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CareCredit, a financing solution for veterinary clients, convened a roundtable of equine veterinary experts in 2021 for a discussion of the current state of the industry and what has and should change. In this article, we share the panelists’ in-depth and passionate discussion, including suggested changes that could help improve veterinarians’ financial relationship with clients, boost the health of their own businesses—and make equine practice a more robust and desirable long-term career.
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The panelists were:
- Amy Grice, VMD, MBA, who practiced for more than 20 years before starting Veterinary Business Consulting. She is the AAEP treasurer until 2023 and a member of the AVMA Economic Strategy Committee.
- Charlotte Hansen, MS, is the assistant director of statistical analysis at the AVMA in the Veterinary Economics Division. She specializes in equine economics and geospatial analysis.
- Wendy Krebs, DVM, is a partner and co-owner at Bend Equine Medical Center in Oregon, where she focuses on equine surgery, performance horse sports medicine, internal medicine and comprehensive preventive care.
- Kyle Palmer, CVT, manages VCA Salem Animal Hospital in Oregon. During his 29 years in the veterinary field he has been manager of a mixed equine and companion animal practice, executive director of Northwest Equine Practitioners Association, a consultant, and an author in veterinary management magazines.
- Kelly Zeytoonian, DVM, MBA, is the owner of Starwood Equine Veterinary Services and Starwood Veterinary Consulting in California. Zeytoonian serves on the Board of Directors of the Northern California Association of Equine Practitioners.
The ‘Gold Standard’ of Client Payment
To kick off the discussion, roundtable participants were asked what should be the norm, or “gold standard,” in how clients pay equine veterinarians for services. Krebs did not hesitate in her response: “The short answer is payment at the time of service.”
That has obviously not been the standard in equine practice, Krebs continued, but about 15 years ago, her hospital decided to change its protocol to getting paid at time of service. They knew they would have to continue to deal with absentee owners and clients who forgot their credit card or checkbook, but they made an expectation for immediate payment their default.
“You start to train your clients on [payment at time of service], and you start to train your support staff that they need to get that credit card number on file or make other arrangements for payment when they make the appointment, and things eventually fall into place,” Krebs stated. “It’s a change of mindset.”
“Absolutely! Exactly like Dr. Krebs said—payment at the time of service,” said Zeytoonian. She pointed out that if a service person such as a plumber, electrician or gardener makes a house call, they expect immediate payment.
“We need to be training our clients that there should be that exact same expectation,” said Zeytoonian. “For those absent owners or the training barns, [you can] have payment information prior to scheduling those appointments. There’s just no reason that we shouldn’t be doing the same thing that other industry professionals do.”
Of course, in a perfect world, 100% of clients would pay at time of service. “But we don’t live in a perfect world,” Hansen acknowledged. “Not everyone budgets for that type of care. So building transparency around the costs of care and democratizing that information, I think, is a huge stepping stone in order to push toward compliance around that topic of paying at the time of service.”
Grice noted that horse owners need to be prepared to pay for care, “just like when you go to the grocery store—you don’t get to leave with your groceries without paying for them.”
Palmer added that small animal practices provide treatment plans or estimates for most treatments, which isn’t common in equine practice. He said veterinarians need to talk with clients about costs up front for wellness care and provide a treatment plan with associated fees.
“It’s not enough, in my opinion, to make sure they understand they’re going to have to pay,” he added. “I know I’m going to have to pay when I go to the grocery store, but I also have the benefit of looking at those price tags as I wander through the store and deciding that I don’t want this or I do want that. If I don’t hear the price until the end of my visit and it’s $400 and I thought it was going to be $200, that can be an issue.”
Palmer also noted the importance of making sure clients have their payment method with them. “So many clients go, ‘Oh my gosh, I left it in the house,’” he said. “And a lot of practitioners are so behind, that’s the trigger to say, ‘Oh, I’m just going to go to the next call; we’ll catch you next time, or we’ll mail you a bill.’ ”
Getting that transaction done right there on the spot is important, Palmer said. “There’s nothing—nothing—better in terms of collecting the debt than not incurring it in the first place,” he emphasized.
A Financial Culture Shift: Is It Possible?
Roundtable participants were asked how they handled talking to clients about financial preparedness—and whether they thought they did a good job.
“Absolutely not!” said Palmer. He said the equine practice he managed tried to become “coin-operated”—meaning veterinarians wouldn’t provide service unless payment had been arranged—but they met with only moderate success.
“The impetus is really on the veterinarian … because they’re the ones that are going to arrive at a call and leave a call with or without payment,” he said.
