As the world faces a pandemic of a magnitude not witnessed for over 100 years, we are reminded of healthcare’s fundamental role in our interconnected world. Marketing as a discipline has not lived up to its potential contributions to this important aspect of our lives. The Journal of Marketing Special Issue on “Marketing in the Healthcare Sector” is dedicated to promoting research on healthcare marketing. Thirteen scholars from across the marketing discipline shared their views on unanswered questions facing marketing in the healthcare sector during a special session at the 2020 AMA Summer Academic Conference. A summary and video clip of their individual presentations follows.
Leonard Berry | University Distinguished Professor of Marketing, M.B. Zale Chair in Retailing and Marketing Leadership, Mays Business School, Texas A&M University
Underuse of Palliative Care and Hospice Services
One of healthcare’s most important jobs is to help people with advanced illnesses live as comfortably as possible until they die. Yet, many patients do not die how they wish, which is to be as pain-free as possible and at home surrounded by family. Two services are available in the U.S. for patients with advanced illness—palliative care and hospice. Both services provide comfort care (such as pain control) and emotional support for patients and their families.
However, palliative care and hospice services are grossly underutilized in the U.S. About 60% of patients who could benefit from palliative care do not receive it and 25% of hospice patients die within three days of enrollment even though insurance covers it for six months. How can marketing help improve the utilization of these valuable services that can help people live better at the end of life?
Poverty and Health
Another important topic is the impact of social determinants on health. Factors such as quality of housing and education, income levels, physical activity, and social support are far more influential in overall health and length of life than medical care. For example, life expectancy in a low-income Chicago area drops 16 years compared to an affluent neighborhood. Poverty’s links to health may seem an impossibly big and complex topic for marketing academics to tackle, but research teams can break this big puzzle into manageable pieces and make extraordinary contributions. Consider, for example, the opportunity for marketing to reimagine housing for low-income people such as being done in designing “purpose-built communities” such as Villages of East Lake in Atlanta, GA. Think of “purpose-built communities” as a complex new product to serve the needs of its customers and other stakeholders. We in marketing have the expertise to make these “products” much better.
Punam Keller | Senior Associate Dean of Innovation and Growth, Charles Henry Jones Third Century Professor of Management, Tuck School of Business, Dartmouth University
Ecosystem goal: The Role of Business and Marketing in the BIG Picture
Multiple factors determine health outcomes. As the current pandemic shows, health outcomes are the result of interactions across global and social elements, technology, governments, and organizations. Thus, to tackle health problems, marketing should work more with the parties that it has not done so very often in the past. For example, collaborative work with global organizations such as WHO, WTO, and COP can be advantageous.
Individual Behavioral Goal: Message-Behavior Tailoring Using Technology and AI
Switching the focus from the ecosystem level to the individual level, marketing should note that technology can be readily adapted to encourage behavioral changes that promote better health outcomes. For example, smartphones can be powerful if combined with tailored messages alerting patients when to take their medications. We can study the efficacy of the types of text messages across segments of patients to understand which types of message are most successful at promoting positive behavioral changes.
Irina Kozlenkova | Assistant Professor of Marketing, University of Virginia
Mitigating the Effects of Physician Turnover through Relationships
Relationships have an important role in healthcare marketing. Among many players in the healthcare ecosystem (which includes payers, purchasers, suppliers/distributors, and regulators), the physician-patient relationship is central to healthcare and is also related to other entities in the ecosystem.
One problem that has not been understood well is mitigating the effects of physician turnover. In 2017, healthcare jobs experienced 21% turnover, which is second only to the hospitality sector’s turnover rate. It is costly to replace health professionals ($100,000 to replace a registered nurse, $1,000,000 to replace a physician) and doing so negatively affects patients and organizations. It has been shown that typical retention initiatives that work in other industries do not work well in healthcare.
Relational mitigation strategies may be key to mitigating the negative impact of turnovers. We conducted qualitative interviews with employees from all levels of a big healthcare organization (from high level executives, physicians, nurses, to receptionists) and a patient survey, which we later matched with turnover data and patient health data. The data revealed a big variance between various departments in terms of staff structure – some had consistent structures, while others were more ad-hoc. We learned that it is important to pay attention not only to physician turnover, but also to other parties (RNs, MAs, PAs). Continuity of care with the other parties improves patient outcomes, such as retention by 45–75%. While often the most attention is paid to the central relationship between a physician and a patient, we found that to many patients, their relationships with other members of the healthcare team (e.g., nurses, medical assistants) were as or more important as the relationship with their physician. Proactive communication with recommendations for a replacement of a leaving party has also been shown to improve outcomes (41–91%).
