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Tuesday, March 20, 2012

Getting Rid Of Prescriptions

I have to admit that vets haven't done a good job of structuring their business model.  For several generations we have relied on product and prescription sales as a large part of our revenue.  In the past this has been great for business.  But in recent years many products have become over-the-counter (Advantage, Frontline, and others) and human pharmacies have been selling very cheap generic prescriptions.  Veterinary practices haven't kept up with changes in medications and business and are hurting from this.

Today I received an email from our state veterinary medical association about a recent article from consumer advocate Clark Howard.  He suggests getting a written prescription from the vet and having it filled cheaper at a large pharmacy.  The VMA appeared to go into panic mode, making some bold comments to members:  
Pet owner cautions-
•    Studies show that pet owners who leave the veterinary clinic with their prescription are more likely to follow the treatment recommended by the veterinarian.
•    Animal pharmacology has many complicated aspects for which human pharmacists are not trained:
o    Many drugs have side effects that might be particular to a breed
o    Drug interactions vary from animal to humans
o    Generics often do not have the same efficacy on animals as humans. Your veterinarian knows what works best for your pets, but a drug store pharmacist most likely will not know this and offer the generic to the consumer.
•    Prescription medications, including heartworm and many flea and tick products, are available only by a prescription from your veterinarian. Pharmacies or retail stores that sell these products directly to consumers are in violation of the law.

When your pets' prescriptions are filled at the clinic-
•    They are guaranteed to be the specific medication and dosage prescribed
•    The veterinarian can forewarn pet owners about side effects -- and if necessary to stop dosage
•    The veterinarian can know what other medications your pet is taking to avoid any potentially harmful drug interactions
•    Refills - the veterinarian is the best resource to determine if the prescribed medications are in fact working or if it is necessary to readjust and/or switch medications

While several of those points may be valid, I also think that this is an attempt to protect the business of veterinarians rather than looking out for the best interest of the client and pet. And I really can't agree with that attitude.

Please don't get me wrong, here.  I manage a business and am all about making a profit.  I also want to make sure that my clients get the best and appropriate medication.  I agree that human pharmacists don't have enough training in the effects of medications on animals.  I don't apologize for our mark-ups on medications because we have considerable overhead that human pharmacies don't.  But I think this is an unfortunate attempt to save an outdated business model.

Human doctors perform exams, interpret lab results, make diagnoses, perform surgery and other medical procedures, and write prescriptions.  The doctors don't actually sell the medications themselves, and so can concentrate only on the actual medical procedures.  Veterinarians, on the other hand, have built a considerable part of their practices on products rather than medical services.  As these products have become cheaper and easier to get from sources other than the vet, they have seen revenues fall.  I certainly saw a big drop in my clinic when the Bayer flea products officially went over-the-counter. Vets have also seen a drop because of cheaper medications available through internet pharmacies.  And many vets have fought tooth-and-nail to keep these prescriptions in-house, either matching prices or refusing to write the prescriptions.

There are some medications that simply aren't available in human pharmacies because they are veterinary-only drugs and have no human equivalent.  Often times dosages are quite different, such as levothyroxine (a thyroid supplement) only being up to 0.2mg for humans, which only treats a 20 pound dog.  These things will always need to be available through vets simply because they can't get them anywhere else.

But vets really need to change how they practice.  Cheap prescriptions and internet pharmacies are not going away, despite the wishes of some of my colleagues.  We need to get rid of things that people can get easily and more cheaply somewhere else.  I've started phasing out medications like cephalexin and amoxicillin where I simply can't compete with the prices of large chain pharmacies.  Basically, anything that someone can get by going to Wal-Mart, CVS, or Walgreens I try not to carry.  I'm also happy to write a prescription when the client asks for one, as that's certainly their right and by honoring the request I help build trust.  The focus should be on the true medicine and surgery, things that they can't get anywhere else.  We need clients to see us as actual doctors and not people who want to push a given product on them.  Though I don't agree with every aspect of the structure of the business of human medicine, I do think this is one area where we can learn from them.


