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“Customer First” Healthcare | Above the Crowd

December 18, 2017:

The topic of the “consumerization of healthcare” has been round for a few years. Most steadily individuals use this phrase in association with personal know-how units (heart-monitors, exercise accessories, sleep screens, and so on) that permit shoppers to take direct control of their well being info. There’s nevertheless, a more essential development that relates alternatively to the consumerization of the “business” of healthcare. Whereas other industries typically converse of being “customer centric” or “putting the customer first,” the U.S. healthcare system not often thinks of the affected person as a buyer. One might go even farther, and recommend that the U.S. healthcare market is the least buyer centric of any customer support business.

David Goldhill, in his enlightening e-book Catastrophic Care, declared:

“…a guiding principle of any reform should be to put the consumer, not the insurer or the government, at the center of the system. I believe if the government took on the goal of better supporting consumers-by bringing greater transparency and competition to the health-care industry, and by directly subsidizing those who can’t afford care-we’d find that consumers could buy much more of their care directly than we might initially think, and that over time we’d see better care and better service, at lower cost, as a result.”

David makes a strong assertion — allowing the affected person to rise to the forefront and to be really be seen as a customer — will result in not only more glad patients, but patients with better medical results and much lower costs. This is able to be a exceptional three-way victory. The excellent news is we are already headed down this path. The mixture of latest applied sciences, knowledge availability, info transparency, shifts in insurance coverage coverage, regulatory reform, and shopper frustration has set the stage for a new period of healthcare service in the U.S. the place the patient really comes first. This powerful development will achieve momentum because it builds, will reshape the current panorama, and can end in the launch of many new and thrilling corporations.

One overt sign of a scarcity of traditional market forces is any business the place primary customer support isn’t a requirement to remain in business. In the event you requested 100 individuals to call a place where you regularly wait, even if you end up on time on your appointment, how many would say the physician’s workplace? The buyer has come to simply accept waiting at the doctor. We are so numb to the ache, that we not often object or complain, and the physician’s indifference to the shopper’s time is so widespread and widespread, that it is a frequent meme in jokes and cartoons.
Different U.S. industries, once subject to far less competitors, have been pressured by the market to study a brand new reality. The phrase “banker’s hours” is a historic metaphor for “short working day.” One web site qualifies “banker’s hours” as 10am-3 pm, which truly have been the open hours at most banks many years in the past. This is clearly not the norm as competitors ultimately pressured a brand new actuality. My local financial institution is now open 9am-5pm (including Saturdays), and naturally, the adoption of ATMs provides us entry to cash 24 x 7. All banks have been pressured to answer the new buyer expectation, driven by aggressive forces. That same shift is now coming to healthcare.

Of their marvelous guide, Lean Solutions, James Womack and Daniel Jones unpack what it means to use the self-discipline of lean manufacturing to service industries. Certainly one of their key rules of recent service excellence is “Don’t Waste My Time.” They increase the hypothetical query “Would there be a queue if the providers had to pay customers for waiting time?” In case you are in the healthcare business and discover such a question absurd, are you not confirming that you simply naturally assume your time is far more invaluable than your patient’s?

In fact, the healthcare business’s lack of customer centricity shouldn’t be limited to time alone. Think about the many business attributes that fall in need of other industries, and ask how properly your personal healthcare service suppliers deliver towards these questions:

  • Hours/Appointments — In your supplier, what hours are they open? Are they out there when its most convenient for you? Do they anticipate you to miss work or faculty to return see them? How far prematurely do it’s a must to guide an appointment (the common is 24 days)? Are you able to simply “walk in” for appointments?
  • Interactive Booking — Can you ebook appointments online? Are you able to cancel or reschedule online?
  • Info Collection — Does your doctor make it straightforward to offer details about your go to? Are you able to do this online earlier than your go to, or are you handed a clip-board filled with varieties where you enter info you will have already offered on previous visits?
  • Digital Communication — Can you ship your healthcare provider e mail? Do they reply? Do they even make an e-mail tackle out there? Can you even depart a voicemail?
  • Response Time — How shortly do they comply with up to a request? Do they have a constant assure on time to appointment? What about in response to a question by way of e mail or telephone?
  • Pricing Transparency — Have you ever seen a menu of pricing for any healthcare providers? Why not? In lots of different nations, tariffs of widespread procedures are publicly obtainable in each clinic and office. In case you are on a high-deductible plan or a Flexible Spending Account that is necessary info to you.
  • Info Sharing — Does your physician ship you an in depth “receipt” of the procedures they carried out, their discoveries, their evaluation, and their conclusions so that you’ve an archive? Do you even get an inventory of the expenses they’re submitting to your insurance company? Are the costs ever discussed or explained?
  • Empathy — Do you find that your healthcare provider makes a concerted effort to deal with you as a buyer with enthusiasm and empathy? A current research of on-line doctor evaluations found that 96% of complaints relate to customer support, and only 4% to high quality of care.
  • Service Degree – Do your docs ask you for suggestions? Do they conduct surveys? Do they measure waiting time? Do they measure NPS scores?
Know-how to the Rescue?

