Tensions build between private practitioners, low-cost service providers

The Feb. 16 article in the Tucson Enterprise features a large photograph of a small dog covered in snow. The headline reads, "Veterinarians protest local spay/neuter clinic." The writer opens the story with an account from DVM Newsmagazine about some Mississippi veterinarians who protest a local spay-neuter clinic associated with an animal shelter.

The DVM Newsmagazine article, "A call to protest," ran in February 2012. It tells the story of 65 veterinarians and family members who "converged on an area shelter to protest the loss of 40 percent of their spay-and-neuter business to a low-cost sterilization program."

The Tucson, Ariz., article does not report a similar protest. But it does lay out one part of the complex tension between private-practice veterinarians and low-cost veterinary clinics. "Here in Tucson," the article states, "the problem is compounded when facilities like Animal Birth Control, which does assembly line style spays and neuters, starts doing other things such as dentals and declaws."

Though the reporter was apparently sympathetic to the economic problems faced by private practice veterinarians, the photograph of the shivering dog tells a different story. This mixed message is probably unavoidable as tensions rise between private practice veterinarians and low-cost alternatives in their communities.

The issue here cleaves along several lines. Low-cost alternatives are provided by two types of organizations: public and private. Public low-cost clinics are often associated with municipal shelters or animal welfare leagues. Private low-cost clinics are typically nonprofit organizations not funded by government entities. Some private practices offer auxiliary low-cost services such as Saturday "spay days" or vaccine clinics. In some cases, those auxiliary services are structured as 501(c)3 not-for-profit tax-exempt units, like other charitable organizations.

Table 1 sources of competitive pressure

Although veterinarians sometimes question the quality of care at low-cost alternative clinics, it's their economic protests that capture headlines. One thing seems clear. Tensions are rising. DVM Newsmagazine's 2012 State of the Profession shows that veterinarians' concern about competition from low-cost providers has increased significantly since 2009—in some cases it's almost doubled (see Tables 1 and 2).

Table 2 veterinarians’ greatest competitive challenge

Recession stokes the fire

James Bias has been involved in the private nonprofit side of low-cost veterinary care since 1980. He's currently chairman of the Society of Animal Welfare Administrators and serves as president and CEO of three private nonprofit hospitals in the Dallas area. He cites some areas of the country where good relationships exist between private practitioners and low-cost providers. "But that's not the norm," he says.

"Practitioners, particularly in the last couple of years, have seen a decrease in revenue," he says. "Now they're looking around and saying, 'What might be impacting this?' Certainly the economy is one factor. Visits to private practices are down. But the other factor is clients who are still seeking medical service but going to private nonprofits for a lower price point."

Martha Smith, DVM, is past president of the Association of Shelter Veterinarians and director of veterinary medical services at the Animal Rescue League of Boston. She imagines nearly the same question on the minds of private practitioners during the current slow-bottoming recession. "Unfortunately," she says, "many pet owners consider veterinary care to be one of the elastic things that, when times are tough, you have to let slide. Veterinarians are feeling the pinch, especially in the number of appointments, so they're looking around and asking, 'Well, if I'm not seeing my clients, who is?'"

Increasingly, she says, the answer is low-cost alternative clinics. "With the professionalization of sheltering, we're seeing more shelters saying, 'We have veterinarians on staff; they can also prevent relinquishment of animals by helping keep them at home. Why don't we have an affordable clinic?'" she says. The shelter impulse, she explains, is to think of expanded services as "preventive medicine": Improving the health of animals in poor families means those pets are less likely to be relinquished.

Some quantitative measures are showing that the number of low-cost veterinary service providers is on the rise. For example, membership in the Society of Animal Welfare Administrators grew dramatically in 2011. The group's annual report noted 63 new executives, 116 new managers, 23 new associates and an 18 percent increase in membership in the United States, Canada, Australia and India. Bias sees another important change. His organization and the American Veterinary Medical Association (AVMA) have traded speakers at their annual events. "The dialogue is starting to happen," he says. "Both sides need to keep that fire stoked. The shelters want the people they help to have a relationship with a veterinarian, and the veterinarian potentially gets a client. It's win-win."

