Dr. Anne Gamalski

Photo courtesy of Dr. Anne Gamalski

Dr. Anne Gamalski tends to a canine patient at her small animal practice in Berlin.

Few people outside Germany would be surprised to learn that, as Europe's biggest economy, the country is home to a thriving veterinary community that typically offers high standards of care.

Many outsiders might be surprised to discover, though, that even in modern-day, capitalist Germany, the cost of veterinary care is regulated by the government.

Under a longstanding law called the Gebührenordnung für Tierärzte (GOT) — in English, "fee schedule for veterinarians" — practitioners must charge within a pricing scale that varies by task, whether it's neutering a dog, taking an X-ray or just offering advice.

For example, should a veterinarian perform a cesarean section on a dog in a nonemergency setting, they can charge only between €183.37 (US$192.97) and €550.11 (US$578.92) for the procedure.

"It's kind of wild," reflected Dr. Anne Gamalski, who owns a companion animal practice in Berlin, "being put into a corset."

The pricing scale dates back more than 80 years, having been introduced during World War II amid the Nazi regime's policy of "Gleichschaltung," or forced coordination of all elements of society, according to a book about the GOT. Its formation was overseen by Dr. Friedrich Weber, the national leader of Germany's veterinarians between 1934 and 1945.

Even as Germany has transformed into an advanced democracy, the GOT has lived on, rooted in the reasoning that the lower pricing limit ensures veterinarians are properly compensated, while the upper limit protects pet owners from excessive bills.

Prices for human medicine and dentistry are similarly regulated in Germany through the Gebührenordnung für Ärtze (GOA) and the Gebührenordnung für Zahnärtze (GOZ), respectively. Those weren't introduced until 1965, and have origins in an older fee schedule set by the Prussian Empire in the late 19th century.

It isn't unusual for some nations to at least partially control the cost of human health care, such as drug prices — especially for public health services funded by taxpayers. But extending government oversight to the pricing of veterinary care is so unusual that Germany's GOT has periodically drawn criticism from the European Union for apparently running contrary to its aim of fostering competitive trade.

Still, the GOT could start being seen in a new light, as governments come under pressure to contain above-inflation rises in the cost of veterinary care pinned on rising demand for more sophisticated treatments, increased corporatization and an apparent shortage of practitioners following the pandemic.

The United Kingdom, for instance, is in the midst of a sweeping probe of veterinary pricing that its antitrust regulator says could see practices forced to clearly disclose prices up front. The British regulator has also raised the possibility of capping prescription fees.

How the price controls work

It is illegal for veterinarians in Germany to charge below the government-set base fee or more than triple the base fee for any given procedure.

The price ranges are higher for emergency care, for which veterinarians must charge between two and four times the base fee. They must also add a €50 charge called the Notdienstgebühr for all emergency care.

Take castrating a male cat as an example. Under the GOT, veterinarians must charge a minimum of €30.32 and no more than three times that amount, €90.96. If the castration occurs out-of-hours, they must charge anywhere between €60.64 and €121.28, plus the €50 Notdienstgebühr.

Veterinarians may charge at any increment within the allowed range but must state on the bill how their charge relates to the GOT. For instance, a veterinarian could state a charge of "1.5 times" for a cat castration, or €45.48.

"It's rather easy to do because if you order software for a practice in Germany, typically, the GOT is in that system already," said Dr. Barbara Schneider, who ran her own practice for about 10 years and now works at a military base in Ramstein.

Within the mandated limits, veterinarians tend to set their prices based on factors like how long it took to perform a procedure, their level of training and their location.

"If you work in the middle of Munich, you're going to be more expensive than in rural areas," explained Dr. Reto Neiger, the medical director for large group IVC Evidensia's practices in Germany, Austria and Switzerland.

Veterinarians could even charge different rates for the same procedure performed on two dogs with the same owner.

"The owner might ask: Why is Fluffy more expensive than Fifi?" Neiger mused. "Well, because Fluffy was a nightmare and we needed two people to hold him, but Fifi was such a sweetie, and I could do it by myself."

The GOT provides pricing ranges for 1,006 procedures. If a procedure isn't specified, veterinarians must find something listed that most closely resembles the procedure they've performed.

"I have to do unusual things sometimes," said Dr. Christiane Stengel, a veterinarian in Horrem. "Whenever I do sclerotherapy [injections to shrink blood vessels], I have to charge the owner for something resembling this like nephrectomy [kidney removal] because sclerotherapy is not in the GOT."

A modicum of protection

German veterinarians contacted by the VIN News Service had mixed feelings about the price control. Some find it constrictive; others maintain it allows them to charge adequately for their services.

All agreed that the minimum base rate helps the profession.

"It makes it harder to undercharge and basically rip off your colleagues by just being a really bad vet offering very low prices," said Neiger.

Gamalski in Berlin recalls recently meeting some Belgian colleagues and being shocked to learn they were charging €250 for a full-mouth feline dental extraction. "I think that's crazy because that doesn't even cover my anesthesia," she said.

Appreciation for the minimum rate goes beyond shielding veterinarians from cheap or low-quality operators.

Veterinarians often are perceived as big-hearted folk who just do their jobs because they love animals, noted Stengel. And although that ascribes a certain level of nobility to the profession, she said it can make veterinarians feel guilty about charging fairly.

"I don't know what's wrong in the brain of vets, but we're doing ourselves a disservice if we always undercharge," Stengel said. "It's good that the GOT gives us some protection."

Schneider, the veterinarian in Ramstein, puts it similarly: "You have a justification," she said. "Everyone must charge that price."

Are the upper limits high enough?

The mandated rates are reviewed periodically by the government to account for factors like inflation and advances in medicine. Still, the GOT isn't adjusted at set time intervals and doesn't change often. The last comprehensive pricing review occurred in November 2022, more than two decades after the previous review in 1999.

