No problem.
And are we starting with the article?
I don't remember what we just said.
Yeah,
I was going to do the article first.
Yeah, perfect.
Yeah.
All right.
Most health care businesses have a number
they're proud of, a number they show off,
a number they track,
a number they think proves they're doing
good work.
Larry's argument in his latest article,
that number might be completely
meaningless.
Today,
we're talking about one of the most
visible metrics in health care.
Google reviews, five stars.
Zero outcomes?
Welcome to The Operator,
a show about running better healthcare
businesses, not from theory,
from people actually doing the work.
If you're responsible for patients,
people, or performance, this is for you.
Larry, welcome to your show.
Well, thank you, Jerry.
Thank you for hosting my show.
Well,
my job is to sort of set you
up.
This is the last part in a series
that you've been doing.
And if people want to go back to
it,
we'll give the link to the sub stack
that they can view as well as the
articles on LinkedIn.
But first,
why did you decide to do sort of
a series on metrics?
What about that made you say,
I'm going to dedicate several weeks of my
writing to just metrics in general before
we get into the specific Google reviews?
Yeah.
What we tend to do in an operating
business and health care platforms is we
tend to get very routinized on certain
metrics that are like sacred cows.
They're the belief that they are the most
important ones.
We've had vast changes in our operating
environment.
If you think of sort of the post-COVID
hangover days,
then you had shortages and you had all
the headwinds of reimbursement.
and all the things around high inflation.
And the business models have had to
change.
You've had to adjust.
And so what we tend not to do
in health care operations is rethink,
challenge our assumptions.
And say,
why are we continuing to measure that?
And then the objective becomes the
measurement rather than the activities and
the behaviors that really get the
operations flowing in the right direction.
And so I've tried to on each one
of these metrics doesn't mean,
as I point out in the articles,
that you shouldn't be measuring them,
but you should be understanding how
they've shifted over the years.
And the whole area around good hearts is
a bias that we tend to default in
over time if we're not careful.
Yeah.
When the metric becomes the measure,
it fails to measure what matters is the
thing that kept sticking with me.
That makes sense.
I mean, you're Russian.
If you want to go back and read
it,
the Russian nail factory sort of
highlights that pretty well.
When you tell me to gamify,
when you gamify a metric and you put
my salary on the on the line for
that,
guess what I get really good at hitting
that number is the letter of the metric
or the spirit of the metric.
Well,
I hit the letter of the metric and
that's what gets me the paycheck.
Just to that point, years ago,
I'm going back into the late eighties.
I had a few clinics and one of
my clinics,
we used to measure no-show cancellation
rate and used to incentivize the front
desk person for a lower no-show
cancellation rate.
And interesting,
she went on maternity leave and she was
a wonderful intake coordinator
receptionist,
what we called DOFI at the time,
Director of First Impressions.
And all of a sudden,
our no-show cancellation went sky high.
And I started wondering,
how is that the case?
Well, as it turns out,
you can game that number.
It's no different than the Russian nail
factory.
Somebody cancels,
you just take them off the schedule and
put them somewhere else and you never were
able to see what really...
happen there.
And so gamesmanship working around it,
our tax laws are the absolute, you know,
personification of good hearts law,
everybody works around the tax laws to try
and save on their taxes.
That's normal.
Yeah.
So we have to, you know,
we have too many tax law issues,
and good heart issues in operation.
And so my challenge is somebody who's in
the field every day operating is for us
to challenge those assumptions.
And you can tell which side of the
argument someone is on with taxes when
they call it a write-off or a loophole.
If it's a loophole,
you can tell they don't agree with it
right there.
All right, so let's jump into this.
If someone logs on Google website,
somewhere where ratings are being
tabulated and shown off,
what is a four point nine star four
point out of five star rating actually
tell you about specifically a health care
business yeah honestly it tells you that
they're good at asking that's not nothing
not what most operators think it is you
know four point nine means your patients
felt well enough to leave a review that
had a positive enough experience to give
you close to a five star
does not tell you about the patient who
dropped off after the two to three visit
cliff in physical therapy or in dental it
doesn't tell you the patient who didn't
show up for the second visit which
oftentimes in dental is the most important
visit from an economic standpoint it
doesn't tell you about your twenty two day
wait period for a new evaluation it
doesn't tell you whether your functional
outcomes improved or whether your hygiene
appointment rate is collapsing
It's a sentiment snapshot from a very
self-directed audience.
And in health care,
that audience skews very grateful,
skews compliance,
skews towards the people who finished
care, the people who like you.
The four point nine is real.
It's just not the whole story.
It might not even be the important or
really key elements of the story.
Yeah, you want to gamify that number.
Don't point out where to scan the QR
code to leave a review to somebody who's
disgruntled, right?
