Conflicts of Interest in Dentistry
According to an article in SmartMoney, as many as 48% of U.S. dentists have seen their profits plummet thanks to the recession.
In and of itself, this isn’t a particularly remarkable statistic – after all, most of our wallets have taken a hit this past year – but what follows is an interesting discussion: how are dentists coping with this drop in income? Angie C. Marek reports a variety of tactics in her article (including lowered rates, freebies, eliminated IOUs, etc.), most of which benefit the patient – but they don’t all. Some dentists are softening the financial blow by upselling and overtreating patients.
One example came from a woman who, upon switching cities and dentists, was surprised to learn that her hitherto problem-free mouth was suddenly rife with problems: several cavities required coatings and two veneers needed replacement forcing the woman to take out short term loans to pay for her dentist bills. Or so her dentist told her. However, this turned out to be just another case of overtreatment.
The problem here is conflicts of interests (COIs), which are instances when professionals are pulled in two directions, torn between personal gain and the good of the patient. And the sad news is that when faced with COIs dentists (or physicians) sometimes end up going the self-interested route, and this can have undesirable consequences for the patient.
Conflicts of interest are nothing new, they have been a problem for as long as there have been professions, and they are very pervasive. For instance, there’s the doctor who accepts consulting fees from a drug company and studies their drug, the one who prescribes the treatment a drug rep pushed on him the week before over a free lunch, and even the doctor who urges a treatment on a patient in part so that he can use his costly new medical equipment.
This isn’t to say that these are dishonorable people who only see dollar signs and say to hell with the patient. Rather, COIs can deeply color the person’s perception, and thereby end up leading even the most upstanding citizens astray, and this happens often.
The long and short of it is, next time you are at the dentist’s office – think about your dentist’s conflicts of interests.
The Honest Truth About Dishonesty: How We Lie to Everyone - Especially Ourselves
I used to defend private practice dentists and think I got a better service from them than National Health dentists.
I was happy to pay the extra money especially with root canals of which I have three, one where the dentist burnt my mouth when he was applying the rubber plug. He gave me a free porcelain crown for that.
However recently I’ve felt that they make it up as they go along. One dentist said that a crown and root canal I had done only about five years ago needed replacing with a bill for about £600. His successor (here when they’ve taken all the money they can get they go back to either South Africa or Australia) made no mention of this job to be done. Very strange.
However he redid a small filling that had some infection due to a leak. Fair enough, it was an old filling and removed a tooth that needed extraction.
The Oral Hygienist wants to do deep cleaning on many parts of my gums citing deep pockets of infection. Ho hum got no bleeding in my gums and they’re THAT bad! Again ordinary Oral Hygiene session two to three times per year I’ve no problem with but now I need so much work and of course lots of money for the hygienist.
It’s for this reason that I’m going back to National Health. NHS dentists are not blameless but at least they’re cheaper and possibly have some sort of regulation put on them.
I think “conflicts of interests” is a nice euphemism for greed
Dan-
Suppose the question were framed this way? I sit down to play a game with you. You tell me the rules. Midway through the game, during which I have to expend a sizable portion of my time and “assets of the game”, you come to me and tell me that the rules have changed, and now instead of being able to use (as in one of your written studies about cheating) only one die to advance, as opposed to two at the outset of the game.
How do I adapt to the changing rules? Does “fairness” come into play? Suppose I took out a big mortgage, have two kids who are five years from college, and both of my cars are coming off-lease in a few months?
I’m not saying any of this justifies cheating. In many ways, this kind of problem speaks loudly to federal funding of health care education, and putting all practitioners on salary, rather than “on commission”.
But there are so many other truths in between. Conservative practitioners who practice “watchful waiting”, could conceivably move the bar of when it’s time to treat a condition and still be in the realm of being responsible care givers. Health is very often a continuum of grey, not black and white.
There is a big difference between being more vigilant in when it’s time to treat and treating problems that aren’t there, which is what this column seems to infer.
Having a trusting relationship with your doctor, and having him or her fully “co-diagnose” health problems with you is the bedrock of every health care situation.
Find someone you trust. As a practicing dentist, I long ago realized that the only things I have to sell are my trust, and my art. Everything else is just “stuff”.
can’t afford the dentist – looking to win the lottery so I can go! this is only a little tongue in cheek – it is mostly true
It’s also interesting to see the contrast between US vs. overseas practices. For instance, after living in the UAE for a year, my dentist here explained to me that she will only perform oral x-rays if she sees reason to after her physical examination (no x-rays yet after 2 regular check-ups). In the US, however, my dentist did not even perform a physical examination until the x-rays were taken and ready to view!
As a former investment and insurance broker, I ran into far too many “professionals” who put their personal interests above those of their clients.
