2019 Klein & Partners National Omnibus Study Results

1. 2019 Klein & Partners National Omnibus Study Results Prepared by: Rob Klein, Founder & CEO, Klein & Partners September 2019

2. introduction

3. Introduction • Each year, Klein & Partners conducts a national online survey among consumers across a wide variety of topics (e.g., in 2018 we focused on female digital healthcare behavior). This year, we focused on a wide range of topics from call center use to chatbots to digital behavior to price shopping, plus so much more! • This year, I have invited several friends to comment on topics in this survey on which they are subject matter experts. • Kathy Divis from Greystone.Net comments on call centers • Brian Gresh from Loyal comments on ‘Chat’ • Dean Browell from Feedback comments on social media word-of-mouth influence • Feel free to use any of these charts and share with colleagues; just acknowledge Klein & Partners as the source of the data. Source: Klein & Partners’ 2019 National Consumer Omnibus Study

4. Methodology Online survey n=1,076  +/-2.6% at the 90% CL Fielded: May 17-21, 2019 National random sample of adult healthcare decision-makers

5. Demographic profile

6. What did we learn?

7. Guest commentator for this chapter is: Kathy Divis President Greystone.Net 770-407-7677 kdivis@greystone.net Call Center Use

8. Call center – Key take-aways • All health systems have a multitude of front doors (e.g., in-person, telephones, websites, virtual visits, social media, etc.) and as today’s care networks evolve in size and scope, linking those points together is a growing priority. The call center is an important cog in the wheel of communication, but all access points need to be woven together into a cohesive brand experience. • While phone calls are the current gold standard, the ground is shifting and will continue to do so as online scheduling offerings expand and population demographics change. We must begin preparing and transitioning the traditional call center into a contemporary contact center that is able to handle omni-channel communications. • And, although a strong brand reputation is an enormous asset, it won’t always compensate for poor customer service experiences. This means, healthcare must begin to put resources into true front-end customer service. • Today’s patients and potential customers want easy access (i.e., easy and timely appointment scheduling), but they also want convenience. We have to look beyond the traditional sites of care and beyond the traditional access processes. We must factor in alternative sites (i.e., urgent care, retail walk-in clinics, virtual care) and alternative communication channels (i.e., web inquiries, texting, chats, video calls, social media posts, etc.).  A contemporary call center can and should be helping in both of those areas. “I think it is a really exciting time for call centers in healthcare, and when we blend a more contemporary call center structure with the service gains that can come from the introduction of chatbots, AI, natural voice processing and other new technologies, it really should make the process easier, quicker, less expensive and free-up call center agents to work with more complicated patients. It doesn’t mean that call centers are going away, only that they will be doing more sophisticated, high value work.” --Kathy Divis

9. Experience with a hospital/system call center Reasons why consumers called Appointment schedule/change 29% Rx refill 14% 50% of consumers have called a hospital or system in the past year Talk with Dr/Nurse 13% Pre-register for test 7% Interestingly four in ten callers say they know they could have gotten their answer on the hospital/system’s website but preferred to call, especially women. Kathy Divis asks us to consider the following: “How do we convince hospital administrators (and the reluctant doctors who don’t want to relinquish control of their schedules) to get on board with online scheduling? I think quite soon offering online appointment scheduling will be ‘table stakes’ – do it, or we go to virtual care or Walgreens. So, how do we help make true online scheduling happen smoothly?” Pay a bill 5% Get test results 4% Insurance question 4% Status of a patient 3% Q1: In the past year have you called a hospital or health system for any reason? Q2: For what reason did you call the hospital or health system this most recent time?

10. Tried to complete task on website first or not Women are significantly more likely than men (43% vs. 32%) to prefer a call with a person than to go to the website. And, other research Kathy Divis has seen shows that 62% of consumers prefer to call to schedule an appointment rather than use an online service. Younger consumers as well as those with college educations and a higher income are significantly more inclined to try the website first. Not surprisingly, they were trying to pay a bill online. gSight℠ website experience research has shown that bill paying online is the number one pain point for hospital website visitors. Billing has fast become the experience touchpoint that can most greatly undo a good experience. Q3: Could you have completed this same task by going to the hospital or health system's website?

11. Experience with the call center Time is the new currency. Time is in short supply for consumers today (we all feel ‘rushed’) so keeping them on hold a long time takes away even more precious time. Q4: Overall, would you say your most recent call with a hospital or health system was…?

