Aaron Smiley.

Photo by Erin Lenardson

Dr. Aaron Smiley, a small animal practitioner in Indiana, says veterinarians should be trusted to decide whether it's necessary for a given new patient to be seen in person before being treated or whether the issue can be addressed via telemedicine. He's pictured with his dog Bonnie.

The veterinary profession spawns new advocacy organizations all the time. Few, if any, have made as big an impact in a short time as the Virtual Veterinary Care Association. Founded in 2020 to push for expanding telemedicine, the VVCA quickly achieved a high profile and scored major legislative gains.

The group is best known for lobbying to ease state rules that require practitioners to examine their patients in person in order to establish a veterinarian-client-patient relationship. A VCPR is needed to make a diagnosis and prescribe treatment in most U.S. states. The rationale is that, unlike people, nonhuman animals cannot tell doctors how they feel, so a hands-on exam is necessary.

As of Aug. 1, veterinarians in Arizona no longer need an initial in-person exam to treat a pet under a law spearheaded by the VVCA. That bill passed with near universal support in the Legislature. The group is also hard at work in California, where the Assembly unanimously passed a bill that would give veterinarians the discretion to establish a VCPR without a hands-on physical exam first. That legislation could reach the floor of the Senate in September. 

Its stance puts the VVCA at odds with the American Veterinary Medical Association and many state VMAs, which oppose efforts to eliminate the in-person exam requirement.

A founding board member and co-chair of the VVCA board of directors, Dr. Aaron Smiley contacted the VIN News Service in June, arguing that a story describing the organization as a lobbying group failed to capture the breadth of its work. Curious about the young, influential group, VIN News invited Smiley to elaborate.

A self-described telemedicine expert who practices small animal medicine in Indiana, Smiley joined the VVCA early on. He was asked to be on the board by Mark Cushing, CEO and founder of Animal Policy Group, a consulting firm, and Dr. Audrey Wystrach, founder of Petfolk, a chain of brick-and-mortar, mobile and telemedicine services in four states. He described the group as their "brainchild."

Smiley didn't always have answers about the nuts and bolts of how VVCA runs, but he shared his perspective on veterinary telemedicine, the VCPR debate and the need for change.

The following is excerpted from interviews that took place by phone and email over several days.

How did your connection to the telemedicine conversation start?

My connection to the conversation started through the Indiana Veterinary Medical Association. It was on the radar screen like, "OK, how does this affect our members in the state of Indiana?" [Smiley was an officer for the IVMA from 2014 to 2021 and served as president in 2020.]

I thought from the very beginning that this conversation was fascinating, because I started practice as an equine ambulatory practitioner. I was like, "Well, guys, this is much to-do about nothing, because if you're an equine ambulatory practitioner and you don't engage in telemedicine, you don't have a job."

That raises an important distinction. There's the discussion of the VCPR, whether it can be established remotely, and then there's the discussion of telemedicine, folding it into your practice. They get kind of combined.

They do. In Indiana a couple of years ago, we had a forum to talk about the virtual VCPR. When we talked about it, the argument quickly started to morph into telemedicine. There were practitioners that stood up and said, "Gosh, I just don't feel like doing any type of medicine remotely is appropriate." And my response was, "OK, but that's not what we're talking about." The only thing that there is dissension or disagreement [about] inside of organized veterinary medicine is this remote establishment. I don't know if there's any facet of organized veterinary medicine that is anti-telemedicine. But it gets convoluted.

Are you surprised by resistance in the profession to remote establishment of the VCPR?

No, not a surprise at all. Change is difficult. I'm encouraged that the profession is willing to have a conversation inside of the profession. I think where we as veterinarians get behind the eight ball … is when we're all in lockstep and outside of what our clientele or the public at large desires. I view it as a wonderful endorsement of how open as veterinarians we are to disagree with each other. For us to bring this to the forefront and discuss and argue amongst each other before the public pushes it proverbially down our throats is so much better because then, as veterinarians, we stay in control of the argument.

What do you think the concerns are about the virtual VCPR? What are the objections you need to address?

I would say there's a traditional argument: Nobody knows how it's going to work out because it's new. You make all the best-laid plans to get to the moon, but until Neil Armstrong steps out, we don't know if it's gonna happen. I think there is some trepidation in it being new, and I'm respectful of that. It's being outside of tradition. That's fair.

I think that there's probably an economic concern. How will this affect how money moves through veterinary medicine? I think that's a real concern. It ought not be our primary concern. But that's the concern. I would say those are probably the two big ones.

What are some people missing in terms of the argument for remote establishment of the VCPR?

