My friend Louie called me the other day to talk about fraud. Specifically, he wanted to talk about a particular kind of putative kickback scheme, and whether it violated the “safe harbor” provisions of Medicare.
I know a little about such things, because over the years I have written and talked about various kinds of fraud, particularly fraud in the health care arena – kickbacks, upcoding, bill-padding, billing for medically unnecessary services, price-gouging, off-label marketing, and the like.
At the end of the phone call, our conversation degenerated to a discussion of the off-label marketing of atypical anti-psychotics to underweight teenage girls; a massive kickback scheme currently under investigation by the U.S. Department of Justice.
”How could so many doctors be on the take,” I asked rhetorically.
Louie laughs. “Well, you know,” he says, “No one ever recommends a bad doctor.”
Louie's right. Any doctor you go to is “a good doctor,” almost by definition. And here’s why: Most doctors don’t do much. They catch the obvious stuff, they treat the obvious ills with the obvious medication, and if the patient does not die (most don’t) and the insurance company pays the bill (they generally do), then we figure we have a good doctor.
Of course, we don’t really know.
Most of the time we don’t even pick our own doctor – we get what’s assigned to us at the “Doc-in-a-box” Health Maintenance Organization or emergency room. The most important qualification of these doctors is not that they are any good, but their ready availability.
And so it is with many things. In truth, my dentist is my dentist for the same reason my mechanic is my mechanic; they are close to a subway stop and are easy to get to in a hurry, with or without a car.
Even when you are in the market for someone in the service sector, how do you know who is good and who is not price-gouging you?
You don’t.
You take a stab in the phone book, and hope you don’t get ripped off too bad. At best, you ask a few friends for their recommendations – never mind that in all probability your adviser would not know a “good one” from a “bad one” if it ran them over in the parking lot.
And, of course, the same is true for veterinary services.
Most people go to the veterinarian that is closest to them, or the one they passed twice on the way to the grocery store that first week they moved into their new house. Maybe they ask a neighbor.
Are they being price-gouged? Is it a “good” vet?
Who knows? How do you compare? The only thing for certain is this: No one goes to a “bad” veterinarian.
Yet, veterinarians are just people. They are no worse than, or morally superior to, car mechanics, roofers, electricians, defense contractors, or insurance salesmen.
They are certainly not morally superior to human doctors who routinely engage in complex schemes to bilk Medicare, Medicaid, and private insurance companies (and by extension, all of us) of billions of dollars a year.
Unlike the human health care system, however, veterinary care is almost unregulated and without sanction.
A veterinarian wants to price-gouge? He is free to do so.
A veterinarian is prescribing medically unnecessary services or medicines? Good luck trying to get a sanction for that.
A veterinarian is getting kickbacks? There’s no law against it.
A veterinarian kills your pet through sheer incompetence? Good luck going to court – it will cost you thousands of dollars in legal expenses, and the court may award you only a few hundred dollars. After all, a dog or cat is just considered property. The court is very likely to rule that your dog or cat is worth no more than its replacement value of a few hundred dollars.
Of course, historically, there has been a governor on veterinary price gouging. It’s that people have not cared enough about their pets to be extorted by vets for over-expensive and medically unnecessary "services." If a veterinarian priced him or herself too high, a lot of owners would simply walk away. It was "time to put Blackie to sleep."
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| Every dog is a potential cash machine. |
Several things have changed that equation over the course of the last 30 years.
One thing has been a significant drop in U.S. fertility rates. The Total Fertility Rate (TFR) of the United States hit 2.1 (the replacement rate) in 1972, and it has more or less remained there to this day.
What this means is that while some folks are still having four, five, six or seven children, a lot of others are having just one or none. For a lot of these folks – and for a rising number of older Americans whose adult children are out of the house – their dogs and cats have become “their children,” and they spend on veterinary care commensurately.
Along with “no kids,” has come the phenomenon of double incomes and rising home equity, both of which have worked to speed the extent to which people are able (and willing) to spend vast sums of money on things that were incomprehensible a generation or two ago.
Finally, we have the rise of suburbia and the advent of dog doors. Not only do people have dogs and money now, they also have dogs that spend a lot of time indoors and on the couch.
With the rise of indoor “companion” dogs has come a change in our relationship with canines. There was always a bit of emotional (as well as physical) distance between a yard or kennel dog and its owner.
A dog that has sat on the couch with you for six seasons of “The Sopranos," however, is likely to have a significant emotional bond with you and other family members. The price quoted at the veterinarian's office is going to have to get pretty steep before you think "it might be time to put Blackie to sleep."
And don’t think veterinarians don’t know that.
In fact, they are being told that by the veterinary trade associations which have gone so far as to commission a host of studies and reports whose primary purpose is convincing veterinarians to raise their prices and invent new services to bill for.
The first study was commissioned from “Big Four” accounting firm KPMG by the American Veterinary Medical Association, the American Animal Hospital Association, and the Association of American Veterinary Medical Colleges, and was designed to get everybody singing out of the same hymnal as far as raising prices was concerned.
Why was KPMG chosen?
Well, one reason might be that KPMG had already established a lucrative business running around the country explaining to human doctors, medical groups and hospitals how to jack up prices through concerted programs designed to “maximize billing.”