12. Experience with the call center “To move more people from satisfied to exceptionally satisfied, we need to streamline workflows to reduce transfers, hold times, question length, etc. That's as much an operational issue as anything and likely reflects how leanly call centers are staffed. It reminds me of what I say all the time ... administrators talk about the importance of handling calls well, but rarely support that talk with the level of resources needed, even though it is the gatekeeper to their organization. To make headway in moving the needle in this area, it will require help from operations with workflow barriers and executive leadership in understanding the role and ensuring the right staffing levels.” --Kathy Divis Women are significantly more likely to be disappointed by the call even though they prefer to call (11% vs. 2%). Q4: Overall, would you say your most recent call with a hospital or health system was…?

13. Called a nurse triage line Again, women are significantly more likely to be disappointed in the nurse triage call (14% vs. 0%). 12% Called a nurse triage line (Significantly higher among Millennials and Gen X as well as parents) “If I had to guess, they were probably disappointed with the time it took for the nurse to call them back. Most formal programs have a front end non-clinical answer and prioritize the call, enter the basic info and then a nurse calls them back unless there is a real red flag. Was the triage done by an organized nurse triage program run out of a call center with protocols and associated dispositions or did the consumer mean a call back from a doctor’s office nurse who listens to your complaints, talks to the doctor and communicates back? Two different things, but the way the question was phrased, I would say it was most likely the former, not the latter.” --Kathy Divis Q6: Next, in the past year, have you called a hospital's nurse triage line to get medical advice about a symptom or to help you reach a decision on whether to schedule an appointment or visit an urgent care or ER? Q7: Overall, would you say your experience calling the hospital's nurse triage line was...?

14. Guest commentator for this chapter is: Brian Gresh President Loyal 801-949-5957 brian@loyalhealth.com Use of chatbots

15. Chatbots – Key take-aways • It's clear from the survey that familiarity with live-chat and chatbots in the healthcare space still is relatively low as well as the utilization of these features. Healthcare consumers have traditionally had few options to connect with a health system so education and marketing of these new offerings is going to be essential for success. For those who have never used a live-chat or chatbot, there clearly is an interest in these options. • A number of factors can impact utilization of live-chat and chatbot features on a healthcare website: • Placement on the page • Number of pages on the site it is available • Whether availability is 24/7 or limited to certain hours • Overall, experience with live-chat and chatbots is generally satisfactory or better. For those users who indicated that their experience was disappointing, many indicated it was a cumbersome experience or the chatbot did not understand the question. • A poorly designed User Interface can certainly impact experience as well as the speed of the response. • Additionally, chatbots that have a limited knowledge base or lack a well developed user intent library can often deliver poor results. Chatbot training and structured data are key elements to providing an exceptional chat experience.

16. Experience with the ‘chat’ feature on a hospital or system website Mostly Gen Z and Millennials Visited a Hospital/System Website in the Past 3 Months Significantly higher among men, Gen Z and Millennials, college educated, and higher income consumers. 29% 2016 44% 2018 48% 2019 = 20% familiar and used chat feature recently. Definitely would use live chat feature – 40% Definitely would use Chatbot Feature – 28% Never Used a Chat Feature 66% Familiar Q8: Next, have you been to any healthcare provider's website in the past few months? Q9: Are you familiar with either of these two forms of 'chat' customer service on a healthcare website? Q10: During any of your recent visits, have you ever clicked on the chat customer service button to resolve a customer service issue or question? Q11: How likely would you be to use this chat feature?

17. Experience with using chat feature “The chatbot had no idea what I was asking and wasted my time giving useless information.” “Too cumbersome, rather speak on the phone!” “They did not solve my doubts a waste of time.” “They also delay to answer I feel better talking by phone and more comfortable.” Q12: How would you rate your experience with this chat feature that you used recently on a healthcare website? My recent Chat feature {RESTORE CHAT TYPE} experience on a healthcare website was... Q13: In what ways, was your {RESTORE CHAT TYPE} experience disappointing to you?

18. Virtual visits

19. Virtual visit experience 7% in 2016 More likely moms using virtual care Other Klein & Partners research has shown that if you provide an exceptional pediatric virtual visit (as well as ‘physical’ pediatric urgent care experience), you create a brand ambassador out of that mom because you have bailed her out of a tough spot. Moms often first turn to virtual visits (or urgent care centers) when their pediatrician can’t see their child immediately. Q14: Have you ever had a 'virtual doctor visit' where you talk with a physician face-to-face using a PC, tablet, or smart phone? Q15: Why have you NOT used a virtual visit for care instead of going to your doctor's office, urgent care center, or other healthcare facility? Q16: Why did you choose a virtual visit over going to your doctor's office, urgent care center, or other healthcare facility?

