The Erosion of Trust in Healthcare by Array Architects

The Erosion of Trust in Healthcare By Neil Carpenter, Jillian Barbaro, Isabelle Moratti, Alexandra Laramee

INTRODUCTION Array wanted to break out of the incremental nature of most health care evolution white papers and focus on long term trends that might not be felt strongly for a decade or more. Just as a major pandemic was eminently predictable but rarely addressed because it was never a likely near-term event—so are the structural forces we describe in our papers. We interviewed 16 leading healthcare executives across the industry, including representatives from the provider side, payor organizations, technology innovators, and academia and asked them to visualize health care delivery in 2040. The study documents and expands upon the perspectives of these leading thinkers and the four major trends that emerged from these interviews. Each installment unpacks one of the four trends: • Deterioration of trust: following the societal trend, patients will no longer simply listen to what the provider says. As the care delivery process becomes more participative, what are the implications? • Segmentation of healthcare: the big sort is coming to healthcare practices and different demographics will demand different focuses. • Whole person care: an integrated vision of health will mean a much broader definition of physical and mental wellbeing, with less traditional providers and methods of care. • Evolution of healthcare settings and employment: a major shift in how health care dollars are spent coming. Discover how care settings and the workforce will be the key drivers. Not only do we provide research behind why we believe healthcare is heading this way, but we also provide implications for how different players within the industry can prepare themselves to be successful for what is to come. New installments of the study will be issued every week. The first follows. To contact the authors with questions, comments or strategic planning support, see p 14 for their information or contact us. This paper will be a four-part series with a new emergent trend to be released each week.

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INTERVIEWEES Shahid Shah Co-Founder of Citrus Health (technology at home), Founder of Netspective Communications (technology strategy & sale), Health Sciences & Technology Advisor at Larta Institute.

Rasu Shrestha, MD, MBA Chief Strategy & Transformation Officer, Atrium Health

Robert Kramer Marcy Carty, MD, MPH EVP of Strategy at Ready Responders

Paul Keckley The Keckley Group, Healthcare Industry Research and Policy Analysis

Trenor Williams, MD

Founder and Fellow at Nexus Insights; Co-Founder and Strategic Advisor National Investment Center for Seniors Housing & Care

Sara Vaezy Chief of Digital and Growth Strategy at Providence Health, Health Evolution Forum Fellow

Dan Durand, MD

CEO & Co-Founder Socially Determined

Chief Clinical Officer & Chair of Radiology at LifeBridge Health

Tom Cassels

Braden Lambros

President at Rock Health

Executive Vice President at Olive

Michael Tangrea, Ph.D. Endowed Professor in Biology, Former Scientific Director of Innovation & Research

Sunny Ramchandani, MD President and CEO, Stream Health Group, Former Payor Executive

