Enabling Healthy Decisions

I’ve talked before about the great experience I’ve had on the Disney Cruise Line, and Disney is often held out as a model company. Well…I just got back from a Disney Cruise last week, and I was disappointed. BUT, I learned several things about the customer experience.

1. A failure at one part of the process can overshadow other successes
   
2. Expectation management is critical
   
3. Front line employees make the difference
   
4. Keep it simple
   

Situation:

Let’s set the stage correctly. Disney just added a new boat (the Dream) which is 40% larger than the old boats. This was the third sailing (for the general public) although people had been on the ship for about 3 months. We booked late which impacted our choices, but we upgraded to the concierge rooms at the port.

Food As A Failure:

When you think of cruising, you think of food. It’s a big part of the cruising experience. Although the boat was beautiful and we had a lot of fun, the food was a failure. They have two seatings – 6:00 and 8:30. We couldn’t get into the 6:00 seating which meant we were at 8:30 (which is my kid’s bedtime). So, we requested to get moved to the 6:00 seating (which the concierge should have been able to help us with). It never happened. (I personally can’t believe that there was never a table any night for us to eat dinner at the restaurants since some people go to the adult restaurants and several hundred people didn’t make the trip due to cancelled flights.)

At first, we didn’t care. We’ve cruised before, and there is always a buffet to go to for lunch and dinner. Not on this cruise. Ok, we decided we could survive on room service. We tried that the first night from a limited menu, and the food was disgusting. I’d rather eat at the airport food court. Ok…in concierge, you can order from the family restaurants for room service. We did that, but the food took almost 90 minutes to get to us. That defeated the purpose. Then, to top it off, we put out our card for breakfast in the morning on the last day, and no one ever picked up the card.

In the end, the kid’s club was great. Bingo was fun (we won 3 times). The new cabanas and private beach on the Disney island were very relaxing. BUT, each night as we went to wind down and have a meal, things fell apart. I spent more time chasing food and eating junk then I thought possible.

Lesson: The experience is a collective set of activities not just a few. (i.e., focus on the weakest link)

• Think about the doctor’s office. If the office staff doesn’t greet you, your visit satisfaction is impacted. If you’re bill is wrong, your satisfaction is impacted.
• Think about the pharmacy. If you have to wait too long for your medication, your satisfaction is impacted. If you don’t understand the instructions, your satisfaction is impacted. If you can’t figure out how to log into the website to order a refill, your satisfaction is impacted.

Managing Expectations:

This was our fourth cruise with Disney. The first three we stayed in the same room on the concierge level. By now, there were certain things we expected. All of them seemed to change.

• My kids love the Mickey bars (ice cream). They no longer carry them on the boat.
• One of my kids likes the Mickey mac n cheese. They no longer carry it and replaced it with some slimy version of bad mac n cheese. (Disney should just stick with the microwave Kraft version… it would be better.)
• The dining was always a little “fancy” in terms of the options, but it had some appreciation for the simple foods that kids like. That wasn’t true anymore. (Although we never made it to dinner, I looked at the menus.)
• One of my kids is super picky. He always defaulted to peanut butter and jelly if he didn’t like the food. They always carried Crustables (frozen PB&J). They no longer carry them, and when I asked for bread, peanut butter, and jelly, they couldn’t get it right.
• The concierge always was out to surprise you in the past – chocolate covered strawberries in your room one night or we always got a drawing to take home and frame on the last night. They no longer do that. They’ve moved to a lounge where we come to them. They no longer come to you.

Would I have been more satisfied if I knew this up front, I don’t know. But, I know that learning piecemeal all the changes and hearing “no” to all my requests was frustrating. (Most of these are things they could have anticipated by tracking my past cruising experiences and behavior.)

Lesson: It’s important to know market expectations or expectations from prior experiences and manage them appropriately.

• If you’ve been getting an Explanation of Benefits (EOB) for years, you’ve probably figured out some way to read it (since it’s not easy). If it’s going to change dramatically, you may want to help people understand.
• If you’ve been sending people a generic version of a drug that is colored red and you switch manufacturers to have a blue pill, you might want to let them know.

Frontline Employees Are Where The Rubber Hits The Road:

It’s always easy to sit in the ivory tower and plan out how things will happen, but at the end of the day, I think the Disney question about “did anyone make this a magical voyage for you” summarizes it. It’s the people who make a difference. In every previous cruise, I felt like there were people who went out of their way to know who we were or who my kids were and what they liked. They then would bring them their favorite bread (banana bread) or bond with them in the kid’s club. This didn’t happen. There was one guy at Bingo who made some connection with us, but that was it.

I also find it frustrating that they don’t have any “memory” of me from cruise to cruise. I have the same allergies as last time. Why don’t you use a CRM system to remember the basics about me and validate them?

Lesson: Remember to empower and encourage your employees to engage the customer not simply go through the routine of talking to them.

