Why should a referral be considered too expensive?

Re: Why should a referral be considered too expensive?

Andrew Kent — Mon, 28 May 2012 20:16:30 GMT

Well then things have changed, mainly because the European residencies are much more prescriptive about this. Equally I believe that universities are getting better at customer service through pressures of the industry. Andy

Re: Why should a referral be considered too expensive?

Hannah Wynne Richards — Mon, 28 May 2012 12:24:00 GMT

If residents are properly supervised then things have changed beyond recognition

I have my doubts

Wynne

Re: Why should a referral be considered too expensive?

Evelyn Barbour-Hill — Sat, 26 May 2012 13:23:54 GMT

[quote user="Stephen Courtney"]

[quote user="Evelyn Barbour-Hill"]

[quote user="Stephen Courtney"]the private referral practices i use are extremely on the ball, very customer focussed and usually can see my patients within a very short time, or even straight away for those critical true emergencies. And you deal directly with the referral clinician.[/quote]

I should b. well hope so.

[/quote]

My point being that I did not get this sort of care from university referral centres. that's why i b. well won't use them unless i get reassurance that they are mending their ways.

[/quote]

Yes I see your point and agree....... although one or two university specialists are notable and honourable exceptions.

Re: Why should a referral be considered too expensive?

Stephen Courtney — Sat, 26 May 2012 08:09:44 GMT

[quote user="Evelyn Barbour-Hill"]

I should b. well hope so.

[/quote]

My point being that I did not get this sort of care from university referral centres. that's why i b. well won't use them unless i get reassurance that they are mending their ways.

Re: Why should a referral be considered too expensive?

Evelyn Barbour-Hill — Fri, 25 May 2012 23:15:33 GMT

I should b. well hope so.

Re: Why should a referral be considered too expensive?

Evelyn Barbour-Hill — Fri, 25 May 2012 23:11:57 GMT

[quote user="Alet Engelbrecht"]

[quote user="Evelyn Barbour-Hill"]I don't do a price list because every case is different, but I can always give a guide.[/quote]

That is precisely my point - to get a guide I will have to speak to you personally and give you all the case details.

[/quote]

Well, not all the details. And you'd have to speak to me anyway. And it wouldn't be difficult.

In your place, if there were a specialist I could never seem to get hold of, I wouldn't use 'em.

[quote user="Julie Innes"]I've recently had good experiences e-mailing our local University with queries, which has sometimes allowed me to diagnose a condition without referring. (eg I had a SBT with L-hydroxyglutaric aciduria, and got really useful info as to where to send bloods etc), and I sometimes get a second opinion on Xrays from a local orthopaedic specialist, which I find really useful in helping to make the decision as to whether referral is the way to go.[/quote]

I'd be very disappointed in any expert that didn't provide free help and advice in that way.

Re: Why should a referral be considered too expensive?

Andrew Kent — Fri, 25 May 2012 22:28:51 GMT

I disagree with the idea that by a case being managed by a resident that the standard will be lower. The format of residencies ensures that whilst a resident may be your point of contact every clinical decision will have been scrutinised and authorised by a specialist. Residents should be encouraged not avoided as they are the future of referral practice. Andy

Re: Why should a referral be considered too expensive?

Stephen Courtney — Fri, 25 May 2012 22:25:03 GMT

We are very lucky in the south east to have a lot of choice for referrals, with pretty much every specialist discipline well represented. I almost never refer to universities , appointments are hard to come by and and if it happens to be a friday/ weekend forget it.

By contrast the private referral practices i use are extremely on the ball, very customer focussed and usually can see my patients within a very short time, or even straight away for those critical true emergencies. And you deal directly with the referral clinician. i choose my referral practices based on reputation and personal knowledge of the people, and proximity. Price is sometimes an issue, some cost more than others, but I don't usually worry too much.

I also make good use of local certificate holders - not every client can manage even a 30 mile drive, so in the right circumstances i am happy to refer to anyone who can help my client more than I can.

Re: Why should a referral be considered too expensive?

