The last time you saw your favorite niece, you told her father, Ed, that she’s ready for braces. The problem is that you cannot locate a trusted colleague in the town where the family lives, which is over 100 miles away. So Ed vowed to scour the Internet and seek referrals for a qualified orthodontist. A week after you suggest treatment, he calls you with an interesting discovery.

In searching for an orthodontist, Ed came upon a Web site of which you were not aware. After the potential patient records some demographic information on the site, including preference for the type of appliance, a bidding service offers to search for the least expensive orthodontic care facility near the patient’s home. The bidding competition is intended to attract the patient to a participating orthodontic service based on finances, not unlike the bidding process for a repossessed automobile. Ed asks you whether this is a wave of the future or just an anecdotal effort at marketing.

Such Web sites actually exist, and dental specialties are not the first to attempt to use this marketing tool. Shoppers previously had the opportunity to bid for medical procedures ranging from gallbladder surgery to facelifts. These Web sites accepted a bid from the customer, with expectation of counteroffers from competing services. The reputed benefits were fee transparency and improved access to care. If one can locate online sources for low prices for toilet tissue and work boots, why not gallbladder surgery, facelifts, and orthodontics?

A prediction that dentistry and orthodontics would assume a tiered level of care quality and quantity was made decades ago. Tier 1 comprises providers who worked in contractually based entities, such as an HMO. A set rate is applied to the fees for service, often as an employee benefit. All insured employees enrolled in the plan are entitled to receive care. The intent is to curtail the employer’s cost of health care benefits for the employees, but this plan assigns strict limitations on the provided services. Tier II is a retail model, in which varied, aggressive marketing strategies are used to lure patients. Tier II providers may decline treatment to patients who have beyond-average needs, in an effort to enhance practice efficiency and profitability. These providers assume that most patients can be treated by routine services within a designated time period. The goal is to appeal to patients who could not matriculate for traditional care delivery. Tier III defines traditional, fee-for-service practices that address a wide array of problems, without limitation of case type or treatment time. These practitioners rely on a covenant relationship in which the providers place the patients’ welfare above that of their own. Although the practitioner’s expectation is to be reimbursed for treatment rendered, the salient objective is quality of patient care rather than profit. Financial compensation is a consequence of treatment, rather than the ultimate motive for care delivery.

Practitioner autonomy gives us the freedom to choose which practice model we will embrace.

If we engage in a bidding war to “sell” our services, must we be compelled to limit the number of visits it takes to treat a patient to compete in an arena where the lowest fees determine his or her opportunity for treatment? Shall we be forced to compromise quality when the clock expires, regardless of whether fundamental treatment objectives are achieved? Can we afford to advocate for patients who value our services but require extra effort or concerted collaboration with other providers—or need we decline to treat them because of decreased profitability from such involvement? Will we need to shepherd an excessive number of patients through our doors each day to satisfy our overhead demands, or can we take the time to treat each patient as an individual with unique emotional, mental, and physical needs?

Which tier fulfills your aspirations? It’s still a no-brainer for many of us, and there remains a niche for tradition. This isn’t “Let’s Make a Deal.” This is a profession.