I want to share some breaking news with you regarding an initiative by the AVMA Group Health and Life Insurance Trust (GHLIT).

In November, 2007 the AVMA Executive Board amended the charter of the GHLIT to include the responsibilities associated with pet health insurance on behalf of our profession. They realized that the consumer market is ripe for developing pet insurance products, as the economic impact of owning and taking proper care of a companion pet is increasing.

In reviewing this growing industry, the Trustees felt that the AVMA Code of Ethics must be the foundation by which all pet insurance companies are built. We want to make certain that veterinarians continue to have the ability to run their businesses in the most efficient way and that they can establish their own business goals. To that end, we want our profession to have a voice in determining the direction of the pet health insurance industry and the GHLIT will take an active role in that development.

As part of our due diligence for this initiative, the Trustees have developed a position paper outlining the standards and guidelines of a quality pet insurance company to assist veterinarians in evaluating the many pet health insurance products in the marketplace. We are pleased to release that white paper to the State Veterinary Medical Associations for your review and ask that you distribute it to your constituents as appropriate.

We have planned a luncheon at the AVMA Convention in New Orleans immediately following the morning session of the House of Delegates on Friday, July 18 in Ballroom D at the Hilton Riverside Hotel. While you will receive an invitation in the mail shortly, we wanted to give you an opportunity to read our paper and plan your schedule accordingly. This will be an opportunity for you to learn more about our initiative and how it may prove beneficial to your state. Please join us at this event.

Sincerely,
Gary R. Holfinger, DVM
Chair, AVMA GHLIT

PET INSURANCE: MANAGING THE PROCESS TO PROMOTE QUALITY MEDICINE

The veterinary profession is being offered a unique opportunity to affect change in the industry and help shape the direction of our profession; a much different approach than the human healthcare system has encountered. If you have a choice between uncollected fees and elective euthanasia of a patient, what will you do? Unlike our peers in human medicine, it’s a hard choice we have to make almost every day. Yet, unlike the human physician, as a veterinarian you are presented with the challenge of practicing quality medicine versus affordability for your clients. One way to mitigate this dilemma is pet insurance.

Pet Insurance is again gaining momentum with insurance companies and pet owners. It seems inevitable that pet insurance is coming to the marketplace. With 12-15 different companies soliciting these products to you and your clients today, and more employers beginning to offer pet insurance as a choice in their employee benefit plans, it is only a matter of time before your practice must make a decision on whether or not to accept and promote pet insurance.

OVERVIEW

As the utilization and standards of care continue to escalate for pets, veterinary medicine must be prepared to provide, or suggest, methods to assist the families of pets on how to pay for that care. Historically, veterinary medicine has been a great bargain and as such the veterinarian is held in very high esteem by the public. However, higher veterinary care costs could come into conflict with our image if not appropriately addressed and understood by the public.

The cost of veterinary care continues to escalate due to increasing demand by pet owners for the best care for their pets. In addition, sophisticated diagnostic and treatment methods continue to improve. Veterinary specialists are becoming the norm, creating more pressure for higher standards of care. These changes will exert more pressure on the affordability of pet care. Consumers need reliable methods, other than credit or savings, to pay for costly veterinary care. Pet insurance is the obvious, and now proven, method because pet owners can afford $25-50 per month for insurance premiums, but not several thousand dollars in unexpected veterinary care.

Veterinarians have witnessed the tremendous advantages that health insurance brought to human health care. However, they have also witnessed the negative changes from “managed care” in restricting fees, dictating levels of care, networks, and the overall lack of management control by the medical community for their own profession. As such, it is imperative that pet health insurance not become a form of predetermined networks and insurance regulated pricing in veterinary medicine. Veterinarians need to be free to set their fees based on quality of care, overhead and profit expectations; not have it set or dictated by administrators of insurance companies. Pet owners need to have a system that allows them to choose their own veterinarian and the quality of care they expect. The public should know, with reasonable certainty, what amounts the insurance policy will pay or reimburse for all claims.

Pet Insurance policy requirements must be consistent with the Principles of Veterinary Medical Ethics, be affordable, provide value, be simple to use, quick with claim payments, portable and financially reliable.

•Pet Families think a serious accident or illness will never happen to their pet, but it does. That is why they need their veterinarian’s advice on how to provide for the expected—and unexpected—expenses of a pet’s care, as much as they need your diagnosis and medical recommendations.

