Dr. Emily Tincher returns to the podcast to discuss how to keep teams working efficiently while implementing a spectrum of care approach inside practices.
This episode is made possible ad-free by Nationwide.
LINKS
Embracing a Spectrum of Care: https://www.petinsurance.com/veterinarians/spectrum-of-care/
Dr. Andy Roark Exam Room Communication Tool Box Team Training Course: https://drandyroark.com/on-demand-staff-training/
Dr. Andy Roark Charming the Angry Client Team Training Course: https://drandyroark.com/charming-the-angry-client/
Dr. Andy Roark Swag: drandyroark.com/shop
All Links: linktr.ee/DrAndyRoark
ABOUT OUR GUEST
Dr. Emily Tincher is a collaborative and data-driven leader who advocates for a pet-parent centered approach to communication and medicine through spectrum of care approaches. She is a second-generation veterinarian and a 2016 Auburn University’s College of Veterinary Medicine graduate. Emily has practiced clinically in small animal emergency and general practice.
As the Senior Director of Veterinary Relations at Nationwide Pet, she oversees operations and strategy in the veterinary space, including industry relationships and outreach to veterinary students, veterinarians, and veterinary teams. Emily serves on the AVMA Early Career Development Committee and is President of the Board of Directors for the Veterinary Leadership Institute.
Outside of veterinary medicine, Emily enjoys traveling with her husband Kyle, competing with her horse (Blue) in the sport of Eventing, and endlessly spoiling her two perfect dogs (Tuxedo and Cricket) and rotten orange tabby (Exploding Poptart).
EPISODE TRANSCRIPT
Dr. Andy Roark:
Welcome everybody to the Cone of Shame Veterinary podcast. I am your host, Dr. Andy Roark. Guys, I am back with my good friend Dr. Emily Tincher. We are talking about spectrum of care making teams more efficient. People talk about, Hey, I understand the need for a spectrum of care. We want to keep care accessible. We want to make sure that we provide the best options for treatment given where different patterns are and that they have different experiences and they face different challenges. I get that. But how do we keep our teams working efficiently while being flexible in this way? And guys, that’s what we get into today. It’s a great episode. I hope you’ll enjoy it. Hope you get a lot out of it. Thanks to Nationwide for making this episode possible ad free. Guys, let’s get into this episode.
Kelsey Beth Carpenter:
(Singing) This is your show. We’re glad you’re here. We want to help you in your veterinary career. Welcome to the Cone of Shame with Dr. Andy Roark.
Dr. Andy Roark:
Welcome to the podcast, Dr. Emily Tincher. How are you?
Dr. Emily Tincher:
I’m great. Thanks so much for having me back, Andy.
Dr. Andy Roark:
Oh man, I always love our conversations. You’re so fun to talk to. For those who don’t know, you are the senior director of Pet Health at Nationwide. You and I have known each other for at least a dozen years now. You were involved in the Veterinary Business Management Association as a student, as was I. And we have been friends ever since you got into that program many years ago. And so now you are changing the world. You’re doing a lot of speaking on spectrum of care, which is something that I’m really excited about and access to care. So lot of my, if you listen to podcasts, I do talk a lot about access to care because it is something that’s important to me. So anyway, I love having you here. Thanks for coming on. How was everything going with you?
Dr. Emily Tincher:
It’s going great. I love talking about Spectrum of Care with you. I also love just listening in and learning from the podcast, especially around communications in the exam room, which I know we’re going to talk a little bit about today too. So fun.
Dr. Andy Roark:
Yeah, well you’re very kind. But yes, I do love that stuff. All right, well let’s get into a little bit because I want to jump in. So one of the things that I want to talk with you about today is general price increases in veterinary medicine. So I’ve seen, we’ve had guests on the podcast before and we’ve talked about generally we’re looking at numbers across the nation. Number of pet appointments is down a bit and prices per appointment has gone up. So we’re not seeing a decrease in revenue, we’re just seeing an increase in sort of appointment prices and stuff like that. And so I know at Nationwide you guys are getting claims, you’re seeing this. Does that kind of jive with what you are seeing as far as pricing in our profession?
