A survey of marketing practices by family practice residency programs.

With the increasing emphasis on ambulatory medical education, particularly in the primary care disciplines, residency training programs and academic medical centers will need to develop, maintain, or expand ambulatory care facilities. Patients needed for teaching will need to be recruited, and particular patient types may be required for different training programs. Family practice residency programs have always required an ambulatory experience in a model office setting. A survey of family practice residency programs was performed to determine what residency programs were doing to attract and hold patients for teaching.

There are several reasons residency programs would want to market their ambulatory practices. Resident practices may need additional numbers to meet ACGME standards for the number of patient visits, or particular populations of patients may be sought to meet curriculum requirements (e.g., geriatrics and obstetrics). In a time of potential changes in resident funding, programs may be looking to increase patient care revenue.

Family practice residency program model offices share many things in common with other types of family practice offices but also differ in several ways. In particular, residents remain in the practice for only three years and have rotational responsibilities that take residents away from the office setting, making them less available to their patients. Strategies that work in attracting and holding patients in a private office setting may not be the most effective ones in the academic ambulatory care center.

Methods

A review of the literature on marketing office practices was performed, and a survey instrument was developed by the authors. The survey was pilot tested with a group of residency directors at a regional family practice meeting and further modified using the method outlined by Dillman.[1] The final survey was mailed to all nonmilitary residency directors listed in the 1992 Directory of Family Practice Residency Programs.[2] Military programs were excluded because that practice environment is potentially different from that experienced by most civilian programs with a fee-for-service component. A second mailing was sent to a randomly selected subgroup of nonresponders. Because the research was descriptive in nature, it was felt that further subsampling of nonresponders would not significantly add to the information already obtained.

Results

A total of 361 questionnaires were sent to program directors and 137 were returned, for an initial response rate of 38 percent. Sixty-five questionnaires were sent to randomly selected nonresponders and 15 were returned for g response rate of 23 percent The total response rate for both mailings was 42.1 percent. Of responders to the survey, 17 (11.6 percent) were university hospital programs, 14 (9.7 percent) were community hospital/university-administered programs, 110 (74.8 percent) were community hospital/university-affiliated programs, and 6 (4.1 percent) were community hospital programs with no affiliations (figure 1, right). The distribution of the, responders included 2 programs in communities less than 25,000, 25 in communities of 25,000 to 50,000, 37 in communities of 50,000 to 100,000, 14 in communities of 100,000 to 150,000, and 65 in communities of more than 150,000 (figure 2, right). Of those responding, 142 out of 153 (92.8 percent) indicated that they complied with the required number of patient visits per hour in the first year as prescribed by the Special Requirements for Residency Training in Family Practice.[3] The second-year requirements for patient visits were met by 137 programs (89.5 percent of those responding to this question), and 120 indicated that they met standard for third-year residents (78 percent of those responding to the question). The average number 6f visits per hour for first-year residents was 1.81 (maximum 3, minimum 0). The average number of visits per hour in the second year was 2.84 (maximum 4, minimum 1.7). The average number of visits per hour for third-year residents was 3.54 (maximum 5, minimum 2). (See figure 3, right.) Eighty-two (54 percent gent) of programs responded that they were seeking new patients for resident practices.

Marketing strategies reported by those completing the survey are outlined in table 1, page 27. Of those sites reporting their clinic hours, 43 (28 percent) reported night hours to 7 p.m. or later at least one time per week. Thirty-nine (26 percent) of the programs reported Saturday hours and three (2 percent) reported Sunday hours. Community size as a predictor of extended hours or weekend hours was tested using Chi-square analysis, and no correlation was found between the size of the community and the likelihood of evening or weekend hours (Chi-square 0.003, P=0.954 and Chi-square 0.105, P=0.746, respectfully). When the payer mix was examined, programs with 50 percent or more private insurance/HMO were more likely to have weekend hours but no more likely to have extended hours during the week (Chi-square 12.637, P < 0.001 and Chi-square 1.773, P= 0.183, respectfully).

Patient satisfaction surveys were reported by 130 (85 percent), with 86 (56 percent) performing them on a periodic basis. Those performing the surveys periodically do them an average of 2.21 times per ye (maximum 12, minimum 0). Thirty-eight sites (25 percent) reported having a marketing plan. Those involved in formulating the plan included hospital marketing (22, 58 percent), hospital administrator (14, 37 percent), residency faculty (29, 76 percent), residents (16, 42 percent), R.A.P. consultant (1, 3 percent), and business consultant (5, 14 percent).

