For those of us that have ever worked in IT, the idea of a waterfall based design always implies a less than optimal strategy.  But, I’m beginning to see an applicability of this framework for communications.

Let’s look at a scenario for a prescription refill where you’re trying to optimize for the lowest cost intervention.

• Identify targets for an intervention
• First push a message to all those that have downloaded your mobile application (~10%)
• Second push a message to all those that have opted into your SMS reminder system (~6% with some overlap)
• Third push a reminder to those that you have an e-mail address on file
• Fourth send a reminder using an automated outbound call with the option to refill during the call
• Fifth (maybe) use agents to reach out to the patient

And, since exchanges will make healthcare a more individual buying experience and satisfaction is tied to loyalty, this is something we all need to figure out sooner rather than later.

As a family, we recently had a few experiences that show the two extremes here:

1. Chevy’s.  This is a Mexican restaurant we frequent.  We go there probably once a week to the point where we have a preferred waiter (who knows our order before we sit down) and know the server and the manager.  Service has been great for years, but it’s begun to go down.  One night, it took 3x as long to get our food with no explanation, and we had to leave without eating.  The next time, the hot plate of food had some oil jump off and burn my wife (to the point of them getting her burn spray and ice).

   This seems like a great opportunity for an intervention by the manager.  But no.  They didn’t do anything.  They still charged us for the meal including my wife who’s leaving with an ice bag.  Oh well…time to find a new restaurant.

2.  Jilly’s Cupcakes.  Here’s a cupcake store and restaurant that we’ve never been to, but we saw that they recently won on Cupcake Wars.  We decided to book a small birthday party there to decorate custom cupcakes.  When we show up, they are surprised.  Apparently, their reservations person wasn’t very good and got fired so they’re dealing with us and another party of 25 that have showed up unexpectedly.  A key opportunity for success or failure.

   I thought the General Manager did great.  She stepped right up and came up with a plan for us.  We got to go behind the scenes and meet the cupcake making team.  We got to customize our own cupcakes and really enjoyed it.  It was probably more memorable that the original party would have been.  In this case, I’m willing to drive people to her store and will send her a personal note to thank her.

One of the big points here is that it’s easy to either lose a lot of credibility or build up some credibility.  But, customers are fickle.  Much like companies strive for Six Sigma from a process perspective we need to keep that in mind from a customer experience perspective.  It won’t always go perfect, but how do you enable your staff and train them to respond quickly to keep the consumer happy and engaged.

Imagine the following:

• I get a 90-day supply of a medication.
• At day 75, I get a refill of the medication.  (I have 105 days left at this point.)
• 75 days later, I get my next refill.  (I now have 120 days left at this point.)
• 75 days later, I get my next refill.  (I now have 135 days left at this point.)

One of the programs we used very effectively at Express Scripts to test our call center was a “mystery shopper” program.  Much like the name implies and has been used in retail for years, this process had a person calling into the call center and asking a series of questions about plan design or other aspects.  This was a great way to see if training had worked and understand the experience that our members had. 

I honestly don’t remember exactly how we set this up to pass the authentication process, but I believe we probably created “dummy” members in the eligibility file with a name and member ID that could be used by the mystery shopper. 

Those calls were then ranked based on quality of response, consistency of response, first call resolution, and other aspects.  This testing process was continued until the quality scorecard passed a certain level. 

With the increasing complexity of plan design, this is something that everyone should look at.

Here’s an example…

This morning, my kid’s school is closed due to snow.  [Although the snow has passed and they've already plowed the side streets.]  When I checked the Internet at 5:15, it wasn’t closed.  At 5:40, I got the call that it was closed.  BUT, the call comes on my home line, our home business line, and both our mobile phones.  Somehow it didn’t wake the kids, but it could have.

I don’t really care about the over-communication in this example, but in a professional setting, this would seem like overkill and potentially a waste of money.  In an integrated communications example, it might work like this:

• An update was put on the Internet and everyone was sent an e-mail
• At 5:50, the system would identify anyone who had either not opened their e-mail or had not visited the website (assuming they had cookies on their PC for tracking website visitors)
• At 5:50, the system would call the primary number to play the recorded message by the principal
• If there was no answer by a live person or the entire message was not listened to, the system would move on to additional numbers

This is always one of the big discussions we [Silverlink Communications] get in with clients in healthcare.  What are the rules for escalation of communications?  How do I track data in an integrated data set?  What is the right timing between communications?

This is critical.  Sending people a letter and a call or a letter or a call (for example) is pretty easy.  Determining the next action based on their final disposition in the initial outreach is not.

