This year I did not achieve Elite status on Air Canada/Aeroplan. For the first time in a decade, I am without status on a major airline. No number to call, no priority service, no lounge. I will probably have to wait in line. As you probably know, Aeroplan has Prestige, Elite, and Super Elite levels available to their best customers. They correspond to taking 25, 50, and 95 one-way trips a year.
As of January 2006, 120 million Americans (about one third of the population) were enrolled in a frequent flyer program. That is about one in three people who thought it was worth their while to register before flying. Of these people, 27-28% were active members (according to frequentflyerservices.com). So about one in twelve people accounted for most of the frequent flyers, and they in turn account for most of an airline’s revenue.
Healthcare too has its “frequent flyers”. A recent article by Andre Picard did a good job of outlining some of the basic information. Two-thirds of the population are either “non-flyers” or occasional flyers, who don’t get much benefit from registration and affiliation. 1% of the population (Elite and Super Elite) account for about a third of healthcare spending. 5% of the population accounts for about two-thirds of the spending. For institutional and home care services the numbers are even more striking, with one study saying that 10% of the population uses 95% of the services.
What would an Elite level look like for healthcare? Would we give them a special web site and phone number to get expedited service? Would we have a separate lounge for them? Perhaps with helpful nursing staff who assisted them on their way? What is the healthcare equivalent of free upgrades? What special offers would we make to them?
Several important concerns/questions/objections would need to be addressed in the design of our Health Frequent Flyer Program:
1. Frequent flyer programs for health will not be elitist. We know that health status declines with income. There will be more frequent flyers among poorer Canadians and the program should be fundamentally progressive from an income distribution point of view.
2. Entirely voluntary. Patients must be able to choose whether to have their chronic conditions managed differently, as well whether to share a broad range of personal information. I voluntarily tell Aeroplan a whole bunch of confidential information. Many patients might choose to share with detailed information with health providers their. Even information beyond their health record.
3. Will this create a two-tiered system? Absolutely not. There need not be user fees. In fact, part of the model could and should be how you get out and stay out of the frequent flyer program. But while you have the need, you get the service and access. The truly needy get in and get processed ahead of the worried well.
4. The revenue model is different in health than in the airline industry. We don’t want to encourage high utilization by rewarding people for it. This is important and true. But ultimately solvable through bundled pricing models and chronic care enrolment programs. The Ministry in Ontario is already moving on implementing these models, which cut across the silo-based funding model. We do want to provide excellent service and care; we need to make sure that funding models support these goals.
5. Will people want to enrol in the higher level of service to gain access and perks? This would be a new and very high-class problem for our health system to have: people seeking to enrol in chronic disease management protocols. Programs would need to be set up with thresholds of behaviour to “achieve status” — we would need to have expectations of participants to be part of the frequent flyer program.
6. Is last year’s usage a good indicator of next year’s usage? No, it is imperfect. Someone will have to do the math to see whether it is better in health or airlines. The airlines supplement it and make special offers to long-term high users and identified “big spenders.”
7. Will we establish the frequent flyer services as part of discharge planning after a hospital stay (e.g. for readmission rate reduction) or prospectively by identifying vulnerable populations with chronic conditions? Probably some mix of the two.
8. Who will be the responsible clinician(s) or clinical group or institution? This may also vary depending on system design, geography, and underlying condition.
The frequent flyer model is based conceptually on the extension of Michael Porter’s (and others) idea that higher quality care is less costly. In this case, I am saying that higher quality and better access care for high needs population will be less costly and free up resources. To state it negatively, many system costs occur when care is delayed due to poor access of identified needy populations. Wrapping a high service customer-focused approach around the care of these patients can and will reduce the costs associated with serving them within the public system.
At a fundamental level, frequent flyer thinking is a natural extension of health prevention and promotion thinking. What it says is that we need to apply more resources to those citizens who have high needs and/or risks. We need to reorient ourselves away from a one size fits all system thinking. If you are running a small hospital or clinic that serves 50,000 people, there are 500 “VIPs” and 2500 “important persons” that you should identify, reach out to, and “enroll” (again, voluntarily!). You should call these people and email them (if they agree). You should give the 500 “VIPs” free tablet computers with video links to your Family Health Team and/or emergency responders, and the 2500 “important persons” a 1-800 Hospital concierge service. Every single one of these people should have a medical record (and 2/3s of your visits will be e-enabled). The other 47,500 people you serve are only potential flyers. Be nice to them by all means, but focus on your key customers — the frequent flyers.