Dr. Bruce Silverman was one year behind me in vet school at the University of Pennsylvania. He was a loudmouth back then and he's a loudmouth now (and I say that in the nicest of ways). You can say whatever you want about opinions, but when they're thoughtful and well written, I'll take 'em.
Here's his take on one veterinary business microcosm: Chicago's. His observations represent the sign of the times and the shape of things to come so pay attention...and discuss...
Vet Wars: How veterinarians in Chicago are battling it out over animal turf
by Bruce E. Silverman, VMD MBA
I received a letter in the mail today from a local veterinary establishment. This letter was from a suburban veterinary emergency room and critical care center on Chicago’s north side. It’s an ER that’s been around for years, complete with a couple of specialists who generally have daytime hours at the same location when the emergency room is closed from dawn until dusk. Apparently, this ER has decided to take the plunge into the world of 24/7 emergency services.
Why wouldn’t they, you might ask? Good question. On the face of it, this is a logical service for an ER to offer. After all, human hospitals don’t shut down their ERs, vampire-like, just because the daylight has come. Yet, this hasn’t always been the case for most veterinary emergency rooms around Chicago and its suburbs. Most have been open only at night. Traditionally, general practice neighborhood hospitals function during the daylight hours, and emergency rooms take over for the city’s pets once the neighborhood hospitals shut their doors and turn off the lights at night. Sure, a few of the metro area’s specialty/critical care centers, chock full of radiologists, surgeons, cardiologists, etc, of technicians and fancy equipment, stay open round the clock. But these have been more the exception. So what’s changed? Simply put: competition. Less simply put: more hospitals, more ancillary businesses, expanded hours, rising supply costs, fewer pet visits and less client discretionary income, and more general practice doctors and specialists.
The peaceful status quo balance in the veterinary medical sector had been kept stable over many years by basic supply and demand economics, segmented markets, and a stable economy with high business and income growth. Neighborhoods had one, maybe two veterinary hospitals, and cities had one, maybe two emergency rooms. Throw in a specialty center or two, maybe a university hospital, and things get more complicated, but not by much if the city, like Chicago, is large enough (for the record, Chicago had no university veterinary presence until recently). The non-profits had their own little niche, as well, in taking in indigent pets, cleaning them up, and finding them homes. But there was ample room for this, and it only helped clinics get new patients, anyway, so this was very welcome. Everyone got along fairly well without too much stepping on toes. The local medical association meetings were congenial. There was lightness in the air.
But then things changed, and continue to change. A number of new hospitals sprung up within or between neighborhoods. Another ER and specialty center were added here or there in a suburb. A specialist was added to one or another general practice hospital. New, non-traditional services are being introduced by some hospitals, overlapping with those of other clinics nearby already offering those services. General practice hospitals have started adding doctors and expanding their hours earlier and later to better cater to clients’ work schedules. Non-profits are expanding their services well beyond simple adoptions and spay and neuter clinics only for those most in need. To these add the plethora of new doggie day care centers, dog-walking services, boarding facilities, pet groomers, homeopathic and therapy centers, and low-cost vaccine clinics that are springing up everywhere, with rumors of more to come. Competition is on the rise at a time when suppliers of all things needed for the smooth functioning of a veterinary hospital are increasing the costs of goods sold, and at the same time that pet owners are losing jobs or seeing their savings evaporate (fortunately, as I write this, the Dow is back over 10,000 points). Doom and gloom? Could it get worse?
In Chicago, it did, and only just recently. The straw that broke the camel’s back (a very sad, yet improbable, cliché in the veterinary world) was the addition of yet another emergency room and critical care center close to an already established nighttime ER. This new emergency room, however, happens to be open 24/7, and is staffed by specialists in critical care and surgery – similar to the specialty and critical care centers already in outlying suburbs, but heavy on the emergency services. And did I mention its impressive new facility with expansive lobby and high-tech equipment? The tension in the Chicago veterinary market has become palpable. Expecting impending devastation if no evasive action were taken, the traditional ER down the street expanded its hours to 24/7, regardless of any foreseeable economy of scale. And this brings us full-circle to the letter I received in the mail today: yet another ER expanding hours in the face of obsolescence.
Is there really a critical mass being reached on Chicago’s veterinary battleground, and perhaps in other parts of the country? From the veterinary business operator’s point of view, the competition for a largely unchanging pet population is becoming much more intense. Perhaps the long established larger hospitals and pet service businesses have had it too easy for too long, and will feel the squeeze much more than the newer, more nimble businesses springing up. Or perhaps the newer businesses will find that reaching an economy of scale while growing a startup is extremely difficult while costs are squeezing from below and pet owners’ financial limitations create a glass ceiling from above. Perhaps on this expanding battlefield, ingenuity and perseverance will be the greatest weapons. Fortunately there will likely be little overt carnage, knowing the overall goodly demeanor of my veterinary colleagues. The weapons will be wielded gently, and with little ill will intended. Who wins and who loses may not be apparent for some time. Perhaps the medical association meetings will still be quite congenial. And while perhaps we’ll all feel some pain, hopefully no doors will ever need to be shuttered.
Will anyone be a clear winner? Absolutely. In this battle for pets, the innocent -- those pet owners reading this story -- will find that these developments mean fairer times ahead. Competition may be the mother of invention, but it’s also the father of better pricing, or at least expanded services and improved client (pet owner) care for the discriminating consumer. So be discriminating, but know that we’ve all made these great investments in knowledge, skills and equipment for you and your pets. And remember, at the end of the day (or night), there may be a thinner smear of butter on our bread, or a thicker layer of sweat on our brow…and the battle will yet go on, and on, and on.
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Where is the consumer, and the patient, in all of this?
