Dr. Boatright is a 2013 graduate of the University of Pennsylvania. She currently works as a small animal general practitioner and emergency clinician in western Pennsylvania at NVA Butler Veterinary Associates and Emergency Center. Her clinical interests include feline medicine, surgery, internal medicine, and emergency. As a freelance writer and speaker, Dr. Boatright enjoys educating veterinary students and colleagues about communication, team building, and the unique challenges facing recent graduates. Outside of the clinic, she is active in her state and local VMAs and serves on the VBMA Alumni Committee. In her spare time, she enjoys running and spending time with her husband, son, and three cats.Read Articles Written by Kate Boatright
For many veterinarians, caseloads have felt overwhelming throughout 2020 and 2021. Even though our caseloads are heavy, we must remember that there are still many pets that don’t receive veterinary care regularly—or sometimes at all. AVMA data from 2016 indicate that 27% of owned pets were not examined by a veterinarian during that year.1
For most owners, pets are considered a part of their bonded family.2 In a survey by the Access to Veterinary Care Coalition (AVCC), the majority of veterinarians stated they also believed pets to be a part of the family.2 They also agreed with the statements that “all pets deserve some level of care” and “not being able to obtain needed veterinary care impacts pet owner’s mental and emotional health.”2 We know that pet owners want to provide the best possible care for their pets, but they are not always able to obtain veterinary care. In the 2018 AVCC report, 28% of U.S. pet owners reported experiencing a barrier to veterinary care during the previous 2 years.2 We must ask ourselves how we can better serve these families and what changes we can make as a profession and individually to overcome barriers to veterinary care.
Understanding Barriers to Care
Financial barriers were the most common barrier across all types of care (preventive, non-emergent sick, and emergency care) in the AVCC study.2 Additional barriers experienced by pet owners included:
- Lack of transportation to veterinary clinics, especially for emergency situations
- Concern that providers would think poorly of them
- Did not know where to go to seek care
- Lack of leash or carrier
- Unable to find a clinic that spoke the same language
While it will be important to address these issues as we move forward, finding creative approaches to overcome financial barriers must be a priority. Michael Blackwell, DVM, MPH, director for the Program for Pet Health Equity at the University of Tennessee, has seen our profession evolve to offer higher levels of medicine in response to consumer demand. But this higher level of care comes with a higher price tag. “We have left families out due to increasing costs,” Blackwell states, noting that while costs have risen, household incomes have not increased proportionally.
New Service Delivery Models
The veterinary profession currently operates on a cash-basis model. Financial barriers to care will likely grow unless there is a shift in how veterinary care is delivered, according to Blackwell. He notes that in the U.S., nearly two-thirds of dogs and cats are owned by 2 generations. Millennials are the largest pet-owning population but won’t earn the income of the previous generation in their lifetime.3 Baby boomers, the second largest pet-owning population, are retiring and moving on to fixed incomes, which will alter their spending.3 “It’s a troubling situation,” says Blackwell, and we must explore other models to deliver veterinary healthcare.
Seventy-one percent of veterinarians agree that the current for-profit model does not work for all pets.2 This problem “is not something we [as a profession] created,” Blackwell says, and “it is not something we can fix on our own.” Instead, he suggests a paradigm shift in how we deliver veterinary care. We will also need to form partnerships with others in the pet health insurance industry and social work fields to help overcome financial barriers. Increasing awareness of pet insurance can help overcome financial barriers for some families. Currently, less than 3% of pet owners have pet insurance policies.4 Educating clients on pet insurance can improve business for veterinary hospitals and improve the level of care pets receive. Owners with pet insurance visit the veterinarian more often and spend more annually at veterinary clinics than those without.4 While pet insurance can ease the financial burden of unexpected veterinary expenses, most plans operate on a reimbursement system, meaning owners must still have a way to pay at the time of service. Pet owners must also be able to afford the monthly premium costs. This is not feasible for all pet owners, making other solutions a necessity.
The Program for Pet Health Equity has piloted a subsidized health care system called AlignCare (pphe.utk.edu/aligncare).3 This model allows pet owners with financial barriers to work with a social worker to enroll in the program. They can then visit a participating veterinary service provider for a small copay. The veterinary clinic will receive payment for the remainder of services, provided at a pre-negotiated rate, from the AlignCare fund. A pilot program was launched in 9 communities in March 2020 and plans for expansion are underway.
Changing Our Mindset Around Standard of Care
Even within the current model of veterinary care, individual veterinarians can find ways to work with client financial barriers. In one study, 57% of veterinarians reported that treatment plans were affected by client finances daily.5 A veterinarian will often start with offering the gold standard option, but when a client cannot afford the first recommended treatment plan, most (85%) will offer alternative treatment options.2
The challenge comes in determining what treatment options are considered “acceptable.” We are expected to provide a certain “standard of care,” but this standard may vary by location and type of practice.6 When there are multiple treatment options available, some veterinarians are left with concerns that they will face judgment from their colleagues or open themselves to liability when offering options that may be deemed below the standard of care by others.
