"The elderly man in the wheelchair next to my grandfather soiled himself because no one came to help him out of his chair for almost half an hour. The food was terrible. They misplaced my grandfather’s wound dressing, and it was only after my cousin, who is a police officer, went to visit my grandfather while in uniform did the employees change their tune. Shame on them! I plan to go to the Modesto Bee with my opinion and my grandfather’s experience. Don’t take your loved ones to this care home. It will break your heart."

In the seven years since this review of a central California nursing care and rehabilitation center was posted on Yelp.com, dozens of Web surfers have read these comments and at least 38 have found the remarks “useful.” However, with several hundred sites across the country, it wouldn’t be a surprise if, when it was posted back in July 2008, operators of this facility simply ignored the complaint.

A Growing Trend

About a decade ago when Yelp and other third-party websites began offering an outlet for consumers to share online their experiences with doctors and medical offices, they seemed to be riding the same wave of success that other digital media entrepreneurs had found upon launching websites where consumers could share their experiences with restaurants and hotels. These websites, sometimes financed by industry ads, served as a means to help people find businesses offering the best service based on the subjective experiences of other consumers.

But unlike a dining establishment, which might respond to a bad review with an offer for a meal on the house, health care providers then may have dismissed a complaint as an unscientific remark that didn’t merit a response. Or, at the opposite end of the spectrum, the provider may have pursued legal action against the poster, the website, or both (see sidebar).

Even as the online review process in this field has some flaws, health care marketing, legal, and quality professionals agree that it isn’t going away. As “rate-your-doctor” website content becomes part of the information patients use to make decisions on where to get health care, experts say physicians and other health leaders need to develop a proactive approach—one that includes encouraging patients to post even more reviews.

Consumer Reviews Move Markets

The stories consumers are sharing online about their personal experience with a product or service across industries, including health care, have social value because they incorporate new data that help make the marketplace more efficient, says Eric Goldman, a professor at Santa Clara University School of Law.

“There’s always been word of mouth and other ways for consumers to share their subjective experiences with the goods and services they’ve purchased,” says Goldman. “Consumer reviews systematize that subjective information and make it easier for other consumers to find and incorporate into their decision-making process.”

At the same time, Goldman, whose 15 years of research on consumer reviews includes compiling a list of lawsuits providers have filed against online posters, acknowledges the challenge of using consumer reviews as valid sources of information, especially in the health care industry.

“Just because consumer reviews have the potential to make markets more efficient doesn’t mean every consumer review will help with that goal,” Goldman says. “In fact it’s likely that some consumer reviews will be ill-informed and other consumer reviews will be fake or deliberately malicious,” he says.

“In order for us to get that social good of consumer reviews helping the marketplace become more efficient, we’re going to have some mistakes—incorrect information injected into the discourse. When it comes to decisions like health care, mistakes are a problem because it means people will be making literally life or death decisions based on mistakes.”

Online Reviews And LTPAC Providers

Even as a health care consumer likely will have a different set of criteria for finding a dentist for her eight-year-old son and selecting an assisted living facility for her 80-year-old father, reliance on consumer health care reviews for medical practice specializations may begin to change as these websites combine both subjectivity and science into their content offerings.

As part of its partnership with investigative news website ProPublica, San Francisco, Calif.-based Yelp last fall began including data alongside its consumer reviews. Yelp pages now offer government statistics on payment suspensions, fines, and emergency room wait times for more than 15,000 nursing care centers, 6,300 dialysis clinics, and 4,600 hospitals. ProPublica compiles the data from its own research and from the Centers for Medicare & Medicaid Services. Yelp says that it will update the data four times a year.

Additionally, a partnership between Colorado-based Healthgrades with the Associated Press in December to offer its consumer-based ranking and review content to the wire service’s network of newspapers, television stations, and other publishers further shows that someone values this content.

In addition to developments with third-party review websites, the venerable Consumer Reports is continuing to refine its online and newsstand rating resources to include patient experience.

New Patients, New Habits

Changes in the demographics of people seeking long term/post-acute care (LTPAC) also may impact how future patients use consumer reviews in decision making. In addition to nursing care and assisted living centers, LTPAC facilities also include rehabilitation centers and home health agencies for patients seeking temporary care after an accident.

According to a recent American Health Care Association quality report, only 854,000 out of the 3.7 million individuals who received care in a nursing facility in 2009 resided in the facility for at least a year. Eighty percent of the remaining 2.9 million residents that year were admitted for short-term rehabilitation covered by Medicare.

