March 26, 2026
4.9 Stars ≠ Good Care: The Problem with Healthcare Metrics (with Larry Benz)
What if the problem in healthcare isn’t a lack of data… but the wrong data?
In this episode, Larry Benz joins the show to unpack a quiet shift that’s happening across healthcare:
We’ve started confusing what’s easy to measure with what actually matters.
Star ratings, patient satisfaction scores, and online reviews have become the scoreboard—but they were never designed to measure true clinical excellence.
So what happens when the proxy becomes the point?
???? What You’ll Learn:
- Why high ratings don’t always mean high-quality care
- How healthcare drifted toward convenience metrics
- The unintended consequences of optimizing for satisfaction
- What better measurement could look like
- How clinic owners and clinicians should think differently
????️ Guest:
Larry Benz is a physical therapist and founder of Confluent Health and Evidence In Motion. He’s spent his career building and scaling healthcare organizations—and challenging the assumptions behind how success is measured.
???? Connect & Subscribe:
- Read this and more from THE OPERATOR on SUBSTACK
- Share with a clinician or clinic owner who needs to hear it
<p>This episode is part of the <a href="/physical-therapy-business-podcast">Physical Therapy Business Podcast</a>, where physical therapists and clinic owners learn how to get more patients, improve operations, and grow their clinic without relying only on referrals.</p>
<p>Looking for more episodes? Explore the full <a href="/physical-therapy-business-podcast">Physical Therapy Business Podcast</a> for real-world strategies on physical therapy marketing, patient acquisition, and clinic growth.</p>
Transcript
WEBVTT
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No problem.
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And are we starting with the article?
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I don't remember what we just said.
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Yeah,
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I was going to do the article first.
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Yeah, perfect.
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Yeah.
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All right.
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Most health care businesses have a number
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they're proud of, a number they show off,
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a number they track,
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a number they think proves they're doing
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good work.
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Larry's argument in his latest article,
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that number might be completely
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meaningless.
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Today,
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we're talking about one of the most
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visible metrics in health care.
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Google reviews, five stars.
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Zero outcomes?
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Welcome to The Operator,
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a show about running better healthcare
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businesses, not from theory,
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from people actually doing the work.
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If you're responsible for patients,
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people, or performance, this is for you.
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Larry, welcome to your show.
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Well, thank you, Jerry.
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Thank you for hosting my show.
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Well,
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my job is to sort of set you
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up.
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This is the last part in a series
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that you've been doing.
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And if people want to go back to
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it,
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we'll give the link to the sub stack
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that they can view as well as the
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articles on LinkedIn.
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But first,
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why did you decide to do sort of
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a series on metrics?
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What about that made you say,
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I'm going to dedicate several weeks of my
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writing to just metrics in general before
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we get into the specific Google reviews?
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Yeah.
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What we tend to do in an operating
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business and health care platforms is we
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tend to get very routinized on certain
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metrics that are like sacred cows.
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They're the belief that they are the most
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important ones.
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We've had vast changes in our operating
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environment.
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If you think of sort of the post-COVID
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hangover days,
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then you had shortages and you had all
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the headwinds of reimbursement.
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and all the things around high inflation.
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And the business models have had to
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change.
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You've had to adjust.
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And so what we tend not to do
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in health care operations is rethink,
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challenge our assumptions.
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And say,
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why are we continuing to measure that?
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And then the objective becomes the
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measurement rather than the activities and
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the behaviors that really get the
00:02:01.968 --> 00:02:03.989
operations flowing in the right direction.
00:02:04.531 --> 00:02:06.632
And so I've tried to on each one
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of these metrics doesn't mean,
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as I point out in the articles,
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that you shouldn't be measuring them,
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but you should be understanding how
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they've shifted over the years.
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And the whole area around good hearts is
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a bias that we tend to default in
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over time if we're not careful.
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Yeah.
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When the metric becomes the measure,
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it fails to measure what matters is the
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thing that kept sticking with me.
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That makes sense.
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I mean, you're Russian.
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If you want to go back and read
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it,
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the Russian nail factory sort of
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highlights that pretty well.
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When you tell me to gamify,
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when you gamify a metric and you put
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my salary on the on the line for
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that,
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guess what I get really good at hitting
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that number is the letter of the metric
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or the spirit of the metric.
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Well,
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I hit the letter of the metric and
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that's what gets me the paycheck.
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Just to that point, years ago,
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I'm going back into the late eighties.
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I had a few clinics and one of
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my clinics,
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we used to measure no-show cancellation
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rate and used to incentivize the front
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desk person for a lower no-show
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cancellation rate.
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And interesting,
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she went on maternity leave and she was
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a wonderful intake coordinator
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receptionist,
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what we called DOFI at the time,
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Director of First Impressions.
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And all of a sudden,
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our no-show cancellation went sky high.
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And I started wondering,
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how is that the case?
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Well, as it turns out,
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you can game that number.
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It's no different than the Russian nail
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factory.
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Somebody cancels,
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you just take them off the schedule and
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put them somewhere else and you never were
00:03:30.900 --> 00:03:32.401
able to see what really...
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happen there.
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And so gamesmanship working around it,
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our tax laws are the absolute, you know,
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personification of good hearts law,
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everybody works around the tax laws to try
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and save on their taxes.
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That's normal.
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Yeah.
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So we have to, you know,
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we have too many tax law issues,
00:03:52.354 --> 00:03:54.295
and good heart issues in operation.
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And so my challenge is somebody who's in
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the field every day operating is for us
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to challenge those assumptions.
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And you can tell which side of the
00:04:03.042 --> 00:04:04.503
argument someone is on with taxes when
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they call it a write-off or a loophole.
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If it's a loophole,
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you can tell they don't agree with it
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right there.
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All right, so let's jump into this.
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If someone logs on Google website,
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somewhere where ratings are being
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tabulated and shown off,
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what is a four point nine star four
00:04:23.259 --> 00:04:25.139
point out of five star rating actually
00:04:25.180 --> 00:04:28.300
tell you about specifically a health care
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business yeah honestly it tells you that
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they're good at asking that's not nothing
00:04:32.622 --> 00:04:35.324
not what most operators think it is you
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know four point nine means your patients
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felt well enough to leave a review that
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had a positive enough experience to give
00:04:41.346 --> 00:04:42.487
you close to a five star
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does not tell you about the patient who
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dropped off after the two to three visit
00:04:46.887 --> 00:04:49.088
cliff in physical therapy or in dental it
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doesn't tell you the patient who didn't
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show up for the second visit which
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oftentimes in dental is the most important
00:04:54.550 --> 00:04:57.512
visit from an economic standpoint it
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doesn't tell you about your twenty two day
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wait period for a new evaluation it
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doesn't tell you whether your functional
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outcomes improved or whether your hygiene
00:05:04.194 --> 00:05:05.814
appointment rate is collapsing
00:05:06.875 --> 00:05:09.418
It's a sentiment snapshot from a very
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self-directed audience.
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And in health care,
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that audience skews very grateful,
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skews compliance,
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skews towards the people who finished
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care, the people who like you.
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The four point nine is real.
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It's just not the whole story.
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It might not even be the important or
00:05:25.391 --> 00:05:26.992
really key elements of the story.
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Yeah, you want to gamify that number.
00:05:29.329 --> 00:05:31.512
Don't point out where to scan the QR
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code to leave a review to somebody who's
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disgruntled, right?
00:05:34.935 --> 00:05:36.216
Although you can look at the other side
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of the argument,
00:05:36.755 --> 00:05:38.716
which is sometimes when people have a bad
00:05:38.757 --> 00:05:39.298
experience,
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they're more likely to go rate you and
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leave a review versus the people who are
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the silent, happy,
00:05:46.242 --> 00:05:48.524
satisfied customer or patient.
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Exactly.
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And it has some meaning.
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It's just not all that much important from
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the day-to-day operations.
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Right.
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So at what point did healthcare cross the
00:05:56.250 --> 00:05:58.512
line from measuring experience to
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pretending experience equals quality?
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Yeah,
00:06:03.038 --> 00:06:04.358
so we gotta go back a little bit
00:06:04.858 --> 00:06:05.959
in place of time.
00:06:06.098 --> 00:06:08.339
In the, call it the late eighties,
00:06:08.480 --> 00:06:09.319
early nineties,
00:06:09.360 --> 00:06:10.940
there was this new thing that happened in
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healthcare called functional outcome
00:06:12.862 --> 00:06:17.163
measures, SF-II, the SF-XXVI, short form,
00:06:17.223 --> 00:06:18.363
long form, XXXVI,
00:06:18.384 --> 00:06:20.925
which is the healthcare quality of life.
00:06:20.964 --> 00:06:21.884
And so we started to say,
00:06:21.985 --> 00:06:23.466
what do outcomes mean?
00:06:24.026 --> 00:06:25.966
And outcomes were defined as days,
00:06:26.026 --> 00:06:29.427
dollars, utilization, functional outcome,
00:06:30.404 --> 00:06:31.305
And on top of that,
00:06:31.345 --> 00:06:32.985
we had patient satisfaction,
00:06:33.065 --> 00:06:35.307
later became patient experience.
00:06:35.346 --> 00:06:37.168
And so the combination of these dollars
00:06:37.228 --> 00:06:38.749
are sort of utilization-driven data,
00:06:39.009 --> 00:06:40.889
clinical functional outcome-driven data,
00:06:41.509 --> 00:06:43.870
and all the things around the experience
00:06:43.911 --> 00:06:46.132
became sort of the three distinct domains.
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But what happened is over time,
00:06:49.153 --> 00:06:50.413
we've tried to simplify it.
00:06:50.434 --> 00:06:50.615
You know,
00:06:50.634 --> 00:06:52.196
we're in business and operations.
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We're always trying to make the complex
00:06:54.576 --> 00:06:56.718
simple from an operation standpoint.
00:06:56.879 --> 00:06:58.040
That's a great thing.
00:06:58.279 --> 00:06:58.720
However,
00:06:58.800 --> 00:07:01.281
sometimes when we make things so simple,
00:07:01.322 --> 00:07:04.663
we destroy what the animal that we're
00:07:04.684 --> 00:07:05.625
trying to create is.
00:07:05.704 --> 00:07:07.386
So the moment we ran out of better
00:07:07.425 --> 00:07:09.627
alternatives and stopped admitting it,
00:07:09.666 --> 00:07:11.528
clinical outcome measurements in the most
00:07:11.608 --> 00:07:14.571
outpatient settings is inconsistent at
00:07:14.630 --> 00:07:16.232
best, absent at worst.
00:07:16.831 --> 00:07:19.774
Functional tools do exist, photo, promise,
00:07:20.653 --> 00:07:22.274
all the things are on Medicare, you know,
00:07:22.334 --> 00:07:24.976
PSFS, for example, but adoption is not,
00:07:25.317 --> 00:07:27.197
you know, is not evenly put.
00:07:28.059 --> 00:07:28.819
And at times,
00:07:28.858 --> 00:07:30.579
we tend to only do it on our
00:07:30.620 --> 00:07:33.041
best patients or those who complete care.
00:07:33.062 --> 00:07:34.062
And so you have to be really,
00:07:34.101 --> 00:07:34.802
really careful.
00:07:35.764 --> 00:07:37.644
And so what fills that volume,
00:07:37.665 --> 00:07:39.646
whatever is visible and Google stars are
00:07:39.846 --> 00:07:40.406
everywhere.
00:07:40.447 --> 00:07:42.149
And so let's use Google stars.
00:07:42.329 --> 00:07:44.411
I had series a couple of weeks ago
00:07:44.451 --> 00:07:45.872
about Net Promoter Score,
00:07:45.891 --> 00:07:47.353
a lot of similarities here.
00:07:47.694 --> 00:07:48.694
They're on your profile,
00:07:48.713 --> 00:07:49.935
they show up in the listing,
00:07:49.954 --> 00:07:51.737
they're a number, numbers feel like data.
00:07:51.797 --> 00:07:52.838
So we promote them,
00:07:52.918 --> 00:07:54.439
not because anyone made a deliberate
00:07:54.899 --> 00:07:55.839
decision about it,
00:07:55.879 --> 00:07:57.961
but that four point nine stars equals
00:07:58.002 --> 00:07:58.862
clinical excellence.
00:07:58.882 --> 00:08:00.884
Somehow or another, we conflated that.
00:08:01.725 --> 00:08:03.206
But because the infrastructure for
00:08:03.247 --> 00:08:05.829
measuring actual clinical excellence
00:08:05.910 --> 00:08:08.411
wasn't there or wasn't fulsome or wasn't
00:08:08.451 --> 00:08:11.214
complete, the proxy became the point.
