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Mayo Clinic has a long international history and has been providing care to international patients since its inception. Despite its history and reputation, however, the marketing staff continues to monitor the international market to gauge the level of awareness, reputation, and attractiveness of Mayo Clinic around the world. A look at how the Mayo Clinic has used word-of-mouth marketing to maintain its global reputation is presented.
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Satisfied patients are the key to creating a global customer base.
EXECUTIVE HIGHLIGHTS
Mayo Clinic has a long international history and has been providing care to international patients since its inception. Despite its history and reputation, however, the marketing staff continues to monitor the international market to gauge the level of awareness, reputation. and attractiveness of Mayo Clinic around the world. Here's a look at how one institution has used word-of-mouth marketing to maintain its global reputation.
Marketing, as most formally defined, has historically not been a critical factor in delivering patients to Mayo Clinic. Indeed, the marketing department at Mayo Clinic has existed for only the past 15 years, and patients have been coming to us for care for more than a century. We like to believe the marketing department provides valuable information to physicians and their support staffinformation that helps them deliver better care, highlights their patients' wants and needs, and educates them as to what's going on in the marketplace.
In reality, however, it's the providers themselves-the doctors, nurses, receptionists, and all the rest of the allied health staff-who bring in business by creating positive experiences for patients. Patients who leave Mayo Clinic highly satisfied with their care will return to their communities in the United States and elsewhere and say good things about us to their family and friends. And these family members and friends in turn travel to Mayo Clinic when they need tertiary or quaternary medical care. While we in marketing strive to provide excellent internal support, we know that it's the doctors and other care providers who have created and maintained a brand of health care excellence.
Despite the hype surrounding what has been presented as the highly lucrative international marketplace, "international" is not something new at Mayo Clinic. We know from experience and research that "international" is a part of who we are, as well as part of how the market defines us. Nearly 100 years ago, our founders, a family of physicians named "Mayo," created an international legacy by traveling around the world to compare notes and surgical approaches with physicians across the globe. In some cases, they even returned with international patients who were in need of additional expertise. As in so many other areas of our medical practice, we continue in their traditions.
In recent years, however, we've begun to more thoroughly study our international patient population in particular and the international marketplace in general. Our studies fall into a few categories and grow in number in proportion to our understanding (or perhaps our greater understanding of how much we don't know) of the international marketplace.
First of all, we track our international patient trends rather carefully. This seems like an obvious place to start. But as in most data tracking, the value of the concept is significantly more straightforward than the logistics of acquiring consistently reliable data. Internal data systems must be coordinated-a significant undertaking for any institution, and particularly hard, we believe, when dealing with a large and complicated infrastructure. To give a simple example, data fields must be made uniform-not just on one data system, but on all of them. Rather than a free-text field, for example, that allows a registrant to enter Venzuela, or Venosuela, or Vensuala, or maybe even Venezuela, we push for a pre-defined field that gives us standardized information.
We monitor our international data by the quarter, carefully watching trends over time by country or region, tracking significant changes in volume, hospitalization rates, and percentage of new patients out of any given market. We know, for example, that we have between 9,000 and 10,000 patients, depending on the year, coming to us from more than 160 different countries annually. Some are third-generation patients-maybe their grandfather was cured here in the 1930s-and others are brand new. Some are our neighbors in Ontario or Monterrey; others come all the way from Indonesia. We know that some markets are significantly less predictable than others, and some countries deliver more "new" patients than others. We probe further to figure out why.
Second, we conduct research with our internal salespeople-the physicians and their support staff who deliver care to our international patients. Through carefully moderated focus groups, we identify the things that are going smoothly as well as the barriers to providing excellent care. And where appropriate, we make recommendations for change.
Third, just as with our U.S.-based patients, we conduct both quantitative and qualitative research in the international marketplace. This includes research with our patients, international physicians, and international health care consumers, designed to help us understand why people choose to leave their own communities for health care, why some of them come to Mayo Clinic, and why others do not. We work hard to understand how health care decisions are made, so we can better assist decision makers, physicians, and their staff in providing care. We position ourselves to perhaps offer counsel on where to best expend valuable institutional resources, both human and financial.