Peter O’Neill

Susan Mani, MD

Executive Director of Cleveland Clinic Innovations & Innovation Consultant

Payor Executive, Former Chief of Population Health at LifeBridge Health

Mark F Victor, MD

Alan Pitt, MD

CEO, Cardiology Consultants of Philadelphia

Neuroradiologist with Dignity Health and Co-Founder of Vitalchat Telehealth

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Healthcare institutions that deliver “good medicine” and demonstrate the ability to engender trust will have far better market and clinical outcomes. Historically trust has been assumed in the health care marketplace; however, as the COVID vaccine situation makes abundantly clear, trust is not inherent to the patient-provider relationship. This paper seeks to describe the micro and macro factors partially responsible for the eroding physician and healthcare system influence as well as a set of recommendations for rebuilding trust. The nature of the factors varies widely, some bold and obvious to laypeople, others barely distinguishable in healthcare settings and easy to forget when strategic planning. Micro-level contributions include large, well-branded entities competing for the attention of patients from their local providers. These disruption forces started with the growth of direct to consumer (DTC) advertising but rapidly took many different forms. The urgent care explosion, the growth of freestanding emergency departments, the rise of Dr. Google, and the introduction of new devices offering to empower consumers with diagnostic insights (e.g., genetic traits, sleep, heart rhythms, etc.) have all provided the healthcare consumer with knowledge and choice. With a newly empowered healthcare consumer in mind, we contemplate if increased population comfort with drug legalization and self-medication through less-traditional means (e.g., supplements, meditation, diet, etc.) are evidence of or a response to the degradation of trust in traditional healthcare providers and their influence. Historically the health care system has tended towards independent companies building independent relationships with consumers in place of integrating into one care team. While a one care team model would build trust with patients and be in their best interest, it may be a cost that companies cannot, or do not want to, bear. As a result, the proliferation of these disrupters has continued and while each incremental step is geared toward empowering the consumer and improving their health, the collective effect is loose attachments across multiple providers and products. Macro level factors progressing the need for trust-enhancement as part of medical care delivery include the overall declines in trust in American society and systems, particularly among younger generations less deferential to perceived sources of expertise. Over the decades one of the constants in American healthcare has been a strong patient-to-physician relationship. In 2020, Gallup reported 51% of respondents saying they had a “Great deal” or “Quite a lot” of trust in the medical system. This level of trust in both individual providers and the “system” overall is an outlier compared to other institutions and peer relationships. Gallup’s survey reported that the percentage of U.S. adults’ trust in institutions has gone down across the board. For example, in 2005, 53% of people had a “Great deal” or “Quite a lot” of trust in Church/Organized Religion, but by 2020 only 42% reported that level of trust. As for institutions such as Congress, the percentage dropped from 22% in 2005 to 13% in 2020.i There is also a growing lack of trust in other people. Pew Research reported that as of 2019, 47% of U.S. adults believe that most people cannot be trusted. Most recently, vaccine hesitancy—particularly for children whose pediatricians are almost universally recommending the vaccine—may be a signal that these same declining trust dynamics are beginning to affect healthcare.

US Trust in Institutions

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Disruptors to Healthcare Relationships Direct to Consumer Disruptors In 1997, money spent on health-related direct-to-consumer advertising was $2 billion. By 2016 it was just under $10 billion.ii Even adjusted for inflation, that equates to more than a tripling in spending. The investment in the trust-yourself-and-this-product messaging echoed by advertising seems to be working. A study by Kravitz, Epstein, and Feldman showed that 75% of patients were likely to ask providers about a drug they saw on TV while ~25% reported that they already had. Out of those that had already asked their doctor for a specific drug advertised to them, 16% said they were prescribed that drug. The natural next question became: “What happens to the relationship and trust between patient and provider when patients, equipped with knowledge from advertisers, influenced treatment decisions?” This same study provides an answer: 16% of patients questioned their provider’s expertise upon being denied the drug they had requested after seeing it on TV and another 23% said if they were denied, they might switch clinicians.iii

Urgent Care Could changes in the local and known provider/patient relationship dynamic account for the steady and continued growth of urgent care centers over the past ten years?iv In 2013, there were 6,100 urgent care centers as compared to 9,616 reported in 2019. Much like the rapid growth in the number of facilities across the nation, there has been an explosion in urgent care visits. Between 2008 and 2015, a research study done by JAMA Internal Medicine showed that visits to urgent care clinics increased by 119% among commercially insured Americans under the age of 65.v The growth in visits to urgent care facilities could also be indicative of the growing belief that a primary care visit is not necessary or desirable when urgent care provides a faster, more efficient treatment option for sudden onset sickness. The industry trends show that urgent care patients tend to be young adults

Change in Urgent Care and Emergency Room Visits per 1,000 Members 120 100

and families. A Kaiser Family Foundation poll found that 26% of

urgent care utilizers did not have a primary care doctor. Most

notably, among future healthcare utilizers (those aged 18-28 in

this survey), 45% of them denied having an assigned PCP.

Motivated by the growth in urgent care and the obvious

0 2008

preference for fast, efficient care delivery models among younger care seekers, online care delivery companies are developing the next urgent care iteration: online urgent care services. Dispatch Health created a platform that allows patients to

45%

2016

Percentage of Respondents (by Age Group) Without a PCP

make appointments through their app or website. Within a few hours, a member of their team makes an in-person, home visit

28%

to evaluate the patient and provide recommendations. In 2021,

18%

Dispatch Health reached a total valuation of $1.7 billion.vii Heal,

12%

a tele-based healthcare company, developed an app for house calls and telehealth visits with clinicians, an unfairly fast alternative when compared to the hassle and wait associated with phoning and scheduling with a PCP’s office. Heal received $100 million in funding from Humana in July 2021.vii i

18 to 29

30 to 49

50 to 64

65+

Source: https://www.ashworthcreative.com/blog/2019/06/ how-healthcare-providers-can-differentiate-themselves/

