In a previous life, I did 'strategy' consulting for large organizations, start-ups, and everything in between. Strategy consulting generally involves thick binders, lots of numbers, and some cool charts.

My particular bent focused on helping my clients really dig into what we called their 'customer value proposition. 'That fancy five dollar consulting term was driving at a couple of issues. What does your organization actually deliver to your customers that they value? And do you deliver a form of value that is special and different, something they can't get anywhere and everywhere else?

We tried to get really honest about whether the 'market' sees as them as differentiated, and if so, where. It is always tough to separate what you believe (or want to believe) about your organization from what the market believes.

You can talk yourself into things, but knowing what the market thinks is pretty easy. Customers express themselves with their feet. If you are really differentiated, if you are really noticeably better, faster, or cheaper, they come.

If people aren't flocking to you, it might be a marketing problem. That is what everyone says and believes initially.

'We're really good, we just have to get our word out. Fire the marketing people and buy some Google ad words.'

Yes, it might be a marketing problem.

But more likely, more often, you're just not really as good as you think. As the old saying goes, sometimes the dogs just don't like your dog food.

You better deal with it or you're going to waste a lot of marketing dollars. Good for the marketers, not so much for you.

For years, healthcare providers, physicians and hospitals alike, have lamented that payers won't pay for better quality. They care only about the price. There is plenty of evidence to support the claim.

Yet, there is also plenty of rebuttal from payers that says you haven't really demonstrated that your quality is better, and even if you did, you'd also have to demonstrate that better quality has financial benefit because our customers, the employers and individuals, need their costs to go down, not up.

It is like Garrison Keillor's famous quote, 'Welcome to Lake Wobegon, where all the women are strong, all the men are good-looking, and all the children are above average.'

Is it possible that not every physician who claims to be better than the pack really is?

And is it possible that even if someone is better, they are only marginally better and it is not better enough for the market to notice?

Or, that even if they were accepted as really better, it just wasn't worth any price difference?

But I want to take a slightly different tack on this subject.

We, on the provider side, have long focused our frustration on this topic around the imbalance of power between the physician and the payer. And rightfully so.

Since most physicians work in small practices, they know they have no leverage with the payer. Whether the discussion is about paying for quality, or rates in general, or administrative processes, or anything else for that matter, the physician usually is on the short end of the stick.

The government, United Healthcare, Blue Cross, Aetna, etc., etc.

They are big, we are not.

They can't, or won't, discern who provides better quality and who does not. So everyone gets paid the same way.

Things may be changing, at least on the fringes.

One of the consequences of patients paying more and more of the bill is that they are becoming more active consumers. They are paying more attention to decisions about where they get their care. They now want to talk about costs ahead of time. They are asking about the physician's qualifications and training. They want to explore alternative treatment options. And of course, they have this Internet thing where they can get a lot of information for the discussion.

This all creates great opportunities for those who really are exceptional, not just Lake Wobegon good. They can now begin to get around the monolithic payer cartel and get directly to the market.

But what is interesting is how we are beginning to see this sword cut both ways.

As patients become prudent consumers, those that fall short of the standard are going to get punished. Most likely, punishment for the sub-standard providers will come faster than rewards for top-tier players.

Since I spend a lot of time selling into the market, I hear lots of stories. I've heard several of the downside stories recently. Here are three.

Patient visits are down in many geographies and clinical specialties. Practice seeing declines can easily rationalize this away and blame it all on the economy. A large specialty clinic has experienced just such a slight decline and initial explanation. However, when they dug into the data, it turned out that the drop in visits for the group was not evenly distributed. Some providers were not off at all, while others were down much more sharply than originally thought. To no one's surprise, the physicians whose volume is off are those who consistently get the most complaints from patients and staff, have more coding and documentation problems, and are not regarded as the best providers by the other physicians in the group. They are all in the same market, all on the same contracts, all supported by the same practice operations, but some are fine and some are declining.

In one market, seniors are reported as having to call physicians as far as 45 minutes away to find a practice that will accept new Medicare patients. Yet in that same market, some internists have had to become hospital employees because they cannot get enough patients.

One female internist had a stellar reputation, especially among female patients, in her community. The result was in a long wait list to get into her practice. Maybe she did not get a different level of reimbursement for her high quality, but she did get a lot of demand, which let her be a little more selective about the payers she accepted. Something must of happened because she has changed. Annual exams, which had been noted for the thoroughness, are now three minute fly-bys. Instead of great probing questions that caused patients to describe her as a great diagnostician, reports now use words like 'distracted' and 'not really listening. 'Patients who had recommended her widely are now directing their friends to look elsewhere. And now, there is no waiting list.The practice is not as busy as it should be.

As the process of restructuring our industry continues, the rise of the active consumers is one of the major changes that we will see.

If you are good, really good and not just a legend in your own mind, it presents a great opportunity.

If you are not good, unfortunately the road that leads to your practice also leads away from it.