I tend to think that veterinarians are extremely bright. So, I don't think that they're missing anything. They just have a different opinion. When I'm in conversations with veterinarians that disagree with me, I reassure them that there will be a veterinarian in charge of all of these decisions.

I try to stress that we trust the veterinarian. We trust her to make surgical decisions. We trust her to make decisions with controlled drugs. We trust her with end-of-life decisions. We can trust her with a decision of whether there's a relationship that ought to be established remotely.

It's not so much that people are worried about individual veterinarians. I think it's more the concern about corporate entities finding ways to push the veterinarian aside.

I think that is definitely something that we need to pay attention to. If you look on the human side through the pandemic, there were a couple telemedicine providers that were getting kind of fast and loose with controlled drugs. Who turned in the corporate people? It was the medical professionals because the medical professional as an individual is held to account. She can't hide behind anything because she has the DEA [Drug Enforcement Agency] license.

We need to make sure that there are rules. But what I found reassuring was on that human example, it was the medical professional who blew the whistle about the corporations who were not as concerned about the patients and were more concerned about money.

What kind of guardrails would you support?

Guardrails I support are consistent with the Arizona law.

The California Veterinary Medical Association pushed for an amendment to telemedicine legislation that would require providers be associated with a veterinary premises. Do you think that it's a good idea that if you're going to have a telemedicine practice, you at least need to have a relationship with the physical practice where pet owners can go, because otherwise you could be sending a pet owner to wait for a month to see a veterinarian?

I don't think that the VVCA has an official position on it. But as Aaron Smiley, the person, I go, "Yeah, that makes sense. If you're strictly remote, you need to have some type of a relationship with a doctor someplace in the physical world because a bulk majority of the cases cannot be done remotely." But at the same time, let's not be so naive to think that it's better to not offer any remote care, because then the alternative is no care.

Take it to the extreme. If you live in the outer reaches of Alaska, would you like to talk to a veterinarian or not? Anytime you bring the animal owner closer to the veterinarian, that improves animal health.

[Smiley pulls up the VVCA model telemedicine regulations on his computer to check its position.]

In the VVCA model telemedicine regulations from July 2022, No. 4 is "Telemedicine must be practiced in such a manner that a veterinarian is prepared to refer or supply the pet owner with contact information for veterinary practices in the pet's location in case the pet owner seeks in-person care." So VVCA does support what you just said.

They're not saying you need to have a relationship with that clinic and know that if you send them there, they're going to get care. They're just saying you need to have a number and a contact.

I would push back, and I would say, careful as we get into semantics. I don't know the emergency clinic that I send people to. I know of the clinic, if you asked me to name two of the doctors, I couldn't name any. I would be very leery of getting into those semantics because I don't think that it would hold true in the physical realm.

Looking at the big picture, most states don't permit remote establishment of the VCPR. How much of an obstacle to VVCA goals is it to have to change the laws one state at a time?

I would say that it's very predictable, and we get that prediction from the human side. Veterinary medicine is notorious for following human medicine. If you look at how on the human side, how they basically made a remote relationship legal, it follows the same course: one or two states, and then, all of a sudden, you got a big wave.

So, we anticipate that [veterinary medicine] follows the same model. We're quite encouraged as far as with Arizona and California — in regards to the unanimous support.

While the VVCA's lobbying efforts are often at the center of stories about telemedicine, you told me your organization does more than lobby. Tell me about that.

Sure. So, specifically, like on the VVCA website, there's a Quick Start Guide.

What do you mean by "quick start"? Do you mean when somebody is trying to begin doing telemedicine in their practice?

I would put a little nuance to that. Ninety-nine percent of veterinarians offer telemedicine, and they're really good at it. I would say there's a significantly smaller percentage of veterinarians who are monetizing that. The Quick Start Guide helps the doctor kind of get their mind around "What is this professional service? Are we offering it? Oh, yeah, we are. OK, do we want to monetize it?" It takes the doctor through those steps of going, "OK, if this is another professional service, how can I then make this part of my business?"

We also have written case scenarios … doctors can see other doctors engaging in paid telemedicine or free telemedicine.

Is monetizing telemedicine usually associated with some kind of technology?

Yes, absolutely. I would say that what we're using right now, just an audio call, is traditional telemedicine. What's so cool, what's revolutionized in the last whatever years, 10 years, is now we have high-definition cameras. So, now the amount of firsthand data that I can get is incredible.

