Will financial constraints influence choice of referral practices? - Veterinary Practice
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Will financial constraints influence choice of referral practices?

Gareth Cross talks to the principal of a referral practice not currently on the “RSA approved” list about the issues raised by this development and how it might affect both practices and patients.

MANY years ago I wrote an article discussing the possibility that one day insurers might start to direct clients to certain referral centres.

This has now become a reality and, as many of you will be aware, the underwriter RSA has now done it. This affects policies from More Than, Tesco, M&S, John Lewis, Argos and Homebase.

In this column in summer 2015 I interviewed RSA on the subject. Now it is actually happening I thought it would be interesting to see how this is affecting practitioners and their patients.

And so this month I interviewed Pat Ridge of Ridge Referrals in South Devon. This is a well-established small animal orthopaedic referral centre with particular expertise in arthroscopy, and is not currently on the RSA list of approved referral practices.

Gareth (GC). Did RSA approach you or did you approach them?

Pat (PR). I approached RSA some months ago when the country-wide list was mentioned to find out more; this was an exercise in information gathering rather than a direct application to be on the list.

I have had very little response from them other than that they were developing the list (this was a few months ago) and then further to that that they were looking at adding more practices in March/April.

My understanding is that they were looking to have larger multi-disciplined referral practices to start with although there are a number of practices on the list that are orthopaedic-only referral practices, many of which are within the same corporate structure group.

I do wonder how other vets feel about many universities being on the list: are they able to subsidise any discounts provided to RSA through the funding they receive through general taxation or student fees?

GC. Have you had feedback from referring vets about this issue?

PR. Yes, mostly that they feel aggrieved that financial constraints may potentially influence their decision as to where they believe a patient should be referred; that is why we are offering a reimbursement of the additional “referral excess” [£200 levied by RSA on referral to a practice not on their list] so that primary care vets and their clients hopefully do not have this conflict.

We have always tried to provide a service that is as free from financial constraint for owners as possible. For example, if I am contacted about a patient with a cruciate injury I will do my best to offer a range of options to that client so we can help treat that patient provided I believe the patient’s welfare is not impaired by any “lesser” treatment – for example, they would all get the same level of analgesia and anaesthesia and nursing care.

This may mean a 30kg dog that is owned by someone with restricted finances (whether that be a limited policy or someone’s personal situation) has a lateral suture technique to stabilise its stifle with an arthrotomy to examine the menisci rather than an arthroscopy and TPLO.

The arthroscopy and TPLO would be considered a “gold standard” treatment for most active larger breed dogs (with peer-reviewed evidence to support this) but is considerably more expensive than a “traditional” lateral suture that will provide an acceptable recovery albeit with some restrictions in function and with a much longer recovery period (but still a better outcome than no surgery at all).

And this gets to the heart of the matter: people take out pet insurance because they want to have options available should their pet need treatment without significant financial implications; often those options can be provided in the primary care practice but sometimes they can’t and this move to try to limit where patients are referred restricts the client’s options.

I can appreciate why RSA have done this: they are a business and if the money received through premiums is less than they pay out there will be no pet insurance but I think they have gone about addressing this in the wrong way.

GC. Have you checked the legalities/RCVS guidance of refunding the £200? We are not meant to charge differently for insured/uninsured clients so this could be viewed as similar?

PR. I don’t see any issues here. Apart from a different consultation fee that I have for a local charity, my pricing structure is the same for all patients from all clients, that is to say that everything is charged the same but for some clients I then put a discount or reimbursement on their card after the invoice is created.

For example, we have an Armed Forces Covenant so that every client who is either a member of the armed forces or has been a member of the armed forces is given a 10% discount on their bill: this applies whether they are insured or not, whether they are insured with an RSA policy or not and whether they have a treatment that would be cheaper than the gold standard (example above) or not.

There are numerous occasions when I will agree with a client that they can pay a discounted price for a procedure I know will directly benefit their pet because they have a financial restriction: again I price the invoice up as I would normally and apply a credit note. It means I can treat a patient that would not otherwise be treated.

From a business point of view it’s not a great idea but provided it doesn’t actually mean I lose money (direct costs are covered) then it’s what I came to the profession for, as did the nurses who work with me, and it helps me sleep at night.

GC. Have you lost any business due to it?

PR. I don’t know yet! It is still early days and those cases that have policies with RSA that we have seen have not been affected because their policies have not yet renewed. We will undoubtedly be affected though; we will take a financial hit because I have not raised our fees in order to cover the additional excesses we will reimburse – that would be wrong.

If that financial hit is tolerable then I will just work harder to achieve the same or simply take home less: that will be a judgement call to be made in time and that judgement call will include whether we have to join the list if they’ll have us. I do hope they see sense though and look at a better solution to their problem.

GC. Geographically, do you think clients will be inconvenienced by it: e.g. is there an “RSA surgeon” within the same area that clients could be sent to?

