Putting Patients First in Routine Clinical Services
When David Berg and his wife, Janice Johnston, moved to Phoenix from Toronto and opened Arrowhead Health Centers in 1997, they found the U.S. health-care system confusing. They had not heard of CPT codes or ICD codes or RVUs. Trying to find their bearings, they took a radical step: They asked their patients what they wanted.
What patients told them is not surprising. They wanted conveniently scheduled appointments. They wanted care plans they could understand and follow. They wanted to be smarter about their choices when they needed non-routine care. What they did not want was to sit in waiting rooms and to be treated coldly and impersonally.
Patient satisfaction has been the overwhelming priority for 20 years as Berg and Johnston have refined and expanded Arrowhead’s operations, now with 10 locations in Arizona and nearly 200 employees. For anyone with an interest in fixing the system, the centers pose an intriguing query, one so simple that it could be dismissed as naïve. Is it possible that if you simply put patients first, everything else will fall into place?
First, consider whether a “put patients first” clinic can be financially viable. After all, giving patients what they want inevitably means doing work that insurers will not pay for. Nonetheless, Arrowhead is financially healthy because Berg and Johnston have worked so hard behind the scenes to operate as efficiently as possible. Second, could a “put patients first” approach improve the system as a whole? It might, if a primary care operation that had extraordinarily high patient satisfaction also kept patients healthier and reduced the need for high-cost services downstream.
As Arrowhead is self-insured, Berg has plenty of data from his own employees’ health plan. He has been sufficiently encouraged by that data to launch a second business venture, Redirect Health, that puts him in position to capture at least some of the savings to the system that Arrowhead creates.
When Berg chose a career in health care, he wasn’t chasing a dream. He was chasing a girl.
In college, his first intellectual interest was mathematics and computer science, but he quickly switched most of his courses over to premed to be around Johnston. (It was a move he says seemed very reasonable as a 19-year-old boy getting attention from a pretty girl.) They married and have gone to school or worked together for most of the 34 years since.
Berg chose to become a chiropractor. He’d been assisted greatly by a chiropractor after a serious injury in his youth and the experience had made a lasting impression on him. Johnston chose family medicine. Primary care and musculoskeletal services later became the foundation for Arrowhead, though the centers have expanded their range of services with an openness to anything that might be called the “routine 90” of the health-care universe: the 90 percent of services that 90 percent of the population needs 90 percent of the time.
In his first few years of practice as a chiropractor in Canada (while Johnston was still in residency), Berg discovered that as much as he appreciated the positive impact he was having on his patients’ lives, he did not love the repetitive nature of the work, patient after patient, all day long. Over time, he became more interested in the business of health care than in seeing patients, and he began studying systems and processes to determine how to improve them. Berg found that he naturally developed productive and synergistic relationships with doctors who were his mirror image—that is, those who loved practicing medicine but did not want anything to do with running the business. He made their work lives easier and enabled them to focus more completely on their patients. Consequently, patients were happier and received better care.
Berg knew he was more of an entrepreneur than a health-care provider. By 2001, Arrowhead’s fifth year, he’d backed out of seeing patients altogether and was focusing all his energies on creating and automating processes that led to the best possible experience for Arrowhead’s patients and the Arrowhead team.
Arrowhead aspires to make every patient feel valued and welcome at every contact. To set the tone, patients are not even referred to as patients at Arrowhead. They are referred to as customers. Berg explains that this choice serves as a constant reminder that the patient, not the provider, is in charge.
The Arrowhead team endeavors to answer every phone call personally, rather than transferring the caller to a voice-mail system. Furthermore, receptionists do not sit behind a glass panel, speaking to visitors through a small hole in the glass. Instead, they sit at an open counter and greet patients by name as they walk through the door. (They have photos of the patients in front of them to help with recognition.) They make it a habit to help patients with forms and sometimes sit next to them in the reception area to answer questions.
Patients hate waiting for appointments when clinicians are behind schedule, so Arrowhead promises no appointment will begin more than 15 minutes late. Berg recalls that physicians on his team initially were reluctant to make such a promise, knowing it would be very difficult, if not impossible, to keep the promise 100 percent of the time.
Berg had data, however, showing that Arrowhead already was meeting the 15-minute goal more than 90 percent of the time. He decided that was good enough to make the promise. The key was what to do when it just wasn’t possible to keep the promise. At Arrowhead, a receptionist sits down next to the patient at the 14th minute, apologizes for the delay, and asks if there is anything they can do to be helpful. Berg says this kind gesture surprises patients and overcomes their frustration with the delay and he notes that Arrowhead’s satisfaction scores are actually higher for patients who have lengthy waits.
Another important driver of patient satisfaction is convenience of access. Understanding that patients may have jobs that prevent them from getting away from during the workday, Arrowhead offers appointments early in the morning, in the evening, and on Saturdays.
Furthermore, the centers aim to do as much as they can over the phone, even when such work cannot be reimbursed. This effort has been successful enough to confuse an insurer who audited Arrowhead’s billings. The insurer noticed an unusually high fraction of Arrowhead’s appointments had been coded as higher complexity visits, a possible indicator of fraud. Berg knew Arrowhead was not overbilling. The explanation was that Arrowhead was giving away lower complexity work by handling what would be simple office visits over the phone. Berg responded to the insurer’s pointed questions by insisting that the insurer analyze total costs of care for Arrowhead patients. After completing the analysis, the insurer asked that Arrowhead “just keep doing what it is doing.”