One obvious answer to this record of issues and alternatives is to leverage know-how to raised serve the needs of the buyer. Unfortunately, a deep dive into the giant and sophisticated market for healthcare IT techniques will uncover an unlucky actuality. You will not discover a large Salesforce or Zendesk of healthcare. Buyer-facing, also referred to as “front office,” techniques have not been the focus of healthcare service providers historical spend. Most giant healthcare IT methods are chosen based mostly on one main objective: income management. Billing and collection in the U.S. healthcare system is complicated and troublesome, and most of those giant EHR techniques’ primary objective is to deliver income. Sadly, as these techniques higher perform their inherent obligation, they actually drive healthcare spending as a % of GDP up, not down. They contribute to the general drawback.

Revenue-management obsession even has a unfavorable impression on how shortly healthcare organizations embrace know-how – know-how that would radically improve the buyer expertise. Do you need to know the actual cause docs don’t reply e-mail? Need to know the actual purpose telemedicine isn’t extensively pervasive? Clearly, many physician visits could possibly be changed by a 10 minute FaceTime name, saving the patient and the follow a substantial amount of time (not simply the time in the office, but the commute time in each instructions). You might be stunned, but the main purpose these technologies go unadopted is as a result of docs simply do not know the best way to cost for them. The issue is primarily an absence of straightforward reimbursement.

Who Is the Actual Customer?

Despite widespread belief to the contrary, the U.S. healthcare system doesn’t function as a free market with the sort of open-competition that we frequently associate with capitalism. It’s definitely not a single-payer system, however that reality alone doesn’t make it a capitalistic system. There isn’t any worth evaluation during the buy. The individual paying shouldn’t be the individual consuming the service, and the majority of decisions are made without comparative options. In many ways, we’ve got the worst of both worlds. Our system, which is the highest in the world as a % of GDP, has the phantasm of a free market and the illusion of regulated market with the apparent advantage of neither.

The fact that the employer plays a central position in our healthcare system is both a coincidence and a possible obstacle to forward progress. In 1942, President Roosevelt worked with Congress to cross the Stabilization Act of 1942. Hoping to offer incentives for full employment and to push back inflation, the government froze wages while simultaneously leaving open a back-door for will increase in benefits. This seemingly innocuous laws had a far-reaching consequence — it launched the widespread U.S. apply of employer sponsored well being care protection. And as we speak, for most employers, this benefit is explicitly required by regulation. While it appears regular to us, the use of the employer as a key constituent in providing shopper healthcare coverage is sort of uncommon and not used in some other industrialized nation.

Clearly, having a reluctant and pointless third-party involved shouldn’t be more likely to deliver peak effectivity. Most employers would choose out of offering medical insurance if they might. They haven’t any particular expertise in the matter, and being a supplier of these providers places the company in the awkward position of getting a perspective on personal personal matters as well as what defines primary nicely being. Additionally, the giant employer motivations are probably contributing to rising costs. A large employer advantages plan must be “competitive.” If there occurs to be a big, renowned hospital group in the area, the employer feels compelled to offer protection that includes this establishment, even if that system is very over-priced (the largest hospital methods sometimes have the highest procedural prices).

