... is in the eye of the beholder. Either it`s on target, encouraging more Americans to become patients, or it`s way off target, leading to a
resurgence of fee-for-service dentistry (and fewer patients). What does managed care really mean to the dental community and its patients?
Tammy Bergmann, RDH
American families typically receive dental treatment from the "family dentist," because "he is the dentist we have always gone to." Routine dental care is sought out because of personal or family values, or the benefit of having dental insurance through an employer. A dentist is usually chosen upon recommendation from friends, family, or co-workers. A person might also seek out a dentist because he is in pain and refer to the Yellow Pages to find a dentist for immediate treatment, as well as a convenient location. The quality of the dentistry is rarely questioned. "You`re the doctor" is a common expression of faith in the services recommended. When quality is questioned, it is due to personality differences. Even in the case of blatant malpractice or poor treatment, the dentist`s hands are slapped by the governing board, and then it`s back to business as usual.
Managed care programs, however, are rapidly changing "traditional" dentistry as we know it. Managed care is a broad term that refers to plans that control costs by restricting the type and frequency of treatment, where treatment may be obtained, and controlling the level of reimbursement for treatment. The National Association of Dental Plans (NADP) reports that enrollment in DHMOs and PPOs is steadily increasing. A recent study indicates 147 million people were enrolled in dental benefit programs at the end of 1998, which was 3 percent higher than the 1997 statistics. Factors contributing to increased enrollment are lower out-of-pocket costs and predictable co-payments for patients.
Another trend as reported by Managed Dental Care (an independent business newsletter) is the movement away from traditional solo practices and toward large group practices. "Managed care`s emphasis on cost savings and efficiency, in combination with the high costs of starting up a solo practice, creates a favorable environment for group practice models, which will reduce overhead through space sharing and centralized administration."
Pros and cons
Managed care in dentistry has caused concern for both healthcare providers and consumers. Managed care was organized to help control the rising cost of health care, but has been met with opposition. Critics say that cost containment incentives may result in undertreatment or lowered quality of dental care. Consumers are concerned with the possibility of undertreatment and loss of control and choice of health care provider.
The American Dental Association (ADA) supports fee-for-service dentistry over managed dental care, worrying that managed care organizations give the patient a reduced fee at the dentist`s expense. Some dentists feel there will be a decrease in the quality of service or that the plan may exert too much control over acceptable treatment modalities.
The adjustment to managed care may be the most difficult for dentists who have been practicing for many years, especially those with traditional solo practices. As a profession, dentistry has been attractive primarily because of the autonomy or ability to practice on your own, set your own hours, and be your own boss. This aspect creates resistance to the philosophy of managed care.
Graduating dentists probably have an easier time adjusting because they haven`t practiced the philosophy of fee-for-service in a solo practice. An established group practice is attractive to new dentists. Within a group practice, the start-up costs are avoided, as well as the increased competition for patients. The group practice enables the new dentist to start providing treatment and earn a salary right away. Managed care can also provide a way to get new patients and establish a practice.
The American Dental Hygienists` Association supports managed care in dentistry. Since dental hygienists are prevention oriented, many hygienists see managed care as an opportunity to improve access to preventive oral health care. An article in Access, for example, stated, "With dental hygiene roots embedded in primary care and prevention, hygienists are a natural fit in the scheme of managed care because they are professionals who provide cost effective, quality oral care."
Managed care organizations can expand career choices and opportunities to dental hygienists. They will likely be able to practice in alternative settings if appropriate changes are made in state licensing laws. Managed care shows promise of encouraging progress within several states to allow hygienists to provide preventive oral health services outside of the dental office, thereby increasing access to care. Hygienists can move beyond just clinical hygiene practice into management, quality assurance, or utilization review positions, among other possibilities. The ADHA position paper on managed care states, "Managed care will enable dental hygienists to practice to the full extent of their experience, education, and expertise."
Managed care can also offer increased flexibility and benefits to hygienists. Many of these larger organizations provide benefits such as vacation and sick days, 401(k) and pension plans, health and life insurance, tuition reimbursement, and job stability. Salaries may be lower in these organizations, but many hygienists feel the benefits make up for it.