Global Market Research
The marketing department conducts periodic and ongoing patient satisfaction studies with our international patients, measuring their assessment of various aspects of the care we provide. To date, we have surveyed nearly 1,500 patients in 20 countries, in four different languages. As any market researcher knows, sound patient satisfaction research requires great attention to detail to ensure reliable data. We find, not surprisingly, that international data collection offers significant additional challenges:
The quality of our own data. The name and address fields designed for clean U.S. addresses often are not sufficient to hold reliable international detail. If we want to do it right, we must manually "clean" thousands of patient records before fielding our studies.
Varying quality of international postal and telecommunications infrastructure. This variance can create significant problems for either phone or mail surveys; consequently, international studies take a lot more time than U.S.-based studies and require much more patience.
Cultural dynamics. In some countries, individuals may be suspicious of an international call; in others, they may spend a lot of time outside of their homes. In still others, a non-family "gatekeeper" must be diplomatically convinced to transfer the call to the targeted respondents. These cultural dynamics pose further delays and require special sensitivities.
High standards for quality. Our own standards for quality compel us to maintain high quality language- and culture-specific fielding of our various research projects. These studies, whether managed internally or through an external vendor, require more oversight than we are accustomed to with U.S.-based research.
Despite these challenges, however, this international research has taught us a lot. International patient satisfaction studies demonstrate that the key driver of our patients' satisfaction seems to hold across borders. This is excellent care-manifested by listening, explaining, and thoroughness on the part of Mayo Clinic physicians. Other factors in the health care experience are important-for example, quality of language interpretation and waiting times-but they don't consistently correlate with overall satisfaction.
The power of word of mouth is also confirmed in the international marketplace. Most of our international patients indicate that friends or relatives provided their most important influence in choosing Mayo Clinic. This finding reminds us of our most powerful marketing "tool"-satisfied patients who say good things about Mayo Clinic and influence others' health care decisions. Exhibit 1 indicates the factors influencing choice of Mayo Clinic by patients from Latin America and the Middle East.
We conducted formal focus groups with international patients and non-patients in six cities around the world, probing to learn more about how those populations make health care decisions, and whether the process is the same or different from U.S. health care consumers. As it turns out, for most aspects of decision making, the process is very similar to that of U.S. consumers. However, for a few others the process is quite different.
The areas where we've found the most difference across borders relate to the role of health insurance. We've been involved in three co-sponsored international research projects that have taught us some good lessons and demonstrated that international health care insurance is as different from that in the United States as it is across countries and regions. Furthermore, many assumptions we take for granted in the U.S. market-for example, name recognition-simply don't hold in certain international markets. Exhibit 2 on page 22 is a graph of responses from a satisfaction study of our patients from Latin America and the Middle East, showing the different history of Mayo Clinic brand awareness in those regions.
We weren't surprised to learn that Mayo Clinic awareness among our patients was much more recent in the Middle East than in Latin America. From other studies, however, we have learned that awareness among non-patients-even those who have purchased health insurance policies that offer them Mayo Clinic care as a benefit-is not as strong.
The international health care insurance market is expanding rapidly, and many providers view this expansion as a significant opportunity to glean additional patients from outside the United States. Commercial and non-commercial contracts comprise a significant body of business in U.S. health care. If this business could be expanded to provide patients from markets outside the United States, all the better. We know, however, that health care systems vary significantly from country to country, and knowledge and use of health insurance vary even more. To study these differences in detail, we co-sponsored two quantitative studies of health care insurance policyholders-in particular, holders of policies that offer some degree of coverage for care at Mayo Clinic.
The first study consisted of face-to-face interviews with 400 policyholders in a particular country and delivered a great deal of information regarding policyholders' preferences, health care behavior, and demographics. In this country, as throughout most of the world, the public health care system exists as a universal "safety net" for all citizens. Even in markets where the private insurance market has expanded, the public system continues to offer care for all citizens. This means that if a private insurance policy does not offer adequate coverage, especially for high-cost procedures, the public system is used to reduce the consumer's financial burden.