Another important problem to address is off-label prescribing. It is legal in many countries to prescribe drugs for conditions for which they have not been approved. This is a very common practice (over 20% of prescriptions are off-label), yet patients are often unaware of it because doctors are not required to tell them. Since drugs are used for conditions for which they have not been tested and approved, it can be risky, and sometimes deadly. Some populations (e.g., children, pregnant women) may disproportionally receive off-label prescriptions. Research shows that over 70% of off-label uses have little to no scientific support.
Two important research questions surrounding this issue are how to regulate off-label prescribing without stifling innovation and understanding how physicians make off-label prescribing decisions. Our preliminary research findings from a field conjoint study, matched with the actual prescription data, show that physicians are more likely to prescribe an off-label drug when they are similar to the patient (in gender or experiencing the same “issue”) and when they have more experience in the specialty. Also, higher prices of the approved drug tend to diminish the use of the cheaper off-label drug.
Cait Lamberton | Alberto I. Duran Distinguished Presidential Professor in Marketing, Wharton School of Business, University of Pennsylvania
Micro: Biases Specific to Care Choices?
While we have done quite a lot of work to show that well-established biases exist in healthcare (as they do in any context), we also have a lot to learn about specific biases that may arise in healthcare choice making. One example is anti-community bias. Health outcomes are superior closer to home, given that closer-to-home facilities offer better accessibility and a closer relationship with doctors. With no other information, patients seem to prefer to stay close to home. However, when given a choice, patients tend to reject community hospitals in favor of more distant university-based hospitals, which do not necessarily lead to better outcomes for many standard procedures. Moreover, in rural areas (where 20% of the U.S. population resides) such biases may have long-lasting negative effects, as we see the increasing closures of community hospitals in rural areas. Given this tension between rural and community hospitals versus urban and university-based hospitals, understanding how patients make choices weighing different factors across these two types of hospitals and contemplating how and when marketing should tip the scales become crucial.
Macro: Satisfaction (with Healthcare)?
At the macro-level, marketing can focus on hospital satisfaction measurement. HCAHPS (Hospital Consumer Assessment of Healthcare Providers and Systems) measures patient experience including communication, pain management, and the quietness of the hospital environment. It is a widely used measure, freely available and, more importantly offers a huge opportunity to conduct interesting research. For example, an interesting area of research is the difference in the mode of delivery where more positive responses are attained through mobile devices than through computers. Researchers can also investigate the role of pain and the way it may be framed to help consumers deal with it in the most healthy manner, what types of advertising work well for healthcare facilities and providers, and how we can more accurately capture patient satisfaction as fully-conceptualized, and likely to be rooted in different, healthcare-specific experiences like empathy and respect for dignity, than might drive satisfaction with other goods and services.
John Lynch | University of Colorado Distinguished Professor, University of Colorado-Boulder
Health Care System Infomediaries
Healthcare expenses have experienced a six-fold increase in inflation-adjusted dollars since 1970. One major factor contributing to this increase is the absence of consumer price sensitivity. Insurers, the payers of this expense, cap the maximum out-of-pocket costs for the consumer. Even when patients are paying, they are often willing to pay all they can for a few more months of expected life. Furthermore, prices are opaque, even to doctors. This means that doctors do not know how much patients will be charged for a given procedure. They view it as impossible to know because it is dependent on insurance and not their job to know. How can marketing help incorporate price sensitivity in healthcare? Can we design pricing infomediary models to help doctors be better price shoppers for their patients?
Health Privacy & Quality of Care
Another interesting topic is health privacy and quality of care. HIPPA regulations govern the uses and disclosures of personal health information. Patients have rights over their health information and can authorize certain health records to be disclosed. How many consumers know who has what records and how does this affect the transmission of health history information that could benefit care?
Utilizing health data is analogous to the literature on customer identification in advertising, pricing, and personalized recommendations. Sharing information has benefits, but there are also risks of exploitation. Can we develop models for patient ownership and sharing of personal health information that promote better health outcomes?
