Brave new practice: Two doctors develop new clinic model

Dr. Dennis Elmer was finishing up his day as a relief veterinarian. He called his wife, Catherine, a licensed veterinary technician at another hospital, to discuss dinner plans. But the evening meal would have to wait. Catherine wasn't sure when she'd get off work—the team at her hospital had been trying to treat a urethral obstruction in a male cat for 45 minutes without success.

Dr. Elmer told his wife that it seemed like the cat needed a perineal urethrostomy. She agreed, but none of the doctors at her hospital performed the procedure, and the owners couldn't afford to go to a specialist. Dr. Elmer told his wife that if the clients would be willing to drive across town and pay the fee at the practice where he was providing relief services, he'd do the surgery. Forty-five minutes later the cat was at his hospital, the procedure was performed, and another life was saved. Later that night, Dr. Elmer asked himself, "How many times a day does this happen?"

Pioneers: Drs. Dennis Elmer (left) and Eric Larsen co-founded the Advanced Veterinary Care Group in Canton, Mich., to provide pet owners with alternatives to economic euthanasia. Here, the two doctors are performing a triple tibial osteotomy on a dog.

That question led Dr. Elmer to set up a meeting with his friend and former colleague Dr. Eric Larsen. Together the two doctors discussed the possibility of starting a referral center exclusively focused on diagnostics, treatments, and surgeries. They would staff the center with general practitioners and enable local clinics to offer more extensive services while keeping costs affordable for pet owners. Advanced Veterinary Care Group (AVCG) opened its doors last October in Canton, Mich., with the goal of extending the capabilities of general practices in the metro Detroit area.

Meet the team: Advanced Veterinary Care Group eliminates extra overhead by keeping the in-clinic staff to a minimum. From left to right are Dr. Eric Larsen; Kristen Waddell, LVT; Nicole DeFelice, LVT; Catherine Elmer, LVT; and Dr. Dennis Elmer with Titus and Lutius.

AVCG has all the diagnostic tools a doctor could hope for and then some. Capabilities and specialized equipment include digital radiography, digital video endoscopy, digital ultrasound with color flow Doppler, electrocardiography, laser surgery, an underwater treadmill, and an MRI system made specifically for veterinary medicine. The procedures the doctors perform range from splenectomies to triple tibial osteotomies to treat canine cruciate ligament insufficiency.

Rehabilitation: Nicole DeFelice, LVT, works with Bowser, who underwent femoral head ostectomy surgery, on strength training and weight shifting.

What makes these veterinarians accessible to others in the area is that their fees align with general practice rather than specialty practice. "If a dog presents to a doctor and needs to see a neurologist, by all means that doctor should refer to a neurologist," Dr. Larsen says. "But if the client can't afford the MRI costs associated with seeing a specialist and is trying to decide whether to euthanize her pet because of a loss of rear leg function, that's where we come in."

Dr. Elmer agrees. The group's goal is to provide struggling pet owners with another option before they opt for economic euthanasia. AVCG does this by offering an extended level of general-practice care that other doctors can't, whether because they lack the ultrasound unit to image a gallbladder or the skill to fix a fractured femur with an interlocking nail.

This idea didn't necessarily fall out of the sky, Drs. Elmer and Larsen point out. The same model has been used successfully in human medicine for some time, as when family physicians send their patients to a separate facility for radiographs or an MRI. However, this is a new concept for the traditionally conservative veterinary profession, so the group's doctors have taken several steps to earn the trust of their local colleagues. "Our client is the referring doctor or practice," Dr. Larsen says.

As evidence of its commitment to ensure that clients return to the referring practice, AVCG offers no wellness care. The practice does not stock a single vaccine or heartworm pill on its shelves. Unlike most veterinarians, the doctors can't take their own pets to work to get caught up on their rabies vaccinations. In addition to mitigating competitive concerns, this also keeps costs at a minimum, since large amounts of cash aren't tied up in inventory. The absence of receptionists also keeps overhead low. At AVCG, the phones are answered by one of the three technicians wearing earpieces—most of the time they're talking to referring doctors, not pet owners, because AVCG won't see owners without a referral.

