Understanding discrepancies in access to animal health services

Due to many factors, most outside the control of veterinary practices, many people cannot access animal health services for their pets.
PetSmart Charities estimates as many as 50 million pets in the U.S. don't get adequate veterinary care. More families are struggling to pay for veterinary care, particularly in urgent or emergency situations, due to static or falling incomes, rising inflation, and other economic pressures, including rising costs for animal health services.

It's a big issue with no simple answers. The report Access to Veterinary Care: Barriers, Current Practices, and Public Policy published by the Access to Veterinary Care Coalition, warns that "Lack of access to veterinary care is a complex societal problem with multiple causes, with socioeconomic status being an important factor. Simply stated, millions of pets do not receive adequate veterinary care because the costs are beyond the family's ability to pay. This may be the most significant animal welfare crisis affecting owned pets in the United States."¹

Who isn't getting veterinary care?
Just as food deserts exist in communities without grocery stores, people also experience veterinary care deserts. Atlanta Rescue Dog Cafe documented how some areas with higher average incomes offer many animal care options that residents of poorer zip codes can't easily access.

Access to Veterinary Care Coalition's report describes pet-loving families without access to animal health services. Michael Blackwell, DVM, MPH, FNAP, chairs the access coalition and clarifies that "the largest subset of those underserved are actually the ALICE group (asset limited income constrained employed), formerly called the working poor."

That distinction upends assumptions. Blackwell says, "Because when we think of the need to realign our efforts, and in some cases make a little sacrifice to help, it's important that veterinary practices understand they're not sacrificing for slackers, people who just take advantage of others or game the system … once [veterinarians] understand that due diligence has occurred and they are not being scammed, then they're more likely to want to help."

Prevalence of the problem

Coalition researchers analyzed the prevalence of not getting the animal health services pets need and which groups, based on income, age, and other factors, experience more barriers to veterinary care.

Barriers to care

Survey respondents provided reasons for not getting veterinary care. Financial constraints, by far, pose the greatest barrier to pets getting needed animal health services. Transportation, worry about judgment, simply not knowing where to go, and even something as simple as not having leashes or carriers to safely take pets for veterinary care all play a contributing role.

Robyn Jaynes, DVM, director of veterinary affairs, PetSmart Charities, says, "In a clinic setting, it's really training your staff not to be judgmental. It's so easy for somebody to come in with a cat in a pillowcase, and for the staff to immediately go, 'They don't know what they're doing,' and that's a bad assumption."

Luanne Strom, MS, DVM, co-founder of Pet Medical Transport, hopes to address issues like transportation and not knowing where to go, especially with veterinary emergency clinics often at capacity. So far, her customers include older people who don't drive at night, those who cannot move their ill or injured large-breed dogs, and even hospital-to-hospital transfers for patients needing overnight care or oxygen supplementation during transport.

Strom continues to work overnights at a veterinary ER and says, "You get a lot of those calls from panicky owners, where there's been a party, and they're all drinking, and there's a massive dogfight or something, and they can't drive … It's heartbreaking, especially when the animal shows up DOA multiple hours later ... Public transportation won't take them most of the time. Most Ubers won't allow them. Not only do they not have space, but if the animal is having any sort of vomiting or diarrhea, it's like a $200 cleanup fee."

Veterinary perceptions and opinions

In the access report, veterinary respondents across urban, suburban, and rural communities and in varied socioeconomic areas always ranked the problem at the national level higher than in their own communities. In other words, people recognize the issue, but right or wrong, believe it isn't as serious where they live and practice.

The survey also measured consensus with statements about rights and responsibilities around pet ownership. Though 94.9 percent either agreed or strongly agreed with “All pets deserve some level of veterinary care," consensus fell dramatically in discussions about the right to have pets.

People often assume those facing financial barriers or who end up with many pets acquire those pets on purpose. Blackwell explains that's not the case and that these pets often come into families because of the instinct to help strays or loved ones who can no longer keep a pet. "That's why we point out they're not proactively going out seeking to be in that situation," he says.

Why does this matter to the profession?

Blackwell describes a "terrible set of conditions" socioeconomically that result in huge swaths of pets not getting adequate veterinary care.
He points out that veterinarians and veterinary teams also take a hit to their emotions and mental health. He says, "We're not built to not help."

Jaynes agrees and adds, “Access to care is a really big piece of compassion fatigue in private practice ... The more we can fix some of these issues, then it would increase morale."

As a retired assistant surgeon general, Blackwell also sounds the public health alarm about such large populations of pets without access to animal health services. "Most of the new diseases, the diseases that have emerged in the last 75 years, have been zoonotic," he adds.

What steps can veterinary teams take now?

Blackwell says, "Veterinary medicine [alone] can't fix a problem veterinary medicine didn't cause." For now, look for places to gain understanding and build connections that address pieces of the problem.

