Feature Raters Gonna Rate What's Your Best Response? By Donald E. Tepper | September 2015 Many patients visit online rating websites to help them choose health care providers. What will they find out about you? Consumers use web rating sites such as Angie's List to choose plumbers, Yelp to select restaurants, and Trip Advisor to pick hotels. Will consumers someday use online rating sites to select their physical therapists (PTs)? In fact, they already do. Mark Disalvo, PT, MPT, OCS, says, "I've had new patients tell me, 'My doctor gave me a list, and I saw that people had good things to say about you.' [The rating] hasn't been the only factor, but has helped." Disalvo, owner of Landmark Physical Therapy in Scottsdale, Arizona, and other PTs are quick to emphasize that online reviews seldom are the primary reason a patient selects a PT. Nevertheless, the influence of review sites is growing, and so PTs must learn how to manage their online reputations. Scott Weiss, PT, DPT, ATC, CSCS, FACSM, puts it this way: "Today, PTs must know how to manage not only their real selves but their digital selves as well. It may sound almost like science fiction, but the digital age is here. It's part of our reality. If you don't learn to swim in the new pool, you may sink." Weiss is co-owner of Bodhizone in New York. Learning to Swim To expand on Weiss' metaphor, PTs aren't swimming in just 1 pool. Rather, they're having to learn how to keep their heads above water in dozens of sometimes deep and unfamiliar pools, ponds, and lakes. PwC Health Research Institute (HRI) recently identified 6 separate types of online sites and sources, ranging from consumer rating sites such as Yelp and Health Grades to state and government agencies, insurers, and independent nonprofit organizations.1 [See "Health Care and Rating Review Sites."] In all, HRI estimates there are hundreds of health care rating sites. The challenge for both consumers and practitioners, HRI explains, is deeper than simply coping with a large number of sites. "Deciphering health care ratings can be a daunting task," the institute notes. "Each site has its own symbols, such as stars or letter grades. Mature government websites may offer 'validated' reviews—where the users are actual patients, members, or customers—but the general public may be less aware of these sites. Newer commercial websites may be better known, but the reviews may not be coming from actual customers." Adding to the confusion, different sites capture different information. One recent study looked at the 10 most frequently visited online physician rating sites containing user-generated content.2 Researchers identified 35 items, which they assigned to 5 different categories: overall rating, communication skills, access, facilities, and staff. Many sites also contain practitioner information such as schools attended, board certifications, malpractice claims history, and years in practice. As Weiss puts it, "Not 1 rating site has emerged as the end-all, tell-all leader of the pack. The whole industry is still very much the 'Wild West.'" The many types of information used in the ratings—from how well a practitioner listens to a patient to whether the practice has adequate parking or access to public transportation—raises another question: When patients visit rating websites looking for a quality practitioner, are they searching for evidence of positive health outcomes and quality of care? Although practitioners might hope so, the answer is no. The Associated Press-NORC Center for Public Affairs Research conducted a study on what consumers look for in physicians. It found:3 When Americans are asked … what they think is the most important factor that makes a high-quality doctor, responses vary widely but most focus on doctor-patient relationships and personality (59%), rather than on delivery of care or the patient's own health outcomes (29%). Most frequently, Americans say that a quality doctor listens, is attentive, or shows interest in them (18%). Other top responses focus on doctor-patient interactions and their traits, including that the doctor has a caring attitude (8%), good bedside manner (8%), various other positive personality traits (7%), and time spent with patients (5%). Relating to the delivery of care or patients' own health outcomes, 11% value most a doctor's ability to accurately diagnose and fix their health problems, and 8% mention a knowledgeable doctor. Are Ratings Important? There are hundreds of sites, but how many consumers actually pay attention to the ratings? An HRI survey found that only 48% of consumers read health care reviews online and that only 24% have written health care reviews. Among consumers who do read the reviews, however, 68% said they use them to choose where they receive health care services.1 