Having experienced first-hand the poor care and bald-faced financial abuse that an emergency clinic can get away with in an atmosphere of no competition, I am curious as to whether there is a benefit to clients involved.
Or does the cut-throat atmosphere just encourage each hospital to shake down the distressed pet owner with even more predatory vigor?
H. Houlahan October 21st, 2009 07:19:56 AM
Silverman has it wrong.
We know what happens when there is too much medicine in a community.
And we know what does NOT happen.
Look at human health care in New Jersey, for example.
There are waaaay too many hospitals, clinics, doctors and pharmacies in NJ.
Are prices dropping? No! Instead prices are going up,
And why? Simple -- FRAUD. Ditto in Florida, by the way. Medicare and Medicaid fraud is through the roof in Florida, and there's no shortage of medical providers, is there? No!!
So what are the doctors and hospitals doing?
Simple: They are are upcoding, keeping patients longer than they should, running expensive (and often unnecessary) tests, precribing more expenisisve medications (in order to collect the kickbacks), doing medically unnecessary proceedures, etc.
And this is in HUMAN health care, where the False Claims Act means triple damages, where doctors can be drummed out of business and debared by Medicare and Medicaid, where kickbacks are illegal, and where insurance companies sometimes question bills.
Think the same thing is happening -- and will happen more frequently -- in a crowding veterinary market? Count on it!
As you know, veterinary care is VERY poorly regulated. Kill a dog or cat, and it's considered property same as a TV. Kickbacks? Not a problem. Referring a patient to someone you have a financial relationship with? Fine. Price-gouging? Of course. Medically unnecessary procedures? Standard operating procedure.
Of course the dog-owning public knows even less about canine and cat care than they know about human health care. Keep the dog overnight after a spay? Sure -- KA-CHING. Annual teeth cleaning? Sounds reasonable -- KA-CHING. Annual booster shots? If you say so -- KA-CHING. Prescrioption dog food? Uh ... sure. KA-CHING. And on and on it goes.
Emergency care is particularyy price insensitive. It is, afterall, supposed to be an emergency. Chinese Fire Drill time! And since nothing in the lobby gives a price, and there is no advice given that if you come in on regular hours this will be a lot cheaper (and maybe you do not need a vet at all), well KA-CHING. Someone has to pay for all that high priced equipment right? And no one is going to roll up their shop or raise to insolvency, when price-gouging the customer and selling them some unneeded services is so much easier (and very easy to rationalize).
So, to repeat, Silverman has it wrong. We know what happens when a health care market gets crowded -- and it's NOT lower prices. Ever.
Patrick
PBurns October 21st, 2009 07:20:25 AM
I have to agree with Patrick. The clinic that I work for is in a small city that has 8 veterinary clinics and so far one emergency center,plus the local humane society is trying to open it's own vet clinic. With so many vets you would think that things would be competitive as far as pricing, instead prices are always going up! It makes no sense for the prices to continually go up with this many vets in town
DNS83 October 21st, 2009 07:47:28 AM
Patrick: you said, "As you know, veterinary care is VERY poorly regulated. Kill a dog or cat, and it's considered property same as a TV. Kickbacks? Not a problem. Referring a patient to someone you have a financial relationship with? Fine. Price-gouging? Of course. Medically unnecessary procedures? Standard operating procedure."
Of course, I agree with you that emergency care pricing is very inelastic. I'll also agree that veterinary medicine is inadequately regulated. Nonetheless, I have seen evidence of positive consumer response to competition in the ER arena in my area (and in Philly when I practiced ER over a decade ago). That's because, sure, you may get killed on one visit, but most clients are smart enough to check out another ER after a bad experience at place #1.
I've worked at two of the six ERs in my area. I send my clients to the one where the docs don't upcharge as a matter of course. It also happens to provide better service--by far. It's growing relative to the others (albeit slowly) because they compete well, knowing as they do that ER services are often utilized multiple times in a pets lifetime.
I'll also disagree on the issue of kickbacks: They are specifically prohibited. We all know there are ways around these laws (as we know happens frequently in the human medical arena) but it's in black and white in the practice act of every state.
Referring to friends? Happens frequently. I refer to my boyfriend all the time (and I disclose). A direct financial arrangement? So, too, though in a "disguised' sort of way. I'll agree that disclosure needs to happen in all these cases.
Yes, we need better regulation. Our Boards need to show their teeth. And non-economic damages need to be granted in our courts.
Still, I'd argue that competition is a good thing in vet medicine as in most every industry. Not everyone responds to a tight market by gouging the consumer. Some of us do strive to offer value to gain a competitive advantage. To say otherwise suggests we're all unethical louts who could care less about our clients and patients.
Dr. Patty Khuly October 21st, 2009 07:54:16 AM
The hospital with the best client service will win. I don't know about Chicago but the attitude in most specialty and emergency hospitals is to stroke the doctors ego not the make the client feel cared for.
Robert October 21st, 2009 08:27:32 AM
I live in chicago and was not aware of another emergency 24/7 clinic opening. The reality is that when necessary (baring any bad experience) I will keep going to the ER that my vet has a working relationship with.
The staff at the vets' office do some type of rotation at the ER and my experience is that they do an excellent job coordinating the case back to my vets office.
Last time, I got a call from my vets office first thing the next morning to check on my cat's progress. They had all the records on hand and the transfer of care was perfect.
I don't know about competition and prices in the vet world - I think for a lot of people price is important, for others the reputation of the practice outweighs all. LIke most things in life, this depends on the pet owners income and priorities.
What is interesting is that we have so many shelters providing low cost spay/neuter clinics. One of the biggest cat shelters in town (Tree House) just opened a new clinic, PAWS has one, Anti-Cruelty has one, there are several others within the city limits but can't think of the names at the moment.
I've been really pleasently surprised that I haven't heard much grousing by vets over these low cost services (at least publically).
