“It was the best of times, it was the worst of times, it was the age of wisdom, it was the age of foolishness.”–Charles Dickens, A Tale of Two Cities
We all talk about how wonderful patient engagement in the healthcare system is, but in today’s flawed healthcare system there is almost nothing worse than to be a healthcare savvy person using it. We know too much. We know what injustices to look out for and what can go wrong. We know when we are being over treated and poorly treated. We know the doctors generally wish we would shut up and stop asking questions.
In the past month I have had occasion to visit a doctor twice. In the first instance I had a pain in my mouth that made me understand where the expression “I thought my head would explode” came from. It was mind-numbing, blackout-inducing pain the likes of which I haven’t felt since childbirth. I had to invent whole new swear words to even describe it. Turns out I needed an emergency root canal due to a broken tooth.
In the other recent encounter I had with the medical system, I voluntarily paid a visit to a cosmetic surgeon to inquire how much money and what kind of promises I would have to make to God to look 25 again. Turns out that there is no promise big enough to make good on that bill–God already has everything and the Devil was on vacation–even if I could afford to pay the monetary part of the tab.
Nevertheless, the experiences of those two doctor visits were so widely different from each other that I felt it warranted writing about, even if I have to admit in writing that I am older than 25. I know, I’m sorry I lied.
A few weeks back I wrote a post called Give Em That Old Razzle Dazzle which touched on the kind of marketing and customer service that spas use to separate people willingly from their money. I contrasted this to how reluctant those same consumers are to part with their cash even for life-saving products and services, when the services fall under the “should be covered by insurance” umbrella. This post offers another flavor of that same dish, but in this case one that reflects on provider behavior when faced with an insured patient vs one who would be footing the bill personally (were either God or the Devil in a negotiating mood).
One would like to think that the source of payment wouldn’t matter and that every patient would be treated like a valued customer, but my own personal experience belies the truth: when you’re viewed as the INSURED MEMBER you are in coach; when you’re viewed as the CUSTOMER, you’re in first class. It’s a bit like the difference between staying at Motel 6 as compared to the Four Seasons. At Motel 6 you’re lucky to get a bar of soap and a towel big enough to dry your hands. At the Four Seasons they put flowers in your room, use your actual name when talking to you and and let you know that someone can be sent to personally towel you off if you just call the concierge. The difference becomes berry meaningful as we have started to make the slow march towards a healthcare system where patients are being moved into the position employers and the government have long occupied–the one between the wallet and the doctor.
The Tooth Ache
I am one of those lucky people who grew up with fluoridated water and thus have had only one cavity in my entire life. I am not one of those people who is afraid of dentists because, for the most part, nothing bad ever happened to me there. So when I showed up unannounced on a Monday morning after a night of hell I was very appreciative that the dentist agreed to see me right away. Granted, I latched myself to his office door and refused to leave, but he didn’t put up a fight. He took one look at me, asked me three questions, looked in my mouth for less than 10 seconds and declared, “You need a root canal on tooth number 31.”. I said, “How do you know?” and he said, “I’ve been doing this for 35 years.”. He followed that with, “But I need to do an X-ray to verify it.” Fine, I figured. Better for me if we know he’s right. I wouldn’t want an unnecessary procedure. This is what I’m thinking as they light me up.
While waiting for the X-ray to process, he calls his pal, the local endodontist, and arranges for me to go right over there to get said root canal, which I do appreciate. Then his assistant hands me the X-ray, which has not been looked at by the dentist, and she tells me to bring it to the endodontist. I say, “Aren’t you going to look at it to be sure you’re diagnosis is right?” He says, ” I know.”
So now I’m thinking why the heck did we do this X-ray if I didn’t need it? My immediate cynical thought was to assume because he gets paid to do it, assumes my insurance will cover it, and that’s that. I try to check my cynicism at the door since I appreciate his getting me seen quickly. I remind myself that the endodontist will need it to know where to do his thing so the X-ray was probably necessary after all.
Fast forward half an hour and I’m now filling out, by hand, form after form of repetitive information at the endodontist’s office. I literally write my name and address on four different forms. Same goes for my medical info. Clearly the whole EMR tsunami has not made it to these shores. I point out that they have asked me to sign a form agreeing to whatever procedures they are going to do when they have yet to tell me what they are going to do One of the guys in scrubs hanging out in the lobby, says, “Yeah, good point. Just sign it and we’ll work it out.” I refuse to sign it until I know what’s happening. He shrugs. By the way, i later find out this guy is the endodontist because later, when I lay in the chair, he is the one with the tools. At that point I say, “Oh, so you are the doctor?” He confirms.
Meanwhile, back in the waiting room, I ask what this whole fun fest is going to cost and what will be covered by my insurance and what will not. They give me a rundown but not a guarantee of costs. In fact, I will find out later when the bill comes that I owe twice as much as I was told it was likely to cost. Not cute.
After a brief wait (I have to say, they were fast to see me and didn’t make me sit around) I sat down in the dental chair of doom and hand the doctor the X-ray, still virginal in its jacket having been unviewed by anyone. The doctor says, thanks, puts it aside and says he will be doing new X-rays. I say, “What the hell? What’s wrong with the X-ray you just dropped into the circular file,” and he says, “Oh no, mine is a digital X-ray and we have to do it here because we use it to guide the treatment.” I have a small fit.