Detelina Marinova | Sam Walton Distinguished Professor of Marketing, University of Missouri
Physician-Patient Digital Communications for Improved Health Outcomes
Provider-patient interactions are crucial in healthcare and we see a shift of the mode of communication from in-person to digital platforms, especially during the pandemic. However, research has just started to address digital communication in healthcare. Digital communication can be beneficial because it reduces office visits, which can improve efficiency. However, it can also increase physician workload in other ways and digital communication bears a risk of miscommunication. Thus, it is important to understand why and under what conditions digital communication between patients and providers contributes to patient compliance, engagement, and improved health outcomes.
Managing Frontline Interactions for Patient Well-Being and Hospital Revenue
Hospital spending constitutes 30% of national health expenditures, yet it is challenging to deliver high quality and cost-efficient health outcomes. With this tension, there are trade-off s between hospital revenue and patient well-being. One crucial aspect affecting both hospital spending and health outcomes is frontline interactions, which includes proactive actions by physicians and nurses and reactive actions by staffs. These often shape patients’ behavioral approach to medical conditions and treatments, thereby influencing the patients’ well-being. Moreover, it can be either a revenue source or a high-cost factor for hospitals. Therefore, one potential research question is how proactive and reactive actions of frontline agents contribute to or alleviate the trade-offs from the dual-emphasis on hospital revenues and patient well-being.
Vikas Mittal | J. Hugh Liedtke Professor of Marketing, Jones Graduate School of Business, Rice University
Health Care & Marketing
Conducting successful research in healthcare has a few issues that are uncommon in other sectors. First, problem-solving and practical relevance is critical in healthcare. Collaborators in health systems may not be interested in laborious “theory.” Hence, it is important to focus on relevant problems with basic rigor rather than thin-slicing or engaging in complicated quantitative analyses.
Second, research modesty is important for successful collaboration. A marketing perspective can contribute to solving healthcare problems, which is a much better approach than trying to solve a marketing problem with healthcare only as a “context.” For example, problem-oriented research questions may be: 1. How can a pharmacy chain manage its segmentation in different locations? and 2. How can nursing homes improve employee retention to improve healthcare outcomes?
Third, it is important to learn the differences in process as well as in incentive structures. In healthcare, grants are more critical than publications, so learning how to contribute to the grant-writing process is vital. Regarding publications, in medical journals, authorship and authorship order follow a pre-defined structure. Lastly, data privacy and data integrity issues are paramount and often university-level permissions are needed, which can be time-consuming.
Despite the unique characteristics of the field, there are many marketing research opportunities to gain a deeper understanding of medical and healthcare problems and teaching opportunities for training health professionals for rewarding careers.
Maura Scott | Madeline Duncan Rolland Professor of Marketing, Florida State University
Stigma and Vulnerability in Healthcare: Solutions through Technology?!
Stigmatized consumers experience a distinct healthcare journey relative to other consumers. Stigmatization can aversely influence the quality of care that patients receive from healthcare providers. Stigmatization in healthcare can limit patients’ willingness to engage in their treatment, thereby potentially further harming their health outcomes. Sources of stigma include certain patients’ characteristics such as race, ethnicity, and body type. Some diseases may be stigmatized based on the perceptions of visibility, controllability, permanence, or contagion associated with the disease. Vulnerable populations (e.g., underrepresented minority groups) may face these two sources of stigmatization at the same time, further affecting their well-being. Identifying interventions that help encourage stigmatized patients overcome the reluctance to engage in their healthcare (e.g., via online healthcare communities) is crucial. More research should identify policies that create an inclusive, equitable, and accessible healthcare system.
Technology in Healthcare: Tensions and Solutions
One potential way to tackle low engagement from stigmatized patients is to leverage relevant technology in healthcare. There are concerns and tensions to consider when developing such solutions. First, technology can reduce stigmatization because it can reduce human interaction; however, technology programmed with inherent bias could increase stigmatization. Second, technology could lower costs and increase accessibility for vulnerable patients. Yet, income level can make a difference in healthcare service quality, for example by separating ‘premium’ in-person service for the wealthy, which might lead back to the current status quo. Third, technology can influence patients’ anxiety levels, which suggests the need for healthcare interventions to help reduce anxiety triggered by technology. More research is needed to identify how to leverage technology in healthcare to increase accessibility and inclusivity of high quality, low-cost healthcare for all patients.
