Managed care spin doctors claim science is on their side. Or is it?
Jim Pride, DDS, and
Kenneth Chung, DDS, MPH
An ongoing debate exists in dentistry today about evi- dence-based care. Rep-resentatives of a new movement claim that there should be irrefutable, scientific evidence for one specific course of treatment for each dental disease. They are also claiming that the desired course may well involve "minimally invasive" techniques. This approach represents "evidence-based care."
Proponents contend that a significant amount of dental treatment is unwarranted by research findings. Is nonsurgical dentistry really on the forefront of science? What is the evidence? Who is gathering it? For what purpose? And where is this movement leading us?
The role of evidence-based care
Evidence-based care is the scientific method of conducting research, publishing one`s findings, analyzing and evaluating literature studies, and drawing conclusions to aid treatment decisions. Evidence-based care allows individual clinicians to go beyond their own personal experiences and benefit from what others have learned. The combined wisdom of the clinicians as compiled in the literature constitutes the body of knowledge of the profession.
However, scientific studies must satisfy certain criteria to arrive at valid conclusions. For example: Is the research carefully designed and free of bias? Are the researchers qualified? Is the sponsor of the research impartial? Has the study undergone peer review? Were enough trials performed to warrant the conclusions? Was there a properly managed control group? Does the study give a balanced review of previous findings, or does it emphasize only one side of an issue? As reported in a chapter, "Reading the Dental Literature," in Dentistry, Dental Practice, and the Community: "The `selective` review to support a particular point of view is unfortunately not unknown." Within the context of carefully controlled research, a clearly stated purpose, and valid conclusions, evidence-based care is essential to dentistry.
The relationship with evidence-based care and clinical judgment
Evidence-based care is an adjunct to, not a replacement for, the dentist`s clinical judgment. The literature findings and the dentist`s first-hand clinical experiences work hand-in-hand to guide treatment and to advance dentistry. Here`s how: Literature reports begin with a clinician who stretches the boundaries and tries something new. It either works or doesn`t work. (These reports are classified in the literature as anecdotal accounts.) Then others try it. (These instances are described in the literature as case reports.) The data and reports that accumulate in the literature constitute the evidence for rendering care.
Evidence-based care begins with anecdotal experiences of clinicians in a practice setting and ideally ends with more compelling case-controlled, double-blind studies. Clinicians then take the new body of evidence and stretch its bounds by trying something different once again. The cycle repeats; the literature and the knowledge in the profession expand.
Once evidence is accumulated, it does not stay static. The freedom of the clinicians to take risks and not be bound by a static body of knowledge has allowed continuous progress and made American dentistry the finest in the world.
Is a well-placed MODBL alloy as durable as an MOD gold onlay? We turn to clinical experiences to tell us. However, relying solely on personal impressions and case reports can be labeled clinical dogma.
Practicing dentists must help develop hypotheses that support the costly case-control, double-blind clinical trials that corroborate personal experiences. If clinicians themselves do not prove the efficacy of their procedures, there is a danger that well-funded outside interests with a limited purpose (for example, controlling costs rather than ensuring quality care) will foster their own hypotheses, gather evidence to support their cause, and launch their conclusions on the profession uncontested. That is a major concern today.
Minimally invasive dentistry
This movement, which advocates sealing over decay instead of removing it, using five-surface alloys instead of crowns, remineralization, delaying the hygiene recall to 18 months, and lengthening the periodicity of radiographs, challenges a fundamental premise of the healing art of dentistry: to treat and treat early. Dental caries and periodontitis are degenerative diseases that worsen with prolonged neglect. The sooner these diseases are treated, the less costly the care, the less discomfort for the patient, and the greater the likelihood of long-term success. Of course, sometimes not treating a condition is the proper decision. Nevertheless, it is the essence of the healing arts to treat.
Minimally invasive dentistry is justified in instances such as public health practice. It is often necessary to delay treatment or temporarily arrest disease because the resources to manage the problem definitively are limited. The focus in this context is to control the disease, not to eradicate it. Arresting decay is an effective method of treatment compared to giving no treatment at all but arresting decay is the inferior choice compared to eradicating it.
Strategies to delay treatment and arrest decay can be valuable in a context in which cost-cutting, rather than comprehensive care, is the focus. These same methods, however, are now being advocated for the population as a whole. Not a third-world population, but an American population, with more discretionary income, more interest in esthetics, and more interest in spending for dental care than ever before. This also occurs at a time when the standard of dental treatment available to Americans is the envy of the world. When we ask today`s patients what kind of dental care they want, they tell us they want the best quality, just as they want the fastest computer and the newest car.
However, there is a movement afoot, spearheaded by managed care companies, that is determined to sell cost-cutting care as the "best" care. Managed-care companies seek a new way to expand their business. Their intent is to control costs by stressing minimally invasive dentistry. In Minnesota, many managed- care dentists are ranked by how well they can switch from surgical dentistry to a minimally invasive approach.
Payments for services are increasingly based on how well dentists do the following:
- Break patterns of periodicity (such as extending the six-month recall to triple that time).
- Switch from sealing all first and second molars to sealing fewer teeth.
