Dan Prince

Health literacy is a problem that confronts nurses, doctors and hospital staff every day. It’s going to be an even bigger problem for healthcare professionals when millions of currently uninsured Americans flood into the system in 2014.

But the organizations that may feel the most pain when the floodgates open are the health plans. I’ve been reading about how they are preparing for the change, and I’m concerned that insurers may be focusing too narrowly – and cutting a few too many corners.

What is “health literacy?”

The US Department of Health and Human Services defines health literacy as “the capacity to obtain, process, and understand basic health information and services needed to make appropriate health decisions.” People with low health literacy are less likely to know what healthy behaviors are and to adopt them.

In testimony Susan Pisano of AHIP (America’s Health Insurance Plans) presented in July 2011 at the Institute of Medicine’s Health Literacy Roundtable Meeting, she said 9 in 10 Americans have “difficulty using health information to make informed decisions about their health, profoundly affecting their health and access to care.” And profoundly impacting their interactions with the companies processing payments for their care.

Health plans’ efforts to raise health literacy

Ms. Pisano’s testimony was about AHIP’s efforts to assist health plans in addressing and improving health insurance literacy.

Health insurers see more and more clearly the writing on the wall for their companies. AHIP conducts health plan surveys every two years on disparities in health, and one of the topics covered is health literacy. Their 2008 study showed 69% of plans had introduced some components of a health literacy program. Two years later, in 2010, this was up to 83%.

A big focus of AHIP’s effort is to assure that the reading level of materials is low enough and the language is plain enough. A little aside here, I have to mention as the head of a healthcare research company: Pisano said consumer testing of materials was an important priority, but that many companies were skipping it, instead testing materials on their own employees who seem similar to the target audience. As a research company, we can, of course, point out all kinds of flaws with this approach, starting with the fact that employees who work in almost any part of a health insurance company are likely to be more health and health insurance literate because of where they work. But the biggest threat to the reliability of this kind of research is the fact that these employees already have health insurance benefits and have dealt with the system as customers. They really can’t stand in for people who haven’t.

Health literacy is about more than reading

Another concern Ms. Pisano’s testimony raised for me was the almost exclusive focus on “materials.” A 2004 study by Dean Schillinger, Andrew Bindman, Frances Wang et al. on “Functional Health Literacy and the Quality of Physician-Patient Communication Among Diabetes Patients” showed that health literacy isn’t just a “reading” issue. It profoundly affects how well people understand verbal explanations and follow instructions they get in face to face or phone encounters.

Schillinger et al. were thinking about doctors’ and nurses’ encounters with patients in offices, clinics and hospitals, but health literacy colors people’s experience of every part of the healthcare system. The implications are very clear for health insurers.

Health plans need to be preparing front-line service people to ascertain the level of the customer’s health literacy and adjust their vocabulary, their pace, their tone and possibly the language they’re speaking in – to fit the need.

As millions of people open their first EOBs ever in 2014, the phone banks will be lighting up. Health plans who step up to the health literacy challenge now will be the winners – or at least the survivors.

Seize the opportunity

There’s an opportunity here as well as a threat. I hope that health insurers, along with the rest of the healthcare system, will see the opportunities in the 2014 challenge. In addition to bracing themselves for millions of customers with even less health literacy than their current customers, they should be doing what they can to increase Americans’ health literacy across the board.

What do you think? How is your company getting ready to deal with customers who have little to no experience with the healthcare system? And let me know what your company is doing to increase customers’ health literacy. Comment on this post or send me an email at dan.prince@catalysthcr.com.

Dan Prince

Healthcare Reform opens up whole new vistas for improving the customer experience, but if the story I am about to share with you is any indication, the horizon is far, far away when it comes to individual health insurance.

One of our part-time employees, Becky Clark, recently undertook an odyssey with her husband – they needed to buy individual health insurance for their family because Heath was going out on his own as a healthcare attorney.

What they experienced as young and healthy buyers is sobering as the nation gets ready for millions of people to purchase individual health insurance through the exchanges envisioned by the Healthcare Reform.

I’ll let Becky take it from here:

Even though we both work in healthcare – and I deal with a wide variety of patient satisfaction research on a continuing basis — we were unprepared for the experience of buying individual insurance.