Steven Shugan | McKethan-Matherly Eminent Scholar Chair and Professor, Warrington College of Business, University of Florida
Changes in Healthcare Markets
Marketing can address several interesting issues in changing healthcare markets. Service mix has been addressed in recent work, highlighting the fact that services offered by non-profit hospitals differ from those offered by for-profit hospitals. More research on service mix is needed. Websites hosted by hospitals and other healthcare providers can serve multiple roles—information provision (education) and selling (referrals). Research on multiple role healthcare websites would be valuable. New product launches are also an interesting problem in healthcare, with many new devices facing complications when being brought to market because of licensing issues and multiple players (including regulators, competitors with patents and courts).
Block-chain is a new encryption technology that may enable the storage of sensitive healthcare data. Marketing research can address the interaction of these databases with multiple parties also with privacy concerns. The interaction of these databases with consumers is a typical marketing communications issue. Artificial intelligence also has made its way into healthcare integration, from reading x-rays to making diagnoses, yet the AI-consumer interface is a marketing issue with many unanswered questions.
Other changes in healthcare markets that merit further research include the effect of changes in government regulation of the healthcare industry, the impact of for-profit entry in the existing market, and the implications of declining patient co-pays. Marketing communication in a heavily regulated environment with both business-to-business and business-to-consumer issues provides many research topics.
Healthcare Data Sources
There are many publicly available data sources in healthcare. Links for these data sources appear in the attached slide. Many of these datasets can be integrated based on geography (e.g., zip codes, FIPS, states, counties, etc.). My slides indicate many sources of free healthcare data. I and coauthors have also purchased data from American Hospital Directory and combined that data with data from free sources.
Jagdip Singh | AT&T Professor, Case Western Reserve University
Frontlines in Hyper-Markets
The pandemic has underscored the importance of getting ahead of the healthcare curve in uncertain and fast-changing healthcare markets. Research opportunities lie in the study of “outside-in” and “inside-out” frontline capabilities in healthcare organizations for demand anticipation and response agility that yield effective outcomes. These capabilities require an integration of ground-level experience with data-based analytics at speed. Several research contributions in Marketing can be useful to facilitate understanding of these capabilities including adaptive foresight, strategic flexibility, velocity and marketing excellence. Some potential ways to seed research is to leverage public data such as ‘Red Dawn’ emails or data from wearable-sensor technology.
Temporary Organizing for Public Health
The uncertain nature of healthcare markets can sometimes stem from public health and humanitarian crises such as climate change, war, disease, migration, and other conflicts. Many different organizations, such as the Red Cross, NGOs, and Doctors Without Borders, come together to address these crises. The challenges involved collaboration, coalition, and conflict in temporary meta-organizations to yield effective outcomes. Several research contributions in Marketing can be useful to facilitate understanding of these challenges including cause-driven marketing, mega-marketing and temporary marketing organizations. Potential for funding projects and data comes from Gates Foundation grants, Business Roundtable priorities, and community data.
Hari Sridhar | Joe B. Foster’56 Chair in Business Leadership Professor of Marketing, Mays Business School, Texas A&M University
Marketing in the Healthcare Sector: Improving Cancer Outreach Effectiveness
Marketing research in the healthcare sector can complement and embellish medical research. It is important to recognize that not all patients are created equal. We can leverage more than 60 years of marketing research on customer needs and the latest developments in machine learning. Using predictive models, we can also demonstrate the social and financial impact of healthcare interventions. Doing so can help the field of marketing become a value-added support arm to healthcare.
In our study1 of cancer outreach effectiveness, we use patient data and predictive models to improve returns on cancer outreach efforts. Only 4-8% of the general population undergoes regular cancer screening, despite massive spending on preventive outreach campaigns. In an National Institute of Health (NIH) supported study in partnership with UT-Southwestern, we conduct a large scale randomized field experiment to study how cancer screening visits are impacted by different types of cancer outreach efforts. Using a smorgasbord of variables concatenated from medical histories, geographical information, and the outreach program CRM data, we apply causal forests to estimate the causal effect of outreach efforts for every individual patient. We find that patient response to cancer screening varies dramatically across the population, enabling the dream of personalized outreach programs. By targeting the right people with the right intervention, we show that cancer outreach programs can save money and improve yield (over 74% in returns) in preventive cancer screening. Can marketing save lives and money? Our answer is a resounding yes.
It is also critical to understand the innards of the healthcare value chain and move beyond just the study of patient-physician and patient-facility interfaces. Other marketing scholars are now addressing issues surrounding multiple players in designing care facilities and improving quality of care, the complexities of hospital purchasing contracts, and the impact of regulatory interventions on payment disclosures. The field is ripe with other relevant questions and we are merely scratching the surface.
