Retail thinking is spreading quickly in health care. It promises greater convenience and speed for delivering basic health care services — but it isn’t what patients really want.
Retail thinking views patients as consumers: faceless targets for buying services and products that aren’t always health-related. It’s the thinking behind technology-assisted health care services, like ZocDoc, Amwell, and One Medical, which quickly triage symptoms or serve up medical advice. It’s the thinking that makes it possible for me to walk in, no appointment needed, to my local CVS or Target to have a cough or sore throat examined.
At the same time, it gives web-based apps opportunities to sell some of your information to advertisers, who want to sell you other things. It gives brick-and-mortar organizations cross-selling opportunities for everything from allergy medications to Halloween candy as I walk down the store aisle to get my flu shot from the pharmacist or have the nurse practitioner apply guideline-driven diagnosis and treatment. The providers I see during these interactions know nothing about me, offer little tailored advice, and the services they provide will be both limited and standardized in how they are delivered.
Being viewed through the retail lens also means that I am asked to consume other offerings pitched to me by whoever provides me with health care, be it my insurance company or my employer. They try to get me interested in legal and babysitting services, gym memberships, pedometers, mail-order pharmacies, round-the-clock nurse help lines, life insurance, and more. They do this to help them earn more of my loyalty, generate more revenue for themselves, or reduce their costs.
The hospitals and medical offices I visit seek to keep me within their system of care delivery, make me a long-term customer, and refer me only to their providers and services, both of which they control. By using retail tactics like offering one-stop shopping — where I can get primary, specialty, and other types of care all without leaving the same building — and marketing their brand to me with simplified rating systems that show their high quality, they want me to trust that they have my interests at heart and can deliver any type of health care transaction I require.
Retail thinking has its place in health care today because there are some services and products that people need quickly and which do not require a personal touch or someone who understands them as unique individuals. Such services might be low-level acute care (think strep throat), flu shots and immunizations, and some forms of simple chronic disease management, such as blood sugar checks or foot and eye exams for people with diabetes, especially if they are guideline driven. There’s no question that retail thinking can also create purchasing opportunities for things patients find useful, if not always essential, and perhaps do so in ways that are cost-effective or convenient for us.
But retail health care is impersonal, lacks relational warmth, and isn’t what patients really want.
I interviewed 80 patients and doctors for a new book on the doctor-patient relationship in the era of efficiency-driven innovation, corporate care, and retail medicine. What I heard from patients is that the impersonal nature of retail thinking is frustrating them and lowering their expectations about the levels of emotional support and customized help they can get from any doctor, or from others in the health care system.
No patient with whom I spoke wanted transactional care at the expense of relational care. No one prioritized Fitbits, web-based assessments of symptoms, or seeing a stranger about a sore throat in a big-box store over a long-term personal connection with a doctor. What these individuals wanted most in health care was something human and more intimate, maintained through regular one-on-one interactions with experts they knew and trusted who were compassionate, empathetic, friendly, and respectful.
The physicians with whom I spoke wanted the same things.
This type of sustained personal experience between two people who know something about each other, and who are motivated to really talk and listen as care partners, is something retail thinking does not do well. It is not concerned with the emotional aspects of care, building interpersonal trust between doctor and patient, or getting to know people as individuals with their own relevant life stories.
Yet existing research demonstrates that these are the very features that are good for patients. For example, care continuity through a stable doctor-patient relationship improves health care quality and patient satisfaction. Doctor-patient trust, established through extended interpersonal contact, helps patients become more engaged in their care; creates a positive patient experience; and increases perceived effectiveness of care. Extended dialogue between patient and doctor positively affects health outcomes ranging from high blood pressure to mental health problems. Physician empathy is linked to more accurate diagnoses, better health outcomes, and an enhanced patient experience.
If you don’t believe the literature, just ask the patients I interviewed. Teddy, a healthy man in his 30s, believed that without feeling trust towards a specific doctor — which for him was forged over time through regular face time and conversations with that doctor — little could be uncovered of the more intimate, life story information that he felt was most important for keeping him healthy. He said he had never been completely honest with clinicians he didn’t know.
Hallie, a 50-year-old woman with several chronic diseases, talked confidently about better understanding how to manage her many conditions, and how they affected her everyday life — the result of having a doctor who knew something about her personally, who spent time not reading off a care guideline but instead asking her real-time questions about how she felt, and then showing genuine compassion with her daily struggles. Hallie felt better able to self-manage her care, which kept her from using the system unnecessarily.
Cliff, a stressed-out dad in his 50s, talked excitedly about finally having the same physician he could see on a consistent basis; a doctor who in their first visit had spent time just listening to him, nothing more; then taking that information and asking him questions about his own life; and finally tailoring therapeutic advice based on the entire dialogue. Janell, a career-minded mom in her 40s, recalled with joy the memory of a past primary care physician who remembered conversations they had during previous visits and who used that knowledge to give Janell tailored guidance about how to manage her life stressors more effectively.
Can an industry that wants to use retail tactics also deliver on the relational excellence that patients and research say is important? It’s not easy, given retail thinking’s focus on speed and efficiency. Here are four ways that might meld these two approaches.
First, put more thought into where not to use retail thinking in health care. It may make sense for care delivery that is routine, care that can be standardized in a straightforward way, and in situations where the patient wants convenience above all else. But that actually amounts to a limited menu of services, and even routine care can often reveal deeper problems in patients, requiring the kinds of relational features I’ve described.
Second, better measure and monetize the components of relational excellence, making it matter to health care organizations and third-party payers. That means carefully assessing dynamics like interpersonal trust between doctor and patient; analyzing those data to see how they positively affect health outcomes; and then giving this metric the same relative importance in high-quality care delivery compared to other things like prescribing a particular drug for a particular condition.
Third, look for innovative ways to strengthen the doctor-patient relationship, not undermine it. For example, the industry should experiment with using technology as a tool to give doctors more face time and direct contact with their patients. Right now, both doctors and patients perceive technology, primarily the electronic health record, as interfering with their relationship.
Fourth, and most important, the patient voice must be heard. This could include adopting greater transparency with respect to assessing patient satisfaction with retail tactics, say through Yelp-type accountability mechanisms, and conducting market research that goes beyond simple binary questions of “would you use this” or “would you like greater convenience in accessing your care” and instead delves deeper into discovering what patients really value.
In thinking about my discussions with patients, there is one other important thing they want. They want to decide when their health care should work like the drive-through at McDonald’s or buying with one click at Amazon and when it should be more personal than that, involving extended human-to-human interaction, highly trained experts who know their patients, and an abundance of the time, trust, and soft skills required to make us healthier long-term and see health care as the important part of our lives that it really is.
Timothy J. Hoff, Ph.D., is professor of management, health care systems, and health policy at the D’Amore-McKim School of Business and the School of Public Affairs and Policy at Northeastern University in Boston; a visiting associate fellow at Green-Templeton College and visiting scholar at Said Business School, both at the University of Oxford; and the author of “Next in Line: Lowered Care Expectations in the Age of Retail- and Value-Based Health” (Oxford University Press, September 2017).
This story was originally published by STAT, an online publication of Boston Globe Media that covers health, medicine, and scientific discovery.