Julie Innes — Fri, 25 May 2012 22:14:59 GMT

I don't really have a problem with referral fees being higher than (my) first opinion fees. The client (or insurance company!) is paying for a higher level of expertise, and often more complicated procedures (eg TPLO, hip replacement)

Ultimately, it is the client's choice. And while referral may indeed be "too expensive" for some clients, it may be reasonable and affordable for others. I have clients for whom a simple pyometra op would be deemed "too expensive"- expense is in the eye of the beholder!

I've recently had good experiences e-mailing our local University with queries, which has sometimes allowed me to diagnose a condition without referring. (eg I had a SBT with L-hydroxyglutaric aciduria, and got really useful info as to where to send bloods etc), and I sometimes get a second opinion on Xrays from a local orthopaedic specialist, which I find really useful in helping to make the decision as to whether referral is the way to go.

Re: Why should a referral be considered too expensive?

Alet Engelbrecht — Fri, 25 May 2012 20:38:43 GMT

[quote user="Evelyn Barbour-Hill"]I don't do a price list because every case is different, but I can always give a guide.[/quote]

That is precisely my point - to get a guide I will have to speak to you personally and give you all the case details. Alternatively, I need to fax you all the information and wait for your reply - waiting time for a specialist response is extremely variable. Trying to coordinate schedules to speak to a specialist is not always as easy as it sounds, my receptionists know to call me out of a consult, but they may not necessarily phone me when I am off-site unless it is an emergency. Apart from the time aspect, the client is breathing down your neck on the other side of the line, waiting to hear what's happened, because for them, every case is urgent.

I think people understand that every case is different and therefore we do estimates and not quotes, but it may help to have a rough guide for the basic things as a reference.

Re: Why should a referral be considered too expensive?

Bob Russell — Fri, 25 May 2012 16:25:04 GMT

[quote user="Mark Holmes"]

[quote user="Bob Russell"]

My general feeling is that the universities should be offering a budget version of referral as they have 'subsidised' premises, some cheap labour and want an interesting range of teaching materials.

[/quote]

If they did that there would be complaints from competing services on the "Subsidised" fees.

[/quote]

As long as the fees charged are in line with overheads and costs there is nothing inappropriate with charging less. This is a commercial world and everyone has to compete for the work out there!

I have no problem with fair competition! First opinion practice is close to being overwhelmed by it!

Re: Why should a referral be considered too expensive?

Mark Holmes — Fri, 25 May 2012 16:18:40 GMT

[quote user="Bob Russell"]

My general feeling is that the universities should be offering a budget version of referral as they have 'subsidised' premises, some cheap labour and want an interesting range of teaching materials.

[/quote]

If they did that there would be complaints from competing services on the "Subsidised" fees.

Re: Why should a referral be considered too expensive?

Evelyn Barbour-Hill — Fri, 25 May 2012 16:17:59 GMT

[quote user="Alet Engelbrecht"]Not many referral centres send 'pricelists' out. It may be helpful for first opinion vets as it is very time consuming to ring around different referral centres trying to find the 'cheapest' option for the client. Bearing that in mind that I don't always suggest the cheapest option, I would often suggest the centre that I have the best professional relationship with (i.e. who the specialists are, how approachable they are and what feedback I receive, price is a relative small factor in my consideration).[/quote]

Hmm. I would hope that the first opinion vet phones an expert they already know and trust (or at least already know of and have no reason to distrust), discusses the case, and asks for an estimate or cost guide.

I don't do a price list because every case is different, but I can always give a guide. Sometimes people who have been expecting thousands and thousands are pleasantly surprised.

[quote user="Alet Engelbrecht"]I have mostly tried to use these guys in house to get an opinion on a radiograph or to discuss a case with (alongside my own reading), but I can imagine the pressure on an impressionable new grad to keep things 'in-house' to increase practice revenue.[/quote]

Oh yes, indeed, but surely it wouldn't be the junior assistant's decision whether to refer out?

Re: Why should a referral be considered too expensive?