In the U.S. healthcare system there’s full obfuscation and confusion relating to who the real buyer is. The worker picks a provider from a plan picked by the employer from the insurance coverage service. The buyer sees no costs because it makes decisions and selections. The cost and reimbursement process includes all 4 events. Quite often, the service “rejects” the reimbursement request despatched in by the doctor. That is then despatched though the employer to the worker. Now the employee is uncovered to the worth for the very first time, and informed the worth was too high, but guess what — this is after the work is already finished. Now the worker has the joy of negotiating after the reality.

When you have been a U.S. healthcare supplier, who would you view as the buyer? The employer bears the eventual costs. The insurance carriers process the cost. The worker makes use of the service, however they didn’t selected you based mostly on the prices of your providers, and also you by no means mentioned or disclosed worth to them. Those costs have been negotiated between you and the totally different carriers that placed you on the numerous plans chosen by the employer. As you’ll be able to see, its not unreasonable that, as a supplier, you would not truly view the employee that utilizes your providers as the buyer. They’re far out of your solely constituent in the system, and they are absolutely NOT the get together that’s paying the bill or negotiating worth.

Winds of Change

As talked about in the introduction, we have now a robust perception that change is afoot in the U.S. healthcare market. Specifically, we consider various elements are coming together concurrently that may drive healthcare suppliers to answer market forces and undertake a “customer-first” mindset. Recognizing sufferers as “true customers,” service providers will provide unprecedented responsiveness, conveniences, service levels, and knowledge transparency. People who undertake this mentality will discover new ranges of productiveness, and consequently, will ship larger high quality care at lower and lower costs. People who choose not to align with this new reality will fall behind, ultimately dropping clients to those extra nimble and responsive providers.

Listed here are an inventory of the new forces pushing the U.S. healthcare system to be customer-first:

