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Are you incentivizing overtreatment?

Oct. 15, 2020
DSOs' efforts to set goals may be backfiring on them, says Dr. Chris Salierno. And if dentists are recommending treatment to meet a goal and not primarily to help a patient, he believes patients will lose faith in them.
Chris Salierno, DDS, Chief Editor, Dental Economics

If you are managing multiple practices or a DSO, you can gain perspectives on practices that may elude solo dentist owners. You get more data. You spot trends in that data. You can see ways to guide your dental teams to improve their productivity and efficiency. But one system you should never, ever implement is a quota.

I would love to explore the philosophical reasons why health-care practitioners should not be held to quotas. But let’s just refer to the ADA Principles of Ethics and Code of Professional Conduct, Section 5: Veracity.

5.B.6. Unnecessary Services. A dentist who recommends or performs unnecessary dental services or procedures is engaged in unethical conduct. The dentist’s ethical obligation in this matter applies regardless of the type of practice arrangement or contractual obligations in which he or she provides patient care.

If a dentist is going to recommend a crown for a patient, it should be because the dentist thinks this is a reasonable treatment and not because he or she has to provide a certain number of crowns per month or hit a certain production goal that day. You’d be hard pressed to find someone who would argue against that premise, and yet we have seen many examples to the contrary, including:

Dental boards rarely punish dentists for unnecessary treatment

Patients, pressure, and profits at Aspen Dental

Dentists say targets and bonuses leading to unnecessary procedures on patients

So, we’ve agreed that quotas can lead to overtreatment and unnecessary treatment and that’s bad for patients, bad for the profession, and bad for business. I think the problem is that some practices implement systems that aren’t exactly quotas, but which can still lead to overtreatment and unnecessary treatment.

As a practice owner, the more I produce, the more I earn. That is an inherent ethical dilemma that all dentists who are not paid a flat wage must overcome. When dentists fail that test, they should face the consequences.

Multipractice managers should carefully consider the compensation structures that they have in place to make sure they are not additionally incentivizing overtreatment and unnecessary treatment. I believe it is perfectly ethical to pay a dentist based on his or her production/collection above a flat wage. Yes, that means there is the same inherent ethical dilemma for those providers that I face as a solo practitioner. We can and should monitor that. If we were to notice that one employee-dentist is prescribing a significantly higher number of crowns than otherwise expected, it would be prudent to check in with the person and make sure he or she is adhering to professional standards.

If you incentivize employee providers beyond a production/collection-based wage, then I urge you to carefully consider whether or not your system is ethical. 

Originally posted in 2020 and updated regularly

Chris Salierno, DDS, is the former chief editor of Dental Economics. He is also a contributing author for DentistryIQ and Perio-Implant Advisory. He lectures and writes about practice management and clinical dentistry. Additional content is available on his blog for dentists at thecuriousdentist.com. Dr. Salierno is the Chief Dental Officer at Tend. He can be reached at [email protected].

About the Author

Chris Salierno, DDS | Chief Editor, Dental Economics

Chris Salierno, DDS, is the chief editor of Dental Economics and the editorial director of the Principles of Practice Management and Group Practice and DSO Digest e-newsletters. He is also a contributing author for DentistryIQ and Perio-Implant Advisory. He lectures and writes about practice management and clinical dentistry. He maintains a blog to answer patient questions at ToothQuest. Dr. Salierno maintains a private general practice in Melville, New York. You may contact him at [email protected].

Updated Dec. 4, 2020