The Rise of the Hospitalist and Segmentation of Care

PCP relationships with their patients could be downgraded by the rise in the hospitalist, a term coined in 1996. At that time, there were less than 1,000 of these hospital-based physicians and they administered only 9% of inpatient care.ix As of 2018, there were more than 57,000 hospitalists in the USx accounting for more than 67% of hospital-based services.xi The use of hospitalists has risen as admitted patients have become more complex over time. These providers offer easier accessibility, improved efficiency, improved LOS and are generally considered better for hospital-based quality.xii However, in a quarter or more of cases, the patient’s PCP did not The Erosion of Trust in Healthcare | PAGE 5

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even know that they had been hospitalized, and the open question is whether the systems of care can have strong relationships with patients when so much care is segmented across such a broad care team.xiii At some level, the health care system today views patients as widgets to be efficiently treated with the latest tools and technologies, but that process today exists in a cultural environment of declining trust. While individually everyone is working hard to keep the trust of the patient, do the individual actions undermine the collective trust of patients in the system or in the pinnacle of the system, primary care?

Direct-to-Consumer Testing The direct-to-consumer genomic testing market has exploded in the past few years. Pew Research reported that 15% of American adults have taken a mail-in DNA test.xiv Over the past 15 years, genetic at-home tests paved the way for several similar at-home tests that claim to measure food sensitivity, fertility, and genetic risk for diseases such as Parkinson’s or diabetes. Access to compelling (albeit still medically scrutinized) self-health data empowers the patient to seek a medical response customized to their specific needs. Armed with information from tests like these, patients expect to have more involvement and control over their healthcare decisions. One professional we spoke to had asked the question “Why would I need to go to an annual wellness visit if I can access all that data from my home?”.

Continual Monitoring Another form of direct-to-consumer advertising exists within new remote monitoring tools, like the Apple Smart Watch. In 2018, a survey was conducted to ask U.S. adults if they would purchase the then-new “Apple Watch Series 4.” The watch included new FDA approved services such as an EKG app, the ability to detect atrial fibrillation, and an emergency services alert that activates if a fall occurs. Among the respondents, almost half of Baby Boomers affirmed their interest in purchasing the new watch.xv Recently, Samsung released their latest smart watch that has additional health sensors—optical heart rate, electrical heart, and bioelectrical impedance analysis—allowing users to monitor their blood pressure, detect AFib, measure blood oxygen level, and calculate their body composition in addition to all the other usual health tracking features found in other watches.xvi The OTC diagnostics and monitoring market is currently valued at $20B but will grow at double-digit rates for years to come.xvii It remains to be seen whether this instantaneous and omnipresent access to personalized health data will drive long term engagement with primary care or independence and be yet another source of dissemination from primary care.

Self-Medication As self-medicating with supplements, health diets, caffeine, illicit and non-illicit (but not prescribed) drugs become more ubiquitous, determining whether self-medicating as a practice is evidence of the provider influence erosion or part of what contributed to the erosion in the first place becomes harder to decipher. A recent poll defined self-medicating as consuming alcohol, illicit drugs, or medication without a prescription to mitigate symptoms of mental or physical illness and reported that nearly 80% of respondents who experienced health issues had self-medicated. Of those self-medicating, 43% continued self-medicating daily despite having seen a physician for their ailment, 26% of those who received a prescription from the physician reported not taking it because they did not trust the ingredients, and 50% of those respondents feared the effects of the prescription.xviii After alcohol, the most popular drug used for self-medicating is marijuana. With more than half of the US legalizing marijuana in some form, an increasing number of people have turned to weed for relief. In states where marijuana use is legal, the drug provides an easily obtainable solution for the symptoms associated with some pain and mental health syndromes. Obtaining a medication script from a local doctor for the same syndromes would require finding an available provider, enduring long office wait times, complying with mandatory follow-up examinations, covering insurance visit co-pay fees, and potentially jockeying conversations between the insurance company and medication provider to have the cost of the medication approved. The bottlenecks that stymie the process and the level of health literacy required to navigate it successfully make the traditional, in-office healthcare experience an unappealing and frankly unrealistic option for many.

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It was only nine years ago that Colorado and Washington’s move to legalize marijuana for recreational use was considered a ‘groundbreaking’ decision. Indicative of the growing acceptance of alternative treatments, since legalization of marijuana for both recreational and medical use has quickly spread across the country: there are now only 16 states in which weed is not legal in some form. In an even bolder display of changing attitudes (that would have been unfathomable 10 years ago), in January of 2021 Oregon decriminalized possession of all drugs—including heroin, cocaine, methamphetamines, and LSD—for personal use.xix

Notable Cohorts Responding to Lower Trust Environment Young people and those with lower health literacy are most at-risk of decaying trust levels in health care and following the broader societal distrust slide. Young people tend to fall into the low trust/high empowerment category while those with lower-thanaverage health literacy tend to have a low trust/low empowerment profile.

