Everyone in the business knows that healthcare is in the middle of dealing with a number of troubling trend lines. The population is aging, which both increases demand for service AND often transitions people away from private insurance and towards Medicaid.1 Meanwhile the number of available doctors and nurses is not keeping pace with the increased demand for care. Factored into this is the uncertainty of what direction (if any) the federal and state governments will take in facilitating access to healthcare. These challenges are different for different hospitals, small community or critical access hospitals have a different set of pressures than large urban hospitals do, but they all have a set of pressures that make delivering best-practice medicine to their communities challenging.
And this was before COVID provided its own set of issues. Ask any CEO, CFO, or VP of HR and they will likely trace most of their current challenges back to problems created (or exposed) by the pandemic. It is interesting that public opinion seems to have forgotten the tremendous impact of COVID and reduces the event to an opinion on lockdowns, masking, or social distancing. Even most conversations within hospitals that I have heard don’t discuss the causes of the challenges that they face, so much as they are focused on digging themselves out of the hole that COVID created.
Now, this is NOT an essay about the economics of post-COVID healthcare. It is an essay (or more accurately a series of essays) about what COVID did to affect how the patient’s experience is managed and delivered. One of the essential debates in healthcare is whether things will slowly return to normal, or, if patient’s attitudes and usage of healthcare have permanently changed and we are in a “new normal.” As much as I hate that overused phrase, if we don’t examine the impact of COVID on patient experience, we won’t be able to become better prepared for a return to the status quo or be able to use the advantages of a “new normal” to improve our staff’s and our patients’ experiences with healthcare. In this essay, I will explore how COVID accelerated the migration in stepping down care from more costly and intrusive settings to less costly and intrusive settings.
Even before COVID, hospitals were transitioning care from more expensive to less expensive care spaces. I have spoken of this before, but anyone who has a daughter who delivered a baby will recognize the difference between that experience and their own experience in child delivery. There are plenty of things that twenty years ago would have been inpatient experiences that are now outpatient experiences just as there are things that would have been performed at outpatient centers that are now performed in a clinic setting. A visit with a doctor in a clinic might be transitioned to a nurse-only visit, or even a video visit or phone call. COVID forced an acceleration of this, whether it was because of a desire to avoid bringing people into a social settings (like a waiting room) or simply because hospital occupancy taxed availability of space and forced other creative solutions. In many ways, this is a valuable transition. It often satisfies both the organization’s desire to utilize resources more efficiently as well as answering patients’ general desire to have less intrusive care experiences that fit better into their highly scheduled lives with competing demands.
From a PX perspective, though, stepping care down to less demanding spaces also means that the organization (the hospital, clinic, or clinician) has less control over that experience. I remember when COVID hit, the organization I worked with immediately moved as many clinic patients as possible to video visits. Further, these appointments were executed over a host of different platforms, all with their own limits and advantages. Those familiar with the world of video meetings know that Webex, Teams, Zoom, Meet, etc., all function similarly, but each have their own differences that can make it about 12% more annoying than it should be to switch between one and another. As a result, the top complaints from patients were about the functionality of the application and the quality of the internet.2
When confronted with these concerns, the response from doctors and administrators alike was “I can’t control that.” My response was that, regardless of your ability to “control,” it is affecting how patients feel about the care they are receiving. Even if a patient realizes that their internet connection is crappy, they will still hold the clinic/doctor responsible for the quality of the experience. Especially during COVID, when the decision to switch to a video visit was not even the patient’s choice.
I have often defined PX as an ability to establish a relationship or connection with a patient. Building consistency in this interaction is its own problem, but generally it is easier to build a connection when you have multiple interactions with nurses, pharmacists, lab techs, food service people, transport, imaging, and administrators. As hospitals step-down the complexity of that interaction, the opportunities to build a positive PX experience become scarcer. As these in-person experiences become on-line experiences, a lot of the associated niceties, like a friendly receptionist or available coffee or convenient location or ample parking disappear. Each of these corollary benefits that lead to stickiness or a commitment to THIS clinic or doctor versus any other clinic or doctor also disappear. If my interaction with a doctor is reduced to a 3×5 video screen, why should I choose this doctor over another one. And, if this doctor’s video feed is glitchy or drops out, that interface is certainly something that the administration or doctor should care about, since they have no other ways to build that connection. In other words, if you remove all the other things that form an encounter, what is left is dramatically more important. If you have two dozen interactions in a healthcare encounter, having one or two that don’t reach the high standard you set for yourself might not be world-ending. But if you only have ONE interaction, you cannot afford that interaction to be anything other than world-changing. Saying that this one factor is not in your power means ceding any control over the experience.
