The doctor is in.
In 1847, Dr. Ignaz Semmelweiss, a physician working in a Vienna hospital, came to believe infections were being spread by doctors who did not wash their hands between patients.
Semmelweiss instituted a new procedure: all doctors and nurses had to wash in a chloride of lime solution after autopsies, and with soap and water between patients. Doctors also had to change into clean lab coats before examining patients.
The doctors protested: "Are you saying we are dirty?"
The protests were to no avail. Semmelweiss was a powerful hospital administrator, and the rule went into effect. As a result, hospital mortality rates dropped like a rock. Patients stopped dying.
I bring up this story because over at the Pet Connection blog Christie Keith has written a very good post about conflicts of interest in veterinary medicine.
Conflicts of interest? What are those?
Conflicts of interest are the unseen dirt that lead to sickness in America's heath care system, both human and veterinary. The most obvious examples are kickbacks, payola, and incentives from companies to doctors or veterinarians in order to get them to use their products, even when those products and services are over-priced, inferior, or medically unnecessary.
Conflicts of interest may be disguised as "Continuing Education" courses paid for by drug companies, paid vacations to the Caribbean for selling a lot of "prescription" dog food, and quid pro quo arrangements in the form of extra "free samples" (that can be sold to patients) if a certain number of "legitimate" prescriptions for a product are written.
Am I saying that America's health care system -- human as well as animal -- might be unclean?
Yes, I am.
And the lack of cleanliness is one reason health care is so expensive.
In the arena of human health care, people naively think patient-support groups must be honest brokers. Yet, in the area of diabetes, insomnia, mental illness, and heart disease, we find clearly corrupt and conflicted relationships.
Most folks are so oblivious to how human health care works that they do not even wonder why their doctor put them on Zocor rather than Lipitor for cholesterol, or why their surgeon installed a Zimmer knee rather than a Stryker knee. Why would a psychiatrist prescribe Zyprexa for psychosis, when another drug has fewer side effects and is cheaper? Why does the ambulance turn left to deliver them to Mercy General, rather than right to deliver them to Baxter Hospital Center?
The answer, in nearly every case: kickbacks, payola, and other unnamed "conflicts of interest."
And this is human medicine, which is highly regulated, and where kickbacks, self-referral, upcoding, and prescribing medically unnecessary services are clearly illegal and punishable by fines that can rise to millions of dollars.
Does this kind of stuff occur in veterinary medicine as well? Of course. There is no magic line between human health and veterinary health.
Veterinary health is far less regulated than human health care, and as a consequence there is even less incentive to do the right thing.
The American Kennel Club has now gotten into the veterinary referral business, and both vets and the AKC are now in the business of selling veterinary insurance.
The veterinary insurance industry pays a kickback to the AKC and to referring vets, while the presence of pet insurance softens the economic blow from rapidly rising veterinary costs.
In essence, what you have here is a feed-back loop, in which the customer may be triple-gouged; first by veterinarians who bill-pad, and then by the insurance industry which is making a profit by simply monetizing high veterinary bills into monthly insurance premiums. Finally, the very presence of pet insurance means vets have less incentive than ever to hold down prices and a ready-made rationalization to suggest more testing, and more extravagant health care interventions.
But, of course, a vet will not tell you this. Vets like paid vacation packages to the Caribbean courtesy of Science Diet or Novartis.
Vets like free pens, posters, literature racks, and "samples" that can be sold to their clients.
Vets like pharmacy-sponsored open-bar receptions at their conferences, and low-cost continuing education credits.
If you have the temerity to ask if there might be a conflict of interest here, they will express outrage that you even raise the question.
"Are you suggesting my medical opinion can be bought for note pads and pens," one human doctor asked me.
Yes indeed. And I am not the first. Jamie Reidy, a former rep for Pfizer and Eli Lilly, puts it this way:
“[Doctors and pharmacists] are like pigeons. Only instead of bread crumbs, you toss them pizzas and sticky notes.”
As Newsweek has noted,
"Almost every [human] doctor in the country has some type of relationship with pharmaceutical manufacturers, whose clear goal is to influence physicians to prescribe the company's newest, most expensive drugs. The companies offer physicians everything from scratch pads to trips worth thousands of dollars to attend medical conferences."