00:08:11.615 --> 00:08:13.257
And that's always how it happens.
00:08:13.336 --> 00:08:16.019
We make a proxy a conclusion,
00:08:16.160 --> 00:08:18.161
and Google stars are now that conclusion,
00:08:18.182 --> 00:08:18.442
unfortunately.
00:08:19.511 --> 00:08:19.690
Yeah.
00:08:20.230 --> 00:08:21.732
It's funny that you bring up four point
00:08:21.791 --> 00:08:22.552
nine stars.
00:08:22.752 --> 00:08:23.833
And I think I know why.
00:08:24.153 --> 00:08:26.935
To me, five feels too perfect.
00:08:27.035 --> 00:08:29.255
It feels like I can't trust that because
00:08:29.295 --> 00:08:30.896
it's nothing's perfect.
00:08:30.937 --> 00:08:32.557
So four point nine feels as close as
00:08:32.577 --> 00:08:33.198
you can get.
00:08:33.558 --> 00:08:34.099
Really good.
00:08:34.119 --> 00:08:35.480
But obviously there's some real in there.
00:08:35.539 --> 00:08:36.480
So it matters.
00:08:37.160 --> 00:08:38.841
Isn't that funny how that like we've even
00:08:39.042 --> 00:08:40.722
even on the receiving end said five's too
00:08:40.743 --> 00:08:40.863
good.
00:08:40.883 --> 00:08:41.562
I don't trust it.
00:08:42.163 --> 00:08:43.783
A four point eight that four point nine
00:08:43.803 --> 00:08:45.125
that feels perfect.
00:08:45.325 --> 00:08:46.506
More authentic.
00:08:46.667 --> 00:08:47.327
Feels more authentic.
00:08:47.488 --> 00:08:47.807
Right.
00:08:47.908 --> 00:08:49.529
Right.
00:08:49.570 --> 00:08:51.832
So you mentioned like sort of the
00:08:51.893 --> 00:08:52.874
pre-COVID, right?
00:08:52.913 --> 00:08:56.118
So are operators still chasing Google
00:08:56.158 --> 00:08:57.500
reviews based on a version of the
00:08:57.539 --> 00:08:58.701
algorithm that doesn't actually exist?
00:08:58.821 --> 00:09:00.864
Are we still having a twenty sixteen
00:09:00.923 --> 00:09:03.086
mindset in twenty twenty six?
00:09:03.806 --> 00:09:05.106
No, that's absolutely right.
00:09:05.226 --> 00:09:06.048
A lot of them are.
00:09:06.067 --> 00:09:07.729
And that's really what my research started
00:09:07.769 --> 00:09:08.249
to show,
00:09:08.328 --> 00:09:09.889
that the old mental model was pretty
00:09:09.929 --> 00:09:10.250
simple.
00:09:10.311 --> 00:09:12.312
More five star reviews equals higher
00:09:12.491 --> 00:09:14.474
ranking equals more patients.
00:09:14.573 --> 00:09:16.475
So it was all driven by how high
00:09:16.514 --> 00:09:17.115
on the Google
00:09:17.932 --> 00:09:19.913
best search engine, period.
00:09:19.932 --> 00:09:20.514
It's interesting.
00:09:20.533 --> 00:09:22.174
We're switching now from search engine to
00:09:22.355 --> 00:09:24.395
AI, LLL.
00:09:25.355 --> 00:09:25.996
And for a while,
00:09:26.037 --> 00:09:29.879
the volume of reviews was the dominant SEO
00:09:29.979 --> 00:09:30.339
signal.
00:09:30.360 --> 00:09:32.020
And this really is the main teaching point
00:09:32.061 --> 00:09:32.681
of the article.
00:09:33.020 --> 00:09:34.461
So that logic held true.
00:09:34.501 --> 00:09:36.903
But the algorithm has gotten way more
00:09:36.962 --> 00:09:38.884
sophisticated, as they always do.
00:09:38.945 --> 00:09:41.446
Technology always outpaces everything we
00:09:41.485 --> 00:09:42.287
do in health care.
00:09:42.907 --> 00:09:45.067
proximity, relevance, behavior signals,
00:09:45.087 --> 00:09:46.730
how people interact with your listing,
00:09:46.769 --> 00:09:48.291
whether they click, whether they call,
00:09:48.691 --> 00:09:50.432
these matter now as well.
00:09:50.631 --> 00:09:52.133
So it's the behavioral elements,
00:09:52.212 --> 00:09:53.833
not just the star elements.
00:09:54.455 --> 00:09:56.596
Review recency matters more than raw
00:09:56.635 --> 00:09:57.135
volume.
00:09:57.476 --> 00:09:59.998
So if you took a hundred reviews,
00:10:00.457 --> 00:10:02.200
it's like golf handicap system.
00:10:02.240 --> 00:10:04.441
It's the five top most recent ones that
00:10:04.500 --> 00:10:05.461
really matter.
00:10:06.001 --> 00:10:08.325
So the operators who ran an aggressive,
00:10:08.365 --> 00:10:10.447
let's get to two hundred review campaigns.
00:10:10.626 --> 00:10:12.769
I still see this all the time.
00:10:12.849 --> 00:10:15.052
And they sort of stop.
00:10:15.552 --> 00:10:16.893
They're potentially losing ground to a
00:10:16.952 --> 00:10:18.335
competitor with eighty reviews.
00:10:18.375 --> 00:10:19.615
So that was kind of like I got
00:10:19.676 --> 00:10:20.096
two hundred.
00:10:20.116 --> 00:10:20.756
You got eighty.
00:10:20.797 --> 00:10:21.778
So therefore, I'm better.
00:10:22.119 --> 00:10:24.421
In fact, we are competitiveness.
00:10:25.302 --> 00:10:27.863
around google stars surpassed our
00:10:27.883 --> 00:10:29.764
competitiveness around clinical excellence
00:10:29.803 --> 00:10:31.264
and doing the right thing for the patient
00:10:31.365 --> 00:10:33.485
right you know the we got we got
00:10:33.546 --> 00:10:36.347
diverted by all this um so chasing the
00:10:36.388 --> 00:10:38.489
number at one time made sense now it's
00:10:38.649 --> 00:10:41.311
it's it's table stakes and the operators
00:10:41.350 --> 00:10:43.152
treating it like it's a competitive moat
00:10:43.312 --> 00:10:45.413
are you know probably optimizing for a
00:10:45.493 --> 00:10:47.533
version of local search that's already
00:10:47.573 --> 00:10:49.475
moved way way past that right you know
00:10:49.514 --> 00:10:51.035
by the way at least in physical therapy
00:10:51.615 --> 00:10:53.155
Why do we care about local surgery much?
00:10:53.176 --> 00:10:54.596
Don't we have we have plenty of patients
00:10:54.616 --> 00:10:56.596
now, plenty of volume.
00:10:56.616 --> 00:10:56.876
Yeah.
00:10:56.976 --> 00:10:58.996
You know, really optimizing,
00:10:59.037 --> 00:11:00.217
as we talked about last week,
00:11:00.278 --> 00:11:03.298
optimizing that volume and not the churn
00:11:04.357 --> 00:11:05.499
is really, really important.
00:11:05.519 --> 00:11:07.239
So keeping the patients you have and what
00:11:07.259 --> 00:11:09.479
we're saying, milking your own cows first,
00:11:09.538 --> 00:11:10.639
you have those patients.
00:11:11.220 --> 00:11:12.740
Make sure you're getting the treatment
00:11:12.779 --> 00:11:15.559
completion on them so that you can focus
00:11:15.600 --> 00:11:16.561
attention on there.
00:11:16.600 --> 00:11:18.480
And that's where that, you know, really
00:11:19.360 --> 00:11:20.562
being extremely,
00:11:20.662 --> 00:11:22.923
extremely intentional about visit two and
00:11:22.942 --> 00:11:25.303
three and showing value there rather than
00:11:25.403 --> 00:11:26.524
routinize the visit.
00:11:27.184 --> 00:11:28.485
What you're basically saying to the
00:11:28.524 --> 00:11:29.706
patient is you don't need to come in
00:11:29.725 --> 00:11:30.907
anymore because we're going to do the same
00:11:30.927 --> 00:11:31.687
thing every time.
00:11:32.106 --> 00:11:32.586
Yep.
00:11:32.746 --> 00:11:35.408
I can actually hear someone creating a KPI
00:11:35.448 --> 00:11:36.089
just for that.
00:11:36.129 --> 00:11:37.490
But isn't there one?
00:11:37.610 --> 00:11:38.309
Isn't it churn?
00:11:38.330 --> 00:11:39.791
So when you don't have real clinical
00:11:39.870 --> 00:11:42.532
outcome data, what does fill that gap?
00:11:42.871 --> 00:11:44.753
What is the right thing or the better
00:11:44.812 --> 00:11:46.153
thing to measure?
00:11:47.408 --> 00:11:48.210
Yeah,
00:11:50.552 --> 00:11:52.154
so what happens is we use Google Deck,
00:11:52.395 --> 00:11:53.116
Google Stars,
00:11:53.417 --> 00:11:55.919
and Net Promoter Scores because leadership
00:11:55.980 --> 00:11:57.863
needs something to say in a board deck.
00:11:58.583 --> 00:12:00.304
And this is a different topic for another
00:12:00.345 --> 00:12:01.485
time, but I think, you know,
00:12:01.544 --> 00:12:04.485
PE backed platforms and even private
00:12:04.546 --> 00:12:07.927
practices do not have the right type of
00:12:07.966 --> 00:12:08.706
board members.
00:12:08.746 --> 00:12:11.067
They have people playing by old rules of
00:12:11.107 --> 00:12:13.129
an old game, a, you know,
00:12:13.168 --> 00:12:15.808
call it college before we professionalize
00:12:15.828 --> 00:12:17.529
through revenue share and NIL.
00:12:17.570 --> 00:12:19.831
That's the type of people that are on
00:12:19.931 --> 00:12:22.250
boards right now is this new game that
00:12:22.291 --> 00:12:23.792
took place post COVID.
00:12:24.692 --> 00:12:26.754
You show me an operator who's really done
00:12:26.815 --> 00:12:28.475
well the last few years and you've got
00:12:28.535 --> 00:12:30.778
an operator because they they're the ones
00:12:30.798 --> 00:12:32.721
who've dealt with incredible amounts of
00:12:32.780 --> 00:12:34.383
inflation at the supply level,
00:12:34.442 --> 00:12:36.325
inflation at the compensation level,
00:12:36.365 --> 00:12:38.047
shortages of your suppliers,
00:12:38.606 --> 00:12:40.089
all of those kinds of things.
00:12:40.950 --> 00:12:42.770
And so we use Google stars and net
00:12:42.812 --> 00:12:44.854
promoter scores for those board members
00:12:44.894 --> 00:12:46.315
because we want to fill a board deck.
00:12:46.335 --> 00:12:47.035
It sounds cynical.
00:12:47.135 --> 00:12:49.398
but it's accurate organizations under
00:12:49.457 --> 00:12:51.460
performance pressure from either PE
00:12:51.539 --> 00:12:51.840
owners,
00:12:51.879 --> 00:12:53.841
from franchise benchmarks from year over
00:12:53.922 --> 00:12:56.283
year need visible proof of quality.
00:12:56.644 --> 00:12:59.527
And so this proxy of Google stars is
00:12:59.626 --> 00:13:02.889
now what your compliance is showing up as
00:13:02.950 --> 00:13:03.350
quality.
00:13:03.370 --> 00:13:04.552
And if you can't pull functional
00:13:04.572 --> 00:13:06.232
improvement data, very hard to do,
00:13:06.273 --> 00:13:06.693
as you know,
00:13:07.114 --> 00:13:08.575
If your outcome tool adoption is
00:13:08.654 --> 00:13:09.355
inconsistent,
00:13:09.375 --> 00:13:10.875
it's very hard to be consistent.
00:13:11.196 --> 00:13:13.517
If your discharge documentation is a mess,
00:13:13.756 --> 00:13:15.758
very hard to have that consistent as well
00:13:16.077 --> 00:13:19.740
because most patients don't read their end
00:13:19.799 --> 00:13:21.179
of treatment discharge.
00:13:21.500 --> 00:13:22.841
You reach the number you have.
00:13:22.900 --> 00:13:24.182
Google stars makes it easy.
00:13:24.241 --> 00:13:26.001
Net promoter scores make it easier.
00:13:26.062 --> 00:13:27.842
Patient satisfaction makes it easier.
00:13:28.062 --> 00:13:29.163
Those aren't bad metrics.
00:13:29.183 --> 00:13:30.923
They're just getting asked to carry weight
00:13:30.943 --> 00:13:31.804
they weren't built for.