Becky Clark

Our goal was to spend $500 or less a month for our family of four. We dealt with a broker, an insurance company and an association. The initial process of getting a quote wasn’t bad — the only questions they asked were: Age, gender and smoke/not smoke. But that was only the beginning of what was mostly a very frustrating customer experience.

The broker

We went to see a broker for one of the largest insurers in the state and got initial monthly quotes ranging from $400 to over $1,000, depending on the nature of the policies. The only reasonably priced policies were high deductible HSAs, so we applied for a $7500 deductible HSA.

We applied online – and the application process was intense and violating. There was a checklist of at least 50 questions regarding medical conditions or illnesses. If we had ever been treated for one, we had to go deeper for a detailed explanation.

We had to recall all doctor visits over the past 5 years and all conditions we’ve ever been treated for in our lives, how long we were treated, the physician that treated us, his/her location, and whether or not the condition was resolved. We also had to list all medications taken over past 10 years and why.

This may sound like a simple process to some, and we thought it would be easy to recall all this information, but it took hours! And we are very healthy people. We both are at or below ideal weight, exercise on a regular basis, eat well, don’t smoke, enjoy a glass or two of wine, have no chronic conditions and have no serious family history going against us. We have a pretty boring medical history – which is good!

But our son was scheduled for a procedure once he reached 6 months of age. Even though doctors told us that once the procedure was done, the problem should be taken care of and even though it is by no means a chronic issue, it still raised a red flag. This particular insurance company raised his rate 300%.

I called to ask why, and they said that with the changes brought by healthcare reform, children could not be denied coverage for pre-existing conditions. Since they had to cover this “condition,” the price of the policy was raised by a few hundred dollars a month.

And can I just say that I heard back from this company the next day with the increased rate. They did not take the time to look at medical records or ask any questions. Just a simple increase of 300%.

The insurance company

So I forgot to mention that when shopping for individual health insurance, you have to decide if you want maternity coverage or not. Don’t all plans provided through an employer offer maternity coverage – no matter what?

We are pretty sure that we are done having kids … but no permanent measures have been taken to prevent that. Human error is always possible. When my husband’s cousin unexpectedly became pregnant, we learned that they, too, had individual health insurance and elected not to get the maternity coverage. They, too, thought they were done having kids. So we decided to opt for the maternity coverage, which of course, is much more expensive.

We had begun to explore purchasing coverage directly from another insurance company. But with the decision about maternity benefits, this was no longer an option. They didn’t offer maternity benefits
So yet again, we were forced to keep shopping.

The association

Our journey took us next to a trade association that offered coverage partially administered by the same insurance company represented by the broker. Got that?

Even though the insurance company administered the plans offered by the trade association, the offerings themselves were different and the trade association did its own underwriting. The good news: maternity benefits could be included.

There were five different plan options, and different deductibles within each plan. I was extremely impressed with many of the offerings. The plan that we applied for actually had everything I would want: it’s a PPO, fairly low deductible, good coverage, dental and vision. Wow! I thought it was too good to be true – and it was reasonably priced, according to the quote. So this was the plan we wanted and we were extremely anxious while waiting for the underwriters.

The final application we completed was on paper and mailed to their corporate office. We waited three to four weeks to hear back. They requested my son’s medical records, which we provided in a timely manner. They actually took time to review medical records — not just see a scheduled procedure and immediately respond by jacking up the rates.

At one point, I called to check the status of our application, and they were able to tell me that two underwriters review the application. One underwriter had signed off on it and they were waiting for the second to review it. I was really impressed that they were able to provide me with that information.

So another week went by and we received notice in the mail that we were approved for their policy. They raised our rate because of our son, but it was only about $50 a month. And they listed two other heath issues with our kids that raised concerns, so I’m sure those were included in the $50 increase. They excluded chiropractic care for me, which no other underwriters did. I hadn’t been to the chiropractor in over a year, but I had gone maybe once a month for the previous few years just to keep my back comfortable with running and because hauling around two kids all the time takes a toll on the back.

I can’t tell you how relieved we are to have a policy that includes all we want, with a reasonable deductible, and that costs under $500 a month.