Another benefit for hygienists is that there is more accountability in management. In the corporate environment, the dental personnel, including the dentist, work as a team. A dentists is considered a colleague instead of the "boss."
Some disadvantages to hygienists in a managed care setting is that there may be an increase in pressure on hygienists to provide services in less time in order to be cost effective. Also, many organizations have longer workdays and require working some weekends.
The effect of managed care on the public has many advantages, including reducing the expense of oral health care. It can increase access to preventive services. More time is also spent on preventive aspects in order to reduce the amount of restorative dentistry required. Managed care provides access to people who have never been able to afford treatment before. Managed care has also removed some limitations, such as pre-authorizations, so treatment can commence in a more timely manner.
A disadvantage is that some patients may have to change providers if their dentists are not on a PPO list or part of a managed care organization. Employers looking for cost savings may change to a managed care plan that may limit the patient`s access to providers; then the patient has no choice except to change dentists or pay out of pocket.
Ethics and quality
With more managed care dental plans being offered, quality is becoming a criterion when comparing plans - not just the quality of the dentistry, but the quality of service provided as well. In order to measure quality, these organizations have had to implement quality assurance and improvement measures. Some methods to measure quality in a dental facility are reviews of the facility and patient records, credentialing, and utilization review. Statistics are monitored and measured, for example, under utilization review, providing data about the type of care provided. This is used to provide information about practice patterns or trends. Utilization review is used in PPO managed care to monitor for possible overutilization and "creative billing practices." This can also be used to monitor for underutilization of services and timeliness of the care delivered in prepaid managed dental plans. Utilization review provides a means of keeping the entire dental team accountable for treatment.
Ethics play a big role in quality. When managed care programs began, the first thing cut was quality. For example, dental assistants performed rubber-cup polishing in a reduced appointment time and the managed care company was billed for a prophylaxis. By implementing utilization review and quality assurance programs, this type of problem is being reported and resolved. Obviously, this problem existed prior to managed care, so clearly it is an issue of ethics and accountability.
Dentists state a wide variety of philosophies. Many are now practicing cosmetic dentistry only. Many feel they should only present and perform "ideal" treatment to their patients, instead of presenting alternate (perhaps less expensive) treatment plans, giving the patient choices based on need and cost. These ideal treatment plans can vary greatly from one dentist to another and can be very elaborate and expensive.
Even before managed care, treatment could range from blatant neglect, undertreatment, conservative or necessary treatment, to overtreatment. Ultimately, overtreatment leads to more treatment, because the less sound tooth structure there is, the more potential for breakdown. Managed care can provide a way to help standardize quality of care and ensure that services are rendered at the most appropriate level while also avoiding excessive cost.
Dr. Gary Allen, director of clinical support and quality improvement for Denkor Dental Management Corp. in Beaverton, Ore., believes many quality improvement functions are implemented because of requirements from outside organizations. For example, the state mandates requirements for dentists who provide service to Oregon Health Plan patients. Dr. Allen also says managed care companies frequently commit to quality standards that are not required.
But Dr. Allen adds that allegations of undertreatment are common. "My counter is that there is no more incentive for us to undertreat than there is for the traditional, fee-for-service model of dentistry to overtreat." If they were truly under-treating, he says they would just be delaying treatment, which would not be a good business decision.
Denkor`s delivery model emphasizes appropriate care using an evidence-based approach. "We are rewarded for keeping people healthy. That is our professional goal and our financial incentive," Dr. Allen says. The dentists and hygienists employed are educated to provide the appropriate level of treatment.
Denkor`s philosophy of quality is that it is a continuous process. Not only do they engage in quality assurance measures, they also plan and implement quality improvement projects. They generally use evidence-based treatment models for these projects. Dr. Allen said they have enjoyed great success in implementing supportive periodontal therapy for the dental hygiene department. He said this project worked successfully because of good organization and commitment from administration and clinical members of the organization. The committee is now implementing an evidence-based treatment model for caries management. They have nearly completed development of the process and guidelines and are planning to train providers and support staff soon. They are also modifying several chart forms to accommodate the changes.