00:13:32.985 --> 00:13:34.826
The danger isn't that operators track
00:13:34.846 --> 00:13:34.986
them.
00:13:35.027 --> 00:13:36.368
The danger is that over time,
00:13:36.388 --> 00:13:38.528
the proxy becomes the definition.
00:13:38.568 --> 00:13:39.370
You stop asking,
00:13:39.389 --> 00:13:40.571
are patients getting better?
00:13:40.870 --> 00:13:41.652
And start asking,
00:13:41.751 --> 00:13:43.293
are patients happy enough to leave a
00:13:43.312 --> 00:13:44.133
five-star review?
00:13:44.153 --> 00:13:46.654
That's entirely different dimensions.
00:13:47.034 --> 00:13:47.716
They're related,
00:13:48.216 --> 00:13:49.596
but they're not the same questions.
00:13:49.777 --> 00:13:50.738
Yeah.
00:13:50.778 --> 00:13:52.698
You highlighted something in this article
00:13:52.759 --> 00:13:54.580
that I guess I didn't think about too
00:13:54.620 --> 00:13:54.941
much.
00:13:55.581 --> 00:13:56.601
And I bet you a lot of people
00:13:56.642 --> 00:13:57.222
didn't either,
00:13:57.263 --> 00:13:59.945
which is responding to one of these
00:13:59.985 --> 00:14:02.366
reviews, if it's negative or in a way,
00:14:02.788 --> 00:14:04.708
could open you up to liability.
00:14:05.370 --> 00:14:08.393
So why are healthcare providers the only
00:14:08.432 --> 00:14:10.335
businesses that really can't actually
00:14:10.355 --> 00:14:11.716
defend themselves in public?
00:14:11.775 --> 00:14:12.355
Or they can,
00:14:12.375 --> 00:14:13.658
but they have to be really,
00:14:14.018 --> 00:14:15.139
really careful about it.
00:14:15.447 --> 00:14:15.667
Yeah.
00:14:15.706 --> 00:14:16.187
So first of all,
00:14:16.206 --> 00:14:17.908
the reviews tend to reflect sort of your
00:14:17.988 --> 00:14:20.908
interpersonal and logistical experience as
00:14:20.948 --> 00:14:22.288
your wait times, your parking,
00:14:22.328 --> 00:14:23.089
the front desk,
00:14:23.448 --> 00:14:25.210
not clinical decision making.
00:14:25.610 --> 00:14:28.171
And so the population leaving reviews is
00:14:28.270 --> 00:14:30.711
really not a representative population.
00:14:31.851 --> 00:14:34.354
people are complex they leave incomplete
00:14:34.835 --> 00:14:37.557
survey data disappointing outcomes are
00:14:37.596 --> 00:14:39.938
less likely to review stars of any any
00:14:40.620 --> 00:14:43.162
nature at all and what ends up happening
00:14:43.442 --> 00:14:45.283
is it's you know do you like your
00:14:45.323 --> 00:14:47.285
provider all those kind of things they
00:14:47.346 --> 00:14:50.028
review it but that selection bias is baked
00:14:50.087 --> 00:14:52.870
into every star rating in the industry
00:14:53.629 --> 00:14:55.089
But the biggest thing is what you're
00:14:55.129 --> 00:14:56.330
referring to on the question,
00:14:56.350 --> 00:14:58.951
which has HIPAA in the background,
00:14:58.971 --> 00:15:01.171
which limits how providers can respond to
00:15:01.230 --> 00:15:02.270
negative reviews.
00:15:02.611 --> 00:15:04.011
You can't get into details.
00:15:04.052 --> 00:15:05.412
You can't correct the record.
00:15:05.451 --> 00:15:07.133
You can't explain context.
00:15:07.673 --> 00:15:09.754
So one-star review about a billing dispute
00:15:09.793 --> 00:15:11.274
sits on your profile essentially
00:15:11.333 --> 00:15:13.335
unchallenged because your response has to
00:15:13.375 --> 00:15:14.215
be generic.
00:15:14.875 --> 00:15:17.618
It lands and people people ignore that.
00:15:17.658 --> 00:15:19.259
And so now we've developed this whole
00:15:19.278 --> 00:15:21.120
niche industry about how to respond to
00:15:21.160 --> 00:15:22.423
bad, bad reviews.
00:15:22.462 --> 00:15:23.764
It's almost like all of us need our
00:15:23.803 --> 00:15:26.326
own PR crisis when we get a bad
00:15:27.047 --> 00:15:27.508
review.
00:15:28.268 --> 00:15:30.210
We also have to remember, you know,
00:15:30.471 --> 00:15:32.432
I always tell my therapist this and the
00:15:32.493 --> 00:15:34.073
PT side and I say the same thing
00:15:34.094 --> 00:15:34.595
in the dental.
00:15:34.654 --> 00:15:37.376
If a patient left your local clinic.
00:15:38.097 --> 00:15:40.840
because they refused to accept some level
00:15:40.879 --> 00:15:43.182
of self-responsibility in physical therapy
00:15:43.201 --> 00:15:45.864
that manifests itself by a home program or
00:15:45.903 --> 00:15:47.625
compliance with instructions.
00:15:48.206 --> 00:15:48.787
And in dental,
00:15:48.826 --> 00:15:50.727
it manifests itself with compliance with
00:15:50.788 --> 00:15:52.970
instructions on hygiene care and other
00:15:53.129 --> 00:15:55.831
aspects of post procedural care.
00:15:56.393 --> 00:15:58.934
And they would not take and therefore they
00:15:58.975 --> 00:16:00.875
disliked you because they wanted to put
00:16:00.936 --> 00:16:02.256
all their problems on to you.
00:16:03.057 --> 00:16:04.899
It's OK to fire a customer every once
00:16:04.918 --> 00:16:05.359
in a while.
00:16:05.418 --> 00:16:07.600
And if that leaves you a bad review,
00:16:08.100 --> 00:16:10.260
you could still sleep at night because
00:16:10.321 --> 00:16:13.101
self-responsibility and an active role in
00:16:13.121 --> 00:16:14.042
your own health care,
00:16:14.101 --> 00:16:16.543
your own recovery and in your own in
00:16:16.562 --> 00:16:18.604
the dental world and your own treatment is
00:16:18.683 --> 00:16:19.224
critical.
00:16:19.244 --> 00:16:21.664
A lot of patients don't want to assume
00:16:21.745 --> 00:16:23.745
any responsibility and they might write
00:16:23.765 --> 00:16:24.625
you a bad review.
00:16:24.946 --> 00:16:28.106
You can't get overly intrusive on it
00:16:28.147 --> 00:16:28.767
because you're violent.
00:16:28.807 --> 00:16:29.847
You could be violating HIPAA.
00:16:30.475 --> 00:16:33.636
Yeah, it's the juice versus squeeze ratio.
00:16:34.118 --> 00:16:35.578
You might chase after and put so much
00:16:35.599 --> 00:16:36.438
effort in this one patient,
00:16:36.458 --> 00:16:37.580
you're probably never gonna make that,
00:16:38.000 --> 00:16:40.001
you might never make that person happy.
00:16:40.402 --> 00:16:42.464
Let's take that juice versus squeeze ratio
00:16:42.844 --> 00:16:43.784
over to this question,
00:16:44.184 --> 00:16:46.005
because this takes time, effort, money.
00:16:46.046 --> 00:16:48.827
There are firms who you can hire that
00:16:48.847 --> 00:16:49.849
are specialized in this.
00:16:50.288 --> 00:16:52.291
So what are people actually spending,
00:16:52.350 --> 00:16:53.451
even if you're not hiring a firm,
00:16:53.471 --> 00:16:55.352
you're also spending brainpower, time,
00:16:55.413 --> 00:16:56.653
staff time, effort, money.
00:16:56.994 --> 00:16:58.754
What are we actually spending to maintain
00:16:58.794 --> 00:16:59.035
that
00:17:01.356 --> 00:17:04.157
And has anyone proven that it does
00:17:04.198 --> 00:17:04.618
anything?
00:17:05.259 --> 00:17:07.640
Does it drive business or patient growth
00:17:07.720 --> 00:17:08.160
at all?
00:17:08.580 --> 00:17:08.740
Yeah.
00:17:08.820 --> 00:17:11.261
So one of the questions I ask operators
00:17:11.281 --> 00:17:14.223
to think about is the concept of what
00:17:14.304 --> 00:17:17.484
is your return on the cost of quality?
00:17:17.925 --> 00:17:20.446
The cost is the time, effort, resources,
00:17:20.567 --> 00:17:20.967
money,
00:17:21.507 --> 00:17:24.888
all these things we do to ensure some
00:17:24.949 --> 00:17:25.950
level of quality.
00:17:26.609 --> 00:17:28.171
And so you have to be cognizant of
00:17:28.191 --> 00:17:28.431
that.
00:17:28.911 --> 00:17:31.551
The spending is extremely real and it's
00:17:31.652 --> 00:17:33.413
often invisible in the budget.
00:17:33.893 --> 00:17:34.113
You know,
00:17:34.133 --> 00:17:35.794
people aren't you're not budgeting this as
00:17:35.834 --> 00:17:38.375
much staff time training and review
00:17:38.815 --> 00:17:41.476
technology platforms with automatic post
00:17:41.536 --> 00:17:43.016
visit review sequences.
00:17:43.076 --> 00:17:45.156
Now we have all this stuff that goes
00:17:45.217 --> 00:17:47.637
into your phone that automatically asks
00:17:47.738 --> 00:17:49.318
you all of these kinds of things.
00:17:49.939 --> 00:17:51.700
And for a multi-site operator, man,
00:17:51.740 --> 00:17:52.460
that adds up.
00:17:52.579 --> 00:17:54.461
fast and keep in mind all the SAS
00:17:54.481 --> 00:17:55.702
software providers,
00:17:55.742 --> 00:17:56.804
how do they make more money?
00:17:57.223 --> 00:18:00.146
The same customers adding additional APIs
00:18:00.547 --> 00:18:02.848
that allow you to do more functions is
00:18:02.909 --> 00:18:04.190
how they make more money.
00:18:04.250 --> 00:18:04.410
You know,
00:18:04.430 --> 00:18:06.031
we'll talk about the EMRs and other kinds
00:18:06.051 --> 00:18:08.493
of things later because the LZRs miniature
00:18:08.534 --> 00:18:09.034
versions.
00:18:09.434 --> 00:18:11.757
So now I'm not only doing your EMR,
00:18:12.217 --> 00:18:14.698
I'm doing your point of service pay at
00:18:14.758 --> 00:18:15.358
times.
00:18:15.578 --> 00:18:17.298
I'm doing your outcome studies.
00:18:17.680 --> 00:18:20.181
I'm doing your documentation AI.
00:18:20.580 --> 00:18:22.422
All of these things keep adding costs.
00:18:22.461 --> 00:18:23.682
And so we say as operators,
00:18:23.701 --> 00:18:25.303
where's my cost of RCM?
00:18:25.343 --> 00:18:26.363
Should be going down.
00:18:26.544 --> 00:18:27.523
All of a sudden it's going up.
00:18:27.544 --> 00:18:28.304
Why is it going up?
00:18:28.324 --> 00:18:29.785
Because all these providers are adding
00:18:29.884 --> 00:18:30.525
APIs.
00:18:30.805 --> 00:18:33.826
They're increasing your cost and you have
00:18:33.866 --> 00:18:35.567
to do the tough decisions and make
00:18:35.607 --> 00:18:36.048
choices.
00:18:36.528 --> 00:18:38.348
about all of those kinds of things.
00:18:38.410 --> 00:18:40.151
And so in health care,
00:18:40.171 --> 00:18:42.211
a lot of choice is constrained.
00:18:42.272 --> 00:18:44.054
Insurance networks, referral patterns,
00:18:44.094 --> 00:18:44.713
geography,
00:18:44.773 --> 00:18:46.875
they're still doing an incredible amount
00:18:46.915 --> 00:18:47.517
of routing.
00:18:47.557 --> 00:18:49.817
And so if you're investing to maintain a
00:18:49.857 --> 00:18:52.079
four point nine in a market where a
00:18:52.140 --> 00:18:53.820
meaningful portion of your new patients
00:18:53.861 --> 00:18:55.502
are coming through other referral channels
00:18:55.823 --> 00:18:57.544
that aren't looking at your Google rating
00:18:57.604 --> 00:18:57.884
at all,
00:18:57.924 --> 00:18:59.266
that doesn't mean the investment is
00:18:59.826 --> 00:19:00.226
wasted.
00:19:00.626 --> 00:19:02.867
It just means that ROI calculation is
00:19:02.948 --> 00:19:03.269
messy.