Dr. Emily Tincher:
It does and we’re seeing that for a number of reasons and certainly our nationwide claims data where we process a lot of claims every year for over 1 million pets that are insured actively. But we also see that just looking across various data sources. So one of them is the consumer price index for example, which is way outside of veterinary medicine in what they monitor. But veterinary services are one of 200 categories that they look at. And we’ve seen the consumer price index for veterinary services was pretty significantly higher than the rest of the consumer price index for 2022, for example, prices went up by over 11% in that year, which is pretty significant.
Dr. Andy Roark:
What are the main drivers? What is pushing prices up? Are we doing different kinds of services? Is it just straight up increases in pricing technology? Is it labor, the main drivers of these price increases?
Dr. Emily Tincher:
A great question. I think it’s one that we again, have to look at multiple data sources to understand. And I think our partners at Source do a really awesome job trying to explain this and a lot of industry leaders that are looking at our workforce crisis for example. So how do we help to support both recruitment and also retention of our staff members? That’s a driver one of the reasons. But we also know, especially during covid, kind of the prices for pulling in the goods that we need to do our jobs every day. They changed, they went up a little bit more than we saw before the pandemic. And there are probably other things too. We have the way that we practice medicine has changed in the last 10 years, whether that’s adapting business models, whether that’s, and we can talk about things like stratification or really knowing, honing in on who your client is, which I think you’ve done a really awesome job and a lot of platforms just understanding the complexities for this, it can get hard quickly to think about.
It’s helpful for me to simplify it down to there are a lot of reasons why this is happening. Cost is increasing amongst other reasons that pet owners are feeling the change. But the result is pet owners are feeling that. And to your point about we’re not decreasing revenue, we’re actually increasing it in the vet profession, but we are decreasing in visits in the year of 2022 saw not just because of costs. I want to inappropriately correlate those, the 17% decrease in visits compared to a year over year compared to 2021, which is pretty significant as well.
Dr. Andy Roark:
Yeah, it is significant. When you think of 2021 was kind of post pandemic people coming back, you should think our visit count would be going up as opposed to down. Yeah. That bothers me when we start to look about it, when we start to look at it, I think everyone who’s been in vet medicine, whether they’re a technician or a doctor or even probably someone at the front desk has at some point felt a pinch where you feel like, I’m here because I want to help. That’s an important part to me. And when people say to me, I can’t afford this, or one of the reasons that we get asked for advice all the time I think is that people are like, I don’t want to go to the vet and have to pay this money. I think people are trying to figure out how to get around going into the vet kind of more and more.
And it bothers me because I don’t want to be the vet police who’s like, don’t not helping you need to go to the clinic. And at the same time I go and I can empathize with them and sort of say, I get it. Don’t, not easy to throw around a couple hundred bucks every time your pet throws up on the carpet. And so I get it, but we’ve all been kind of stuck there. I think that’s why a lot of us get frustrated when people say, I don’t understand why you won’t just give me advice on the phone or I don’t understand why, you know, told me to go into the clinic as opposed to just taking care of this here at our dinner party. Yeah. Anyway. Yeah, I feel like that’s a real pain point.
Dr. Emily Tincher:
It’s a pain point from multiple perspectives, again, from the pet family side of things. We know from a couple of reports that as little as 200 to $300 in an unexpected veterinary expense can be really stressful. And for a lot of families across the US, something greater than $500 can throw a pet family into debt, which is, I don’t think a lot of us would expect necessarily. But the data and the access to care coalitions report for example, says that about three quarters of middle income families still live paycheck to paycheck. And so things like the unexpected, especially for pets, it’s a little bit easier sometimes to plan for wellness. But the unexpected of, we got to figure out this vomiting dog on the carpet, we, it’s happened five times today. We’ve got to go figure this out and help the pet out. That gets really hard for people.