“What was the point of the first X-ray then?,” I ask, “Why are you guys double-treating me? I don’t want the extra radiation to my head, for one thing–I can kill my brain cells all on my own thank you.” Now my cynicism comes roaring back. I tell the doctor that I think he is suggesting an unnecessary procedure. He, smiling, says to me, I won’t treat you without the X-rays.” He knows that I can’t continue in pain like this and in fact I have a flight to the East Coast scheduled to depart in 6 hours. “It’s your choice,” says the doctor.” Checkmate. I am furious but despite what he said I feel I have no choice. I feel very annoyed and they haven’t even started drilling yet. In case you were wondering, the drilling did, in fact, amplify my annoyance.
I am told after it’s all over–5 more X-rays later–that I am done and that is that. I am given no information about how to take care of myself except “Keep it clean and don’t bite on that side until the anaesthetic wears off.” I am told I will also need to go back to the regular dentist for a crown within no more than 3 weeks. An appointment is set for 4 weeks hence because I am told that is the first available time. On top of that, the dental assistant calls me to reschedule the appointment no less than three separate times, further pushing out the timeline. I say that i thought i needed to be seen within 3 weeks. They tell me not to worry. I am worried.
Yes, after all this, my tooth is fixed and the pain is gone, but the entire experience left me very cold. There was little regard for my interests here and I felt like a victim, not a consumer. I know dentistry is supposed to be unpleasant, but when you add in the lack of transparency, inaccuracy around costs and the feeling like my X-rays were paying for a couple of dentists’ Porsche payments, unpleasant was an understatement.
The Age Defier
Meanwhile, back at the ranch, I have decided I am curious about all these minimally invasive plastic surgery procedures that all my VC friends are funding and making a bundle from. Of course when I ask them about this stuff they tell me it is great, but I decide I want to find out for myself. I ask around and through my research come across a guy in San Francisco who is supposed to be both good and honest and highly experienced. While I am suspicious that this combination can occur in nature, I call to set up a consultation. I brace myself for the pain of visiting a new doctor.
My suspicions are amplified when they try to set the appointment around my schedule, not caring that I am suggesting evenings and other strange times when physicians rarely work. They tell me this is no problem and that they will make it work at my convenience, which they actually do. They send me both an email and text confirmation of the time selected. They also send me an email link to their EMR so I can input my relevant personal and medical history. Once.
When I show up for my appointment, the assistsnt introduces herself, shakes my hand and thanks me for coming. I am offered a cold beverage and a nice cushy seat in which I wait approximately one minute before being shown to the back. I again wait for about a minute before the doctor comes in, shakes my hand and introduces himself. He tells me a bit about his background and qualifications. He asks me why I am there. I give him my story. He offers to explain in great detail the technology and clinical information relevant to all of the products about which I enquire. He is patient and detailed and says, “I love it when people ask me lots of questions-it means they care about their health.” he goes and gets props and photos to explain. He proactively describes how he minimizes unnecessary procedures and visits.
When we are through, his assistant, who is beautiful, of course, and has a soothing accent, goes through costs, risks, process, everything you can imagine in extraordinary detail. The pricing document has a guarantee about virtually all costs so you cannot be readily surprised. There is an extensive package of take home patient education information. After the appointment I receive a thank you email. Seriously. It’s like I went to a wedding shower, not a doctor’s appointment. I email back one lingering question I had. I receive a response within the hour. I have not decided whether I am going to do anything service-wise yet, but I want to go back to the office just because it was so pleasant.
“We had everything before us, we had nothing before us, we were all going direct to Heaven, we were all going direct the other way. . . .”–Charles Dickens, A Tale of Two Cities
I found the contrast between these two experiences very interesting in light of the thinking I have been doing about what happens in a “reformed” U.S. healthcare system where people directly choose their insurance products through exchanges. These decisions will be based largely on benefits offered and cost, but if history is any judge, they will also be based in large part on the doctor network they will be assigned. In this brave new world, consumers will be able to fire their health plan and switch doctors when they are unsatisfied with the services received. This is in stark contrast to how things work today. It is nearly impossible to switch health plans unless your employer does it for you and changing doctors is a hassle extraordinaire. In a world where data is portable and consumers can vote with their feet and wallets, customer service is really going to matter in a way it does not today.
I have seen a proliferation of programs for doctors to teach them more about technology and finance for the new world healthcare system, but I have seen little to suggest they are being trained to live in a Nordstrom-style world. This is probably a great opportunity for healthcare consultants that used to teach doctors how to “code” aka overbill. Perhaps we will see medical schools open up their curriculum to include a little foray into hospitality services and how to remember that the customer is always right, even when they are a pain in the neck. That plus a little charm school would go a long way toward ensuring the brand loyalty that providers will need to prosper in a more complex world where the financial transaction has been simplified from a three-way (provider-payer-patient) to a two-party relationship between provider and patient.
And in case you’re wondering, all those extra X-rays have given me a special irridescent glow and previously absent super powers. If they need a female Hulk for the Avengers sequel, I am ready to go.