What I learned about the customer experience

But even with that good result, our total customer experience was frustrating:

• The overall process is a mystery to my husband and me, even with our healthcare backgrounds. You call up a company, get an immediate quote based on age, gender and smoking, then you are to use that information to decide if you want to invest the time and energy in their application process. And it’s just a quote – more than likely, it won’t be that low!

• Maternity coverage should not be an issue. No one should have to fret and worry about health insurance if they find themselves pregnant. (There are other reasons to panic about pregnancy – this should not be one of them!)

• There is obviously a huge discrepancy between obtaining health insurance individually versus through an employer. Employers never ask if you smoke or are overweight or have chronic issues or if you took this medication 10 years ago. I suspect over half the employees in this country would not qualify for individual health insurance, and if they did, it would not be affordable.

• The link between health insurance and employment status is frustrating. My husband started his own law firm – a small business. While starting your own business is wonderful, health insurance has been the biggest barrier. I don’t know how many times we thought – “OK, at what price point do we go close up and go back to corporate employment?” The cost of health insurance should not be the barrier that it is to self-employment. Efforts should be focused on business development and client work, not shopping and paying for health insurance, especially when your business model is no work; no pay.

• There is still much work to be done by insurance plans to improve the customer experience. The differences between how we were treated by the first company we checked with and the one we ultimately chose are ample evidence of that.

Dan Prince

If a hospital or healthcare system decides to install a “chief experience officer,” what would this person actually do?

Several of the presentations at the recent Association for Patient Experience conference hosted by the Cleveland Clinic focused on this exact question.

A Forrester Research study of about 150 “chief customer officers” at a variety of organizations across the country led to a “job description” that included these roles:

• Developing a clear understanding of the organizations’ customers, and their wants, needs, and desires
• Acting as the customer’s “chief advocate,” in order to be their champion in conversations with management and internal staff
• Breaking down customary silos within a company to promote cross-functional improvements that stick
• Defining customer metrics, to be sure that measurements tie to things that really matter to the business and the customer
• Demonstrating financial impact, so that others in the organization, including senior leadership, will lend their support to cultural change and tactical improvements

Three broad definitions of roles

Another perspective came from Anthony Cirillo, a healthcare consultant who many credit with coining the term “chief experience officer.”

He outlined three “broader” roles that an effective experience director must implement to be effective:

–Chief Promise Keeper, which I took to mean the person in the organization, who along with marketing, makes sure that the organization is living up to its promise of being patient-centric, and being the one to point out to others when it is not (i.e., when staff walk by trash on the floor and don’t bend over and pick it up).

–Chief Healing Officer, which I understood to mean healing in its broadest sense. This role might include supporting efforts to introduce (or use more widely) music and art therapy, or redesigning the process for the orientation of new employees, so all staff see themselves as “caregivers.”

–Chief Context Setter. This idea was more abstract for me, but I think it points to the notion of being sure that managers and teams within a healthcare setting look at the full context of delivering patient-centered healthcare. For example, it could mean asking what do our valet parking attendants say to the departing cancer patient who no longer has hair? How good a job is the hospital doing in terms of signage that is both welcoming and instructive? Can bills be simplified to make them more understandable to patients? In other words, it suggests looking at the context in which the actual delivery of clinical care happens.

A recent study that we did for The Beryl Institute found that about one in 10 hospitals or systems in the U.S. have assigned accountability for patient experience to a specific person and that person has the word “experience” as part of his or her job title.

We are on the front edge of taking the new concept of a “chief customer officer” and applying it in provider settings. It’s an exciting move … and a potentially game-changing movement for American healthcare!

Dan Prince

While attending The Beryl Institute’s 2011 Conference on Patient Experience this week, two of the most interesting sessions I attended have been led by hospital executives who were previously hotel industry execs.

If you are charged with making change happen, coming into the world of hospitals as an “outsider” may be the best thing that can happen, especially if your former employer was a world-class service business. Gerard Van Grinsven, CEO of the Henry Ford West Bloomfield Hospital in suburban Detroit was previously an executive in charge of worldwide food and beverage services at Ritz-Carlton. So, clearly, he knows a thing or two about how to render memorable service, and how to do so consistently.

He challenged the audience: “Do you REALLY know your customers?”