And so I think even bringing that into our staff and saying they also struggle with that. I know one of the questions that’s been rattling around in my head a lot since the Uncharted conference in April was our mutual friend, Dr. Adam Little, he asked a question in his session and it was his first question of talking about costs for pet owners. And he kind of flipped it on it its head and said, who do we agree with the statement across a range? And ask everybody to get up and move around and then have a conversation in the room. Do we agree or disagree with the statement that our staff should be able to afford the most expensive levels of care that we offer and at usually the most expensive correlating with the most advanced or gold standard level care? And it really started some really interesting conversations of we are us in vet med, we are the people that we serve sometimes.
And I know for me when I worked at a specialty hospital, I as a veterinarian couldn’t have afforded a lot of the estimates that I sometimes handed out. And so that brings us back a little bit to the idea of, okay, we know costs are rising, but we also know the level of care that we can offer is rising. Those things together really make these conversations around cost of care so uncomfortable. Especially if the care being offered isn’t something that the person talking about it that the technician in the exam room talking about it also couldn’t afford.
Dr. Andy Roark:
Oh yeah. Well there’s that credibility issue too. We talk about exam room communication stuff all the time and one of his credibility is to be able to say, if you don’t say it outwardly, the fact that I do this from my own pet lets me talk with an ease where I can sort of say, yeah, I walk my talk here. This is something I actually do it. It’s important psychologically, I have thought a lot about that over the years because what does it mean to say this is the standard that we believe is required to be a good pet owner? And your technicians are like, I can’t do that for all of my pets. And I know around now there are some technicians that have 37 pets and I’m like, well that’s a whole different thing. You can’t have Noah’s Ark and make me feel bad because Cause parasiticide are expensive.
Yeah. Where’s the car? Yeah, exactly right. No, it’s all shades of gray when you get into it. But I do really feel like at some fundamental level, I want the people working in the clinic to say, yeah, I do this stuff cause otherwise, you know, get this cognitive dissonance where you’re like, man, all day long. I tell people how important this is, but I don’t do it for my own pets, which either means that I’m lying to them or it means that I’m not a good pet owner or I’m not doing something that’s important. And that’s the mental trap that people get into it. It hurts people. And so that is, I’ve wrestled with that for a long time as cost of care continues to go up. And at the same time, you know, talked about the labor shortage and trying to keep people in even before the labor shortage, we have radically underpaid people in our profession for a long time. And there’s sort of this ethical wrestling for the steering wheel of what is the greater good? Is the greater good to extract revenue so that we can pay our people a higher salary? Or is it to not extract a higher pay point to is to keep care as priced as low as possible and to let our people let our eat people eat ramen noodles. And again, I think it’s easy to think that, and we’ve kind of wrestled over that. I like to believe that there are some solutions in the middle.
Dr. Emily Tincher:
I think there’s a lot to unpack in what you said there. So that idea of if our staff can’t access or the average pet owner is stressed by accessing the level of care that we’re offering, maybe an alternative. It comes back to that idea of, well, we don’t all have to want or access the same level of care. Sure. What does it look like to provide instead and recommend actively a spectrum of care to say we have a range of options across basic to advanced that we can tailor these solutions to whatever the pet family’s goals, values and resources of course, including finances. We’re talking about cost of care today. How do we tailor those conversations as efficiently as possible? And to your point about underpaying, I think especially our staff, our technical staff, how do we work so that we collaborate with them to let them work to the very best of their ability and then also compensate them appropriately for doing that.
Dr. Andy Roark:
Yeah, that’s kind of where I wanted to go with you today specifically. And so I, I’m really interested in this cause we’ve, you and I have talked a lot about running best practices for a long time and I think that we’re pretty much in alignment that vet medicine’s a team game and as a doctor and you’ve worked as emergency doctor for many years, leveraging your technicians is smart medicine, how we get things done. And so I want well leveraged texts, I want consistent communication. I want the pet owners to kind of get a plan and I don’t want them to feel like they got told one story and then fun. Andy shows up and tells them a different story, you know what I mean? And then people at the front desk tell ’em a third story. I really want us as communication to be on the same page.
