A Splitting Headache

A Splitting Headache

Michael A. Kurkowski, D.D.S.*:
Some individuals in our offices are particularly effective at recruiting new patients to our practices. They readily share their confidence and enthusiasm for our care and practice setting.  This response is very gratifying to any medical provider and is critical to maintaining a successful dental practice. Their motivation may be a desire to help us as a business or hoping to  turn their friends onto a better experience; sometimes both. If they are involved in a small business themselves, they clearly understand the value. Practice management advisors  emphasize internal marketing and asking for referrals or recommendations from our patients. It is one of the first topics they discuss. It can be the lifeblood of a growing practice. 
 
In order to recognize and encourage these recruiters within our patient pools, we need to reinforce their behavior. Typically offices send personal notes, gift cards, or small promotional  items (mugs, flowers etc). When patients refer additional friends to our offices, we work to keep the reward system fresh. We are encouraged to escalate our rewards to larger and more  memorable gifts to keep the referral engine humming. This scenario is a logical progression but could be a violation of guidelines outlined by the Minnesota State Board of Dentistry. 
 
150A.11 UNLAWFUL ACTS Subd. 4. Dividing fees. It shall be unlawful for any dentist to divide fees with or promise to pay a part commission to, any dentist or other person who calls the  dentist in consultation or who sends patients to the dentist for treatment or operation…
 
Most of us aware of this rule are cognizant that it applies to general dentists-specialty relationships. It helps prevent bidding wars among specialists who inappropriately reward referral  sources. The choice of specialists should be based on quality of care, clear communication between practitioners, and patient convenience. Referrals based solely upon promised or  expected meals, gift cards, or rounds of golf would be considered fee splitting and discouraged. Similarly, creating a reward environment for our patients (beyond token gifts of  appreciation) is likely also a violation of the intent of this rule. 
 
Recent complaints have focused on social media coupons (Groupon, livingsocial etc.) as a potential fee splitting mechanism. A dentist will often provide a service at a substantial discount  as an incentive for new patients. The problem occurs because these companies are typically compensated on a per person basis, so its use could be in violation. Usually the consumer pays  these companies, who typically forward 50% of the promotion fee to the dentist. This would likely be construed as fee splitting. Furthermore, the promotion sells a service that may not be appropriate without an exam and reduces that service to a commodity. It both diminishes the value of the service and demeans the decisionmaking involved in undertaking a procedure.  Discount ads convince consumers that we recommend certain procedures randomly and suggest we have high profit margins. It can also appear a little desperate to the public and recruits  some patients who are only shopping for the best price. These “shoppers” can also end up with fragmented care that fails to best address their needs. 
 
We have all had years of education and significant experience that we utilize to make our procedures efficient and seem routine. Do we really want to fight the uphill battle to overcome  the fear of dental treatment and promptly diminish its value? 
 
Dentistry’s professional technology is continuing to suffer from ever-decreasing half-lives (the amount of time until half of our technology becomes obsolete). We continue to face a brave  new world driven by information technology. Unfortunately, the accelerated changes in marketing are leap-frogging and perhaps stampeding our ethical principles and image. The “deal of  the day” industry is projected to exceed $6 billion in sales by 2015. Do we want to voluntarily place ourselves in competition with nail salons and oil changes? 
 
The American Dental Association’s Council on Ethics and Judicial Affairs (CEJA) is in the process of investigating this area of social coupons and providing guidance to our membership.  existing written ADA opinion found on the ADA website is as follows: 
 
ADA Section 4-Principle: Justice (“fairness”) 
Advisory Opinion
4.E.1 Split Fees In Advertising and Marketing Services. The prohibition against a dentist’s accepting or tendering rebates or split fees applies to business dealings between dentists and any  third party, not just other dentists. Thus, a dentist who pays for advertising or marketing services by sharing a specified portion of the professional fees collected from prospective or  actual patients with the vendor providing the advertising or marketing services is engaged in fee splitting. The prohibition against fee splitting is also applicable to the marketing of dental  treatments or procedures via “social coupons” if the business arrangement between the dentist and the concern providing the marketing services for that treatment or those procedures  allows the issuing company to collect the fee from the prospective patient, retain a defined percentage or portion of the revenue collected as payment for the coupon marketing service  provided to the dentist and remit to the dentist the remainder of the amount collected… 
 
The MDA Ethics Committee’s recommendation at this point would be to tread very carefully in this potentially hazardous area. It is, however, quite likely that we will see this form of  marketing evolve until it finds a less conflicted business model. Hopefully the short term temptation of this marketing approach will not lower the ethical bar for our entire profession. 
 
 
*Dr. Kurkowski is Chair of the Minnesota Dental Association Committee on Ethics,Constitution and Bylaws. He is a general dentist in private practice in Saint Paul, Minnesota. Email is  mmkurkowski@msn.com.