In this conversation with Paul D. Vanchiere, MBA of Pediatric Management Institute, we explore the financial implications of practices and clinics offering nurse telephone triage.
ClearTriage: It’s exciting to be able to talk with you today about telephone triage from a practice management perspective! So far in our blog articles we’ve interviewed nurses and other clinical staff about triage, but you have a unique perspective with your practice management background. Before we jump into your thoughts about telephone triage, could you share your story with our readers?
Paul: Well, I grew up in a medical practice that was run by my father and I literally spent my summers working in a medical office. After graduating from college, I worked for my father helping him to grow from eight pediatricians in three locations to eighteen providers in eight locations in just a few years. During that time I really sank my teeth into the operational and financial issues of the business.
After that I worked with a couple of other specialties including a pathology laboratory and a group of cardiothoracic surgeons, then I oversaw collections for a third party network. But my first love has always been pediatrics and so I ended up at Texas Children’s Hospital managing a practice. From there I transitioned to the corporate office and worked with issues related to physician compensation. While doing this, I discovered that there is a great need for independent practices to have someone who understands the business of medicine as well as the realities of being an independent physician, finding ways to help them remain competitive. That’s why I formed Pediatric Management Institute five years ago.
ClearTriage: You really have a wide background in running a practice, both within pediatrics and also other specialties. Let’s jump right in with the big question: From a business perspective, why should a pediatric practice offer nurse telephone triage?
Paul: First of all, telephone triage is a vital service that needs to be provided by the practice rather than by someone else. Today there is competition for information from Google and other places and it really is in the practice’s best interest to position themselves as the provider of accurate information for their patients. The second part is customer service. It is getting more competitive for practices to compete with urgent care centers and retail-based clinics and that has taken a big toll on a typical pediatrician’s office. That being said, phone triage really allows you to excel in customer service. And then the final part is that obligation to keep our patients from utilizing unnecessary services. Sometimes a quick phone call to the pediatrician’s office can save a $500 trip to the ER for something that can be handled over the phone or by way of an office visit. Those three different areas are the primary reasons why a pediatric practice needs to be well equipped to offer triage service.
ClearTriage: The last issue you mentioned is interesting because I would think that if you saved someone that trip to the emergency department, you’re going to build a lot of loyalty to your practice.
Paul: Yes. Unfortunately in today’s age some people operate more out of convenience rather than considering the long-term consequences. Offering triage services really dovetails with the concept of a medical home. If you want to call yourself a medical home, then you need to be available to parents who have questions. Having an effective triage service compliments and supports the philosophy that so many pediatricians subscribe to, which is providing a medical home.
ClearTriage: To be balanced in this discussion, I know that some doctors will argue that offering telephone triage doesn’t make financial sense for their practice. Can you explain that argument and their thinking to our readers?
Paul: I can’t explain it. I don’t understand and I don’t see how it makes financial sense not to offer triage services because you’re building that loyalty among your core patients.
ClearTriage: The reasoning that I’ve heard is that it doesn’t make financial sense because you’re paying a nurse for an unreimbursed service that keeps people out of your practice. One doctor I met had a short version of this argument: “If they’re sick enough to call, they’re sick enough to come in and be seen.”
Paul: Yeah, unfortunately I don’t think that is a very strong argument because the value you derive from the customer service far exceeds what you’re paying for that nurse. A lot of times they’re going to offset their cost by encouraging patients to come in and get something checked out. So it’s not totally a sunk cost. The other portion of the cost is customer service, marketing and being there for your patients. It really needs to be viewed as a marketing angle: we are here for you when you need us. Because whenever a pediatrician abandons the concept of a medical home, their patients are going to seek care elsewhere. And I’ll be honest. I know people who’d rather go to the urgent care center where they are going to get in and out quicker. The quality of care is going to be worse. And they may end up going back to the pediatrician. At the end of the day it’s really about supporting the concept of a medical home. To do that you have to be available to guide your patient.
The other thing I find is that a nurse who is assigned triage is not spending 100% of their time just working on phone calls. A lot of time they’re doing other administrative duties that would fall to someone else. So if they’re spending half their time on the phone and the other half helping with referrals or follow up and other things, it’s not really all of their salary on telephone triage, it’s just a fraction of that. Does that make sense?