While LTPAC organizations typically have relied upon word-of-mouth referrals from patients, hospitals, and senior centers, a shift in the demographics of patients seeking LTPAC services may include consumers who have become accustomed to gathering information from online as they shop for their short-term care.

With customer satisfaction being added to the equation for Medicare reimbursement, rather than viewing the consumer reviews as a nuisance, experts say medical groups should begin to see consumer reviews as a tool to improve their services.

Unscientific Reviews

The biggest objection providers have had to consumer reviews about health care services is that they may tell only one side of the story, or they could include remarks that don’t reflect medical knowledge. Even as experts acknowledge these faults, they say that is no reason to dismiss them and it could be all the more reason to pay attention to them.

“Consumer feedback on whether or not they understand discharge instructions, for example, and whether or not they understand what medications they are on are critically important for their outcomes,” said Nancy Foster, vice president of quality and patient safety policy at the American Hospital Association, in a PwC Health Research Institute report. “These are things that patients can tell us that we can’t assess without them.”

Ron Harman King, founder of Vanguard Communications, a Denver-based marketing firm that creates website content for specialty health care groups and advises them how to maintain their online reputations, says that he has this conversation often with his clients.

“Yes. It is hugely unscientific, this thing called ‘rate-your-doctor’ websites,” he says. “There are going to be reviews by patients that are not fair in their judgment of the doctors. In some cases we’ve seen instances in which reviews were posted by people that were not patients. We’ve even seen evidence with cases that suggests the physician’s competitor has falsely posted bad reviews trying to smear his colleague’s reputation,” King says.

Hidden Expertise

“But I see a couple of things to keep in mind,” King adds. “There are legitimate praise and complaints on these websites, and the praise should be reassuring and the complaints can be important feedback every small business owner, including me, can act on to deliver a better service and product,” he says.

“Even as they may be unscientific, they have their own expertise,” Goldman says. “When it comes to medicine, the doctors are the experts, but when it comes to the consumption of doctor services as a customer, there’s lots of things patients have plenty of expertise about.” Goldman, whose work on online consumer reviews includes serving as an attorney for Epinions, goes one step further in his rebuke of physicians who dismiss online consumer reviews as “unscientific.”

“There’s an embedded arrogance in that retort that assumes that the people who are providing the review don’t know what they are talking about. Consumer reviews are an outstanding source of feedback about how your customers are evaluating your service, and savvy doctors listen carefully to the feedback they get,” Goldman says.

Garden City Healthcare Center

The images on Garden City Healthcare Center’s website offer consumers 360 degree views of the facility’s physical and occupational therapy gyms. They show a well-maintained patio area overlooking a landscape of greenery. Future patients also can see its sunny, semi-private rooms furnished with mahogany headboards and nightstands, blue bedspreads, and burnt-orange pillows.

But the granddaughter of one of their patients was unimpressed with this nursing and rehab care facility, which provides both short-term and long term care for patients recovering from stroke or hip surgery, as well as those with dementia.

“If you have loved ones, don’t leave them here. They will let them be in pain and negligence,” she wrote on Garden City’s Yelp page, describing the facility’s floors as dirty and the nursing staff unprofessional and inattentive to her grandmother’s needs. Since her remark was posted in February 2015, four people have marked the review “useful.”
Three days later, Aaron Bloom, administrator of the 104-bed care center in central California, posted a response.

“On behalf of the many caring professionals at Garden City Healthcare Center, we regret the sentiments you’ve described in your review of our facility. We are confident in the care and service we provide our community, but always welcome opportunities for improvement,” Bloom wrote. “In response to your review, I have met with all associated personnel to address your concerns. To further address your experience and review, I would welcome further discussion at your availability. Thank you.”

Even as he says consumer reviews of health care facilities can be one-sided, Bloom sees their value.

“I see them as being increasingly important. Consumers are more aware about the products and services they buy, and health care is no different. It’s important to have another person’s perspective,” he says. “There are many dynamics in health care, but at the same time I see value of providing an outlet for people who want an immediate form to respond.”

Based upon the average of its nine reviews, Yelp ranks Garden City three and a half out of five stars. Three of the reviews give the facility one star while the six others rank the facility three stars or better.

“Everyone here cares for the patients and loves their job!” the daughter of a patient wrote about the care her father received at Garden City after a stroke. “Forever thankful to everyone. Great team they have there.”

“Garden City was our favorite of the five we have experienced,” wrote the son-in-law of a physical therapy patient. “The management is very efficient, nursing is spot-on in their attentiveness and care, and their rehab is by far the best as to facility, equipment, and rehab therapists. … If you are looking for serious rehab, go to Garden City.”

