Lab fees

Re: Lab fees

Rob Loxley — Sun, 25 Oct 2009 00:24:26 GMT

[quote user="Laurence Webb"]I suppose that glucose curves demonstrate that there isn't a single rule for every eventuality[/quote]

Very much so. Generally we charge lab fees at cost, blood sampling fee and interpretation/reporting fee - as seems to be the general case.

Re: Lab fees

Laurence Webb — Sun, 25 Oct 2009 00:08:11 GMT

[quote user="robloxley"]

[quote user="Mike Martin"]But I do have the impression that owners complain more about invoices that are 'over-itemised' like a car-mechanic.[/quote]

A balance has to be struck

[/quote]

Absolutely. 3 invoices for the same procedure may be

1) Blood tests £X.XX

2) Blood sample fee £X.XX; External Lab fees £X.XX; Interpretation fee £X.XX

3) Syringe £X.XX; Needle £X.XX; Swab £X.XX; Blood Tube (heparin) £X.XX; Blood Tube (EDTA) £X.XX; Blood Tube (FlOx) £X.XX; Blood Smear £X.XX; Sample packaging £X.XX; Sample Postage £X.XX; External lab fees £X.XX; Interpretation £X.XX

A balance must be struck. Our clients don't' appear to dispute seeing invoice type 2. At my last practice we used invoice type 1 and had lots of complaints about lack of value for money (despite the mark-up being so lucidrously low that it was cheaper than what we currently charge for except tests costing over £150). We've had clients who have been given invoice type 3, either from previous practices or after being referred elsewhere). They see it as nit-picky and often complain more about the fees than the costs (as they have them laid out for them to see)

To go back to the original question (is it reasonable to charge £100 to send a urine sample away) I'd say no. You can get a decent urinalysis (SG, chemistry, sediment exam, culture and sensitivity) done for £22 plus VAT. The practice is therefore taking around £65 in fees which seems unreasonably expensive to me.

Re: Lab fees

Laurence Webb — Sat, 24 Oct 2009 23:51:25 GMT

[quote user="robloxley"]However, by the same calculation a test that the lab fee is a small amount (e.g. single biochem repeat e.g. Ca: £3-4) ends up costing the client 10-15 times that amount.[/quote]If, for example, you want to charge a 100% mark-up for each lab fee you need to decide if you are losing out by only charging £6,00 to a client to interpret and act upon a lab fee that costs you £3.00. If you want to charge your professional time out at £120 per hour then that gives you 90 seconds to send the blood off, get the results, formulate your treatment plan and phone the owner up to discuss all of that. I reckon it takes about 10 minutes to do that, so I'd charge £27 to the owner, which I don't think is unreasonable although it is an 800% mark-up. A standard biochem/haem profile may cost £40, will still take around 10 mins to interpret etc and would cost the client £64 - an 60% mark-up. At our practice there is a standard charge for taking the blood sample which is charged in addition, but that takes account of the time taken at the time of sampling, not when the results come back.

In-house bloods are charged differently as there is a significant cost in the purchase and maintenence of lab equiptment.

I accept Alex's comment that the time taken to interpret complex/unusual test results may be more than that to interpret 'routine' blood tests, but as I do 1st opinion practice most of what I do is routine anyway!

At our practice we have a different charge for in-house glucoses run on a glucometer to those run on a Vet-test or sent away - it takes much less time and skill to get 1 drop of blood with a lancet for a hand-held glucometer which gives the answer in 20 seconds than it does to take a venous sample into heparin (if being run straight away) or floride oxalate, centrifuge it then run on a Vet-test taking around 10 minutes each time.

We don't send bloods away for glucose curves, but it we did we'd charge for taking the blood samples (reduced charge for repeat sampling) then 1 interpretation fee. If the glucose curve was continued overnight for 24 hours then extra charges would be levied. I don't interpret a glucose curve as 12 unrelated results, each one requiring 10 minutes consideration and therefore a seperate interpretation fee for each sample.

