Managed Care in Dentistry!!!

[Deciduous Teeth]

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I read somewhere that managed care might be affecting the dental profession in the future. They say it could because a lot more dentists are practicing part time, and more females are practicing........who take time off to have children. So they are saying the managed care companies could come in and offer their own rates for everything to make life easier for those 2 groups....and thus there goes the idea of running your own dental practice!!I personally hope that managed care doesn't affect the dental profession. What do you all think?

 

[dentalman]

Yeah, I read that in Barron's guide to Medical and Dental schools today... not a very reputable source. (It brought back memories of applying.)

 

[klfb80]

troll

 

[12YearOldKid]

troll

Just because somebody says something you don't want to hear doesn't make them a troll. Managed care in dentistry is a serious issue in many areas today. Yes, dentistry has been lucky enough to avoid the total beating that medicine has taken, but it is still a problem that needs to be actively addressed.

 

[Hardbody]

Just because somebody says something you don't want to hear doesn't make them a troll. Managed care in dentistry is a serious issue in many areas today. Yes, dentistry has been lucky enough to avoid the total beating that medicine has taken, but it is still a problem that needs to be actively addressed.

In what way is the lack of managed care in dentistry a "a problem that needs to be actively addressed".

 

[Frank Cavitation]

What is the way to fight off insurance companies? Banding together, showing solidarity against stable-income plans?

 

[toofache32]

I heard that dentists will soon be replaced by denturists.

 

[12YearOldKid]

In what way is the lack of managed care in dentistry a "a problem that needs to be actively addressed".

In the field of dentistry we like to congratulate ourselves and give pats on the back for keeping the insurance companies from raping us the way they have done to MDs. We have been very lucky in that area, but if you think that means dentistry is free from third party interference in the patient-doctor relationship you are deluding yourself.

Managed care is possibly the worst of offenders and it is not going away anytime soon. Why? Because some people have found ways to make it pay - almost always at the expense of the patient and new dentists. The participating companies are expanding at an increasing rate. I would be surprised if your school and mailbox aren't blanketed with flyers from these companies promising huge salaries, gold plated handpieces, and supermodel assistants - none of which they actually deliver.

 

[groundhog]

The way to beat this is to be proactive. So, OK let me start off with some ideas that can be debated here.

1: Dentists must remain united on this issue but not to the point of being obstructionists.

2: Promote the idea of mandatory PGY's nation wide for state licensure to practice dentistry. The PGY curriculum would primarily consist of treating the so called "underserved populations." This would give the dental community great influence with state legislatures.

3: All dentists (GP's and specilaists) ban together and develop a national evidence based mimimum standard of treatment for all patients from cradle to grave. All dentitsts would agree to offer and abide by the minimum plan for all patients seen. Treatments that are above and beyond the minimum standard of treatment would be left to the individual practitioners to offer as they desired. This would cut out the "managed care" middle men who profit by driving economic wedges between health care providers.

 

[Typo]

troll

troll

 

[Hardbody]

What is the way to fight off insurance companies? Banding together, showing solidarity against stable-income plans?

Yes, I am proud of the my the profession I am aspiring to join.

 

[Hardbody]

The way to beat this is to be proactive. So, OK let me start off with some ideas that can be debated here.

1: Dentists must remain united on this issue but not to the point of being obstructionists.

2: Promote the idea of mandatory PGY's nation wide for state licensure to practice dentistry. The PGY curriculum would primarily consist of treating the so called "underserved populations." This would give the dental community great influence with state legislatures.

3: All dentists (GP's and specilaists) ban together and develop a national evidence based mimimum standard of treatment for all patients from cradle to grave. All dentitsts would agree to offer and abide by the minimum plan for all patients seen. Treatments that are above and beyond the minimum standard of treatment would be left to the individual practitioners to offer as they desired. This would cut out the "managed care" middle men who profit by driving economic wedges between health care providers.

Yes, hopefully the ADA will organize something similar to your proposed plan in the near future in your point #3

 

[12YearOldKid]

3: All dentists (GP's and specilaists) ban together and develop a national evidence based mimimum standard of treatment for all patients from cradle to grave. All dentitsts would agree to offer and abide by the minimum plan for all patients seen. Treatments that are above and beyond the minimum standard of treatment would be left to the individual practitioners to offer as they desired. This would cut out the "managed care" middle men who profit by driving economic wedges between health care providers.

