Make every minute count, counsels physician
By Maureen Glabman
the views you would expect of a managed care expert: That solo
practices can thrive, that there are no economies of scale from
grouping physicians and that cutting practice expenses makes offices
But that's what nationally known consultant and author, Greg Korneluk,
told an intrigued Baptist Hospital audience of 50 physicians,
spouses and office managers June 18.
Korneluk chairs the International Council for Quality Care in
Boca Raton, a physician advisory company that takes a decidedly
contrarian approach to managed care. His philosophy is backed
by time motion studies of 5,000-10,000 physicians.
"I don't have a problem with managed care,' he says. "But
it has forced doctors to focus on dollars. Physicians who focus
on making money make less money. Doctors who focus on quality
make more money."
The Council's main philosophy mimics that of other consulting
groups: The most successful doctors improve quality and patient
satisfaction while increasing volume and efficiency though
that often seems to physicians a contradiction in terms.
Korneluk takes an industrial engineer's approach to physician
work. For 13 years, the chairman has shadowed physicians from
dawn to dusk, equipped with a stopwatch and clipboard. He attached
pedometers to labcoats to observe how much time is spent in wasted
"High quality physicians that are highly productive are efficient
in time management," he says. "Minimize motion and your
day will have less stress."
A minute saved is a minute earned
The results of his research are dozens of physician-friendly,
time-saving recommendations that run from shaving seconds by removing
exam room doorknobs to hiring "documentation assistants,"
that is, transcriptionists, who sit alongside physicians in exam
rooms and keep records. "Every chart needs to be finished
by the next morning at 9 a.m. or you're at risk when patients
call," Korneluk admonished.
The Council estimates primary care physicians' office time is
valued at $3 to $4 per minute. 'Make every minute count"
is the unofficial company motto.
Doctors spend lots of wasted time looking for their nurses. Korneluk's
suggestion: install a $50 cordless doorbell chime available at
do-it-yourself home stores. At least one audience member said
she had carried out that idea with success.
Korneluk found an average physician walks four to six miles per
week in the office. His suggestion: reduce time spent walking
and productivity will increase. Merely taking off rubber gloves
and putting them in a wastebasket three steps away costs two minutes
a day, or the equivalent of $6.
That's $1,200 per year in one activity alone. Solution: move the
basket to where the physician sits.
out the negative
goal is to show physicians how to preserve quality in a system
paying them less and less. Doctors who heard the talk called his
ideas "profound" yet remained skeptical. 'I don't believe
that managed care companies look for superior quality. They look
for average," said Miami internist Mark Kutner. "Taking
good care of people pays off but it costs more."
But Council research turned up the opposite results. "If
you cut staff to save expenses, you see less patients, you are
less efficient and less productive. You have to spend more to
make more," says the Council chairman.
Another internist voiced reservations. "Even if you make
yourself more efficient, the insurance companies continue to lower
fees. I don't see managed care rewarding physicians for efficiency,"
says Miami internist Robert Friedman, MD.
Korneluk says the most successful doctors are good clinicians
whose practices hum with happy staffers and satisfied patients.
Much of his advice for achieving such harmony hinges on delegation
and personalization. For example, he believes that to build a
successful practice, the doctor, his nurse and receptionist should
randomly call three patients daily and ask them how they are doing.
He suggested doctors take Polaroid pictures of patients and list
At times, Korneluk seemed a cheerleader for downhearted physicians
fed up with managed care. 'There's a lot going on in medicine
that's negative. Tune out the negative," he said. He told
physicians the most successful doctors wake up in the morning,
look forward to going to work and try to make each day a perfect
day. "When you study successful people, they imagine being
successful, they have that vision," he said.
For burned-out physicians, he suggested re-engineering practices
to focus on what doctors truly enjoy. One Toronto physician he
coached, for example, enjoyed treating body builders best. Another
young doctor enjoyed treating seniors. Both changed their practices
to specialize in those groups.
New York Times
April 16, 1984
A Push to Market Health Care
By N.R. Kleinfield
to the Methodist Medical Center in Peoria, Ill., never worry about
parking their cars. The hospital started offering valet parking
a few months ago. The place also has a doorman. After he swings
open the door, patients are handed over to an escort, who shepherds
them to their destination.
"These things are going over really well," remarked
Ellen Barron, the hospital's vice president for marketing and
planning. "People appreciate the little things."
Hospitals and doctors, faced with competition at every turn, are
resorting to the sort of marketing tactics more commonly found
in the airline business or the quick-burger industry. With increasing
frequency, they are advertising in newspapers and on television.
According to figures from the Television Bureau of Advertising,
for example, health-care professionals spent $41 million on TV
spots last year, compared with just $3.7 million in 1977.
To be sure, many doctors and consumers who feel that the saving
of lives is a lot different from the selling of pudding, look
with half-lidded eyes on the idea of health-care advertising.
