VetInfo Digest
May 2006
Table of Contents:
Twice Yearly Physicals
Year Round Heartworm Prevention
Specialized Pet Foods
Presurgical Lab Work
Geriatric Lab Work
Competing with Mail Order Pharmacies
Vaccinations
Pricing Advice
This Month's Note:
Veterinarians graduate from veterinary school with lots of medical training and
almost no business training. As a result much of the business acumen that
veterinarians acquire comes from learning on the job, learning from business
mentors and from magazines such as Veterinary Economics, which covers the
business aspect of practice and provides management advice quite frequently.
There are several other journal, news or magazine sources that cover management
advice as well. Some of this business advice impacts directly on the health care
of pets and so I thought it was reasonable to devote this issue of the VetInfo
Digest to veterinary business and management advice that your vet may be
receiving and acting upon. Hopefully it will help you understand some aspects of
the business of veterinary medicine and also prepare you to deal with some of
the elements of this advice that seem to favor economics over medicine.
There is a saying that proponents of providing aggressive medical care at all
times like to use. They say something similar to "good medicine is profitable
medicine." This would be a really useful statement if there was any kind of
consensus for what constitutes good medical practice in all instances but we are
nowhere near having that consensus in veterinary medicine. The reality of
veterinary practice is much more complex. Compromise is the rule since very few
clients have the financial resources to pursue the very optimum treatment in all
cases for their pets, even if we could agree completely on what the optimum
treatment was. Looking closely at the recommendations that are made can be
helpful in deciding which ones make sense for you and your pet and can also help
you understand why your vet might make some recommendations that don't make
total sense to you.
Twice Yearly Physical Examination
There is a very strong push right now among the folks who write veterinary
management articles to get veterinarians to schedule twice yearly physical
examinations for pets. The people who push this concept say that due to the
metabolic aging of pets compared to humans twice yearly physical exams make
sense. A cat who is going to live 20 years and who has annual physical exams
will have an examination interval they compare to having a physical exam every
three to four years for a human. A dog who is going to live to be 12 years of
age who has annual physical examinations is only being seen roughly the
equivalent of a human being seen every 6 years, using this logic.
It is obvious that this logic makes some sense. On the other hand, it is also
possible to see that there are some pretty broad generalizations going on. There
is a big difference between the expected metabolic changes between examinations
of a one year old dog and a fifteen year old dog, for instance. Perhaps it would
make the most sense to schedule an examination every few weeks during the pet's
pediatric year, then yearly or even every other year during their young adult
years and going back to yearly during the early senior years and twice yearly or
even more frequently during the truly older age years when little dogs are over
12, big dogs over 10 and cats over 15 or 16 years of age. Even a scheme like
this would fail to take into account the needs of individual pets, though.
My thinking at this time is that the physical examination schedule probably
should be tailored to the needs of individual pets. I suspect that at least half
of my feline patients would benefit from twice yearly examination if for no
reason other than we scale the tartar from their teeth during physical
examinations when they are cooperative. This isn't possible for canine patients
so we have to schedule dental care as a separate issue. This means that many of
my canine patients are already being seen twice yearly, once for a physical
examination and once for dental care. Since we anesthetize dogs for dental
procedures they are getting a preanesthetic physical exam anyway. These patients
don't need a third examination during the year. Patients who don't need frequent
dental care might have other health concerns that require more frequent visits
or we might decide that once a year is fine for them.
I'm not sure how other veterinary practices handle examinations for common
problems like skin disease, ear infections, bladder infections, etc. We try very
hard to do a good physical examination regardless of the suspected problem, just
to make sure we don't miss clues that would help us care for the pet more
efficiently. So a pet who comes in for an illness may not need to be seen a
month later for a routine annual visit. We tend to change our physical exam
recommendations for these patients but once in a while we forget. I have seen a
pet one week for a skin problem, done a thorough physical exam that week and had
the owner bring the pet back the next week because they got a reminder card for
a yearly physical exam. If we didn't do fairly complete physical examination for
most illnesses this might make sense but for our patients, it is usually
unnecessary. Fortunately, most of the time we recognize that the visit is
unnecessary at the time scheduling is requested.
One aspect of the yearly physical exam that might impact the need for it is the
need for testing procedures, such as heartworm testing, fecal examination or
other test procedures. Most of the time it possible to do this type of testing
if a pet comes in for any other reason, but occasionally we do have to schedule
these tests despite recent office visits. Vaccinations can also be problematic
since it isn't a good idea to vaccinate a stressed or ill pet unless it is
absolutely necessary which makes it necessary at times to schedule routine
visits even though a pet has been examined and treated recently.
