Friday, June 24, 2011

What choice does she have?

Happy Friday!

I don't know if I told you, but my family and I are going out of the country tomorrow. Yeah, my wife's family is in Miami and we are taking a trip there this weekend. Miami is so crazy, I feel like we are not in the same country. There are people everywhere and they all drive crazy, people speak a different language and I don't know my way around. But they all smoke cigars and I am cool with that.

Kind of going along with what we have been talking about, I had a patient come in last week. Good patient. She has been a patient here for about 7 years. Married with a couple of kids. Husband comes here but the kids go to a specialist.

This particular person is a bit money-conscience. What I mean by that is she might say, "Will my insurance pay for that?" Or, in June, "I had a lot done this year and I know I am out of benefits, so I don't want to do that cleaning appointment until next year."

But, you know, she did ortho about 3 years ago. She needed perio surgery a couple years back and I sent her to my periodontist. She decided to go to a specialist, (that I was not that familiar with) on her insurance list. Kind of like that.

She came in and had broken the Facial cusp off of #5. The break went right through the pulp horn. The nerve was just sitting there. We all would do the same thing: this tooth needs a root canal. It needs some sort of build-up depending, on how big the break is, a post and core or just a CorePaste build-up, then a crown. The day she came in I happened to be wide open.

I told her all this could be done that day if she had the time ("Please, please, please have the time.") She made some calls to work and she was in for the long haul. Sa-weet. She asked, "Is this going to be expensive?"


All we talked about was money. Then we got started. Root canal turned out great.

For some reason, the back-fill didn't go all the way down, but the apex looks Tres bon. Things were going great. Move to step II. We did a post and core, and it turns out fine.

Move to step III. Prepped the tooth for an onlay. There was a pretty good chunk of the ling cusp left. I took it down 2mm and did basically a 3/4 crown. Impression came out like money in a bank. Locked on a temp and she was done.

My morning turned out great. Great patient, work was great, made some money (a lot more than if I was doing a couple fillings, which would make my friend happy). Just good all around. I am on cloud nine for the rest of the day.

I called her that afternoon to see how she was doing. I left a message on her voicemail and left all my digits. She sent me a text. "Everything seems fine....I was a little shocked it cost $2300....thanks." There goes cloud nine.

I guess part of my being happy is that my patients are COMPLETELY satisfied. Not kind of satisfied. It's a "value my work, value me" kind of thing. I mean, my root canal fee for a premolar is $825. My post and core is $375 and crowns are $1150. Nothing too crazy, I don't think.

Let's just say my fees are a little higher than yours. So let's lower them. Let's make my premolar root canal is $725, my post and core fee $275 and my crowns an even $1000. It is still going to be $2000. It is still expensive. It is still going to blow her insurance benefit out of the water.

I know. I know you are going to say, "Didn't you discuss prices before you started?"
And that would be a valid question. The short answer is no. I told her what she needed. I told her, "You did a number on your tooth. You are going to need a root canal and a crown."

This is an educated woman. She has plenty of dentistry in her mouth. She knows the cost. So if I had said, "This is going to cost you $2300." What was she going to do? Not do it and have a hole in the front of her mouth?

I am going to talk out loud for a sec. If I need tires on my car, I go to the tire place. I know that tires are expensive. I know if I walk in there and say I need four Bridgestones, it is going to be about $600.

If the guy behind the counter says "Well, they are $150 a piece," what are my choices? Do I get one at a time? Do I get two at a time? No, I suck it up and get tires. I NEED THEM. And doing one or two at a time is just going to make the wear on the tires different and it is not really good for them or the car anyway. Nothing I do is going to make $600 not $600. And if I don't have it? Well, that is what credit cards are for. I pay with a credit card and pay it off slowly. But I am not going to be angry with the tire guy because tires are expensive.

She could have said, "Well, I only want to get the root canal today and I want to do the post and core and crown next year when I have full benefit on my insurance." Then she would have a broken down tooth in her mouth for almost a year. A disaster waiting to happen.

I know most of you deal with this same thing. And probably most of you just blow this off. I kind of do too. I have to blow it off. She is just venting. I think she likes me and kind of values my work. What more can I ask for, right? I don't know. I must have a screw loose somewhere. I can't get over people not being 100% satisfied.

I am going to stop here because it is Friday and I am supposed to keep it short. I would like to know your thoughts. Do you have the same issues? Do you think I did it wrong?

Have a great weekend.


jamie said...

i think that you were right on with your treatment. if i was concerned that her eyes were gonna pop afterwards, when she saw the final treatment cost, i would have perhaps given her at least a verbal estimate of cost up front (get front desk staff to make one up while you're talking). just so that she has an idea of what's coming. i do that all the time, simply because i hate dealing with the "i had no idea it would cost this much". even educated people are ignorant to such things (i'm the same way when i go to the mechanic...i like a ballpark cost of what the total will be).

just a question tho; does the $1150 for a crown include lab, or is that the dentist fee only? just curious.

Barry Polansky said...

You did everything right. Her response is out of your control. She took responsibility by saying "yes." Have a great weekend ---put this behind you. You have nothing to feel bad about...nice work by the way.
Barry Polansky

Joe said...

I think you handled it pretty well but like first commenter I would have had staff go over cost figures so there were no surprises. Similar situations in my office have resulted in a cost-dictated compromise: root canal, post & core now, crown later. I know the post & core will hold up and look reasonably good--but not so good that they will not come back for the crown.

Joe said...

