Diagnosis for Democracy
Insights into the State of Our Union
A Blog by Rob Tenery, MD

June 10, 2013: Maybe I Should Have Been a Veterinarian?

By Rob Tenery, MD on June 10, 2013

Recently our new puppy decided that acorns were his favorite snack and it ended him up in the veterinary hospital for a three-day stay to heal his bleeding gastric ulcer. Even though our puppy’s errant behavior cost us several hundred dollars, we were appreciative for the care he had been given and glad he was home, apparently unfazed by his recent experience.

When I returned to the veterinarian’s office to pick up our puppy, there were two assistants working at the front desk. One nestled a telephone on her shoulder while she typed in a new appointment into her computer. The other stopped to print off a copy of my bill after she ran the charges through on my Visa card. Then she disappeared into the adjacent room to retrieve my puppy’s pills that I was to take home. Unlike my office, at no time did I notice that either of them was on the telephone with a pharmacy trying to find an alternative medication that was listed on the patient’s formulary, or to an insurance company, trying to justify her vet’s charges.

Back at my desk the next morning, I was reviewing some of the correspondence that had piled up from the day before. I came across the latest mailing from my state specialty society. Most of it profiled the latest coding dictums set down by Medicare for the new calendar year. A few of the codes paid more, but as usual, most paid less.

Handing the material over to my billing secretary, she informed me that she was still waiting for Medicare to make their final decisions on my reimbursement levels. She went on to explain that she would bill under the old codes and Medicare would make the adjustments on my reimbursement levels when the Congress and our President worked out their differences. “By the way,” she continued, “Medicare notified us that they will be holding up all payments for the first fifteen days in January.”

I wondered what my puppy’s veterinarian would say, if all the owners of her patients decided to not pay for her treatments and the medicines her office dispensed for two weeks. I also wondered what she would think if a ‘select’ panel, appointed by the President, decided what she could charge, what she would get paid and which pets were eligible for care depending on their age and likelihood of outcome--- especially if the members of that panel were not necessarily pet-owners themselves.

Scanning a breakdown of my puppy’s bill, two items caught my eye. First were the laboratory charges for the blood ‘panels’ that were drawn to evaluate his condition. Physicians use this same approach. Since the Congress passed the Clinical Laboratory Improvement Amendments (CLIA) in 1988 to regulate laboratory testing, except for a few basic tests, most physicians contract out this part of their practice to independent laboratories. It seems the complexity of the requirements set down by the CLIA regulations, in order to acquire and maintain certification, discourage in-office testing.  Additionally, the private or federal insurance programs will not reimburse for these tests without a CLIA certification.

Except in rare cases, such as the Coggin’s test that screens horses for equine infectious anemia that must be sent to a state certified laboratory or tests of high order complexity, the veterinarians perform and charge for any laboratory testing that they deem necessary. Since owners are responsible for their pet’s bills, the veterinarians are not bound by CLIA regulations, other than abiding by the community standards.

Gazing over at the two bottles of pills my veterinarian had dispensed to me when I picked up our puppy, I realized that they were still able to dispense medications, even controlled substances, out of their offices. There was one restriction--- they were required to maintain careful records on their ‘scheduled’ pharmaceuticals. Physicians lost that ability a long time ago. There are a few exceptions: One is if there is an urgent need by the patient for a particular medication that can’t be filled quickly enough by local pharmacy. The second exception is in isolated areas where pharmacies are not readily accessible. The law concerning physician dispensing was put in place to protect patients from physicians’ over-prescribing. The irony is that in the last five years or so, several of the national pharmacy chains have set up on-premises,  ‘drop-in’ clinics that are usually staffed by nurse practitioners, and have even more potential for over-prescribing because the providers are often employed by the pharmacy.

Although there is health or death insurance available that covers some animals’ care, in virtually all cases, the veterinarians still hold the owners responsible for the bill. It is then up to the owners to collect from the insurance company. This is similar to the early stages of health insurance before Medicare and Medicaid started determining of allowable charges.

Except for show animals, exotics and racehorses, you generally don’t hear much about owners of animals suing their veterinarians if the results didn’t turn out the way they wanted. Although adverse outcomes can be devastating, usually the owner moves on to another veterinarian with their next problem or pet and doesn’t seek damages through the courts. Comparing costs of malpractice insurance for veterinarians versus that of physicians clearly demonstrates the increased risk of liability and costs incurred by physicians.* In risk/ratio comparisons, premiums for malpractice insurance average 39x more costly for physicians in the high-risk categories compared to their counterparts in veterinary medicine and almost 47x more costly in the lowest risk groups.

There are several defenses that may reflect on this more lenient approach to filing lawsuits against veterinarians: First, because domestic animals are considered personal property of the owner, the statute of limitations usually only runs 2-3 years. Second, if the veterinarian being sued can claim his/her defense under the Good Samaritan statute, or that the care was rendered in an emergency situation, the veterinarian may only be liable for acts of gross negligence. Finally, there is the burden of proof on the part of owner of the animal that negligence on the part of the veterinarian had caused significant monetary damages to the owner.

No billing secretary! No large malpractice premiums! No hassles with pharmacies or insurance companies! Able to prescribe medications, perform laboratory tests and charge for them! Isn’t that the way medicine used to be practiced until the feds and the payers stepped in?

Obviously happy to be home after his three-day stay in the hospital, I watched as our new puppy drifted comfortably off to sleep on the sofa beside me. It was then I realized that sick animals and my ill patients have a lot in common. Both are scared, usually in some type of distress and just want relief. Physicians are not much different from their counterparts who treat the sick and injured in the animal kingdom. The difference is the veterinarians just do it with a lot less hassle.



*According to the American Veterinarian Medical Association’s AVMA PLIT insurance rating codes posted January 1, 2013, the yearly premiums for $300,000/600,000 coverage varied from $1791 for the equine that is considered the highest risk category to $192 to the lowest risk for small animal practices.  Comparing costs quoted by a representative of the Texas Medical Liability Trust for the same coverage limits varied from $65-75,000 for the high risk specialties to $8-10,000 for the low risk specialties such as Family Practice.

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"I enjoy a rich orthopedic practice, so I can't say I am unhappy. However, I spent one spring day making rounds with my brother-in-law, a veterinarian in an equine practice. It should be mentioned that he has an enviable practice with Hagyard Equine, treating mainly very expensive racehorses. I noted that he worked very hard, but really only practiced veterinary medicine. He dictated no notes, pre-certified nothing, submitted his bill directly to the horse's owner and was paid immediately, and pretty much smiled all day. When his son, my nephew, asked if he should look at medicine for people or horses for a career, I told him that, with his opportunities, he would be foolish to not follow his father." - Steve Brotherton MD

"It has always frustrated me that people don't seem to mind paying big bills for their pets but not their own children. The price we all pay for government and third party intrusion is incalculable. But veterinary medicine has its own issues - according to a recent workfoce study by the AVMA, there is an oversupply of vets in the US and they, too, are facing declining incomes. But the smartest of us are still choosing veterinary medicine over human medicine - current graduating classes are over 3/4 female! :) https://www.avma.org/KB/Resources/Reports/Documents/Veterinarian-Workforce-Final-Report-LowRes.pdf" - Sue Bailey MD

"Here's a Forbes blog from the Physicians Foundation: Your Doctor Is Likely Unhappy: Do You Know Why? I believe it is apropos to your recent blog. You can view the piece by clicking the link here: http://www.forbes.com/sites/realspin/2013/06/05/your-doctor-is-likely-unhappy-do-you-know-why/ " - Lou Goodman PhD

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