What medicine teaches us about managed care

Medical managed care does not provide a good model for dentistry, but the good news is dentists can learn from the flaws.

Jan 1st, 1998

Medical managed care does not provide a good model for dentistry, but the good news is dentists can learn from the flaws.

William T. Brown, DDS and

Jeffrey C. Bauer, PhD

Pundits give the impression that the history of managed care in medicine can now be written. The conventional story line suggests managed care is a mature industry. Why? Because health maintenance organizations (HMOs) and preferred provider organizations (PPOs) have defeated traditional indemnity-based, fee-for-service (FFS) insurance plans in the battle of the marketplace. Managed-care organizations (MCOs) allegedly provide comparable quality at a lower price. The final chapter apparently reads: If FFS isn`t dead yet, it is supposed to be dying - along with the independent practice of medicine.

Well, the conventional wisdom is wrong again! The battle between managed care and indemnity insurance may have made life miserable for many physicians, but dentists can learn from the mistakes of their medical counterparts. Further, dentists have an opportunity to avoid the mistakes made by physicians - and to develop a better system that improves quality by providing optimal oral-health care while maintaining the independence of dentistry.

The reality of managed care?

Managed care defies simple definition. It certainly is not a standardized, universally meaningful term. The saying, "If you`ve seen one managed-care plan, you`ve seen one managed-care plan," is appropriate. Medical managed-care plans vary a lot in terms of covered benefits and operating principles. However, the most common element in medical "managed" care is arbitrary or unexplained restrictions that place the financial gain of the managed-care company above the clinical needs of the patient and the professional judgment of the physician.

Many medical MCO plans have made exceptional profits by using the power of the purse to negotiate discounts from providers while reducing covered benefits for patients. Their success has been based much more on shrewd negotiating skills than on sound clinical judgment. Medical MCOs would like us to believe their restrictions on care and payment are based on scientific studies that identify waste in the health-care delivery system (that is, overutilization).

The reality of the situation is something quite different. Rather than basing payment on carefully conducted studies to identify optimal care for the patient, medical MCOs have created a concentration of economic power that gives them the upper hand in negotiations with the relatively unorganized communities of providers and patients. Overall, medical managed-care plans have not - as their promoters would like us to believe - passed saving on to consumers in the form of long-term reductions in health-care costs.

Fewer covered, spending climbs

Indeed, total health-care spending continued to climb over the past few years when managed care presumably was saving us a lot of money. The percentage of Americans covered by health-care plans also fell precipitously at the same time, and the costs of medical managed-care plans now are starting to rise at the accustomed rates of increases in indemnity plans.

Patients and purchasers have not gotten a better deal, just a different deal with medical managed care. Managed medical care is starting to look a lot like the emperor`s new clothes. There`s not much there.

Published studies don`t show convincingly that patients are healthier or wealthier because they were shielded from unnecessary services. To the contrary, the media has publicized numerous examples of patients who were harmed when treatment was denied under managed care. Last, but not least, large numbers of physicians have lost patients and income to managed care. No wonder dentists and their patients do not want to jump on the managed-care bandwagon! They don`t want these types of health plans to get in the way of choosing the dental services that maintain optimal oral health for their patients.

How should dentistry be different?

Dentistry has an opportunity to assume a position of leadership, avoiding the problems medical-managed care has created over the past decade. This leadership can be exercised in the development and application of outcomes-based practice guidelines as the foundation of 21st century health care and the next generation of health-insurance products.

The key to professional leadership will be good, comparative data on the outcomes of different approaches to care. Unfortunately, these data do not yet exist in dentistry. The profession`s leaders must begin a concerted effort to create and manage the outcomes database. If organized dentistry fails to develop the data to defend good practice, someone else will do it for them - and the results will be just as disastrous for dentistry as they were for medicine.

Once clinicians have access to valid and reliable data that shows what works and what doesn`t work, they can focus on beneficial interventions through outcomes-based, clinical-practice guidelines (CPGs). With the merger of cost information and clinical-outcomes data, clinicians also can provide the most cost-effective care - that is, the least-cost intervention that produces the desired improvement in a patient`s lifetime oral health.