Veterinarians are no different from family physicians, hospital administrators, specialists in cancer clinics, or the folks that run nursing homes. All of them consider kickbacks, price-gouging, upcoding, and billing for medically unnecessary services a core part of their business plan, and an important profit center.
And, for the record, I am speaking here solely of those items that are actually illegal in the arena of human medicine. And since these things are generally not illegal in veterinary medicine, you find them there as well.
In fact, veterinary ethics sit on such a slippery slope that what is considered criminal behavior in human medicine is actually treated as a normal business practice for pets.
Take the business of dog food and veterinary medicine sales. As The Wall Street Journal reported back in 1999:
Over examining tables across the country, more pet doctors lately are trashing trusted brand names like Purina and Kal-Kan, calling them 'junk food,' and directing people to shell out an extra $20 or so for a month's supply of super-premium 'high science' foods.
The biggest beneficiaries: Hill's Science Diet lines, made by toothpaste giant Colgate-Palmolive Co., and Eukanuba and Iams brands from Iams Co. of Dayton, Ohio. Sold only through pet stores and veterinary clinics, the designer brands pack more calories per bite and promise higher-quality ingredients based on "pioneering research in animal nutrition" tailored to a pet's "life stage" or age.
The result: Vet suggestions ringing in their ears, many pet owners have switched brands - and the life-stage category has amassed a Doberman-sized $2 billion chunk of the market.
But few pet owners know just how far premium-market-leader Hill's has gone to sew up the vet endorsements.
Borrowing a page from the pharmaceuticals companies, which routinely woo doctors to prescribe their drugs, Hill's has spent a generation cultivating its professional following. It spends hundreds of thousands of dollars a year funding university research and nutrition courses at every one of the 27 U.S. veterinary colleges. Once in practice, vets who sell Science Diet and other premium foods directly from their offices pocket profits of as much as 40%.
And yet, most of these "super premium" dog and cat foods are the same old stuff, made in the same factories, as lower-priced grocery store dog foods.
Dog food sales by veterinarians are about more than profit-per-bag, however. They are also a way to keep you coming back to the veterinarian's office every month.
Each visit is a chance for the vet to "get you up-to-date on shots," to sell you more flea and tick medication, to enquire about teeth cleaning and grooming, and to "schedule an annual check up."
Vets know the more times you come in, the more they will be able to sell you, and the the more they will be able to "market the relationship."
And how about prescription drug sales by veterinarians?
As a general rule, human doctors in the U.S. are not allowed to sell drugs directly; they must prescribe drugs sold by a third-party pharmacist. The one exception is in cases where a drug is administered directly to a patient in a doctor's office or hospital. Most of these are cancer drugs such Zoladex and Lupron, and the markups here are phenomenal. In fact, at one point 60% of a cancer doctor's income was likely to be coming from kickbacks from drug companies "marketing the spread" on cancer drugs.
So what are we to make of veterinary drugs and foods sold directly by prescribing vets? Are we being price-gouged? Are we being sold brand name drugs and fancy dog foods when generic drugs and off-the-shelf supermarket kibble would do just as well? Are our pets being over-prescribed expensive medicines? Are we being sold medically unnecessary foods and services?
The answer is "probably yes." How often this occurs, of course, will differ from, veterinary to veterinary. No all vets sell "prescription" dog food. Not all vets load up on expensive tests for every vague condition.
But a lot do. And the number is increasing.
Of course, the veterinary trade will protest. Like the doctors in Herr Semmelweiss' hospital, they will protest they are not contaminated. They are running a clean operation.
But of course, the pharmacy and dog-food vendors know better, don't they? They know how easy it is for a doctor or veterinary to become self-deluded. As long as things appear to be clean on the surface, then it's only too easy for a doctor to believe he or she has not been contaminated.
"The trick is to give doctors gifts without making them feel that they are being bought," says former Pfizer salesman Michael Oldani. The trick is to make a gift feel personal so it does not come off as a bribe.
"Drug reps must try their best to influence doctors, while doctors must tell themselves that they are not being influenced. Drug reps must act as if they are not salespeople, while doctors must act as if they are not customers."
All of this, of course, is completely normalized. In the world of medicine, this is business as usual. And it's no different in the world of veterinary medicine.
For a new doctor or a vet entering an already established practice, it's hard to stay clear of the ethical traps. "This is the way it's done," they will be told. And the message is not just implied; often it is said overtly.
