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Thursday, June 12, 2014

Vets, We Did It To Ourselves....Vaccines Vs. Office Visits

Three weeks ago I saw a client for a routine checkup and vaccines for her dog.  I had seen her for the same thing a year ago and she had liked me enough to want to come back this year.  In 2013 she only allowed me to give a rabies vaccine, but this year she allowed me to do heartworm testing, distemper-parvo, and all basic preventative care.  When everything was done her bill was around $200, which she paid without problems.  One of the vaccines had never been given previously, and based on currently accepted immunology we needed to boost that vaccine in three weeks to properly stimulate long-term immunity.  The appointment was made and she came in today.

That's when the problem happened.

As she was being checked in our receptionist went over the charges for the day.  The vaccine was $16 and the office visit was $39.  She started to flip out and absolutely refused to pay for the office visit since we had just seen her dog three weeks prior.  She started to get irate, so my office manager checked with me in the back.  I'm not willing to back down unless there is a legitimate reason, and a client not wanting to pay for something we charge to everyone is not such a reason.  So I told my manager that the client would have to pay.  She went back up front while I was working with a patient in the back, but the owner wasn't satisfied.  She insisted on speaking to me, even though the office manager told her that the decision came from me.

I finished my patient, took a deep breath, and went up front to talk to the client.  She was obviously upset, but she had calmed down enough to be able to talk to her.  She simply didn't understand the need for the office visit charge, and kept saying that it was "a racket".  I informed her that we did a full exam on every patient and therefore there was a charge for every patient, regardless of the reason.  This didn't make sense to her, as we were the ones who set up the appointment, not her.  Because we set it up, she shouldn't have to pay.  I asked her if we were not entitled to compensation for our time.  She said that when she had follow-up appointments with her kids' doctor, she didn't have to pay for that visit.  

Well, actually, she didn't have to pay a copay.  That's when I pointed out the differences.  With her insurance she paid a copay (probably around $20, though I didn't ask).  On some visits there was no copay.  So in her mind the value of the first visit was $20 and the value of the follow-up was $0, since that's what she paid for them.  But she didn't seem to realize that the doctor still got paid, just by the insurance company, not her.  Even if she didn't have to write a check for it, the doctor still charged an office visit and still received compensation.  In my experience most human physicians have an office visit around $75-100, but if someone has insurance they only pay a fraction of it.  I think that realization surprised her a little, though it didn't change her attitude.

I didn't offer to waive the office visit and she didn't want to pay.  So in the end I provided her a copy of her medical records and wished her well with another veterinarian.  And I'm not at all bothered by the loss of the client, as she wouldn't have understood most things we wanted to do.

She's not the only client that hasn't seemed to understand the need for office visit charges, especially for vaccinations, and even more especially for booster vaccinations.  Though I've rarely gotten into arguments with clients, I've had plenty who thought they only needed to pay for the vaccine itself and shouldn't have to pay for the office visit.  

And we're the ones to blame.

Yes, that's right.  The veterinary profession is at fault for this perception by clients.

I started working for vets in 1984.  The practice that I worked at had a policy that when someone came in for vaccines, an office visit wasn't charged.  This way of charging encouraged competition and helped entice people to come to the clinic and have their dog or cat vaccinated.  It was pretty common then and I still know vets in my area who do this.  "No office charge if you come for vaccines!"  And the idea works to bring in the people who are most cost-conscious.

But this idea does a great disservice to our profession and what we actually should be doing for pets.  For decades veterinarians who have avoided or undercharged for office visits have devalued the importance of a physical exam.  They have trained the clients to think that the vaccine was the most important part of the visit and the doctor's time and skill in medical observation was essentially worthless.

Vets were and still are in essence saying "Come in for vaccines and while you're here we'll do a quick exam."  What we as medical professionals should be saying is "Come in for an annual exam and if everything looks good we'll give vaccines."

Last month I saw a client with an 11 year old cat for a routine visit.  Three years prior to that another vet had told her that the cat didn't need to get any vaccines the rest of its life and didn't need to come to the clinic unless it was sick.  Essentially this was like a human physician telling a person that after their 50th birthday they never needed to be examined, have routine testing, or get any kind of preventative medical care.  Does anyone really think that a human at that age doesn't need to have regular exams?  Yet that is what a veterinarian was advocating for their patients.

The single most important part of any medical service is the physical exam, no matter which species is being discussed.  "Why do I need my dog/cat to get an exam?  I know they're healthy.  If they get sick I'll bring them in."  Really?  I have diagnosed numerous problems on "healthy" pets during a routine physical on an annual visit.  Some of the health concerns have included cataracts, bladder stones, tumors, heart murmurs, gum infections, advanced periodontal disease, arthritis, and others.  All of these were diagnosed with an exam using my own eyes, ears, and hands, and without any equipment other than a stethoscope, otoscope, and ophthalmoscope.  And I can think of specific cases for each of these disease where the client was completely unaware of the disorder, thinking their pet was completely healthy. 

When we include diagnostic testing, our ability to make early diagnoses goes up considerably.  Well over 90% of the cases of heartworm disease I diagnose are on dogs that don't show any obvious outward symptoms.  With blood tests we can detect kidney disease well before the patient starts acting sick.  And I can't guess at how many cases of liver problems I've found on annual blood tests, all while the dog is acting like nothing is wrong.

As medical knowledge advances we are seeing greater duration of immunity for vaccines.  Most immunizations are valid for three years and some argue that they are actually good for 7-10 years.  I expect this viewpoint to be upheld and embraced by the scientific community at some point before I retire.  As honest, scientifically based professionals we should welcome such news, as it means less risk for our patients.  But because veterinarians have over-emphasized the vaccines for literally a couple of generations, when we advocate longer periods between vaccinations our clients think that this means they can go longer without their pet being seen.  And I believe that the biggest reason for this trend (which is happening and has been the subject of many studies and articles) is because veterinarians have "trained" their clients to think this way.

