Eliminating in-person VCPR requirement for telemedicine, proposed midlevel position discussed at information forum

Updated January 09, 2024

Some proposals for change in the veterinary profession that have garnered attention in the past few years would create more risk than reward. One is the idea of a midlevel position (MLP) that would overlap the roles of the veterinarian and veterinary technician. It remains unclear what the scope of practice would be and how it would address workforce shortages. The other proposal is to eliminate the requirement to establish a veterinarian-technician-patient relationship (VCPR) in person for telemedicine, which has been adopted in very few states.

These topics were discussed during the AVMA House of Delegates’ (HOD) Veterinary Information Forum, which took place during the HOD’s regular winter session, held in conjunction with the AVMA Veterinary Leadership Conference, January 5-6 in Chicago.

Several AVMA staff, allied organization leaders, and subject matter experts presented on these topics, as well as on future veterinary workforce needs and approaches to addressing recruitment and retention challenges in specific segments of the profession.

Dr. Janet Donlin, AVMA CEO, explained it is important for the profession to have diverse voices talk about these topics, as well as accurate information and reliable data.

“The challenge is, when it gets in the legislative arena, if (legislators) don’t have good accurate information there, crazy things can happen,” she said. “It is up to you as veterinary leaders to make sure your state hears good, accurate information.”

Future veterinary workforce needs

“Unfortunately, suggestions of crisis-level shortages,” said Dr. Gail Golab, associate EVP and chief veterinary officer, “that are based on calculations using challenging single proxy variables and without consideration of context, have precipitated broad-reaching proposals for changes in how veterinary medicine is delivered and regulated; for example, a midlevel position and relaxing the VCPR. These proposals pose substantial risks to animal health and welfare, as well as to public health.”

Large-scale, disruptive macroeconomic events over the past several years have presented no shortage of challenges for the veterinary profession: The Great Recession of 2007 and the COVID-19 pandemic. The former decreased demand for veterinary services, while the other increased it for companion animals; but both temporarily.

While national veterinary practice revenue increased an average of 5.7% between August 2021 and August 2023, the number of client visits fell 2.7% during the same time period.

“Recent data and analyses show pandemic tailwinds falling away, continuing macroeconomic uncertainty, and increasing value-seeking behavior on the part of consumers. This suggests a medium to longer term moderation of demand for companion animal veterinary services,” Dr. Golab said.

Demand for veterinary services and demand for veterinarians are related, but they are different. In fact, she said, veterinary economists consider there to be four distinct, but interrelated veterinary markets—the market for veterinary education, the market for veterinarians, the market for animals, and the market for veterinary services.

When considering future workforce needs, a key question is how demand for veterinary services translates into demand for veterinarians. This translation is impacted by the extent to which the veterinarian-led team is leveraged, operational system and process efficiency, and how technology is used.

“The estimates currently circulating around veterinary workforce needs have been derived by using the veterinary services revenue compound annual growth rate as a proxy for demand. This is a challenging choice because, among other things, it doesn’t consider the impacts of price and service type,” Dr. Golab said. “As an example, while one veterinary visit may contribute $100 of revenue and another may contribute $500 of revenue, that doesn’t mean that the second veterinary visit requires five veterinarians, rather than one veterinarian, to deliver the services involved.”

Then, when looking at the supply of veterinarians, it appears the next several years will see an inflection point in the growth rate of new veterinarians entering the profession.

In addition to recent unprecedented growth in the number of veterinary college seats at existing colleges, three new colleges have been added to the roster, veterinary colleges have close to doubled their cohorts to produce additional graduates this decade, and at least 12 new veterinary colleges are in various stages of development. The cumulative effect of these changes will be a significant increase in the number of veterinarians entering the workforce into the 2030s.

Dr. Golab said some sectors of the profession have unique and long-standing barriers to attracting and retaining veterinary professionals, including emergency practice; specialty practice; shelter practice; academia; rural practice, particularly food animal and equine; and public health. Workforce challenges in these practice areas have continued despite times of excess capacity.

In addressing solutions, Dr. Golab said, “There are tangible actions that can be taken today that will have immediate and long-term positive impacts on the veterinary workforce. These include fully leveraging the veterinarian-led team, especially veterinary technicians; focusing on improvements to workplace culture, increasing staff retention to create operational continuity, closing system and process efficiency gaps, and the responsible adoption of technology. For practice types with long-standing challenges, collaborative efforts designed to address sector-specific needs are key.”

Midlevel position

The proposed MLP would overlap the training and responsibilities of veterinarians and veterinary technicians. Proponents envision that these individuals would be able to diagnose, formulate treatment plans, prescribe, and perform surgeries and other procedures.

