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2.2 The Role of Incremental Care

David Haworth, DVM, PhD

Vidium Animal Health, Phoenix, AZ, USA

BASICS

2.2.1 Summary

Veterinary medicine has made incredible strides regarding the sophistication of care that can be provided by veterinarians in practice. The training of veterinary students by board‐certified specialists, usually in tertiary care facilities, has had numerous advantages but has also resulted in generations of veterinarians trained to only provide the very best options, which are usually also the most expensive. When other options are given, it is only at the behest of the client, and is clearly considered a compromise.

There is a different approach that could yield multiple benefits. By establishing that there are many diagnostic and treatment choices that fall along the cost spectrum for almost all conditions, and that responsible pet owners are those that seek out care for their pet, we can increase the number of pets that receive medical attention as well as the satisfaction of clients and veterinary team members.

2.2.2 Terms Defined

Gold Standard Care: Focusing on the most successful, most complete course of action for a given health condition, irrespective of cost.

Human–Animal Bond: The emotional connection between a person or family and their pet. This is sometimes expanded to include any emotional connection between a human and an animal.

Incremental Care: The philosophy of providing all options for treating or diagnosing a specific condition, along with the costs of those options. This is juxtaposed to providing only the best option and then negotiating “down” to what the client can afford.

MAIN CONCEPTS

In practice, incremental care has been a part of veterinary medicine since its founding. However, cementing the practice into daily management philosophy is a relatively new development. The effort to do so stems from the belief of many that the pendulum has swung to a point where only advanced care, involving the best (and most expensive) diagnostics and therapies, is being offered to pet parents. This becomes an issue when financial or other constraints cause those owners to ask for other options and they are made to feel as though they have compromised their pet's health (see 7.8 Providing Care for Those Unable or Unwilling to Pay). This results in a negative interaction between the owner and the veterinary health team, and sometimes in the pet receiving no care whatsoever. Incremental care offers an alternative approach.

The veterinary healthcare team are informed service providers. This means that they have more information and can better contextualize information about the health of an animal than the vast majority of their clients. That is where the added value of seeking out veterinary care should be created. All too often, team members are led to believe that client value derives from the amount of money they bring into a clinic, or how many high‐margin procedures or products they can provide. This is misguided and has led to an erosion of the credibility of veterinarians in the eyes of the public, and several high‐profile discussions of how veterinary medicine has become a profession driven by profit instead of compassion. Pet owners often do not fully comprehend how expensive it is for teams to actually provide veterinary services, or that profitability of such services is often quite modest, but this is not their primary concern. Additionally, it can lead to emotional stress in veterinarians and other team members, forcing them to feel that the reason they pursued veterinary medicine in the first place – the healing and comforting of animals – has been subsumed by the need to make money (see 8.17 Dealing with Compromise Fatigue).

Against this backdrop, veterinary medicine faces a real revenue crisis. There are many reasons driving this, but one is an overall decrease in the number of client visits. It can be postulated (and survey data bear this out) that the significant and unexpected costs of veterinary care drive many to put off taking their pet to the veterinarian until disease has progressed. If this pattern can be reversed, if steps can be taken to decrease average invoice prices for clients but increase the number of times they come in, then the lifetime value of a client will be maintained or increased along with the overall revenues to the profession. This can partially be addressed by incremental care. Additionally, there is a very large percentage, some surveys place it as high as 50%, of pets that do not see a veterinarian after their initial series of vaccinations, largely due to real or perceived financial constraints.

There are both ground‐up and top‐down approaches to implementing incremental care practices in the profession.

The first step is to raise awareness of and in some cases change perception of responsible pet ownership. Pets in society are seen as a right, and the profession cannot allow pet ownership to become a privilege of the wealthy. Veterinary medicine is paid for directly, and pet health insurance is almost exclusively reimbursement based, so all costs are carried by the owners themselves except in rare and specific programs subsidized by governments or charities. This means that the responsible owner is the one who seeks out medical help in the first place. They are responsible when they pick up the phone or walk in the door. Specifically, when they cannot or do not choose to pursue a treatment or diagnostic because of cost, clients need to be reminded that they are doing the right thing for them, their pet and the rest of their family, and should not be made to feel in any way negative. While this may be frustrating to some on the veterinary health team (because there are available treatments) and some may even be tempted to absorb the costs into the organization, this is ultimately a losing proposition because it weakens the viability of the practice and cannot be scaled to meet the true need (see 8.17 Dealing with Compromise Fatigue).

What can be done if the gold standards of care are not affordable to a client (see 2.10 Affordability of Veterinary Services)? Everything else. Diagnostic and treatment options exist on a spectrum – from a complete physical examination costing only time and skill to the most expensive courses of treatment costing many thousands of dollars (see 10.14 Providing Cost‐Effective Care for Those in Need). Understanding all options, their relative costs, and relative efficacies is a critical part of veterinary medical training. While veterinary schools are typically poorly equipped to do that – faculty selection, size of veterinary teaching hospitals and the multitude of specialty services would make this very difficult – early career mentors need to make sure recent graduates are given the time, tools, and exposure to better understand the variety of treatment plans available for any given condition. It is likely unreasonable to expect this to be part of the curriculum pursued at most veterinary schools, but is, anecdotally, an area where the “distributed” model of veterinary education (in which actual veterinary practices are used as places of training as opposed to a centralized veterinary teaching hospital) exceeds the more traditional teaching model. By being exposed to a wide variety of practices, clientele, and treatment plans early in their career or education, veterinarians will be more comfortable offering those plans to their clients.

Organized veterinary medicine also has a role to play. Clinical guidelines that include all options should be developed for the major health conditions of dogs and cats (see 9.3 Guidelines). The full spectrum of care choices should be elucidated and discussed, understanding that more sophisticated and expensive treatments may yield more favorable outcomes, but that more cost‐effective, lower‐probability‐of‐success options should also be included and offered, if needed. In the absence of clinical guidelines provided by national organizations, state or local organizations could produce such documents, and they could even be generated by individual practices. The most important aspect is that veterinary health professionals collectively agree upon a set of options to offer for the most commonly encountered health concerns.

Lastly, it should be recognized that some conditions do not have low‐cost options available. In these circumstances, it is doubly important for the owner to understand that financial limitations are valid reasons for not pursuing treatment. Humane euthanasia is always an option when quality of life concerns are present. This may feel unsatisfactory at the moment but by incorporating incremental care philosophies into a practice, clients will feel they are an integral part of healthcare decisions, which in turn helps bind them to a practice regardless of ultimate outcome for this pet.

TAKE‐AWAYS

Incremental care is a philosophy that holds that there are medical options falling along the entire cost spectrum for most health conditions and that all the available options should be discussed with pet owners.

This is in contrast to “gold standard care,” in which only the most effective and (usually) most expensive treatment options are, at least initially, presented.

This philosophy recognizes that responsible pet ownership is demonstrated when a veterinary care team is contacted and is not dictated by the subsequent healthcare decisions, which may be constrained by financial or other factors.

By engaging in a conversation about the range of possible options, pet parents are more likely to consider themselves a partner in their pet's care, as opposed to a customer simply paying for a service.

It is recognized that there are some conditions that do not have low‐cost options available and therefore humane euthanasia must always be considered an acceptable course of action if quality of life could deteriorate to an unacceptable level.

MISCELLANEOUS

2.2.3 Cautions

Licensing boards and legislatures are inconsistent in their approach to standards of care in veterinary medicine (see 9.5 Better Understanding Standard of Care). Be sure to understand the current interpretations of standards before offering any healthcare option that may be considered “substandard.”