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The Growth You Buy vs. the Growth You Earn: Measuring Patient Trust · The Operator | Healthcare Business

• 0:05
  Most healthcare companies can tell you
• 0:07
  what they spend on marketing,
• 0:09
  cost per lead, cost per patient,
• 0:10
  conversion rate.
• 0:12
  The latest article on The Operator asks
• 0:14
  about a number most organizations can't
• 0:17
  answer, but should.
• 0:18
  What percentage of your new patients came
• 0:21
  from friends, family, or former patients?
• 0:25
  Because that number might tell you
• 0:27
  something much more important than whether
• 0:29
  your marketing is working.
• 0:30
  It'll tell you whether people actually
• 0:32
  trust you
• 0:34
  So let's start here.
• 0:36
  Larry,
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  you say this may be one of the
• 0:37
  most strategically important numbers in
• 0:41
  your business,
• 0:41
  yet most groups can't answer it.
• 0:44
  Why has it been so invisible?
• 0:47
  When I say it like that in the
• 0:48
  intro, it seems obvious.
• 0:49
  Why is it so invisible?
• 0:50
  Yeah, I mean,
• 0:51
  you got to look at the fundamentals of
• 0:53
  what you're measuring.
• 0:55
  There's the old adage,
• 0:57
  you manage what you measure,
• 0:58
  and practice management systems, EMRs,
• 1:00
  they were built to measure billing,
• 1:02
  not built to measure relationships.
• 1:05
  Referral source is a free text field or
• 1:07
  a flip down field,
• 1:09
  or if it gets filled in at all
• 1:11
  in some things like dentistry,
• 1:13
  for example.
• 1:16
  And so digital sort of attribution
• 1:19
  launders the truth.
• 1:21
  Grandma tells her bridge club about you
• 1:23
  three or the Marjan club.
• 1:26
  That's the greatest game right now.
• 1:27
  So everybody's playing that one.
• 1:29
  Three of them Google your address and the
• 1:30
  marketing report says Google earned the
• 1:33
  three patients.
• 1:33
  Right.
• 1:34
  The last click gets the credit.
• 1:36
  The relationship did the work.
• 1:38
  And so I've come up with that term
• 1:40
  relationship density,
• 1:42
  which maybe we can talk about.
• 1:43
  But as any operator in the chair,
• 1:47
  You'll get an answer to two decimals.
• 1:50
  Ask what share of new patients arrived on
• 1:52
  trust and you get a shrug.
• 1:54
  A lot probably.
• 1:55
  A lot probably is not a number, right?
• 1:58
  So, yes,
• 1:59
  this is a big flip for practices who
• 2:04
  are more used to straight relationship or
• 2:08
  straight numbers,
• 2:09
  not relationship driven numbers.
• 2:11
  Right.
• 2:11
  Yeah.
• 2:12
  You draw this line between these two
• 2:13
  phrases, right?
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  transactional practice and relational
• 2:17
  practice.
• 2:18
  If you walked into each one tomorrow,
• 2:21
  what's the difference in terms of feel?
• 2:23
  How do they feel differently?
• 2:25
  You know, it's interesting,
• 2:27
  and I wonder if physical therapy is going
• 2:29
  the same way, Jimmy,
• 2:30
  because traditionally I would view PT as a
• 2:32
  very relationship-oriented business.
• 2:36
  But dentistry, I've viewed,
• 2:37
  is a lot more transactional, oddly enough.
• 2:41
  And maybe with higher volumes,
• 2:43
  other things in healthcare are that as
• 2:45
  well.
• 2:45
  But let's face it,
• 2:46
  you could tell within the first thirty
• 2:48
  seconds and probably the last thirty
• 2:50
  seconds, right?
• 2:51
  In a transactional relationship,
• 2:53
  nobody looks up.
• 2:54
  Insurance card and ID, you know,
• 2:56
  everybody's eyes are, you know,
• 2:58
  in the system.