Be aware that your veterinarian is being persuaded by management experts to
schedule your pet for twice yearly physical examination. Decide if that seems
appropriate to you based on your pet's health needs. If you think your pet needs
to be seen more often don't depend on the vet's reminders. Schedule the visits
at the intervals you feel they need to be done. If you think your pet doesn't
really need to be seen twice yearly because he or she is young and acting
healthy that is usually a reasonable assessment for a pet owner to make and you
might want to ignore one of the reminders you get each year if your vet is
sending two physical exam reminders per year. If your pet is seen for any other
problem close to the time of annual visits ask if it is OK to go ahead and do
the test procedures and preventative medicine procedures necessary so that you
don't have to come back in a month for a routine physical examination visit.
Year Round Heartworm Prevention Medications
An organization was formed in 2002 under the name "Companion Animal Parasite
Council" (CAPC). Almost immediately this organization began to advocate year
round parasite control, along with diagnostic, environmental decontamination and
sanitation procedures. While I don't doubt that some of the parasitologists and
other health care professionals that belong to this organization believe deeply
in controlling parasites and in their recommendations, I think it is important
to note couple of things. The first is that the organization claims to be
independent but has been largely funded by contributions from a manufacturer of
monthly heartworm and parasite control medications, Novartis. The second thing
is that prior to the founding of this organization the American Heartworm
Society guidelines for heartworm transmission control were markedly different
then they are today, which makes me think that this organization is exerting
influence on other organizations or that shared membership is at least changing
the thinking at other organizations dealing with various aspects of parasite
control. I am not at all sure that this is a good thing.
In order to explain my objections to the recommendation to use heartworm
prevention medications all year, all over the United States and other countries,
I need to explain a little bit about heartworm transmission. Heartworms are
carried by mosquitos. The mosquito picks up a heartworm microfilaria (baby) and
carries it to another dog or cat. If that was the only thing that had to happen
for heartworms to develop in the next dog I would agree with the CAPC
guidelines. That isn't the case, though. The heartworm microfilaria undergoes a
transformation in the mosquito to a new stage, the infective larva stage. This
process takes 8 days. During at least 8 day long periods during the mosquito's
life span the temperature has to remain above 56 degrees Fahrenheit for the
transformation to occur. If you combine this information with the expected life
span of a mosquito and historical information from weather maps it is possible
to see that the heartworm transmission period for most of the United States is
six months or less.
Advising year round heartworm prevention medications doubles the necessary
expense for most pet owners in the United States. This can have a major impact
on the money available for other health care measures for pet owners with very
large dogs. In our practice we estimate that the heartworm transmission period
is seven months long. A large dog owner who gives heartworm prevention
medications for this time period rather than all year might save $60 or more,
per dog. This can be a significant savings with no additional risk to the pet
from heartworm disease. Most of the monthly heartworm prevention medications
also control roundworms and hookworms. I find it hard to justify the additional
cost as a means of reducing roundworm or hookworm infections which are not
nearly as difficult to treat as heartworms and which will be controlled again
once the heartworm prevention medications are used in the next season. I really
think that this recommendation is based more on economic concerns than on a real
need for pets to have protection against roundworms and hookworms on a year
round basis.
Some veterinarians won't sell heartworm prevention medications to a pet owner
who takes the winter months off from giving preventative medicine without
testing the dog for heartworms again. There really is no good justification for
this practice with the currently available monthly heartworm prevention
medications. Testing is a good idea on a periodic basis. We like to test every
other year. Testing is not very likely to show a problem at the end of a winter
stretch when a dog has not been on prevention medications, though. It takes
almost 6 months from the time a mosquito infects a dog with heartworm larvae
until it is possible to test for heartworm disease. If your dog has been off of
heartworm prevention medications for less than 6 months the test won't be
positive, even if infection has occurred. There simply is no rational reason to
insist on testing a dog when they have been off heartworm prevention medications
for less than that time. As a screening test to ensure the medications worked
you can make a good case for testing periodically, but to require a test prior
to dispensing heartworm prevention medications when a dog has been off of them
for less than 6 months doesn't make sense.
There is one good argument for year round heartworm prevention medications even
in areas in which heartworm transmission can not occur all year. Some pet owners
who stop giving heartworm prevention medications in the winter months don't
start up again when they should. Using the medication all year prevents this
problem. If you know that you might be one of those people who don't start the
medications on time you probably should use them all year. Of course, if you
live in the deep South or Gulf Coast states it is necessary to give heartworm
prevention medications all year because heartworm transmission can occur all
year in these areas.