While there were a few exceptions, the financial services industry was–and still is, I imagine–plagued by selfish brokers and agents who were willing to place their own wants above the needs of those whom they ostensibly served. That’s an easy thing to do when you’re in a profession that benefits from commissions every time you buy or sell and regardless of the client’s gains or losses.
It’s also easy to do in other professions where the “needs” can be faked or exaggerated. There are many ways that predators can get away with bilking those who trust in them to fix their bodies, finances, automobiles, minds, relationships, homes, etc.
Caveat emptor.
This post could have been written about literally any self-employed small business person that do not determine contracts by bidding: lawyers, car mechanics, or even economic consultants. Any reason to choose dentists in particular?
No and two wrongs don’t make a right. And in any case lawyers, car mechanics and consultants are also often in the spotlight and deservedly so.
Either dishonesty is on the increase or buyers are more aware of it or maybe a mixture of both.
I think we have a certain responsibility to educate ourselves about this and also to take firm action. There still is far too much passivity these days.
Agreed, the singling out of Dentists seems bizarrely highly targeted. Is this the result of a bad personal experience with a Dentist? The SmartMoney article, on which this post relies, is sloppily written, never directly making the argument showing that Dentists are taking advantage of patients anymore than anybody else.
Dental profession is irrelevant. COI is. Assume you have problem X and you go to expert Y for help. Expert Y has a financial incentive to overtreat. There are no two ways about it. That does not mean expert Y will overtreat, but the incentive is undeniable.
The question is what to do about it systemically and what to do about it as the lay patient/client/chump getting an oil change who suddenly “needs” a new set of tires.
As a dentist and a fan of predictably irrational, i feel compelled to write something…
i saw the little interview video (from the hammock) and thought the Dan/new_dentist story was pretty funny!
Dan asks the dentist to show evidence of the superiority of one filling over the other. Had she had shown that evidence, would it have changed your mind about her? Do you think any large randomized outcome paper would have any relevance to the specific chances of success of your specific tooth?
To preface, I’ve had a lot of dental work in the past year, a lot in high school, and typical amounts during the rest of my life (all in the US), and it’s generally been a positive experience.
As non-experts, I think we’re more likely to defer to the man in the white coat than question his judgment. I have to make a concerted effort to actually bring up concerns and objections during a visit.
When told I need a cavity filled, we probably won’t question it, because we’ll be sold on its preventive benefits. A filling in the present costs less and hurts less than more extensive restoration in the future. Also, insurance usually bears 80% of the cost of minor procedures like these.
When told I will probably need a *2nd* dental implant after going through more than a year of painful and expensive procedures to prepare my jaw for the 1st implant, I’m going to take a more critical stance and I’m going to require a convincing rationale. My assertiveness comes from my large out-of-pocket investment in the majority of my treatment, since either the patient responsibility is higher for such procedures or they’re not covered by insurance. I’m also more personally invested in ensuring a successful outcome, prompting me to follow the post-operative dental hygiene instructions to a T.
What requires just as much vigilance as overtreatment but is perhaps slightly more under a patient’s control is staying on top of the accounting.
In anticipation of major upcoming dental work, I wanted as much of the cost as possible to be funded by insurance or at the very least tax-deductible. I joined both my husband’s and my company’s dental insurance plans – each allow up to $1500 of expenses per year, which is more than enough for the average patient, but not nearly enough for an implant and associated procedures. I funded a pre-tax, use-it-or-lose-it flexible spending account (FSA).
But planning ahead and *accurately* predicting out-of-pocket costs (and thus just how much FSA to get) requires a superhuman feat of accounting and attention to detail. The pre-treatment estimate is supposed to facilitate that, but it’s confusing. There may be multiple dental professionals involved and multiple insurance companies (I have 2 of each). Each estimate contains lists of codes for dental procedures.
If treatment occurs during two calendar years, it’s necessary to figure out which procedures in the list occur in which year, and thus decide my FSA contribution in each year
I tried and had a hard time matching the codes in the insurance pre-treatment estimates to those listed in the invoices generated by the doctors’ offices over the course of treatment. If a doctor requires payment at the time of service, there’s still a lag time between the service date and the date the insurance reimbursement is processed. It becomes hard to keep track of how much you’ve already paid toward each procedure, how much insurance has paid toward each procedure, which procedures have or haven’t yet been submitted for reimbursement, and what costs are yet to be incurred. Identifying discrepancies and errors (which do happen) takes a lot of work.
There is also the issue of double-billing of insurance for people covered by two policies. Exactly how that works depends on how the insurance handles coordination of benefits (COB). I figured a favorable COB policy could only be a good thing for us patients. For example, if one policy normally pays 50% toward a major procedure, then having two policies would mean each pays 50%. The dentist still gets paid in full, but the patient owes nothing.
