Friday, April 29, 2011

Ethics during tough times

It's Friday, and I have had a tough week. Not tough like I am crazy busy but more emotionally draining. I think if I'm not that busy at work, it is really emotionally draining. So I got a lot of that stuff going on. And the Magic lost.

I am not that busy at work, and people have come in that have challenged my ethics. I want to talk about a couple of scenarios that have I had to deal with this week.

Here in Orlando, I deal with a lot of snow birds: retired people who have two homes. They have one home in the South for the winter and another home in the North for the summer. Great people for the most part. A little tough because you are not their only dentist, but for the most part, they are people with means and that makes it a little easier to say, "Hey, you have a cavity. We should fix this." Most of the time they say, "No problem. When?"

But I saw a woman yesterday and we were replacing an amalgam filling that had a hole in it. Then she had some decay on the incisal of #26 and a small cavity on the facial of #11. I told her that when people "mature," their teeth nerves get smaller and sometimes they don't even need anesthetic. I told her, "Why don't I start and if you have any issues please let me know." She was game.

The facial on #11 took about 2 minutes, the incisal took about 4 minutes, and the MO took about 12 minutes. After all the talking, after the fillings, all the saying goodbyes for the winter the max amount of time she was in my chair was 30 minutes - tops.

Now, in the talking time of this appointment, we got to talking about the cruise she was going to go on next week. I talked about how I am looking forward to the days where tuition for the kids, school loans, practice loans, and mortgages don't consume my thoughts. I am looking forward to being able to take my grown kids on cruises.

She then goes on to tell me that her and her husband love cruises and one time she paid for all her kids and her grandkids to go on a cruise - THIRTEEN PEOPLE in all. So, although you would never know it, this was a woman of significant means. Back to the 30 minutes in my chair. You are thinking, "What is the dilemma so far?"

Well, my one surface anterior restoration fee is $160; she got two of those. I then did a three surface posterior restoration which, in my office, is $280. If I charged her full fee this is a grand total of $600. For 30 minutes of my time? To me, this is too much. Some people might say, "This is what she got, this is what she is going to pay for."

Not me. I can't stomach charging someone $160 for something that really only took me 2 minutes to do. I know. I used products to clean the room, I used the same amount of bonding materials, but I don't want people to feel ripped off here. So she was going to pay for her and her husband's cleanings, her and her husband's x-rays and exams. So really if I charged her full feel, she wasn't going to notice because it was going to be expensive.

I just couldn't do it. I think I charged her the full fee for the posterior restoratio,n but only $100 each for the two facials. I took off $120 of the bill. Her total bill was $980. AND I am just finding out now that my front desk person told her how much it was going to be (full fee) before we started. So, she was even prepared to pay the whole thing. Arghh!!!

I still think I am ripping people off if I charge someone $160 if it literally takes me two minutes. But $120 more for the day would really be nice, especially if I do it 4 times during the day.

What do you do? Is it full fee regardless? Do you feel the same way as me? Let me know. I don't think I am devaluing myself; I just think I am being fair. Kind of the way I want to be treated. Like if you go to a mechanic

(definitely the sphitzer valve)

and you know that it doesn't take very long to do X but the book allows them to charge 2.5 hours of labor for that X. Just because you can charge something doesn't mean you always have to.

Okay, next one. I am a tooth saver. My Pankey training has brainwashed me to always thinking of ways to save a tooth (that can be saved). Now a guy comes with a tooth that is broken off at the gum line. The tooth could have been saved. But you know as well as I do this is some major dentistry.

He just got a new job and is going to be getting insurance soon. I start telling him how much it is going to be to save this tooth: $850 for the root canal, $375 for the post and core, $1150 for the crown. I am thought this was a ton of money for this guy, so I told him that I could put him on antibiotics until he gets his insurance stuff squared away with his new job. I just wanted to help this guy, but wouldn't just taking his tooth out be helping him too?

In last 10 years or so, I have softened my "not taking teeth out" stance. I have died on that hill before and I feel great about it. I have told people that they are at the wrong office if they want that tooth taken out. Some have actually gotten up and left and others have tried to save the tooth.

But $2400 could have been a month's worth of pay for this guy. He had missing teeth in two other quadrants. I think it can be done case by case. I don't think that prognosis on this tooth would have been excellent. It would have been good, but not excellent. Is it okay to just take 15 minutes and take this tooth out? He thought about it for a sec and decided to have it out, and I was okay with this.

