The Tyranny of the Device:
Conducting a Bloodless Revolution
Brian Taylor
Faustian Bargain
Mainly due to the commoditization of technology and the incredible efficiency of retail chains, our traditional value as product dispensers has been significantly wounded….possibly a death blow. Creative Destruction
Joseph
Schumpeter
1883 -1950
“All established businesses are standing on ground
that is crumbling beneath their feet.”
3 Declarations
Declaration #1 A bloodless revolution requires us to understand the market from the patient’s point of view. Inside the Head of our Current Patient
Consumer‐Oriented Studies
• Kochkin, 2010
• Ross & Stika, 2011
• Dawes, et al 2014
What is offered to patients (post‐fitting)?
Referred to self-help group (HLAA)
Auditory retraining software therapy
Received self-help video
Customer satisfaction measurement
Aural education group
Subjective benefit measurement
Received self-help book
Real ear measurement verification
Objective benefit measurement
Loudness discomfort measurement
Hearing tested in sound booth
0
10
20
30
40
New User
Kochkin, et al, 2010
50
60
70
80
Experienced user
90
100
Ross & Stika, 2011
Information/Services
Audio‐
logists
Provided clear explanation of my current audiogram
Provided reason for selecting my hearing aid
Discussed care of the hearing aid
Discussed care of the battery
Discussed earmold hygiene
77.7%
78.6%
79.2%
66.6%
59.8%
(n = 651)
Information/Services
Discussed coping and communication strategies
16.9%
Discussed with my spouse and/or other family members the specifics of my hearing 20.8%
loss and communication strategies
Invited to participate in group meetings to help orient me to my new hearing aid(s)
7.7%
Provided information about Self Help for Hard of Hearing People, Inc. (SHHH), Association for Late Deafened Adults (ALDA), or other consumer resources
19.1%
Discussed communication strategies for dealing with my hearing loss at work
13.3%
Dawes, et al 2014
• Focus group, 16 adults hearing aid users
• Uncovered 4 themes:
•
•
•
•
Annoying/Distorted Sounds
Practical Use
Experimenting with Use
Psychosocial Factors
• Audiologist did not play a central role in the process of getting used to hearing aids
Conclusions
• In the mind of the experienced patient, the audiologist is anonymous.
A beefier service experience is needed
Less Product, More Service
Provide information in smaller chunks, over more appointments
Supplement the verbal with written information
Overtly involve the family
Use of tele‐audiology, website, social media
Support groups for new users
Performance Perceptual Discrepancy Counseling
Compares actual performance in noise to patient’s perception of understanding speech in noise
Difference between two score is PPDis
Performance – Perceptual Test (PPT)
1. Performance Component:
Patient repeats speech in noise audiometry
Find measured performance in noise
Performance – Perceptual Test
2. Perceptual Component:
Patient tells you whether he can
understand sentences in noise
The difference between their measured performance and their perceived ability is the PPDis
Overestimating ability
Measured SNR loss: 12 dB
Perceived SNR loss: 5 dB
PPDIS = 7
“Deniers” – have
more difficulty than
they acknowledge
Underestimating ability
Measured SNR loss: 7 dB
Perceived SNR loss:15 dB
PPDIS = ‐8
“Complainers” – may
never be happy with
ability to understand
in noise.
Performance Perceptual Counseling (PPC)
PPC for “under‐estimators of ability” Unrealistic high expectations
Reluctant to take risks and guess at what is being said
Lost confidence in communication ability in challenging listening places
Results of these behaviors:
‐ Become withdrawn and fearful in these situations
‐ Dependent on others
Behaviors to change:
‐ Encourage to try guessing
‐ Make assumptions they heard corrections
PPC for “over‐estimators of ability” Reluctant to acknowledge the extent of communication difficulties
Unaware of extent of problem because onset was so gradual
Results of these behaviors:
‐ “Faking it” might be frustrating others
‐ May appear to others as unintelligent or arrogant
Behaviors to change:
‐ Encourage them to ask for clarification or help
‐ “It’s okay to ask for some help” Saunders & Forsline, 2012 “single session” study:
Two types of counseling: Informational and Performance‐Perceptual Counseling
74 participants between 45 and 75 years of age
Wore hearing aids at least 3 months, 45% wore more than 5 years
Session 1 – PPT and counseling conducted
Session 2 – PPT and counseling conducted, 8 to 10 weeks later
Results
For the majority of participants a single session of PPC improved:
Daily Usage
Outlook toward hearing aid use
Perception of hearing handicap
Action Item for Next Week
 Learn PPT Counseling  Offer all Patients not seen in 2 years this fee‐for‐
service
Declaration #2
Conducting a bloodless revolution requires us to create new demand for services.