And at the same time, I really like this idea of meeting people where they are and trying to talk about what the individual person’s needs are inside the context of what we do in our practice. And trying to say, okay, given what your needs are and given who our practice is and how we practice, what is the Venn diagram overlap there where we say, hi, your needs are getting met and our needs are getting met to feel good about the work that we’re doing and this works for everybody. And so how do I set myself up to take advantage of a well leveraged staff, consistent communication, things like that. And then also have this flexibility, try to meet people where they are and understand what’s happening. Can we start to talk about what that looks like in practice?
Dr. Emily Tincher:
Yeah, I think it might be helpful to break it down into two pieces a little bit. So let’s talk a little bit about leveraging the staff first, since we’re talking about kind of dollars and cents and pay paying our staff appropriately. Why don’t we start there? I think one of the things that we always really try and do here at Nationwide is not advocate for something that we don’t see an evidence base for. And so leaning on what do we know as far as research or case studies that we can lean on? And I think what’s really tricky when we start to talk about workforce is I, I’m sure we have some listeners now that are thinking it would be great to leverage technicians, but I can’t find none of them. None of them are available and I am desperate to hire or potentially even willing to pay for their training so that I can find them. So I hear you want to acknowledge that it is a challenge that we have to find license or credentialed technicians. The other challenge that we have though is retention of them in the field. And if we look at a study that Avta conducted, I think in 2016, a couple of years ago, they asked technicians, what’s the greatest reason that you leave the field of veterinary medicine? And are you familiar with that one? What kind of pops to the top of your mind of why they might leave?
Dr. Andy Roark:
Oh yeah. So there was not being able to work at the top of their skills I think was one or no developmental path. Wasn’t that one of the big ones career path, the pay was on there, of course
Dr. Emily Tincher:
Pay, yeah, of course on there. But it’s actually not number one. Number one is exactly what you said. First is utilization of their skills to the maximum amount and actually recognition, feeling like they’re seen and valued was in the top five too. So those very quickly all come together. So yes, we have a problem with we need more technicians, but we also need them to stay. And so I think part of what our conversation can be here is how do we say, okay, we understand those are some of the reasons you’re leaving. Let’s talk about how to get you to stay in a way that helps vet healthcare teams to be able to provide more care, to be able to hopefully be a little bit more efficient and have see a few more appointments, but also do so profitably. So I think that’s really interesting is there’s another JMA study from a couple of years ago that, and I think it’s a older one at 2010 or 12, we’ll find it for the show notes of if you have a credentialed technician, they can contribute, I think it’s like $93,000 a year to profitability in a general practice if they’re leveraged, well, pretty significant improvement in the value from a business owner, from business manager to have and to use those technicians as much as we possibly can.
We also, in our college program where we speak on behalf of nationwide to all of the vet schools across the us this last springs our partnership with the V B M A where we met one of our team members, Dr. Kristen Walker, built out a case study of, okay, what does it look like to not leverage technicians in a way that we probably have all seen? And so what she built out was looking at a really common problem, ear infections, and that’s always in the top five for the most frequent claims for us for dogs, top 10 for cats too, actually every year is ear infections. So we know it’s common. We know that general practices and me in emergency and urgent urgency, urgent care are seeing these. So this is a universal problem in companion animal medicine. So what are we typically doing for ear infection?
Dr. Andy Roark:
Yeah, right, so ear cytology, ear cleaning, yeah, yeah, no, nothing Crazy. Ear
Dr. Emily Tincher:
Medications, yeah, ear medications, ear cleaning, probably
Dr. Andy Roark:
Possibly a culture, but it depends on what we see and probably not,
Dr. Emily Tincher:
Probably not, but possibly we are, especially if it’s a chronic case, we might consider something like that. But minimally, most of the time, not always, but a lot of the time we’re going to do an ear cytology. Okay, great. So we’ve done an ear cytology. Who’s doing that in most cases in your experience?
