Chapter 20 Health Care Marketing: Yesterday and Today Two Types of Advanced Practice Nurse Marketing Marketing Frameworks and Concepts Preparing for an Advanced Practice Nurse Position Preparing to Market Advanced Practice Nurse Services Marketing Avenues, Media, and Technology The current changes in the health care environment for advanced practice nurses (APNs) brought about by the Institute of Medicine (IOM) report, The Future of Nursing (2010), the Patient Protection and Affordable Care Act (PPACA; U.S. Department of Health and Human Services [HHS], 2011) and the changes in regulation based on the Consensus Model for APRN Regulation (National Council of State Boards of Nursing [NCSBN], 2008), all affect how advanced practice nurses (APNs) market themselves and negotiate practice contracts. Marketing is an important way for APNs to achieve stature as principal players in the health care arena during these unsettled times. To market themselves successfully, it is essential that APNs integrate clinical expertise, leadership, collaboration, other APN competencies, and business skills. In addition to understanding reimbursement payment mechanisms discussed in Chapter 19 and regulatory and credentialing requirements discussed in Chapter 21, all APNs—new graduates, seasoned professionals and those APNs striving to develop and maintain their own independent practices—must understand marketing and contracting. This chapter will focus on marketing the role of the APN as new graduates and experienced clinicians and marketing APN practice. It includes contracting skills and strategies for all APNs. Basic marketing concepts that any APN can easily use will be discussed. Although nursing has been consistently rated as the most trusted professional in terms of honesty and ethical standards for the 10th time in 11 years (Gallup Poll, 2010), health care has had its share of individuals who were labeled as charlatans or quacks, those who dealt in secret remedies, dubious procedures, and patented medicines. In an effort to distance themselves from these unsavory health care providers, the American Medical Association (AMA) created a Code of Ethics when it was founded in 1847 to address this issue. Chapter 2, Article 1, Section 3 of that document states (AMA, 2012a, p. 18): This policy continued into the 1903 revision, which stated that “It is incompatible with honorable standing in the profession to resort to public advertisements or private cards inviting the attention of persons affected with particular disease” (AMA, 2012b, p. 3). In 1922, the AMA Judicial Council amended its Principles of Medical Ethics and outlawed the solicitation or marketing of patients by physicians. This particular policy remained in effect until 1980. This historic prohibition must be addressed, corrected, and appropriately applied so that APN services can be made known to the public. Health care marketing is an evolving science. APNs, whether new graduates or experienced clinicians, have often relied exclusively on referrals, recommendations, and word of mouth to market themselves and their practice. Today, although marketing continues to include these venues, there is a trend toward specific marketing strategies and the socialization of health care marketing (e.g., via social media), which is changing the way marketing of any business or product will be done for years to come (Kingma, 1998; Segbers, 2010; Somers, Finch, & Birnbaum, 2010). APN marketing can be divided into two separate and distinct areas. First, new APN graduates must market themselves as they prepare to embark on their positions as APN providers. In this case, the APN is focused on preparing a portfolio that describes credentials, skills, and competencies that will induce a future employer to offer an interview, subsequent employment, and a contract. The portfolio allows the new APN to explore practice venues and to be as competitive as possible in the marketplace. The second form of marketing occurs when an APN chooses to embark on a business venture. This type of APN marketing is more complex and includes marketing to the community, populations of interest, and other health care providers. Both types of APN marketing will be discussed in detail throughout this chapter. Chapter 19 offers APN entrepreneurs further guidance in marketing strategies. According to Kotler (2011), marketing is “The process by which companies create value for customers and build strong relationships to capture value from customers in return.” That definition can easily be applied to APNs by rewording it as “the process whereby APNs create value for their patients and build strong relationships with them to meet goals and to capture value from them in return.” In other words APNs create the value by caring for patients and families and achieving better outcomes; in return, they are reimbursed for their work, more clients come to see them, and patients have improved health. One author’s working definition for marketing is broader: “Marketing is everything you, an APN, does, everyday to promote your practice, your ideas, your profession and you, the APN” (Phillips, AANP CE Center, 2010). Any health care–related business should be an ethical one. This implies that everyone—clients [patients], community, and APN—will win, getting what they need and want. So, this actually does include everything that the APN does to promote the practice, business, and advanced practice nursing. Although the previous definition makes marketing look rather simple, in reality it is a science that is based on psychology, neurology, sociology, and biology. Marketing aims to see how people are influenced by what they experience—see, hear, smell, taste and touch. People receive 3,000 to 20,000 images daily, which includes walking down an urban street, but more accurate research suggests that individuals visualize or take in an average of 247 messages a day (http://www. fluiddrive media.com/advertising/marketing-messages). The four classic concepts of marketing, often termed the 4Ps—product, price, place, and promotion—are the hallmarks of marketing (Chang, Pfoutz, & Price, 2001; Letz, 2002). Each of these categories provides opportunities to expand APN practice in diverse areas. A fifth concept, “partnering,” has become important as health care providers collaborate to provide better outcomes for patients. Many believe that the most important P is people, who are the recipients of the product being marketed (Reel & Abraham, 2007). The product is the entity that is offered to the market, such as a book or service, that is for sale. For the APN, the product is the APN and the services