Thursday, June 29, 2017

United Airlines Fiasco Should Be a Healthcare Wakeup Call




The forcible removal of a passenger from the United Airlines flight has reminded flyers of their general dissatisfaction with the airline industry. Perhaps surprisingly, it should also be a stern warning to physicians. The brunt of dissatisfaction in healthcare delivery will fall on the providers although the real culprits are the insurers; they too should take notice.

The airlines do not appreciate the real basis for the outburst by the traveling public. The forcible eviction, despicable as it was, was really just the “straw that broke the camel’s back.” Airline travel was once a special, adventurous part of the journey. Today it is an undesirable but necessary means to an end. Why? Because the airlines treat their customers with disrespect at every part of the process. It is not just United; it is all of the airlines. The uproar is not about the rules, “the contract of carriage,” but about the manner in which airlines think about their passengers – definitely not customers who deserve respect. Respect and dignity are the key words.

The public’s general consensus – it's not fun anymore; there has been complete loss of autonomy and dignity; flyers often feel they are herded like cattle with total loss of all control and definitely not treated as valued customers. The sense is that the corporate view is "stockholder value "as the priority, not customer satisfaction, preference and loyalty as a means to generate that value.  "The friendly skies" are no longer, if they ever were. There is no sense that the airline executives who set the employee standards and culture remember that a customer pays the employees’ salaries, their bonuses and ultimately the stockholders’ dividends. In this environment, the employee from captain to gate agent to luggage handler is captive. They may – and I suspect to a large degree do – want to treat their passengers as real people, real customers deserving of real respect but it is clearly not the corporate ethos.

In any business, for profit or not for profit, it is true that "no money, no mission" but money has become the mission.

Such is the case with much of healthcare. Patients are frustrated feeling that they are not respected, not afforded autonomy or control and not valued. As a retired physician and academic hospital CEO I have witnessed and felt the transformation within medicine over the past 50 years. As with the airlines, most physicians, nurses, pharmacists and other staff are all well-meaning and caring. But patients are at the breaking point. In short, the patient is not treated like a valued customer but more like a commodity.

 It takes about three weeks to gain an appointment, there are long waits in the “waiting room” and then just a few minutes with the doctor.  You may personally like your physician but you are not pleased with the situation and feel helpless to rectify it because you are not the customer, the doctor’s customer is the insurer.  The insurer will determine if and how much the doctor is paid; the patient is a bystander to the transaction yet saddled with copays and deductibles. The patient cannot even request more time for more pay – the insurer prevents direct payments to the doctor. 

From the doctor’s perspective, he or she is undervalued by the insurer who acts capriciously, produces extensive rules, regulations and requirements that do not add to patient care but require extra work – time not spent with the patient. And since insurance payments for primary care especially are notoriously low yet with ever rising overheads, the physician is obliged to shorten visits often to about 8-12 minutes of actual face time.

It is a situation right for an outburst – from both patient and doctor although for different reasons. An event – not malpractice but just something totally unacceptable like being dragged off the plane – could dramatically upset the status quo. Patients will cry out that they “will not take it anymore.” They will demand accommodation for privacy, courtesy, autonomy and especially respect and dignity. They will expect to be treated as valued customers. 

Physicians are in a bind as well. If the time per patient is short and the PCP only deals with “simple” problems, referring all of the rest to specialists, then the patient comes to feel that the PCP (e.g., internist, family medicine doctor or pediatrician) is irrelevant, often unavailable and yet expensive. The patient is increasingly likely to go to CVS, Walmart or Walgreens and get seen promptly for minimal cost. Here is an example from a friend: “For Boy Scout camp it is necessary to have a health form filled out by the pediatrician. In our son’s case, our insurance covers one physical a year, and we usually go around his birthday in June. But the form is due April 17th so I found myself in a Catch 22 situation. The insurance company won't pay for a physical until June, the pediatrician won't fill out the form without doing a physical. So I ended up taking him to CVS WellCare and paid them $69 to fill out the form, much less than what the pediatrician would have billed.”

There is a clear difference between the airline industry and the healthcare industry, even above and beyond the obvious that one is an option much of the time and the other is frequently not an option. The issue with the airlines is not price which is generally reasonable; it is the lack of being treated as a customer. In healthcare, the prime issue is also about not being treated as a valued customer – with respect and dignity. But now, where price never mattered in the past, it has become very important. Previously, I have suggested some “fixes.”

Healthcare needs to open its eyes and realize that its bread-and-butter is highly vulnerable. Yes, the insurers make life difficult if not near impossible. But the object of healthcare delivery is, or at least should be, for the patient. The hospital and the physician may be vulnerable to the whims of government and insurers but – more importantly yet unrecognized– may be exceedingly vulnerable to the very patients who have entrusted their care to them. Let this be a wakeup call and let it begin a careful look in the mirror rather than looking for external demons. When the uprising occurs, the blame will be heaped on the providers – hospitals and physicians alike. If it is a hospital issue, the doctor can’t escape – the patient looks to the doctor as the face of the hospital.
Insurers should take a close look as well. In their effort to reduce costs, they – beginning with Medicare - have systematically held primary care reimbursements low yet added excessive nonclinical work requirements. The result is the morass of today with frustrated, burned out physicians, angry patients and increased costs.

The initial response of United Airlines completely missed the depth of societal outrage and later did not appreciate how deeply the traveling public feels devalued. More recently, the board chair stated that this was a “defining moment in the history of United Airlines pivoting to customer service and customer delivery.” If he means it, it will mean a momentous change in corporate ethos and business practice. Let’s hope.