Of course, the other question this begs is how many companies actually track return mail.  I know a lot of companies don’t.  If it keeps getting returned, they’re not processing this return mail and taking the bad addresses out of their member database.

“We get brilliant results from average people managing brilliant processes. We observe that our competitors often get average (or worse) results from brilliant people managing broken processes.”

Sources: “Decoding the DNA of the Toyota Production System,” Steven Spear and Kent Bowen, Harvard Business Review, September-October 1999

I think this is so important especially in times like this when we are all focused on doing more with less. It is critical to understand how your process works; how to apply automation; and how to learn and improve it over time.

I came across a presentation from a webinar I gave back in 2007 on Business Process Management (BPM) which made me think about this. (Some of the vendors in this space include Pega Systems, Lombardi, and Appian.)  It’s also very relevant given Gartner‘s recent report on Business Process Outsourcing (BPO) in the payor space.

“Healthcare insurers should view business process outsourcing as a means to achieve business transformation while minimizing risk. Therefore, using BPO for nondifferentiating business processes is an essential step toward achieving competitive success and business growth.” Joanne Galimi in Healthcare Insurers Business Process Outsourcing Trends (January 23, 2009).

Finding a business partner that can work with you to understand your processes, understand what measures matter, help you improve your approach, and that is willing to take risk based on your success is important.   I always encourage people to not think of companies as vendors but as partners that bring them innovative ideas and help them iterate to improve.  I don’t believe in the big bang theory that I can do it right the first time and never need to change.  That flies in the face of everything that has been observed in different industries.

Additionally, my peers are giving a webinar on closing the adherence gap which should be another hot topic for many of you.  (Sign up here for their sessions on April 30th and May 22nd)

When I run, I have a GPS on my wrist, my iPod, and often (for long distances) a phone in my pack.  I then download my running to my PC which has some great reporting tools but limited analysis tools.  The personal coach response will vary by person as different people respond to different “encouragement”.  I may have to put this on my wish list to try out at some point.

Now, of course it requires specific shoes, which I think is an issue for runners.  I have been using the same brand of shoes for 4 years.  And, I go out of my way to get them.  There is no store in St. Louis that sells them so I have to order them every 3 months or so.

I was also somewhat confused on the website about how to get the products.  There was no buy here function (unless I missed it).

But, I think the key here is the idea of device convergence and the blending of clothes with technology.  Just one sign of the many interesting things to come.

1. Why do it at all?
2. If you’re going to do it, why have humans involved?

I haven’t seen the data on prior authorizations and how many people who hit a reject at the point-of-sale (POS) actually get a fill ever, but I imagine it is like step therapy (ST). With step therapy, only 50% of the people who hit the reject get a claim. (As I have mentioned before, 90% of those that don’t get a claim get samples, buy an OTC, pay cash, or find another solution.) But, the huge step therapy savings that plans and employers realize is not really about the movement to generics but about the lack of claims. Reduce your claims by 50% in a category and you save money.

So, I have to assume that PA has a similar role. The people that don’t really need it (or don’t understand the process) will either pay cash or find another solution, but they won’t have their doctor call the PBM for approval. (aka – The Sentinel Effect) Those that really need it (and understand the process) will call in and get approved.

So the next question is why are people doing this. I have heard from some pharmacists that it has to be humans so that physicians can’t figure out the approval algorithm and “game” the system. Somehow, I doubt that is what they are staying up at night trying to figure out. And, the agents taking the calls are following a very tight script anyways. I have argued for years that either a website or an inbound voice IVR that asks questions and based on answers determines the next question until the physician either fails the request or gets approval. Only exceptions would require a live person.

When I was focused on this technology challenge (see old blog), I used to talk about SOA (service oriented architecture) and BPMS (Business Process Management Systems) where you could create a process abstraction layer that sits above your existing legacy environment. This abstraction layer allows companies to make rapid changes within a controlled environment.

The one example I always use is when we decided to move from the word “member” to “patient”. To do this systemically, you have to change call scripts, job titles, system fields, metadata, contracts, letters, etc. Of course, you also want to change the website. When I put this request into IT, I got back an estimate of $200,000 to make that change (or 2,000 hours at $100 internal cost transfer per hour). How do you justify the business case for this other than strategically and qualitatively? And, given a shortage of resources, why would you focus on this rather than some other web development project?

It was an interesting and frustrating process. We obviously wanted to show clients that we had fully transitioned to focusing on patients. We wanted to show consumers that we were thinking of them differently. But, we were stuck in the project prioritization process for scarce resources.

This ability to drive branding through every interaction and evolve your branding as you learn about your consumers will be an interesting challenge to an industry like healthcare where companies are slow to change and change takes time.