PR. This comes down to the client’s options again. The choice of where a client is referred and where a client wants to be referred is multifactorial and proximity and travel distance is one factor which for some clients is more important than others, but who are we or the insurers to make these decisions for the clients?

I still think that a better system can be introduced than a potentially restrictive practice system. Limiting payments for certain conditions is an option provided this is done with transparency: maybe an independent board (independent of both the insurers and the practices) could be created that could set guidelines. This could then, of course, be applied to not only referral practices but also the primary care practices.

I would point out that there is currently no restriction on the primary care practices if they are to undertake procedures. I understand that RSA are trying to limit referral costs but it would be interesting to know if the same increase in referral costs that has been widely quoted as the reason for this has been mirrored in primary care; after all, the same reasons why referral costs are increasing are applicable to primary care (improved range of diagnostics, improved and more expensive treatments both medical and surgical).

GC. How do your prices compare with equivalent practices/surgeons?

PR. I don’t know exactly. I can provide you with a list of our prices but this is not an advert for Ridge Referrals! We have always tried to provide a high-quality service with what we think are reasonable costs. Our fees have risen about 10 to 15% in the six-and-a-half years that we have been running. This is in stark contrast to the more significant cost in implants and disposables that we feel have improved our outcomes.

The one thing I do think is important, and something that is very difficult to explain in a simple short sentence without seeming contrite, is that you can’t compare apples with pears! To better explain that, take for example another common orthopaedic situation I see: a dog with medial coronoid disease (or fragmentation as it was traditionally called).

There is a huge variation in how these dogs present, some as the “classic” young dogs with very painful swollen elbows and true fragments, some are older dogs with subchondral bone fissures, some are younger dogs with fragments and no cartilage, some are middle-aged dogs with just very subtle subchondral bone defects.

They all have medial coronoid disease but they all have wildly different requirements to management: they may need a very simple arthroscopy and fragment removal, they may need much more significant open surgery to resurface the joint, they may just need a longer course of NSAIDs and some advice on weight control.

The fact that we know there is such a wide presentation (and how we are able to differentiate these) is linked intrinsically to the reason why the cost of treatments has risen: we understand better the condition (for example we now have access to CT) so we have developed better treatments than the old-fashioned approach to an open arthrotomy (and that’s shown through peer review).

Those improved treatments are, however, significantly more expensive: the arthroscopy equipment I have in theatre is worth in excess of £50,000; a scalpel and a set of Gelpis will set you back around £500.

GC. How does it make you feel after all your training and efforts to build your practice that some distant number-cruncher can direct patients away from you and influence the treatment pathway for patients?

PR. Change is inevitable. Look at the situation we have in the NHS: for exactly the same reason, the cost to the taxpayer of funding is ever-increasing because we can better treat ourselves.

One thing that has not been considered is the value of preventive medicine. It would not stop the need for treatment but it could reduce it and so reduce the costs. How many dogs do we see that are overweight? Could the insurance companies provide a financial incentive to owners to have healthier pets so they are less likely to need veterinary treatment?

To some extent they do already (they won’t pay for the treatment of disease that can be vaccinated for if the pet has not been vaccinated) but there must be a quantifiable cost of obesity, inappropriate diet or poor breeding. Maybe dogs with low hip scores could be given a small reduction (actually we would need to introduce Penn HIP assessment for this) but I’m sure you get my point.

To answer your question, I do worry and it is yet another headache to deal with! We had another case a couple of months ago that we saw, a 14-year-old Westie with a painful knee. It had a long history of stiffness that had been managed with NSAIDs but then suddenly it couldn’t.

The long and short was that the dog had a meniscus tear on the back of chronic cruciate failure. All it needed was a meniscectomy to get it back to where it had been before. We did this arthroscopically which meant its recovery was shorter than by an arthrotomy and there was less risk involved to the patient: the clients asked to come here because we offer this – it was their choice.

I worry that we will not be able to help patients like this in the future. RSA would say they still have this choice but it is not actually very clear to the clients that they do. Out of interest, because all we had to do was trim a meniscal injury, the cost was less than a complete cruciate stabilisation (even less than if we had examined the joint by arthrotomy and stabilised the stifle), and it was less invasive to the patient, professionally more satisfying to me and what the clients wanted. Win, win all round!

GC. I have heard mention of “terms” for being on the RSA list. What do they involve? Is it a limit on fees for some sort of commission?

PR. I too have heard various rumours but as I have not been party to any specific discussions with RSA it would be unfair of me to comment.

GC. Has the RCVS had any comment/ help on this for you?

PR. Not yet, but maybe after reading this they will! I just want to be able to look at myself in the mirror every morning and feel proud of what I and my team have done and what we hope to achieve that day. I have a family to raise and a mortgage to pay like everyone else but I certainly don’t think that as vets we are swimming in money, I get satisfaction from my job (most of the time)!

  • Gareth is interested in hearing from practitioners who have been affected by the RSA’s policy. Please contact on e-mail: garethcross@hotmail.com.

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