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$1,080 an hour

From 8:02 until 8:58 this morning, I was in the care of an excellent endodentist, having a root canal. At the end of that hour, I was presented with a bill for $1,080, a number I associate more with high definition TVs than with hourly wages.

My endodentist was excellent. She’s highly skilled and had great chair-side manner, narrating each step, and preparing me for every delightful little surprise ( “You’ll feel a dull thud as I jam this this phillips-head screwdriver into your tooth, handle first.” “The smell of your own body burning may be a little pungent.”) I am old enough to remember when root canal was the standard measure of pain, just as “the length of a football field” is the standard measure of distance and “as many books as in the Library of Congress” is the standard measure of volume, so I have no complaints about a procedure that has become merely uncomfortable with occasional sharp twinges.

But $1,080 an hour? In Boston, that’s seems to be the going rate, albeit at the high end. On the other hand, after dental insurance, it only cost me $1,080….because there’s no practical way for me to get dental insurance.

I seriously don’t understand the pricing model. The endodentist is part of my dentist’s general practice. She shares the facilities and uses the same rooms. There doesn’t seem to be a whole lot of complex special equipment involved, outside of some rasps, a keyhole saw, and a cash register. She’s had some specialized training, but are root canals really that much more complex than the range of procedures my general dentist can do, from reconstructing a tooth to diagnosing gum problems? Meanwhile, the endodentist is in danger of getting repetitive stress syndrome from doing the same motions — drill, scrape, fill, phone her broker — over and over.

Is it pure scarcity that drives the prices up? At those prices, why is there a scarcity? And why aren’t other dental procedures broken off and priced as exorbitantly? Or is this a residue of the days when root canals were so painful that people wanted to feel like they were getting their money’s worth? [Tags: ]

18 Responses to “$1,080 an hour”

  1. Malpractice insurance.

    On a related note, plot the price of refrigerators as a function of volume, starting with the little cube ones and going up. Right at the point where the volume becomes large enough to trap a child, the price goes up $350, all of which is liability insurance.

  2. Wow I could’ve saved $300 by going to Boston for my last root canal.

  3. David, I have the same problem with dentists’ fees, especially the specialists. My last root canal, about 2 years ago, was, I believe about $1300 in our suburban town. I got “professional courtesy.” I paid about $1100 and it took maybe a few minutes longer than yours (and I have the same absence of dental insurance). She is an acquaintance-friend of ours. My periodontist who does the implants (and is terrific and very nice) charges similar rates.

    I’ve never known why they can charge these amounts and have mentioned it to the endodontist and my regular dentist (whose rates are not as bad). They have not discussed it at any length. I’ve always wished I could collect a mere fraction per hour of what they can.

    I doubt that malpractice insurance is the main cause, although I know what mine costs as a physician, but not theirs. I think dental suits in NJ are less common than medical ones and probably settle for less, but I don’t have facts.

    Dental equipment is fairly expensive and may account for some of the cost. Their total time in education as dental specialists did not exceed my time in training, I am sure, however.

    I think the main reason is, that they can charge it and collect it. Too bad about our genes and childhood dental care.

  4. Had you insurance, the dentist would expect to see payment of about 40% of the bill. You’re subsidizing that to the tune of $648. What a great system!

  5. $1080 is cheap. My last one cost about $1500. But I did have fun. With the cooperation of my endodontist I tweeted the whole procedure live. (BTW, what’s the diff between an endoDOntist and and endoDEntist?)

  6. I haven’t ever had a root canal, but I know my dentist (who does them) charges less than what you (and some of the commenters) paid.

    However, my dentist has another very lucrative gig going on. She is the only dentist in Victoria BC (maybe even in all of BC, not sure) who is certified by the dental board to do Botox injections (which I also haven’t had — but I’m getting to the point where I almost wish I could afford them).