Doctors and hospital managers were told how to maximize testing, how to upcode, how to disaggregate tests so they could be billed separately, and how to choose treatment regimes based on how much money they made for the doctor or hospital.
The fact that much of this advice crossed the line into illegality for which KPMG and its clients were nailed for hundreds of millions of dollars, was not too germane to the veterinary profession. After all, veterinarians operate with little regulatory oversight. And in a world without laws, there are no law-breakers.
The KPMG study was entitled “The Current and Future Market for Veterinarians and Veterinary Medical Services in the United States,” and its purpose was to frame a rationalization for raising vet prices and determining how high -- and how fast -- they could be raised.
At about the same time that the AVMA, AAHA and AAVMC were commissioning the KPMG "megastudy," Bayer Animal Health gave a grant to the American Veterinary Medical Association to hire Brakke Consulting to "conduct a study of the business behaviors of small animal practitioners, both clinical owners, and associates."
Once again, the question on the table was a pretty simply one: How could veterinarians increase their revenue stream by raising prices and performing "more procedures?"
According to KPMG and Brakke, two economic forces were at work undermining the veterinary trade.
One problem was that there were simply too many vets, and demand for veterinary care for cats and dogs was not increasing very much.
A second problem was that the veterinary profession was increasingly being dominated by women who were less likely to price-gouge and bill for every little thing.
Since there was nothing to be done about the number of vets, the focus had to be on changing the culture of the veterinary profession, especially among women veterinarians.
Veterinary care is not just about making sick animals healthy, after all. It is also about getting paid. Which is fair enough. Veterinarians have bills like the rest of us. They too have to go to the dentist, get their car fixed, and send their kids off to college. No harm or foul there.
And, truth be told, veterinary billing has never been simple for the vet. While a human doctor is generally free to practice medicine and send off the bill to a third party to be paid (a private health insurance company, Medicare or Medicaid), the veterinarian generally presents the bill in person, and before the work is done.
This last veterinary billing practice -- the so-called "prospective bill" -- comes as a shock to most customers, and is more than a little distasteful for all concerned. It feels so mercenary.
Yet, experience has shown that if vets do not collect a credit card before the work is done, they may not get paid at all, and they are certainly in a poor position to haggle over the price. Better to present the bad news on the front end.
It may seem heartless for a vet to ask for a credit card before beginning emergency services on a dog or cat (especially if it is your dog or cat, and you are broke), but the alternative for the vet is to get stiffed in a predictable number of cases, in which case they will have to pass on the bill (in the form of higher fees) to the rest of us.
Veterinarians also point out, quite correctly, that people often seem to manage to pay for other things in life, but often cry poverty when it comes to veterinary bills.
Point made, and it's not a small one. With dog or cat ownership comes a responsibility to squirrel away money for emergency health care needs should those needs arise.
But, of course, this ethical see-saw within the veterinarian profession is not a new one, is it?
In fact, it is the old paradigm -- the paradigm that once kept vet prices reasonably low, dogs and cats reasonably healthy, and a lot of people interested in becoming a veterinarian.
So what was "the problem" that the veterinary trade associations set out to address by trying to get veterinarians to raise their fees en masse?
Simple: Greed.
The veterinary trade associations wanted vets to get greedier. They decided that something was wrong with any veterinarian that was not eager to embrace the "Greed is Good" ethics of Gordon Gecko. It was not enough to make a profit. Now was the time to profiteer.
Or, as Dr. John Albers, the Executive Director of the American Veterinary Medical Association put it in an article entitled "The Golden Age of Veterinary Medicine, "I really believe that we [veterinarians] are the biggest barriers to achieving financial and economic success in our practices."
Of course, when Dr. Albers talks about a "Golden Age" in veterinary medicine, he is not talking about quantum leaps being made in veterinary care for sick animals. He is talking about quantum leaps being made in veterinary billing.
The "golden age" is not about health care; it's about gold. Money. Cash. Moola.
And Dr. Albers' message is that it's time more veterinarians began to systematically rip off their customers.
And don't worry: customers won't mind, says Dr. Albers. After all, "people tend not to be price sensitive when it comes to their pets. People will pay for quality care and service for their pets, which are no longer valued primarily for practical utility, but for companionship."
In short, veterinarians should milk the changing relationship people have with their pets for all that it is worth. It's time to get paid!
And vets should not feel guilty about ripping off their clients. After all, if the vets don't rip them off, then someone else will -- a car mechanic, a dentist, or someone else jacking up the prices on other things people want or need.
Or, as one columnist for Veterinary Economics magazine put it in a presentation made to vets from across the country: "The less money a family makes, the more TV channels they have."
So don't feel guilty about ripping off the rubes. They are only going to waste their money on cable television anyway.
The drum beat from the veterinary trade associations is non-stop, and their primary message is that avarice is good, and that it is an itch that can be scratched without cost.
"There has never been a clinic that has priced itself out of business," one CPA told a panel of vets. Later, in the same presentation, the CPA noted that "Practices that charge more will make more money and work less hours."
As for the notion that perhaps some clients might not be able to afford a steep price hike: never fear. Income and willingness to pay have no relationship to each other. Or, as one CPA put it, "People can afford anything they want, just not everything they want."