Nine programs (6 percent) reported restricting residents from taking patients from the practice upon graduation, while two programs reported that they planned to implement this policy in the future. Five programs reported encouraging residents to take their patients when they complete the program. Twenty programs reported complaints from medical staff about competition. On a Likert scale of 1 to 5, with 1 being the most serious, medical staff concerns about competition were rated by respondents at a mean of 3.7. When respondents were asked whether their institutions encouraged them to compete (using a Likert scale where I indicated strong agreement and 5 indicated none at all), the mean response was 3.46.

Respondents were asked to list their three most effective and three least effective marketing strategies. The distribution of responses is outlined in table 2, page 28. The strategies, most frequently reported as most effective include HMO membership (49 responses), emergency department referrals (36 responses), patient referrals (35 responses), hospital-based referrals (27 responses), and community presentations (16 responses). The strategies most frequently reported as least effective include health fairs (21 responses), Yellow Pages listings (15 responses), performing sports physicals (14 responses), use of resident business cards (10 responses), and advertising (10 responses).

Table 2.

              Three Most/Least effective Strategies

Strategy                        Most Effective        Least Effective

HMO                                 49                       3
Emergency dept. referral            36                       5
Patient referral                    35
Hospital-based referral            27                       3
Community presentations             16                       1
Extended hours                      13                       3
Hospital staff referral             12                       2
Medical staff referral              12                       8
Medicaid listing                    10
Yellow Pages listing                 8                       15
Resident business cards              6                       10
Medicare listing                     5                        3
Newsletter                           5                        8
Student health                       4
Health fairs                         4                       21
Urgent care referrals                3                        2
Practice brochure                    3                        9
Occupational health                  2                        1
Resident contacts                    2
Sports physical exams                2                       14
Advertising                          2                       10
Price                                2
Insurance listing                    1
Team doctor                          1                        8
Worker's compensation                1                        5
patient education                    1                        2
Letter                               1
School programs                                               9
Newcomers guide                                               2
Community press                                               5
Handouts                                                      1

Discussion

Ambulatory teaching practices may perform patient marketing for a number of reasons. They may be looking for an increase in patient numbers to make accreditation standards, to increase revenues, or to increase patient numbers in particular categories. Several respondents indicated that many of the reported activities were not done to attract patients but were felt to represent elements of good patient care. Fried and Stine[4] point out that marketing is not synonymous with advertising but rather is a process of identifying patient needs and providing services to meet them. In the development of a marketing program, the internal environment of the practice must first be evaluated. In particular, it is important to identify the strengths and weaknesses of the family practice center as well as the specific goals to be obtained.[4,5]

The external environment must also be evaluated. In particular, demographics of the target population must be determined and unmet needs of the patients identified. Patient surveys will demonstrate how the practice is seen by the patient and can identify why patients chose the practice. This information can help in evaluating present marketing strategies and in formulating future marketing plans. In programs looking for a particular patient type, patient surveys may identify which strategies may work and which may not. In a study performed in a psychiatric practice, it was found that patients that the practice attracted with its Yellow Pages advertisement were less satisfied with their clinical outcomes than were patients that came to the practice from other sources.[6]

Satisfied patients are an important source of referrals to the family practice center. This was identified as an important element in marketing the resident practices by 35 (23 percent) of the respondents. It has been suggested that satisfied patients will tell on average of four other people; dissatisfied patients will tell nine other people about their experiences.[7] Suggestions for encouraging patient referral include leaving a place on the bill for patients to refer others for the practice to contact. While business cards were not judged to be particularly useful by the respondents (table 1), they are inexpensive and require little effort. An often untapped source of patient referrals is local pharmacists.[8]

Table 1.

