In recent months, columnists and reporters writing for the veterinary trade journals are discussing the NCVEI/Brakke consulting study which concluded that the number of veterinary visits are down largely because of the perceived cost of care and the lack of owner awareness of the necessity of annual visits. Articles such as the headline article in the March 2011 edition of DVM Newsmagazine1, opine about the causes for this trend and ways this trend can be reversed including consumer education, standardizing pet wellness recommendations2 and educating pet owners about financing expensive procedures through loans and other financing programs3.
One item that these consultants overlooked is “referral fatigue.” Although this new and previously undocumented disorder is not the largest cause for the decline in veterinary visits, it is likely a significant contributor to the perception that costs associated with veterinary medicine are out of control. It is not clear what effect “referral fatigue” will have on the general veterinary practitioner but we suspect, overall, it is not helping the situation.
Referral Fatigue – defined
Referral Fatigue is the reluctance of pet owners to spend money, any amount of money, on a pet after they have been to a referral hospital and paid for expensive treatment on their pet. The problem is not the money they spent. It is the perception that they were fleeced at the referral hospital. Owners affected with referral fatigue would rather see their dog die from an inexpensively treatable condition, than risk another visit to a referral hospital.
While working as a road warrior in Boston, at an imaging center in San Diego, and through numerous teleradiology outlets4, as a radiologist I fill a unique role in referral medicine and see a subset of cases that has largely not been identified or studied. The cases that I see are “kind of” referred out by the referring veterinarian who asks for assistance but remains in control of the case. In most instances, case selection is appropriate and veterinarians know which cases I can assist with and which cases to send to the referral hospitals.
Over time, however, I am seeing a trend where I am working on larger numbers of cases where the owner will not, under any circumstances, go to a referral hospital. They would rather see their pet die at the hands of their primary care veterinarian (who has implored them to go elsewhere) and watch their vet muddle through trying to treat their dying pet than suffer through what they perceive to be an unacceptable alternative of going to a referral hospital.
In nearly all cases, these pet owners had a previous bad experience at the referral hospital. Almost invariably the story goes that they went to the referral hospital, they were charged thousands or tens of thousands of dollars, treated like a red headed stepchild, and were left with an urn full of expensive ashes5. Pet owners describe these experiences with visceral descriptors such as “I got raped at the referral hospital” or “they just abused me and spit me out.”
It is not clear what effect “referral fatigue” will have on the general veterinary practitioner. It is expected that a growing number of pet owners will decline referral to regional specialty centers. On the positive side of things (at least if you are a GP) this could increase visits for the referring veterinarian and raise revenues for the GP as they are asked to tackle cases they previously would have referred. On the other hand, we fear that it may decrease visits in general because it adds to the perception that veterinary medicine is too expensive and bad experiences5,6 at the referral hospital create an overall negative impression of veterinary medicine and all veterinarians.
This negativity created by “referral fatigue” also seems to have consequences that reach far beyond cases that should be referred. Once a pet owner is "abused"5 at a referral hospital an suffers "referral fatigue", if they do get another pet, we are seeing more and more cases where they are less likely to spend any money (above and beyond initial diagnostics) on their pet for any reason.
We see this repeatedly when we discuss treatment recommendations with our referring veterinarians who are at a loss to understand why a pet owner would rather put down a dog with a broken toe nail or a bladder infection than spend even minimal amounts of money on these curable diseases. Unfortunately, these owners, because of their "referral fatigue", deeply distrust any recommendation made by a veterinarian because they perceive the veterinarian to be driven solely by profit. This distrust is so pervasive that they will decline all therapy even for disorders that are curable and inexpensive to treat.
This consequence of “referral fatigue” does nobody any good. Not the pet owner. Not the pet. And certainly not the veterinarian.
Please do no target your local specialist – it is not their fault, they are not to blame, and they are only doing their job (which is getting more and more difficult over time)
In much the same way as home owners followed the advice of financial planners who told them to take out home equity loans because the price of their house would always rise, specialists (like their GP counterparts) were lead to believe that what pet owners wanted was more and more advanced veterinary care and they would pay anything. All they needed to do was build a megaplex hospital and raise fees every year and things would be OK.
Unfortunately, in many markets, things did not turn out OK and we are now seeing a “shake out” in veterinary referral medicine. Referral hospitals are declaring bankruptcy, specialists are competing with specialists (whose salaries are subsequently suffering BIG TIME), and pet owners would rather have a radiologist take care of their pet than someone who is better qualified.
Bottom Line: It is not clear how “referral fatigue” will impact veterinary medicine but it looks like things are coming full circle as we barrel forward into the days of Veterinary Medicine 3.0 where we don’t sell flea products, vaccines are not a profit center, wellness programs will be a tough sell, corporate ownership of pet hospitals will be the norm, and a specialty degree is no longer a license to print money.
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1. In the same issue (DVM Newsmagazine, March 2011) there is a blazingly good article in the opinion/analysis section titled “Does the new normal seem abnormal?” where Richard Langford DVM, does a significantly better job identifying the real issues affecting veterinary medicine. Perhaps, the NCVEI should have just hired Dr. Langford. Kudos Dr. L.
2. Our early research, albeit unscientific and performed wile riding a bike and drinking beers at bars suggests that attempting to replace profits from flea products and vaccinations by “wellness exams” will flop. There is already too much chatter by pet owners who proclaim “that vet only wants to get me in there so he can tell me my dog needs it’s teeth cleaned and charge me like $1000.” If wellness is the future, we have ALOT of work to do. AVMA – you listening?
3. Is encouraging pet owners to mortgage their future really a good idea? Didn't the housing bubble burst because lenders encouraged consumers to take on too much debt? Isn't this another form of predatory lending? Do we really think that creative financing is a long-term solution? In our opinion this is a band-aid. Owners will reach for the creative financing option once and only once. After that, they will likely opt for no pet or inexpensive pet care (sch as a shot clinic) because they will be paying off that debt for years to come resenting the vet who pushed them to take out a loan in the first place.
4. Sight Hound Radiology and Shadowsmiths
5. Who knows what the reality of these situations is. I suspect that, in many (if not most) cases, the referring specialists were doing a fine job and adequately outlined all of the risks and costs before hand. That is irrelevant for our purposes. The only thing that really matters is the owner perception. That is a perception that is increasingly negative toward referral medicine.
6. Owning a dog will cost upwards of $15,000 to $20,000. Don’t believe it? Play with the Breedfreak Cost of Ownership Calculator and let us know what you think it costs. Breedfreak is a new project of ours. Get the book. Every vet hospital needs one in the front room. Let us do the dirty work of telling your pet owners that their dog is an expensive medical disaster for you.