What makes patients loyal? It may take more than you think

Just because you score well on patient satisfaction surveys doesn't mean your patients will stick around. Here are steps to discover your patient loyalty rate -- and how to push, or keep, it up.

By — Posted Dec. 4, 2006

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Four years ago, David L. Albenberg, MD, found out the difference between patient satisfaction and patient loyalty.

The Charleston, S.C., family physician estimated that nearly 100% of the patients at his busy group practice were satisfied with him. But when he decided to leave the traditional setting and start a cash-only practice, only 17% of his patients followed him.

Dr. Albenberg's experience exemplifies the harsh lesson many physicians have learned: Satisfaction doesn't always equate to loyalty.

Many practices measure patient satisfaction, particularly if doctors are paid based on performance. But if you want to make sure your patients follow you through thick and thin -- whether you move to a cash-based practice, drop their health plan, set up shop elsewhere or merely try to stay competitive -- you need a loyal patient. The "loyalty gap" is the chasm doctors must have their patients cross from satisfied to loyal.

Closing that gap, experts say, requires doctors to dig deeper in finding out what their patients think of them and their practice. Whether through surveys or informal chats, physicians need to communicate with patients to find out how they're doing, and accept nothing less than the highest marks.

Minding the gap

Most practices become aware of the loyalty gap when a major event affects their practice.

Vicki Kunkel, CEO of Leader Brand Strategists, recently worked with a small physician group in Chicago's western suburbs and now uses it as an example of how quickly the tide can change.

The four-physician practice, which declined to be identified for this story, was scoring a satisfaction rate of about 89% on patient surveys. But when a hospital-based convenience clinic opened across the street, their patient volume went down in a hurry.

"The good news is, it was a very busy practice," Kunkel said. "But if they kept losing patients at the rate they did, they wouldn't stay busy for very long."

The doctors commissioned another survey to test loyalty, asking how many patients would stay with them in any situation. Only about 49% would. Patients were frustrated by their inability to make immediate appointments and were easily pulled away when the new clinic offered same-day appointments. And because the senior physician, who had the bulk of the patient load, routinely passed off his patients to other doctors when he became overbooked, patients felt the doctor wasn't loyal to them, which made it easier for them to leave.

It took the senior physician humbly picking up the phone to personally urge his patients, one by one, to give him a second chance to help stem the patient exodus.

Experts say physicians shouldn't wait for a major wake-up call event before striving for higher rates of loyalty.

Matt Mulherin, a spokesman for Press Ganey, a South Bend, Ind.-based company that conducts health care satisfaction and improvement services, said physicians should be especially focused on retaining younger patients.

Press Ganey's 2006 Health Care Satisfaction Report found that older patients have the highest rates of loyalty. Therefore, patient volume could literally die off. This and other unavoidable factors, such as patient relocation or changes to insurance plans, cause an average of 25% of patients to leave annually, Kunkel said. So doctors should try to build loyalty to 75%.

The personal and emotional reasons patients decide to leave are different for every practice. For some, it might be frustration at routine billing mistakes, or it could be they don't like the demeanor of the front desk staff. But this much is clear: It's generally not distrust in the physician's clinical skills that sends them packing. And experts say the busiest practices could have the lowest rates of loyalty, without doctors realizing it.

"People are quietly voting with their feet, and physicians don't know it," said Randall Hutchison, director of customer service and performance enhancement for Geisinger Health Services, a 700-physician system that includes several hospitals and primary care clinics in central and northeastern Pennsylvania.

The only way to find out what the patient is thinking is to ask, experts say. But because patients don't always say what they mean or mean what they say, it's crucial to ask the right questions in the most appropriate manner, which can be different for every practice.

Elaine Berke, founder of EBI Consulting, a customer service consulting firm based in Westport, Mass., said it's not hard for a doctor to make a patient happy. But the true test of loyalty, she said, is whether the patient will recommend the practice to someone else.

Surveys rank on a scale of one (lowest) to five (highest) a patient's likelihood of recommending the doctor to someone else. The surveys that come back with a rating of five are the ones that show loyal patients, Berke said. But asking new patients if they were referred by someone also can be a good indication of loyalty.

Dr. Albenberg said sometimes it takes a doctor seeing a patient through a major illness to build true loyalty. But there doesn't have to be a major event for a relationship to form, he said.

Mark Rosenberg, MD, a pediatrician who runs a seven-physician office in Chicago, said consistently providing a high level of satisfaction makes a patient loyal and develops sound relationships between patient and doctor.

These relationships pay off. From a business perspective, it's cheaper to retain old patients than spend money replacing the ones who left, said Bob Spahr, MD, a neonatologist who serves as Geisinger's vice president for service quality,

Plus, a good relationship built on trust between the patient and doctor can only help doctors better diagnose and treat their patients, which leads to better outcomes, Dr. Spahr said. Geisinger rewards physicians for high ratings and requires extra training for doctors scoring in the lower percentiles.

