GRADUATE

ESSAY

Consumer-Driven Healthcare Marketing: Using the Web to Get Up Close and Personal
Keila Rooney, University of Central Florida, Orlando, Florida

EXECUTiVE

SUiVIMARY

This essay examines the emergence of consumer-driven healthcare marketing, including its operational definition, how it has been used in the past, and how it has evolved. Specifically, marketing practices in other industries are inspected to understand the factors that have contributed to their successes and to determine the relevance of these efforts to healthcare marketing. The advantages of new, technology-enabled marketing opportunities are considered as well, such as stealth ads, blogs, podcasts, and corporate participation in social networks. The implications of the regulation on healthcare websites, along with the work-around strategies used, are analyzed. Lastly, the essay submits recommendations for the healthcare executive when implementing a consumer-driven healthcare marketing plan.

For more information on the concepts in this essay, please contact Ms. Rooney at KeiIa.Rooney@health-first.org. Ms. Rooney is the first-place winner ofthe graduate division ofthe 2009 ACHE Richard J. Stull Student Essay Competition in Healthcare Management. For more information on this competition, please contact Reed Morton, PhD, FACHE, at (312) 424-2800.

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" D ^^^ skies, shining on me. Nothing D b u t blue skies do I see." These pleasing words, penned by Irving Berlin and sung by Cole Porter, lofted from television speakers across America. The song accompanied a hot air balloon drifting across a backdrop of cloudless blue sky. Then, a gentle voice encouraged the viewer to "see your doctor about Claritin" because a "clear answer is out there" (Pines 1999). With this vague yet revolutionary commercial that aired in 1996, Claritin set the precedent in the era of consumerdriven healthcare marketing. Although it was not the first pharmaceutical commercial to air on prime-time television, the Claritin ad was unparalleled in capitalizing on the healthcare consumer's desire for control. At the least, the commercial transformed the pharmaceutical industry into a multibillion-dollar enterprise that spends twice the amount of capital on promotion as on research and development (York University 2008).

distribution channels, customer service orientation, public relations, and overall strategic planning. The term "healthcare marketing" builds on this definition, relating traditional marketing activities and processes to the healthcare field. This transition seems simple, but it dramatically affects the functional characteristics of marketing itself. Healthcare marketers promote a service that is complicated, expensive, and even frightening (Shaw 2008). Many people refuse to envision themselves as users of hospital services and adamantly avoid advertising that declare the statistical chances of their future medical need. Therefore, the traditional practice of targeting products and services to specific audiences and communicating brand images to the community are often ineffective in the healthcare context. Toward the end of the twentieth century, challenges in profitability, customer loyalty, quality of care, and market dominance drove hospitals to install a formal marketing function, which emulated the practice in other industries. However, the dilemma of promoting a brand versus identifying and meeting customer needs muddied the healthcare waters to the point that, by 1991, only 20 percent of hospitals demonstrated a high degree of marketing orientation (White, Thompson, and Patel 2001). The pervasive challenges of healthcare marketing have plagued more than just hospitals; nearly every sector of healthcare has struggled to determine an effective means of marketing. Even for the nursing home sector, "marketing practices have remained focused on traditional and relatively

THE E M E R G E N C E OF CONSUMER-DRIVEN HEALTHCARE MARKETING

"Marketing," according to the definition by the American Marketing Association, is the activities and processes for creating, communicating, delivering, and exchanging offerings that have value for customers, clients, partners, and society at large. Marketing is not embodied by any one technique; it is a broad endeavor that involves relationship-building methods that rapidly multiply as technology evolves. Also, marketing is not just limited to promotional techniques; it extends into product conception, pricing structure.

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constrained practices" (Galhoun, Banaszak-Holl, and Hearld 2006). In 1995, Newt Gingrich, former Speaker ofthe U.S. House of Representatives, boldly announced that the approaching information age would mean more decentralization, more market orientation, more freedom for individuals, and more opportunity for choice (Gingrich 1995, 92). Shortly thereafter, the Internet was introduced for public use, which promptly connected more than 25 million computers in more than 180 countries. The Internet pioneered a new approach to acquiring information. Suddenly, a wealth of data was available to the general public that could be exchanged and archived in real time from the comforts of home. For marketing, that availability presented new challenges to developing "face time" with consumers through new media and limited the control over consistency of messages: Advertised claims could easily be verified, and electronic sources provided a sounding board for disgruntled consumers to voice their dissatisfaction. The change in mind-set of consumers greatly affected the healthcare industry as well. Many hospitals elected to take a proactive approach to Internet marketing by instituting websites that were "online business cards" in nature. These early websites provided straightforward information pertaining to the services and products offered, the equipment used, and the locations where services were available. However, these sites offered little interaction with visitors and failed to incorporate the multi-user advantages offered by online applications.

