With experience in both 503A pharmacies and 503B outsourcing facilities as a veterinary practice management consultant, Debbie Boone brings her expertise to Epicur Pharma’s Advisory Council. Our team recently got to talk with Debbie about how saving money on compounded medication is not really a bargain, and how this impacts veterinary clinics.
Thank you for joining us today, Debbie. Tell us about your work in consulting and with Epicur.
Originally, I was on the advisory board for Stokes Healthcare, and now Epicur Pharma. Outside of the advisory council at Epicur, I am a practice management consultant focusing mostly on team communication and improving culture. I managed AAHA-accredited hospitals for 23 years, but I’ve been consulting since 2005. I work privately with clinics to help them with their systems, marketing, team communication, human resources, and other general business needs. I’m also a speaker on the national speaking circuit and have spoken at all the major conferences. I’ve written for magazines as well, and I had a column for a couple years. Most of the content I write has to do with communication, the operations of a practice, inventory control—or lack thereof, making wise decisions with pricing and technology, and general practice efficiencies.
In your work with Epicur, are there particular areas that you’re engaged in advising?
I’ve helped them see the practice manager’s role in purchasing and what goes on in the back side of the hospital. When you look at Epicur and the quality of the medications that they manufacture, there’s a big safety net there. I don’t believe that clinics typically understand the differences in how an FDA manufacturing plant works as opposed to the local compounding pharmacy. There’s a gap of knowledge. I’m the one who helps acknowledge that gap and works to inform the managers. Practice managers have been trained to look for the best deal for a certain drug and buy it. If a drug is equally safe, equally consistent, and manufactured in an FDA plant where there are rules and regulations, then this works well. However, the regulations are different when it comes to compounding, and I don’t think that most managers really understand there is a difference.
Do you see those clinics changing how they make prescribing decisions and where they source medication?
When you’re working with specialists, especially oncologists, they are very particular about where they are getting medications for their patients. This is because they realize that consistency of dosing is vital. Incremental changes can make vast differences in outcomes. I see that specialists and veterinary professionals who are hyper-focused on very difficult cases almost always go to Stokes or Epicur for their products. Other general practitioners are likely using some more common generic ointments or drugs.
What are the challenges that you’ve seen this year, and are there any trends?
The majority of hospitals are performing curbside care because of COVID-19. The clients are staying in the parking lot in their cars and their pets are transported in and out by staff members. All our normal systems are broken, and our typical workflow routines have been changed, so we’re taking much longer to do work than we have in the past. Sanitation has dramatically increased, but there have still been multiple cases in hospitals where somebody was exposed to COVID-19 by a client or a team member. It has been very difficult for animal hospitals to get into a flow again, although it is getting better. Another challenge is that people—veterinary hospital staff and clients—are tense and emotionally stressed. When 100% of the people are in a stressed-out state, it creates more conflict to overcome.
Veterinarians are doing their best to release tensions by making curbside care easier for clients and patients. By using apps that allow for text messages and forms to be sent and pictures to be shared, communication is improved. Telemedicine is a great way that veterinarians are combating client stress because they can assess the pet’s situation digitally, and the patient is examined while the client observes over video. This can also be done from clients’ homes. It also means that no human has to come into contact with each other, and greater safety precautions are taken.
With curbside care, do you see a greater propensity to increase in-house dispensing? How does that change some drug supply chains?
With curbside care, there has been a big shift to dispensing through online pharmacies. There’s been a big uptick in outsourcing pharmacies like Chewy, Pet Meds, and Pet RX. Clients don’t want to leave the house, so they are looking for ways to get their medications delivered. Hospitals are looking for ways to become more efficient because other systems have slowed down and utilizing online pharmacies for dispensaries helps them keep clients from making extra trips to the practice.
Does that decrease in revenue cause harm to the practice?
Many practices view it one of two ways: either dispense the medication at a lesser price and take a cut in revenue to utilize their own online pharmacy or lose the sale completely and gain nothing by scripting it out. I think they have taken the lesser of two evils, and decided they are going to go through their online pharmacy provider, when necessary, to satisfy the client.
These online pharmacies can mean a risk of quality, right? What is your advice?
My advice is to fight it with education. It’s a conversation that takes time, and when time is of the essence, it’s harder to allocate the limited amount of time veterinarians have to this conversation. The rest of the team can be leveraged if they are trained. The easier route is to just write the prescription or approve meds from an online pharmacy, but quality can be a concern. Specifically, there are counterfeit products on the market that have slipped into the supply chain. Even the FDA had a Buyer Beware brochure on their website for many years about buying from non-VIPPS-approved online pharmacies. You don’t always know the origin of these products, how they were stored, if they are real, or if they are about to expire.
