Are you on Angie's list--yet?

In this article ...

Meet Angie Hicks, founder of Angie's List that rates plumbers, painters and, yes, doctors.

Quick! What do plumbers, painters, movers and doctors have in common?

Give up?

They're all service providers, of course.

That's why they all rub shoulders in the Angie's List underwriting announcement on National Public Radio, which explains that Angie's List provides "first-hand consumer reviews on local service like plumbers, painters, movers and now doctors. Details at Angieslist.com."

Are plumbers, painters and movers happy about this? Maybe. Are doctors thrilled? Probably not so much. But Angie's List is all about helping consumers find high quality contractors and service companies, and as of April 2008, that includes health care providers.

Founder and chief marketing officer Angie Hicks has no problem adding doctors to plumbers, painters, movers and more than 300 other categories of service providers.

"The medical industry is no different from other industries in that consumers need independent information from other consumers that they can make decisions on," says Hicks.

This "ask your neighbor" business model caught on in a big way with the 650,000 consumers in 124 cities across the country who now subscribe to Angie's List. "Putting reliable, unbiased information on local companies at the fingertips of consumers in major cities across the country" is how the company describes its mission.

Fast growth

In 1995, Hicks started the business by going door to door in Columbus, Ohio, collecting ratings on local services from friends and neighbors. Today, Inc. magazine ranks Angie's List among the fastest growing privately held companies in the U.S., with $24 million in 2007 revenues and a respectable 100 percent annual growth rate.

The company has been written up in numerous local and national publications, including The Washington Post, The New York Times, Kiplinger's Personal Finance and The Wall Street Journal. A recent $35 million infusion of venture capital "allows us to grow our member base faster and to invest more dollars in our medical offering," Hicks says. It was members, Hicks adds, who kept asking Angie's List to add health care providers.

Angie's List now includes dozens of health care provider categories, from "cardiology general" to "urology." Consumer members describe the work done, the approximate cost and whether they would "Hire Again." They rate price, quality, responsiveness, punctuality and professionalism on an A through F scale. An "Overall" letter grade is calculated exactly like a grade point average.

Members have unlimited space to describe their experience in their own words under "Member Comments" and may also choose to complete a more exhaustive battery of "Additional Questions Answered when completing this report."

Headquarters is in downtown Indianapolis, a little closer to home for the 35-year old Hicks, who graduated from DePauw University in Greencastle, Indiana, with a BS in economics before getting her MBA at Harvard.

The corporate campus is a 13-acre swath of the old Holy Cross neighborhood in the heart of Indianapolis, complete with an eclectic collection of 11 historic nineteenth century business, light industrial and residential buildings interspersed with mature trees and shrubs, and a monster parking lot.

There's the Yellow House, a two-story house with a front porch and a lawn, headquarters for Member Services. The Blue House is home base for the Angie's List magazine staff. Over there is a concrete block box of a building that used to be campaign headquarters when "My Man Mitch" Daniels made his successful run for governor in 2004.

The daycare center is housed in another well-preserved residence on the other side of the parking lot, and so is the employee health club presided over by a personal trainer.

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On a recent visit, the entire Angie's List C-suite team, including Hicks, sat in adjoining cubicles, along with a score of staffers, in a nondescript one-story concrete block structure that used to be a tile factory. The inbound call center is a charming 1896 fire station on busy Washington Street, complete with fire engine in the lobby. Ninety percent of Angie's List members use the angieslist.com Web site, but 10 percent still like to call.

The campus teems with Angie's List staffers walking purposefully from one building to another, paperwork in hand. Coming to the top of a wooden staircase in one of these buildings usually means entering a quiet space with high ceilings, populated by youngish staffers working on computers. Look out one of the tall windows and you might see a picnic table with umbrella and chairs on the flat roof of a porte-cochere.

Hicks clearly relishes this low-key, high-touch corporate culture, and the Gen-Xers and Millennials who work at Angie's List thrive on it. The implicit message seems to be 'We're not about corporate bling."