Young People: The Do-It-Yourself Generation Spectrum of Personal Trust Distribution by Age

Generalized feelings for trust in healthcare remain favorable when compared to trust for other American industries and establishments, but there is a significant difference between older and younger generation’s trust in information. Only 42% of adults aged 18-29 believe that doctors “Provide fair and accurate information” compared to 55% of those over 50. In general, young people are a low trust segment, Pew research looked at these levels of trust and

All Adults

30—49

As a whole, 22% of the population are considered “high trusters.”

50—64

11% of those aged 18-29 fall into this category.XX

MEDIUM

LOW

22%

41%

35%

Ages 18—29 11%

categorized citizens as “high trust,” “medium trust,” and “low trust.” However, while 37% of those aged 65+ are “high trusters,” a mere

HIGH

65+

42%

18%

46% 41%

25% 37%

39%

41%

31% 40%

19%

With their eroding trust in institutions, young people show more willingness and comfort with utilizing technology for answers. Google receives more than one billion health questions every single day.xxi A younger generation appears to have placed their trust in the most responsive, customized and reliable experience they know. Their lives are structured around and habituated to technology and its ability to provide access to obtain information, goods, and responses quickly. Etactics’ report, “What Different Generations Want in Healthcare,” analyzed how expectations and buyer behavior within generations would shift the model of healthcare. They reported that younger generations or Gen Z had concerns of decision making and convenience pertaining to healthcare and a primary want of digital options. This cohort makes healthcare engagement decisions based on convenience and digital offerings and information.xxii The information they access about health, health-providers, and health systems via media or online, will heavily influence their care decisions. Given their habituation to a responsive tech society, they expect their treatment preferences to be considered when healthcare decisions are being made. As discussed earlier, adults under the age of 30 are more than twice as likely not to have a primary care physician as their older counterparts, according to a new report by Vitals, a healthcare information website. The trend points to the increased use of alternative care facilities, such as retail health clinics and urgent care centers, with 41% of people aged 18-29 indicating they used urgent care centers to address health concerns.xxiii A former payor emphasized the impact of generational trust and the future of healthcare stating, “There is a generational thing around trust…some demographics trust Google more than a doctor.”

Americans with Lower Health Literacy Low health literacy is most prevalent with older adults, people with limited access to higher education, populations in lowerincome brackets, non-English speakers, and patients with chronic medical conditions (diabetes, hyperlipidemia, congestive heart failure etc.). This group is associated with high utilization of the emergency department for primary care needs, difficulty managing multiple medications or treatment providers, poor health outcomes and high healthcare costs when compared to healthcare utilizers with higher health literacy.xxiv Competencies required for health literacy include: “the ability to access health information (seeking, finding, and obtaining health information); understanding, applying, and appraising health information.” xxv

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Spectrum of Personal Trust Distribution by Education Level

This lower health literacy population expresses less willingness to trust health information from treatment providers and is more likely to trust health information being shared by television, social media, blogs/celebrities, friends, and pharmaceutical companies.

All Adults

HIGH

MEDIUM

LOW

22%

41%

35%

This group is the most vaccine-hesitant and expresses a lack of trust in institutions in general. Turning back to the “high trust” to

High School or Less 15%

“low trust” spectrum, we see that one attribute associated with

Some College

this population—those with limited access to higher education— has only 15% “high trusters,” less than half the amount compared

Bachelor’s Degree Post-graduate

to their most educated counterparts.xxvi

22% 29% 33%

40%

43%

39%

37% 46% 44%

24% 20%

How do we understand the lack of trust here? From one report, many within this group perceive health providers as uncaring and that information shared is not valued by the provider. Additionally, this population reports not understanding provider instructions and is more likely to be seen by multiple providers without opportunity for establishing a relationship that results in trust or patient empowerment.xxvii Given the disempowered stance of these care utilizers, systems are unlikely to hear complaints about poor performance with this group unless they ask for it directly. Backlash of inadequate care pathways for and lack of trust from this group is more likely to be felt fiscally due to high care costs that result from this population being mismanaged and by institutions and providers within geographic proximity to low health literacy populations.