I think you handled it pretty well but like first commenter I would have had staff go over costs so there were no surprises. Similar cases in my office have resulted in cost/affordability-dictated compromise: root canal, post & core, then crown later. I know post & core will hold up and look reasonably good but not so good they will not come back for the crown.

Anonymous said...

Did the tooth really need an endo? if it was a vital recently exposed pulp with no periapical pathology,not tender to percussion and no history of irreversible pulpitis/spontaneous pain, how about a direct pulp cap with MTA (a cvek pulpotomy) and then a bonded core?wait to see if it has worked,then consider an onlay.

i would say there is a decent amount of evidence to support this technique in mature teeth with exposed pulps in crown fractures. unless you had lost the lingual cusp as well and needed a post for retention for the core then an endo would be the only way to go.

im not questioning your strategy as a traditional treatment option.just consider that there might be a more conservative and cheaper way to potentially treat this situation.the situation she is in now is the last step in that tooth's life cycle.once it fails,in lets say 15-20 years at best,the tooth will need to be extracted.if we can delay doing this as long as possible would that not be beneficial?

once again not criticising, just a different your blog by the way,keep it up!

Anonymous said...

You both are at fault. She did not ask the cost and you did not tell her the cost. You should know better than that by now. For the timely service, doing a great job and doing it in one appointment, your fees certainly justified.

Anonymous said...

Hey John, I think you just summed it up best yourself - the patient may have needed new tires before a new tooth. We all deal with them the best we can. It's the bain of our existence and I too sit in my pool and wonder what the hell went wrong. The only way to manage these cost issues is to provide a written estimate of costs before treatment. It's the patient who, now informed, will decide what is "needed" or not. On another note about your fees, I live in BC and our provincial fee guide is 466.90 for a 2 canal RCT, the post is 141, the comp core is 139 and the crown is 643 plus lab (280-300). And no, I don't have a pool or live in Florida for that matter. If you raise your fees 10%, you will lose 20 % of your patients but you will make more money per patient. Sort of quality, not quantity. But, I believe it was Lenin who said that "quantity has a quality all its own". If you aren't busy, which I am not right now either, you should lower your fees to keep a competitive edge. Very few people understand "value" versus "cost". And I don't think there is anything we can do to alter that perception. So we just have to work with cost and try to emphasize value, like your dad, at any chance we get. Oh, and to the second last writer, that tooth needed an RCT 100% of the time, not just for the infected pulp but also for retention with the post. An endo that looks good won't fail in 15_20 years "tops" like is suggested. This guy must be pretty new. Ah, I remember the days...

gatordmd said...

I appreciate all your comments.
I agree that getting it all out of the way up front is probably the best way.
But you know sometimes you just don't feel like messing with all that.
And again, she agreed to the treatment. Who is responsible to ask for the fee?
We could debate all day on this one.

Now about the pulp horn. I first have to tell you that I would never take any offense to someone discussing treatment options in a non offensive way. I actually appreciate it. I appreciated your opinion and the way you said it.

I have to say that I debated not doing a root canal. But because so much tooth was gone and the pulp horn exposed I needed to do a root canal and a post and core. There was quite a bit of tooth gone AND he is a major grinder (hence the reason for the break in first place) so the post was a must.

Thanks again everyone,
Loved the "work with cost and emphasize value".

This was definitely good conversation.

Michelle S. Weddle said...

She said she is a little shocked at the price, but she didn't say it was too expensive or not worth it. She said thanks after mentioning the price. She also said everything was fine. Her comment about cost is probably her usual comment about the cost of anything - as per the history you described. She probably would have thought $1000 was expensive. But she didn't say that she didn't find the value in your work. Plus, if price was a concern, she was educated enough during previous occassions to ask about insurance and delay treatment. The fact that she didn't bring up the fees meant that she knew that she needed the treatment.

Re: treatment, RCT post/crown on a bruxer - I think most of us will agree with this. Sure you could do it other ways, but this is the most predictable. And if she was cost conscious to begin with, I doubt that she will agree to a treatment that you would have to come back and redo later if it doesn't work out. And I disagree with the comment that said that there is no other option for this tooth now when it fails but extraction. 2 of the top 4 reasons for crown failure is decay and need for endo. You already took care of the endo. You just have to watch out for decay. And I've replaced plenty of crowns with another crown due to decay. No extractions yet unless the patient hasn't seen a dentist in 10-15 years and they come in with crown in hand because it's all mush. Even then, cast posts are there for a reason.
Don't sweat this. You did the right thing, and the fact that your patient is still w/ you after 7 yrs shows that she appreciates your work.

But to answer your question re: What choice did she have? I'm assuming that you're not a "participating provider w/ her insurance", so if she did not have the treatment with you, she could have gone to a dentist who participated with her insurance plan. I'm in NJ, and the average cost for this treatment w/ insurance fees would have been around $1884 (crown -$890 including lab; post/core $212; rct $782), with insurance covering 50% of post & crown and 80% of RCT on average. So that would be her only other option. But since we already established that she valued your work, it probably wouldn't have been an option that she would have liked.

gatordmd said...

Thanks Michelle,

Great comments. I appreciate it.
Hope you are liking the blog.


drtomas said...

I realize my comment is way behind the bus, but here's my 2cents anyways......I would love to meet the patient that truly understands is a supplemental benefit, not a cover-all/cure-all for their teeth and wallet, otherwise their dental insurance would cost as much as their "rest of the body" insurance with regards to premiums and co-pays. But we understand that. I understand the UCR but who am I to tell you what is high or low. I think you should charge whatever you want, the market will dictate where you end up.


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