Diagnosing surgeon

Dentistry is procedure based. Generally speaking, we do all kinds of procedures to fix problems with the teeth, gums and jaws. That’s what dental school trained us to do. With the exception of some newer “medical model” treatments, most dentists spend their days doing fillings, crowns, root canals, extractions, placing implants, making removable prostheses and doing periodontal therapy. These procedures typically have a starting point and end point (except dentures in dental school…those never really end) that is easily denoted.

That isn’t to say that dentists aren’t diagnosticians. We become expert at recognizing all kinds of pathologies of the teeth, gums, jaws and muscles. In order to treat our patients effectively (usually using procedures at which we become more and more proficient), we need to effectively diagnose their problems and communicate to them what we’ve found and their options to treat (or not treat) as the case dictates. Most dental offices are one stop shopping unless the dentist chooses to refer procedures out to specialists.

Broken armOur colleagues in the medical industry operate differently. In many cases the physician that diagnoses the problem doesn’t actually treat the problem. If I fall off a ladder and break my arm it’s likely that an ER doc is going to assign a differential diagnosis to the problem and order a radiograph that’s read by a radiologist, who diagnoses the fracture. At that point, it’s likely that I would be referred to an orthopedic surgeon to treat the broken arm.

What you don’t see very often in this multidisciplinary track of care is the patient being concerned that there is “overtreatment” going on. For one thing, it’s often very problem based. I wouldn’t have shown up in the ER if my arm wasn’t bent in a funny direction. For another thing, there are several clinicians that are coming to an agreement about the care you’re going to receive. That’s a big difference from what typically happens in dentistry. Not that we don’t refer to specialists, but it’s pretty rare that a patient’s diagnosis and treatment plan is put together with that many brains.

Some patients, especially ones that don’t know you very well, may believe that you are treating problems that they don’t have. A big cavity can remain painless until the pulp is involved. Sometimes even after the tooth is abscessed the patient doesn’t feel pain. Gum disease is almost always painless. Often the patients don’t realize they have a problem even though it’s obvious to you as a clinician. I find this to be one of the less fun parts of being a dentist. I’ve got to be the guy to deliver unexpected news in a way that doesn’t seem like I’m hoping to cover my boat payment. And it’s always a boat payment, right?

Spear Online education posted a video that I found helpful. It’s entitled “Managing Fear When Presenting Findings to Your Patients.” I related to a lot that he discussed. One thing I walked away with is that presenting findings is a lot different than presenting a treatment plan. That may seem obvious to you, but sometimes I get hung up in that. When I’ve got two hygiene checks per hour and I’m doing a bunch of time consuming restorative dentistry at the same time, I often don’t separate the two.

“A treatment plan scares people away.”

Dr. Frank Spear

I need to remember to share the findings of my exam. A few months ago I moved my microscopes from my treatment operatories to my hygiene operatories (I only have two scopes). Each one of the microscopes has an HD camera that’s connected to monitors in the operatory. I do all of my hygiene and new patient exams through the microscope. This has been the greatest tool I’ve ever used to explain conditions to patients without automatically moving to a treatment plan. Also, I get a lot less of the “boat payment” comments now, too. I’m still just beginning with this technique. I think my patients have a much better understanding of their condition than I’ve ever been able to offer. Another pleasant surprise…treatment acceptance is way up!

I just need to remember that my exams are not just a way to create a treatment plan for a patient but a chance to explain the conditions that I’m seeing to the patient. It’s about diagnosis and education. The treatment plan will come from that discussion.

Questions or comments? Please leave them in the comments section below or email me at alan@meadfamilydental.com.  If you’re a dental peep you owe it to yourself to listen to my dental podcast. It’s called The DentalHacks Podcast and it’s made with 50% unicorn tears and 50% sweat from Chuck Norris’s brow.D

Human first

I had two patient interactions this week that got under my skin. I hesitate slightly to write about them because they may come across as petty to some. But I think they illustrate an interesting perception about dentists and maybe health care providers in general.