•If you and your staff recommend pet insurance, the client can be confident that they have an affordable and reliable method to pay for their pet’s healthcare needs; they can make an informed decision about how to pay for their pet’s care. Otherwise, we only increase the incidence of elective euthanasia because of the potentially higher cost of appropriate treatment.

•Client criticism of increasing expenditures can be avoided by providing pet owners with their own self-financed option: pet insurance. When you walk into the exam room to treat an insured sick or injured pet, clients will thank you for your advice that saved them money and helped them avoid a difficult economic, versus humane, decision.

•Recommend pet health insurance to your clients. By doing so, you are presenting them with a proven, reliable method of paying for pet care. As a veterinarian, you now have the ability to perform evidence-based medicine.


WHAT’S IN IT FOR YOU?

The Group Health and Life Insurance Trust (GHLIT), with the support of the American Veterinary Medical Association (AVMA), is concerned with the direction that pet insurance will take if proper guidelines and standards are not established now. To that end, they have created the foundation by which pet insurance companies should adhere in order to be recommended by veterinarians. By following these guidelines, pet insurance will not only allow companion pet owners to give their pets longer and healthier lives, it gives you a powerful tool in providing better medicine for the animals under your care.

When recommending pet insurance endorsed by the AVMA-GHLIT to your clients, you can feel confident knowing:

•Your clients now have a greater ability to pay for the services you recommend.

•No fee schedules will be developed which can reduce your reimbursement.

•You and your clients have more freedom to decide what treatments to administer, with less emphasis on the dreaded discussion about fees.

•Your clients have another source of money for the procedures their pets need, making them more willing to do the treatments you recommend; thus allowing you to practice better medicine and maintain practice revenues.

•Pet Insurance motivates your clients to seek wellness care on a regular basis.

•Pet owners can continue to select the veterinarian of their choice.


SELECTION CRITERIA

1. Any pet insurance company should be admitted, filed and a licensed insurance carrier within each state’s jurisdiction. Non-admitted or surplus line carriers should be avoided as costly and not as protective for the policyholders.

2. An A.M. Best “A” rating for the insurance carrier taking the risk is preferable. This rating indicates the company is financially stable.

3. Limited consumer complaints history with their state of domicile and other states. Especially important would be that no complaint required State sanctions or corrective notices or fines for the carrier and/or agent.

4. Companies should have top management positions experienced in insurance and veterinary medicine in order to understand this different market and its demographics. They should have a history of integrating the two (insurance and pet medical conditions) successfully. The reason for these criteria is that many “traditional” and “A” rated insurance companies that were very capable in their field of insurance have attempted pet insurance, but failed. These failures were due to:
•Inability to manage pre-existing conditions
•Costly and ineffective underwriting
•Lack of understanding pet claims and veterinary medicine (i.e. identify valid claims and expenses)
•Lack of access to viable pet owner marketing channels
•Excessive loss ratio of claims paid to earned premium

5. Companies need veterinary management at a high level with involvement in strategy, direction and communication of the Company, not simply providing input. Otherwise, business decisions can be counter to the best interest of pets and their care.

6. Policyholder satisfaction as verified from independent surveys of policyholders on coverage, service and reimbursement.

7. A high level of automation and robust software is a must due to larger claim volumes and low margins from pet insurance. Pet insurance has much higher levels of claims submissions, especially when wellness plans are considered where there may be 3-5 visits per year. Robust systems and integrated software cannot be underestimated as to its value for service, flexibility and efficiency. It is important to have these features in order to avoid service issues centering on non-performance due to the volume of claims.

8. Companies should demonstrate a history of community involvement for pets with programs that benefit non-insured pets and contributions to non-profit organizations helping pets.

9. A history of innovation in providing coverage and service to meet the needs of pets, pet owners and the veterinary profession are important fundamentals of a pet insurance company.