2CatMom October 21st, 2009 09:09:46 AM
We have one of those gee wiz fancy Vet facilities in our town and can attest to the fraud. The facility is known as a "Clinic and wellness center" and is easily three times the size as my vets recently updated facility, and that' doesn't includne the huge boarding facilty off the back of the place.
I boarded our dog with this facility once as our vet only has cages and our dog will NOT do a cage, she has to have a run. Anyway, all was well. Then the second time I wanted to board her they told us prior to boarding the dog needed another "Kennel Cough" (Bordetella) vaccine. I said "But according to my vet, it's an annual." The receptionist told me that they have had dogs catch Bordetella even when being vaccinated and the "Doctor" felt that the vaccine was wearing off early.
I called my vet, a vet who was listed in a prominent magazine as one of the top 200 in the nation. In his thick, New York Jewish accent (and we're in Rural Ohio, go figure) he said "That's BS." He explained that the Bordetella vaccine is similar to a flu vaccine for humans in that it's a "shot in the dark" and is only a preventitive. A dog can absolutely still get sick by being boarded if there is a different strain of Bordetella or other "funk" regardless of the vaccination though he felt it was rare for that to happen.
Now I am no vet but I know business like the back of my hand. Businesswise, the manufacturer of the vaccine would NEVER promote a vaccine to be administered less often then they could get away with. In fact, if they say it's an annual, I would bet money it migth be good for longer.
The vet? Well, if he is giving this vaccine to all of his patients twice as often as needed, as well as other vaccines, as they say in the mob, "it's good money if you can get away with it."
A few months later at the dog park I got to meet "Gretta, a beautifule doberman. I was petting the dog when all fo the sudden the dog took a snap at my hand for what I felt was no reason, and immediately went back to being calm. The owner said "Oh, you must have brushed her ear. The vet that did the cropping screwed up her ears and they are in pain all the time and don't look right. Now I didn't go into a question answer session about cropping (as in "WHY!!!!????), but I did find out that the very same "vaccination happy" vet I am discussing here also screwed up the ears.
I know cars as well. There are very large auto repair centers in our area and very few of them know what the hell they are doing and most of their services are profit motivated. I would be willing to bet that these large vet medical facilities are much the same way, as are the human medical facilties. No one builds a gazzilion dollar facility out of the goodness of their heart. My vet expanded because they ran out of room, not because he had any visions of a retirement yacht. Other's motivation may vary.
EAB October 21st, 2009 09:13:31 AM
It's interesting that there's this much competition in some markets while there's still a shortage of services in others. I guess it's not likely that practices in large cities, like Chicago, would uproot and move to smaller towns where there's less competition. : )
Posey October 21st, 2009 09:24:09 AM
This is the part I are about:
"expanded services and improved client (pet owner) care for the discriminating consumer"
As this article points out, in the past, most pet owners have simply defaulted to taking their pets to whatever clinic was closest. Thus, vets get the idea that certain pet owners within a geographic area are "theirs" by right, which should not be true.
If more efforts are made to educate consumers about QUALITY issues in veterinary clinical care, then those who value it and can afford to seek it will do so.
There sadly will always be those who base their choice on lowest price alone, and I will die yelling at those people about how dangerous that can be.
Stefani October 21st, 2009 09:28:57 AM
LOL, I meant CARE about, not "are about."
Stefani October 21st, 2009 09:29:31 AM
After the $1200 bill for laceration staples on two dogs at the monopoly emergency vet, I made a proactive move to forestall any future unnecessary wallet-ectomies by this particular racketeering operation.
It's called a skin stapler, it cost $15, and I used it this week. Cephalexin is now FREE at one of the local grocery pharmacies. My regular vet gave me a script that should keep a small army covered for the next year. I already have irrigation syringes and plenty of normal saline, and a clipper. I'm a wilderness EMT for Chrissakes. This about covers the barbed wire/raccoon encounter/etc. eventualities around here.
I like $15 better than $600 when it is outgoing. Also, got to go to bed at a reasonable hour instead of sitting up all night in a waiting room while the techs gossip and the receptionist pads the bill. And my dog is recovering much better, having been quickly attended to and put to bed without general anesthesia for sutures! And she isn't shaved half-naked for a two-inch cut. (She has abrasions all over the huge area they shaved on her shoulder last time, after I asked them not to and explained why.)
Thing is, if they hadn't killed the goose with their mythical $7 surgical gloves and $32 e-collars and (attempted) $150 Ceflex, I'd still be driving down there for non life-threatening "urgent care" and they'd have a repeat customer who was NOT telling everyone she knows to avoid them at all costs unless the animal is actually bleeding out and shocky.
It's not my responsibility to pay for their new MRI.
I truly do hope they go tits-up, and force the local vets to do a reasonable after-hours emergency co-op.
H. Houlahan October 21st, 2009 09:46:08 AM
This is really no different then the greed we see within the human health care. People (vets or their business counterparts) see $$$ opportunity and are acting upon it. However, they have chosen poorly in this economy and but the client will suffer for their greed and poor planning in hiked prices that in turn will drive people away from care so ultimately the animals these expansions propose to help will suffer in the end because of them.
I really really wish more people would take a realistic view of the economy and act accordingly. We've still got some seriously rough days ahead even if the dow has climbed back up...just wait the business foreclosures/collapse hasn't even hit a high yet and oil is on the way up again due to greed and speculation.
LorriM October 21st, 2009 09:54:51 AM
"The discriminating consumer" is industry code for "Lexus owner who is mightily impressed by the espresso maker in the tastefully-tiled waiting area." It is also code for "Daddy needs a new boat."
Just thought you'd like to know.
The best veterinary clinician I ever had was also the cheapest I ever had, and the cheapest in her area.
