The false promise of ROI
During the last healthcare conference I attended in my career in 2025, I facilitated a panel titled “Defending ROI.” The panel featured three very senior, very respected health system CMOs, and the room was so full people were sitting in the aisles and standing in the hallway entrances. Kicking off the session, I sarcastically said, “Wow, look at this attendance! People must be curious about this new thing called ROI.” After laughter, I then shared the sad truth: before the session, the panelists and I were discussing a copy of the conference agenda from 20 years ago that showed sessions on how to build ROI. I turned to the panelists and said, “So here we are again two decades later and we’re all still trying to figure out ROI. What the hell is up with that?”
I had my own views back then about why ROI was still a hot topic, but after a year away from healthcare marketing, those views have shifted. Today, I would humbly suggest that chasing ROI as a health system marketer is a losing proposition. I hesitate to discourage health system marketers from chasing marketing ROI. Indeed, if you are having success receiving praise at your organization for the ROI you’ve shown, more power to you. And it’s not the pursuit of ROI that is the problem – it’s the belief that you can attain it in a meaningful way and receive due credit for it from your leadership that now rings false.
The primrose path
For those of you that know me, that may sound a bit crazy. After all, I spent the better part of my 25-year career in healthcare marketing imploring marketers to pursue ROI. And before we go too far, let’s just level set on what I mean by “ROI.” I’m talking about financial ROI, where you employ a standard formula to calculate the financial return on a marketing effort, typically shown using contribution margin as a ratio. So an ROI of 4:1 on a marketing effort costing $1 million means the effort has netted $4 million in contribution margin. Let’s leave aside the nuances of that calculation – they are many, and some contribute to the dearth of true ROI reporting in the space. The point is, I’m not suggesting marketers don’t strive for impact, which can be measured in 1,001 ways. Demonstrating the impact of your work is critical to demonstrating the value of your role no matter what role that is. But showing financial ROI is just one way to show marketing impact or results, and my contention is that financial ROI is overvalued in the space and will not deliver what either marketers or their organizations truly need or value.
But back to my changing perspectives. Back in 2009, I authored my second book, “A Marketer’s Guide to Measuring Results,” where I called financial ROI “the holy grail of financial metrics for marketers.” In the 2011 book “Joe Public Doesn’t Care About Your Hospital,” the fifth means of transforming health system marketing I outlined was “Measure, Measure, Measure!”, including measuring ROI. In 2018’s “Joe Public III: The End of Hospital Marketing,” ROI was cited multiple times as a key goal for successful marketing. Even recently, in discussing the future role of the CMO in 2024 and 2025, we implored, “don’t forget about ROI!”
So 25 years of advocating for ROI measurement, and I of course was not alone in that pursuit – many others in the health system marketing space have pushed as well. Along the way, I had firm beliefs about why health systems struggled to show financial ROI for their marketing efforts. Primarily:
The industry was still relatively young and needed time to mature
Systems needed more budget to afford the martech systems necessary to measure ROI effectively
Health system executives needed more time to educate themselves on the value of marketing
All of those perspectives were based on research, conversations over the years, and personal experience with dozens of health system marketing functions. Yet something funny happened on the road to ROI enlightenment…not much changed. As evidenced by a 2025 overflow panel on defending ROI, most health system marketers still struggled to achieve meaningful ROI for their marketing efforts. And while I used to think eventually we would, I now believe we never will.
The false promise
So why the 180 on chasing ROI? Again, it’s not that striving for ROI is inherently bad. Nor do I take away from those who have proven it (assuming it was proven correctly, but that’s a post for a different time). And to reiterate – it’s critical to always seek to demonstrate the impact of your work and its value to the organization. But there are three reasons I would use to advocate that health system marketers stop making financial ROI a priority:
If it hasn’t happened by now, it’s not going to happen. Health system marketing has been around as a formal discipline since the 1980s, so roughly 40 years. And throughout that time, we have not achieved a consistent level of financial ROI approaches, metrics or results. Not even close. We can’t even agree on the specific definition or factors of financial ROI. (For example, some marketers claim ROI based on gross revenue – they might as well be using Monopoly money.) If we haven’t figured this out by now, I’m no longer confident it will ever happen. That means the reasons I cited earlier – industry maturity, martech budgets, executive understanding of marketing – will likely never reach levels that make measuring financial ROI mainstream. That’s not a criticism of marketers; that’s just a reality check on the industry we’re in. Health systems are mission-driven organizations (at least the non-profit systems are anyway), and marketing will never achieve the status it has in other industries. And a big reason for that is…
CEOs will never equate marketing with growth. This is another tough message to hear, but most will have a hard time arguing with it. Based on years of experience, research and conversations with C-suite executives, there are three things executive leaders believe will materially impact their financial growth: mergers and acquisitions, payor contracts, and geographic/service expansion. In other industries, marketing leaders would be involved at a strategic level in those strategies, or maybe even driving them. And of course, in other industries, promotional marketing and advertising do materially impact growth – retail, automotive, consumer packaged goods, etc. But not in the health system space. As evidence, just talk to those CMOs who have figured out how to measure the financial ROI of their marketing efforts. How do CEOs, CFOs or other top executives respond to their ROI reporting? With a yawn. After all, for a health system with a net patient revenue of $4 billion, a net return of $500,000 on a marketing initiative would be a rounding error. One CMO I spoke with said, “Honestly, my CEO is not calling me and asking for this. It’s not one of my annual goals he sets for me.” Or as good friend and colleague Chris Boyer tells it, when he once shared strong financial ROI with a CEO, he was told that the numbers were “quaint.” Throw in the fact that many health systems are overflowing with patients, causing CEOs to question the value of marketing overall. Or that many C-suite executives and physician leaders value your marketing activities for their visibility, not their business impact. All of these combined help show why even marketing activities showing actual ROI are not valued in your organization.
In 2020, I co-authored “The Gospel of Growth,” where I wrote the following about growth:
“For hospital and health system marketers, this is your watchword. Your North Star. Your one thing. Your vision. Your goal. Your objective. Your mantra. Your raison d’etre. It’s all about growth.”
Over the past few years, I’ve come to believe that I was wrong. It’s not. At least not through trying to measure ROI.There are better ways to demonstrate your value. If your head is spinning from this fire hose of bad news, don’t despair, because there’s light at the end of the tunnel. The ServingOverSelling movement calls for a reallocation of promotional marketing to focus on areas like the consumer experience, access, internal engagement and community health for a few reasons. The primary reason for this movement is that wasting money on promotional marketing that is for the most part ineffective and expensive should give anyone pause when millions of Americans can’t afford healthcare in this country. But also because moving away from promotional marketing to those other strategies will actually make your organization stronger and will allow you to demonstrate even greater value in your role as marketing leader. Because while we call for a curbing of brand advertising, we still know how important brand reputation is to your organization. Chasing minimal ROI on that service-line campaign will do little for your organization’s long-term success. Helping improve the patient journey, or helping local organizations combat community health issues, or ensuring your organization’s workforce is satisfied and productive – these will all build a stronger brand reputation with actually staying power.
So again, if you’re one of the lucky few who have been able to measure financial ROI, or if your C-suite is demanding it, by all means go for it. But I believe it’s time to call out ROI for what it really is – a “quaint” result that needs to be put in its proper place so we can instead prioritize ServingOverSelling.