I can get behind all of your points except this one. The ADA has been asked multiple times to define basic standards of care; they have wisely declined. Appropriate care is left up to the judgement of the practitioner as it should be.

On one hand, a definite "standard of care" would quickly become a legal cudgel used by lawyers to beat dentists over the head in court.

On the other hand, a legally defined standard of care would immediately become the "proof" that insurance companies need to deny any treatment beyond the bare minimum of acceptability.

This would leave dentists trying to provide care in the impossibly small area between undertreatment as defined by lawyers and overtreatment as defined by inscos. I see very little good coming from that.

 

[klfb80]

troll

Not even close. Your the troll, TROLL!

 

[aphistis]

troll

troll,

TROLL!

troll

Knock it off, guys. 🙄

 

[12YearOldKid]

Knock it off, guys. 🙄

troll

 

[12YearOldKid]

 

[DrJeff]

I can get behind all of your points except this one. The ADA has been asked multiple times to define basic standards of care; they have wisely declined. Appropriate care is left up to the judgement of the practitioner as it should be.

On one hand, a definite "standard of care" would quickly become a legal cudgel used by lawyers to beat dentists over the head in court.

On the other hand, a legally defined standard of care would immediately become the "proof" that insurance companies need to deny any treatment beyond the bare minimum of acceptability.

This would leave dentists trying to provide care in the impossibly small area between undertreatment as defined by lawyers and overtreatment as defined by inscos. I see very little good coming from that.

The ADA is currently exploring the idea of creating two distinct "intermediate" dental caregivers to help address the acces to care issues in underserved populations. The first one is what's being termed a DHAT (Dental Health Aid Therapist), this person would essentially be a cheerleader for oral health preventative education, and then also be able to place sealants and using hand instruments, excavative most (if not all) decay and restore the tooth with glass ionomer. 🙄 This concept is based on a program currently implemented in New Zealand with some success.

The second one is whats called and EFDA(Expaned Function Dental Assistant) this concept is currently in existance in many individual states based on each states own indivdual regualtions. In the most "progessive" states, assistants can place selants AND RESTORATIONS 😱 (can't prep the teeth though) and polish teeth and deliver fluoride tx(basically do prophies)

The last part of the equation that is trying to come into play in many states is the hygienists. A few of the "militant factions" of hygenists want to basically be able to do most everything that a dentist can do(including tooth prperation, pulpotomies, and "simple extractions" ) all with basically a few more months of didactic education and clinical evaluations before essentially practicing on their own.

In general though with the managed care issue, as a whole dentistry is flying under the main stream gov't radar since compared to medicine it's such as small piece of the healthcare pie. Basically though, WHEN dental insurabce companies come knocking at your door and ask you to sign up for their DMO's because of "all the patients" they'll give you. Just say no. It's simple, if their aren't any (or very few) dentists as signed up providers, then the employees of the company that enrolled with the DMO hears its employees incessantly griping that their aren't any dentists "on their plan", the inurance company can't provide, and the DMO dies 👍 The longer your out in practice, the more you'll come to realize that insurance companies are more trouble than their worth with alot of hassles both for you as the dentist and your patients. There is a reason why more and more dentists aren't participating providers for insurance plans.

 

[aphistis]

I can get behind all of your points except this one. The ADA has been asked multiple times to define basic standards of care; they have wisely declined. Appropriate care is left up to the judgement of the practitioner as it should be.

On one hand, a definite "standard of care" would quickly become a legal cudgel used by lawyers to beat dentists over the head in court.

On the other hand, a legally defined standard of care would immediately become the "proof" that insurance companies need to deny any treatment beyond the bare minimum of acceptability.

This would leave dentists trying to provide care in the impossibly small area between undertreatment as defined by lawyers and overtreatment as defined by inscos. I see very little good coming from that.

Great post. 👍

Troll. 😛

 

[groundhog]

Dr. Jeff and 12YearOldKid make good points. It is all about uniting, but I think the profession will need something to unite around. Two ideas.