I suppose that glucose curves demonstrate that there isn't a single rule for every eventuality. In fact this discussion has got me condering if we should charge a small mark-up on external lab fees in addition to out interpretation fee.

Re: Lab fees

Rob Loxley — Sat, 24 Oct 2009 23:12:52 GMT

[quote user="Mike Martin"]But I do have the impression that owners complain more about invoices that are 'over-itemised' like a car-mechanic.[/quote]

A balance has to be struck. At the end of the day everything has to be charged for, but do we itemise every last blood tube and bit of cotton wool? We don't break down on the client's invoice how the blood test cost is calculated, but can explain it to the client. At the other end of the spectrum I failed miserably to get my dentist to break down the cost of my crown between even materials, diagnostics (xrays) and professional time.

Maybe one of the factors pushing more detailed breakdown is practices running tighter, automated stock control - certainly by billing each individual pack of suture material and ml of ACP used, we can very easily control stock ordering across the ?thousands of items we use.

Re: Lab fees

Rob Loxley — Sat, 24 Oct 2009 23:04:00 GMT

[quote user="Laurence Webb"]If the practice adds a percentage mark-up to external lab fees then expensive tests become more unaffordable to the client without requiring more effort or skill from the clinician.[/quote]

However, by the same calculation a test that the lab fee is a small amount (e.g. single biochem repeat e.g. Ca: £3-4) ends up costing the client 10-15 times that amount. How much does one charge in "blood sampling professional fees" for a glucose curve every 2 hours for 24 hrs: 12x what you charge for taking a sample to send off for a single test? Just some thoughts...

Re: Lab fees

Mike Martin — Thu, 24 Sep 2009 17:26:08 GMT

[quote user="alex gough"]

I would say there is more client dissatisfaction with being charged a lab interpretation fee on top of the external lab charge than an all in one fee.

[/quote]

I tend towards Alex's view on this too. As a referral practitioner, I do sometimes end up in conversation with owners about various aspect of their own vet care. (And before I go on, vets are my customers, so I tread as carefully as a I can... for a fallible human that is). But I do have the impression that owners complain more about invoices that are 'over-itemised' like a car-mechanic. They seem to pick out the small items (not the expensive ones) and moan about why that was not included in the fee for a procedure...it makes vets seem money-grabbing. I would prefer to simplify my invoices and make them look more like professional fees.

But there are arguments both ways. And like many arguments, one vet may argue in disapproval of the way another does something, but equally that person may do things that others disapprove of. Who's throwing stones.....

Re: Lab fees

Alex Gough — Thu, 24 Sep 2009 17:07:00 GMT

[quote user="Laurence Webb"]

To my mind the time taken to interpret a lab result is generally fairly standard whatever the lab fees are. Recommending action to the owner depending on the interpretation is more dependant on what the case is than how expensive the test was - it costs the same for histology to tell a lipoma from a lymphoma but a marked difference in how long it takes to talk through the implications of the diagnosis.

[/quote]

I think there is a lot of variation in this. The time taken to interpret the significance of say a PTH assay, erythropoietin, or an insulin:glucose ratio, are often more than requried to interpret a urea and creatinine, or a T4 in a cat.

[quote user="Laurence Webb"]Comparisons with drugs aren't quite the same thing to my mind as there are overheads in the stocking, and supply of drugs kept at the practice until they are required. Wasteage can be expensive especially on infrequently used items which go out of date. [/quote]

With next day deliveries, this becomes less of an issue. Is it fair that a 50% mark up is put on for example Viagra (the most expensive drug I have prescribed recently - there must be a powerful effect of hoping it works given how much you have to spend on it!) as well as a 50% mark up on say potassium bromide. I would probably spend a lot more time making sure I got the bromide dose right than I did the Viagra dose.