  • Excessive-Deductible Plans — With a view to scale back insurance coverage premiums and make catastophic healthcare out there to extra individuals, high-deductible plans have been rising as a proportion of all plans. In 2015, 46 % of staff have been enrolled in a plan with an annual deductible of $1,000 or more, up from 38 % in 2013 and 22 % in 2009. The Reasonably priced Care Act’s (ACA) most reasonably priced plans are all high-deductible (despite the fact that many voters didn’t understand this when it was handed). As such, the ACA has been a key driver for the continued rise of high-deductible plans. The fascinating (and maybe unintended) consequence of high-deductible plans is that sufferers turn into actual “consumers” for the very first time — at the very least up until their deductible. Having never been educated to be worth conscious, and with most suppliers loathe to publish tariffs, this is an fascinating evolution for the business. However sure providers are moving into the void, and they are rising market share consequently (more under).
  • Rising Coinsurance — Like high-deductible plans, coinsurance is one other approach of offloading, or sharing, healthcare prices with the affected person. Coninsurance plans require the affected person to pay a proportion (often 10-30%) of the healthcare prices as much as the deductible limit. Additionally like high deductibles, coinsurance utilization in on the rise. From 2004 to 2014, the average payments for coinsurance rose 107% from $117 to $242. Growing coinsurance prices even have the effect of turning patients into buyers/shoppers. If you take up a proportion of the prices, you will pay extra consideration to cost.
  • FSAs/HSAs — Versatile Spending Accounts, also referred to as Well being Financial savings Accounts, are pools of money set aside by an worker and their employer for use for healthcare spending. The worker is usually allowed to allocate money to those accounts pre-tax (up to a limit), and as specified in the ACA, $500 in unused funds can now be rolled over into the subsequent yr. Whereas these plans have traditionally been focused as “non-covered” bills, they are more and more getting used for deductibles, copayments, and coinsurance, which as we said are already rising as a proportion of contribution. As like the earlier two points, the rise of those spending automobiles once again pushes the healthcare affected person to assume increasingly like a client. Spending correctly permits them to get increasingly more services underneath their given plan or program.
  • Slender Networks — Slender networks are an fascinating response to the above market prices that the giant hospitals and groups are pushing on the broader market. With a slender community plan, the shopper or employee is allowed to “opt-in” to a plan that has decrease premiums, with the specific tradeoff that this plan has fewer decisions for service providers. Specifically, the “narrow network” sometimes aggregates these providers which are prepared to simply accept decrease prices for his or her providers (theoretically you possibly can have a “premium” slender community, but they’re sometimes used to create more reasonably priced plans). Some employers even supply the employee a profit to choose these plans, in essence sharing the savings with the employee. Obviously, if slender networks improve in reputation, increasingly more market share shifts to providers which might be prepared to answer aggressive market-based worth calls for. These are extremely more likely to be the similar actual suppliers which are embracing these other market forces.
  • Rise of Pressing Care — Pressing Care amenities, initially created for the function of providing a less intimidating various to the Emergency Room for off-hour care, are more and more serving the primary healthcare wants of an ever rising proportion of healthcare shoppers. This reality won’t sit properly with people who embrace the idyllic notion of the “family doctor,” however just keep in mind that similar idyllic physician used to do home calls. On a number of dimensions, these pressing care suppliers are creating an providing that isn’t merely on-par together with your conventional GP, but typically materially better. Shoppers come to an urgent care facility during an emergency, but the expertise is so nice, they arrive back for on a regular basis healthcare needs. Some members of the “urgent care” group are intelligently rebranding their providers as “convenient care.” This progressive market entrant places constructive strain on the general well being care system.
    1. These providers are often situated in additional convenient places with better parking options for the shopper.
    2. They are extra more likely to disclose, or maybe even promote their prices.
    3. Following their legacy of after hours care, they typically have broader hours than a standard GP. For instance think about Pediatrics After Hours which operates in Dallas as a pediatric pressing care facility. They are open from four:30-10:30pm, Monday by way of Friday, Saturday from noon-10pm and Sunday from 10am-9pm. Now in case you are a working father or mother who prefers to not take their youngsters from faculty for medical visits (or simply can’t take them as a consequence of work), how do these hours sound?
    4. Most pressing care amenities permit non-appointment walk in visits (does your GP?). Additionally they permit on-line booking.
    5. An growing number of urgent care amenities measure wait time, ask for shopper suggestions surveys, and even calculate NPS (internet promoter rating) in an effort to ship a superior customer expertise.
    6. Each CVS and Walmart have entered the pressing care race with their retail clinics. CVS operates MinuteClinic at over 1,100 places in 33 states, they usually have seen over 20 million patients. They are open 7 days every week, including evenings and weekends. No appointment needed. Likewise Walmart operates Care Clinic in lots of its shops. Both supply pricing online.
    7. Integrated managed care suppliers like Kaiser Permanente, HealthPartners (MN), UPMC (PA), and Baylor Scott & White (TX) have all added “Urgent Care” places as a part of their broad mix of choices. Clearly the market is talking.
    8. Many of those “Urgent Care” suppliers favor to be regarded as “Convenient Care” providers, highlighting their differentiation and their move from solely episodic usage to more of default provider of well being providers.
  • Rising Use of CRM Sort Tools — While not traditionally a key priority, main healthcare providers are beginning to undertake “front office” applied sciences which are used to offer better customer service. These tools may enable online reserving, provide the means for extra frequent customer-provider communication, facilitate surveys and suggestions, automate follow-up correspondence, and anticipate customer wants. As shoppers experience these greater levels of “customer-touch” they’ll possible develop accustomed to them and anticipate them from all providers.
  • Internet Net Sites/Consumer Generated Content material (UGC) — On the internet, info availability evolves in one path solely — increasingly more. Over time, as more providers embrace customer feedback, and as more shoppers are prepared to share their opinion, we’ll start to see increasingly buyer feedback on healthcare suppliers. As we speak, 77% of shoppers say they use on-line evaluations as the first step find a brand new doctor. Additionally, as worth schedules turn into “expected” the leading gamers will embrace publishing their worth schedules to the public. This reality is already present in most service supplier industries, so it must be no suprise when it arrives full throttle in healthcare.
CVS Care Clinic Worth Schedule:
Benchmark Healthcare Investments

Our venture capital agency, Benchmark, has made 4 investments in step with the “customer-first” theme.