Implications We evaluated micro and macro factors that illustrate how standard practices within healthcare and external factors devalued and eroded trust within the practitioner/patient relationship. Given the trends outlined above, we recommend providers, institutions, regulators and new healthcare entrants follow a two-pronged approach that both leverages practices that may have eroded trust in the first place (urgent care, DTC advertising, self-medicating, at home testing) and re-establishes trust in a format that is newly defined by a younger, more tech-savvy generation.

For Providers: Encourage online peer — reviews and feature positive reviews on your website

Ensure patients understand instructions by using alternate forms of instructions and making

longer appointments when needed

Adjust traditional care philosophies to allow room for patient participation in their health experiences

AT ACT TR

to improve your practice

NVERT CO

action on that feedback

RET A

Solicit feedback from patients and then take

Niche Down – Establish yourself as a specialists, expert, ally, or advocate for a particular disease, population, or type of treatment experience

Invest in digital systems that

enhance responsiveness and improve front office efficiency so potential patients receive quick responses and to not have to deal with duplicative forms and processes

Train on mission and values so all staff implement them during micro interactions with patients from start to finish

Improve communication techniques – Hone and implement active listening, validation, and collaborative problem solving

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Niche-down. Younger generations favor a customized treatment experience from providers displaying integrity to mission and stated purpose. To the extent that you can establish yourself as a specialist, expert, ally or advocate for a particular disease, population, or type of treatment experience, you should. Niching not only improves your trust and likeability factor, but it also leaves you better positioned for search engine optimization. Invest in developing your mission and train staff in expression of company values in micro interactions. These signals of purpose and integrity to the customer, in addition to quality care provision, help engender trust and cultivate loyalty. This “niching” of yourself is easier in a digital environment than a physical one, since geography is a much more limited factor in the former. However, the tendency towards self-segmentation is strong in both the online and offline world. We will write in more detail about the strong trend towards self-segmenting ourselves in society generally and health care specifically, in our next white paper, “The Big Sort Comes to Healthcare” Invest in digital systems that collect data for personalization, enhance responsiveness and improve front office efficiency. You can’t niche what you don’t know. Every interaction between a provider and patient is an opportunity for data collection that can lead to patient customization. As discussed, systems and providers that are highly responsive will be favored over those that usher callers through phone trees to unattended voice mailboxes. Offering chat features for administrative questions/to triage need and online scheduling will improve patient satisfaction. Eliminating pen, paper and duplicative forms in favor of forms that integrate with the electronic record and physician practice will be necessary to attract and maintain a patient load. The healthcare consumers of tomorrow will track responsiveness to their complaints as well as their recommendations for quality improvement. Solicit brief feedback often in 1-2 question electronic format (i.e. ‘What could we improve before your next visit?’ ‘What is your best suggestion for how we can improve that?’) and be ready to take action towards implementation of suggestions. This data will also give you a view of your team’s performance over time. Finally, harness the power of peer-reviews by soliciting them, replying when possible (avoiding any HIPAA violations), and featuring text from positive reviews on your website. Broaden care philosophy. The healthcare customer is and will continue to seek treatment and testing alternatives that are not comfortable to all providers due to a lack of rigorous evidence base. However, care providers will need to develop an openness to the care alternatives, as we will detail in a future white paper in this series (Whole Health). The customer base will only grow in their expectation to be regarded as an informed expert in their own health experience. Make time for understanding. To consider the unique needs of everyone, particularly the low health literacy population, enhanced provider communication strategies are needed. Providers who can train and hone communication skills that prioritize active listening, validation and collaborative problem solving will generate a loyal patient roster. This new strategy could extend appointment times for providers still honing these skills. If you remain in an FFS model, be aware of costs associated with populations that are likely to require extra time. Hire doctors who like patients and help give them patients they will like. Part of the value for a refined patient provider matching process will mean more providers who actually…. like their patients. Anyone who has spent time in a medical staff lounge knows very well the mixed feeling that many providers have with their patients and in light of the refusal of millions of Americans to be vaccinated, this is only increasing. As we will discuss in a later paper, providers emotional intelligence (EQ) will matter more over time, and we will need to use data to help match providers to patients based not just on clinical needs but communication fit: the better the fit, the better the trust. Adjusting to this future state will help you find the right patients for you, give you better outcomes, and help you keep those patients.