Vets, this has to stop.  If we really, honestly want what is best for our patients and want to diagnose diseases in the earliest stages, we need to change how we talk to clients.  Right now I'm deliberately calling out vets who operate vaccine clinics without full examinations, and vets who give vaccines without an office visit.  Sure, I expect some vets will lash out at me, but that's okay.  I'm firm in my beliefs and I have a thick skin.  I also know that my views are supported by the American Veterinary Medical Association and countless medical specialists.  We need to charge appropriately for our time by charging an office visit on every single case.  Increase the office visit charge and decrease the charge on vaccines.  Changing our policies, outlooks, and pricing structures will help guide the next generation of pet owners to the right way of thinking.

Pet owners....please understand that if you are simply going to a low-cost shot clinic and the vet barely looks at your pet that you are not helping yourself out.  You are missing out on the chance for a skilled doctor to catch problems before they become severe, expensive, or life-threatening.  Understand that the emphasis on pet health needs to be on the exam, not the vaccines.  And your vet is absolutely justified in charging for their time and expertise.  If you aren't already, be willing to step up and stop supporting clinics that devalue the importance and meaning of a physical exam.

Being a pet owner is a big responsibility, and our fuzzy, furry, feathered, and scaly family members rely on us to make the best decisions about their health.  If you can't afford proper care, you may need to re-think owning that pet.  And being a doctor is just as big of a responsibility.  Veterinarians need to be a true advocate for their patient's health, which means a shift in paradigm regarding vaccines and office visits.


  1. I firmly believe that annual wellness visits are extremely important. That is not up for debate. But in the case of the client experience that you share here, I would have also been extremely upset to have been charged the office visit. The clinic where I take my animals offers what they call "tech appointments." These are used in situations like you described above, where someone just needs a booster but it has been less than a year since their last annual appointment. I actually just did a tech appointment for my oldest dog's rabies and DHLPP booster. My regular vet was not available on the day I requested and the vaccinations were coming due. I took him in and the tech gave him the vaccinations (my only charge was for the vaccinations), and I came back about a week and a half later for his yearly exam with our regular vet, a blood draw and Lyme booster. On that visit I did pay an exam fee.

    Because I do not believe in bombarding my dogs with a multitude of vaccinations all at once, I split up their appointments (also nice in the bill-paying department...). During the wellness visit for one, someone else will often be due for a booster of something or another, so I bring them in as well. My vet only charges me an office visit for the one getting the wellness check and I pay only vaccination costs for the second dog, even though he does spend some time with an put his hands on the dog who is only there for vaccinations.

    I love my vet.

  2. A couple of things to comment on....

    First, in my state what you describe wouldn't be possible, at least with the rabies vaccine. Where I practice a rabies vaccine must be given by a veterinarian. Even a licensed technician couldn't legally give it, let alone an unlicensed one (which most staff in vet clinics are). So here if a rabies is given it is only legal if done by a vet.

    Second, there isn't any harm with giving multiple vaccines at once, something backed up by several studies. Medically there isn't any reason not to do all of the vaccines at the same time. And since the core vaccines required by dogs at cats are valid for three years, there isn't a need to have to do all vaccines every year.

    Third, even a few weeks can make a difference on the exam. I've found problems at a booster visit that didn't exist previously. So yes, those visits are very important.

    Lastly, this vet is still emphasizing the wrong thing. The tech is still providing a service, has training to repay, and is being paid a salary plus benefits. By not charging any sort of fee for the tech's time and skills, the emphasis is still placed on the vaccines. Even if the doctor isn't involved, the situation is still a bit backwards.

    I'm not opposed to changing the practice model so that highly trained veterinary staff do a brief exam, check vitals, and administer routine vaccines. It would be similar to the role of LPNs and PAs in human medicine. However, there should still be some sort of exam fee, office visit, or so on, even if it's not the same as with the doctor.

    I still stand firm on my idea. Charge appropriately for the exam, charge a lower price for the vaccines. Put the emphasis on what is actually the important part of the visit.

  3. Ya, I hate to say it but I disagree with you too.

    I think the key words are "follow-up" - if I was in the client's position, I'd consider the appointment three weeks later as a true part of the visit I had paid for the last time. And let's face it, $200 is a large chunk of change. I can understand your wanting to look over the pet again, but after only three weeks?

    Also, it's difficult to make ends meet these days. Sure I want to provide the best care for my pet, but sometimes I need to turn down a blood test or an x-ray if I feel I just can't afford it. I'd be ok with paying $200 to have a vet do the procedures and shots you specified, but I'd also make sure before leaving the office on the first visit that I understood the charges for the follow-up visit.

    I have a very skilled and empathetic vet, and she's very cognizant of money that her clients have to spend to keep their pets in good health. It's become almost as expensive for vet care as it is to pay for human care. It's no wonder some people say "I just can't afford that" - again, I understand your position and the enormous costs involved in keeping an office, staff, and repaying student loans.

    Love your column, but I respectfully disagree.

  4. My vet would also offer a tech/vaccine only appointment for that sort of thing also, and would not charge an exam fee.
    Sure, something might change in a few weeks that you could find - but - the dog isn't normally examined every few weeks, and another actual exam probably wasn't really indicated in this case. If the dog hadn't needed a vaccine, you wouldn't have suggested another exam I don't think.
    So I too, while your column is great, respectfully disagree.


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