00:19:03.909 --> 00:19:06.131
They're the platform selling requests.
00:19:06.471 --> 00:19:08.553
So we see all of these efforts now
00:19:08.673 --> 00:19:11.776
in the AI world of lead generation and
00:19:11.895 --> 00:19:13.218
all of these things around it.
00:19:13.778 --> 00:19:15.759
And I talk to practices and they say,
00:19:15.779 --> 00:19:17.121
I'm not having trouble getting new
00:19:17.161 --> 00:19:18.021
patients right now.
00:19:18.442 --> 00:19:18.742
Well,
00:19:18.923 --> 00:19:20.443
you're spending an incredible amount
00:19:20.483 --> 00:19:22.445
between your foot marketers,
00:19:22.826 --> 00:19:25.308
your advertising, your digital marketing,
00:19:25.788 --> 00:19:27.430
and all of these things have accreted to
00:19:27.471 --> 00:19:27.810
a level.
00:19:27.891 --> 00:19:28.490
And you have to say,
00:19:28.530 --> 00:19:30.032
does the business model support it
00:19:30.053 --> 00:19:30.192
anymore?
00:19:31.128 --> 00:19:32.069
And in healthcare,
00:19:32.230 --> 00:19:33.612
it's a penny nickel business,
00:19:33.652 --> 00:19:34.893
a nickel dime business.
00:19:35.012 --> 00:19:38.136
You can't afford to spend an enormous
00:19:38.156 --> 00:19:39.698
amount of money on a problem that you
00:19:39.738 --> 00:19:41.099
think is there, but it really isn't.
00:19:41.519 --> 00:19:42.159
Yeah.
00:19:42.179 --> 00:19:42.359
All right.
00:19:42.380 --> 00:19:43.220
So I'm going to hold your feet to
00:19:43.259 --> 00:19:43.640
the fire.
00:19:43.819 --> 00:19:47.021
I actually put your article into test.
00:19:47.041 --> 00:19:47.382
I said, hey,
00:19:47.982 --> 00:19:51.125
how would some leading brands actually
00:19:51.244 --> 00:19:51.944
optimize this?
00:19:51.984 --> 00:19:55.686
And one of the best responses was Disney.
00:19:56.248 --> 00:19:58.848
They said Walt Disney himself would
00:19:58.929 --> 00:20:01.611
optimize for miles per hour,
00:20:01.651 --> 00:20:03.531
not miles per hour, not stars.
00:20:03.912 --> 00:20:06.012
So if Google stars don't tell the truth,
00:20:06.814 --> 00:20:08.994
what should operators be measuring
00:20:09.476 --> 00:20:10.056
instead?
00:20:10.753 --> 00:20:11.193
Yeah,
00:20:11.413 --> 00:20:13.275
so we'll get into this a little bit,
00:20:13.295 --> 00:20:14.736
but I noticed one of the comments from
00:20:14.756 --> 00:20:18.117
the article last week was somebody saying
00:20:18.137 --> 00:20:20.759
the best metric they measure is how many
00:20:20.818 --> 00:20:22.279
smiles are leaving their clinic.
00:20:22.728 --> 00:20:24.167
And I thought that was a real interesting
00:20:24.228 --> 00:20:24.728
one.
00:20:24.827 --> 00:20:26.409
In dental, at least in our company,
00:20:26.469 --> 00:20:28.009
we say our mission is to create a
00:20:28.048 --> 00:20:29.548
lifetime of healthy smiles.
00:20:29.608 --> 00:20:30.930
And how are we doing that?
00:20:30.970 --> 00:20:33.190
Doing meaningful and purposeful work and
00:20:33.230 --> 00:20:33.789
remembering.
00:20:34.230 --> 00:20:35.711
In fact, that's what we're here for.
00:20:36.310 --> 00:20:38.431
But there's a short list with teeth.
00:20:38.510 --> 00:20:41.011
New patient arrival rate is a real
00:20:41.051 --> 00:20:41.672
critical one.
00:20:41.711 --> 00:20:43.291
Are new patients choosing you?
00:20:43.811 --> 00:20:45.432
Is that number growing?
00:20:45.553 --> 00:20:47.673
Is your number of new patients growing?
00:20:48.393 --> 00:20:51.134
We talk about growth in organic and all
00:20:51.153 --> 00:20:52.253
these things and platforms,
00:20:52.273 --> 00:20:55.095
and most PT operators measure that wrong.
00:20:55.435 --> 00:20:59.757
They measure growth in terms of number of
00:20:59.797 --> 00:21:01.518
visits per patient, all kinds of things.
00:21:01.538 --> 00:21:02.998
They ought to be measuring it by growth
00:21:03.038 --> 00:21:03.798
and cash flow.
00:21:03.917 --> 00:21:05.298
Different topic for another time.
00:21:05.959 --> 00:21:06.980
But is the number growing?
00:21:07.000 --> 00:21:07.980
That's a market signal,
00:21:08.060 --> 00:21:10.123
not just a sentimental drop.
00:21:10.182 --> 00:21:11.703
PlanetCare completion, very,
00:21:11.743 --> 00:21:13.265
very difficult, but really, really,
00:21:13.605 --> 00:21:14.205
really difficult.
00:21:14.346 --> 00:21:16.448
Are patients staying through their episode
00:21:16.508 --> 00:21:17.288
of completion?
00:21:17.628 --> 00:21:19.131
To me, that would be the best proxy.
00:21:21.115 --> 00:21:23.135
of a patient you know satisfaction really
00:21:23.615 --> 00:21:25.896
because dropout is the quiet killer that a
00:21:25.957 --> 00:21:27.917
four point nine doesn't capture right
00:21:27.978 --> 00:21:30.018
functional outcome improvement discipline
00:21:30.157 --> 00:21:33.459
specific systematically collected not
00:21:33.538 --> 00:21:36.740
cherry-picked reactivation rate are former
00:21:36.779 --> 00:21:38.540
patients coming back when they have a new
00:21:38.601 --> 00:21:40.701
need i call it friends family and former
00:21:40.760 --> 00:21:42.682
patient percentage what percentage of your
00:21:42.721 --> 00:21:45.462
new patients fall into that bucket that is
00:21:45.522 --> 00:21:47.182
really critical to me because it means
00:21:47.202 --> 00:21:48.844
you're spending zero dollars
00:21:49.364 --> 00:21:51.424
under what you should be doing to get
00:21:51.464 --> 00:21:52.026
your marketing,
00:21:52.066 --> 00:21:53.807
which is providing great care.
00:21:54.207 --> 00:21:55.867
That's continuity and it's its most
00:21:55.928 --> 00:21:56.749
measurable form.
00:21:57.729 --> 00:21:58.950
None of these are as clean or as
00:21:58.970 --> 00:22:00.270
visible as a star rating.
00:22:00.490 --> 00:22:00.810
You know,
00:22:01.511 --> 00:22:03.212
in order to get to the answer,
00:22:03.272 --> 00:22:05.034
it's not a simple answer like a star
00:22:05.074 --> 00:22:05.354
rating.
00:22:05.374 --> 00:22:06.974
That's exactly why they matter more.
00:22:07.035 --> 00:22:09.156
The metrics that are easy to show off
00:22:09.196 --> 00:22:10.477
are usually the ones that have already
00:22:10.518 --> 00:22:11.137
been gained.
00:22:11.178 --> 00:22:12.778
The ones that are harder to show off
00:22:12.818 --> 00:22:14.259
are the ones that's actually happening.
00:22:14.894 --> 00:22:15.976
Yeah.
00:22:15.996 --> 00:22:17.396
Anything you'd want to leave the audience
00:22:17.436 --> 00:22:19.157
with as we wrap up?
00:22:19.198 --> 00:22:20.179
Your parting thoughts?
00:22:20.618 --> 00:22:21.900
No, just, you know,
00:22:22.119 --> 00:22:23.901
not telling you not to do Google ratings.
00:22:24.000 --> 00:22:26.403
Just don't overvalue them and don't spend
00:22:26.462 --> 00:22:28.163
all you're trying to get more of them.
00:22:28.663 --> 00:22:30.746
Reroute that same effort into something
00:22:30.786 --> 00:22:32.507
that brings meaningful change into the
00:22:32.547 --> 00:22:33.768
operations of your practice.
00:22:33.788 --> 00:22:34.488
I mean,
00:22:34.587 --> 00:22:36.769
as a guy who's spent some years in
00:22:36.809 --> 00:22:37.950
marketing and communications,
00:22:37.970 --> 00:22:39.391
the best marketing is a really,
00:22:39.451 --> 00:22:41.613
really great product and or service.
00:22:42.212 --> 00:22:43.253
If you're trying to become a better
00:22:43.354 --> 00:22:44.315
operator in healthcare,
00:22:45.111 --> 00:22:45.833
you're in the right place.
00:22:45.893 --> 00:22:46.775
If this episode hit,
00:22:46.815 --> 00:22:48.419
Larry goes deeper inside his writing.
00:22:48.819 --> 00:22:50.304
Look for the operator on Substack.
00:22:50.324 --> 00:22:51.948
We'll also drop a link below.
00:22:51.968 --> 00:22:53.191
That's where the full breakdown lives.
00:22:53.211 --> 00:22:53.873
We'll see you next time.
00:00:00.070 --> 00:00:00.718
No problem.
00:00:01.843 --> 00:00:02.863
And are we starting with the article?
00:00:02.923 --> 00:00:03.984
I don't remember what we just said.
00:00:04.105 --> 00:00:04.264
Yeah,
00:00:04.285 --> 00:00:05.445
I was going to do the article first.
00:00:05.464 --> 00:00:05.945
Yeah, perfect.
00:00:06.506 --> 00:00:07.966
Yeah.
00:00:08.026 --> 00:00:08.207
All right.
00:00:08.246 --> 00:00:10.489
Most health care businesses have a number
00:00:11.028 --> 00:00:13.029
they're proud of, a number they show off,
00:00:13.189 --> 00:00:14.031
a number they track,
00:00:14.230 --> 00:00:17.292
a number they think proves they're doing
00:00:17.373 --> 00:00:17.833
good work.
00:00:18.493 --> 00:00:20.135
Larry's argument in his latest article,
00:00:20.495 --> 00:00:22.957
that number might be completely
00:00:22.977 --> 00:00:23.516
meaningless.
00:00:24.018 --> 00:00:24.178
Today,
00:00:24.198 --> 00:00:25.318
we're talking about one of the most
00:00:25.439 --> 00:00:27.600
visible metrics in health care.
00:00:28.239 --> 00:00:30.181
Google reviews, five stars.
00:00:31.109 --> 00:00:32.869
Zero outcomes?
00:00:32.990 --> 00:00:33.850
Welcome to The Operator,
00:00:33.890 --> 00:00:35.530
a show about running better healthcare
00:00:35.549 --> 00:00:36.831
businesses, not from theory,
00:00:37.331 --> 00:00:39.131
from people actually doing the work.
00:00:39.192 --> 00:00:40.692
If you're responsible for patients,
00:00:40.771 --> 00:00:44.213
people, or performance, this is for you.
00:00:44.292 --> 00:00:45.573
Larry, welcome to your show.
00:00:45.594 --> 00:00:47.533
Well, thank you, Jerry.
00:00:47.594 --> 00:00:48.914
Thank you for hosting my show.
00:00:50.286 --> 00:00:50.426
Well,
00:00:50.466 --> 00:00:51.826
my job is to sort of set you
00:00:51.947 --> 00:00:52.106
up.
00:00:52.226 --> 00:00:55.207
This is the last part in a series
00:00:55.228 --> 00:00:56.048
that you've been doing.
00:00:56.067 --> 00:00:57.167
And if people want to go back to
00:00:57.228 --> 00:00:57.328
it,
00:00:57.648 --> 00:00:59.689
we'll give the link to the sub stack
00:00:59.709 --> 00:01:00.829
that they can view as well as the
00:01:00.868 --> 00:01:01.829
articles on LinkedIn.
00:01:02.530 --> 00:01:02.990
But first,
00:01:03.329 --> 00:01:04.650
why did you decide to do sort of
00:01:04.670 --> 00:01:05.790
a series on metrics?
00:01:06.031 --> 00:01:07.590
What about that made you say,
00:01:07.611 --> 00:01:09.391
I'm going to dedicate several weeks of my
00:01:09.492 --> 00:01:11.611
writing to just metrics in general before
00:01:11.652 --> 00:01:13.733
we get into the specific Google reviews?
00:01:14.379 --> 00:01:15.099
Yeah.
