This post really hit a nerve, since the vets at the second ER I worked at being changed to commission was a major factor in my leaving that practice. Not only does it mean charging clients more, sometimes for procedures that really should have waited for their day practice, but it meant no more rerouting any cases on even the worst, craziest nights. Ordinarily, if there are several good ERs in a metropolitan area, as there were for us, clients who called ahead might be sent to another hospital as close or closer to them, on a night when they might not be seen for 2 hours or more. The other practices returned the favor when they were swamped. So what having an ER vet who won't turn anything away due to being paid via commission means is having patients die or suffer needlessly. I saw this happen several times before I quit - one toxic cat waited 5 hours for a C-section and died as she was being anesthetized, a hit by car dog waited 1 -1/2 hours for x-rays when it desperately needed surgery to correct a diaphragmatic hernia, and a parvo puppy didn't get treatment started for nearly 2 hours. So I would say, be warned if it's a busy night and your ER pays its staff on commission!

Maria Shanley November 7th, 2008 11:04:00 AM

Interestingly, this subject came up THIS MORNING in our treatment room, and I though I might pass the idea along to you as a blog subject.

I work on the base salary plus a percentage model--its not perfect--I'd probably be paid more if I went on straight percentage, but honestly, that idea terrifies me and I could not sleep at night.

Where I get aggravated is when my boss harps on my ACT--we had a couple part time vets, so what happens is they see new clients and do these big workups, and I end up doing all the communications and doing the follow ups. I feel that this artificially lowers my numbers and artificially inflates the part timer, but my boss disagrees. We've very recently transitioned one of the part timers to full time status, so I guess we'll see who is right this quarter. FWIW, I have no idea how the part timer was paid, and I do feel that they went on a few fishing expeditions without having a solid plan--I then had to spend a lot of time trying to figure out what they were thinking (they worked on my day off) and explaining that to a client...so I did a lot of work for free, but hopefully I also built some trust with these people and that will pay off later.

It would be wonderful if I did not have to worry about my own bills--I do try and live well within my means--I own my car (a 2002 PT Cruiser) and have no credit card debt. I don't have expensive habits (though there are a few I would love to cultivate again--I had a horse once) I try and be understanding when a client can't afford what I recommend--we discuss how that limits what we can do, and so long as everyone is OK with the potential consequences, we go forward.

I am honest on the rare occasion I've been asked by a client how I am paid--and its generally with a person I DO have a good relationship with.

DrSteggy November 7th, 2008 11:12:00 AM

I do rescue work and have been to about 10 different vets in the NYC area for various reasons with different dogs. I am sorry to say that I have learned not to trust most vets because I can see that they are just trying to run up the bill unnecessarily. They must be paid based on a percentage of their charges. Sad to say, but by doing this, most vets in my area have completely lost their credibility.

Tara November 7th, 2008 12:24:00 PM

I'm very familiar with the different types of compensation models - I work for a corporate-type practice in which our head vet and the office manager have just partnered due to the hospital's high profitability over the last fiscal year. Vets employed by the practice start off on a base salary and then are transitioned w/in a year or so to base + production, with the base being lower than it was originally. Support staff also have a base + production model too - nurses earn bonuses for averaging a certain amount of dollars per hour, and receptionists earn bonuses based on the number of clients they check in.
The idea is not necessarily to run up each client's bill (although there is an "average patient charge" that we work towards), but to be efficient enough to see and treat lots of pets per day, and to focus more on what's best for the pet rather than what's best for the client's pocketbook. That doesn't mean that some vets don't run the bill up w/little justification - I've worked for a few that did just that...and I hated it. Then there are some vets who are so wary of the client's bill that they whittle it down as much as they can and simply hope for the best. The client is usually pleased, but was the pet best served?
The problem, as Dr. K said, really comes down to trust. I can discuss an estimate for charges for any given situation with an established client and the client, more often than not, is okay with the fee and pleased with our work. I can take that same estimate to a new client (or a client who is only seeing us b/c their regular veterinarian is unavailable) for the same situation, and they get very defensive and accusatory if the fee is higher than what they consider "reasonable" - and their determination of reasonable doesn't always equate to how badly their pet needs treatment. And it's because they don't trust us.
And I'll 'fess up, too - being able to bonus for the amount of money I average per hour sometimes changes how I work. I'm much more likely to bust my tail if I know I can get extra out of it. I'm much more likely to allow someone to come in 10 minutes before close (instead of referring them elsewhere) if I know I can profit for having stayed late. I'm not at work to volunteer - I'm at work because I need to get paid, and I'm there for money, plain and simple. Yes, I love animals and I love helping clients and treating pets, but if my wage were cut, I'd be finding another job. Vets and their staff are in the awful position of being frowned upon because we want to make money...as if our clients aren't the same way at their jobs!
I will say, though, that no matter how much money I bring in for the practice on any given day, it's ruined if a client is justifiably unhappy with me or if I ended up having to half-*ss things just to get everything done. I truly do believe that you can do what's best for yourself and what's best for your patient.