that APNs provide, regardless of the setting. Although professionals are not in the habit of thinking of themselves as products, doing so helps establish the value of APNs to the consumer when they offer high-level, nurse-driven care. Box 20-1 provides examples of the many types of products that APNs provide. Goods—direct care, health care applications, supplements, books Services—health care practice in APN’s specialty, health and wellness coaching, teaching patients and students Events—Continuing education conferences, other educational events, health fairs Persons—providing a service (e.g., motivational speaker, researcher, consultant) Places—healing centers, adolescent pregnancy clinics, professional offices, event, service Properties—Not always connected to health care, but a property can also be considered (e.g., clinics, hospitals, community) or intellectual (e.g., research, technology) Ideas—can lead to breakthroughs in research and other products that enhance practice and outcomes Information—educational materials provided to patients, students, and professionals for basic and continuing education; includes books, CDs, DVDs Organizations—national, international, specialty professional associations and organizations; universities Place refers to the accessibility and various tasks necessary to make the product available to the market (Chang et al., 2001). Places can be real or they can be virtual. In the past, patients, clients, and employers accessed APN services from a real place, such as a hospital, clinic, professional office, operating room, conference hall, or classroom. Today, and well into the future, APNs will find themselves using more technology and providing many of their products and services in a virtual space. Promotion encompasses activities that communicate the value of the product to the market (Chang et al. 2001). The terms marketing and promotion are often used interchangeably. On one hand, promoting (marketing) is educating patients, clients, and employers to increase their awareness of the service that the APN provides. Another use of promotion is an event or specific campaign within the overall marketing plan. In both cases, the desired outcome is to increase awareness and sell the product or service. Several strategies used to promote or market APN services will be described later in the chapter. One scientist frequently referred to in marketing circles is Dr. Robert Cialdini, who explored the concepts of influence and persuasion. Cialdini (2009) has studied how influence, persuasion, and compliance affect human behavior. He outlined six major factors that affect how individuals behave and how persuasion and compliance influence our buying patterns. • Reciprocation. Reciprocation has to do with give and take. For the purposes of marketing, the APN marketer gives something away or does something kind for someone else. In return, people have a strong overpowering urge to want to reciprocate. This phenomenon is frequently observed in fundraising (for example, receiving address labels along with a letter requesting a donation), free samples, and political lobbying (dinner with a celebrity). • Commitment and Consistency. Most people have a strong desire to look and be consistent in terms of their words, beliefs, attitudes, and deeds. They not only want to be seen as respected and highly valued in society, but they realize that consistent behavior benefits them in daily life. Consistency provides guidelines that allow people to streamline the process of living. In other words, people can make assumptions and rely on prior procedures without having to think each step through. An example would be preparing a meal or getting ready for work each day. Commitment is equally important; committing to daily exercise or committing to a life partner. In health care, APNs understand that getting people to commit to an idea (e.g., quitting smoking) is a large part of the battle in changing behavior. Once patients have made the commitment to change this behavior, they are far more likely to follow through. • Social Proof. Social proof is experienced in almost every aspect of one’s life. We may ask our friends which restaurant they would recommend. We ask our colleagues which Doctor of Nursing Practice (DNP) program we should look into. Also, our patients ask which health care provider they see and what they think of that individual. We usually are more comfortable with referrals and recommendations than we are with striking out on our own or paying attention to the marketing of others. This is why social media has become so important in marketing and will continue to play an important role in the future. • Liking. Liking is self-explanatory. Everyone likes to be around and say “yes” to people they know and like. Factors that influence liking are physical attractiveness, talent, kindness, intelligence, similarity, and familiarity. Liking can directly affect marketing efforts, regardless of the product. Social media has taken this to a new level. Patients, clients, and health care policymakers are more likely to do business with or champion a cause of the APN who they know, like, and trust. • Authority. Studies referenced by Cialdini (2009) paint an almost chilling picture of how the idea of authority exerts influence over people. It seems that humans feel a strong pressure to listen and defer to authority. This has been played out numerous times, including studies done showing how nurses in the past almost blindly deferred to physicians. Today, in many circles, APNs are recognized as authority figures for their expertise and trustworthiness. This promises that APNs can have a great deal of influence in their marketing efforts. • Scarcity. Scarcity is another center of influence that has been experienced by people worldwide. According to Cialdini (2009, p. 200), “opportunities seem more valuable to us when they are less available.” One example is the limited launch of a product such as an iPad or Nike shoes, or having limited quantities of influenza immunizations. The limited availability of these products caused some stores to put up crowd control barricades and have police on hand. People seem to give more value to an item or opportunity that is less available. APNs can observe this in employment and educational opportunities. Patients may experience this in the possible limited availability of a favorite health care provider. Resumés and curriculum vitae (CV) are often regarded as being one and the same. However, they have different structures and serve different purposes. Both reflect an APN’s professional life; the more extensive his or her nursing