Press Room

Medical BusinessÆ
June 30, 1998
Make every minute count, counsels physician advisor
By Maureen Glabman

They weren't the views you would expect of a managed care expert: That solo practices can thrive, that there are no economies of scale from grouping physicians and that cutting practice expenses makes offices less productive.

But that's what nationally known consultant and author, Greg Korneluk, told an intrigued Baptist Hospital audience of 50 physicians, spouses and office managers June 18.

Korneluk chairs the International Council for Quality Care in Boca Raton, a physician advisory company that takes a decidedly contrarian approach to managed care. His philosophy is backed by time motion studies of 5,000-10,000 physicians.

"I don't have a problem with managed care,' he says. "But it has forced doctors to focus on dollars. Physicians who focus on making money make less money. Doctors who focus on quality make more money."

The Council's main philosophy mimics that of other consulting groups: The most successful doctors improve quality and patient satisfaction while increasing volume and efficiency — though that often seems to physicians a contradiction in terms.

Korneluk takes an industrial engineer's approach to physician work. For 13 years, the chairman has shadowed physicians from dawn to dusk, equipped with a stopwatch and clipboard. He attached pedometers to labcoats to observe how much time is spent in wasted motion.

"High quality physicians that are highly productive are efficient in time management," he says. "Minimize motion and your day will have less stress."

A minute saved is a minute earned

The results of his research are dozens of physician-friendly, time-saving recommendations that run from shaving seconds by removing exam room doorknobs to hiring "documentation assistants," that is, transcriptionists, who sit alongside physicians in exam rooms and keep records. "Every chart needs to be finished by the next morning at 9 a.m. or you're at risk when patients call," Korneluk admonished.

The Council estimates primary care physicians' office time is valued at $3 to $4 per minute. 'Make every minute count" is the unofficial company motto.

Doctors spend lots of wasted time looking for their nurses. Korneluk's suggestion: install a $50 cordless doorbell chime available at do-it-yourself home stores. At least one audience member said she had carried out that idea with success.

Korneluk found an average physician walks four to six miles per week in the office. His suggestion: reduce time spent walking and productivity will increase. Merely taking off rubber gloves and putting them in a wastebasket three steps away costs two minutes a day, or the equivalent of $6.

That's $1,200 per year in one activity alone. Solution: move the basket to where the physician sits.

Tune out the negative

Korneluk's goal is to show physicians how to preserve quality in a system paying them less and less. Doctors who heard the talk called his ideas "profound" yet remained skeptical. 'I don't believe that managed care companies look for superior quality. They look for average," said Miami internist Mark Kutner. "Taking good care of people pays off but it costs more."

But Council research turned up the opposite results. "If you cut staff to save expenses, you see less patients, you are less efficient and less productive. You have to spend more to make more," says the Council chairman.

Another internist voiced reservations. "Even if you make yourself more efficient, the insurance companies continue to lower fees. I don't see managed care rewarding physicians for efficiency," says Miami internist Robert Friedman, MD.

Korneluk says the most successful doctors are good clinicians whose practices hum with happy staffers and satisfied patients.

Much of his advice for achieving such harmony hinges on delegation and personalization. For example, he believes that to build a successful practice, the doctor, his nurse and receptionist should randomly call three patients daily and ask them how they are doing. He suggested doctors take Polaroid pictures of patients and list their hobbies.

At times, Korneluk seemed a cheerleader for downhearted physicians fed up with managed care. 'There's a lot going on in medicine that's negative. Tune out the negative," he said. He told physicians the most successful doctors wake up in the morning, look forward to going to work and try to make each day a perfect day. "When you study successful people, they imagine being successful, they have that vision," he said.

For burned-out physicians, he suggested re-engineering practices to focus on what doctors truly enjoy. One Toronto physician he coached, for example, enjoyed treating body builders best. Another young doctor enjoyed treating seniors. Both changed their practices to specialize in those groups.

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The New York Times
April 16, 1984
A Push to Market Health Care
By N.R. Kleinfield

Patients going to the Methodist Medical Center in Peoria, Ill., never worry about parking their cars. The hospital started offering valet parking a few months ago. The place also has a doorman. After he swings open the door, patients are handed over to an escort, who shepherds them to their destination.

"These things are going over really well," remarked Ellen Barron, the hospital's vice president for marketing and planning. "People appreciate the little things."

Hospitals and doctors, faced with competition at every turn, are resorting to the sort of marketing tactics more commonly found in the airline business or the quick-burger industry. With increasing frequency, they are advertising in newspapers and on television. According to figures from the Television Bureau of Advertising, for example, health-care professionals spent $41 million on TV spots last year, compared with just $3.7 million in 1977.

Some Concerns

To be sure, many doctors and consumers who feel that the saving of lives is a lot different from the selling of pudding, look with half-lidded eyes on the idea of health-care advertising. Marketing expenditures, moreover, might contribute to higher healthcare costs and needless utilization. A spokesman for the American Medical Association remarks, "Lots of physicians still associate advertising with quackery. Some doctors don't want to even list their names in the Yellow Pages."

