“That’s Very Expensive, Doctor!”

moneyI treat patients from all walks of life.  Contrary to a reputation that mysteriously precedes me, I don’t have a practice full of wealthy people with bad teeth and open wallets.  I wish!  But, my patients do span the spectrum.  A significant portion of the “big cases” I do (which have been few and far between since 2008) are for patients that are very much middle class.

I understand that times are tough for many people, and I’ve kept my fees steady for the good part of this “recession.”  Furthermore, about a year ago, I implemented an in-house membership-based dental savings plan called, “Quality Dental Plan” or QDP.

For a tooth??  That’s too much money!

I am occasionally frustrated by those patients who “cry poor” when it’s quite obvious they’re not.  I am not at all bothered by the fact that some people just don’t value their teeth or the services of a good dentist.  Really… they’re not MY teeth.  I’ve “matured” to the point of being very comfortable presenting treatment options and letting the patient decide.  They can do:

  1. All of what I suggest.
  2. Some of what I suggest.
  3. None of what I suggest.

I present the advantages and disadvantages of each.  In the Navy, we used to say, “Run it up the flagpole and see if anyone salutes.”   It’s all good.  I’ll be here when you’re ready.  Dr. Bill Blatchford once said, Some will. Some won’t. Some wait. So what? Next!

But, I’m on a fixed income!

This week, I had two patients who are “snow birds.”  That means they live here in Florida for the winter and spend the rest of the year up north.  They have TWO homes.

One of these patients was referred by a long-time family of patients.  She broke tooth #6.  The distal half of the facial fractured, leaving the big DL amalgam behind it exposed (and loose).  There is obvious recurrent decay underneath, and I expect it is pulpally-involved.  I explained that the tooth needs a crown and likely needs root canal therapy and maybe a post.

To have time to do it all (RCT, P/C, crown prep) in one visit, we’d need to schedule it in the next couple of days.  No problem with that, as she was in no discomfort.  She went to the front desk where the fees were presented.  She exclaimed that she was “shell-shocked,” and did not schedule the appointment.  She was dripping in jewelry, including a diamond “tennis bracelet” that probably goes for $20k.  Two homes and expensive jewelry, but she balked at paying me to save her front tooth.  Alrighty, then!  NEXT!

And, on the same day…

The other patient, also a two-home snowbird had a loose bridge.  She was referred by a retired dentist who knows me.  It turns out the bridge came out, and her retired friend recemented it for her with some drug store cement.  He did a mighty fine job of it, too.  It was still mobile and had loosened on one end.  I tapped the bridge out to inspect what remained.

The bridge spanned #12 – 15 with a pontic #14.  The abutment #12 was decayed to the point of being a residual root.  Tooth #13 was intact, but it had lost more than half of the supporting bone and was class 3 mobile.  The only salvageable tooth was #15, which was intact and had decent bone.  The teeth anterior to this area were intact but showed some significant attrition / wear facets.  She was in no discomfort.  The bottom line… she was going to lose #12 and #13, leaving three teeth missing (12-14).  The way I saw it, she has a choice between placing implants or a partial denture.

Sorry for the fuzzy photo. I forgot to change the setting on my camera from "Program" to "Aperture Priority."

Sorry for the fuzzy photo. I forgot to change the setting on my camera from “Program” to “Aperture Priority.”

I began to present her options.  I started with implants.  And before I could finish my first sentence, she shook her head and said, “No way I will do implants.”

OK… why not?  (It could be for a variety of reasons.)

“They’re too expensive.”

OK… I understand that.  They ARE expensive.  But, may I finish explaining the advantage of implants in your case?

“Yes.”

And, so I did.  I also explained the other option – a partial denture.  She shook her head on that one, too.  We talked about it being removable and having visible clasps.  I also explained why a traditional fixed bridge is not an option.

In the end, I recemented her bridge with temporary cement and agreed to send the information to her dentist up north and her retired dentist friend.  We also gave her a printed treatment plan with fees.  The plan was for two implants (#12 and #14) with a 3-unit bridge and a single crown #15.  We also presented the fee for a partial denture.  She’ll be down here until March.  I don’t think that bridge is going to make it.

So… How do you handle these situations?  Any different from what I’ve presented here?  Post your comments below!

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19 Responses to “That’s Very Expensive, Doctor!”

  1. Dawn says:

    Did you happen to find out what she wanted for herself and why prior to the exam? I have found this to be very helpful. The value must been seen from their eyes.