ClearTriage: Yes it does. There are a couple of other angles to this that I’ve always wondered about. When someone says, “If they’re calling I’m going to book an appointment – I’m not going to pay someone to tell them not to come in.” But what if they need to go to the ED instead of coming to the office? There may be a liability there if you’re booking a non-urgent appointment for someone who needs to be seen urgently. Let’s say a call comes in at three or four in the afternoon, you don’t have any appointments and you book the appointment for tomorrow. What if it’s an emergency and the patient has a bad outcome because you’re not providing triage?
Paul: Right, a triage call can help keep a train wreck from happening. If a child fell off the playground and hit their head, you know the triage nurse can counsel them on what they should be looking for and deciding whether or not the child needs to be seen in the office, at the ER or if everything’s okay. If you don’t have a triage service, the child falls in the playground and bangs their head, then an hour later their pupils are dilated and they’re vomiting. Then they show up inside your office when they should have gone to the ER. You may have been able to avoid that from happening.
ClearTriage: The worst case, the horrible case with the scenario you describe is that it’s the end of the day and you schedule an appointment for tomorrow and something goes horribly wrong overnight. It’s a very low likelihood, we don’t want to sell based on fear mongering. But those small percentages can wind up in a lawsuit that can wreck havoc on a practice. Triage isn’t just telling people to stay home instead of coming into your office. Triage also identifies potential life-threatening issues that need to go the ED.
Paul: Correct. It is really about steering the patients to the appropriate resources to avoid the train wreck walking into your office. Pediatrics is in the service business. Part of providing good quality service is an effective triage program.
Also, there are some patients who demand that they speak with someone about their child. A lot of times talking to a triage nurse is actually much more cost effective than having them talk to the physician. Now some patients will still insist on talking to the doctor, but if you don’t have a triage nurse, you’re going to have more patients who are going to consume more time from the pediatrician or they’re going to go somewhere else to satisfy their expectations.
ClearTriage: But I believe the pediatrician can charge for their phone time.
Paul: There’s a lot of ambiguity as to who’s going to pay for what. In an ideal world there needs to be some value assigned to nurse triage calls. It may be several years but hopefully eventually the insurance companies will start paying for them.
ClearTriage: You also have the fact that more and more people are moving to high deductible plans. If someone calls into the office and talks to the provider, then later gets a bill that they weren’t expecting – they’re not going to be happy about that. And that gets back to customer service.
Paul: Correct. This is not a situation where you’re going to get paid for every piece of advice you’re giving. Triage supports the idea of a medical home and providing a service that people have come to expect. And if a pediatrician chooses to ignore the ever-changing dynamics of today’s market, it’s going to be hard to remain competitive.
ClearTriage: Let me switch the focus of this discussion a little bit. If parents want to talk to the physician and the physician is booked up with appointments all day, that means the physician ends their day and then has an hour or two of phone calls to return. Which can be horrible for their work-life balance.
Paul: In some of my more successful practices, the last patient appointment is at 4:45, they are done by 5:00 and they are out of the parking lot by 5:15 because they stay on top of their coding, they have good triage and they don’t have to worry about phone calls at the end of the day. They are very efficient in managing their time. In order to be efficient, you’ve got to leverage resources to help you get out of the office at the end of the day. Nurse triage is a vital part of that efficiency.
ClearTriage: You’ve spoken highly of ClearTriage in the past and we certainly appreciate that. Why do you think ClearTriage is a valuable tool for a practice that offers nurse triage?
Paul: Well, when I first saw ClearTriage, I thought it was the best thing since sliced bread. And the reason is because of compliance and consistency of service. When your nurses are using ClearTriage, if they’re following the way the program is designed and set up, you can rest assured that the same consistent and appropriate advice is being given to your patients day in and day out. From a compliance perspective, using protocols really is the acceptable level of care. And then there is the documentation piece. The integration with an electronic medical record to have documentation of what was said is paramount in today’s society with so much litigation. Finally, from a customer service aspect at the end of the call the parent can get a text that says, “Hey, this is what we talked about.” I can think of a lot of people who are going to have a hard time remembering exactly what the nurse told them. The ability to have appropriate information provided in a compliant fashion that easily reminds the patient of what was said is a trifecta in terms of delivering effective triage services.