Although you can look at the other side
of the argument,
which is sometimes when people have a bad
experience,
they're more likely to go rate you and
leave a review versus the people who are
the silent, happy,
satisfied customer or patient.
Exactly.
And it has some meaning.
It's just not all that much important from
the day-to-day operations.
Right.
So at what point did healthcare cross the
line from measuring experience to
pretending experience equals quality?
Yeah,
so we gotta go back a little bit
in place of time.
In the, call it the late eighties,
early nineties,
there was this new thing that happened in
healthcare called functional outcome
measures, SF-II, the SF-XXVI, short form,
long form, XXXVI,
which is the healthcare quality of life.
And so we started to say,
what do outcomes mean?
And outcomes were defined as days,
dollars, utilization, functional outcome,
And on top of that,
we had patient satisfaction,
later became patient experience.
And so the combination of these dollars
are sort of utilization-driven data,
clinical functional outcome-driven data,
and all the things around the experience
became sort of the three distinct domains.
But what happened is over time,
we've tried to simplify it.
You know,
we're in business and operations.
We're always trying to make the complex
simple from an operation standpoint.
That's a great thing.
However,
sometimes when we make things so simple,
we destroy what the animal that we're
trying to create is.
So the moment we ran out of better
alternatives and stopped admitting it,
clinical outcome measurements in the most
outpatient settings is inconsistent at
best, absent at worst.
Functional tools do exist, photo, promise,
all the things are on Medicare, you know,
PSFS, for example, but adoption is not,
you know, is not evenly put.
And at times,
we tend to only do it on our
best patients or those who complete care.
And so you have to be really,
really careful.
And so what fills that volume,
whatever is visible and Google stars are
everywhere.
And so let's use Google stars.
I had series a couple of weeks ago
about Net Promoter Score,
a lot of similarities here.
They're on your profile,
they show up in the listing,
they're a number, numbers feel like data.
So we promote them,
not because anyone made a deliberate
decision about it,
but that four point nine stars equals
clinical excellence.
Somehow or another, we conflated that.
But because the infrastructure for
measuring actual clinical excellence
wasn't there or wasn't fulsome or wasn't
complete, the proxy became the point.
And that's always how it happens.
We make a proxy a conclusion,
and Google stars are now that conclusion,
unfortunately.
Yeah.
It's funny that you bring up four point
nine stars.
And I think I know why.
To me, five feels too perfect.
It feels like I can't trust that because
it's nothing's perfect.
So four point nine feels as close as
you can get.
Really good.
But obviously there's some real in there.
So it matters.
Isn't that funny how that like we've even
even on the receiving end said five's too
good.
I don't trust it.
A four point eight that four point nine
that feels perfect.
More authentic.
Feels more authentic.
Right.
So you mentioned like sort of the
pre-COVID, right?
So are operators still chasing Google
reviews based on a version of the
algorithm that doesn't actually exist?
Are we still having a twenty sixteen
mindset in twenty twenty six?
No, that's absolutely right.
A lot of them are.
And that's really what my research started
to show,
that the old mental model was pretty
simple.
More five star reviews equals higher
ranking equals more patients.
So it was all driven by how high
on the Google
best search engine, period.
It's interesting.
We're switching now from search engine to
AI, LLL.
And for a while,
the volume of reviews was the dominant SEO
signal.
And this really is the main teaching point
of the article.
So that logic held true.
But the algorithm has gotten way more
sophisticated, as they always do.
Technology always outpaces everything we
do in health care.
proximity, relevance, behavior signals,
how people interact with your listing,
whether they click, whether they call,
these matter now as well.
So it's the behavioral elements,
not just the star elements.
Review recency matters more than raw
volume.
So if you took a hundred reviews,
it's like golf handicap system.
It's the five top most recent ones that
really matter.
So the operators who ran an aggressive,
let's get to two hundred review campaigns.
I still see this all the time.
And they sort of stop.
They're potentially losing ground to a
competitor with eighty reviews.
So that was kind of like I got
two hundred.
You got eighty.
So therefore, I'm better.
In fact, we are competitiveness.
around google stars surpassed our
competitiveness around clinical excellence
and doing the right thing for the patient
right you know the we got we got
diverted by all this um so chasing the
number at one time made sense now it's
it's it's table stakes and the operators
treating it like it's a competitive moat
are you know probably optimizing for a
version of local search that's already
moved way way past that right you know
by the way at least in physical therapy
Why do we care about local surgery much?
Don't we have we have plenty of patients
now, plenty of volume.
Yeah.
You know, really optimizing,
as we talked about last week,
optimizing that volume and not the churn
is really, really important.
So keeping the patients you have and what
we're saying, milking your own cows first,
you have those patients.
Make sure you're getting the treatment
completion on them so that you can focus
attention on there.
