How Medical Ratios Support Best Medicine – Every Time

by Stith Keiser / August 2, 2018


We hear a lot about the importance of practicing “best medicine.” Conceptually, many of us would agree that practicing best medicine is, in fact, best. Even so, the question lingers, how do we do it in the real world and how do we measure it?

To help our practice teams reach their full potential in delivering quality care to every patient, every time, the first hurdle we must overcome is the mindset that our clients can’t afford, or don’t want to at least be given the choice to decide, what’s best for their pets.

If you think you practice better medicine than most, you’re not alone

I was recently speaking at a conference where I asked a room of practice owners to raise their hands if they felt like they practiced above-average medicine. Not a single hand remained down!

The idea of average is that it represents the masses, which means that I was either surrounded by exceptional owners (which is possible), or that some were overestimating their quality of medicine. After all the hands went up, I asked: “How do you know you’re practicing better medicine than everyone else in town? Or in this room?” I received a lot of stares, but no real answers.

Several years ago, we — one of AAHA’s VMG groups — decided it was time to figure out how to answer the above question. We spent several years analyzing the data we reported to determine which metrics and benchmarks most accurately portrayed the level of medicine we strove to practice with our teams.

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Understanding the value of metrics and benchmarks

Within our research group we utilized some of the standard, national benchmarks, such as revenue centers, expense centers and Key Performance Indicators (KPIs), like Average Doctor Transaction, Average Client Transaction, Gross Production per DVM, among others.

Though I still find these benchmarks useful, one of the issues I have with them is that they are often reported as national averages, and while they can reflect the level of medicine we practice, there is not always a direct link.

frenchie dog at the vet getting the best medicine Benchmarks may be useful, but they are often reported as national averages, and while they can reflect the level of medicine we practice, there is not always a direct link. Click To Tweet

To help solve this problem, we created a new set of KPIs in the form of ratios to truly help us measure thoroughness and quality of medicine. The ratios we track are based on four centers: nutrition, dentistry, laboratory and imaging. I’ll explain the concept of ratios soon, but for now, let’s explore the four centers.

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The role nutrition plays in delivering best medicine

Roughly 75% of the money that people spend on their pets is at pet stores. While we support pets being spoiled (to a point!), why do we allow our clients to spend their money on things such as highly sugary treats, mediocre food, and bones/chews that have large amounts of calories in them? Why do we not discuss the benefits that our nutritional supplements, e.g. vitamins and joint protectants, have to offer young, growing kittens and older dogs respectively?

Pick a line of diet products you and your team believe in and present those to your patients. Almost every patient has a specific need that we can address with diet – from joint, to teeth, to heart, even to liver. These diets are supported by us and their manufacturers to provide what they promise. Why would we not want our pets to be on this quality of care food instead of over-the-counter nutrition that does not support individual needs?

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The importance of preventative dentistry

Dentistry may be easy to discuss when a patient has a rotting tooth or a tooth root abscess but what about preventative measures? We know how important dental health is to our patients, but do our clients?

An oral cleaning when a patient shows only grade 1 or grade 2 symptoms is less expensive for the owner and less traumatic to the pet. Don’t wait until a pet’s teeth are falling out to recommend a dental. Start having that conversation about dental diet with the Yorkie owner, for example, as soon as she comes in as a puppy. Proper dental care is an easy solution that prevents patients from developing kidney, liver, heart disease, and nasty breath.

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Why the laboratory ratio is invaluable

The lab ratio includes fecals, UAs, HWT, ear cytologies, cytologies, FIV/FeLV and obviously blood work. Very rarely should a patient enter our doors without at least one of these diagnostics being performed.

Parasites are easy to control, Lyme disease can be treated, and kidney insufficiency and thyroid can be caught early to slow down the progression of severe disease. Remember, every patient over the age of seven (and even some as young as five or six) is showing signs of becoming geriatric. Senior blood work, as well as non-senior blood work, not only gives us a baseline but allows us to catch concerns early.

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Imaging is just good medicine — period

Unless you’re blessed with x-ray vision, you owe it to your patients and clients to get a good look at things you can only speculate on without an x-ray.

Now that we’ve established the center we measure to gauge our quality of medicine, let’s talk about the ratios themselves.

The purpose of ratios and how to use them to support best medicine

The purpose of ratios is to determine how well your entire veterinary team is doing when it comes to educating clients and recommending best medicine. Click To Tweet

The purpose of ratios is to determine how well your entire team is doing when it comes to educating clients and recommending best medicine. As a result, you want a number that reflects not just the opportunities your veterinarians have, but also opportunities your staff have.

