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
Veterinarians are in the unique and challenging position of balancing the medical needs of their patients with the financial needs of their clients. Pets are considered family members by over 80% of pet owners and veterinarians.1 The strength of the human-animal bond can lead to emotionally charged conversations between pet owners and veterinarians, especially when finances are limited and decisions about care become life-or-death.
The Impact of Client Financial Limitations
The majority of veterinarians feel that all pets deserve some level of veterinary care and know that when clients are unable to afford care, it negatively impacts the emotional and mental health of the client.1 This can lead to clients lashing out on social media about vets who are “only in it for the money” when their pet does not improve after they have declined all diagnostics or died after they were unable to afford a life-saving procedure, such as a C-section or foreign body removal.
What many clients may not realize is that the veterinary team’s emotional and mental health also suffer in these cases, even when there is no social media backlash.2,3 Over two-thirds of veterinarians report that client financial constraints have a moderate or large contribution to their feelings of professional burnout.2
Because veterinary medicine is a business, hospitals must charge for their services, and veterinarians should not feel guilty for doing so. Financial constraints are a reality of practice and are the most common reason pet owners do not seek veterinary care.1 In a recent survey, nearly two-thirds of veterinarians reported having at least 1 case per day where client finances affected the level of care received.2 As veterinarians, we must find ways to work within our clients’ financial means to fulfill our ethical duty to our patients. Sometimes, euthanasia may be in the best interest of the pet, but many times, there are alternatives that can be offered that will allow us to successfully manage a sick patient and support the human-animal bond.
Mindset Shift: From Gold Standard Care to Spectrum of Care
While it is essential for veterinarians to know the ideal diagnostic and treatment plans for common diseases, equating this gold standard with the standard of care limits a veterinarian’s ability to treat patients in the real world. The standard of care is a legal definition that represents the minimum level of care that should be provided, while gold standard care is considered “best practice.”4
There is increasing recognition that veterinary medicine operates on a spectrum and the defined standards of care need to be revisited.5 In a spectrum of care, the standard of care will “reflect a continuum of acceptable care that takes into account available evidence-based medicine, client expectations of care, and financial limitations that may limit diagnostic and treatment options.”4
By shifting the professional mindset to a spectrum of care as opposed to all-or-nothing, veterinarians can provide differing levels of care to clients with less fear of opening themselves up to professional liability or board disciplinary actions.
This mindset is similar to the concept of incremental care, which is “patient-centered, evidence-based medicine in the context of limited resources.”1 The Access to Veterinary Care Coalition (AVCC) recommends this type of care be provided to allow patients to receive some level of treatment when needed, even if it may fall below the accepted standards of care. This type of care relies on veterinarians limiting diagnostics to those that could provide results that will change how the case is handled, being open to starting with a treatment plan, and re-evaluating the pet and altering the plan if the patient does not improve. The success of this plan also relies on clear communication with the client and compliance with recommendations for follow-up.
Approaching Emergencies Within the Spectrum of Care
One of the most common times to face difficult financial conversations is when a pet is sick or during an emergency. A recent population study of veterinary clients found that 74% of pet owners could not afford sick care for their pets and 56% of pet owners could not afford emergency care.1
Take, for example, the presentation of a blocked cat to the emergency hospital. In an ideal situation, the patient would be anesthetized to have the obstruction relieved and hospitalized on IV fluids with an indwelling urinary catheter. Diagnostics would include bloodwork, urinalysis, and radiographs. In many hospitals, this bill will approach or exceed $1000.
An owner who cannot afford this bill might be offered euthanasia as an alternative, but there are treatment options between the ideal and euthanasia. Perhaps the patient’s obstruction could be relieved and hospitalization time reduced to a single day or, in situations of extreme limitations, a few hours. Diagnostics could be minimized or skipped altogether. In this situation, the life-saving procedure of unblocking the cat is performed and the cat is given a chance to recover and survive.
For this treatment plan to be successful, the client must be thoroughly educated on what they are giving up by not following standard protocols, the risks of re-obstruction, the importance of monitoring, and indications to return to the hospital for further treatment. Another critical component to success is appropriate patient selection, which is based on physical examination and diagnostics, when available. The cat that is laterally recumbent and bradycardic at presentation is often not an ideal candidate for a shortened hospital stay and may benefit more from humane euthanasia.
In the context of a spectrum of care, it is the veterinarian’s responsibility to use their judgment as to which options are in the best interest of the patient and client and present all available options to the client ranging from gold standard to euthanasia. Some veterinarians may worry that offering treatment options below the gold standard, and sometimes even the standard of care, may put them at risk for judgement by other veterinarians and governing boards. Clear communication with clients and documentation of all options offered to the client during these conversations can help to protect the veterinarian should these concerns arise.
Veterinarians are well aware that client financial constraints are not going to go away. With an increasing number of pets in the United States, this problem is likely to grow. While third-party payment options such as Care Credit or Scratch Pay, pet insurance, and grants from rescue organizations or charity groups have been helpful for some pet owners, they are not a solution for everyone. Credit scores can affect approval for third-party options, most pet insurance plans operate on a reimbursement system that requires clients to have money available up front, and grants are limited and can take time for approval so are often not helpful in life-threatening emergency situations.
Focusing on client education regarding preventative care and preparing for sick and emergency care costs can help, but this education will not reach all pet owners. Nearly one-quarter of pet owners report being unable to obtain preventative care, because of both finances and availability.1 New models of veterinary care are being explored. The University of Tennessee, with financial support from Maddie’s Fund, is launching AlignCare, a pilot program that will test models similar to Medicare in 10 communities.6
Ultimately, it is up to members of the veterinary profession to continue the conversation about the cost of veterinary care and the best ways to provide care for pets when finances are limited. Many veterinarians already offer alternative care options to clients who cannot afford gold standard, though nearly half fear they could open themselves up to professional liability by offering options that do not meet the current standards of care.1 Data on patient outcomes when incremental care practices are utilized is needed and will help increase practitioner confidence in offering options.5
Increasing comfort with the spectrum of care, offering incremental care, and thinking outside the box of traditional business models can help veterinarians continue to fulfill their oath to protect animal health and welfare and prevent and relieve animal suffering while working within the financial limitations of clients.
1. Access to Veterinary Care: Barriers, Current Practices, and Public Policy. avcc.utk.edu/study.htm. Accessed July 2019.
2. Kipperman BS, Kass PH, Rishniw M. Factors that influence small animal veterinarians’ opinions and actions regarding cost of care and effects of economic limitations on patient care and outcome and professional career satisfaction and burnout. JAVMA 2017;250(7):785-794.
3. Moses L, Malowney MJ, Boyd JW. Ethical conflict and moral distress in veterinary practice: a survey of north american veterinarians. J Vet Intern Med 2018;32(6):2115-2122.
4. Block G. A new look at standard of care. JAVMA 2018;252(11):1343-1344.
5. Stull JW, Shelby JA, Bonnett BN, et al. Barriers and next steps to providing a spectrum of effective health care to companion animals. JAVMA 2018;253(11):1386-1389.
6. Zimlich R. Access to Care: Removing the Barriers that Keep Pets Out of Clinics. veterinarynews.dvm360.com/access-care-removing-barriers-keep-pets-out-clinics?pageID=1. Accessed August 2019.