Monday, 10 January 2011

The economics of my moldy molar

I should have suspected, given the grievous headaches and blueness of my molar, that something was amiss when the dentist told me that all I needed was a simple filling. It was unthinkable that she would mistreat me; surely dentists follow an ethical code and she couldn't be benefiting from carrying out a filling - one of the most basic and cheapest dental procedures.

Even when I went back because I was still suffering she said "sometimes fillings don't fit properly, we'll just have another go...". Alarm bells did then begin to ring and I decided to get a second opinion. It turned out that I needed root canal treatment, a much more involved and costly procedure. That dentist HAD MISTREATED ME. 

Perhaps she was inexperienced or lazy or...? I think the answer lies in the fact that she was an NHS dentist. Now, I don't think all NHS dentists would have behaved as she did, but on learning how the NHS system works it becomes apparent that there are strong incentives for dentists to avoid certain procedures. Under the system dentists are paid a flat rate for all fillings - about 40 quid - irrespective of the size or intensity. If my dentist had given me a root canal, she would not have been paid enough to cover the costs of the procedure. On the other hand, when she gives a standard filling, she will be paid more than the cost of the procedure (watch out for trigger happy dentists who keep finding new fillings in your mouth!). 

my rogue denticle
There are higher payment bands too, for more expensive treatments, but all of these bands group together several treatments that have very different costs. You would think that dentists should be paid the cost of the treatments they carry out. That was how the system worked until 2006 and it was misused. Dentists were over-influenced by the fact that more treatments meant more money. The result was very expensive, there were too many treatments and little emphasis on preventative care. 

At the root of the problem is the fact that dentists are experts who have more information than us. We have to trust what they recommend, and they might not always have the patient's best interest in mind. The fact that NHS dentistry is in short supply exacerbates the problem because the forces of competition and reputation building aren't able to keep dentists in check, and on top of this the NHS creates perverse incentives by distorting how dentists get paid. 

While my molar may no longer be rotten, the system of dentistry is. Economist John Maynard Keynes famously wished that economists would aspire to be “as humble, competent people on a level with dentists”. He wrote this at a time when moral judgement, in his opinion, was playing too large a role in economic policy. My own experience has made clear how, within the current system, a lack of moral servitude in the dental profession leads to malpractice. You don't need to make any normative judgements to see that the system requires change. 

1 comment:

  1. Interesting, and worrying! Where can I find out what NHS dentists (and doctors!) get paid for different procedures?