The first thing was a patient that came in with “an emergency.” In my office, the patient gets to decide what an emergency is. We go out of our way to see people with emergencies as soon as we can. Quite often we see emergencies the same day that they call. This patient had made an appointment to be seen by a hygienist the day before and didn’t show up. They also didn’t call. Honestly, that’s strike one. I feel like grown ups that schedule their own appointment should be able to show up and if they can’t, a phone call or some other acknowledgement is the least a patient can do unless there’s some kind of emergency that keeps them from contacting us (which of course, we understand). As you may have guessed, they patient has missed appointments before. Furthermore, the patient showed up 15 minutes late for their “emergency” appointment the day after. No apologies for being late. Nothing.

I saw the patient and was pleasant and professional, but purposefully aloof. We took care of the emergent problem and made a plan for a long term fix.  I probably was not my normal “bubbly” self. Frankly, I was annoyed. The patient didn’t show the day before, showed up late today and had an “emergency” that consisted of a broken tooth that has been treatment planned to fix for years. Literally years.

phone photo smallLater that day we received a phone call from this patient. They wanted to give us some customer service tips. They told us that because we didn’t seem all that busy that I should have spent more time explaining what I was going to do instead of chit chatting about things that didn’t have to do with the patient.

You can’t make this stuff up.

The second interaction happened later in the week. We got an “emergency” call from a patient that we hadn’t seen for a long time. They prefaced the call with “I don’t have any money…” Of course we saw the patient, did and exam and made a plan. Furthermore, we helped explain ways that we could help them afford dental treatment and even helped them find another provider that might take their government provided dental benefits.

I understand that some people aren’t in a position to pay for ideal dental care. I feel bad for them and we always go out of our way to try and help them. But I always wonder how that same phone call goes with the grocery store.

“Hello, this is Kroger. How can I direct your call?”

“I need some cantaloupe, but I don’t have any money.”

“Ummm. Well, we have cantaloupe, but we sell them for $2.15. I’m not sure what else to tell you…”

So now you’re either totally empathizing with me (which probably means you’re in the dental field or you’re some other kind of health care provider) or you think I’m an insensitive jerk. But there’s a little bit more to this.

How do people get to a point where they feel this is appropriate? I’m pretty sure it’s because we don’t think of health care providers as people. The fact that we think of them as “professionals” means that we hold them to a different standard. It’s almost like we don’t think of them as providing a service in the same way that other service providers do. Because we have specialized skills and a license granted by the state, health care professionals are different.

In fact, they are somehow less human. Doctors are not allowed to be irritated by my behavior because they’re doctors and I’m a sick person. A nurse in the ER has to be nice to me even when I’m acting unreasonably because I’m the patient and she’s the nurse. Dental offices cannot hold me accountable for appointments that I’ve made because they are health care professionals and I’m a patient.

Patients and providers alike, I’m going to let you in on a little secret. We’re all human beings first. No matter the skills we’ve accumulated and positions we hold, we’re still just relatively fragile and mostly squishy bags of emotion and meat. All the degrees and training in the world won’t change that.

Since that is undoubtedly the case, I want everyone on each side of the patient/health care provider to acknowledge this. There are always consequences to the way that you treat others. That doesn’t mean your surgeon won’t do their best for you even though you treated them like a jerk. However, they may be less likely to worry about your feelings in a post op exam. And dentists, if you’re paternalistic and not particularly kind to your patients, they may well decide to find an office that they feel like appreciates their presence more.

For the people that treat everyone poorly, there’s probably nothing that can be said that would change your behavior. But if you ever wonder why people don’t like to be around you very much, you might take a look in the mirror. For everyone else, I’d like to make a suggestion.

If you’re a fearful patient, be honest with your dentist. Starting the appointment with “I hate dentists” goes over differently than “doctor, I just want you to understand that coming to the dentist makes me really anxious.” I’d much rather work on a patient who tells me the latter. Dentistry has lots of options available to anxious patients to make treatment easier. But if you just tell me that you hate dentists it doesn’t help me understand your fear and it makes me think you don’t like me. Who wants to work on a patient that doesn’t like them?

As an FYI…I hear that “I hate dentists” line at least weekly. Maybe more often. Every dentist will tell you the exact same thing.

For the patient who starts the conversation with “I have no money,” it’s kind of similar. I’d much rather you tell me, “doctor, I have concerns about how much treatment is going to cost. I don’t have much of a budget for dental care right now and I need to know my options before you get going.” I don’t know a dentist in the world that isn’t going to help with that. Seriously.

