In a perfect world, every client would have the financial resources to provide all of the care that their pets need. Unfortunately, we don’t live or practice in a perfect world! Every client experiences periods of financial stress. Sometimes, it seems like all of our clients are under financial strain at once.

When a client can’t afford all the care that their pet needs, your job is to provide information. Clients are free to make their own decisions regarding which items on the treatment plan to consent to and which items to decline, but you can provide information to help them select those treatments that are most valuable for their pet.

A General Framework for Preventive Care Priority-Setting

The first preventive care priority for healthy pets is rabies vaccination. This core vaccine is typically required by law and not having an in-date rabies vaccine can have a number of serious consequences. If a client can afford a rabies vaccine but not a physical exam, you may be able to administer the vaccine without charging for an exam (depending on your practice’s policies). If this is not an option, consider referring the client to a location that is able to do so.

After the rabies vaccine, the next area of focus is the physical exam. An exam allows you to assess the pet’s medical condition and talk to the client about individual risk factors. Your physical exam will help you determine what other care is recommended and provide you with an opportunity to explain that care to the client.

Core vaccines are typically the next priority, after rabies vaccination and a physical exam. The DAPP vaccine in dogs and the FVRCP vaccine in cats protect against serious diseases that pose a risk to pets. Core vaccines are regarded as more important than non-core vaccines, which typically protect against diseases that can be prevented by a change in lifestyle.

In my part of the country (North Carolina), I consider heartworm prevention in dogs to be nearly as important as core vaccines and typically prioritize heartworm prevention over non-core vaccines. Obviously, this may vary depending on where you live, but I would rather see my clients administer heartworm prevention than get a Bordetella vaccine, because I can treat Bordetella much more easily than I can treat heartworms! If you live in an area where heartworms are less common, however, you may prioritize non-core vaccines first, then focus on parasite preventatives. There’s honestly no right or wrong answer to this, as long as you can walk the client through your logic and the risks to declining either option.

Finally, there are diagnostic tests, such as intestinal fecal parasite exams and wellness bloodwork. I consider fecal parasite exams very important in pets that aren’t receiving heartworm prevention, but less essential in dogs receiving heartworm prevention that protects against hookworms, roundworms, and whipworms. While wellness bloodwork is certainly valuable, it’s often my lowest priority when seeing a young, apparently healthy pet whose owner has financial constraints. If the pet has physical exam abnormalities that suggest a possibility of intestinal parasites or metabolic disease, however, these lab tests may become more of a priority!

Case Study: Fluffy, a pampered Maltese

Fluffy is 3-year-old Maltese that lives almost entirely indoors, with brief forays into a screened porch. She eliminates on a potty pad, is never boarded, and is groomed by her owner. There are no other pets in her home. Fluffy has always received all of her recommended preventive care on schedule, including monthly Trifexis^®. Unfortunately, her owner has recently lost her job and therefore has limited funds available today.

You perform a thorough physical exam and note that Fluffy does not have any significant health problems that need to be addressed at this time. She has very mild dental calculus and the remainder of her exam is within normal limits.

In reviewing Fluffy’s preventive care, you note that she is up-to-date on her rabies vaccine. Given that she never leaves her home or interacts with other dogs, you recommend discontinuing her Bordetella and leptospirosis vaccines; the owner agrees to this recommendation.

You tell her owner that you would prioritize her remaining preventive care as follows:

1. DAPP vaccine
2. Heartworm test & refill Trifexis^® (or discuss alternatives)
3. Intestinal fecal parasite exam
4. Wellness laboratory testing (CBC, serum biochemistry)

Fluffy’s owner authorizes the DAPP vaccine and heartworm test today, but elects to switch Fluffy to Interceptor^® instead of continuing Trifexis^®. She says that she will return for flea prevention, a fecal exam, and wellness bloodwork at a later date, when she has the funds available.

You are okay with a brief lapse in flea prevention, because you know that Fluffy primarily remains indoors. You are also okay with postponing the intestinal fecal parasite exam, because she receives heartworm prevention on a monthly basis. Finally, there are no exam findings to suggest that wellness bloodwork is an urgent need at this time.

Case Study: Felix, an outdoor cat

Felix’s owner describes him as “a scrappy guy” and often sees him fighting with other neighborhood cats. He comes indoors occasionally, but lives mostly outside. Overall, he has been doing well at home. On physical examination, you do not note any obvious health problems.

Felix’s owner recently moved to your area and does not have any prior vaccine records. He says that Felix received vaccines when he was younger, but it has been at least five years since his last veterinary visit.

You present Felix’s owner with an estimate to update all of his preventive care. The estimate includes an exam, rabies vaccine, FVRCP vaccine, FeLV/FIV test, FeLV vaccine, intestinal fecal parasite exam, wellness bloodwork, and heartworm/flea prevention. Felix’s owner looks over the estimate and immediately states that he cannot spend that much today. He asks you what is most important to do during today's visit.  

Based on Felix’s lifestyle and exam findings, you prioritize your recommendations as follows:

1. Rabies vaccine
2. FVRCP vaccine
3. FeLV/FIV test & FeLV vaccination
4. Heartworm/flea prevention
5. Intestinal fecal parasite exam
6. Wellness laboratory testing (CBC, serum biochemistry)

After a thorough discussion of why you would prioritize his care in this manner, Felix’s owner authorizes only the rabies vaccine and flea prevention. You again explain the risks associated with infectious disease and why you would prefer to administer his other vaccines, but Felix’s owner is primarily concerned about Felix bringing fleas into his home.

You perform the rabies vaccine and send home flea prevention. You also send home an estimate for an FVRCP vaccine, FeLV/FIV test, FeLV vaccine, intestinal fecal parasite exam, and heartworm prevention, realizing that Felix may or may not return for these services.

Priority-setting depends upon the individual pet

While there are some sweeping generalizations that you may adhere to in most cases (for example, core vaccines are typically more important than non-core vaccines), how you prioritize care is often specific to each patient.

All of the care that you are recommending is important, otherwise, you would not have recommended it. However, the relative importance of each item on the treatment plan is largely a function of the pet’s lifestyle and your exam findings.

Document everything

Any time a client declines a recommended service, you need to document it. Your medical records software may provide you with an easy way to do this, by crossing items off on the treatment plan or marking them “declined”. If this is not the case, however, ensure that you put detailed notes in the medical record that list every service that was recommended and declined.

Don’t take it personally

In some cases, it’s easy to come to a compromise that works for the client’s budget while also leaving you comfortable with the level of care that you were able to provide. Those cases are a win and should be celebrated!

In other cases, however, you may feel frustrated. Clients may authorize services that you consider low-priority, while declining other, more-important treatments. All you can do in these situations is reiterate your recommendation, document the declined services, do the best that the client will allow you to do, and move on to the next patient. Learning not to take these cases personally and brush off the frustration will go a long way toward improving your job satisfaction as a veterinarian!