by Damon C. Adams, DDS
We are witnessing a slower rate of growth in the use of indirect composite restorations than with direct composites or other indirect crown and bridge alternatives. Ironically, the manufacturers are increasing their commitment to indirect composites. Concept HP (Ivoclar Vivadent), Cristobal+ (Dentsply Ceramco), Tescera ATL (Bisco), Sinfony (3M ESPE), belleGlass HP (KerrLab), Gradia (GC America), and Sculpture Plus (Pentron Laboratory Technologies) are some examples of new or recently improved materials now available for clinical use.
One of the main reasons cited for the slower rate of growth of indirect composites is the lack of insurance coverage. If a prior authorization rejection occurs, the patient typically will refuse the indirect composite and instead opt for a covered procedure — any procedure — as long as the insurance policy pays a benefit. Is a subsequent patient rejection of a recommended treatment option entirely the insurance company's fault? Or, is it also — partly at least — a result of our own inability to establish value for a particular service in our patients' eyes?
As a technical consultant and doctor-technician liaison for DH Baker Dental Laboratory in Traverse City, Mich., for the past eight years, I have had the unique opportunity to interact and learn from both the dentists and technicians who work with us. Dr. Ted Kuball, a comprehensive restorative dentist in St. Joseph, Mich., recently wrote to me for advice about an insurance dilemma related to indirect composites. With his kind permission, this article is based upon the dialogue that took place on issues involving nonpayment from the insurance company. Let's now go to Dr. Kuball's letter on this subject:
In my reply to Ted, I applauded him for wanting to base his treatment decisions on what was best for his patients, not what treatment would be eligible for insurance reimbursement. I have had indirect composites placed in my own mouth for seven years, and they have served me very well. As a result, I share Ted's enthusiasm and reasons for choosing them (when indicated) as a viable treatment option.
The ADA's new CDT-4 code book seems to be indirectly assisting the cost-cutting whims of the employers who are purchasing dental-care policies. The "polymer/ceramic" descriptor that was found in the previous CDT-3 codes is no longer there. That previous descriptor was a more accurate one for these highly filled, lab-fabricated, resin-reinforced restorations. Despite the effect these decisions may have had, all the blame does not belong on the American Dental Association, our patients' employer, and insurance companies. We also must examine how we are handling these matters in our own offices. If indirect composites are ever to achieve the recognition and acceptance they deserve, we must continue to offer and prescribe them (when indicated), whether they are a covered benefit or not.
There is no simple, single answer to this dilemma. Much of the answer has to do with the way we present a particular treatment option to our patients. Let me explain by including some possible dialogues that could be used with your patients to help improve case acceptance. Consider giving your patients an explanation similar to this:
"The insurance company often will pay a higher benefit for a crown than an indirect composite. However, keep in mind that we must remove more of your valuable tooth structure to do a crown."
Let patients see the difference by showing them a full-crown preparation and an indirect-composite preparation, with the respective restorations on preprepared models. While they are holding and comparing the models, you can further explain:
"Remember, nothing we can do for you will last forever. That's why it is best to save as much of your valuable tooth structure as you can for any future treatment that you may need. It is like saving money in the bank for a rainy day. This is both the most conservative and best aesthetic choice we can recommend for your particular situation. How do you feel about that?" (Pause silently, and listen to the patient's response.)
Saving tooth structure can hit the emotional buttons of many patients. The business experts tell us that people buy for emotional reasons and then back up their decisions with logic. This would suggest to us that the issue of saving valuable tooth structure, coupled with optimal aesthetics, might be the emotional keys to emphasize with our patients. Spending too much time on logic-based procedural or technical explanations will nearly always fall short in motivating a patient to accept treatment.
When patients complain
At some point, patients may begin to complain about their insurance coverage with respect to your proposed treatment. If this occurs, listen empathetically. They may be distressed, negative, or resistant to have the recommended treatment done due to a lack of insurance coverage. Stay positive in all of your discussions with your patients. Remember, they work very hard to have an insurance benefit of any kind. They might consider themselves fortunate in these days of benefit cutbacks to have any dental coverage, no matter how inadequate we may consider it. In the art of diplomatic persuasion (selling), it is best to be positive while relating the facts, rather than setting up a negative emotional environment in which patients are making their buying decisions.
When appropriate, you might want to share some caring thoughts with your patient on the insurance dilemma. For example:
"It really is good that you have insurance coverage for at least a portion of your dental services. It also is fortunate to know it is always your choice in what you want to have done. You and your health are very important to us. We make every effort to base sound treatment options on what we feel is best for you, not just on what your insurance covers. That is why we took this extra time to inform you of your treatment choices today. Now, is there anything else you would like to know to help you make your decision?" (Pause, look the patient in the eyes, and listen.)
Your patient may need more time to think about it or to discuss the treatment with a spouse or significant other. No patient should ever be pressured to learn about and accept care under a mutually unacceptable time frame. This can introduce stress and distrust into relationships from which future lawsuits can be born.
If patients cite financial reasons for declining the best treatment option, you may wish to offer them an in-office payment plan. You also could refer these individuals to an outside banking service specializing in dental-care credit lines. If appropriate, patients also could be scheduled at a later time for "optimal treatment." If needed, this would allow them time to fully commit to the treatment and to plan for it in their budget.
If insurance coverage turns out to be the only discernable issue affecting your patient's decision for care, then you will have at least discovered more about that individual's personal health-care priorities.
However remote the chance for change, it might also be helpful to encourage your patients to visit their employer's Human Resources Director (if employed by a medium or large company) to discuss their specific benefit coverage. This is a way for employees to let the companies they work for know that they would appreciate coverage for indirect composite restorations.
You could help in this effort by providing information about this class of restorations for patients to share with their employers. If enough patients are educated about the benefits of a service — and they, in turn, voice this to their employers — it may influence changes in specific policy benefits. (It is interesting to note that two major insurance companies in Michigan do cover these restorations for certain employers willing to pay for their inclusion in the benefits schedule. They are covered with the same benefit payment as a posterior high-noble metal onlay.)
Beliefs are the key to motivation
Our overall success is measured by what we can do to motivate our patients to accept optimal care as we see it. As Dr. Paul Homoly, a respected leader on the subject of doctor-patient communication, simply states, "Patients will buy what they want, when they are ready." Creating the balance of emotional and logical conditions in which the patient will "buy"' is directly related to the collective experience, skill, and wisdom of our entire dental team. One of the keys to patient acceptance for an indirect composite — or any other noncovered procedure — is to spend adequate time developing trusting relationships with our patients. They must know and believe that we have their best interest in mind. We must also believe in our hearts and minds that the restoration and service we are offering is the best choice possible. It should be the same option that we would want for ourselves.
I am in somewhat of a quandary over what is best to do for my patients regarding indirect composite restorations. As you know, with the CDT-4 codes, there are very specific, new codes for indirect composites. As I see it, these changes were in the insurance industry's best interest to get out of paying benefit dollars. Like many quality-oriented dentists, I have become non-par and have virtually eliminated silver amalgam restorations from my practice. I have done a large number of indirect composite inlays and onlays. Overall, my patients and I have been very pleased.
Unfortunately, my patients are getting either no insurance benefits for this or a benefit equal to an amalgam restoration at best. One of the last things I want to do is to turn away more conservative tooth reduction in favor of full crowns just so my patients get a better insurance benefit! We charge $675 for any indirect composite that we do, and the patient receives $0 to $150, depending on the insurer, as reimbursement. If we place a full-coverage crown at my usual $828 fee, the patient receives $350 to $424.
Is there any advice that you can give me based on what you know and hear from other dentists with whom you work?