While healthcare's online presence remained relatively stagnant, other industries devised innovative ways to use their websites to engage consumers. Sites were designed to harvest information about their visitors for future marketing efforts, and interactive abilities allowed consumers to customize online tools and features to fit their preferences. Southwest Airlines, the first ' major airline to launch a website, generates more than 57 percent ofits annual revenues through online bookings. The website is today considered to be the largest in the airline industry and ranks as one ofthe largest e-commerce sites (Ruano 2004). For healthcare, the monumental influence ofthe Internet has begun to tip the scales on the deficiencies of conventional marketing. As consumers have become more sophisticated with their use ofthe information superhighway, the locus of control in healthcare has shifted from the provider to the consumer. The new focus on customer wants, needs, and expectations has fueled the rise of consumerdriven healthcare marketing. This fresh approach to marketing recognizes the participant's role in the delivery of care and the promotion of health education and Wellness (Galhoun, Banaszak-Holl, and Hearld 2006). The buzz of opportunity in consumer-driven healthcare has attracted several big-name companies, such as J.D. Power and Associates and Nielsen. That interest could prove to be pivotal for healthcare marketers. Most patients do not understand hospital ratings assigned by the Joint Gommission and other healthcare entities, but most

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consumers know the meaning of the J.D. Power trophy (Robeznieks 2007). These recognizable merits could change the way healthcare stimulates relationships with its online consumers. Table 1 compares conventional marketing techniques and characteristics with those of consumer-driven marketing.

Disney has had a profound effect on the way healthcare organizations engage consumers (Lee 2004). The precedents established from learning by imitation can easily extend into the marketing arena.

Example from the Banking Industry

In many ways the evolution of healthcare parallels that of banking. Both industries are highly regulated, offer relatively universal services, and work to combat stereotypes of giving impersonal service and having self-serving agendas. In recent years, both hospitals and banks have attempted to reinvent their image by renovating their campuses into sophisticated spaces designed with a markedly retail flair and comparable in comfort with coffee houses and elite hotels. The difference for banks, however, lies in their ability to transform the mechanics of burdensome regulation into a selling point of the marketing plan. The majority ofthe banking industry is regulated by the Office ofthe Comptroller ofthe Currency. One of the criteria used to monitor the performance of banks is the degree of compliance with the Community Reinvestment Act (CRA), which was originally passed in 1977. CRA mandates that all banking institutions that receive Federal Deposit Insurance Corporation (FDIC) coverage be evaluated to determine if they have met the credit needs of their entire community in a manner consistent with safe and sound operations. The three main evaluation aspects of CRA include community investments, community service, and loans to community-based not-forprofit organizations.

INDUSTRY

COMPARISONS

In 2004, the Society for Healthcare Strategy and Market Development ofthe American Hospital Association published a report on marketing effectiveness that reveals a chasm between what chief executives want and what most hospital marketers are delivering (Sturm 2005). Further, the study states that many healthcare executives believe that growth is, almost exclusively, a function of patient acquisition, whereas CEOs from other industries expect revenue growth to come from existing customers. Because many healthcare markets have limited options for growth through acquisition, healthcare marketing plans must be reformulated to address retention strategies and measure how marketing influences patient satisfaction. To do so may require an evaluation of how other industries have grappled with the challenge. Seeking inspiration from beyond the constraints of the healthcare industry is far from a novel approach. Patient safety and quality in healthcare have both been improved by borrowing best practices from other industries (Shaw 2008). For example, factory principles have contributed to streamlining hospital operations, the airline industry has provided models to improve communication and enhance safety, and

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TABLE 1 Comparison of Conventional Marketing Versus Consumer-Driven Marketing Conventional Marketing

Print ads Radio/TV spots Billboards Awareness by branding Marketing to the masses Limited response-measurement ability

Consumer-Driven Marketing
Customized interactive websites Podcasts and stealth ads Blogs and social networks Word-of-mouth referrals Mass customization Extensive response-measurement ability