anna November 7th, 2008 01:32:00 PM

Amen, Anna!

Dr. Patty Khuly November 7th, 2008 03:20:00 PM

In 1996 I walked into Dr. Edwin Fisher’s practice in my new rural hometown in Kansas. There I stood with my tiny carrier containing kitty Myth, in a vast room that was the personification of “LARGE animal clinic” – I instantly felt put off by the expense invested in the facility and regretted my decision to seek out a local veterinarian. After a few minutes wait Myth and I met “Eddie” Fisher. He had silver hair, a lopsided smile and the kindest eyes I have ever encountered in a veterinary clinic. After tempting Myth out of her carrier with soft words, he performed one of the most thorough and gentle examinations of an elderly cat I have ever seen. I returned to the farm, ecstatic with “my” new EXPENSIVE vet.

For twelve years I watched Eddie handle those cats that grace my path – the feral, the hurt, the ill or dying – with the same focused, devoted attention as he gave my few healthy cats. After a few years he started to call me: this cat didn’t need to be euthanized, the owners won’t take it back, was there any chance I had room…?

We grew into a routine Eddie and I - I’d simply stand back and watch as he examined some of the rescue cats, ready to jump in if four hands were needed. His eyes would soften, he’d rub noses with them, call them “Tweakie” (I knew if the “T” word came out they were going to survive) then he would smile that lopsided grin, straighten up and say “Well, gal, we saved another one.” A few minutes later I’d be settling up with the front desk and he’d have his boots on, headed out to the cattle pen or headed into another exam room shaking his head at a loudly barking dog. Twelve years - over 25 cats, countless “not quite road kill” animals and I spent a lot of time in that exam room. The bill was never quite right, Eddie would waive his personal fees time and time again knowing that I had rescued this one, someone had mistreated that one, or this particular one I’d trapped because I’d seen her with a 3rd litter. When it was one of my personal pets, however, I paid the full and somewhat high price. In 2005 my animal care bill exceeded $2800. I always appreciated Dr. Fisher doing what he could, when he could, as a partner of the clinic to help us in our efforts.

Eddie Fisher died doing what he did exceptionally well – being a vet. On October 20, 2008 he was trampled by a 3,000 pound bull that got away from its handlers. I don’t expect to have the relationship I had with Ed with another vet, but I know there are other vets out there who respect the efforts of private TNR/Rescuers and do what they can. I’ll take the INVESTED veterinarian any day of the week!

Rachel November 7th, 2008 03:42:00 PM

Re:

"a lazy ER vet is easy to find if you don’t provide the right incentives. Pay her a straight amount for every night she works and she’s liable to want to take a nap . . . nothing sinister here . . ."

Frankly, that sounds pretty sinister to me.

Why can't care offeed and provided be based on what the patient NEEDS and will benefit from, RATHER THAN what the vet FEELS like offering (lazy vet) or COMMISSION (vet motivated by profit, not appropriate patient care)?

What? The patient's needs dictating care? What a novel idea!

I've seen both. Vets who want to run every test imaginable on an animal that clearly has a problem that will soon be fatal no matter what you do, racking up $$$$$$ in the last weeks of an animals life knowing full well it will come to naught but not disclosing this. And on the other hand, the lazy vet that says the veterinary equivalent of "take two aspirin and call me in the morning" rather than do the tests needed to figure out what's wrong and really help the pet.

Where's the right path -- the one driven by neither $$ nor inertia and absence of conscientiousness?

Stefani November 7th, 2008 06:48:00 PM

Here's a better idea:

Not pay as a % of sales. But OUTCOME BASED pay.

They are starting to do this in human medicine in some groundbreaking places. Are your patient's healthy? Are their chronic diseases well controlled? You make more money.