And what if customers complain? Well they should! As this same CPA told his audience: "Peter Drucker said 25% of clients should be complaining about your prices." So if you are not getting a lot of complaints about pricing, then you are not ripping off the rubes enough!
And for God's sake, don't offer discounts to your customers: "Discounts are bad. There is no way you will make that up in new clients. Discounts do not increase client satisfaction and satisfaction is all people remember about their trip to the vet."
In fact, you should be ripping off your most loyal customers the most. "Over the years people pay more if they keep coming to the same practice. Bills can be increased 80 percent between years one and three. Exploit the trust."And remember "People associate high prices with quality," so if you jack up your prices a lot people will think they are getting something better even if they are getting the same-old, same-old.
So how should these rip-offs be accomplished?
Simple: Use the same scams that other professions, from car mechanics to human doctors, have used to rip-off their customers.
Sell folks goods and service they do not need. "People are used to the idea of visiting the doctor more when they get older, so it will make sense to them that their pet needs to do the same thing. About 50% of your client base are geriatric."
Charge more for all services, including the ones that are not needed: "Perform more services and charge more for services rendered."
Do a lot of expensive diagnostic work: "[You are missing opportunities if] lab work is not more than 10% of gross income. It should be more than 30%. You should require all pets to have a preanesthetic [lab] exam. The lab work brings in money and any diseases that are unmasked also bring in money."
Make sure customers know they are just there to pay the bill: "Don't let the client make choices about animal health. Your job is to offer the best only. Use the weight of your authority and knowledge."
Be friendly in order to bill more: "There is a relationship between the face time with the vet and the amount of money they will spend. So spend more time with clients in the slow months so that they will spend more money."
Offer Candy and Soft Drinks: "Give candy to kids and the mom will pay for that blood test. Bottled water given at the door and Fritz [the cat] bought an $800 office chair."
Make customers feel guilty for questioning your billing: "If a client says you are expensive then tell them that quality medicine is expensive. Then ask why the client thinks others are not charging more?"
For the record, all of the above quotes come from a real presentation made to a national convention of veterinarans by a columnist for Veterinary Economics magazine.
This is the mantra that veterinarians are being bombarded with these days: It's time to rip off your customers, and here's how to do it.
Not all veterinarians are listening, of course. There is a real war going on for the soul of the veterinary profession. A lot of vets decry the "greed is good" mantra of the AVMA.
But not all are. As time goes on, more and more veterinarians are slipping to "the dark side." Corrupt practices such as bill padding, kickbacks, price-gouging, and prescribing medically unnecessary procedures are becoming normalized. Young veterinarians are being told, "this is the way you do it."
So what can dog owners do about it?
Plenty.
The simple truth is that most dog owners are taking their dogs to the vet too often and for no reason at all other than a vet has sent them a notice that it's time to bring Blackie in for a "well dog" checkup.
Most of what a vet does at these checkups does not need to be done at all, and what does need to be done can be done, most of the time, by the owners themselves for a fraction of the cost.
But of course, that's not something a veterinarian is going to tell you, is it?
Just as a mechanic will never have a literature rack in the waiting room telling folks how to change their own oil, a veterinarian will never have a simple sheet telling folks how long vaccines are really good for, how to get medicines for less, how to worm a dog at home, or why most of the routine laboratatory tests (and some of the most recommended procedures) are bunk.
The business of a veterinarian, after all, is not a healthy dog for less money, but a healthy dog for more money.
Should you be surprised at the price-gouging and bill-padding?
No.
In fact, if you are surprised, you are probably naive.
Of course, that's not what the veterinary profession will call you. They will call you a "really great customer" and a "responsible pet owner," because you are both ignorant and compliant.
And veterinarians use the word "compliant" a lot when they talk about their ideal customer. They do not want tight-fisted clients who know about canine health any more than the average car mechanic wants someone who understands a little about cars looking under the hood to see whether the work is really needed, is really being done, and whether factory parts are actually being installed.
You don't trust me? I am outraged!
And, of course, not everyone minds being price-gouged. Some folks are more than willing to pay a lot of money to a vet to avoid doing the most perfunctory stuff themselves. A lot of folks do not want to make waves and are uncomfortable challenging any bill, while others are only too eager to swallow the excuses and rhetoric used to rationalize price-gouging.
For example, if you point out that veterinarians typically charge $100 or more for nothing more than a "well puppy" visit, a lot of dog owners will parrot their veterinarian: So what, a plumber charges $85 just to show up.
Which, of course, is true but pretty close to irrelevant. Yesterday, for example, my plumber drove 30 miles to get to my house on icey roads, and when he got to my house he had to lug in the tools (and lug them out again) while working for more than an hour on things that were (ahem) ... not clean.
A veterinarian, on the other hand, generally has his clients delivered fresh and clean to his door, can do several exams an hour, and if a booster shot is needed, that costs all of $2 in material.
Of course, well-puppy exams are the least of it. The real expenses with dogs comes with procedures and medicines that are not needed at all, kickbacks and markups on foods and medicines, frequent bill padding, and the "annual checkup" that somehow balloons to $350 or more for absolutely nothing.
Which is not to say that veterinary services are never needed, or that all vets are crooks trying to sell you goods and services at absurd prices.
That is NOT true. In fact, there are still a lot of good honest vets around, and if you are going to them for the right stuff (fixing a bone, removing certain tumors, etc.) then they are worth their weight in gold.
