Finance and ethics in dentistry

FINANCE & ETHICS IN
DENTISTRY
Presented by : Dr. Arpit Viradiya
Guided 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. Justices
5. Truthfulness
6. 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 kept
3. Bills for services will be paid in a reasonable
time
4. 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 Research
on 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 RESPONSIBILITIES
of 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.

• 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

• 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.

• Not informing patients regarding change of
ownership, change of address
• Dentists name in dental health education
pamphlet which is distributed to public.

• 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

1.Private fee - for services
2. Post payment plans
3. Private third party service plans
3a. Commercial insurance companies
3b. Non profit health service corporations
E.g.: Delta dental plans
: Blue cross Blue shield
3c. Prepaid group practice
3d. Capitation plans
4. Salary
5. 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 allowances
A 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 organization
2.It delivers comprehensive dental care
3.It enrolls group members and families
4.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 parts
Part A: Hospital Insurance
Part 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.

Medicaid
It is the name given to title XIX of the social security
amendments of 1965
It 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 insurance
plan:
• 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.

Finance and ethics in dentistry

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