In this situation, healthcare is now in the space that banking was in a couple of decades ago. On-line banking has changed how people interact with their bank. I have been in a bank once in the past twenty years and that was when I found a 50,000 Peso bill in some old boxes in a relative’s basement. Google said I had $3000 dollars in exchange, so I went to deposit it.3 Otherwise, my relationship with my bank is online. I have direct deposit; I can take photos of checks to deposit them as well. I haven’t even written a check in forever. So my connection to my bank is not based upon any direct experience. It is, frankly, primarily inertia. The thought of transferring my money and redirecting all of my online payments to a new account seems burdensome, so, unless they piss me off in some way, or someone else offers a much better interest rate or fewer fees, I am not likely to bother with it.
Likewise, if we experience our care primarily through an online portal or video visits, a patient’s motivation to stay-put will be more about the stress and costs with establishing with a new doctor and a new system more than a commitment to the existing provider. Since a majority of the motivation comes from pressures from an insurance company, healthcare systems spend far more time laboring to maintain positive relationships with insurers than anything else. But without attending to the patient’s experience, they leave themselves vulnerable not just to other health systems, but other entrants into the market.
It seems highly unlikely that this COVID-aided transition is likely to reverse course. While some elements of healthcare will always require some in-person component, both the drugstores and grocery stores in my hometown will give me a flu or COVID vaccine. Many now offer quick-care options for routine issues and even lab services. Home glucometers, EKGs, and blood pressure cuffs allow for more attentive monitoring at home than a clinic could ever provide. In this new world, health systems need to ask two questions:
- Why should someone come to us for simple routine care?
- Are we better off without those encounters?
The first question is a simple marketing conversation, but not one that the Marketing department usually has. I worked with a member of clinic leadership who was trying to get coffee service in his clinics. While there are certainly questions about infection prevention and whether some patients should have coffee at all, the conversation primarily revolved around whether this was a worthwhile expense. I am not saying that it definitely IS a worthwhile expense, but I did point out that the unspoken question of how we keep patients choosing us over any other source for care was a worthwhile one. Marketing is uniquely trained to champion the conversation of why we are a preferred provider for care. Why they don’t often have this conversation is a topic for another time.
The second question is more complicated. Any industry will mature to the point of having to determine if there is value in being all things to all people. They, then, will figure out how to satisfy their core mission without getting sidetracked. If they are smart, they will also evaluate their core mission to see if it still aligns with the market. This often involves simple economic concerns but also should reflect on connectivity.4
Healthcare is not immune to this. In the abstract, this conversation often involves the terms “keepage” and “leakage” referring to keeping patients in their clinically integrated network as they pass from primary care to specialty care and from clinics to hospitals. This is best-captured in the sentiment that if you can get a new mom to give birth in your hospital system, you will keep that child in your system until they leave home.
This, though, is balanced against healthcare’s focus on keeping people working at the top of their license. This essentially means that you need doctors doing doctor-things and nurses doing nurse-things and CNAs doing CNA-things. Every time a doctor does a nurse-thing or a nurse does a CNA-thing, it is seen as wasted expertise. If everyone is working to the top of their ability or license, the organization can be as efficient as possible.
This means that there might be things that are inefficient and therefore are not worth doing in a clinic setting. Perhaps it is not profitable for clinics to give out ad hoc flu vaccines. Perhaps it is more cost-effective to let grocery stores, drugstores, schools, or employers distribute flu vaccines. Now some of you are immediately thinking about the collateral benefits to vaccines in communities or thinking about how this might lead to cost savings for individuals or health systems. It is easy to descend down this rabbit hole considering the secondary and tertiary costs and benefits for individual care acts. My point is that I have never seen a health system engage in that conversation. By not having that conversation, we are not discussing how to maintain a positive connection to patients even as we push them to accept more care that is more remote and less sticky.
If we accept that for a multitude of reasons, the stepdown in care spaces is here to stay, we need to discuss how this stepdown affects a patient’s experience and whether we are doing enough to maintain the connection that will both improve our chances to keep them as a patient as well as improve their chances to effectively and completely follow their self-care instructions.
1For those who are not aware, generally, private insurance companies provide better reimbursement rates to hospitals than state or federal healthcare plans. So, at the point at which people increase their demand for care, especially continuous care for chronic conditions, the less money hospitals make on providing that care because those patients move to Medicare.
2As someone who lives in rural America, I can attest that the digital divide—both in the access to high-speed internet and the technology to use high-speed internet—is real.
3Sadly, I did not realize that in 1993 Mexico introduced the new peso to address the problems with inflation, which was set at 1 New Peso = 1,000 Old Pesos. So, my three-thousand-dollar windfall became a $2.91 windfall. ¡Qué lástima!
4This gets into the concept of “loss leaders” where businesses may sell things at or even below cost in order to get them into their store, where they can sell them more profitable items.
PX Matters with Joseph Snipp 
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