Senior Lecturer in Dental Ethics at the University of Sydney, reports below on a study that included perspectives from Australian dentists working in private practice on over-servicing, which found most had felt pressure to provide unnecessary care, either from practice owners or their own financial commitments, and that is also driven by our fee-for-service model.
Alexander Holden writes:
If your dentist recommends a crown, your wisdom teeth extracted, or some other common treatment, you may wonder whether it’s really necessary.
We don’t know how common such over-servicing is. However, our research, which includes interviews with Australian dentists in private practice, shows it is an issue.
Not only is this a problem for patients, some dentists say they feel pressured to recommend unnecessary treatments. And the way dentists are paid for their services actually encourages it.
Read more: How often should I get my teeth cleaned?
What is over-servicing in dentistry?
Over-servicing can occur in many types of health care, with various definitions. But in dentistry, our research defines over-servicing as when dental treatments are provided over and above what’s clinically justified, or where there is no justification for that care at all.
And we’ve known about it in Australia for some time. In 2012, a Sydney dentist went to court and was fined more than A$1.7 million for performing almost $75,000 worth of treatment on one patient, knowing it was unnecessary and would be ineffective.
In 2013, another Sydney dentist was found guilty of over-servicing elderly nursing home patients, some of whom had dementia. He filed down their teeth to fit them for crowns they did not need, without anaesthesia.
However, over-servicing can be less extreme than revealed in these landmark court cases. Dentists we interviewed said they often felt pressured to over-service as part of their day-to-day practice.
What we found
We analysed interviews with, and diary entries from, 20 Australian dentists working in private practice, the first study of its kind to include their perspectives on over-servicing.
Most dentists we interviewed had felt pressure to provide unnecessary care. Pressure came from practice owners, or their own need to meet financial commitments.
They spoke about a culture in some practices of “finding treatment” to do, rather than simply treating the issues patients had:
I quit my first job because they were overly commercial and I figured that out about two weeks in because there it was very much a matter of, “how many crowns are you doing per week? We expect our clinicians to be doing at least a crown a day” and there was no real care factor towards, what does the patient actually need? It was very much a matter of, “Okay, you’re seeing a new patient, see if you can get this much revenue out of that one”.
Why does this happen?
Most private dentists in Australia earn their wage linked to how much treatment they provide. So this fee-for-service model provides an incentive for them to provide more treatment, rather than less.
However, over-servicing isn’t inevitable. Some participants said their professional identities as dentists helped them place patients before profit:
Look, I’d always put my professionalism first. There’s been a couple of times when I’ve recommended a crown and I sort of thought “OK, am I doing this because the crown is a high-end item or because I really believe it’s the best thing for the patient?”, and I always go with what I believe is the best thing for the patient.
The dentists we spoke to also said they spent a lot of time considering how they managed patient care in a system inherently skewed to promote over-servicing.
So what happens when you shift away from purely a fee-for-service model? This might include a monthly fee for having a patient registered with a practice or service, as trialled in the United Kingdom.
The amount of clinical treatment reduced, with patients noting little change in the service they received.
How do we tackle this?
We could address the culture of over-servicing by changing the way dentists are paid, away from a pure fee-for-service model. Payments could be linked to measurable improvements in oral health, rather than purely just how much dentists do.
However, with fee-for-service being so entrenched in Australian dentistry, we admit this would be a difficult task, despite the increased awareness of the topic that research like ours brings.
What if I’m not sure I need a recommended treatment?
If you’re not sure why your dentist is recommending a certain treatment, ask. You can also ask about the pros and cons of other options, including doing nothing for now and keeping an eye on things.
If you’re not satisfied with the answer, you can ask for a second opinion. One thing to consider is that you’ll need to ask your dentist for a copy of your clinical records and x-rays (to avoid these needing to be taken again). And if visiting another dentist, you probably will need to pay for another consultation.
If you’re unhappy with your care, the best place to complain to first is your treating clinician; dentists really value receiving feedback and the opportunity to put things right.