1: Have the ADA form a nonprofit "provider plan" to compete against the outside dental insurance companies. A few good actuaries employed by the plan should be able to devise various apple to apple plans (basic to comprehensive) that would more fairly treat providers and enrollees alike than those plans which are now offered by the insurance companies. Such a plan could keep administrative costs low by building on the trust already established between the ADA and practicing dentists. Imagine if a dentist could electronically bill the "provider plan" up to the amount alloted for a covered procedure and the dentist would electronically receive reimbursement from the plan for said procedure no later than the next business day. No questions asked, no second guessing, no money floating games etc. Patient based random audits (did you receive said procedure on said day?) should suffice to discourage most of the rare few who might be tempted to scam the system because if you do cheat and get caught you,ll be up for fraud, reported to the dental licensing board, and barred from the plan.
2: A repeat of my suggestion that the dental community actively promote mandatory nation wide PGY's as a condition for licensure to practice dentistry. Again, as stated before, the PGY curriculum would mainly consist of treating the underserved. Yeah, it will result in a year or two of lowered life time income, but I see this as an adaptation of the old addage "if you are being ran out of town get out front and make it a parade." The future is all conjecture, but I believe the things that Dr Jeff mentions (DHAT's, EFDA's solo RDH's ) will only be defused if the licensed dentist community gets behind a viable alternative to such ideas.

 

[QCkid]

Dr. Jeff and 12YearOldKid make good points. It is all about uniting, but I think the profession will need something to unite around. Two ideas.

1: Have the ADA form a nonprofit "provider plan" to compete against the outside dental insurance companies. A few good actuaries employed by the plan should be able to devise various apple to apple plans (basic to comprehensive) that would more fairly treat providers and enrollees alike than those plans which are now offered by the insurance companies. Such a plan could keep administrative costs low by building on the trust already established between the ADA and practicing dentists. Imagine if a dentist could electronically bill the "provider plan" up to the amount alloted for a covered procedure and the dentist would electronically receive reimbursement from the plan for said procedure no later than the next business day. No questions asked, no second guessing, no money floating games etc. Patient based random audits (did you receive said procedure on said day?) should suffice to discourage most of the rare few who might be tempted to scam the system because if you do cheat and get caught you,ll be up for fraud, reported to the dental licensing board, and barred from the plan.
2: A repeat of my suggestion that the dental community actively promote mandatory nation wide PGY's as a condition for licensure to practice dentistry. Again, as stated before, the PGY curriculum would mainly consist of treating the underserved. Yeah, it will result in a year or two of lowered life time income, but I see this as an adaptation of the old addage "if you are being ran out of town get out front and make it a parade." The future is all conjecture, but I believe the things that Dr Jeff mentions (DHAT's, EFDA's solo RDH's ) will only be defused if the licensed dentist community gets behind a viable alternative to such ideas.

I like the ideas mentioned above and I don't disagree with them. What I'm wondering about, Dr. Jeff, is what access to care issues are you talking about? I personally don't agree with the whole access to care argument and I think that this is basically a political smoke and mirrors show created by certain individuals to further their own personal agendas. I'm not saying that their aren't some areas that lack dentists (like the Navajo reservation or in certain Eskimo communities in Alaska), but how does the ADA and practically every dental school in the country justify opening up all of these new schools while increasing class sizes at preexisting schools? I don't think that their is any concrete proof af a nationwide problem with access to care (I think that their are some localized areas but the way that its being taken care of will have the net affect of doing nothing to help the access to care issues in those areas). When I see the dog and pony act put on by most schools about access to care, they are usually quoting all of these trends that involve some future predictions about what might be. Its basically a politcal bandwagon that a bunch of people have jumped on to further their own cause and the rest of us just sit back and let it happen because we assume that someone, somewhere must know what their doing.

 

[groundhog]

You are right. And I don't think Dr Jeff would disagree with you. He just pointed out some of the political realities of the present situation regarding the so called "underserved population" issue. If you want the public to back your decision to go to war in Iraq you don't say "our long term economic well being is at risk" you say "they have the capability and intention to drop the nuke on us." Likewise, if you want the public to back your desire to hold lesser credentials and still do what dentists do you don't say "we want to grab some of that lucrative market for ourselves" you say "dentists show little capacity and intent to treat a significant portion of the population." Hence my position that the ADA needs to very assertive and proactive regarding this matter before the political battle is lost.