He thinks the “pay at time of service” message must be put in front of the client right from the start. Communicate this simple financial policy thoroughly to every client, and make sure to stick to the fee schedule.
“I’ve always believed that discounting drives back to guilt that the fees are too high in the first place, and that’s a mindset that has to be overcome,” said Palmer. “It’s important to understand that what we’re charging is fair; it’s reasonable; it represents the value that I bring as practitioner.”
Krebs agreed, noting that equine practice management expert Andy Clark, DVM, MBA, has a saying she finds particularly pertinent in this situation: “Never surprise the client.”
“You should never surprise the client when you ask them for payment at the time of service,” Krebs said. “You should not surprise them with the invoice that they’re not prepared for. So you need to start that homework when the appointment is made. Our CSRs (customer service representatives) ask, ‘How do you plan to pay today?’ Or better yet, ‘Do you have a credit card we can put on file?’ ”
Krebs confirmed that “equine vets are not the best at waiting around. They might be trying to get to another emergency.” But, she added, “if you already know you have a credit card on file and at the end of that appointment can say, ‘We’ll just put those charges on the card you have on file, right?’ and 95% of the time the client will agree.’”
Zeytoonian said her practice also makes client education a focus. When they do a new patient visit or general wellness exam, they discuss expectations for general horse care and the costs associated with that care. They even include anticipated care in pre-purchase exams. “We say, ‘We think this horse is going to need X, Y and Z; here are the costs,’ ” she says. “Before they even buy the horse, they know what a number of those fees will be, and I’m proud of doing that.”
In Zeytoonian’s practice, payment at time of service is a policy—“and I’m a stickler to it,” she said. That means payment must be arranged before a veterinarian will go out on a weekend or see a new client. “They say, ‘Once I see that email [about payment] come through with the paperwork, then we can get something on the schedule,’ ” she said. “That has been super helpful for our team.”
Dr. Kelly Zeytoonian Video—Making a Policy and Sticking To It
Hansen said the AVMA’s Language of Veterinary Care study, conducted in mid-2020, was focused mainly on pet owners but featured some important findings for equine veterinarians: “One thing that was loud and clear was that there was an elephant in the room and that was cost. A lot of the pet owners wanted the veterinarian to talk to them about costs up front for the services, but they weren’t getting that. And that also deterred them from going to the veterinarian, because they didn’t know what to expect.”
Charlotte Hansen Video—Cost of Services: The Elephant in the Room
To help bring about a fundamental shift in this area, veterinarians must make their care relational, Hansen stated. When veterinarians focus on building the client relationship, their recommendations become personalized, then conversations about cost become much more comfortable.
Grice affirmed Hansen’s comments, adding, “Veterinarians really need to do a little soul searching and realize that most of them have a hard time talking about money. It makes them feel kind of squeamish, like they don’t deserve to receive payment for taking care of somebody’s horse. It’s almost like they feel it’s wrong to profit from somebody else’s misfortune.
“We’re helpers, we’re there to serve,” Grice continued. “And bringing money into it sort of dirties it or sullies this feeling of helping.”
The reality is that many horse owners value the services provided by veterinarians, she said—veterinarians do themselves a disservice when they feel guilty about the hard work they do every day.
“When I advise veterinarians, it tends to be a supportive conversation that you provide an excellent value and feel proud of what you’re doing,” said Grice. “Don’t feel weird about the money because the clients don’t feel weird about the money as long as you’re providing that valued service for the animal that they love.”
Zeytoonian succinctly stated, “It is not our job to subsidize somebody’s hobby.”
Krebs said horse owners know horses are expensive, adding that in most cases they are paying the farrier more per year than they’re paying the veterinarian.
“I think removing that guilt factor is huge,” said Krebs. “We all want to be guilty, that’s just our personalities as helpers, but get rid of it!”
Proactive vs. Reactive: Client Financial Preparedness
Veterinarians can either have a proactive or reactive approach to client financial preparedness. In light of this, roundtable participants were asked what they thought needed to change in the equine industry.
Hansen said she’s had a few experiences as a pet owner where the veterinary team was proactive about discussing costs, and she appreciated the transparency. “That’s what I want,” she said. “Just tell me straight, ‘This is how much it’s going to be; you’ve got to pay this up front right now.’ ”
Grice said she thinks many equine practices do a good job with new clients when it comes to payment policies and collecting credit cards—“they’re sort of slowly turning the cruise ship to a more sustainable and rational financial policy,” she said. But, legacy clients can be a challenge. “[They’ve] been getting billed at the end of the month for 30 years, and they pay whenever they get around to it,” noted Grice. “It’s very difficult to convince senior partners to change those legacy clients’ financial agreement with you.”