• 2:59
  And what happens at the end?
• 3:00
  You end with checkout, reach the desk,
• 3:03
  do you want a receipt, you know?
• 3:05
  Relational,
• 3:06
  someone greets you by name before you
• 3:08
  reach the desk.
• 3:10
  In dental,
• 3:10
  the hygienist picks up the conversation
• 3:12
  from six months ago, mid-sentence.
• 3:15
  The kid's braces,
• 3:17
  a trip that they went on.
• 3:19
  And the visit ends with a plan and
• 3:21
  a relationship affirmed,
• 3:23
  and you're coming in for your next visit.
• 3:26
  A big data point in dentistry is how
• 3:29
  many percentage of patients when they left
• 3:31
  were scheduled within six months.
• 3:34
  Same chair, completely different business.
• 3:37
  Now,
• 3:39
  from my own conversation, you know,
• 3:41
  the day I understood,
• 3:42
  I still will get is in two thousand
• 3:44
  two in my physical therapy practice.
• 3:47
  And I use this term I coined.
• 3:48
  It's not about treatment anymore.
• 3:50
  Treatment is table stakes.
• 3:52
  Everyone in the market is clinically
• 3:54
  competent.
• 3:54
  The experience around the treatment
• 3:56
  decides whether the patient comes back and
• 3:59
  who they tell.
• 4:00
  It's just that that way.
• 4:02
  I've been running that play for twenty
• 4:03
  four years and
• 4:05
  Dentistry is just the latest here.
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  I'm running it from now,
• 4:08
  but it is the same.
• 4:10
  And in fact,
• 4:11
  I think it's going to be easier in
• 4:12
  dentistry because it's easier to shift
• 4:14
  from transactional to relationship and to
• 4:19
  really create a culture around it rather
• 4:21
  than traditional DSOs always think about
• 4:24
  lead generation and marketing and all the
• 4:27
  leaky bucket of spending.
• 4:29
  And now you've got social media and AI
• 4:31
  and all of these different factors.
• 4:34
  Which are important.
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  Those can generate leads.
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  I'm not saying they can't.
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  And you need some effort there.
• 4:39
  But you could spend silly there without
• 4:41
  having a direct understanding of a
• 4:43
  relationship.
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  If you spend directly on
• 4:46
  relationship-driven positive psychology,
• 4:49
  high-quality communications,
• 4:50
  peak end effect, empathy,
• 4:53
  exquisite empathy, boundary empathy,
• 4:55
  all of those kind of things,
• 4:57
  what you're really investing in
• 4:59
  is the ability to turn them into
• 5:00
  relationships.
• 5:02
  And we know the lifetime value of a
• 5:04
  customer in healthcare and in dental is
• 5:06
  extremely valuable because of the direct
• 5:08
  benefit and the indirect benefit of the
• 5:10
  people they refer like friends and family.
• 5:13
  all right well we should get more people
• 5:15
  to refer friends and family and former
• 5:16
  patients is nice but you actually have a
• 5:19
  number you have a number that you're
• 5:21
  aiming for right now it's thirty five
• 5:22
  percent of new patients to come from those
• 5:25
  things friends family or former patients
• 5:27
  why thirty five what does that number tell
• 5:29
  you about a normal that a normal growth
• 5:31
  metric might not yeah so let me give
• 5:34
  you some context first you know um where
• 5:37
  the number came from years ago
• 5:40
  we demonstrated in our clinic model,
• 5:43
  our physical therapy clinic model,
• 5:45
  particularly in de novos,
• 5:46
  which take a while to ramp up.
• 5:49
  We found that if you can get to
• 5:51
  forty percent,
• 5:53
  you could be in the hardest hitting
• 5:55
  referral for profit POPs areas
• 5:58
  you know,
• 5:58
  physician owned practice areas and it
• 6:00
  wouldn't matter if forty percent of your
• 6:02
  patients were former friends and family.