 

[DrJeff]

You are right. And I don't think Dr Jeff would disagree with you. He just pointed out some of the political realities of the present situation regarding the so called "underserved population" issue. If you want the public to back your decision to go to war in Iraq you don't say "our long term economic well being is at risk" you say "they have the capability and intention to drop the nuke on us." Likewise, if you want the public to back your desire to hold lesser credentials and still do what dentists do you don't say "we want to grab some of that lucrative market for ourselves" you say "dentists show little capacity and intent to treat a significant portion of the population." Hence my position that the ADA needs to very assertive and proactive regarding this matter before the political battle is lost.

Exactly, what's going on in my home state (Connecticut) is they're roughly 300,000 children aged 12 and under enrolled in the states medicaid plan, and less than 50 dentists enrolled as a medicaid provider(of course the fact that the states medicaid plan only re-imburses dentists at roughly 25 cents on the dollar isn't an issue to politicians 🙄 The bigger problem though, and one that many politicians have is that they think that if they just blindly throw $$ at the problem that it will go away. Not the case, atleast in my home state. Here's why atleast in my state it won't work. First off, even if the state decides to increase the re-imbursement rate to say 70% of the usual fees, there are still 300,000 mouths to potentially treat (hey only basically 50% of the general population sees the dentist on a regulat basis), and only about 1,500 general dentists/pedodontists in my state to see those patients. Now the second issue with the access to care problem, and I'm not that much different than many of my fellow CT dental colleagues on this. I'm booked up solid for roughly 6 weeks with all of my "regular" full fee patients, so now your asking folks to try an find space to fit in potentially 200 more patients into my already full schedule 😕 Then, as I'm sure mnay folks in d-school have seen, the medicaid patient often has a higher no show rate. So now your asking the general dentist to see patients for less money who often no-show at a higher rate, and thus actually decrease your ability to take care of all your patients in a timely manor 😕

The wild card is the state legislatures, since they can with one wild and wacky addendum to most any bill attach a cluase that would make your license contingent upon treating X number of medicaid patients a year 😱 And since we as dentist are perceived by the public (an often rightly so 😉 ) as rich folks, the thought of negative press via print or media about acces to care could be a potential issue. We'll have to see how this plays out in the years to come, but it is a potentially BIG issue that we'll all have to deal with!

 

[TKD]

Agree with the mandatory PGY training. Treat underserved, improve skills, and pathway to licensure through regional board exams gets thrown out the window.

Access to care is a real issue in several parts of the country. fact of the matter is new grads want to stay and saturate the cities. personally, i would go rural if the reimbursements were reasonable, loan repayment, etc. I really think that's the solution. instead of building new dental schools, proposing some new dental auxiliary, etc. just make the right package, and young dentists will relocate. case in point, i know of 2 female dental graduates with kids, who both signed on for an associate position in rural PA. was a good package - 3.5 day weeks, paid vacation, loan repayment, etc.
Another good idea (i think I may have gotten the link from SDN) - some underserved areas have reserved a seat or two at the state dental school for someone from a specific area, who will return - sure, the dentist loses the option to relocate, but a good option for those who are set on returning home.

ADA should strongly come out against anyone other than dentists performing dentistry. Two-tiered system will have devastating results. I've seen so much bombed out decay under improperly placed sealants (by hygienists) it's ridiculous. we'll just be stuck with cleaning up their mess, more emergencies. don't get me wrong, hygienists and assistants are great at what they are trained to do. but if they want to do dentistry, go to dental school.

