Are GPs giving away the store?
Advances in technology are making in-office surgery safe and convenient, but general practitioners seem to be referring more procedures than ever to board-certified surgeons, according to those with whom Veterinary Advantage spoke.
“It really depends on what our definition of surgery is,” says practice management consultant Ernie Ward, DVM, when asked about surgical referrals. “In the traditional sense, surgery revenue has declined, as general practitioners aren’t conducting as many spay and neuter procedures, because shelters and nonprofit organizations are doing them.”
Moreover, “it has become more common in the last decade or more for general practitioners to refer surgical procedures to specialists, especially for injuries like cruciate tears, cancer treatments and orthopedic issues,” he says.
“One reason is that there has been a generational shift among veterinarians, who have become more comfortable referring to surgeons, as they have seen the positive results and great care for the pet. Also, more and more pet parents are looking for specialization, especially as pet insurance becomes more popular and eases economic pressures,” says Ward, who serves on the advisory board of Petplan pet insurance. Plus, specialists are more common and accessible than they were in the past.
Even so, “it’s an exciting time, as veterinary surgery intersects with technology,” he says. “Many of the advancements have turned a procedure that used to have an overnight recovery into one with a recovery time of just a few hours.”
Progressive clinics are performing more outpatient procedures, such as biopsies and lumpectomies, that can be completed during normal clinic hours, says Ward. This is being driven in part by better in-clinic patient monitors, which allow the practice to monitor the health of the pet during and after procedures, speed up recovery time and make patients safer and more comfortable.
“Next-generation anesthetics will allow veterinarians to induce and recover patients in less time and with even greater safety and fewer side effects,” he continues. “Ultimately, the safer and more convenient a procedure becomes, the more likely a veterinarian and pet owner are to pursue it.”
Advances in laser technology will make procedures less painful and reduce the risk of nosocomial infection, he continues. “I also imagine that laparoscopic procedures will improve as well, and become increasingly accessible and affordable in the veterinary profession.”
A middle range
Like Ward, Karen Felsted, DVM, sees a generational issue at work. Felsted is founder of PantheraT, a Dallas-based management consulting firm working with veterinary practices and animal health companies.
“Older veterinarians grew up in a time when you performed a lot of surgery, because there weren’t many other options,” she says. “They were almost forced to get good at it. So they are comfortable with surgery in a way that many younger veterinarians aren’t.
“In all fairness to those younger practitioners, it’s a tough position to be in,” she continues. They may find it difficult to get surgical training after graduation, unless they are lucky enough to be in a practice that is willing to mentor and train them.
Referring cases might be best for the pet, but it creates its own set of drawbacks, says Felsted. “Yes, you can feel confident the pet will have a good surgical experience, but it can add to the owner’s cost significantly, and you may lose people who can’t afford to pay.”
General practitioners may be leaving some revenue on the table that they needn’t, she adds. Granted, a certain amount of spay/neuter procedures – the traditional bread and butter for many practices – has drifted to lower-cost practitioners, such as for-profit spay/neuter clinics or nonprofit organizations, she says. “And there certainly are procedures that should be referred.
“But I think there’s a big middle range. Some general practices do a lot of surgery, because they’ve taken the time to get training, get the experience, and get comfortable with it.”
Today, mobile surgeons are doing very well, says Felsted. “Most are board-certified, or at least have a wealth of experience.” Generally, surgery performed by a mobile surgeon might be a little more expensive [for the client than if the GP performed it], but it will still cost less than if a specialist performed the procedure. “That’s kind of a middle ground,” she says. “The practice retains some revenue, and I think it’s easier for the client.”
The mobile surgery option
One such mobile surgeon is Justin Harper, DVM, founder of Texas Specialty Veterinary Services.