Palmer said most of the equine veterinarians he has worked with are “100% reactive in financial conversations.” But he said they also practice in a reactive fashion. “That’s somewhat the foundation of why they’re reactionary in general,” he said. “To use [an] analogy with farriers, most horse owners do pay farriers more than veterinarians. But farriers are also telling them, ‘I need to be back in six weeks.’ They’re managing their business proactively, not reactively, and we are not.”
Krebs added that it’s very easy to fall into the reactive camp. “But as Charlotte touched on, animal owners actually appreciate the financial communications,” she said. “You start to reformulate that in your head to, ‘I need to respect the client enough to have that financial discussion up front with them.’ ”
Dr. Wendy Krebs Video—A Financial Cultural Shift: It Is Possible
When Krebs presents an estimate to a client, she tells them she wants to be candid about the financial picture and that it’s only fair that they know what treatment will cost. “And I haven’t had a single person give me a negative connotation when I presented it in that way,” she stated.
She added that veterinarians need to try to get away from the mindset that “it’s rude to talk about money” or “we’re going to make the clients uncomfortable talking about money.”
“It’s really the opposite,” Krebs stated. “We’re going to make them uncomfortable if they don’t know how much they’re going to spend.”
Zeytoonian added that veterinarians need to be proactive not only in their policies but also in education. “Where we really need help is shifting the mindset of our clients, to change their expectations so that it’s not a surprise when we want to be paid at time of service,” she said.
The Working Capital Gap
The roundtable moderator read this quote from equine veterinary consultant Mike Pownall, DVM, MBA: “Veterinarians have to pay bills and clients owe veterinarians money. This is the working capital gap. The working capital gap describes the time between when suppliers need to be paid by veterinarians and when payments from clients are received. Veterinarians need to close this gap in order to be more profitable.”
Panelists were then asked how this statement resonated with them, as well as how they saw late, partial or nonpayment of bills affecting their businesses and the veterinary industry.
Zeytoonian said Pownall’s remark hit home. “The way it has affected our practice specifically, we start to get to that crunch time, and if there’s money being owed, then you’re looking at the budget and thinking, ‘Well, am I going to be able to pay my supplier?’” she said. “Then it turns into this vicious cycle of now the supplier’s giving me delayed billing, and they’re having me buy all of these things on credit. … And so it goes.”
She added that when clients don’t pay bills, it affects whether veterinarians and support staff get paid. “We need to be starting from the top and shifting the way that we are expecting payments so that we’re not compromising ourselves or our employees,” Zeytoonian said.
Hansen reiterated that when clients owe veterinarians payment for services and veterinarians don’t collect, veterinarians can’t run their practices the way they want. And this can affect the entire team’s well-being.
“It’s all interrelated,” she said. “The affordability and perceived value of veterinary care is the biggest issue when talking about access to care. … Veterinary care isn’t going to get more affordable. And we can take action to bolster the value proposition. But you can implement strategies to address those gaps and help your practice function well. And that is linked to well-being for the whole team.”
Palmer noted that recruiting and retention of young veterinarians into equine practice are two major issues for the industry. When he talks to new vet school grads who work in small animal clinics, he often asks them if they ever considered equine practice. He said most new vets say no because of the low compensation and financial instability in the equine industry.
Krebs agreed. “I think Kyle has touched on the real heart of the matter here,” she said. “There are practicalities in terms of cash flow, certainly, and the seasonality of equine practice, and those put financial stress on the practice when we don’t get paid at the time of service. But the big picture is that we don’t get to reinvest into our practice and pay our support staff what they need to be paid to stay in the industry or pay the veterinarians what they deserve to be paid to stay in the industry.”
Grice reminded the group that horses are a luxury item, and between 50% and 75% of horse owners make more than $100,000 a year*: “If we’re not making them pay because we feel uncomfortable about talking about money—uncomfortable about setting expectations that we deserve to be paid—then they’re going to choose to spend their money somewhere else.”
*Source: “Economic Impact of the United States Horse Industry,” American Horse Council, 2017, www.horsecouncil.org/resources/economics
Improving On-Farm Bill Pay
The technology learning curve can impede payment at the time of service, particularly on farm calls, according to Palmer. “A lot of it comes down to vets feeling that running a card is difficult,” he said. “Teaching them how to use things like a Square reader or a credit card reader, or to understand [financing] plans and be able to speak that language, is important if they don’t have [support staff] to do it for them.
“I think they collect money easier if it’s easy for them to do,” he summed up.
