Your first appointment of the morning is an obese female beagle you spied three-legging it into the exam room. The likely diagnosis, you ruefully muse, is a cruciate injury, which at this time of day means more caffeine is in order. After a dose of Cuban coffee, you’re onto the physical, the pre-rad discussion, sedation radiographs and the pièce de resistance: a lengthy post-rad discussion of options. It’s on this last stretch that I always seem to get hung up. It’s inevitably a tough slog. That’s either because: • The client is having a tough time accepting the diagnosis. (“It’s just a limp!”). • The expense of the board-certified option you recommended has occasioned a swoon. • The discussion has stalled on the subject of obesity denial. (Sixty-five pounds on a beagle is no mean feat.) “Surgical intervention is the well-accepted gold standard for the treatment of canine cruciate ligament ruptures,” you tell the client. “Sure, that’s $2,400 for a dog her size, but your alternatives are Y and Z. And while Y might be better than doing nothing, you definitely don’t want Z.” Second ‘Opinion’ Fast-forward to that evening, when your client is scheduled to have a few cold ones with his Friday night drinking buddies. From your vantage point as a fly on the wall, you hear him describe his dog’s depressing condition and the prospect of an unwelcome hit to his Amex. Commiseration ensues. But wait, there’s more: Buddy No. 3 says things went to hell with his mistakenly-pregnant Lab and his regular vet, Dr. Arm-And-A-Leg, wanted to charge him “through the nose.” Instead, he went to Dr. Reasonable Price, who reportedly did a bang-up job for half the price. No more puppies. “This guy’s a genius! You gotta see him!” Buddy says. Your client bypasses the specialist in favor of the veterinary version of Einstein. Anyone who can cut $2,400 in half has got to be the real deal, right? Sure enough, your patient gets the $1,200 surgery and all is well for six weeks, at which point the limp returns. And now it’s worse. To which “genius” vet says: “Clearly it’s another soft tissue tear within the joint, which is wholly separate from her initial diagnosis.” Which apparently requires another knee surgery and another $1,200. By the way, this is a client with means, a smart guy by all measures, and heretofore the kind of client who normally would call if there’s any question as to what he should do. Which is why he’s kicking himself right about now. Lessons Learned You learn all this during the patient’s routine annual, during which your tongue suffers toothmarks as you struggle to contain your opinion of the self-styled “specialist.” When bad financial decisions meet bad veterinary decisions, they usually intersect most egregiously at the blameless patient. Sadly, strongly recommending a second opinion “with a credentialed specialist this time” is as far as you’re able to go on behalf of this particular patient. What you really want is an attorney to take the neighborhood parasite to the mat for screwing up another knee he had no business cutting. In Spanish we have the saying “Lo que cuesta barato sale caro.” Roughly translated, it means, “What comes cheaply will cost you dearly.” Because anyone who’s offered a $1,200 procedure in place of a $2,400 version should probably be asking a lot of questions ahead of time, right? When faced with a much more expensive bill, many of my otherwise reasonable clients will abandon all kinds of rational purchasing criteria they employ for their other financial decisions. Simple decisions potentially entrustable to a trained monkey often fall by the wayside when it comes to veterinary surgery. Sure, any carpenter can handle a bandsaw without cutting off a finger. It’s easy to do, but hard to do well. Hence, the difference between mediocre and great in this case is all about the intangibles—manual skill, experience, tool quality, trained assistants, etc. Trouble is, high-priced carpentry is easier to judge than the mysterious black box that is health care. But that doesn’t begin to explain why veterinary care is different from the human variety. It doesn’t reveal why clients who would do most anything I recommend while their pets are in my care would defect so egregiously toward much less expensive, lower quality options, especially in areas where competency matters most. All About the Money Here’s one answer: In human medicine we ask about experience, training, outcomes and reputation––oh, and whether they’re “on our plan.” In veterinary medicine, price is a ginormous issue we typically gloss over when it comes to making health care decisions. And when faced with a pure price-point decision between two individuals who look pretty much alike, it makes sense that the pocketbook might win out over a careful screening. After all, most clients really want to believe that the inexpensive vet offers the same level of service as the pricey vet (and to be fair, it sometimes happens that they do). Most clients don’t want to ask about all those murky intangibles. They want badly to believe that they’re outsmarting a needlessly expensive system, even as their brain fends off the inevitable pangs of insecurity by repeating the numbers $2,400, $1,200, $2,400, $1,200. As with any business, what any veterinarian or veterinary hospital offers is value. Hence, the expensive and the inexpensive deserve to coexist in the same neighborhood so the price/quality axis can be tweaked according to each pet owner’s needs and desires. But the trouble is threefold: • In veterinary medicine the idea of value is hampered by a lack of transparency in our rapidly evolving system of specialization. • The standard of care has begun to vary so drastically within any given community that some of us wonder whether we’re in the same profession. • We practice in a sensitive landscape in which those who want to do right by their pets typically have to either max out the Amex, pick a lower-cost option or go without. See where this is headed? We can thump our chests over the high quality of our care, but veterinary medicine is still only as good as its lowest common denominator. This gap will be reconciled only when we resolve all three of the issues above on behalf of our clients. Sure, low-cost, low-quality alternatives will always exist. Poor actors who mock our profession’s ideals will forever abound. But surely there’s a limit to what we should tolerate on behalf of our profession’s standards of care. How low do we allow the standards to fall before tainting the entire profession with the stain of the lowest quality care for the lowest price—or worse, by the stink of our creepiest clinicians? I don’t have the answers, but I do know this: Until we begin to offer financial alternatives that make smart decision-making possible, even our most “reasonable” clients will continue to make decisions based on cost rather than on value. Patty Khuly, VMD, MBA, is a small-animal practitioner in Miami and a passionate blogger at PetMD.com/blogs/FullyVetted. She earned her veterinary degree in 1995 and her business degree from Wharton in 1997. <HOME>
