Of Purell and payment reform
Healthcare payment reform should happen faster.
This is an understandable sentiment for providers who have found it increasingly difficult to operate under the current system, and are under constant threat of further payment reductions. So I was sympathetic when the Partnership for Sustainable Health Care called for a speedier shift away from fee-for-service last week — and I also thought about Purell.
Yes, that Purell.
The story of how the alcohol-based hand sanitizer became inescapable in nursing homes, doctors' offices and hospitals, as reported last month in The New Yorker, is interesting and possibly instructive for the payment reform debate.
Purell was invented in 1988 by GoJo Inc., a family-owned soap company, and it promptly began losing money. Potential customers were fascinated by it, but “they didn't know what it was for.” This is according to GoJo C.E.O. Joe Kanfer, who remained a true believer in Purell despite its failure to catch on. He made it 25% of the company's annual sales target, Kanfer told The New Yorker, even though “they couldn't sell the stuff.”
There were some positive developments. GoJo scored a notable success when the Wegman's supermarket chain in New York installed dispensers in its stores in the early 1990s. Nurses who encountered the product loved it, and requested samples from the company. Yet, Purell was still losing money more than a decade after its invention.
So how did Purell become the behemoth it is today? Recognizing that people who used Purell loved the product, and seeing a market niche even before demand was high, Kanfer doubled down. GoJo launched an aggressive marketing campaign to make Purell the Kleenex of hand sanitizers. Kafner's timing was spot on: As his company went aggressive in its marketing, a series of studies confirmed that alcohol-based sanitizers are more effective than soap and water for killing pathogens on hands. When the CDC and World Health Organization changed their handwashing guidelines for medical professionals, Purell was there to meet the exploding demand.
One takeaway: Health professionals can implement rapid change, but they are driven by the hard data. For years, nurses and other healthcare workers knew that regular, rigorous handwashing slowed them down and harmed their skin, and many of them loved Purell. But the entrenched systems of handwashing were immoveable until respected scientists showed that through a different system, doctors and nurses could work more efficiently by cleansing their hands on the go, without compromising patient care.
This suggests that the Partnership for Sustainable Health Care and other groups are absolutely right to push for more rigorous data collection and data sharing about pilots of accountable care organizations and other innovative payment systems. Many providers recognize the current system isn't working, but just as in handwashing and Purell, large-scale change won't come quickly through leaps of faith in new alternatives, no matter how appealing they seem. Providers need to see the numbers.
Another takeaway: When it comes to implementing change, healthcare insiders may have a warped perception of time.
“The rise of Purell, as it was experienced by Kanfer and his employees, must have seemed agonizingly slow,” wrote David Owen in The New Yorker. “When viewed from outside, though, the arc seems different. The alcohol-based hand sanitizer was invented by a small private company that also made a hand cleaner for automobile mechanics … yet, less than fifteen years after its introduction, it led America's main public-health agency to dramatically change its recommendation for how doctors should clean their hands.”
With baby boomers aging and Medicare under pressure, the nation's healthcare system may not have the luxury of fifteen years to change. Long-term care providers taking regular hits from Medicare and Medicaid cuts are right to press for swift action to ensure their continued solvency and effectiveness. But no matter how quickly the process moves, it may feel “agonizingly slow” for those who see their margins shrinking week by week.
At moments of acute impatience, healthcare professionals may want to visit the nearest Purell dispenser and cleanse their hands, even if they can't quite calm their minds.