My current vet is neither the cheapest nor the most expensive, but is clearly the best in this area. The most expensive clearly is not.
The most beautiful spays I've ever seen were done for about $20 per, on an assembly line at a clinic.
Suturing does not require a full blood panel. (But paying for the fancy in-house diagnostic equipment may.)
Wanting the best for an animal is not the same thing as opening your wallet and letting the vet shake you up and down.
H. Houlahan October 21st, 2009 09:55:20 AM
There's a vet (a bad vet) in NEOhio who opened a (supposedly) 24 hour practice less than 100yds away from a traditional emergency-at-night, daytime-specialty-practice, and sadly, many people have made the mistake of ging to that place, where the care is much worse and although claims are made of being less expensive, that doesn't bear out, generally.
It's not that I like the 'real' specialty-emergency clinic (2 bad experiences there, so I now go to places further away), but in this instance of providing competition, the consumer who chooses wrong, and their pet, are not better served.
KateH October 21st, 2009 10:14:59 AM
My regular vet clinic is a feline-only clinic with two ABVP feline certified vets, and specialists that travel to the clinic for things like ultrasounds. They are able to cover most of ouer cats needs, and actually a few years ago ended their Saturday hours. The clinic is AAHA certified.
December 2007 was my first visit to an ER with my cat Bo. After fighting his vomiting and IBD for long enough, my regular vet recommended exploratory surgery, and recommended having a boarded surgeon do it over herself. So we packed him up and brought him to the ER/Speciality clinic. This was a new clinic and I will admit expensive. But I really felt Bo got the best of care, in a very clean environment, and as little stress as possible considering where he was. I would have been very unhappy if he would have needed to be carted between the two clinics for care. His stay was short - we confined him at home.
Bo had another visit this past December when we couldn't get his vomiting under control Again, I felt their service was very good.
About a month ago, Bo was limping on a Saturday (turned out it was just a sprain). We found out that our new, very nice clinic was no longer 24 hours. Their phone diverted us to an older clinic. Our decision after taking Bo to this old ER was that our cats would have to be very, very, very sick to ever do an ER visit again. The place seemed dirty and run down. It was very, very noisy between dogs, children, and some bell that went off every 2-3 minutes. Bo who is usually very vocal at the vets hid behind me - he was terrified. There was dog fur all over the floor. The vet herself was nice, but the place was a dump and very stressful for a cat.
Jenny October 21st, 2009 11:50:44 AM
Many apologies to those who feel I've offended their sensitivities and sensibilities. Without spending much time on rebuttals, etc, my main thrust was a description of the general supply-side trend within the animal care market in Chicago and likely in other cities around the country. I ABSOLUTELY AGREE with those who strongly pointed out the situation in human medicine with greater competition leading to abuse of patient trust and higher healthcare costs. It's a dismal state of affairs. Yet, while not the core focus of my story, but since we're on the subject, I'll expound upon what I've seen through my work in many, many animal hospitals...
1) Overall, veterinarians remain quite trustworthy and eager to please their clients in the effort to help the pets (but there ARE exceptions).
2) The average pet owner is FAR MORE READY TO QUESTION FEES both before and after a procedure is performed than any patient visiting their physician or human hospital.
3) More scrutiny of fees allows for a more palpable system of checks and balances. When people are paying for pet care from their own pockets, there is created a more competitive environment between hospitals. Those hospitals charging at the higher end of the market also tend to attract a more demanding clientele who will be that much more discriminating when those bigger ticket items are recommended. Those charging at the lower end tend to attract those looking at price and conservative care over anything else. These hospitals aren't providing too much on the expensive side, so fraud would more lean toward poor services rendered rather than a pet owner having their funds depleted. Those charing in the middle, the majority of hospitals on this bell-shaped curve, either are catering to value shoppers or to a segmented community where there's more competition and some pressure not to drive away clients with blatant abuse. Then it comes down to doctor skills and doctor's justification for services offered, as well as the pet owner's interest in seeking their own knowledge on reasonable treatment for their pet. We all have to find our own comfort zone, and having options is always better for the discriminating consumer.
4) Having a number of 24/7 emergency rooms is NEVER a bad thing for a consumer community.
5) Having a number of specialty centers is NEVER a bad thing for a consumer community.
6) Having options for western and eastern medicine is NEVER a bad thing for a consumer community.
7) As I've suggested above, consumers still have to empower themselves, questioning the services and products offered to them. This should also be the case with physician care of patients, yet hasn't been until recently.
8) Regardless of some respondents' views on rising costs, there is still a glass ceiling on the outlay of funds that many families have for their pets. A hospital that prices itself out of the market won't have too many clients after awhile.
9) There will ALWAYS be abuse, and it takes many forms. In the veterinary market, I've especially seen it from the over-recommending of vaccines (in your lower or middle-charging hospitals), to the gross overcharing for generally-offered services from one particular culprit (which I will refrain from mentioning). Unfortunately, for the latter, word-of-mouth and a thorough web search will likely be the best way to dissuade pet owners from seeking out this one culprit's services (perhaps the subject of a future blog).
Again, while the human healthcare world has seen competition foster abuse from greedy doctors and administrators at the expense of the patient consumer and insurance companies, the foundation of morality in veterinary medicine, its out of pocket consumption, and general economic forces such as expanded options, will hopefully protect pet owners from extremes of abuse, should they use their heads as well as their hearts.
Thanks
Dr. Bruce Silverman October 21st, 2009 12:12:33 PM
Dr. Silverman, I'm sorry but I believe you've donned the same rose tinted glasses for your profession as most do of their own professions. "Well, there are some problems BUT they're really good at heart..." I'm sorry but NO they're not, not in any profession any more; greed has stolen the day, as evidenced by the new bubble being invented and evidenced by the Dow skyrocketing back up.