But I would not have guessed that a cleaning/exam, normally 100% covered by insurance, would be paid in full by *both* insurance policies. Of course the dentist is pleased to be paid twice. However, two payments are deducted from the patient’s annual coverage allowance, when the patient only received one payment’s worth of services.
Is this a problem worth arguing over? I don’t know. The patient having major work still probably comes out ahead. What is clear is that the health care market still has a long way to go before patients can be treated as “consumers” armed with the data to make educated choices between products and service providers.
Hey!!! I cannot wait to read more of this. I mean, you just know so much about this. So much of it Ive never even thought of. You sure did put a new twist on something that Ive heard so much about. I dont believe Ive actually read anything that does this subject as good justice as you just did.
I experienced this same problem. We moved to a new city and found a new dentist. At our previous dentist, we generally needed cleanings but at the new dentist, my wife, myself, and my stepson all needed major work done, particularly a crown. Not only that, when I reviewed the EOBs afterward, I discovered that all three of us had our crowns replaced on the exact same tooth. Very unlikely. So we switched dentists and surprisingly, we generally need cleanings again. Your article was spot on.
dentists and honesty are distributed on a spectrum. I wonder if the current economic situation is making us notice one end of the spectrum more than the other? or is the spectrum shifting? Making causality statements like that are very difficult… im not sure if Dan’s research can make causality statements?
having said that, the dentist price structure has definitely issues that need resolving. moreover, the oldschool approach of dentist-patient authority-subordinate is on its way out, the newer generation is taught a more equal dentist-patient partnership relationship.
Could this be where the Internet benefits patients/customers when considering a dental practice or any other service where quality of care and cost can effect their choices? Checking online reviews. And impressions from others online has replaced word of mouth, but both can work to Keep businesses in check to the public.
Let’s say that I’m a dentist and I’m taking your article and hammock interview to heart. I really don’t want a patient to think I’m pushing unnecessary treatment. And let’s say that I come across a patient that’s never really had any dental problems before, but all of the sudden I’m seeing 4 or 5 new cavities upon examination. The patient probably has had some medications recently which might be causing a dry mouth or perhaps the patient recently went to college and has had some radical dietary changes. But since I don’t want them to think I’m overtreating…what should I do? It’s my duty as a dentist to explain to them what I’m seeing and recommend changes in their habits and home care as well as recommending treatment. But if it’s Dan Ariely in my chair, he’s already pretty sure that I’m proposing overtreatment. After all, I’m a dentist…
There comes a time that you have to trust the people you’ve chosen to provide your care. If you don’t, get a second opinion, or find another dentist. (http://meadfamilydental.com/2011/05/your-cousin-in-the-business/) But seriously…just having a general attitude of “this guy is going to sell overtreatment” while maintaining a relationship is just ignorant.
So as one of the earliest,’professions’ how does prostitution rate on the conflict of interest scale? I guess keeping secrets, not overcharging newjohns or holding out on your pimp are the working girl’s weak areas?
as for dentists or any other high cost service, it pays to be vigilant. Whatever the situation, always compare prices / fees, and if they tell you after your $150 check and clean that you need a $600+ of crown, fillings, root canals, etc, dont be a sucker. Take a raincheck and visit another dental clinic to compare results, maybe the first guy is overcharging, or selling you something you may not even need., maybe he’s honest and worthy and this is the only way you can ever know for sure. By the way, dont look for the ferrari in the carpark–dentists all have an ordinary car for work.
The COI problem is intractable when the diagnosis and the treatment are performed by the same person or people who share a financial stake. This would include folks working in the same office or just providing mutual professional referrals.
One solution is removal of financial incentive–get paid the same regardless of work performed. Sounds socialist. Or separate the jobs of diagnosis and treatment–easier said than done. The incestuous nature of professions particularly in smaller markets could make such a move irrelevant and more expensive and time-consuming.
From the patient/client perspective a second opinion is about the only way to make sure that you are not being run over. Or comparison shopping? What is the sticker price for a root canal? I don’t know. One pays for the knowledge and expertise of the professional to make an opinion and fix the problem.
Profit motive is simply at odds with a model of professional conduct.
separating diagnosis from treatment is quite simple where GPs are concerned–the Doctor makes a diagnosis based on your test results, then refers you to a specialist(s) for treatment, which may include a pharmacist–who have infinitely more current and concise knowledge about what they are dispensing than any GP could ever hope to have. in many countries this is the normal doctor:patient relationship, and to that degree it works well, and partly helps to curb the issue of web-/self-diagnosis and public loss of faith in the medical profession.
unfortunately it leaves the (pharmacist/druggist/chemist/apothecary) wide open to conflict of interest from malignant medical sales representatives.
as an attempt to address this situation (well before i read Dan’s book… it seemed not right to me as well), i set up my fees so that my profit margin is higher on preventive treatments and lower on restorative treatments. ie, it’s in both of our interest (patient and i) for them to remain caries free and gum disease free.
most slash prices on the exams and the cleanings, thinking it would attract more clients.. however, psychology has to be weighed in in economics. not just do it purely utilitarian/rationally. imo.