[quote user="Laurence Webb"]You can mark-up your vet's time as you wish, indeed that is what is being done when you charge a set fee for interpreting a lab fee rather than a mark-up on the lab charges.[/quote]

In effect, isn't the lab working for us when they perform those tests? So cannot we mark their time and costs up appropriately, as we do with drugs and our own vets?

"Ultimately is is up to you to determine how to contruct your charges, but that's the logic behind how our fees are constructed."

I don't know what the right answer is to be honest. I can certainly see the arguments on both sides. I'm just not sure I see the logic of making lab fees a special case. I have worked in practices that have done it both ways. I would say there is more client dissatisfaction with being charged a lab interpretation fee on top of the external lab charge than an all in one fee. I think if someone is hit with a standard £30 fee say on top of a £10 test, then that is probably fair enough to be irritated. However, if marking up lab fees isn't done, then practice owners will move to lab interpretation fees set at a level that make the overall income the same. This will mean that people having cheaper tests done will be relatively more heavily penalised.

Re: Lab fees

Laurence Webb — Wed, 23 Sep 2009 22:05:53 GMT

[quote user="alex gough"]

So what can we mark up and what can't we? If we can't mark up lab fees, can we mark up drugs? I didn't make the drugs. Can I mark up my vets time? They don't earn as much per hour as they bill per hour. What about a locum or an external visiting specialist? I dont quite understand why lab fees have been taken to be a special case that aren't subject to mark ups?

[/quote]

There is a difference between lab fees any most other costs though. The amount that a lab charges is not necessarily proportional to the skill required to take the sample, send it away and to act on the results. 1 expensive test may cost more to run than a biochem/haematology screen containing 30 or more results but may require less time to interpret and act on the results.

An example of this would be a fPL test at IDEXX. As a stand-alone test (or if sent there by another lab as a referral) it will cost about £35. As an add-on to a profile it costs £15 and at the moment it is being done at an introductory price of £4.95 if run with a profile. As you can get a basic non-interpreted profile done for about a fiver you end up with the situation where you can request just the fPL for £35 or run the fPL with a biochem screen for about a tenner.

Is it fair, or even good business sense, to put a 100% mark up on these tests? the fPL would be charged out at £70 + VAT to the client or you could get more information needing more skill to interpret but only charge the client £20+VAT which seems ludicrously cheap.

Assuming that it will take an average of 10 minutes to discuss a lab result and charging for that time means that the average owner pays an appropriate fee.

Comparisons with drugs aren't quite the same thing to my mind as there are overheads in the stocking, and supply of drugs kept at the practice until they are required. Wasteage can be expensive especially on infrequently used items which go out of date. You can mark-up your vet's time as you wish, indeed that is what is being done when you charge a set fee for interpreting a lab fee rather than a mark-up on the lab charges. Doing otherwise undervalues their time on cheap tests and overvalues it on expensive tests.

Ultimately is is up to you to determine how to contruct your charges, but that's the logic behind how our fees are constructed.

Re: Lab fees

Gillian Mostyn — Tue, 22 Sep 2009 13:55:59 GMT

[quote user="alex gough"] I dont quite understand why lab fees have been taken to be a special case that aren't subject to mark ups?[/quote]

From what I would think - itemising something as a 'lab fee' on the invoice would indicate that the fee is going outside the practice - when, in fact, a proportion of it isn't. Other fees, including for drugs etc, would have been assumed to have been purchased by the practice already and therefore would be expected to be bringing in an income. I suppose it comes down to client perception.

Re: Lab fees

Alex Gough — Tue, 22 Sep 2009 11:57:06 GMT

Well the powers that be, (is that RCVS or competition committee) want us to itemise as much as possible so that costs aren't hidden.

Of course if we want complete transparency, then a procedure should be charged at the hourly salary of the vet and nurse, plus every consumable, plus a charge for rental, plus charges to cover light, heat, insurance, etc etc. Then maybe on top of that an extra charge just marked "profit?"

Im not sure I really understand where we are going with this!