• When the patient comes into the pharmacy, does the pharmacist or pharmacy technician know their name? Do they at least remember them?
• When your call center agents talk to someone on the phone, do they reference the prior conversations? Do they know what the customer was doing on the website 10 minutes ago that prompted them to call?

Keep It Simple:

This issue has been around forever (aka – KISS). They gave me so many examples of over complicating the process. Let’s just stick with the room. My room (one-bedroom suite) had two TVs. First, one wouldn’t work, but after they fixed it, it made a constant buzzing sound. After 3 calls for service and waiting from 9-11 PM, I finally figured out where the wires were and pulled them out of the wall to stop the buzzing so we could sleep. (It turns out it was just the surround sound which needed to be turned off. Never mind the fact that surround sound isn’t necessary on a cruise, or the fact that there was nothing telling me there was a separate system.)

We also had a whirlpool tub which my son loves, BUT after he used it, it kept going. We couldn’t figure out how to turn it off. (It turns out it takes several minutes after you press the button to clean the tubes, BUT no one tells you that.)

Then we had several lamps in the room, but they didn’t have light bulbs for them. (We didn’t need the lamps, but why put lamps in the room if you can’t supply light bulbs.)

We had two bars of soap – one for the shower and one for the sink. Of course, I grab the sink one to use in the shower. Well, guess what…It didn’t have rounded edges so once it dried you could move it. It was “cemented” to the soap dish. Not to mention that the sink design was such that it wasn’t functional. (Who let the designer in here without any practical experience.)

Now, to top it off, the concierge level is in a gated area which I think is unnecessary, BUT the gates didn’t work. ½ the time the gates were propped open or I had to get down on the floor and put my hand thru the iron fence to reach the inside handle and open it.

Lesson: Focus on what matters and doing the simple things right. Don’t over complicate the process if it doesn’t add value.

• How user friendly is your website? I’m sure most people use the pharmacy website for refills and formulary look-up. Are those prominent and easy to navigate.
• When you get information about your benefits, can you navigate it and understand it? What about lab reports?

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My overall impression is that someone messed up. They brought too many new cast members into a situation without enough experience. They tried to reengineer and change too many things. This should have been a great experience. Being the “chief experience officer” for Disney or the Disney Cruises has to be one of those jobs that people strive for, but my impression is that this person (a) doesn’t have kids; (b) probably never cruised with Disney before; and (c) didn’t spend enough time with the repeat cruisers to understand what they like.

I’ll be interested to see if they respond to my comment card from the cruise. I always hate customer satisfaction surveys that no one takes action on. I see from the message boards that I’m not the only one disappointed with the cruise.

If this was my first cruise with them, I would never cruise with them again. Now, I’m struggling with whether to go back to the old boats in the future or risk the new boats again. We originally booked for the inaugural cruise of the next Disney boat in 2012, but then they changed the inaugural cruise (what a jerk move). But, what this taught me is that experience has residual value. I had three good cruises so I’m likely to try them one more time. I hope they get it right.

And, I hope you see how this translates to healthcare. We overcomplicate healthcare. We make process changes all the time. We don’t manage expectations. There is so much to do to improve this. We have to improve the customer experience in order to get them to trust us and improve our ability to influence outcomes.

There has been lots of discussion over the past year about readmissions. With healthcare reform, it is estimated that we can save billions over the next 10 years by addressing this problem.

The new regulations will cut federal reimbursements for ALL discharges if hospitals have a greater than expected 30-day readmission rate. In FY 2013, the cut is one percent, but it goes up from there. I think everyone agrees this is a problem. I’m sure some would debate if this is the right metric, but it certainly is a tangible one.

For those of you that don’t know…In 2009, the NEJM published the article that set this in motion but you can see some of the discussions before this in this nice piece by Academy Health.

“Almost one fifth (19.6%) of the 11,855,702 Medicare beneficiaries who had been discharged from a hospital were rehospitalized within 30 days, and 34.0% were rehospitalized within 90 days; 67.1% of patients who had been discharged with medical conditions and 51.5% of those who had been discharged after surgical procedures were rehospitalized or died within the first year after discharge. In the case of 50.2% of the patients who were rehospitalized within 30 days after a medical discharge to the community, there was no bill for a visit to a physician’s office between the time of discharge and rehospitalization. Among patients who were rehospitalized within 30 days after a surgical discharge, 70.5% were rehospitalized for a medical condition. We estimate that about 10% of rehospitalizations were likely to have been planned. The average stay of rehospitalized patients was 0.6 day longer than that of patients in the same diagnosis-related group whose most recent hospitalization had been at least 6 months previously. We estimate that the cost to Medicare of unplanned rehospitalizations in 2004 was $17.4 billion.”

I think the interesting question here is what is the patient’s responsibility post-discharge.

