This article will provide a framework for a paradigm
shift that you might wish to consider. Read this opinion
and editorial piece carefully and understand the intent
first. The suggestion is not that you change your current
relationship with dental insurance, rather that you come
to understand its potential role in impacting providers
and patients’ behaviors. The thesis is referencing dentistry’s
evolution and the stagnant, non-evolving function
and role of dental insurance and how that has the opportunity
to handicap caregivers and care receivers. The basic
behavioral equation is pretty straightforward but how we
got to where we are now is complex.
Patient + Dentist = Informed Choices Regarding
If we substitute a patient with dental insurance, the
costs of care, provider profitability, treatment choices,
entitlement mentality and third-party influences all
become variables that can mess with the solution. What
was once intended as a simplifier that would improve
access to care for our patients has often become a barrier
or handicap to making patient-centric choices for both
doctors and their clients.
When first introduced, indemnity plans did and
were intended to help more patients seek care and transfer
some of the cost to employers through third-party
payers. As dentistry and restorative solutions
have evolved and costs have increased
over the last 40 years, the dental insurance
coverage has not kept up, in
fact, it has “devolved.” PPO, HMO
and UCR limitations along with
other creative managed cost (not
care) alternatives have further limited
reimbursements and clouded
both doctor and patient decision
frameworks. No longer does a dentist
simply do a comprehensive and thorough
examination, craft appropriate
treatment plan recommendation(s) and
present that in an educational
framework to the patient. All
of the aforementioned variables
that have been added
to the equation might or
might not come into play and impact the delivery of
optimal dental care. Consider the following handicaps:
- Maximum coverage that has not kept pace with inflation
and the cost of care.
- Discounts to reimbursement schedules designed to
reduce premiums without considering quality of care.
- Pressuring caregivers to make financial decisions
about patient care that protect practice profitability
over the patient’s best interest.
- The misleading use of the word “insurance” to
describe a basic coverage “maintenance” plan.
- Almost fraudulent use of the term “managed care” to
describe “managed costs” initiatives. Marketing and
spinning changes to plans to make subscribers think
they are getting more or better, not less coverage.
- Creating an entitlement mentality surrounding dental
- Limiting freedom of choice in caregiver selection.
Years ago, $1,200 annual coverage allowed us to do
much more. We never thought that something so wonderful
would one day handicap us in our practice. Fastforward
45 years and coverage is still at $1,200. If you
were to adjust for inflation over the years, that coverage
would be more than $7,000. How does this happen?
Gasoline has gone from 29 cents to $4 a gallon! Where
was the inflation adjustment for dental insurance?
If a practice were operating with an overhead of 70
percent and accepted a PPO that required a fee discount
of 15 percent, that dentist would have to do twice as
many procedures (now only netting 15 percent) to make
the same profit margin as he did when he was making 30
percent. Because we went to dental school instead of business
school, these impacts are not often well thought out
when we make these decisions.
Alternatives to reduced coverage would be to use
cheaper offshore laboratories, purchase less expensive
materials, pay staff less or beat up dental supply companies’
reps or landlords. If we were talking about a
$700,000 fee for service practice (netting 30 percent = $210,000), that practice would have to grow to $1.4
million to keep the same net in the previous example.
That is not fair. This is basically what happened recently
in Washington State when its largest insurance cut reimbursements.
Is your state next?
If car insurance worked liked dental insurance and
the Geico gecko only offered to pay $1,200 if you
totaled your car, you would flip out. You would take
that little gecko and choke him until he paid up. Dental
insurance-type auto policies might only cover oil
changes, lube jobs, filters, tire rotations, hoses and
belts, and only up to a $1,200 a year maximum, not
collision or catastrophic losses. My medical insurance
policy has a $2,500 deductible. That is more than double
the average dental insurance covers. Homeowners,
medical and life insurances have kept pace reasonably
well with the inflationary changes to their risk coverage
and have no illogical limitation. Perhaps “dental assistance”
or “maintenance plan” would be a more apt
name. $1,200 is a worthwhile sum, but it is not catastrophic!