20. A quote in Ad Age from Rich Silverstein of Goodby, Silverstein & Partners who just won a lifetime achievement award at the Cannes Lions International Festival. He was asked how he felt about awards… “Do I want to win at Cannes? Yes. Do I want my people to win at Cannes? Yes. Do I want the clients to look good? Yes. Do I want my people to start thinking of Cannes before they think of the problem to solve? No. That’s the only thing I wish people would do is go, ‘OK, how am I going to solve the client’s problems brilliantly?’ And, when you do it brilliantly, you win at Cannes.” Online ranking and review sites

21. Total unaided awareness of online quality ranking and review sites Web MD 11% Yelp 7% Google 6% Hospital site 6% Healthgrades 2% Insurer 2% ZocDoc 1% Rate My Dr 1% Social media 1% Vitals.com 1% US News 1% None 69% Significantly higher among men, Boomers and Silent, no college, <$60k income consumers. Q18: When you think about online quality ranking and review sites for hospitals and doctors, which site comes to mind first? What other quality ranking and review sites can you think of?

22. Aided familiarity with these online healthcare quality ranking and review sites Significantly higher among  Women, Younger, Parents, College Higher socio-economics Women, Younger, Parents, $60k+ Younger, Higher socio-economics Women, Younger, Parents, College Women, Younger, Parents Higher socio-economics Women, Younger, Parents Higher socio-economics Higher socio-economics Women, Parents Q19: Next, how familiar are you with each of the following online healthcare quality ranking and review sites?

23. Trust levels Do not trust at all Trust completely Q20: How trustworthy are the following sites as a source of quality healthcare ranking and reviews? Please tell us how much you trust each using a scale of 0 to 10 where 0 means you 'do not trust them at all' and 10 means you 'trust them completely.'

24. Visited site Q21: Have you ever gone to {RESTORE SAME SITE AS IN Q20} to look at hospital or physician quality rankings or reviews to help you make a healthcare decision?

25. Familiarity, trust, and use of these online ranking/review sites Higher Affect/Higher Behavior Lower Affect/Higher Behavior Although US News is more well-known, Healthgrades is the most visited site for reviews and rankings. Visited Quality Review/Ranking Site (i.e., Behavior) The Mind Bubble Size = % familiar with that site (i.e., Cognition) Lower Affect/Lower Behavior Higher Affect/Lower Behavior Do not trust at all Trust completely Trustworthiness (i.e., Affect)

26. Where in the decision-making process do these sites come into play? X Most quality ranking/review sites are an early warning system for consumers. e.g., 41% X 13% X 43% = 2% of consumers nationally have used US News to weed out low ranked/poorly rated hospitals or doctors early on. Q22: When you think about using the {RESTORE SITE} website to help in your healthcare decision-making, where in your decision-making process do you feel this site is most useful to you?

27. Purpose of quality ranking/review site visit X Most consumers visit these quality ranking/review sites for the express purpose of confirming or refuting positive things they already heard or learned offline. In contrast, positive online reviews/ratings can’t undo or reverse negative offline word-of-mouth. Q23: Did you use the {RESTORE SITE} website primarily to...?

28. Usefulness of the information on these quality ranking/review sites X If consumers visit that quality ranking/review site, it tends to influence their decision, but that ends up being very few consumers. Q24: Was the information on the {RESTORE SITE} website useful to you in your healthcare decision? Would you say...?

29. Did experience on the quality ranking/review site match expectations? X None of these sites disappoint visitors. Q25: Did your experiences with the healthcare provider you chose match up to the expectations the {RESTORE SITE} website created in your mind?

30. What medical conditions do consumers check online quality ranking/review sites for? * ^ ^ * ^ + * ^ + * = significantly higher among women ^ = significantly higher among younger consumers + = significantly higher among parents Can’t remember – 10% Q26: What medical condition(s) did you check out any online ranking and review sites for?

31. Medical conditions online quality ranking/review sites are useful for *e.g., 43% x 35% x 22% = 3% of all consumers Q27: Are online healthcare quality ranking and review sites useful across all medical conditions, or does it depend on the condition? Q28: What medical situations would you be most likely to search out online rankings or reviews for?