You have several gaping issues:

1. Health Literacy: 2/3rds of US adults over 60 have marginal or inadequate literacy skills and in one study, 81% of patients over 60 couldn’t even understand instructions on a prescription bottle. How are they supposed to navigate the system? (see this site for research on health literacy)
2. Memory: Most patients forget what their physician or nurse tells them. I’d always heard that patients remember about 10% of what they’re told (see NYTimes article on this), but thanks to @trishatorrey, I found this study that showed that 40-80% of information is forgotten immediately. Now, some of this could be addressed by having companions at the encounter (see 2002 paper on this), but there have to be better ways to address this systemic issue.

I guess I would add these two together to equal understanding. How are patients who can’t read and don’t remember going to be successful at home.
This article suggests 12 ways to address readmissions. Additionally, our Chief Medical Officer at Silverlink Communications, Dr. Jan Berger, shared some of our research and also did a podcast on the topic last year.

We’ve always struggled with home monitoring. We can’t force the patient to take the pill. It’s also possible that they get prescribed a medication that they can’t afford and therefore don’t fill. They might have transportation issues and not be able to get to a pharmacy.

Another issue is access to a primary care physician for follow-up after discharge. One study estimated that one in five Americans had limited or no access to a primary care physician.

I don’t know about you, but these statistics scare me. You have people at high risk who are the primary cost drivers in our healthcare system, and they aren’t necessarily equipped or supported to be successful.

Now, we’re going to put the burden on the hospitals to fix this. I agree that it has to start there. The question I wonder is how do we link the patient to this somehow. Is there a way to make them responsible for avoiding readmissions by following the discharge instructions? Is there a way to incent them to be successful? What would we systemically have to do to enable them to be more accountable?

This will require a major effort to address physician and patient interactions, address the discharge process, create a follow-up process to education and monitor the consumer, and ultimately to create a system that provides the support they need to improve their health.

I think we all want the right thing, but I’m sitting here trying to figure out how it gets done.

I was reading a Barclay’s Capital report this morning put out by Larry Marsh and team. In it, it included some data on the PBM market. What I found interesting were two key data points:

1. The average number of prescriptions PMPY (per member per year) by insurance type
   1. Medicare Part D uses approximately 30 Rxs PMPY
   2. Commercial uses approximately 15 Rxs PMPY
   3. Medicaid uses approximately 11 Rxs PMPY
   4. Uninsured uses approximately 5 Rxs PMPY
2. As you might expect, the costs per member per year are also different
   1. Medicare Part D is approximately $1456 PMPY
   2. Commercial is approximately $844 PMPY
   3. Medicaid is approximately $522 PMPY
   4. Uninsured in approximately $257 PMPY

Interesting, if you look at the assumptions and data around the uninsured, they pay more per generic script than anyone else, and less (on average) per brand script. BUT, the brand script number is deceiving since they have no specialty scripts in there (since the uninsured could never afford those prices).

[Note – I use the term “approximately” since these were derived numbers based on CMS, CBO, and Barclay’s estimates.]

Well, I’m finally getting around to hosting a blog carnival. Next week (January 18^th), I’ll be hosting Grand Rounds which a weekly round-up of the best medical and healthcare blog posts (see here for more information). While I’m open to any submission, I’d like to make the theme “engagement”. How to get patients more involved in their healthcare or the role of other healthcare constituents (MDs, RPhs, RNs) and healthcare entities (Payor, PBM, Employer) in getting consumers engaged.

You can see this week’s Grand Rounds at FDAzilla.

Please send me your submissions by Sunday night (1/16/11) at 10pm EDT, and I promise to use as many submissions as possible especially if their on this week’s topic. You can e-mail me at gvanantwerp at mac dot com with a subject heading of “Grand Rounds Submission”. Please include your name, Blog Name, and blog post URL.

Thanks.

For those of you that haven’t downloaded it yet, here are the key themes of the whitepaper. [BTW – I know many of you don’t like to comment publicly, but I welcome your feedback privately or publicly on the whitepaper.]

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While there are certainly some opportunities for PBMs or pharmacies to differentiate by specializing in certain markets (e.g., Medicare, Worker’s Compensation), the best opportunities for sustained differentiation are found in two areas of innovation:

1. Using an evidence-based approach to consumer engagement and
   
2. Developing integrated solutions that are patient-centric.
   

These business strategies go beyond the traditional fundamentals – location, operational excellence, customer service, reporting, account management, managing trend, and leveraging efficiencies of scale (network pricing, rebates). While it’s possible to create some differentiation in those areas, they are often difficult to maintain over time especially as you approach a point of diminishing returns.

Ultimately, understanding and succeeding at engaging the consumers whose choices drive the costs in our healthcare system is the path to success. This is a change for the PBMs more than the retail pharmacies, but, to succeed at this transition, both PBMs and pharmacies have to be nimble organizations that innovate and learn quickly. They have to understand the consumer from the outside-in and make decisions from an experiential perspective.

Download the complete whitepaper to see:

• Recent changes in the PBM and pharmacy industry.
• Examples of innovation
• Why consumer engagement matters?
• Examples of Silverlink insights into consumer behavior

An example of a multi-channel adherence solution