Take a One Health perspective

Blackwell uses the One Health model, which addresses all aspects of pet owners' lives, including culture, relationships, finances, and their physical environment, for the best possible pet health outcomes.

The process often includes social workers who help people resolve or process the challenges they face. For example, a common scenario sees older pet lovers facing increased health, mobility, and transportation issues of their own, which often leads to relinquishment. Yet, the ensuing grief and loneliness of giving up a beloved companion likely results in additional health issues and medical expenses for that person. So, yes, it costs money to care for nonhuman family members, as Blackwell refers to pets, but it costs even more human strain and medical expenses to end that bonded relationship.

Welcome nonprofit help

Veterinary medicine primarily operates on a for-profit, cash basis, with most clients self-funding and paying in full (either via cash or credit) at the time of service.

PetSmart's Jaynes says, "This is a real issue, and when there are low-cost clinics in your area or vaccine clinics or spay/neuter clinics, they're not there to compete with you. They're not there to take money away from you. They're there to help and provide a service to people that can't pay for your services anyway."

She suggests knowing what's available nearby and actively referring people as well as understanding that "even a free service isn't always something people can take advantage of" due to transportation, language, or other barriers.

Offer incremental care

The top thing Blackwell says veterinary practices can do to improve access to care, help underserved populations, and create a safe-feeling environment is to practice incremental care, rather than always going straight to gold-standard veterinary diagnostics and treatment plans.
He explains that general practitioners provided incremental care before the rise of specializations in practice and veterinary school curriculums, so it isn't new.

The PetSmart Charities team supports this approach and points to research looking at outcomes for different types of conditions. "How do we start to put some data together to prove that this type of care is not lower quality care, it's just a different approach?" Jaynes asks. "How do we get more data around what's working and what has to happen to have good outcomes versus doing everything right up front?"

The outpatient parvovirus protocol developed at Colorado State University is a good example of options for families who cannot afford inpatient care.

One way to integrate incremental care is by simply changing the order of options presented to clients. Rather than starting with the gold standard and working backward, which often results in people feeling embarrassed or ashamed about their financial constraints, start with the lower-end options and work upward to create a safe space.

What possible solutions are organizations testing?

Various organizations continue to implement and evaluate possible solutions.

AlignCare

Later in 2022, the Program for Pet Health Equity at the University of Tennessee, Knoxville, will publish results from Blackwell's AlignCare pilot study. In test cities, need-qualified families received incremental veterinary care focused on helping pets with better chances of recovery and survival. Participating practices agreed to 20-percent discounts. Families paid 20 percent, with the rest covered by funders. Social workers also helped with cases needing euthanasia or palliative care in particular so that available funds helped as many pets as possible.

Dumb Friends League Veterinary Hospital at CSU Spur
This hospital does not require income qualification. Jodi Buckman, vice president of community services for the league, says, "We consider that a barrier." The hospital offers $150 flat-rate diagnostics and flat-rate treatment plans using a spectrum of care focused on quickly getting the family back to normal. That means more amputations for fractured limbs, blocked cats getting surgery the first time it happens, and going straight to surgery in classic cases of open pyometra, without all the diagnostics.

PetSmart Charities

Notice the absence of pleas for donations as the only solution. Jaynes says, "We know we can't fix it just by granting money to it. We have to fix the foundation. The estimated dollar amount if you did try to do it that way would be somewhere in the world of $20-$23 billion each year. Even if you compiled all the animal welfare agencies together to help fund it, you can't fund your way out."

In addition to studying outcomes from a spectrum of care, PetSmart Charities also issues grants for self-sustaining, nonprofit veterinary clinics. "We also know that even that alone won't fix the foundation," Jaynes says. “We have some foundational issues within veterinary medicine that need to be addressed, and whether that's the way we're training our students or whether that's the use of telemedicine to make things cheaper, or [non-credit-based] payment plans … I think veterinarians are probably the only place that buy now, pay later is really a challenge."

How can you help?

The access report concludes with five recommendations for improving access to veterinary care for all socioeconomic groups.

1. Understand the barriers people face
2. Suspend judgment for those struggling to access and afford animal health services
3. Show pet owners patience and grace
4. Give pet owners options
5. Point them to nearby, reputable help

If the profession accepts that inequity in access to veterinary care is in fact the crisis that the Access to Veterinary Care Coalition states it is, then possible solutions start with a willingness to look at the beliefs, business models, and systemic issues that perpetuate the problem.

Reference
1. Access to Veterinary Care. Barriers, Current Practices, and Public Policy. Access to Veterinary Care Coalition. 17 December 2018. Accessed 1 August 2022. Available at: https://pphe.utk.edu/wp-content/uploads/2020/09/avcc-report.pdf