Over eighty five percent of American families believe their companion animal is a member of the family; a third of those give their pet people status. So deliver healthcare like you believe this! - Dr. Tom Cat

There was great pride when we announced in May 2001 that Iowa State University Press published Promoting the Human-Animal Bond in Veterinary Practice. This human-animal bond text was twenty years in the making, with only fifty-six pages of chapters, but with twenty-six program-based appendices to allow any practice options for new human-animal bond activities. Appendix Z is specifically the bond-entered practice profile, which has a caring heart toward staff, patients, and clients. We followed the text with the VCI® Signature Series Monograph Building the Bond-centered Practice, with a CD "tool kit" to help staff implement the programs. We have always said, "If it was to be, it is up to me!", and this is the central issue of a bond-centered practice.

The most common veterinary shortfall in promoting the bond appears to be "wallet medicine" decisions, giving options to clients who do not have the education to understand. We need to tell the client what is needed, from a professional perspective, then be quiet and listen to their response. It is not "We recommend X-ray"; it is "I need to take X-rays so we know if we can treat this medically!" Then stop talking and listen, and if you need to break the silence, the phrase is always the same, "Is this the level of care you want for Spike today?"

In a bond-centered practice, geriatric care starts with the first puppy or kitten visit, with promotion of proper nutrition, current preventative medicine, and behavior management. It is estimated that over six million animals a year are euthanized due to poor behavior. It is continued with the semi-annual life cycle consultation, which is not tied to any invasive procedure. The semi-annual life cycle consultation is a discussion time with the client about the needs of the pet being stewarded.

 We believe sequential weights are good medicine, but seldom do practices enter a body condition score (BCS) behind the weight or in the computer for tracking. If we really think weight is an important indicator of health, we must both weigh the animal at each visit, and enter the BCS, using the nine-point Purina, or five-point Hills/IAMS/Pfizer systems. This allows a higher continuity of care by the healthcare delivery team for each patient.

 If we believe in quality nutrition, every pet needs a nutritional counselor assigned to help monitor it during the growth years. This is a staff area of pride. The food companies recommend a geriatric diet with the fall "senior pet" programs. We need to ensure diet is a twenty-four-seven issue in all client/patient discussions, starting with smaller stools and less smell, due to better digestibility, and a cost per day at proper feeding levels.

 Hills tells us the clients only keep their pets on diets for about three-point-three months, when they have to come back to the practice to buy food. That we start over thirty-five percent of our patients on premium diets, but less than eight percent stay on the program. We don't seem to care enough to follow these cases.

 VetCentric tells us the home-delivery clients keep their pets on premium diets for about eight-point-nine months, which is easy to follow during the semi-annual consultations. We still need to care enough to follow these cases, with follow-up nursing consults every three to four weeks.

 A bond-centered practice records the risk assessments of every animal pre-anesthesia. Five "levels" are described in the VCI® Signature Series Monograph Veterinary Medical Records for Continuity of Care and Profit, with CD. Staff members may be sequentially credentialed in anesthesia procedures at each level of risk, so there is a competency-based progression of understanding, patient safety, and healthcare delivery expectations.

 Some say veterinarians do not charge enough. In fact, what we usually do is take the travel sheet away from doctors and put them into the hands of staff, and find that both fee compliance and income increases as much as fifteen to twenty percent more net. The "three Rs" (recall, recheck, and remind) are on each travel sheet, and the staff ensures the next contact is scheduled, as described in the VCI® Signature Series Monograph Zoned Systems & Schedules, with CD.

 Many practices make IV TKO (to keep open), pain management, and pre-anesthetic blood "optional choices", and then wonder why the clients do not understand how important they really are to quality healthcare. If we do not place a value on them as providers, most clients do not have the education to "fill in the gaps". Assess the anesthetic risk of the patient, tell the client what is needed with a value-added statement, then be quiet and just listen for the response.

 In April 2000, the AVMA executive committee moved "pain medication as needed" to above the signature line on their consent form. It now reads, "...anesthesia and pain medication will be administered as needed..." The days of allowing animals to stay in pain are fast becoming a thing of the past. Are you a leader or follower?