For instance, in the current legislative session, there is a bill introduced in Florida that, if enacted, would allow an individual with a master’s degree to perform sterilization procedures and dental procedures under indirect supervision. Dr. Kent McClure, AVMA associate executive vice-president and chief advocacy officer, said, “This means someone with a master’s degree could be performing major abdominal surgery under the supervision of a veterinarian who is on the telephone.”

Proponents also argue such a position would address an increasing demand for companion animal services and labor shortages. During his presentation, Dr. McClure reiterated that the circulating workforce information used to support the need for a MLP are fundamentally flawed and misleading; that the demand for companion animal veterinary services is normalizing post-pandemic; that causes for veterinary workforce shortages are sector-specific and multifactorial; and that more veterinarians are in the pipeline with veterinary schools increasing class sizes with at least 12 new veterinary schools in various stages of development.

He referenced a recent AVMA survey of pet owners showing that, nationally, 76% of pet owners can see a veterinarian for routine care or minor issues in less than a week. Additionally, the study showed that 78% of pet owners can get emergency care in two hours or less, with almost half being less than an hour. The study also showed that eight out of 10 (79%) pet owners want a licensed veterinarian to be in charge of their pet’s care.

Dr. McClure indicated that the formation of a MLP would not be a quick fix for any workforce issue. In fact, changes to state law in all 50 states and other jurisdictions, as well as changes to federal law and regulations, would all be necessary.

For example, he said, federal law requires on-label use of prescription drugs to be under the professional supervision of a licensed veterinarian, and they may only be dispensed by or on the order of a licensed veterinarian in the course of their professional practice. 

For extralabel drug use, the veterinarian must have also conducted a physical examination of the animal or have made medically appropriate and timely visits to the premises where the animal is kept.

Additionally, current proposals to establish a MLP would place the legal responsibility for any of the MLP’s acts or omissions on the supervising veterinarian. According to Dr. McClure, information from the professional liability program sponsored by the AVMA Professional Liability Insurance Trust (AVMA PLIT) shows that the top drivers for malpractice claims against companion animal veterinarians are spays and neuters, dental procedures, adverse anesthetic events, and drug errors.

Entrusting these procedures that carry the highest legal risk to a person who has less education than a veterinarian, and making the veterinarian responsible for any and all of their errors would be misguided, he said. 

Telemedicine and the veterinarian-client-patient relationship

Offering telemedicine can be a great way for veterinary clinics to strengthen relationships among practices, clients, and patients as well as improve continuity in patient care and enhance practice efficiency. It is a valuable tool for veterinarians, explained Dr. Lori Teller, AVMA’s immediate past president and clinical professor at the Texas A&M University College of Veterinary Medicine & Biomedical Sciences.

Dr. Teller, who focuses her academic work on the effective utilization of telemedicine, added that telemedicine should be implemented only after establishing an in-person VCPR.

She explained that teleadvice—which provides animal owners with basic answers to questions and preventive care education—and teletriage—which is used to determine whether an animal needs to be seen by a veterinarian and with what urgency, do not require a VCPR. Telemedicine, Dr. Teller further clarified, is used to provide patient-specific recommendations and follow-up, including owner compliance, with a recommended treatment plan and requires a VCPR.

“There’s so much we learn from the initial visit, if we go to the premise or the patient comes to us,” Dr. Teller said. “We can collect diagnostic samples and see how the owner or caretaker interacts with animals.”

Addressing some external pressures on states to relax their VCPR laws, Dr. Teller said this would be misguided. That’s because eliminating the initial in-person visit increases veterinarians’ risk for misdiagnosis, delayed diagnosis, inappropriate treatment—meaning inappropriate prescribing of medications, including antimicrobials and controlled substances.

Federal requirements also apply. The Food and Drug Administration (FDA) has said veterinarians need to do an in-person examination or premise visit before prescribing extralabel—which is extremely common in veterinary practice, including compounded products—and when issuing veterinary feed directives (VFD). The U.S. Department of Agriculture (USDA) requires an in-person visit for issuing certificates of veterinary inspection and when evaluating and testing for certain diseases. It becomes confusing for veterinarians and for clients when states take an alternate route, said Dr. Teller

Currently, 43 states mirror language from the FDA and 22 states have language prohibiting VCPR from being established virtually.

Proponents of eliminating the in-person VCPR requirement have said telemedicine can help increase access to care. Dr. Teller agreed that while it can be a component of improving access to care—once the relationship has been established—most animals that do not receive regular care have acute issues that need to be addressed with an in-person visit.

“Having people, especially those with limited financial means, pay for a telemedicine visit, when they need to be sent to the veterinarian anyway, actually increases the financial burden on them and leaves less funds available to follow up on diagnostic and treatment recommendations that are provided,” Dr. Teller said.