The point is that health care providers put their (scrub) pants on the same way everyone else does. It’s worth remembering that they are human and have feelings just like everyone else. They are likely to respond to the way you present yourself the same way everyone else does.

Health care professionals…this works the same way for you, too.

Questions or comments? Please leave them in the comments section below or email me at alan@meadfamilydental.com.  If you’re a dental peep you owe it to yourself to listen to my dental podcast. It’s called The DentalHacks Podcast and it’s made with 100% fresh squeezed awesome.

 

Doing reps

Let’s say you need a procedure. Perhaps a filling or a crown. You have a choice between two dentists to do the procedure for you. You can choose yourself at this moment or you can choose yourself 10 years ago. Or 5 years ago. Or 20 years ago. The point being you are choosing yourself at a time when you had significantly less experience than you do right this second.

Who would you choose? I’d wager that you would choose yourself at this moment. Why is that? It could be that you’ve started using a new instrument or learned a new technique. It could be because the technology has come a long way since you were the other you. But most likely it’s the reps you’ve put in.

I look back on some of the work that I did 15+ years ago. Some of it I’m kind of proud of, but more often I cringe a little. I see underprepared crowns. I see overprepared direct restorations. Mostly I see things that were done to the very best of my ability at that time. Which is good. But much of it I would do quite differently today.

When I was a newly licensed dentist I planned to take the world by storm. I thought I knew a lot. And let’s face it, I did. I knew how to pass tests. National boards, clinical boards, microbiology exams, operative practicals. I knew how to play within the rules that were set by others that proved I was qualified to be a part of the profession.

What I didn’t know a lot about was how to be a dentist. I had done a bare minimum of clinical work on patients. I sometimes complain about how little clinical training I had, but let’s be honest. How much would have been enough? If I had done 5 more crowns in a setting where I had to check in with an instructor at every step would that have made me “experienced?” Probably not.

I’ve become the clinican that I am through reps. I’ve diagnosed real disease on real patients and then treated them. And make no mistake, I’ve learned how to treat patients by treating patients. It isn’t that I’m asking patients to be guinea pigs. But to some extent I ask them to believe in my abilities and experience up to that day.

Your patients trust your judgement and ability even though they really can’t know much about either. A poorly done restoration can be done painlessly. I’m not trying to make newcomers to the profession feel bad. You can’t get experience without doing the reps. But understand that most of us learn best by doing. I was never any good at reading the directions and then doing exactly as the directions said and having success. Those directions were written by someone with experience but were being read by me: someone with much less or different experience. For me, dentistry is a “learn by doing” profession. The only way I learn is by being open minded enough to see that there are different ways to get the job done and being patient enough to try something new.

The profession continues to evolve and as clinicians we evolve as well. I believe that most of us really do the best that we can at any given moment. But make no mistake, we get better by doing reps. This isn’t an excuse to be cavalier about treatment but a call to humility. Do your best, but be committed to being better next time.

Delivering bad news

Most dentists have gotten really good at the delivery of bad news. Most of us are pretty good at explaining our findings in a dispassionate way. We’re supposed to explain what we’re seeing, recommend different treatment options, explain the pros and cons of each option and then let the patient ask questions and make a choice. The trick is that you can’t own the patient’s problem. It’s really important that you don’t care more than the patient does.

Straightforward stuff, really. I mean, it’s not like we’re oncologists or something. The great majority of dental problems are not life and death.

I’m here to tell you…I still struggle. I’m not as good at delivering the bad news. I sometimes struggle because I do care more about the problem than the patient does. I think that’s because I understand the problem better.

Tooth decay doesn’t hurt until the tooth is in real trouble. Gum disease is painless right up until the teeth get wiggly. I see what’s going on in their mouth in HD. I use high powered loupes or even a microscope to see what’s going on and sometimes it’s hard for the patient to get as concerned about it as I do.

Some days I get really discouraged about it. I’ve got to let people know what I’m seeing. Modern dentistry can do some amazing things, but getting people to choose that is the difficult part, in my opinion. Some days I get burned out. Sometimes I have patients with multiple and serious problems that have no clue. That is so hard for me. It’s times like those where I don’t even know where to start.