Krebs said switching to cloud-based software and taking the time to set up invoicing templates has worked well for her practice. “When you’re on the farm, it’s a matter of two minutes to get the invoice and put in your drug amounts and have that total ready to present to the client without having to sit down with your carbon copy invoice and write out the 23 things you did to the horse and get out your calculator. We need to move at a faster pace than that,” she said.
Even if a practice can’t get veterinarians on board with swiping the card, Krebs continued, customer service representatives can still get credit cards on file: “As you leave the farm the client says put it on their card, and you’re done.”
Zeytoonian said technology is key in her practice, as is having support staff accompany veterinarians on calls. “We have a technician or an assistant with us, and when a sedation is being given, it’s being entered in the system as we go,” she said. “You’re essentially populating that invoice in real time as long as there’s internet that you can access.”
She added that it would be interesting to compare aged receivables for a solo practitioner without assistance to aged receivables for a practitioner with support staff. “I think you could probably pretty quickly make an argument for hiring help just based on your accounts receivable,” she said.
Grice noted that younger solo practitioners in her Decade One management group have “started as they intend to continue … they are getting paid at the time of service.” That means they have client paperwork filled out and credit cards on file. They might not get an invoice written till the end of the day, but they email it the same night and have permission to charge the credit card within 24 hours.
“Practitioners that have started that way don’t have accounts receivable,” Grice said.
The Non-Client Emergency and Other Challenges
Roundtable participants were asked how they handle bill pay for non-clients, particularly if they are asked to go out on an emergency call.
Grice noted that it’s important to start with empathy because you don’t already have a relationship with that person. “Maybe say, ‘This must be really hard for you. You weren’t expecting this. We can offer you these different options for payment. Do you need a few minutes to think about it?’ ” she said.
Zeytoonian said the non-client emergency is actually her practice’s biggest pain point. “Those are the individuals that we’re not being paid by right away,” she said. For example, an associate who wants to get out and help a horse and owner in an urgent situation might skip the practice’s step-by-step protocol of getting the paperwork, giving an estimate and arranging payment.
“Nine times out of 10 when I run end-of-month—and I share with everybody who we’re running into issues with–it’s those non-clients,” she said.
She tries to offer some perspective with her associates: “ ‘You’ve just walked away from your dinner, your plans or your partner, and you’ve just done it for free. How do you feel about that?’ And when they can put it in that perspective, it’s a little easier to stomach telling people, ‘I’m sorry; I can’t help you until I get this information.’ ”
Palmer said his response to non-client emergencies would have been completely different 10 years ago compared with today. “Ten years ago, our mindset was always build, build, build,” he said. “I can remember saying to our staff, ‘There are no non-client emergencies; there are only clients that haven’t become our clients yet. And every person out there with a horse is potentially our client.’ But that left us with higher aging in our accounts. I agree with Dr. Zeytoonian that it’s just not prudent anymore to just be the empathetic doctor who’ll see every case.”
Krebs said her practice is unique in that it handles both referral emergencies and primary care emergencies. “We do fall into that position of having emergencies with non-clients pretty frequently,” she said. “I agree with Dr. Zeytoonian that that is our Achilles’ heel. If there are cases that we’re not going to get paid on, those would be the ones. We have to start that conversation with them when we take the phone call initially and set up the expectation that we do need to get paid at the time of service.”
Like Grice, she noted the importance of empathy and building the relationship while still setting appropriate payment expectations. “When I get out to the call, the first thing I do is not hand over the paperwork to get their credit card number; it’s to start with the examination on the horse and show them that I care,” she said. “I do a thorough exam and report to them my findings and what my treatment plan is, and then I have that conversation about money.
“I think there’s a fine line that we have to walk in showing that money is not our only objective, but we do have to get paid or nobody is going to be there to take care of their horses,” Krebs said. “It’s a reality that there are some places in the country where there is no one to take emergency calls.”
Strengthening the Veterinarian-Client Financial Relationship
The experts who participated in the roundtable were asked these questions: What does a healthy financial relationship between an equine veterinarian and client look like? How does this healthy relationship affect the veterinarian, the client and the horses in that veterinarian’s care?
Palmer said a proactive approach is once again called for. “That healthy relationship has to be defined right out of the gate,” he stressed, adding that the practice owner must stick to the financial policy like everyone else. “If the doctor completely undermines it even one time, there’s no credibility left. It is key to make financial responsibility transparent to begin with, then support it at every step along the way.”