This is, after all, the Midwest, and Hoosiers don't like to put on airs. What Angie's List is about may be best distilled on a laser-printed sheet of 8 1/2 x 11 on a wall that reads "It's not how big you are. It's how smart you are."

Angie joins the fray

Angie's List may be the 800-pound gorilla in the quest for better plumbers, painters and movers, but it's actually late to the game when it comes to health care providers. Long Beach, California-based health care economist Ruth Given, PhD, recently completed a detailed survey of health care Internet initiatives that provide user-generated content. She lists 34 in her report, including the recently launched WellPoint-Zagat collaboration.

The reasons for this intense interest are the same ones that convinced Angie Hicks to add physicians, hospitals, dentists and health insurance companies to her other service providers.

"It's a combination of three factors," says Paul Keckley, PhD, executive director of the Deloitte Center for Health Solutions in Washington, DC. "First, 24 million Americans now own individual insurance policies with high deductibles, and the number of people purchasing these policies is increasing dramatically.

"Second, the system is doing a better job of communicating these types of provider data in ways that people can understand. Third, a significant understanding is now emerging among consumers that there's wide variation in how doctors practice."

In other words, consumers are paying more attention to their health care costs because they're paying a bigger share and more sites like Angie's List are doing a better job of presenting important information about health care and health care providers.

If all this seems like an annoying intrusion by lay people into areas in which they have no expertise, it's really no different than what American consumers do when they shop for cars, digital cameras, washing machines, plumbers, painters and movers. Except now they want to be smart buyers of services that will help them when they're sick.

Keckley's findings come from the 2008 Survey of Health Care Consumers, (1) a survey of more than 3,000 Americans between the ages of 18 and 75 conducted by the Deloitte Center for Health Solutions.

Think of this as informed health care consumerism or "guided self-care management," as the Deloitte survey refers to it. "Consumers want physicians to help them make judgments about their health and health care," Keckley explains. "That is the primary trusted source, but increasingly they look to sources other than the doctor."

Those other sources include Web-based communities (like TheHealthCareBlog.com, Angie'sList.com or diabetesmine.com) and health plans that play an increasingly important role in directing consumers to their treatment option, to providers that practice evidence-based medicine and to pricing information.

"This triangulation of knowledge is not a world that most physicians live in today," Keckley adds. "They like a linear model. They like to be the filtering mechanism, and the fact is, they are decreasingly that."

All this does not apply uniformly to all consumers. Survey data found that respondents fell into six discrete segments ranging from "content and compliant" consumers who accept the status quo to "out and about" health care shoppers who tend to be more independent.

None of this is news to Jim Conway, senior vice president at the Institute for Healthcare Improvement (IHI) in Cambridge, Massachusetts. IHI is also a major stakeholder in the state's widely publicized health care reform experiment.

After 42 years as an executive, first at the Children's Hospital in Boston and then as executive vice president and chief operating officer at the Dana-Farber Cancer Institute, Conway understands the largely untapped potential of consumers in health care.

"The only way we will be able to provide everybody access without going bankrupt is by driving the harm, waste and inefficiency out of the health care system," Conway asserts. "In Massachusetts, we believe that a way to do this is by actively engaging consumers as participants in their care."

According to Conway, nationwide focus groups reveal that consumers want to know a provider organization's infection rate, its mortality rate, and other consumers' experience with a doctor or hospital.

When the CMS Hospital Compare (2) site added consumer-generated content in 2008, the number of hits spiked. Conway believes that's because "consumers respect the voice of other consumers."

"At the end of the day, the only people who really understand the experience of care are the people who receive it," Conway says. "You only think you know how the system works. You don't know the experience of care, and while you know your piece, you don't know how the various pieces do or don't fit together. Until you build the health care system around the patient, nothing else is going to be possible."