Where do you think veterinarians’ biggest opportunity is right now to increase margins?
I would say through unique products or services that can’t commonly be sold anywhere else. Long-acting injectables, when appropriate, have good profit and eliminate the problem of poor owner compliance. Diagnostics are also an important workflow change. There are practices that typically don’t do preventative diagnostics like blood panels; instead, they find an issue and then do diagnostic workups. It’s smarter for practices to perform preventive screenings on all animals at their annual visit. It certainly is a boost to margin, but it also helps with early disease detection, so it’s beneficial to the pet, the pet owner, and the practice.
Is there an 503B education wave coming?
I certainly hope so. With the pandemic, millions of people have adopted a pet. What is going to happen when we return to work, and these animals have been at home with their owners the entire time? Is there going to be separation anxiety in the pets when they are home alone for the first time? Are the owners going to find they no longer have time for the pet or can’t afford it and shelters fill up again?
The other thing that’s interesting is the differences between generations. Generation Z, which is the newest generation after millennials, are pet owners who are looking for a great deal of education online. They want to be a great pet owner, but the concern is they might be looking in the wrong place for advice. It’ll be an interesting shift from older to younger generations as the “Z’s” are debt averse. Generation Z is more focused on subscription models and installment payments for products and services than prior generations. If veterinarians are not embracing things like wellness plans, split payments, and installment plans they are going to lose opportunities.
What about technology? We know telemedicine is growing; are you seeing other technology advancements?
Most veterinarians embrace technology for in-house things like diagnostics and X-ray machines, but we are losing out on the management technology tools. Practices have a lot of phone calls coming in right now, especially with having to talk to clients who are in the parking lot. On average there are 5-10x the calls we would normally have. There’s technology that we could be utilizing through text messaging or websites for new client and patient history forms that would save us a lot of time.
There are also workflow optimizations, such as speech recognition tools for charting. This would almost triple the speed of charting notes, creating far more efficiency by using “talk to type.” There are other tools available that take temperatures, heart rates, and respiration rates remotely through Wi-Fi by pointing a device at the patient rather than having a technician physically go into a cage. To have this information instantly recorded in the medical chart saves an enormous amount of time. This also adds the benefit of reduced anxiety in animals who are nervous around strangers.
We have all these little incremental time-savers, but adoption has been fairly slow. Telemedicine is a big opportunity for veterinarians. Vets who are immunocompromised and can’t be in the workforce during this time could still give advice and could still drive revenue by working from home. There are so many moving parts and the technology moves so fast, the downside is that it’s hard to keep up. With a predicted veterinary shortage by 2035, we must learn to use technology to leverage the people that we have to meet the needs of our patients.
What positives do you see on the horizon?
One thing I think will change things dramatically is the increase in corporate veterinary groups. There are more than 60 right now, when five years ago there were only about 30. The increase in corporate medicine is going to give us better systems. Corporate medicine understands profitability better than most independent veterinarians. I think that they will capture fees appropriately because they have more backend experts to calculate true cost of products, services, and time studies. There’s real business-science behind veterinary medicine, which the corporate entities are trying to capture. They have learned that their role is to manage the backend of the business while letting veterinarians practice quality medicine. Their downfall is the notion of cookie cutter medicine and sales quotas can be off-putting to doctors who like autonomy. I do see many positives in staff salary and benefits with a larger group.
How does Epicur play into this?
There is always going to be a group of pet owners that values quality and safety over price. Getting more people to understand how Epicur produces products, the great safety involved in it, and the standardization involved in it, will encourage practices to choose that standard of product. If there are cost concerns, veterinarians have the information to share with their clients about the benefits to their pets. Many veterinary hospitals fail to share enough client education on “what makes them different.” We are not constantly informing our clients and teaching them about these nuanced aspects of pet care.
Anything else you wanted to share with us today?
One last thing that comes to mind is the importance of making less inventory decisions. In the past I have seen practices spend an enormous amount of time working to save a nickel only to end up spending $1 of labor time researching the savings. It is critical to find a trusted supplier with consistent quality and purchase from them. We expect the same thing from our clients when they state that we are too expensive, but we know that we’re reasonable for the quality that we offer. It’s about educating those clients to see the difference between price and value, and this is the same solution to the problem with veterinarians and 503B knowledge.
Thanks for making time, Debbie!
Looking for tips and education on how to navigate the challenges this year brought to your practice?