http://talk.qa.collegeconfidential.com/parent-cafe/2081538-im-done-with-those-questionnaires-at-the-doctors-office.html is a thread where posters are complaining about questionable practices regarding selling additional procedures in dentist and physician offices.
From the point of view of someone in or considering a career in medicine or dentistry, how big an issue is this?
As to someone considering a career in med/dent, I wouldn’t think it’s a barely, if at all, issue on their radar as they may see their future is something more noble that trying to sell elective or unecessary treatments. They may not see their future as a business with overhead that has to be met every month.
As to someone in a career of med/dent: I think it’s in part related to who you work for (eg self v group), nature of one’s practice (eg derm v IM), etc. An ER/IM MD working for Kaiser is not going to try to push elective procedures.
A solo practitioner DDS (or his staff (aka hygienist)) with very high office overhead may be pushing elective/unnecessary procedures on his patients. I know DDSs who operated at +70% monthly overheads pretax. By the time taxes get paid, there may not be a lot of $$ remaining to pay off student loans, or to cover cost of the lifestyle extras they feel their DDS degree entitles them to (eg big house, Mercedes, etc.). The end result may be a need to push elective or unnecessary treatments.
How big of an issue is unknown? Who knows, as:any reports are very limited to one’s individual experiences.
And sometimes they are covered up. We once filed a complaint against a dentist who clearly was trying to upsell a service that second opinions showed was completely unwarranted. The state dental board (made up of — surprise! other dentists) declined to take action. They filed it in their (not visible to the public) database.
I agree w/@Jugulator20
It’s depends on the specialty and setting. It’s more common in dental offices for 2 reasons–
some low cost dental chains are notorious for upselling. Its their entire business model. Employee dentists (typically young dentists who can’t afford the start up or buy in costs for an independent practice) are expected to upsell to keep their jobs and are often given sale performance quotas they have to meet. This is not to say that upselling doesn’t occur at for-profit medical healthcare businesses–Cancer Centers of America comes to mind. But it’s less common since for-profit medical centers/chains are less common.
dentistry is still a more cash only business than medicine. Dental insurance is much less common than medical insurance. Medicine is dependent upon insurance/Medicaid/Medicare reimbursement and upselling just won’t fly with insurers. The exceptions are any cash payment dominated field like derm or cosmetic/plastic surgery–and to some extent, orthopedic surgery.
Dentistry is a “cash” business because dental insurance is not insurance at all. It’s a fixed dollar cash benefit that doesn’t work anything like medical insurance.
Most dental plans offer $1000-1500 annual maximum benefit per year, an amount virtually unchanged since I started in dental practice 30+ years ago. When the benefit money is gone, it’s gone, unlike medical which continues to pay, so dental patients pay more out of pocket than ever as costs continue to rise. 30 years ago that amount covered prevention visits, fillings, maybe a root canal and a crown. Every year. Now patients max out all the time. Unfortunately, necessary work gets delayed (“if my insurance won’t pay for it, I can’t do it”), and small problems turn into bigger, more expensive problems. A dental plan I participate with hasn’t raised my reimbursement rates in 9 years, even though employer premiums and my expenses increase annually.
Dental school debt can be crushing; it is not unheard of for graduates to owe $400-500K (plus all the accrued interest). Add that into new employment, pressure from corporate to produce daily quotas, and up selling becomes second nature. I’m not saying that’s right, but I understand the motivation, and sometimes, desperation.
In my office I offer elective home whitening kits, custom whitening kits, mouth guards for grinding/clenching, sleep appliances for patients who can’t adjust to a CPAP, limited cosmetic makeovers, and prescription strength products for oral use. But, it’s a conversation, and we’re not pushy.
Is that necessarily true? Seems that some MDs “upsell” by recommending more tests and stuff than normally indicated (e.g. ECG for asymptomatic patient without risk factors), or recommending higher cost options (e.g. colonoscopy as primary screening instead of annual FIT as primary screening with colonoscopy if FIT finds something), and insurance companies are fine with it.
At this time, FIT is not considered “customary standard of care” in the US. A screening colonoscopy is.
(Although that is evolving. FIT may be SOC for a patient depending upon the patient’s age, gender, personal & family medical history–and probably most importantly, on the patient’s willingness to participate and follow test prep instructions. But until FIT is widely accepted and endorsed as a ‘best practice’ by the appropriate medical bodies, it’s not SOC. I will also note that reliability of the FIT results is at the mercy of the lab/lab technician who reads/processes the test since it’s not an automated test. There are large areas of the country where a well trained, reliable lab is not available. )
So a colonoscopy is not necessarily an upsell.
An ECG in asymptomatic patient is a judgement call. It’s also part of CYA medicine in the US.
Also some patients insist on specific tests–even though medical judgement says the test is unlikely to yield meaningful clinical results. (You can thank Dr. Google and medical advertising for this… even at times television news coverage. Like the time a patient who presented to the ER with generalized UR symptoms–think mild cold w/ cough-- and insisted she had hanta virus, despite no history of travel outside of the Northeast US and no exposure to rodent droppings. Dr. D1, who is from the SW and has treated hanta patients, explained to the patient hanta wasn’t a possibility, but the patient persisted and went over D1’s head to the department head in her complaints. The patient eventually got a chest x-ray and blood panel, but not because D1 ordered it… )