00:01:15.120 --> 00:01:17.141
What we tend to do in an operating
00:01:17.180 --> 00:01:19.141
business and health care platforms is we
00:01:19.201 --> 00:01:21.942
tend to get very routinized on certain
00:01:22.003 --> 00:01:23.962
metrics that are like sacred cows.
00:01:23.983 --> 00:01:26.084
They're the belief that they are the most
00:01:26.123 --> 00:01:27.043
important ones.
00:01:27.885 --> 00:01:29.644
We've had vast changes in our operating
00:01:29.685 --> 00:01:30.225
environment.
00:01:30.266 --> 00:01:32.046
If you think of sort of the post-COVID
00:01:32.066 --> 00:01:32.927
hangover days,
00:01:32.947 --> 00:01:34.706
then you had shortages and you had all
00:01:34.746 --> 00:01:36.427
the headwinds of reimbursement.
00:01:37.188 --> 00:01:39.530
and all the things around high inflation.
00:01:40.251 --> 00:01:42.753
And the business models have had to
00:01:42.793 --> 00:01:43.153
change.
00:01:43.174 --> 00:01:44.254
You've had to adjust.
00:01:44.314 --> 00:01:46.917
And so what we tend not to do
00:01:47.177 --> 00:01:49.739
in health care operations is rethink,
00:01:50.140 --> 00:01:51.540
challenge our assumptions.
00:01:52.302 --> 00:01:52.641
And say,
00:01:52.742 --> 00:01:55.063
why are we continuing to measure that?
00:01:55.263 --> 00:01:57.346
And then the objective becomes the
00:01:57.406 --> 00:01:59.406
measurement rather than the activities and
00:01:59.427 --> 00:02:01.868
the behaviors that really get the
00:02:01.968 --> 00:02:03.989
operations flowing in the right direction.
00:02:04.531 --> 00:02:06.632
And so I've tried to on each one
00:02:06.671 --> 00:02:07.852
of these metrics doesn't mean,
00:02:08.112 --> 00:02:09.253
as I point out in the articles,
00:02:09.274 --> 00:02:10.735
that you shouldn't be measuring them,
00:02:10.794 --> 00:02:12.796
but you should be understanding how
00:02:12.836 --> 00:02:14.298
they've shifted over the years.
00:02:15.157 --> 00:02:18.020
And the whole area around good hearts is
00:02:18.080 --> 00:02:20.222
a bias that we tend to default in
00:02:20.282 --> 00:02:21.703
over time if we're not careful.
00:02:22.164 --> 00:02:22.384
Yeah.
00:02:22.425 --> 00:02:25.586
When the metric becomes the measure,
00:02:25.687 --> 00:02:27.487
it fails to measure what matters is the
00:02:27.527 --> 00:02:28.848
thing that kept sticking with me.
00:02:29.229 --> 00:02:29.889
That makes sense.
00:02:29.929 --> 00:02:30.569
I mean, you're Russian.
00:02:31.110 --> 00:02:31.911
If you want to go back and read
00:02:31.931 --> 00:02:31.991
it,
00:02:32.031 --> 00:02:34.412
the Russian nail factory sort of
00:02:34.512 --> 00:02:35.812
highlights that pretty well.
00:02:35.893 --> 00:02:37.473
When you tell me to gamify,
00:02:37.493 --> 00:02:39.594
when you gamify a metric and you put
00:02:39.634 --> 00:02:42.195
my salary on the on the line for
00:02:42.216 --> 00:02:42.477
that,
00:02:42.616 --> 00:02:44.176
guess what I get really good at hitting
00:02:44.197 --> 00:02:46.399
that number is the letter of the metric
00:02:46.459 --> 00:02:47.860
or the spirit of the metric.
00:02:47.879 --> 00:02:48.000
Well,
00:02:48.020 --> 00:02:49.120
I hit the letter of the metric and
00:02:49.139 --> 00:02:50.221
that's what gets me the paycheck.
00:02:51.002 --> 00:02:52.944
Just to that point, years ago,
00:02:53.465 --> 00:02:55.506
I'm going back into the late eighties.
00:02:56.426 --> 00:02:58.027
I had a few clinics and one of
00:02:58.048 --> 00:02:58.709
my clinics,
00:02:59.149 --> 00:03:01.250
we used to measure no-show cancellation
00:03:01.290 --> 00:03:03.331
rate and used to incentivize the front
00:03:03.372 --> 00:03:05.212
desk person for a lower no-show
00:03:05.252 --> 00:03:06.093
cancellation rate.
00:03:07.250 --> 00:03:08.129
And interesting,
00:03:08.169 --> 00:03:09.670
she went on maternity leave and she was
00:03:09.691 --> 00:03:11.931
a wonderful intake coordinator
00:03:11.951 --> 00:03:12.532
receptionist,
00:03:12.572 --> 00:03:14.073
what we called DOFI at the time,
00:03:14.092 --> 00:03:15.394
Director of First Impressions.
00:03:16.054 --> 00:03:16.593
And all of a sudden,
00:03:16.693 --> 00:03:19.414
our no-show cancellation went sky high.
00:03:19.914 --> 00:03:20.855
And I started wondering,
00:03:20.895 --> 00:03:21.996
how is that the case?
00:03:22.056 --> 00:03:22.997
Well, as it turns out,
00:03:23.037 --> 00:03:24.437
you can game that number.
00:03:24.516 --> 00:03:26.177
It's no different than the Russian nail
00:03:26.217 --> 00:03:26.698
factory.
00:03:27.139 --> 00:03:27.878
Somebody cancels,
00:03:27.899 --> 00:03:29.158
you just take them off the schedule and
00:03:29.199 --> 00:03:30.780
put them somewhere else and you never were
00:03:30.900 --> 00:03:32.401
able to see what really...
00:03:33.020 --> 00:03:33.681
happen there.
00:03:34.081 --> 00:03:36.122
And so gamesmanship working around it,
00:03:36.582 --> 00:03:40.246
our tax laws are the absolute, you know,
00:03:40.306 --> 00:03:42.568
personification of good hearts law,
00:03:42.668 --> 00:03:45.789
everybody works around the tax laws to try
00:03:45.810 --> 00:03:46.931
and save on their taxes.
00:03:46.971 --> 00:03:47.890
That's normal.
00:03:47.911 --> 00:03:47.991
Yeah.
00:03:48.812 --> 00:03:49.953
So we have to, you know,
00:03:49.992 --> 00:03:51.954
we have too many tax law issues,
00:03:52.354 --> 00:03:54.295
and good heart issues in operation.
00:03:54.716 --> 00:03:56.537
And so my challenge is somebody who's in
00:03:56.576 --> 00:03:59.179
the field every day operating is for us
00:03:59.199 --> 00:04:00.340
to challenge those assumptions.
00:04:00.659 --> 00:04:03.002
And you can tell which side of the
00:04:03.042 --> 00:04:04.503
argument someone is on with taxes when
00:04:04.524 --> 00:04:06.906
they call it a write-off or a loophole.
00:04:06.985 --> 00:04:07.826
If it's a loophole,
00:04:07.847 --> 00:04:09.829
you can tell they don't agree with it
00:04:09.868 --> 00:04:10.269
right there.
00:04:10.288 --> 00:04:12.270
All right, so let's jump into this.
00:04:12.671 --> 00:04:15.835
If someone logs on Google website,
00:04:15.935 --> 00:04:17.797
somewhere where ratings are being
00:04:18.036 --> 00:04:19.699
tabulated and shown off,
00:04:20.617 --> 00:04:23.218
what is a four point nine star four
00:04:23.259 --> 00:04:25.139
point out of five star rating actually
00:04:25.180 --> 00:04:28.300
tell you about specifically a health care
00:04:28.321 --> 00:04:30.322
business yeah honestly it tells you that
00:04:30.362 --> 00:04:32.603
they're good at asking that's not nothing
00:04:32.622 --> 00:04:35.324
not what most operators think it is you
00:04:35.343 --> 00:04:37.264
know four point nine means your patients
00:04:37.485 --> 00:04:39.446
felt well enough to leave a review that
00:04:39.485 --> 00:04:41.326
had a positive enough experience to give
00:04:41.346 --> 00:04:42.487
you close to a five star
00:04:43.067 --> 00:04:44.927
does not tell you about the patient who
00:04:44.968 --> 00:04:46.848
dropped off after the two to three visit
00:04:46.887 --> 00:04:49.088
cliff in physical therapy or in dental it
00:04:49.149 --> 00:04:50.410
doesn't tell you the patient who didn't
00:04:50.430 --> 00:04:52.329
show up for the second visit which
00:04:52.389 --> 00:04:54.490
oftentimes in dental is the most important
00:04:54.550 --> 00:04:57.512
visit from an economic standpoint it
00:04:57.552 --> 00:04:59.112
doesn't tell you about your twenty two day
00:04:59.153 --> 00:05:00.872
wait period for a new evaluation it
00:05:00.892 --> 00:05:02.293
doesn't tell you whether your functional
00:05:02.334 --> 00:05:04.173
outcomes improved or whether your hygiene
00:05:04.194 --> 00:05:05.814
appointment rate is collapsing
00:05:06.875 --> 00:05:09.418
It's a sentiment snapshot from a very
00:05:09.497 --> 00:05:11.060
self-directed audience.
00:05:11.160 --> 00:05:11.860
And in health care,
00:05:11.899 --> 00:05:14.903
that audience skews very grateful,
00:05:15.062 --> 00:05:16.343
skews compliance,
00:05:16.363 --> 00:05:18.165
skews towards the people who finished
00:05:18.225 --> 00:05:20.307
care, the people who like you.
00:05:20.367 --> 00:05:21.708
The four point nine is real.
00:05:21.728 --> 00:05:22.809
It's just not the whole story.
00:05:22.829 --> 00:05:24.990
It might not even be the important or
00:05:25.391 --> 00:05:26.992
really key elements of the story.
00:05:27.389 --> 00:05:28.649
Yeah, you want to gamify that number.
00:05:29.329 --> 00:05:31.512
Don't point out where to scan the QR
00:05:31.531 --> 00:05:32.793
code to leave a review to somebody who's
00:05:32.833 --> 00:05:33.774
disgruntled, right?
00:05:34.935 --> 00:05:36.216
Although you can look at the other side
00:05:36.235 --> 00:05:36.735
of the argument,
00:05:36.755 --> 00:05:38.716
which is sometimes when people have a bad
00:05:38.757 --> 00:05:39.298
experience,
00:05:39.317 --> 00:05:41.839
they're more likely to go rate you and
00:05:41.899 --> 00:05:44.120
leave a review versus the people who are
00:05:44.161 --> 00:05:45.603
the silent, happy,
00:05:46.242 --> 00:05:48.524
satisfied customer or patient.
00:05:49.004 --> 00:05:49.444
Exactly.
00:05:49.786 --> 00:05:50.665
And it has some meaning.
00:05:50.706 --> 00:05:52.848
It's just not all that much important from
00:05:52.887 --> 00:05:53.908
the day-to-day operations.
00:05:54.048 --> 00:05:54.288
Right.
00:05:54.588 --> 00:05:56.230
So at what point did healthcare cross the
00:05:56.250 --> 00:05:58.512
line from measuring experience to
00:05:58.591 --> 00:06:02.214
pretending experience equals quality?
00:06:02.877 --> 00:06:03.017
Yeah,
00:06:03.038 --> 00:06:04.358
so we gotta go back a little bit
00:06:04.858 --> 00:06:05.959
in place of time.
00:06:06.098 --> 00:06:08.339
In the, call it the late eighties,
00:06:08.480 --> 00:06:09.319
early nineties,
00:06:09.360 --> 00:06:10.940
there was this new thing that happened in
00:06:10.980 --> 00:06:12.822
healthcare called functional outcome
00:06:12.862 --> 00:06:17.163
measures, SF-II, the SF-XXVI, short form,
00:06:17.223 --> 00:06:18.363
long form, XXXVI,
00:06:18.384 --> 00:06:20.925
which is the healthcare quality of life.
00:06:20.964 --> 00:06:21.884
And so we started to say,
00:06:21.985 --> 00:06:23.466
what do outcomes mean?
00:06:24.026 --> 00:06:25.966
And outcomes were defined as days,
00:06:26.026 --> 00:06:29.427
dollars, utilization, functional outcome,
00:06:30.404 --> 00:06:31.305
And on top of that,
00:06:31.345 --> 00:06:32.985
we had patient satisfaction,
00:06:33.065 --> 00:06:35.307
later became patient experience.
00:06:35.346 --> 00:06:37.168
And so the combination of these dollars
00:06:37.228 --> 00:06:38.749
are sort of utilization-driven data,
00:06:39.009 --> 00:06:40.889
clinical functional outcome-driven data,
00:06:41.509 --> 00:06:43.870
and all the things around the experience
00:06:43.911 --> 00:06:46.132
became sort of the three distinct domains.