Dr. Andy Roark:
Oh man, this is hard. So I’ve been spoiled. I have great technicians, so it’s always been my technicians, but I know a lot of places that it’s not true.
Dr. Emily Tincher:
I, I’ve been really spoiled too, but I’ve also been as a relief at some practices that are really short staffed and so let’s imagine we’re at one of those or somebody’s day p t o or maybe in a practice that sometimes we’re doing great and having the technicians or the assistants being the ones that are taking the cytology, preparing it and then hopefully our technicians are reading that well, if a veterinarian is the one doing that and someti, I’ve definitely done it myself. Preparing that slide, going and looking at it, reading it and then saying, okay, we have a bacterial infection in this Labrador ears. It doesn’t feel like a big impact and if you do it on occasion, it’s pitching in and helping. If you make that systemic, if you start to do that every day, every week, every month, the case study that Dr.
Walker built out for us says that you can pretty quickly lose up to about $2,400 a week in revenue by just not by veterinarians doing tasks like that, putting in catheters. Other things that are technical staff are much honestly better than doing than me for sure. All of that adds up pretty quickly and from a business profitability perspective, we can see where that’s going, but then having to pass on that cost of the veterinarian’s time to the pet owner perspective, it doesn’t just stop at us. It doesn’t just stop with technicians feeling under underutilized. We also have to pay for that veterinarian’s time somehow. And if we’re chronically, systemically using veterinarians or sometimes licensed technicians in place of assistance where cleaning kennels perhaps that has knock-on impacts to really making it more difficult for pet families as well.
Dr. Andy Roark:
Yeah, I like that a lot. Just as far as increasing efficiency and you’ve kind of look at where do you need your people to be? I have a hundred percent seen practices. I used to do relief work as well. I have a hundred percent seen practices that were short staffed and they were very nice practices, don’t get me wrong, but the vet would swap the ear and do the cytology and then the technician or assistant, it would be the assistant. The assistant would hold the pet while the vet cleaned the ear and I’m like, oh man, you guys are putting in the vets here doing this. The actual technical, a hundred percent the technical work of the case. And I go, this is got to be a smarter way to use this doctor’s time for the benefit of the practice and also for the pets.
Talk to me a little bit when we talk about efficiency and I really like where you’re sort of going as far as letting technicians work at the top of their license is a big way that we retain them. A big part of spectrum care that I think is really interesting is the communication aspect. It’s how we talk to people about what they need and where they’re going and where we sort of understand what support do, are they looking for? What support, what ways can we support them and things like that. Can you talk to me a little bit about using your paraprofessionals, your room assistants or especially your technicians in those types of conversations? What does that look like in a well leveraged practice?
Dr. Emily Tincher:
And it’s another great place that we can lean on some already published data and then talk about the future as well. So in 2022 there’s another jamma publication about the ability and kind of engagement from pet owners when discussing care plans, when there’s some involvement from the veterinarian and some involvement from the technician, that it has this additive effect of really helping pet owners to feel like they understand the value, they understand the buy-in, and to your point from earlier, they’re not hearing two different stories from across the practice. And so how do we talk to pet owners in a way that makes them feel like they know what their options are across that spectrum of care? Again, back to the basic to advance, these are some of the options, these are some of the pros and cons that are associated with that, and then how do we do that in as efficient a way as possible?
Well, one of the things that we’ve done here at Nationwide is to say that’s a pain point and how can we help understand the subconscious drivers behind what people are looking for in pet healthcare? So we conducted some research that we’ve talked a little bit about before to understand that really they’re kind of three different groups of people across demographics and what they’re looking for. And we’re really advocating with be working on a tool that’ll be released later this year, but really advocating for involving the whole team with those conversations. We can set it up sometimes, and it depends a little bit on setting. If you’re in a wellness situation and a general practice, we can really have that education in advance and our technical staff can have most of that conversation already of what is it that is helping this PA family to make their decision?