But the concept is clearly gaining acceptance among nonprofit and profit-making institutions alike. Two different approaches are being tried," said William Flexner, head of Flexner & Associates, a health care consultant. "Some places are advertising that they care, which I don't think works because you have to experience caring. Others are advertising 'we have such-and-such service' prenatal care or ambulatory surgery, for instance. Some hospitals advertise an image. A popular one seems to be the high-tech image."

In addition, health-care dispensers are cooking up some unorthodox enticements. Some hospitals, including a number of the 89 facilities in the Humana Inc. chain, guarantee that they will inspect a patient within a prescribed time of arrival in the emergency room. Eastwood Hospital in Memphis gives refunds to patients of between $5 and $15 if various standards are not met, such as if the floor nurse does not answer a call signal within a minute, the linens are not changed daily or a meal is not served piping hot. In the program's first year, infractions resulted in the hospital's trimming a total of $140 from patients' bills.

When Southwood Community Hospital in Norfolk, Mass., was converted to a general hospital from a cancer treatment center recently, the community was saturated with direct mail brochures that enclosed coupons good for a free medical encyclopedia. To get the volume, a patient had to show up at the hospital's walk-in clinic, but did not have to be treated. And an Albuquerque, N.M., obstetrician-gynecologist advertised his practice using a hot-air balloon with a stork painted on it.

One of the more memorable marketing gimmicks was used by Sunrise Hospital in Las Vegas. A number of years ago, the hospital staged a lottery that was open only to patients who checked in on the weekend, a typically slack time at hospitals. The grand prize was a cruise for two. Utilization soared by 60 percent in 18 months.

"Hospitals and doctors have suddenly found themselves in a competitive situation which didn't exist 10 years ago," says Dan Beckham, head of Healthtmarket Inc., a health-care consultant.

Mr. Beckham guesses that perhaps 50 percent to 60 percent of the nation's hospitals now employ a marketing professional, compared with perhaps 5 percent to 10 percent just three years ago.

Until recently, medical societies and hospital associations frowned on or actually barred their members from soliciting patients. It was as recently as 1977 that the American Hospital Association published its first guidelines for hospital advertising. The Federal Trade Commission ruled in 1980 that the American Medical Association could not bar its members from advertising, and the A.M.A. has revamped its code of ethics to allow advertising in a truthful manner.

Since then, health-care professionals have found different ways of marketing their services.

Ways of Marketing

"Marketing is how your office is decorated," remarks Irwin Braun, president of Braun Advertising and a student of the subject. "Marketing is what kind of service you give people. Marketing is how long you keep people waiting. An ad can get you into an office, and if a person is kept waiting for an hour, he'll take a walk. One famous ear, eye and throat doctor in New. York has his office reception room decorated with portraits of Presidents and actors whom he has treated. That's marketing."

Like many cities, Flint, Mich., is extremely competitive for healthcare providers. To woo patients, St. Joseph's Hospital thought up several special deals. For example, the hospital offers a packaged obstetrical program called "Special Delivery." An expectant mother gets a 24-hour hospital stay and follow-up visits for $799. A normal charge for delivery had been $2,500 to $3.000.

In advertising the offer, the hospital used the theme: "A bundle of joy . . . A bundle of money." It hit home. Deliveries climbed to 1,650 last year, from 1,200 in the previous year, a rise the hospital attributes mainly to the campaign.

Emergency Room Fees

St. Joseph's also noticed that it was rapidly losing emergency room business, especially minor emergencies, to after-hour clinics and emergency clinics not associated with hospitals. A study found that the key elements that affected a patient's choice of emergency rooms were cost and waiting time.

So instead of charging a flat fee of $65 for all emergency room patients, the hospital switched to a tier system of pegging fees to the severity of the injury. Someone with a heart attack now pays about $M, while a person with a bump on the head would be charged $25. A TV campaign promoted the new approach, and the hospital reports that emergency room business has picked up by about 10 percent in the past year.

Greg Korneluk is a Lewiston, N.Y., consultant who specializes in advising doctors on how to sell themselves. "The marketing theory that I use with physicians is that the actual core service offered to patients is pretty homogeneous," he explained. "Things like parking, appearance, staff, courtesy — all those peripheral things matter.

Mr. Korneluk, noting that a number of doctors have video games in their reception rooms, urges his clients to put TV sets in their examination rooms. "While the patient is sitting there he can watch the TV," he said. "I know a doctor in St. Louis, who has color sets in all his exam and reception rooms. That's class."

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City Business
Marketing, the newest idea in medicine
Doctors cater to patients more as competition builds
By Wayne Nelson

In a seminar sponsored recently by Metropolitan Medical Center, Greg Korneluk, a nationally recognized health care consultant, told a group of Twin Cities medical specialists that business acumen will weigh more heavily than medical talent when it comes to deciding who survives the physician shakeout already under way here.

