In this VETgirl online veterinary continuing education blog sponsored by the American Heartworm Society, Dr. Angele Bice, DVM reviews how to balance the care and cost for heartworm-positive patients. Please note the opinions in this blog are the expressed opinion of the author and not directly endorsed by VETgirl.
By Dr. Angele Bice, DVM, Summerville Pet Clinic, Summerville, South Carolina
Balancing Care and Cost for Heartworm-Positive Patients
Is this scenario familiar? You have a new client who has just acquired a dog, not knowing that their new best friend is heartworm-positive. The owner, who happens to live on a limited budget, is excited about their new pet, largely uneducated about canine health and completely unprepared for this kind of serious news. It is my responsibility to ensure the owner leaves my exam room with a solid understanding of the threat heartworm infection poses to their new pet’s health as well as the importance of treating the disease now and preventing it in the future. And while I always give clients my “best care” recommendations, I must also be prepared to face the possibility that owners like this one may not have the funds they need to follow them.
Here’s my approach:
Determine which diagnostics are most needed. It’s ideal to have as much information as possible about a new patient—especially one that has been diagnosed with heartworms. A thorough physical examination is one of the most important steps. Clients should also understand that a microfilaria test is a “must,” since the presence of microfilaria will affect some of our decisions. Additional bloodwork and radiographs can be helpful, especially if the dog is showing clinical signs of heartworms. However, if the dog is asymptomatic and otherwise healthy, the confirmed antigen test and microfilaria status may be sufficient at this point.
Give the client a game plan. Because heartworm treatment requires multiple steps and visits, it helps to give the owner an overview of everything treatment entails up-front. I use the American Heartworm Society (AHS) treatment calculator (heartwormtoolkit.com). Not only does the calculator provide medication dosages for the dog’s weight, but it also generates a timeline for the patient’s medication administration.
I begin talking about treatment cost at this stage, but I am careful not to be too arbitrary or to pre-judge what the client is willing to do and spend. I find it’s best to begin the discussion from the perspective that the ideal treatment protocol will be pursued—even when I know the client has serious financial constraints. I make it clear that he or she and I will work together to create a plan that will work for their pet and for them.
Choose your words wisely. It is easy for owners to feel overwhelmed at the first visit. Not only have the clients just learned their new dog has a disease that can damage his heart, lungs and pulmonary vasculature, but they are learning about concepts like exercise restriction and how the medications will work. At a minimum, the dog will be going home with a heartworm preventive and doxycycline—and if the client can afford it, a mosquito repellent as well. Meanwhile, if the dog is symptomatic, steroids will be prescribed.
While my ultimate goal is to implement adulticide therapy, I typically start pets on a preventive with known activity against adult worms just in case the owner should fail to follow the full treatment protocol with adulticide injections. However, I specifically avoid using terms like “slow kill” to avoid giving clients a false sense of security. Instead, I refer to the pre-adulticide medications as “supportive care.”
Divide the costs into smaller increments. I know the bill for the initial visit will easily range between $150 and $200 for diagnostics and medication alone. I prefer to send clients home with a full four weeks’ worth of doxycycline, but if the client is financially unprepared, I may start with two weeks’ worth and have them pick up the rest later. Ideally, we will be following the administration of a heartworm preventive and doxycycline with three doses of melarsomine. To simplify matters, I bundle the total charge for steroids, pain medications and melarsomine together, then split the costs in half so the client pays for the first half at the time of the first injection and the rest at the time of the second injection.
In my practice, I do not include IV catheters and hospitalization fees with my standard fee. While it is a good idea to include information on rare, unexpected, emergency fees on the treatment waiver, melarsomine reactions that require such measures are rare unless a medication overdose is given. Meanwhile, if your facility charges a fee for dogs to be at the clinic for the day, an alternative is to let the owner take the pet home for monitoring 30 minutes after the injection is given. I also make sure clients understand that the most critical timeframe for adverse reactions to occur is three to five days post-injection when the worms are starting to die.
When possible, be flexible. Even if the client is not financially equipped to have their dog receive the initial melarsomine injection on schedule, I advise continuing the “supportive care” in hopes that they will be able to save up for adulticide treatment over the next few months. While this may not be ideal, it is preferable to not giving melarsomine at all. I have worked successfully with clients who needed to wait until they received a tax refund or got other bills out of the way before they could proceed with adulticide treatment.
I also have had clients who could only afford one or two melarsomine injections versus the three recommended in the AHS treatment protocol. A single injection will reduce the heartworm burden by about 50%, while two injections given 24 hours apart can reduce the burden by nearly 90%. I always explain the trade-offs—that waiting can lead to further damage from the adult worms in the dog’s body and that giving fewer than three shots affects treatment efficacy. My goal is to give patients the best possible plan rather than arbitrarily positioning just one option. I also make sure the client knows we will be retesting their dog nine months after the last melarsomine injection, and that further treatment may be required if the dog is still heartworm-positive.
Maximize in-clinic efficiency. One way we keep treatment costs down while maintaining profitability in our practice is to schedule all melarsomine injections two days a month. By limiting treatment days in this manner, I can schedule approximately six dogs for each treatment date (if you have fewer heartworm patients, you can select just one day a month as a treatment date). This decreases potential waste of open medication vials and is more efficient for my staff and me. My technicians block off several hours to get everything assembled and it only requires an hour of my time to administer the medication.
The AHS provides an ideal heartworm treatment plan and timeline, but there is room to work with clients who don’t have the ability to follow all recommendations perfectly. Instead of quickly defaulting to alternatives that may be detrimental for my patients, I strive to work with individual clients to tailor their treatment plan to their situation.
This VETgirl online veterinary continuing education blog is sponsored by the American Heartworm Society, whose mission it is to lead the veterinary profession and the public in the understanding of heartworm disease. Every three years, the AHS sponsors its Triennial Heartworm Symposium—a premier C.E. event that draws speakers and attendees from around the world.
Please note the opinions in this blog are the expressed opinion of the author and not directly endorsed by VETgirl.