A scientific understanding of outcomes and costs will be the foundation for all clinical practice in the future. Medical managed-care plans have largely failed to base their restrictions on outcome data, relying instead on arbitrary guidelines interpreted by nonclinical personnel who answer calls to 1-800-DOC-NONO. (Some legal proceedings now are being pursued in state courts on the grounds that this common control mechanism of managed care constitutes the unlicensed practice of medicine.)

Because the art and science of dentistry can be more precisely defined for oral health than for physical and mental health, dentistry offers an excellent environment for achieving optimal results at reasonable costs. Indeed, dentistry is ideally suited to the development of outcomes-based guidelines. The desired outcome - optimal oral health - is easy to define, and measurement of oral health status and dental work is relatively standardized.

Also, large numbers of patients maintain regular, long-term relationships with their private dentists, which is an important factor in building good databases.

Standards must be developed

There is, as previously noted, one big problem. The dental profession has not yet embraced the concept of outcomes-based practice. Neither dental schools nor dental associations have come forward to guide the profession in moving to this next step in the evolution of a dental practice.

Indeed, the recent flap caused by an unscientific article in Reader`s Digest ("How Honest Are Dentists," February 1997) could not have occurred if dentistry were driven by uniform, scientifically based practice guidelines. The article really did not have anything to do with honesty, but it did expose the absence of common standards developed by the profession to support informed decisions by the patient.

The logic of outcomes-based dentistry is inescapable - just ask a patient or employer - so the real issue is whether dentists will create new dental-care plans based on clinical data.

The authors cannot imagine a more important task for dental schools and dental associations. A national panel of dental leaders should be convened immediately to lay the foundation for outcomes-based practice. Dentistry`s respected clinical journals should put special emphasis on publishing articles that report outcomes-based expert consensus to guide practicing dentists in the selection of cost-effective treatment plans to discuss with their patients. (A promising example of this new approach, "Evidence-Based Periodontal Treatment," appeared in the June 1997 issue of the Journal of the American Dental Association, pgs. 713-724.)

The ultimate price of inaction will be loss of control to investors, insurance companies, managed-care plans and/or federal and state regulators. On the other hand, the reward for progressive action will be satisfied patients and professional fulfillment. We challenge dentists to get actively involved in conceptualizing and building a better, different system rather than simply fighting the failed system of medical managed care. Dentistry can do better, but it must not wait to get started.

New concepts of optimal care

A good starting point would be defining optimal oral health, including maintenance care needed to promote functional, life-long dentition. Alternative therapies can then be evaluated in terms of their contribution to optimal oral health and their relative costs. The system must also be structured to reward the dentist with a fair fee for correct practice. Reimbursement should be based on providing the right service based on outcome research, which is not necessarily the covered benefit under a typical dental insurance plan.

With a plan based on optimal oral health, the patient would pay the additional charge for any appropriate dental services that cost more than the procedure shown by studies to produce the desired outcome at the least cost. In other words, the plan benefit would be defined as the least-cost effective therapy. Patients would pay the difference if they selected a more expensive solution to a problem (if the patient chose a porcelain crown, for example, when full-cast metal would be as good, but less expensive).

The dentist and patient should not be forced to be cheap just to stay within the boundaries of a list of covered benefits selected by an insurance company. They should be free within the bounds of professional liability laws, dental practice acts and clear, ethical standards to propose treatments above and beyond the least-cost effective services. The patient would understand they will pay the differences - not the plan. In other words, the preservation of balance billing is critically important to the preservation of patient choice. Unfortunately, the medical model is moving in the opposite ? and wrong ? direction.

Who develops protocols?

Based on their work with dental insurance plans, the authors believe that an approach using clinical protocols should be developed by expert consensus ? that is, by groups of practicing dentists and dental researchers who are qualified to conduct population-based outcomes studies and to evaluate the data. The patient would have to earn the right to more expensive treatments by taking responsibility for establishing and maintaining a baseline for optimal oral health. For example, patients must control active dental disease before a plan would cover restorative benefits. Prevention is an absolute foundation, not an option, in a health plan based on the principles of optimal care.