Many shortcomings

Jonathan Goble, MHA, FACHE, confirms that the Goble family is on the Angie's List member roster. He's even checked out the site to see how the hospital he runs is being rated. But he's not convinced that consumers choose their hospital based on consumer ratings in Angie's List.

"If they did, people would pay more attention to it," says Goble, president and chief executive officer of Clarian North Medical Center. "I think it allows an unsatisfied consumer to voice their opinion."

CMS's Hospital Compare Web site gets a more enthusiastic response from Goble, and not just because Clarian North Medical Center would lose two percent of its Medicare reimbursement if it didn't submit its data to CMS for publication on the site.

"You've got a scientific database that people can draw conclusions from," Goble points out, referring to the Hospital Compare site. "That makes a lot of sense to me."

Organized medicine isn't keen about Web sites that rate health care providers, either. In her "President's Page" in the Indianapolis Medical Society's July 2008 IMS Bulletin, Heidi M. Dunniway, MD, takes on Angie's List and asks, "How do you respond publicly, especially to a negative report or specific complaints, without violating HIPPA [sic]?"

The answer is that you don't, but not because of HIPAA, opines James B. Hogan, a health care lawyer with Hall, Render, Killian, Heath & Lyman in Indianapolis.

"If the case went poorly, the patient who submitted this negative rating to Angie's List may be preparing to file a malpractice action, and any response from the physician is likely to be used later," Hogan cautions. "If a physician called me and said, 'I really want to respond to this,' I would say, 'Don't.'"

Better to contact the patient personally, express regret about his or her dissatisfaction and suggest a face-to-face meeting, Hogan advises.

AMA president Nancy H. Nielsen, MD, also endorses better communication between patient and physician. In a prepared statement entitled "AMA Response to Online Opinion Forums of Physicians," Nielsen encourages "all physicians to solicit feedback from patients to determine how to best meet their needs and increase the quality of care. Patients shouldn't hesitate to talk to their physicians about any concerns or questions they may have."

Nielsen goes on to note that "public Web forums have many shortcomings." For example, consumers may express dissatisfaction in these forums because they didn't receive a prescription or service that was denied or delayed by their insurance company or because they wanted a medication that wasn't medically necessary.

The hospitality business

Michael Roizen, MD, chief wellness officer at the Cleveland Clinic has actually had patients who reported him to state regulators because he wouldn't prescribe them the drugs they wanted.

"One person like that can create a feeling of distrust and cause a fairly significant bias in the ratings on sites like Angie's List," says Roizen, co-author with cardiothoracic surgeon Mehmet Oz, MD, of several books, including You: The Smart Patient. An Insider's Handbook for Getting the Best Treatment.

Roizen's mission as chief wellness officer includes radically improving the health of all patients, making preventive care a priority, and lowering the spiritual, physical and economic costs of illness.

The Wellness Institute Roizen directs is responsible for employee wellness, access, a disease reversal program, Web-based coaching programs, alternative medicine, spirituality, and employee wellness programs that are marketed to other organizations.

At the Cleveland Clinic, technical proficiency is no longer good enough. Roizen tells the story of his own parents who told him that they considered his father's flawless knee reconstruction "lousy care" because the coffee was cold, the food was bad and the nurses talked loudly outside the room.

"I decided, okay, we're going to have to change," Roizen recalls. "We're going to have to get the coffee hot, we're going to have to get the food to be not only healthy but to taste great, and we're going to have to make sure that our nurses, in addition to giving superb care, understand that we're in the hospitality business."

Hospitality business notwithstanding, Roizen is quite sanguine about what he calls health care consumerism.

"The push toward consumerism in medicine will, I believe, continue," Roizen predicts. "We should embrace it and learn how to educate our physicians so that the patient experience as well as the patient care is unequaled." Roizen and the Cleveland Clinic are not unique in their approach. Martin Hickey, MD, CPE, FACPE, FACP, is president and chief executive officer of Alegent Health Clinic, a multispecialty group practice in Omaha, Nebraska.

