Evidence-based care is the defense ready?

Evidence-based care is a perfect example of `Be careful what you wish for - you just might get it.` Gear up for a new battle!

Evidence-based care is a perfect example of `Be careful what you wish for - you just might get it.` Gear up for a new battle!

Vicki Anderson

Dentistry has long wished dental plans would consider the individual patient`s needs when formulating their reimbursement policies. We hoped carriers would provide benefits for patients who needed periodontal maintenance every three months or who needed two visits to complete a difficult prophy. We looked forward to the day when carriers would pay for fixed bridges or implants, recognizing that many patients cannot tolerate removable partial dentures. In other words, we hoped that dental plans would tailor their benefits to the patient`s needs rather than the carrier`s financial goals. Unfortunately, we now have a great example of the cautionary old saying, "Be careful what you wish for."

We assumed tailoring a benefit plan to the needs of the patient would mean an increase in coverage for patients. Little did we know that it could result in a loss of coverage, but that is precisely what is happening as carriers leverage science to reduce costs. Major carriers are rapidly developing evidence-based care policies, and are requiring dental teams to prove that patients need even the most basic services.

In theory, evidence-based care makes sense. Acknowledging that all patients are not created equal in their dentition and providing additional benefits for high-risk patients seems like progress. However, most dental teams are not prepared for the negative consequences of the new movement. Evidence-based care will require a complete change in the way we manage our dental practices.

With that in mind, here are some answers to the most frequently asked questions about evidence-based care:

(1) What exactly is evidence-based care?

True evidence-based care integrates clinical judgment with the best available research/evidence and the patient`s values in making clinical decisions. It would be difficult to find fault with any individual or entity whose goal is to use the best evidence available to provide better, more individualized dental care for patients. In its purest form, the goal of evidence-based care is to provide better care.

Unfortunately - just as many in the dental profession feared - major carriers are beginning to implement evidence-based-care policies as a way to control costs, rather than improve care. The question carriers are asking is, "How can we use science to our advantage and/or capitalize on the voids of evidence to reduce costs?" The necessity or cost-effectiveness of some of the most fundamental principles concerning dental treatment - principles taught at dental schools across the country - is now being questioned. The director of a major dental carrier recently commented that 7 percent of all dental dollars are spent on procedures replacing missing teeth. He asserted that although dentists have always been taught to stabilize the arch by replacing missing teeth, recent studies indicate that arch collapse does not predictably occur. He further stated that dentists tend to recommend procedures that profit them financially, and that evidence-based care will particularly hurt dentists who do a lot of crown and bridgework.

Carriers anxious to find a way to control the dental costs of a large, aging, baby-boomer population now are employing a method of risk assessment to classify patients as low, moderate, or high risk for caries and/or periodontal disease. They then develop specific regimens of treatment (or nontreatment) based on certain risk factors. A low-risk patient may only qualify for a recall interval of two years.

The goal of these carriers is to move all patients to a low-risk status, thereby reducing the frequency of hygiene appointments available under a patient`s plan. Not only would this reduce the immediate costs of six-month hygiene appointments, it also would prevent the diagnosis of restorative treatment at those visits, further reducing costs to the plan.

(2) What evidence will insurance companies use to determine coverage?

That is the million-dollar question or, to be more accurate, the 54- billion-dollar question.

Dentists worry that carriers may sponsor or conduct their own research, which would likely be biased and focused on cost-savings rather than quality care. Dental leaders already have expressed concern that some of the literature currently cited by carriers is not scientifically valid, that the results don`t support the data, and/or that the information is taken grossly out of context from the research articles. The quality of dental care available to the average American citizen may depend on how quickly and thoroughly the American Dental Association and the various dental academies evaluate the evidence being used by the insurance industry to justify the treatment regimens it will require of its contracted providers.

(3) When will evidence-based care take effect?

It already has, but we are experiencing only the tip of the iceberg.

Until recently, it primarily has been the managed-care companies that have implemented evidence-based-care policies, some as early as 1992. But concerns are mounting as we see evidence-based care surfacing in the major preferred-provider networks. Dentists in Minnesota are painfully aware of a major preferred-provider program that now equates preventive dentistry with minimally invasive dentistry. According to this particular carrier, there is extensive evidence that once teeth are restored, they generally require retreatment of increasing complexity over time, contributing to a weakening of the natural tooth structure. Consequently, the carrier has determined that treatment should be delayed for as long as possible and the decision not to intervene has become increasingly important. The carrier believes that, over time, a high percentage of carious lesions will stop increasing in size.

This same carrier asserts that the days of every patient receiving the same treatment are over, and it will no longer pay for preventive services on a routine basis. An individual patient`s risk factors will determine if he or she receives benefits for an examination, prophylaxis, or radiographs every six months or every two years. In addition, only teeth that are "at risk for decay" will receive sealant benefits. If patients want and expect two cleanings a year - or want their children`s molars sealed - the carrier expects its providers to inform patients that they do not need the services they think they are entitled to.

This preferred-provider program also has combined evidence-based policies with a utilization review program to determine what fees will be paid to its providers. Dentists who do not adopt this evidence-based, minimally invasive philosophy are penalized financially by being paid lower fees than their evidence-based peers.

Another national carrier has recently increased its cost-control efforts by auditing dentists who routinely take bitewings every six months. If the patient`s chart does not clearly indicate that the dentist requested X-rays due to specific risk factors, the providers must refund the benefit payment within 30 days or the money will be withheld from future claim payments. The fact that the patient`s chart was reviewed by the dentist - as well as by the entire team in the morning huddle- has resulted in no leniency. Early reports indicate providers are writing checks back to this carrier for as much as $15,000 to $30,000.

(4) How will this impact private practices?

Evidence-based care will undoubtedly require a change in the way we manage our dental practices. Contracted providers will find that they need to overhaul their recall systems, assign patient risk profiles, communicate those risk factors in the patients` charts, establish specific treatment protocols, and develop new verbal skills to help patients understand the new treatment philosophy. Noncontracted providers also will need to understand the new evidence-based policies. They need to do this so they can anticipate and address the concerns of patients who will no longer be able to receive benefits for traditional procedures.

Our relationships with our patients will be jeopardized, because they will assume preventive services will be covered as they have been in the past. Since benefits for routine procedures can no longer be taken for granted, hygiene departments will be turned upside down. Patients who are considered low or average risk will discover that prophys now will be only covered once in 12, 18, or 24 months. These patients will be questioning why recommended treatment is not covered. Both clinical and business staff will need new verbal skills to help patients understand why their dental plans only pay for exams, prophys, and/or X-rays every 12, 18, or 24 months.

Depending upon their contractual relationships with various carriers, providers often will find themselves in a defensive position, trying to justify uncovered treatment or forced to write off disallowed services. In our patients` minds, necessary services are covered. So, they will assume that if a treatment isn`t covered, it probably isn`t necessary. They may even intentionally avoid future treatment, fearing it may not be covered either.

The restorative department certainly will be impacted, because fewer hygiene appointments means fewer dental problems diagnosed in the early stages. Dentists will see more emergency patients, many of whose problems might have been avoided with earlier intervention. And, because cost control - not quality of care - will be the deciding factor, dentists will be pressured into doing more extractions and removable dentures. They will be considered more cost-effective than crown-and-bridge or endodontic and periodontal therapies.

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