Over twenty years ago, I read a book called Your Marketing Sucks by Mark Stevens. One of its main tenets has stuck with me ever since. It resonated with me not because I have any connection to marketing, but because I am passionate about math, prediction, cause and effect. He says that marketing that you cannot tie directly back to sales is wasted money. As I said, I am not in marketing, I have no degree in marketing. Still, this concept has encouraged me to reframe a lot of conversations in patient experience. While it can be literally challenging to tie PX work back to improved margins, it still has philosophical power. Stevens’s thesis encourages us to ask the question, “What goal are we chasing with PX and why is that goal valuable to us?”1
The subtext from Mark Stevens’s book2 is that there are certain sacred cows in business, concepts that have embedded themselves so deeply into the foundation that they rarely get examined let alone questioned. For me, loyalty is one of those concepts. It is not that loyalty is good or bad, but that by treating it like a sacred cow, we are not being honest about the resources we are dedicating to it.
Indeed, by not examining it and defining it, we cede the definition and conversation to others. I remember when an article came out in 2012 called “The Cost of Satisfaction”3 that explored how PX impacted utilization, costs, and outcomes. Its conclusion stated that higher patient satisfaction was tied to higher inpatient use, higher costs and increased mortality. Now I have a lot to say about this article, which I will save for another time. Right now, my point is that by not owning the value of patient experience or simply attaching it to broad concepts like loyalty without reflection, we are going to get caught flat-footed when others demand some level of rigor or justification to the work.
In the last essay, I examined what loyalty meant and how it was constrained by the reality of patient and health system perceptions. In this essay, I will explore what loyalty is likely to provide both audiences in the real world. Again, this does not meant to challenge the noble life-saving work and important community care provided by health systems and healthcare professionals. It only considers whether a pursuit of loyalty helps further those goals or confuses those goals.
What do Patients Get from Loyalty
As I mentioned in the previous essay, hospitals are outlawed from providing any significant thing of value to patients in return for their continued patronage. There are no loyalty programs or membership cards for returning patients. This has gotten more confusing and problematic as care has transitioned to less intrusive encounters. To improve convenience, for example, patients are encouraged to document their own maintenance—using home glucometers, blood pressure cuffs, or personal EKG devices and entering that data into the patient portal. This is valuable for all involved, by improving compliance and increasing data points for review. This, though, also creates a technology issue, as those tools are not cheap. But, as beneficial as this would be for doctors to hand out free testing equipment, hospitals and clinics cannot hand out this technology for free, as it would be seen as an inducement. Whether this is good or bad is the subject for another essay. The takeaway here is that traditional models for rewarding loyalty are not available to healthcare. Health systems cannot, through cash or technology, reward patients for their loyalty.
The only value a patient may realize in being loyal is continuity of care. Inserting themselves into a single care umbrella means seeing primary care doctors and specialists who all have unfettered access to their electronic medical record and allow for more seamless scheduling of tests and procedures. The most patient-facing of this is access to the system’s patient portal, where they can see their test results and confirm appointments. But since keeping care in-network preferable from an insurance perspective and access to the portal is not restricted to specific types of patients, these don’t really count as perks of loyalty.
The only perk one could associate with patient loyalty is focused more on immediate elements of care and broad values of commitment. There is evidence to suggest that patients who hold their care team in high regard are more likely to follow their instructions and be attentive to self-care at home. As an adjunct to loyalty, though, this has two problems. First, this commitment is generally with the provider and not the health system. My commitment to Dr. Smith inspires my attention to his instructions for my care. This loyalty does not translate to the health system he works for. If he retired, my desire to get another provider would be driven by network considerations rather than a sense of loyalty. Second, this is more like enlightened self-interest based upon my confidence in my doctor’s authority, caring, and knowledge-base. This might be related to loyalty, but I am not sure this counts as loyalty. I don’t think that taking my statin on a daily basis constitutes loyalty to pharmaceuticals.
The whole objective of care is to provide best-practice care with high success rates and minimal complications in the most convenient way possible. The implication is that all doctors, hospitals and health systems will approach the same problem the same way.4 Since loyalty is usually predicated upon differentiation5 and since healthcare struggles to differentiate,6 it is hard for patients to see any value to loyalty, even after extreme situations.
For example, I am very happy that Nebraska Medicine has been able to battle my father’s cancer and help keep him alive. He has lived long enough to see photos of his brand-new great-grandchild and all signs point to him being able to live long enough to hold him in his arms. I am very thankful. But I am not loyal to them. I would not forego employer-sponsored health coverage if it didn’t include NebMed as in-network. I would still prefer to donate to charities where I can make a more direct impact. So, as grateful as I am, I am not sure that this gratitude generates any appreciable loyalty to them, since I see no value in declaring myself loyal to them. Now, this may be because I am a cold-hearted, soulless automaton. If you think I am, feel free to call out my flinty soul in the comments. But also reflect upon what you are loyal to and why you are loyal to those things. Even if you are loyal to your doctor, are you loyal to the system that doctor works for?