Benefit limits, both annual and lifetime, would be clearly tied to optimal oral health and continuity of care. Financial incentives would encourage the patient to visit the dentist at least once a year (for example, a 25 percent increase in the deductible for patients who do not have an annual preventive/educational examination). For the first time, the patient will see how and why to work toward personal oral-health goals that save money in the long run while assuring a healthy mouth for a lifetime.

Quality improvement key

Optimal dental care also will adhere to the proven concepts of quality improvement, such as Deming?s principles of total quality management. (For an excellent overview of this concept, see OShifting to ExcellenceO by Joan Forrest Eleazer in the February 1997 issue of Dental Economics, pages 22-27.) Rather than being punitive, the optimal-care plan will reward desired responses and ongoing improvement through training and retraining.

By eliminating the need for expensive precertification and other forms of third-party inspection, a plan built on principles of optimal oral health and quality improvement will empower the dentist to be an independent professional. The dentist also will be free to maintain patient records that focus on appropriate treatment based on a patient?s clinical needs rather than paper compliance based on a plan?s covered benefits.

Perhaps most importantly, optimally-managed dental care would instill pride in professional knowledge and create a trust-based partnership between patient, employer, doctor and insurer ? which is definitely not the case for today?s medical managed-care model.

The bad news is that medical managed care does not provide a good model for dentistry. The good news is that dentists can learn from the flaws in the medical model.

Dentistry still has a chance to do managed care the right way by rebuilding dental-benefit plans with the patient?s lifelong oral health as the principal concern. By embracing the value of outcomes-based practices and responding right now with true professional leadership, dentists can create a 21st century model for all health plans.

Do short-term, cheaper solutions help achieve long-term health?

A busy, 45-year-old administrative assistant to a member of Congress fractured some porcelain from the occlusal-lingual surface of a maxillary second premolar porcelain-to-metal crown (PFM). His managed-care plan assigned him to a participating HMO dentist in Washington, D.C.

After examination, the dentist advised the patient that the tooth was covered by metal, so no harm could come to the tooth. Rather than replacing the crown, the dentist patched the existing crown with an acid-etched composite, which was accomplished quickly without any anesthesia or discomfort. When the "spackle" failed a few weeks later, additional porcelain lost from the PFM crown created an open contact and subsequent food impaction. Having been told by the dentist that he didn`t have to worry because the tooth was covered by metal, the patient decided that putting up with the annoyance of food impaction was easier than taking time from his hectic schedule to find time for another dental appointment.

After leaving the nation`s capitol the following year, he made an appointment with his hometown dentist and complained of pain in the maxillary posterior. The clinical and radiographic examination revealed an isolated 8 mm periodontal pocket, alveolar bone loss in that area and root caries on both the premolar and the adjacent molar. Both teeth were endodontically involved. The premolar had to be removed because it was not restorable and the molar was treated endodontically. Periodontal surgery was needed to correct the periodontal defect and crown-lengthening had to be performed so a crown margin could be established. After the appropriate healing time, a three-unit fixed prosthesis was placed to replace the missing premolar.

Was the HMO dentist`s original decision to "patch" the PFM crown influenced by the managed-care plan`s focus on saving money with short-term solutions? Would an outcomes-based plan, tied to long-run oral heath, have led to the same initial treatment? We`ll let you, the reader, decide.

Research defines what crowd thinks is `optimal`

A new type of research is evolving to support outcomes-based clinical-practice guidelines. The studies reported in clinical journals are based on a research method that tests whether observed differences between experimental and control groups are greater than the differences that might be observed by chance.

The foundation of traditional research has been the randomized-control trial (RCT), a methodology developed to infer differences from small samples in the absence of tools to make direct observations from large populations.

In contrast, outcomes-based research in the 21st century will make direct comparisons of different approaches (for example, diagnostic tests, surgical procedures and prescribed drugs) to achieve desired patient outcomes. This research also will compare costs of different approaches so that patients, clinicians and health plans can make decisions based on clinical effectiveness and economic efficiency.

RCT study of small samples will increasingly be replaced by real-time analysis of large population databases. The new approach is made possible by the marriage of computer technologies and communications networks.

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