Emergence of Consumerism in Imaging
Hurried along by economic hard times, consumerism is making an impact on diagnostic imaging choices, and savvy practices are responding As Bob Dylan once sang, “You don’t need a weatherman to know which way the wind blows.” Neither does it take an expert to see that the US primary care delivery model is on the verge of experiencing a tectonic shift. The weakening economy has led to an increase in the ranks of the uninsured; a recent article¹ in Health Affairs predicts that the uninsured population of the United States (currently estimated at 47 million) will increase by at least seven million, or 15%, in 2010 alone. The uninsured, however, aren’t the only ones experiencing reduced access to services: with the advent of health savings accounts and high-deductible insurance policies, even consumers with health insurance are facing a new set of challenges when it comes to selecting and paying for primary care. Jeff Goldsmith, PhD, is president of Charlottesville, Virginia-based Health Futures, Inc, a company specializing in corporate strategic planning and in forecasting future health care trends. He says, “The biggest change we’ve seen is the gradual stripping away of the protection of health insurance. That’s clearly been at work in this most recent recession: We’ve seen a downturn in hospital admissions for elective procedures, a downturn in surgeries, and downturns in prescriptions filled and in physicians’ offices opening. I’ve never seen all those things happen at once, in the 35 years I’ve worked in the field.” Goldsmith says, though, that it is not as simple as health insurance becoming less comprehensive, so consumers are becoming pickier shoppers. He points to a number of trends that have created the current perfect storm of consumer-driven health care. “I think baby-boom women get a lot of the credit here,” he says. “They really originated this movement in the 1970s by demanding that care to them be provided on their terms, according to their needs. To me, consumerism is really synonymous with the woman’s ascendance as her own, and her family’s, chief health officer.” Goldsmith also cites the democratization of information as a key factor in the growing impact of consumerism on health care in general, and on radiology in particular. This sentiment is echoed by Melanie Haymond, marketing director in business development for Epic Imaging, Portland, Oregon. “I think this really started five or six years ago, when consumers began to realize they had a choice,” she says. “Of course, there are limitations on how much you can educate yourself using the Web, but regardless, patients were walking into physicians’ offices armed with reams of Internet research. For the first time, they really wanted to have a voice in where their procedures would be performed.” Harley Hammerman, MD, CEO of Metro Imaging, St Louis, Missouri, concurs: “Before, their physicians were consumers’ only resource. Now, there’s an unlimited amount of material available on the Internet, for better or for worse. For a while now, patients have been experiencing higher and higher deductibles, plus rising copayments; in recent times, we’ve seen more and more patients who don’t have insurance at all. Patients are much more selective about what they get and where they get it.” The New Patient For imaging centers, the notion that the patient needs to be catered to as aggressively and intelligently as the referring physician is a game changer. It also reveals how much the patient has changed in the past decade. “We realized that patients are using the Internet to educate themselves, so we decided to maximize our Web-site opportunities by making sure we had keyword optimization and would pop up often for those consumers,” Haymond says. “We believe, at this point, that you cannot have a patient-service offering without making some statement about price and cost. The fact is, consumers are driving the industry, in the past five or ten years, in a way that we just have not seen.” Hammerman’s practice has taken similar measures to appease the price-conscious patient. “We have a department that helps make patients aware, upfront, of what the exam will cost them before they come in,” he says. “Many patients don’t understand that they’ve got a deductible or a copayment. We help them decide whether they really want the exam.” A few years ago, this type of full disclosure might have been looked upon as an unwise business move. Back then, the party line was that health care was not an area in which to economize. That’s no longer the case, according to Haymond. “We really were rather stealthy when it came to pricing 10 or 15 years ago,” she says. “We didn’t speak about it. We negotiated our contracts through the insurance providers, and that was it. Now I see billboards saying, ‘We’ll do any MRI for $400,’ so we’ve made sure that when patients are calling about price, they are put in the hands of a billing patient advocate who can speak specifically about the cost of an exam.” Susan Lucas Collins, chief marketing and client services officer for Advanced Radiology Consultants, Trumbull, Connecticut, emphasizes the importance of patient education and outreach, dimensions that, in the past, were reserved for referring physicians. “There’s no doubt that patients are starting to do their own research about providers of all sorts, including radiology providers,” she says. “One MRI is not necessarily the same as another, though, so we put information about our technology on our Web site and give materials to our referring physicians to share with their patients,” she continues. “People who wouldn’t have thought twice about having an imaging exam when their insurance was paying