Krebs noted that it’s important to establish mutual respect early on. “If it’s a client that expects to treat you as a bank and pay you willy nilly, you might want to pass on that client,” she said. “It’s OK. We do not need to work for every client. If they are looking for a veterinarian that’s going to give them 60-, 90-day terms, we’re not the vet for them.”
She added that the vast majority of clients—or at least those you want to keep—understand that a veterinarian needs to function as a sustainable business and will agree to pay at the time of service.
“Veterinarians spend a lot of emotional energy on that 5% or 10% of clients that give them trouble, and I think we can free ourselves of that guilt and let them go and focus on the good clients that don’t give us trouble,” she emphasized.
Hansen stressed that a healthy relationship between a vet and a horse owner leads to veterinary compliance no matter what the level of care. “Having that good VCPR (veterinarian-client-patient relationship) and being transparent about these costs and having horse owners understand the value of veterinary care can relay the importance of being paid on time to keep the practice up and running,” she said.
Financial Stress and Veterinary Well-Being
The roundtable participants agreed that financial health and personal well-being are directly related for equine veterinarians. As Zeytoonian put it, “being liked by clients is nice, but paying your bills at the end of the day needs to happen.” This helps a practice grow and also promotes work-life balance.
“And I do want to double down on livable wages for our support team,” she said. “It’s a problem, and this is an area where we need to be focusing. I think having that money and having the cash flow can really help to foster appropriate wages for our support team. And that makes everybody’s life better.”
Hansen noted that the 2020 Merck Veterinary Wellbeing Study highlighted financial stress as the leading cause of burnout. “And I know that this refers more to financial stress with student loans, but I expect that relationship to be the same in this example,” she said. “It goes back to leadership in the practice and the work culture that’s created within that environment.”
Palmer agreed, saying, “If you’re the owner of the practice, living month to month wondering how to pay the next bill is constant stress … I think by and large, most veterinarians would love to pay their staff more. I don’t think enough veterinarians understand how vital it is and that they are under-charging chronically and under-collecting regularly. Those two things cause waves of stress that go throughout the practice.”
On top of that, he added, “having clients not want to pay you for work is emotionally battering.”
Grice agreed, adding that because veterinarians’ giving flows from wanting to help, wanting to make a difference, when payment doesn’t occur, “it feels like a slap in the face … like making a difference didn’t count.
“It starts to feel for people like they’re sacrificing their life on the altar of veterinary medicine,” Grice continued. “They see their friends or people outside of veterinary medicine having a normal life that doesn’t look like that. And they feel trapped in this thing that they love but that is eating them alive.”
The good news is that the profession is finally talking more about emotional well-being and balance. “It’s something that practice owners and managers need to be thinking about—creating an environment that’s safe and healthy for the people that work for them,” Palmer said.
Hansen brought up what she calls the “three wicked realities” of the veterinary profession: “We have practices that are inefficient with how they operate. We have pets or horses that aren’t seeing veterinarians. And we have 40% of veterinarians* that consider leaving the veterinary profession.
*Source: Salois, M. “Supporting well-being during COVID-19 and beyond,” dvm360, November 2, 2020, www.dvm360.com/view/supporting-well-being-during-covid-19-and-beyond
“So, when we don’t have a viable, healthy practice, that can cause burnout,” she continued. “When we don’t have animals getting the care they need, that’s a welfare issue. And when we have burnout, we have veterinarians that don’t want to stay in the profession.
“It’s all connected,” Hansen concluded. If the equine profession can bring about a cultural shift of payment up front, thereby alleviating many financial stressors, well-being in the profession will only rise.
Challenges for Ambulatory Practitioners
For many years, bad cell service has hindered ambulatory veterinarians from getting paid on the spot. Today, with more widespread coverage, that’s less of a problem. But there are still a number of issues veterinarians face in collecting payment while out on service calls.
“The challenge a lot of solo practitioners … face is they’re out there alone,” said Palmer. “They’re trying to get an invoice done immediately. They’re behind. The client left their checkbook in the house … and the vet thinks, ‘I just gotta go to the next call.’”
Having a good support staff member along can help, he continued—as long as that person has some administrative prowess.
Krebs echoed the importance of support staff in the field. “Oh my gosh, the assistants make us so much more productive and so much safer,” she said. “They pay for themselves many times over in both of those factors.
“Our assistants drive for us, and then the doctor has the cloud-based system and is sitting there doing notes, doing invoicing, while we drive to the next appointment,” she added. “If you can utilize that drive time well and make it income-generating, you’re going to be hugely ahead.”
Grice said she thinks about the solo practitioner racing around with a full book who used to have two associates and now is all alone, “and their hair’s on fire,” she said. “The way for those people to get payment at the time of service is to have the credit cards on file. And even if they have somebody part-time in the office running those cards once a week, that’s going to be better than writing invoices later.
