The good news and bad news about insurance

July 1, 1996
I have good news and I have some bad news. First, the bad news. We appear to have lost control of dentistry. This happened about five years ago and we didn`t even realize it as it was happening.

Dentists can cope with managed care by staying informed of what is happening around them.

Bob W. Deason, DDS

I have good news and I have some bad news. First, the bad news. We appear to have lost control of dentistry. This happened about five years ago and we didn`t even realize it as it was happening.

The insurance industry has taken almost complete control of our profession and our leadership has stood by and let it happen. Some even encouraged it to happen.

Dentistry in this country is controlled and moderated by insurance. Let me explain what I mean.

In my practice and those of dentists with whom I have talked, a very large percentage of their patients have dental insurance. By my calculations, the percentage in large cities reaches close to 99 percent. It seems that people who do not have dental insurance often don`t go to the dentist except in the case of an emergency. Our society has reached a point where the people feel that normal health care is out of their reach unless they are covered by some sort of insurance.

Should we condemn the insurance industry for this? No, they have just been doing their job. Actually, they have helped to make dentistry a sought-after benefit and, in some ways, helped educate the public in the need for preventive health care. Their job is to sell insurance and make a profit for their company. This is the principle of capitalism. They don`t worry about the quality of care, simply because they assume that once the patient gets to the doctor`s office, he/she will get quality care. They assume that every doctor who has a license is qualified to treat his/her contract holders.

Please don`t get the impression that I am defending the insurance industry. (As if they need my defense.) There are many things they do that drive me up the wall. I just want you to see that insurance is neither good nor bad, it`s just a fact of life. A natural business progression. A product of business evolution. Insurance is here and it`s not going away. Stick your head in the sand if you want to, but that won`t change the fact that insurance controls dentistry today and has controlled it for over five years.

Most patients come into our offices because they have insurance. Sure, they may have been referred by another patient who told them that you were the best dentist in the world, but the vast majority come because you work with their insurance. I`ve talked with hundreds of you and I can tell you that most of you out there accept the insurance assignment and are very happy to do it! Most practice-management gurus advise accepting the insurance assignment. Am I advising you to accept the insurance assignment? Abso- lutely not! I`m trying to get you to look at insurance for what it is and what role it`s playing in our industry.

The bottom line is this: If you don`t "work with" their insurance, most of those patients who have insurance aren`t going to come to you. Some will, of course. There are a few discriminating patients out there who either have the resources where coming to you doesn`t affect their standard of living or the very few that put the value of their dental health so high that they are willing to have their standard of living affected by coming to you.

We`ve all heard the stories of the low-wage earner who saved and saved and finally came in to have his/her mouth restored. The point is that there just aren`t that many of these people out there. The practice-management people tell us that we have to make the patients perceive the value of coming to our office. In order to separate ourselves from insurance, we must separate ourselves from the other "average" dental offices so that the patients will perceive the value of coming to our office.

There are dentists out there who can do this and have been doing it for years. But, I perceive that the number of offices that are doing it successfully are dwindling. The reason is that the number of patients out there who meet the two conditions above are dwindling.

We`ve all heard that if we give a superior service to the patient, we can separate ourselves from the average dental office. We can refuse to accept the insurance assignment and have the patient pay the entire fee and wait for the insurance to reimburse them. We`ve heard that if we put ourselves above the "average" dental office we can charge more than the average, not accept the insurance assignment, and the patients will come to us in sufficient numbers so that we can be successful. Let me go on record and say that I fully agree with that philosophy; however, most offices won`t put forth the effort and will be content to remain "average."

The facts are very clear. The average dental office will have to work with the insurance plans to survive. The vast majority of patients will go to the office that works with their insurance. If the average dental office refuses to work with the insurance plans in their area, the majority of dental patients will find an office that will.

That`s the bad news. Now, let me tell you the worse news.

The entire insurance industry has been moving toward managed care for several years. The pace at which they are moving in this direction is increasing. The forces that drive this movement are the normal business forces that drive every other business: The need to make a profit.

It doesn`t take a genius to see that the insurance companies would rather pay a percentage of a PPO fee rather than a percentage of your fee or even their "usual and customary." And it did not take them long to realize that with a capitation plan, they don`t even have to pay claims at all! What a savings in administrative costs!

They can reduce their overhead, underbid a traditional plan, get the contract and still make a bigger profit for themselves and their stockholders. Even a dentist like myself can see the logic there. The only thing I can`t figure out is why it has taken them this long to make such a profound effect on our profession.

This change has been occurring right under our noses and most of us have kept our heads in the sand. Some have been screaming at the top of their voices, "The plans are coming, the plans are coming," but most have disregarded the warnings.

Most have felt that it would never happen in their community. "We have a tight bunch and we`ll never let them in." Then, one of the large employers goes for a new plan, a PPO. The new kid down the street has signed on. You know the one. He`s the guy you`ve never invited out for lunch and you`ve never bothered to send him a patient or two. For a while, nothing seems to happen and you feel that your patients would never leave.

Then one day your receptionist comes back and says, "Mrs. Jones is on the phone and wants to know if we are going to work with her new plan, because your name is not on the list of providers." You get a tight feeling in your chest and say, "Tell her I`ll call her back."

More and more patients are saying that they have a new plan and your name isn`t listed as a provider. And then it happens.

The largest employer in your county goes with a capitation plan and several hundred of your patients work there. If you join the plan, you feel you will betray your fellow dentists in the area. If you don`t join the plan, you know that many of those patients will leave you.

Now, at this juncture, let me present two scenarios. First, you decided to join just this plan because you don`t want to lose a large group of your patients. You call the plan and they send a rep out. You sign up and you feel like you have just put the first dagger in Caesar`s back. The second scenario is even worse.

You have agonized over this decision for several days. You have finally come to the conclusion that you must join this plan to stay in business. Just too many of your patients are under this plan. You make the call to the plan and they say, "Sorry, Doctor, we currently have enough dentists enrolled and don`t need any more. But we`ll put your name on the waiting list and should we need another doctor, we`ll give you a call."

You say to yourself, "How could I have let this happen? How could the ADA have let this happen to me? What am I going to do now?"

The moral of this story is that just because you feel it will never happen to you doesn`t mean it won`t. It`s happening every day all over the country. It`s no longer a shout of "The plans are coming, the plans are coming!" The cry that you now hear is, "The plans are here!"

The insurance industry, more than ever, is in control of dentistry. If patients don`t have an insurance plan, many will not go to the dentist. The patients who do have insurance are looking for offices that work with their plan. More and more insurance companies are going to the managed-care type of plan because it is more profitable. Consequently, more and more of our patients are getting managed-care plans. If your name is not on their list, they will go to someone who is on their list.

This is the dilemma in which the average office finds itself. Only the offices that are "above" the average will be able to separate themselves from the rest of the offices so that the patients will perceive a greater value in those offices.

Where`s the good news? The good news is that I still believe that you can decide where your office will fit in. But you must make the decision now.

Whether we sign on with the plans or continue to resist, I feel that we must stay informed of what is actually happening all around us. We should stay abreast of the plans available in our area and study their structure. Just because we continue to tilt at the windmills won`t make them go away. The managed-care plans are here and they are here to stay, like it or not.

We all may be entering into a new era of dental-care delivery, but there will always be a few offices that will rise above the circumstances and continue to practice in the traditional fee-for-service model.

If you haven`t decided exactly where your office fits in, it`s time. If you don`t, the decision may be made for you.

The author maintains a private practice in Jacksonville, Florida.

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