PET INSURANCE STANDARDS

1. Flat rate reimbursement of eligible veterinary expenses. Pet insurance companies should utilize an easy to understand payment formula for claims that meet every geographical area and quality of care provided. Veterinary fees vary greatly, even within the same community, due to a host of factors such as overhead, use of diagnostics, quality of care, quality of staff and facility. No set fee or benefit schedule can address this wide disparity of fees or utilization of care. A benefit schedule will not be able to take into account the many factors that influence the quality of care and final billing. In fact, when a set schedule is utilized and is far below the final billing, the veterinarian is criticized on their charges despite the quality of care or outcome. A benefit schedule is a form of managed care by predetermining fees for services and treatments. Additional benefit limits by body system, such as respiratory or neurological, as well as the diagnosis and diagnostic limits should not be permitted. Setting additional sub-limits for diagnostics are not conducive to quality care or the complexity of some diseases in obtaining a definitive diagnosis. Complex diseases, and difficult to diagnose diseases, become financially punitive for the policyholder with benefit limits and sub-limits for diagnostics. These limits can create conflict for the veterinary care provider as they try to diagnose and treat conditions where set limits greatly increase the client’s financial liability.

2. Co-Insurance and deductibles control utilization by having the insured pet owner involved in the cost of the care. Not having co-insurance or deductibles will only increase the premium cost for policies and ultimately lead to the setting of prices or controlling where the client seeks care for their pet. If the consumer of health care is not involved in partial payment for that care, they are not concerned or do not know what the costs were for their services. The result is no control on utilization or cost.

3. Quick claim payments are a must. Experience and the ability to reimburse claims in a timely and efficient fashion, avoiding delays, is a must to eliminate one of the biggest faults of human health care. In most cases with pet insurance the consumer is “out of pocket” for the veterinary care and is seeking speedy reimbursement.

4. Choice of Veterinarians is a must and cannot be compromised. Consumer surveys historically demonstrate that freedom to choose their own veterinarian is very important. Avoidance of networks or discount groups that lead to provider restriction is paramount.

5. Choice on quality of care and amount of care as determined by the pet owner and the treating veterinarian within the context of a valid veterinarian-client-patient relationship (VCPR), where the veterinarian monitors the health maintenance of the companion animal. This is another consistent and important criterion.

6. Science based coverage that conforms to the latest standards of veterinary medicine must be maintained:

a. Hereditary conditions that are a true genetic link and not simply breed predisposition. Such breed predispositions as disc disease should not be arbitrarily excluded, unless specified clearly in the policy.

b. Provide a list of hereditary conditions, if excluded, to the policyholder or if additional premium is required for coverage.

7. High Level of Policyholder Satisfaction must be routinely measured by the company and independently verified on a regular basis to determine levels of service and customer satisfaction.

8. Independent Veterinary Review of disputed claims should be available to the policyholder or treating veterinarian for pre-existing or ineligible conditions for coverage.

9. No Penalties or Restrictions on future claims, other than per incident or other limits such as annual or lifetime limits. Conditions eligible and paid in one policy term should not be ineligible in subsequent terms unless maximum limits have been reached.

10. Accept Pets of Any Age. Coverage of some type for any age of pet should be offered, especially if the pet is not ill and free from symptoms. There should be no elimination or reduction of coverage due to the age of the pet. Pets, even with serious medical conditions that might make them ineligible for medical coverage should at least be offered Accident Only coverage.

11. Guaranteed Renewal. Pets should not be cancelled due to age only. If the claims history demonstrates there was no material change in the health of the pet or material change in the risk, such as excessive claims submission, then coverage should be provided for the life of the pet.

12. Provide Wellness/Routine Care plans as part of coverage or as optional coverage to encourage routine wellness visits with broad and relevant benefits.

13. Behavior Benefits should be included to address the number one reason for disposal of pets by their owners.

14. Provide Data on the health of pets and statistics on pet medical conditions as to incident rate, cost and other factors to improve the health of pets and advance the veterinary medical profession.

15. Finally, pet insurance companies must reflect favorably, in every aspect, on the veterinary profession. It is imperative that companies providing pet insurance maintain the highest coverage levels, providing broad and relevant medical care for pets.

PRIORITY REQUIREMENTS

1. No Managed Care Principals or Restrictions
•No setting of fees; no benefit schedules
•Choice of any veterinarian for services; no networks to join or discounting of fees
•No restrictions on quality of care
•Straightforward, easy to understand reimbursement on payment of claims
•Accept pets of any age
•Guaranteed issue of Accident Only coverage

2. Superior Service
•Claim payment in a reasonable time period
•Electronic payment options
•Live phone operators, email and web-based help
•Independent customer satisfaction surveys
•Independent veterinarian review of disputes
•Minimal number of valid consumer complaints on file with Department of Insurance
•Good reputation for providing service and value

3. Highly Automated
•Automated underwriting for instant enrollment
•Automated claims management system for processing, data collection and reporting
•Secured customer data
•24/7 automated self service over the Internet
•Robust software with unlimited capacity & accuracy of data