PJBoosinger October 21st, 2009 12:45:56 PM
I have a question about emergency services that I think fits with this thread.
A friend has a dog who was attacked by three other dogs and critically injured last Thursday. She took the dog to the local ER/Critical Care facility, and was given an estimate of $4,000 - $5,000 for his care, including surgery and a 5-day stay. She was asked to pay half of the higher amount at that time, which she did. She does not have the money to pay for this, but is trying to borrow it.
Everything went well. Surgery found nothing unexpected, and when she talked to the surgeon afterwards, he told her that her bill should not exceed the higher estimate.
On Monday, she asked to see her bill up to that point. It was over $6,200, and they were continuing to charge her $275/day for his care, not planning to release him until today. At no point was she advised that there were additional charges, nor did she agree to them. Nothing has gone wrong during his recovery that would account for the higher bill.
Is she obligated to pay the amount over and above was she was quoted? Is it legal/ethical to charge more than the estimate when everything went according to plan? She would not have agreed to pay more than was quoted, and would probably have elected to have the dog euthanized instead, as she simply cannot afford it. Can they refuse to release her dog if she does not pay it? She is in North Carolina, if it matters.
Mary Straus October 21st, 2009 12:55:54 PM
The whole problem with the medical field right now is that they turned it into a "supply/demand" business and frankly it shouldn't be. What is the price limit before the supply increases and demand decreases, the universal control of a capitalist society? Right now it's only limited by the resources that a person has. I doubt if anyone here who has a broken leg or cancer or whatever will let the cost of the treatment or procedure determine whether they have it or not. If you can afford it, you will have it. This applies to all members of your family, of course. So the poor
What some businessmen that also are vets, or know vets, have determined is that there is money to be made from those that feel their animals are family based on the same unvarying demand regardless of price.
With that all laid out for all to read, we are once again on the slippery slope of this falling into a political discussion. I cringe just to think about that...
EAB October 21st, 2009 01:02:55 PM
I know this is a bit of a tangent but Dr. K, I am curious about this issue of referring people to your boyfriend, with full disclosure of your relationship. Do you give people a list of specialists to choose from or just recommend the one (with disclosure)? How often do people ask for a different referral, because of what you disclosed? Like a lot of people, I want to have a good relationship with my vet and I sure don't want to be in the position of saying, I don't trust your motives in referring me to this specialist. Especially if you told me, "I wouldn't refer you if I didn't think he was the best". If I go to him and I have a negative experience (based on the care, the pricing, the staff at his hospital etc.) am I going to tell you that I wasn't happy with the referral? If I don't like him will you take it personally? For my part, I'd prefer a referral with no personal or financial relationship, over one that is disclosed to me.
Anne October 21st, 2009 01:04:04 PM
I doubt if anyone here who has a broken leg or cancer or whatever will let the cost of the treatment or procedure determine whether they have it or not. If you can afford it, you will have it.
Not necessarily. I don't have small children any more, they're all grown up and self-supporting. I fully intend to decline (and have all the written stuff on file with assorted docs and family members) any of the nasty meds or procedures that don't promise an almost complete and reasonably rapid return to the status quo ante. There's a point where hanging on is just a habit indulged for too long. The same goes for the lives of one's pets/companions/mothers/fathers/etc.
Will October 21st, 2009 01:27:38 PM
Anne: Great question. This was actually the topic of a post about a year back. I expressed my chronic concern over referring to him due to our relationship. Though we're not married and our monies are in no way intermingled, it's a relationship nonetheless and I feel that I profit if he profits––even if it's indirectly. It does help that he's a salaried employee at his hospital, but not by much, I think you'll agree.
I started referring to him two years before we dated because, frankly, he was the best, most knowledgeable surgeon I'd ever met. Though then fresh out of his residency, he was a great communicator, a well-rounded clinician and an even better surgeon.
Then, as now, I'd never prefer that any of my clients see another surgeon. Am I biased? yes. But my receptionists will confirm that we have never had anything but excellent reviews on his service throughout the years, more than we can say for any other specialist we deal with on a regular basis. He also has a great reputation among local surgeons––everyone's always trying to hire him away. He does research, he lectures, and he's perhaps the only one in South Florid that maintains this degree of proximity to academia. (Yes, I gush.)
So given that I truly believe he's the best, and as long as I disclose the relationship, I feel it's OK. (Not that my in-house colleagues do when they refer to him, as they don't feel they have to.) People can make up their minds and go elsewhere if it appears to them to be a conflict of interest. But they don't. I guess that's what trust is all about.
Dr. Patty Khuly October 21st, 2009 02:02:53 PM
PS: My clients also benefit greatly by my ability to reach the surgeon on a weekend or at night. And the in-tandem case management is a win-win for everyone.
And as to the expressions of happiness or dismay post referral? 2/3 of our clients are referred to him by my in-hospital colleagues. these owners don't know of our relationship. And they've never been dissatisfied. I've got to say that things would be very different if that weren't the case. For starters, my colleagues wouldn't be referring to him exclusively. I'd have figured it out by now.
Dr. Patty Khuly October 21st, 2009 02:07:55 PM
I still don't see where competition actually enters into healthcare/insurance at all - for humans or animals. Competition truly exists when one can walk away without purchasing goods/services. If you have a sick pet what's the alternative? You need a vet somewhere, treat them yourself, or let them die. Not exactly a walking away without purchasing scenario.
Carol October 21st, 2009 03:10:19 PM
I think more choice is good because it allows you to seek the best available quality of care. I try to objectively evaluate as best I can, but I've been fooled before, and am trying hard not to be fooled again.
