Is my dentist scamming me?

If you need something explained, Vox is the place to go. Now, we’re bringing that ethos to our latest franchise, Explain It to Me, which launches Wednesday, September 18, and focuses on answering your questions through a weekly podcast, a weekly newsletter, and a video series. Every week, we’ll tackle a question from a listener and find the answer.

This week, for our podcast, our Today, Explained colleague Matt Collette asks: Why does going to the dentist sometimes feel like a scam?

“I feel like every time I go to the dentist, it’s like a little bit of a mystery,” he says. “Unlike when I’m at my regular doctor’s office, there isn’t this step where they say, ‘Hey, we recommend you do something, and here’s what it’s going to cost.’ That just feels so [different from] how I think about health care — having to think about not only do I want this procedure, but do I want to pay for this procedure? And how do I want to pay for this procedure?”

Matt isn’t imagining things. There are major differences between the ways dentistry and medicine operate, including the way dental and medical offices do billing and how patients pay for services.

These differences caught the attention of Dr. Lisa Simon. She’s an assistant professor of medicine at Brigham and Women’s Hospital and Harvard Medical School. She’s also a dentist and a doctor. After spending time in a community health care center as a dentist, she went to medical school. “I realized that the ways that dental care and medical care were separate was really harming my patients,” Simon told Vox, “and I wanted to do something about it.”

“I think it’s this legacy, and maybe partly this dichotomy between medicine and dentistry, where we almost act like dentistry is optional and medicine is obligatory, which is not how our bodies work at all,” she said.

We sat down with Simon to discuss the history of dentistry, why dental insurance works so differently from medical insurance, and how to leave the dentist not feeling like you were a Fyre Fest victim.

Below is an excerpt of our conversation, edited for length and clarity.

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Why does the dentist feel like a scam? What is Matt picking up on?

There is a fundamental tension in the way dentistry is paid for, which is that the average dentist is in private practice, and their income is dependent on providing a procedural service to you. So they are incentivized to offer more services to you, and you are disincentivized from wanting to pay for them. There’s this misalignment in terms of what our goal would be, which is to never get a cavity, and what dentists’ goals are, which is to make money doing a lot of procedures that they’re very skilled at.

Have you heard dentistry be described as a scam before? Is this sentiment that Matt has common?

I hear it all the time. Even within the field, I’ve heard it referred to as the mechanic’s principle. [If] I bring my car to the mechanic and the mechanic says, “Oh, yeah, pretty bad confubulator you got there, I definitely need to repair it,” I have no knowledge or expertise to be able to tell if that is true or if I am being scammed.

But the reality is that most dentists are probably not scamming you in this evil, mustache-twirling way, but also there can be legitimate clinical differences in someone’s style.

You may have a more conservative dentist [who is] going to wait and see if this gets bigger and maybe it doesn’t need a filling right now, or you might have a dentist that’s more aggressive and wants to treat something earlier just because they have different clinical experiences, and they’re legitimately recommending what they think would be best for you.

So why is it still so expensive to get dental work done? Why does it feel so different from regular health insurance?

In one way, dental insurance is super expensive: For the average person, a dental procedure like an implant is a crazy amount of money out-of-pocket. In other ways, dentistry is actually super-duper cheap. It’s only 4 percent of our average health care expenses as a country. If you think about the single cost of being in an ICU in a hospital for a day — which can easily be $50,000 — that’s way more expensive than dental care. The idea behind medical insurance is that if this super expensive, absolutely horrible nightmare thing happens to you, you are not financially on the hook for it.

Dental insurance isn’t actually insurance; it just doesn’t work that way. It’s a discount plan. It originated in the ’40s and ’50s with unions who were trying to provide a nice perk for their members.

What it does is it makes the cheapest things — like your cleaning, your exam, or your X-rays that you get every year — free or really cheap. But if you actually need things, you are going to pay progressively more and more of the cost of these more expensive things, which is basically the opposite of how medical insurance was originally designed to work.

So should we even be calling it insurance? Should we call it a discount plan or say, “Here is your dentist loyalty card?”

Honestly, I feel like that’s a great point. It’s not insurance. To call it insurance is maybe more of a scam than any other kind of scamming that’s being done. And it’s not to say that it might not be financially a good idea for an individual person, but as a structure designed to take care of a badly unmet need in our society and to provide health care, it’s not the way I think any of us would design it.

Clarification, September 18, 12 pm ET: Lisa Simon’s title has been updated to reflect her preferred affiliation. She is both a fellow at the Harvard School of Dental Medicine and an assistant professor of medicine at Brigham and Women’s Hospital and Harvard Medical School.