Are your patients dying? Are their chronic conditions poorly controlled? You make less money.

Do audits show a low error rate, careful records, and few or no medical errors? You make more money.

Or do they show sloppy records, out-of-range test results not followed up on, failure to convey information to the client, and patients injured or worse as a result of medical errors? You make less money.

I'd like to see quality based pay. Across the board. Human and vet docs.

Then, the emphasis would be where it needs to be:

Incentives for QUALITY of care, reduction of errors -- in other words, making patient outcome the milestone.

Here is a statement on the topic from the American Academy of Pediatrics:'

http://www.aafp.org/online/en/home/policy/policies...

I realize that death rate measurements would have to be modified for pets -- since they die much more frequently/sooner. But once objective means/medians standards are established, we have something to measure against.

Also, evidence-based assessment of the practitioners adherence to clinical guidlines.

Boy, the vet profession is a long way from that.

Stefani November 7th, 2008 06:57:00 PM

oops, sorry it's the American Academy of Family Physicians!

Stefani November 7th, 2008 07:04:00 PM

I think salaried vet is the best option. Most of the professionals are paid this way and they are expected to give their best. Why would you not expect the same from a Vet or a Doctor. Even for salaried job you can negotiate flexible hours and flex timing so that argument also does not hold true.

"Choosing the salaried vet may mean you may spend less up front, but this vet also has less of an incentive to perform time-consuming tasks that might make the difference between a diagnosis and no diagnosis. Between the option for ideal treatment and a less expensive (but easier-to-accomplish) treatment. "

This is just unprofessional and also unethical.

Dimple November 7th, 2008 07:55:00 PM

I ish there was some kind of mandatory "mood ring" that turns one color for "good" and another color for "bad", and then it wouldn't make a bit of difference how money was obtained.

In my work lifetime, I have been paid in various formats, and though straight commission was one of the most difficult at first, forming a happy client base by working many hours above 8 and often 6-7 day weeks, after awhile, the happy clients came back and sent referrals.

Doctors, dentists, and professionals within private practice are not necessarily salaried, I think more based on "piece count". They are going to lose with some (time-wise, etc.) and make up with others. It still boils down to "trust, personal ethics & philosophy, and professionalism".

Barbara A. Albright/New Hampshire November 7th, 2008 11:05:00 PM

I can't imagine how "outcome-based" compensation could be fair - a pet's outcome is dependent on a combination of veterinary care and client compliance - we can do all the work in the world, but at the end of the day, the client is responsible for maintaining the care of their animals.For example, there's a notorious client at my practice whose two standard poodles are facing ear canal ablations - not because we haven't done what we can for her pets over the years (I'm talking ear swabs, c&s, repeated flushings under anesthesia, countless hours of staff and doctor time thoroughly explaining, etc., etc.) but b/c their owner does ZERO compliance at home...and usually admits it. Who's at fault there? Not only that, so much of any medical field is really out of most people's hands - "80% will get better regardless of what you do, 20% will die no matter what you do".

anna November 7th, 2008 11:46:00 PM

Stefani said: And on the other hand, the lazy vet that says the veterinary equivalent of "take two aspirin and call me in the morning" rather than do the tests needed to figure out what's wrong and really help the pet."

My emergency vet didn't even suggest that--instead, he told me that if my pet died while under his care, he would call! Of course, he didn't even bother to do any testing (just out of curiosity, I would have done a basic blood test), but he had plenty of time to continue reading his book in a empty emergency hospital. The bill was approx $230 for placing my dog in an oxygen cage for 1 hour.

Fotini November 8th, 2008 01:42:00 AM

Dimple: I know it's hard to believe but veterinarians are people too. Much though you might think it unethical and unprofessional for us to conform to human standards, it seems the studies show that our DNA is (here's a shocker) just like yours.

I don't mean to sound so snarky (not to mention cynical) but the truth is we're ALL driven by a variety of factors and money happens to be one of them. Yes, I would like to believe that all of us are idealistic, courageous and upstanding enough to understand our priorities and do our best work all the time for all the right reasons.

Sometimes, however, everyone needs an additional incentive. Appealing to our baser motives ($) has proven to be effective time and again, whether your a human doc in a large urban ER or a tumbleweed counter in Texas.

We know that animal life is motivating enough--otherwise we wouldn't have gone to vet school and worked so hard (as most of us continue to do) to keep up and do our best for our patients. But it's polyanna-ish to assume that incentivized pay doesn't have a place in animal medicine simply because we're somehow supposed to be better than the rest of you.