Bob Russell — Fri, 25 May 2012 15:59:37 GMT

Many referral centres have price lists on their websites, certainly the two local to us do!

We don't make the decision to refer or not, that is for the clients. We suggest and get an idea of costs then the owners chose. We have got a bit of price matching and working within owners budgets where necessary.

Clients don't seem overly surprised with the cost and go for it or don't.

My general feeling is that the universities should be offering a budget version of referral as they have 'subsidised' premises, some cheap labour and want an interesting range of teaching materials.

Re: Why should a referral be considered too expensive?

Hannah Wynne Richards — Fri, 25 May 2012 15:46:20 GMT

I'd second the dissatisfaction with universities relying on residents for the bulk of the clinical service

Wynne

Re: Why should a referral be considered too expensive?

David Mills — Fri, 25 May 2012 15:05:09 GMT

[quote user="Malcolm Ness"]

My conclusion is that while some vets do a good job of researching costs and quality prior to referral, a lot don't bother and go only as far as discovering whether a patient is insured. Yes= poss referral; No= no referral.

[/quote]

I agree with this, mostly, especially the latter. However, in some referral practices (esp universities) one is sometimes misled - one often ends up having the case dealt with by a resident (or, out of hours, an intern) when the 'headline clinicians' are why one referred to that particular centre and it is eminently unclear how much the specialist clinicians had to do with the case. Recently I referred a case to a university and was given 'expert' advice from someone a year above me at college 2 months into their residency. Fees were the same. This, I think, is wrong and akin to mis-selling - whilst conscious that residents/interns need to learn this should be reflected in the fees; of course this does not go for every referral centre. Indeed the local, smaller ones, with whom one can build a relationship are often the most rewarding experiences.

[quote user="Alet Engelbrecht"]

My second point - as a locum in first opinion practice, I have often been told in my 'induction' (especially larger multisite practices) about special interests of other vets and which certificate holders the practice had. This often accompanied the following, said very proudly: 'We hardly ever need to refer outside the practice'. The problem I have is this - I don't know the competency of the vets, even if they were cert holders. A lot of these guys were so-called 'self taught' surgeons, with no information about outcome. I've never seen some of them at CPDs. I have mostly tried to use these guys in house to get an opinion on a radiograph or to discuss a case with (alongside my own reading), but I can imagine the pressure on an impressionable new grad to keep things 'in-house' to increase practice revenue. A step up from the mandatory injection per consult?

[/quote]

This is not something exclusive to cert holders in practice, I fear. As Mr Ness has expounded previously few surgeons - specialists included - audit their own outcomes. I don't think you can blanket categorise this, either, as different expertise take longer to learn - surgery for instance, takes years of training, whereas dermatology is less so (although with arguably more to learn knowledge-wise) - and some are more accessible in general practice. I think that cert holders in large practices are a great asset and, arguably, if one is going to have a large multi-site practice this heightened level of expertise should be expected.

Re: Why should a referral be considered too expensive?

Evelyn Barbour-Hill — Fri, 25 May 2012 14:53:04 GMT

Just to clarify:

I said hugely more expensive, and I pondered why it is assumed that referral is impossible if funds are limited.

As jhl said, the hourly rate might be higher, but the final total could be the same (and better value).

PS I never ask, unless the client brings it up, whether there is insurance.

Re: Why should a referral be considered too expensive?

Alet Engelbrecht — Fri, 25 May 2012 14:44:36 GMT

Two points:

[quote user="Malcolm Ness"]My conclusion is that while some vets do a good job of researching costs and quality prior to referral, a lot don't bother and go only as far as discovering whether a patient is insured.[/quote]

Not many referral centres send 'pricelists' out. It may be helpful for first opinion vets as it is very time consuming to ring around different referral centres trying to find the 'cheapest' option for the client. Bearing that in mind that I don't always suggest the cheapest option, I would often suggest the centre that I have the best professional relationship with (i.e. who the specialists are, how approachable they are and what feedback I receive, price is a relative small factor in my consideration).

