FINANCE & ETHICS IN DENTISTRY

Presented by : Dr. Arpit ViradiyaGuided by : Dr. Prashant P. Shetty

Introduction

• “Ethics” is derived from the Greek word ‘ethos’ meaning custom or character.

• Ethics is the philosophy of human conduct, a way of stating and evaluating principles by which problems of behavior can be solved.

• Ethics is concerned with standard judging whether actions are right or wrong.

What is Ethics?

• It’s a branch of philosophy concerned with the study of those concepts that are used to evaluate human activities, in particular the concepts of goodness and obligation.

• Dental ethics would mean moral duties and obligations of the dentist towards his patients, professional colleagues and to the society.

Definition of Ethics

• Is defined as "the science of the ideal human character and behavior in situations where distinction must be made between right and wrong, duty must be followed and good interpersonal relations maintained".

Micro-ethical principles

• They focus primarily on individuals’ rights and duties and do not see individuals as part of a wider social order.

Macro-ethical principles

• These are a set of principles designed to protect the human dignity, integrity, self-determination, confidentiality, rights and health of populations and the people comprising them.

History of Ethics • The "Hippocratic oath" has been regarded as a

summing up of a standard professional ethics. • Over years various theories have been put

forward regarding ethics. – The theory of utilitarian ethics focuses on

utility of services. – The theory of deontological ethics focuses on

the morality of the act rather than the consequences of the action.

– Virtue ethics focuses on what a virtuous person would do in the particular circumstance.

The Indian Scenario

• ‘Ethical rules for Dentists’ were initially formed by the DCI, and the Dentist Act was amended via section 17A.

• The code of ethics was framed by the Dental Council in 1975 and later notified by the Government of India as Dentists Regulations 1976.

• It is in force from August 1976.

• A systematic body of rules is needed in order that dignity and honor of the dental profession may be upheld, its standards exalted, its sphere of usefulness extended and the advancement of dental science promoted.

• And the members of the dental association may understand the duties and obligations clearly to the dental profession, to their patients and to the community at large.

Ethical Principles • Ethics is the part of Philosophy that deals

with moral conduct and judgement, there are certain principles that the health care professional should be aware of in the practice of their profession. The major principles are:

1. To do no harm (non- Maleficence)2. To do good (Beneficence) 3. Respect for persons 4. Justices5. Truthfulness6. Confidentiality

I. Duties and Obligations of the Dentist towards patient / population

• The first principle of medicine in the Hippocratic Oath is that the doctor’s first duty is to his or her patient.

To do no harm (Non-Maleficence)

• It is considered to be the foundation of social morality.

• It is clear that although dental care professionals support this principle in theory they are at times guilty of transgressions that go beyond a limitation.

• For example : Iatrogenic diseases. • In population based research the investigator has

a dual responsibility, i.e. to the individual and to the population of which they are a part.

To do good (Beneficence) • It should be the role of dentists and dental

hygienists to benefit patients, as well as not to inflict harm.

• The expectation of the patient is that the care provider will initiate beneficial action and that there is an agreement between the doctor and patient that some good will occur.

• In the process of treating a patient what has to be weighed are the consequences of treatment versus no treatment, e.g.: questionable dental caries.

• The attempts should be to maximize the benefits and minimize harm.

Respect for persons

• This incorporates at least two other ethical principles of which

1. Autonomy dictates that health care professionals respect the patients capacity for self determination in making decision regarding their treatment

2. And informed consent is an essential component of a patient’s right to autonomy.

• Dentists sometimes attempt to direct a patient toward a particular mode of treatment stressing certain advantages and not mentioning disadvantages.

• It is unethical to mislead or misinform the patient.

• Dentists are seen as a paternalistic figure and Paternalism in health care can take the form of withholding information, restricting choices, or making the choice for the patient.

Informed Consent

• It is the first stated and the largest principle of the Nuremberg code.

• The Nuremberg code identified four attributes without which a consent cannot be considered valid.

• Consent must be– Voluntary– Legally competent– Informed and – Comprehending

Informed Consent

• This term first appeared in American Common Law in the late 1950’s.

• Although Nuremberg code calls for “Voluntary Consent” it has been customary, since 1950 to refer it as “Informed Consent”.

Informed Consent

• Though the process of informed consent empowers subjects to pursue and protect their own interests, its an instrument designed to protect the interests of investigators and their institutions and to defend them against civil or criminal liability.

• Hence a witness may be required to countersign and attest to the fact that the subject received the information.