• 6:05
  Right.
• 6:06
  So in PT business,
• 6:08
  we thought it was forty.
• 6:10
  What I'm saying in dental right now,
• 6:11
  our number right now is thirty five
• 6:13
  percent.
• 6:13
  That's sort of the actual I want to
• 6:15
  get it higher because the higher it gets
• 6:17
  it, the cheaper my marketing costs are.
• 6:21
  They arrive, as I said,
• 6:22
  more than a third of our new patients.
• 6:24
  That's the growth engine running on trust.
• 6:27
  you know that we didn't have to purchase
• 6:29
  a lead from um what it tells me
• 6:31
  is that a growth metric doesn't you know
• 6:36
  a growth number tells you that you grew
• 6:38
  the number tells this number tells you why
• 6:40
  you grew you follow me like i can
• 6:42
  tell you my same store organic sales are
• 6:44
  three to five to seven percent that
• 6:46
  doesn't tell me why though this number
• 6:48
  tells you why and whether the patient
• 6:49
  growth survives you turning off any ad
• 6:51
  spend um i can tell you
• 6:55
  And I think most retail businesses can
• 6:57
  tell you the same thing.
• 6:58
  If you spend more money on marketing,
• 6:59
  you're going to get more business.
• 7:01
  But the question is the return.
• 7:03
  And in healthcare and in dental,
• 7:05
  it's really whether that patient is
• 7:07
  transactional versus relationship.
• 7:09
  So referred patients come in with a lot
• 7:11
  higher trust.
• 7:12
  And in dental,
• 7:13
  they come in with a lot less anxiety,
• 7:15
  better treatment case acceptance,
• 7:17
  and again, a better, you know,
• 7:18
  lifetime value.
• 7:19
  It's a compounding readout of how the
• 7:21
  relationship practices actually are.
• 7:23
  And so one number, you know,
• 7:25
  on the dashboard that you can't be faked
• 7:27
  with a budget, right?
• 7:28
  Yeah.
• 7:28
  Yep.
• 7:29
  And so could a practice be growing
• 7:31
  quickly?
• 7:31
  I think you sort of alluded to this.
• 7:34
  Could a practice be growing quickly
• 7:35
  hitting production targets and still be
• 7:38
  actually getting weaker relationally under
• 7:41
  the surface?
• 7:44
  Yeah,
• 7:44
  I've got a phrase we have now at
• 7:46
  DCA called earn it because you have,
• 7:49
  this is something that is intentional and
• 7:52
  systematic and has to be baked and
• 7:54
  embedded into your organization
• 7:56
  culturally.
• 7:58
  Because if not,
• 7:59
  you're going to have failure underneath it
• 8:01
  and it's going to be inconsistent,
• 8:03
  you know, from month to month,
• 8:04
  production up, new patients up,
• 8:06
  referral share quietly sliding.
• 8:08
  That's not growth.
• 8:09
  And so, yeah,
• 8:11
  You don't want to be on a treadmill
• 8:12
  here.
• 8:13
  And so the day the ad budget blinks,
• 8:15
  the growth blinks with it.
• 8:16
  You can gain weight and lose muscle at
• 8:17
  the same time.
• 8:18
  And most dashboards only have the scale.
• 8:21
  That's a great analogy.
• 8:23
  Yeah.
• 8:24
  So let's get back to that phrase you
• 8:25
  mentioned before.
• 8:26
  And let's sort of define it so people
• 8:27
  can maybe use it themselves.
• 8:29
  Relationship density.
• 8:32
  What exactly are you trying to measure
• 8:33
  with that?
• 8:35
  Yeah.
• 8:35
  So this is just an evolving concept,
• 8:37
  Jimmy.
• 8:38
  And where I would say we're going with
• 8:39
  it is that
• 8:41
  it's really the number and strength of
• 8:43
  trust
• 8:45
  which carries connections per patient,
• 8:47
  not visits, connections.