ClearTriage: Thank you. Is there anything else about telephone triage that you haven’t had the opportunity to share yet in this conversation?
Paul: I think the only thing I can harp on, and it is really a broken record at this point, is that in order to truly deliver on the concept of a medical home, you have to have a triage service. And if you subscribe to the fact that you’re going to have a triage service, you need something like ClearTriage to be able to help you manage it in a way that is efficient, compliant and mitigates liability.
Too many times I walk into an office where they have a couple of nurses or medical assistants doing triage, and there’s Barton Schmitt’s protocol book at the bottom of a pile of papers in the far right-hand corner of the desk. Nobody is using it! Granted, for common issues it may not be a big deal. However, from a liability and consistency perspective, it’s important to have the right processes in place. This becomes especially problematic when medical assistants are handling phone triage. Don’t get me wrong, I know some MAs who are better qualified at triage than some registered or licensed nurses. But from a liability standpoint, there is too much at risk for the practice. The practice should give them resources to help them succeed. It is just another tool in the shed to help them do their job. Doctors need a stethoscope to do an assessment of a child; a triage nurse needs resources to be able to answer questions competently and effectively when the patient calls.
The Pediatric Management Institute
ClearTriage: That makes sense. Finally, leaving the topic of triage, you talked at beginning of this call about your practice management consulting business. I think our readers would be interested in understanding what kind of services you are offering. Could you give us a little more detail?
Paul: We do a lot of things. Primarily, we help practices with their workflows and we offer assessments on the financial and operational side. We host our annual PMI Conference helping attendees better manage their pediatric practices. And just recently Alisa Vaughn from Dawson Pediatrics joined our team to offer Office Practicum optimization services. She can really help practices that are using Office Practicum to leverage all the bells and whistles of their systems.
But I think the future for our company is business intelligence. We have a new product that’s called IntelliTraq. It’s an online system that allows physicians to monitor their practice from an iPhone or iPad or a computer. They can quickly see all of the financial metrics that are needed to monitor their practice.
ClearTriage: So when you say monitor the practice, you mean monitoring the finances of the practice and the financial health of their business?
Paul: Yes. So far we have over 400 providers in our system. We have 3.5 million encounters that are being analyzed every single day for benchmark comparison. And with this IntelliTraq really provides a nice platform for medical organizations to very quickly ascertain how well they’re doing. There are billing systems out there that make you spend 8, 16, even 24 hours a month trying to put all of this information together. Our service is an automated service and within 24 hours of IntelliTraq getting the data from an automatic feed, you have that information at your fingertips.
ClearTriage: Did I hear you say that they have both financial information about their own practice and they also have comparisons against other pediatric practices?
Paul: Yes. You can review what percentage of sick visits am I seeing vs. other pediatric practices, where is my revenue coming from by the age of the child… When I look at my patient population, which age category is driving my business? With that you can see whether or not your patients are aging out or whether you’re heavy on newborns, which is always a good sign. So IntelliTraq allows you to continually compare yourself to make sure that things are progressing as they should. And there’s also a coding compliance to it as well. Are you leaving money behind on the table? Are the insurance companies paying you correctly? We provide all that in over 80 different charts, graphs and grids that allow the physician to truly understand exactly what’s going on in their practice on the financial side.
ClearTriage: That sounds like a fantastic tool for practices and I’m sure that your customers really value it.
Paul: They do, the response has been phenomenal. We’re continuing to grow it, finding ways to help practices leverage the technology and the data for their benefit. If you go to www.intellitraq.com you’ll see some more information there.
ClearTriage: I see an interesting parallel in that ClearTriage provides practices and clinics with the ability to access to Dr. Schmitt’s and Dr. Thompson’s protocols in a way that was only available in the past to hospitals and institutions with large call centers. IntelliTraq provides the same practices and clinics with business intelligence that was previously available only to larger organizations.
Paul: It’s an exciting time! Thanks for letting me share some of my thoughts with you today.
ClearTriage: Thank you!
