Internet pharmacies -- don't get mad, get real

Dr. Vernon Wolinski looked at the faxes piling up on the fax machine.

The first fax offered an opportunity to make more than $40 million in Nigeria if the pre-selected doctor would just wire $23,000 to an off-shore facility in Morocco as seed money to participate in a syndicate.

"Your first check for three million American dollars is waiting to be mailed" was written on the bottom.

The remaining faxes were demands from an Internet pharmacy that he send his authorized signature to complete prescriptions from patients he had just seen this morning. The tenor of the faxes was somewhat threatening if immediate authorization was not forthcoming.

Dr. Wolinski, in his mid-50s, was livid. He marched to the pharmacy and demanded to know instantly what he was charging for several heartworm and flea medications. In another staccato delivery that to the staff simulated a singular expanded microburst of sound, he asked for every chart of every client who has ever asked for medications by any means other than from his practice. Vernon was now a mixture of white heat and crimson. His countenance seemed to radiate explosive energy in full circumference from his portly little body. His staff was now frozen in both fear and awe of the erupting volcano before them.

Suddenly Katie, the most senior member of the staff, jumped to action having seen this phenomenon before on selected occasions. The rest of the staff needed time to fully digest the fullness of the spectacle before them. Then slowly, as if released from a spell, they emerged at random and scurried to help seek the information in question.

As several clients waited up front, they could hear the commotion and gnashing of teeth in the back. Some were wondering if they needed to call family members or drive home and tune in CNN for disaster information. Things certainly were not right in this office, they thought.

Spreading storm

Now Dr. Wolinski grabbed the closest phone and called Charlie Odum, his best friend and classmate across town. The conversation became quite animated with an ebb and flow of vitriol evident from both ends of the receiver. Finally, he put the phone down and announced to everyone within earshot that clients could wait while he called the Dept. of Consumer Affairs, FDA, EPA, the attorney general, the governor and a number of other agencies with acronyms that seemed to trail off his tongue in a bizarre alphabet soup of dialogue.

Vernon ultimately discovered from Katie that his prices for an assortment of quasi-OTC medicaments were substantially, and in some cases ridiculously, higher than those reported through the grapevine from a range of Internet sources. He just shrugged. Vernon, now calmed to the point of slow boil, proceeded to pontificate to those within earshot that these companies are either buying these products from nefarious sources in the Middle East or from worthless cads within the profession.

He next implied that some of these contraband items must have been hijacked (Brink's truck-style) from the back docks of some unknown industrial zone where all these drug products seem to emanate. At this point he smiled and seemed satisfied with the progress he had made in establishing his vaunted position within the properly established and hallowed market channel.

Meanwhile, Betty had been waiting for her moment to intercede on behalf of the clients and the disappearing morning. She stated that a client was waiting in one of the exam rooms.

Final straw

Vernon entered the room to see "Billy," an obese Weimaraner, with a penchant for urinating every time someone made eye contact with him.

"Hello, Mrs. Schmidt. How is Billy today?"

"Is something wrong, Doctor?" she said, with only a slight hint of her German heritage.

"We are having a great day," he purred in a completely straight and benign manner.

"Billy's fine, he just needs his heartworm test and I need to be on my way to my bridge party. I am a bit late now," she said without any noticeable inflection.

Vernon proceeded to pull the blood for the test on Billy while his thoughts were meandering back to the Internet problem. While working on Billy he was brought back to reality only to regularly mop up the unending drainage from Billy's underside. He then mused to himself that at his clinic certain dogs seem to be able to endlessly manufacture urine on a logarithmic scale.

Vernon was awakened from his musing by a somewhat bashful cough from Mrs. Schmidt.

Mrs. Schmidt cleared her throat and asked, "Doctor, will you please sign this authorization for heartworm medications for Billy?" She hesitated briefly and continued, "Assuming his test is negative, of course."

Mrs. Schmidt, unknowingly, had just thrown cold water into Vernon's face. His heart rate doubled as he gazed over the scene. His wastebasket was brimming with soppy urine and his shirt compromised with moist saffron spots.

He was aghast, bewildered and not just a little bit hurt. He was speechless for a moment and then lit into a sermon that would have made Billy Graham envious.

Unfortunately, Mrs. Schmidt had little understanding for the internal dynamics of veterinary economics and 20 minutes later left the practice with a newfound resolve to find a veterinarian she could "work with."

Later that day while Vernon was sitting at his computer, his wife called concerning the airline tickets to the AAHA convention. It seems that George Jenkins, a very good client and owner of a new travel agency in town, had a pretty decent airline price for those dates. He scribbled the figures down and without a second thought double-clicked on Expedia.com…

Shoe on the other foot

The drug problem in veterinary medicine is not new. In fact, all veterinarians inherited the way they charge for services based on the premise that the veterinarian is entitled to make a significant portion of income by inflating the perceived value of drugs and products and minimizing the value of professional services.

In the old days, most farmers were less educated and drug companies sold to veterinarians exclusively because it insured throughput of their products. Veterinarians and drug reps were a tight knit fraternity. In effect, veterinarians viewed themselves as druggists with an exclusive franchise for drug distribution. A bonus was the medical and surgical oversight of local farms thrown in at little cost to the farmer.