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For Systems:

Scale • Algorithmic infrastructure • Small players join forces • Home is the new influence point (expand care locations) • Integration in relationships, not just medical information

Differentiation • Shape the review marketplace • Responsiveness builds trust • Recognizable brand identity • Create a unique experience • Position with purpose

Algorithmic infrastructure. Begin to find your algorithm of influence. Today, there is significant data driven research on what providers should tell patients, but very little on how to communicate with patients in a way that generates influence. The industry will benefit from exploring use of data driven archetypes to match communication and treatment approaches with a patient profile type. Healthcare has largely borrowed from other industries on invented anecdotal profiles. This will not cut it in the world we are headed. Other industries have been doing AI testing on every word electronically communicated to consumers to determine which messages move which consumers to action and healthcare efficiency will improve from doing the same. Small players join forces to become builders not buyers. Investing in an algorithmic infrastructure is not a recommended undertaking for a solo hospital or even a smaller system, but rather will require alliances to fund and build. If how you communicate with patients is central to your value proposition, don’t just buy the tool—help create and own the tool. Otherwise, systems could repeat the mistake of EMRs and end up funneling billions to EMR vendors who drive nicer cars than their own staff. There is nothing wrong with JVs even for systems of $5, $10 or $15B of Net Patient Revenue with developers and other systems. This might require expertise to be a Google/Apple/Amazon level lift. One big benefit of doing this in a collaboration, beyond capital risk and expertise sharing, is the political messaging to providers and the community is stronger. It’s not a toy some CEO saw, but an expensive tool that lots of players collaborated on to build, test and deploy with the rigor of a new drug or medical device. This infrastructure should be validated and published in peer reviewed journals. The ask for providers to communicate in new ways might otherwise draw skepticism and resentment for yet another add to their workflow. Showcasing that these communication styles will generate enhanced patient outcomes and time-saved for providers will be necessary for systems to take on the change. Integration in relationships not just medical information. While the health care sector has made great strides in patient data being shared across care settings regardless of the organization delivering the care, less progress has been made in relationships management. While some systems are aggressively deploying CRM, it’s only within organization walls and often not even with its JV partners in care. Systems need to think about how to expand clinical data portability to a more complete picture of the patient’s life and care environment. Shape the review marketplace: Three out of four Americans say that they use online patient reviews as the first step in choosing a new providerxxviii, and 90% say they consider online reviews before deciding.xxix Based on the evidence we see, a hospital’s Yelp reviews have more credibility with patients than their CMS star ratings or other much more objective measures. If you want to build trust learn from other industries on how to shape reviews. That investment not only pays a likely market share dividend but also could offer a compliance bonus as a cultivated narrative of the health care experience is created helping itself shape patient choices.

