Environment

http://www.chicagotribune.com/features/chi-1104_zagat_d_r_nnov04,1,1307466.column Accessed 11/5/07http://phx.corporate-ir.net/phoenix.zhtml?c=130104&p=irol-newsArticle_general&t=Regular&id=1065430& Accessed 11/5/07

Wellpoint – Zagat Collaboration

• The four qualities of trust, availability, communication, and office environment mirror the Zagat restaurant guide of food, décor, service, and cost

• The rating system is “solely designed to reflect a consumer’s experience with a physician and not to reflect the quality of the care they received.”

• “It gives consumers the power to make smart decisions about selecting doctors based on other people’s experiences.” Nina Zagat

http://www.chicagotribune.com/features/chi-1104_zagat_d_r_nnov04,1,1307466.column Accessed 11/5/07http://phx.corporate-ir.net/phoenix.zhtml?c=130104&p=irol-newsArticle_general&t=Regular&id=1065430& Accessed 11/5/07http://www.usatoday.com/money/industries/health/2007-10-21-wellpoint-zagat_N.htm Accessed 11/5/07

Word of Mouth Customer Satisfaction

• “More consumers are asking for information about what other consumers think about their doctors to help them make better choices.”

– Jason Gorevic, Chief Marketing Officer, Wellpoint Insurance

• One of every nine Americans is a member of a WellPoint health plan.

http://www.medicalnewstoday.com/articles/86306.php Accessed 11/5/07http://phx.corporate-ir.net/phoenix.zhtml?c=130104&p=irol-newsArticle_general&t=Regular&id=1065430& Accessed 11/5/07

US Dept HHS Hospital Service Website

• New survey website on hospitals sponsored by the US Department of Health and Human Services

• Government will start withholding portions of Medicare funding if hospitals don’t participate

• “Most questions…deal with whether the hospital always meets service expectations”

• “Survey resembles restaurant guides that rate waiters attentiveness, dining rooms’ attractiveness and the quality of culinary experiences.”

http://www.chicagotribune.com/news/chi-hospital-ratings_11apr11,0,3129797.storyAccessed 4.13.08

US Dept of Health and Human Services Survey Site

• How often did nurses communicate well with patients?

• How often did doctors treat you with courtesy and respect?

• How often were patients' rooms and bathrooms kept clean?

• How do patients rate the hospital? • Would patients recommend the

hospital to friends and family? http://www.hospitalcompare.hhs.gov/Hospital/Static/Data-Consumers.asp?dest=NAV|Home|DataDetails|ConsumerInfo#HCAPHSMain Accessed 4.13.08

Details on HHS Website

• Website will give you percent comparison of patient responses such as, “How often were the hospital rooms kept clean?”

• These responses can be graphed and compared to other hospitals.

http://www.hospitalcompare.hhs.gov/Hospital/Search/compareHospitals.aspAccessed 4.13.08

Satisfaction Does Not Equal Loyalty

• How do we measure patient loyalty?

• Patient satisfaction scores by themselves are insufficient, as a satisfied customer does NOT mean a loyal customer

• As customer expectations increase in healthcare, scores of 1-4 on a scale of 5 in customer satisfaction will not be sufficient.

Reasons for “5” Equating to Loyalty

• Fred Lee: The Hotel Analogy:• “After receiving an evaluation of a hotel I

stayed at for several days…I think back and remember nothing special and nothing bad…Everyone was polite, my room was clean, everything worked. What would I put on the survey? Probably a four- satisfied…..Loyalty is generated by memorable things that we didn’t expect.”

Lee F. If Disney Ran Your Hospital, Second River Healthcare Press, 2004

Ways to Increase Patient Loyalty: Basic is Not Enough

• Meeting basic and spoken requirements is expected. Going beyond what is expected makes the patient’s experience memorable, differentiates physicians, and builds patient loyalty.

http://www.pressganey.com/products_services/readings_findings/satmon/article.php?article_id=238Accessed 3/7/07

What Does This Data Mean for Radiology?

Possible Suggestions for Radiology – Patient Loyalty

• Radiologists should think about increasing our interactions with our customers.

• This may mean: Introducing ourselves Reviewing results with patients / referring

physicians more Calling patients at home with discrepancies if

they don’t have primary care doctors

Six Weeks Later……

Plus a Thank You Note to the Department!!

Unexpected Outcome as Imprinting

• To build loyalty, a failure can be a success.

• This patient certainly was not happy to have a missed finding, but she did not expect a personal call from the radiologist the next morning.

• This unexpected situation made an imprinting.

Other Ways to Build Loyalty

Taking the time to coordinate their radiology care if an abnormality is found

Explaining the patient’s condition to them

Helping the patient take the next step in finding a doctor

Chronic Abdominal Pain

Precontrast Early Post-Contrast

Excretory PhasePost-Contrast

Listening to the Patient and Personalized Service Can Make

a Huge DifferenceTwo weeks of pelvic pain

What if We Don’t Have Time to Personally See Patients?