Are they a cost focused family or are they a group that’s really focused on convenience in their decision making? Those are the two of the three and helping to identify which, what kind of things does this particular pet family value? And then I can talk to ’em about the pros and cons of two or three options that we might have for wellness. Sometimes from a sickness perspective, something’s wrong. Sometimes it can be a little bit easier for the veterinarian to enter into that conversation first and say, I’m seeing we have a pet here that is vomiting on the carpet five times, and we can do things like based on the history you’re telling, based on the physical of what I’m seeing, we’re going to tailor it down to these three stepwise options or go full tilt and go get an abdominal ultrasound after we do some blood work. We can pull those together sometimes as a vet first, but then following up with the details of and the validation, helping our technical staff to feel like they have permission to not just push the most advanced level of care is helpful too. Again, coming back to the very beginning of our conversation of if what we’re asking them to always recommend may not be even accessible to our teams, really how do we feel comfortable instead off offering those options and doing it in a non-judgmental way. Our team can really, really help with that.
Dr. Andy Roark:
Yeah, that’s fantastic. No, I completely agree. It’s going to drive me absolutely nuts. The three types of people, there’s the cost conscious person, the convenience conscious person, well, what is the third one trying? Is it the care focus person? What is it? Yeah,
Dr. Emily Tincher:
Okay. I thought that it’s an optionality focused person, so they really want to know what all their options are. Choice if you like to turn it into three Cs, which is sort that little branding and marketing working there, but the evidence base, that last group, they’re a little bit more complicated. They really want to hear more about, well, your chances of success with parvo are nine out of 10 if we do this. And not everyone needs that level or wants that level of conversation, but I think employing our technicians who can have that level of conversation when they’re experienced and they’ve been with us and sometimes if they’re new grads just like vet new grads, they need to come in the room with us and he hear us have those conversations, but they can, and if Jab MA’s publication about the willingness for pet owners to buy in is if we take that as true, they need to be part of those conversations.
Dr. Andy Roark:
Yeah, no, you are such a wealth of information. I’ve got, well, I’m going to be getting links from you to the wealth of resources that you mentioned today. Is there anything else that you recommend for people? Are there any resources that we didn’t talk about that you really particularly, yeah,
Dr. Emily Tincher:
I think it’s just deciding how is it and having that conversation with your practice. If you’re not yet talking about a spectrum of care or we don’t always have to call it that, really just offering that range of options. That’s just a term so we can all talk about something that many of us have been practicing for a long time. How do we make sure that we’re all on the same page as a practice to say, yes, we agree with this, we want to meet pet families Where they are, whether we do it or not, pet families are they’re, they’re going to ask for options and so how do we just take that barrier down and proactively do that? We have our own website, spectrum of care.com that we can include in the show notes as well. That kind of helps talk about some of those concepts and how you might talk about it with your team and it will be growing with more resources coming later this
Dr. Andy Roark:
Year. That’s fantastic. Where can people find you on online, Emily?
Dr. Emily Tincher:
They can. I’m fairly active on LinkedIn, so it’s probably a reasonable place, but yeah, I love chatting with people and can find me in the uncharted community as well.
Dr. Andy Roark:
Yeah. Cool. Alright, awesome. Thanks for being here guys. Thanks for tuning in everybody, take care of yourselves. Thanks again, Emily, for being here. Thanks for having
Dr. Emily Tincher:
Me.
Dr. Andy Roark:
And that is our episode guys. I hope you enjoyed it. Hope you got something out of it. Thanks to Emily for being here and being my guest. As always, she’s amazing. Thanks to Nationwide for making the podcast possible ad free. Guys, thanks to you for your time and attention. I hope that you guys will be well. I hope you have a great day. See you later. Bye.