“If you or a loved one needs to spend time in a skilled nursing facility, I highly recommend Garden City,” wrote the daughter of a patient recovering from a grave medical condition. “I’ve seen many others, throughout California, and this center is heads-and-shoulders above the rest.”

The facility actually has gotten new patients based on the sentiments in these reviews.

“Yes. Absolutely we have. It’s usually in addition to other experiences,” Bloom says. “We have heard, ‘I’ve read your reviews on Yelp.’”

Before taking on his current post as Garden City administrator, Bloom spent six years working in a business development in an acute care setting.

“When I took this position I didn’t expect I would be checking Yelp.com every day, but I do,” he says. In addition to monitoring Garden City’s Yelp reviews, Bloom also has added photo and video content to its Yelp page to provide more information about the facility, one of 60 in the Plum Healthcare Group located in California, Arizona, Nevada, and Utah.

Advice To Providers, ‘Order More Reviews’

To promote positive public reviews and curtail negative remarks, King advises his clients to ask patients to review their experience.

“There are ethical ways to do this. Have patients fill out customer service satisfaction surveys. It takes less than three minutes, and they can do it as they leave the appointment,” he says. “This gives instant feedback, and if someone is unhappy, we have the opportunity to resolve the issue.”

In its own research, Vanguard Communications found that the majority of providers get good rankings on public websites. In a 2014 study of 46,000 physician reviews on Yelp, Healthgrades, Vitals, and other third-party sites in 100 cities across the country, 77 percent ranked three stars or better, while 12 percent received an average of less than two stars.

King says that the negative reviews often were the result of poor customer service and bedside manner. In a 2013 study of 3,617 online reviews of doctors in four U.S. cities, Vanguard found that 21 percent of the low marks reported physician skill as a major concern, while 43 percent cited the doctor being tardy or dismissive of their concerns, and 35 percent complained about customer service issues related to billing and office procedures.

Yelp’s ranking of Garden City’s ranking also seems to illustrate the “wisdom of the crowds” phenomena, a theory
first introduced in 2005 by New Yorker staff writer James Surowiecki.

“Rather than chasing just the one expert who can tell you what to do, we are much better off when we can have lots of data points and then find the average or the consensus view,” says Goldman in an explanation of the theory. “Consumer reviews follow that pattern. In other words, any individual review is not necessarily reliable, but in aggregate they’re actually startlingly reliable.”

Managing An Online Reputation

Applying this principal to health care reviews might help Garden City and other LTPAC facilities offer a fuller picture of their facility on third-party websites, he says.

“If we believe that any individual review isn’t necessarily credible, but the aggregate of reviews is credible, then doctors should be encouraging a larger number of reviews so there’s a larger number of data points to confirm or rebut any individual review,” he says.

And that can have a positive effect on a health care company’s bottom line.

“We’ve already seen some savvy doctors who have embraced consumer reviews, and they have market leadership now over their competitors because they are already getting that power of the wisdom of the crowds in recruiting new customers,” Goldman says.

For King, the relationship between third-party review websites and health entities doesn’t have to be antagonistic. Maintaining a good online reputation on consumer review venues is easy, he says.

“We have done exhaustive research on ‘rate-your-doctor’ websites. The surprising conclusion is that people overwhelmingly want to love their doctors, and it doesn’t take too much effort to have them love their doctors,” he says.

King’s top advice to his clients for maintaining their online reputation is to first give good customer service. Second, he advises clients to use “rate-your-doctor websites as feedback tools” to improve their service and finally to realize that they won’t be able to please every patient.

“Everybody in business these days is likely to have an Internet presence and someone complaining publicly about their goods or services,” he says. For example, “It’s easy for a doctor to be liked and respected by his patients, particularly when that doctor makes an effort to be good not only clinically, but to be a good, caring caregiver and extending that culture to his entire clinic.”

To be sure, monitoring a half dozen websites on which their patients could post a review can be challenging. But providers should view the infancy of this industry as an opportunity to help shape it. Right now each site has a different approach to the content that it allows patients, residents, or family members to post and the level of interactivity providers can have with reviewers.

“There are several sites that have a little bit of leadership compared to the others, but there’s not a single site that we associate with doctor reviews,” Goldman says. “With no dominant provider dictating the terms, it’s a great opportunity for the health care industry to think about what it wants from a review website and speak up.”

See Privacy Concerns.
Cassie M. Chew is a health care reporter based in Washington, D.C.