She is part of a project at Texas A&M that provides in-person care people and their pets in underserved communities and then uses telemedicine to follow up and do remote patient monitoring. Dr. Teller said mobile veterinary options, that can incorporate telemedicine for follow up, are a much better option for these clients and patients.

Integrating tools of telehealth can work for many situations in practice, but should be done so responsibly, she said. 

Tailored approaches for unique practice segments

Providing detail on the unique aspects of equine and bovine practices, Drs. Katie Garrett, president of the American Association of Equine Practitioners (AAEP), and Fred Gingrich, executive director of the American Association of Bovine Practitioners (AABP), spoke about the focused work they are doing to identify and address recruitment and retention barriers.

“Keeping veterinarians in equine practice is perhaps the most significant issue ever faced by our area of the profession,” began Dr. Garrett. Currently only 1.3% of veterinary graduates go directly into equine practice, with another 4.5% going into an equine internship. Yet, 50% leave within the first five years. The reason why? “Salary and lifestyle,” said Dr. Garrett.

The AAEP launched its Commission on Equine Veterinary Sustainability at the end of 2022, with five subcommittees working to address individual "pain points" specific to the equine profession. The commission conducted a salary survey, which provided more accurate information than had been previously available and worked to develop actionable deliverables to help alleviate the identified pain points.

A best practices guide was developed for optimally hosting an intern, as well as several webinars and training sessions to help practices make the internship experience a more meaningful and rewarding experience for both parties. The commission also developed a comprehensive toolkit addressing emergency coverage, which is a significant source of stress for equine practitioners.

One subcommittee focused on student recruitment, with the goal of getting enthusiastic equine practitioners into veterinary schools to speak to students about their personal experiences with practice life. Ultimately, over 200 equine practitioners have participated in the effort, visiting with over 25 AAEP student chapters and preveterinary clubs thus far. 

Another important focus of retention is creating a positive workplace culture, and the commission’s practice culture subcommittee identified seven pillars that make up the culture of a particular practice, developing a toolkit complete with actionable resources to help build a positive culture.

Dr. Garrett added that mentorship is another important to addressing retention, explaining that young equine veterinarians who had been enrolled in mentorship programs showed a much greater likelihood of staying in equine practice. The AAEP has provided tuition assistance to eligible members to participate in mentorship programs, providing support for over 170 young members to date.

Armed with these newly developed resources and accurate information, AAEP is focused on reaching target groups to make progress in these critical areas.

Next, AABP’s Dr. Gingrich addressed workforce challenges in the bovine segment, pointing out that some of the workforce issues currently being experienced in other areas of veterinary practice, such as recruitment, retention, and attrition, are a chronic problem in rural food animal and mixed animal practice, adding that the AABP began attempting to address them nearly 15 years ago.

Retention may be a bigger problem than recruitment and that is a multifactorial problem. “Our greatest loss of AABP members occurs within the first five to 10 years after graduation,” he said, “and the No. 1 reason for that loss, based on our survey data, is a migration to companion animal practice.”

There are many opportunities to improve rural practice, such as better pay, more reasonable hours of work, mentoring, safe and inclusive environments, and opportunities for advancement.

The AABP has offered many resources, including a recent graduate conference and practice management workshops to improve financial health and human resources management of rural practice. The AABP recently convened a task force to develop guidelines for how credentialed veterinary technicians can be better leveraged in bovine practice under direct and indirect supervision by veterinarians.

“We believe that there are many opportunities for us to focus our attention on these valued professionals versus a proposed midlevel practitioner, which we do not support,” he said. "In addition, rural veterinarians can be supported by continuing to advocate for the VCPR, the importance of the establishment of this relationship through an in-person visit to the farm and utilizing telemedicine to supplement that established VCPR.”

Putting it into perspective

Jack Advent, recently retired executive director of the Ohio VMA, said it was important to talk about all of these issues in a public forum, particularly before they come up before legislators.

“Many of you agree that, for better or for worse, it’s at the state level that many issues are fought, debated, and outcomes determined,” he said “What happens in your state ripples into other states. The implications are at a national level.”

He encouraged delegates and their colleagues to further study these issues and access the existing information and resources available, particularly from the AVMA, which reflects the national brain trust for the profession.

Reaching out to other states and organizations that have already dealt with these issues and learning from their experiences can also prove valuable.

“I am certainly not here to try and convince you as to what position your organization should take on the issues being discussed, but simply that you take the time, individually and collectively as an organization, to engage in thinking, talking, and preparing to provide a foundation for if and when you face issues of substances like these,” Advent said.

He continued, “I would encourage you to ask yourself: Is your response and your thought process simply based on an intuitive first reaction? … And, also, to consider the completeness of the information that has been put out there. Have you thought about the implications both in the short and long term for your profession?”

A version of this story appears in the February 2024 print issue of JAVMA