And that's where that, you know, really
being extremely,
extremely intentional about visit two and
three and showing value there rather than
routinize the visit.
What you're basically saying to the
patient is you don't need to come in
anymore because we're going to do the same
thing every time.
Yep.
I can actually hear someone creating a KPI
just for that.
But isn't there one?
Isn't it churn?
So when you don't have real clinical
outcome data, what does fill that gap?
What is the right thing or the better
thing to measure?
Yeah,
so what happens is we use Google Deck,
Google Stars,
and Net Promoter Scores because leadership
needs something to say in a board deck.
And this is a different topic for another
time, but I think, you know,
PE backed platforms and even private
practices do not have the right type of
board members.
They have people playing by old rules of
an old game, a, you know,
call it college before we professionalize
through revenue share and NIL.
That's the type of people that are on
boards right now is this new game that
took place post COVID.
You show me an operator who's really done
well the last few years and you've got
an operator because they they're the ones
who've dealt with incredible amounts of
inflation at the supply level,
inflation at the compensation level,
shortages of your suppliers,
all of those kinds of things.
And so we use Google stars and net
promoter scores for those board members
because we want to fill a board deck.
It sounds cynical.
but it's accurate organizations under
performance pressure from either PE
owners,
from franchise benchmarks from year over
year need visible proof of quality.
And so this proxy of Google stars is
now what your compliance is showing up as
quality.
And if you can't pull functional
improvement data, very hard to do,
as you know,
If your outcome tool adoption is
inconsistent,
it's very hard to be consistent.
If your discharge documentation is a mess,
very hard to have that consistent as well
because most patients don't read their end
of treatment discharge.
You reach the number you have.
Google stars makes it easy.
Net promoter scores make it easier.
Patient satisfaction makes it easier.
Those aren't bad metrics.
They're just getting asked to carry weight
they weren't built for.
The danger isn't that operators track
them.
The danger is that over time,
the proxy becomes the definition.
You stop asking,
are patients getting better?
And start asking,
are patients happy enough to leave a
five-star review?
That's entirely different dimensions.
They're related,
but they're not the same questions.
Yeah.
You highlighted something in this article
that I guess I didn't think about too
much.
And I bet you a lot of people
didn't either,
which is responding to one of these
reviews, if it's negative or in a way,
could open you up to liability.
So why are healthcare providers the only
businesses that really can't actually
defend themselves in public?
Or they can,
but they have to be really,
really careful about it.
Yeah.
So first of all,
the reviews tend to reflect sort of your
interpersonal and logistical experience as
your wait times, your parking,
the front desk,
not clinical decision making.
And so the population leaving reviews is
really not a representative population.
people are complex they leave incomplete
survey data disappointing outcomes are
less likely to review stars of any any
nature at all and what ends up happening
is it's you know do you like your
provider all those kind of things they
review it but that selection bias is baked
into every star rating in the industry
But the biggest thing is what you're
referring to on the question,
which has HIPAA in the background,
which limits how providers can respond to
negative reviews.
You can't get into details.
You can't correct the record.
You can't explain context.
So one-star review about a billing dispute
sits on your profile essentially
unchallenged because your response has to
be generic.
It lands and people people ignore that.
And so now we've developed this whole
niche industry about how to respond to
bad, bad reviews.
It's almost like all of us need our
own PR crisis when we get a bad
review.
We also have to remember, you know,
I always tell my therapist this and the
PT side and I say the same thing
in the dental.
If a patient left your local clinic.
because they refused to accept some level
of self-responsibility in physical therapy
that manifests itself by a home program or
compliance with instructions.
And in dental,
it manifests itself with compliance with
instructions on hygiene care and other
aspects of post procedural care.
And they would not take and therefore they
disliked you because they wanted to put
all their problems on to you.
It's OK to fire a customer every once
in a while.
And if that leaves you a bad review,
you could still sleep at night because
self-responsibility and an active role in
your own health care,
your own recovery and in your own in
the dental world and your own treatment is
critical.
A lot of patients don't want to assume
any responsibility and they might write
you a bad review.
You can't get overly intrusive on it
because you're violent.
You could be violating HIPAA.
Yeah, it's the juice versus squeeze ratio.
You might chase after and put so much
effort in this one patient,
you're probably never gonna make that,
you might never make that person happy.
Let's take that juice versus squeeze ratio
over to this question,
because this takes time, effort, money.
There are firms who you can hire that
are specialized in this.
So what are people actually spending,
even if you're not hiring a firm,
you're also spending brainpower, time,
staff time, effort, money.
What are we actually spending to maintain
that
And has anyone proven that it does
anything?
Does it drive business or patient growth
at all?
Yeah.
