The Impact of PNVEP and Future Needs on Private Practice
John W. Albers, DVM
Executive Director of the American Animal Hospital Association in Denver, CO.
As a component of the Pew National Veterinary Education Program (PNVEP), the report Future Directions for Veterinary Medicine focused the attention of the profession on a number of new directions that veterinary medicine must take in order to meet the changing needs of society. I will first review the changes that have occurred in the private practice segment of the profession, as related to these new directions, and then review key factors currently impacting private practice. Finally, I will address two initiatives that are needed if we are to successfully serve society in the future. While my perspective is from that of companion animal practice, I believe much of this report is applicable to other aspects of private practice as well.
The Effect of the PNVEP on Private Practice
Of the 13 new directions contained in the Future Directions report, private practice in general has responded to five.
Change the focus of the veterinary medical profession from animal disease to animal health in all its dimensions. While there has not been major change in this area, at least we can see some movement. A key change has been the increasing interest in the discipline of animal behavior, as evidenced by significant increases in the amount of continuing education offerings in this area, as well as by the emergence of animal behavior as a recognized clinical specialty. While practitioner attention to animal behavior has not been overwhelming, current growth suggests that practitioners are recognizing the need to provide for all the needs of pet owners, including the appropriate role of the pet in the family environment.
In addition, the American Animal Hospital Association (AAHA) has produced a videotape training program for practitioners and their staffs on the topic of pet loss and bereavement. Veterinarians are addressing the needs of the pet owners beyond that of treating disease. Further, the focus of medicine for pet birds, exotic pet species, and small mammals is clearly on husbandry and nutrition, rather than disease treatment. In spite of these changes, the major focus of private practice continues to be on disease prevention through immunization and on the restoration of health following injury or illness.
Improve the quality of veterinary services delivered to all species of animals in response to the escalating expectations of the public as to the health care of all animals important to people. Clearly, medical knowledge and equipment continues to evolve rapidly, and our ability to deliver higher quality care has increased. If quality of delivery is measured by the degree of sophistication available, we are making progress. If, on the other hand, we include increased quality of everyday primary care, progress is less apparent.
Abandon the unrealistic concept of the universal veterinarian who can minister the health needs of all creatures great and small. We see some changes pertinent to this goal in state practice acts and licensing bodies. Some states are now licensing board-certified specialists without requiring examination in all species. Some states now have provision for licensure by endorsement for practitioners licensed in other states, without the need to be examined on species outside the practitioner's area of practice.
Restructure veterinary practice to better serve the needs of society and the veterinary profession in the future. The vertical structure of practice delivery has changed dramatically, with a significant increase in the number of specialists in private practice, providing a secondary level of care. Whether this change is driven by increased supply of specialists or by an increased demand from referring veterinarians or clients is not clear.
Within primary and secondary care delivery, there remains a hodgepodge of delivery models, with no evidence of increased efficiency. A significant duplication of services and the accompanying inefficiencies still exists, all of which continue to raise questions regarding the quality of care being delivered, particularly at the primary care level.
Focus the professional educational process and the practice of veterinary medicine on the ability to find and use information rather than the accumulation of facts. In this area there has been some progress noted on two fronts: the delivery of continuing education (CE) and the use of computers to access information. The AAHA is helping to train veterinary school faculty in interactive formats of teaching, and is committed to incorporating case-based interactive learning in our CE programming.
There is good evidence that practitioners are increasingly using computers to store and access information. Several of the major national veterinary CE meeting organizers, including AAHA, now offer proceedings on computer disks with search capabilities. Veterinary electronic networks and literature search services for the practitioner are emerging. A recent AAHA survey indicated that 82% of small animal practitioners use a computer for some purpose related to their practice, and 60% expressed interest in a literature search service accessible through the use of a computer and modem.
Two Major Factors Impacting Private Practice Today
Diversity of delivery models. At one time 90% or more of companion animal care was provided through a common model of practice delivery, consisting of an identifiable practice entity of between 1.9 and 2.4 veterinarians and delivering a full range of primary care services. Alternative delivery models began to emerge in the early 1970s. The last five years has seen a virtual explosion of new models.
Companion animal care today ranges from almost rudimentary care provided from the veterinarian's home to very sophisticated large practices with full complements of specialists and high-tech equipment. In between are practices that are limited by species (such as feline, avian, and exotic) or by service (such as spay-neuter on the one hand and animal fertility on the other). To this mix is added diversity of practice ownership, from private to corporate to public. Finally, specialists in private practice add another set of equally diverse delivery models. The result of the diversity is that quality of care is increasingly difficult to assess, and efficiency has further declined.
Changing competitive environment. A rapid increase on the number of low cost providers of veterinary services in the companion animal market has resulted in tremendous competitive pressures. Most of the pressure comes from the so-called pet superstores, most of which feature low cost vaccinations delivered in the parking lot or in the aisles between rows of pet foods, or alternatively, have veterinary "wellness clinics" incorporated into the stores. These stores have proliferated rapidly, and significant growth is anticipated in the next few years. These organizations have tremendous resources and market power and are having a major impact in the economics of veterinary services delivery.
Additional pressures have come from veterinarians themselves, who have decided to compete on price and who have offered their own version of low-cost services. Other veterinarians have sought to increase income by purchasing small animal biologicals and reselling them to drug stores, who in turn market them to the pet-owning public. These changes have created confusion in the minds of pet owners who are often unable to differentiate between a $3 vaccine purchased at a drug store, a $7.00 vaccine administered in a parking lot, and a $30 visit to a veterinary clinic for a thorough exam and accompanying vaccinations.
As a result of these competitive pressures, practices will have to respond appropriately or face the potential of demise. A shake-out and consolidation of the industry is likely. In some respects, our free market system will drive some inefficiency out of the profession.
Initiatives That Are Needed
Two initiatives are currently needed within companion animal practices. Both are consistent with the recommendations of the PNVEP and the general recommendations contained in the most recent report of the Pew Health Professions Commission, Health Professions Education For the Future: Schools in Service to the Nation.
1) We must have a clearer understanding of client needs related to animal care, and in particular, we must better understand the role of the pet in the family and in human/animal relationships. Clearly, there is a wide range of client needs. Intuitively we know that pet owners want and expect more from veterinarians than restoration of health following injury or illness. We need research that clearly demonstrates client needs to practitioners, and then we must provide an interpretation of those needs, as well as programs that give veterinarians new skills so that they can effectively assess needs and meet them.
2) We need to study and understand the current delivery systems with regard to efficiency and effectiveness. Further, we must encourage the development of new models of increased efficiency, with a clear goal of providing a higher level of care in a cost-effective manner. This effort will require research and the creation of new models. Further, implementation of new models must be encouraged and facilitated, perhaps as demonstration projects. The information and knowledge obtained from research and new model development and implementation must also be disseminated to the profession.
Some progress has occurred and there have been positive developments since the inception of the PNVEP and the issuance of Future Directions for Veterinary Medicine. The companion animal practice segment of the profession meanwhile is undergoing significant change, unprecedented in its relatively short history. The world of private practice is vastly different and continues to change. Are we preparing students for entry into this environment? Are practitioners prepared to cope with these changes? How will we respond? The challenges that lie ahead are significant, and we have a long way to go before we can truly say we are meeting the needs of society.