Why health care services are so bad, and what might make them better
By José Colucci Jr.
Anyone who has been to a FedEx store or a Starbucks has experienced service design at its best. Every detail of these companies’ offerings — colors, logos, furniture, aesthetics and store style, employee uniforms, and the way they are trained to greet and serve customers — has been designed to be “on brand” and offer a carefully curated experience to each customer, every time.
At FedEx, the customer meets a uniquely crafted service experience. The whole ecosystem — from the design of the packages and drop boxes to the convenience of online shipping through their website or the app — has been considered from the user’s point of view in a constant quest to eliminate every possible friction point. After all, connecting “people and possibilities” means you probably consider people who use your services.
Starbucks, by its turn, knows that smells are a powerful influencer and may even control how much money people spend; they did not neglect that aspect of the experience. They only use odorless cleaning products and removed a few menu offerings that olfactorily compete with coffee, such as hot breakfast sandwiches. Employees are trained to repeat the name of the customer multiple times as well as the name of the product. That way, the customer gets a “these people know me” feeling and, at the same time, this customer is quietly being trained to order Starbucks-branded products. Notice that the next time you order a Venti® Latte or a Trenta® Cold Brew.
Contrast these experiences with what you get in health care. Very often, the first greeting you receive upon entering a clinic is “Name, date of birth, and insurance card, please,” with the “please” part being optional. Then you wait, usually for a while and with no regard for your appointment time. In most of the United States health care system, the simple act of booking a visit to a doctor is an ordeal. Why can’t I book an appointment online? Restaurants let me do that. Most restaurants do not make waiting a mandatory part of the experience if you have a reservation. And you never order a dish at a restaurant before knowing how much it will cost you.
When confronted with comparisons like that, many people in health care get defensive. They will say that “health care is different.” By that, they mean health care cannot be compared to most consumer experiences. Health care requires a depth of expertise unmatched by these other businesses. Health care requires extensive and recurrent training. Health care has higher stakes than a good meal. Health care is surrounded by regulatory red tape. Health care is unpredictable. We never know how long a visit will take and what treatments will be required. That is why we cannot tell you beforehand how much your treatment will cost. You will hear this again and again.
Each of the statements above is true, and to each we can find an equivalent consumer experience that is complex, unpredictable, regulated, and generally better addressed by their industry segment than health care. My dentist, my veterinarian, and my mechanic let me know how much their services will cost before they perform them. The restaurant business is also unpredictable. Restaurants may not know how many people will show up on any given day or night, how long they will stay, and what they will order. Despite that, I am often able to make a reservation, not wait, and order the food I want to eat. Hotels are no less eager than health care to make sure I will pay my bill, but at least they are nice to me before they ask me for my credit card number and might even thank me for being a repeat, loyal guest.
Why are services so bad in health care? Many factors contribute to that, but a few of them overpower the others.
What you cannot measure (yet) matters
The first is the focus on evidence-based medicine. Please, do not get me wrong, if I had to choose between two physicians, one who is all about measurable outcomes, data, and evidence, and another who is not, I would have no doubt about which one to choose. Evidence-based medicine integrates the best research evidence with clinical expertise and patient values. In practice, however, practitioners tend to focus more on the clinical aspects of care to the detriment of patient values, which often include the need for the comfort and reassurance that comes with a positive experience of the non-clinical aspects of care. That is understandable; doctors are taught to focus on what they can measure, and there are not yet good, hard metrics for psychological comfort and delight. Back to my analogy with consumer experiences, it would be as if FedEx focused on the expediency of shipping to the detriment of the overall consumer experience. Or if Starbucks focused on brewing the best coffee but ignored the ordering process, store aesthetics, seating, and employee courtesy.
Payment models and consumer choice
The second factor is that health care, because of its urgency and payment models, does not behave as a true free market. No one with acute appendicitis can afford to shop around for the best value. A true free-market system in health care might look like consumers purchasing insurance for rare, expensive events directly in a competitive market and paying out of pocket for routine medical care. But that is not how it works for most people (see: United States: One country, five different healthcare systems). Most health care plans in the United States are tied to employment or paid for by the government. Consumers do not have a good way to clearly compare value, costs and, even if they wanted to do so, cannot compare quality of care in an emergency. In a truly consumer-driven market, health care providers would have incentive to eliminate friction in the process and optimize the non-clinical aspects of the experience. But, wait, that already happens! Look at services provided by clinics that specialize in elective procedures not covered by the government or by most private plans, such as Lasik and plastic surgery. If they seem to behave as if they were in a consumer market, it is because they are. They compete on the whole package; not just the clinical aspects of the procedure. I am not advocating for free markets in health care. The topic is more complex than we can discuss here. I am just pointing out that, in a free market system, consumer choice influences provider behavior, and consumers have a louder voice.
