"Improving the patient experience": an interview with Alan Spiro, part one
If you're seeking insights on how healthcare companies today are emphasizing the “care” in their businesses, a conversation with seasoned industry thought leader Alan Spiro, M.D., offers a wealth of wisdom. As co-founder, chief medical officer, and executive VP of Accolade, Spiro served as program architect for the company, which raised $220M in its initial public offering this year. More recently, he served as chief medical officer and chief growth officer at Blue Health Intelligence, where he was able to develop data-driven solutions to help BCBS Plans and their provider partners deliver value-based, contextual care solutions. Among other roles, he has also served as chief medical officer at Anthem National Accounts and Medica.
Spiro recently joined Pager’s Board of Advisors, and Nick D'Addezio, Pager's VP of Business Development and Strategy, took the opportunity to speak with him about building trust with members, improving the patient experience, and listening to the data. This is part one of a two-part series.
Nick D’Addezio: We find ourselves right now – especially in the pandemic world – at the intersection of clinical technology in business. This is something that you've been very involved with throughout your career. How did that come about for you? What was the driving force behind you becoming a doctor and also leveraging that clinical expertise into the business world?
Alan Spiro: I grew up in New York City and am a child of immigrants. Growing up, I perceived that my options were to become a doctor, a lawyer, an accountant, or a teacher. I chose ‘doctor’. In college, I was both an English major and a biology major.
I'm just curious, and I'm inherently curious about people.
Based on your experience as a doctor, how do you think about building trust with patients in some of the businesses you've built? What have been the keys to building that trust and relationships?
The first thing to realize is that there is research about this.1 At its root, it's about understanding the patient is a whole person, and having respect for them, because they're going to recognize that respect. But besides that, there are techniques, and there is a science to it. It crosses into the psychology of influence, economics, and certainly the psychology of decision making as well.
“You have to get people to tell their story, which is sometimes not the story that you want to hear. ”
When you're trying to form a trust-based relationship, you have to start by listening – not just listening peripherally, but listening often to what is not said, listening to what is behind the story, and then asking follow-up questions. A friend of mine who's involved in research around life context in healthcare2 always likes to say that, "Questions means caring." When you're asking questions, it's an indication that you care.
It can sometimes seem like people will get angry at you, or you don't want to overstep bounds. But if you care, you're going to want to find out what's going on in that person's world. So that's a big part of trust.
How can we enhance the quality of patient experiences within a virtual healthcare solution?
Jeff Rubin, Ed.D, joined Accolade at its founding in 2007 and developed the LEARN2 model. Its function was to listen, engage, assess, resolve, influence, and enhance, in order to encourage behavior change. The key to this model is drawing from a number of scientific backgrounds and maintaining the understanding that people think, feel, and behave in the context of their environment.
The “enhance” part of the model was to get past what the person was calling about, to what some of the underlying issues were – and then to get them to want to address those issues. A lot of that was just getting them to speak to a nurse. They'd call and say, "I need to find an orthopedist who's in-network."
And the answer would be, "Of course. We'll help you with that. But what's going on?"
"Well, I think I may have twisted my knee."
And the ‘enhance’ was, "Wow. That must really hurt and we will certainly get you to see someone. I'm going to look for an orthopedist for you, but I'm also going to get a nurse on the phone to speak to you about that knee pain." The nurse would determine that they hurt their knee, but it could be dealt with through home remedies, and the real reason they were so upset is because they had also just lost their job.
I often speak about the difference between “disease” and “illness.” The disease is the biology and the physiology of a health issue, but the illness is the person’s perception of that disease.
When you're upset about something else, your pain is magnified. So the “enhance” is getting past that to the related root causes, which might be medical, which might be psychological, which might be familial. It’s about not only treating the disease, but also treating the illness. And that “enhance” was something we measured.
You mentioned that patients don’t always want to engage when you start asking about their history. How have you worked to defuse that and encourage patients to share that information?
You have to get people to tell their story, which is sometimes not the story that you want to hear. When I was in consulting, I used to listen in on phone calls by nurses in care centers. There was a wonderful nurse, and she called a patient who had diabetes and said, "Mrs. Smith, how are you today?" And Mrs. Smith said, "Well, my dog just died, my husband broke his leg, and I have to care for him, and my son just got arrested."
And the nurse, in her most caring voice, said, "Oh God, I'm so sorry to hear that. And what was your last glycosylated hemoglobin level?" This woman wanted to tell her story, and the nurse did not create an opportunity for that.
