Fishbone Diagram: Promotion Category

Product Place and time Price Promotion Process People Productivity Purpose

There are many strategies for well run promotions. The AMA employs a promotional strategy to gain members by allowing medical students to join at greatly reduced rates. The AMA follows a strategy that uses elements of discounts, limited time offers, and versioning.

Hopefully, for the individual medical student, the discounted rate is a limited time offer and they are eventually eligible for the more expensive physician rate. The experiences available as a Student differ slightly from those enjoyed by a Physician. The distinction between these two versions is most evident during the National Meeting when two separate House of Delegates are maintained in a fashion similar to a House of Lords (Physicians) and House of Commons (Student section).

Versions work best when different tiers more closely approximate the individual needs of users. For example, only the most gunner Medical Student would think that they benefit professionally from spending time in the Physician House of Delegates. While the pomp and circumstance of that venue is an enriching experience, the small talk with physicians that ensues is unlikely to make a lasting impression. Working with peers has more peripheral benefits. The versions employed by the AMA appropriately assign members to work with their colleagues and are priced accordingly.

Price doesn't equal Value (Fishbone Diagram)

Product Place and time Price Promotion Process People Productivity Purpose

When setting prices, a business avoids going too low. Of course, we understand this fails to maximize profit. More importantly, consumer behavior demonstrates that a product which is sold for a lower a price than its competitors, is first considered a value. Eventually, the price difference becomes too great. Then the discount is no longer judged to be a better value, and begins to suggest that the product is inferior. For many consumers, the product which they believe has the most value is the second most expensive. For this reason, a business will develop a luxury version of their product. While it may manage to sell a few of these highest end items, more benefit is derived by the now second most expensive item being perceived as a better value.

The price schedule for the AMA is cheap when compared to other professional organizations such as that for trial lawyers. Could the low cost lead many physicians to question how relatively inexpensive professional organizational fees can return value? What if the annual dues were doubled? Would physicians anticipate more value and respond by joining the AMA?

Zane highlighted that much of the cost of participating in the AMA is incurred by traveling to the national meetings. His recognition again raises the question whether a national organization is needed. Or, perhaps Annual and Interim meetings are not regularly required. More productive work may be invested in local improvement, rather than preparing for the next national meeting. When the total cost of participation is largely related to travel expenses, then the disconnect between price and value widens further.

Reviewing the price we find a lot of wasted value. This concept of waste, arises repeatedly in medicine. In the case of the AMA annual events the waste takes the form of travel. Going to Chicago is a fun time, no doubt. However, many physicians would just assume take a legitimate family vacation. Travel to Chicago for CME and professional development workshops allows value to dribble away as hotel receipts, cab fares, and hasty lunches.

Instead, physicians could receive more value by attending regular meetings at which local financial consultants educate attendees on choosing a medical equipment loan from options locally available. They would attend such conferences with neighboring physicians and discuss the local problems they face. Rather than mulling over what they'd like to do about those problems, then only delivering their decision as a single vote to a national legislative body, they could take action--locally and immediately. Of course there are national problems physicians face which require a national organization. One such problem is how to best adopt EMRs to achieve the furtively defined, "meaningful use." Perhaps a local forum in which physicians can offer lessons learned from their adoption of EMR would be more beneficial. As more and more small clinics merge to grapple with increasing overhead, the need to know local fellow physicians increases.

Now, we'll put more meat onto our Fishbone Diagram. The new problems identified:



By picking apart price, we have noted additional problems with Place. Creating a fishbone diagram should allow this sort of active brainstorming. We can quickly categorize this newly identified problem under its appropriate Place label as we fill in the Fishbone Diagram.

Political or Practical (Fishbone Diagram)

In his recent post, David shared reactions to the recent AMA Annual Meeting in Chicago. Its dwindling membership has led us to question the direction the organization is heading. While we at Two Directions agree there are numbers in healthcare which should not rise, we look to reduce costs and would prefer to increase participation.