for it are now looking into the costs and expected benefits, and are weighing alternatives. In this market, there can be a substantial difference in the cost of a given study among providers, and if people don’t understand that there’s a difference in the service, that’s a problem for someone like me.” Hammerman has observed that patients increasingly expect exceptional customer service, in addition to price transparency. “We decided to start marketing to consumers a couple of years ago,” he says, “and that’s when we started our on-site results program. We give patients the results of their exams in the office, before they leave. I also interview every member of our staff, and we won’t hire anybody unless he or she could work at Disneyland.” Goldsmith agrees that customer service will be a key differentiator in the future. “It really matters how you’re treated,” he says. “It really matters how long you wait. Communication matters.” He has also seen imaging centers make other surprising, patient-driven changes. “The movement to operate outside the customary 9-to-5 hours was certainly targeted at working women,” he notes. “There’s a huge potential impact of market-share growth among people who don’t have a choice because they are busy with school, work, or both. Consumers are saying that 9 to 5 just doesn’t do it for them anymore.” Doubling Up on Marketing In the past, imaging centers’ marketing efforts have primarily centered on referring physicians. Now that patients are increasingly taking responsibility for their health care choices, doubling up on marketing is crucial, Goldsmith says. “Most marketing activities in this space have been directed toward referring physicians rather than consumers,” he says. “So much energy has gone into economic relationships and into siting imaging centers where the physicians are. Consumer marketing has always been secondary, but I think that’s going to change.” Collins warns that the change will not be easy. “You don’t just wake up in the morning and say, ‘I think I want a lumbar MRI. I’ll call up Advanced Radiology Consultants,’” she says. “Radiology practices tend to lack expertise in reaching out to consumers, and that expertise can be expensive to acquire. We’re also not necessarily the best purchasers of that kind of service, because we haven’t historically done a lot of it.” Collins characterizes the tired mainstays of consumer marketing of imaging services as awareness-raising campaigns, which traditionally have been popular among imaging centers, but are not very effective in an increasingly consumer-driven marketplace. “You see a lot of campaigns like, ‘October is Breast Cancer Awareness month; have your mammogram today,’” she says. “Is that really effective? It’s probably not horrible, but it’s not the most compelling, either. It tends to feel a bit generic. Raising awareness is good, but what it conveys to people is that they should get a mammogram, not that they should get it at a specific practice.” Advanced Radiology Consultants has addressed this issue using a propensity-marketing tool that leverages a complex database to target patients via direct mail. “The database identifies people who have a higher likelihood of requiring a specific service, and they categorize their mailers by procedure,” Collins says. “There are templated, professional designs, and you customize the existing pieces they offer. They’re highly personalized. If I send it to you, it will have your first name on it. It will say, ‘Did you know about vein ablation?’ and follow that with information on the procedure and our practice.” Hammerman has increased his practice’s volumes by advertising price transparency to consumers through local television and radio spots, as well as using more extreme measures. “We want to show consumers how going to a hospital costs much more than coming to us,” he says. “We have two buses that drive around town (including in hospital parking lots). On them, there’s a picture of a radiologist who is holding up a radiograph of a skeleton, with the words, ‘A hospital can cost you more. Take a closer look at Metro Imaging.’ Hospitals in the area aren’t fond of what we’re doing, but why would they be? Our message is, ‘Look before you leap,’ so consumers call us, they call the hospital, and they find out who offers the better deal.” Because patients are more educated than ever, Haymond says that it is also important to market your technology, making sure that consumers understand that all imaging services are not created equal. “We’ve done radio, television, and print media,” she says. “We’ve positioned ourselves as the experts in the marketplace. We often speak about the fact that our organization has made a commitment to the latest technological advances, and that this commitment drives our prices.” Buyer Beware Collins says that radiology benefit management companies (RBMs) are increasingly shaping patients’ and clinicians’ perceptions of what imaging services should cost, and where to get them. “When a patient or referring physician calls to get the authorization, the insurance company’s representative will say, ‘We’re going to authorize this procedure and suggest you have it at this lower-cost facility,’” she says. “That kind of steering is very common now. It’s certainly a challenge we have to overcome. Our scheduling and billing organizations are available to help patients with questions about cost. Everyone in our organization can explain the value, for example, of our 3T open MRI, compared with the lower-cost facility down the street, but that opportunity doesn’t come up if the referring physicians’ staffs are setting up appointments based on the conversations they have with those RBM representatives.”