The informed consent is a two step process

• First information is presented to the subject by the investigator.

• Secondly, the subject satisfies himself or herself that he or she understands and based upon this understanding either agrees or refuses to participate in the research projects.

Justice • The primary duty of the health professional is

service irrespective of class, creed etc. • Justice demands that each person be treated

equally. • It calls for an obligation to protect the weak and to

ensure equity in rights and benefits, both for groups and individuals.

• It calls for universal coverage and for care according to need.

• The principle of justice in relation to health care calls for community participation in decisions and care which is effective and affordable.

Truthfulness • The patient – doctor relationship is based on trust.• Lying shows disrespect to the patient and threatens

relationship.• Studies in 1950 and 1960 (on terminally ill patients)

had shown that the physicians had the right, indeed duty to withhold bad news when they believed it would upset the patient.

• It is an example for hypocratic paternalism, that is, the doctor knows the best.

• Nowadays, in certain areas, there is a reversal of this dominant physical pattern.

Confidentiality • Is a principle that can be traced to the Hippocratic

Oath and exists today in the international code of Medical Ethics.

• Every patient has the right to expect that all communications and records pertaining to his/her care will be treated as confidential.

• It is very natural to want to gossip about a patient, particularly if it is someone special or possibly a neighbor, but to do so would break a bond of trust between dental professional and patient.

Confidentiality • Earlier it was widely accepted that confidentiality

could be breached if it was thought it would benefit the patient.

• Now patient’s permission has to be taken.• In no instance other than in the court of law or the

patient changes the dentist, should confidentiality be breached.

Duties and Obligations of the Dentist towards the society

• The dentist has to assume leadership in the community on maters pertaining to dental health.

• People should be urged to seek care without influencing choice of dentists.

Ethical Rules for Dentists (Prescribed by the DCI)

• The duties and obligations of dentist towards the patients:

1. Every dentist should be sympathetic, friendly and helpful.

2. He should observe punctuality in fulfilling his appointments.

3. He should establish a well merited reputation for professional ability.

4. The welfare of the patient should be conserved to the almost of the practitioners ability.

5. A dentist should not permit consideration of religion, nationality, race, party politics to intervene between his duties and his patients.

Duties of Dentist Towards One Another

1. Every dentist should have pride in his/her colleagues and should not disparage them either by act or word.

2. When the dentist is entrusted with the care of the patient of another, during sickness or absence, mutual arrangement should be made.

3. If a dentist is consulted by the patient of another dentist and the former find that the patient is suffering from previous faulty treatment, it is his duty to institute correct treatment and in such a manner as to avoid reflection on his predecessor.

Duties of the Dentist to the Public: Police and Law courts

• A dentist is not bound to disclose professional secrets unless called upon by the magistrate or judge to do so.

• Knowledge of a patient gained in the course of examination and treatment is privileged and should not be disclosed without the consent of the patient or an order from the judge in a court of law.

• Accepted measures to improve the general and dental health of the public should be promoted by the dentist.

Doctor-Patient Contract

• The legal foundation of the doctor - patient relationship is contract law.

• At the moment a dentist expresses a professional opinion or performs a professional act, to an individual who has reason to rely on it, the doctor patient relationship begins and the doctor is burdened with implied warranties.

• Dentist may refuse to treat a patient for any reason except race, creed, color or national origin.

• The refusal to accept a patient based upon a persons disability may be in violation of the law.

• Patients suffering from AIDS, fall into the category of disabled persons and may not be refused care.

Doctor-patient relationship ends

• When Both parties agree to end it. • Either the patient or dentist dies• The patient ends it by act or statement• The patient is cured• The dentist unilaterally decides to terminate

the care.

Express terms • An express term is one in which both parties are in

agreement. • Usually the express terms define items such as fee,

the treatment and the manner in which payments are to be made.

• These may be written in separate form, because the treatment record should contain only treatment notes and patient reactions to treatment.

• Guarantees made by the dentist constitute an express term in the agreement.

Implied Duties Owed by the Doctor

1. Use reasonable care in the provision of services as measured against acceptable standards set by other practitioners with similar training in a similar community.

2. Be properly licensed and registered and meet all other legal requirements to engage in the practice of dentistry.

3. Employ competent personnel and provide for their proper supervision.

4. Maintain a level of knowledge in keeping with current advances in the profession.

5. Use methods that are acceptable to at least a respectable minority of similar practitioners in the community.

6. Not use experimental procedures.7. Obtain informed consent from the patient before

instituting an examination or treatment.8. Not abandon the patient.9. Ensure that care is available in emergency

situations.10. Charge a reasonable fee for services based on

community standards.

