Over the past decade or so I’ve witnessed the rising popularity of a practice style I’ve snarkily termed “frogmarched” vet care; To force (someone) to walk forward by holding and pinning their arms from behind.
In its most effective manifestation, clients are shuttled through a scripted process involving rapid-fire assessments and minimal human interaction. The goal is to increase productivity and maximize profitability by minimizing time-consuming client-staff interactions. In this way, patients are attended more quickly, and clients’ wait times are curtailed. Here is how it works in emergency care settings, where it is most often employed:
Upon presentation, receptionists immediately convey basic client and patient details to triage technicians, who then assess the patient, confer with the attending veterinarian, devise a plan, present it to the client (via vet or tech), and provide an estimate (via reception or tech). Reception will collect payment or ensure a quick AMA kiss-off if the client is unable or unwilling to comply with the terms proposed.
This way, clients are effectively vetted for financial enthusiasm and capacity up front with minimal in-person interaction, so the clinic avoids unduly expending limited space and personnel resources on less profitable cases.
When deployed to perfection, this operation leaves clients minimal room to maneuver without an initial financial outlay for the estimated amount. There is almost no opportunity for nuanced conversation regarding alternate levels of care. Only after a financial transaction is complete does more detailed client interaction come into play. Thereafter, the same tactic will be successively re-deployed—incrementally, and at prescribed frequencies—for inpatient care.
Militaristic? Yes
If it all sounds vaguely militaristic, that is because it is. Though some may recoil at the application of any military reference to our industry’s practices, these extrapolations are by no means inappropriate or unhelpful. After all, there is much to be gleaned from military tactics—everything from human resource management to everyday life hacks. Why not veterinary medicine, too? If doing so gets more critical patients onto OR tables and into oxygen cages more quickly, then it is saving animal lives, right?
So, yes, the frogmarching approach absolutely has much to offer us veterinarians. In a busy ER with long wait times, more patients will get the care they need quicker if attention to these practices are paid. It is also just good business, of course.
Concepts such as these were drilled into us at business school, too. The core-curriculum class “operations management” was either revered or reviled, but always most appreciated by the minutia-minded among us. Its goal was to teach us to build and manage systems by which widgets could be moved through a process efficiently and inexpensively for optimized profitability. This was achieved by reducing the number of steps involved in a process, identifying and addressing its rate-limiting steps, and generally maximizing throughput for optimized efficiency at the lowest possible cost.
The human health precedent
Attention to operations management makes total sense in a veterinary context, too. Hence, the emergence of frogmarched care. Offering binary choices at each step compels clients to make immediate decisions, which emergent cases typically demand.
This also benefits the practice, of course. It is inherently less burdensome than lengthy, complex explanations regarding the pros and cons of different paths—never mind the slew of alternative estimates required and the serial conversations that inevitably ensue. These expend precious time and manpower, thereby reducing productivity.
Human hospitals have long since adopted this approach. Their version involves verifying insurance info, doing the necessary work however they see fit, and hashing out patient payment on the back end with a battalion of billing experts. Whatever the outcome of that, the patient or the public is always on the hook.
For us, though, it is a bit different. We have to battle on the front end, which makes our approach intrinsically confrontational and explains why the “our way or the AMA highway” increasingly holds sway at overburdened ERs. It also explains why so many of our after-hours facilities are plagued by one-star reviews posted by financially disaffected pet owners claiming we are “all about the money.”
As a practice manager or owner, it is tempting to dismiss these reviews. After all, these are not the clients you are targeting. Your job is to offer the best medicine; and, as we are always told by practice management gurus, what is best for the patient is best for the practice. So those who cannot afford ER-level care should probably consider waiting to see their regular vet in the morning or perhaps, as some veterinarians blithely contend, they should not have pets at all if emergency care isn’t feasible.
I’m clearly headed in an uncomfortable direction here. If we accept that only those willing to throw down a credit card without blinking can access treatment, we may as well start asking clients to pay a premium to skip the line to prove their financial merit. The two are standing on the same ethical footprint as far as I’m concerned.
Further arguments against this care delivery option, though optically more attractive than a mind-blowing exam fee, is inherently more deceptive. In fact, one might even argue it is fundamentally coercive since it forces clients to make split-second financial decisions in emotionally charged settings. If you cannot afford to treat your blocked cat our way, you get offered euthanasia, bare bones outpatient care, or an AMA that effectively says you are giving up on your pet.
Not OK in ER
Now, I’m not saying there is anything wrong with targeting a specific clientele, and I’m all in favor of increased productivity. Nor is triage based on expedient acceptance of no-holds-barred emergency care necessarily an ethical nonstarter. I am, however, increasingly frustrated by after-hours facilities that employ extreme “workflow productivity” enhancing tactics—especially in areas with limited ER options.
A variety of factors have made way for adopting these sophisticated strategies. These include diminished competition through corporate consolidation, the advent of COVID protocols, and limited human resources, among other issues. It only makes sense we would see streamlined workflow tactics emerge. These, however, come at a price.
They may help cut costs while leveraging a practice’s limited staff, but should the quality of client communication decline, they can adversely affect client satisfaction, along with long-term patient outcomes. Additionally, they have the power to negatively impact ER-referring relations and fundamentally alter the pet-owning public’s view of veterinary medicine writ large.
One additional problem cannot be ignored: Speedy human interactions around money always mean we run the risk of effectively institutionalizing discrimination based on outward appearances. We all know it is true because we have ears. You cannot work in a busy ER without overhearing negative comments about a client’s presumed financial status based on superficial details alone.
Perhaps most troubling overall is the fact tactics like these are being normalized. As veterinary care becomes more corporatized, standardized, and streamlined—and, yes, also smarter and more profitable—extreme versions will only gain further traction.
Still, I get it. When the practice is abominably busy, a nuanced touch is not always high on the list of priorities. Still, it is a hard pill to swallow for referring practices—more so when we routinely see garden-variety GI patients get Cadillac treatment with insane workups, while blocked cats get AMA-ed away or euthanized.
Veterinary medicine already has affordability and accessibility issues, which can be justified in large part by personnel shortages and other economic factors specific to the veterinary industry. Our reputations have already been affected by the rapidly evolving economics of our profession, especially since the start of the pandemic. I fear this my-way-only approach to vet care will only enhance the ugly optics already trickling down to practices like mine.
Frogmarching is smart medicine, and I will not deny my practice is also streamlining in ways that mirror this approach. that said, this is an ethically fraught area that deserves closer scrutiny and a more nuanced hand with greater input from veterinarians themselves. After all, not one veterinarian I know wants to euthanize a blocked cat because a $4,000 deposit is not doable.
Patty Khuly, VMD, MBA, owns a small animal practice in Miami, Fla. and is available at drpattykhuly.com. Columnists’ opinions do not necessarily reflect those of Veterinary Practice News.