In reality, “for most conditions treated by veterinarians there are multiple acceptable diagnostic and treatment protocols,” says Carolyn Brown, DVM, the ASPCA’s vice president of medicine for community medicine. These options “span from simple and less invasive, intensive, and expensive to more aggressive, invasive, technologically advanced, and expensive,” continues Brown. This concept is called the spectrum of care.
“Offering spectrum of care [options] allows owners to choose the diagnostic and treatment plan that most aligns with their goals for caring for their pet and their available resources,” says Brown. It allows the veterinary team and pet owners to work together to find a treatment plan that is the best choice for all involved. When selecting a treatment plan within the spectrum of care, veterinarians can meet their moral and ethical obligations to advocate for the patient and serve society; quality of life is maximized for the pet; and the client’s financial, emotional, and physical goals can be met.
A closely related concept is the practice of incremental care, which is defined by the AVCC as “patient-centered, evidence-based medicine in the context of limited resources.”2 When practicing incremental care, veterinarians avoid excessive testing and procedures and prioritize patient health and comfort within the owner’s socioeconomic limitations. This approach relies on picking a starting point and taking a step-by-step approach to a condition. For example, if presented with an acutely vomiting patient that is clinically normal on physical examination and has an unremarkable history, a veterinarian may offer a full spectrum of options ranging from symptomatic care to full diagnostics including bloodwork and imaging. The way the veterinarian communicates the options within the spectrum of care can influence the client’s decision.7 Veterinarians must “be able to explain the advantages, disadvantages, comparable costs, and expected outcomes of each [option],” says Brown.
The veterinarian can then also employ an incremental care approach to the case should a client choose symptomatic care. They can communicate clearly what patient monitoring should be employed at home and when the client should follow up, especially if the condition is not improving. Expectations can be set at the initial appointment as to what the next step would be should the first plan be unsuccessful. Veterinarians can protect themselves from liability concerns by documenting all options offered and client communication in the medical record. Many veterinarians already practice incremental care and regularly offer spectrum of care options to their clients, though they may not be familiar with the terminology. The 2 concepts are linked, and further education and consensus about the best terminology to use is needed. But no matter what term is used, the key to success in these practice models is clear: 2-way communication between the veterinary team and pet owner.
When it comes to developing treatment plans, “veterinarians must be confident in the treatment options offered,” says Brown. “For both new and more experienced veterinarians, research and data published in respected peer-reviewed journals demonstrating that less invasive and expensive treatment options offer similar outcomes to more intensive and expensive protocols will bolster veterinary confidence and ease anxiety about offering options,” says Brown. A prime example of this is the outpatient treatment protocol for parvovirus developed at Colorado State University that is now widely accepted as an alternative to hospitalization.
“We have a wonderful story to tell as a profession about responding to consumer demands for higher care,” says Blackwell. But as we have responded to these demands and become a more technologically advanced and specialized field, the level of care that many veterinarians practice has evolved beyond the reach of many pet owners. Ultimately, our profession must embrace multiple strategies to overcome financial barriers to care. While the profession explores new service delivery models and improves owner education on pet insurance, individual veterinarians can work to maximize their communication skills and understanding of spectrum of care and incremental care. We must also address our current approach to educating veterinary students to continue to maximize communication training and increase exposure to community practice settings and concepts such as spectrum of care. Some schools have embraced these ideas, which will help our future colleagues be more prepared for a world where financial barriers are common.8
Ultimately, it is up to us to write the next chapter of our professional story. This will hopefully include improved access to care and a robust approach to overcoming financial barriers. Doing so will improve not only the lives of our patients but also the health and wellbeing of their families.
- Bir C, Ortez M, Olynk Widmar NJ, et al. Familiarity and use of veterinary services by US resident dog and cat owners. Animals (Basel). 2020;10(3):483. doi: 10.3390/ani10030483
- Access to Veterinary Care Coalition. Access to Veterinary Care: Barriers, Current Practices, and Public Policy. Published December 17th, 2018. Accessed October 25, 2021. pphe.utk.edu/wp-content/uploads/2020/09/avcc-report.pdf
- The Program for Pet Health Equity. AlignCare® Community Manual, version 2.5. Accessed November 16, 2021. pphe.utk.edu/wp-content/uploads/2020/08/AlignCare-Community-Manual-v2.5.pdf
- Williams A, Williams B, Hansen CR, Coble KH. The Impact of pet health insurance on dog owners’ spending for veterinary services. Animals (Basel). 2020;10(7):1162. doi: 10.3390/ani10071162
- Kipperman BS, Kass PH, Rishniw M. Factors that influence small animal veterinarians’ opinions and actions regarding cost of care and effects of socioeconomic limitations on patient care and outcome and professional career satisfaction and burnout. JAVMA. 2017;250(7):785-794. doi.org/10.2460/javma.250.7.785
- Block G. A new look at standard of care. JAVMA. 2018;252(11):1343-44. doi.org/10.2460/javma.252.11.1343
- Brown CR, Garrett LD, Gilles WK, Houlihan KE, et al. Spectrum of care: more than treatment options. JAVMA. 2021;259(7):712-717.
- Fingland RB, Stone LR, Read EK, Moore RM. Preparing veterinary students for excellence in general practice: building confidence and competence by focusing on spectrum of care. JAVMA. 2021;259(5):463-470. doi.org/10.2460/javma.259.5.463