That said, most people are not going to vets for the right stuff. And, as a consequence, a lot of dog owners are wasting thousands of dollars over the the life of their dog for absolutely no reason what-so-ever.
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, annual 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.
More on all these points later.
For now, it's enough to know the kind of message veterinarians are receiving from their trade associations -- and the kind of message these same vets receive from us when we acquiesce to unneeded procedures and inflated prices.
Caveat Emptor. Buyer beware.
It's high time that dog owners come to terms with the fact that the veterinary business is changing, and that because of that we need to: 1) get better educated; 2) do more routine veterinary work ourselves, and; 3) be a little less "compliant" when prospective bills are submitted for approval.
A repost from December, 2007.
25 comments:
Wow. I'd hate to think that the only medical practitioners I trust, vets, would go down that road.
I always find them ethical and honest, with varying degrees of expertise.
Vaccinations are really cheap and I haven't even seen a flea since 1995 with the new meds, so there's no need to treat them.
I go when something is wrong and I'm always right. I don't wait for things to deteriorate.
It's true they are more expensive than they were decades ago but so is everything else. Also, they can do more now than in the '50s when our dogs were indoor dogs, by the way, and sat on the couch with us.
I definitely will heed this warning though, and watch for this crassness to creep into my clinic.
Thanks for the heads-up.
Oh my gosh this is a touchy subject for me. At one point I discovered a vet I had been using for years (also the most expensive in this small town) had a vet "practice" in the Bahamas with some colleagues. When he explained it, it seemed more like a time share vet practice that included boats, planes and a condo.
And more frequently and unfortunately, I have encountered absolutely incompetent vets. A vet that x-rayed my horse's hind leg with a machine the size of a shoebox and then told me to have him put down because his leg was broken. The next day I was able to get my favorite vet out and as he got out of his truck at 50 feet away he asked me if my horse had been playing baseball. He said my horse broke the same bone that people do when they slide into home plate. He said to put him up in a pen for a month and he'd be fine. A week later my horse jumped the pen, and never had a problem after that.
And then, just this year, our vet diagnosed my 13-year old Jack Russell with spondylosis and put her on what he called a benign supplement to give her relief. Then she developed ulcers in her stomach and esophagus and had to be treated at a university veterinary hospital to recover. And, yes, you guessed right. The vets there could not corroborate the spondylosis diagnosis. The supplement he had given us was almost 10 years past the expiration date and had degraded to something very harmful.
A truly good vet, like my old horse doctor that has more common sense than other vets have pharmaceutical salesmen is worth his weight in gold. But the rest of the lot I wouldn't give you a plug nickel for them.
I worked summers for an excellent, ethical, smart veterinarian through high school and college.
Then I moved, and found an excellent, ethical, and smart veterinarian, who did things like check in on my puppy, who had caught parvo between his boosters, every hour through the night- with NO extra charge.
Then she burnt out and moved away.
I've been trying to find a decent one- not great, not excellent, just not trying to gouge me but still paying close attention rather than throwing amoxicillin at every hiccup- ever since. No luck. Until recently, the closest clinic to me charged three times as much as my last good vet did for all the same services, and kept getting my dog's name wrong in the bargain. Now, hurray, I only have to deal with one that charges twice as much.
*sigh*
Lets give you a couple of other things to ponder on.
Why would a study be done to find ways to increase money for veterinarians? Greed could be one, which you have stated, but how about survival as the other. For example, you are correct about the vaccines I have been pushing for several years now that dogs are overvaccinated and there is a new protocol for vaccines which means there will be less given. Why has it not been pushed in several vet clinics, because they can not afford not to give them - 33% of vet clinics income comes from vaccines (on average). That is a huge chunk to be cut, so in order to survive and actually have your veterinarian still in business, other means need to be found to make money.
Also your comparison to the plumber is completely misleading, you forgot about the veterinarians expenses maintaining a clinic. The plumbers truck is nothing in comparison to the building and the costs to maintain the building. Did the plumber have an assistant? How about a whole staff including a receptionist, a vet tech, one or two vet assistants and a kennel person, maybe a groomer. Not to mention the associate veterinarian who is being paid on average $50K to $75K depending on area of the country, which is pathetic considering the 8 years of schooling and knowledge required to be a veterinarian. Did the water pipe try and bite the plumber? Did the nasty anal sacs of the pipe explode all over the plumber, or how about the blood or pus from the infected cat abscess? A vet is not a clean job either in many circumstances.
I am not angry about your post in fact it is good that you bring to light the terrible business practices that I and many others in my profession do not condone. However you are painting the entire profession with a broad paintbrush without knowing or telling the entire story.
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I understand everything you are saying Daniel.
Strip it away, however, and you will find you are rationalizing theft the very same way that most thieves do on a construction site: "Our boss doesn't pay us enough, so a lot of my colleagues steal tools."
Except in the case of the vet, they say, "I want more money, so I will not tell folks that vaccines are good for many years -- I will just steal a THOUSAND DOLLARS per dog over the life of the dog."
If a veterinarian’s patients were human, the FBI would be knocking on their door; that is how serious this kind of conduct is when doctors do it to humans. People go to jail.
