THE EDITOR'S CORNER
In a recent action, the Federal Trade Commission unanimously voted to issue a complaint against the American Dental Association charging that the ADA has "illegally restrained competition among dentists in violation of the FTC Act by preventing solicitation of business by advertising or otherwise, and by preventing price competition". In a separate action, the FTC authorized its San Francisco office to investigate practices which may illegally restrict entry and otherwise restrain competition in the dental care industry. The practices that are proposed for investigation include: price information disclosure; restrictions on ownership of dental practices; enforcing principles of ethics to restrict a dentist's freedom to advertise, solicit patients, or independently determine fees for service.
The FTC seems to view dentistry as a closed business group, united in an effort to control fees and eliminate competition by enforcement of principles of ethics. If anything might be said about the ADA Principles of Ethics it is that the profession has not been able to Police itself adequately with them. But to charge, as the FTC has, that these principles fix prices (sic); or deprive the consumer of the benefit of competition; or restrain the development of innovative systems for the delivery of dental services . . .
Perhaps the FTC could explain how dental fees have been unique in rising at a rate that has been lower than the inflation rate for the last five years and still be the result of unfair restriction of competition.
Making the advertisement of fees the basis for creation of competition and supposedly therefore to give the public a lower fee, presumes that competition does not exist; and that a lower fee is automatically possible and desirable; and it does not take into account the characteristics of a profession or a professional person. The selective process required to become a dentist has tended, with good reason, to produce a dentist whose main characteristics are academic and technical. You will find little or no training in the commercial aspects of life in the dental curriculum. You would think that experience with Medicaid would have convinced the government that all the advantages under such circumstances go mainly to a relatively few less scrupulous, more money oriented and more commercially minded professional people, and that the public is not well served when the professions are placed in such a position or judged by such an experience, or when the standards and the image and the reputation of the profession are lowered in such a manner.
It is a characteristic of professional service that it is not a commodity that you can price too well; and if price is your only measure of value, you overlook the value of experience and continuing education. Is a practitioner who is a good advertiser at supposedly lower fees worth the same to the public as a practitioner of long experience who also has maintained and upgraded his knowledge and skills with substantial continuing education? And, ought the advertiser be able to bring down the fee of these other practitioners?
Quality is an important consideration in professional service and, if we are not completely satisfied now with the level of quality, it will not be improved by attempting to lower fees and to emphasize commercialism.
Dentistry is a sophisticated health care which is based largely on one-on-one interpersonal relationships. If either side loses respect for the other, that relationship will break down. The high standards of excellence which have been attained in dentistry and the caring relationship between doctor and patient should be the standard to which this country aspires and they should not be lost in an unplanned and unproven attempt to lower fees with the competition of advertising, to permit non-dentists to own dental practices and presumably to install business type of competition in the profession.
No matter how sophisticated we get or how precise we by to become, orthodontic treatment is not machined. It is still more art than science, still more skill than automation. It is still one individual caring for the needs of another. It is an error to try to stimulate competition through advertising with the expectation that this will automatically lower fees before you determine that it will automatically lower fees (it may raise fees); and that dental fees need to be lowered (which is belied by the facts concerning the rate of increase of dental fees); and before you evaluate what the effect will be on the quality of dental services.
Furthermore, we have had some experience with advertising in dentistry and the government ought to investigate that experience very carefully to be sure that it resulted in lower fees and better dental service to the public before they travel further on their present course. They will find that the opposite was true and that this was the basis for the present restrictions on advertising and for the origin of the principles of ethics.
It takes eight years of education to become a dentist and ten years to become a specialist. The cost of the education is in the area of $30-40,000. The cost of establishing a practice is roughly the same. The country cannot expect to continue to attract the necessary highly qualified people into dentistry at such a cost in time and money and in lost earning power during that time, if the practice of dentistry is made unattractive and unrewarding in both professional and financial terms.
While dentistry certainly involves manual skills, it would be well for the government to keep in mind that dentistry stands in the same relationship to other crafts, as a surgeon does to a butcher.
The government considers that the doctor controls the fee and the patient is submissive; that the patient therefore is at the mercy of the doctor who escalates his fees as he pleases and in concert with the other doctors. I don't see evidences of dental fees being unscrupulously or scrupulously escalated. Orthodontists have raised their fees since 1970 about 37%, while inflation in that time has been 51%. It doesn't look to me that orthodontists are subjecting the public to indiscriminate fee increases. Orthodontic fees have not kept up with inflation, let alone with increased operating costs. Orthodontic fees have also not kept up with declining numbers of patients. I can demonstrate that orthodontic fees should have increased 81% in the period from 1970 to 1976, rather than the 37% which was the actual average increase, just to keep up with inflation and increased costs.
While the orthodontist was determining his fees for himself, he has not been doing a very good job of relating fees to the maintenance of his standard of living; and if the FTC and others are successful in lowering fees, his standard of living will be eroded further, even if the number of patients can be maintained or increased through third party activity. So, don't let anyone tell you that orthodontic fees are too high, or that we have been raising fees indiscriminately. If the actual story means anything, we need a guardian.
The submissiveness of dentistry to attack on professionalism is a cause for concern. The danger in the "shoot first and ask questions later" attitude of the FTC is that they seem to have a preconceived notion of professional practice and a closed mind about it. One wonders on the basis of what facts their position was arrived at. They surely ought to be called to account in some way other than by our defending ourselves against charges. It is hoped that the courts will have the good sense not to upset professionalism in this country, at least until it can be demonstrated that that would be in the public interest.
The Congress is very much concerned with principles of ethics for the conduct of its members in their legislative practice. It is difficult to believe that they would support a backward step for principles of ethics in professional practice.
The FTC action points the way to an immediate goal. The professions may well go under in this country just for having to conform to regulations governing a trade or a business, which make no distinction between a profession and a trade, between a practice and a business, between a fee and a price. There is an immediate need for the professions to seek transfer from the jurisdiction of the Federal Trade Commission to a more congenial regulatory agency.
