The Lowest Common Denominator

March 1, 1996
The profession of dentistry in America is a war and practicing dentists are intimately involved in the conflict. On the battlefields, we find several main participants, each representing their own interests: 1) the insurance industry; 2) the government (federal, state and local); 3) organized dentistry (national, state and local components); 4) patients (the recipients of care); and finally 5) dentists, the providers of care.

Eugene L. Antenucci, DDS

The profession of dentistry in America is a war and practicing dentists are intimately involved in the conflict. On the battlefields, we find several main participants, each representing their own interests: 1) the insurance industry; 2) the government (federal, state and local); 3) organized dentistry (national, state and local components); 4) patients (the recipients of care); and finally 5) dentists, the providers of care.

The issues are complex and multi-faceted and deserve full consideration. From the standpoint of the private practitioner, the ultimate goal of dental practice always has been twofold: providing quality, comprehensive care for patients who require and desire care, while at the same time realizing a fair compensation. Patient care always is the reason that we, as dentists, do what we do. The patient-doctor interaction is the hub of the wheel and the product of this relationship is the beginning and the end of what dentistry is all about.

North American dentists are among the best-trained and highly-skilled professionals in the world. The profession has succeeded in dramatically reducing the severity and incidence of dental disease, while at the same time providing patients with care that predictably restores function and esthetics. There are no other professionals in America that can straighten a crooked smile, restore a worn dentition, treat a diseased root canal or replace a missing tooth. The value of these, as well as all other services provided, is recognized by our patients, who have come to have high expectations regarding their dental care. Esthetics, comfort, function and service are hallmarks of quality dentistry and, because the dental profession always has performed well in delivering care, dentists have enjoyed the right to be compensated fairly for their efforts.

The business aspect of dentistry (the part about compensation) is potentially lucrative and is at the core of the war being waged. There are a great number of people in America who either have teeth or who have a need for what teeth do for them. As a group, dentists do not approach dentistry as a business, but rather, primarily, as a profession, and dentists are not known for their prowess as astute and efficient businesspeople. The business aspect of dentistry rarely is given the attention it requires.

The insurance industry does not share the viewpoint that dentistry is mainly a profession. In its view, dentistry is a business that happens to be run by "professionals." The dental market deals with something all people have or need-teeth. Maintaining and fixing teeth yields money. From a business standpoint, and where teeth are concerned, the application of cold and hard business principles should equal great profits. The market is huge, and when costs can be controlled, the potential for profit is substantial. The only thing standing in the way of tremendous profits for the insurance industry are the providers of care themselves: the dentists who stubbornly cling to notions of patient relationships, genuine care, low volume, respect for people`s time, continuing education, fair compensation and quality of services.

In the boardrooms of the insurance industry, it appears that the decision has been made to usurp the control of dental care-to steal control away from the providers of care. Our patients are being re-educated to view health care, in and of itself, as an inalienable right; not simply the right to be healthy or to freely pursue health care, but rather the right to health care itself. The concept of health insurance, in general, as a means of dealing with catastrophic occurrences, is not the norm. We are being led to believe that health-care insurance today exists to pay for fixing whatever may be broken. The same market of patients who expect quality and service today also expect to not have to take financial responsibility for the care that they receive.

The insurance industry is the main recipient of the benefits from this paradigm shift. The more the public perceives that it has the right to health care itself, the more the insurance company will be able to sell its policies for the delivery of managed care. Considering the limitations for profitability within the existing patient-insurance-doctor relationships, the insurance industry is implementing the changes it considers necessary. These changes involve removing the doctors from the decision-making part of the equation as much as possible, while still allowing the doctors to commit their own time and money for education, taking financial risks in setting up and running practices and taking legal responsibility for providing care. The insurance industry`s interests lie solely in realizing a share of the income produced by doctors. The end result is 20-40 percent less money for the dental practitioners and a transfer of revenues to the insurance industry.

The insurance industry is packaging its product for sale. The purchasers of the product-the employers of our patients-must manage the costs presented to them by the insurers, and they are counseled to purchase plans that happen to give the insurance industry the control it requires for greater profitability.

The government also realizes the value of teeth. Behind each dentition is a vote, and votes equal political power. The electorate-our patients-like to hear politicians say that health care is a right. The politicians, however, have failed to consider the rights of the care providers, as well as the ability of the providers to deliver care adequately under the set of definitions, rules and regulations set forth by government and regulatory agencies.

What is occurring needs to be put into perspective. Dentists spend years training in formal institutions at considerable personal expense. Degrees and licenses are earned. Financial risks are taken in setting up practices, and more time and effort is expended in continuing education. The insurance industry has contributed nothing in this venture, but at this point enters the arena and seeks to dictate to the profession the terms of its business:

* How much patients will pay for services;

* What services may and may not be provided for patients;

* Who may deliver emergency care;

* Who patients will be able to seek for services;

* What legal risks the providers will bear.

The government tends to view issues regarding the delivery of care from its own viewpoint, with political power as the profit motive for our elected decision-makers. The rights of dentists as small-business people are abrogated and distorted. Plans and regulations are proposed and implemented that seek to further control our right to freely deliver care in an open marketplace.

