At $54,000, the reported price of the trip that an American dentist took to Zimbabwe is nearly as shocking as the death of Cecil, the widely known and universally beloved lion he killed while he was there.
The neighborhood dentist seems far removed from the upper echelons of medicine, someone who comes in for a few minutes at the end of a cleaning to check your teeth and ask about your kids, occasionally doing a filling or root canal. No doubt these services are critical to patients and our overall health, but some might be surprised to learn that a dentist could afford to spend $50,000 on a hunting expedition.
It turns out, however, that dentists are quite well paid. According to official government statistics, the median dentist in the U.S. in 2012 earned $149,310 per year. But that median figure obscures variation around the country and among dentists with different specialties. In some high-priced cities, dentists make a lot of money with non-medical, cosmetic procedures from teeth whitening to botox. And according to the American Dental Association, the average dental specialist earned $283,900 in 2013.*
Dentists in some places are so well compensated that they earn more than the average doctor. According to a 2012 report in The Journal of the American Medical Association, the average hourly wage of a dentist in America is $69.60 vs. $67.30 for a physician. As recently as 1996, dentists were making less than doctors. Meanwhile, the average general dental practitioner took in $181,000 in 2013, according to the dental association, compared to $175,000 for a family doctor, according to WebMD Medscape's annual compensation report.
Behind the high salaries
Behind the high wages is a debate over whether Americans ought to be spending so much on dental care.
Critics of the U.S. dental industry have long complained that dentists are insulated from market forces, resulting in higher prices.
"They're afraid of the competition," said Jay W. Friedman, a dentist and researcher in Los Angeles who has long advocated for dental reform.
He contends that in order to make it easier for more Americans to receive dental care, dental nurses and hygienists — who have less training — should be allowed to perform basic services independently of dentists. In most states, hygienists are barred from cleaning teeth unless they are employed by a dentist.
One study concluded that allowing hygienists to offer services independently, like nurse practitioners in general medicine, reduced dentists' incomes by 16 percent.
The dentists had more competition from people whom they otherwise could have employed, forcing them to lower their prices. Not only that, but since hygienists' options for treatment were legally limited, they might have recommended less expensive treatments, and patients would have spent less overall. Hygienists who were not allowed to perform fillings, for example, might have recommended less costly sealants instead.
As it happens, Minnesota — where the trophy hunter practices — is one state that recently gave dental personnel besides dentists more freedom to serve patients.
Minnesota recently began licensing "dental therapists," and there were 32 people practicing with the designation in the state as of last year, according to a report from the state Department of Health.
Minnesota's law allows these therapists to clean, fill and pull teeth under the "general supervision" of a dentist, who does not have to be on site. The report found that therapists cost about half as much as dentists, which suggests that incomes for dentists in Minnesota could decline as more therapists are licensed.
In response to questions about expanding the dental workforce, the American Dental Association pointed to a study claiming that the main challenge facing patients acquiring care is not the limited number of dentists but the underlying cost of receiving dental services.
National spending on dental care
According to the National Association of Dental Plans, an industry group, about 39 percent of the population — 124 million Americans — did not have dental benefits of any kind in 2013, compared to the 13.2 percent of adults who the Obama administration now estimates lack medical insurance. President Obama's health care law requires dental coverage for children, but not adults.
"Fifteen years ago, everybody lamented the poor care that the population was getting," Friedman said. "Fifteen years from now, we're still going to be saying the same thing."
Overall, spending on dental services is increasing in line with spending in the rest of the health care system, according to data economists published Tuesday. The country is projected to spend $119.1 billion overall on dental care this year, up from $97.3 billion eight years ago.
Experts say dentistry can have unusually high costs because of the nature of dental insurance. Medicare has never covered routine dental work, which is part of the explanation for the large number of Americans who lack dental insurance.
At the same time, dental insurance is costly relative to other kinds of medical insurance. Insurers must charge more because they know that people will use their dental insurance on a routine basis rather than just in case of a medical emergency. Given the high cost, few Americans seem to think that dental coverage is worth paying for.
In the rest of medicine, insurers have an important function in limiting costs and promoting quality. The market power of Medicare and major national insurance companies allows them to insist on better rates for their customers when they negotiate with doctors and hospitals.
"There's been less presence from all kinds of insurance payers in the dental sector," explained Andy Snyder, who is in charge of oral health at the nonpartisan National Academy for State Health Policy. "Medicare does not cover routine dental services, and private dental coverage is far less common than private medical coverage. So, the dental industry has faced less of the cost containment and quality improvement pressures that the rest of the health care sector’s experienced over the last couple of decades."
* Note: After this post was published, Wonkblog received a number of comments from readers asking whether this post takes into account the cost of running a dental practice. It does. The figures from the American Dental Association cited above are net incomes: the average general practitioner took in $646,440 a year in billings, earning $180,950 after expenses. The report in The Journal of the American Medical Association likewise relies on data for earnings, net of costs. To be sure, many dentists are repaying student loans, but that is an expense shared by other health care professionals as well.