[English] Mert pay for dentists?

[Scott Bulfin]

Here is an interesting reframing of merit pay

Merit Pay For Dentists

  My dentist is great! He sends me  reminders so I don't forget  
checkups. He uses the latest  techniques based on research. He never  
hurts me, and I've got all my teeth.

  When I ran into him the other day, I was eager  to see if  he'd  
heard about the  Federal Government's latest program for improving  
the dental health of  our children by introducing merit pay for dentists

  "Did you hear about the new federal program to  measure   
effectiveness of dentists with their young patients?" I  said.

  "No," he said. He didn't seem too thrilled. "How will they do that?"

  "It's quite simple," I said. "They will just  count the number of  
cavities each patient has at Grades 3, 5, 7, 9, and average that to  
determine a dentist's rating. Dentists will be  rated as excellent,  
good, average, below average, and unsatisfactory.  That way  parents  
will know which are the best dentists. The plan  will also encourage  
the less effective dentists to get better," I said.  "Poor dentists  
who don't improve could lose their licenses to  practice."

  "That's terrible," he said.

  "What?  That's not a good attitude," I said. "Don't you think we  
should try to improve children's dental health in this country?"

  "Sure I  do," he said, "but that's not a fair way to determine who  
is practising  good dentistry."

  "Why not?" I said. "It makes perfect sense to  me."

  "Well, it's so obvious," he said. "Don't you see that dentists  
don't all work with the same clientele, and that much  depends on  
things we can't control? For example, I work in a rural area  with a  
high percentage of patients from deprived homes, while  some of my  
colleagues work in upper middle-class neighborhoods.  Many of the  
parents I work with don't bring their children to see me  until there  
is some kind of problem, and I don't get to do much  preventive work.  
Also, many of the parents I serve let their kids  eat way too much  
candy from an early age, unlike more educated  parents who understand  
the relationship between sugar and decay. To top it all off, so many  
of my clients have well water which is untreated  and has no fluoride  
in it. Do you have any idea how much difference early use of fluoride  
can make?"

  "It sounds like  you're making excuses," I said. "I can't believe  
that you, my dentist,  would be so defensive. After all, you do a  
great job, and you needn't fear a little accountability."

  "I am not being defensive!" he  said. "My best patients are as good  
as anyone's, my work is as  good as anyone's, but my average cavity  
count is going to be  higher than a lot of other dentists' because I  
chose to work  where I am needed most."

  "Don't' get touchy," I  said.

  "Touchy?" he said. His face had turned red, and  from the way he  
was clenching and unclenching his jaws, I was  afraid he was going to  
damage his teeth. "Try furious! In a system like  this, I will end up  
being rated average, below average, or worse. The  few educated
patients I have who see these ratings may believe  this so-called  
rating is an actual measure of my ability and  proficiency as a  
dentist. They may leave me, and I'll be left with only  the most  
needy patients. And my cavity average score will get even  worse. On  
top of that, how will I attract good dental hygienists and other  
excellent dentists to my practice if it is labeled  below average?"

  "I think you are overreacting," I said. "'Complaining, excuse- 
making and stonewalling won't improve dental  health'... I am quoting  
from a leading member of the DOC," I  noted.

  "What's the DOC?" he asked.

  "It's the  Dental Oversight Committee," I said, "a group made up of  
mostly lay  persons to make sure dentistry in this state gets improved"

  "Spare me," he said, "I can't believe this. Reasonable people won't  
buy it," he said hopefully.

  The program  sounded reasonable to me, so I asked, "How else would  
you measure good  dentistry?"

  "Come watch me work," he said. "Observe my  processes."

  "That's too complicated, expensive and time-consuming," I said.  
"Cavities are the bottom line, and you can't argue  with the bottom  
line. It's an absolute measure."

  "That's what I'm afraid my parents and prospective patients will  
think. This  can't be happening," he said despairingly.

  "Now, now," I  said, "don't despair. The Federal government will  
help you some."

   "How?" he asked.

   If you receive a poor rating, they'll send a  dentist who is rated  
excellent to help straighten you out," I  said brightly.

  "You mean," he said, "they'll send a dentist  with a wealthy  
clientele to show me how to work on severe  juvenile dental problems  
with which I have probably had much more  experience? BIG HELP!"

  "There you go again," I said. "You aren't  acting professionally at  
all."

  "You don't get it," he  said. "Doing this would be like grading  
schools and teachers on an  average score made on a test of  
children's progress with no regard to influences outside the school,  
the home, the community served and stuff like that. Why would they do  
something
so unfair to dentists? No one would ever think of doing that to  
schools."

  I just shook my head sadly, but he had  brightened.

  "I'm going to write my representatives and senators," he said.  
"I'll use the school analogy. Surely they will see  the point."


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