    Her expert knowledge of all the facial muscles gives her an edge, and now she does a roaring business with these cosmetic procedures. Her clients continue to visit “the dentist” (she shares the practice with several other owners), so they’re never “caught” getting botoxed. I believe she also fluffs lips/ injects collagen.

    In Canada I’m pretty sure dentists make more money than doctors, because dental care isn’t part of the universal health care system and so dentists have private practices and can charge what they can get (although private dental insurance is a perq offered by many larger employers).

    But my smart dentist is *really* killing it, because she leveraged her expertise to get into the booming cosmetics business.

    It’s probably already pretty common in other parts of the continent, and we’ll see more of it. A lot of the money in dental care is already in procedures to make clients look good, so working right on the face instead of just the teeth is a next logical step.

    All that said, I still don’t know why a root canal should cost over $1K.

  7. Not in the dental industry so no idea about their pricing, but I am reminded of the old dentistry joke:

    A man has a horrible toothache and decides to go to the dentist. The dentist looks at the tooth and says, “It has to come out. But don’t worry, it will only take a few minutes to extract it.”

    The man asks, “I can’t stand the pain – but how much will it cost?”

    The dentist replies, “$1,000”.

    The man angrily responds, “$1,000? That’s robbery for a few minutes’ work!”

    The dentist calmly responds, “If you want, I can take it out more slowly….”

  8. There’s a lot of truth to Jesse’s joke though.

    Endodontist’s fees need to recoup the cost of running a dental office from both an admin and supplies persepective. We generally don’t run hygiene services as most general dentists do. Hygiene can generate half or more of a practice’s income.

    We also need to make some money. We were in school for a long time (12 years total University for me) so haven’t had as much time to put away for retirement as others have. Those are the typical points that we make when asked about our fees.

    The less obvious point is that root canal procedures take a good amount of time to do properly. Dentistry is a fee-for-service profession (usually) and so the faster a procedure is done, the more we make…

    I won’t say more on that point because the implication is obvious.

    Dental equipment is expensive. There are a few instruments that I’m sure I could get at Home Depot much cheaper.

    Endodontics is argueably the most techincally challenging aspect of dentistry. Almost all of the work we do inside the canals is done blindly. We depend upon experience, training, and feel to get the job done well.

    It’s because of how much the procedure costs, however, that I stress. No medical or dental procedure has a 100% prognosis. Root canal treatment is no exception. Imagine how angry you’d be to have spent all of that money on a root canal and then find out in a couple of years that it is failing?

    Thanks for your post. I enjoyed reading it…

  9. I don’t have any problem with people being rewarded for their expertise, as long as the market supports and unfair structures aren’t in place that ensure high prices.

    Dentists and doctors, however generous or not individually, don’t live in an ideal world. As one commenter noted, your lack of insurance crazily subsidizes those with insurance. If you pay retail, you’re usually less likely (outside dentistry) to be able to afford to pay, and paradoxically charged more even though you consume fewer doctor office cycles: you’re usually required to pay upfront, there’s no billing, no waiting, no denied charges, no whatever.

    My former GP converted his office to a retainer-based practice a decade ago (he recently semi-retired into a smaller retainer-based practice), and he and his fellow doctors were able to reduce staff by two because they no longer dealt with insurance companies.

    Now the real issue is whether the endodentist was charging $1,080 retail because she has a special position that allows her to charge more than a fair market would bear. Clearly not: you paid the charge for work that, if you price compared, would have cost about the same elsewhere, or even more. So the market is “efficient” in that sense.

    The dentist is likely, unless in practice for more than 10 years already or from a wealthy or poor family, still paying off hundreds of thousands of dollars of student loans. I believe it’s 10 years or more for an average specialty medical doctor or dentist to get out of debt. Even if you start medical school young, that could be 35 before you start actually earning money that you could put aside.

    Malpractice costs are often overstated or used as an excuse. I just did a quick scan through Google, and find that costs may run from $25,000 to $250,000 per year depending on the profession. So let’s just pretend that given the risk involved for an endodentist, she’s paying just $50,000 per year. So that’s maybe $50 to $100 per appointment, depending on how many appointments she can schedule.