4. Experience
•Five years or more of pet insurance experience by management team
•Veterinary experience in senior management team
•Proven ability to process high volumes of claims, manage a stable loss ratio of claims to earned premium to provide profitability & continuity of rates
•Proven ability to manage and grow a company of substantial size ($100 million or more)
•History of leadership and innovation
•History of community involvement with pets and veterinary industry

5. Proper Size of Pet Insurance organization
•Rapid growth must be serviced and managed
•Direct communications and dialogue must be maintained
•Veterinary business must continue to be vital and important to the company
•Maintain AVMA and GHLIT influence in the business partnership and direction of company. Otherwise arbitrary decisions that are negative to the profession, or not in the profession’s and/or pets’ best interest, may develop.
•AVMA and GHLIT will do an annual review for reendorsement. Penalties may apply. Review will be conducted by a selected panel of general practitioners and specialists.


Alignment of philosophy, attitudes and goals of the GHLIT with business partners as it relates to veterinary profession, pet owners and pets relative to pet insurance is essential. Without maintaining the above dynamics, conflict and differences will be unmanageable to the veterinarian

Veterinary Hyperbaric Medicine Society

We would like to invite you to attend two seminars on the new, cutting edge therapy of veterinary hyperbaric medicine.

These seminars will occur on Thursday, September 18, 2008 during the International Veterinary Emergency and Critical Symposium, Phoenix AZ.

Hyperbaric Oxygen Therapy in the Emergent and Critical Small Animal Patient
Dr. Ronald Lyman DVM, Diplomat ACVIM
The Animal and Emergency and Referral Center
Ft. Pierce, Florida

Putting Pressure on Disease: An Overview of Large Animal Hyperbaric Therapy
Dr. Dennis R. Geiser DVM, Diplomat ABVP – Equine
Professor, Large Animal Clinical Sciences
College of Veterinary Medicine
University of Tennessee

Registration is open for the 2008 IVECC Symposium

We are excited to announce a new partnership between Veterinary Learning Systems and the Veterinary Emergency and Critical Care Society that will be of great benefit to our membership. Since 1999, Veterinary Learning Systems has published a monthly publication called Standards of Care in Emergency Medicine/Critical Care. Each issue provides two articles on current topics in EM/CC. The information is up to date, practical, and presented in an easy to use bulleted format. Beginning in 2008, the articles will be written exclusively by VECCS members and ACVECC Diplomates, and peer-reviewed by ACVECC members.

We are extremely pleased to announce the following special on-line and hard copy Standards of Care subscription rates exclusively for VECCS members:

• Online rate for VECCS subscribers (US and international, including Canada and Mexico): $29.00 (Non-VECCS subscribers: $60)

• Print and online rate for VECCS subscribers (US only): $49.00 (Non-VECCS subscribers: $90)

• Print and online subscription rate for international VECCS subscribers, including Canada and Mexico: $60.00 (Non-VECCS subscribers: $100)

This subscription fee not only includes current issues for 2008, but also allows the subscriber to access all past issues of Standards of Care since its inception in 1999. This online library will provide easy access to a wealth of practical and reliable information to our membership. As an added bonus, subscribers will also be able to access other publications on the vetlearn.com website, including Compendium, Veterinary Forum, Compendium Equine, Veterinary Therapeutics, and Veterinary Technician. You will receive more instructions but be assured there will soon be a link from our web site for to you subscribe.

Dr. Dougie Macintire, VECCS Past-President, will act as the Editor-in-Chief of the Standards of Care publication, and will serve as a liaison between the VECCS and VLS while facilitating topic selection, article solicitation, and peer review of submitted papers.

We are very excited to be able to offer this special subscription opportunity to our membership. We look forward to a rewarding partnership with Veterinary Learning Systems as they help VECCS fulfill our goal of “continuing to raise the level of patient care in seriously ill or injured animals” through quality education and communication programs. Check out the Veterinary Learning Systems website at www.vetlearn.com to see a sample of their publications, and then sign up for this great subscription offer! You will find that it is easy to search for topic areas, and you will have a wealth of information at your fingertips.

We are excited to announce that the International Sepsis Registry is now a live website! This web database enables you to enter information about your septic small animal patients on a case-by-case basis as well as any serial data or follow up. The data collected will help define sepsis in small animals and will be available for research purposes by application to the registry overseers through Dr. Cindy Otto cmotto@vet.upenn.edu.