Increasingly, patients are concerned about the portion of the health-care bill that they will have to pay out of pocket, especially when they are about to receive expensive services in a hospital. Berg and his team have learned as much as they can about the relative costs of the various hospitals in the region, and the centers freely pass along what they’ve learned to patients. Berg notes that since he started doing so, not a single Arrowhead employee has chosen to have their baby delivered in the area’s most expensive hospital. Smaller cost items are not beyond Arrowhead’s concern. Berg’s team has developed processes for following up with patients soon after prescribing a medicine and gently nudging them towards locations where they can receive the best prices.
In Berg and Johnston’s view, however, the most crucial driver of patient satisfaction may be the effort that Arrowhead makes to ensure every care plan is clear, straightforward, and likely to be followed by patients, their caregivers, and their family members. Such plans make patients feel like they have been well served, not simply told what to do. Berg elaborates:
We could give you the best care plan in the world, but if you don’t follow it, it is not going to work. On the other hand, if we offered a care plan that was simplified and imperfect but you followed it, you are probably going to see better results. What I’m saying is that compliance is more important to outcomes than the actual care plan in many situations. But it is not the patient’s job to comply with our orders; it’s our job to comply with their life circumstances, their financial constraints, and their barriers to health.
In Berg and Johnston’s view, devising a sensible care plan is a team effort. Every patient contact can offer insight into patients’ lives and any obstacles they may face to better health. For example, medical assistants at Arrowhead do much more than take temperatures and blood pressures. They converse with patients to get to know them a bit and begin a first draft of their medical history before the physician arrives. Even schedulers can gain insight into the chaos of patients’ daily lives just by listening closely as they set up appointments.
In recruiting new physicians, Johnston, who serves as Arrowhead’s chief medical officer, looks primarily for doctors who are interested in improving the health-care system and are willing to operate as a team. She doesn’t see that a physician long accustomed to working independently and in a silo has much of a chance to thrive, nor does someone who thinks the entire job is diagnosing and treating.
Johnston described how physicians respond to the Arrowhead environment in their first few days on the job:
Many physicians are used to having to take the patient’s whole history themselves and make a lot of entries into the medical record. As a result, they are really surprised at how much work has already been done when they walk into the room to see the patient. The chart is complete, a lot of the history is done, and everything is ready to go. They have to review it all, obviously, but they are delighted to work with a staff that can do so much and pleased to be able engage with patients without feeling tugged away to the computer screen.
It may be efficiency that pleases physicians at first, but they stay at Arrowhead because of the patients. Simply put, happy patients make for happy physicians, and happy physicians make for happy patients.
Sustaining the team environment takes effort, however. The staff must be trained to operate at the top of their license and capability. Teamwork also requires conversations between team members, and conversations take time. Each department at Arrowhead meets at least once every day to discuss patients. To further support communications, Arrowhead has worked to develop routines and protocols for effective electronic messaging.
Each patient has a team “quarterback,” often the primary care physician, but the quarterback may explicitly shift depending on the patient’s medical condition. A pain doctor or chiropractic physician might lead the patient’s team for an interval following an injury from an auto accident, for instance. There are additional staff for patients with greater needs. For example, a care logistics team looks after patients with certain medical conditions, including diabetes, to ensure they have the help and support they need in their effort to stay healthy.
Clinical teams cannot be effective unless patients also welcome the arrangement. Johnston says most Arrowhead patients are so pleased with the overall care experience that they naturally start to view their relationship as with the team, not just with a single clinician. Few patients insist that they will speak only with the physician; no explicit “patient training” is needed.
In Arrowhead’s early years, Berg paid little attention to the employee benefits package. To contain costs as health benefits became more expensive, Arrowhead had increased the fraction of cost borne by employees. Around 2007, however, many hourly employees were leaving the company to find positions with better benefits at larger corporations in the area, and Berg discovered that losing his best trained employees was incredibly expensive; hiring and training required a great deal of time and energy. Arrowhead’s margins deteriorated. Berg feared for the viability of the business.
Arrowhead responded by choosing to self-insure its employees and offer better benefits. After doing so, Berg and his team became diligent, even aggressive at times, about managing the total cost of care. They began examining every bill and following up on those that seemed excessive. If a bill indicated that there were “complications,” they would phone the physician and ask about the nature of those complications. They found they often were able to negotiate lower bills and suggest to employees that they consider health systems that offered better value. As health systems in the area got to know Arrowhead, Berg noticed instances of overbilling became less frequent. He then began injecting the same cost consciousness into the entire organization so that Arrowhead’s patients, not just its employees, would benefit.
Soon, Arrowhead began paying 100 percent of the cost of the “routine 90” for its employees, on the theory that if you minimized the barriers to good health and health care upstream, you’d save money, time, and hassle downstream. The results seem impressive. Arrowhead is paying less in health-care costs per employee in 2016 than it paid in 2007. The savings have restored Arrowhead’s healthy margins and given it the flexibility to continue investing in patient satisfaction.
In 2014, Berg and Johnston partnered with former Phoenix Mayor Paul Johnson and launched Redirect Health to extend the same impact to other employers. Redirect offers Arrowhead-style health services to companies that employ lower-wage workers. The proposition is straightforward: Pay for the routine 90 percent of health care with us, and we’ll remove all co-pays and make most of the paperwork go away. Your employees will be thrilled because they have never experienced health care nearly as good as what we offer, and you will reduce the costs of downstream care.
By mid-2016, Redirect had already signed its 100th company.