32. How high of a ranking is needed? And how low can you go? 13 or higher to influence decision whether to choose hospital of not. But, 42% say rankings do not influence their decision where to go. Bottom Line: You really need to be top-10 ❶ ❷ ❸ ❹ ❺ ❻ ❼ ❽ ❾ ❿ ⓫ ⓬ ⓭ ⓮ ⓯ ⓰ ⓱ ⓲ ⓳ ⓴ 11 or lower would take that hospital out of consideration. But, 45% say rankings do not influence where they would NOT go. For these next few questions, let’s focus on one of the online quality ranking and review sites from earlier in the survey – US News & World Report. Assume it is a medical situation where you felt seeking out online rankings and/or reviews might be helpful in your decision-making. Q29: How high of a US News & World Report ranking does a hospital have to achieve for that ranking to influence your decision whether to choose that hospital or not? Q30: And, how low of a US News & World Report ranking would take that hospital out of your consideration set?

33. Hospital decision-making

34. Consumer trade-offs in healthcare decision-making Service line strategy under a strong and consistent brand strategy umbrella! (See chart on next page.) Regardless of the seriousness of the medical situation, when it comes to making trade-offs, consumers look for reputation, physician direction, and a good prior experience. Q31: We would like to understand what factors are most important to you in choosing a hospital for… *Note: These are weights (not means) based on a trade-off exercise. They are based off of the Max-Diff trade-off exercise.

35. Brand  service line communication strategy Klein & Partners ad recall research is showing that ‘brand linkage’ is very low for healthcare advertising although ad recall is high. We need to do a better job making the brand the ‘star’ in the advertising. Healthcare is a ‘passive’ consumer category (much like home and auto insurance) and that means the brand must be clearly identified right up front and the message has to be catchy, simple, and consistently delivered over time (e.g., Geico is widely recognized as having the most remembered and effective ads in a passive category). How you sell it Unifying Umbrella Brand Strategy What you sell Service Line Advertising Service Line Advertising Service Line Advertising A brand strategy unifies your service line messages – each service line message becomes a ‘chapter’ in a single book (i.e., same theme and tone across all the messages that tie them back to the brand).

36. What would consumers do first when looking for a new physician?

37. Physician influence – they are the ‘5th P’ in the 4Ps of Marketing Millennials (12%) Q32: Next, suppose your primary care physician told you that you needed to see a specialist for a particular condition, what is the first thing you would do?

38. Looking for a new PCP Other Klein & Partners research has shown that consumers typically go through the following steps to find a new PCP: Check their insurer’s physician directory Find doctors that are close to them See who is taking new patients Ask around for recommendations (i.e., W-O-M) (includes online searching too) Q33: Suppose you just moved to a new area and needed to find a primary care physician, what is the first thing you would do?

39. Physician ratings and reviews

40. Sharing physician experiences online Significantly higher among Gen X, parents, and those with a higher socio-economic status. 17% Shared physician experiences online Shared their experiences on: The doctor’s/system’s website – 38% Ind consumer-driven review site – 33% Both – 11% Q43: Have you ever gone online and shared your experiences (good or bad) about a physician you recently visited (i.e., rated and/or wrote a review online on the doctor or hospital's website, on a social network or consumer review site, etc.)? Q44: Did you post your rating and/or review on the doctor's or health system's website or did you post your rating and/or review on a consumer-driven review site such as Angie's List, Yelp, Vitals, etc?

41. Online physician ratings and reviews Importance of Online Physician Ratings/Reviews Purpose of Using Online Ratings/Reviews Minimum Stars Rating to be Comfortable Choosing Physician 62% have looked at physician rating/review sites to… Confirm positive things heard from others – 23% Confirm negative things heard from others – 9% See if any negative things to counter positive things heard – 37% See if any positive things to counter negative things heard – 9% Not sure 22% Most important – 5% One of a few very important – 20% Other factors are more important – 32% Tie-breaker if all else equal – 14% Not important – 20% Not sure – 9% Significantly higher among Gen Z and Millennials (45%) 3.84+ Stars Q45: If you were looking at online 'Star' ratings of different physicians, on a 1 to 5 Star rating scale, what is the minimum stars rating that you would want any doctor to have for you to feel comfortable choosing them? Q46: Where do online physician ratings and reviews fall in importance in choosing a physician? Q47: Do you typically use online physician ratings and/or reviews to...?