But of course a vet's patients are not human; they are dogs and cats. Which is pretty great, because if a plumber screws up and breaks something in my kitchen he has to pay. But if a vet screws up, "that's the way it is," and there is no recourse.
As for the notion that vets have to price-gouge to "survive," I am not quite buying it. What you REALLY mean is “I have to price gouge so I don't have to join a group practice" like most human doctors already have.
You see, all that redundant equipment and personnel you have around the office is a choice. Your choice. Not only are there TOO MANY veterinarians (according to your own trade association), but almost all of you are operating independently from each other which means you have tremendous amounts of redundant equipment and personnel. Or, as one of your own trade association publications puts it, “there are 22,000 animal hospitals and 4,000 human hospitals, and there are twice as many people as dogs.”
So what do vets do to pay off the costs of their chosen inefficiencies? A lot of them (not all) price-gouge the customer with inflated prices or prescribe medically unnecessary services.
And it adds up.
Most folks are spending THOUSANDS of dollars over the life of each dog that they do not need to. That's grand theft, and the fact that it is being done by someone in a white lab coat who went to college does not make it better, it makes it worse.
As for vets “surviving,” I am not too worried about it, as I have yet to hear of even one “going broke.” In fact, veterinarians have a lot of choices – jacking the customer is simply the easiest way to make more money while changing nothing else.
Which is fair enough. There is a not a darn thing a pet owner can do to change veterinary practices.
What a pet owner CAN do, however, is change what he or she does.
Above all, we can stop going to the vet for “well pet” visits and unneeded shots.
We can end the yearly teeth cleaning nonsense, and take control of end-of-life decisions.
We can give our pets their own vaccines.
We can worm our own dogs, and we can stop giving heart worm medicines all winter long.
We can treat our own dogs for Lyme disease, and stop the testing altogether.
We can stop buying "diet” dog foods from the vet and start feeding less.
We can learn more about cruciate ligament injuries and be a little less quick to operate at a cost of $3,000 per leg.
And, of course, the most important thing we can do is find an honest non-price gouging veterinarian.
They exist within 15 miles of all of us, if we will only take the time to research and look.
And no, these honest vets are not “going broke.” They are merely not getting rich. They were told they would not get rich if they went to vet school, and unlike so many others, they are not changing the rules.
The bottom line, as noted, is that there is a war going on for the soul of veterinary care, and we customers need to choose sides. Not all veterinarians have slipped over to the dark side of being liars, cheats and thieves despite all “the water is warm” lectures from the vet trade associations.
It’s time more of us began to vote with our feet AND our wallets. And, above all, it's time we stopped rationalizing theft.
Patrick
Case in point -
I had a c-section done on a bitch, my cost was $425, everything included.
I moved the bitch on and my friend just had a c-section done on her, her cost was $1148 for the same service!
It is awful! I continually have to watch out for "add on's" that are not needed.
I am lucky in the fact that my vet has discussed with his other partners that I will question every thing being done, the charge and the benefit of doing it at that VERY moment, as some things are not needed until another test comes back, and depending on the result, it may NOT be needed. I am lucky that he is available 24-7 and I don't have to go to the emergency clinic to be gouged.
I'm one of those pushy, know it all dog breeders that some vets hate. I refuse unnecessary services, self diagnose, and frequently come in asking for what I know my dog needs, rather than asking for twenty tests to confirm what I already know. I'm also more than willing to ask for help when I need it, or it's something I know nothing about.
For years, I had a great relationship with a vet who was supported me, trusted me, and treated me as a partner in the care of dogs. His bills were reasonable, and I never once resented paying them.
Then I moved, and my first experience with the new vet was when he tried to charge me $540 for first shots on a litter of nine puppies - $15 each for the shots, and $45 EACH for a 'well puppy visit'. When I complained - vehemently - he accused me of being 'one of those puppy mills who only care about profit'. I accused him of being a charlatan, and a con artist. It wasn't pretty.
I now live back out in the country, with a great vet who respects my opinions, and works with me, as opposed to against me. It took a month and a poll of every other dog owner and breeder in the area to find them.
Now I maintain a database of do recommend/do not recommend vets. I love my vet, but I know full well there are scammers out there. One of them just charged one of my puppy buyers $1800 for a neuter and microchip implant...Oy.
Persimmon Hill said...
Case in point -
I had a c-section done on a bitch, my cost was $425, everything included.
I moved the bitch on and my friend just had a c-section done on her, her cost was $1148 for the same service!
*****
Gee, Persimmon Hill, how much did you charge your "friend" for a "breeding bitch" that had already failed to whelp naturally?
Maybe the problem there is regarding surgical removal of puppies as a "normal" breeding practice.
Did it ever occur to you that the price was higher because --
* Second c-sections are inevitably more complicated than the first one (which should have included a spay anyway)?
* There may have been other complicating factors in the surgery?
* The vet may have been disgusted that your "friend" was once again breeding a bitch that required surgical intervention the first time? Or just not interested in providing cut-rate surgery to someone who is deliberately producing dogs that can't reproduce non-surgically?
"The vet may have been disgusted that your "friend" was once again breeding a bitch that required surgical intervention the first time? Or just not interested in providing cut-rate surgery to someone who is deliberately producing dogs that can't reproduce non-surgically?"
