A declaration of independence

Sept. 1, 2002
In response to the tragic events of September 11, 2001, the patriotic flag-waving across the nation generated a 4th of July spirit that resembled the air in our office. Since last July, we have been celebrating our own declaration of independence … from Delta Dental!

William Hsiang, DMD

In response to the tragic events of September 11, 2001, the patriotic flag-waving across the nation generated a 4th of July spirit that resembled the air in our office. Since last July, we have been celebrating our own declaration of independence … from Delta Dental!

Early last year, our office attended Dr. Gordon Christensen's seminar in Utah, where we were inspired with the reaffirmation that we are members of a public-service profession. In that spirit of public service, I have maintained my affiliation with Delta Dental because so many patients do rely on insurance benefits to help with their dental care. So why did we terminate our 25-year relationship with Delta? Well, things have changed.

As PPOs were coming into dentistry, our dental society hosted a forum to inform us of the concept. A panel of experts described a PPO as a program where doctors provide discounts to patients enrolled in such a program. PPOs were represented as being profitable, because the discount would be made up by increased patient volume.

Dr. John Field, then vice president for Delta (California Dental Service at the time) and a panelist, responded that Delta would always advocate indemnity as the best type of insurance, and that any doctor who discounts to a PPO program was charging too much to begin with. In the audience of some 300 dentists, one applauded. "That doctor will never have a problem with (Delta) again," Dr. Field said. I was that doctor.

I applauded because his statement of principle upheld the tradition of our profession - to provide patients with a consistent level of quality care for a given fee. I applauded because he recognized the consequence if ethical principles are disregarded in pursuit of profitability. PPOs evolved into various managed-care programs, and we saw the impact on the quality of care, doctor-patient relationship, and professional morale. Dr. Field was right, and I was proud to stand with him as a Delta dentist.

Since then, things have changed. Dr. Field is gone, along with the principles that he espoused. Delta has adopted PPOs and other managed-care programs. Delta claims it has done this to stay competitive and profitable. And how have the changes in Delta's corporate philosophy affected us? Here are some examples of problems (that I was never again to have) with patient benefits:

  • A new patient in our practice had radiographs taken at another office not long ago. Since they were not available to us, we took new radiographs to do an examination and render a diagnosis. Delta refused benefits for the radiographs. As a member of Delta, we were not allowed to charge the patient.
  • A new patient presented with moderate to severe periodontal disease, with gross accumulation of plaque and calculus. Quadrant scaling and root-planing were performed. Delta refused benefits for the service because it had already paid for such service to another office within the past two years. As a Delta member, we were not allowed to charge the patient.
  • A surgeon placed an implant for a patient who lost an upper incisor so that he could replace the tooth in six to nine months following implant integration. We placed a temporary so the patient would not be toothless. Delta refused to pay a benefit for the service. As a Delta member, we were not allowed to charge the patient.

Delta is in business to provide a service and to be profitable, as we all are. Delta has every right to exclude benefits for services that are not covered or repeated within less then the prescribed time. But what is the justification for denying us the right to charge the patient for the service when the patient wanted the service and accepted responsibility for the fee? Was providing pro bono care to patients who need no charity our benefit for being a Delta member?

Another case (my favorite):

•Root-planing was prescribed to a patient for treatment of generalized periodontal disease. After completing two quadrants, the patient went overseas. She returned nine months later to complete the remaining two quadrants. Delta refused to pay a benefit for that treatment because the services were not completed within a prescribed period of time from the start of the treatment. Incredibly, Delta chan ged the claim submitted for those two quadrants of root-planing to a prophy and paid the benefit that way. (Consider the legal jeopardy this situation places on the doctor.)

In all of these cases, Delta reversed itself when we challenged their decision on the patient's behalf. When we asked for a written explanation in these cases, Delta only would respond verbally.

Here is an example of our problem (that I will never again have) with Delta's fee policy:

•Being sensitive about the cost of dental care to patients, we were hesitant to raise our fees. While Delta allowed fee increases every six to 12 months, we sometimes went two to three years without raising our fees. (Practice consultants would describe us as being not too bright.) As a result, our fees fell further and further behind (duh), and we were not allowed to catch up. Consequently, we were at risk of losing valuable team members who were crucial to our ability to provide quality care. When we tried at last to raise our Delta fees - the fee we use for all of our patients - Delta repeatedly denied these increases. We tried over and over again to fit into Delta's acceptable fee profile, but to no avail. When we gave up and submitted our notice to terminate, Delta approved our fee increases immediately!

