When the 2013 Townie Choice Awards was in full swing this summer, and dentists and hygienists were voting for all their favorite products and services, we asked all the voters to answer the question “what’s the biggest crime in dentistry?” We got some interesting answers – overtreatment, managed care, insurance reimbursement, indifference, embezzlement – just to name a few.

Dentists deal with all sorts of ethical dilemmas on a daily basis, and the Dentaltown the ethics forum on our message boards are filled with debate. This month we’re starting a series called “Ethical Dilemma” that will address some of the stickier, less black and white, 50- shades-of-gray areas in dentistry. These articles will run throughout the duration of 2014. I’m kicking off the series with the topic of managed care.

There are some ethical issues the majority of us can agree on. Right now most of the world agrees we shouldn’t eat cats, dogs and dolphins even though I bet they all taste like chicken anyway. But sometimes the lines are more blurred, or aren’t universal. I once lectured at a dental school in India. A dental student came up to me and said she couldn’t listen to my talk because I eat cows. When you go to McDonalds in India, there is no Big Mac on the menu. It’s a McVeggie Burger or a fish sandwich.

Everyone sees everything differently. It’s hard to get 150,000 dentists (that’s about how many are on Dentaltown.com) to even agree what day of the week it is, let alone about how managed care should or shouldn’t work.

When it comes to ethics, most people, dentists included, fall within a midrange. This middle is the silent majority. A normal distribution curve (Fig. 1) says 68.5 percent of people make up the middle ground. The further out from the middle, the fewer the people, but the more extreme. I envision this Ethical Dilemma series sparking conversation on the boards, but chances are only the extreme outliers will argue. This series is meant to start a conversation, not be the world according to Howie! It’s meant to get you thinking and discussing your views and experiences from what you see going on in your practice and in what ways you deal with the ethical issues that arise everyday. Can’t we just have an honest conversation?

About Half the U.S. Market is Focused on Price.

If someone asks you “What’s the best car?” you’re going to say something like Lamborghini or Maserati or Ferrari, or some luxury car that costs an absorbent amount of money. While this is ideal, a $200,000 car isn’t realistic for the average buyer.

Jay Leno might throw these numbers off, but the most popular cars, according to Forbes are: Ford Focus, Toyota Corolla and Volkswagen Jetta—all midsize, reasonably priced sedans. These are the top cars because they are what most of us can afford. No, they’re not the best cars, per se, but they are the most practical based on cost, safety and mileage.

This same idea can be applied to dentistry. Sure, you could have a high-end boutique style practice in a lower economic area, but it would be like setting up a Mercedes-Benz dealership in Parsons, Kansas. It could work, and would depend entirely on the dentist being exceptional in many areas, but a Ford dealership would probably do a lot better, and would be a lot easier of a sale. Demographics act like gravity, they’re hard to deny. In business we call this market segmentation and markets are usually carved up by price, quality and service.

Americans basically divide the dental market in half meaning half are primarily focused on cost and will go wherever their dental insurance, employer, Medicare or Medicaid tells them to go while the other half sees dentistry as a relationship and they absolutely want to pick their dentist. They have a special relationship with their dentists and do not want to go to another dentist just because a third party told them to, and they will pay more for this privilege.

I hear so many dentists say that the problem with third-party insurance fees is they can’t do the treatment a patient really needs, and they’re only willing to do treatment that they’d do for themselves. I personally think this view is a little extreme, especially having traveled the world over.

If someone has a cavity, the decay needs to be removed and you need to fill it. If you’re getting $300 for the filling, then get out your fanciest materials from 3M and Ivoclar, do your tooth-colored adhesive restorations, and make some money. That’s basic; Cost + Profit = Price. But when managed care comes in and sets an exact price, you’ve got to switch to Price – Profit = Budget. A budget means you will need to have a plan. Why are you doing a tooth-colored restoration when bonding agents cost nearly $1 million a barrel? Is it because it’s the only thing you would have in your mouth? Why is it that you don’t place amalgams when research says they’re lasting 30-35 years and 3 billion earthlings live off of $3 a day? This was the only material available when I was a kid and at least a few people would say I turned out just fine!

You might have very different values and priorities than the patients you are treating. Your patient has the right to have different values than you, the dentist. I heard a speaker once say how horrible a parent was because he didn’t have money for his kid’s braces but he took his whole family to Disneyland. I’m good with that. I still remember driving from Kansas to California with five sisters in a green station wagon playing Monopoly in the back the whole way to Disneyland, without seatbelts, I might add, and it still is an awesome memory.

If you’re doing low-cost dentistry then treatment plan accordingly. Be aware of all the upgrades that are not covered like ortho, implants, bleaching, bonding and veneers. And if a patient only has enough resources or dental values for an amalgam, then place one.

I’m not a firm believer that the highest price is always the highest quality. Southwest Airlines is a testament to this. Southwest is the lowest cost airline and no one has ever died in one of its planes. If the plane doesn’t fall out of the sky, and it takes off and lands on time (and preferably doesn’t lose my luggage), it passes my test. High-cost dentistry isn’t necessarily the best quality or what’s best for the patient anyway. Which lasts longer, amalgam or composite?

You can never afford to get complacent and ignore your own unique dental marketplace. You must cultivate relationships and provide exceptional service at a fair price. The case of low cost dental offices and those who don’t participate is not about the quality of dentistry. It’s perceived value. Managed care fills a necessary market. For a free enterprise system to successfully exist, you must have different market providers for different price points. If this does not happen it is called a market failure and this almost always invites the government in to correct the failure. Do you want government-owned dental offices? If the answer is no, then start treating the low end providers with more respect.

Don’t try to dictate what people can choose or afford. That’s not your decision to make. They’re the consumers. They’ll make their own decisions as to how to spend their money based on what they want and how much they have to spend. It’s our decision as to how we deal with their choices. – See more at: http://www.dentaltown.com/Dentaltown/Article.aspx?i=351&aid=4778#sthash.v4VaGYlH.dpuf