A recent Kaiser Health Tracking Poll produced similar results.4 It found that 31% of adults remembered seeing information comparing physicians, hospitals, or health plans. Of those, 61% said they used the physician-comparison information, 41% used the health plan information, and 35% used the hospital information. Even among those who used the information, however, the rating seldom was a deciding factor. One recent survey asked US adults, "When selecting a primary care doctor for yourself, how important is each of the following?" Eighty nine percent rated "accepts my health insurance" as very important. Lower down on the list of "very important" factors were convenient office location (59%) and physician's years of experience (46%). One fairly significant factor in this and other surveys was word of mouth from family and friends—38% rated word of mouth as "very important" and another 47% rated it "somewhat important." Lowest in the rankings was a physician's rating on websites. Only 19% considered the provider's website rating "very important." Forty one percent deemed it "not important." And that's actually okay with many of the PTs interviewed for this article. Weiss explains, "When it comes down to selecting a health care practice, online rating sites should not be the ultimate deciding factor. I still think people should base their opinions and search options on good, old-fashioned firsthand accounts and references from peers. While these, too, are subjective opinions, you can trust the person providing the feedback and know that it is authentic." Should You Pay Attention to Your Ratings? So, if only a minority of the public even recalls seeing ratings of health care providers, and if most people don't consider ratings very important, are ratings websites worth your time and attention? The PTs interviewed for this article said that they pay attention, for a variety of reasons, and that other PTs should, too. Kosta Kokolis, PT, MSPT, links the value of rating sites with direct access. "These sites actually can help promote the benefits of direct access," he says. "Patients can rely on them to find the necessary information on PTs, and then hopefully seek the PTs out in person to form their own opinions of their professionalism and expertise. These sites may help consumers find PTs and go to them—rather than to [other health care providers]. If not for these sites, many patients might never show up on a PT's doorstep." Kokolis is the owner and founder of TheraMotion Physical Therapy, in Bayside, New York. Nitin Chhoda, PT, DPT, agrees and suggests that visibility on rating websites may be particularly important in highly populated areas. "If I'm a PT in New York or Chicago, I need to have positive reviews. Especially if the patient depends on Internet research—then the impact on the selection of a therapist is significant. If I'm a PT in a small town or community where people know each other, it's less important," he says. Chhoda is CEO of In Touch EMR and a former practicing PT. Robert Fay, PT, MHSc, OCS, STC, CSCS, says rating sites and, more broadly, social media can be a valuable part of a practice's overall marketing plan. Fay, clinical director and owner of Armonk Physical Therapy and Sports Training in Armonk, New York, describes aspects of the practice's marketing program. "I've hired a person who does Facebook and our website. He handles small marketing items. We post on Facebook every day. Twice a month we send a newsletter to our entire email list. We all have advance certifications, and I want to heighten our profile and promote that we're experts in our field," Fay says. "The results of our Facebook postings are hard to track, but the posts keep us on people's minds. It's hard to know the extent, but since we've had a more active approach on Facebook, we've gotten more patients." Overcoming Negative Reviews Most online reviews are positive [see sidebar below]. But what should you do if you receive a negative review? As Weiss puts it, "If you don't know how to block or evade the proverbial punch from negative reviews, you can get hurt." The first step is to reduce the chances of a negative review. "PTs have been conditioned to believe they need great websites and reviews," Chhoda says. "But more important are the fundamentals." Those, he explains, deal with the entire patient experience. "There's a 'before,' 'during,' and 'after' experience for the consumer. It all matters. PTs typically do a phenomenal job 'during.' But we drop the ball when it comes to the 'before' and 'after.'" The "before" includes making sure a patient's phone call is answered promptly and that clinic staff give that individual their undivided attention. Test your staff, Chhoda advises. Call your own practice and pretend to be a patient. See how your