The private policy might cover, for example, access to primary and secondary care at private rather than public clinics as well as the price of a private room, or the option of receiving care at a more upscale facility. But for high-cost, life-threatening procedures, the co-pay or deductible for having these procedures conducted exclusively in the private sector remains significant. The end result, of course, is that the lower cost procedures are transferred to the private system, while the higher cost procedures remain in the public safety net. The implication for U.S. tertiary providers is that, while private insurance might reduce some of the financial risk for traveling out of country for care, in many cases the risk is not completely eliminated. Therefore, the policies might not deliver the volume of patients initially anticipated.
Other factors, such as a lack of brand awareness and limited perceived need for U.S. medical care, may be impediments to attracting patients in the international health care insurance market. In our first study, when we probed for brand awareness among those 400 consumers who had purchased a health insurance policy touting Mayo Clinic coverage as a benefit, we discovered no unaided recall of that coverage as a benefit of the policy. (See Exhibit 3.) In an aided list, Mayo Clinic coverage was ranked as the least important benefit of the policy, on a par with eyeglass coverage at the bottom of the list.
Furthermore, when we asked policyholders to name a leading medical center in the United States, most (72%) didn't know a single one. Twenty-five percent (25%) named Mayo Clinic, and the other 2% named other U.S. medical centers. We were not particularly surprised that citizens in the studied country were not familiar with Mayo Clinic. However, we were surprised that policyholders who had purchased an insurance product that very publicly advertised the Mayo Clinic benefit were unable to name Mayo Clinic as a leading U.S. medical center.
As it turned out, many of these policyholders had no intention of leaving their home country for medical care. They were buying insurance to facilitate care in the more desirable private system. Furthermore, most felt that the health care in their own country was very good and that there would be little if any reason to ever leave home to obtain care elsewhere. We've encountered this phenomenon repeatedly in our research with U.S. patients. Most believe in the abilities of their own doctor and feel very confident about medical care in their own community. Even though "quality" may be regionally or culturally defined, almost everyone considers his or her doctor to be a good one.
A second co-sponsored study consisted of 353 telephone interviews with individuals who had purchased a health care insurance policy specifically for international coverage. Once again, confidence in local care was very high-in fact, significantly higher than in the country of our first study. Nonetheless, this group of individuals had purchased a product that offered them coverage for medical care outside their home country, should they decide it was necessary or appropriate. In this study, our aided brand recognition among policyholders was higher than in the first; when asked directly whether they'd heard of Mayo Clinic, 75% responded affirmatively. But when asked unaided to name the best medical centers in the United States, the vast majority (nearly 70%) of policyholders indicated they didn't know. And while the majority had heard of Mayo Clinic, fewer than 10% were aware of any benefit of their health insurance policy that related to Mayo Clinic.
In both of these studies, we learned substantially more about the nature of international insurance agreements, policyholders' wants and needs, and their disposition toward traveling out of country for medical care. But we also learned that the knowledge of our brand is limited outside the United States and that a high number of policyholders does not necessarily translate into a high number of patients. Our research has taught us to be more selective, to be cautious in expending significant resources to pursue insurance arrangements, and to conduct further research to expand our understanding.
The Future
We anticipate that "international" will continue to be part of who we are at Mayo Clinic. Our doctors, hailing from all corners of the globe, will continue to collaborate with their colleagues around the world. Mayo Clinic researchers will conduct clinical trials in collaboration with researchers on many continents. Our students and residents will continue to offer us rich diversity, as Mayo international alumni now number 1,500, representing 67 countries. But most important, Mayo Clinic will strive to provide the best medical care possible to those patients around the world who need us the most.
To support that mission, those of us in "marketing" will continue to support our medical staff by studying our patients' wants, needs, preferences, and behavior patterns, and learning all that we can about the ever-changing, rich and diverse worldwide health care market. In the end, outstanding medical care and sensitive service to patients and families will be our most productive marketing strategy, because it creates positive word-of-mouth about something very important-health care. As the stories of satisfied patients chum-sometimes for decades-in the minds of their friends and family, Mayo Clinic remains an option if they ever need the care we offer.
ABOUT THE AUTHORS
Misty Hathaway conducts market research and planning projects at Mayo Clinic, with primary focus on the international market. She may be reached at [email protected].
Kent Seltman is the director of marketing for Mayo Clinic. He may be reached at [email protected]
Copyright American Marketing Association Winter 2001