The fact that there is a recession is fundamentally a red herring. Overtreatment in medicine and dentistry is endemic and probably done to a far greater extent in the USA than Europe. Yes- a massive generalisation with many exceptions but that does not mean to say there is no truth to it. How else does American medicine spend so much more money om medicine with no better outcomes. In dentistry there is massive overtreatment and overselling particularly in the fields of esthetic and implant dentistry where little is said to the patients of the long term implications both in terms of health and finance of recommended treatment.Dan just touches on these areas in his new book but he is way too cautious and polite about the reality.
Bottom line- Patients (and doctors) must keep their critical faculties at all times.Find a dentist you can trust and then stick with them!
You only have to find a dentist of thurst, can be recommended by a friend.
I’m a dentist. Overservicing always seemed to be bad kharma to me. But, as for unnecessary xrays, blame the lawyers- we have a saying ‘no xray, no defence’.
Yanno, I’m glad someone came out and said it. We went to the same family dentist while I was growing up — I must’ve had fifty ‘cavities’ filled, between one and three at every six-month visit. When I went off to college, I somehow managed to put off going to the dentist for eight years. The dentist I saw afterwards found three cavities, which I didn’t treat at the time. Two years later, a third dentist found four cavities… in *different* teeth. (Wasn’t aware that ‘cavities’ would vanish on their own. Wish I’d been told this before.) I’m afraid I give up on the dentist thing, unless something actually feels wrong.
TS,
So you’re going to wait until something actually feels wrong. Since dentists are going to overtreat, how do you avoid them ripping you off when you know something is wrong? Aren’t you even more susceptible to it when you know you something needs to be done?
My daughter had perfect teeth for 25 years. When our family dentist retired, she went to see another dentist who told her she had no less than ten cavities. A second opinion quickly revealed she still has perfect teeth, no cavities.
It would have been criminal to drill into those perfect teeth in exchange for cash.
In addition the news of ten cavities was shocking and intially depressing for
Please don’t ‘throw out the baby with the bath water’.
Yes there is overtreatment. Yes there are dishonest dentists.BUT and it’s a big but-it doesn’t mean most or even many over-treat. Preventative dentistry is the best approach to healthy teeth and lower dental bills. Treating early cavities is a ‘no brainer’ but you do need to find an ethical dentist who will look after you professionally in the long term. I am a ‘third generation dentist’ and treat a whole bunch of third and fourth familes- (my grandfather and I treated the great- grandmother of some of my patients) and needless to say they all need very little invasive treatment!
Your article is spot on related to dentistry or dental treatment issue people face by the dentist. But first we all know that all fingers are not equal like all dentist doctor are not honest to their profession. Dentist always charge the massive amount as a dental service provider so the question is that did they join dental profession to only earn the dollars or to provide the services to people?
Hi, I had the worst case of dental malpractise done by not one but 3 different NHS dentists. One of those dentists was struck off UK Dental board! It left me with years of agony, successive dental resorations which were not done very well and continued to erode my remaining teeth years of abcesses than failed restorations!
It left me at 38 years with 50 per cent of my teeth most post and crowns 90 per cent root filled, and some of my teeth have little remaining of roots! The next future dentists want to do implants I cant afford anymore! And had to come to the UAE to work to pay for my teeth still the costs are nearly those for a buying a new flat!
Warning bad dentistry over treatment and conflict of interest! Is a criminal act and can ruin someone’s life. Once the damage is done its done and you will pay for it for the rest of your life!!
Lightening does strike more than once! and for sure in dentistry.
Miss x
P.S. Then my Arabic boy friend/partner damaged a few more teeth with beatings
That some people will consciously rip you off is not new, not interesting. COI is interesting precisely because it changes behavior unconsciously. If the person recommending a good or service gets rewarded if you accept, then his or her behavior will be altered without him/her knowing.
My brother in law is a doctor who is very honest. A drug company pays him to speak once a quarter to other doctors about a specific drug. He and wife are flown to Carribean for a week every year. I asked if he’s bothered by the conflict of interest. He said there’s no conflict; he genuinely thinks the drug is good. I know he believes this, but somehow I don’t believe his enthusiasm and commitment to this drug would be the same. I said as much to him, adding that it wouldn’t change his judgement when it’s black and white, but what about when its gray? He denied any possible shifting even if gray.
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