If you had to have open-heart surgery, your
home was destroyed by fire or you totaled your car,
those would be unexpected and catastrophic losses.
Dental insurance is not insurance.
If there were really managed care initiatives, people
would be rewarded for flossing and seeking long-term
solutions with the highest predictability! More frequent
periodontal therapy visits to prevent the need for surgery
would be covered! They would support the long-term savings
of doing fixed restorative and implants over removables,
crowns over the uncertainty of large composites or
alloys, bite guards, sealants and more. Instead, the shortterm
cost-saving procedures take precedent over the longterm
because the subscriber and employer might change
carriers on a whim. The risk of investing in future savings
and not being the carrier over time is too great. Another
crippling effect for many of us is the insurance company’s
expectation that you pre-authorize and wait two to six
weeks for determination of coverage. Meanwhile the float
is carried as unpaid claims and the patient might change
his or her mind. Both save the insurance company money.
They manage their costs not patients’ care.
We complained about gas prices hitting the $2, $3
and now the $4 mark but we forget that bottled water
runs between $8 and $20 per gallon depending on the
brand we choose. People will pay for what they want. As
dentists, we need to do our job and help our patients
understand and want what we know they need. People
always seem to have the money for what they really want.
Private schools are an example of making choices based
on values rather than the entitlement of a public school
education. Cadillac, Lexus, Mercedes Benz and BMW are
another. In the United States, we spend more on gambling,
cigarettes and alcohol than we do on dental care.
Marketing trumps our one-on-one education every time
if we do not invest the time in doing it. We owe it to our
patients to help them want what we know they need.
Patients’ freedom to choose someone they trust and
not just the least expensive provider and co-payments
should be the rule and not the exception. When insurance
companies supported by employers create economic
penalties for choosing trust over cost, it is not fair. If a
crown is a crown is a crown, and if all dental practices and
teams were the same, it would be fine, but they are not.
Trust is part of the equation in the individualized delivery
of custom-manufactured restorations, solutions and oral
health care. Patients deserve choice.
So What Can We Do?
Sometimes how we look at the problem is the problem.
I believe that is the case with dental insurance. If we
want to heal, we cannot continue our strong reliance on
dental insurance. If we do, it can become a crutch that
limits our capabilities and cripples us. Chasing the easy
$1,200 case acceptance in lieu of creating an environment
where patient education is foremost and informed choice
as the norm would be a flawed model. We can keep insurance
in place if desired as the maintenance system it truly
is, but we need our financial treatment reward structure
and systems to support what is best for the patient, not
reward managing costs. Profits will come when we do
what is best for the patient at fair fees.
Close your eyes and picture a dental world where your
practice was free of these limitations. You could focus on
patients and develop relationships that serve the mutual
best interest. Your patients would be free to choose what
they want done based on your education for them, their economic ability and the perceived value. Dental insurance
would cover some maintenance costs and care, but not be
perceived as the all-healing entitlement plan providing
comprehensive care. Patients would have to learn to be
more responsible for that or the premium/reimbursement
structure would have to actually be adjusted for 40-plus
years of inflation!
I would not recommend dropping insurance because
it only covers $1,200 or creates an entitlement mentality.
I would recommend that we take back the relationship
as trusted caregivers. Stand up and be the voice for complete
education for our patients regarding dental care.
That might just include explaining how dental insurance
works, how it doesn’t and how it has not evolved during
the last 40-plus years. Being our patients’ oral health
advocates is more than just doing good dentistry. It is
also about helping them value good dental care. We have
to market the value of individualized comprehensive and
appropriate optimal dental health… not just sell crowns
This evolution, no let me say de-evolution, has
occurred slowly on our watch (dentists, patients and
employers). If we are to accept a leadership role in our profession
and seek a preferred future for our relationship with
dental insurance, we will have to stand up and be the voice
for what is fair and right. It will not be easy, or quick. It will
involve having real conversations with our colleagues, our
teams and our patients. We will have to change behaviors.
It will require us to shift the paradigm. Be the voice for
change... one patient at a time.