• Keep the patient informed of his or her progress.

• Not undertake any procedure for which the practitioner is not qualified.

• Complete the care in a timely manner. • Keep accurate records of the

treatment.

• Maintain confidentiality of information. • Inform the patient of any untoward

occurrences in the course of treatment.

• Make appropriate referrals and request necessary consultations.

• Practice in a manner consistent with the code of ethics of the profession.

Implied Duties Owed by the Patient

1. Home care instructions will be followed 2. Appointments will be kept3. Bills for services will be paid in a reasonable

time4. That the patient will co-operate in the care. 5. That the patient will notify the dentist of a

change in health status.

Evolution of Protection of Human Participants in Research

• Prior to World War II there was little concern with the treatment of human subjects / participants in research.

• Thus, there were no formal protections.

Nuremberg Code

• In 1948 the Nuremberg Code laid down 10 standards for physicians to conform to when carrying out experiments on human participants.

• The Nuremberg Code was the result of judgment by an American military war crimes tribunal conducting proceedings against 23 Nazi physicians and administrators for their willing participation in war crimes and crimes against humanity.

• The doctors had conducted medical experiments on concentration camp prisoners who died or were permanently affected as a result.

Briefly, the 10 standards of the Nuremberg code are as follows:

1. Volunteers freely consent to participate 2. Researchers fully inform volunteers concerning the

study 3. Risks associated with the study are reduced where

possible 4. Researchers are responsible for protecting

participants against remote harms 5. Participants can withdraw from the study at any

time 6. Qualified researchers conduct the study

7. Termination of the study if adverse effects emerge 8. Society should benefit from study findings 9. Research on humans, should be based on previous

animal or other previous work 10. A research study should never begin if there is a

reason to believe that death or injury may result

Ethical Guidelines for Biomedical Researchon Human Subjects- ICMR 2000

• The first International Statement on the ethics of medical research using human subjects namely, the Nuremberg Code was formulated in 1947, which emphasized consent and voluntariness.

• Based on the preliminary efforts of the Council for International Organizations of Medical Sciences (CIOMS) in 1964 at Helsinki, the World Medical Association formulated general principles on use of human subjects in medical research in addition to specific guidelines for biomedical research, known as the Helsinki Declaration

BASIC RESPONSIBILITIESof IEC (independent ethics committees) /

IRB (institutional review board)

• To ensure a competent review of all ethical aspects of the project proposals received

• To ensure the scientific soundness of the proposed research

• Provide advice to the researchers on all aspects of the welfare and safety of the research participants

• In smaller institutions the Ethics Committee may take up the dual responsibility of Scientific and Ethical Review.

• To protect the dignity, rights and well being of the potential research participants.

• To ensure that universal ethical values and international scientific standards are expressed in terms of local community values and customs.

• To assist in the development and the education of a research community responsive to local health care requirements.

Some Unethical Practices by Dentists

• Practice by unregistered persons employed by the dentist.

• Dentists signed under his name and authority issuing any certificate, which is untrue, misleading or improper.

• Use of bogus diplomas. • Allowing commission• Dentists advertising whether directly or indirectly

for the purpose of obtaining patients or promoting his own professional advantage.

Some Unethical Practices by Dentists

• Practice without a dental qualification• Use of Dentist’s name who is no longer

practicing (can continue only for 1 year)• A dentist practicing medicine• A dentist’s clinic termed as hospital• Dentist’s board displays a membership• Use of terms like tooth puller, Denture

maker etc

Some Unethical Practices by Dentists

• Commercial advertisements regarding practice, but dentists are allowed to advertise when they need some staff.

• It should be in normal type and should state only the nature of vacancy

• To sell physicians samples in clinic at a profit • If a dentist whishes to announce in

newspaper, the announcement should not contain his professional degree, his address and announcement should not appear in more than 3 issues of the publication.

Some Unethical Practices by Dentists

• Not informing patients regarding change of ownership, change of address

• Dentists name in dental health education pamphlet which is distributed to public.

DENTAL PAYMENTS

• Traditionally health care services have been provided as a fee for service basis.

• Here the patient receives specific services and pays the provider for them directly.

• As the costs of health care continues to rise, methods to ease costs either by legislation or by development of a variety of funding approaches.