Hiding from having to charge appropriate professional fees, of course, is a self-esteem issue that goes back further than anyone can remember. This ideology also infected the optometry profession where professional services were packaged inside the cost of "a pair of glasses." This worked well until Wal-Mart et al, changed the playing field. Now optometrists, as well as many pharmacists, are employees, not business owners. This is called the "doc in a box" phenomenon and is the next logical step for our profession unless some pretty narrow-minded thinking is addressed.

Self-esteem issue

We can go back about 50 years and see the nidus for this pricing approach.

Nidus of issue

Back in the days of yore, veterinarians made a significant income vaccinating hogs for hog cholera. Hundreds of thousands of pigs were vaccinated. Also millions of dollars (mostly government subsidized) passed to the veterinary community from this disease. Veterinarians could give away practically all other services while on the farm if they were able to vaccinate hogs in the process. Farmers grew used to this approach and were only too happy to see their veterinarians working tirelessly on their farm.

When the hog cholera situation "deteriorated" into a mop-up operation, veterinarians were obliged to find the next golden goose and a series of products flowing through "their hands only" became the darlings of every practitioner.

Let us go down memory lane in a somewhat chronological order:

• Sulfas

• Combiotic®

• Various castration procedures

• LA 200® (long-acting tetracycline)

• "Tube worming" horses

• Juggin' horses

• Certain "veterinary only" diets
• Flea/tick medications

P.S. For those of you too young or too "small animal" to remember the aforementioned, let me paraphrase a famous quote-those who ignore (or are ignorant) of the past are destined to repeat it.

As the savvy owner and farmer became much more educated and watched "Ole Doc" perform these procedures and administer drugs, they became quick learners. "Ole Doc," the self-satisfied druggist, never seemed to see it coming. Those who did see it coming tried inventive ploys such as adding food dye to Combiotic®, re-labeling and selling it as something special to a trusting clientele.

Regardless, these products or procedures have been mostly removed "by attrition" from the veterinary channel and are largely in the lay channel. Most are doing just fine without veterinary oversight.

And so for the past several years, veterinarians have been trying to play catch up by truly charging for their time both on the farm and in the exam room. These veterinarians are fighting an uphill battle but will do just fine. Others who cling to the past will fade away like a Douglass McArthur soldier.

Playing catch up

Meanwhile, small animal hospitals in the '70s and '80s watched the happenings of their colleagues in the large animal sector with amused smugness. At that time, there were a few vaccination catalogs and the Internet was a curiosity. It seemed that small animal medicine was immune to the problems in the large animal sector.

The Internet has changed everything. Although a large portion of the veterinary information on "the net" is slanted, ungoverned and anecdotal, it has certainly done wonders for those distributing pet or veterinary products of any type. It is a retailer's bonanza. Although this is soon to change, Internet customers enjoy interstate commerce free from state taxes*. Of course, local retailers (and veterinarians) must add state tax to every non-prescription purchase.

Along comes the Internet

Additionally, drugs are not particularly heavy and are easy to distribute for a reasonable fee by retailers seeking an easy-to-reach "global clientele." These entrepreneurs can easily determine the large margins veterinarians enjoy on bread and butter items, and this and this alone is the reason these companies have moved aggressively into this market niche. They are primarily trying to establish a large market share before other entrepreneurs move in on their grubstake.

In other words, it is a gold rush, and the veterinarians are home panning for "fool's gold."

Now our "come-uppence" is at hand and the small animal sector must face these issues as did the large animal veterinarians in the 1980s. If fact, there was a time not so long ago that consultants recommended that small animal hospitals change their whole approach and add a whole section to our hospitals of pet accessories. They most assuredly did not understand the market dynamics of the pet industry. The Internet has changed everything.

Day of reckoning

Gone are the days when we can monopolize the channel for all medications that we deem within our control. We found out that the words "for veterinary use only" mean that the product is to be only used on animals-not by and on the order of a veterinarian. If fact, it is not over yet. The following are sure to change in the near future due to advances in biotechnology:

• Spays/neuters (OTC via oral pills targeting reproductive tissues).

• Safe and effective oral vaccinations

• Safe and effective heartworm medications going OTC.

• Easy-to-use home diagnostic kits for pets and horses.

• Early food/equine pregnancy detection from urine.

• Other inventions too ghastly to speculate.

First, those fighting the Internet are modern day Don Quixotes. Secondly, the FDA and the EPA are glacial behemoths that are unlikely to move on our behalf.

What to do now?

Thirdly, clients are becoming suspicious of our motives, and it appears to some that we "doth protest too much."

Therefore, we must address the Internet pharmacy issue directly and intelligently on our own terms.

These are the boundaries as I understand them:

We are legally bound to offer written prescriptions if requested by an owner. Therefore, we cannot refuse to write a prescription for a particular diagnosis if a client-patient relationship exists.

Some attorneys feel that faxing anything that contains a doctor's written signature is dangerous and is not recommended.

Writing prescriptions is a service similar to writing health certificates, and no prohibition exists to charge for this service.

Here is how my practice is addressing this issue, and it seems to work well for us. When presented with Internet prescriptions:

We decline to fax them. Instead, we offer our own written prescriptions to any pharmacy for a nominal fee of $5.

The owner is free to fill the prescription anywhere they wish, including the Internet pharmacy.

We then offer to fill our written prescription at our own hospital pharmacy. If they do so within 30 days of the date of our prescription, the $5 fee will be waived (reversed). It is amazing how many will do just that.

In other words don't get mad-don't get even-just get real.

*Currently buyers are required to report and pay state tax on all Internet purchases to their state tax authorities but enforcement is nil.