Veterinarians look to fundamentals to help the underserved afford care
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An owner brings his Beagle into a clinic after seeing it eat rocks. On examination, the veterinarian feels that the stomach is bloated, but the owner has only $100 for veterinary care. Should the doctor even bother recommending surgery? Consider another veterinarian’s options when examining a backyard horse that’s lame. Should she do a full work-up, knowing that the owner still hasn’t paid his bill from the last visit? Or would it be better to simply recommend a wait-and-see approach?
Veterinarians today are able to provide better and more advanced medical care for pets than ever before, but the cost of that care makes it out of reach for many owners. The growing gap between underserved pet owners and veterinary service providers has consequences for overall pet health.
Fifty-six percent of U.S. households owned a pet as of year-end 2011, according to the 2012 edition of the U.S. Pet Ownership & Demographics Sourcebook published by the AVMA. Results also showed that 44.9 percent of cat owners did not take their cat or cats to a veterinarian in 2011, up from 36.3 percent in 2006. Among dog owners, 18.7 percent did not take their dog or dogs to a veterinarian during 2011, up from 17.3 percent in 2006. Further, 21.5 percent of cat owners and 29.3 percent of dog owners who did not visit a veterinarian said they could not afford it.
Findings such as these raise concerns that the current veterinary health care system may not be able to address the needs of all animals. Meanwhile, small animal practitioners in low-income areas say they’re learning to adjust to their clients’ financial constraints while still providing an adequate level of care and maintaining profitability. The AVMA’s top economist says even veterinarians in high-income areas should pay more attention to what they provide and at what cost, lest they lose their current clients or miss out on potential new ones.
Crisis in the making
Veterinarians are well-known for doing what they can to help animals, said Dr. Michael Blackwell, chief veterinary officer for the Humane Society of the United States.
“I don’t know any veterinarian who hasn’t on many occasions adjusted a fee or tried alternative means to treat a problem,” he said. At the same time, some of the public believes that veterinarians are more concerned about making money than treating animals, he said. That sentiment has resulted from a confluence of trends.
For one, the price of providing medical care has risen along with the costs associated with materials and drugs, veterinary education, and running a practice. At the same time, the public has made it clear that it expects the quality of veterinary medical care to be on a par with that seen in human medicine, especially with regard to companion animals, Dr. Blackwell said. Meanwhile, economic recovery from the Great Recession continues to be slow, particularly in certain parts of the country. The median household income in 2015 was $56,500, up 5.2 percent from the previous year but still 1.6 percent lower than in 2007, after adjusting for inflation. The percentage of people living in poverty also remained high at 13.5 percent, although that’s down from 14.5 percent in 2013.
“When you put these three together, it starts to help us understand where some of the tension and concerns surface around access to veterinary care,” which is a crisis in the making, Dr. Blackwell said.
He says while veterinarians have done a great job serving the needs of most of the public, “We have a large sector of the American population who frankly are poor and can’t afford private care. Some veterinarians say if you can’t afford them, you shouldn’t have pets. The fact is, pets are in these homes and need care as we speak. It’s there, and it has to be dealt with. The model the profession built—this robust private veterinary industry, in all of its glory—is not a panacea. It is not complete in its ability to address the needs of all animals.”
Dr. Blackwell is part of a coalition that is advocating for shelters and nonprofit clinics to supplement and complement the veterinary industry by addressing unmet needs. Its first step is to gather more information on how many of these low-cost providers are out there and whether they are taking business away from private practices, as some veterinarians say (see story).
Dr. Jeffrey F. Powers owns two veterinary clinics in a low- to moderate-income area in northern Michigan that’s three to four hours from a referral center. By circumstance, he’s learned to encourage clients to pay for medical care for their pets by offering more economical choices. Take, for example, how he addresses cranial cruciate ligament rupture in dogs. He gives clients the option of taking the dog to a clinic that performs tibial plateau leveling osteotomy or tibial tuberosity advancement, or of seeing a boarded specialist. Many times, however, the clients, especially those with low incomes, can’t afford the $2,500 to $3,000 for the procedure, so he’ll present the option of doing a modified retinacular imbrication technique with lateral suture stabilization at his clinic for half the cost.
“We always want to recommend the gold standard, but should we do silver and bronze to reduce euthanasia and treat lower-income clients’ pets?” Dr. Powers asked. He believes that charging less for some services not only enables more clients to agree to veterinary care but also attracts more clients in general, increasing caseload and income overall.
At his clinics, Dr. Powers will run a full blood profile for $110; a practice where he did relief work charged more than $200. He says many of that practice’s clients would balk at the full profile because of the cost, even though many were in a higher income bracket.
Another method Dr. Powers employs to increase the use of veterinary services is to offer prepayment plans. He also works with local non-profits that are willing to help pay for part or all of the cost of services for in-need clients.
On a national level, the American Veterinary Medical Foundation’s Veterinary Care Charitable Fund provides veterinarians with a way to offer charitable services to clients facing personal hardships (see JAVMA, Sept. 15, 2016). There is no enrollment fee for AVMA members. The AVMF accepts donations from an enrolled clinic’s clients and disburses payments directly to the clinic for charitable care it provides. Donations are tax-deductible, an advantage over the angel funds at many practices. In addition, any donor can contribute to the general AVMF Veterinary Care Charitable Fund, without directing the gift to a particular clinic.