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The regional Alegent Health system, already ranked near the top nationally in patient satisfaction and quality, surpassing Mayo Clinic according to the Gallup Health Care Practice, is implementing open access [sometimes referred to as advanced access] scheduling to enable customers to make appointments on the Alegent Web site.

Scientifically validated internal systems will continue to monitor quality and satisfaction, Hickey says, but allows that "there's a lot to be learned qualitatively from the outside, and Web sites like Angie's List are a viable mechanism for receiving that feedback." "Personally, I welcome this," Hickey adds. "It's part of the reality of health care that we're all going to be dealing with, which is becoming vastly consumer-oriented and transparent. At the end of the day, we will probably all be better clinicians as a result."

Keckley mentions Cleveland Clinic, Vanderbilt Medical Center, Intermountain Healthcare "and many others" as examples of health care organizations adapting successfully to "disruptive innovations," a concept introduced by Harvard Business School professor Clayton Christiansen in his 1997 book The Innovator's Dilemma.

Keckley's research indicates that more disruptive innovations in health care are growing, including medical tourism, retail clinics, disease management and the medical home. (3)

Even more radical departures from the status quo may be imminent. Health care futurist Jeff Goldsmith, PhD, of Health Futures in Charlottesville, Virginia, is working with a company that wants to build a FaceBook-like interface through which primary care doctors provide medical services online in real time via IM (instant messaging) and video chats.

As generational demographics shift from Boomers to Gen-Xers to Millennials, Goldsmith sees feedback loops getting a lot tighter (because these new consumers will be online almost continuously) and market segments smaller (because they'll consist of more Web-based "defined communities.")

"Expect more user-generated content and expect a lot of experimentation," Goldsmith forecasts. "If I had a large group practice, I'd have a service that monitored consumer feedback about their clinical experience."

A sticky trend

What is the evidence that the information on these Web sites actually makes a difference in how consumers choose their health care providers? Keckley concedes that, with some exceptions, "they've had marginal impact thus far." But he expects that to change as trusted Web sites such as Hospital Compare and The Partnership for Healthcare Excellence (4) get better at presenting information in ways that are relevant to a specific search query and that consumers can easily understand.

"We anticipate they will have significantly more impact on choices consumers make because of the ability to synthesize this information, the incentive that people have because of their insurance programs, and the growing public awareness of variation in medical practices," Keckley says. "We've been looking at this in a variety of perspectives, and we think it's not a fad. It's a sticky trend, and I don't think it's going to be less so in the next few years."

The California Healthcare Foundation commissioned Harris Interactive to survey the state's consumers to gain insight into who the seekers of health information are, what kind of information they use, and what actions they take after seeing that information.

The May 2008 report (5) concludes that although a large majority of Californians see the Internet as an important source for health-related information, most are still not taking advantage of it as a tool to manage their health.

But Hicks and others argue that such conclusions are premature. "This is just the start of consumers sharing information with one another," Hicks argues. "I think we're just at the tipping point. Providers can really embrace and learn from this and grow their practice by using it in a constructive manner."

References

(1.) The 2008 Survey of Health Care Consumers conducted by the Deloitte Center for Health Solutions. URL: http://www.deloitte.com/dtt/article/0,1002,sid%253D80772%2526cid%253D193730,00.html

(2.) CMS Hospital Compare site. URL: www.hospitalcompare.hhs.gov

(3.) These are titles in the Deloitte Center for Health Solutions' series "Disruptive Innovation in Health Services." URL: http://www.deloitte.com/dtt/article/0%2C1002%2Ccid%25253D219071%2C00.html

(4.) The Partnership for Healthcare Excellence. URL: www.partnershipforhealthcare.org

(5.) "Just Looking: Consumers Use of the Internet to Manage Care," a Harris Interactive report commissioned by the California Health Care Foundation. URL: http://www.chcf.org/topics/view.cfm?itemID=133641

Bob Carlson

Health care writer

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By Bob Carlson, MHA