Marketing expenditures, moreover, might contribute to higher healthcare
costs and needless utilization. A spokesman for the American Medical
Association remarks, "Lots of physicians still associate
advertising with quackery. Some doctors don't want to even list
their names in the Yellow Pages."
But the concept is clearly gaining acceptance among nonprofit
and profit-making institutions alike. Two different approaches
are being tried," said William Flexner, head of Flexner &
Associates, a health care consultant. "Some places are advertising
that they care, which I don't think works because you have to
experience caring. Others are advertising 'we have such-and-such
service' prenatal care or ambulatory surgery, for instance. Some
hospitals advertise an image. A popular one seems to be the high-tech
In addition, health-care dispensers are cooking up some unorthodox
enticements. Some hospitals, including a number of the 89 facilities
in the Humana Inc. chain, guarantee that they will inspect a patient
within a prescribed time of arrival in the emergency room. Eastwood
Hospital in Memphis gives refunds to patients of between $5 and
$15 if various standards are not met, such as if the floor nurse
does not answer a call signal within a minute, the linens are
not changed daily or a meal is not served piping hot. In the program's
first year, infractions resulted in the hospital's trimming a
total of $140 from patients' bills.
When Southwood Community Hospital in Norfolk, Mass., was converted
to a general hospital from a cancer treatment center recently,
the community was saturated with direct mail brochures that enclosed
coupons good for a free medical encyclopedia. To get the volume,
a patient had to show up at the hospital's walk-in clinic, but
did not have to be treated. And an Albuquerque, N.M., obstetrician-gynecologist
advertised his practice using a hot-air balloon with a stork painted
One of the more memorable marketing gimmicks was used by Sunrise
Hospital in Las Vegas. A number of years ago, the hospital staged
a lottery that was open only to patients who checked in on the
weekend, a typically slack time at hospitals. The grand prize
was a cruise for two. Utilization soared by 60 percent in 18 months.
"Hospitals and doctors have suddenly found themselves in
a competitive situation which didn't exist 10 years ago,"
says Dan Beckham, head of Healthtmarket Inc., a health-care consultant.
Mr. Beckham guesses that perhaps 50 percent to 60 percent of the
nation's hospitals now employ a marketing professional, compared
with perhaps 5 percent to 10 percent just three years ago.
Until recently, medical societies and hospital associations frowned
on or actually barred their members from soliciting patients.
It was as recently as 1977 that the American Hospital Association
published its first guidelines for hospital advertising. The Federal
Trade Commission ruled in 1980 that the American Medical Association
could not bar its members from advertising, and the A.M.A. has
revamped its code of ethics to allow advertising in a truthful
Since then, health-care professionals have found different ways
of marketing their services.
Ways of Marketing
"Marketing is how your office is decorated," remarks
Irwin Braun, president of Braun Advertising and a student of the
subject. "Marketing is what kind of service you give people.
Marketing is how long you keep people waiting. An ad can get you
into an office, and if a person is kept waiting for an hour, he'll
take a walk. One famous ear, eye and throat doctor in New. York
has his office reception room decorated with portraits of Presidents
and actors whom he has treated. That's marketing."
Like many cities, Flint, Mich., is extremely competitive for healthcare
providers. To woo patients, St. Joseph's Hospital thought up several
special deals. For example, the hospital offers a packaged obstetrical
program called "Special Delivery." An expectant mother
gets a 24-hour hospital stay and follow-up visits for $799. A
normal charge for delivery had been $2,500 to $3.000.
In advertising the offer, the hospital used the theme: "A
bundle of joy . . . A bundle of money." It hit home. Deliveries
climbed to 1,650 last year, from 1,200 in the previous year, a
rise the hospital attributes mainly to the campaign.
St. Joseph's also noticed that it was rapidly losing emergency
room business, especially minor emergencies, to after-hour clinics
and emergency clinics not associated with hospitals. A study found
that the key elements that affected a patient's choice of emergency
rooms were cost and waiting time.
So instead of charging a flat fee of $65 for all emergency room
patients, the hospital switched to a tier system of pegging fees
to the severity of the injury. Someone with a heart attack now
pays about $M, while a person with a bump on the head would be
charged $25. A TV campaign promoted the new approach, and the
hospital reports that emergency room business has picked up by
about 10 percent in the past year.
Greg Korneluk is a Lewiston, N.Y., consultant who specializes
in advising doctors on how to sell themselves. "The marketing
theory that I use with physicians is that the actual core service
offered to patients is pretty homogeneous," he explained.
"Things like parking, appearance, staff, courtesy
all those peripheral things matter.
Mr. Korneluk, noting that a number of doctors have video games
in their reception rooms, urges his clients to put TV sets in
their examination rooms. "While the patient is sitting there
he can watch the TV," he said. "I know a doctor in St.
Louis, who has color sets in all his exam and reception rooms.