    Office overhead is divided up all kinds of ways depending on the practice. If she has specialized equipment and additional support staff, the costs might be a few hundred dollars per appointment as a share of overhead.

    The other costs of doing business, such as taxes, back-office stuff, etc., is probably at least $100 per visit, divided out that way, although you were paying directly, so your visit was cheaper.

    The lack of real return on insurance visits means the endodentist charges you more to actually draw a salary in the range of her peers. If she wants to make $200,000 per year (again, in the early years, a significant portion goes to loans, building a practice, and taxes), she needs to make $100 at the end of the day (before her own taxes).

    And none of this factors in being paid for expertise. If I had those specialized skills, I’d be happy to charge $1,000 per hour if people were willing to pay it and I thought it a fair exchange.

    Dave, what do you charge per hour in consulting? On the few occasions I’ve done consulting, I have charged in the $150 to $200 per hour range. I know folks who charge $300 to $500. Lawyers charge more, even.

  10. […] Joho the Blog » $1,080 an hour […]

  11. Except for the comments about endodentistry (and I got the spelling off of a dental glossary site, but it looks like I got it wrong) being a specialized skill, none of the explanations offered explain why endodentists charge so much more per hour than does my general dental practitioner (who is also highly skilled). Well, except for the pointing to the magic hand of the market, which may be the final, brutal explanation.

  12. I am also well-trained (with nine years of training after 4 years of college) and did not start practice until age 33 (2 years of which were due to being drafted into the Army as a doctor, and I would not have been drafted if I had not been one).

    I can not charge fees in the range of my endodontist and I don’t know anyone in what we refer to as the cognitive fields (we do not do much in the way of procedures, we mainly listen, examine and think) who does. If I didn’t accept insurance I would make more per patient, but nowhere in the endo- or periodontal range. I might get into the lawyer range, but that isn’t clear.

    I have similar expenses to my dental colleagues, except for the equipment and I don’t need someone handing me my instruments (a pen, in my case).

    I doubt that dental malpractice insurance is in the $50,000 range-it is likely much less.

  13. davidw: Any MD can do plastic surgery. Would you be happy having your family physician do a face lift on your mom, or would you prefer a plastic surgeon do that? A huge part of my practice is redoing root canal work done by “highly skilled” general dental practitioners.

  14. Andy W wrote: ” I have similar expenses to my dental colleagues, except for the equipment and I don’t need someone handing me my instruments (a pen, in my case).”

    Let’s agree to not be specious. I don’t denigrate your expertise one whit, but equipment and overhead isn’t an incidental expense.

    “I doubt that dental malpractice insurance is in the $50,000 range-it is likely much less.”

    I’d love to know. It’s seemingly a well-kept secret. Do OBs really pay $250,000 a year in some states? GP’s in the $35,000 to $50,000 range? That’s what my research showed, but I could find no authoritative sources.

  15. Glenn, knowing my brother, you’re mis-taking his tone. He wasn’t being flip about endodentists. He doesn’t need someone handing him instruments because in his line of medicine he generally only needs a pen; he wasn’t saying practitioners in other fields don’t need people handing them their instruments.

    One of my points, way back when, is that as far as I can tell (i.e., not very far), the endodentist isn’t using a whole lot of expensive equipment that the general dentists aren’t. She’s using the same rooms, and thus the same seat, x-ray machine, and drills. She seemed to bring a specialized set of drill bits and probes, which don’t seem to be such an intense capital expense that she has to charge 5x (or more) what the other dentists using that room charge.

  16. “I seriously don’t understand the pricing model.”
    My brother and his friend have this discussion regularly. His friend is a composer of many famous songs. Whenever one gets used, he gets paid “royalties.” My brother digs septic systems. He wants a similar pricing model – a penny per flush.

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