Of the many fundamental changes brought about by the passage of the Affordable Care Act (ACA) in 2009, one of the most significant is the newfound emphasis on patient/member satisfaction.
Prior to the ACA, payers viewed members as captive audiences (more or less). Most members obtained their health insurance through their employers or another group and were unlikely to go outside of that option no matter how they actually felt about the health payer. Providers had to be a little more careful since it was easier to change hospitals or doctors, but even then most patients were willing to unquestioningly accept a low level of service as part of the package of obtaining quality healthcare.
Not anymore. The sweeping changes and heightened awareness of the entire process brought about by the ACA have led to a new era of consumerism in healthcare. Many are paying more out-of-pocket thanks to higher deductibles and co-pays in both individual and group plans, and for the first time ever are starting to question what they're getting for the money. In other words, they have expectations. Not just for the quality of care (as they always have) but also for the quality of the way in which that care is delivered.
Answers now
One significant change in expectations is the ability to obtain answers quickly.
A decade ago, if Mrs. Johnson's daughter Hannah was running a fever of 102 degrees Fahrenheit and having trouble keeping liquids down at 10:00 pm, Mrs. Johnson would call her physician and then patiently wait an hour or two while the answering service tracked the physician down and the physician got back to her to let her know what to do.
Today, Mrs. Johnson will likely pack Hannah into the car after waiting 15 minutes and head to the local emergency department (ED), racking up needless costs for herself and her payer. She will also be unhappy that her physician wasn't able to get back to her in a timely manner.
It is scenarios like these that have led to the growth of nurse triage services for payers and providers. The primary advantage of a nurse triage service for patient satisfaction is that it provides an immediate answer to member/patient health concerns.
Guidance that drives member/patient decisions
A good nurse triage service that is staffed by registered nurses and others with the proper healthcare certifications can provide evidence-based, experience-based guidance on whether a current or developing condition is an immediate cause for concern or can wait for either a call from or visit to the physician.
This guidance helps members/patients make better decisions regarding care while reassuring them that their health payer and/or provider has the utmost concern for whether their needs are being met, not just during office hours but 24/7. The result is greater member/patient satisfaction and loyalty – a critical factor in a social media world where a negative comment or review can quickly go viral.
At the same time, quickly directing patients to seek the appropriate level of care instead of having them automatically default to the ED in times of uncertainty helps lower payer benefit expenditures while delivering a value-added service that helps drive renewals. Given that 80 percent of premiums are spent on managing member health, reducing that cost by driving better care decisions in the beginning will improve profitability as well as benefits to members.
Further to this point when these interactions are tracked through a CRM and linked directly to claims data for that particular member there will be a clearly defined ROI as well as quantifiable figures which can be used to measure the effectiveness of these interactions on your member base and assist with providing positive health outcomes to members.
Providers benefit by generating additional revenue that might have gone somewhere else while delivering better care. Everybody wins.
In-house or outsourced
There are two core options for 24/7 nurse triage services: build the capabilities in-house or partner with an organization that already has these capabilities.
Although an in-house nurse triage operation fit the organization's typical business model, there are a few considerations to keep in mind – starting with the fact that building a contact center is not usually a core capability of payers or providers. The organization will need to acquire the proper technology and real estate, hire a qualified staff, train them and develop reporting capabilities. All of this can take months to start, and months more to get just right. In the meantime, any bad member/patient experiences are amplified.
Even payers that have contact centers to answer technical questions about policies and deductibles will have a steep learning curve to add nurse triage capabilities. In the end it will likely be a separate operation that shares a few technology resources.
In contrast, working with the right partner enables payers/providers to bring nurse triage services to market quickly. The technology will already be in place, the staff already hired and trained and reporting will already be enabled. With a minimum of behind-the-scenes work the nurse triage service can begin answering member/patient questions and delivering an outstanding customer experience almost immediately.
Selecting the right partner
If the organization decides it would rather partner for nurse triage services than build them in-house it is important to proceed with caution. Sometimes general call centers looking to expand their footprint will offer nurse triage services without understanding everything that is involved. This approach creates all types of risk, from poor advice that adversely affects the health of members/patients to inadequate systems that don't meet Health Insurance Portability and Accountability Act (HIPAA) and other healthcare industry standards for safeguarding protected health information (PHI). The last thing any payer or provider needs is a data breach when the original intention was to drive member/patient satisfaction.
A good nurse triage partner must:
Create trust – Trust in the knowledge and expertise of their staff, trust in their abilities to safeguard PHI, trust that they are going to run the payer's/provider's business as if it were their own. Organizations are essentially handing their members/patients to these partners, so if there are any concerns they are probably not the right partner.
Have clinical experience – There is no getting around this one, no matter how attractive the pricing may be or how many promises are made. Members/patients want to speak with a healthcare expert rather than someone with who is merely following a script. (Think about the typical consumer tech support experience.) Members/patients need advice from clinical professionals who can deliver real guidance, not add to the frustration and confusion. Before signing an agreement, look at their hiring profiles and see who they have on staff and/or plan to bring in. Do they have clinical degrees and/or certifications? Do they have field experience? If not, that should be a huge red flag.
Communicate effectively and transparently – Receiving regular reports is important, especially during the initial transition period. But the real key is having transparency into the partner's operation so they can check at any time to ensure everything is up to their standards. This same transparency is critical given the never-ending changes to regulations as well as evidence-based medicine. Payers and providers want to be sure they're meeting all requirements and that their nurse triage service is keeping up with the latest standards for care.
Be dedicated to constant improvement – It's easy to fall into a pattern of meeting minimum standards. But customer satisfaction is driven on excellence. The partner should always be looking for ways to improve quality, reduce costs and improve the member/patient experience.
One of the consequences of the ACA, social media and the general consumerization of healthcare has been a need to meet the same 24/7 customer service expectations as other industries. This focus is only expected to increase in the coming years.
Implementing a nurse triage service can help payers and providers address this need while managing members/patients more effectively, improving revenue, building a more positive reputation and driving down costs. That's a lot of value from one simple investment.
Austin Ridgeway is Director of Sales Support and Business Development for the Healthcare Vertical at HGS.
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