Specialty, primary veterinarians navigate evolving relationship as demand continues to grow

Veterinary medicine has become increasingly complex in recent years. With over 22 specialty organizations and 46 veterinary specialties recognized by the AVMA American Board of Veterinary Specialties (ABVS), referrals have become integral to providing comprehensive care.

Despite the greater prevalence of advanced veterinary medicine, most pet owners are not prepared for specialty care, with over half admitting limited knowledge about it. That’s according to a survey of just over 300 pet owners published last year by Synchrony, a consumer financial services company, for Care Credit.

General practitioners (GPs), too, struggle with deciding when and what type of patients would benefit from referral to a specialist. That said, findings from studies published by the Collaborative Care Coalition have shown improved quality of life for pets and improved client perceptions result when clients are offered early referral for their pets’ conditions.

Referrals on the rise

Trupanion released data on February 20 that revealed substantial increases in the number of specialty veterinary care claims and average claim amounts in recent years. Analyzing over 5.7 million veterinary claims from December 2019 through November 2024, these data underscore rising demand for specialty veterinary care, at least among insured pet owners, even as costs of care increase.

In the five specialty areas studied—dermatology, dentistry, cardiology, oncology, and neurology—all saw increases in the range of 34% to 55% in the number of claims for dogs and 20% to 47% in the number of claims for cats, except for oncology, which was not included due to a small sample size.

Neurology and cardiology claims have seen the most substantial growth. The number of neurology claims for dogs has grown by 47%, while the number of cardiology claims for dogs and cats have increased by 55% and 47%, respectively.

Total neurology claims paid out by the insurer went from $7.49 million in 2020 to $30.51 million in 2024. And for cardiology, total claims paid out increased from $3.40 million to $15.53 million in the last four years.

Average claim amounts have increased substantively across all specialty care areas, with the most notable increases seen in dentistry and cardiology. Specifically, the average dentistry claim amount in 2020 for dogs was $1,490 compared to $2,059 in 2025, while for cats, the average dentistry claim was $1,380 in 2020 and $1,893 in 2024.

The conditions referred varied by species, with neurology claims showing meningitis, intervertebral disc disorder, and vestibular disease at the top for dogs and intervertebral disc disorder, mass lesion, and hydrocephalus at the top for cats.

More client education needed

While pet owners may be seeking more advanced care, they still largely remain in the dark about how to find it and how much it costs. The Care Credit study results, released late last year, showed that, when pet owners were asked about their top concerns about specialty care, 80% of those responding indicated its cost, with 69% indicating they were worried about how they would afford treatment. Half reported looking up information about payment options before seeking specialty care, and 38% tried to find information on the cost of specialty care.

Yet, more than a third of specialty clinics don’t share the cost of care or payment information in any client communications. Of those that do, most communicate at the point of care, and just 25% provide that information prior to the appointment, according to the study results.

Fifty-four percent of surveyed pet owners claimed “little” to “no knowledge” of specialty care. They also shared that if they did seek it out, they often had to independently research specialty hospitals, treatment costs, and payment options. Surveyed pet owners reported that their primary care veterinarian topped the list (34%) when looking for information about specialty care, followed by “general online search” (32%).

At the same time, nearly two-thirds of respondents seeking advanced care went straight to the emergency practice without a referral.

Among pet owners who were referred, 63% said they were provided the reason for their pet’s referral, while only 36% report being provided information about referring veterinarians’ experience with the specialist or hospital, and 30% received details about the specialty hospital.

The importance of the triad of care

The triad of care—in which patients and clients travel from generalist to specialist and then back again, working as a harmonious whole—is one of the most important arrangements in veterinary medicine.

Dr. Tiffany Hall, a double-boarded specialist at the Equine Medical Center in Ocala, Florida, takes a holistic view of the referral relationship.

“We want our referring vets to know we are here to support them,” she says. “I see the referring vets as my clients as much if not more so than the animal owner, because they're the ones that I’ll be seeing over and over again.”

A 2023 study by the Collaborative Care Coalition (CCC) indicated that clients perceived an early referral as good value for the cost regardless of a pet caregiver’s financial situation. In the study, 70% of clients across all income brackets agreed that referral resulted in a good outcome, and client perceptions of the GP were six times more likely to improve after referral. The study also indicated that clients valued the GP’s involvement and willingness to work with other veterinary professionals.

The top predictors of client satisfaction with GPs, according to the study results, were as follows: responsiveness to questions, staying involved with their client’s pet’s care, and willingness to work with other veterinarians and specialists. For specialists, top predictors were providing accurate cost estimates, cancer knowledge, and effectiveness of care.

When to refer

But the question of when a patient would benefit from a referral to a specialist isn’t always so obvious.

The short answer is that veterinarians should refer any case that is outside their scope to manage, says Dr. Michael Merkhassine, clinical professor of small animal internal medicine at Cornell University College of Veterinary Medicine.

In addition to emergency cases that require extensive monitoring or specialized stabilization, he recommends surgical cases that require advanced equipment; cases that require additional workup beyond what the GP can offer, including ultrasound, CT, MRI, echocardiogram, or endoscopy; and cases where there are multiple comorbidities that need to be managed concurrently, such as Cushing’s syndrome, chronic gastrointestinal diseases, or kidney or heart disease.

In a 2016 study published in JAVMA, dogs diagnosed with congestive heart failure due to myxomatous mitral valve disease experienced increased survival times when treated collaboratively by a cardiologist versus by the GP alone. Median survival time increased from 146 days to 254 days. The GP also experienced a revenue boost owing to the increased life span of the pets.