To analyze the problem we’ll use the Fishbone Diagram tool, and hope to accomplish the aim of this blog: to demonstrate how QI tools are used so they can be more widely applied to healthcare. In doing so, we also hope to consider solutions to the AMA’s dwindling membership. Given that several of us writing are members, we hope this process can inform our own engagement with organized medicine.

Fishbone Diagrams are a tool to conduct root cause analysis. Here, we’ll look for the root cause of the problem: why do so many doctors not participate in their main professional organization? To analyze this problem, we will organize our brainstorming into categories. This structured approach to problem solving is a technique for physicians to approach QI. To be not only creative, but effective, brainstorming often needs to follow a method; especially when working with a group. Because the AMA is essentially offering services to members, we will seek root causes by organizing our thoughts into the following service oriented groups.

Product Place and time Price Promotion Process People Productivity Purpose

As a happy coincidence, each group starts with P. A few notes about them:

• The first 4 P’s listed above are the classic 4 P’s of marketing
• While QI analysis usually considers “Process” in the scope of a product delivery or manufacturing, in this post we want to focus on the AMA’s legislative process. In a sense, it is a manufacturing process for crafting its organizational objectives
• Since the AMA acts as an advocacy organization, its Purpose is an important factor in determining its quality

To begin filling out this bare-bones diagram, consider how the AMA’s products alienate or fail to meet the needs of potential physician members. As we begin to fill an empty white board, we'll recognize that the product faults we identify are better categorized into another group, such as Place and Time.

CPT Codes. The use of the Current Procedural Terminonology codes to bill insurers is responsible for a large part of back office overhead. Physicians are often required to use these codes to receive reimbursement. Since the coding system changes often, physicians must hire employees who maintain this specialized skill.

Yet, the process adds no value to the Patient-Physician relationship nor does it improve patient health. Sometimes regarded as a cozy monopoly fostered by the AMA and insurers, CPT codes complicate the relationship between physicians and patients. The complexity of the coding system edifies the overhead expense of a medical coder, and facilitates the insurer practice of holding up or denying legitimate claims. Despite this detriment to physicians and the practice of medicine, CPT licensing generates annual revenue on the magnitude of tens of millions of dollars for the AMA.

Advocacy. Many physicians feel the AMA advocates for positions which they don’t agree with. Rather than advocate, the AMA may do better to inform. Individual physicians could then better assess how the actions of Congress fit with their personal views. Rather than pay professional lobbyists millions of dollars, the AMA could further shift its focus towards empowering physician's to use their voice in public forums. Again, the AMA's current approach fails to add value for physicians but does reward the lobbying firms the AMA retains. (Product)

Development.The AMA purports to be a professional organization, but has been overtaken by physicians with a fetish for politics. My own experience at A-11 had few opportunities for professional development. The main event was the legislative process. Medical students were exposed to JAMA, AMPAC, pomp and circumstance, but essentially no guidance on the transition from medical education to medical professionalism. A review of the AMA website points to some professional guidance. However, much of it seems to reinforce other AMA products such as the CPT codes. Google is appreciated by its users because the new technologies it offers are designed with the intention of making Google more useful. The AMA is unappreciated as its products seem to only reinforce its necessity.(Product)

The AMA does provide a generous experience to get involved with politics. Participation would likely bolster professional skills; politics and marketing have much in common. However an intensive course, set in Washington, D.C. is impractical to the demands of medical training and practice. (Place/Time)

Continuing Medical Education is a component of a physician's ongoing training which does have the potential to add value to the Patient-Physician relationship. CME offerings compete in a crowded market. The AMA offers CME credits through JAMA and via its Annual and Interim Meeting. Overall, a physician's specialty is typically more successful at meeting educational needs by offering more relevant CME topics. (Product & Place).

A fishbone diagram could capture and portray this analysis as: