PROGRAMS = NET INCOME
You can only take home the net!

This chapter is only an introduction to the Appendices, and it is up to the practice to pick and choose between the programs to make practice life more fun again. Yes friends, practice can be and should be fun; that is why we entered this very special profession. As I was surfing the net (e.g., VIN, NOAH, E-Vet and who knows what links), I watched veterinarians discuss their increase in gross, the percentage of gross which was due to vaccines or dentistry, and other such "first liar loses" type discussions. When are we going to learn? The secret of practice success lies in celebrating the human animal bond with clients, not comparing arbitrary numbers on the Internet.

The Front Door Must Swing

The secret is what makes your front door swing. Every practice has a different formula, but there are common components, and they are called programs (as in program-based budgeting). The days of annual vaccines are over; extended Duration of Immunity Vaccines are here to stay. In WA and OR, the revised Practice Acts even allow the nurses to administer rabies vaccine as well as all other vaccines; South Australia passed similar Practice Act provisions late in 2006. Vaccines are becoming an incidental protection level, offered at the level of the "school nurse" for family members. Practices that are trying to hang onto annual vaccines are condemning themselves to obsolete programs.

In 2004, the AVMA/FDAH rolled out a new initiative (Dr. Jack Walthers, President of AVMA at that time, asked Dr. Tom Cat to develop the 90-minute practice program and roll out the thesis to veterinarians. Concurrently, FDAH had Dr. Marty Becker do the client roll-out Public Service Announcements. The program which Dr. Tom Cat developed and rolled out has been expanded onto the client web site each year (www.npwm.com) and thus provides every practice a web page linkage for their clients...... by 2007, only half the USA companion animal practices had accessed the free annual training kits offered by the AVMA ....... thus we have seen the enemy, have met the barriers, and they are all us!

We realize that a pre-anesthetic laboratory screen is required in virtually every case (although the intensity and scope varies), and as stated in a recent Nevada State Board letter and VECCS protocols, 80 percent of the surgery cases should have fluids running. (When was the last time you took a fluid therapy refresher for CE?) We have stressed the grades of dental conditions, and recording of the grades in the medical records, to the point where those doing it have doubled their income. We even have practices who contact Dr. Marv Samuelson (V.A.R.L.) for assistance to develop dermatology as an income center program (e.g., even in Colorado, 15 percent of the dogs coming in the front door have atopy).

But let's go forward with fundamentals and see what you are taking for granted, especially in surgical cases. We know in our hearts that pre-anesthetic blood screening is essential. As stated, one State Board has publicly informed every practitioner in the State that 80 percent of surgery cases should be on fluids. We read about pain management, and listen to seminars, yet believe clients can make a knowledgeable decision about pain management with no training - post-surgical pain killers are not optional - everyone knows pain is inhumane! Yet every day, there are practitioners putting animals at risk, and themselves into liability, by practicing "wallet medicine" instead of quality medicine.

How about radiology? Fact: most practices have forgotten that a radiographic baseline of the thorax is good medicine. A boarder who is coughing does not always have kennel cough. Dogs do have other problems. For instance, a negative Difil test tells you about circulating microfilaria, not adult heartworms in the thorax. Current literature shows that some of the coughing cats previously diagnosed as asthmatic are actually heartworm infested, even in non-endemic areas. Only an X-ray can do this effectively. Consider this: Dr. Bob Smith (radiologist, University of California Davis) believes that dogs with a negative OR positive heartworm test still deserve a thoracic X-ray series before starting the preventive care or treatment protocol. Moving on to the abdomen, when was the last time you did an IVP or cystogram? There are more things than just foreign bodies occurring in the abdomen. Have you ever considered the diagnostic advantage of Baro-spheres when doing laparotomies, since leakage is not a by-product of these pellets? During a short course recently held, it was stated, "Use of the Penn Hip technique to aid in the diagnosis of hip dysphasia and the introduction of Baro-spheres for barium studies have proven diagnostic advantages." One of our clients attended and knew he could go back to practice and virtually double their income in this area. For those who were Penn-Hip certified, the Wisconsin release of JPS surgical prevention of hop dysphasia at 18 weeks made the certification really a money maker!

Look at the advances in cardiac evaluation. The handheld ECG which gives a lead-II rhythm strip can be used with every semi-annual life-cycle consultation (yes, I know you call it an annual exam, but which sounds more accurate when looking at the www.npwm.com AVMA initiative?). Dr. Larry Tilley (CardioPet fame) is an advocate the handheld ECG; it is economical enough that if it is used for each "semi-annual". At a fee of $2.00 additional, it would be totally paid for in less than six months; then it is a NET-NET program every time it is used! The use of echo cardiology is on the rise; within five years most quality practices will be using it regularly. This modality is technique-driven and relatively easy to read; the difficulty lies in determining where and how to place the transducer. As Dr. Larry Tillet states so often, "Telemedicine now allows a practice to be in contact with a specialist - even across the country - within minutes."

Reflect on the blood pressure diagnostics of your practice. It cannot be emphasized enough. Every practice should be using a blood pressure device daily (e.g., Doppler is great for inpatient assessments, since it can assess flow as well as pressures). It has been shown that 60-plus percent of the cats in renal failure can have hypertension. It has also been shown that hypertension can be manifested in such unusual signs as anisocoria. Dr. Mike Garvey (AMC, NY) has stated that blood pressure measurement is paramount - for more than hypertension.......up to 30 animals die every day from hypotension for every animal that dies from hypertension. The Cardell 9401 was the cornerstone for outpatient screening until the petMap came on the scene. Many practices overbought their Cardell (e.g., Maxi or 9406), or tried to use a Doppler, and the Outpatient Nurse Technician (OPN) was overwhelmed, and the doctor was too rushed to use them as screening tools, so the blood pressure era was initially by-passed. The petMap made nurse technicians into perceived skilled professionals in the client's eyes, even when the doctor reran the atypicals. A better Human-Companion Animal Bond was established, as well as the OPN credentials!

In 2006, we started realizing that the PCR (Polymerase Chain Reaction) screening process had a significant role in wellness surveillance and genetic predispositions. Pet Parents want to know if their four-footed furry family member has any form of predisposition to genetic shortfalls or problems. The savvy practices have added PCR testing to their wellness Standards of Care (SOC), and integrated them into the semi-annual life cycle consults (www.npwm.com).

We are seeing great client return rates with the Photonic Therapy programs, a five wave length "red light" system, using acupressure points, for non-invasive pain management - it is great on suture lines too, no seromas and reduces swelling. I prefer to get them from the inventor, Dr. Brain McLaren (www.photonictherapy.com.au) in Australia, his literature is far better, and the cost a few pennies LESS than the USA source. This is a non-invasive pain management system that can be done by the nursing staff three times a week in short 10-15 minute appointments. I have not used the new three wave length red light torch yet, so I do not have that comparison.

Economics

"Tom Cat, we will damage our relationship if we add these unneeded diagnostics."

You are right, if they are unneeded. In Australia, the fear of adding programs is called "over-servicing" by fearful veterinarians. But in every case stated above, there was a medical need. The fact that you have taken radiology for granted means the overhead is still larger than the income from the program center. Yes, program center -- not income center, not profit center. The front door swings because we believe in our healthcare programs and share that conviction with clients as needs for their animal(s). If you don't medically believe it is needed, never do it!

And for those of you who take one film to "save the client money," remember what every text and radiologist has stated, "If it looks like a duck, sounds like a duck, and walks like a duck, it must be considered a duck.......and ducks state very clearly, quack, quack, quack!" If radiology is needed, two views are needed. To provide half the care is a violation of professional ethics and the Practice Act. Think of lameness cases where you have said, "If this does not get better, we may need to take radiographs." The client brought a suffering animal to you because they wanted "Peace of Mind," and you only offered them "tincture of time." And you wonder why they never come back? Lameness generally requires radiology to determine the appropriate treatment as well as the prognosis. Set your fee schedule at two films as a minimum; in some emergency practices, we set two films plus sedation as a the baseline minimum, since we usually do not have night staff to lay atop the animal (and I do not care if both films are on the same sheet of film, it was two techniques and two firings of the machine head, so it is a two film fee)!

Most existing Fee Schedules are not logical; they are based on traditional, linear, doctor-centered habits. As consultants, we have often talked of $250-$300 per hour for doctors on outpatient and $300 to $500 an hour for doctors in surgery of other inpatient diagnostics. This is because no one ever knew the real costs, or the real costs were too difficult to compute. Those days must come to an end!

The above example includes most of the quality medicine factors: appropriate (Risk Level 1) pre-anesthetic lab screen, pain management, Intra-operatory fluids (protocol-based), induction agents without post-surgical effects, and gas anesthesia that is easily reversible. If the patient is risk level 2, it becomes case management, which is a doctor-directed and patient-specific tailored program, not the protocol based system demonstrated in the above box, so the fees shown are not applicable. We assumed an ambu-bag was available for ventilation in case of anesthetic misadventure, and the inpatient team was available for induction and recovery, so the dental hygiene nurse specialist and/or surgical nurse can do consecutive cases without having to stop for induction or recovery, increasing the workload output (i.e., multi-tasking training techniques - mt3 - as described in the VIN Press 2008 text, The Veterinary Success Formula: Team-based Healthcare Delivery).

The ability for providers to believe in good medicine is the cornerstone of a successful practice. The ability to convey this need to clients at every level of staff communication is the cornerstone of a profitable practice. The overhead of a veterinary practice is pretty fixed (in well managed practices, less than 50 percent of the gross income is spent on monthly expenses, not counting rent, doctor monies, and ROI benefits). So, it is the delivery of services and products within existing staff and facility capabilities which can make the net income difference.

Today is the First Day of the Rest of Your Life

We really don't care what you have already done; that is past. What we care about is what you are willing to do. Every year, new continuing education courses mean you have the opportunity to enhance practice programs. The continuing education experience which does not add one new program per day of CE attended was a wasted expense. The Shirt Sleeve Seminars, conducted by Veterinary Practice Consultants (www.v-p-c.com, now www.drtomcat.com) were designed to be economical weekend programs for staff and doctors; the energy levels seen when staff gets to plan the programs to promote the human animal bond was exciting to experience (and very profitable when they were supported). The new programs needing to be designed to provide better care, and there is a value associated with that client benefit. That value, as assessed to clients, should be reflected in your program-based budget for the year. The cash flow reports from that computer in your office only reflect the "belief level" of the providers in the new program(s) being offered. The choice is yours, we are here to help, but the belief starts in your gut and ascends to your heart. When your heart believes in the program, the clients will accept the care as needed and essential. It is your choice--lower the net each year, or provide better healthcare delivery programs.