call is handled. Chhoda adds that when patients arrive at your office, front desk staff should greet them and remain in contact while they wait to be seen. Answering phones and greeting patients may not seem related to quality of care, but a recent survey of US adults found that that such factors affected patients' choice of a health care provider.3 Specifically, 77% of respondents said that how long it takes to get an appointment is either "extremely important" or "very important." The same percentage deemed helpfulness of staff at the health care provider's office either "extremely important" or "very important." Revealingly, those factors were ranked higher in importance than "whether a doctor or other health care provider provides the highest quality care at the lowest possible cost." If PTs are weak on "before" interaction, they tend to put even less effort into "after." "No one pays attention to it," Chhoda says flatly. "Practice what I call the 'ascension ladder,'" he advises. "That includes a follow-up—a letter in the mail, a phone call once a month, or an emailed newsletter. Or, it could be an event, such as a patient appreciation day. If you're going to forget about your patients, they'll forget about you even faster." Negative reviews may be few and far between, but, as the saying goes, you can't please all the people all the time. Some unhappy patients and negative reviews are inevitable. That's not necessarily a bad thing, however, Chhoda says. "When you grow, you're inevitably going to have some unhappy patients. If a company has no naysayers, it's likely a sign that the company isn't growing fast enough or is irrelevant. It's okay to have a few negative reviews, but it's your responsibility to make it right and to demonstrate online that you tried to fix the problem." In discussing negative reviews, Kokolis draws a distinction between sites that rate practices and sites that rate practitioners. "In the past," he explains, "we have had mixed experiences with rating websites. For example, ZocDoc and HealthGrades have been very beneficial because individual practitioners are graded on their knowledge and treatment experience. The practice itself—where clerical errors at the front desk, for instance, can result in a bad review—isn't graded. Sites such as Yelp or Yahoo Local can be detrimental to knowledgeable PTs who just happen to work in an environment that may not be optimally organized or experienced." In any case, the first step in addressing negative reviews—whether of practices or individuals—is to discover them. Few rating websites have a process to notify the health care provider, much less seek out a response. For that reason, Disalvo uses Google Alerts (www.google.com/alerts), a free service that emails you whenever someone mentions specific words—your own name or your practice's name, for example—on a site indexed by Google. "My wife, who is my business partner, gets an alert every time someone mentions us online," Disalvo says. "We check it regularly—maybe 2 or 3 times a week—monitoring for new posts. If someone does post something negative, we can respond with a comment and try to make the situation right." Weiss checks the more prominent sites—he mentions ZocDoc, Yelp, Google, and HealthGrades—but he doesn't let a few bad reviews bother him. "These sites are pretty much 50/50 when it comes to accuracy," he notes. "The majority of the responses are patient driven and are not objectively rated by our peers or others who could honestly evaluate the level of health care provided. We obviously don't like bad reviews and will try to learn from critiques as best we can. However, at the end of the day, these are mostly subjective reviews that we take with a grain of salt. In our experience, there always are plenty of positive reviews, and the negative ones are not always worth the time or effort [to address]." One technique to counter a poor review is to counterbalance it with many positive ones. Ask satisfied customers to post comments, Disalvo advises. "We've asked patients who have had positive experiences to share them on ratings sites," he says. "So, we know that we're going to get some positive reviews." Part of an Overall Presence As Disalvo noted earlier, many patients go online to check out a referral. Searching for the name of a specific practice or practitioner often leads first to the practice's own website or Facebook page. That's why Disalvo puts a lot of effort into Google and social media. "If you want your search to come up on the first page of Google—most people don't get past the first page—the more links and hits you have posted to different areas of your site, the higher your website will appear on search results," Disalvo notes. Chhoda agrees. "PT private practices need good websites. You also need