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Responsiveness builds trust. The algorithmic approach can be relied upon to generate motivation for action within a healthcare consumer, but the human-to-human interaction is a large part of what systems must upgrade to re-establish trust. On a micro scale this requires training validation and collaboration skills within providers, most especially when discussing alternative treatment options a patient may be interested in. On a macro scale, this means creating healthcare systems that are sensitive and responsive to the patient care experience. We recommend continued investment in tele-treatment platforms that integrate with existing billing/ coding, registration, and medical records. This offers convenience and efficiency to consumers and staff and presents a cohesive online and in-vivo care experience. The seamless experience from online to in-person care reinforces trust in an establishment. Young healthcare consumers expect alignment between their experience of you on the internet and their experience of care at your institution. Systems can position themselves as highly responsive by obtaining and merging patient care feedback from multiple sources (website, app, electronic bedside rounding tools, call centers, chat communication streams) to generate a patient composite. That composite should be utilized to communicate what a patient favors and expects from their healthcare system. Currently the information and communication channel between actual bedside providers and patient experience/marketing teams is not heavily prioritized. Which is to say that patient complaints are addressed individually and manually but rarely compiled in trends to generate opportunities for improvement. Since restoration of trust in medicine and creation of a loyal customer base hinges upon a system being perceived as able and responsive, we recommend enhancement efforts here. Recognizable brand identity. Influential brand messaging and language should be utilized to enhance one-to-one patient care interactions but also to draw patients from competitors. Health systems have been organized for economic scale and clinical excellence and have thought much less about the science of engaging with communities or individuals towards creating an emotional impact. To get people to listen to the system about both clinical and economic matters (e.g., take this medicine, use this provider), a public facing message of purpose and public interfacing team will need to be created. That could mean taking on community health workers, but even more intriguing is the idea of utilizing health influencers since most consumers will go online for trusted sources of information. Regardless of what the medical establishment or their local doctor says, millions of Americans are getting their sources of COVID information online. Learning to have online influence for your patients is one of the greatest research challenges for providers today. To those hospitals and health systems who use their Medical Staff or Board as the ultimate brand focus group—stop it. The board and providers are incredibly important stakeholders but simply not representative of the vast majority of your stakeholders. Other industries use front line feedback as branding input—not judges. Creating a unique experience in healthcare. Younger generations are showing preference for brands that generate a novel experience in their industry. We recommend health systems invest more in integrating at-home testing and metabolic tracking results with an existing and patient responsive medical record so that providers and consumers can make joint care decisions even when geographically separated. Predictive analytics as a staff-monitored portion of this patient responsive medical record would allow for quick processing of home data towards a care recommendation. Adjust business models. Recognize that those referral pipelines from primary care to sub specialists that are central to health systems’ business models will be under strain in a lower trust environment. It is often said “patients go where you send them”. The data doesn’t fully back that up in today’s environment and certainly won’t tomorrow. Systems should also think twice about how they evaluate and deploy disruptors in their own market. Remember there is a price to be paid when you disrupt the provider patient relationship, but if done right it could strengthen the PCP relationship by tightly coordinating and deferring to primary care. Most of all, consider investing in disruptors which can find new, deep patient influence points that can wrap around your key providers. Home is the new influence point. Expanding and tightly integrating with assisted living, independent living, home health providers, mental health and mental health in-home providers to influence patient behavior via apps to meet shared goals (i.e. reduce hospital readmissions) has potential. Imagine having a small primary care workforce living in those kinds of communities. In addition, while before COVID it would be unimaginable for a patient to change physician providers based on who their home care aid recommends, it is very imaginable today. With less trust given to fewer people, this part of the workforce could have significant influence over patient loyalties over time. These workers earn patients’ trust with their near-constant physical presence and acts of support and caring—literal sweat equity. Are we talking about home care aids as an important part of the care teams, yes.

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Position with purpose. Commitment to improved health literacy for all and building trust with a low health literacy population will be challenging. It will require correctly identifying low health literacy risk through social determinant and health literacy screening tools at every care point of entry and providing practitioner education around non-judgmental and collaborative response at the time of a positive screen. Utilization of medical interpreters, assessing patient understanding and comfort at various points during care delivery, tailoring interventions, as well as health and diagnosis education to various learning styles (audio, visual and kinesthetic) will go a long way to generate trust from this group. Systems investing in generating evidence-based but easy to follow medical infotainment can position as a trusted source of information for the low health literacy and younger consumer populations.

For New Entrants: Every incumbent who loses trust is an opportunity for a new entrant to gain that person’s trust. Look at the demographic data to see areas where trust is likely to have fallen as a criterion to screen or prioritize markets. However, you can get bitten by the same forces that bit your competition, so have a trust plan for each market segment you wish to attract. Algorithm development for patient management is the great white whale of the coming years. Today the media and politicians are ahead of health care in knowing how to scientifically frame and communicate to get desired outcomes.

For Regulators: Psychosocial factors as a SDOH. Regulators and payors are already burdened thinking about how to incorporate existing social determinants into health risk adjustments. While very important work, it may not be the deepest we can go. It is not just physical realties that drive clinical risk. The ultimate social determinant of care outcomes might be trust and the interwoven social networks that drive trust. Those countries with more broken social trust are clearly having more problems getting their populations vaccinated. Rethink CON laws: We tend to focus CON laws on obvious economic and clinical outcomes for communities without thinking about the relationships that get formed and how to promote them. Technology will make CON laws weaker over time, but regulators need to think about them as tools for social cohesion within health care.

In our next paper we will discuss more directly the self-segmenting of society and how navigating that and building patient trust will be intertwined healthcare challenges.