I feel like I educated him on what his issue was, on what we could do, and on what would happen if he took it out. I let him make the decision. I took the tooth out.
I don't think I am selling out or doing him a disservice. I think I met a guy where he was at.

What do you think? Any Pankey guys out there who are shaking their heads at me?

Okay, that is it for this week.
Have a great weekend.


Anonymous said...

I see your viewpoint on the pricing/time equation, and also understand what the patient might think.

But a couple of things you might think about. First of all, sometimes things are speedy because you are more experienced or skilled. It takes me longer to figure out a case sometimes than some of my more experienced colleagues. Should they charge less because they can do it more quickly? Because it takes them less brainpower?

Also, do you get to charge above your standard fee when you start a procedure and it turns into a nightmare for some reason and takes twice as long as expected? When I'm stressing and taking forever on some difficult pigmented lesion, trying to figure out if it's melanoma, making more and more slides and showing it around to 5 other people and sending it out to an expert, the reimbursement is the same as if I am reading a straightforward basal cell carcinoma that takes 15 seconds. I figure, it all averages out.

As a patient of yours, I think you have knocked down the fee for me for something on at least one occasion because insurance didn't pay for it. I don't remember the details, and I never expected you to do it, and I could have afforded whatever it was. So, I'm glad you're a nice guy who cares, but maybe you do this a little too much :).

Just my 2 cents...

Anonymous said...

I'm just as guilty as you John, I am an associate and sometimes i get people who had some minor chip in the anterior occurring from some accident at work (for which they will be paid in full) but i still charge them for a simple MI (two surface) filling than MIBL. I just can't justify myself charging that much for a 10 minute procedure. I got in trouble recently for that from the owner of the clinic because he found out. But i still think i am doing the right thing. And it just reinforces my belief to know that i am not the only one doing it. You are doing the right thing and don't second guess yourself. Money or no-money, everybody should be treated the same unless your treatment option is different. Let's not discriminate.

And as far as saving the tooth-again, we do the same thing after going over the options with the patient. If it is fractured at the gum line and patient can't afford all the treatment right now, then flipper is the best option till he/she can afford an implant (if they want to). It is removable, and you are taking out the source of possible infection. But then again each clinical scenario is different.

It's great reading your blog... i look forward to each and every one of these.

Great work!


Kallie said...

one of my professors will do anything to save a tooth and thats the attitude i want to carry to practice, too, within reason. in school, what i am learning daily is that money talks. you told the patient you could save the tooth and then gave him other options if that was not how he wanted to spend his money. he was informed and then made his decision. sounds like you did the exact right thing. you cant make your patients want to save their teeth, ie you can lead them to water but can't make them drink.

drjudd said...

You did the right thing. You informed and educated and the patient decided what they wanted. You made the patient happy by doing what they wanted. Who knows later when he is financially better off he will ask you to do a bridge or by then you will have learned how to place implants and will do an implant/abutment/crown for $4500. If you said my way or the hyway you would have lost a patient and any possibly future income from treating him and any possible refferals.

I used to give people deals when I felt sorry for them but I seldom do now. Often times I find out later that they did have the means.

Anonymous said...

I think this is what irritates me- No patient disputes anything when they see a physician for a physical for under 20 minutes, meanwhile most of the blood work, radiology, etc are all done by other people, yet the physician will charge their full fee for their time. We are trained professionals that paid more money than we needed to perhaps for our education, board exams, licensure and the endless continuing education. We ought to be compensated fairly. Stand by your fee- it represents not only your costs but your expertise. While you may think those restorations were "simply" incisals, that patient was in your care. THAT is what she is paying for. She relies on you to make sure that the chip isn't the result of a larger microfracture originating from bruxing (just an example). She is paying you to pay attention to her tooth and to fix in a speedy but superior manner. So why the guilt? Just take a peek at medical or attorney fees, I'm sure they will make you change your mind!

gatordmd said...

I totally get what you are saying.
BUT how do you feel when you get rooked by the attorney or a physician.
Are you thinking, "I feel so good that he know so much and is taking such good care of me"
No you are thinking, "That mother @#$%er just charged me 150 f!@#E$%king dollars for showing his face for 1 f@Q#W@#Eking minute."

Is that what you want your patients to think of you?

I understand the whole education thing but...
That isn't going to endear your patients to you.


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