positive reviews, because what patients say about you matters more than what you say about yourself." Disalvo urges practices to be cautious, however, when it comes to spending money to enhance their visibility online. "When you're starting out, or have a small organization, you have to figure out where you want to allocate your dollars," he says. "We want to increase our visibility organically"—ie, from traffic resulting from Internet searches. Disalvo's advice is to "know your budget and know your numbers. Track everything meticulously. Know where your hits are coming from. Look at your return on investment and decide what's acceptable. You can't just say, 'It didn't work for a month.' You have to do it longer. And, where do people find you? We track all of that. Don't blindly throw money at a bunch of things." In the end, online rating sites are just another element of marketing and communications efforts. "The fundamentals—marketing effectively, being in a good location, adding value, distributing educational materials, and so on—don't change," Chhoda says. "PT practices should have the fundamentals in place. Provide patients with an outstanding experience before they come in, during treatment, and afterward." Donald E. Tepper is editor of PT in Motion. Good News: Most Online Reviews Are PositiveDespite a practitioner's understandable concern that unhappy patients may flood sites with negative reviews, it turns out that most online reviews are positive. One study of more than 112,000 physicians rated on RateMDs came to this conclusion:6 Although some physicians are concerned that online ratings will become a channel for disgruntled patients to vent their complaints, our findings suggest that this is not the most common reason patients use the rating system. In fact, given that nearly half the physicians received a perfect 5 out of 5, online ratings appear to be driven by patients who are delighted with their physicians. Conversely, only 12% of ratings were below 2. These findings should allay concerns that online rating sites disproportionately attract dissatisfied patients; however, the prevalence of high ratings may reflect ratings selection regarding which physicians are rated.Another study of reviews of 46,300 physicians nationwide on Yelp and Google came to a similar conclusion. With a possible rating of 1 to 5 stars, 31% received a 5-star rating while only 12% received ratings of 2 or below. The study was conducted by Denver-based Vanguard Communications. Ron Harman King, the company's CEO, commented, "From our findings, it appears that doctors tend to get much better reviews than hotels, restaurants, and retail businesses. While some doctors indisputably suffer from unjust online comments, our snapshot of American healthcare providers indicates doctors in general enjoy widespread respect and gratitude from patients."APTA ResourcesAPTA has many resources and tools for PTs and PTAs seeking to establish or maintain a strong positive presence both online and offline. These include:BrandBeatAPTA's "Move Forward" branding campaign is designed to help PTs and physical therapist assistants (PTAs) strengthen their brand identity with consumers. Find videos, ebooks, and more to help you "live the brand."Market to Health Care ProfessionalsRelationships with other health care professionals—primary care physicians, nurse practitioners, psychologists, dietitians, and others—can be essential to the growth and health of your practice. Learn how you can develop an effective marketing strategy that targets potential referral sources.Public Relations and Marketing: Reach the ConsumersSections include:Guidance and Best PracticesSocial Media Tips and Best PracticesMarketing to Consumers ToolkitMarketing to Health Care ProfessionalsMarket Your PracticeWebsite TemplatesTV AdsAPTA's "Find a PT" ServiceEducate Consumers"Move Forward" on Facebook, Twitter, and YouTubeWeb GraphicsHealth Care Rating and Review SitesListed below are some of the online review and rating sites that include health care practices and practitioners. This article has focused on consumer ratings sites, but it's important to note that myriad other sites also exist.Consumer ForumsFacebookWebMDPatientsLikeMeConsumer Ratings SitesVitalsYelpHealthGradesCheckbookYP ZocDoc Angies List RateMDsKudzu Rating AgenciesConsumer Reports The Leapfrog GroupJD Power and AssociatesIndependent, Nonprofit OrganizationsNational Committee for Quality AssuranceCalifornia HealthCare FoundationThe Joint CommissionGovernment/State AgenciesMedicare.govMinnesota Health InformationMassachusetts Health ConnectorReferencesKadry B, Chu L, Kadry B, et al. Analysis of 4999 online physician ratings indicates that most patients give physicians a favorable rating. 2011. J Med Internet Res 13(4):e95. Doi:10.2196/jmr.1960.