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Footnotes: i. ii. iii.

https://news.gallup.com/poll/1597/confidence-institutions.aspx https://pubmed.ncbi.nlm.nih.gov/30620375/ Kravitz RL, Epstein RM, Feldman MD. Influence of patients’ requests for direct-to-consumer advertised antidepressants: a randomized controlled trial. JAMA. 2005;293(16):1995–2002. iv. https://healthcareappraisers.com/urgent-care-center-industry-in-2020/ v. https://time.com/5386256/urgent-care-centers/ vi. https://khn.org/news/spurred-by-convenience-millennials-often-spurn-the-family-doctor-model/ vii. https://hitconsultant.net/2021/03/03/dispatchhealth-series-d-funding/#.YUDt5o5Kjcs viii. https://techcrunch.com/2020/07/29/humana-partners-with-heal-and-invests-100-million-in-the-companys-doctor-on-demandservice/?guccounter=1&guce_referrer=aHR0cHM6Ly93d3cuZ29vZ2xlLmNvbS8&guce_referrer_sig=AQAAAAqiV7h6-vhPbcX-ufM5IoierAWK_aasl_S2H56uWSWXcdZFvhVRav07sfk38rtCUHf2QrEBf1Zvnvp9XEyIrl6GaziKUzuxuAllppbCKTX69bLAQhyATzJiHUx9QBEnQ0 aqXYJbvKiQRZWaCVC2b9dHCIUVbYoIFnk-Ittl3tix. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5804680/ x. https://www.aamc.org/news-insights/many-hospital-patients-doctors-are-house xi. https://www.beckershospitalreview.com/hospital-physician-relationships/4-statistics-on-hospitalists.html xii. https://www.aamc.org/news-insights/many-hospital-patients-doctors-are-house xiii. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2642573/#CR9 xiv. https://www.pewresearch.org/fact-tank/2019/08/06/mail-in-dna-test-results-bring-surprises-about-family-history-for-many-users/ xv. https://www.businessinsider.com/baby-boomers-appetite-for-apple-watch-4-2018-9#:~:text=In%20an%20informal%20survey%20 of,%25)%20who%20said%20the%20same. xvi. https://news.samsung.com/global/galaxy-watch4-and-galaxy-watch4-classic-reshaping-the-smartwatch-experience xvii. https://www.chiefoutsiders.com/blog/growth-for-in-home-diagnostics xviii. https://www.niznikhealth.com/research-articles/self-medicating-in-america/ xix. https://www.google.com/search?q=is+lsd+a+methamphetamine&rlz=1C1GCEU_ enUS948US948&oq=is+lsd+a+methamphetamine&aqs=chrome..69i57.5969j0j7&sourceid=chrome&ie=UTF-8 xx. https://www.pewresearch.org/politics/2019/07/22/the-state-of-personal-trust/#people-sort-along-a-continuum-of-personal-trustdepending-on-their-views-about-trusting-others-and-the-risks-that-might-arise-from-that xxi. https://www.beckershospitalreview.com/healthcare-information-technology/google-receives-more-than-1-billion-health-questionsevery-day.html xxii. https://etactics.com/blog/generations-in-healthcare xxiii. https://www.fiercehealthcare.com/healthcare/young-adults-more-likely-to-turn-to-urgent-care-centers-instead-primary-carephysicians xxiv. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6391993/ xxv. Institute of Medicine, 2004; Baker, 2006; Manganello, 2008; Nutbeam, 2008; Sørensen et al., 2012; Squiers, Peinado, Berkman, Boudewyns, & McCormack, 2012 xxvi. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6295319/ xxvii. Predictors of health care system and physician distrust in hospitalized cardiac patients. Gupta C, Bell SP, Schildcrout JS, Fletcher S, Goggins KM, Kripalani S, Vanderbilt Inpatient Cohort Study (VICS).J Health Commun. 2014; 19 Suppl 2():44-60. xxviii. https://www.patientpop.com/blog/running-a-practice/internet-new-ways-patients-find-physicians/ xxix. https://www.softwareadvice.com/resources/how-patients-use-online-reviews/

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About Array Advisors Array Advisors is a healthcare strategy consulting and operations optimization firm dedicated to both improving the way healthcare is delivered and helping clients overcome their business challenges. The team can help clients with strategic plan development including market analysis, ambulatory and service line planning, provider strategies and integrated capital and facility planning as well as operational analysis including scenario modeling, benchmarking, and lean design.

Author Contacts

NEIL CARPENTER, MBA

JILLIAN BARBARO, MHA

Vice President Strategic Planning

Strategic Planner

d: 202-795-3707

d: 202-788-5631

m: 917-576-9980

jbarbaro@array-advisors.com

ncarpenter@array-advisors.com

ISABELLE MORATTI

ALEXANDRA LARAMEE, LCSW

Array Advisors Intern

Behavioral Health Clinical Operations

imoratti@array-advisors.com

alaramee@array-advisors.com

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