Alex

Re: Lab fees

Gillian Mostyn — Sun, 20 Sep 2009 12:20:24 GMT

Because the cost of the catheter is a low percentage of the overall cost, any wastage would, I guess, just mean a little less profit. Don't know whether that is correct for the business - but I would hate to get the stage where I get annoyed at my staff, or charge the clients extra, if some are wasted. I have worked at practices where the boss got a bit paranoid about wastage - even down to pulling a little too much suture off the roll. I am as concious as any owner about needlessly lost revenue, but my profit margins are plenty big enough without finding something else to worry about - we have enough already! But as someone said above, I guess it also depends on what income you expect to take.

Re: Lab fees

Clive Ansell — Sun, 20 Sep 2009 08:43:20 GMT

[quote user="Gillian Mostyn"]

[quote user="Clive Ansell"]I would normally only charge for 1 catheter, but I suppose if 3 are used they should be charged for. Someone has to pay for them one way or another. [/quote]

So a new graduate or an SVN would be more expensive for the client? They are bound to waste more...

[/quote]

Not being a business man or a manager I am not sure of the answer. I guess the fairest way is to spread the cost. if you set up 10 iv drips and use, I don't know - lets say, 12 catheters. charge 1.2 each. how do you factor in natural wastage in your costs?

Re: Lab fees

Gillian Mostyn — Sun, 13 Sep 2009 21:52:43 GMT

[quote user="Clive Ansell"]I would normally only charge for 1 catheter, but I suppose if 3 are used they should be charged for. Someone has to pay for them one way or another. [/quote]

So a new graduate or an SVN would be more expensive for the client? They are bound to waste more...

Re: Lab fees

plantagenet — Sat, 12 Sep 2009 22:27:37 GMT

Although it seems initially laudable for us to charge primarilly for our professional services, if taken to its logical extension, we will be like the private medical consultants who charge £75 - £100 for a consultation (I may be out of date) What happens to the very numerous elderly, poor or just strapped-for-cash pet owners who will no longer be able to afford our advice? "Not my concern" I can hear echoed from the rafters. Well, sorry, I feel it is mine and, if by flogging dog food and wormers and flea treatment - and, by the way, giving people the right advice about their use - I can keep my consultation charges and surgery charges affordable for as many people as possible, I will sleep easier. My solicitor and accountant seem to have the same opinion, thank goodness, or how would I afford them. It matters more to me that I am a trusted member of my community than that I can fling my head back and say "I'm a professional, respect and pay me for that!"

If the veterinary profession ever becomes really well paid, it will probably at the expense of animal welfare - perhaps those who wish to be well paid, would do well to pursue a different profession.

Re: Lab fees

Hannah Wynne Richards — Fri, 11 Sep 2009 16:31:04 GMT

On a previous thred, I mentioned how disgusted I once was with a CPD lecturer. It was a BSAVA CPD course on therapeutics, towards the end of 2006. The lecturer said that if we examined urine sediments under a microscope, we could save the client the cost of sending to a lab. I was so disgusted, I had to point out that if he charged for his time, then I thought it would be impossible to undercut the lab. He just laughed, and said he wasn't a businessman. A few of you seemed to agree with him on that occaision!!!!

What made me even more amazed that he was so ignorant of very basic practice economics was that he was a Cambridge grad from the Steele-Bodger era-he was actually taught by the man who pre-empted the Competition Commission by 40 years, and was saying what we are all now begining to realise, that we shouldn't be ashamed to properly charge for our expertise, back in the early 1960s !!!!

Wynne

Re: Lab fees

Clive Ansell — Fri, 11 Sep 2009 14:28:19 GMT

[quote user="Gillian Mostyn"]

[quote user="Clive Ansell"]The charge for an intravenous drip for example could be made up of a professional fee for the time, skill and expertise involved, plus consumables as they are used, i.e. giving set, catheter, t connector, 1 litre saline etc. [/quote]

Absolutely agree that all the above should be charged for - all I am saying is that I feel that the charge for setting up a drip, as estimated and charged to the client, should include it all from the outset. Charging 'optiva catheter', 'giving set' etc as seperate items isn't more transparent as the average owner wouldn't know what they are anyway! If you had trouble catherising, would you then charge for 3 catheters?