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  Does the patient see the same hygienist
• 8:52
  year over year or a stranger every recall
• 8:57
  patient, right?
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  How consistent do they carry through in
• 9:00
  that lifetime value of a customer?
• 9:03
  Do we know the household,
• 9:05
  not just the chart?
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  Do you know the spouse, the kids,
• 9:08
  the sister who moved just into town?
• 9:10
  Did anything in the visit create a moment
• 9:12
  worth retelling?
• 9:14
  The proxies are all measurable,
• 9:16
  referral share of new patients,
• 9:17
  hygiene reappointment rate,
• 9:19
  patients per household,
• 9:20
  reactivation of former patients.
• 9:23
  All of those things are metrics and kind
• 9:26
  of operating flow things.
• 9:27
  But this relationship density kind of goes
• 9:30
  a bit further.
• 9:32
  There's some science behind this trust
• 9:34
  issue, by the way.
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  So Jane Dutton,
• 9:36
  who developed the concept of high-quality
• 9:39
  connections, and Kahneman,
• 9:40
  who put the concept of peak-end rule.
• 9:44
  Kahneman proved that endings dominate
• 9:45
  memory of all things.
• 9:47
  He started with a colonoscopy study,
• 9:49
  right?
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  If an ending can redeem a colonoscopy
• 9:52
  patient,
• 9:54
  It can redeem a crown.
• 9:56
  It can redeem a filling.
• 9:57
  Right.
• 9:58
  The last two minutes of a dental visit
• 10:00
  are a growth strategy for a clinic,
• 10:03
  not just a good way to end the
• 10:05
  treatment.
• 10:06
  Does that make sense?
• 10:07
  So you're you're investing again in these
• 10:09
  growth strategies around connections that
• 10:12
  lead to other connections and other
• 10:13
  patients, not just a gimmicky.
• 10:16
  There's a difference between good customer
• 10:18
  service and good human connection.
• 10:21
  Sometimes it's subtle,
• 10:22
  but both can be growth strategies if they
• 10:25
  are completely attended to, emphasized,
• 10:29
  and really become embedded in your
• 10:31
  culture.
• 10:31
  Yeah, well,
• 10:32
  then one concept should flip some value
• 10:35
  sort of on its head.
• 10:37
  One of the things you mentioned in the
• 10:39
  article is that hygienists might be the
• 10:41
  actual real owner of the relationship,
• 10:44
  the real relationship engine of a
• 10:46
  practice, the face, the vibe.
• 10:49
  Why have many operators historically
• 10:50
  undervalued that one?
• 10:51
  And there's parallel roles with a
• 10:53
  hygienist or a PT or PTA in other
• 10:56
  practices as well.
• 10:57
  Yeah,
• 10:58
  so as best I've learned in dentistry,
• 11:00
  it's this idea, well,
• 11:01
  we started with this hygiene model.
• 11:03
  We're going to have the hygienist do
• 11:04
  hygiene, clean teeth,
• 11:06
  then put them on a maintenance program,
• 11:08
  get them in every six months,
• 11:10
  and the doctor will do the production.
• 11:12
  And so all of the metrics around
• 11:14
  production follow the doctor.
• 11:16
  And hygiene got reduced to a schedule and
• 11:18
  a perio percentage.
• 11:20
  We measure what hygienists produce today
• 11:23
  and almost never what they actually are.
• 11:25
  Right, so now we're on the FaceTime math,
• 11:27
  same chair twice a year,
• 11:30
  oftentimes for a decade or more,
• 11:32
  most patients see their hygienist more
• 11:34
  reliably than they see any other clinician
• 11:37
  in their life.
• 11:39
  More visits, more conversations,
• 11:41
  less drama.
• 11:42
  They spend time with them.
• 11:43
  And so more trust is built in that
• 11:45
  earning there, including myself.
• 11:49
  The doctor's name might be on the door,
• 11:50
  but the hygienist is in the room.
