It may have become second nature to most of us but in reality the decision-making process for a consumer when deciding whether to purchase a good or service is anything but straightforward. The potential influences on consumer behaviour are many and varied and will differ from one person to the next. The marketing analysts, for example, cite a wide range of factors affecting purchasing decisions. These may include, but are not limited to:

• External Influences – culture, group, situation;
• Internal/Personal Influences – perception, attitude, knowledge, personality, income, opportunity cost, lifestyle, role;
• Marketing Influences – product, promotion, price, distribution, service.

It is worth noting that these matters are not, for the most part, mutually exclusive. They interconnect in a way that influences who we are and how we behave.

After feeding the available information through our personal decision-making sieve, we arrive at our own conclusion – to buy or not to buy? It may, of course, be the case that we still decide to proceed with a purchase despite having formed the perception that the good or service is “expensive”. We have simply satisfied ourselves that the outlay is justified given the outcome we expect to achieve by making the purchase. Confronted with similar circumstances, however, another person may deem our “expensive” purchase to be a “bargain” and vice versa. Indeed, none of us are really in a position to speak for others in the marketplace as to what constitutes value for money.

Is dentistry any different? Whether we are comfortable with the terminology or not, our patients are consumers. Are we as dentists able to predict how any patient (given their individual circumstances, many of which we are not privy to) will perceive the fees we charge for the services we provide? The reality is that we are unlikely to be able to predict their perception but we may be able to have some input in to how they arrive at their conclusion.

At the heart of this process is information, which takes a number of different forms. In broad terms, a patient needs first to understand (on a technical level) and agree to the treatment procedure(s) being recommended. This is classically referred to as Informed Consent. Secondly, but no less importantly, the patient should be made aware of the costs they are likely to incur in receiving the treatment. It is this latter issue, Informed Financial Consent, which is addressed here.

There is nothing in the Competition and Consumer Act 2010 (Cth) that regulates the prices charged by professionals. As such, professionals are free to decide what fees they will charge clients for their services. Because of this, the Australian Competition and Consumer Commission (ACCC) believes that professionals have an ethical duty to inform their patients about the cost of the services they provide while consumers have a right to obtain information on these costs – “where possible, in advance of the services being provided”. The ACCC contends that consumers are often not as well informed about professional services as they are for other sectors because of the imbalance between what they know of the service provision compared with what the provider knows. It follows that better information needs to be provided about professional services to enable consumers to make better-informed choices about purchasing services and whether to provide consent for such services to be provided.

The source of protection for consumers is provided by the Australian Consumer Law (ACL), which is contained in a schedule to the Competition and Consumer Act 2010. Generally, the ACL requires that professionals do not, in their promotional activities, act in a way that is misleading or deceptive, or is likely to mislead or deceive. Through its enforcement of the consumer protection provisions of the ACL the ACCC is concerned that professionals obtain informed financial consent from their clients. Practitioners should be aware, for example, that failure to disclose material information such as fees may, in some circumstances, put them in breach of ACL provisions.

The issue of misleading and deceptive conduct is an important one to consider in relation to “failure to disclose material information”. In its 2010 publication Professions and the Trade Practices Act the ACCC states:

“Misleading and deceptive conduct – whether that conduct actually misleads clients or is merely likely to mislead them – is prohibited. Generally this type of conduct involves leading someone into error, or being likely to, and includes behaviour such as:

• lying
• leading someone to a wrong conclusion
• creating a false impression
• leaving out (or hiding) important information
• making false or inaccurate claims

It is irrelevant whether these are done intentionally or not. A business can break the rules by both deliberate and inadvertent actions”.

What, then, does this all mean in real terms for the practitioner? We know from the above where the legislators stand, but what about consumer organisations? CHOICE has published several articles in recent years which touch on the issue of Informed Financial Consent as it relates to the provision of dental services. The articles Guide to choosing dental care (12 June 2007) and Can you trust your dentist? (23 November 2009) are worth reading if only to put yourself in a patient’s shoes and to understand what a consumer advocate body feels is appropriate. Both articles refer to the benefit of patients having a written quotation for proposed dental treatment. There are also several statements which acknowledge the need for dentist and patient to understand the perspective of the other. To the dentist, CHOICE urges the need to explain:

“Dentistry is said to be a notoriously inexact science, or even art based on scientific knowledge. With most people now assuming they’ll keep their teeth for life, dentists have an unprecedented duty of care. While preventative care is simply good practice, unnecessary work could ultimately destroy a tooth. Most people aren’t in a position to judge whose opinion best serves their long-term interests”.

To the patient, CHOICE endeavours to explain some of the reasons for fee variations:

“…there’s a wide cost range for most item numbers. Charges vary for many reasons, including the surgery overheads, the expertise of the practitioner and the time it takes. Even a single item number can be charged differently by the same dentist: a filling on one surface may be particularly large or hard to access, for example, and require more time; or if you’re having several fillings done at once there may be a discount (because it takes less time than doing each as a single filling)”.

And a cautionary note to patients from the same publication:

“Don’t let leading questions sway your judgement, and watch out for the sales pitch that doesn’t sound like a sales pitch. Is your dentist in the business of dentistry or the practice of dentistry?”

Would it not be reasonable for a dentist to operate in both of these spheres? It may just be that the perception of only being in the “business of dentistry” could be largely reversed by the open disclosure of fees prior to the commencement of treatment (together, of course, with a patient-appropriate explanation as to why the treatment is being recommended).