Melanie Haymond
To overcome this obstacle, Haymond is heading a redesign of Epic Imaging’s Web site that is intended to bolster consumer access to pricing information. “Patients aren’t just looking for cost information,” she says. “They’re researching what’s appropriate. They’re comparing. We haven’t fully designed what the Web site will look like, but I visualize some kind of comparison chart. It’s a buyer-beware situation. We’ll hear things from the competition like, ‘We’ll provide a 30% discount for cash-paying patients,’ but 30% off retail is still more than what we’d charge them. We want to help patients understand what those claims really mean.” For Metro Imaging, offering price transparency is another tenet of the campaign promoting freestanding (versus hospital) imaging. “We let patients know, up front, what they should expect,” Hammerman says. “Certainly, the insurance companies don’t make it easy for them to understand. We want to let our patients know that we charge a third of what the hospitals do.” Attempting to simplify the billing process is not without its hazards, Haymond says. “There are so many variables in the billing side of what we do,” she notes. “What we don’t want to do is somehow misrepresent our fees to the patient. There’s nothing worse than committing to A and then billing B. That’s why we’ve spent a significant amount of time scripting our folks to be cautious, to use words like estimated, and to make clear that these numbers are not set in stone.” Goldsmith believes that the trend toward price transparency is still in its infancy. “It’s very difficult to tell whether pricing transparency has had any impact yet,” he says. “I think we’re a long way off; my perception is that this is an area where there’s a lot more talk than action. If it were actually generating business, I think people would be talking about it more, but I do think it’s going to help in the future. It’s easier with imaging, where there’s a relatively limited scope of product.” Opportunity Knocking There’s one thing on which everyone seems to agree: The growing impact of consumerism on health care will create new and exciting opportunities for freestanding imaging centers, which are faster to change and nimbler at adapting to patient needs than hospitals are. “Hospitals have yet to hear the message loudly enough to change their business models,” Goldsmith says. “That’s created a big opportunity for freestanding imaging. They’ve had to be more flexible to grow.” He adds, however, that’s there’s no reason for hospitals to miss the opportunity to disclose their prices as well. While it’s impossible to tell people what a visit to the emergency department will cost, he says, “With imaging, the physician has ordered a procedure. That procedure has a billing code. The billing code is attached to dollar amounts, so why not disclose them?” Collins notes that while referring physicians have the luxury of focusing on quality of service, it is increasingly incumbent upon patients to focus on both cost and quality, giving imaging centers a chance to gain market share. “People like me are going to have to be prepared to explain why we’re priced the way we are,” she says. “It’s certainly a challenge for practices like mine, but I also think it’s an opportunity, and I’m excited to embark on some of these new efforts. I think, in the long run, it will mean that the differentiation between practices will become more apparent to everyone.” Haymond also predicts that the rising tide of consumerism will have the effect of lifting all boats, spurring patients to become more empowered when it comes to their health care. “The consumer now has a better understanding of the role of diagnostic imaging,” she says. “Right messages for right reasons are always good. I don’t see this as a black cloud on the horizon. I see this as a time of huge opportunities.”