What do Hospitals Get from Loyalty
Obviously, hospitals want the same thing out of loyalty that every other industry does. Having people choose you over your competitors is prima facie valuable. In healthcare, though, this takes a slightly different slant. Just as every industry has more and less profitable product lines, hospitals do as well. The reason why healthcare is worried about Walmart or Amazon entering the healthcare field is not because we are days away from having a Walmart Memorial Hospital. It is because those companies are setting their sights on cleaving off profitable pieces of the healthcare market and leaving the less profitable pieces behind. Hospitals balance out low-profit services and non-paying patients with services that have better reimbursement. If hospitals lose market share in urgent care, physical therapy, imaging, etc., they lose important economic flexibility. Protecting a loyal patient base is a hedge against market forces.
Outside of this, having loyal patients generates other collateral values. As I have often said in presentations, patients don’t give money to shitty hospitals, hoping that they will get less shitty. They give money to awesome hospitals in order to help further their reach. Hospital foundations are the biggest beneficiary of patient loyalty. Having positive relationships to the community means more support for hospital initiatives and health fairs. It means more support for expansion. It can encourage changing public transit routes and schedules or providing preferred attention in road maintenance or snow removal.
For health systems, then, it is not about the value of loyalty, but the ecological fallacy associated with loyalty. Ecological fallacy is the logical error of ascribing group behaviors to individual motivations. For example, there is clear evidence that there is a home-field advantage in sports where home teams win more often than road teams do. An ecological fallacy would be to take that broad fact and then claim that in one specific game the outcome was determined by advantages the one home team received. In other words, evidence of patterns in a large dataset does not explain outcomes in every single data point.
Here, then, hospitals value community loyalty. They want the reputation that comes from being a valued member of a city and the perks it provides. If a hospital assumes that community loyalty translates down to individual patient behaviors, they are committing ecological fallacy. Broad community-wide positive feelings cannot be used to explain an individual person’s behaviors. Smart hospitals don’t commit the fallacy but are still left trying to figure out how to square that circle. They want group commitment, but at a loss as to how to create it through the microtransactions they have hundreds of times every day. Instead, they often focus on inviting important community members to sit on their board and, in turn, sit on other important boards and committees within the community and the CEO will develop a good relationship with the mayor. It is not that hospitals care more about the Chamber of Commerce than they do about an 84-year-old with lymphedema, but they understand the connection better.
So, on one side, patients can’t get tangible benefits from loyalty and therefore don’t see an up-side to declaring loyalty to a health system. On the other side, hospitals want it, but don’t see how to get it in any meaningful way. When both sides say that that value it, but cannot define it, loyalty becomes a sacred cow. Or, maybe, more accurately, a vengeful giant. We don’t know how to satisfy it but are afraid to speak out against it. So, we focus on patient experience hoping that it will lead to loyalty, except that it is not clear that it does. I remind those of the national consumer study I spoke of in the last essay. After all the hard work that health professionals have dedicated to improving the patient experience, the patient loyalty numbers stubbornly do not move, with two-thirds expressing no loyalty to their preferred hospital. Maybe the time has come to stop talking about loyalty as a goal, and instead focus on more granular, if less majestic, concepts that might actually mean something.
1There are those who will bridle at the notion that PX must provide healthcare a value, but we cannot demand to have PX as a fully-realized element of healthcare without treating it to the same clear-eyed examination that we give other elements. The question and the exploration of loyalty is not meant to discount the important contribution healthcare makes to patients and communities. It is meant to examine if we are working in service to the right goal.
2Or maybe this is explicit in his book. It has been a few years since I last read it. Hey, Mark, if you are reading this, feel free to hold forth in the comments.
3“The Cost of Satisfaction,” Joshua J. Fenton, MD, MPH; Anthony F. Jerant, MD; Klea D. Bertakis, MD, MPH; Peter Franks, MD, online publication, JAMA Internal Medicine. (doi:10.1001/archinternmed.2011.1662)
4Yes, there are situations where a problem is misdiagnosed by a few clinicians before correctly identified by one. My point is not that healthcare is perfect, but only that it tries to execute clearly established protocols. It is not the case that one hospital has the ‘real medicine’ and every other hospital is handing out TicTacs.
5Consider why you are loyal to any service. You are likely to describe them as DIFFERENT from other like services. They are “friendlier,” “have a better selection,” “cheaper,” “are locally-owned,” or are better in some concrete way. That differentiation is important in your decision to buy their product/service over other competitors.
6Unless you are Mayo or the Cleveland Clinic, where you can play the “we are cutting-edge care” card, what is a hospital’s market differentiator? Frankly, outcomes seem the obvious choice, but I have never seen an advertisement saying, “we have better clinical outcomes than the clowns across the street.” So, instead, every hospital or health system advertisement I see has either a new baby or a doctor patting an elderly person’s hand in a comforting way. No differentiation.
PX Matters with Joseph Snipp 
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