Independent practitioners answer only to the patient

Nov. 1, 1997
They rise from the ashes of managed care by taking advantage of the opportunities that modern dentistry offers.

They rise from the ashes of managed care by taking advantage of the opportunities that modern dentistry offers.

David C. Steele, DDS, FAGD, FICD

A new era of opportunity descends on dentistry, and we might miss it. New dental insurance plans arrive daily on the desks of dentists, promising an increased patient base and improved fee schedules. Closer examination often reveals rules, limitations, exclusions and pre-treatment review. PPOs, HMOs and the various combinations require careful scrutiny to understand the treatment and financial implications.

Along with the new proposals, dentists are experiencing new interfaces with existing dental insurance. There is increased zeal for requesting multiple radiographs, study models, pictures, narratives, copies of chart entries and lab invoices by consultants and reviewers. This is fostering an adversarial relationship, or complete submission, by the dentist. Finally, there is the rejection of payment or the alternative benefit provision employed. As one opined, "It is the `dumbing down` of dentistry."

But wait - along comes a company with a plan that seems just right. It appears to eliminate the frustration of control and intervention. The insurance company calls its plan a "traditional" plan - the service is rendered, the patient pays and the insurance company pays whatever is in the contract. Integrity of the dentist`s fee and treatment plan is maintained.

However, careful examination of the plan indicates that it is no more than a PPO with an agreed-to fee schedule, often at a reduced level. The fees always are subject to review by the carrier and can be changed on short notice. Fee-for-service, yes - at a reduced level, but certainly not "traditional insurance."

Will this myriad of plans really take the place of the existing patient/doctor relationship?

Enough is enough

If you go to enough dental meetings, listen to association attorneys or read the journal, you soon become convinced that you must carefully consider whether discussing any dental plan at your next dental society meeting might land you in a heap of trouble. The supposed issue is collusion - banding together against participating with a carrier. No matter if the plan is the worst one that ever was proffered, the Federal Trade Commission is looking at you. Its job is to preserve the arena of fair competition according to its rules.

But how can this affect a practitioner`s discussing a plan at a dental meeting? Three dentists in Arizona stood up at a meeting and said they were not going to participate. That is all they did. The FTC came along and, by the time it was all over, they had signed a consent decree with the FTC. One practitioner lost most of his pension. For what? Just speaking his mind.

Never mind that insurance companies are exempt from FTC anti-trust action. You just cannot speak up as a group. I had enough. I developed a newsletter to express my opinion - David Steele`s Dental Opinion.

As dentists, we train and involve ourselves in continuing education so that we can perform at the highest level, only to be confronted with a new managed-care term, LEPEAT, which means least expensive, professionally adequate, alternative treatment. It`s not for my profession, my patients or me.

Why is it here?

Managed care is here because someone asked for it. That someone was U.S. industry. As global competition increases, manufacturers find themselves competing with workers who earn $2,500 annually in Mexico and $500 in Malaysia while Americans are receiving $25,000. In response, employers are looking for dental plans that cut care and costs to improve their bottom line.

One benefit manager told me they changed to a managed-care plan "because it was natural to follow medicine`s lead." That rationale is in error. Dentistry represents about 4 percent of the health-care dollar. For that small amount, dentistry can show that it has made prevention work for the past 20 years.

Medicine is low use with high cost while dentistry is just the opposite with high use (prevention) and low cost. Medical doctors sold out to hospitals and became employees - set for life, some thought. But what is happening?

Medical Economics (June 1997) reports that there are over 1,000 antimanaged-care bills before state legislatures. The Wall Street Journal (June 18, 1997) quoted an HMO executive as saying, "We see people as numbers, not patients . . . We`re a mass-production, medical assembly line, and there is no room for the human equation in our bottom line." No wonder patients feel rejected by rationed care and the gatekeeper complex of pre-authorization and 1-800 permission.

The dental population does not like the dictates of the new dental plans. Dentists abhor their new insurance-company relationships which, in large part, are based on confrontation. How many times have you had a patient say, "but they said I was 100 percent covered just like my last plan." 100 percent of what? Mediocrity!

A great opportunity

There is a great opportunity for the concerned and astute practitioner. Patients are begging for the relationship they always have enjoyed with the dentist.

Your patients have come to expect the best from you. CE always has been a priority far above any mandated state requirement. The young adults in your practice have benefited from early prevention and entered life caries-free and periodontally sound.

Adhesive dentistry has opened new vistas for aesthetics and superior restorative strength. Quadrant crown restoration of failing alloys and composites means maintenance of the sound dentition without the inconvenience of fracture or premature loss. Extraction has almost been eliminated by endodontics, and partial dentures frequently have been made archaic by fixed prosthetics and implants. Occlusion techniques are being taught by high-level practitioners, leading to superior full-mouth reconstruction.

The best is here now, and opportunity is staring many of us in the face. Just be ready to change your office, your attitude and your staff.

How can we do it?

To be a truly independent practitioner, you and your staff must be dedicated to superior service. This means first-class treatment. Prevention must predominate every area of your office, including doing indicated preventive crown and inlay restoration before breakage occurs.

The patient will become the overriding concern, with more time for personal conversation and caring. Rush will be part of your past. Treating patients` dental needs as you would your own produces a whole new mindset.

While insurance certainly can play a part, it will not be the dictator of treatment protocol for you and your patients. You now can fill out the form and tell the patient, "We`ll go to bat for you." The patient understands that insurance is only a contributor to the financial equation, not the engineer of the treatment modalities.

When you decide not to sign any kind of contract, you have taken the most important step to independence. Insurance becomes secondary. No fee reviews, rules or review boards to contend with. You answer to the patient and that is the way it should be.

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