    • The Dental Warrior says:

      Can you elaborate on that? I may be misunderstanding. I’m seeing it this way:

      What do you want for yourself?

      What do you mean?

      What would you like to do?

      I don’t know, yet. You’re the doctor. My tooth is broken. I want you to fix it.

  2. Lance says:

    Along the same lines as Dawn suggests, I precede the exam (after their story) with, “Do you have specific goals? Time frame? Budget?” If they say 2 weeks and $200 (or express a desire for close to nothing out of pocket) I state, “OK, we will skip the $30,000 option and discuss dentures.” The “shock and awe” part has already happened and if they ask about other options, my $10,000 implant option doesn’t sound that bad.

  3. Michael Nugent says:

    I would of done the same. I have a very attractive lady in her late 40s that always is dressed super nice, jewelry, hair and nails…etc

    She has about 7 teeth with large rampant decay. She lost a bridge 11-12-13. I made a bleaching tray to hold the bridge in place as an emergency fix.

    She did not want to schedule to come back because she is remodeling her house.

    She comes back in a couple weeks as an emergency. She does not like the color of the bleaching tray as it has turned yellowish. She wanted us to redo the tray because she and her husband were riding their matching Harleys to a motorcycle rally.

    She eventually comes back for a “flipper” to replace the bridge. Her CC got denied. We did not sent the case out.

    People just don’t put their health and teeth as a priority. I’ll be happy to swap dentistry for her Harley!!!

    And I would have done the same as you on your two patients.

    When I get patients that balk about cost , treatment or bitch about cost I tell them to go across the street to “Dental Land” Medicaid clinic. (yes that is the name of the clinic)

  4. “Savings make sense. Fees do not.”

  5. Brian says:

    hi mike
    out of curiosity how much is RCT, P+C, Crown for #6 in your office?

  6. Todd Resek says:

    Mike, I really enjoyed that post. Really felt like I was right there along side you experiencing those cases. I also am maturing and but after 20 years of practice those scenarios burn my behind. Why do I still feel jilted after all this time if someone doesn’t value my suggestions?

    Todd

  7. Paul O'Boyle says:

    Hi Mike, I had a similar situation and eventually Dave went for the implant option. He resented the cost so much that he “forgot” about his 90 min appointment. I forgave this and rescheduled and the implant crown was restored. Now he’s back for the lower equivalent. Whatayaknow? He failed to show for his lower 90 min appointment. I really could not be bothered to help him out. I asked for a deposit and I dont care if he takes offence and goes elsewhere. People have their own priorities and dentistry is often very far down the pecking order. (Until they need us!)

  8. Mike Rice says:

    I’ve handled things the same way many times. I think it sometimes bothers me/us because we have gone to school for so long, taken so much CE, spent so much money, bought so much equipment, invest blood, sweat, and tears, only to have them reject us/our ideas as “not worth it”. And other times I just don’t give a shit.

    One thing that has helped me to “feel out” patients (not feel up – don’t go there!) is to simply say “I have learned, over the years, that there are three types of people. There are those who want to know all of their options, those who just want the quickest, easiest, cheapest fix, and those that are somewhere in between. Which type of person are you?”

    3% say cheap and fast.
    5% say all options.
    92% say somewhere in the middle, which really means they want to know what’s available, so I tell them everything and let them decide.

    Mike

  9. Steven Brill says:

    Nobody here has mentioned actual cost. It is one thing to say “the patient is too cheap” or “the doctor is too expensive”, but are we talking about $1,000, $10,000, or $100,000. There is quite a difference.

    Also, nobody discussed if the costs in question are in line with what is generally charged for that procedure in that geographic area. That is also important.

    I usually pay top dollar for medical services, and I rarely complain, but I have also had doctors try to charge me tens of thousands of dollars for two hours work, and I think that is pretty outrageous.

    • The Dental Warrior says:

      The actual fees are irrelevant to the discussion. The patient rarely has a basis for comparison (unless they’ve had an identical procedure done in recent memory). If we polled a random group of people and asked them what the cost of a root canal, post & core, and crown is…. We would get a very wide range of GUESSES. And, if they’ve never had a root canal or a crown, for example, they have no idea. Whether it’s $500 or $1,000… it’s “expensive.”

      And, to be more specific and more accurate, we’d have to ask what it would be for tooth #6. We’d surely get more puzzled looks. Tooth #6??? What does that mean? Well… to a dentist, it means a lot. A root canal for #6 will have a different fee that a root canal for #3.