Profound or residual:
5%
70%
30%
Moderate to Severe:
20%
50%
Mild to Moderate:
75%
10%
Aided population
50%
90%
Unaided population
Profound or residual:
5%
70%
30%
Quasi‐Medical Channel
Moderate to Severe:
20%
50%
Mild to Moderate:
75%
50%
Consumer
10%
90%
Electronic
Channel
Aided population
Unaided population
Profound or residual:
5%
70%
30%
Quasi‐Medical Channel
Moderate to Severe:
20%
50%
Mild to Moderate:
75%
50%
Consumer
10%
90%
Electronic
Channel
Aided population
Unaided population
Use scaling questions as part of motivational interviewing techniques
The Gentle Nudge
On a scale of 1 to 10 , 1 being the worst and 10 being the best, how would you rate your overall hearing ability?
Bucket 1: 8‐10 rating
This is 15 % of the patient population, and you should provide educational information
1
2
3
4
5
6
7
8
Worst
9
10
Best
• Add them to a patient recall list
• Direct them to your website for hearing loss awareness information
• Fit them with a PSAP or “hearing app”
Bucket 3: 1‐5 Rating
This is 50 % of the patient population.
1
Worst
2
3
4
5
6
7
8
9
10
Best
Move more quickly into the hearing aid selection process
• Performance
• Lifestyle
• Cosmetics
• Cost
Bucket 2: 6‐7 rating
This is 33 % of the patient population.
1
2
3
4
5
6
7
8
9
Worst
10
Best
Need more information prior to making a decision:
• Offer at‐home test drive hearing aids Second Scaling Question
On a scale of 1 to 10 (ten being ready today and 1 being not ready at all), how ready are you to take action on a solution?
Service Innovation Matrix
On a scale of 1 to 10 , 1 being the worst and 10 being the best, how ready are you to accept my recommendation for help?
Creating Demand for Services
Preminger, 2014
Declaration #3
Conducting a bloodless revolution requires us to think and act like an economist with an MBA degree…..
…or pay someone to do this work for you.
What is a price?
In healthcare prices are typically not transparent
Prices are Signals to the Market
Prices are Signals to the Market, Wrapped in an Incentive
Price Maxim #1
The market solves the “lack of information problem” by collapsing all relevant into the price.
Tyler Cowen & Alex Taborrek, Economics Dept
George Mason U.
Marginal Revolution blog
When the device is the center of our universe….
Customers purchase from the place with the best deal because it is easy to comparison shop a tangible product.
Price Maxim #2
The market solves the “incentive to buy ” problem
because consumers will purchase a product or service only if its value is greater than the price.
Pine & Gilmore, 2012
Progression of Economic Value
Experience
Service
Good
Commodity
Progression of Economic Value
Emotional Logical Experience
Service
Good
Commodity
How to accomplish this?
INDIVIDUALISE
THERAPEUTIC
RELATIONSHIP
INFORM
Grenness, et al 2014
INVOLVE
Wrap a Memorable Experience Around a Therapeutic Relationship Signal to Market: Itemized Bundling
5‐step process
Objective: Inform customers about your prices and their associated value, so they have an incentive to buy from you.
Step 1: Develop Your Strategy
What do customers value?
Performance/ Innovation
Price
Service
The Discipline of Market Leaders
Innovation
Operational Excellence
Wiersma and Treacy, 1997
Customer
Intimacy
Step 2: Do the math
A. Optimize COG/Margins  High Performance
 Mid‐level Performance
 Basic Performance
B. Calculate your cost per hour
Step 3: Determine Your Minimal Service Offerings
Define it and Defend it!
 Professional Time & Expertise
 Auditory/”Brain Training” Exercises
 Personalized Fitting Fee: Verification & Validation
Step 4 List all value‐added extras  Auditory Training
 Support Groups
 Brain Training Exercises
 Wireless Accessories
 Dry & Store Global II unit
 Additional Warranty
 Comprehensive Aural Rehab Services
 Additional Batteries
 Unlimited Service Visits Step 5: Establish Service Packages Level 3 Premium Rehab Plan (service package)





2 Devices – high performance technology
3 year warranty and supply of batteries
3 year comprehensive care plan – unlimited office visits
2 wireless accessories
Dry and Store unit $_________
Level 2 Mid‐level Rehab Plan (service package)





2 Devices – mid‐level performance technology
2 year warranty and supply of batteries
2 year comprehensive care plan – unlimited office visits
1 wireless accessories
Dry and Store unit
$_________
Level 1 Economy Rehab Plan (service package)
 2 hearing aids – basic performance technology
 1 year warranty  1 year comprehensive care plan
$
Itemized Bundling (another example)
Single Unit Hearing Aid : $______
‐ 60 days of service
 Assessment and Fitting Fee: $____
Annual Service Package: $______
Or
Single Unit Hearing Aid: $_____
‐ 60 days of service
‐ Assessment and Fitting Fee
Pay per Visit: $20 ‐ $100