Rather than produce the minimum amount of effort required to receive a satisfactory rating, innovative banks learned to capitalize on the mandate. Armed with the information that 84 percent of Americans say they are likely to switch brands to support a worthy cause when price and quality are equal, marketers for these banks took their CRA activities to the press (Retail Merchandiser 2005). Gradually, the negative connotation of banking gave way to the well-intentioned actions and media images of their directors and officers volunteering within the community. In light ofthe current global economic crisis, banking marketers are challenged to once again devise ways to realign public perceptions. Healthcare has the same opportunity to capitalize on data for marketing gain. Healthcare marketers can use the outcomes dataon quality, pay for performance, operational efficiency, care effectiveness, and community impactthat the organization compiles and reports, as required by regulatory bodies. Marketers should infuse the organization's messages of mission.

goodwill, and community service with these outcomes data to make the advertising initiatives believable, evidence based, and valuable to the consumer (Wanless 2005). Consumer-driven marketers should begin with a rich understanding ofthe organization's quality ratings through detailed analyses of its performance data. Outcomes that show the greatest positive differentiation from outcomes achieved in other organizations should serve as a starting point for developing a marketing campaign (Wanless 2005). From there, a story will evolve that directs the advertising activities and provides credible evidence to back up those efforts. The modern healthcare consumer wishes to know how an organization's products or services will directly benefit him. How quickly will he receive care when he visits the hospital? How advanced is the hospital's body of knowledge, and how does that translate into his chances for a full recovery? How does the hospital contribute to the community in which he lives? These are the pertinent questions being asked by a population accustomed to getting

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answers through the abundance of online resources.

Example from the Airline Industry

Southwest Airlines provides another stellar example of how an organization can use online marketing to foster relationships with its consumers. Southwest has exploited the Internet in a variety of relationship-building campaigns, which include weekly electronic newsletters and special-offer e-mails (Levinson 2001). The online booking process (mentioned earlier) costs the airline $ 1 per booking, as opposed to the $10 per booking it pays for a brickand-mortar travel agent. Furthermore, this system makes booking simple for consumers by forgoing data-mining mechanisms that require visitors to log in or register to purchase tickets. The design of southwest.com has provided travelers with the convenience of one-stop shopping for airfare purchasing, rental car reservations, and hotel room booking. Strategically, Southwest does not partner with other travel sites because it cannot control the service a Southwest customer gets from the online agent nor can it guarantee the ease of buying a ticket online (Levinson 2001). Southwest's preoccupation with ensuring consumer satisfaction through online interfaces serves as an influential model for the future of consumerdriven healthcare marketing. Healthcare organizations could economize the appointment-setting process by using sophisticated software for their websites; the time-saving advantage and convenience of such a system can then be advertised to consumers. In regard to one-stop shopping, healthcare

websites could be set up to automatically schedule recurring appointments (but could be changed according to the consumer's preference) and to prepare referral appointments through the main portal so that patients do not have to arrange for the next step and thus avoid fragmented care. In addition, the online system could provide maps to office locations, supplemental education material, patient forms, written doctor's orders, and a list of prescribed medications at the same time the appointment is scheduled. This kind of web interface can enhance the patient experience. Thus far, limited evidence is available to suggest that consumer-driven healthcare marketing is gaining steam in the market. However, in conjunction with the highly publicized marketing successes of a handful of healthcare companies, the industry is beginning to recognize that failure to engage in innovative marketing could lead to a hospital or health system's demise. Take, for instance, HealthAllies, a consumer-focused healthcare company that aggregated purchases of medical services not typically covered by insurance (e.g., orthodontia, in vitro fertilization, plastic surgery) and negotiated discount rates for those services with providers. While HealthAllies arguably cornered the insurance market in terms of innovation, the main obstacle to its success was the absence of marketing and distribution channels in the healthcare industry for individual consumers (Herzlinger 2006). HealthAllies was bought out by UnitedHealth Croup in 2003, a company whose established marketing and distribution channels reduced the costs of customer acquisition to make the program a viable endeavor.

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NEW, TECHNOLOGY-ENABLED MARKETING OPPORTUNITIES

From the perspective of the modern consumer, a dynamic, interactive web presence is a prevailing component of an organization's perceived legitimacy. For the marketing professional, dependence on electronic sources to receive and disseminate information and to forward marketing efforts represents a more economical approach to traditional consumer campaigning. In addition, the traditional restraints of paper-based advertising are lifted, leaving behind only the limitations ofthe marketer's imagination.