      There are geographic differences, of course. But, within the same geographic area, the DENTISTS are different. A crown from Dr. A is not the same as a crown by Dr. B. Their skills and outcomes can be QUITE different. The labs they use can also be quite different. So, to go by whether the fee is “in line with what is generally charged in that area” can be folly. Treating dental services as a commodity (a crown is a crown) is a big mistake.

      There would be no point in publicizing my fees in this blog article, as it would distract from the discussion. The point is that (at any fee), some patients value their jewelry and cruises more than their teeth. That is my challenge… not that my fee may be $100 or $200 more than the guy down the street. The differences in fees are not orders of magnitude as in your example ($1,000 vs $10,000 vs $100,000). I’d guess that the fees in any given area are probably within 20% of each other, at MOST.

      But, to give you a bit of perspective, saving her tooth would cost about 1/10th of the cost of the bracelet she was wearing.

      (Steve is a relative who is not a dentist.) 🙂

      • I have had some very well heeled patients express shock at the implant fee – paying for quality dental care just doesn’t register in their minds for some reason.

        Recently I waived of BIG for some patients who I thought could use the discount – since then I seemed to be getting more requests to slash my fees. I had to stop that stuff.

  10. z says:

    This happens weekly. Even worse to me are the cases where the person really probably doesn’t have the money. Don’t have a job, wearing scruffy clothes, family member is picking up part of the bill.

    Had a dude in last week with a #6 that was in bad shape. I’ve pulled a few teeth on this guy before… someone he knows always picks up the bill.

    Tooth either needs a RCT/BU (I didn’t even bother pitching the crown) or TE.

    I know before I even have my OM present the idea… it’s a classic case of pitching the idea he can’t afford, or the option he doesn’t want… Dentistry has so many lose-lose scenarios present themselves each week… it’s the frustrating part of the job you never think about when you’re in school.

  11. ellebelle says:

    I agree that it doesn’t matter about the fee. I did a GPR and began practicing in 2008 so what a great time to get started, huh? Good dentistry is expensive and it takes time, period. It used to bother me to quote a 10K case, it no longer does. I am pretty conservative and will repair around crowns and do pin amalgams (or pin composites it the pt. prefers and cannot afford a crown). Fortunately for me I “only” had to borrow 160K due to a great scholarship for merit. Unfortunately for me I still owe around 118K.

    Anywhoo…the sad state of dentistry is that this lady will undoubtedly find someone to make her a bridge from that canine to #15. Totally violating Ante’s law, but patients are more and more dictating treatment and will find a cash crunched dentist to do their bidding. I am along your lines that I will not violate my ethics or sanity for these kind of patients.

    The only alternative treatment plan I see is implant bridge 12-14 and extract the molar (assuming there is no opposing tooth). Most people can function well on single molars or even premolars. Which would bring me to the other treatment plan of #12 stand alone implant crown (again assuming no opposing lowers, or even if there are and depending on the age of the patient supraeruption may not be that bad or could be taken care of by occlusal adjustments, again, depending on the patient).

    Sorry to sound jaded, but at 35 and practicing in an urban environment in the Northeast, has made me so. Best wishes and a great post!

    PS. My favorite is the patient’s who cry poor after just paying 5K on Fido’s chemo or whatever. Now I love my pets too…and I have multiples rescue pets. But my kids’, my husband’s, and my health comes first. With my debt, if Fido needs chemo then it’s Fido Heaven for Fido. That is just the way it is. People are free to make their own choices, but they should not blame us if they choose inferior dentistry or an experimental procedure and then blame us if it doesn’t work out!
    Fortunately I have many great patients, but there are always a few…

  12. ellebelle says:

    patient’s = patients. is = are. sorry for the typos

  13. Richard says:

    Yeah I am not to the comfortable point yet but I am getting there. Some will, some won’t hahaha. Good stuff dental warrior. I am gonna be as good a blogger as you one day.

  14. prateek says:

    i was astonished to say the least when i read this post.i am a maxillofacial surgeon practicing in india.
    patients complaining about fee and charges is a routine thing here.
    the shock some of them express at the amount presented to them makes me wonder at times why is it so hard for patients to believe that we dentists have undergone years of training have put in hours of hard work ,so as to come up with a treatment plan..
    sometimes i feel my engineering friends have had it so easy in life…
    a tooth is just a tooth for general public till it becomes a source of discomfort for them…then and only then we come in picture

  15. prateek says:

    i was astonished because never did i imagine that even patients from developed countries behave exactly in the same way as do patients in india!

  16. Petra says:

    Good oral health should always be someone’s top priority. Vacations and jewellery should come after.

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