But he admits that this might be a tough sell in the current economic environment. "We'll have to get creative on what that relationship will look like," he says. A few years ago, he recalls, SPCA of Texas took over another private nonprofit spay-neuter clinic in south Dallas. A private practitioner in the area called him to say the clinic "is putting me out of business. My clients think I'm gouging them because your prices are so much lower." Bias says he listened to the practitioner—something he suggests both sides do more often—and came up with a creative solution. Thinking about how charity hospitals work, he began framing the services at his low-cost clinic around the concept of co-pays. Clients who utilized the clinic were told that a spay cost $200 but their co-pay would be $25. The remainder would be made up by grants and donations.

"People understand that phraseology on the human side," he explains. "And our veterinarians who worked for us appreciated it because they aren't doing discount work."

Alas, the co-pay idea was abandoned later because it created accounting and software problems, Bias says. And he's not sure it helped smooth the feathers of local practitioners. "The point," he says, "is that we need the willingness to learn what each side is trying to accomplish and make adjustments."

Peacemaking efforts under way

The CATalyst Council is one veterinary group making efforts to bridge the divide. Jane Brunt, DVM, is executive director of the organization, which also champions improved feline healthcare in traditional practices. CATalyst's effort to smooth relations between shelter medicine and private practice is called "Top to Top" and she says it pivots on "the handoff"—the transition of the client from low-cost shelter services to a lifetime of care by a private practitioner. "That's going to be the game changer," Brunt says. "But we're a ways from saying exactly what that entails."

Brunt says CATalyst strives to be "evidence-based and evidence-driven." Toward that end, Top to Top is prepraring to survey communities, shelters, veterinarians and pet owners. The survey will provide a benchmark, she says, to assess whether shelter-veterinary initiatives "move the needle." The organization lists five cities—Omaha, Neb.; Wichita, Kan.; Baltimore, Md.; Albuquerque, N.M.; and Ledgewood, N.J.—with initiatives in place to improve communication and collaboration.

The first step, Brunt says, is to evaluate the current relationship between veterinarians and low-cost clinics in a city. In some areas, she says, the sides are at the "We don't speak to each other and we don't get along" level. At others, the temperature is more "We know each other and we shake hands." The goal, of course, is "We're dating and we get along really well," or even "We've got an intimate relationship going." The Top to Top goal, she says, is to develop ideas communities can use to move their relationships from level to level. "The holy grail," Brunt says, "is that when adopted pets—dogs for sure—go to the veterinarian within a short time after adoption, there's much less chance they'll be returned to the shelter or relinquished. So the idea is, let's keep these animals in homes by involving veterinary care from the get-go.

"This is particularly important with cats because some people think, 'I adopted a cat, it's been spayed or neutered, it's had all its vaccines, it's had parasite prevention and I'm not going to let it go outside. It's done. I don't need to bring it to the vet unless it's sick.' We know there's a whole lot more education that has to happen to provide that continuity of care. The question is, how can we make sure the adopted pet gets an appointment with a veterinarian and goes there within a short period of time? That's the handoff."

An important point, she says, is for private practitioners to be realistic about the existence of shelter medicine. Municipally funded or privately funded low-cost services are not going to go away, she says. "So how do we make that a good thing?"

Smith, of the Animal Rescue League of Boston, says relationships between her organization and private practitioners in the area are already good. "We haven't experienced much tension because we established what animal welfare organizations would do in the beginning, and in other areas of the country this is a new phenomenon; therefore it's seen as a threat.

"I think what's most vital in our relationship is professional regard," she continues. "We are a profession with a long and rich history of respecting one another. If you're a shelter veterinarian, the key is understanding the pressure the private practice veterinarian faces. And if you're a private practice veterinarian, the key is understanding why somebody would be motivated to practice veterinary medicine in a shelter."