So you are advocating that vets should rip people off if they don't 'approve' of their dogs, or their breeding practices?
If a vet is an anti hunting activist, they should be able to charge Patrick quintuple the normal rate to fix an injury on one of his dogs?
If they're a peta wonk who thinks that all breeding is 'evil', they can charge a gazillion dollars for shots on a breeder purchased puppy?
If they object to the 'use' of horses for riding, they can charge a zillion times the normal rate to treat a injury on a sport horse?
And you think all of this is not only peachy, but rational and to be expected? And that they should show their objection, not by saying 'Hey, sorry, I prefer not to treat (insert scenario here) for ethical reasons', but should just blatantly rob clients to express their indignation - sort of like "Hey, you suck, but I have a boat payment to make, so I'll charge you extra".
Please, for the love of baby Jesus, tell me you are not a vet, because if you are we are all so screwed.
"I'm one of those pushy, know it all dog breeders that some vets hate. I refuse unnecessary services, self diagnose, and frequently come in asking for what I know my dog needs, rather than asking for twenty tests to confirm what I already know."
If you know what your dog needs and don't need tests to confirm what you already know, then why don't you just treat it yourself? Why come in at all? Maybe you need some antibiotics or other prescription medications. And you can't get those unless you're licensed. There's a reason for that. It's because, no matter how smart you are or how much experience you have w/your dogs, there are some things you just don't know, period. A doctor who dispenses medication or initiates treatment based on his client's diagnosis alone is a poor doctor, and is certainly not doing the animal any favors. The reason why vets dislike "pushy,know-it-all breeders" is not because these people choose to do things themselves or because they want to pick and choose their pet's health treatments...it's because they show a total lack of respect for the doctor's training, experience, expertise, and liability as a practitioner w/a license to maintain. You can't walk into your doctor's office having decided you need a certain medication for a certain condition and expect him to just sign the prescription pad. Shame on whomever expects a veterinarian to do the equivalent.
Regarding the comments on c-section cost, the problem is not necessarily the price discrepancy - the problem is the inherent inability on the client's part (not necessarily through any fault of their own) to gauge value for services rendered. $425 for a c-section is a deal given the raw cost of supplies to perform such a procedure w/utmost safety and thoroughness, and probably very little of that compensated the veterinarian for her/his skill/time. The second price includes both - compensation for raw cost as well as compensation for the vet's skill/time. Therein lies the overall problem - most people simply do not take into account that the price needs to reflect both aspects of value. Surgical procedures (especially ovariohysterectomies [spays]) are often the most deeply discounted procedures performed by veterinarians, mostly b/c people would balk at the price if both aspects were taken into account.
Times are changing. Veterinarians are no longer willing to pay for and go through years of schooling to work long hours and receive mediocre pay for their services. Nobody scowls at the successful doctor or lawyer driving the BMW - b/c they've earned it and they're worth it and they charge accordingly. Why would veterinarians be any different? When clients speak of prices that are "fair" or "reasonable", they really mean "fair" or "reasonable" to them, not to the person performing the service.
I'm staying out of the C-section debate.
On antibiotics, however, I am solid, and you do NOT have to get a prescription or a "license" to get antibiotics or many other prescription medicines. That is simply NOT TRUE as every veterinarian knows (but none will tell you).
Flesh wound? You can treat it yourself if antibiotics, glue, and Father Time are all that are needed to set things right.
Basic urinary tract infection? Treat it yourself, with the same antibiotics the vet will give, but at a fraction of the cost.
Ear infection? Treat it yourself
Again, if you WANT to go to a vet and get dinged $180 (or more) for stepping through the door for a common "dog is peeing in the crate" urinary tract infection, you are free to do so so.
All others, however, should check out >> http://www.terrierman.com/antibiotics.htm where I tell folks not only WHERE to get perfectly fine antibiotics for less, but also how to dose your dog by weight.
As for the notion that the "times they are changing," I have to laugh. YES, they are! That is exactly what the post was about.
A lot more vets are swooning to the "greed is good" siren call that the AVMA is pumping out. More and more vets are getting on board, writing magazine articles about how to screw the customer, and goading each other into price gouging. "Go ahead," they tell each other, "it feels so good when you get the Lexus."
And, of course, some are not happy with a mere Lexus, are they? One Vet I know in this area has pictures of his airplanes in his waiting room! Not a lie -- I have asked them about them myself. And I never went back (or had the $5,000 work done that he said was "vital" to my dog). According to him, my dog's ear infection required surgery for a "permanent fix." Riiiight. I fixed the problem with $12 worth of antibiotics, and the dog lived happy and infection-free into old age. A true tale.
And yes, a vet has "a right to price gouge." Customers also have a right to walk away. Presented with a prospective bill, I have walked out. I have also cut $1,000 off of a $1,250 quote in 10 seconds flat by simply saying NO. Caveat emptor. And for God's sake STOP ARGUING WITH THE RECEPTIONIST AND THE VET TECH. They have no power. Nor are they competent. They will scribble down a "heart worm" check on a puppy if you let them, and sell you heart worm medication in December as well. "Oh, and you will need the Lyme test too..." LOL. Caveat emptor. Drilling the wallets of ignorant pet owners for cash is the BUSINESS PLAN of a lot of veterinarians today, and so too is having the vet tech or the recpetionist right down the "needs" of the dog. Then, if you call them on it, it's a "staff mistake" and it's not about the vet being a crook. But of course, it is: the vet instructed staff to sell everything to everybody all the time.