"The three A's in building a practice are availability, affability and ability — in that order," he told the group. "Successful physicians will be those who cater to their customers."

While many physicians will find that advice a bitter pill to swallow, there is logic behind Korneluk's assessment. Since most patients are not in a position to judge their physicians' medical abilities, they rely heavily on a physician's communication skills and demeanor in deciding whether he or she is a good doctor, Korneluk says.

Korneluk advises doctors to take advantage of that fact, rather than fight it, by adopting marketing and management principles learned decades ago in other service industries. Eliminate patient waiting time whenever possible, he says. Or, at the very least, make the wait more comfortable and less demeaning.

Read the patient's chart before walking into the examination room instead of after. Follow up with patients on diagnostic findings and recommendations. Send them birthday and holiday cards.

And don't stop with patients, Korneluk told the doctors. Work on winning the loyalty of other physicians who might send referrals. This should be a special consideration for medical specialists, who depend upon referrals from other doctors for much of their business.

Korneluk suggests that specialists distribute newsletters to referring physicians that include up-to-date information and relevant clips from professional specialty journals.

The marketing device requires little effort, he says, and sends two important messages to primary care physicians: that the specialist wants to help them be up-to-date, and that the specialist is current with research findings and new technology in his or her chosen specialty.

Korneluk also suggests that specialists stay in touch with the needs and wants of referring physicians. Generally, beginning physicians want comprehensive reports from doctors who have seen their patients, while doctors who have been in practice five years or longer tend to prefer abbreviated reports of diagnostic findings.

"They like to keep their files tight," Korneluk says.

"Ask the referring physicians what they want, and give it to them promptly."

Why the sudden interest in patients on the part of doctors, who in the past have equated marketing with hucksterism? In a word: competition. A growing surplus of physicians, and the increasing success of health maintenance organizations (HMOs), which pay their doctors a salary and compete with private practitioners for patients, have private doctors worried.

They are also concerned that they might be the federal government's next cost containment target. (Hospitals were the government's first target because they consume the largest share of the U.S. health care dollar, about 40 percent).

Korneluk predicts that next year the federal government will extend controls to physicians like those it imposed on hospitals two years ago for Medicare inpatient treatment. Medicare's regulations for Diagnosis Related Groups (DRG) set a payment ceiling for each Medicare patient treated by a hospital.

Korneluk also warns that, as early as next year, Medicare might require physicians to accept a set monthly rate for outpatient care.

The squeeze these competitive forces are putting on private practitioners, in addition to continuing rises in insurance and other costs is likely to get worse, according to Korneluk and others. They believe private practice physicians have no alternative but to practice medicine more efficiently.

Ironically, doctors are finding that a former foe has become an ally. The very hospitals that doctors often fought with for control of the old health care system are teaming up with doctors in order to survive the shakeout.

Korneluk's seminar (sponsored by Metropolitan Medical Center) and similar forums for physicians hosted by other Twin Cities hospitals reflect some of the newfound common ground hospitals and doctors have discovered.

The alliance stems from Twin Cities hospitals and private practice physicians both having lost patient volume as a result of HMOs' growth. Together, the two groups are working to find ways to compete with this new and powerful force.

In the past two years, the hospitals that have succeeded most have been those that have learned to manage themselves and market their services. Now, those hospitals are providing that management and marketing know-how — and, in some cases, even capital — to private practice physicians to help them maintain and expand their patient bases, says Richard Reece, a physician and editor of Minnesota Medicine, a magazine published by the Minnesota Medical Association.

What's in it for the hospitals? The hospitals, which are in their own battle to keep their beds full, are betting that the new alliances eventually will translate into patients.

While these shifting alliances will largely be invisible to health care consumers, patients can expect to see more effort by physicians to turn office visits into "health care experiences," as Korneluk puts it. Just a few of the conveniences he expects to see are coffee pots and televisions in waiting rooms, recorded telephone messages (similar to those that provide flight information for airlines) so patients can find out whether the doctor is behind schedule, and maybe even house calls.

Look also for the actual time spent with a physician during an office visit to shrink from the current 12 minute average to perhaps 8 minutes. As their costs rise and competitive pressures and government payment ceilings limit fee increases, physicians will have to see more patients if they want to maintain their current income, according to Korneluk.

But reducing the length of office visits need not undermine the goal behind these marketing efforts, which is to improve the doctor-patient relationship, Korneluk says. Quite the contrary: Marketing and management goals should be complementary.

For instance, he urges specialists who have just finished examining a patient not to sit there writing themselves notes for a letter to be dictated later for the referring physician.

"I'd say put a tape recorder in front of you, and tell the patient, 'This is what I'm going to tell your doctor in a letter,' " Korneluk says. Then, give the tape to a clerical person and let him or her write the letter to the referring physician.

"Physicians have to learn to be more efficient with their time," says Korneluk.

"[Medicine] is another service sector at the end stage of a cycle, having to pull up its socks, just like everyone else."

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