Base your treatment plan on saving enamel!

Dec. 1, 2003
Can you relate to my story? Four years ago, I was driving home from a long day at work. I reflected on my day and realized that in addition to doing one implant impression and a root canal, my day had been filled with composites.

Lou Graham, DDS

Can you relate to my story? Four years ago, I was driving home from a long day at work. I reflected on my day and realized that in addition to doing one implant impression and a root canal, my day had been filled with composites. My production for the day did not reflect how hard I had worked. "Why is this so tiring?" I wondered. In that day, I did 14 composites, which amounted to 14 etchings, 14 bonds, at least 56 incremental buildups, six sectional matrix bands, multiple rubber dams, at least 60 minutes of finishing and polishing the composites, and thus a day of what I term, "microdentistry." Darn right, that's a tough day!

At the time, my fees ranged from $90 to $225 for composite dentistry. The fees were based on insurance codes, regardless of whether the patient had insurance or not.

I now have changed my attitude regarding composite dentistry. First off, ask yourself, are you good at it? Yes, I'm serious, are you good? Do you follow all the right steps from etching to bonding, from liners to incremental buildups, from finishing, to polishing, and final sealing? Do you isolate well, insuring long-term success? If your answer is yes, read on! If your honest answer is, "Well, I could be better," do it! Take a hands-on course and turn yourself into an excellent restorative clinician — it is definitely rewarding! Then, reread this article.

My practice is located on the south side of Chicago in a community known as Hyde Park, which houses the University of Chicago. Over 10 years ago, the university started offering a very cheap HMO to its employees as an alternative to expensive private insurance ... and off went hundreds of my patients! Humbling to say, our monthly income was dramatically affected, but I would not submit my care to such low fees and low expectations. I think what truly hurt was that I thought my patients would see the "value" in my care, but for those who left, I guess I was wrong.

Within three years, most of these patients returned, many with work that was never done, worsened periodontal conditions, and poor relationships with their new dentists. I realized then that they now understood the value of my high standards of care.

The university still carries that insurance plan, yet we rarely see patients leave our practice even though we do not accept the plan's reimbursement level. In fact, our routine discussion with patients is that unless major work is required, flexible spending is much more creative in conjunction with financing available from dental finance companies. The plus side for our patients is that they save paying premiums for a poor dental plan that really only benefits insurance companies.

It's no secret in our practice that insurance companies could not care less about their customers and that they simply want the premium payments. In my 21 years of practice, I have never had an insurance company call me to discuss a customer's treatment plan unless it was to try to minimize the treatment ... and the treatment cost. The insurer's goal was to save money in terms of benefit payouts — without any concern for making sure the patient received quality care.

The bottom line is that whether patients have insurance or not, our care should be based on what is best for them. This also means we should offer and perform the care that is best for the patient, not the treatment plan which can best line our pockets. But hold on ... I'm not altruistic to the point of poverty, because we should all make healthy livings and provide for our families. I do know how hard a full day of dentistry is, and, for that reason, I would like to suggest a few guidelines to help you set fees for composites.

Establish hourly-rate production goal

The first and most important step is to establish an hourly-rate production goal that will make your office profitable and reward you for excellent work. For example, let's say that my goal is to bill $450 an hour plus hygiene. If I am booked with composites for an entire morning, that's approximately three hours worth of work. To reach my hourly goal, I know I have to bill $1,350 for those three hours.

Now let's say the first patient I see has two Class II composites that take one hour to do and the bill is $500. My next patient has two Class V composites and one Class I composite and the fee is $475. The last patient requires a Class II composite and two, small Class I deposits for a total bill of $475.

If a large composite crown takes me an hour to do, the bill is $475 to $500. This sounds simple, but most dentists bill Code 2332 or 2391, whether or not it's a difficult restoration and time-consuming. The bill is the same, regardless of the amount of time the restoration takes. This is wrong! Patients should pay you for your time and expertise, not for a code and a fee that someone who wears a suit and tie and works for an insurance company established.