00:06:47.692 --> 00:06:49.134
But what happened is over time,
00:06:49.153 --> 00:06:50.413
we've tried to simplify it.
00:06:50.434 --> 00:06:50.615
You know,
00:06:50.634 --> 00:06:52.196
we're in business and operations.
00:06:52.255 --> 00:06:54.497
We're always trying to make the complex
00:06:54.576 --> 00:06:56.718
simple from an operation standpoint.
00:06:56.879 --> 00:06:58.040
That's a great thing.
00:06:58.279 --> 00:06:58.720
However,
00:06:58.800 --> 00:07:01.281
sometimes when we make things so simple,
00:07:01.322 --> 00:07:04.663
we destroy what the animal that we're
00:07:04.684 --> 00:07:05.625
trying to create is.
00:07:05.704 --> 00:07:07.386
So the moment we ran out of better
00:07:07.425 --> 00:07:09.627
alternatives and stopped admitting it,
00:07:09.666 --> 00:07:11.528
clinical outcome measurements in the most
00:07:11.608 --> 00:07:14.571
outpatient settings is inconsistent at
00:07:14.630 --> 00:07:16.232
best, absent at worst.
00:07:16.831 --> 00:07:19.774
Functional tools do exist, photo, promise,
00:07:20.653 --> 00:07:22.274
all the things are on Medicare, you know,
00:07:22.334 --> 00:07:24.976
PSFS, for example, but adoption is not,
00:07:25.317 --> 00:07:27.197
you know, is not evenly put.
00:07:28.059 --> 00:07:28.819
And at times,
00:07:28.858 --> 00:07:30.579
we tend to only do it on our
00:07:30.620 --> 00:07:33.041
best patients or those who complete care.
00:07:33.062 --> 00:07:34.062
And so you have to be really,
00:07:34.101 --> 00:07:34.802
really careful.
00:07:35.764 --> 00:07:37.644
And so what fills that volume,
00:07:37.665 --> 00:07:39.646
whatever is visible and Google stars are
00:07:39.846 --> 00:07:40.406
everywhere.
00:07:40.447 --> 00:07:42.149
And so let's use Google stars.
00:07:42.329 --> 00:07:44.411
I had series a couple of weeks ago
00:07:44.451 --> 00:07:45.872
about Net Promoter Score,
00:07:45.891 --> 00:07:47.353
a lot of similarities here.
00:07:47.694 --> 00:07:48.694
They're on your profile,
00:07:48.713 --> 00:07:49.935
they show up in the listing,
00:07:49.954 --> 00:07:51.737
they're a number, numbers feel like data.
00:07:51.797 --> 00:07:52.838
So we promote them,
00:07:52.918 --> 00:07:54.439
not because anyone made a deliberate
00:07:54.899 --> 00:07:55.839
decision about it,
00:07:55.879 --> 00:07:57.961
but that four point nine stars equals
00:07:58.002 --> 00:07:58.862
clinical excellence.
00:07:58.882 --> 00:08:00.884
Somehow or another, we conflated that.
00:08:01.725 --> 00:08:03.206
But because the infrastructure for
00:08:03.247 --> 00:08:05.829
measuring actual clinical excellence
00:08:05.910 --> 00:08:08.411
wasn't there or wasn't fulsome or wasn't
00:08:08.451 --> 00:08:11.214
complete, the proxy became the point.
00:08:11.615 --> 00:08:13.257
And that's always how it happens.
00:08:13.336 --> 00:08:16.019
We make a proxy a conclusion,
00:08:16.160 --> 00:08:18.161
and Google stars are now that conclusion,
00:08:18.182 --> 00:08:18.442
unfortunately.
00:08:19.511 --> 00:08:19.690
Yeah.
00:08:20.230 --> 00:08:21.732
It's funny that you bring up four point
00:08:21.791 --> 00:08:22.552
nine stars.
00:08:22.752 --> 00:08:23.833
And I think I know why.
00:08:24.153 --> 00:08:26.935
To me, five feels too perfect.
00:08:27.035 --> 00:08:29.255
It feels like I can't trust that because
00:08:29.295 --> 00:08:30.896
it's nothing's perfect.
00:08:30.937 --> 00:08:32.557
So four point nine feels as close as
00:08:32.577 --> 00:08:33.198
you can get.
00:08:33.558 --> 00:08:34.099
Really good.
00:08:34.119 --> 00:08:35.480
But obviously there's some real in there.
00:08:35.539 --> 00:08:36.480
So it matters.
00:08:37.160 --> 00:08:38.841
Isn't that funny how that like we've even
00:08:39.042 --> 00:08:40.722
even on the receiving end said five's too
00:08:40.743 --> 00:08:40.863
good.
00:08:40.883 --> 00:08:41.562
I don't trust it.
00:08:42.163 --> 00:08:43.783
A four point eight that four point nine
00:08:43.803 --> 00:08:45.125
that feels perfect.
00:08:45.325 --> 00:08:46.506
More authentic.
00:08:46.667 --> 00:08:47.327
Feels more authentic.
00:08:47.488 --> 00:08:47.807
Right.
00:08:47.908 --> 00:08:49.529
Right.
00:08:49.570 --> 00:08:51.832
So you mentioned like sort of the
00:08:51.893 --> 00:08:52.874
pre-COVID, right?
00:08:52.913 --> 00:08:56.118
So are operators still chasing Google
00:08:56.158 --> 00:08:57.500
reviews based on a version of the
00:08:57.539 --> 00:08:58.701
algorithm that doesn't actually exist?
00:08:58.821 --> 00:09:00.864
Are we still having a twenty sixteen
00:09:00.923 --> 00:09:03.086
mindset in twenty twenty six?
00:09:03.806 --> 00:09:05.106
No, that's absolutely right.
00:09:05.226 --> 00:09:06.048
A lot of them are.
00:09:06.067 --> 00:09:07.729
And that's really what my research started
00:09:07.769 --> 00:09:08.249
to show,
00:09:08.328 --> 00:09:09.889
that the old mental model was pretty
00:09:09.929 --> 00:09:10.250
simple.
00:09:10.311 --> 00:09:12.312
More five star reviews equals higher
00:09:12.491 --> 00:09:14.474
ranking equals more patients.
00:09:14.573 --> 00:09:16.475
So it was all driven by how high
00:09:16.514 --> 00:09:17.115
on the Google
00:09:17.932 --> 00:09:19.913
best search engine, period.
00:09:19.932 --> 00:09:20.514
It's interesting.
00:09:20.533 --> 00:09:22.174
We're switching now from search engine to
00:09:22.355 --> 00:09:24.395
AI, LLL.
00:09:25.355 --> 00:09:25.996
And for a while,
00:09:26.037 --> 00:09:29.879
the volume of reviews was the dominant SEO
00:09:29.979 --> 00:09:30.339
signal.
00:09:30.360 --> 00:09:32.020
And this really is the main teaching point
00:09:32.061 --> 00:09:32.681
of the article.
00:09:33.020 --> 00:09:34.461
So that logic held true.
00:09:34.501 --> 00:09:36.903
But the algorithm has gotten way more
00:09:36.962 --> 00:09:38.884
sophisticated, as they always do.
00:09:38.945 --> 00:09:41.446
Technology always outpaces everything we
00:09:41.485 --> 00:09:42.287
do in health care.
00:09:42.907 --> 00:09:45.067
proximity, relevance, behavior signals,
00:09:45.087 --> 00:09:46.730
how people interact with your listing,
00:09:46.769 --> 00:09:48.291
whether they click, whether they call,
00:09:48.691 --> 00:09:50.432
these matter now as well.
00:09:50.631 --> 00:09:52.133
So it's the behavioral elements,
00:09:52.212 --> 00:09:53.833
not just the star elements.
00:09:54.455 --> 00:09:56.596
Review recency matters more than raw
00:09:56.635 --> 00:09:57.135
volume.
00:09:57.476 --> 00:09:59.998
So if you took a hundred reviews,
00:10:00.457 --> 00:10:02.200
it's like golf handicap system.
00:10:02.240 --> 00:10:04.441
It's the five top most recent ones that
00:10:04.500 --> 00:10:05.461
really matter.
00:10:06.001 --> 00:10:08.325
So the operators who ran an aggressive,
00:10:08.365 --> 00:10:10.447
let's get to two hundred review campaigns.
00:10:10.626 --> 00:10:12.769
I still see this all the time.
00:10:12.849 --> 00:10:15.052
And they sort of stop.
00:10:15.552 --> 00:10:16.893
They're potentially losing ground to a
00:10:16.952 --> 00:10:18.335
competitor with eighty reviews.
00:10:18.375 --> 00:10:19.615
So that was kind of like I got
00:10:19.676 --> 00:10:20.096
two hundred.
00:10:20.116 --> 00:10:20.756
You got eighty.
00:10:20.797 --> 00:10:21.778
So therefore, I'm better.
00:10:22.119 --> 00:10:24.421
In fact, we are competitiveness.
00:10:25.302 --> 00:10:27.863
around google stars surpassed our
00:10:27.883 --> 00:10:29.764
competitiveness around clinical excellence
00:10:29.803 --> 00:10:31.264
and doing the right thing for the patient
00:10:31.365 --> 00:10:33.485
right you know the we got we got
00:10:33.546 --> 00:10:36.347
diverted by all this um so chasing the
00:10:36.388 --> 00:10:38.489
number at one time made sense now it's
00:10:38.649 --> 00:10:41.311
it's it's table stakes and the operators
00:10:41.350 --> 00:10:43.152
treating it like it's a competitive moat
00:10:43.312 --> 00:10:45.413
are you know probably optimizing for a
00:10:45.493 --> 00:10:47.533
version of local search that's already
00:10:47.573 --> 00:10:49.475
moved way way past that right you know
00:10:49.514 --> 00:10:51.035
by the way at least in physical therapy
00:10:51.615 --> 00:10:53.155
Why do we care about local surgery much?
00:10:53.176 --> 00:10:54.596
Don't we have we have plenty of patients
00:10:54.616 --> 00:10:56.596
now, plenty of volume.
00:10:56.616 --> 00:10:56.876
Yeah.
00:10:56.976 --> 00:10:58.996
You know, really optimizing,
00:10:59.037 --> 00:11:00.217
as we talked about last week,
00:11:00.278 --> 00:11:03.298
optimizing that volume and not the churn
00:11:04.357 --> 00:11:05.499
is really, really important.
00:11:05.519 --> 00:11:07.239
So keeping the patients you have and what
00:11:07.259 --> 00:11:09.479
we're saying, milking your own cows first,
00:11:09.538 --> 00:11:10.639
you have those patients.
00:11:11.220 --> 00:11:12.740
Make sure you're getting the treatment
00:11:12.779 --> 00:11:15.559
completion on them so that you can focus
00:11:15.600 --> 00:11:16.561
attention on there.
00:11:16.600 --> 00:11:18.480
And that's where that, you know, really
00:11:19.360 --> 00:11:20.562
being extremely,
00:11:20.662 --> 00:11:22.923
extremely intentional about visit two and
00:11:22.942 --> 00:11:25.303
three and showing value there rather than
00:11:25.403 --> 00:11:26.524
routinize the visit.
00:11:27.184 --> 00:11:28.485
What you're basically saying to the
00:11:28.524 --> 00:11:29.706
patient is you don't need to come in
00:11:29.725 --> 00:11:30.907
anymore because we're going to do the same
00:11:30.927 --> 00:11:31.687
thing every time.
00:11:32.106 --> 00:11:32.586
Yep.
00:11:32.746 --> 00:11:35.408
I can actually hear someone creating a KPI
00:11:35.448 --> 00:11:36.089
just for that.
00:11:36.129 --> 00:11:37.490
But isn't there one?
00:11:37.610 --> 00:11:38.309
Isn't it churn?
00:11:38.330 --> 00:11:39.791
So when you don't have real clinical
00:11:39.870 --> 00:11:42.532
outcome data, what does fill that gap?
00:11:42.871 --> 00:11:44.753
What is the right thing or the better
00:11:44.812 --> 00:11:46.153
thing to measure?
00:11:47.408 --> 00:11:48.210
Yeah,
00:11:50.552 --> 00:11:52.154
so what happens is we use Google Deck,
00:11:52.395 --> 00:11:53.116
Google Stars,
00:11:53.417 --> 00:11:55.919
and Net Promoter Scores because leadership
00:11:55.980 --> 00:11:57.863
needs something to say in a board deck.