But I’m a doctor. I owe my patients the truth. I don’t have to be mean about it, but I have to be truthful to the best of my ability. Patients need to understand that I don’t enjoy giving bad news any more than they enjoy hearing it. But we’re in this together. They always have the choice to do nothing, but my duty as a doctor is to let them know what’s going on and give them ideas on ways to treat it. We’ll get through this together.

medical insurance vs. dental “insurance”

“Dental insurance” isn’t even close to being actual insurance. Real insurance is about investing a small amount to help manage the risk of rare but potentially catastrophic events. From Wikipedia:

Insurance is the equitable transfer of the risk of a loss, from one entity to another in exchange for payment. It is a form of risk management primarily used to hedge against the risk of a contingent, uncertain loss.

You buy car insurance in case of a car accident or theft. These are relatively rare events, but they’re also undesirable events. You’re glad  you have insurance when you have a car accident, but rational people are more interested in avoiding them.

Even “health insurance” (which is probably better termed medical insurance) is mostly like real insurance. You (or your employer, or the taxpayers) pay a premium so that catastrophic and expensive medical treatment is available to you if you need it. Imagine someone having some kind of cancer and their medical insurance carrier explaining to them: “I’m sorry, but you’ve spent all of your insurance dollars this year on that broken wrist back in February so I’m afraid you’re going to have to wait until January for your chemotherapy unless you just want to pay out of pocket.” The ramifications of the ACA (a whole other topic) notwithstanding, the idea of health, or medical, insurance mostly lines up with what real insurance is about.

Dental “insurance” is a contract, usually between your employer and a 3rd party payor. If a patient breaks a tooth or needs a root canal their benefit should pay a certain amount each year for certain procedures specified by the contract. The insurance company isn’t interested in your dental health. They are interested in paying out as little as they can while still staying within the specified conditions of the contract. In almost all cases there is a maximum dollar amount that the insurance company will pay and no more. What you’re getting here is a crappy gift card that pays toward some dental treatment. This has been covered by myself and others ad nauseum and isn’t really the point of this rant.

Something that’s really important to realize is that the patient’s dental health and potential need of dental services is completely independent of what dental benefits they have. You can have a low caries nonsmoker with a premium dental benefit that only uses a small amount of the dental benefit for prevention or a chain smoking, pop drinking dude with ectodermal dysplasia and “Healthy Kids Dental.” The two things have no bearing on each other.

So, is it reasonable to ask the question: “what’s the right amount to spend on dentistry in a given year?” Not really. This is obviously going to depend a lot on the patient’s individual risk factors and habits. However, I promise you that insurance companies have given a lot of thought to that question. I would suggest that the dollar amount of a patient’s dental benefit has a huge bearing on what they perceive as being the right amount of treatment necessary.

For many, perhaps most of our patients, the right amount of treatment in a given year is how much their insurance will cover and no more. I think this comes from the experience we have as patients with medical insurance. When you go to the doctor’s office or hospital for something, there is an expectation that your insurance will cover any services there. It’s rare that there is a conversation about costs incurred by whatever services the patient receives. Whether it’s a $200 office visit or a $50,000 knee replacement, it’s a reasonable patient expectation that their medical insurance is going to cover it once their deductible (if they have one) has been met.

This is not so with dental benefits. If a patient needs a certain amount of dental treatment and it costs significantly more than any given year’s benefits, they’re less likely to pursue any treatment at all. I promise you that insurance companies are banking on this reaction.

I think this is where patient expectations get mixed up. Medical insurance covers what you need, no matter what the need is. If they apply this logic to their dental benefit, then whatever their dental benefit amount is must be the right amount to spend on dental care! So clearly if a dentist diagnoses a patient’s dental needs and it’s more than their insurance will cover, a patient might become suspicious of the diagnosis.

This is a complicated problem. To pretend that patients simply don’t value dental treatment enough is short sighted. It’s probably accurate for some people, but for others they just can’t or won’t spend any more than they need to on dental care. People react to incentives and if a patient has dental benefits, they’re going to want to use them. After all, they paid for them…either directly or indirectly. They shouldn’t be made to feel ignorant for wanting to use the benefits that they have. But I think it helps to illustrate the differences between medical insurance and dental benefits and how that plays into a patient’s expectations of how much treatment should cost.

 

Meet the new guidelines. Same as the old guidelines.