And so the new vet entering a practice that has swallowed the "let's rip off the patients" spiel of the American Veterinary Medical Association (AVMA) has to go-along to keep his or her job. It's just that simple.
And so the new veterinarian learns that every limping dog must be billed for an x-ray, that every 10-week old puppy should get a heartworm test, and that every dog or cat should be encouraged to have annual vaccines.
Never mind if this is bad medicine, it is good business.
Similarly, the receptionist is instructed to pressure every owner of a boarded dog to buy "extras," from additional walks, to toe-nail paintings to baths and "updates" for all shots.
At some vets, any surgery, no matter how minor, seems to require an overnight stay. To hear some vets tell it, every dog, no matter where they live in the U.S., should be on heartworm medication year-round.
And the teeth? They will require annual cleaning, and with it expensive pre-anesthesia blood work.
This is how a veterinary career starts today.
Never mind that canine dentistry is a scam invented about 15 years ago, and that dogs do not need annual vaccines.
Never mind that a 10-week old puppy cannot get heartworm and does not need to be tested for it.
Never mind that no dog north of the Mason-Dixon line needs to take heartworm medication year-round.
Never mind that most limping dogs have nothing wrong with them that time alone cannot fix.
As one doctor observed, marveling at how fast he slipped his own ethical tenets when he began his own medical career:
"It’s kind of like you’re a woman at a party, and your boss says to you, ‘Look, do me a favor: be nice to this guy over there.’ And you see the guy is not bad-looking, and you’re unattached, so you say, ‘Why not? I can be nice.’ The problem is that it never ends with that party. Soon you find yourself on the way to a Bangkok brothel in the cargo hold of an unmarked plane. And you say, ‘Whoa, this is not what I agreed to.’ But then you have to ask yourself, ‘When did the prostitution actually start? Wasn’t it at that party?’”
Yes it was.
So what can you, the dog owner, do about it?
Well one thing you can do is forget about the veterinary trade reforming itself. As I have noted in a previous post (Veterinary Trades Say It's Time to Rip-off the Rubes), the American Veterinary Medical Association, the American Animal Hospital Association, and the Association of American Veterinary Medical Colleges, all see their jobs as taking money from drug companies while instructing veterinarians on how to bill-pad, price-gouge, and recommend medically unnecessary services to customers. This is the core message of the veterinary trade associations today.
And, as noted, more and more vets are falling victim to this siren song. "This is the way you do it," young veterinarians are being instructed. This isn't fraud: this is a business plan.
So what can you do about it? Simple: Stop going to the vet so damn much. As I noted in a previous post:
The simple truth is that most of what a vet does -- and most of what they bill for -- you can do yourself.
Pet owners do not need to go to the vet for dog food, annual booster vaccines, regular teeth cleaning, routine worming, and "well puppy" checkups.
Not every mass needs to be biopsied, and not every limp needs to be x-rayed.
You can treat your dog yourself for ring worm and ear infections, and you do not need to buy flea and tick medicine from your vet at sharply inflated prices.
You are still in control of your own dog, and if you will only take the time to KNOW a few things, then you will soon know enough have a pretty good handle on when to say NO.
Let me make 10 recommendations right now that could save you many thousands of dollars over the life of your dog. Some of these are common-sense tips to help you avoid harming your own dog through carelessness or ignorance. Most, however, are simple tips to prevent you from being ripped off by the veterinary trade.
- Control your dog. The simplest step to avoiding a high-cost problem is make sure you have solid and secure fencing, a garden gate that is self-closing, a good collar and tag on the dog at all times, and an old-fashioned leash when you go for a walk. If your dog is hit by a car, the cost of veterinary care can skyrocket through the roof. If your dog is an escape artist, you may need to install a hot wire at the top and bottom of your solid fence, or else run an invisible fence (aka radio collar fencing) alongside the solid fence. Be sure to add a spring to the garden gate so that it is self closing and self-locking, and if you have small children in the area, a keyed lock on the garden gate is a good idea.
- Control what your dog has access to, especially when it is young. Young dogs will eat anything, and if you leave tennis balls, shoes, socks and plastic toys around the house, you are very likely to end up paying for surgery to get these same things removed from your dog's stomach. Not all dogs are chewers and swallowers, but enough are that veterinarians count this problem as a major profit center.