[/quote]

I just think our profession should be getting the message out that we should be charging more for our professionalism, and relying less on drug mark ups and peddling of antiparasite products. Giving a full breakdown of costs would highlight to the client the skill and time involved in , for example, administering IV fluids where the cost of materials is very little.

I would normally only charge for 1 catheter, but I suppose if 3 are used they should be charged for. Someone has to pay for them one way or another.

As a locum I work in many different practices and they all do things their own way, but I find more are starting to price individual items. In one OOH emergency clinic they were charging 7p for each blood tube - taking things a little far perhaps? it would take longer to price a case and write notes than carrying out the procedure! it is difficult to know where the line should be drawn.

Re: Lab fees

Gillian Mostyn — Fri, 11 Sep 2009 11:27:51 GMT

Re: Lab fees

Clive Ansell — Fri, 11 Sep 2009 06:54:35 GMT

[quote user="Ian Mostyn"]

[quote user="Clive Ansell"]

£100 for full urinalysis including; biochemistry, SG, crystal analysis, microscopy, culture and sensitivity, and prot:crea ration is not unreasonable at all

take off the VAT for a start, that leaves £86.96 with the remaing £13 going directly to captain Darling without passing go or collecting £200

External lab fees for this around £40 I guess, plus P&P, then interpreting a fair amount of results in light of clinical signs, a professional fee for your time and expertise of £30 - £50 is perfectly justified.

[/quote]

You are using the wrong labs! Urinalysis including culture can be found for less than £30 and most labs provide postage paid envelopes so no P&P. Based on £25 consult fee for 10 mins (more expensive than us), that gives 20 mins to interpret urine results. Seems a lot to me but if it takes that time, fair enough - just mark it as a seperate item on your invoice. I don't understand why people hide their charges, blaming the lab for expensive tests. If you think you deserve you time and charges, be up-front about it.

Ian

[/quote]

I agree with you, being open and honest and itemise about the fees is the right way to go. £100 is a lot for urinalysis and is more than most practices I work in would charge. That said, I do think we should all be charging more for our professional skills, expertise and time though.

To put charges in perspective; a recent appointment with a consultant dermatologist cost me £140 for a 30 minutes consultation, and a recent telephone conversation for tax advice with my accountant lasting 10 - 15 minutes generated a £40 bill

Re: Lab fees

Clive Ansell — Fri, 11 Sep 2009 06:41:26 GMT

[quote user="Gillian Mostyn"]

-suture material. Surely for most pre-priced procedures, such as an enterotomy or a cystotomy, the price of the likely type and length of suture used can be predicted and included? Only if the procedure is more complicated than predicted would it need to be added.

-anaesthetic drugs, even though a 'general anaesthesia' charge has already been levied.

-consumables charged seperately for setting up an intravenous drip - how can a practice have a 'set up drip' charge and then have to add in an intravenous catheter and giving set? Can it be done without?

[/quote]

I think it is a good idea to charge a professional fee for what we do, then add all consumables as extras. That way there are no hidden costs and a client can see on their bill exactly what they are paying for.

The charge for an intravenous drip for example could be made up of a professional fee for the time, skill and expertise involved, plus consumables as they are used, i.e. giving set, catheter, t connector, 1 litre saline etc.

Re: Lab fees

Gillian Mostyn — Thu, 10 Sep 2009 23:39:58 GMT

To give a little more information, the client showed me the invoice as she felt the total bill for the treatment the cat had received with another practice was excessive. I don't criticise other vet's fees to clients so didn't enter into any discussion about it. However, I personally felt the lab fees were excessive for what was done. I didn't go into specific details as I didn't intend to start a debate about the actual fee for external lab tests - I simply wondered how people are charging clients for external lab fees.

