Orthodontics and the Health Care Industry
In recent years the delivery of health care has undergone major changes in the United States. Most of these changes have been economically driven. Indeed, lowering the cost of health care has been the rallying cry of the medical care reform movement.
One critical factor in this evolution is the classic issue of supply and demand. On the supply side, the medical providers have been traditionally a fragmented cottage industry. On the demand side, the patients also used to be a fragmented group, until the growth of third-party coverage. Once demand became concentrated under commercial corporations, eg, insurance companies, the issue moved into the business world. Then it became possible for the corporations to negotiate, first with the employers (the demand) and later with the providers (the supply), to control payments and/or benefits and to get health care delivered on their terms.
This whole scenario took place following the unprecedented explosion of business and MBA graduates in the 1980s. These new corporate builders must have seen the health care field as the last great frontier waiting to be developed—a virtual medical Alaskan North Slope. The opportunity to sell contracts to the employers, thereby acquiring the demand for health care, coupled with the absence of any collective opposing voice from the service-providing doctors, must have seemed like a bonanza waiting to happen—and happen it did.
What of dentistry and orthodontics? On the supply side, we were no more prepared for such changes than was the medical community. However, the demand for dental care has long been far more fragmented than the demand for medical care. This was important. Absent the third-party payer, the businessperson's ability to concentrate the dental demand and follow the medical model was limited. The dental community is also a much smaller market. The result has been that, thus far, orthodontics has escaped most of these changes.
Does that mean we are unchanged? Not at all. Although commercial corporations have not been able to capture the orthodontic delivery system, they still have had a major impact on our specialty. Consider the organization of orthodontists into groups of service providers with their practices under corporate management. Mergers have made giant corporations out of yesterday's small suppliers. Anyone who watches television has seen orthodontic appliances advertised directly to the public, complete with offers by the advertiser to refer consumers to company-certified orthodontists.
More and more, we see professional activities reflecting the influence of large commercial concerns. Many speakers have corporate sponsorship and, in some cases, work completely under the aegis of commercial firms. More and more commercial booth space is sold to support meeting expenses. Professional meetings are taking on more and more the character of trade shows. Just the other day, one of the people of the business world told me of an orthodontist approaching him and asking for help in commercializing an orthodontic constituent society meeting.
These changes are neither intrinsically good nor bad. What is important is that orthodontists consciously recognize that moves in this direction carry the potential to make our orthodontic profession lose the characteristics that differentiate it from the business profession. Yes, there is a business component to the practice of orthodontics, but no, orthodontics is not a business.
Clearly, an orthodontic professional needs to make a living, and we have been fortunate that most members of our specialty make a very comfortable living. This makes our specialty attractive to young dentists and brings us the very best of recent dental school graduates. However, we also need to guard against the allure of personal gain alone as the only goal. This may be a worthwhile goal to a businessperson who regards success in business as synonymous with profit. However, it is clear that orthodontic success is not synonymous with profit alone. Success in the specialty of orthodontics carries far more responsibilities than simply being profitable.
One salient difference is that society grants orthodontists a license. This license essentially amounts to a legal monopoly, and the monopoly carries with it a service obligation. The term service obligation is not a platitude. Inherent in our service obligation is a trust—a trust that represents a contract entitling the patient to know that we will pursue the patient's best interests over the profit motive. This is in distinct contrast to the profit-driven concept of caveat emptor, or “let the buyer beware.” It is a slippery slope should the profit motive begin to crowd out the service aspect of our professional life.
Orthodontics is undergoing, and will continue to undergo, evolutionary changes. Now, more than ever, we must be acutely aware of the direction in which the changes are moving. As orthodontically interested commercial corporations merge and grow ever larger, we must avoid allowing the tail to wag the dog. As commercial business interests become more concentrated and centralized, they become more powerful. To paraphrase Voltaire, “Power corrupts, and absolute power corrupts absolutely.”
Dr Malcolm Moos, a speechwriter for President Eisenhower, coined the famous and cautionary phrase “beware the military-industrial complex.” His message clearly was that big money could corrupt, a phenomenon with very contemporary applications. If Dr Moos were writing today, he might also caution us—beware the health-industrial complex.