Thinking Straight IV: Throw Them a Bone

Published on Jul 29 by Daniel Guidera under Dentistry

At a recent dental convention I was looking at the program and noticed a lecture being given on current topics called “managed care dental insurance”. I never go to these lectures. I’ve always figured, and so far it’s worked, that there were enough smart consumers out there that if I focused on being knowledgeable, skillful, and honest that would be enough. Nevertheless, I went.

When you go to these lectures and look up front you often see a couple of people who look official, but you can usually pick out which one is the speaker. As I watched the guy I picked out (and I was right), I somehow imagined him wearing a Darth Vader outfit. As I thought about all the “garbage – crap – lying – etc” I was about to hear, I nearly got up and left. I’m glad I didn’t.

The speaker was a high ranking insurance executive and a dentist with good training. It appeared that he had spent time in private practice which is good for his perspective. Practicing in some environments that are insurance heavy oriented for survival, can tweak a professional’s thinking. Nevertheless, he clearly knew dentistry. He also knew the insurance business. I don’t know if he had integrity. I do know he had a product to sell, “dental insurance.”

What is Good Dental Insurance?

As I listened to him, I realized that dental insurance companies and I have something in common. I’m squeezed between dental insurance company’s allowances and what patient’s want from me. Insurance companies are squeezed between what employers are willing to pay for insurance premiums and what subscribers want insurance companies to cover. Additionally, as I listened, it was clear that layered over all this is the occasional dentist who lies or exaggerates on their claims to get more compensation and many patients who are completely clueless with regard to their insurance coverage. Don’t worry, I figured it out.

In order to explain what’s going on I need to digress for a moment. I don’t know much about medical insurance but what I do know is that without it a major medical catastrophe can bankrupt you. My mother spent her last 6 days in a cardiac ICU. The bill was over two hundred thousand dollars and that was in 2004. That’s not dentistry. Major dental problems treated honestly, rarely can bankrupt someone. If it did nobody would be buying 10 year old used cars.

In our culture many people think that without insurance they’re in a dental wasteland. Many people also believe that if they have a job they’re pretty much entitled to dental insurance and it should take care of all their needs without costing them anything. Employers or in some cases unions, want to save money on premiums. So what happens? They throw employees a bone. Here, here’s your dental insurance. That’s o.k. but what you have to understand is it’s just a bone. There’s little or no meat on it. It represents a benefit. It usually offers something tangible but often confuses and misleads people. That’s why I often tell patients that no insurance is better than bad insurance.

What is good insurance? It’s anything that has a cost-benefit in your favor as long as you don’t get fooled into thinking it will always take care of everything.

Describing bad insurance is a difficult blog to write because there are many things that come into play. I thought of writing multiple blogs but many factors are interrelated. I’ll give this a try since the overall message in this series is “thinking straight.” I’d like to start with two stories.

When I was a young dentist, I practiced with two older partners in a group. One day a prospective patient called and asked what kind of car the senior partner drove. An odd question but this person thought they had a clever way of finding out if the partner was too expensive. This dentist wasn’t into fancy cars. He drove a 1968 Ford Galaxy 500 and this was 1982. The patient scheduled. What he didn’t know was that the partner was into flying and owned both a hanger and an airplane at a local airport. The patient got lucky because the dentist was reputable but it was a clever choice. This goes back to my intro blog. When your outside the dental industry and you think ** you know how to make choices, you risk being a fool.

Listen to Your Wife

Photo: psyberartist

We bought a new house thirteen years ago with no landscaping in the back-yard. When you buy a house one thing you rarely know ahead of time is what kind of soil you have. I soon found out that soil was too generous a term, I had rock and clay.

I went to Home Depot and bought a $9 shovel. Within a few weeks I broke it. My wife knew all this and said nothing. I went back to Home Depot and bought another $9 shovel. In another few weeks, I broke it. At this point my wife said in no uncertain terms “would you please go down and spend the money for a good shovel!” I went back to Home Depot, bought a $24 shovel and went back to work. If you saw my backyard you would see that landscaping this thing was no small job. It’s thirteen years later, I still have the shovel.