Yesterday, the American Dental Association and the American Academy of Orthopedic Surgeons released new, evidence based guidelines regarding antibiotic prophylaxis before dental treatment in patients with joint replacements. The press release states that there is no evidence that dental procedures cause joint infections. Prior to this statement, we were to assume that a dental cleaning or placement of a filling had a special and dangerous power to seed the blood with frightening bacteria that somehow knew to go directly to the joint spaces of innocent artificial knees or hips with the malicious intent to infect.

For years I’ve been complaining to anyone who would listen about the joint replacement conundrum. Even though there was no evidence that premedicating patients was doing anyone any good, we did it. Because giving a patient a giant dose of antibiotics before having dental treatment is a much better option than having to treat or replace an infected joint, right? So just shut up and give them the antibiotics, Doc.

And that’s what we do. Each time I consult with a patient’s surgeon I get similarly frustrated. Some surgeons want premedication for the the rest of the patient’s life. Some surgeons want 6 months. Some want 2 years. Some think Amoxicillin is the way to go. Some say it’s Keflex or nothing. The one thing that all surgeons agree on is that they aren’t going to write the prescription for the antibiotics. That’s the job of the dentist. Which also means it’s the liability of the dentist. Let’s face it. Some patients can develop hypersensitivity to antibiotics and a huge dose of antibiotics could cause a reaction. Even a potentially severe reaction. And no one wants to be the one who wrote that script, right?

Let’s just get this out of the way. Most dentists don’t believe we’re doing a valuable service by premedicating our patients. Most of us know that eating a Dorito is at least as great of a risk as a dental cleaning for seeding the blood with oral bacteria. But we’re not rushing to premedicate patients prior to Dorito consumption. We’re doing it to cover our asses! We’ve been trained to cover our asses about this stuff since dental school. It has nothing to do with excellent patient care and everything to do with making sure we did everything right so that if some future joint infection or infective endocarditis event comes along we can prove that “it wasn’t us.” If it was really about excellent patient care, we’d have the ADA lobbying Frito Lay to bring out “Blazin’ Amoxicillin” Doritos.

I’m a dentist. My strength is treating dental disease. I’m a pretty smart guy, but frankly I’m not really up on the real risks of artificial joint infection or antibiotic allergies. How can I be expected to weigh the likelihood of two incredibly rare but very serious outcomes (joint infection vs. antibiotic reaction)? I don’t think it’s legitimate for the dentist to have their own policy. How about if the professional group that represents me, the American Dental Association, gives me some solid guidance so I don’t have to worry that I’ll be 1) harming my patients by not correctly weighing the risk factors and 2) you know…the lawyers.

But now, the evidence (or lack thereof) is in! We can stop worrying about the premedication for people with joint replacements because there’s no evidence of harm, right? 

Ummm. No.

What the joint ADA-AAOS actually gives us are 3 “guideline recommendations.”

But recommendations are good, right? After all, the American Heart Association passed down (many times!) their recommendations on stone tablets for all dentists to know and heed! And by following recommendations it means that the lawyers can’t get us! I mean, as long as we follow the recommendations!  

You’d think so. I mean, you’d think that having recommendations from the two big professional groups representing dentists and orthopedic surgeons would give us actual guidance on this issue. But it’s just not true.

The ADA-AAOS statement made me skeptical almost as soon as I started reading.

This summary of recommendations is not intended to stand alone. Treatment decisions should be made in light of all circumstances presented by the patient. Treatments and procedures applicable to the individual patient rely on mutual communication between patient, physician, dentist and other healthcare practitioners.

I read that and think, “these guidelines are perfectly fine, except you still have to evaluate patients on a case by case basis and if you get sued, we don’t have your back.”

I have to admit that I haven’t taken the time to read the full guideline, so my comments are based on the summary. The full guideline is somewhere around 100 pages and my own inability to concentrate for that length of time (thanks, internet!) has kept me from reading it. If someone does read it and find that I’m completely wrong, please let me know. I’d love to be wrong about this.

The recommendations strike me as incredibly watered down. They seem to be written as obliquely and indirectly as possible. Then each of them is given a “strength of recommendation” rating which means nothing to me. And they know this. So they give a definition about the strength of rating. Right after they give the strength of the rating. Honestly, it’s kind of bizarre.

The first recommendation addresses the use of prophylactic antibiotics:

The practitioner might consider discontinuing the practice of routinely prescribing prophylactic antibiotics for patients with hip and knee prosthetic joint implants undergoing dental procedures.