00:11:58.583 --> 00:12:00.304
And this is a different topic for another
00:12:00.345 --> 00:12:01.485
time, but I think, you know,
00:12:01.544 --> 00:12:04.485
PE backed platforms and even private
00:12:04.546 --> 00:12:07.927
practices do not have the right type of
00:12:07.966 --> 00:12:08.706
board members.
00:12:08.746 --> 00:12:11.067
They have people playing by old rules of
00:12:11.107 --> 00:12:13.129
an old game, a, you know,
00:12:13.168 --> 00:12:15.808
call it college before we professionalize
00:12:15.828 --> 00:12:17.529
through revenue share and NIL.
00:12:17.570 --> 00:12:19.831
That's the type of people that are on
00:12:19.931 --> 00:12:22.250
boards right now is this new game that
00:12:22.291 --> 00:12:23.792
took place post COVID.
00:12:24.692 --> 00:12:26.754
You show me an operator who's really done
00:12:26.815 --> 00:12:28.475
well the last few years and you've got
00:12:28.535 --> 00:12:30.778
an operator because they they're the ones
00:12:30.798 --> 00:12:32.721
who've dealt with incredible amounts of
00:12:32.780 --> 00:12:34.383
inflation at the supply level,
00:12:34.442 --> 00:12:36.325
inflation at the compensation level,
00:12:36.365 --> 00:12:38.047
shortages of your suppliers,
00:12:38.606 --> 00:12:40.089
all of those kinds of things.
00:12:40.950 --> 00:12:42.770
And so we use Google stars and net
00:12:42.812 --> 00:12:44.854
promoter scores for those board members
00:12:44.894 --> 00:12:46.315
because we want to fill a board deck.
00:12:46.335 --> 00:12:47.035
It sounds cynical.
00:12:47.135 --> 00:12:49.398
but it's accurate organizations under
00:12:49.457 --> 00:12:51.460
performance pressure from either PE
00:12:51.539 --> 00:12:51.840
owners,
00:12:51.879 --> 00:12:53.841
from franchise benchmarks from year over
00:12:53.922 --> 00:12:56.283
year need visible proof of quality.
00:12:56.644 --> 00:12:59.527
And so this proxy of Google stars is
00:12:59.626 --> 00:13:02.889
now what your compliance is showing up as
00:13:02.950 --> 00:13:03.350
quality.
00:13:03.370 --> 00:13:04.552
And if you can't pull functional
00:13:04.572 --> 00:13:06.232
improvement data, very hard to do,
00:13:06.273 --> 00:13:06.693
as you know,
00:13:07.114 --> 00:13:08.575
If your outcome tool adoption is
00:13:08.654 --> 00:13:09.355
inconsistent,
00:13:09.375 --> 00:13:10.875
it's very hard to be consistent.
00:13:11.196 --> 00:13:13.517
If your discharge documentation is a mess,
00:13:13.756 --> 00:13:15.758
very hard to have that consistent as well
00:13:16.077 --> 00:13:19.740
because most patients don't read their end
00:13:19.799 --> 00:13:21.179
of treatment discharge.
00:13:21.500 --> 00:13:22.841
You reach the number you have.
00:13:22.900 --> 00:13:24.182
Google stars makes it easy.
00:13:24.241 --> 00:13:26.001
Net promoter scores make it easier.
00:13:26.062 --> 00:13:27.842
Patient satisfaction makes it easier.
00:13:28.062 --> 00:13:29.163
Those aren't bad metrics.
00:13:29.183 --> 00:13:30.923
They're just getting asked to carry weight
00:13:30.943 --> 00:13:31.804
they weren't built for.
00:13:32.985 --> 00:13:34.826
The danger isn't that operators track
00:13:34.846 --> 00:13:34.986
them.
00:13:35.027 --> 00:13:36.368
The danger is that over time,
00:13:36.388 --> 00:13:38.528
the proxy becomes the definition.
00:13:38.568 --> 00:13:39.370
You stop asking,
00:13:39.389 --> 00:13:40.571
are patients getting better?
00:13:40.870 --> 00:13:41.652
And start asking,
00:13:41.751 --> 00:13:43.293
are patients happy enough to leave a
00:13:43.312 --> 00:13:44.133
five-star review?
00:13:44.153 --> 00:13:46.654
That's entirely different dimensions.
00:13:47.034 --> 00:13:47.716
They're related,
00:13:48.216 --> 00:13:49.596
but they're not the same questions.
00:13:49.777 --> 00:13:50.738
Yeah.
00:13:50.778 --> 00:13:52.698
You highlighted something in this article
00:13:52.759 --> 00:13:54.580
that I guess I didn't think about too
00:13:54.620 --> 00:13:54.941
much.
00:13:55.581 --> 00:13:56.601
And I bet you a lot of people
00:13:56.642 --> 00:13:57.222
didn't either,
00:13:57.263 --> 00:13:59.945
which is responding to one of these
00:13:59.985 --> 00:14:02.366
reviews, if it's negative or in a way,
00:14:02.788 --> 00:14:04.708
could open you up to liability.
00:14:05.370 --> 00:14:08.393
So why are healthcare providers the only
00:14:08.432 --> 00:14:10.335
businesses that really can't actually
00:14:10.355 --> 00:14:11.716
defend themselves in public?
00:14:11.775 --> 00:14:12.355
Or they can,
00:14:12.375 --> 00:14:13.658
but they have to be really,
00:14:14.018 --> 00:14:15.139
really careful about it.
00:14:15.447 --> 00:14:15.667
Yeah.
00:14:15.706 --> 00:14:16.187
So first of all,
00:14:16.206 --> 00:14:17.908
the reviews tend to reflect sort of your
00:14:17.988 --> 00:14:20.908
interpersonal and logistical experience as
00:14:20.948 --> 00:14:22.288
your wait times, your parking,
00:14:22.328 --> 00:14:23.089
the front desk,
00:14:23.448 --> 00:14:25.210
not clinical decision making.
00:14:25.610 --> 00:14:28.171
And so the population leaving reviews is
00:14:28.270 --> 00:14:30.711
really not a representative population.
00:14:31.851 --> 00:14:34.354
people are complex they leave incomplete
00:14:34.835 --> 00:14:37.557
survey data disappointing outcomes are
00:14:37.596 --> 00:14:39.938
less likely to review stars of any any
00:14:40.620 --> 00:14:43.162
nature at all and what ends up happening
00:14:43.442 --> 00:14:45.283
is it's you know do you like your
00:14:45.323 --> 00:14:47.285
provider all those kind of things they
00:14:47.346 --> 00:14:50.028
review it but that selection bias is baked
00:14:50.087 --> 00:14:52.870
into every star rating in the industry
00:14:53.629 --> 00:14:55.089
But the biggest thing is what you're
00:14:55.129 --> 00:14:56.330
referring to on the question,
00:14:56.350 --> 00:14:58.951
which has HIPAA in the background,
00:14:58.971 --> 00:15:01.171
which limits how providers can respond to
00:15:01.230 --> 00:15:02.270
negative reviews.
00:15:02.611 --> 00:15:04.011
You can't get into details.
00:15:04.052 --> 00:15:05.412
You can't correct the record.
00:15:05.451 --> 00:15:07.133
You can't explain context.
00:15:07.673 --> 00:15:09.754
So one-star review about a billing dispute
00:15:09.793 --> 00:15:11.274
sits on your profile essentially
00:15:11.333 --> 00:15:13.335
unchallenged because your response has to
00:15:13.375 --> 00:15:14.215
be generic.
00:15:14.875 --> 00:15:17.618
It lands and people people ignore that.
00:15:17.658 --> 00:15:19.259
And so now we've developed this whole
00:15:19.278 --> 00:15:21.120
niche industry about how to respond to
00:15:21.160 --> 00:15:22.423
bad, bad reviews.
00:15:22.462 --> 00:15:23.764
It's almost like all of us need our
00:15:23.803 --> 00:15:26.326
own PR crisis when we get a bad
00:15:27.047 --> 00:15:27.508
review.
00:15:28.268 --> 00:15:30.210
We also have to remember, you know,
00:15:30.471 --> 00:15:32.432
I always tell my therapist this and the
00:15:32.493 --> 00:15:34.073
PT side and I say the same thing
00:15:34.094 --> 00:15:34.595
in the dental.
00:15:34.654 --> 00:15:37.376
If a patient left your local clinic.
00:15:38.097 --> 00:15:40.840
because they refused to accept some level
00:15:40.879 --> 00:15:43.182
of self-responsibility in physical therapy
00:15:43.201 --> 00:15:45.864
that manifests itself by a home program or
00:15:45.903 --> 00:15:47.625
compliance with instructions.
00:15:48.206 --> 00:15:48.787
And in dental,
00:15:48.826 --> 00:15:50.727
it manifests itself with compliance with
00:15:50.788 --> 00:15:52.970
instructions on hygiene care and other
00:15:53.129 --> 00:15:55.831
aspects of post procedural care.
00:15:56.393 --> 00:15:58.934
And they would not take and therefore they
00:15:58.975 --> 00:16:00.875
disliked you because they wanted to put
00:16:00.936 --> 00:16:02.256
all their problems on to you.
00:16:03.057 --> 00:16:04.899
It's OK to fire a customer every once
00:16:04.918 --> 00:16:05.359
in a while.
00:16:05.418 --> 00:16:07.600
And if that leaves you a bad review,
00:16:08.100 --> 00:16:10.260
you could still sleep at night because
00:16:10.321 --> 00:16:13.101
self-responsibility and an active role in
00:16:13.121 --> 00:16:14.042
your own health care,
00:16:14.101 --> 00:16:16.543
your own recovery and in your own in
00:16:16.562 --> 00:16:18.604
the dental world and your own treatment is
00:16:18.683 --> 00:16:19.224
critical.
00:16:19.244 --> 00:16:21.664
A lot of patients don't want to assume
00:16:21.745 --> 00:16:23.745
any responsibility and they might write
00:16:23.765 --> 00:16:24.625
you a bad review.
00:16:24.946 --> 00:16:28.106
You can't get overly intrusive on it
00:16:28.147 --> 00:16:28.767
because you're violent.
00:16:28.807 --> 00:16:29.847
You could be violating HIPAA.
00:16:30.475 --> 00:16:33.636
Yeah, it's the juice versus squeeze ratio.
00:16:34.118 --> 00:16:35.578
You might chase after and put so much
00:16:35.599 --> 00:16:36.438
effort in this one patient,
00:16:36.458 --> 00:16:37.580
you're probably never gonna make that,
00:16:38.000 --> 00:16:40.001
you might never make that person happy.
00:16:40.402 --> 00:16:42.464
Let's take that juice versus squeeze ratio
00:16:42.844 --> 00:16:43.784
over to this question,
00:16:44.184 --> 00:16:46.005
because this takes time, effort, money.
00:16:46.046 --> 00:16:48.827
There are firms who you can hire that
00:16:48.847 --> 00:16:49.849
are specialized in this.
00:16:50.288 --> 00:16:52.291
So what are people actually spending,
00:16:52.350 --> 00:16:53.451
even if you're not hiring a firm,
00:16:53.471 --> 00:16:55.352
you're also spending brainpower, time,
00:16:55.413 --> 00:16:56.653
staff time, effort, money.
00:16:56.994 --> 00:16:58.754
What are we actually spending to maintain
00:16:58.794 --> 00:16:59.035
that
00:17:01.356 --> 00:17:04.157
And has anyone proven that it does
00:17:04.198 --> 00:17:04.618
anything?
00:17:05.259 --> 00:17:07.640
Does it drive business or patient growth
00:17:07.720 --> 00:17:08.160
at all?
00:17:08.580 --> 00:17:08.740
Yeah.
00:17:08.820 --> 00:17:11.261
So one of the questions I ask operators
00:17:11.281 --> 00:17:14.223
to think about is the concept of what
00:17:14.304 --> 00:17:17.484
is your return on the cost of quality?
00:17:17.925 --> 00:17:20.446
The cost is the time, effort, resources,
00:17:20.567 --> 00:17:20.967
money,
00:17:21.507 --> 00:17:24.888
all these things we do to ensure some
00:17:24.949 --> 00:17:25.950
level of quality.
00:17:26.609 --> 00:17:28.171
And so you have to be cognizant of
00:17:28.191 --> 00:17:28.431
that.
00:17:28.911 --> 00:17:31.551
The spending is extremely real and it's
00:17:31.652 --> 00:17:33.413
often invisible in the budget.
00:17:33.893 --> 00:17:34.113
You know,
00:17:34.133 --> 00:17:35.794
people aren't you're not budgeting this as
00:17:35.834 --> 00:17:38.375
much staff time training and review
00:17:38.815 --> 00:17:41.476
technology platforms with automatic post
00:17:41.536 --> 00:17:43.016
visit review sequences.