Of course, the "greed is good" evangelicals are not going to go quiet into that good night because someone calls them on their business practices. They will rationalize theft by saying "everyone else is doing it." That is exactly the line the anonymous poster above closes with.
And of course, it may be true, but so what? YOU do not have to get screwed, do you? Get your antibiotics for less. And remember that the person that lies to you about prices will probably lie to you about a lot of other things as well. One things is for certain: they will not tell you where to get antibiotics for less.
Patrick
.it's because they show a total lack of respect for the doctor's training, experience, expertise, and liability as a practitioner w/a license to maintain.
I have nothing but respect for my vet, because he never, ever tries to push unnecessary treatments on my animals, and he always offers us a homeopathic alternative. I trust him implicitly, and he trusts me to be a partner in the care of my animals, rather than an adversary. If more vets felt that way, 'pushy' breeders like me would have a much longer list of vets to refer puppy buyers to.
Regarding the comments on c-section cost, the problem is not necessarily the price discrepancy - the problem is the inherent inability on the client's part (not necessarily through any fault of their own) to gauge value for services rendered.
In my area, the going rate for a section ranges between $450 and $850. In most cases, the higher price reflects either an increased level of skill, or, more usually, a shinier, newer clinic. There is one glaring exception to this, and that's a local vet who apparently charges well north of $1800. Is it coincidental that this one vet also has the largest, glossiest clinic, with the most toys and perks? Cappuccino in the waiting room, full wall fish tanks, an in house MRI.
Do you really, truly believe that his price is the price that best reflects 'value for services rendered', simply because it's highest? By that reasoning, Gucci's pet beds must be a gazillion times better than the ones I get at the co op, just because they cost so much more...
Maybe that kind of reasoning works on some people, but it doesn't work on me, and it doesn't work on any of the other breeders I know in my area, all of whom go to the mid range priced vet who has 20+ years experience, skill with anesthetic, and a clinic made out of a converted garage.
Not as shiny, perhaps, but certainly just as good at saving the lives of my dogs.
By the way, when vets talk about client "compliance," that has nothing to do with paying the bill. It refers to whether the client actually follows through with the treatment on which the vet and the client have agreed (key term here) - did Mr X give Spot the pills/flea treatment/special diet he said he would?
For all the complaints you hear about vet costs, you wouldn't believe how many clients don't bother to take the advice they paid so much for.
Case in point - flea control. Clients come in self-diagnosing hundreds of dollars of allergy testing for "Fluffy" who's scratching herself silly. Is the owner using flea prevention? No, because "Fluffy doesn't have fleas."
Then a flea jumps off onto the exam table. Classic.
So, should the vet run the hundreds of dollars of tests, anyway? No. The owner should buy (and USE, *on schedule*) a $20/month flea control product.
*That's* what "compliance" means.
Hi Vetswife:
Yes, compliance *can* mean that, but that is not what it always means in the case of health care or veterinary care, and it is NOT the meaning using by the AVMA and the economics groups in the articles to which I have linked and to which I refer in this post -- read them yourself, they only are a click away.
In the context of these articles, compliance means the client does not question and does as he or she is told.
For an example of a THIRD meaning of compliance, see the hat I got as a "thank you" gift for speaking at a health care compliance conference put on by the Health Ethics Trust >> http://www.terrierman.com/hat2.jpg In this case, compliance means you follow the rules preventing Medicare and Medicaid fraud (the kind of rules that do not cover veterinarians who are free to rip off customers as they see fit). I joked with the conference organizer that it was almost the perfect color to wear while out hunting, but I thought better of it later, as the hot pink color and the words "Crazy 4 Compliance" suggests something too kinky for words ... and not my idea of a good time, if you know what I mean.
Bottom line: Compliance always means what it does in Webster's Dictionary -- you do as you are told. The idea that the customer and the veterinarian have agreed and discussed it all is a convenient fiction. In fact, veterinarians expect clients to question nothing, and do not value clients who do. That is the kind of "compliance" that the AVMA values and to what they were refering. It had nothing to do with good medicine, and was all about mamimizing billing.
Patrick
So where can a dog owner find trustworthy first-aid/triage information about their dogs?
Hi Patrick,
This is a really good article, and thanks. But there is one analogy here that is pretty lame for an otherwise well-presented set of arguments:
In arguing that it's fair for a plumber to charge $85 for a visit, but not for a vet, you say:
"... pretty close to irrelevant. Yesterday, for example, my plumber drove 30 miles to get to my house on icey roads, and when he got to my house he had to lug in the tools (and lug them out again) while working for more than an hour on things that were (ahem) ... not clean.
A veterinarian, on the other hand, generally has his clients delivered fresh and clean to his door, can do several exams an hour, and if a booster shot is needed, that costs all of $2 in material."
But the vet also has to pay for a LOT more things than the plumber, who doesn't maintain a store or office: more years in expensive universities, an expensive office and clinic, and usually 2-4 staff persons (I know, 1-2 would probably be enough if it weren't for all those other frills like boarding and daycare!).
There are plenty of good solid points to be made on this subject but this one isn't solid. I loves ya though.