Perhaps healthcare – including Medicare and commercial insurers – will come to recognize that it too must change or ultimately feel the wrath of dissatisfied patients – their customers. Meanwhile physicians need to take the offensive to direct change. Unified they can force the changes needed for the benefit of their patients, themselves and the total costs of care.
The forcible removal of a passenger from the United Airlines flight has reminded flyers of their general dissatisfaction with the airline industry. Perhaps surprisingly, it should also be a stern warning to physicians. The brunt of dissatisfaction in healthcare delivery will fall on the providers although the real culprits are the insurers; they too should take notice.

The airlines do not appreciate the real basis for the outburst by the traveling public. The forcible eviction, despicable as it was, was really just the “straw that broke the camel’s back.” Airline travel was once a special, adventurous part of the journey. Today it is an undesirable but necessary means to an end. Why? Because the airlines treat their customers with disrespect at every part of the process. It is not just United; it is all of the airlines. The uproar is not about the rules, “the contract of carriage,” but about the manner in which airlines think about their passengers – definitely not customers who deserve respect. Respect and dignity are the key words.


The public’s general consensus – it's not fun anymore; there has been complete loss of autonomy and dignity; flyers often feel they are herded like cattle with total loss of all control and definitely not treated as valued customers. The sense is that the corporate view is "stockholder value "as the priority, not customer satisfaction, preference and loyalty as a means to generate that value.  "The friendly skies" are no longer, if they ever were. There is no sense that the airline executives who set the employee standards and culture remember that a customer pays the employees’ salaries, their bonuses and ultimately the stockholders’ dividends. In this environment, the employee from captain to gate agent to luggage handler is captive. They may – and I suspect to a large degree do – want to treat their passengers as real people, real customers deserving of real respect but it is clearly not the corporate ethos.

In any business, for profit or not for profit, it is true that "no money, no mission" but money has become the mission.

Such is the case with much of healthcare. Patients are frustrated feeling that they are not respected, not afforded autonomy or control and not valued. As a retired physician and academic hospital CEO I have witnessed and felt the transformation within medicine over the past 50 years. As with the airlines, most physicians, nurses, pharmacists and other staff are all well-meaning and caring. But patients are at the breaking point. In short, the patient is not treated like a valued customer but more like a commodity.

 It takes about three weeks to gain an appointment, there are long waits in the “waiting room” and then just a few minutes with the doctor.  You may personally like your physician but you are not pleased with the situation and feel helpless to rectify it because you are not the customer, the doctor’s customer is the insurer.  The insurer will determine if and how much the doctor is paid; the patient is a bystander to the transaction yet saddled with copays and deductibles. The patient cannot even request more time for more pay – the insurer prevents direct payments to the doctor. 

From the doctor’s perspective, he or she is undervalued by the insurer who acts capriciously, produces extensive rules, regulations and requirements that do not add to patient care but require extra work – time not spent with the patient. And since insurance payments for primary care especially are notoriously low yet with ever rising overheads, the physician is obliged to shorten visits often to about 8-12 minutes of actual face time.

It is a situation right for an outburst – from both patient and doctor although for different reasons. An event – not malpractice but just something totally unacceptable like being dragged off the plane – could dramatically upset the status quo. Patients will cry out that they “will not take it anymore.” They will demand accommodation for privacy, courtesy, autonomy and especially respect and dignity. They will expect to be treated as valued customers. 



There is a clear difference between the airline industry and the healthcare industry, even above and beyond the obvious that one is an option much of the time and the other is frequently not an option. The issue with the airlines is not price which is generally reasonable; it is the lack of being treated as a customer. In healthcare, the prime issue is also about not being treated as a valued customer – with respect and dignity. But now, where price never mattered in the past, it has become very important. Previously, I have suggested some “fixes.”

Healthcare needs to open its eyes and realize that its bread-and-butter is highly vulnerable. Yes, the insurers make life difficult if not near impossible. But the object of healthcare delivery is, or at least should be, for the patient. The hospital and the physician may be vulnerable to the whims of government and insurers but – more importantly yet unrecognized– may be exceedingly vulnerable to the very patients who have entrusted their care to them. Let this be a wakeup call and let it begin a careful look in the mirror rather than looking for external demons. When the uprising occurs, the blame will be heaped on the providers – hospitals and physicians alike. If it is a hospital issue, the doctor can’t escape – the patient looks to the doctor as the face of the hospital.
Insurers should take a close look as well. In their effort to reduce costs, they – beginning with Medicare - have systematically held primary care reimbursements low yet added excessive nonclinical work requirements. The result is the morass of today with frustrated, burned out physicians, angry patients and increased costs.


The initial response of United Airlines completely missed the depth of societal outrage and later did not appreciate how deeply the traveling public feels devalued. More recently, the board chair stated that this was a “defining moment in the history of United Airlines pivoting to customer service and customer delivery.” If he means it, it will mean a momentous change in corporate ethos and business practice. Let’s hope.

Perhaps healthcare – including Medicare and commercial insurers – will come to recognize that it too must change or ultimately feel the wrath of dissatisfied patients – their customers. Meanwhile physicians need to take the offensive to direct change. Unified they can force the changes needed for the benefit of their patients, themselves and the total costs of care.
20,2017

Originally appeared in Medical Economics, May 

3 comments:

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