            Marketing Strategies Reported

Marketing Strategies                         Number

Emergency Dept Referrals.....................108 (71%)
HMO membership................................96 (63%)
Resident Business Cards.......................83 (54%)
Yellow pages Listings.........................73 (48%)
Hospital Staff Referrals......................68 (44%)
Medicare Listing..............................55 (36%)
Medicaid Listing..............................50 (33%)
Night Hours...................................43 (28%)
Patient Education Materials...................40 (26%)
Urgent Care Center Referrals..................34 (22%)
Practice Brochure.............................30 (20%)
Student Health Programs.......................28 (19%)
Community Volunteer Work......................12 (8%)
TV Ads.........................................2 (1%)
Hospital Referrals...........................102 (67%)
Medical Staff Referrals.......................93 (61%)
Patient Newsletters...........................82 (54%)
Sports Physicals.............................73 (48%)
School Programs..............................61 (40%)
Community Presentations......................51 (33%)
Health Fairs.................................49 (32%)
Team Physician...............................42 (27%)
Weekend Hours................................39 (26%)
Counseling Services..........................30 (20%)
Workman's Compensation.......................29 (19%)
Occupational Health Programs.................24 (16%)
Newspaper Ads................................10 (7%)
Radio Ads.....................................1 (1%)

Patient education activities can improve the efficiency and effectiveness of resident practices and help to promote the family practice center. Among the media that can be used are print material, audiotapes, videotapes, and large and small group presentations. In this study, practice newsletters were judged not to be helpful by eight of the responders and to be helpful by four. A newsletter's value depends on the target population. The estimated cost of a two-page newsletter is $400-$600 for 2,000 copies.[9] Community presentations can increase practice visibility, assist in meeting community medicine curricular requirements, and reach a large patient base at low cost.

While advertising is a small part of a total marketing plan, more physician offices are using print and broadcast advertisements. In the study, 10 programs reported using newspaper advertisements, 1 program used radio advertisements, and 2 programs advertised on television. For those respondents rating the effectiveness of advertising, 2 rated it most effective and 10 rated it least effective. As noted above, this may in part relate to the desired target population. In a study done at a university family practice center, an advertising flier was distributed door to door to a target population. The community was then surveyed to determine awareness of the center six months after the mailings. Twenty-seven percent of those surveyed remembered the flier; 48 percent of those surveyed claimed to have used the center since the mailing, compared to 19 percent before the mailing.[10]

Extended hours may be an important marketing tool in some settings. Thirteen respondents rated extended hours as one of the three most useful strategies, while three programs rated it as least useful. While it was found that programs with weekend hours had a higher percentage of private insurance/ HMO patients, it is not clear whether this was a result or the cause of the patient mix seen.

Conclusions

This study reflects the subjective interpretation of the respondent to the usefulness of different marketing strategies. What worked in one environment may not work in another. While some programs listed an activity as most useful, others listed it as least useful. This disparity may be the result of bias on the part of the responder, differences in the quality of the activity, or differences in the practice environment among programs. Programs interested in marketing should incorporate specific goals and objectives into a marketing plan and use it as a dynamic document to measure their progress and assess their strategies.

References

[1.] Diliman, D: Mail and Telephone Surveys. New York, N.Y.: John Wiley & Sons, 1978. [2.] 1992 Directory of Family Practice Residency Programs Kansas City, Mo.: American Academy of Family Practice, 1992. [3.] Directory of Graduate Medical Education Programs 1993-1994, Sections I and II. Chicago, Ill.: American Medical Association, 1993. [4.] Fried, R., and Stine, C. "Developing a Marketing Plan for a Residency Practice." Family Medicine 17(6):251-3, Nov.-Dec. 1985. [5.] Beck, L., and Salmon, P. "A Checklist of Practice Marketing Ideas." North Carolina Journal of Medicine 46(6):345-7, June 1985. [6.] Solomon, R. "Using a Patient Survey for Marketing a Professional Health Practice." Journal of Health Care Management 10(2):47-53, June 1990. [7.] Beaton, G. "Marketing in Medical Practice. Part Four - the Marketing Tools." Australian Family Physician 17(10):887-8, Oct. 1988. [8.] Borshoff, M. "Effective Communication Tools for Marketing Your Practice." Indiana Medicine, June 1989, pp. 466-9. [9.] Van Doren, D., and Blank, K. "Patient Education: A Potential Marketing Tool for the Private Physician." Journal of Health Care Marketing 12(1):71-7, March 1992. [10.] Ricer, R., and others. "Evaluation of an Advertising Method for a University Family Practice Center." Family Medicine 21(2):144-6, March-April 1989.