The change in 2022 was "long overdue" to ensure practices could run economically, the Federal Veterinary Association, a group that represents the profession, said in an email.

The adjustment raised prices on average by about 50%, Neiger estimated; increases differed markedly among procedures. For instance, the base fee for applying a bandage to a dog more than tripled, to €17.25. For a canine lameness examination, it rose by a more modest 33%, to €42.63.

Gamalski doesn't think the increases were big enough. "And that's been the tradition with the GOT prices, actually," she said. "They've always been too low — and people have been expecting low prices for so long that it's hard to push through big enough rises for us to pay our people properly."

Most of the veterinarians contacted by VIN News agreed that the cost of veterinary care in Germany is generally lower than in many other places, such as the U.S. and U.K. Castrating a male cat in the U.S., for instance, often costs around US$200 (€190), according to price comparison group Pawlicy Advisor (though the cost could be lower in a shelter). That's a lot higher than the €90.96 allowed by the GOT in a nonemergency setting.

However, there is a caveat: The GOT allows veterinarians to charge for things associated with a given procedure. So, for instance, if a male cat is given fluids during a castration, the veterinarian must charge additionally for the fluids. That's partly why IVC Evidensia's Neiger thinks the prices in the GOT are high enough for veterinarians to run a profitable business.

"If you do three times the base rate for everything you do, the bill gets really, really expensive," he said.

Veterinarians, he added, could effectively charge more than the maximum rate by increasing the charge for associated procedures to make up the shortfall. "If you use the GOT correctly — don't overdo it, but use it correctly — you can make a very decent living."

Still, Neiger observes that a prevailing tendency for veterinary fees in Germany to be lower, on average, than in many other countries indicates a reluctance by veterinarians to squeeze as much as they can from the GOT.

Gamalski agrees that you can "be creative." But nobody, she added, wants to be that veterinarian who always charges triple. "We need the range to be high in order to feel comfortable about charging even nearly enough," she said.

All agreed that the GOT had to rise in 2022. Veterinary technicians, in particular, Stengel said, were very poorly paid until that point. Still, she and Schneider said veterinarians could theoretically have made enough money under the older pricing scales.

"Go and find a clinic that charges the three-fold price," Schnieder said. "The rise in 2022 wouldn't have been needed if everyone had charged, for example, two-fold or three-fold prices. But no one did."

Corporate consolidators, which are acquiring an ever-larger number of clinics in Germany, may feel less abashed about charging fees closer to the maximum Stengel observed. But doing so might risk upsetting their employees.

"You could have this corporate saying, 'Now you have to charge three times for everything,' " she said. "Before you were making quite good money and people were happy. And now you are making money only for people who sit in an office and are not working on the clinic floor. But they make more money than the vet and the vet nurse."

'Room for improvement'

One criticism some veterinarians have of the GOT is that its 1,006 listed procedures aren't reflective of many of the tasks they perform, forcing them to hunt for the closest comparable procedures and exposing them to accusations of misinterpretation.

"It's just not detailed enough," said Stengel. "You would have to have 10,000 GOT points to do everything we are actually doing every day."

The rising adoption of pet insurance in Germany could make the inexact science of "inventing" a procedure not listed in the GOT further problematic, Gamalski said, should an insurer dispute the veterinarian's interpretation.

Moreover, she said that the pricing list, which was first drawn up when food animals were of more importance to veterinarians, still lacks adequate coverage for procedures pertaining to companion animals.

The Federal Veterinary Association is pushing for an overhaul of how procedures are listed. Currently, there are a multiplicity of fee scales distinct to an assortment of animals such as pigs, parrots and even fish. It wants to see the GOT simplified by dividing procedures among just three groups: small and exotic animals, farm animals, and equine animals.

Stengel also would like the GOT to offer pet owners more insight into quality. Giving an extreme example to make her point, she said a €20 cat castration might not seem so cheap if the owner discovered the veterinarian didn't use anesthesia.

"It would be very good to have some addition like a supplementary element that would detail the recommended methods for carrying things out," she said.

Could other countries learn from the system?

Although none of the veterinarians contacted by VIN News could foresee other countries adopting a GOT-style system, some felt that governments — and even companies — could learn from the German approach.

IVC Evidensia, for instance, is transposing its pricing catalog for Germany to its clinics in Switzerland, Neiger said. "Now, of course not with the same pricing, because in Switzerland, the prices are completely different, but we use the same catalog because the catalog is really helpful."

Neiger, however, doubts adopting a GOT-style system would prevent the runaway price increases for care that have occurred recently in the U.S. and elsewhere. "Even with our system, you can still charge a lot," he said. But he acknowledged the GOT can curb unscrupulous pricing, particularly with the minimum fee. "It stops the extremes."

The risk of steep price rises becoming more commonplace may increase if the take-up of pet insurance expands in Germany and elsewhere, Stengel opined. That's because people with pet insurance tend to feel more comfortable about spending more on care. "So the pricing could go up, and then the insurance would pay, and then the insurance fee would go up," she said. "So I do think [the GOT] can help with keeping prices reasonably steady."

Price transparency might be valued by other countries, Stengel said. "People do compare. And if you have a system that prevents people from undercharging, too, people have more realistic expectations."

Gamalski agreed, reflecting on the amount of abuse she hears of colleagues in the U.K. suffering for apparent overcharging.

"In 11 years of owning my own practice, I've never had anyone come back and say, ‘Hey, you've charged more than the base price of the GOT,' " she said. "They were always happy with what I charged."

At the same time, she'd still stop short of charging three-fold. "I'm a bit more confident now," she said. "I go: ‘Okay, I can go up to 1.35!"