- Say NO to annual teeth cleaning. Because dogs have much shorter life spans than humans, they do not require the same type of dental maintenance. Annual teeth cleaning is expensive, and anesthesia is dangerous (especially for some breeds of dogs). Say no to annual teeth cleaning, while saying yes to hard kibble and a weekly tooth brushing, and you will pocket at least $2,000 over the life of your dog while not reducing its lifespan one day.
- Say NO to dog food sold by your veterinarian, and you may save another $1,000 or more over the life of your dog, and your dog will live just as long and just as well. As a general rule, avoid all the boutique-label dog food brands and simply serve a good bagged kibble from a company like Purina. And I speak as someone with working dogs. As Tony Buffington, a veterinary professor at Ohio State University, has noted, "The nutritional requirements of neutered, sedentary adult animals are so low that they could be met by anything." So stop feeding your dog like it's a race horse when it's actually a couch potato that sleeps 18 hours a day. Not only will your wallet be fatter, but there's a good chance your dog will actually be healthier as may be a little less likely to add on unneeded pounds.
- Say NO to annual vaccine boosters and "well dog" checkups, and you will save another $2,000 over the course of the life of your dog, and your dog will be just as covered from communicable diseases and will live just as long. "Well dog" annual checkups make your vet economically healthy; they do not do a thing for the dog.
- Research limp and tumors a litte bit, and you may save $10,000 or more on your dog. Does your dog's cruciate ligament injury really need treatment? Probably not if the dog is under 40 pounds, and maybe not if it is over 40 pounds. Does that lipomas tumor really need to be biopsied and removed? Probably not. What happens if nothing at all is done?
- Buy your prescription drugs and your flea and tick medications mail-order and you can easily save $1,000 or more over the life of your dog or cat. If your veterinarian will not write you a prescription, change vets -- he or she is a price-gouger who clearly does not respect you as a customer.
- Do not let the receptionist bill-pad. Most veterinary practices instruct their receptionists to add a lot of nonsense to "prospective" bills. Go through that bill and cross things out. You are in charge of the bill. Look for double-billing, the addition of medications you have not requested, unnecessary blood and lab work, and non-requested services. This is especially important to do if high-priced emergency services are being rendered, as this seems to be a time for full-scale price gouging. I have saved more than a $1,000 at a crack by questioning veterinary bills, and I have done this more than once.
- Feed your dog less and run them light. Not only will your dog live longer and be more energetic, running your dog light will generally save you a lot on veterinary care as well since joint and ligament injuries are often weight-related, as are many kidney, liver, and heart problems. A higher quality-food is also not necessarily better for your dog, especially if it is a large breed. High-quality foods loaded with calcium tend to make large-breed dogs grow too fast too soon, and are implictated (along with too much weight, inbreeding, and slick floors) in the rising incidence of hip dysplasia. With small dogs, such as terriers, weight control is particularly hard and you may find you have to skip all meals one day a week; the dog will do fine under such a regime, I assure you.
- Make your peace with death. Spending vast sums of money to prolong the life of a very old and sick dog or cat is a bit like shoveling sand against the tide. Every pet deserves a good life and a good death. If you are spending $4,000 to keep a 15-year old dog or cat alive another two months, your emotions are running riot over common sense. Just as seriously, your are probably doing a disservice to the animal, who deserves to die free from pain, in peace, and with some shred of dignity left. A good death is part of a good life.
Let me close by saying that not all veterinarians are money-grubbing price-gougers. In fact, most veterinarians enter the field because they genuinely care about animals and people. Veterinary prices, in general, have risen less steeply than human health care costs.
That said, a full-court press is going on right now in the field of veterinary field, and price-gouging practices first pioneered in the field of human health care are now crossing over into the world of veterinary care.
Conflicts of interest are now "baked in" to every veterinary practice, and vets are just as susceptible to marketing and the chattering voice of greed as anyone else. If you think veterinarians are more honest than car mechanics, you are wrong; they are in the exact same business, and have the exact same economic pressures.
For you, the pet owner, the only good defence is a good offence. This means that you need to become more proactive and less passive. The more informed you get about basic veterinary care, the more you will be able to do yourself (at considerable savings), and the better you will be able to push back when price-gouging veterinarians begin to pad the bills.
In sum: When you KNOW more, you will be able to NO more, and the savings, over the life of your dog or cat, will be considerable.