Recently, I received a challenging letter from an executive in one of the major dental insurance companies, which condemned my Viewpoint article (August 1997). Among the rather derogatory comments from this executive were:
- "Opponents of managed care will do anything to protect their financial turf."
- "Since `quality` has never been demonstrated to differ among dental benefit plans with varying plan designs, why should a purchaser not choose such plans based upon price?"
- "To those blinded by financial fears, `facts` are not important in this issue. For them, perception and ignorance carry the day."
- "If you are ever serious about truly learning and understanding both the traditional and managed-care, dental benefit industry, I would be more than happy to have you spend time with us applying the "scientific method` rather than hearsay and innuendo exemplified by your Viewpoint comments."
He wants to debate the subject. Here is my response to this dentally educated insurance executive:
Thank you for your recent letter. I appreciate hearing from you concerning your beliefs on managed care. I respect your views, and I feel that the freedom we enjoy in America allows us to agree to disagree on this charged topic.
Dentistry has evolved significantly in my nearly 40 years as an educator, researcher and, most importantly, practicing clinician. In 1960, dental therapy was basically pain-oriented, only slightly preventive, and it had just a few elective procedures. Even orthodontic procedures were rudimentary and encountered infrequently.
Currently, the majority of dental-oral procedures have some elective slant. Only very rural or public-health dentists deal primarily with pain-oriented procedures today, (Unless, of course, you consider developing countries such as India, Africa or South America).
I have made extensive evaluations of managed care programs in the U.S., including the procedures they include, the fees (or lack of same) and the profits of companies involved. My elder brother`s career was in insurance. He is a Stanford MBA who spent most of his life as president of a major U.S. insurance company. He is one of my main consultants.
Unfortunately, most current dental managed-care programs pay primarily for pain-oriented procedures common in the past in the U.S., but less frequently encountered now. Many plans are almost oblivious to the current major elective procedures that are dominant in modern dentistry. By the way, I think you distorted the ADA dental income figures to support your beliefs on managed care. Many increases in dental income in the U.S. represent the increase in elective procedures with more people electing to have "quality of life dentistry."
When you or your family want implants, veneers, tooth-colored direct restorations, inlays or onlays, all-ceramic crowns, orthognathic surgery, orthodontics, tooth bleaching, occlusal equilibration, fixed prostheses vs. removable prostheses, gingival plastic surgery or myriad other elective procedures, let`s see how DHMOs and PPOs treat you at an average of a few dollars per person per month for DHMOs and PPOs at 20-30 percent reduced fee levels. By the way, a 20-30 percent reduction in gross income cuts net before-tax profit by around 70 percent. Let`s cut your salary by 70 percent and see how you feel. You want data on managed care? I have data! I have spoken with numerous young dentists sucked into DHMOs and PPOs in desperation considering going back to their old vocations to support their families. Some are paying more for their hygienists than they can take home themselves after eight years of education.
However, this battle you and I are discussing should not be about more or less money for dentists! It is about freedom of choice. It is about leaving decisions about oral care up to educated, experienced practitioners and patients who trust them. It is not about more profits to insurance companies, executives with high salaries, reductions in ability to have elective care or treatment decisions made by clinically inexperienced insurance executives. Why do you think scores of insurance companies are interested in managed care? This battle is about more money to companies - yours included!
You made some rather unwarranted derogatory comments about my articles on managed care. I assure you my comments are based on fact. I stand face-to-face with about 40,000 dentists per year, co-publish a research newsletter read by 100,000 dentists per month in nine languages and run a prosthodontic practice treating hundreds of people per month. In other words, I think I have my finger on the pulse of American dentistry. I would love to debate you in a national videoconference. In fact, education of the public is my goal for this entire question. When the American public really knows what they get from most dental managed-care companies, they don`t want it. The backlash is very evident now. You can`t deny that.
Yes, I could operate in a DHMO or PPO environment, as some of our colleagues are doing, but I could not do so without avoiding seeing most or many of the DHMO patients and without cutting quality on the PPO patients. You are the MPH with public-health education. You tell me how to produce quality dentistry and provide elective services in such a mediocre financial environment.
Before we debate, I would suggest that you have at least five years of day-to-day practice in today`s mainstream U.S. practice system, attempting to operate on less than 60-65 percent overhead to meet your low PPO fees, and taking care of all of your DHMO low-budget patients on a few dollars per month.
I love dentistry and what it does for the people of America. I remain strongly supportive of the free enterprise, freedom-of-choice system for dental care. I support direct reimbursement and direct assignment. (Unfortunately, they would eliminate your salary.) I know that eventually logic will prevail and both your system and mine will survive for those who want each.
If your blood pressure is higher after reading this letter, don`t worry, so is mine after writing it. Let`s get together and talk sometime.
Gordon J. Christensen, DDS, MSD, Ph.D