Money Talk: Easing the Angst

• Money Talk: Easing the Angst (616.2 KB)

Of all the challenges in veterinary practice, broaching the subject of payment for services is the one that is likely to create angst even among even the most seasoned practitioners. We are caught between the world of healing and the world of business. Many veterinarians share that their entering the profession had little to do with an interest in the business aspect of practice and much to do with the love of animals and medicine, yet conversations about money are integral to patient care, client satisfaction, and practice success.

"After all, when you come right down to it, how many people speak the same language even when they speak the same language?" —Russell Hoban

Knowing that providing healing and asking for money is an inherent component of the rendering of professional services does not automatically dilute ambivalence about it.

Our Own Worst Critic
“If you only cared enough, you would do the work without profit.”

“You’re a veterinarian; you’re supposed to be in this for the love of animals.”

These are words flung at veterinary teams by sad and fearful clients. A wide range of emotions may be triggered by a client’s implied accusation of professional insensitivity. The veterinarian may worry that clients will judge her to be “greedy” despite the fact that charging for services is an accepted part of all professions.¹

Not surprisingly, the client is also challenged by money discussions. The client may measure his own compassion by the money he is willing to spend. Clients often feel guilt, resentment, anger and fear when they are unable to care for their pets in what they perceive to be an adequate way (see I Want My Records...Now! page 12). Clients may also worry that the veterinarian and practice team may perceive them to be an irresponsible pet owner “Will my veterinarian feel that I value my dog less for questioning the fee” or “… for my reluctance to continue treatment beyond my ability to pay?”

Compounding this angst is that health outcomes have a degree of uncertainty. Anticipatory grief may be triggered and the client may feel frightened and helpless. And money is intertwined into it all. An animal may need to die because the client cannot or will not pay for treatment. A beloved dog may have a tumor that needs extensive and expensive care—all with no guarantee that the tumor will not return or treatment successful. These scenarios can lead to high emotions and can be uncomfortable for all parties involved.

One Size Does Not Fit All
Money conversations require direct and honest dialog with clients based on a foundation of trust and openness. Clients must feel comfortable enough to discuss options that meet their needs and preferences with a clear understanding of the resources required. While the onus is on the client to share this information, your skillfulness at communication is needed to encourage or discourage such open discussions.

It is also important to understand that the treatment plan ultimately chosen may not necessarily be your ideal plan. Instead, there may be some compromises to bring the treatment cost down to a level that is acceptable to the client. In some cases, the decision by the client may be voiced as, “I can’t pay for any of these options.”

This may occur despite your best attempts to offer payment options (with written estimates) and community resources to assist them. Nearly all veterinarians have had the experience of recommending a less effective medical solution and/or have euthanized a pet because the owner could not afford treatment.² No doubt these circumstances evoke reaction and emotion on the part of the client, you, and your practice team.

It is useful to try to step back from an encounter that may feel potentially distressing and consider what may be fueling the difficulty. This requires self and “other” awareness—what thoughts (especially assumptions) are going through your mind? Consider your own feelings that arise in your interactions with clients. How may your own thoughts and feelings contribute to the likelihood that the interaction will be productive or problematic? What is your client communicating verbally or nonverbally? If unsure, it is better to ask than operate from assumptions that may be erroneous.

While self-awareness is key, we also recommend a set of communication tools to help prevent, manage and address these challenging interactions with clients. These tools are demonstrated in a communication model, ADOBE.

ADOBE Model
The ADOBE model has been used for educational training in veterinary schools, in internship programs and at continuing education seminars with veterinarians in practice.⁴

Awareness
First , identify and acknowledge your own thoughts or feelings when engaging in client discussions about fees. Be aware of how you may have an impulse to behave and respond to a client in a certain way. For example, if you feel challenged by a client who is angry about the “high price,” your impulse may be to respond with a defensive tone that will only add to the tension. Instead, pause and focus on your internal messages that indicate “something is wrong.” Being self-aware and mindful will lead to discovering a more relationship-building response to the client. This often means beginning by acknowledging the difficulty of the situation and stating it explicitly.

“Mr. Smith, I can see you’re upset to hear about the cost of this surgery and I really would like to work with you to arrive at the best treatment decision together.”

Discover Client Experience
In addition to paying close attention to your own feelings and thoughts, find out what the client is experiencing. When an interaction is heading toward shaky ground, pause and pay attention. If you feel yourself getting angry, “be curious not furious.” Consider that he or she may be expecting or experiencing something very different than you think; only through asking will you find out. Be mindful of the client’s thoughts, feelings and reactions.

“Are these costs what you expected?” or, “We both want Luke to feel better AND we may have different ideas about how to make that happen. I want to work together to find a plan we both…”

Opportunity for Compassion
Expect these discussions to evoke client feelings and emotions. This is apparent through tone of voice rising on the part of a client who states, “I can’t afford this! What am I supposed to do?” Commonly, veterinary professionals may assume that a response such as, “We accept credit cards,” or, “We can refer you to apply for Care Credit,” or explaining other less expensive options will be successful.

However, if the client is starting to interrupt or repeat themselves (and getting more agitated in the process), use a compassionate statement that conveys empathy and understanding such as, “I can see how difficult it is to balance the care you want with the amount of money you have to spend,” or, “ These decisions are hard for everyone.”

Boundaries
The boundaries you set, verbally and nonverbally, tell your clients what you consider to be acceptable and unacceptable of others. To someone who keeps reiterating that the prices are too expensive, you could express your understanding, and redirect the content of the conversation: “I know you’d like it if this treatment was less costly. Perhaps, it might be helpful if we talk about some less expensive options for Jack’s care.”

For those few who will not allow themselves to be redirected, you may need to, warmly but firmly, clarify your boundaries: “I’m happy to talk with you about options to reduce expenses for Quincy’s care. However, our fees have been set with a lot of thought and we feel they are quite reasonable.”

Extend the System
Sometimes we need to reach outside the boundaries of the practice to assist a client in the fee aspects of their decision-making. There are two questions to consider, before reaching outside of the relationship for help:

1. What help is needed? (eg, financial difficulties, social and/or mental health services, etc)

2. Who can help? What are the resources? (eg, listing of community resources with contact information). This may include payment plans (if appropriate), referral to other clinics or community services (written referral materials), and/or reminding clients of their safety nets and external supports on hand. ⁵

Money talk is often an emotional yet essential component of client conversations and deserves attention, training, and expertise so that those who engage in these conversations are skilled, confident, and helpful. Consistency among the practice team is essential to uphold all billing and estimate-giving policies. Clarify within the practice and with your clients who will be available to discuss financial issues. The ADOBE framework provides one model for providing essential relationship-building communication tools to more effectively navigate through these interactions.

References
1. Talking with veterinary clients about money. Klingborg DJ, Klingborg J. Vet Clin North Am Sm Anim Pract 37:79-83, 2007.
2. Pet health insurance gains ground in North America. Rubin H. JAVMA News, avma.org/
onlnews/javma/mar07/070301a_pf.asp.
3. Difficult clinician-patient relationships. White MW, Keller V. J Clin Outcomes Manag 5(5):32-36, 1998.
4. Module 8: The Elephant in the Room. Institute for Healthcare Communication, Bayer Animal Health Communication Project, healthcarecomm.org/bahcp/homepage.php.
5. What you can do if you are having trouble affording veterinary care. The Humane Society of the United States, hsus.org/pets/pet_care/ what_you_can_do_if_you_are_having_trouble_affording_veterinary_care.html.