Then, there are other times when you can't get the patient to say a word. And sometimes you can say, "You know what? It really seems like you don't want to talk now, but I'm really concerned about you, and I would love to talk more with you. Is there a good time I can call you back?" When you are proactive, when you take another step, it helps build trust.
“At its root, [healthcare] is about understanding the patient is a whole person, and having respect for the person you’re with, because they’re going to recognize that respect.”
It is important to meet people where they are. And if you allow and encourage people to tell their stories, you get a sense of how wonderful and interesting people are. When I was with Accolade, I would tell staff that the people we help are heroes. The people we help are often going through terrible times, and despite being sick or having a family member who's sick, they're still managing to take care of what they need to. So you have to start out with an interest in people and an understanding that everybody's got a story, and that those stories are often reflective of real strength. You can tap into that strength.
Can you expand on your thoughts on the language of care and why understanding how to communicate with patients is so important?
It's extremely important to think about the language you're using. I had a professor in medical school who put great emphasis on the use of normal language. People would ordinarily say, for example, "The patient had upper extremity weakness." And he would always stop them and say, "Upper extremities? Oh, do you mean arms?"
There's a need for plain language when you're talking to people. There's also a need to consistently check what people hear when you're talking by saying things like, "Do you understand? Can you tell me what you think I mean?" Simple things like that allow for better communication, because what people hear is very often not what you say.
When you look at how to encourage behavior change, if you ask someone, “Would you like this?” they’re almost hardwired to say no. There's a cultural aspect of us not wanting to accept help.
In one project, we were trying to get people to speak to a nurse when they were already on the phone with a counselor, because there were often other medical issues to address. But you could never directly say, "Would you like to speak to a nurse?" 80% of the time, people would say no. If, on the other hand, you said, "I'd like to bring a nurse into the conversation to help me, because I need to understand some of the things you're talking about," 80% of the time, they'd say yes.
Words are powerful, and it's really striking how powerful.
You've spoken in other conversations about this concept of “CMO Squared”. Can you describe what that means and why it's so important in healthcare?
The CMOs that are “squared” are the Chief Medical Officer and the Chief Marketing Officer. Medicine is a communication art. You can know exactly what's wrong with the person, but if you can't understand who they are, if you can’t communicate effectively and get them to change their behavior, you won't be successful.
“I believe you can measure anything; you just have to decide what’s important to measure. In my mind, people’s lives, and how they’re living their lives, is always important to measure.”
The good marketing people I know are quantitative. They understand that there's this translation of data into communication that can really encourage behavior change. So, in any healthcare organization, I've always taken the position that the chief medical officer and the chief marketing officer should be joined at the hip. They should be working together, because they're both trying to do the same thing.
They're trying to turn data – in one case it's clinical data, in the other case it's marketing data – into an influence model. The chief medical officer is trying to influence people to improve their health status. The chief marketing officer is trying to get the resources of that healthcare company accepted and used by more people. So ultimately, the two have the same goal.
Can you tell us about how your clinical background informed your vision of concierge medicine? How did that vision become a reality?
I have often argued against traditional disease management [models], because people aren’t diseases. I have always believed that the person was more important than the disease. There's a wonderful quote which states, "As a physician, it is more important to know the person who has the disease than the disease the person has." And when you looked at the way many programs were designed, they were designed to create fragmentation. You are a diabetic, rather than a person with diabetes who also happens to have a family, and who also happens to work.
We were looking at things the wrong way. I've always argued for helping people through a complex system by understanding who they are as people, rather than just what their disease is. That's the easiest part.
When I practiced medicine, I practiced on the south side of Chicago, and found that the problems my patients had, the medical diseases were the least of it. It wasn't just the fact that they had cancer, it was the fact that they had nowhere to live, no money, and no support. You couldn't be involved in just the illness alone. So when I went into the business world, I was very focused on creating businesses that focused on the humanistic side of medicine, which I was convinced would make sense financially.
I believe you can measure anything; you just have to decide what's important to measure. You can measure dollars, you can measure clinical outcomes. And in my mind, people's lives, and how they're living their lives, is always important to measure.
References
Cialdini, R. The 6 Principles of Persuasion. Influence at Work. <www.influenceatwork.com/principles-of-persuasion/>
Weiner S, Schwartz A, Altman L, et al. Evaluation of a Patient-Collected Audio Audit and Feedback Quality Improvement Program on Clinician Attention to Patient Life Context and Health Care Costs in the Veterans Affairs Health Care System. JAMA Netw Open. 2020;3(7):e209644. <https://jamanetwork.com/journals/jamanetworkopen/fullarticle/2768922>