• 11:52
  Read your own Google reviews.
• 11:53
  Notice how often the five stars named the
• 11:56
  doctor for trust that the hygienist
• 11:58
  actually built.
• 12:00
  And so one of the major chapters I
• 12:02
  wrote in my dental call to care book
• 12:04
  upcoming,
• 12:05
  it was a lot of research on that
• 12:06
  relationship.
• 12:07
  And it's like everything else,
• 12:09
  when people leave an organization,
• 12:10
  they don't leave the organization,
• 12:12
  they leave the case of a dental practice,
• 12:14
  they may leave a doctor who's obstinate,
• 12:16
  you know, who's hard to work with.
• 12:18
  Hygienists are one of the most valuable
• 12:21
  clinicians in all of healthcare,
• 12:24
  and their salaries are now starting to get
• 12:26
  reward for it.
• 12:27
  A starting salary in dental hygiene,
• 12:30
  which can oftentimes be a two-year degree,
• 12:32
  makes more than a physical therapist
• 12:33
  starting salary.
• 12:35
  Um, so think of what,
• 12:36
  think of what that has evolved to over
• 12:38
  the past, uh, uh,
• 12:39
  half a dozen or so years.
• 12:41
  Yeah.
• 12:41
  Someone started paying attention to what
• 12:43
  that result is.
• 12:45
  Um, you argue that it's not,
• 12:47
  it's not soft.
• 12:48
  So make, make the CFO case for me,
• 12:50
  make it, make it tangible.
• 12:52
  When does the stronger relationship
• 12:54
  density start to show up in real hard
• 12:57
  numbers?
• 12:58
  Yeah.
• 12:59
  So three lines,
• 13:00
  the CFO stares at every month.
• 13:02
  The first one is, um,
• 13:04
  the marketing cost per new patient.
• 13:07
  So every referred patient is a marketing
• 13:09
  patient you didn't have to buy in this
• 13:11
  particular case, right?
• 13:12
  And like I said, in dentistry,
• 13:15
  that could be a hundred and fifty to
• 13:16
  two hundred bucks per case in these
• 13:18
  services that we talked about.
• 13:20
  Second is case acceptance and lifetime
• 13:22
  value.
• 13:23
  So referred patients,
• 13:25
  Treatment case acceptance is more in the
• 13:28
  eighty percent rate than the fifty to
• 13:30
  seventy five percent.
• 13:31
  And they stay longer.
• 13:33
  That's not just revenue quality.
• 13:35
  That's that's that is revenue quality,
• 13:37
  not just not just quantity.
• 13:39
  And then the third, I would say,
• 13:40
  is payer mix relationships.
• 13:42
  Patients choose you,
• 13:43
  not a network or a grid.
• 13:44
  Right.
• 13:46
  And the payer mix reflexes.
• 13:48
  This isn't a culture slide.
• 13:50
  It's a P&L strategy, you know,
• 13:52
  wearing a culture costume.
• 13:55
  so all right talk to everybody out there
• 13:56
  who's might run a pt organization medical
• 13:58
  group other multi-site healthcare platform
• 14:01
  what is the equivalent of that thirty five
• 14:03
  percent number for them that they should
• 14:05
  be trying to understand
• 14:08
  Yeah, again, the exact same number,
• 14:10
  the percentage of new patients who arrive
• 14:12
  as friends, family, or former patients.
• 14:16
  Former patients meaning separate diagnosis
• 14:18
  effectively or a separate episode of care,
• 14:21
  yeah.
• 14:22
  And I'd argue it's even more,
• 14:24
  I think it's actually more revealing
• 14:26
  outside dentistry because you don't have
• 14:28
  this kind of hygienist concept in most
• 14:30
  healthcare.
• 14:32
  In PT where a physician referrals dominate
• 14:35
  the funnel,
• 14:36
  The patient's source share is only part of
• 14:38
  the funnel you actually own.