Harper finished his residency and moved back to Texas in 2008, just as the economy tanked. Boarded in large animal and equine surgery, he traveled throughout the state doing procedures. Harper had an opportunity to retrain in small-animal surgery with small-animal-boarded surgeons including Don Hulse and Andy Baker. While doing so, he met a general practitioner, Bruce Turner, who had left general practice to do mobile surgery in the Dallas-Fort Worth area. Intrigued, Harper traveled with Turner for a few days, then decided to do something similar in the San Antonio area, because the service wasn’t being offered anymore since Dr. Andy Baker stopped flying to San Antonio from the Rio Grande Valley offering similar services.
That was mid to late 2009, he says. Today, Texas Specialty Veterinary Services serves about 100 hospitals, 85 miles in any direction, and performs more than 800 surgeries a year, including TPLO, fracture, and other orthopedic and soft tissue surgeries. “We work with small-animal and mixed-animal practices, and we perform any type of surgery that will allow the veterinarian to offer a value-added service to their pet owners,” he says. “Choosing the right cases that will allow for success in this relationship is a key ingredient.”
Dental specialists have been providing this type of service to general dentists for years, says Harper. And the trend is growing in veterinary medicine, for two reasons, he says:
- Veterinary students typically lack hands-on exposure to advanced and in-depth surgery cases at the university. And they are used to seeing difficult and sometimes routine cases referred to their professors, surgical residents and interns. This can include large mass removals, amputations, or other similar cases that should be offered in routine veterinary practice. The more advanced cases require specialty training and equipment. “This gives them the mindset, ‘If I encounter this type of case, perhaps I need to refer it,’” he says.
- The number of referral and specialty hospitals is growing, particularly in metropolitan areas, offering a convenient option for general practitioners who may be intimidated by surgery, or who want to maintain a lifestyle with predictable hours and low stress of handling these cases.
Typically, when the veterinarian refers a case out to a specialist, the specialist evaluates the patient, performs the surgery and does the follow-up work as well, he says. The relationship between the pet, pet owner and primary veterinarian is sometimes lost.
“We train and work with our veterinarians to help them maintain their relationship with the pet and the pet owner,” he continues. The GP does the pre-op bloodwork and imaging work, follow-up, suture removal, X-ray checks, etc. “We serve as a specialty extension of their practice. If they have questions about cases they want to tackle on their own internally, we support them in any way possible as well.”
The arrangement makes economic sense for the veterinarian and the pet owner, Harper continues. The practice captures revenues it otherwise would have ceded to the specialist, including anesthesia, bandaging and hospital stay, if necessary. And, while the mobile surgical specialist is performing surgery, the practice can see other patients and build its business.
“Mobile surgery is a win for the practitioner who wants to stay involved and provide value-added services. And it’s a definitive win from a revenue standpoint as well.
“Finally, pet owners are happy to have this type of service offered within the primary veterinary hospital setting, where they have a developed, trusted relationship with their veterinarian.”
The dentistry opportunity
With the sheer number of competitive forces pulling at their traditional sources of income (flea, tick, heartworm, spays, neuters and vaccines), GPs are looking to fill the void, and dentistry is an untapped clinical and business opportunity for most of them, says Andrew Schultz Jr., director of business development and clinical services, Midmark Animal Health. “The work Midmark is
doing to bring post-grad dentistry training to veterinarians is growing by the day.
“The specialist is the boarded veterinary dentist, and heretofore, referrals were made to them for anything but routine teeth cleaning and tooth extraction – or worse, ‘tooth pulling,’” he says. Five to 10 years ago, the average GP lacked the training, skills and tools to even recognize periodontal disease, let alone treat it. “To directly quote one of our dental study participants, ‘If a tooth was obviously loose, we might remove it, but we didn’t go looking for extras. In fact we erred on the side of caution and left a lot of teeth that I know now probably needed to come out.’
“With the growing adoption of digital dental X-ray and the availability of quality dentistry training, GPs are better equipped, so they can recognize disease that was ignored in the past, and have more confidence because of their training to do oral surgery to treat periodontal disease. This creates a synergy with the boarded dentists, because as GPs recognize and treat more disease, they are more cognizant of their limitations and thus refer more to their specialists.
“A rising tide lifts all ships, and I believe this trend will continue.”