Does it seem that Delta was dealing with us in good faith?

Things have changed at Delta. Yes, the changes at Delta reflect changes in the ethical climate in the corporate world and in all aspects of society. Delta may claim that it is only reacting to the abuse and fraudulent claims from doctors, who, as a group, are certainly not immune to ethical compromises. But in abandoning the principles Dr. Field expressed on Delta's behalf and adopting PPOs and managed-care programs as well as curiously arbitrary policies, Delta has compromised its reputation in our eyes. In doing this, is Delta selecting its participating doctors to provide ethical care for the patients insured with Delta … or doctors who can be profitable under any system or in any circumstance? Is Delta now selecting the type of doctors who are more likely to victimize the company, its patients, and society in general?

I have been naive … a bit slow to see the change. I failed to see that the corporation whose core belief I once applauded now seems to be boosting its bottom line by "playing games," taking advantage of patients and doctors, and trying to get away with as much as it can in denied benefits. Is that why some patients seem to respond in kind and expect doctors to be "creative" in "milking" the insurance company on their behalf? Who started this game - the doctor, the patient, or the insurance companies? For those who do not believe in playing the game, does it matter? What matters is that we do not become pawns in the game. What matters is that we quit the game if we care about our integrity.

Dental consultants tend to evaluate a practice for independence from insurance programs based on profitability. Those who have severed their ties to insurance for the right reasons tend to find their practices to be more fulfilling, if not more profitable.

The step to an insurance-free practice is not to be taken lightly. There are serious risks. But if we recognize the ethical principles involved, then we must be ready to pay the price. There is a price to pay in every patient who may leave our practice. Delta will do its best to penalize the patients who choose to remain loyal to us. The company will further reduce benefits, refuse coverage, withhold information, and seemingly develop a predisposition toward losing our patients' claims. All of these experiences seem aimed at making sure our patients find it inconvenient - or even aggravating - to remain with us, thus forcing us to stay with Delta.

Why do we not seem to have these experiences with the other dental insurance companies that we continue to work with, even though we are not members? Does it seem that Delta is conducting business above board?

Will patients understand why we left Delta? When conflicts over benefits arise, who will the patient believe? Even if the patient is willing to accept the added cost in choosing us, consider the obstacles we still must contend with:

A Delta influences public opinion with a multi-million-dollar public relations budget. We try to counter with 34-cent postage stamps to explain our side of the story to patients.00 Or, we assign our overworked staff the added responsibility of communicating with patients about an issue that is a challenge to the most articulate members of our profession. (Even dental consultants who teach us enhanced verbal skills do not seem inclined to address the issue.)

A Patients seem to have the impression that we charge (take from them), while insurance companies provide benefits (give to them). They overlook the fact that insurance has taken from them (in premium dollars) with the promise to give those dollars back in benefits when they need care. So, when a benefit is denied, has insurance reneged on its promise?

Leaving Delta has been a tough challenge, but doing what is right is never easy. The challenge can be managed. A good starting point is talking to the colleagues who have "gone before" and to appreciate them for paving the way. We may think that their circumstances were different or better than ours. But, most likely, they have simply bit the bullet to do what is right. We need to communicate sincerely with our patients. Hopefully, we have been scrupulously safeguarding our professional and personal reputation, so that our patients will always have confidence in our ethics. All of this takes time. It takes effort. It is tedious. It is the price we pay.

In view of the tragic events of September 11 - and crises that continue to unfold - this issue might seem trivial. But at a time when so much is going wrong, perhaps it is even more important that each of us do what we can to make things right - to uphold and promote the ethical principles essential for the integrity of our profession and our society. Perhaps it is time to join in raising our flag of professional freedom … and declare our independence!

Dr. William Hsiang is a general dentist in Irvine, Calif., and a graduate of the University of Pennsylvania. He may be contacted by email at [email protected].

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