• 14:40
  The physician relationship can be lost to
• 14:42
  a hospital, acquisition tomorrow, right?
• 14:44
  They can go into a POPs relationship,
• 14:47
  but the patient who sends their sister
• 14:49
  can't be bought out from under you.
• 14:51
  Medical groups, same thing,
• 14:52
  plus track households and former patient
• 14:55
  reactivation.
• 14:56
  You know, what we do
• 14:58
  is we have this reactivation that started
• 15:00
  about ten years ago where all of a
• 15:02
  sudden you'd go through your CRM,
• 15:04
  you'd go through your email,
• 15:05
  you'd go through your EMR database,
• 15:07
  and you'd send them a reminder.
• 15:09
  And you know what?
• 15:09
  Statistically, you can't argue.
• 15:11
  There are a certain number of patients
• 15:13
  that come back.
• 15:14
  But I would argue that if you're relying
• 15:16
  on reactivation campaigns,
• 15:19
  that reactivation,
• 15:20
  that former patient percentage,
• 15:21
  is never going to get to that thirty-five
• 15:23
  to forty percent because you're reacting
• 15:25
  on a transaction, not a relationship.
• 15:28
  All right.
• 15:29
  So right now,
• 15:29
  if an operator listening could add one
• 15:31
  metric to their dashboard tomorrow,
• 15:33
  what would you be in their ear telling
• 15:35
  them to start tracking first?
• 15:38
  You know, I would probably start simple,
• 15:40
  embarrassingly simple.
• 15:42
  You know,
• 15:42
  have the front desk ask every new patient
• 15:45
  one question asked, you know, really well.
• 15:48
  Who could we thank you for sending you
• 15:51
  in?
• 15:52
  Not a form field,
• 15:54
  a warm question recorded in, you know,
• 15:57
  not some type of pick list,
• 15:59
  not a free text.
• 16:01
  Put it in a free text.
• 16:02
  Thirty days later,
• 16:02
  you have a number most of your competitors
• 16:04
  will never have.
• 16:05
  Put it on the dashboard next to production
• 16:08
  and trend it monthly.
• 16:10
  You manage what you measure.
• 16:12
  And this is the one number that measures
• 16:14
  where all the other numbers will still be
• 16:15
  there in five years.
• 16:18
  And that's not anything difficult to do.
• 16:23
  And yes,
• 16:23
  you can automate it and all of those
• 16:25
  kind of things.
• 16:26
  But what you can't automate and what AI
• 16:28
  cannot automate is the humanness behind
• 16:31
  this.
• 16:32
  Who can we thank for sending you in?
• 16:35
  Oh, I've been here before.
• 16:36
  Oh, my sister.
• 16:38
  Oh, whatever.
• 16:39
  Most people are saying,
• 16:40
  how did you get here?
• 16:40
  Again,
• 16:41
  that goes back to how they got here
• 16:42
  by Google.
• 16:43
  They Googled you.
• 16:44
  That's not who sent you.
• 16:45
  That's a who.
• 16:46
  You're asking for a who question.
• 16:47
  Exactly.
• 16:48
  Yeah, that's the magic.
• 16:50
  All right.
• 16:51
  Yeah.
• 16:52
  Most growth dashboards tell you how many
• 16:53
  patients walk through the door.
• 16:55
  But Larry, again,
• 16:56
  wants you to ask the different question.
• 16:58
  Why'd they walk the door?
• 16:59
  Or more accurately, who can they thank?
• 17:02
  Who can you thank for sending them your
• 17:03
  way?
• 17:04
  Because if more than a third of your
• 17:06
  growth comes from people who already trust
• 17:07
  someone you cared for,
• 17:09
  it's not just marketing efficiency.
• 17:11
  That's evidence that the relationship
• 17:12
  itself is working.
• 17:15
  Check out this and more articles now on
• 17:17
  the operator on Substack.
• 17:19
  And until next time, keep operating.