Please feel free to begin entering data at any time using these instructions:

1. Enter this URL, http://www.vetsepsis.org/vision/, in your browser. If you have not seen or used the registry yet, please select “click here to register.” Otherwise enter your username and password.

2. Accept the Terms of Use to access the database.

3. The next page will offer you a list of studies for which you can register.

4. If you have not used the database in any capacity yet, you may find it helpful to run through the Demo Sepsis Registry first. Your data will NOT be captured from this site, it is for training purposes only. If you want to do the demonstration and register to enter real case data, select BOTH the Sepsis Registry and the Demo Sepsis Registry checkboxes.

5. Complete the Account Information form on the lower half of the page and select Submit.

6. When this form is submitted, it will be checked for omissions. If the information is complete, you will be sent to the logon page. Once logged on, if you have registered for more than one Registry, you will have a drop-down menu of choices at the top right. Otherwise you will default to the only registry you selected.

7. You may now begin the demonstration or enter your case data.

If you have any questions or feedback regarding the registry, please do not hesitate to contact us via cmotto@vet.upenn.edu

We would like to thank our sponsors, The Barry & Savannah French-Poodle Memorial Fund, ACVECC, Pfizer Animal Health, and the University of Pennsylvania, School of Veterinary Medicine for their support of this endeavor.

On Thursday, September 27, 2007 a round table discussion convened at IVECCS in hopes of creating an awareness of the issues surrounding the dilemmas presented to the criticalists and emergency clinicians in every day practice. Moderating was Dr. Ira Zaslow; and panel members included Drs. Jennifer Devey, Karol Mathews, Dennis Burkett, Pam Wilkins, and critical care nurses Leslie Carter and Andrea Battaglia. An audience of approximately 15 doctors and technicians were also in attendance.

The two hour discussion focused on the theme question of "Is Critical Care Medicine Viable?” After a brief discussion of the history of critical care and emergency medicine in the veterinary profession, opening remarks included identifying the goals of critical care medicine, identifying who should be admitted to the ICU and defining considerations from which to focus the discussion. The list included:

First:
The Goals of Critical Care Medicine

- To provide specialized medical and nursing services
- To provide both routine and specialized therapy, care and treatment
- To continuously evaluate the physiological state of the patient by both routine monitoring and specialized techniques, and
- To provide resuscitative procedures

Secondly:
Who should be admitted to the ICU?

- Those patients with hematological disorders
- Those with renal insufficiency
- Those patents seizuring
- Those patients with metabolic and electrolyte imbalances
- Those patients subjected to poisonings
- Those patients with severe injuries and multiple fractures
- Those patients in respiratory insufficiency or distress
- Those patients with severe GI disturbances
- Those patients with cardiac dysfunctions
- Those patients with certain neurological disorders
- Those patients with insurmountable pain, and

Thirdly:
The Defining Considerations from Which to Focus the Discussions

- Cost
- Qualifying those patients for admittance
- Morbidity/mortality
- Euthanasia
- CPR vs DNR

The overall consensus was that the pursuit of excellence is the driving force behind emergency and critical care medicine and that this is a continually evolving process. Communication is the key and is essential to the process. The following summarizes the major issues and concerns that were identified in the discussion that followed:

- Defining the concept of informed consent under stress
- The need for an ethicist or an advocate presence in daily rounds
- A need to look at the cost-effectiveness ratio in treating low risk to high risk patients
- the need for developing a severity scoring system using evidence based medicine for admitting patients into the ICU
- Defining the use of prognostic indicators in evaluating and classifying patients
- Defining heroic measures in treating some patients
- Understanding the cost of treatment and quality of life in treating some patients
- When considering euthanasia, defining futile care, pain and suffering and the client's position in treating their pet.
- Defining the events of CPR vs DNR and the ethics of urgency vs the of ethics of common sense
- Defining what's humane and less intrusive
- Defining the need and role of a liaison person, an advocate or a triage nurse to improve doctor client relationships from the time of admittance to the time of finalization of the event.
- The need to create and utilize more support services (bereavement, hospice care/home assistant pet care support groups) for the client(s) and their pet(s) along with possible alternatives in palliative treatments.

I. M. Zaslow, DVM, Diplomate, ACVECC
Jennifer Devey, DVM, Diplomate, ACVECC