I might consider discontinuing antibiotics. Sure. I might. I might consider explaining my position to the patient, too. I mean they are the ones that are taking the very slight (but real!) risk here. But did I really need a recommendation from the ADA and the AAOS to tell me that I might think about it?

Further bolstering my opinion of this recommendation is the “strength of recommendation” score it’s given: “limited.”

A Limited recommendation means the quality of the supporting evidence that exists is unconvincing, or that well-conducted studies show little clear advantage to one approach versus another.

Practitioners should be cautious in deciding whether to follow a recommendation classified as Limited, and should exercise judgment and be alert to emerging publications that report evidence. Patient preference should have a substantial influencing role.

Recommendation 2 speaks to the use of preoperative topical oral antimicrobials:

We are unable to recommend for or against the use of topical oral antimicrobials in patients with prosthetic joint implants or other orthopaedic implants undergoing dental procedures.

So, they won’t say whether use of chlorhexidine prior to your filling is worth it or not. Great. Thanks for that. This strikes me as unnecessary because the risk profile of a swish of Peridex is a lot less than a megadose of Amoxicillin. In any case, they want us to know that we should feel “little contraint” in deciding whether to follow this recommendation. Gee, thanks.

Finally, the most bizarre recommendation.

In the absence of reliable evidence linking poor oral health to prosthetic joint infection, it is the opinion of the work group that patients with prosthetic joint implants or other orthopaedic implants maintain appropriate oral hygiene.

Really? Was there a time when I was supposed to be telling joint replacement patients that the risk of joint infection was so great that the shouldn’t floss? Or am I to assume that the ADA and AAOS feel that maintaining oral hygiene is vital to the health of an artificial joint? Honestly, I don’t even know what they’re trying to say. But at least they all agree on it. They give this recommendation a strength of: “consensus.”

A Consensus recommendation means that expert opinion supports the guideline recommendation even though there is no available empirical evidence that meets the inclusion criteria.

I had high hopes that the ADA would come through for us on this issue. I was hoping for an “AHA-like” guideline that would take the guessing out of this very common event for dental patients and dentists alike. It didn’t happen.

The most hopeful statement I got from the new guidelines is this:

Patient preference should have a substantial influencing role.

Although this statement was made specifically in reference to recommendation 2, I think it’s worth contemplating for the whole thing. Taking a large dose of antibiotics prior to dental appointments is not a risk-free event. I honestly don’t know if the data exists to weight the risk of taking antibiotics against the risk of joint infection at the dental office. I think patients can and should be part of the decision here.

The whole inconclusive data issue cuts both ways. Sure, there is no data to conclude that dental treatment causes joint infections. However, outside interests can just as easily claim that there isn’t data that dental treatment doesn’t cause infection in artificial joints. As a profession, we’re in the exact same spot that we were before these so called recommendations came out. We’re still going to cover our asses for the wrong reasons. It wasn’t good medicine before and it still isn’t.

What do I think should happen? I think the ADA and AAOS should sound off like they’ve got a pair. I think they should put a statement out that they’re going to help fund research on this topic to really answer the question and in the mean time they need to make a statement to dentists that “this is the recommendation and we’ve got your back if there’s a problem.” I think that the ADA should set aside a fund for the inevitable legal challenges that will come along to such a definitive statement and let member dentist’s know that they will be represented. It’s time to do the right thing for the right reason.

Am I right on the money? Am I completely dead wrong? I’d like to hear what you think. Feel free to leave a comment here or email me at alan@meadfamilydental.com.

 

 

 

 

 

The check stops here

Imagine yourself sitting at a long table of friends in a restaurant. You’ve all come together for a big meal. Everyone is hungry, the restaurant is supposed amazing and the company is lovely. It’s been awhile since you’ve all been in one place and it’s nice to see each other. It’s only slightly awkward that one of the guys, Bill, is wearing handcuffs. It works out O.K. a couple of your friends help Bill eat and his conversation is dazzling, so it ends up being no big deal. 

Dinner is amazing! Seven courses. The finest wine. A terrific dessert. One of the best meals you’ve ever had. Then the waiter brings the check. Your buddy Joe picks it up and takes a peek. The look on his face says it all! Dinner was awesome, but clearly…so is the bill. And Joe passes it to Fred. 