I understand that it cannot always be pinned down to say a TPLO will cost £x, although I had a cruciate operation done privately a few years ago and I found out before the appointment with my consultant (who I have also researched extensively) that the procedure, hospital stay for 1 night and 10 sessions physiotherapy (starting in the hospital and continuing for the next 2 months) all inclusive was £5100 (this excluded the MRI that I had prior to the procedure). I mention this price specifically as I referred a Rottweiler shortly before this for a TPLO to a vet school and the bill was just under £5k, which I found interesting. I don't think the Rottie had as many physio sessions (if any at all), nor a private room with a call button for the nurse.

Back to researching the option of referral - our practice had a fee for referring a patient. I have not been very good at charging it, because in most cases I knew the centres that I am referring to and it does not take long to write a short referral letter, print a history and hand it over to a receptionist to fax through to the centre and make a few phone calls. But, if I am to research in depth for referral after consulting hours and all ops, phone calls etc are done - how much do I charge and how do clients perceive this? This can take a considerable amount of time and presumably would be most important for the uninsured patients.

Re: Why should a referral be considered too expensive?

Malcolm Ness — Fri, 25 May 2012 14:00:31 GMT

[quote user="james herriot lied"]

I think much of it comes down to expectations and headline rates. If local referal is seen as just too expensive for all but insured cases, then either:

a) The referral practice is too expensive

b) The referral practice is in the wrong place, and needs to move to a more affluent area

c) The referral practice needs to do a better job of marketing itself locally

[/quote]

That is true, but only partly so - it assumes that the primary care vet knows all the costs/fees and also that they are able to comparing like with like. My experience suggests that only very infrequently are those conditions met.

An example - Hip replacements are expensive. Almost all (95%+) of our first side THRs are done on insured dogs. Many of those dogs will subsequently benefit from a second THR and of those approx 40% are covered (often only to a limited extent) by insurance so about 2/3 are paid for by the client. In contrast, about half of the THRs generated from our own primary care practice are insured. My conclusion is that while some vets do a good job of researching costs and quality prior to referral, a lot don't bother and go only as far as discovering whether a patient is insured. Yes= poss referral; No= no referral.

Re: Why should a referral be considered too expensive?

Mark Holmes — Fri, 25 May 2012 13:34:16 GMT

[quote user="james herriot lied"]

When dealing with solicitors, I prefer to avoid juniors on low headline hourly rates, and instead get more experienced practitioners to get involved. They have more experience, and charge accordingly, but the pay-off is that it generally takes them less time, which brings a surprising amount of parity to bills. Would that this applied to referrals.

[/quote]

How many vets actually charge on a time basis, very often its on a proceedure by proceedure basis. I have long felt that a better business model would be closely related to the time spent per animal. Take it out of the kennel and put it back and charge accordingly. Where is the logic that my time carries different value perfroming cystocentesis rather than a blood sample, taking a radiograph or even phoning the client?

In strictly economic terms a Specialist should charge more if they can. If they are busy and operating at or close to capacity expand or increase fees to put off some of the lower paying clients and make room for the higher paying ones. Insurance eliminates this effect.

Re: Why should a referral be considered too expensive?

Neil Wheadon — Fri, 25 May 2012 13:20:07 GMT

Of course it should be more than first opinion practice, after all they've funded extra CPD and put in hours of reading, auditted by the certificate, diploma they hold.

I qualified and gained experience before MRI/CT so I'm more reliant at isolating a condition down to something that I need a specialist to look at

For example in the case of collapse the heart sounds 'not quite right' so I'd rather the client spent their money getting a work up by a cardiologist and for this a premium payment is required. It means that the client doesn't pay twice and referral should be regarded as a natural extension of diagnosis.

Neil

Re: Why should a referral be considered too expensive?

james herriot lied — Fri, 25 May 2012 13:17:36 GMT

I think much of it comes down to expectations and headline rates. If local referal is seen as just too expensive for all but insured cases, then either:

a) The referral practice is too expensive

b) The referral practice is in the wrong place, and needs to move to a more affluent area

c) The referral practice needs to do a better job of marketing itself locally