Little things matter

Berke says loyalty is built throughout the patient's entire experience. starting with the phone call to make an appointment. Attitude and communication are among the most important elements, she said. While medical excellence used to be considered a differentiator, it's now more of a qualifier, she said.

One of Berke's clients runs a busy practice where long waits sometimes cannot be avoided. When the wait time gets excessive, the doctor will come out and personally apologize to everyone waiting and explain the delay. People appreciate that, she said.

According to Press Ganey's 2006 report, physicians have the greatest opportunity to cultivate patient loyalty by focusing on sensitivity to the patients' needs. Also ranked high was the overall cheerfulness of the practice and the overall comfort and pleasantness of the office. Berke said successful physicians "seem to hire the right people" who make patients feel welcome.

Kunkel said physicians also can develop loyalty by doing a better job of branding. But doctors are often fearful of that concept.

"Branding is nothing more than a promise," Kunkel said.

One of her favorite tactics is to ask a patient to describe the branding of their physician's practice. Responses will help physicians know what sets them apart. Gaining loyalty could be as simple as building on those strengths.

According to Dr. Albenberg, this type of communication can be done informally by simply spending more time with patients and really listening to what they have to say.

With a smaller patient load after he converted to a cash-based practice, Dr. Albenberg said he was able to spend more time with each patient to build those relationships. Three years into his cash-based model, he thought of making the switch to a retainer model.

This time, Dr. Albenberg spent several months talking with patients and "feeling them out" to make his own loyalty assessment. He then asked the patients to fill out a survey. Both outcomes found loyalty rates to be at more than 74%.

But surprisingly, what patients said motivated them to stay with the practice was not what Dr. Albenberg concluded in his own assessment. Dr. Albenberg said he thought the greatest percentage of his patients came to him because they did not have financial concerns about seeing a doctor who didn't take insurance. But from patient assessments, he learned that none of his patients were loyal to him for that reason.

Instead, loyalty was based upon Dr. Albenberg's promise of spending more time with patients and offering more services than he could in a traditional practice model. Loyalty was driven less by patients' ability to pay than by the physician's ability to make the patients happy.

That doesn't mean money never matters. But Dr. Rosenberg said he has learned that patients who leave because they have lost insurance or changed plans don't always stay away permanently. Plus, patients who leave still might refer new patients, he said. So loyalty remains a goal physicians should strive for.

Work and life situations, as well as insurance plans, are constantly changing, Dr. Rosenberg said. And a loyal patient will always come back if given the opportunity.

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Testing loyalty

By using a formal survey asking questions rating satisfaction for all aspects of the practice, from friendliness of staff to ease in making appointments, doctors can help sort loyal patients from those who are merely satisfied.

  • Do you feel you can have an open dialogue with your physician?
  • Do you feel your doctor is loyal to you?
  • What do you think sets this practice apart from others?
  • What are things we could do to make your visit more pleasant?
  • What would prompt you to switch to another doctor?
  • Would this practice be your first recommendation when referring friends or family to a doctor? If not, what does your first choice have that we don't offer?

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Increase loyalty by increasing sensitivity

Be sensitive, give good care and inspire confidence. Those are the top requests of physicians derived from a poll of 1.4 million patients treated at 5,400 sites nationwide. The survey was conducted by Press Ganey Associates of South Bend, Ind., who ranked responses. All terminology is theirs. Mean refers to the average percentage of patients who were satisfied. Correlation refers to the likelihood of using a certain factor in recommending another patient to a physician or hospital; the higher the number the greater the likelihood. The two categories combined create the priority index, ranking the traits most likely to foster loyalty.

Priority Mean Correlation
1. Our sensitivity to your needs 87.8 0.680
2. Overall cheerfulness of practice 89.5 0.698
3. Overall care received during visit 91.2 0.832
4. Comfort and pleasantness of exam room 85.8 0.517
5. Waiting time in exam room before being seen by care provider 83.0 0.495
6. Amount of time care provider spent with you 89.5 0.633
7. (tie) Care provider's efforts to include you in decisions about treatment 91.0 0.659
7. (tie) Instructions given about follow-up care 90.6 0.651
7. (tie) Convenience of office hours 86.7 0.500
10. (tie) Our promptness in returning your phone calls 84.0 0.489
10. (tie) Concern nurse/assistant showed for your questions or worries 89.3 0.558
10. (tie) Information given about medications 90.6 0.640
13. Concern care provider showed for your questions or worries 91.6 0.673
14. (tie) Our helpfulness on the telephone 88.3 0.507
14. (tie) Length of wait before going to an exam room 81.1 0.458
14. (tie) Your confidence in this care provider 92.3 0.720

Source: Press Ganey Associates

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