 

[Dr. Pedo]

The ADA is currently exploring the idea of creating two distinct "intermediate" dental caregivers to help address the acces to care issues in underserved populations. The first one is what's being termed a DHAT (Dental Health Aid Therapist), this person would essentially be a cheerleader for oral health preventative education, and then also be able to place sealants and using hand instruments, excavative most (if not all) decay and restore the tooth with glass ionomer. 🙄

Dr. Jeff 😱

You couldn't be further from the truth! 😕 The ADA is not exploring the idea of creating DHATs or Exp. Funct. RDHs. They are in the process of DESTROYING the DHATs. They have been fighting the concept since their beginnings in Alaska. They have recently filed a lawsuit against Alaska and the DHATs for allowing people to practice dentistry without a license! The expanded function hygienist is a concept that the hygienist have offered to the gov. to help with access to care and is nothing but a thorn in the ADA's butt. RDHs have recently sent a bill to congress and a new curriculum for a masters degree program for the expanded functions. Hey here's an idea: you want to do dentistry go to dental school like the rest of us! Bottom-line is they won't survive. Especially if they go to an area of need------the complexity of the disease in those areas will be way over their skill level. And the law-suit happy society would prey on their incompetence.
The ADA realizes there is an access to care issue----but they aren't exploring solving it with anyone but license dentists-------------------------yet.

http://www.ada.org/prof/resources/pubs/adanews/adanewsarticle.asp?articleid=1771

I may have missed some literature on the subject but not much---let me know if I'm misunderstanding something.

 

[DrJeff]

Since that article was published in January, things in Chicago have been changing. My business partner is on the ADA committee concerning access to care and goes to Chicago every 6 to 8 weeks for a weekend of meetings on this subject, so I hear ALOT on this subject in my office. And while the exact acronym is still being debated, the concept of an expanded function assistant/hygenist/dental therapist is alive and well. The concept may not go over well with everyone, but the ADA is looking at this as a chance to be proactive both from the political side to hopefully appease some legislatures before they decide to implement some legislation, and from the patient care side where the ADA would have a greater control over how this potential intermediate level dental care provider is trained/credentialled.

 

[TKD]

Since that article was published in January, things in Chicago have been changing. My business partner is on the ADA committee concerning access to care and goes to Chicago every 6 to 8 weeks for a weekend of meetings on this subject, so I hear ALOT on this subject in my office. And while the exact acronym is still being debated, the concept of an expanded function assistant/hygenist/dental therapist is alive and well. The concept may not go over well with everyone, but the ADA is looking at this as a chance to be proactive both from the political side to hopefully appease some legislatures before they decide to implement some legislation, and from the patient care side where the ADA would have a greater control over how this potential intermediate level dental care provider is trained/credentialled.

I guess that means we have to be vocal with the ADA and local politicians.

 

[TKD]

And the law-suit happy society would prey on their incompetence.

That hasn't stopped other mid-professionals. See optometrists in some states having their domain expanded waaay beyond their training. same thing with psychologists. the list goes on. i have friends in opthalmology and psychiatry so i gotta listen to their gripes almost weekly!

 

[Dr. Pedo]

That hasn't stopped other mid-professionals. See optometrists in some states having their domain expanded waaay beyond their training. same thing with psychologists. the list goes on. i have friends in opthalmology and psychiatry so i gotta listen to their gripes almost weekly!

However, expansion of mid-level providers rarely consist of them doing irreversible procedures requiring a surgical degree. And those optometrists doing some procedures have a minimum of a doctorate. Not looking for a pissing match with you----it's not the point.

 

[Dr. Pedo]

Since that article was published in January, things in Chicago have been changing. My business partner is on the ADA committee concerning access to care and goes to Chicago every 6 to 8 weeks for a weekend of meetings on this subject, so I hear ALOT on this subject in my office. And while the exact acronym is still being debated, the concept of an expanded function assistant/hygenist/dental therapist is alive and well. The concept may not go over well with everyone, but the ADA is looking at this as a chance to be proactive both from the political side to hopefully appease some legislatures before they decide to implement some legislation, and from the patient care side where the ADA would have a greater control over how this potential intermediate level dental care provider is trained/credentialled.

Hey Dr. Jeff,

I do agree a lot is changing. Main point was for our young students (SDN) to realize their organization is not standing for incompetent trained personnel performing dentistry.

