“…But we have created a two-tier system. Great care for those that can afford it. More challenges for those that have limited resources.” Dr. Chip Myers, DVM
I recently chimed in on a local Facebook page where a neighbor was asking where they could find the most affordable, best veterinary practice for their family. A place where they wouldn’t be overcharged for unnecessary items and where the vets really cared about the animals and not the money. As a veterinary specialist in Small Animal Internal Medicine, I receive cases as referrals for input on complex Internal Medicine issues from all across Western Pennsylvania. I would never recommend one practice as the best for every animal or every client. My input into the conversation on the chat (many of which echoed the financial concerns embedded in the original post) was that in my 30 years working as a specialist (coming up on 40 years since getting my DVM) I haven’t, to my knowledge, ever met a veterinarian in the profession who was there to get rich. Most work long hours, with a dedication to do what’s best for each and every pet they work with. When I told my own veterinarian (in the 1980s) that I was thinking of applying to vet school, he cynically said that if I wanted to make money I should save the tuition and buy a McDonald’s franchise. My education, back in the last century, cost <$100,000…. Nowhere near what undergrad and vet school debt is today. Veterinary Technicians, the backbone of the profession, earned $5/hr or less. There are good reasons why many veterinary costs have climbed over my career.
I do have strong concerns about the future of Veterinary Medicine. Three elements of our current state of affairs combine to have a massive impact on the state of Veterinary Medicine:
1) The cost of education
2) The corporate consolidation of veterinary care
3) The procedure-based model of financing medical care that mirrors the many errors of human medicine in the US
As was discussed previously, new veterinarians come out of school with a massive debt. New vets may be wiser than my generation in trying to balance career time with family time and recreation time to maintain their mental health. Combined, these factors mean that fewer and fewer vets want to establish their own practices. Most will become employees for established practices. More and more of these established practices are no longer privately owned. The upside for new vets is less investment risk in building a practice, more flexible scheduling and time off and more ability to move around the country or fluidity in jobs ( to find a more fulfilling practice for oneself or if one’s partner needs to move for their career). The downside is a loss of control of the practice philosophy, the fee structuring, loss of a long-term investment in the practice or its evolution. This has been especially the case in Specialty referral-based veterinary practice. My business [PVIM] was one of four entities that established the first referral-only clinic in Pittsburgh in 1996-1997. Now there are three referral-only multi-practice specialty centers with six locations (I believe) currently. All were initially privately owned. All are now corporate entities. Even more than in general veterinary practice, I think I read recently that 90+% of the members of my specialty college (The American College of Veterinary Internal Medicine) work for Corporations.
When I got to Pittsburgh I spent the first 10 years of my practice career trying to convince general practitioners to refer to specialists for our advanced knowledge and the new technical skills we brought to our profession. What we can do for our veterinary patients today is truly remarkable. What used to only be available at The Ohio State University, the University of Pennsylvania or Cornell University is now available at several locations in our city. But we have created a two-tier system. Great care for those that can afford it. More challenges for those that have limited resources. More animals are being euthanized with chronic illnesses (cancer, heart disease, kidney disease, liver disease, chronic bowel conditions, etc.) than ever before. These cases used to be the core of my Internal Medicine practice. To pay for the high tech, well equipped, well staffed (more appropriately compensated – I hope) referral clinics has involved increased costs. An underappreciated contributor to the costs of specialty medicine is that Veterinary Medicine is following the human model of procedure-based financing. There is no incentive for efficiency if to be paid (since most vets receive a percentage of their gross revenue) one has to perform tests or procedures. In human medicine this has made procedure-based specialties (surgery, oncology, neurology, cardiology) much more attractive than internal medicine, family medicine, and general practice. But these are the doctors who are responsible for the whole patient (not just a kidney, liver or bone). I am very worried that my specialty (veterinary internal medicine) will also suffer the brain drain seen in human medicine. Procedure-based medicine pushes costs upward and may not be contributing to general good health, or the ultimate goal of “quality of life”. In human medicine procedure-based care is based, to some degree, on our health insurance system. Veterinary medicine, and specialty medicine in particular, are becoming more and more dependent on the rising numbers of pet insurance policies out there. People without pet insurance may be priced-out of care. Who will look out for the whole patient (and the needs, financial limits, emotional factors of pet owners) if medicine is dictated by corporate practice owners or insurance algorithms?
Back on my listserve soapbox that I started describing at the start of this essay, I inquired if anyone on the community page had an MD spend as much time listening and explaining on an office call as their veterinary practitioners. I emphasized that nothing could replace a veterinarian that took a good history and knew a pet over years of annual examinations. While the cost of a vaccine is just a few dollars, the history taking, thoroughness of the examination and time spent in a typical wellness exam is where the money is and should be going. As a referral specialist, reviewing page after page of electronic records I can tell you that saving money at a free or cheap vaccination clinic often leaves long gaps in medical records. Sometimes chronic diseases can be avoided or detected earlier by spending a few extra dollars at the high quality vet who takes the time to know you and your pet.
Dr. Nathaniel “Chip” Myers, DVM
