Formulating prognoses and cost estimates in colic (Proceedings)

Veterinary care versus owner care

Generally, horse owners are astute at detecting signs of colic. These may include subtle not being enthusiastic about coming up from the field in the morning, not showing interest in other horses and people, or not finishing their feed. These signs should be taken seriously because in a number of occasions, these are the first signs of colic. From a veterinary standpoint, the onset of subtle signs of colic should be logged into the record because the overall goal of colic management should be to cut down the time to referral, when it is warranted. This means that owners should be encouraged to call their veterinarian during the first signs of colic so that veterinarians can give instructions over the telephone, or examine the horse. Both of these events (telephone consultation or examination) should be charged for appropriately. Telephone consultations are particularly difficult to charge for, and some discretion can be used. For example, a quick call to tell the receptionist that colic treatment has been instituted may not be appropriate to charge for, but a consultation in which the owner is looking for advice that requires veterinary expertise is worth considering charging for. Charge levels for consultation can be distributed via newsletters, or the owner can be advised by the receptionist when they call to try to reduce any misunderstanding or feelings of guilt by the veterinarian.

Allowing the owner to institute medical treatment for colic following telephone consultation is a difficult decision. At the very least, the veterinarian should be alerted to the first signs of colic so that the total duration of colic can be estimated. This will help when considering when to refer, and ultimately reducing mortality. In some states, it is not legal to allow an owner to give medical treatments, even with the permission of the veterinarian. North Carolina is an example of such a state. The next step in decision making is whether owners or trainers should be giving medications such as flunixin meglumine without veterinary supervision (in those states where it is legal). The major problem with this practice is that flunixin has a relatively long half-life (approximately 8-12-hours) so that if a horse does need to be referred, particularly where clinical signs are not recognized by owners, the likelihood of survival is reduced and the level of the medical bill is increased. One of the best medications to allow owners to administer is a short duration medication such as xylazine, because it will only last approximately 40-minutes, and the opportunity to assess a horse that has potentially more serious signs will not have been lost by a long duration analgesic. In addition, flunixin is frequently overdosed by giving it at its full dose more frequently than every 12-hours. Overall, the goal is to get any horse that requires intensive treatment for colic to the referral clinic within 3-4-hours.

Decision making

For any farm that a veterinarian is familiar with, someone should always be present that can make difficult decisions. Specifically, if a horse requires extensive treatment, or needs referral, it can waste precious time trying to track down the owner. Trainers can be informed of this so that owners sign a document that allows that trainer to make decisions. This document can also include medical information, insurance information, and information related to payment, such as credit card information.

Medical Insurance

All owners should be asked to what extent they are prepared to pay for medical treatment of horses with colic. This will make the decision making process much easier for the veterinarian. For example, if it is known that a horse is insured and no expense should be spared, aggressive treatment and referral should be considered, Alternatively, some owners may wich to set a limit on expenses and may not elect referral. These cases are always more problematic because the veterinarian is compelled to call the owner if higher cost treatment, referral, or euthanasia is required. A lot of owners change their minds when faced with these realities.

In my opinion, all owners should be asked and encouraged to consider insurance. The optimal policy is a mortality policy coupled with a major medical policy. This is because owners can re-coup their horse, if euthanasia is required. However, euthanasia is only permissible on humane grounds. In other words, owners cannot cash in on a mortality policy if further treatment is deemed possible and humane. Veterinarians are often asked to euthanize a horse so that an owner can get the funds from the mortality policy. Just to re-emphasize, this has to be the veterinarian's decision, and has to be done on the basis of what is humane for the horse. A request for euthanasia will be questioned by an insurance company adjustor, so the veterinarian has to be sure of this decision. Major medical insurance (typically $7,500) will cover the large majority of intensive medical care or surgical care of a horse. I would not recommend surgical insurance, because although it is less expensive, the majority of the expense for surgical treatment of a horse with colic is postoperative medical care and this will not be covered. Similarly, owners may ask about loss of use policies. It is difficult to convince an insurance adjustor of loss of use, and if it is proven the insurance company will typically require that the horse be turned over to them. They can then re-coup some of their costs by selling the horse for another purpose. Once owners find this out, they are usually upset and do not wish to pursue it. In other words, they want to keep the horse and get the loss of use money. Generally speaking, insurance companies are very reasonable, and will do whatever the veterinarian requests for treatment of colic. In addition, insurance policies are not that expensive.

The cost of colic

Costs vary widely depending upon the region of the country. In the mid-Atlantic region, for example, it costs approximately $3,500-$5,000 for medical treatment of colic, and $6,000-$8,000 for surgical treatment (including postoperative care). Owners need to be prepared to pay the lower end of the estimate at the time of admission, and the remainder at discharge. If insured, the owner will then be reimbursed. Third party billing has not become a part of veterinary practice as it has in human medical practice (and this is to the veterinarian's advantage). An initial colic examination to determine the need for further treatment is typically $1,000-$1,500, so it is worthwhile calling the referral colic to find out how they bill and what the charges will likely be so that the owner is not surprised when they arrive. At the same time, it is the duty of referral centers to keep in close contact with both the owner and the referring veterinarian, particularly when difficult decisions or rising costs are a problem. In most cases, the owner knows the referring veterinarian better, and may trust this individual to a greater degree on difficult decisions, even if they require a telephone call during surgery. The most positive approach is to have everyone working together as a team. Referring veterinarians should not be surprised by decisions, changes in quotes, discharges, and euthanasias. These all require calls by the veterinarians working at the referral center so that the owner realizes that everyone is working together for the sake of their horse.

Costs can all be minimized by early referral, so it is in the best interests of the horse, owner, and veterinarian to be thinking about this option as early as deemed necessary. In my opinion, any horse that requires a second visit for treatment of colic is a candidate for referral since the majority of horses will recover with simple medical care after the first visit. The decision to refer can be made over the telephone, especially when colic recurs, and it is never wrong to refer a horse that does not need surgery. This is because we are trying to capture the entire surgical population as early as possible, so that a lot of horses will end up being medical when using this approach. Again, talking to owners about their options ahead of time, and particularly during a colic episode, is very important. The reason colic remains the leading cause of mortality is because of poor medical condition at referral (such as signs of endotoxemia and severe pain). We are all trying to impact the mortality of colic by getting to horses in need of care as early as possible.