To be sure he understood the true wishes and needs of his customers, he (personally!) went on “home visits.” He called patients, and said I want to bring you dinner, then he’d go out and “break bread” with the family, engaging in an open-ended conversation that might go on for several hours.

He learned, firsthand, what people want and expect from a hospital experience. And in so doing, he set quite an example for his staff!

Another hotelier turned hospital executive, Richard Corder, Senior Director of Service Improvement at Massachusetts General Hospital, came to this reknowned academic medical center from Four Seasons, the arch competitor of Ritz-Carlton.

In addition to radically re-vamping employee orientation, he’s on a personal quest to get staff at all levels of the medical center to spend one hour a month in the lobby of the medical center … greeting visitors and patients, answering their questions, and walking with them to their destinations. The CEO now does this, and the practice is taking hold.

This formal welcome, he firmly believes, creates a tone, and a first impression, that will go far in communicating through action this institution’s mission. And the concept comes right out of the world of luxury hotels. Their staff never just point to a distant meeting room or restroom, they take you there!

Both Ritz-Carlton and Four Seasons have well-developed systems for delivering top-quality service by picking the right people for the team, reinforcing the vision and values on a daily basis, providing positive reinforcement in both obvious and subtle ways, gathering meaningful feedback from their guests, and implementing effective service recovery.

Transforming the cultures of many American hospitals toward a “customer-first” orientation is not going to be easy. These two leaders know and understand the importance of creating outstanding customer experiences. As they transfer their knowledge from one sector to nother, they challenge us all to rethink the way we deliver on our brand promise to create the kind of patient experience we all seek.

Dan Prince

Health plans are increasingly becoming a focal point for customer experience research as various constituencies, from patients to politicians, look to them to save money and help improve wellness.

So what should plans be asking to learn how their performance is graded? Here’s a Top Five list:

1) Am I the “first stop” when my client is looking for healthcare information?

If your health plan is viewed as a trusted source of information, your standing will rise in the eyes of both your current customers and the potential customers who hear about you. So what kinds of information do you want to be the first stop for? Customers are likely to assume that you would be a good, easily understood source on such questions as how health insurance works, how claims are processed, and what plan must be “right” for them. But increasingly customers are assuming that health plans ought to know a lot about the quality of providers and what it takes to be healthy. How well are you meeting that challenge?

2) What messages are getting through to my members?

Some touch points are obvious places to look – advertising, for example, or your customer service department. But how is your health plan being portrayed when members interact with their physicians or with hospital staff? How about your Explanation of Benefits form – does it provoke befuddlement? Do your members know that you offer a wellness program? Are they engaging with you based on what you are telling them about the program?

3) Am I ready for the “Retail Revolution?”

Most everyone has seen commercials featuring Flo, the perky saleswoman for Progressive Insurance who dresses all in white. Progressive has good reason to set the commercials in an insurance “store” – people increasingly shop for auto insurance like they shop for any other retail product. The same is true of health insurance as more and more consumers become responsible for their own choices – either because they do not have employer-provided health insurance or because they are using a Health Savings Account. Does your plan understand the psychology of retail customers? Do you offer them the option to “shop by price?” Do you make “comparison shopping” easy?

4) Do my members perceive that it is easy to do business with me?

Have you done usability testing on your website? Basic usability testing captures actual online behavior while allowing customers to explain in their own words what they are truly experiencing as they navigate a site. This sort of testing is usually qualitative in nature – conducted one-on-one or in a small group setting. Cutting edge testing injects an emotional component into research through the use of video and can be done remotely with up to 200 participants. Usability testing is critical for understanding whether customers are finding what they need on your site and how they feel about their overall experience.

5) Am I connecting with my customers on an emotional level?

Traditional economic theory says that financial market prices reflect efficient, rational decisions based on the best information available at the time. But market bubbles in housing and Internet stocks show just how much emotion is involved in financial decisions, even for sophisticated high rollers. Is it any surprise that emotion is heavily involved in healthcare decisions and that some choices seem to fly in the face of a large volume of easily-accessed data? How well does your plan understand these emotional drivers?

In summary

In personal affairs as well as business, it is difficult to see yourself as others see you, yet it is vital to success in both arenas. Health plans that energetically seek answers to these five questions will have a deep pool of knowledge about their customers’ experiences. This knowledge will position them well for the challenges ahead.