Selling Specialized Pet Foods
The companies that make veterinary "prescription" diets often push not only the
medical benefits of these diets but also the financial benefits. If a pet is
eating a diet that is only available through its veterinarian then the
veterinarian stands to make more money. Especially for foods that are necessary
life long. There are a lot of cats on Hills c/d (tm) diet or Purina's UR (tm)
diets that probably shouldn't be and part of the reason is that these diets make
money for veterinarians. On the other hand, there is no question that some of
the specialized diets serve very useful purposes and can extend the life of pets
who truly need them.
I really would like to see veterinary medicine move towards a practice situation
in which pharmaceuticals, diets and other inventory items that create a conflict
of interest are sold through outlets other than the veterinary practice.
Unfortunately, a great deal of the profit of veterinary medical practices is
tied up in the medications, diets and other treatment products sold through the
practice. Until the time comes when veterinarians no longer act as pharmacists
and pet supply retailers, it will be necessary to purchase some diets through
your vet for individual problems.
It is really important to ask your vet what the potential problems are from a
specialized diet as well as the benefits. In addition, it is a good idea to try
to obtain information on the specific goals the vet is trying to achieve using
the diet and to see if there are alternatives that might work better for you and
your pet. For some conditions, such as kidney disease in older dog and cats, the
specialized diets do seem to confer significant benefits and there aren't really
good alternatives available. For other diets, such as the urine acidifying diets
mentioned previously, the risk of the diet itself sometimes outweighs the risk
of the condition being treated and there is very good reason to question whether
the diet makes sense for your pet.
This is not an easy situation for making specific recommendations. There are so
many diets and so many conditions that may or may not benefit from them that I
just can't cover them all. You really do have to be careful to ensure that your
pet really needs these diets when they are recommended for long term use. Most
of the companies that produce specialized diets have web sites that at least
explain the purpose of the diet and specific situations for which they are
inappropriate. Take the time to check these sites out when a diet is
recommended.
Just as an aside, there isn't a provision for the FDA to make diets prescription
only. The name "Prescription Diets" trademarked by Hills is a marketing name
only. Despite this, the diets exist in kind of a no man's land between being
unrestricted and being prescription items. The diets are often not labeled as
suitable for maintenance use according to AAFCO standards so they really can't
be sold in grocery stores. They aren't truly prescription items, either. The
current work around for this problem is that the diets are sold through
veterinarians as a means of controlling their use but there is no official
sanction from the government for this arrangement. This doesn't mean much to the
average consumer except that it may or may not be possible to purchase these
diets from veterinarians other than the original vet who recommended them, since
there isn't a true prescription process, yet vets aren't really supposed to sell
the diets without evaluating the patient first since they may not meet the
recommendations for maintenance diets and may have adverse effects when used
improperly.
Presurgical Laboratory Work
You might be surprised to know that drawing blood routinely as a presurgical
precaution has very little bearing on the safety of the surgical procedure. This
is fairly well recognized now in human medicine but the veterinary literature
still seems to run more in favor of pushing the concept of presurgical blood
panels as "good medicine".
This is another example of the difficulty in defining good medicine. If the
definition is cost effective medicine there is almost no question that drawing
presurgical blood panels is not cost effective. Knowledge gained by presurgical
blood work that directly impacts patient safety was estimated to be discovered
in about 1 in 10,000 cases in one human study. This obviously helps the one
patient but from a cost analysis standpoint it is pretty hard to justify, unless
of course you use "priceless" as your standard. It would be nice if all of my
patients truly were priceless but I know that isn't true. There is also the
problem of what happens when the lab work isn't normal. Another study estimated
that concerns about lab work that were unjustified caused delays in surgical
procedures or adverse treatment decisions more frequently than patients were
benefited by the lab work.
If you wish to take every precaution and if you and your vet can work together
to assess the overall picture, including deciding that surgery is necessary in
some cases even when it appears the risk may be high due to laboratory findings,
it is probably reasonable to do preanesthetic lab panels. If you or your vet
will put off necessary surgical, dental or other procedures due to an inability
to assess the meaning of abnormal laboratory values as part of the overall
picture, having the lab work done may be more harmful than just skipping it and
hoping for the best. You have to be prepared to deal with the findings of
presurgical laboratory panels in a rational manner, even if you view your pet as
priceless.
