Who will be the purchasers of tomorrow`s benefit plans? How about these folks?
Tom Limoli Jr.
What will tomorrow bring? Will the economy continue to grow? Is the disposable income of our patients going to remain at an all-time high? Are we in for a serious stock market correction? When all is said and done, prosperity in the future will go to those who have learned the lessons of the past.
To examine this issue, let`s look at three critical subcomponents.
1) What is the future of dental-benefit plans?
2) Who are the purchasers of these plans and what are purchasers demanding?
3) How will these changes impact the delivery of dental care?
The future of a dental-benefit plan can best be summarized with one word: change! Gone are the days of the indemnified-benefit product. An indemnity product is one in which the payer (the insurance company) is assuming the risk-reimbursement loss in exchange for a premium paid by a purchaser. In other words, it is the funds of the insurance company that pay out the benefit claims. Your homeowners and/or automobile insurance are most likely indemnity products. You pay a small amount of premium into a risk pool, so that, in the event of a loss, you are indemnified (restored) to the same position you were in prior to the loss.
Today`s health-benefit plans are designed along the ASO (Administrative Services Only) and/or MSO (Management Services Only) formats. With these designs, the plan purchasers assume the risk and maintain control of the money via a self-funded plan. In today`s reality, claims are not paid with insurance company money. This trend will continue beyond the start of the new millennium, as both the banking and insurance industries move to consolidate their respective market shares.
Looking at the role of the plan purchaser, we will need to first identify this changing customer. In the past, the primary customers have been labor and management. In this scenario, the employer purchased and/or supervised the design of the benefit plan on behalf of its employees. Tomorrow`s plan purchaser will very likely be the same customers that we treat in the dental office! Patients will have a more active role in choosing - as well as paying for - their own dental-benefit plan.
Will dental insurance be a thing of the past? Will the patient simply pay out of pocket without some form of benefit plan? I think not!
Tax reform and benefit plans
Income-tax reforms will foster the growth and development of newer and more cost-effective tax credits and benefit-plan designs. The benefit plans of the future will be designed on behalf of the needs of patients and their families, rather than the needs of the employer.
Individual plan structure will be a direct reflection of dentistry`s changing practice composition. Group practices, as well as Individual Practice Associations, will continue to embrace and develop dental-delivery models geared to the overall health of the patient, rather than to the performance of individual procedures.
Evidence-based utilization review will be largely ignored by individual solo practitioners as they continue to focus their efforts on the emotions - rather than overall wellness outcomes - of the patient. Plan purchasers will continue to drive the benefit industry and dental profession to provide quality treatment. The purchasers also will look for ways to quantify the value of the delivered treatment.
Medicine embraced the role of the physician`s assistant. Dentistry will follow suit by acknowledging the hygienist`s place in the theater of data-gathering, prevention, and primary care. As trends continue to mature, innovations in dental- hygiene education and its health-care delivery options will propel the profession of dental hygiene beyond the simple tasks of removing plaque, calculus, and stain from teeth.
The blame game
I laugh in utter amazement at the number of useless legislative proposals that intend to place blame for poor treatment on anyone other than the doctor-of-record. Both political forces are looking to do nothing more than try to please their constituents by redirecting the wayward finger of blame. How is it that legal documents are now rendering care? Let`s face it; they aren`t! Dental professionals are rendering treatments! Corporate entities and benefit plans are nothing more than money managers and benefit administrators. Nothing more!
Don`t fight technology
Our future is in the hands of the young. Like it or not, our children will technologically surpass any and all expectation of our past.While in the midst of last week`s prewinter cleaning, I found in the attic several stacks of computer keypunch cards. I momentarily reminisced about the many hours and nights I spent in the computer laboratory entering formulas and data that were later fed into the University of Georgia "supercomputer." (For those of you who have no idea what I`m talking about, one card held only 80 characters, while a 31/2" disk holds 1.44 megabytes of data.) These relics of my undergraduate statistics curriculum will soon be kindling in the fireplace.
In that same box, I found my trusty Texas Instruments SR (slide rule) 10 calculator. It carried me through high school algebra and trigonometry, as well as my freshman year of college. These aging implements of technology were at one time considered benchmarks of analytical progress. Who would have dreamed that technology would enslave the few while bewildering the many?
What`s your excuse?
So tell me - what are you doing with that old amalgamator? How about that molten metal sterilizer? When did you do your last gold foil restoration? And why are you still not submitting your claims electronically?
It costs too much. The average cost of an electronic claim is between 35 cents and 60 cents. Many insurance companies and third-party administrators are paying the bill for you and their claims are free. By the way, did you know that the administrative cost in your office to produce and mail a paper claim is approximately $6? Let?s see, 50 cents or $6. What will it be?
My computer company says that not all claims can be processed electronically. This is not true. A high quality Oall-payerO vendor can accept all the claims and encounter forms from your office and forward them to the appropriate payer. In many instances, you needn?t be locked into the claims-processing vendor chosen by your practice-management software.
I have no computer in the office. Thirty-five percent of dental offices still are not automated. Now, with a simple fax machine, dental offices can fax all their dental claims and, through very sophisticated OCR (Optical Character Recognition) software, the claim is then turned into an electronic claim. The cost to you is $5 per month and 60 cents per claim Let?s see, 60 cents or $6. What will it be?
I will still have to send in X-rays and perio charts. Don?t fall into the trap of separating claims into electronic and paper. You are shooting yourself in the foot. Payers will continue to request radiographs and perio charts from you until they are satisfied your claims are clean and straightforward. Once this probationary period has passed, your office probably will be placed on an Oattachment- freeO status. This means only one or two X-rays per year will be requested by the payer, and reimbursements will, in most cases, be generated to your office in seven to 10 business days. If your office does not finish or successfully pass the probationary period, you still will be required to send radiographs and perio charts.
Traditionally, the dental market has followed the medical model some seven to nine years later. Technological advancements in the delivery of dental care have now reduced this time lapse to a period of less than three years. Medical- and dental-utilization review and outcomes-assessment criteria soon will be singing from the same song book, no matter how loudly we scream the battle cry ODental is different.O
Only the plans that balance the needs of the purchasers, the providers, and the patients will continue to be competitive. The dynamics of that struggle will create new plans designed to achieve that balance better than ever before.
For more information about this article, contact the author at (404) 252-7808.
Visit Tom Limoli Jr. online at