Fax machine required?
The third is a commitment to antiquity. When I moved from Massachusetts to Texas, I asked my doctor’s office to transfer all my electronic medical records to my new provider in Austin. They said the cost of the copies would be $30. I thought I misunderstood them. Thirty dollars to type an email address and click a button seemed excessive, but alas… I was wrong. It was $30 to physically copy all of my records to paper. I came to Austin with a 3-inch-thick stack of paper that no doctor will ever read. Recently this year, I needed a record from another provider — a large and prestigious hospital in Boston. They sent me some forms and asked me to fax them back. Fax! In 2021! They would not accept email or any other electronic form of consent.
Health care’s treatment of information, however regulated it might be, is absurdly complex when we compare it to banking — another highly-regulated sector. Banks not only routinely transfer information in a seamless way between them but also allow third parties to read their data with the client’s consent. I never physically met anyone at the bank who gave me a mortgage. Nevertheless, I exchanged confidential and sensitive personal and financial information with them. I can go to Mint right now and now about the status of my finances with all the detail I want to understand a comprehensive picture of my financial health. However, I cannot do the same for my health. There is no Mint-like aggregator for my personal health information.¹
Lessons from Dell Medical School
When Dell Med opened the UT Health Austin clinics, the Design Institute for Health contributed to the design of the environment, tools, systems, and services (see: Provoking New Behaviors). From the outset, Dell Med made a strong commitment to value-based care and patient values. We organize care around medical conditions, we try to measure outcomes and costs for every patient, we seek to align reimbursement with value for patients, as well as other elements of value-based care. Each of these elements can be tied to a service design component in the way care is delivered, communicated, and considered from the patient’s point of view. But services proved to be a particularly challenging aspect of health care to change, even to us.
Whereas most healthcare institutions will proclaim they “put patients first”, few do what it takes to truly do that. We often treat patients as if we are doing them a favor. There is an immense distance between the self-proclaimed focus on patients and maintenance of health and the sad reality of volume and transaction-driven systems.
Measuring what matters to patients
I said above that an obsessive and exclusive focus on evidence-based medicine is detrimental to a great patient experience. What I will say next will make it look like I am contradicting myself, but stay with me... I also think that improving the quality of the experience in health care hinges on measuring outcomes that matter to patients. I also believe — and there is evidence to back it up — that the non-clinical aspects of the experience have an impact on health outcomes.
Capturing the non-clinical aspects of the experience is difficult. The tool we have for that are PROs (Patient Reported Outcomes), which generally take the shape of standardized questionnaires. PROs are key in value-based care. Otherwise, how do we show we provided value? But while PROs are great at capturing objective aspects of patient complaints and outcomes, they are not so great at capturing patient personal goals, the anxiety induced by health care itself, the quality of their interactions with providers, compassion, responsiveness, and participation in the clinical decision-making process, just to name a few.
However difficult they might be to measure, these non-clinical aspects of the patient experience are key to improving health care. The Design Institute for Health is currently working with the UT Health Austin Musculoskeletal Institute (MSKI) to improve PROs both to increase the completion rate of PRO questionnaires and to make them more meaningful to patients.
A well-known principle in behavioral economics is that to measure is to change behavior. A scale placed in the bathroom often helps people control their weight, even in the absence of other measures. Fuel consumption gauges on car dashboards tend to improve mileage. We hope that by measuring outcomes that matter to patients we will change our own behavior, and make the health care experience a better one.
¹ I am aware of the various startups developing apps meant to aggregate health information. Unlike Mint or Personal Capital which consolidate data from multiple and not-always-cooperative banks, these apps require that the user inputs all their health data. Making the user do the work of aggregating the data was the problem with the now-defunct Microsoft HealthVault and Google Health.