Geriatric Examinations
I think that it is good that veterinarians are beginning to consider the needs
of geriatric patients. It is often disheartening to me when people write and say
that their veterinarian has recommended against a procedure or treatment because
their dog is too old. This should not be the major turning point in the decision
making process. If a pet will benefit from a surgery, treatment or dental
procedure and then go on afterwards to function well it is reasonable to
consider the treatment even if the patient is in an age range in which life
expectancy is fairly short regardless of the treatment outcome. This is more an
economic issue when the expected results are likely to be good for the patient
even if only for a short time. The client should decide whether the cost is
reasonable, not the veterinarian.
On the other hand, all good things seem to be taken to excess at times. There
have been several articles in veterinary publications lately promoting the
concept of special geriatric examination packages in which multiple test
procedures such as blood panels, X-rays, ECG exams or ultrasound examination is
recommended for patients over some set age. Once again, these recommendations
usually fail to take into account the individual patient. This is especially
important when considering geriatric patients because of the tendency to allow
age to influence decision making when lab work indicates a problem, even if it
is inapparent in the pet's general appearance and behavior. I have had clients
who immediately wanted to euthanize an older pet with abnormal lab work on the
presumption that it would inevitably lead to suffering. These are somewhat
unusual reactions to lab work but even more commonly the lab values stick in the
client's mind as an existing illness even when the pet shows no clinical signs
of illness. When something else occurs they add the two conditions together and
then start to think that their pet's health is declining too rapidly -- again
leading to consideration of euthanasia. This is another time when you have to be
capable of evaluating the meaning of lab work very carefully. There are lots of
older dogs and cats living very good lives with elevated liver enzymes or
elevated BUN and creatinine due to kidney disease. If you opt for geriatric work
ups keep in mind the fact that you have to look at the patient as well as the
lab work before making any drastic decisions. A pet who reaches its geriatric
years has a body that has served it well and it may continue to do so despite a
few abnormalities in its overall function.
Competing with mail order pharmacies
When I started in veterinary medicine it was sometimes hard to get a pharmacy to
fill a prescription for a veterinary patient. Pharmacists called the office to
make sure that the prescriptions were really from a veterinary hospital. Now
there are Internet pharmacies devoted to filling prescriptions for veterinary
medications that advertise aggressively on TV, the Internet and by mail. As a
result, there have been lots of letters to veterinary journals with suggestions
for dealing with Internet pharmacies as a profession or as individual
practitioners. This has led to management articles with opinions from marketing
experts, lawyers and veterinarians working with regulatory agencies on how to
best deal with the new phenomenon of Internet pharmacies.
There are a number of ways to look at this problem. From a marketing standpoint
most of the advice seems to be to keep the price of products such as heartworm
medications much the same as they have always been but to offer to match prices
from Internet or mail order pharmacies if a client asks why the medication costs
more from the vet. We won't do this at our practice but it isn't unusual for our
prices for common heartworm prevention medications and flea control products to
be within a dollar or two of the online prices, anyway. You should at least
check with your vet to see if they sell the medication at a higher price than
the Internet pharmacy before just assuming they do. If the price is higher, many
vets will negotiate on the price of medications if you simply ask. Vets are also
likely to agree to mail medications if you really do find driving to the office
to fill the prescription to be a problem for you, as long as the proper
veterinarian/patient/client relationship exists.
Legally, Internet pharmacies present a different set of problems. Many of our
clients who contact online pharmacies are trying to avoid coming in to our
office at all. This wouldn't bother me if the medications were over-the-counter
products, but they aren't. The heartworm medications are prescription
medications. While personally I would really prefer that they go OTC, that isn't
the current situation. So in order to write a prescription I have to have a
proper "veterinarian/patient/client" relationship with the pet and pet owner. I
have never seen a written description of exactly what that means to the FDA or
state regulatory boards. This is a significant problem because the standard then
depends on the individual vet's idea of what such a relationship is. In our case
we think it means that we have seen the pet within a year and that we have
tested dogs for heartworms within two years if they are old enough for testing.
For cats we just try to be sure that there are no obvious contraindications for
the medications. Other vets may have entirely different standards. At times the
online pharmacies use these differences to browbeat vets, insisting that testing
isn't necessary or that a vet can't require a client to bring a patient yearly
in order to meet the prescription requirements. So far the Commonwealth of
Virginia supports the position that I can require these things if that is the
standard that I feel is necessary.