  • Brighter — Brighter is a cloud-based medical insurance platform that seamlessly connects sufferers and docs to dramatically improve the affected person and provider experience whereas decreasing prices for patient, supplier and insurer. The company offers its built-in suite of providers to main well being providers organizations reminiscent of Cigna, Aetna and Delta that embrace enhanced supplier search and listing, verified affected person evaluations, worth and quality transparency, online appointment scheduling and affected person communications reworking a standard well being benefit into a digital health plan. Brighter has rapidly achieved nationwide scale with distribution to tens of hundreds of thousands of insured patients and over 100,000 providers. Word: Last Thursday, Cigna acquired Brighter to speed up the improvement of Cigna’s cellular and desktop platforms and create new end-to-end experiences that join health shoppers and suppliers with the steerage, help, and incentives they should improve quality of care and maximize cost-savings.
  • OneMedical — One Medical is a member-based and technology-enabled main care network that challenges the notion that delivering high-quality, accessible health care is both unachievable or prohibitively costly. In truth, they are working to prove that simply the reverse is possible — a system where quality care is reasonably priced and out there to everybody. By 2018, they’ll operate 75 workplaces in 8 markets with over 400 main care clinicians. They are sometimes situated in city areas close to shopper’s administrative center but are additionally in residential areas. They sometimes see appointments inside 60 seconds of scheduled appointment time and reply to medical communications in less than two hours, whereas offering 24×7 virtual care from its employed clinicians typically within 60 seconds. Because of their dedication to service quality, they have a 90 internet promoter rating. Additionally they drive a lot lower costs via the use of better evaluation, info, and care that helps scale back pointless costs almost about downstream specialists, hospital utilization, and diagnostic testing.
  • Solv — Solv is a market for same-day healthcare, connecting patients to pressing care clinics and suppliers who’re dedicated to delivering a handy and top quality expertise. For shoppers, Solv solutions easy questions which, till now, have been very frustrating in healthcare: where ought to I’m going, when can I be seen and how much will it value me? For providers, Solv’s software program improves the in-clinic expertise by way of mobile-first scheduling, online paperwork, wait time discount and feedback collection. Solv launched in Dallas-Fort Value earlier this yr and shortly expanded nationally after suppliers throughout the nation requested their consumer-centric healthcare platform. When individuals get sick, they sometimes wait days to see a main care physician, waste a whole lot of dollars at an emergency room, or have to juggle their life to fit a visit into their schedule. Solv’s mission is to make entry to top quality, final minute care easy, quick and easy by connecting shoppers to their nationwide network of suppliers, who are eager to offer the service.
  • Sew Well being — Our most recent healthcare investment, Stitch is a Y-Combinator seeded SaaS company that serves as residence base for healthcare groups that goal to deliver customer-first healthcare. The corporate is HIPAA-compliant, cross-platform (desktop, iOS, or Android), searchable by patient ID, and integrates with present digital health data (EHRs). Stitch replaces the fragmented use of pagers, telephone calls, EHR message baskets, and emails with a single product. It does this by means of a user-friendly software that models medical supplier workflow and presents affected person health knowledge in the context of group chats, direct messaging, personal teams, and protracted chat rooms. By making a product that solves the drawback of archaic, fragmented tools in the healthcare system, Sew hopes to make it straightforward for healthcare groups to offer distinctive care.

As enterprise capital buyers, we worth investment alternatives which are exposed to large shifts in a given market — notably actually giant markets resembling the U.S. healthcare market. The timing might be tough, nevertheless. It is advisable to enter the market when (1) shoppers are displaying a unquestionable favoritism for a brand new strategy, (2) they’re voting with their pocketbooks in favor of this new strategy, and (3) the incumbents in the market recognize the development is unstoppable and start to react (quite than deny or ignore) that development (which creates the “tipping” drive). We consider all this stuff are presently in place on the subject of “customer first” healthcare. Moreover, because of the systematic modifications outlined above, the U.S. healthcare shopper is rising as a true “shopper” for the very first time. It will add gasoline to the hearth and accelerate the transformation. We are prepared to guess on it.

Background: I spent the better part of two-years surveying the Healthcare market in quest of an investable alternative or probably a key investable theme. At 18% of GDP and rising, it seemed tautological that many entrepreneurial opportunities ought to exist to make use of at present’s applied sciences, purposes, and units to construct many value-added corporations. The primary part of this journey was both tedious and eye-opening. This US healthcare market is as flawed and sophisticated as it is giant. In case you are considering my general learnings from that journey, take heed to the podcast (transcript also out there) I did with Ezra Klein for Vox’s The Ezra Klein Present. In the second part of that very same journey, I stumbled upon what I consider to be a giant and investible development — and that is the key subject of this blog publish.