 The fall geriatric program needs to be replaced by a semi-annual life cycle consultation program, including genetic predispositions (go to www.npwm.com). The "over-forty" promotion, based on one dog year equaling five to seven people years, needs to be a comparison of family needs, based on the client's awareness of increased surveillance for preventative reasons for themselves. The arthritis awareness can be a fall program when the weather cools.

 Most practices now grade teeth, but many have not restructured their fees to reward the clients who comes in every four to six months with their pets for a prophy. This client deserves an $114 price tag door-to-door, which becomes "less than $40", if they have wellness care pet insurance, especially since staff can do three Grade 1 prophys per hour. Grade 2+ is a prophy that takes thirty-five to forty minutes, so the fee increases to plus or minus $220, while Grade 3+ is actually oral surgery, which takes about an hour, with the doctor in attendance. It requires X-rays and higher levels of healthcare delivery, over $400, which is the amount a doctor should minimally make for an hour of inpatient time. Grade 4+ is actually more than just oral surgery, since the spread of bacteria is often systemic and the oral disease is down into the bone. Care takes more than an hour, often weeks, and requires X-rays and higher levels of healthcare delivery, usually over $550 for the restoration of wellness if caught in time.

We could use many more examples, but that would steal from the appendices of the other references. This is a "heads up", since a bond-centered practice will attract and keep the "A" and "B" clients, but concurrently become accountable for "family member care", not just pet care. This will be a time for team-based healthcare delivery, since the nurturing of staff must accompany the nurturing of the bond. After all, how we treat the staff is how the staff will treat the clients. The tradition of the doctor-centered control will shift to a team-center of control of the patient and client needs. It will be an exciting evolution for us all.

Making Pet Care Affordable

There are three arenas of activity to discuss under "affordable pet care" in companion animal practices: the traditional veterinary services of curative medicine/surgery, which is twenty to forty percent of the case load; the traditional preventive medicine programs, which is sixty to eighty percent of the case load; and the wellness surveillance programs. As the large format retailers (LFM), veterinary catalog sales, and Internet pharmacies expand their markets into the homes of pet owners, the traditional "preventive medicine" of parasite prevention and control, vaccines, and even routine nutritional needs will become reduced income centers in veterinary practices. The economical link-pin to success is to pursue what we all wanted to do from the day we decided we wanted to enter this very special profession: client-centered patient advocacy to extend and enhance the quality and duration of an animal's life.

The first "affordable" client assistance items to be added to any practice program would include introduction to the third-party payers who are available. Many practices have added it to every new client access interview, using the DSL line in the comfort room. We introduced these third-party payers back in Chapter Seven:

 Pet insurance: Showing the client what the premiums would be, in the case of VPI^® and PetsBest^®, the wellness rider costing $99 and returning over $200, makes the premiums a break-even deal, and provides someone else to share the risk, not risk transfer. VPI® pet insurance is indemnity insurance, just like you car or house insurance.

 CareCredit^®: A no-interest pet credit card, like a department store revolving charge card, with the practice receiving payment within seventy-two hours, with a business bank-charge rate approximate to American Express.

 VetCentric^® store: A web link is available to only your own clients, so they have Internet access, when they want the convenience of home delivery. Your practice still gets a net income dispensing fee check monthly.

To accomplish the new wellness surveillance mission, veterinary practices must start to "appropriately price" the surveillance healthcare, rather than continuing to escalate the traditional "one price for all" concepts. A few examples would be:

 Single dental price versus levels of pricing based on dental grades.

 Single hospitalization price, or hospitalization based on cage size/weight, versus charging for the amount of nursing support required.

 Using vendor pricing for static laboratory screens, versus aligning screening tests to the risk assessment of the patient.

As any veterinary practice calibrates its fee schedule to a national standard, such as the AAHA Fee Survey for its region, the AAEP Fee Survey, the Veterinary Pet Insurance (VPI®) reimbursement schedule, or even the NCVEI "Exam Room" web site, which is available to AVMA and AAHA members for free, one thing usually becomes very obvious. The practice's prices have been too low. The most recent information from VPI® states that reimbursements are only about sixty percent of the established indemnity reimbursable rates.