Health care delivery historically has not been a service- or consumer-oriented field. Patients had open-access insurance plans with low deductibles and were not too concerned about price or out-of-network charges. Physicians were the primary source of referrals and hospital admissions. So, providing physician amenities and convenience were more important than a consumer’s preferences.

But all of this has started to change. Health insurance exchange products and defined contribution benefits are leading to higher patient copays and cost sharing. Patients have turned into consumers who are spending more out of their own pocket for their own care. Now, price matters — as does the value and perceived worth of the service they are buying. And as more health systems partner or establish their own health plan products, consumer choice on providers is moving even more upstream and closer to consumers' paychecks.

In this environment, knowing and improving your customer loyalty can help drive these key consumer decisions on health plans and where to get care when it’s needed. It is this loyalty in consumer choice that is now the driver of market share, patient retention and the proportion of individual health care spending.

Measuring patient loyalty

At Advocate Health Care, we have recently started to move away from using traditional metrics of patient satisfaction, such as the Centers for Medicare & Medicaid Services-mandated Consumer Assessment of Healthcare Providers and Systems measures, and more toward metrics that try to gauge patient loyalty. This shift makes a lot of sense for us. We now have a narrow-network product on the health insurance exchanges. And like many in the industry, we are seeing more price shopping and cost comparisons, especially for some routine services like radiology.

Other retail-oriented industries have been measuring their consumers' loyalty for a while. One of the most popular approaches is the Net Promoter Score, developed by Fred Reichheld, of Bain & Co., with Satmetrix. It is a measurement that typically reflects customer responses to a single question about their likelihood to recommend a service on a scale of 0 to 10. Customers/respondents who rank the service 0-6 on the 10-point scale are considered detractors, while customers ranking your service a 9 or 10 are considered promoters. The percentage of detractors is subtracted from the percentage of promoters for an overall score. Responses of 7 and 8 are considered passive and are excluded from the calculation.

Costco was the highest-scoring company in 2015, with a score of 79, followed by USAA Financial Services at 75. Scores are also tracked by industry. Leading industries in the U.S. include department/specialty stores (with an average score of 58), brokerage/investment services (45) and tablet computers (44). Health insurance (the only health care-related industry tracked) is the third-lowest-performing industry, with an average score of 12 — just ahead of cable/satellite service and intranet service, scoring 3 and -3 respectively. Health care has a long way to go.

At Advocate, we use a modification of the Net Promoter Score that we internally refer to as the Patient Loyalty Score. Our measurement is built off our existing required CAHPS surveys for hospitals, physician office visits and home care. We utilize a specific question in that survey on the “likelihood to recommend” the facility, typically phrased as, “Would you recommend this hospital to your family and friends?” This question can be rated on a 5-, 4- or 3-point scale depending on the CAHPS survey tool used (hospital, home health or physician office visit).

For example, let’s assume the question is rated on a 4-point scale, ranging from “definitely no” through “probably no” and “probably yes” to “definitely yes.” We classify the “definitely yes” respondents as promoters and the “definitely no” and “probably no” respondents as detractors. The “probably yes” answer is considered passive and is excluded from the calculation. So, to get our patient loyalty score, we calculate the percentage of promoters minus the percentage of detractors: (% “definitely yes” responses) – (% “definitely no” responses + % “probably no” responses).

Our preliminary results show us that we have a score of 79 for the system overall; scores vary anywhere between 58 and 81 for our 12 hospitals, the medical group scores 90, and the home health division scores 74. We realize this metric may not be as meaningful in services where the decision-making authority of the patient is constrained by factors such as insurance coverage. For example, medical group (physician office) practices tend to have a higher score than other sites of care, indicating a deeper relationship between physician and patient that fosters a stronger sense of loyalty but also reflects the fact that patients often can and do choose their physicians based on the patients' specific preferences.

To establish targets for improvement, we leveraged our patient satisfaction vendor to compile a comparative analysis of patient loyalty scores for area hospitals, medical groups and home health providers. This benchmarking allows us to gauge our results in the market as well as identify an objective target using an “apples to apples” approach. Although we aspire to the results of higher-performing industries like retail and financial services, we have started an improvement journey with a goal of achieving the 75th percentile in our local health care market in the next two years.

Improving patient loyalty

Improving our Net Promoter Score will require more than incremental tactics and small changes in our patient-facing approaches. So, we at Advocate have started a combination of initiatives to redesign the entire health care experience for our consumers, an effort focused on pricing transparency, consumer access and care coordination.

The goal of our pricing transparency work is to respond to consumer requests for the price and estimated out-of-pocket costs of common diagnostic procedures such as CT scans and mammography. This is in response to more and more requests by consumers for prices before they schedule an appointment. This project has had several challenges, including examining our charges across all of our locations and standardizing across one price, and implementing systems and tools for our financial call center so its staff can quote a fairly accurate price based on an individual’s benefit plan. Ultimately, we also aspire to having one bill that includes both the procedure price and the physician billing component.

The goal of our access work is to be able to provide convenient care — in person and virtually — wherever and whenever a consumer wants. This has required us to have more same-day appointments and extended office hours available in our physician practices. It has also meant providing more options — both physical and electronic — for consumers to receive their care. This has translated into a partnership to operate retail clinics in Walgreens stores in our service areas to provide more-convenient, easy-access, lower-cost options for nonemergency care. We are also developing the ability for patients to have video and text eVisits with their providers. This will supplement a portal that already allows patients to schedule appointments, view test results and manage their prescriptions.

And last, our work on care coordination is to ensure continuity with our organization during the multiple transitions that can occur during an episode of care. This includes navigator services for oncology patients to manage the multiple appointments and disciplines involved in cancer care; outpatient care managers for high-risk patients at risk for unnecessary utilization; and transition coaching services following hospitalization for patients who may not be eligible for home health services. We believe these services help provide a high-touch experience across the continuum of care and engender patient loyalty.

Measuring and improving patient loyalty is rapidly becoming a critical competency for health care systems. We believe that other organizations can take an approach similar to ours  — first by adapting measures of patient loyalty from their existing patient-service surveys, and then by embarking on a redesign process that focuses on the principles of transparency, access and care coordination. This will allow other health care organizations to move from a system that is fragmented and transactional to one that is consumer-centric, continuous and value-oriented.

Rishi Sikka, M.D., is senior vice president, clinical operations, at Advocate Health Care, Downers Grove, Ill. Tina Esposito, MBA, FACHE, is vice president, Center for Health Information Services, at Advocate Health Care. Jim Skogsbergh, M.H.A., FACHE, is CEO and president of Advocate Health Care and chair of the American Hospital Association.