Increase in health care costs due to :• Increasing demand • Ever-growing technology • Lack of incentives in medical care to keep down the costs• Higher quality of care• General inflation• Defensive medicine

• Increase in expenditures of public funds for health care• Excessive number of hospital beds• Unnecessary duplication of resources.• Difficult economics of scale• The aging population• Third party payment

MECHANISM OF

PAYMENTS

1.Private fee - for services2. Post payment plans3. Private third party service plans

3a. Commercial insurance companies3b. Non profit health service corporations

E.g.: Delta dental plans : Blue cross \Blue shield 3c. Prepaid group practice 3d. Capitation plans4. Salary5. Public programs

Private fee for service• Private fee for service the two party

arrangement, is the traditional form of payment for dental services.

• Dentists overwhelmingly prefer to practice under the fee for service arrangement and the ADA defends fee for service as the most efficient way of financing and providing dental care.

• Fee for service care is an integral part of private practice as a delivery method.

Advantages

• Culturally acceptable• Flexibility – Fees can be changed in accordance with market conditions •Administratively simple• It is the only system in which some form of dental care likely will ever be provided.

Disadvantages•Though flexibility and price discrimination exist, there are still some potential patients who simply cannot afford the dental care offered if private fee for service were to be the only financing mechanism for dental care.

Post payment plans

•First introduced in late 1930's by local dental societies in Pennsylvania & Michigan.•Here, the patient borrows money from a bank or finance company to pay dentist’s fee. •After the application is approved by the lending institute, dentist is paid entire fee. •Patient then repays the loan to the bank.

Disadvantages• Was used more by middle-income group then low-income group• Low-income group people were not considered credit worthy by lending institution

Private : Third party payment plans

• Based on "Payment for services for some agency rather than directly by beneficiary of those services ". • The dentist and the patient are the first and second parties & administrator of the finances is the third party .• The third party is also known as the carrier, insures, under writers or administrative agent.

INSURANCE PRINCIPLES AND DENTAL CARE

•Earlier dental care was considered uninsurable by carriers because of the vary nature of dental need violated the basic principle of insurance.

•To be insurable, the risk must–Be precisely definable. –Be of sufficient magnitude that if it occurs it

constitute a major loss. –Be infrequent–Be of an unwanted nature such as destruction of a

home through fire. –Be beyond control of the individual.

•Insurance company have found that dental insurance can be made more feasible by

•Having patients pay a share of costs •Limiting the range of services– e.g. implants and cosmetic restorations not covered•Offering coverage only to groups – to avoid

adverse selection•Including waiting periods•Using preauthorization and annual expenditure

limits

U.C.R. Fee•U-Usual: The fee usually charged for a given service by an individual dentist to private patients i.e. his or usual fee. Dentist enrolls at insurance company, a confidential list of fee that he charges. The company uses this information to decide the customary fee•C-Customary fee: A fee is customary when it is in the range of the usual fee charged by dentists of similar training and experience for same service in specific area•R-Reasonable: A fee is considered as reasonable if certified by special circumstances, necessitating extensive complex treatment.

Table of allowancesA table of allowances is defined as a list of covered services that assigns to each service a sum that represents the total obligation of the plan with respect to payment for such service but that does not necessarily represent a dentist’s full fee for that service.

• If the dentist’s fee becomes more than that assigned to that service by the carrier, the remainder will be collected by the dentist from the patient.

• This method is not entirely satisfactory because the patients are often unaware that the plan may not cover them in full for dental care.

Commercial insurance companies characteristics• They can be more selective about the group to

which it chooses to offer dental insurance.• They claim no obligation towards the dental health

of the community.• Commercial insurance companies also organize

their level of reimbursement differently.• Commercial companies also do not conduct fee

audits & post treatment dental examination. • These charges higher premium in order to make

profit.

Non profit health service

corporations

Delta Dental Plans• In June 1954, the District Dental Society in Washington State was approached by the International Longshoreman’s and Warehouseman’s union Pacific Maritime Association (ILWU/PMA) with a request that the society submit a proposal for a comprehensive dental care program for children up to 14 years of age. •This gave birth to the first dental service cooperation.

• A participating dentist is defined as any duly licensed dentist with whom a delta plan has a contractual agreement to render care to covered subscribers.

• Dentists participating in the plan have to agree to the following conditions,

• Pre-filling of their usual and customary fees.• Acceptance of payment for their services at 90th

percentile of fees as payment in full.

• Fee audits by auditors from delta plan, who may check their office records from time to time.

• Post treatment inspection of randomly chosen patients to monitor the quality of care.

