By Larry Marsh, Kansas City Star Midwest Voices columnist 2009
President Barack Obama has promised to change the perverse incentive structure in our health care system, which currently pays our doctors and dentists per procedure rather than by salary or by successful health care outcome per dollar of health care spending.
The Obama administration sees this incentive structure as the primary cause of our runaway health care costs. Dentistry is one profession that clearly needs reform.
Anecdotal evidence suggests a range of prognoses based on the same set of dental X-rays. Some dentists may be too conservative in their treatment while others may go well beyond what’s necessary.
Repaying mortgages and loans for dental equipment can put some dentists into financial difficulty with the rest of us. This is aggravated by a cutback in the demand for cosmetic procedures during recessions and the limits insurers place on dental fees. Under such circumstances some dentists may find themselves desperate for additional cash. No matter how much time and effort you put into taking good care of your teeth, it won’t matter if your dentist has decided to give you a few more crowns, needed or not.
Almost all dentists are honest. State dental boards are designed to police the dental practice to protect the public. Sometimes dental fraud is discovered and the convicted dentist is held to account. An ABC News investigation last year, “Drilling for Dollars,” reported unnecessary fillings, root canals and even jaw surgery. It is not clear whether this reveals the full extent of the problem or just the tip of the iceberg. Is the DNA of a dentist so different from that of a mortgage banker so as to make a dentist immune from excesses? After all they are both "just trying to help people."
The official state dental board Web sites are www.pr.mo.gov/dental.asp for Missouri and www.kansas.gov/kdb/ for Kansas. To help protect the public and the dental profession’s reputation, report any suspicious cases to your state dental board at or .
Getting a second opinion is costly because it usually requires getting an additional set of X-rays. Too-frequent exposure to X-rays has been linked to cancer. Even if the proposed treatment is expensive, it is usually at least partly covered by insurance. This coverage further reduces the incentive of the patient to get a second opinion.
As Cass Sunstein and Richard Thaler demonstrated in their book “Nudge” and Malcolm Gladwell showed in his book “Tipping Point,” small changes can make a big difference. A small change might substantially reduce dental costs.
The 2001 Nobel prize in economics was awarded for revealing the distortions that emanate from markets with asymmetric information — when at least one party to a transaction has more information than the others. As it turns out, dentistry is a prime example. Dental patients are not trained to read their own dental X-rays.
The asymmetric information problem in dentistry can be easily corrected. At about 10 cents per patient, dentists could be required to give their patients a copy of their X-rays on a CD every time new X-rays are taken, regardless of whether the patient requests them. This “nudge” might just motivate a patient to get a second opinion.
With luck, every good dentist at some point will reach retirement age. With sufficient demand and easy access to a patient’s dental X-rays, retired dentists could offer to review a patient’s X-rays and provide a second opinion for a fee.
Dental insurance premiums and licensing fees could be reduced to allow for this limited service. With digital X-rays this could even be done over the Internet. Patients can then send their X-rays by e-mail (or regular mail) or hand carry them to their favorite retired dentist to get a second opinion. In some cases, a follow-up physical exam may also be needed.
This could help discourage dental fraud, reduce unnecessary dental procedures and expenses, help protect the reputation of the dental profession and give retired dentists a little extra income.
Larry Marsh of Kansas City is professor emeritus at the University of Notre Dame, where he taught economics for 30 years. He served as director of Notre Dame’s Ph.D. program in economics for 13 years.
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Dental x-rays alone aren't enough
What the author proposes is an interesting take on reforming dentistry and is worth exploring. However, although dental x-rays are a very useful diagnostic tool, they rarely tell the whole story. It is very common for x-rays to not show evidence proving the need for fillings or crowns. For example, a defective restoration that requires replacement may not be evident on an x-ray. Frequently caries (dental decay) is only detectable via visual or tactile examination; conditions that don't lend themselves to inexpensive second opinions.
The science and art of dentistry is something that takes a lot of work and experience before it can be practiced competently. There's a reason why patients are wary of the newly graduated associate but are more comfortable with the seasoned practicioner.
Furthermore, it would take a patient that is highly dedicated towards their own dental care to seek second opinions. Sadly, it is my experience that most people don't care that much. It is too easy to take the doctor's word. Fortunately most dentists are ethical and only a few take advantage of patients uneducated in dentistry.
While fraud and waste are responsible for some increased costs to the public, it is important to understand the often prohibitive costs required to become a dentist. In addition to a four year undergraduate degree and the student loans associated with getting one, an aspiring dentist then must undergo an additional four years of dental school. Student loans covering tuition, fees, instruments, supplies and living expenses (full time dental students often can't work while in school) can easily average between $60,000 to $70,000 per year.
While some new dentists might choose to work as an associate, the brave who set up or buy a practice often take our additional loans start practicing. The cost of purchasing a practice can range anywhere from $100,000 to $300,000. It is very common for new dentists to have debt obligations of nearly a $500,000 (not including mortgages and car loans) before they have made their first dime.
These are the costs our society incurs to produce the modern and excellent dental care available to Americans today. The same principles hold true to the cost of medical care also.
Our country is about to engage in an attempt to reform our health and dental care systems in an attempt to contain and reduce such costs. It is important to remember that there are always hidden pitfalls to any reformation suggestions.
As noted previously, second e-opinions from retired dentists reviewing digital x-rays sounds like a great way to save costs. But if you go deeper, you realize that the truth is that there are very real limits to the usefulness of such second opinions based strictly on x-rays.
So it goes with healthcare reform. Any meaningful debate on the merits of upcoming reform measures will have to dig deeper than soundbytes and Orwellian propaganda we are sure to encounter.