For some it's about haves and have-nots

Smith is clear about her motivation for shelter medicine. After she graduated from Tufts University, she did an intense internship at Angell Memorial. "There I saw the dichotomy between the haves and the have-nots," she explains. "There were people who came into Angell Memorial because of the reputation and the specialists and they were going to pursue care regardless of cost. At the other end of the spectrum were people who loved their animals just as much but had to make harder choices over much more simple diseases—fixable diseases. They had to walk away because they couldn't afford to fix that fixable thing. And they were no less heartbroken."

In fact, the question of income qualification for low-cost services, or means testing, has been a trigger for tensions between private practitioners and low-cost providers. "That's where the conversation gets sticky," Smith says. "No, we don't do means testing. We have an outpatient clinic priced competitively with local veterinarians. We do have a fund for animals owned by people with financial needs, and for that program we do means testing to assure ourselves we're helping the truly needy."

But means testing is not part of the mobile sterilization program she leads called the Spay Waggin'. In that program, she says, the goal is simply to prevent unwanted pregnancies, no questions asked. "We're not going to pass judgment on why you came to us over your regular veterinarian," she says. "The Spay Waggin' program breaks even. We can provide spay and neuter surgeries for a low cost because we support ourselves in volume. I do 40 spays or neuters a day so I can pay my staff, pay for supplies, pay for fuel, pay for the garage, pay for the autoclave and charge $75 a surgery. We need the volume to be sustainable.

"Yes, we spay cats in wealthy neighborhoods," she says. "People vary in terms of their sense of responsibility regarding cat ownership, no matter their economic ability."

But when the Spay Waggin' pulls up in poor neighborhoods, she says, the reception is sometimes overwhelming. "We have scores of people from the community lining up with their cats in carriers," she says. "People will stand in line for four or five hours to be seen. Their pets mean that much to them."

Smith says her organization studied the areas of greatest need in the city, drawing maps of the ZIP codes where animal control workers found the most sick and dead cats. It was no surprise, she says, that these were the same neighborhoods where people were in the most economic need. "And it was also no surprise," she says, "that when we overlaid that map with a map of where veterinary practices were located, there was a big circle of them outside the 'red zone.'"

Brian Forsgren, DVM, a private practitioner in Cleveland, Ohio, says he has seen the same rings around the poorest areas of his city. His Gateway Animal Clinic is located in the center of those rings, in a poor neighborhood not served by other veterinary practices. "Last Tuesday night," he says, "seventy people came in between five and seven o'clock. You get the picture."

The picture is that his inner-city practice now has nine veterinarians and is projected to gross $4.7 million this year. But he claims his work has never been about gross revenue. "I've never looked at this as a business situation," he says. "I've always looked at it as a doctor situation."

Fosgren's practice is closer to humane clinics and low-cost providers than most in his city, but he says it doesn't worry him. "I don't look on vaccine clinics or spay-neuter clinics as a problem," he says. "A lot of poor people come to me because I've developed a relationship with them. And when the spay-neuter clinics have a problem, they ship the dogs over to us and we fix them. That's what doctors are supposed to do."

Fosgren thinks more veterinarians should establish practices in poor neighborhoods. "We need as a profession to accept the fact that if general practitioners aren't going to provide services within these communities, somebody is going to," he says. "If veterinarians are the leaders in providing care for animals, it can't be just individual animals with money."

One strategy he's employed is to establish a 501(c)3 not-for-profit tax-exempt arm of his practice. That status does allow a practitioner to raise funds from donations, apply for grants and exist in a tax-exempt bubble. But, Fosgren explains, if you use the funds to reimburse the for-profit side of the hospital, you need an independent board of directors and clear criteria for eligibility. While such an arrangement is possible, it's difficult to maintain.

The real key to solving the tension between private practices and low-cost clinics is for veterinarians to adopt the notion that "we're all in this together," Fosgren says. "Those of us in private practice, in humane societies, in universities, in rescue groups—the whole litany of people who have emerged in our field—we're all part of a team effort.

"Animals are at risk and our job is to not let them be at risk," he continues. "We have to figure out a way. And the best way is for private practices to collaborate with shelters and other humane organizations. We need to make sure they're doing things correctly. Help them. Be the good guy. Put the white hat on again."