So one of the questions I ask operators
to think about is the concept of what
is your return on the cost of quality?
The cost is the time, effort, resources,
money,
all these things we do to ensure some
level of quality.
And so you have to be cognizant of
that.
The spending is extremely real and it's
often invisible in the budget.
You know,
people aren't you're not budgeting this as
much staff time training and review
technology platforms with automatic post
visit review sequences.
Now we have all this stuff that goes
into your phone that automatically asks
you all of these kinds of things.
And for a multi-site operator, man,
that adds up.
fast and keep in mind all the SAS
software providers,
how do they make more money?
The same customers adding additional APIs
that allow you to do more functions is
how they make more money.
You know,
we'll talk about the EMRs and other kinds
of things later because the LZRs miniature
versions.
So now I'm not only doing your EMR,
I'm doing your point of service pay at
times.
I'm doing your outcome studies.
I'm doing your documentation AI.
All of these things keep adding costs.
And so we say as operators,
where's my cost of RCM?
Should be going down.
All of a sudden it's going up.
Why is it going up?
Because all these providers are adding
APIs.
They're increasing your cost and you have
to do the tough decisions and make
choices.
about all of those kinds of things.
And so in health care,
a lot of choice is constrained.
Insurance networks, referral patterns,
geography,
they're still doing an incredible amount
of routing.
And so if you're investing to maintain a
four point nine in a market where a
meaningful portion of your new patients
are coming through other referral channels
that aren't looking at your Google rating
at all,
that doesn't mean the investment is
wasted.
It just means that ROI calculation is
messy.
They're the platform selling requests.
So we see all of these efforts now
in the AI world of lead generation and
all of these things around it.
And I talk to practices and they say,
I'm not having trouble getting new
patients right now.
Well,
you're spending an incredible amount
between your foot marketers,
your advertising, your digital marketing,
and all of these things have accreted to
a level.
And you have to say,
does the business model support it
anymore?
And in healthcare,
it's a penny nickel business,
a nickel dime business.
You can't afford to spend an enormous
amount of money on a problem that you
think is there, but it really isn't.
Yeah.
All right.
So I'm going to hold your feet to
the fire.
I actually put your article into test.
I said, hey,
how would some leading brands actually
optimize this?
And one of the best responses was Disney.
They said Walt Disney himself would
optimize for miles per hour,
not miles per hour, not stars.
So if Google stars don't tell the truth,
what should operators be measuring
instead?
Yeah,
so we'll get into this a little bit,
but I noticed one of the comments from
the article last week was somebody saying
the best metric they measure is how many
smiles are leaving their clinic.
And I thought that was a real interesting
one.
In dental, at least in our company,
we say our mission is to create a
lifetime of healthy smiles.
And how are we doing that?
Doing meaningful and purposeful work and
remembering.
In fact, that's what we're here for.
But there's a short list with teeth.
New patient arrival rate is a real
critical one.
Are new patients choosing you?
Is that number growing?
Is your number of new patients growing?
We talk about growth in organic and all
these things and platforms,
and most PT operators measure that wrong.
They measure growth in terms of number of
visits per patient, all kinds of things.
They ought to be measuring it by growth
and cash flow.
Different topic for another time.
But is the number growing?
That's a market signal,
not just a sentimental drop.
PlanetCare completion, very,
very difficult, but really, really,
really difficult.
Are patients staying through their episode
of completion?
To me, that would be the best proxy.
of a patient you know satisfaction really
because dropout is the quiet killer that a
four point nine doesn't capture right
functional outcome improvement discipline
specific systematically collected not
cherry-picked reactivation rate are former
patients coming back when they have a new
need i call it friends family and former
patient percentage what percentage of your
new patients fall into that bucket that is
really critical to me because it means
you're spending zero dollars
under what you should be doing to get
your marketing,
which is providing great care.
That's continuity and it's its most
measurable form.
None of these are as clean or as
visible as a star rating.
You know,
in order to get to the answer,
it's not a simple answer like a star
rating.
That's exactly why they matter more.
The metrics that are easy to show off
are usually the ones that have already
been gained.
The ones that are harder to show off
are the ones that's actually happening.
Yeah.
Anything you'd want to leave the audience
with as we wrap up?
Your parting thoughts?
No, just, you know,
not telling you not to do Google ratings.
Just don't overvalue them and don't spend
all you're trying to get more of them.
Reroute that same effort into something
that brings meaningful change into the
operations of your practice.
I mean,
as a guy who's spent some years in
marketing and communications,
the best marketing is a really,
really great product and or service.
If you're trying to become a better
operator in healthcare,
you're in the right place.
If this episode hit,
Larry goes deeper inside his writing.
Look for the operator on Substack.
We'll also drop a link below.
That's where the full breakdown lives.
We'll see you next time.