“If you take it in little bites to start to change your work processes, you can get back to something where your cash flow sustains you so much better,” Grice said.
The Evolution of Financial Care
Equine medical and diagnostic technology has changed quickly in the last 20 years, and financial tools for veterinarians have evolved as well. Roundtable panelists discussed where financial needs are being met and where gaps still exist for equine veterinarians.
Hansen said, “If I speak to soft skills like communicating to clients around financial matters, I think we still have a way to go. I think there are tools out there to help guide the conversations and [there are] more to come.”
Grice added that equine veterinarians often lack business knowledge in general. “A veterinary practice is a small business, and that makes veterinarians uncomfortable,” she said. “They don’t really have the ability to forecast their cash flow in a seasonal business. They’re feeling challenged by their workload, but they don’t know if they can afford to hire somebody. Those [issues] are just understanding basic business management.”
Palmer said the number one financial tool that has evolved and is now being used by many equine veterinarians—but is not widely used enough—is the practice manager. “That’s a position that may be out of reach for a solo practitioner,” he said. “But I know several veterinarians who see those records only one day a year when they go to tax meetings for the previous year. So, get somebody to do that.”
Participants were enthusiastic about online payments as a financial tool. Krebs said her practice is implementing online payment via the ezyVet practice management system with embedded credit card processing. “It’ll be a link that goes out with the invoice on email and the client can just hit the button,” she said.
Zeytoonian said that in her practice, “clients can access an online portal at any time where they can access not only their bills, but their clinical summaries. It’s been great!”
Palmer said his practices uses the Text2Pay platform and has its own proprietary online portal where people can access and pay bills. “We had it in place before COVID, but it really was developed deeper during COVID,” he said. “It’s worked very well. It’s a great tool and, by all rights, the next big evolution in payment processing.”
Wireless payment transmission, paperless billing and collaborative work arrangements were additional strategies panelists mentioned that help them get the work done and get paid for it. On collaboration, Krebs said, “Whether that is group practices or whether that is individual practices that go together to afford a practice manager … I think that truly has to be the way forward for us.”
Handling Client-Driven Financial Stress
Panelists agreed that horse owners sometimes try to make veterinarians feel guilty when it comes to paying for their animal’s care. Krebs says she’s over it.
“As I’ve matured, I just don’t let them put that financial stress on me. It is not my responsibility,” she said. “I am there to help them to the best of my capability and within their resources, but it does not fall on my shoulders to enable them financially. I absolutely acknowledge to them the stress of the situation that they’re under. I acknowledge that it’s expensive, and I’m empathetic. I can help provide solutions that are within their means. And that does not mean that I need to be the one that subsidizes their animal’s health care.”
Zeytoonian heartily agreed: “My job is to provide you [the client] with all of the options for care and give you a path to health and wellness for your horse. And my job is to also educate you on insurance opportunities, coverage opportunities, payment options—none of which involves putting somebody on a payment plan or subsidizing the care of the animals.”
Hansen said this issue goes back to a lack of transparency around costs and trying to avoid sticker shock owners can experience. “If clients can anticipate what they’re going to need to budget for, that will be less stressful for them. And it will be less stressful for you and the veterinarian-client relationship,” she said.
Grice said she suggested that practice owners create an account for each veterinarian that allows them to give away a certain amount of services every year. “That veterinarian … can dribble it out over a lot of cases over the course of the year, or they can spend it all on one case. But it feeds their soul. It feeds their heart. That’s why they’re in this business,” she said.
Zeytoonian said her practice allocates associates $5,000 each year that they can spend how they choose on behalf of clients. “And it does help,” she added.
Krebs emphasized that not every client has to have the gold standard. “It is important to offer that to them, but it is not always the right solution for every client,” she said. “And what truly is the gold standard? Because I think that can be a different answer for every animal and every client. So, really, our job is to offer them all of the options and what the economics look like associated with that, and what the potential outcome differences are amongst those choices. And then the client … gets to choose.”
“I’ve seen the most success where we’ve offered people a couple of different choices and encouraged them to know that there isn’t a wrong answer here,” Palmer said. “There’s just which answer’s right for you. And I can’t make that decision for you. I can provide the education and the support for you to make it yourself.”
Finding Joy: The Good News About Equine Practice
While the equine profession is facing serious challenges, roundtable participants also discussed a number of positive developments and rays of hope. For example, advanced technologies such as ultrasound are now more affordable for veterinarians, Zeytoonian said. This type of equipment can be a revenue-producer for practices and a money-saver for clients who don’t have to travel to a referral clinic.