A 2021 study, also published in JAVMA, showed dogs experienced longer intervals between bouts of ear infections when treated collaboratively with a dermatologist versus when managed by the GP alone (171 days versus 21 days). This same study also measured client frustration, showing clients would not return to their GP after three visits or $925 if they did not see significant improvement in their pet’s condition.

Dr. Hall also includes situations in which common solutions to the problem are not working.

“If you’ve already done what routinely helps most animals that walk into your practice, that's probably a good sign it's time to loop in a specialist,” she says.

Dr. Hall believes that prompt referrals may be more expected in the equine world.

“Of course, many owners care deeply about their horses, but they may also be a business investment to the owners, too,” she says, noting that much of her practice focuses on elite Thoroughbreds. “Both owners and their regular veterinarians may be prompt to suggest a specialist, but I do hear from small animal specialists that they often wish they would be referred sooner.”

Dr. Christopher Byers, a double-boarded emergency and critical care specialist in Omaha, Nebraska, works as a consultant to veterinarians around the world. His experience has been that American veterinarians are quicker to refer than their counterparts in other countries who tend to want to exhaust their own resources first. He appreciates that U.S. veterinarians may refer sooner but wonders at the reasons why.

“I hear from American primary care colleagues that they don't have enough time in their clinical schedule to do the type of workup that they think a patient needs, which is unfortunate,” Dr. Byers says, who is a member of the American Association of Veterinary State Board's Regulatory Policy Committee. “These colleagues say they feel an implied pressure to refer to specialists out of fear of litigation or a complaint being filed with a state board.”

Blueprint for successful referrals

One of the most important ingredients for a productive referral relationship is mutual respect and clear communication. Here’s what some specialists suggest for a blueprint for successful referral:

• The referring veterinarian should educate the client about why they’re referring. “We often see pets with multiple chronic conditions, and it is not unusual for there to be a disconnect between what the referral paperwork says and what the client thinks they are being referred for,” says Dr. Merkhassine. “I’ll then have to pivot quickly, especially if the case requires a more expensive diagnostic, and the client had no expectation of the costs associated with those procedures.”
• Before the appointment, the referring veterinarian should send the patient’s records, including any test results. “Please send the original test results, not your interpretation of the test results, so I can make my own interpretation,” Dr. Byers says.
• After the consultation, the specialist should update the referring veterinarian promptly. “Inevitably, a client will touch base with their primary care doctor after their consultation and they'll often say, ‘Here's my understanding of what's going on. Is that what they shared with you?’” says Dr. Byers. “Shame on us as specialists if that doctor has to tell the client they haven't received an update from the specialist yet.”
• As the patient returns to their own veterinarian, the client and both veterinarians should be clear on follow-up care. Candid communication helps avoid the “too many cooks in the kitchen” syndrome, says Dr. Jessica Larson, a board-certified small animal internal medicine specialist and president-elect of the CCC. “It’s important to be very clear about which veterinarian is doing what in terms of follow up, including communicating test results back to the pet owner, making recommendations, and prescribing medications as well as ordering follow-up lab work,” she says.
• The generalist should provide the specialist with a progress update as a courtesy. “I appreciate getting an update on how the pet is doing, what medications they are taking, and what they are eating along with the lab work, especially if it is a month or longer after the initial appointment,” Dr. Merkhassine says. “There are many cases where we need to know how the pet is feeling to help interpret the lab work and decide if we need to make changes.”

Dr. Genesis Jones, a general practitioner in Raleigh, North Carolina, admits she’s had some negative experience in the past when doing referrals. Much of the frustration stemmed from the process, which can have gaps in communication and take up a lot of time if not done properly.

She chaired a task force that recently developed the 2025 American Animal Hospital Association (AAHA) Referral Guidelines, the intent of which is to provide a framework that fosters stronger partnerships between GP teams and specialty care teams.

The goal is to have the referral process become better organized so it can run more smoothly for veterinary practices and pet owners. One of the major recommendations is use of a referral coordinator who is responsible for providing case-specific communication with clients and between the veterinary teams.

“If we can free up time for the GP and specialists with a referral coordinator, it not only makes more sense but also helps achieve the collaborative care we’re striving for,” Dr. Jones said.

Limitations and possibilities

Of course, limitations exist with referrals, particularly the expense of specialized care.

Clients can also encounter longer wait times for appointments to see a specialist or there may be unavailability of specialists in certain areas, such as rural locations and those not near a veterinary college.

Dr. Jones says in those cases, GPs have other options they can pursue. One is a phone or video consult. She does this frequently with veterinary behaviorists because it often takes months for their availability in her area.

“This helps because it allows us to recommend something in the short term until the (onsite) evaluation. That comes with a fee, but a lot of owners appreciate the jump start to things. If they have an aggressive dog and they have to wait six months to get that under control, it can be disheartening,” Dr. Jones said.

She also pointed out that many industry partners have clinics and services that allow practitioners to contact them for case discussions and general advice.

“If I’m having trouble interpreting results or have a specific question, it’s an awesome tool I use all the time,” Dr. Jones said.

She says, at the end of the day, the goal is about getting the best care for pet, “and as long as everyone is on same page, that is what they’re going to get. Time and again, that’s what owners are appreciative of—professionals working together and on the same page about the care of their pet.”

Darcy Lewis is a freelance health and medical writer based in Chicago.

Correction: An earlier version of this article misstated Dr. Michael Merkhassine’s title.