My question is:
HOW do we consumers learn to discern QUALITY in vet med? Because most of us haven't a clue and don't ask questions. We follow the "blind trust" model, until something horrible happens. (Please don't mention AAHA as an indicator because my cat was OD'd on insulin by an unlicensed unsupervised assistant at an AAHA hospital and left alone for stretches of 10 and 13 hours respectively afterwards -- seizing, hypoglycemic, hypothermic, comatose, the works. They never even called me when they found him, they dropped him off at an after-hours-only ER place with a note saying they would pick up his dead body in the morning if he didn't make it. That's what trusting AAHA cert got me. And of course they never lost their AAHA cert because of this -- in spite of a vet board ruling regarding failure to supervise unlicensed staff.)
Blind trust isn't just a problem for us and our pets, it's a problem for you because:
Your clients don't know the difference between you (assuming you provide high quality care) and a guy who has a surgical complication/death rate 3 or 4 times normal due to poor practices, who hires high school kids as "techs", etc. If they don't know the difference, then they won't understand WHY your spay may be $450 while the clinic around the corner is $150. And THAT's a problem.
I of course no longer believe that there is a "foundation of morality" in vet med. It is an illusion that most vet clients share with vets themselves, and one I once shared and was rudely and tragically, heartbreakingly, stunningly disabused of.
http://www.TheTooncesProject.com
http://badvetdaily.blogspot.com
Stefani October 21st, 2009 03:26:16 PM
<<Wanting the best for an animal is not the same thing as opening your wallet and letting the vet shake you up and down.>>
amen...
<<I of course no longer believe that there is a"foundation of morality" in vet med. It is an illusion that most vet clients share with vets themselves, and one I once shared and was rudely and tragically, heartbreakingly, stunningly disabused of.>>
there is no foundaiton of morality anywhere when the almighty dollar rules the day.
remember..it IS all about power and money for a huge % of people.
LorriM October 21st, 2009 03:31:27 PM
Anne:"For my part, I'd prefer a referral with no personal or financial relationship, over one that is disclosed to me."
Please know I am not picking on you, but since when do you receive a referral based upon "no interest", and that goes for human health care too!
Nobody opens a phonebook yellow pages and says "pick one & we will set up the referral". Nobody!
And just recently, since the secretary of state in NH has posted an online "business lookup", you can now discover for yourself (as if anyone would bother) the financial interests between various clinics to those 24/7 ER centers.
So some are wising up & disclosing it themselves now, to at least present the "proper" picture.
Again, I am just making a reasonable statement that is applicable in most every profession & line of work.
Whether $$ are 'kicked back' or simply favors returned, there are reasons unbeknownst to the client.
http://walnut-hill.bravehost.com
example of one heck of a "referral"!
Barbara A. Albright/NH October 21st, 2009 03:48:58 PM
Barbara, I take your point. I think what I was trying to say was, if a doctor or vet handed me a sheet of paper with a list of three specialists they recommend, and they told me, by the way, the second one is my sister, but I would not have put her name on the list if I and my colleagues didn't think she was the best of the best - I'd still probably pick one of the other two. If I tell my referring vet I wasn't happy with the specialist, or ask for a different referral, I don't want to be wondering if they will take it personally, second-guess my impressions or handling of the situation or talk about my complaints to the other party without my knowledge. I suppose it's a separate issue from the financial connections - yes, those concern me as well for different reasons.
Anne October 21st, 2009 05:33:51 PM
In trying to guess the future effect of having an emergency service run by a veterinary school in an urban environment, it is probably well to look at what is probably the one with the longest history -- University of Pennsylvania. I am sure that Drs. Khuly and Silverman have more recent experience working there. However back when I was a student, the E-clinic did not even have a cash register (much less credit card machine or Care Credit). Payment was usually in Pizza and beer and the service dealt mostly with local folks in a neighborhood which did not have much veterinary coverage even in the daytime. Now the E-service draws patients from all over and the costs to clients are probably the highest in the area. Indeed, in some of the practices where I have done relief, sending the folks to Penn is called a "punitive referral." This is in spite of the Univeresity being tax-exempt and able to raise money by donations and grants. I guess it is a whole 'nuther thread whether the care is better than what is available in the other emergency services in the metro area, but I would say that the take-home message is "Don't expect having a University clinic to drive down prices of veterinary care. If anything it will raise them as local practitioners try to practice defensively to avoid being second guessed by interns and residents."
Dr. Steve Dubin October 21st, 2009 06:08:26 PM
Anne, Thanks for clarification & I recognize your point; particularly in light of not wanting to jeopardize a good relationship with the possibility of a referral "gone badly"!
My point, exactly~ my referral was so fraudulent & corrupt, I'm aghast when asked if I continued business with the "home-based" clinic! And then the response is: well, I should hope NOT!
Dr. Silverman, such an excellent guest post, I can't help but wonder if you will receive 20 lashings from your colleagues.
Why was this inevitable economic downturn such a surprise? Euphoric stock market, speculation buying and oversupply, unrealistic home pricing, no document mortgages, heavy personal debt?
While my personal income has shrunk, my expenditures have risen despite "deflation", still don't understand that concept. Never understood all the claims of veterinary shortages either, when a clinic is on every corner.
Personally, as many could feel the impending economy, I became more & more baffled to the pressures of increasing pricing in services, including veterinary & veterinary specialist care.
Something had to give, and as a result, people are simply eliminating, trimming, and dispensing all together.
A person that was bombarded with suggestions to get this & that, is reluctant to put themselves on that guilt trip.
And then to echo some comments above: greed & shame has taken its toll. No longer, are some willing to turn a blind eye to it. Of course I can't speak to the highly populated areas, but one would not be surprised to learn what a "small world" we do live in. Maybe word does not reach certain individuals, but it does indeed travel, as you mentioned.
What is my concern? Economics driving the professional to teeter across to unethical & unprofessional methods, at the expense of the patient (and yes, this goes for human care too!)