experience and accomplishments, the stronger will be the CV and resumé. The curriculum vita has been described as the so-called whole cloth of an APN’s experience and is a complete array of all her or his achievements over time. CVs are standard in format and content, are concise and organized, and content is added throughout a career. Usually, CVs are used for academic employment. On the other hand, the resumé is tailored to a particular job; it is marketing oneself to a prospective employer. The goal of a resumé is a visually clear and interesting representation of accomplishments. The average resumé receives about 20 seconds of review but may make the difference in getting a face to face interview with a potential employer. Table 20-1 lists the content categories for the CV and resumé. It is important to think through salary needs clearly prior to an interview, but past or current salary requirements should not be included in a CV or a resumé. Finally, and most important, is the need to proofread the document. Spelling errors, typos, poor grammar, and misleading data are certain avenues to failure. Exemplar 20-1 provides an example of an APN applying for a position as an acute care nurse practitioner (ACNP). Content Categories for Curriculum Vitae and Resumé To accomplish this goal, Jack considers his career goals and why this job is important to fulfilling his dreams of an ideal practice environment. First, he prepares a letter of inquiry that opens the door for an interview (Box 20-2). He updates the design of his resumé and CV so it is crisp and professional. He creates a portfolio highlighting his ACNP graduate education, volunteer work with community-based programs, and his emergency medical technician (EMT) experience. Also, he works with a faculty mentor to practice his interviewing skills to ensure that his presentation will be polished. He thinks carefully about what questions he might be asked, how he would answer them, and what questions he might have. He writes down important points that he wants to be sure to include if he is asked. Jack requests letters from faculty and patients who have benefited from his care as an ACNP DNP student. He looks forward to this exciting opportunity to fulfill his dream of practicing as an ACNP and teaching in a major medical center. Query letters are a marketing tool used to explore or create a need in a potential area of practice. They are personalized in the first sentence or two through the name of the referrer or through interest or ties to the clinical or geographic area. It is important to emphasize experiences that particularly qualify the person for the job. Query letters are short, longer than a paragraph but not a full page. They should be written as a business letter and carefully proofread before they are sent (see Box 20-2). New graduate APNs are often unsure of themselves when interviewing for positions. Being as prepared as possible may include having a resumé or CV professionally edited and formatted, or hiring a coach to improve interviewing skills, as Jack did. How much the APN will want to do and how much to invest is up to the individual. The SBA published guidelines about 3% to 5% of gross or projected revenues (www.sba.gov) is likely much more than most APNs will want or even need to spend, unless they are doing a major marketing effort to launch a practice (see next section). Successful interviews require careful preparation (Reel & Abraham, 2007). It is useful first to think about what APNs bring to the table. Asking these questions of yourself will build confidence: • Why are you the “ideal” APN provider in this case? • Why are you the person they should choose for the job? • Have you packed your portfolio with a current resumé, CV, credentials, and other information that this employer may want to see or that you want to present (e.g., example of a presentation, successful grant, community honor received)? • “Tell me about a time when you had to make a decision that you were unsure of.” • “How would you respond if you were facing ‘push-back’ from a physician?” • “So, why community-based primary care after all these years in acute care nursing?” • “How do you organize your day to get your work done?” • “We practice according to guidelines. What would you do if you thought it was not in the best interest of the patient to follow the guideline? An important concept for APNs to understand is that the service they offer as an employee or through their own private practice is a business (see Chapter 21). Practice generates revenue for the APN and/or employer. Although all APNs may not seem to generate revenue directly, all save money by preventing complications, improving outcomes, assisting others to do a better job, or educating patients to be healthier. This is particularly true if APNs are allowed to function to the full scope of their education and training as recommended by the IOM Future of Nursing report (IOM, 2010) and the PPACA (HHS, 2011). APNs who do not think of themselves as a business may not recognize that they have customers and clients who have different needs and require a myriad of services. Box 20-3 shows the people and entities considered to be potential customers and clients for APNs. Every business, whether an individual or a company, has a product—that is, something they are selling. For many APNs, that product will be themselves and their services (Box 20-1 lists other product categories). Note that several products can actually belong to more than one category, depending on how they are marketed.
Marketing and Negotiation
Health Care Marketing: Yesterday and Today
Two Types of Advanced Practice Nurse Marketing
Definition of Marketing
Marketing Frameworks and Concepts
The Four Ps of Marketing
Product
Box 20-1 Product Categories
Place
Promotion
Marketing Influence
Preparing for an Advanced Practice Nurse Position
Resumé Versus the Curriculum Vitae
Exemplar 20-1 Applying for an Advanced Practice Nurse Position
TABLE 20-1
Curriculum Vitae
Resumé
Education
Career goals
National certification
Professional accomplishments
Professional experience
Education and certification
Honors
Targeted professional experience
Publications
Community, leadership activities
Research and grants
Other pertinent CV items related to the position
Presentations
Consultations
Workshop, conference attendance
Professional memberships
Activities and committees
Community involvement
Query Letter
Interview Process
Health Care as a Business
Preparing to Market Advanced Practice Nurse Services
What is your Product?
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Marketing and Negotiation
Box 20-2
Box 20-3