Fred looks at the check and the color fades from his face. Then he passes it to Jill, who just glances at it as she passes it to Mike. Mike grabs a pen and adds it all up and figures a tip. “Yup,” he says. “It’s right.” Then he passes it to Larry. Larry gazes at the check and starts laughing…hard. Then he passes it to you. You don’t even bother seeing how bad the damage is. You just pass it on to Steve.

And so it goes. All the way around the table. Finally, John puts the check in front of Bill. He looks up at the table sheepishly as everyone else gets up. Slowly, the table clears except for Bill. Alone. With the check.

The Patient Protection and Affordable Care Act was signed into law on March 23, 2010. Some of the act has already gone into effect, but much of it will continue to go into effect over the next year and a half. On January 1, 2013 an excise tax on medical device manufacturers will go into effect. The tax will cost manufacturers of medical devices 2.3% of their revenues. Many have complained that it will kill innovation in medical technology. A 2.3% haircut on revenues at the level of the manufacturer is noticeable. A startup company may be operating on pretty tight margins so 2.3% of their revenues could amount to a large percentage of their profits.

I’m a dentist. Also, I’m a human being and I generally think about things in terms of how they will affect me. I love Ultradent, GC, Tulsa Dental and the rest as much as the next dentist, but they’re going to pay this tax. Not me. Right? Well…I’m not so sure.

Yesterday I received a fax from my primary dental supply company. They have received notice from dental supply and equipment manufacturers that this tax is going to cause them to raise their prices at the beginning of the year. The fax said that the increase would be upward of 5-6%. The supply company wanted me to know that they’re going to do their best to hold the line, but in no uncertain terms, they were going to have to pass this cost increase on to their dentists.

One of the other problems with this tax is that the people affected by it don’t know how it’s going to work. The regulators tasked with clarifying this are still working on it. By my count this tax will go into effect 47 days from today. I’ve talked to a lot of people in the dental lab industry who are way more knowledgeable about it than I am who are just not sure how it’s going to affect them. Dental labs aren’t sure whether they will be considered manufacturers and thus pay the tax on their lab output, or will they simply be paying higher prices for their raw materials. Dentists aren’t sure how it’s going to affect them, either. If you’re doing chairside CAD/CAM restorations does that make you manufacturer? The rumors are flying around and I’m here to tell you, I don’t have any specific answers. I’m not really sure that specific answers would be all that important, though because people are getting ready to react whether they have the information or not.

If you’re keeping score you’ve followed the fallout of the tax from manufacturers who pay it directly to suppliers and labs. The manufacturers are raising their prices and passing that onto the suppliers and labs. The suppliers and labs are going to pass the tax increase onto dentists in the form or higher prices for supplies and lab fees. So now, the providers (dentists and doctors) are holding the check. Many dentists that I’ve talked to are planning on raising their fees to cover the added costs that are heading their way. For better or worse, the dentists will pass the check to patients and insurers of patients.

What about dentists who participate with dental benefit plans. Many dental benefit plans limit the fee that a dentist can charge an insured patient. This is one of the selling points for employers that buy dental benefits for their employees. Costs can be limited because the dentists have agreed to a certain fee set by the dental benefit companies. When you add an additional expense on top of the dentists current expenses (labor, supplies, rent, etc.) and no ability to raise their fee, the dentist that works with dental benefit companies will have reduced profit due to the increased expenses.

Do you remember our friend Bill? You know, the guy with the handcuffs? He couldn’t pass the check because his hands were bound. So he kind of got stuck with it. That’s how providers are going to be in the current scenario. Since I’m a dentist, I tend to see everything colored by those lenses. But when I look at the bigger picture I see physicians dealing with identical problems. Most physicians and hospitals are contracted with many medical insurance companies. Many of them are operating on pretty slim margins as well. How many of  you believe that insurance companies are going to happily increase their reimbursement for medical and dental procedures because of the new costs imposed by the health care law? Yeah…me neither.

As far as I can tell, this indirect tax is actually aimed at doctors and dentists that participate with insurances. Since the actual implementation of the tax is still mostly a mystery, this could change. Since people generally respond to incentives, I could see dentists and doctors moving away from participation with insurance because the added costs of the new health care law seem to be aimed at providers.

Am I ready to take off the handcuffs?