How to present treatment

Now you are saying, that makes great sense, but my patients won't pay the higher fees. Yes they will — it's all about how you present treatment! Getting back to my original point, if you feel you are a darn good dentist, then keep reading.

I present multiple treatment options to a patient. I never let the finances interfere with the plan, so I truly offer the treatment I would do for myself or a member of my family. I inform all my patients that I do not do amalgams (with the very occasional exception of a few in those impossible areas), and that quality work takes time — and it does! I offer my patients both direct and indirect restorations, and when I feel direct restorations will be as successful long-term, I move in that direction. If I have a severe bruxer who needs a large MOD restoration, I routinely move to my Ceromer restorations.

The key is to treatment-plan with a philosophy that relates to enamel! Yes enamel, not money! Save enamel, and this equates to fewer full-coverage crowns and bridges, and more direct composites, implants, and indirect Ceromers such as Sinfony™ by 3M ESPE, belleGlass HP by Kerr Corporation, Cristobal®+ by DENTSPLY Ceramco, or Tescera™ by Bisco .

It doesn't matter if my patient is a 25-year-old or a 65-year-old, I want to save tooth structure. Given life spans of 85 to 90 years, a crown on a 65-year-old might not last into that individual's 80s. But, if a large Ceromer preserved enough tooth so that the patient didn't require a crown until he or she reached 80, great! Crown it then! If a large composite can give a patient 15 years, do it! If not, do a Ceromer. A crown should be a last resort.

Cost of a crown vs. composite

I then bring up the cost of a crown and buildup to the patient, which will be double the cost of a direct restoration and it will not preserve the tooth. My patients now refer to my practice as "conservative" and they get it — it's not about money! So, if I do a composite crown and save buccal- and lingual-tooth structure for 15 years, it beats a crown and the patient is happy.

But what if the patient has insurance? I knew you would ask that question! Here's how that discussion goes with my patients. Let's say a procedure involving a posterior crown and a buildup costs $950. If that seems high to you, raise your fees. If that figure seems low ... congratulations. Insurers in my zip code tell me that my crowns should have a fee of $600. I have no idea who charges these fees in my area, but there is no way anybody who spends the time I do and works with quality labs would charge such a low fee!

In this scenario, the insurance company will pay a benefit of $300 to $400 for the crown. Buildups often are excluded altogether because I guess some insurers feel we should leave a 30-year amalgam in as a core!

Now shift gears. Tell the patient you would like to preserve tooth structure and do a direct restoration. Let's assume it's a large restoration and it will take 45 minutes to do. I would tell the patient my fee for the crown and buildup ... and then go on to give that patient my fee for a direct composite on the same tooth. Let's assume the fee for the direct composite is $400. Insurance will reimburse the patient for the cost of an amalgam, leaving the patient with an out-of-pocket cost of $275. This is half of what the patient would have to pay out-of-pocket for a crown, and you are saving tooth structure. This is a win-win situation for everyone! I never bring up the fee for an alloy because I don't believe in them, and thus they never enter the picture.

Your work is your signature

You might lose a few patients because they think your fees are too high. My attitude has always been that my work is my signature. If patients only see my work as a dollar sign, I could charge half the amount I quoted them and it would still be too much!

Our office is in a community with numerous dentists who charge lower fees and do a lot of crowns. But as I said before, my patients "get it," and thus refer a ton of patients to my practice. They understand the value of their care ... and it's never about money!

In closing, I will ask you one question. If a patient comes into your office and that patient's net worth is $200 gazillion, do you treat this person any differently in your treatment-planning? If so, think about this. The very rich patients are born with the same amount of enamel that average-earning patients have. Once that enamel is gone, any patient — regardless of income level — has no resistance to recurrent decay. Are we giving our patients their money's worth when we allow this to happen by not offering them the kind of dental work that will serve their best interests in the long term?

This is a great profession! Our patients trust us to do what is right. Billing based on the time it takes to do a procedure, rather than a procedure code, allows us to make healthy living, and, more importantly, allows us to sleep at night knowing we have done what is in the best interest of our patients' long-term health.

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