Stealth Ads
Online videos are the key to converting web surfers into engaged viewers. YouTube and similar online video forums pay tribute to people's desire to be entertained. To combat the pervasive use of professional video advertising, some companies have shifted their efforts to creating "stealth ads"videos that appear to be homemade yet are created by big business. Corporate giant Nike commissioned professional basketball player Kobe Bryant to appear in one of its premiere stealth ads. The ad looks like a home video of Bryant performing a daring stunt: Jump over a car as it drives toward him. The Nike brand is never flashed, and no credits are presented. Several weeks after the viral video flourished throughout the web and received more than one million views, Nike finally admitted that it had indeed sponsored and created the ad. Considering that humans are inherently attracted to putting themselves in circumstances that may subsequently require the use of healthcare services, stealth ads could serve the purposes of healthcare marketers. Take the nation's preoccupation with television programs Grey's Anatomy and ER and, most recently, the hospital docu-drama Hopkins. What better way to allow potential patients to peer into the core of a healthcare organization than through video broadcasted widely? The bonus is that compared with the expense of traditional print advertising, the costs associated with recording amateur-style video and distributing it on the Internet are minimal.

Auctions and Matchmaking

The enormous success of web-based strategies such as online auctioning (e.g., eBay) and online matchmaking (e.g., eHarmony) adds an interesting concept to the tool kit of healthcare marketers. Similar to the functions of eBay, physicians could be viewed as "sellers," who can be rated on various measures by the feedback from past and current patients. In this scenario, the patients could be seen as "buyers," who shop for doctors who specialize in a specific medical condition or who fit their personal preferences. Along the lines of eHarmony, patients could be matched with physicians. Patients would provide information about themselves and state their physician preferences, while physicians would supply information pertaining to their practice such as fees, specialties, and preferred treatment approaches. Even the most effective or reliable provider scorecard system would likely not trump the peer-grading system created by eBay and eHarmony.

Social Networks and Blogs

Simply stated, healthcare is a service industry that places great value in

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fostering relationships with its consumers. Presence on online social networks (e.g., Facebook, Linkedin) serves to extend the healthcare organization's agenda. However, this strategy is often overlooked. Recently, consumer-driven healthcare marketing pioneer Mayo Glinic enabled patient communication by developing a Facebook page, among the most popular ofthe so-called Web 2.0 venues for online social networking (Rollyson 2008). Facebook members use the page to share stories about Mayo Glinic and depict the care they or their friends and family received. The technology-enhanced word-of-mouth advertising creates the impression of peer-determined credibility and achieves an economy of scale that is elusive to traditional marketing: Mayo's director of marketing claims one word-of-mouth recommendation is worth 600 media impressions (Johnson 2008). Blogsa chronicle of information, commentary, and other materials such as images and videosare another online method for reaching out to a company's customers. The addition of blogs to a website can enhance it in a number of ways. First, websites that are home to active blogs that are frequently updated and generate viewer traffic are often viewed favorably by search engines (which means that the site will be among the firsts to show up on an Internet search). Perhaps more importantly, blogs by members ofthe healthcare team can soften the antiseptic feel common to many corporate websites and the healthcare industry in general. Adding blogs on healthcare websites can be regarded as an operational nightmare. The organization must seek to

portray a professional image yet appear warm and personable, maintain control but allow input as a normal function of a relationship, and be current enough to stimulate interest without consuming an inordinate amount of time. Kaiser Permanente, an integrated managed care organization based in Galifornia, responded to these challenges with a notably unique approach. Instead of addressing topics in its blogs that would create legal exposure, it focused on themes that were inherently noncontroversial, such as promoting proactive Wellness and self-care. The first blog published by Kaiser Permanente was contributed by Preston Maring, MD. Dr. Maring was the local guru on sustainable farming and wrote colorful blog entries relaying farming stories and delicious recipes and cooking tips (Weber 2008). The weekly entries became a productive public relations tool that was well recognized beyond the boundaries of Kaiser Permanente's geographic locations. Visitors to the blog were able to submit comments that were moderated by Dr. Maring at his discretion, and Kaiser Permanente retained authority over the boundaries of conversation. Table 2 provides a listing of webbased marketing tools.