That's where a lot of doctors go, "Whoa, Smiley, you went too far. What are you talking about? I don't like any of this remote medicine." And then I'll push back and go, "Well, you're out of step with the AVMA." And they go, "Now, what?" I say, "Oh, my gosh, the AVMA has done a wonderful job endorsing telemedicine. I mean, you can't find a bigger proponent."

You're saying telemedicine used inside a profession isn't really up for debate?

My opinion is, it is so ubiquitous inside of the profession, people are unaware that it's offered. The doctor is so good at it; she does it without thinking. Not to pick on the physicians again, but before Covid, it was very difficult to get your physician on the phone, right? The physician put up a barrier between the patient and herself in a remote setting. You had to go into the doctor. The veterinarian never put up that kind of a firm wall.

I have a few general questions about VVCA, the organization. What does it cost to be a member and what are the benefits?

It's $100 to be a member. Benefits include continuing education events, a state of the veterinary virtual care industry report, educational materials, a network of like-minded professionals, a pet insurance comparison tool for comparing various pet insurance companies' coverage of virtual care, and more. 

How do you get listed in the VVCA directory?

There's nothing that's monetarily connected to being in the directory. The previous executive director, she was just trying to do a cattle call as a resource for people. But there's nothing monetary, as far as you donate or whatever, and then you get on that list.

Do you know how many members there are?

I don't, and I should have asked. I apologize. I don't mean to be coy about that. I don't know.

I know from other reporting that Chewy and Dutch help fund the association. Can you give me an idea of how that all breaks down? [Chewy, an online pet product retailer, and Dutch Pet have online veterinary advice platforms.]

Now I'm going to sound like a politician. I don't know the inside finances as far as what the breakdown is of sponsors and members. And yes, they're sponsors.

It would be nice if it was more transparent, so people don't feel like, "Oh, they're hiding the fact that Chewy and Dutch are trying to make this happen so that they can dominate the telemedicine." That's the concern.

I think that you're right. What I would say to the veterinarian is, remember, these are all veterinarians. So, if it be Dutch, if it be Chewy, they're employing veterinarians. The analogy would be 20 or 30 years ago, the corporate consolidator was considered a pariah. Well, that's no longer the case. Right? I don't know what the percentages are of locally owned practices to consolidators but that's just no longer the argument.

As the VVCA, what we're saying is, we want this decision to be made by a veterinarian. You may not like that the economic model of your world is changing, but it's a free society. As you start picking economic winners and losers, that's no good. I don't want to live in that society. Because what if I don't get picked? I would encourage the veterinarian to flex her robust muscles of ingenuity and her entrepreneurial prowess, and compete.

Did you follow the closure of Fuzzy Pet Health, a veterinary telehealth company, which shut down suddenly in June?

No, did you? I didn't know anything till the very end.

A bit, and I wondered if Fuzzy's demise tells us anything about the standalone virtual care model.

That's a great question. I would say, as far as VVCA is concerned, we're very staunchly in support of the market figuring that out. I don't know what business model is going to work. I know a lot of people have spent a lot of money, and from my vantage point, it doesn't seem like anybody's really landed on it yet.

I think some veterinarians worry that telemedicine will be a repeat of when clinics lost a lot of revenue from the sales of medicines to the big box stores and online retailers.

I think that you can make that parallel. I remember as a high school kid — this sounds hokey, but it's true — I was on a career day with a guy, and he was a salesman. He sold seed corn. "Aaron," he said, "change is like waves in the ocean. You cannot stop that from coming in. My goal is to try to ride it in. I don't want to get rolled over." And so inside of veterinary medicine, you have veterinarians that look out and go, "Hey, what's the new wave of change coming in? How can I ride that?" And there are other veterinarians that go, "I see that coming in, and I'm gonna stand here like a soldier." And that's that doctor's prerogative. It doesn't make me frustrated or angry. I respect that opinion. It's just not where I'm going to be on this issue.

Is there anything that you want to bring up that I missed?

The only thing I would be a broken record on is just a nuance of telemedicine versus remote VCPR because I haven't figured out how to parse those out. I always get lost in the minutiae. I'm excited to read your article to see how that's going to take shape because you'll probably do a lot better job explaining it than me.

I'd give you an opportunity to do it now. This is your opportunity to tell me the difference.

OK, I'll tell you the difference. The difference for me is that organized veterinary medicine supports telemedicine. I have not found any disagreement in any organized veterinary medicine about the practice of remote medicine. None.

The only point of contention is if that telemedicine can be initiated without a physical exam. That's it. If we can stay laser-focused on the argument of whether or not the doctor has the ability to establish the relationship remotely, I think it's a more healthy argument.