Point conceded!
My only defense is that evn a Gold Mine is 98 percent dirt.
Patrick
How about the veterinary emergency clinic that has diagnosed your dogs condition on the phone and told you to come right away, time is of the essence, knowing that this dog would have to undergo major surgery and be monitored for at least 1 day .Come in immediately, then inform you that you must pay upfront and pick your dog up by 7 am because they are not open during the day. When you try to negotiate terms because you don't just happen to have an extra $3,000 dollars , they tell you well there is always "euthanasia". There was a 24 hour veterinary hospital less than a mile away that they should have sent me too, but that was too much money to give up. So I paid, and the dog died as a result of being moved and taken off the IV's. Whose interest did they have at heart?
Hi Patrick.
I wish that I had read your well researched comments earlier. I happened upon them after a recent experience my daughter had with a local vet practice that is clearly gouging her and I assume their other clients as well. Basically, she paid about twice what we recently did for the same services at clinics not 15 miles apart. The "interesting" aspect of the geography is that our vet is located in a blue collar neighborhood while hers is in a tony beachside setting (although she is an elementary school teacher and hardly wealthy). When I saw her bill and asked their office about the price disparities and (to me) obvious unwarranted add-ons and unrequired meds, I was brushed off as a know-it-all nuisance. I am certainly not a vet but anyone with common sense knows a scam when they see one. The fact that I had side by side billing references made no difference to them except for them to let me know that they had no reason to defend their prices to a layman. So I conceded the point and made sure they knew that we also did not need to defend our choice in vets going forward. After reading your essay, it is clear to me that the "greed is good" culture is definitely prevelant here but by the same token people who do not educate themselves about animal care have only themselves to blame for letting it perpetuate. This recent experience has taught me that there are both principled and shady veterinary practitioners just as there are both naive and thoughtful consumers. Please continue blogging on this subject. Knowledge is power and knowledge in this arena can only help keep the cost of pet care within the means of responsible people in all walks of life. This is especially true for people willing to adopt any of the untold number of animals now waiting for a loving home.
Thanks for this post, I just was told by my vet that my 8 month old puppy needs another heartworm test before they will prescribe another refill of heartguard. The test is $75. It just seemed silly to me since he's been on the preventative since he was 8 weeks old, and isn't that the whole point? I started googling what my alternatives were and came across this.
About a year ago I accidentally injured a cat in a parking lot. I brought it to a shelter vet and paid for it to be immunized, xrayed etc and then a few weeks later I had it spayed while I tried to find it a home. I wasn't successful so my mother in law took the cat being an owner of four and a cat lover.
She didn't realize I had spayed the cat and brought it to her vet. The vet claimed the cat was not and charged her to do it again. A few weeks later she told me about it and I was so mad. Both Vets claimed the other was the liar, but I know that the first Vet did open up the cat and I took care of it post surgery. The second Vet in my opinion absolutely stole $300 from my mother in law.
BRAVO!!!!!!!!!!!!!!!!!!
Love your stuff! www.facebook.com/regretavet
Beautiful expository writing. Well done. I put in subjects in the search box or often just Google some question about dogs and i'll come to some other corner of the blog which is new to me. About things canine I put you up top because of your skeptical attitude and your obsession with working the JRT. Nice work.
The most unethical form of price gouging by the veterinary industry today.
Veterinarians are educated as healthcare professionals and then tossed out into a highly competitive market to either sink or swim. With need as the mother of invention, desperation as catalyst to bad behavior and inflated ego as the fuel, it doesn’t take long for once well intentioned vets to turn predatory in their pricing practices. And by god they do……
Veterinarians hold a position of unquestioned trust with consumers. They sit on a pedestal like some sort of pontiff. That puts them in a unique position to take pricing gouging to a whole new level, both in degree of financial gain AND the gross lack of professional ethics.
When a pet dies at a veterinary hospital, what happens? Every veterinary hospital in the country contracts with an outside firm to provide pet cremation or cemetery services. When a pet dies, the veterinarian presents the pet owner with a service that has been chosen by the vet based on wholesale price or kickbacks and perks. If a pet owner is charged $350 by their veterinarian for a cremation service, the veterinarian pockets $250 to $300 as ill-gotten gains.
Moral? Ethical?
Not by any stretch of the imagination. Not only is it a gross conflict of professional interest, but if asked about it, they will lie directly to your face. Wouldn’t you be embarrassed to admit that if you were a vet? I know I would.
Write to your vet and see what kind of response you get. They will likely claim that all the money paid for such a service is passed through to the service provider. It’s a bold faced lie. Write to your state veterinary board or to the AVMA. Don’t hold your breath for an honest answer any longer than you would for your hens to grow old having left the fox to guard them.
Yep. I had a dog with epilepsy. I had the first vet who tried to treat him with ORAL phenobarbital. I later found that it would take about a week to get a blood level that would stop the seizures. But for the rest of his life once they got him to stop having attacks they insisted on testing him every 6 months to confirm his levels were OK. My thinking was that if he wasn't having seizures he didn't need his meds adjusted. I did find a vet that charged half as much for the testing, but never did find one that would just renew his prescription. I think it also upset them that instead of paying them 10 bucks a month I went to Sam's and got the pills for under 2 bucks.
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