Dr. Patty Khuly November 8th, 2008 08:25:00 AM

Re:

"I can't imagine how "outcome-based" compensation could be fair - a pet's outcome is dependent on a combination of veterinary care and client compliance . . "

Although you make a good point, they struggle with this issue in human medicine as well, and they DO find a way to develop measures that take this into account. I am not fully educated on the finer points of HOW exactly they do this, but they DO address the concern you raise.

And, there are certain performance based things that very simply are entirely within the practitioners control.

Stefani November 8th, 2008 10:03:00 AM

Sorry about my last comment...I just re-read it and the tone's way harsh. Mea culpa...

Dr. Patty Khuly November 8th, 2008 10:25:00 AM

One comment about vets who might appear to "want to run up the bill with unnecessary tests, etc."

This is where communication between the vet and the client is of extreme importance. Some vets are better than others at interpreting the wants and needs of their clients, but even the best can't read minds.

It's true that there are some bad apples out there who are happy to run up bills, but that certainly isn't always the case. Most vets simply want to offer their clients the best medical care they are able, and that often means expensive diagnostics, etc. When pet owners are up front about how much they want or are able to pay from the beginning, everyone goes home happier. The vet can offer the best standard of care for a given budget and the client can get the services he or she needs without feeling they've been taken for a ride. Sometimes (not always) there are less expensive alternatives that are nearly as safe and effective. If you feel a test is unnecessary, ask your vet for more information about it--perhaps she can help you understand why it is important. Often, the things which we do not understand seem less valuable than they really are.

I've worked in clinics and I'm in vet school now, so I see things from both sides of the fence. But no matter which side you're on, communication is key.

abc November 21st, 2008 09:12:34 PM

Well, I'm coming at this from a slightly different angle of working in the office of a specialty type practice. I'd prefer to have my personal pets treated by a vet to has something to gain out of their treatement, since spending time on employee pets takes their time away from the "paying" customers. I, along with other of my office-type coworkers often opt to take our personal pets to a nearby 'regular' vet and pay full price for what we perceive as more attention and better care.

T November 29th, 2008 11:25:54 AM

From what I've read here and what I have experianced in my line of "jobs", the results are still the same. Both the Client and the Vet care about money. I agree that when it comes to the Pets needs and Health that money should not even be thought of but that's not how life goes. If you had a job that kept cutting your pay or did not give you a stable/admired amount. Most likely You would be biased. You would be unhappy therefore work half-assed. You may care for animals/the purpose but you will not want to work there. Everyone wants to feel secure. Everyone wants to do what they can to help or improve their specialties/abilities. That being said. If people are paid more or have a kind of reward system they would work harder and be able to focus more on the customer/animal. If the world could live on the income of kindness and selflessness this planet would be in a better state. Unfortunately, this is the real world. People put more effort into things when they feel secure. 98% of the best vet care you'll recieve will be "overpriced." That's just how it is. That's just how it is. Now a way to fix the financial problem for both the vet and the owner would be the government to step in. Since they decide that Animals aren't important enough to provide income for the vets and free medication, exams, surgery for the pets.. the NEXT best thing to do would be to get EVERY vet clinic to work off of a get "Help now and pay later or with payments" kind of billing. (basically a salary but find a way to throw in a reward system like suggestive selling NOT required selling) If the pets could get the help they needed now without the owner having to worry about paying up front or in one lump sum and with the Vets not having to worry about an unsecure income, than I'm quite sure everything would work out. The pets would come first! Their needs above the humans. And get this, I bet you the Customer/Owner wouldn't mind paying a higher price if they got they care they needed now and could pay you vets in payments or at a later date. I mean come on. How else do you think Matress Mac and all those other overpriced furniture companies do it? Get the item now, Pay later or in reasonible payments. Everyone gets what they want and everyone gets paid. PS. Yes, I know some Clinics already do that, But EVERY one of them needs to. If a hospital cannot deny a bum (who most likely created their own horrid lifestyle) medical care, why is it okay for a vet to deny care to a helpless/innocent animal? *knock knock* Hey government, see anything wrong with this?

Victoria December 6th, 2008 01:56:29 PM

I had that in paragraphs where it was easier to read but for some reason when i submitted it, it showed up like that. Sorry.

Victoria December 6th, 2008 01:58:08 PM

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