Last September, Dental Economics printed our article, "A declaration of independence" from Delta Dental (September 2002 Dental Economics, page 16). We received many supportive emails; some asking for advice that might help them. For what it's worth, we suggest they do not "pull the insurance plug" just before a "9-11" tragedy as we did. But, despite the hardships we still face from our unfortunate timing, we go forward with the conviction that "There is never a wrong time to do the right thing."
Dental offices that choose to become insurance independent can experience a real test of character. Consultants can show us steps to minimize the risks and pain, and remind us that the decision should not be based on ego or emotion, but on sound business principles. But what if they challenge us to base our decision on a conviction that it is the right (ethical) thing to do?
Why do offices choose to become insurance-independent? Mostly, it is a matter of profitability. Consultants focus on profitability because we will pay handsomely for that expertise. So they tell us it is OK to keep discount insurance programs as long as it is profitable (we need the patients), and dump the programs when patient flow is up.
Consultants teach us that we can cleverly maximize our benefit from these programs. We can use our verbal skills (which they will teach us) to educate patients on the benefits of paying out-of-pocket for "ideal" care not covered by insurance. (That should save the insurance companies a tidy sum.) And, we can impress our patients so much that they will stay with us even after we drop their program. Or, we can pass the program off on a young associate. We can't lose! Right?
If it is such a winning proposition, why do some dentists object? Perhaps they recognize that while we think we are taking advantage of these programs, we are actually contributing to their growth and proliferation. Knowing there will always be more dentists who will join, these programs can squeeze reimbursement to improve their own bottom lines and competitive edge against other programs. By participating, we are passing off the growing burden of the insurance problem onto those who come after us and profiting in the process.
What are the ethical implications? Do we question if it is "fair" to charge different patients different fees for the same service? Is it fair that patients with insurance pay a discounted fee, while those without it pay the full fee? But discounts bring in customers to fill empty seats. That business model works for the airlines, why not dentistry?
Could it compromise our quality of care? Could we even subconsciously start to provide disparate services as a result of disparate fees? We would never! Then why is it such a prevalent problem? It must be the other doctors! Why is that not an issue for the airline industry? Perhaps airlines offer all passengers the same amenities — soda pop and peanuts — along with a brutally fair policy: If the plane goes down ...
Dental consultants suggest that the question of fairness is irrelevant. They regard such discounts as an "advertising cost." (So, the program that pays the least charges the highest advertising cost?)
Are there ethical implications in advertising? When we pay the advertising cost to join a discount program, we become "preferred" providers. Does that undermine the principle of earning the patient's trust — a cornerstone of our profession? Does trust matter anymore, or is it just an old-fashioned concept?
But lighten up; it's just advertising. Don't take it literally. So we just go along because it is profitable? Then what else might we do that is profitable?
It is illegal to waive co-payment. Even if there is no law pertaining to the practice, is it ethical? What about offices that offer patients an "insurance" for a $1 premium to cover (waive) their co-pay? It is clever and it may be profitable, but is it OK?
At the "Intensive Bioethics in Dentistry" program at Georgetown University, a highly esteemed ethicist said in a lecture that waiving co-payment could be considered an act of "civil disobedience." Doesn't that have a nice ring to it? After a private conversation challenging his assertion, he showed integrity in admitting publicly that perhaps he had not fully considered the implications of his statement. What if he had not been challenged?
If an ethicist could inadvertently overlook the ethics of an issue, could our consultants? Consultants are good people. We value their guidance in helping us succeed in business, but we need to be alert to ensure that ethics are not being taken for granted or dismissed as "emotion."
We had that concern with two very prominent and highly respected consultants. We signed on with a management program after being assured that they are very ethical and sensitive to our ethical concerns. (Would a consultant say otherwise?) But when a lively discussion on the ethical implications of discount programs erupted among the doctors during a workshop, the consultants stood by in silence. Later, when asked about it, they said their role was to discuss business practices and numbers. They didn't "do ethics" after all!