00:17:43.076 --> 00:17:45.156
Now we have all this stuff that goes
00:17:45.217 --> 00:17:47.637
into your phone that automatically asks
00:17:47.738 --> 00:17:49.318
you all of these kinds of things.
00:17:49.939 --> 00:17:51.700
And for a multi-site operator, man,
00:17:51.740 --> 00:17:52.460
that adds up.
00:17:52.579 --> 00:17:54.461
fast and keep in mind all the SAS
00:17:54.481 --> 00:17:55.702
software providers,
00:17:55.742 --> 00:17:56.804
how do they make more money?
00:17:57.223 --> 00:18:00.146
The same customers adding additional APIs
00:18:00.547 --> 00:18:02.848
that allow you to do more functions is
00:18:02.909 --> 00:18:04.190
how they make more money.
00:18:04.250 --> 00:18:04.410
You know,
00:18:04.430 --> 00:18:06.031
we'll talk about the EMRs and other kinds
00:18:06.051 --> 00:18:08.493
of things later because the LZRs miniature
00:18:08.534 --> 00:18:09.034
versions.
00:18:09.434 --> 00:18:11.757
So now I'm not only doing your EMR,
00:18:12.217 --> 00:18:14.698
I'm doing your point of service pay at
00:18:14.758 --> 00:18:15.358
times.
00:18:15.578 --> 00:18:17.298
I'm doing your outcome studies.
00:18:17.680 --> 00:18:20.181
I'm doing your documentation AI.
00:18:20.580 --> 00:18:22.422
All of these things keep adding costs.
00:18:22.461 --> 00:18:23.682
And so we say as operators,
00:18:23.701 --> 00:18:25.303
where's my cost of RCM?
00:18:25.343 --> 00:18:26.363
Should be going down.
00:18:26.544 --> 00:18:27.523
All of a sudden it's going up.
00:18:27.544 --> 00:18:28.304
Why is it going up?
00:18:28.324 --> 00:18:29.785
Because all these providers are adding
00:18:29.884 --> 00:18:30.525
APIs.
00:18:30.805 --> 00:18:33.826
They're increasing your cost and you have
00:18:33.866 --> 00:18:35.567
to do the tough decisions and make
00:18:35.607 --> 00:18:36.048
choices.
00:18:36.528 --> 00:18:38.348
about all of those kinds of things.
00:18:38.410 --> 00:18:40.151
And so in health care,
00:18:40.171 --> 00:18:42.211
a lot of choice is constrained.
00:18:42.272 --> 00:18:44.054
Insurance networks, referral patterns,
00:18:44.094 --> 00:18:44.713
geography,
00:18:44.773 --> 00:18:46.875
they're still doing an incredible amount
00:18:46.915 --> 00:18:47.517
of routing.
00:18:47.557 --> 00:18:49.817
And so if you're investing to maintain a
00:18:49.857 --> 00:18:52.079
four point nine in a market where a
00:18:52.140 --> 00:18:53.820
meaningful portion of your new patients
00:18:53.861 --> 00:18:55.502
are coming through other referral channels
00:18:55.823 --> 00:18:57.544
that aren't looking at your Google rating
00:18:57.604 --> 00:18:57.884
at all,
00:18:57.924 --> 00:18:59.266
that doesn't mean the investment is
00:18:59.826 --> 00:19:00.226
wasted.
00:19:00.626 --> 00:19:02.867
It just means that ROI calculation is
00:19:02.948 --> 00:19:03.269
messy.
00:19:03.909 --> 00:19:06.131
They're the platform selling requests.
00:19:06.471 --> 00:19:08.553
So we see all of these efforts now
00:19:08.673 --> 00:19:11.776
in the AI world of lead generation and
00:19:11.895 --> 00:19:13.218
all of these things around it.
00:19:13.778 --> 00:19:15.759
And I talk to practices and they say,
00:19:15.779 --> 00:19:17.121
I'm not having trouble getting new
00:19:17.161 --> 00:19:18.021
patients right now.
00:19:18.442 --> 00:19:18.742
Well,
00:19:18.923 --> 00:19:20.443
you're spending an incredible amount
00:19:20.483 --> 00:19:22.445
between your foot marketers,
00:19:22.826 --> 00:19:25.308
your advertising, your digital marketing,
00:19:25.788 --> 00:19:27.430
and all of these things have accreted to
00:19:27.471 --> 00:19:27.810
a level.
00:19:27.891 --> 00:19:28.490
And you have to say,
00:19:28.530 --> 00:19:30.032
does the business model support it
00:19:30.053 --> 00:19:30.192
anymore?
00:19:31.128 --> 00:19:32.069
And in healthcare,
00:19:32.230 --> 00:19:33.612
it's a penny nickel business,
00:19:33.652 --> 00:19:34.893
a nickel dime business.
00:19:35.012 --> 00:19:38.136
You can't afford to spend an enormous
00:19:38.156 --> 00:19:39.698
amount of money on a problem that you
00:19:39.738 --> 00:19:41.099
think is there, but it really isn't.
00:19:41.519 --> 00:19:42.159
Yeah.
00:19:42.179 --> 00:19:42.359
All right.
00:19:42.380 --> 00:19:43.220
So I'm going to hold your feet to
00:19:43.259 --> 00:19:43.640
the fire.
00:19:43.819 --> 00:19:47.021
I actually put your article into test.
00:19:47.041 --> 00:19:47.382
I said, hey,
00:19:47.982 --> 00:19:51.125
how would some leading brands actually
00:19:51.244 --> 00:19:51.944
optimize this?
00:19:51.984 --> 00:19:55.686
And one of the best responses was Disney.
00:19:56.248 --> 00:19:58.848
They said Walt Disney himself would
00:19:58.929 --> 00:20:01.611
optimize for miles per hour,
00:20:01.651 --> 00:20:03.531
not miles per hour, not stars.
00:20:03.912 --> 00:20:06.012
So if Google stars don't tell the truth,
00:20:06.814 --> 00:20:08.994
what should operators be measuring
00:20:09.476 --> 00:20:10.056
instead?
00:20:10.753 --> 00:20:11.193
Yeah,
00:20:11.413 --> 00:20:13.275
so we'll get into this a little bit,
00:20:13.295 --> 00:20:14.736
but I noticed one of the comments from
00:20:14.756 --> 00:20:18.117
the article last week was somebody saying
00:20:18.137 --> 00:20:20.759
the best metric they measure is how many
00:20:20.818 --> 00:20:22.279
smiles are leaving their clinic.
00:20:22.728 --> 00:20:24.167
And I thought that was a real interesting
00:20:24.228 --> 00:20:24.728
one.
00:20:24.827 --> 00:20:26.409
In dental, at least in our company,
00:20:26.469 --> 00:20:28.009
we say our mission is to create a
00:20:28.048 --> 00:20:29.548
lifetime of healthy smiles.
00:20:29.608 --> 00:20:30.930
And how are we doing that?
00:20:30.970 --> 00:20:33.190
Doing meaningful and purposeful work and
00:20:33.230 --> 00:20:33.789
remembering.
00:20:34.230 --> 00:20:35.711
In fact, that's what we're here for.
00:20:36.310 --> 00:20:38.431
But there's a short list with teeth.
00:20:38.510 --> 00:20:41.011
New patient arrival rate is a real
00:20:41.051 --> 00:20:41.672
critical one.
00:20:41.711 --> 00:20:43.291
Are new patients choosing you?
00:20:43.811 --> 00:20:45.432
Is that number growing?
00:20:45.553 --> 00:20:47.673
Is your number of new patients growing?
00:20:48.393 --> 00:20:51.134
We talk about growth in organic and all
00:20:51.153 --> 00:20:52.253
these things and platforms,
00:20:52.273 --> 00:20:55.095
and most PT operators measure that wrong.
00:20:55.435 --> 00:20:59.757
They measure growth in terms of number of
00:20:59.797 --> 00:21:01.518
visits per patient, all kinds of things.
00:21:01.538 --> 00:21:02.998
They ought to be measuring it by growth
00:21:03.038 --> 00:21:03.798
and cash flow.
00:21:03.917 --> 00:21:05.298
Different topic for another time.
00:21:05.959 --> 00:21:06.980
But is the number growing?
00:21:07.000 --> 00:21:07.980
That's a market signal,
00:21:08.060 --> 00:21:10.123
not just a sentimental drop.
00:21:10.182 --> 00:21:11.703
PlanetCare completion, very,
00:21:11.743 --> 00:21:13.265
very difficult, but really, really,
00:21:13.605 --> 00:21:14.205
really difficult.
00:21:14.346 --> 00:21:16.448
Are patients staying through their episode
00:21:16.508 --> 00:21:17.288
of completion?
00:21:17.628 --> 00:21:19.131
To me, that would be the best proxy.
00:21:21.115 --> 00:21:23.135
of a patient you know satisfaction really
00:21:23.615 --> 00:21:25.896
because dropout is the quiet killer that a
00:21:25.957 --> 00:21:27.917
four point nine doesn't capture right
00:21:27.978 --> 00:21:30.018
functional outcome improvement discipline
00:21:30.157 --> 00:21:33.459
specific systematically collected not
00:21:33.538 --> 00:21:36.740
cherry-picked reactivation rate are former
00:21:36.779 --> 00:21:38.540
patients coming back when they have a new
00:21:38.601 --> 00:21:40.701
need i call it friends family and former
00:21:40.760 --> 00:21:42.682
patient percentage what percentage of your
00:21:42.721 --> 00:21:45.462
new patients fall into that bucket that is
00:21:45.522 --> 00:21:47.182
really critical to me because it means
00:21:47.202 --> 00:21:48.844
you're spending zero dollars
00:21:49.364 --> 00:21:51.424
under what you should be doing to get
00:21:51.464 --> 00:21:52.026
your marketing,
00:21:52.066 --> 00:21:53.807
which is providing great care.
00:21:54.207 --> 00:21:55.867
That's continuity and it's its most
00:21:55.928 --> 00:21:56.749
measurable form.
00:21:57.729 --> 00:21:58.950
None of these are as clean or as
00:21:58.970 --> 00:22:00.270
visible as a star rating.
00:22:00.490 --> 00:22:00.810
You know,
00:22:01.511 --> 00:22:03.212
in order to get to the answer,
00:22:03.272 --> 00:22:05.034
it's not a simple answer like a star
00:22:05.074 --> 00:22:05.354
rating.
00:22:05.374 --> 00:22:06.974
That's exactly why they matter more.
00:22:07.035 --> 00:22:09.156
The metrics that are easy to show off
00:22:09.196 --> 00:22:10.477
are usually the ones that have already
00:22:10.518 --> 00:22:11.137
been gained.
00:22:11.178 --> 00:22:12.778
The ones that are harder to show off
00:22:12.818 --> 00:22:14.259
are the ones that's actually happening.
00:22:14.894 --> 00:22:15.976
Yeah.
00:22:15.996 --> 00:22:17.396
Anything you'd want to leave the audience
00:22:17.436 --> 00:22:19.157
with as we wrap up?
00:22:19.198 --> 00:22:20.179
Your parting thoughts?
00:22:20.618 --> 00:22:21.900
No, just, you know,
00:22:22.119 --> 00:22:23.901
not telling you not to do Google ratings.
00:22:24.000 --> 00:22:26.403
Just don't overvalue them and don't spend
00:22:26.462 --> 00:22:28.163
all you're trying to get more of them.
00:22:28.663 --> 00:22:30.746
Reroute that same effort into something
00:22:30.786 --> 00:22:32.507
that brings meaningful change into the
00:22:32.547 --> 00:22:33.768
operations of your practice.
00:22:33.788 --> 00:22:34.488
I mean,
00:22:34.587 --> 00:22:36.769
as a guy who's spent some years in
00:22:36.809 --> 00:22:37.950
marketing and communications,
00:22:37.970 --> 00:22:39.391
the best marketing is a really,
00:22:39.451 --> 00:22:41.613
really great product and or service.
00:22:42.212 --> 00:22:43.253
If you're trying to become a better
00:22:43.354 --> 00:22:44.315
operator in healthcare,
00:22:45.111 --> 00:22:45.833
you're in the right place.
00:22:45.893 --> 00:22:46.775
If this episode hit,
00:22:46.815 --> 00:22:48.419
Larry goes deeper inside his writing.
00:22:48.819 --> 00:22:50.304
Look for the operator on Substack.
00:22:50.324 --> 00:22:51.948
We'll also drop a link below.
00:22:51.968 --> 00:22:53.191
That's where the full breakdown lives.
00:22:53.211 --> 00:22:53.873
We'll see you next time.