• The withholding of a small amount of each fee to go into the delta capital reserve fund.

• Non participating dentists can also treat patients covered under Delta dental plan, they are paid at a considerably lower percentile than the 90th.

Blue cross blue shield association

• It is a federation of 38 separate health insurance organizations and companies in the united states.

• Combined they directly or indirectly provide health insurance to over 99 million americans.

• These non profit health service corporations have for years offered limited dental coverage as a part of medical policies.

• Dental coverage was usually limited to services provided in a hospital.

Prepaid group practice

• Group practice is that type of dental practice in which dentists, sometimes in association with the members of other health professions agree formally between themselves on certain central arrangements designed to provide efficient dental health service.

• Types:– General practice groups– Single speciality groups– Multi speciality groups

Advantages for the dentist

• It provides better ways of organizing one’s life.• There is less disruption in the practice caused by

illness to a dentist.• Quality of care is said to be improved because of

the built-in peer review.• Financial fringe benefits such as sick leave and

pension plans can be built into a group organization more readily, thus easing the day to day economic concerns of dental practice.

HEALTH MAINTAINANCE ORGANIZATION (H.M.O)

An HMO is defined in the 1973 Act as “A legal entity which provides a prescribed range of health services… to each individual who has enrolled in the organization in return for a pre –paid, fixed, and uniform payment”

The H.M.O is based on ‘4’ principles:1.It is a non-profitable organization2.It delivers comprehensive dental care3.It enrolls group members and families4.It expects a ‘fixed or pre-paid’ fee.

Salary• Dentists are employed by public agencies as

salaried personnel.• Common especially in closed-panel clinics• Good for new graduates ; can obtain good

clinical experience.

Advantages

• Dentist is largely free of the business concerns of running a practice thereby allowing him/her to concentrate on clinical matters.

• Fringe benefits attractive.

Disadvantages

• There could be lack of financial incentive for some dentists who are highly productive.

Public Programs (Public financing of dental care)

Medicare• In USA title XVIII of the social security Amendments of

1965 is the program known as “medicare”.• It removed all financial barriers for hospital and

physician services for all persons aged 65.• It had two partsPart A: Hospital InsurancePart B: Supplemental Medical Insurance Its dental segment is limited to services requiring hospitalization for treatment, usually surgical treatment for fractures and cancer and hence constitutes a negligible proportion of the program.

MedicaidIt is the name given to title XIX of the social security amendments of 1965It was designed to assist low-income families in providing health care for themselves and their children. It also covers certain individuals who fall below the federal poverty level. It covers hospital and doctor’s visits, emergency room visits, drugs and other treatments.

Dental insurance in India

• The efforts of the Indian Dental Association to bring out a comprehensive Indian dental insurance scheme have seen partial success so far.

• Indian dental insurance plans are mainly of two types:– Stand alone dental insurance plan– Dental insurance cover as part of general health

insurance plan

Stand alone dental insurance plan:

• This type of plan covers the expenses related to general dental problems such as periodontitis and extraction of permanent teeth due to ailments such as caries.

• The amount of expense to be reimbursed as well as the period of such cover is fixed.

• This type of plan is generally provided by the popular dental care product companies in association with one of the insurance companies.

• The first of its kind dental insurance scheme in India was launched through oral care brand, Pepsodent (HLL) in 2002.

• This plan was in partnership with the New India Assurance; the plan offered a dental insurance of Rs. 1000 on purchase of any pack of Pepsodent.

• Insurance cover against expenses for the extraction of teeth due to caries and periodontitis was also provided.

• But this plan was time bound and also did not cover other aspects of dental rehabilitation.

Dental insurance cover as part of general health insuranceplan:

• This type of dental insurance is provided by the general insurance companies as part of their own general health insurance schemes such as health advantage policy or student medical policy.

• One can claim dental expenses along with the other kinds of reimbursements such as the cost of medicines or hospitalization.

• These plans also offered tax benefits up to a certain fixed amount under the income tax act.

• Example: The insurance plan provided by ICICI Lombard Dental Insurance Cover is not a comprehensive plan and is clubbed with the general health insurance scheme.

Conclusion • Prevention is always better than cure• Not all the ethical dilemmas that arise in daily

practice can be foreseen• The ethical dentist needs a core of knowledge and

working methods• This knowledge expresses a high standard of

approach to ethical matters in an area where there is no absolute right and wrong.

• It is incumbent on all professionals to embrace the principles in everyday working life.

•Thank you