Now the first lesson here is obvious. “Men, listen to your wife.” The second lesson is that you tend to get what you pay for. It’s not always true but it’s a general rule. An exception could be if the merchant was greedy and/or dishonest. However, I would suspect that merchants who charge less are just as capable of being greedy and dishonest as those who charge more. In fact, I would say that those who charge less can be under more pressure to be dishonest because of the pressure to make ends meet.

Here’s how this plays out in dentistry:

You don’t save money if you pay for something you don’t need. I can’t tell you how many times people have come to me with insurance that works out of network in my office or doesn’t work at all. They have an estimate for a procedure they think they need. When I get done getting rid of the tooth cleanings they don’t need, the post that’s unnecessary, the special crown that isn’t special, the gum treatment that’s not indicated, the medications that have pseudoscientific justification, or worst of all the procedure doesn’t even need to be done, the patients cost is sometimes the same, sometimes slightly more, and can be dramatically less in my office. You might say this is just a matter of judgment. I would respond that I can’t make a living telling people they don’t need things they need.
I like government regulations. It protects consumers and creates a level playing field. I sincerely wish this was true. I like to play by the rules. Unfortunately there’s more to it than that. Following the rules usually cost money. There are more regulations than the government can or is willing to enforce. Those that don’t follow the rules have a competitive price edge. They do run the risk of being caught but if they do others will take their place. This is not unique to dentistry. Ask roofing or painting contractors. I could get specific in dentistry but suffice to say it often comes out in office cleanliness and employee-employer regulations.
After market products and offshore lab work are not rare. On the information sent out by a medium sized dental lab in Orange County I saw in bold print “All of our lab work is done in the United States of America.” We have great labs in the USA. I thought, do dentists really send work offshore? Guess I was naive.My son-in-law works for a major dental supply house. He has told me about the preponderance of gray market dental products.
A while back, I was talking to a dentist in a social situation. He was telling me that sometimes he has to tell patients there will be an extra charge beyond the contracted insurance fee because he can’t afford to do the procedure at this cost. The patients usually accept this. Some of the patients are there because he’s on a list of contracted dentists. He’s breaking the law and could get in trouble but I applaud him for being honest with patients.
Advertising in dentistry can easily be a bait and switch. I described in a previous blog a sign for cleaning, exam, and, x-rays for $29. The small print said cleaning is for those without periodontal disease. This ad may be an honest willingness to take a loss in order to draw in legitimate business. What I’ve seen often is that patients end up being told they need deep cleanings when they don’t. It can be an important and effective treatment but is often over used because unlike basic cleanings it has a significant profit margin.
This point is similar to the first point but with a twist. You don’t save money if you clearly get treatment you don’t need. A patient was told they needed an extraction. The general dentist referred the patient to an oral surgeon. This could be good. The dentist may not do extractions or felt it was out of his league. On the other hand the dentist may have referred it because his contracted compensation for the extraction was less than he was willing to accept. The patient goes to the oral surgeon who says that in addition to the cost of the extraction there will be a $300 fee for sedation. The patient said he didn’t want the sedation. The oral surgeon said he had to have the sedation. The patient said he didn’t want the sedation. The oral surgeon said he wouldn’t take the tooth out without the sedation. The patient left with his tooth in place. Now this could be good. The oral surgeon out of concern for everybody, the patient, the staff, and himself, may have known that this would be a stressful extraction and best done under sedation. On the other hand the surgeon’s insurance compensation for the extraction may have been so low that he felt the need to augment his income.

I know these examples seem quiet negative toward the dental provider community. What I hope you get from this is that you need to understand the possibilities. On the positive side, there are some great dental practitioners out there, our modern dental materials are fantastic and you have access to both.

You just need to make sure your thinking straight.