Grice recently interviewed about 20 veterinarians asking what brought them joy. “They all answered pretty much the same way,” she said, “which was having their clients let them know that they were making a difference in their horses’ lives … The thank-you note, the update on how the horse did, feeling like you truly are a part of the team in that horse’s life.”
Palmer said discussions of work-life balance and wellness are making a difference in the equine profession. “I know a couple of doctors specifically who probably would not be in this industry—they’d have transferred over to companion animal work or left—if they weren’t working for a practice that recognized that and started providing structure and boundaries for them in their job,” he said. “The more that discussion progresses, the better it is for our industry.”
Where We Go From Here
Panelists were asked to discuss changes in the profession that could lead to greater well-being, professional reward and a sense of success in veterinary medicine.
“I’m very passionate about the sustainability of equine practice,” stated Krebs. “There are fewer veterinarians going into equine practice. I think we need to be extremely proactive if we hope to continue to have people come into equine practice.”
She said she knows of new grads who have gone to work for corporate small animal practices for $120,000 a year and been offered signing bonuses of $200,000. While the equine veterinary industry can’t compete with that (at least yet), quality of life can be improved.
“New graduates are averse to being on call,” she noted. “We have to reinvent the model of equine practice to make it something that people are willing to take on. Part of that is making the fee structure such that we can pay those veterinarians well and that we can support them with well-trained staff that are going to stay in this profession and make our lives better. The staffing model in small animal is something like five support staff to one veterinarian. Whereas we think we’re doing really well in equine medicine if we have one assistant.”
Shared emergency duty will be a major part of making equine practice sustainable in the future, Krebs continued, and so will group practices that let veterinarians be on call just one night a week.
Zeytoonian said elevating support staff so they aren’t just assistants but actually keep cases moving proactively will help with efficiencies and offset “the drive times that we just can’t fix.”
She added that establishing boundaries is important for practice owners and associates. “That can be stopping work by 5:30 every night so soccer games can be attended or horses can be ridden,” she said. “But also thinking outside the box as far as what our workweeks look like. We do a four-day workweek, and we have some people that are part time and just do two days a week. You can effectively use and share equipment and resources when you have alternative work schedules to make the practice more profitable and also spread out that emergency coverage.
“I like seeing that practices are picking up on that, and we don’t have to fall into that six-day workweek where you work till you drop,” stressed Zeytoonian.
Palmer described advising a veterinarian recently that his recruitment ad needed to include three things: “I need to see the words ‘flexible scheduling,’ I need to see the term ‘mentorship,’ and I need to see the term ‘work-life balance,’ ” Palmer said. “I was laughed at, and he said, ‘That’s all ridiculous.’ I said, ‘It isn’t, but even if you think it is, I promise you, you have no chance of hiring somebody if you don’t not only say you’re going to do it, but actually do it. You are resigning yourself to being a solo practitioner and probably being out of business at some point because you’ve driven yourself crazy without any help.’ ”
Palmer also said certified veterinary technicians are not being drawn to equine work, “because what they get to do for a lot of ambulatory veterinarians is stock the truck, put everything away, clean the tube, put the X-ray machine back. They’re not handed the syringe and told to draw a blood sample or do the bandage change. They’re hardly ever even taking X-rays.” At the same time, Palmer noted, younger associates want the assistance of a confident technician.
“I think that we are at a moment in this industry where things could go really, really bad, or we could make some good decisions to change our pay scale, our fee schedules, increase compensations, start making equine work a better prospect for people,” stated Palmer. “Otherwise, I don’t know what kind of conversation we’re going to be having if we come back in five years and do this again.”
Hansen agreed that staff utilization is important for the future of equine practice. “We see that in companion animal practice, utilizing a veterinary technician increases revenue 16% in a practice*,” she said. “I would really love to see what those efficiency numbers look like for an equine practice.”
*Source: AVMA 2019 Economic State of the Veterinary Profession.
In wrapping up the roundtable discussion, Grice noted that consolidation of the industry into group practices is unlikely unless the culture of group practice changes. “Young veterinarians are aware that ownership of a veterinary practice is the path to financial success,” she said. “Being a cog in a wheel where the profit that you earn for your practice goes in someone else’s pocket may not make you feel very comfortable, and you may want to be that person yourself.”
If the culture of group practices remains that of several owners at the top who reap the benefits of a stable of associates below them and do not provide for their needs through flexible schedules, robust salaries, good vacation, good benefits, and a shortened workweek, veterinarians will continue “voting with their feet” and not come into equine practice, Grice continued.