When a referring doctor calls AVCG, he or she is quoted a fixed price for the service in question, with no fluctuations. And the referring doctor decides how to proceed after the procedure. If, for example, an AVCG veterinarian performs an ultrasound on a patient, he'll call the referring doctor to discuss his findings and determine what the referring doctor would like to do next. "If it turns out the animal requires surgery, we'll offer options," Dr. Elmer says. "We can send the client back to the referring doctor for the surgery, or we can do it here."

Referring doctors also have the option to charge pet owners through their own hospitals. AVCG can bill the referring veterinarian directly and let that doctor handle the fees in accordance with his or her overall treatment plan for the patient. "We're exactly like a reference lab in that regard," Dr. Elmer says. "Few hospitals have a pathologist on staff, but they routinely charge pet owners for histopathology services."

If the referring doctor doesn't want to use that option, AVCG will add 30 percent to its list fee for the service and bill the pet owner directly. The group keeps its fees in line with those of other local practices that offer the same services. "If a doctor doesn't perform cruciate surgeries but wants to keep control of a patient's care, we're a great option," Dr. Larsen says. "If a doctor does do cruciate surgeries, we're still a great option because he or she can send the patient to us for physical rehabilitation after the surgery to enhance the pet's care."

Drs. Larsen and Elmer are not specialists, nor do they claim to be. While they acknowledge that certain procedures are best performed by board-certified surgeons, they believe that they have the experience and education necessary to perform other surgeries that fellow practitioners can't or won't perform themselves. And they're prepared to take full legal responsibility for their work. As for diagnostics, "We don't have to know it all," Dr. Elmer says. He and the other doctors rely heavily on telemedicine technology to reach specialists for advice on ECG and blood gas analysis results, as well as interpreting ultrasound and MRI images.

Still, the owners of AVCG understand that many in the profession will be skeptical. In an attempt to reassure referring doctors, they've established a high standard of care for every patient. All presurgical patients receive a thoracic radiograph, an ECG, a coagulation profile, and a blood gas analysis the day of surgery in addition to the tests already performed by the referring veterinarian. They understand that last week's serum chemistry profile does not suffice as preoperative blood work; it needs to be performed that day. All of these diagnostics are included in the set price quoted to the referring veterinarian. In some patients' workups, the doctors have found results that caused them to cancel or postpone a procedure. When this happens, the referring doctor is the first to know so that he or she can weigh in on how to proceed. Drs. Elmer and Larsen have also reached out to specialty hospitals in the area to explain that they're not in competition with them. Instead, they're just filling a niche that otherwise left pets without proper care or at risk for economic euthanasias.

AVCG sees itself as a bridge between general practitioners and specialists, and the owners hope to expand the services they offer in the future. While Drs. Elmer and Larsen are the only on-site doctors, they employ a doctor who has completed a surgical residency to perform back surgeries and a licensed ultrasound technician to expand in these areas. They are also currently negotiating with doctors specialized in acupuncture and avian surgery. "Through our group they'll have an opportunity to use these skills and interests," Dr. Elmer says.

Starting a business in Detroit in 2009 isn't an easy expedition to say the least. But so far AVCG is seeing growth—especially in the most critical area. "Seven and counting," Dr. Elmer says at one point. That's the number of pets that would have been euthanized so far if AVCG had not been an option for local pet owners. As they head to work tomorrow, they may be helping number eight.

Dr. Andrew Rollo is a Veterinary Economics Editorial Advisory Board member and an associate at Madison Veterinary Hospital in Madison Heights, Mich. Send your questions and comments to ve@advanstar.com or post your thoughts on our message boards at dvm360.com/community.