42. Guest commentator for this chapter is: Dean Browell Principal Feedback 804-893-3437 dean@discoverfeedback.com Digital healthcare dialogues

43. Digital healthcare dialogues – Key take-aways • Almost half of patients are sharing experiences digitally at a frequent enough pace that they aren’t even sure where they shared them. And, those patients are informing others who researched a medical issue and posted in a forum, looked for specific ratings and reviews, plumbed their own network for advice, looked for it quietly (i.e., reading others’ stories), or asked questions. • This confirms that patients are both “lurkers” and “participants” online, not one or the other. Behavior may change based on when in the decision path they are searching for answers, personal medical context, or even by channel. Consider that asking a question in front of friends and family on Facebook is very different than asking anonymously on a message board for a very specific condition and only filled by those diagnosed (or caregivers). Communities can range from those they have been a part of for years, such as local Mom groups, or ones they have only recently joined after a diagnosis. • When asked elsewhere in the study, 17% said they shared their experiences on a consumer review site - and yet when asked to articulate which or how, the number plummeted to 4%. While this may seem contradictory, what we may be seeing is the ubiquity of social sharing displaying as more second nature - and how asking can make it tricky for recall. This may indicate the difference between simply leaving a star rating, hitting the “recommend” button on Facebook, leaving a review on Yelp or Google, or posting a full testimonial on a message board for their condition. • What’s not as tricky? The resounding “no” that comes with interacting with a hospital on their official social media, which declines even more sharply as age goes up. Bringing it all together suggests a clear red flag: If you’re only looking at how people talk on your official channels you are missing what patients are saying and how they are informing prospective patients. This is a comfortable trap to fall into, especially now that our social channels have been around for several years and likely through multiple handlers internally: we get comfortable with our content and, more importantly, our engagement. Keep in mind that those who participate on your owned social channels (outside of reviews) are likely only a subset of your total audience and may not be representative. Don’t rest on your laurels and keep in mind this resounding “no” in that most patients don’t really want to interact.

44. Digital healthcare dialogues – Key take-aways • Among those who share their healthcare experiences digitally, nearly a third share only on their own pages indicating possible concerns over privacy if they share on a broader scale and/or just wanting to help those in their own network or circle. Conversely, they may be sharing but doing so more anonymously. In other studies we have seen an incredible amount of information shared about treatment (including procedures, physicians, geography) but keenly without personal identifiers such as last names. • While consumers may see your official channels as a place to gather information, this isn’t where they expect to find the unvarnished experiences of peers that they crave before making decisions (i.e., 82% of consumers do not interact with or follow any healthcare organizations on social media). • It is worth exploring this further with some difficult questions about our own social media channels: why would someone seek out certain channels? The reasons may differ based on what else they get from the channel. For example, on Facebook they might see what you have posted, but it’s likely they are actually on your Facebook Page to see what reviews have been left by peers, not your post about a national ranking. A few worthwhile questions: • Do you allow reviews on your Facebook Page? • What service lines are present in your reviews? Do particular ones dominate? • Take a service line as an example: how many reviews would consumers have to look through before they find one of that service line? • What’s more, consumers want a relationship, and before they make their choice they seek relationships with those who have sought and experienced solutions (rather than the institutions with the solutions). They might seek these quietly or very loudly, in communities they already visit every day or the new ones they found after diagnosis. Digital word-of-mouth IS the new word-of-mouth.

45. Digital healthcare behaviors Talked about my medical experience through my network: 7% Looked for online reviews/ratings about a hospital or doctor: 22% Researched medical issue; posted question on a forum: 22% Read healthcare stories from others in my network: 10% Wrote a Dr/hospital review/rating online: 4% Asked my network for opinion: 4% Wrote Facebook/ Twitter post: 2% None of these health-related digital behaviors: 55% Q38: Which of the following, if any, have you done in the past year?

46. Where online consumers have shared medical experiences – among the 45% that have shared online 31% 15% Doctor website 10% Hospital website 6% Condition forum 6% 5% 5% 5% Patient support group 5% 5% 2% Wikipedia 2% 34% Not Sure Q38a: Where online have you shared your medical experiences?

47. Where consumers share healthcare experiences – among the 45% that have shared online I share my health experiences: Only on my pages: 30% Only on others’ pages: 9% Mix of pages: 20% Not sure: 41% Q39: Do you tend to share your healthcare experiences on your own social channels or others' channels?

48. Interact with or follow hospital/system on social media (total) 82% None of these 10% 5% 2% 3% 3% 3% 1% Wikipedia 2% 2% Which means only 18% of adults interact digitally with a hospital/system. Interacting with a hospital/system declines significantly with age MillennialsGen XBoomersSilent 38% 22% 10% 3% Q40: Have you interacted with or do you follow a local hospital or health system through any of the following social media sites?

49. Healthcare attitudes

50. Attitudes towards healthcare decisions More to come on this. I’m working on creating segments from these questions… stay tuned! Q41: Next, for each of the following statements, how much do you agree or disagree?