THE H A N D C U F F S OF HIPAA
Many organizations have confused the concept of using the web to "get up close and personal" with the process of regurgitating patient information to a targeted group of end users. With this mind-set, it is easy to understand how the Health Insurance Portability and Accountability Act (HIPAA) represents a tangible barrier in the implementation

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of healthcare marketing plans. However, HIPAA is simply a set of consumer protection standards implemented in response to the unethical or discriminatory use of patient information and abuse of information exchange that were common before the inception of the act. Efforts to reach consumers in meaningful ways without the exchange of patient-identifying data eliminate the need to comply with HIPAA regulations. Interestingly, a divide exists in how healthcare providers and patients define "relationship." For providers, healthcare relationships place emphasis on collecting and applying data effectively through new database techniques that aim to improve health outcomes as well as marketers' overall return on investment (Levins 1998). This form of relationship building is highly dependent on abiding by the regulations

imposed by HIPAA. From a patient's perspective, healthcare relationships are forged in the exchange of information. Patients want knowledge of, access to, and the power to participate in health services that can help and heal them. This style of relationship allows for a level of anonymity that bypasses HIPAA constraints and yet satisfies consumer needs. Contrary to conventional wisdom, the general public is not averse to divulging personal information for the benefit of health improvement. The most influential talk show hosts on television, including Oprah Winfrey and Dr. Phil McGraw, have tackled taboo topics on health in response to consumer demand. A market has evolved for consumers who are hungry for detailed information on Wellness and disease management yet whose

TABLE 2 Web-Based Marketing Tools, Definitions, and Function Marketing Tool

Stealth ads

Definition
Videos that appear to be amateur/ homemade yet are created by big business to promote a product or service A chronicle of information, commentary, and other materials such as images and videos A series of audio or video digitalmedia files that are distributed over the Internet by syndicated download Websites whereby various users can join networks to interact with other people across the globe

Function
Convey marketing messages in places where the audience expect noncommercial reality; effective through proliferation Interact with current/potential consumers regularly and produce content consistently Deliver audio or video messages; portable, targeted, and emotionally stimulating Advertise new events or products and dialogue with various stakeholders in the healthcare process

Blogs

Podcasts

Social networks (e.g., Facebook)

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primary care physicians are unable to supply information because they could not devote the time needed. Constimers turn to physicians in mainstream media (e.g., Internet, TV) to serve as guides in healthcare matters and as providers of medical information. The best representation of this movement is Columbia University's cardiothoracic surgeon Dr. Mehmet Oz, whose rise to fame is due in part to frequent appearances on the Oprah Winfrey Show, hosting a satellite radio program, and authoring more than 350 publications. Dr. Oz, who has a dynamic personality and extraordinary compassion, encourages audiences to become partners with their doctors in the delivery of care and to become experts on their own health. Dr. Oz's innovative model of relationship marketing allows physicians to address issues of personalized information that facilitate HIPAA compliance; thus, it warrants review by progressive healthcare organizations. The magnitude and depth of resources available on the Dr. Oz website is remarkable. Every imaginable aspect of diseases, ailments, mental health, physical fitness, diet, and healthy living is uniquely identified and analyzed in a catch-all approach for meeting individual consumer needs. Another advantage to technologyenabled relationships modeled by Dr. Oz is that consumers have unrestricted access to the physician by way of online videos, blogs, podcasts, and other means that continually reinforce healthcare messages, as opposed to the transitory nature of a traditional doctor appointment. A patient's relationship with her physician extends beyond the

office and into a realm that falls outside of HIPAA compliance parameters.

R E C O M M E N D A T I O N S FOR T H E HEALTHCARE EXECUTIVE

Do not be afraid to introduce new, technology-enabled marketing strategies. In many cases, contemporary marketing methods are less expensive than traditional, paper-based methods. Learn from leaders in other industries. Companies such as Coca-Cola, Toyota, and Starbucks have been examples to healthcare organizations in terms of developing new metrics, creating exceptional experiences, and using new technologies to promote their services (Johnson 2008). Do not become too engrossed in the quantitative and qualitative results of marketing effortsthe Mayo Clinic, for example, recognizes the inherent value of certain marketing practices that are, albeit, impossible to measure. Promote the safety of consumerdriven, personalized online applications by investing in the most current website security technology. Most websites lose consumers when they fail to implement privacy and confidentiality features.

CONCLUSIONS
As this article demonstrates, the fundamentals of healthcare marketing have changed. Consumer-driven healthcare marketing has had a profound impact

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on the organizations that have dared to experiment and implement it. In reality, the costs of investing in new, technology-enabled marketing opportunities often are lower than those associated with traditional methods of mass advertisingprinting, for one. The Internet has created a new landscape in which relationships may be developed between companies and consumers, providing a variety of means to satisfy needs and encourage recurrent interaction. The marketing successes of prominent healthcare organizations and companies in other industries highlighted in this article provide a compelling case for the proliferation of consumer-driven healthcare marketing. REFERENCES Calhoun, J. G., J. Banaszak-Holl, and L. R. Hearld. 2006. "Gurrent Marketing Practices in the Nursing Home Sector."
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