THE EDITOR'S CORNER
It is difficult to understand the antagonisms that are created among orthodontists by transfer cases. There is little or no problem with cooperative patients whose treatment is moving along on schedule. They can pass from one practice to another with rarely any trouble about treatment plan, treatment time, fee, or even appliance. It is the uncooperative patients who create the problems in transfer and there are more of them than we care to acknowledge. More often, transfer merely exposes our problems with patient cooperation rather than, as Orthodontist #2 frequently believes, the greed or incompetence of Orthodontist #1.
This is especially true of cases using extraoral appliances. When these procedures are started in the mixed dentition and will be carried through a period of changeover from deciduous to permanent teeth, the orthodontist may not be as concerned with how long it takes to complete this step as he should be. He sets his fee, let us say, on the basis of one year of headgear therapy prior to additional correction with a banded appliance. If the headgear treatment drags along for two years and the correction sought with it is achieved in that time and coincides with the eruption of the permanent teeth, the orthodontist has become accustomed to slide along into the banded phase of treatment without a second thought. A transfer that occurs somewhere in the second year of headgear wear makes him take that second thought. The later along that it is, the more difficult the thought.
Most of us are optimists and harbor the conceit that correction of a Class II molar relationship with a headgear should take no more than one year. When the correction takes more than a year and the patient does not transfer, the extra treatment visits are absorbed. Transfer exposes the problem. The case is beyond a year in treatment and the initial correction of the molar relationship either has not been completed or has taken longer than was planned for in the fee. In any case, more money has been paid than the fee allotted to that portion of treatment.
The question is: Who pays for the lack of cooperation that prolonged this step in treatment or for the misjudgment on how long this step would take? Certainly Orthodontist #2 should not be expected to take this into account and present the parents with a lower-than-usual fee in a one-man public relations effort. Nor should it be automatically assumed that Orthodontist #1 should limit his fee to his estimate of that step and return any overage to the parents. If he has placed the parents on notice to start with that his fee is predicated on certain cooperation on the part of the patient and parents, this gives him some protection of his rights in the matter. This does not mean that any overage in time can be attributed to lack of cooperation and justify a change in fee structure, but it provides a basis for such a change in instances of specified lack of cooperation of which the patient and parents have been made aware.
Should a rule prevail that if Orthodontist # 1 would absorb the extra visits without charging an extra fee for a patient who remained in his practice, that he should absorb them on transfer and refund the fee for that period of time? Not necessarily. His unwillingness to return the money for that treatment period might rather point to the folly of absorbing long months of extra treatment time, than to the correctness of that idea. It is up to Orthodontist # 1 to make an honest appraisal of the situation and settle his fee accordingly. One would think that in cases of obvious lack of cooperation, the fee should be charged; that in cases of misjudgment of time on the part of the orthodontist or poor treatment planning or mechanics, money should be returned.
All of this points to a need for better structuring of fees, especially in two-stage treatments. In this issue of JCO, Dr. Greer makes a point of how to manage fees in two stage treatment. While the presentation applies specifically to the treatment procedures in the offices of Drs. Greer and Wagers, the idea is adaptable to any system and is worth some thoughtful consideration. It may not solve the problems of transfer, but it might provide a better approach to the problems of management of two-stage treatments which transfer frequently exposes.