I trust you're not suggesting the ADA is supporting or exploring the option of a mid-level providers doing irreversible procedures. That's plain ridiculous. You are absolutely right when you stated that the ADA is trying to be proactive and letting the legislation know our stance: They sued Alaska for allowing mid-level providers to perform irreversible procedures. Can't get more proactive than that. Point is: It would be political suicide and the end of organized dentistry as we know it to support or recommend such a provider. They are however promoting a different kind of mid-level provider and here is their document to legislation and Alaska:
http://www.ada.org/prof/advocacy/legal/alaska/media_proposal.pdf

We are in a crisis due to access to care. If we can't figure it out someone will (gov., RDHs, reservations, etc...) but it won't be a mid-level provider doing irreversible procedures supported or recommended by the ADA. Enron was able to fool everyone----so maybe you have insider knowledge---but it would look pretty funny to sue and than support that very notion. 😉

 

[DrJeff]

I guess that means we have to be vocal with the ADA and local politicians.

Whether you realize it or not the ADA, and most likely the state society of your state, if not even the component society in your area have put in place the groundwork to give dentistry an organized view on this topic.

Often one of the most basic ways to help keep the best interests of dentistry where we want them on a poltical front will involve you writing out a check to your local/state dental PAC (political action committee), who employs lobbyists to "get our dental voice" out to politicians. If you get involved with organized dentistry, even on a component society, you'd be amazed at how easy it is to get one of your local state legislators out to speak at one of your meetings(politicians generally like to speak to a group of folks who are perceived as affluent since we're more likely to give them campaign contributions) 😀

 

[Demeter]

2: Promote the idea of mandatory PGY's nation wide for state licensure to practice dentistry. The PGY curriculum would primarily consist of treating the so called "underserved populations." This would give the dental community great influence with state legislatures.

I do not agree with the idea of mandatory PGY's.
Currently the requirements for an AEGD are extremely simple i.e you need to complete 2 of every basic dental procedure. 2 crowns, 2 bridges, 2 quads SCRP, two 3rd molar ext's, 2 perio surgeries, 2 post endo, 2 ant endo, 2 treatment plan cases.
These requirements are ridiculous.

Unfortunately, there are several AEGD's that are exploiting young dental graduates as a cheap labor source. AEGD's that should be closed down will now find an ample source of applicants because NY now requires a mandatory PGY. At my AEGD I saw the previous resident waste 10 months plugging in amalgams and completing simple exts's basically taking over a large population of the medicaid patients. During the last 2 months he was encouraged to complete his requirements.
Creating a nationwide PGY requirement will only make this situation worse.
It is very upsetting to go through 20+ years of education only to be taken advantage of. Have you ever been put on an amalgam assembly line for 15$ and hour with a DDS on your title?
I think the ADA needs to set some real guidelines to ensure that PGY residents are receiving a high level of training. Programs that are flooded with complaints from residents and on paper are not showing that advanced procedures are being completed need be shut down.

 

[TKD]

However, expansion of mid-level providers rarely consist of them doing irreversible procedures requiring a surgical degree. And those optometrists doing some procedures have a minimum of a doctorate. Not looking for a pissing match with you----it's not the point.

whoa there ...no pissing match here at all! (now if you talk to my old roommate -opthalmology resident he'd love to get into a pissing match about how optometrists are not trained nearly enough to perform procedures they are lobbying for -in some states succesfully) but we'll agree to disagree on that point. just saying, common sense says anyone other than a dentist should not be doing irreveresible, etc. (like i said earlier, having seen so many bombed out sealants, they shouldn't be doing even those), would sure open up lawsuits, BUT politicians and licensing boards don't always use common sense, and don't make decisions thinking about potential lawsuits. it's a tough fight because employing a expanded function whatever is cheaper than a dentist and that's what they often look for.

Still stand by the PGY idea. sure, some AEGDs and GPRs suck. so they shouldn't be accredited, ya shut em down. the concept of mandatory PGY is something i agree fully with. of course, they should be ADVANCED general dentistry, not amalgam line ups.

alot of good points on here. will follow up DrJeff's advice. same ol story, if the profession is united and puts their money where there mouth is...

 

[toofache32]

...Unfortunately, there are several AEGD's that are exploiting young dental graduates as a cheap labor source....Have you ever been put on an amalgam assembly line for 15$ an hour ....

This is no different from the medical residencies. In fact, they're worse.