Marketing, the newest idea in medicine
Doctors cater to patients more as competition builds
By Wayne Nelson
In a seminar sponsored recently by Metropolitan Medical
Center, Greg Korneluk, a nationally recognized health care consultant,
told a group of Twin Cities medical specialists that business
acumen will weigh more heavily than medical talent when it comes
to deciding who survives the physician shakeout already under
"The three A's in building a practice are availability, affability
and ability in that order," he told the group. "Successful
physicians will be those who cater to their customers."
While many physicians will find that advice a bitter pill to swallow,
there is logic behind Korneluk's assessment. Since most patients
are not in a position to judge their physicians' medical abilities,
they rely heavily on a physician's communication skills and demeanor
in deciding whether he or she is a good doctor, Korneluk says.
doctors to take advantage of that fact, rather than fight it,
by adopting marketing and management principles learned decades
ago in other service industries. Eliminate patient waiting time
whenever possible, he says. Or, at the very least, make the wait
more comfortable and less demeaning.
Read the patient's
chart before walking into the examination room instead of after.
Follow up with patients on diagnostic findings and recommendations.
Send them birthday and holiday cards.
stop with patients, Korneluk told the doctors. Work on winning
the loyalty of other physicians who might send referrals. This
should be a special consideration for medical specialists, who
depend upon referrals from other doctors for much of their business.
that specialists distribute newsletters to referring physicians
that include up-to-date information and relevant clips from professional
device requires little effort, he says, and sends two important
messages to primary care physicians: that the specialist wants
to help them be up-to-date, and that the specialist is current
with research findings and new technology in his or her chosen
suggests that specialists stay in touch with the needs and wants
of referring physicians. Generally, beginning physicians want
comprehensive reports from doctors who have seen their patients,
while doctors who have been in practice five years or longer tend
to prefer abbreviated reports of diagnostic findings.
like to keep their files tight," Korneluk says.
the referring physicians what they want, and give it to them promptly."
Why the sudden
interest in patients on the part of doctors, who in the past have
equated marketing with hucksterism? In a word: competition. A
growing surplus of physicians, and the increasing success of health
maintenance organizations (HMOs), which pay their doctors a salary
and compete with private practitioners for patients, have private
They are also
concerned that they might be the federal government's next cost
containment target. (Hospitals were the government's first target
because they consume the largest share of the U.S. health care
dollar, about 40 percent).
that next year the federal government will extend controls to
physicians like those it imposed on hospitals two years ago for
Medicare inpatient treatment. Medicare's regulations for Diagnosis
Related Groups (DRG) set a payment ceiling for each Medicare patient
treated by a hospital.
also warns that, as early as next year, Medicare might require
physicians to accept a set monthly rate for outpatient care.
these competitive forces are putting on private practitioners,
in addition to continuing rises in insurance and other costs is
likely to get worse, according to Korneluk and others. They believe
private practice physicians have no alternative but to practice
medicine more efficiently.
doctors are finding that a former foe has become an ally. The
very hospitals that doctors often fought with for control of the
old health care system are teaming up with doctors in order to
survive the shakeout.
seminar (sponsored by Metropolitan Medical Center) and similar
forums for physicians hosted by other Twin Cities hospitals reflect
some of the newfound common ground hospitals and doctors have
stems from Twin Cities hospitals and private practice physicians
both having lost patient volume as a result of HMOs' growth. Together,
the two groups are working to find ways to compete with this new
and powerful force.
In the past
two years, the hospitals that have succeeded most have been those
that have learned to manage themselves and market their services.
Now, those hospitals are providing that management and marketing
know-how and, in some cases, even capital to private
practice physicians to help them maintain and expand their patient
bases, says Richard Reece, a physician and editor of Minnesota
Medicine, a magazine published by the Minnesota Medical Association.
it for the hospitals? The hospitals, which are in their own battle
to keep their beds full, are betting that the new alliances eventually
will translate into patients.
shifting alliances will largely be invisible to health care consumers,
patients can expect to see more effort by physicians to turn office
visits into "health care experiences," as Korneluk puts
it. Just a few of the conveniences he expects to see are coffee
pots and televisions in waiting rooms, recorded telephone messages
(similar to those that provide flight information for airlines)
so patients can find out whether the doctor is behind schedule,
and maybe even house calls.
for the actual time spent with a physician during an office visit
to shrink from the current 12 minute average to perhaps 8 minutes.
As their costs rise and competitive pressures and government payment
ceilings limit fee increases, physicians will have to see more
patients if they want to maintain their current income, according
the length of office visits need not undermine the goal behind
these marketing efforts, which is to improve the doctor-patient
relationship, Korneluk says. Quite the contrary: Marketing and
management goals should be complementary.
he urges specialists who have just finished examining a patient
not to sit there writing themselves notes for a letter to be dictated
later for the referring physician.
say put a tape recorder in front of you, and tell the patient,
'This is what I'm going to tell your doctor in a letter,' "
Korneluk says. Then, give the tape to a clerical person and let
him or her write the letter to the referring physician.
have to learn to be more efficient with their time," says
is another service sector at the end stage of a cycle, having
to pull up its socks, just like everyone else."