Private practice is facing the control and management of the delivery of care, from both the government and the insurance industry. Our patients are being trained to accept the notion of health care itself as an inalienable right. As practicing dentists, we feel threatened and confused about what we need to do. It is natural for us to look to our national, state and local dental societies for leadership. But where is the practitioner to find representation when it comes to educating our patients effectively about the true value of dental care and the services dentists provide? The large majority of the members of organized dental associations are in private practice and private practitioners stand to lose the most if the insurance industry and the government have it their way.

Hopefully, there are very few ADA, state or local dental-society leaders who would disagree that dentists must strive to deliver comprehensive and quality care for their patients who require care. Few would disagree that dentists have the right to receive fair compensation for their services. I would hope that few of our leaders believe that the insurance industry has, as its primary motivation, the delivery of quality and comprehensive patient care. Hopefully, our leadership does not believe that institutional control of care is a positive and desirable goal.

As individual practitioners seek leadership, what becomes apparent is the reactionary nature of our leadership`s actions. As a profession, we are not leading the charge; we are being led by the actions of others. Instead of striving to elevate the level of care, organized dentistry is taking reactionary positions that will inevitably lead to meeting the qualifications of the lowest common denominator. There are few dentists today who would admit to entering this profession in order to strive for mediocrity.

Insurance industry-sponsored, managed-dental care is not in the best interests of either doctors or patients. Employers who purchase cheaper premiums are buying cheaper care. Cheap care and high-quality, comprehensive care cannot go hand-in-hand. Organized dentistry appears to be taking the position that it is duty-bound to represent all of its members` needs, and since managed care is here to stay, it must support and allow the insurance industry and government to usurp control. In essence, this is the same as taking a firm position in support of mediocrity. The lack of vocal and organized opposition by our elected officers and delegates results in defacto support of insurance industry-controlled care.

As professionals who have devoted our lives to learning the skills and techniques necessary to deliver comprehensive quality care, and as dues-paying members of organized dentistry, we have the right to expect our elected representatives to strive for more than the lowest common denominator. Where managed care is concerned, our leadership needs to support its membership by proactively educating the public, influencing the government and opposing the interests of the insurance industry when these interests conflict with our ability to deliver care.

Steven Covey, in The 7 Essential Habits of Highly Effective People, states: "The word `proactive` means more than merely taking initiative. It means that as human beings, we are responsible for our own lives. Our behavior is a function of our decisions, not our conditions-we have the responsibility to make things happen."

The elected officers and representatives of organized dentistry must fulfill their responsibility to the profession they represent. As individuals, we need to take positions of leadership and do all that we can do to make things happen. There are few dentists I speak with across the country who think that managed care is good for our patients or for our profession. Perhaps, when our leadership fails to ask what its membership desires, we need to make it known to them. Perhaps we, as individuals, need to stop looking to others to fight for our rights, but need to take responsibility and stand for what rightly belongs to us.

Managed care will only impact us to the extent that we allow it to. Do you accept the notion that managed care is a good thing for dentistry? If not, you have a responsibility to yourself and to your patients-present and future-to stand for something better. Collectively, we have the right to expect and demand that our representatives act on our behalf. Individually, we have the responsibility to stop complaining and to begin doing.

This issue requires immediate attention. Our profession, the health of our patients and our own economic livelihood are at stake. Our collective capabilities demand more than mediocrity. Our services never can be as mere commodities to be purchased, sold and traded by others who sit at mahogany-tabled boardrooms across America.

Organized dentistry does much good in support of its membership, but unfortunately fails at times to remember its overall mission of representing its membership`s interests and desires. The lowest common denominator is not good enough. Our leadership cannot allow concerns such as antitrust issues to blind them when it comes to taking a stand on the clear-cut issues at stake. There is more than one way to fight the threat of institutionalized mediocrity. There are no laws in existence that prevent organized dentistry from educating the American public about the positive benefits of fee-for-service dentistry. There are no laws that prevent organized dentistry from showing our patients what to seek in quality care-whether it be children`s dental care, esthetic dentistry or the magic of implants: from the cradle to the grave.

From the standpoint of the practicing American dentist, our organized, educational efforts leave much to be desired. The fact remains that the insurance industry is doing a great job telling the public what it wants them to know and the only significant press attention we receive deals with amalgam, AIDS and the occasional, sensational malpractice case.

The profession needs to strive for excellence in all that it does. Dentistry belongs in the hands of dental practitioners-the individuals who deliver care. The insurance industry, the government and organized dentistry need to remember that their true mission is service to the people they represent. Our patients are best served when the dentistry they receive allows for optimal restoration of function, structure and esthetics. This can be accomplished only when dentists are allowed the freedom to perform the work they uniquely are capable of doing. We need to remember that we are gifted individuals. We must demand of those who serve us that they assist us in accomplishing our mission and in reaching our goals.

The author maintains a full-time, private practice in Greenlawn, New York. He has lectured nationally, conducting seminars on lasers, technological advances in dentistry and practice management. He is a founding member and lecturer for the Academy of Dental Consultants.

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