Adventures in Vet-Ophthalmology

An eye chart for dogs hanging in the specialist's office

The past week ushered in a surprise adventure in veterinary ophthalmology. Readers know that Humphrey is not entirely new to this type of adventure: several years ago, he developed a puzzling condition that was initially misdiagnosed as pink eye. When his regular veterinarian made a referral to Toronto’s veterinary ophthalmologist, Dr. Wolfer, Humphrey investigated fees. Just to get “in the door,” Humphrey would have to be re-tested for diagnostics, because the specialist would not accept the results furnished by the regular vet, and was subject to a steep specialist consultation. The total fee was estimated at $1,000.00. Humphrey did a little research and decided he would go to Blue Pearl veterinary hospital in Southfield, Michigan, since he was travelling to Detroit later that week. His diagnosis (blepharitis) and treatment (oral cyclosporine) totalled about $110.00 and the problem resolved.

Given that history, it’s no surprise that Humphrey is wary of veterinary fees to this day. He is reeling from the sticker shock of on day of veterinary procedures and drops: $3,000.00.

But, in an emergency situation, there’s no option for comparison shopping! This past week, Humphrey had his regular consultation because his right eye was read and sensitive. He had an immediate referral to that same ophthalmologist Dr. Wolfer, who accommodated him on a cancellation. The diagnosis this time was melting corneal ulcer, and Humphrey had to make a quick decision whether to attempt to save the eye with the recommended procedure called corneal crosslinking or CXL. That procedure involves putting riboflavin drops into the affected eye at 5 minute intervals, then shining a UVA light into the eye. The riboflavin promotes collagen production, which can speed healing. The estimate for the procedure was $1,100 for the process, $90.00 for the riboflavin, and another $300.00 for various drops to be used post-operatively. And about $700 worth of tests from his regular vet earlier that day. Plus HST.
UPDATE: Four and five days later, Humphrey didn't know whether the appearance of his eyes were normal, so he called Dr. Wolfer's office and got little insight. Upon their advice (which included "Why don't you photograph it and send that?", he sent and email and got a response from the specialist. Then, he went to his regular vet to inquire if the eye required immediate attention. The regular vet was unsure, so the vet took photos and Humphrey sent those to the specialist. The response he got was appalling. The Doctor "read your email and reviewed the photographs you so kindly included. Unfortunately photos are rarely (if ever) truly diagnostic. If you feel Humphrey's left eye is deteriorating you may want to consider having him seen prior to your scheduled progress exam." Humphrey did not respond but wondered why they would instruct him to send photos, when they are not useful. And he wondered why, given the prose description, the "specialist" would not offer specific advice beyond "suit yourself."

The moment Humphrey was out of the procedure, looking very glam-rock with tousled hair and
asymmetrical streaks of  riboflavin on his temple, cheek and ear

Humphrey is hoping for the best and that his right eye will survive. While he heals, his is satisfying his curiosity about late capitalism and healthcare costs, and the difference in costs for the same or similar procedures for dogs versus humans.  

The psychological trauma of the "cone of shame" exceeds any physical discomfort.

Let’s take a moment to contrast fees billed for Ontario humans versus dogs. In the province, OHIP (the universal, single-payer medical system) dictates maximum fees physicians and other health professionals can charge. For humans, a regular appointment with a family physician is $77.20 (though a comprehensive assessment is $144.75 for 50 minutes or $217.15 for 75 minutes. The veterinary equivalent is an appointment with a generalist or “regular” vet, and the base fee is comparable (Humphrey’s vet charges $77.90 for an “office examination and consultation” plus $156.30 for an “advanced wellness check” (the equivalent of a physical). While a human emergency room (ER) exam is $76.90, a veterinary ER exam is substantially more expensive, varying by hospital though at least double that fee in Humphrey’s experience.