And so to the practicalities. Where does your Association stand on this matter and how can we help you? ADA Inc has an excellent resource for you to consider and I commend it to you. The Policy Statement Informed Financial Consent (“The Policy”) is complete in its coverage yet concise in its expression. You can find it on the Federal ADA website at www.ada.org.au/Professional-Information/Policies/Third-Parties/5-16-Informed-Financial-Consent. The document deals with the relationship between dentist and patient and additionally considers the impact of third party funding bodies. Some of the major points to note from this document are:

• Informed financial consent is sound ethical professional practice. This is also good business practice and will result in fewer disputes over accounts, lower debt recovery costs and fewer bad debts;
• Many patients will be unfamiliar with what is involved with their dental procedure. In some instances, patients may have wrongly assumed that the fee for the dental service is fully covered by their health fund;
• Patients may be apprehensive over the pending dental procedures. They may be unwell, distressed, disoriented, or affected by more than one of those conditions. Discussing financial implications with some patients at this time may be impractical and unworkable;
• Dental fees may be based on an itemised schedule of treatment or on the time taken to complete the dental procedure. Accordingly, the dentist may only be able to estimate a range of fees based on the expected time to undertake the procedure. Similarly, if the planned procedure is changed during surgery, due to unforeseen circumstances, this may also result in a change to the final fee charged by the dentist. Of course, any such fee should be advised at the appropriate time.

The Policy sensibly advises that any information about expected charges, provided to the patient prior to treatment, should include advice that the estimate is not guaranteed and the cost to the patient may increase if the planned procedure takes longer than expected or other procedures are required. The point is also made that dentists should ensure that patients are in a fit state to give informed financial consent.

In the public domain your Association has made its position on informed financial consent clear. On October 2008 the then Federal President, Dr John E Matthews, issued a media release in response to statements made by the Federal Minister for Health and Ageing, Nicola Roxon. In a speech to the Australian Health Insurance Association Annual Conference Minister Roxon mentioned Dental Services in relation to out-of-pocket costs, “Insurers publish information about the benefits they pay for dental treatment – but consumers often don’t get information about the actual charges until after they’ve had the treatment and receive an account”. Dr Matthews responded “The Minister is generalising when she makes such a statement as often patients request or are offered a treatment plan before commencing treatment. The ADA supports the principle of full disclosure of fees before a course of dental treatment and encourages dentists to provide and patients to seek a full estimate of treatment in advance. This is part of the ADA’s policy on informed financial consent”.

So how could you go about managing the issue in your day-to-day working life? Every practice has a different “feel” to it and there are no hard and fast rules. You know your business and your patients better than anyone else and have to decide what will work best in your particular circumstances. For some, it may be a blanket policy of providing quotations for all treatment proposed for all patients. Many current software programs make it quite easy to produce a quotation document based on the treatment plan you have entered. Given the compliance requirements of the Medicare Chronic Diseases Dental Scheme (CDDS) this should, by now, be routine for many. For others, you may choose to place a sign at reception with wording such as “We are happy to provide you with an estimate of fees for your treatment. Please advise if you would like us to prepare a quotation for you”. Other practices may take the decision to only provide quotations for treatment above a certain dollar amount and still others may just leave it to the practitioner’s discretion to suggest a quotation at the time when treatment is being discussed. Whatever the case, be mindful that what seems in prospect to be an imposition on your time (and that of your staff) is as nothing compared to the time and emotional energy you will need to invest in responding to a complaint about fees made by a patient (either to yourself or a statutory authority) after the event.

The issue of disputes over fees is very real. At the Dental Defence Advisory Service (DDAS) we are regularly assisting members on matters relating to treatment costs. The database of matters reported to DDAS currently contains some 130 files specifically on issues of fees. These are broadly categorised into one of two areas: Failure to Advise All Treatment Costs and Excessive Fees. So what are the types of circumstances that give rise to problems? Examples include:

• Differences between what was quoted and what was subsequently charged with no explanation as to why the change occurred. The difference between the fee for a simple extraction and a surgical removal, for instance, needs to be discussed;
• Seeing a patient for the first time and at the initial visit undertaking examination, prophylaxis, radiographs and multiple restorations – all without any discussion of what the fee payable would be at the end of the appointment;
• Misunderstandings regarding ongoing costs such as subsequent denture relines where the patient may believe such fee was included in the original cost of the prosthesis;
• A patient not being aware that the fee quoted for endodontic treatment was not inclusive of the subsequent restoration of the tooth. Similarly, a patient quoted for an “implant” needs to understand what this term means as a dentist’s usage of the term may be vastly different than the patient’s mental picture of a complete new tooth;
• Unexpected additional procedures being required. An example would be the need to graft at an implant site which is only determined at the time of surgery. This possibility should ideally be canvassed prior to the event but, at the very least, addressed with the patient as soon as the practitioner becomes aware of the need to do so;
• A patient’s monetary limit under the CDDS being exceeded such that the patient will unexpectedly incur out-of-pocket expenses;
• Patients not understanding their gap payment obligations under either the CDDS or with health fund cover.

There are many, many more. Whatever dentistry you practice you will justifiably seek remuneration for the provision of this service, however it cannot be stressed enough just how important it is that you discuss fees with your patients prior to treatment and document these matters in your treatment notes. As a consumer yourself, would you expect anything less than to know the cost of the good or service you are considering purchasing?

At DDAS we are always just a telephone call away to provide an ear, a shoulder and, of course, advice. This is delivered in a non-judgemental way to help members deal with some of the problems that unfortunately arise as a result of dealing with people and being only human ourselves. Nonetheless, it is hoped that reading this article may stimulate you to rethink how you approach the matter of informed financial consent and perhaps, just perhaps, save you some trouble in the times ahead.

Article on Informed Financial Consent for NSW Dentist June 2011
Craig Brown, DDAS Peer Advisor