Yesterday I had a conversation with a patient about her daughter. The gist of it was that her daughter's husband had lost his job and his insurance (he was a carpenter), and they had public aid for their kids' medical and dental needs. When her daughter caller our office, our patient said, she was told simply that we didn't take public aid.

Which is true. We don't. Few dentists around my area do. The patient said her daughter was distraught upon being told this, but I don't know what she asked beyond that. It is true that we don't offer "payment plans" to new patients. But we will, based on circumstances, offer them to existing patients who have been reliable and who have shown we can count on them to make an effort to settle the accounts.

I spoke to the front desk employee who the patient said her daughter spoke with, and she had no recollection of even talking to her. But she said that she gets so many calls every week asking about public aid that, if the patient didn't identify herself or follow up with further questions, she would have left it at that. We don't take public aid.

The discussion went on in two interesting directions. First was the cost of dental care. It's so high, she said, that someone without insurance could never afford it. It's true that it isn't really cheap, but coming in for regular cleanings isn't THAT expensive. Not thousands of dollars. Usually the cost is below 200 bucks for the visit. Closer to 100 if no x-rays are required on that visit. We do not take x-rays every single time on every single patient. Some patients need them that often, but some don't need them more than once every 1 1/2 to 2 years. And full mouth complete series radiographs (16 different angled films) we only take once every 5-10 years. So, figure around 125 dollars for a cleaning. A bit less for kids. Okay, you have two kids, that's starting to add up. But we would likely offer the patient the opportunity to pay it in 2 or 3 months, until they prove unreliable. If they make their payments as agreed, or call us to let us know of problems with a particular payment, we're very flexible.

Is this unreasonable? It costs me a bunch of money per hour to open my doors. And we haven't even touched on my staff costs. Staff costs are somewhere between 50 and 60 bucks an hour, maybe higher. That doesn't include the salary of the dental hygienist who does the cleanings. It also doesn't include any income for me. So a couple of kids cleanings we can probably do in about an hour or a little more. Say a hundred or a little more of that 250 goes to pay for the staff, then something for the rent, the utilities, the liability insurance, the supplies we use, the debt service on the equipment, and so on and so on. After all that, I probably don't make more than a couple of dollars from hygiene. So I don't think it's unreasonable to provide a service at a price that covers the overhead and just a few dollars extra. Is it expensive? Yeah, but so is everything about running a business.

The second direction was the revelation that the patient's daughter took the kids to a dentist that does accept public aid. And apparently the experience there was so bad that the little girl is now afraid of the dentist. I don't know these public aid dentists personally, but have heard the stories from patients. And frankly if this is the level of care we are going to get from publically funded health care, we're in trouble.

I've thought a bit about why I don't take public aid. One major reason is because the reimbursement levels are too low. You are contractually obligated to provide your services at a price point that just doesn't make a profit. I think the way these offices do it is they pay their staff poorly, they pay the dentists poorly (the owner dentist is often not the dentist actually doing the work), and they work too fast. Now I'm a fast worker, but I'd burn out working fast enough and seeing the number of patients I'd have to see to do public aid.

Plus, none of my colleagues in the area take it. If a bunch were taking it, I'd feel better about joining, even at the crappy reimbursement levels. I once did a "capitation" plan and when one of the other dentists taking the plan left, all of his patients started coming to me. And I found out why he had done "okay", in his words, taking the plan for several years. He didn't do any actual work on these patients!

I'm a good dentist. I'm maybe not the best in the area, but I'm right up there with my skills. And I might be the best when you factor in the other things I try to bring to the table, like flexibility, compassion, and a willingness to stand behind what I do. I practice the way I practice because it's the way I want to and need to practice. I can't lower my standards to do cheap dentistry, even if cheap dentistry is what I'm being paid for. On that capitation plan, I quit when I realized that I'd lose my shirt if I practiced as I needed to with that patient list. I don't want to do that again.

There's a stigma attached to being a "public aid" dentist, or a dentist that accepts reimbursement from "public aid". I don't want that stigma at this point in my career.

I really think the only way to manage this is to open state-run clinics, employ dental school grads at a decent salary, escalate that salary as they gain seniority, and take all comers...if you pay taxes you can go to these places. If you have private insurance or have funds available, you can go to a private dentist, but these clinics would almost have to take everyone, not just poor people or jobless people. It's a whole shift in the idea of how dentistry is delivered, but like medicine, I guess it's something that is going to have to be explored...