Managing to Care-Not Managed Care

We, as dental professionals, must realize that the dental model differs greatly from the medical model in terms of managed care. Most dental procedures in the United States are discretionary as opposed to crisis in nature. It is not uncommon for individuals to have a $200,000 medical or hospital bill. The outcry of the public via the media stemmed from hospital charges increasing 25.1 percent annually and physician fees escalating at a rate of 15.2 percent annually for a 15-year period of time (

Tom M. McDougal, DDS

We, as dental professionals, must realize that the dental model differs greatly from the medical model in terms of managed care. Most dental procedures in the United States are discretionary as opposed to crisis in nature. It is not uncommon for individuals to have a $200,000 medical or hospital bill. The outcry of the public via the media stemmed from hospital charges increasing 25.1 percent annually and physician fees escalating at a rate of 15.2 percent annually for a 15-year period of time (U.S. Department of Labor, Bureau of Labor Statistics, Washington, DC 20212). Additionally, many expensive pharmaceuticals were introduced into the market during this era. Is it too late for dentistry and medicine to recapture fee-for-service, free-enterprise care?

The dental profession needs a sentinel today as never before. We have watched the encroachment of economic forces begin the devouring of the medical profession and I fear that, without a powerful group of vanguards, dentistry will be affected in a very similar way.

Many say it is inevitable; that the public demands that we join managed care. Don`t bet on it. There are multitudes of individuals with discriminating life themes who are actively searching for the "master" dentist. We have a theme in our practice that says, "Quality cannot exist without profitability." The medical practices in the United States had an average overhead of 30 percent when managed care began its metastasis. Dental practices had an average overhead of 67 percent. It was not a major problem for the medical practitioner to reduce his/her fees by 20-40 percent, but it will economically devastate the dentist who decreases fees by this amount. A dental practice with an overhead of 70 percent that reduces fees by 15 percent must double productivity to remain at the same level of profitability.

An April 1995 issue of the New York Times reported that eight HMOs in 1994 paid their chief executive officers an average of $8 million. The lowest paid executive was paid $2.8 million and the highest paid was $15.5 million. Yes, the profit incentives for the insurance companies, oversupply of physicians and lack of unity or avant-gardes within the medical profession allowed the insurance industry to get in the driver`s seat. The same threat is postured toward dentistry. We certainly have a demographic climate giving managed care a foothold. Where was our sentinal in the early 1970s when we were told by the federal government that there was a need to double the number of dental-school graduates? Profit potential for insurance companies and an oversupply of dentists have allowed managed care to begin its push for control.

What can the quality-oriented dental team do to remain fee-for-service in this "hostile takeover" environment? Let`s examine some strategies that will enhance your commitment to providing excellent care.

1. Communicate with your patients through a letter, newsletter or in person why you and your staff have chosen not to participate in managed-care plans.

2. Focus on patient retention. It costs five to six times the amount to attract a new patient as it does to keep an existing one. Patients in your practice have confidence in you or they would not remain in your practice. Most offices draw 40 percent of their aesthetic/restorative dentistry from continuing care (hygiene) flow. Patients lost to managed care can be invited back to your practice by finding out the renewal date of the insurance contract from the employer. Three to four weeks prior to this time, send your former patients a letter telling them you would be honored to have them return to your practice.

3. Establish a philosophy of comprehensive excellence. A thorough and impressive new-patient examination is essential to the office desiring to remain quality-oriented and fee-for-service. Investing enough time for relationship-building, in addition to the following, make this two-hour experience an integral part of the beginning of a long-term relationship:

A. Interview obtaining personal, dental and medical history

B. Oral cancer examination

C. Clinical dental examination

D. Periodontal screening

E. Flossing of all proximal contacts

F. Occlusal, muscular and TMJ evaluation

G. Diagnostic model impressions (frequently two sets: one set mounted from interocclusal records and one unmounted)

H. 20 film radiographic survey with duplicate film packs

I. Panoramic radiograph

J. Tour of the mouth with intraoral camera allowing the patient to see the screen as each tooth is shown

K. Photographs, slides, intraoral video prints

L. Smile evaluation checklist completed by patient while looking at intraoral prints and using hand mirror

It is essential that the timing and format of the consultation be well-planned. Overwhelming the patient prior to the patient`s complete understanding of conditions and treatment options will lead to failure in the relationship. Our objective in the new-patient examination is to stimulate a participatory or co-discovery learning experience. Frequently, we have to time the treatment to match the comfort zone of the patient. Routing the patient through hygiene or phasing preliminary treatment is sometimes mandatory in order to gain the "yes" response to comprehensive treatment at a later date.

4. Position your practice so that the competition is very thin or nonexistent. Managed care and the indemnity-insurance coverage provide few, if any, benefits for complex restorative dentistry, implant prosthodontics and aesthetic services. Providing these services in an atmosphere of ultra service and ultra quality will insulate you from the $8 per patient, per month capitation program.

5. Recognize that your team is the "internal patient." I once asked an outstanding staff member to profile a solid "10" team member. Her characterization:

A. Genuinely loves people in a nonjudgmental way. Extending unconditional love to patients causes them to eventually "bloom" in our dental family.

B. Is an excellent communicator. Listens actively and understands the necessity of relationship-building with each patient.

C. Displays warmth as well as professionalism with each patient. Establishing congruence of mood with the patient will nurture the patient in a compassionate manner.

D. "Carefronts" (confronting in a spirit of loving-kindness). The key to fostering meaningful relationships is to be courageous enough to confront the individual with whom we have cause. This should be done soon after the offense and in privacy. Our motto should be "Confront in privacy and compliment in public."

E. Has an innate sense of excellence. The quality standards of our practice are communicated to the patient at every opportunity. After exposing a pre-cementation radiograph, an explanation about technical quality is given to the patient. Such phrases as "integrity of margins," "perfect fit," "excellent proximal contacts," "proper occlusion," "emergence profile," "shade zones of porcelain" and "beautiful restoration" are used to demonstrate our standards of quality.

F. Is a team player. She attempts to memorize the schedule each morning in the huddle so she knows the flow of the day and can help circumvent bottlenecks.

G. Chooses to be elevated by service and humility. She seeks to serve and not to shine. Staff members who demand to be elevated seldomly rise to the occasion. A team member with a servant`s heart will find herself progressing toward a leadership position.

H. Is perpetually on an improvement track both technically and behaviorally. She will select, with the doctor`s approval, challenging and enriching continuing-education courses, books, tapes, etc.

I. Possesses "Factor X." Factor X is defined as the ability to establish a meaningful relationship with a person in a relatively short amount of time.

J. Is flexible in her duties-she`s a basketball player rather than a football player. Rather than permanently being assigned the fullback position, the power forward may have to play point guard. "That`s not my job" is not in her vocabulary.

True caring by the entire team in addition to superb quality technically, being both routinely done and perceived by the patient, will allow the quality fee-for-service practice to weather the current insurance-company coup.

The author currently practices in Richardson (Dallas) TX, with emphasis in restorative, esthetic and implant dentistry. He serves on the L.D. Pankey Institute`s Board of Directors and lectures throughout the United States.

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