The progression of managed care can have a positive influence in dentistry. National accreditation of DHMOs by organizations such as the Joint Commission for the Accreditation of Healthcare Organizations and the National Committee on Quality Assurance appears to be on the horizon for dentistry. The establishment of an accrediting body for managed oral healthcare may help standardize the quality of care throughout the profession.
Certainly, there is a niche for traditional dental care and fee-for-service dentistry. A portion of the population desires high quality, OidealO dental care and is willing to pay for it. It all depends on the values and needs of an individual.
Managed care was designed to target a large portion of the population that previously did not have access to care, and to help the population become healthier as a whole. The focus is on keeping the population healthy by preventing illness. Traditional care focuses more on the individual and keeping the patient healthy by treating illnesses, which means that care may be provided at a level higher than the treatment requires. By inquiring and learning, healthcare providers can accept, adapt, and improve to make the most of the continuous change in healthcare.
Tammy Bergmann, RDH, practices in the Eugene/Springfield area in Oregon. She has been a part-time instructor at Lane Community College since 1994. She can be contacted at [email protected].
Y Allen, Gary, Director of Clinical Support and Quality Improvement for Denkor Dental Management Corporation, Beaverton, OR. Personal/telephone interview. Aug. 1999 and Mar. 2000.
Y American Dental Hygienists? Association Position Paper on Managed Care. Access May-June 1996: Special insert.
Y ADHA Position Paper on Managed Care: A Perspective. Access May-June 1997: Special insert.
Y Chandler-Cousins, Lois, OThe Move Toward Managed Care is Opening Doors for Hygiene.O RDH July 1995: 6-8.
Y Harvey, Linda, OWorking in the Managed Care Environment.O Access Mar. 1997: 47-55.
Y Harvey, Linda, OCapitation and the Dental Hygienist.O Access Nov. 1999: 32-37.
Y Limoli, Tom M. and Limoli Jr., Tom M., OManaged Care-Don?t Let Quality Patient Care Slip Away.O RDH Sept. 1995: 13-16.
Y Lyons, Steven and Scott, Bryant L., OAccess Extra-Dental PPO and HMO Enrollment Increases.O Access Aug. 1999: 29.
Y Managed Care: Glossary of Terms. Education Update Fall/Winter 1995: 6-7.
Y Newell, Kathleen J., et al., OComparison of Quality Dental Hygiene Care in a Managed Care, Fee-For-Service and PPO Dental Care Delivery System.O Paper from the University of Minnesota Metro Dental Center. April 1996. http://jeffline.tju.edu/DHNet/papers/dhh/ paper129.html
Y Schmidt, Catherine A., OManaging Managed Care.O RDH May 1998:34-36, 60.
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Y Tekavec, Carol D., OPractice Management for the Practical Hygienist-Answering Patient Questions.O The Journal of Practical Hygiene (Reprint/copy: no volume listed): 20-21.
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Types of managed care plans
Many common terms relate to managed care. The following is a short glossary of terms used in regard to managed care in dentistry:
- Dental Health Maintenance Organization (DHMO) - A prepaid dental health plan run on the HMO model. A DHMO is a type of managed care plan that contracts with dentists to provide comprehensive dental care for a fixed monthly rate to all people enrolled in a plan. Dentists who are providers under a plan must provide all covered services for all enrolled for a set contract fee paid to them by the DHMO.
- Preferred Provider Organization (PPO) - A formal agreement between a purchaser of a dental benefits program and a defined group of dentists for the delivery of dental services at discounted fees to people enrolled in the plan. Enrollees must select a dentist from the PPO list.
- Capitation - Means "by the head." Capitation contract dentists must provide all or most of the dental services covered under a plan for payment on a "per person" basis (not a per treatment basis). This type of reimbursement is also referred to as per capita or per member per month (PMPM). Payment is made before services are rendered and no claims are submitted. The theory behind capitation is to average the cost of care among all members of the plan. There is usually a co-payment for certain procedures.