Consider adding physician assistants to personally explain radiology procedures and call patients before and after they come to the radiology department to answer questions

Other Means of Increasing Service

• Web-based scheduling…

• Encouraging patients and/or families to write down questions by providing pens and notepads in the waiting area… and then having someone in our office answer them

• Think about small steps to improve patient experiences

http://www.pressganey.com/products_services/readings_findings/satmon/article.php?article_id=238 Accessed 3/7/07

Wait Times and Patient Satisfaction

• Communicating with patients about wait time and letting them know their time is valuable is key to a positive office visit.

• Keeping the patient informed about wait time may be more important than the length of the wait itself.

http://www.galluppoll.com/content/?ci=14935 Accessed 4.3.07

Minimizing Wait Times

• More efficient scheduling & convenient office hours

• Activities to Minimize wait – • educational DVD about procedure• Jigsaw Puzzle in waiting room• Massage chairs in waiting room• Work spaces with internet hook-up

• If long delay unavoidable, front-line employee should apologize & re-schedule

http://jacksonorganization.com/site/english/KnowledgeNetwork/PatientDiscoveries/TopPerformOutpatient Accessed 3.10.07Gabriel BA. Your Complete Guide to Patient Service, Physician’s Practice, March 2008

Privacy and Patient Experience

Privacy: • Important both in the radiology department

and the hospital at large. Waiting rooms where patient name was visible or said out loud are not desirable.

Consider other ways of identifying patients (pagers or first names)

Patient Observations

• Billing:

Being asked for your insurance card and social security number every time you step in the door is disconcerting.

Solution: Attempt to solicit billing information before the patient’s visit – possibly on-line

What is covered? A point person coordinating this would be helpful.

Building Patient Loyalty Through Employee and Physician Loyalty

• In addition to increasing service for patients to gain loyalty, organizations need to build employee and physician loyalty. Why?

Employee and Patient Satisfaction Linked

http://radio.weblogs.com/0143030/2005/02/06.html#a47 Accessed 3/10/07Table from Press-Ganey Satisfaction Monitor

Importance of Loyal Employees

• “You can’t achieve high patient satisfaction when your staff is unhappy. Patients can easily detect the dysfunctional atmosphere bred by a team of quarreling, dissatisfied employees.”

Gabriel BA. Your Complete Guide to Patient Service, Physician’s Practice, March 2008

Sentiments Reflecting Employee Loyalty (1)

• Gallup Organization has found high agreement with the five following sentiments correlate best with employee loyalty:

I have the materials and equipment to do my job right

At work, I have the opportunity to do what I do best every day

www.gallup.com

Sentiments Reflecting Employee Loyalty (2)

The mission or purpose of my organization makes me feel my job is important

My associates or fellow employees are committed to doing quality work

This last year, I have had opportunities at work to grow

www.gallup.com

Improving Employee Satisfaction

• What can we do to improve employee loyalty? Improve communication by administration and

management Solicit the opinions of employees about their

work environment Help employees feel pride in the work they do

http://radio.weblogs.com/0143030/2005/02/06.html#a47 Accessed 3.10.07

Physician Engagement

• “The solution to (the problem of poor physician engagement) is simple -- ask physicians for their opinions, listen to what they have to say, act on the information, and tell them what actions have been taken”.

www.gallup.com Premium Content Accessed April 2007

What Does Patient Loyalty and Service Values Mean for Radiology and Radiology

Practices?

Factoring Service Values Into Our Own Radiology Practices

• How do we address the increasing need for service?

• Factor service values into your own practices and mission statements!

• Patient Convenience Ease of Scheduling Minimizing Wait Times / acknowledging

problems and informing patients as to why there is a wait (if there is one)

Staff Interaction

• Staff Interaction: Rewarding staff for “beyond the call of duty”

service, which may include an acknowledgement and reward for an unsolicited thank-you note

Point person to answer questions about the radiology procedure

Follow-up call after the radiology procedure to answer questions

Patient Privacy

• Patient Discretion

The need for patient privacy and concerns for patient safety cannot be over-emphasized.

Letting patients know their privacy and safety are paramount

Billing Factors to Increase Service

• Billing: Storing patient demographic information so it doesn’t

need to be repeated with each visit Acquiring information before the patient comes in the

door as much as possible Consider hiring a point person to work with patients

and answer their billing questions. This may include a follow-up call to answer questions about forms they may have received from their insurance carriers about coverage.

The Role of Radiologists

• To keep up with service, the interactions between patients and radiologists will increase. This may encompass: Introducing ourselves to patients Meeting with patients before & after exam to

answer questions Having a staff member hand patients a form

with the radiologist scheduled to read their exam if exam was performed off hours

Follow-up calls by radiologists

Increasing Staff Loyalty

• Loyalty among physicians and non-physicians in radiology practices should be cultivated as well. Similar factors increase loyalty in both groups:

Regular Meetings to discuss work environment Focus on identifying strengths of all group members

and attempt to foster those strengths Forums displaying actions based on employee

suggestions

How Do We Do It All?

• Even though the stakes continually get higher with quality and service requirements, the needs for these attributes only increases.

The Future

• By focusing on patient loyalty we can insure viability of our profession and prevent commoditization of our product.