Featured in JM Webinar: https://www.ama.org/events/webinar/jm-webinar-series-insights-for-managers/
S Sriram | Professor of Marketing, University of Michigan, Ann Arbor
Technology has the potential to have a significant impact on the healthcare ecosystem. More importantly, the impact is likely to be felt by all stakeholders in the ecosystem. I consider two examples here.
The Internet of Health Things
In recent years, there has been a considerable increase in the use of wearable devices and apps by consumers, who use these devices for monitoring various markers of physiological and psychological well being. Broadly, these hardware devices and software applications come under the realm of Internet of Things (IoT). Do these devices, which are supposed to monitor health actually lead to better health outcomes and well being? Extant literature has documented mixed results because of several reasons. First, purchasing a device or downloading an app does not necessarily translate into repeat usage. Researchers have documented that consumers routinely lose interest after a few months. Second, even in instances where interest does not wane over time, routinely monitoring markers of health can lead to excessive obsession, which can be detrimental to overall well being. Third, even if we can establish a positive effect of these devices on health outcomes and overall well-being using observational data, one needs to be careful to control for patient self-selection – purchasers of these devices are likely to be different from those who chose not to purchase them.
The effect of these devices and apps can extend beyond patients. In this regard, how an individual’s health monitoring efforts can benefit other stakeholders in the whole ecosystem can be studied. For example, providers might see the reduced hospital readmission rate as shown in some literature and can potentially ensure adherence to medication taken outside hospitals. Drug manufacturers can increase the speed of drug development faster with regularly monitored data, as opposed to relying on self-reported measures. Of course, the downside is that such regular monitoring can be intrusive and raise concerns about loss of privacy. A careful quantification of the benefits of monitoring patient health information can help in assessing whether the benefits of sharing consumer data outweigh the risks associated with the violation of privacy.
Although the idea of telemedicine has been around for a few years, COVID-19 has made it a reality for many consumers of healthcare. The promise of telemedicine lies in its potential to relax wealth, accessibility, time, and skills constraints. This, in turn, can democratize healthcare. However, there are several important questions that need to be answered in order to assess whether and how this promise is realized. First, is the actual and perceived quality of a telemedicine service as good as in-person visits? Are there any particular risks of misdiagnosis from telemedicine? Second, the benefits delivered by telemedicine might not be evenly distributed across different stakeholders. For example, what benefits do patients and other stakeholders such as providers, payers, and telemedicine platforms derive from the new mode of healthcare delivery? How are these benefits distributed among the various stakeholders? How does the relaxation of the aforementioned constraints benefit patients? Does the benefit vary across patients’ socioeconomic status? Lastly, one can study the challenges that telemedicine might face in building a stable platform.
Richard Staelin | Gregory Mario and Jeremy Mario Professor of Business Administration, Fuqua School of Business, Duke University
Patient Experience Questions
Patient experience data has been collected for decades. However, until recently, most of these data came from standard surveys given to patients after they received treatment. Over the last few years free-form texts, such as reviews, have become increasing available. This new source of input from the patients may provide additional information to more traditional “rating-only” surveys. Do patient reviews of doctors differ substantially from customer reviews in other sectors? Do these reviews provide new information over the standard surveys?
There may be distinct segments of patients that vary in terms of their ability to judge the quality of service received. What is the size of the sophisticated market segment and can it influence the behavior of medical professionals? It would also be interesting to understand whether patients’ view of the quality of care differs across venues of service (e.g., emergency room, hospital, clinic). How is the perceived quality different from the objective quality measures currently used by medical practitioners?
Organizational Reaction to Patient Experience Data
Patient experience data are relevant to hospital management and insurance companies. Do they pay more attention to some databases over others depending on the source? How much should they weigh patient experience data compared to objective or clinical measures of quality? What are the profit implications for the hospital/company? The reaction of the medical staff is also a critical factor in understanding the impact of patient feedback data. Are providers receptive to such feedback by the patients and, if so, do their ability to adapt to feedback depend on the type of information? For example, patient feedback may be regarding bedside manners, receiving faulty advice, or being overcharged. Medical professionals may try to improve bedside manners and avoid billing mistakes, but it may be very difficult (or costly) to alter diagnostic practices.