  1. Could not agree more. I'm a first year vet student and while I do have some experience in small animal it is NOT what I plan on doing, mostly because I was so "turned off" by practices such as these when I was getting my small animal experience. Now, as I realize I can be a factor of change, I may consider leaving small animal open as an option.....if I can support the best interest of my client - which includes their pocket book. I think consumers know when they are being ripped off, and how the vet approaches such things prescriptions affects the clients view of the entire practice. The client isn't stupid. And when they realize they paid 3x as much money to fill an antibiotic prescription at the clinic that would have been 5 bucks at Walmart, they are going to feel duped - which usually makes people feel irritated and angry. They will start wondering what else those "money grubbing" veterinarians are charging unnecessary fees for. Veterinarians provide a very real and valuable service for their clients, the patient, and their communities, which often gets lost amid the products and marketing strategies. I wonder how many times clients turn down valuable services such as CBC panels and other diagnostics because the "pet budget" was used up by flea medications that should be over the counter, vaccines that can be given every 3 years, or diets that can just as easily be found at the pet store. IMO, a move away from a model that relies on the ignorance of the client will only help the bottom line. I am constantly amazed how little credit my colleagues give clients - yes, there are those ones that seem perfectly competent in the clinic only to go off and do something that leaves you shaking your head, BUT 95% of the people you see are trying to do the best for their animal, and aren't nearly as helpless and can easily run the numbers and do some internet research and make vetting decisions based on a perception of the value of the service. I must admit that it's been YEARS since my cats have seen a vet, and the only reason my dog has is because of an injury, and now, getting spayed. I refuse to use products that are by "prescription only" that should be over the counter as I feel manipulated when I pay $$ for drugs that are over the counter in another form. I'm working hard to overcome my bias of small animal clinics, but it's hard when the overwhelming number of experiences I've had at small animal clinics is that they try to convince me to buy products from them that I can get elsewhere cheaper, all while trying to make me feel like by buying them anywhere else I won't get the same "quality control", and only recommending products that are by prescription instead of discussing all options that have a proven ecathacy, both prescription and over the counter.

    Sorry this is so long! I should probably continue this over at my blog instead of hijacking your post :). I'm a regular reader, seldom commenter - but the joys of spring break has given me some free time.

  2. I also agree. The traditional veterinary business model is outdated. I think this is a testament to why the Pet Industry is growing by BILLIONS of dollars a year why the Veterinary Industry is struggling to survive, jobs are sparse, and clinics are struggling to break even. Things have to change!

  3. From the client perspective I very much agree with you. As part of an animal rescue, I am always so appreciative when I take a foster dog to the vet and the vet makes recommendations for certain prescriptions that can be purchased OTC, saving me and the rescue money. I don't fully understand the veterinary business model since I've only worked as a vet tech for a couple years before moving into research, but from what you say I would think the sensible direction to go would be more modeled after human medicine where you only carry certain prescriptions that can't or really shouldn't be filled at a human pharmacy, but give into the reality that people want to be able to shop around for best deals on whatever medications they can.

  4. This is one topic that does invoke a lot of spirited debate over at the Veterinary News Network. Especially in light of the recent generic HWP release by FidoPharm, we have been creating messaging helping our members understand that, as you said, the real value lies in the relationship between the veterinarian and the client. That is something that OTC drugs, cheap online pharmacies or any other venue can EVER replace. Thanks Dr. Bern...nicely stated!

  5. Great comments, everyone! Glad to see that I'm not the only one with this viewpoint. Tomcat, I couldn't agree more about the relationship between a vet and a client. We as an entire profession need to move away from product sales and concentrate on true medical services and relationship building. I'm more than happy to shift prescriptions to human pharmacies when it is appropriate, as this allows me more time and resources to build other aspects of my practice.

    I've also heard the argument of keeping medications in-clinic as a form of quality control, and even advocated that at one point. But the more I've applied critical thinking to this issue, the less sense it's made to me. Our human colleagues never worry about quality control, trusting the pharmacies and the clients to follow directions. If such things were really that much of an issue, don't you think the human doctors would have a tight control on them considering the magnitude of lawsuits in that profession? To me it's a non-issue and we have to lay much of the responsibility on the client themselves.

  6. Related to this is the need for veterinary professionals and clients to have access to unbiased information on veterinary medicines. Veterinary Prescriber has been started with this in mind. Www. Veterinaryprescriber.orgn

  7. Oh man..I agree. I have always hated filling scripts like benadryl and famotadine when I wish I was able to tell the client to go to CVS right down the streets. However the problem with removing some of these medications, means removing that convenience for our clients. I sometimes feel that the profession has become so centered around making the client happy, that it is detrimental to the profits.


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