2006: Pocket's Story from NH
Barbara A. Albright/NH October 21st, 2009 08:07:39 PM
To answer the question about how to tell if you're in a good practice- while AAHA is a good indicator most of the time, and I'm terribly sorry that it wasn't in your situation, a great indicator is who the vet has hired as their support staff.
Registered/Licensed/Certified Veterinary Technicians are generally proud of their certifications that say that they are trained, schooled, and knowledgable veterinary caregivers. Great vets have great staff- staff that know what they're doing.
Not to knock any of the vet assistants out there, there are some very good ones doing some very good work.
But for my pets, the first questions I usually ask if I'm checking the ER clinics in my area (just in case!) or when I was looking for a vet for my first cat was - "Are your technicians all certified? How many of them are there vs. how many assistants? Who will actually be working on my pet?" If the answers weren't satisfactory, I continued my search.
I think the idea of competition will, despite the overall cynicism, drive practices to do better medicine. Because people -talk-. People don't take bad care and high prices lying down anymore. With the internet especially, people are more likely to voice their opinions, and their experiences. Enough bad experiences of either the medical or the fiscal kind, and that clinic will be out of business faster than you can Twitter! These things don't happen in a vacuum anymore, even rural practices (which in Chicago they aren't) are having to be more circumspect about the treatment/costs they offer their clients because people -are- willing to drive out of their way for their animals.
Regarding ER clinics, responsible pet owners will learn about their ER clinics before they ever have to use them. They will know the reputations of those clinics and (hopefully) will research a little about their prices. My local ER was incredibly forthright when I did have an emergency- they didn't try to rook me, they told me I'd save a good chunk of cash by waiting for my normal vet to open in 2 hours. They told me what to do with my pet, how to keep it comfortable, and what to watch for that would take it from "bad" to "life-threatening". Good clinics will do that- because they know that clients REMEMBER that kind of treatment.
The "almighty dollar" is always on our minds. Good people (vets, techs, assistants, practice managers, whathaveyou) won't let it change how they treat people's animals. And if you're not dealing with good people, then you need to find a new clinic.
Andrea H. (Vet Tech Student) October 21st, 2009 08:36:35 PM
Mary Straus, Sorry for your friend! What the clinic is doing is likely legal. IMO, it is quite unethical. Of course, your friend is now between a rock and hard spot and may well be dealing with the type of practice that will hold her dog hostage, seems to go with the same personality that would blithely give an inaccurate estimate.
EAB, people regularly go without medical care for themselves and their families because they can't afford it, either because they have no insurance or the treatment or drugs aren't covered by their insurance. Many without insurance simply don't seek care anywhere because they can't even get through the door and already know they'll be turned away. All too many business, including most health care (human and animal) are operating inefficiently and charging the maximum the market will bear, opting to have free time rather than reduce their prices. While I understand the argument for super dooper care, I simply don't see how no care beats nominal care; for example, how it's better for pets to go without a rabies vaccine than have it administered assembly line style. And, yes, I get the argument that some can afford better care and opt not to do so. However, each needs to do their own prioritizing too.
PJBoosinger October 21st, 2009 11:28:30 PM
Mary Straus: What PJB said. But I would add that a sit-down with the veterinarian and/or hospital manager is in order. Lots depends on the document she signed but most of the time these docs allow for estimate increases up to a certain percent.
Dr. Patty Khuly October 22nd, 2009 06:53:11 AM
Sorry, Andrea H - I like what you said but it's a pet peeve of mine when people refer to living beings as "it"! They are NOT inanimate objects and I believe language can influence attitudes and behavior.
OK - off the soapbox.
dottie October 22nd, 2009 08:22:51 AM
Dr. Bruce Silverman:
Do you want to see greed???
www.alabamavetboardwatch.110MB.com
Fotini October 22nd, 2009 09:47:11 AM
Dr. Silverman, I hope you read this. I just wanted to say, I still have Parvo Pete. I don't know if you remember him, or me for that matter, but he was the little black & white puppy tied to the tree outside the Banfield in 2000, who had the horrible case of Parvo, that all of us "nurses" thought should be put down, but you decided to save. He is still here, and is still a little hellion. Great guest post. I read Dolittler every day. I was so surprised to see your name. -Nicole
Nicole Freedman October 22nd, 2009 03:16:30 PM
Update on the situation I reported with my friend: She talked to the surgeon and explained that (a) she could not afford the additional charges, and (b) she was never told about them. After discussion, he agreed to waive the additional charges except for $300 related to one additional problem found after the surgery was done.
The excuse she was given was that the original estimate was for the surgery and initial treatment alone; it did not cover the five days of aftercare, even though she was told that's how long he'd need to be hospitalized at the time of the estimate. This doesn't make any sense to me, as it's all part of the treatment needed to save his life. How can someone make a decision on the spot as to what they can afford when a huge chunk of the projected cost (over $1,500) isn't mentioned in the estimate?
My friend was very grateful that I encouraged her to discuss the charges, since she said otherwise it would not have occurred to her to ask for "a discount," as she called it. She wonders how many other people just pay the extra without questioning it. Seems shady, but at least it worked out for her and her dog, who came home yesterday and is recovering well.
Mary Straus October 22nd, 2009 04:58:22 PM
Mary: I'm glad you could help. Simple expressions regarding reasonable humanity can go a long way––in any situation. Communication is underrated.
Dr. Patty Khuly October 22nd, 2009 08:31:24 PM
I'm in a rural area, and up until last year my vet office did their own emergency services. Then the head vet retired and sold the practice, and now I'm told night/weekend emergency cases will have to go 30 miles to the next town where there is an ER. Frankly, I'm considering switching vets on account of that. The last thing I want in an emergency is a vet I've never met before, and a 30 mile drive on top of that which could be life or death in an emergency (not to mention expense).