Human specialist fees vary. For instance, a “normal neurology consultation” (one of the more expensive ones) is $176.35 with subsequent visits in the following six months capped at $31.00, but a special consultation of 75 minutes or longer is $300.70. The cost for similar “normal” veterinary specialist consultations (as is the case with Humphrey’s internal medicine doctor, and the ophthalmologist) are double those of humans (the going rate in Toronto is about $300.00 for a normal consultation – something Humphrey has paid to several specialists in different practices over the past year). Additional diagnostics are paid for individually, on top of the specialist consultation fee. Follow-up visits have never been less than $85 for Humphrey. Two years ago, he was urged to have a cardiac workup. In Toronto, the consultation and tests were estimated at about $1000 and with a lengthy wait (6 weeks to 3 months). At Blue Pearl in Michigan, the same workup was about $230 and could be done within days.

Frances Wolley’s October 21, 2011 Globe & Mail article, “Visit to vet an eye-opening adventure in private care,” described the ten-fold difference in the price of identical cataract surgery for dogs versus humans. In the 8 years since that article was published, little has changed. Consider the following ophthalmology fees:

Procedure	Current OHIP billing fee	Approximate veterinary fee for same or similar service in Toronto
Major eye examination and/or ocular assessment in office	$48.90 to $51.10	$300.00 for first visit, $85 for subsequent
Corneal testing (pachymetry, keratometry, etc.)	$5.00 per test	Within consult
Local anasthetic for ophtho	153.00	Within procedure fee
General anaesthetic for ophtho	150.00	Within procedure fee
Human chelation of band keratopathy with EDTA VS canine CXL for keratosis with riboflavin and EDTA	$496.00 plus anaesthetic (approximately $650)	$1,350.00
Cataract (with no complications) including retrobulbar injection administered by surgeon and including insertion of intraocular lens	$397.75 Plus $50.00 per post-op visit	$5,000.00 Plus approximately $3,000.00 for post-op follow up

No wonder the veterinary staff are grinning! That's Humphrey being brought out from his initial tests.

One other important financial consideration for health care professionals is who profits (and how much) from pharmacological dispensing. While perhaps some physicians have a stake in a pharmacy, veterinarians often dispense on their own medications – and often with steep mark-ups beyond those applied to humans for the same medications (the CBC reported on this). Humphrey usually performs price-comparisons with local pharmacies and compounding pharmacies, and has been successful in negotiating reduced medication prices from veterinarians. For instance, the cost of Caninsulin varies between $85 per case from most veterinary pharmacies, to upwards of $200 at some veterinary clinics. Accompanying needles vary in price between $19 and $50 per carton for identical or nearly identical products. Pain medications are often half (or less) the price at a human pharmacy (they accept veterinary prescriptions).

This time around, price comparisons were impossible since Humphrey had to begin medications immediately. However, it appears that at least some of the drops (most of which were $75 to $80 per bottle from the specialist) cost only about $25 from a human pharmacy based on a cursory investigation.
UPDATE: a price check before refills revealed that the  most staggering difference was Atropine 1% which is $77 from the vet, but $17 from the local pharmacy. Wow.

Humphrey in his protective "Doggles" from last year.
The ophthalmologist recommended Rex Specs (since they are a single unit) over these,
so Humphrey went ahead and ordered himself a pair. 

To be clear: Humphrey is grateful for the competent veterinary care he receives, and he strongly supports living wages for all workers (not just in health care!). He recognizes that operating a clinic is costly, and veterinarians must be fairly compensated for their education, expertise, and skill. But undoubtedly some of the fees he has experienced seem to be unjustly inflated. The College of Veterinarians of Ontario considers charging fees that are excessive in relation to what is normally charged professional misconduct, but since fees are high across the board, the examples here would not be problematic under Reg. 1093 of the Veterinarians Act.

AND ONE MORE UPDATE: The seven-day follow up revealed healing! The eye is saved, but drops and protective gear will continue for 2 more weeks and then be re-assessed.

Sources:

OHIP Physician Billing

OHIP Lab Services Billing