- Attempt remineralization or seal over decay, rather than fill cavities.
- Use large alloys instead of crowns.
- Delay treatment as long as possible.
- Do the minimal amount alleged necessary.
In Boston, another experiment sponsored and funded by managed care businesses has dentists establishing minimally invasive practices. Researchers are judging its effect on the dentists` bottom line.
The banner of science?
There should be no pretense that minimally invasive dentistry is going to provide the highest quality care. One managed-care company explicitly states that its new ranking of dentists is not based on technical skill, but on economics. One news story reports: "The dentists` ranking [in Minnesota Delta`s new PRIME program] has nothing to do with clinical or technical skill, the company says, but with the comparative economic value a dentist brings to a dental benefits purchaser when compared with his or her peers."
However, the same managed-care company also claims that minimally invasive dentistry is supported by science. "... Delta emphasized that Delta PRIME is not about what Delta wants dentists to do, but rather what the science justifies ..." Indeed, the very concept of "evidence-based care" is becoming synonymous with minimally invasive dentistry. The dental profession must not allow evidence-based care to become the domain of cost-controllers.
At issue is the matter of evidence accumulated for the select purpose of controlling cost, absent ensuring quality care. We must not confuse the two. We also must not devalue the evidence-based approach, i.e., conducting research studies and publishing results, as the proper scientific method to prove the effectiveness of quality treatment. Clinical experiences in the office and research studies - the art and science of dentistry - are both important.
We must critically evaluate the studies now being performed and not assume they are valid just because their sponsors say so. For example, if remineralization is effective, its advocates should prove through valid scientific studies that in at least 90 percent of cases tried, the decay did not recur in three to five years. Do we know the percentage of sealed teeth vs. non-sealed teeth that are restored within five years? Does the evidence for minimally invasive treatment meet the criteria for sound inquiry?
It is possible for a research sponsor to support the collection of data favorable to its purposes. Managed-care companies, whose stated purpose is "economic", are currently collecting selective evidence slanted to support a particular viewpoint. This must not be accepted unquestioningly.
In the 1960s and 1970s, when the concept of dental insurance was just beginning to take hold, dentists feared the day when insurance companies would dictate treatment. Today, their fears are realized. Concerned dentists again envision a chilling future if minimally invasive dentistry takes hold. If unscientific, cost-control measures are permitted to dominate dentistry, the American standard of care, the finest in the world, will be eroded:
-The dentist?s clinical judgment will be undermined in treatment decisions. Dentists will be pressured into conforming to minimally invasive protocols set by insurance companies. Creativity and innovation will be critically compromised. Dentists will not be free to take risks when they are financially penalized. If dentists can no longer stretch the boundaries, further advances will be stifled and the profession will stagnate.
- Minimally invasive protocols will lower the standard of care. Cost control, not quality of care, will be the deciding factor in treatment. The edentulism rate will rise, because extracting teeth and providing removable dentures is more cost-effective compared to crown and bridge, endodontic, or periodontal therapies.
- The patient-doctor relationship will be severed. Treatment options and materials are as varied as our patients. Forcing treatment according to the parameters of a third party erodes the autonomy of the doctor and patient in making treatment decisions.
Should insurance companies be the primary parties gathering evidence to set standards and dictate treatment? If high quality care is to prevail, clinicians should be gathering data and conducting research to support the finest care. While insurance benefits are a great value to Americans, their worth is severely diminished when insurers dictate treatment decisions.
The need is to provide dental benefits without insurers controlling treatment and to maintain the autonomy of dentists and patients when making treatment decisions.
Dentists can and should emphasize that the managed-care industry?s interest in the scientific method is economic in nature, rather than about the art and science of optimal health.
Clinicians must gather evidence to prove or disprove the effectiveness and cost of dentistry?s mainstay procedures. Research cooperatives and study groups can gather data. Computers can greatly facilitate the compilation of data to validate procedures now under attack which are Otraditionally provenO winners for patients.
The authors gratefully acknowledge the valuable contributions made to this article by Dr. Dale Redig, former dean of the University of the Pacific School of Dentistry, former executive director of the California Dental Association, and founding board member of the Alliance of Direct Reimbursement Plans.
The crown under siege
A managed-care company states that since the average crown only lasts seven years, a large alloy may be more economically sound. Dentistry must challenge such viewpoints and pose questions:
- What is the evidence for concluding that a crown only lasts seven years? Examples abound in every practice of crowns lasting 15 to 30 years.
- If the average crown does last only seven years, is this really a poor result? If the crown has improved the patient`s oral and general health for seven years, it may have been a good thing.
- If the average crown only lasts seven years, why not bring the average up? Educational efforts at all levels would enhance the techniques for treatment planning and crown placements and result in ever higher "averages."
- Some clinicians err in placing crowns, due to periodontal or other problems. The preferred solution should be the fine-tuning of treatment planning and implementation, rather than eliminating the crown. Why throw out the baby with the bath water?
There are many questions to ask and solutions to propose before jumping to the five-surface alloy as the solution. Integral to this point is the fundamental question: Who is collecting the evidence, and for what purpose?