When I see other vet's invoices these days there does seem to be a developing tendency for added extras which actually add up to a very significant proportion of the bill. Examples can be:

-anaesthetic drugs, even though a 'general anaesthesia' charge has already been levied.

Obviously what a practice charges is entirely their decision. But most of the comments I get as regards other's fees are about the final bill bearing no relationship to an estimate given beforehand. It isn't surprising when their invoice is for 20 seperate items when the estimate is for a single procedure. Often the priced procedure will be £300 and then all the 'added extras' will double that.

Anyway, I've drifted off my own subject....

Re: Lab fees

Ian Mostyn — Thu, 10 Sep 2009 23:38:30 GMT

[quote user="Clive Ansell"]

£100 for full urinalysis including; biochemistry, SG, crystal analysis, microscopy, culture and sensitivity, and prot:crea ration is not unreasonable at all

take off the VAT for a start, that leaves £86.96 with the remaing £13 going directly to captain Darling without passing go or collecting £200

[/quote]

Ian

Re: Lab fees

Laurence Webb — Thu, 10 Sep 2009 22:50:10 GMT

[quote user="Clive Ansell"]

£100 for full urinalysis including; biochemistry, SG, crystal analysis, microscopy, culture and sensitivity, and prot:crea ration is not unreasonable at all

[/quote]

Gillian - what tests were undertaken, as this influences whether they are 'justified' or not? £20 of lab fees charged out to a client as £100 is a bit diffferent to £80 of lab fees! I'd also be interested to hear if the clients thought they had good value for money or not.

At our practice a voided urine sample sent away for analysis would incur charges equivalent to a standard consultation (we asume that it takes around 10mins to read the results and decide what to do inlight of the findings) plus the lab fee.

If we took the sample, whether by walking the patient around the car park, squeezing its bladder or performing a cystocentesis an appropriate fee is charged. Samples that require special sampling techniques (eg blood cultures) or handling (eg frozen samples with guaranteed delivery by 10-am) are charged extra. Interpretation of results is a standard fee.

It doesn't take me significantly more time to interpret a comprehensive bichem/haem/endocrine profile than it does a more limited profile. Indeed, although the lab fees will be less, it takes me considerably more time and head scratching to work out what to do with only a handful of results than a comprehensive data base.

The key issue is whether it it is right to charge a % mark-up on lab fees compared to a standard charge for sending a sample away and interpretating the results.

Re: Lab fees

Clive Ansell — Thu, 10 Sep 2009 19:01:56 GMT

£100 for full urinalysis including; biochemistry, SG, crystal analysis, microscopy, culture and sensitivity, and prot:crea ration is not unreasonable at all

take off the VAT for a start, that leaves £86.96 with the remaing £13 going directly to captain Darling without passing go or collecting £200

Re: Lab fees

Holly Lee — Thu, 10 Sep 2009 15:59:02 GMT

Likewise we have a fee for obtaining sample, charge lab fees to the O as they're charged to us and add an interpretation fee all invoiced separately. In theory interpretation fee should probably be different for different tests as it takes longer to interpret a full biochemical blood screen than a negative faecal sample for example but since this isn't really practical to charge on a time basis we have a single interpretation fee for any test. Agree this helps the client see what is what. Internal lab fees are charged differently with interpretation being included in the cost of running the test and invoiced as one thing.

Re: Lab fees

Toby Birch — Thu, 10 Sep 2009 13:45:51 GMT

I may be wrong , but I was under the impression that you could not put a mark-up on work that you had not actually done. i.e. lab fees had to be charged at the cost price because the work was not actually being done by the practice itself. Obviously there is practice time, effort and costs involved and so this is why the sample/submission/interpretation fees are charged. Under RCVS guidelines this can be almost whatever the practice wishes.

As I said, I may be wrong.