The Internet pharmacies, or at least PetMed Express (tm), would like you to
believe that the whole doctor/patient relationship is optional and that you can
avoid it by dealing with them. At least that's what their commercials imply. In
addition, this particular company has a history of ethical compromises. This
creates a lot of friction with vets. One way that vets deal with this is simply
to refuse to write prescriptions. This is legal in some states and illegal in
others. We refuse to fax prescriptions to online pharmacies because there have
been cases in the past in which faxes have been altered to change the number of
refills or in other details. We do provide written prescriptions for our clients
to send to whoever they want since it is a little more difficult to alter these.
I really think that it is unethical to refuse to provide a prescription for a
product that I would dispense from my office but some vets will do this and it
has been advocated in some of the letters to veterinary publications. It is
legal for a veterinarian to charge a reasonable fee for providing a prescription
in most states but I think it is petty to do so. Of course, that's just my
personal opinion.
There is another legal issue that remains quite fuzzy when dealing with
pharmacies that a veterinarian can't evaluate personally. At least one
veterinary regulatory expert has written that veterinarians may be risking their
licenses if they facilitate the unethical sale of pharmaceuticals, even by
something as simple as agreeing to phone in or fax in prescriptions to a
pharmacy that uses those prescription authorizations unethically. While I think
that this is a stretch, I would really like to keep my license. So if I have
good reason to suspect that an online pharmacy is not following my directions
faithfully or is using the refills I authorize for patients other than the one
that I write the prescription for am I obligated to refuse to provide
prescriptions that will be utilized by that particular pharmacy? This is one of
the reasons that we just give written prescriptions directly to the client. It
takes us out of the loop when the client chooses to deal with a pharmacy that we
have sincere reservations about.
I suspect that this particular issue is going to remain a point of controversy
between veterinarians and their clients for some time. I have wondered for a
long time whether it was really ethical for veterinarians to be both the
diagnostician and the pharmacist. It seems to me it would be more ethical if
veterinarians chose medications without having a financial stake in the choice
but it isn't likely that situation will change during my practice career.
Vaccinations
There is one national veterinary chain whose policy is to vaccinate all pets
will all vaccines that are approved for the pet's species. This is simply wrong.
There is no room for equivocation on this issue. Vaccinations can and do cause
harm in some patients. Overall they are a very important part of veterinary
preventative medicine and our pets are far better off because effective vaccines
exist. That doesn't mean that every pet should get every vaccine, though. A pet
should be vaccinated against diseases that present a real risk given its
lifestyle and even then only when the risk of the disease exceeds the risk of an
adverse event associated with vaccination. Your vet should be evaluating your
pet's individual risk and administering only the vaccinations that make sense
for your individual pet.
Vaccines have traditionally been the draw used by veterinarians to get clients
to bring their pet to the office for yearly physical examination. This was a
real mistake but an easy one to make. People just seem to be more compliant
about coming in for a "shot" than for an examination. Now that we know that many
of the core vaccinations do not need to be given yearly a new recommendation
that is getting some play is to split up the individual components of the
vaccine so that each year something is due, rather than giving a vaccination
that combines the core vaccine on an every three years or so. To date, no study
has shown that combining the core vaccinations is likely to induce any more
problems than giving individual vaccinations at intervals. So, there is no
medical justification for this practice but it is not any more likely to cause
harm, either. Personally, I like having some years when pets don't get
vaccinations so that we get some time with the pets when nothing too bad happens
to them.
Some vaccinations have to be given twice a year to provide really effective year
round protection. Bordetella (kennel cough) intranasal vaccine and leptospirosis
vaccines are two examples of vaccines that must be given twice yearly since they
do not provide protection for most pets for more than 6 to 8 months.
Pricing advice
There is a great deal of advice in veterinary journals regarding the pricing of
services and medications. Pretty much all of it says that veterinarians don't
charge enough for either services or medications. You might find this hard to
believe, especially if you have more than one pet, but it probably is true.
Veterinary medicine is still an extraordinary bargain in most places when
compared with prices charged by professionals in similar fields in which humans
are the patients. Unfortunately, the real difference in pay isn't between the
veterinarians and the other professionals, it is between the veterinary staff
and the staff at human medical facilities. Our technicians are particularly
poorly paid when compared with nurses, the closest counterpart in human
medicine. Our other staff members are usually making much less than their
counterparts in human facilities as well. It may be tough to spend hard earned
money on a pet's medical care but if you take the time to think through the
marketing schemes and stick to the things that are best for your pet, you will
be getting a bargain for the health care dollars devoted to your pet's care.
Thanks for Your Support!
VetInfo Digest
P.O. Box 476
Cobbs Creek VA 23035
All opinions expressed in this newsletter are those of the author, Michael
Richards, DVM
Copyright 2006
TierCom, Inc.