In the Knoxville, Tennessee, area, Dr. Sam Meisler has taken basic care to another level. He owns two full-service hospitals as well as three walk-in wellness clinics dedicated to making preventive care affordable and convenient. Each PetWellClinic offers veterinary services in four areas: wellness care, care for minor illnesses, care for chronic conditions, and laboratory testing.
“We shaved off the radiographs, surgery, and skill level of the support staff and hospital so everything else can be offered cheaper,” says Dr. Meisler, who likens the clinics to Walgreens Take Care clinics. “Our mission is to serve as many pets at as many levels as possible.”
He doesn’t always require heartworm testing, as he sees the cost as a barrier to owners seeking care. Going one step further, he doesn’t require an examination prior to vaccination— something he and the other doctors at his practices have debated at length.
“We know an annual examination is probably the most important thing a veterinarian can do, followed by rabies vaccination, then fecal test. We know, medically, it’s the most appropriate, but it doesn’t always work out,” Dr. Meisler said.
We have a large sector of the American population who frankly are poor and can’t afford private care. ... The model the profession built—this robust private veterinary industry, in all of its glory—is not a panacea. It is not complete in its ability to address the needs of all animals.
Dr. Michael Blackwell, chief veterinary officer, Humane Society of the United States
Clients can opt for various wellness packages that include vaccinations. For dogs, the cost ranges from $65 to $160; for cats, from $65 to $105. All the packages are available without an examination for $30 less than the listed price. Plus, any of the vaccinations and elective laboratory tests can be purchased individually. For example, a rabies vaccination costs $10, and canine DAPPv or feline FVRCP vaccination is $26.
Another way Dr. Meisler has saved clients money is through the use of communication technology. Clients can use the clinics’ site to register their pet’s information ahead of time, choose the appropriate wellness package, and even buy the package they want ahead of time. More recently, the clinics started a system by which clients can get in line for service virtually from home using the website.
“Anywhere we can save time for the client and for us, we can ultimately save on costs which are passed on to the client,” Dr. Meisler said. “It’s not about doing wellness in the traditional way—as in making appointments by telephone, having a receptionist there to answer, using veterinary assistants and technicians who are being constantly interrupted by more pressing cases, and lots of waiting time for the client. Rather, it’s about thinking of new ways to deliver the business of care at lower cost without sacrificing quality.”
He says the PetWellClinics attract two groups of clientele: people who can’t afford as much and are looking for a cheaper way to treat their pet, and people who can afford more but like the convenience and features the clinics offer. Dr. Meisler maintains that the clinics create new demand; ear infections are an example. “Since our services are so affordable, we do a lot more ear cytologies and ear cultures than some traditional hospitals. I would argue this allows us to do higher-quality medicine.”
Price sensitivity is something all veterinarians need to understand and pay attention to, not just those in low-income areas, according to Michael Dicks, PhD, director of the AVMA Veterinary Economics Division. He wrote in his essay “Supply and Demand” this past May—available at jav.ma/supplydemandessay—that low-cost care providers, including spay-neuter and nonprofit clinics, enter the market and establish themselves because they can, even in areas where clients can afford higher prices.
“Those clients who have been able and willing to pay, because they feel obligated to provide care to their pets, may no longer be seen as willing when presented with a lower-cost alternative for the same perceived level of services. So the new low-cost clinic can capture those who were unable to pay and those who felt obligated to provide care but were troubled by the price of the services.”
He continues, “Once a low-cost provider has entered the market and gained a foothold, recapturing lost clients is an uphill battle. The key then is to maintain market share by understanding demand and addressing each segment of the market so that the low-cost practice is unsuccessful in establishing a presence. This multi-tiered pricing structure occurs in many markets: Car dealerships sell low- to high-cost vehicles, spas charge for various levels of services, banks have different types of credit cards and bank accounts, and cellular service providers offer multiple plans.”
That’s why veterinarians must understand what services they can provide to maximize the health and wellness of pets and be willing to provide that set of services at prices each segment of the local population is able and willing to pay. Establishing one level of service and one price for those services will only net one segment of demand, Dr. Dicks wrote.
Echoing those sentiments, Dr. Meisler encourages veterinarians to consider whether the way they’ve always charged for their products and services actually makes sense for today’s clientele.
“For example, I would challenge everything we as veterinarians are taught to do in an exam room with a client during a pet visit. One of the things we veterinarians love to do is to educate our clients. But there are other ways to deliver information, make the visit more efficient, and treat more pets affordably,” he said.
Dr. Powers calls for veterinary colleges to better teach students how to adapt protocols to the circumstances of the areas where they practice while maintaining an acceptable standard of care. More academic institutions have started to partner with shelters and nonprofit organizations to give students hands-on training while providing care to underserved pets. These include Louisiana State University School of Veterinary Medicine (see JAVMA, Dec. 1, 2013), the University of Wisconsin-Madison School of Veterinary Medicine (see JAVMA, Dec. 1, 2015), and Tufts University Cummings School of Veterinary Medicine and its Tufts at Tech Community Veterinary Clinic, a student-run veterinary clinic providing low-cost care for family pets in underserved communities in central Massachusetts (watch for a story on the clinic in the Dec. 15 JAVMA News).
Dr. Powers says educating students about shelter medicine and various levels of care “opens their eyes to the fact that there is more than just the gold standard in treating everything. The more advanced and technical, and in turn, costly, the gold standard becomes, we have to be cognizant not to eliminate the greater percent of animals needing treatment.”
The AVMA has resources to help pet owners make financially informed decisions regarding the care of their animals here.