Seems to me a lot of this could be solved if vets went back to doing their own emergency calls.
Mary October 22nd, 2009 08:55:39 PM
Mary: So many of us are increasingly incapable of taking on on-call duty. The influx of women in the profession means some of us single moms can't take jobs that require these hours. Though my son is getting to an age where he might be able to stay home alone, his heavy homework schedule means no weeknights out.
Then there's the issue of overnight care. When patients are critical, who's going to stay at the hospital to watch them? You couldn't pay me enough to lose a night's sleep for a bloat on a school night.
As we as a culture begin to demand higher quality care for our pets, the days of on-call vet medicine continues to recede into obscurity––and I think that's appropriate for all but the simplest emergencies.
Dr. Patty Khuly October 23rd, 2009 07:15:02 AM
The increase in the number of ER/and or specialty clinics in Chicago and some other places (like here in Portland OR) sounds just like more of the continuing boom and future bust that will occur in veterinary practice. Of course it is good to have more specialty/24 hr hospitals but the same has beeen said of the general vet practices of which there seem to be one on every corner often only housing 1 or 2 vets with alot of core diagnostic equipment sitting idle alot of the time. But I guess that is ok if it is "breaking even". Increased supply eventually leads to lower prices and thus lower profits and incomes. ER care seems so expensive since routine veterinary care is so relatively cheap as a result of the stiff competition between a large number of small, fragmented firms. Eventually, the ER/specialists will saturate their market and the price will come down. Booms happen when everyone thinks they can make a killing in the market. Remember the internet stock boom of the 90s and the housing boom we are just getting out of.
The veterinary industry has failed to innovate with a new business model that will serve both veterinarians and patients better. If notoriously independant minded veterinarians could learn to cooperate, there could be group practices that could provide 24 hr care that would live up to the moniker of "hospital" even in more rural areas. In NC where my mom was from there is a hospital in a rural county that provides 24 hr care and emergency (www.reidsvillevet.com) in a general practice. Veterinary medicine needs to get out of the old mindset of proprietorship with multiple small shops and innovate a new model of organization for practice that is win-win for everyone.
Just another Veterinary Joe here ...
josephknechtdvm October 23rd, 2009 10:32:12 AM
Dr. K, I too was a single mom with a professional practice. I hear you; HOWEVER, women can't expect the professions to completely change to accommodate their child rearing years any more than we should go back to dads never being home. Those are the 2 extremes. We need something in the middle, like Joe's input. Yep, need innovation and cooperation and compromise.
PJBoosinger October 23rd, 2009 11:10:17 AM
Having needed emergency medical care for our dog three or four times during his last few years, I am eternally grateful not only to have access to 24-hr vet ERs nearby but even a choice of which one to go to.
One thing that really helped us was to check out the vet ERs in advance. Since our dog had a lot of problems, we wound up seeing one specialist at each of them so had a chance to work with that hospital... an unfortunate but probably best way to get a feel for the place.
But absent that, even just a visit, during the day or the evening. A brief chat with the front desk staff and ask about their policies, whether they take care credit, etc... you could get a at least something of a feel for the place.
That way, when the time comes, you will know what your options are at a time when you really need to think fast - twice our dog's gums went white and he couldn't walk so time was of the essence, how to get there (can make a big difference in a crisis), and what kind of place it is.
Maybe this would be pain for them, but you could even call with a hypothetical situation in the evening and see how they respond.
I think it's helpful to identify your 24-hour vet resources before you need them and even better to learn something about them if you can. Even though it's expensive, I just don't think I could leave a pet with a serious health problem unattended at a GP vet overnight. If it's that serious, I'd want them in a place where someone is watching over them.
Natalie October 23rd, 2009 06:05:12 PM
If I trust my vet's advice, then I'm going to put a lot of stock in his/her referral. If I thought the vet was just padding the specialists pocket because they were cozy, I'd have major concerns about all of the vet's other advice. So if Dr. K was my vet and I was comfortable that she gives sound, objective advice about my pet's care, absolutely I'd give heavy weight to her referral. If I don't trust my vet to make objective referrals, I need a new vet.
Natalie October 23rd, 2009 06:16:16 PM
"Dr. Silverman, I hope you read this. I just wanted to say, I still have Parvo Pete. I don't know if you remember him, or me for that matter, but he was the little black & white puppy tied to the tree outside the Banfield in 2000, who had the horrible case of Parvo, that all of us "nurses" thought should be put down, but you decided to save. He is still here, and is still a little hellion. Great guest post. I read Dolittler every day. I was so surprised to see your name. -Nicole"
Thanks, Nicole!!! It's wonderful to hear from you, and hear that I made a difference for Parvo Pete and you (and how could I forget Parvo Pete? The name alone just had such a great ring to it that's too hard to forget!). For all the cynics out there, for a lot of vets, THIS sort of feedback is why we're in the profession. Sure, there are the greedy ones, and the ERs and specialists charging an arm and a leg, but a lot of us general practice vets still have a passion for helping the animals in need. Thanks, again, Nicole. You put a smile on my face. And thanks to Patty for bringing us together on the web. You were great to work with, as well as the rest of the crew back then. Give Parvo Pete a scratch on the head for me.
Dr. Bruce Silverman October 25th, 2009 11:20:49 PM
Dr Silverman, Any one of us on this blog sincerely feels that an honest, compassionate, and skilled veterinarian GP is worth their weight in gold.
I have made the above statement repeatedly on this blog, in writing, and verbally to many pet-owners.
Us , myself included, (occasional cynics) have posted many success examples with well-deserved praise for the many fine people in your profession.
Barb A./NH October 26th, 2009 11:38:01 PM
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