“Alternatively, what I also see is many of them establishing their own practices so they get to make the rules,” she said. “Those practices are thriving. Those are the practices where graduates that go into equine practice want to work.”
Bottom line? Equine practitioners need to embrace the value they provide and feel confident in charging appropriately for what they do, Grice said. Part of the solution is providing clients with ways to pay for veterinary care and creating financially educated clients from the very beginning so they know what to expect.
“That requires veterinarians to overcome their discomfort talking about money,” she said. “And a lot of that comes from … feeling like, ‘Yeah, I work really hard, and I do a great job and this is what the value is, and I’m not afraid to ask for that to get paid.’ ”
Grice predicts that instead of consolidation, the equine industry will see collaboration. “Collaborative emergency coverage, collaborative use of equipment; some of those practices may come together in mergers, but they may not,” she stated.
Dr. Amy Grice Video—Where Economics and Emotions Meet
In conclusion, Grice said, “we have the capability to have a positive future. We just have to create new paradigms in equine practice.” A culture shift that empowers financial success and client connection will allow those horse girls who come into veterinary medicine having always wanted to be an equine doctor to thrive, said Grice.
“We need to have them come to something that is as wonderful a career as we all know that it can be,” she said.
Click here to download a PDF of the CareCredit survey article that appeared in the winter 2021 EquiManagement magazine: Hate Talking About Money? You Are Not Alone!
Click here to download a PDF of the CareCredit Roundtable article that was published in the winter 2021 EquiManagement magazine: The Balance of Practice and Passion.
BONUS TAKEAWAY TIPS: Experts Share Practical Pointers for Clinic Operations, Workflow, and Cash Flow
While the roundtable discussion reflected here focused on weighty issues facing the profession and inspiration for a brighter tomorrow, these experts from the front lines of equine care were full of practical insights as well. Keep reading for ideas you can apply in your own practice.
Group service calls geographically. Grice said she recently asked some of her networking group members to track their billable and non-billable activities. She found that the efficiency for ambulatory practitioners was about 50%.
So she recommended that multi-doctor practices create “area days” for routine work, where veterinarians go to certain geographic locales on certain days and clients understand when a doctor will be in their area and start to plan ahead. Another veterinarian keeps a lighter schedule on those “area days” so they can handle emergencies. The person in the “area” handles the emergencies in that region.
Create a hard stop to the workday. Grice also noted that since most younger veterinarians are female—often with family responsibilities—those vets need a hard stop to the day. Not scheduling routine appointments past a certain time can help them know when they’ll be done. “And that means that somebody needs to start doing emergencies at that time so people’s days don’t get out of control,” Grice said.
Be vigilant about capturing fees. “When we’re talking about fees, probably more important than anything is managing fee capture,” Palmer said. “That’s less of an issue as we start becoming more automated and more and more people have support. But everything you don’t charge for drops right to the bottom line, and that’s a disaster.”
Complete invoicing by end of day. Krebs said her practice’s biggest challenge has been getting invoicing completed by doctors in a prompt fashion. “Honestly, that adds more to our accounts receivable than clients not paying,” she said. “So, we are working really hard at trying to get invoicing done by the end of every day. It doesn’t always happen, but having shifted to the cloud-based software has helped us with that.”
She added that her practice’s doctors always have a support staff member with them, which also helps with invoicing. “It doesn’t matter which of them enters the invoice originally, we always have two people check that it is correct,” she said. “It’s amazing how much that adds. I think probably 75% of the time it’s an additive process and the technician will be like, ‘But you handed them a tube of bute at the end of the appointment,’ or ‘You gave them three tubes of Banamine for their first aid kit.’ ”
Grice said research shows that the more time that elapses between the service and the writing of the invoice, the more the percentage of missed charges rises. “One of the ways to get people to write invoices is to hit their pocketbook,” she said. “You could say, ‘If invoices aren’t done within 48 hours, that production is not going to be eligible for compensation.’ ”
Bond clients to the practice, not an individual. Krebs said her team has worked hard to help horse owners bond with the practice rather than individual doctors. “We work four-day weeks for the most part. So they have to be comfortable with another doctor and have confidence with that other doctor,” she said. “That means that Dr. Newton’s notes have to be up to date so I can pick that [case] up and roll with it.”
Zeytoonian said her practice works the same. “We’re two-day workweeks or four-day workweeks,” she said. “People get the work done and then pass the cases on, which is one more shift in the culture of the practice. That makes it … feel like a team effort versus everybody in their own sandboxes. And that’s been such a game changer.”