In a second case, we engaged a consultant to help us align our mission — dentistry — with our vision — ethics — only to have the consultant ask dismissively, "So how many patients did that bring you?" Perhaps this consultant sees ethics as just another gimmick or knows that good ethics does not necessarily mean "good business."
Is good ethics good business? A patient who was referred to us asked if we would waive her co-payment as her previous dentist did. We explained the legal and ethical implications. She said she admired our principles, but still asked if we would waive her co-payment. She seemed quite confident that someone would accommodate her.
A professor of a university graduate school of management was referred to us by his periodontist for restorations. His insurance claim for our services was denied because he had unknowingly exceeded his benefits for the year. He insisted that he should not have to pay, and that we should resubmit his claim with a different date of service. When we explained the legal and ethical implications, he declared that the situation had nothing to do with ethics, just business, of which he is the expert. He seemed to know that the practice was not uncommon.
As long as ethics are so easily shoved aside, such encounters with patients will always be a no-win proposition. Does anyone really relish asking ethics questions that make people (especially potential patients) uncomfortable or upset? Do patients really care to know the reason a doctor chooses not to participate in a discount insurance program for ethical reasons when it means it will cost them more? Patients, just like dentists, tend not to look beyond the immediate benefit to see the bigger, ethical picture.
Who should speak up for our profession? Consultants suggest that we (and our staff) should talk to patients about these issues (they will teach us the right things to say). Our overworked staff must be thrilled to take on this challenge, especially when our most articulate leaders seem far too eager to side-step the issue. Yes, we may be able to influence a few. But imagine the impact consultants and leaders could make if they used their immense talents to influence the ethical conscience and climate of our profession! Is there a more noble challenge for a leader?
For our consultants, here is the dilemma. The problems created by discount insurance programs may be one of the biggest reasons driving the demand for their services. It is profitable for them to help individual clients manage the problem, but it may not be to their advantage to help eliminate the problem. But ultimately, isn't it the right thing to do?
Suppose we are responsible for a group of students who know and abide by the rules of ethics, and another group of students who don't know or don't care about such rules. Would the first group be at a disadvantage in their effort to get the best grades in the class? What if these students decide to join the second group? Should we do anything about the situation? Should we wait for students to take the initiative? (Imagine what the proportional numbers in the two groups might be.) Should we encourage students in the first group to study harder, pay for tutors, buy more sophisticated computers, or improve their communication and social skills? All these steps will be beneficial, but it benefits only the individual who has the opportunity to take such steps. Does anything preclude the students in the second group from taking these steps also so they can maintain their unfair advantage, or should we take the responsibility to ensure that everyone in the classroom is held to a common ethical standard? Isn't that what we teach our children? Should it apply to us?
Then what is the solution to the problem in dentistry? How can we correct the ethical compromises associated with such programs (fairness, trust, responsibility to patients)? The problem is not with discount insurance programs per se, but how we implement them. Any program can offer any level of reimbursement, just as we can choose to charge any fee for our services. The ethical problem arises when we sign on with programs and have different fees for different patients.
The solution is simple — If an office accepts a "for-profit" reduced-fee program, that fee should be available to all the patients in the practice. That would alleviate risks of disparate care and ease the access-to-care problem. Patients win. It would compel insurance programs to set reasonable reimbursement rates. We win. And insurance companies can be confident that the dentists who sign on with them accept their reimbursement as reasonable and fair, and would have no incentive to "game" the system. Insurance wins.
Fraud is the most pernicious reason for the escalating healthcare costs that hurt everyone. Insurance companies have every right to protect themselves against the perpetrators and control cost. But ironically, by implementing discount programs that disregard ethical principles, insurance companies are selecting against the ethical doctors who would not participate on principle. These same unethical doctors can profit in any system. The proposed change is ethics-based. Everyone benefits! Isn't that a policy everyone can support?
Solutions to the ills of society — slavery, discrimination, fraud, etc. — are found only when someone sees through the ethical flaw, refuses to accept things as they are, shares a vision of how things should be, and acts courageously to bring about the change. Who will step up for our profession? There is never a convenient time, but there is never a wrong time to do the right thing.
William Hsiang, DMD