There has long been a debate about whether an orthodontic fee should be for the appliances and the amount of time involved or for successful completion of the case, regardless of the time it takes.
In the early days of orthodontics, fees were divided into an initial amount, for diagnostic records and appliance installation, followed by monthly payments until the case was completed. This open-ended fee arrangement virtually mandated monthly visits. Over time, however, many reasons developed for mutual dissatisfaction with open-ended fees:
- Patients were uncomfortable with the uncertainty about the cost of treatment, and orthodontists came under suspicion if treatment was prolonged.
- Orthodontists felt short-changed if they finished a case sooner than expected.
- The course of treatment could be adversely influenced by the monthly payment arrangement. If patients or parents didn't want to make their monthly payments, they simply broke their appointments.
- As treatment became more systematized, a consensus was reached that the average full-treatment case took about two years, reducing the need for an indefinite treatment period.
- Improved treatment procedures no longer required monthly visits.
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In light of these developments, there was a swing toward the mini-max fee--a range within which the ultimate fee was expected to wind up, perhaps with a contingency for non-cooperation. Although there was an effort to divorce the treatment from the monthly payment regimen, this remained a convenient arrangement. It was then a short step to the fixed fee.
Initially, the installment method stretched out a fixed fee in convenient monthly amounts over the length of actual treatment. As treatment times became shorter, however, there was a well-founded fear that people would resent making monthly payments after active treatment was completed. This has been mitigated by the creation of several fiscal intermediary and factoring arrangements. Still, there remains the basic question: What is an orthodontist being paid for-- appliances plus time or successful treatment?
The average number of treatment visits may vary from an average of 10-12 in one practice, over 14-18 months, to 30-40 in another, over 30-36 months. The difference may depend on treatment techniques, intervals between visits, and numbers of emergency and broken appointments. One might also add delegation, staff performance, and the orthodontist's experience and ability. Assuming that the treatment results are equally satisfactory, should the quicker finisher be paid one-third the fee of the prolonged finisher for the same result?
Some have tried to cost-account orthodontic fees, but this is an irrational attempt to appear rational by breaking down the time and material ingredients of a typical two-year full-treatment case and extrapolating those to all varieties of cases. The time and materials approach doesn't work in orthodontics because too much is unquantifiable. There is also the danger that third parties would seize on such numbers as the actual cost of treatment and refuse to pay anything more.
The truth of the matter is that the market decides the issue. An orthodontic fee is what the orthodontist and patient agree is an acceptable charge. Incidentally, you can bet that most people would pay an equal amount or more for an excellent finish in a shorter period of time. If that is the case, it should be more than mere inquisitiveness that would prompt an orthodontist who consistently performs longer-than-average treatment to investigate how someone else can get equivalent results in a fraction of the time.
ELG