With that in mind, we determined it would make best sense to use the number of invoices for any given period as our denominator. The equation looks like this:

Ratio = total revenue for a chosen center (nutrition, dentistry, laboratory, radiology) for a given timeframe (most of our practices run this weekly and monthly) divided by total number of invoices across all services.

To put some context around this, I’ll use a real example from a three-doctor, companion animal, general practice in our group. This example is based on one month’s worth of data:

 

Center Revenue Total Invoices (opportunities) Calculation Ratio
Nutrition $2,289 375 $2,289/375 6.1
Dental $120,803 375 $120,803/375 322
Laboratory $27,564 375 $ 27,564/375 73.5
Imaging $1,424 375 $1,424/375 3.8

 

You’ll notice that I did not assign a dollar figure to any of the ratios. While dividing total center revenue by total number of invoices does give us an average dollar spent per client, we simply want to use that number as a benchmark for how well our team is doing when it comes to educating clients and recommending best medicine.

It’s easy to look at a chart, but what is actually behind the data? Let me provide a real-world scenario to demonstrate how various medical philosophies impact ratios.

Candy is a nine-year-old SF Maltese with a one-week history of ADR. For various reasons, obtaining a clear history from Candy’s owner is difficult. (Background: This owner had to euthanize their Daschund a while back after a ruptured disc in his back.  The owners elected to do back surgery, however, a poor outcome left the dog paralyzed and they were faced with a difficult decision. This experience is still in the forefront of the owner’s mind)

Let’s see how three different doctors approached the situation with Candy and her owner:

Dr. A:

    • Performed a complete physical exam and observed discomfort in Candy’s mid-abdomen/lower back area.  ​
    • Relayed the need to for radiographs in order to understand the cause of the pain. The owner consented. ​

 Dr. B:

    • Performed a minimal physical exam and found pain in the mid-lumbar area.  ​
    • Suggested radiographs. The owner declined. Pain medications were dispensed.  ​

Dr. C:

    • Performed a minimal physical exam and found pain in the mid-lumbar area.  ​
    • Diagnosed Candy with back pain.  ​

Let’s take a look at the three outcomes:

Dr. A:

    • X-ray showed several stones within the urinary bladder.  Full bloodwork, urine analysis, urine culture and bladder surgery were performed.
    • The patient recovered uneventfully and has remained stone-free on RC Urinary SO.​

Dr. B​:

    • Candy started urinating blood the next evening. The owner rushed her to the local ER where bladder stones were diagnosed and removed via bladder surgery.
    • Client confidence in Dr. B was lost and Candy and her owner never returned. ​

Dr. C​:

    • Candy was euthanized because of a fear that was instilled in the owner after their experience with their Daschund.

In this scenario, Dr. A generated a total revenue of $2,000 from this one ‘opportunity.’ Dr. B and Dr. C each generated a total revenue of $120 from a single interaction. As discussed, though, it’s not about the money. What’s important is what the ratios tell us about the quality of care and the final outcome. Dr. A’s quality of care and ability to communicate with the client resulted in a positive, healthy outcome for Candy. Dr. B’s quality of care led to an emergency situation and cost the clinic not only Candy’s owner, but probably several more through negative word of mouth. Dr. C’s quality of care caused a worst case scenario, especially in this case because it was truly driven by thoroughness of care.

veterinarian giving the best medicine

Ratios aren’t about the numbers themselves.

They’re about the quality of care behind those numbers.

I realize there will be some “opportunities” tracked through invoices that are not true opportunities for our four revenue centers. For example, there may be a doctor coded to an invoice when it should have been coded to the hospital. However, I can assure you that tracking these ratios will demonstrate room for improvement from the whole team. As veterinary professionals, we’re not here to push unnecessary diagnostics or nutrition recommendations, but we are here to offer best medicine — to every patient, every time.

I’ll delve into more detail on each of the ratios we’ve covered in upcoming posts. For now, take some time to reflect on how your team defines ‘best medicine’ and consider the role ratios might play in helping you measure how well you’re delivering on our mission.


Stith Keiser is the Chief Executive Officer for Blue Heron Consulting. He and his team of veterinarians, hospital owners and managers coach new and seasoned practice owners alike to improve their lives and the lives of their team members while simultaneously enhancing client experience, building sustainable practice profitability and elevating the quality of care for pets. You can reach Stith at skeiser@bhcteam.com.

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