Editor`s Note: In the September 1996 issue, we asked readers for their opinions about the presence of managed care programs in dentistry. The Dialogue survey asked three questions. The first question asked for an evaluation based on a personal experience with managed care or for their perception of the impact of managed care on their dental practice.
Secondly, we simply asked readers if they agree or disagree with the position paper issued by the American Dental Hygienists` Association in support of managed care.
Finally, we asked for an opinion how managed care will influence the way patients are treated by dental hygienists.
Here are some of the responses collected from readers. Although not everyone`s response is recorded here due to space limitations, the proportion of hygienists disenchanted with managed care is accurately reflected. The December 1996 RDH issue will contain more responses from this survey.
Question #1: If your office participates in any managed care programs (capitation plans, for example), what has been the impact, if any on the practice, patient care, or how you do your job? If your office does not participate, why not? What do you perceive the impact of managed care would be on the practice?
-"We have not signed any contracts for about 10 years. We want to make all of our recommendations based on patients` needs and wants - not on what their insurance plan does or does not allow. We want to work for our patients and not the insurance company."
- 20-year veteran from Minnesota
-"I work two days a month for an office that does managed care. It is horrible! I saw 18 patients in seven hours - a nightmare - but numbers are the bottom line. I feel the quality of the dental work is poor, at best. There is no follow-through or follow-up with treatment, no time for any kind of patient education - ultimately the patient suffers."
- 22-year veteran from Florida
-"I have worked in two offices - one with managed care and one without. I feel that managed care only provides the insurance companies with more profit and the dental patients less quality of care. Most managed care programs in the city I work in usually run the typical `prophy mill` and poor quality dentistry."
- 5-year veteran from Nebraska
-"I worked for 11 1/2 years in a dental office in an HMO. I took the job because I saw that it would be great for the practice of dental hygiene because prevention of dental disease is our goal. It was great! I was able to have the patients back as often as necessary. I treated a lot of perio and became very good at it. (We did refer as needed.)"
- 15-year veteran from Michigan
-"My office does not participate in managed care, because we believe it is not in the patient`s best interest. We offer quality treatment, never try to oversell dentistry, and offer personalized service. Many of our patients choose to stay and pay when their insurance changes to a preferred provider.
"I feel that managed care in dentistry has come about for three reasons. I will state each reason and then comment on how self-defeating they actually are.
"1. Some dentists view managed care programs as a means to build a quick patient base, thereby ensuring their income. However, this can only be accomplished by the dentist accepting lesser fees for the same services. In today`s marketplace, there will always be another dentist just a little hungrier and willing to accept less, ultimately driving income downward. I have known several dentists who contracted to be providers in managed health plans, only to be underbid by other dentists as time went by.
"Some dentists look for the quick fix, rather than taking the time and energy to build a quality patient base over the years. The result is that they hurt themselves and the profession in the long run.
"2. Some dentists are greedy. Too often, I see patients coming from other practices that have been clearly overtreated. The result is that the consumer patient feels that he needs these managed care insurance plans in order to afford dentistry for his family. This is another case of some dentists looking for immediate income, rather than seeing the big picture.
"3. The consumer is led to believe that they will receive the same quality of care under managed care plans that they would receive under fee-for-service, but that it will cost them less. That is simply not possible and unrealistic, especially as office overhead expenses continue to rise with OSHA requirements. The contracting dentists make up these costs, for example, by altering treatment plans to allow for co-pays for crowns and composite occlusal fillings where a simple amalgam would suffice. If patients were educated about the true cost of the two modes of delivery in actual practice, I`m sure a lot more would opt for fee-for-service.
"As a hygienist, I have worked both in offices with managed care plans and fee-for-service, and I feel that the best quality of care is delivered under fee-for-service. Patients are so appreciative when they are regarded as a unique person by caring professionals who never wish to exploit them by overtreatment. These patients are happy to refer to their family and friends. They take more responsibility for their own dental health and, interestingly, they are also more respectful and less demanding than the average managed care patient.
"For me, the most rewarding aspects of the dental hygiene profession are the relationships I have built with my patients. I know that everyone of them chooses to be treated by the dentist and staff in our office and that they aren`t there because we were on a required list. For that reason, I think that the relationships between patients and staff are mutually beneficial and satisfying."
- 23-year veteran from California
-"We do not participate in managed care programs because they are too intrusive on the care decisions patients want to make. `Temping` in clinics participating in managed care has given me a poor impression of these systems - high appointment failures, for example. How does this contribute to cost-effectiveness? Downtime is paid by someone."
- 27-year veteran from Wisconsin
-"My office does not participate in managed care programs because my employer feels that we could not provide adequate care for our patients due to the restriction of specialists we could refer to and that the patient load would strain our resources. He does not believe in being paid even if the patient does not seek therapy. Financially, the fees would not cover the services."
- 30-year veteran from Virginia
Question #2: The American Dental Hygienists` Association recently published a position paper supporting managed care. The ADHA feels today`s health care system has "moved dramatically away" from fee-for-service traditional health care. The association says that managed care and dental hygiene complement each other due to the emphasis on prevention and cost-effectiveness. Do you agree or disagree with their position?
-"I do not agree. One must have the appointment time to spend to work with patients teaching home care and prevention. No managed care allows time enough to do a thorough cleaning, let alone home care. I am not willing to take a pay cut, my hourly rate is fair at best. I do not want to lower my standards by delivering reduced quality care but also do not want the added stress of trying to do twice as many patients to keep production up. I do not like any managed care program I have been exposed to. People`s right to choose is being taken away. Everyone has to get their name on `a list` these days. No thanks! As long as we can afford and have the choice, no member of my family will be a part of a managed care program."
- 15-year veteran from Pennsylvania
-"Managed care and dental hygiene complement each other as so much of the program is prevention."
- 25-year veteran from California
-"On the average level, many more patients are able to come to the dentist with managed care systems. Basic care is affordable. A lot depends on the dental office, but people can receive good care and keep their teeth longer."
- 24-year veteran from Illinois
-"I disagree. You get what you pay for. Why should our office subsidize the care of others! As long as the dentist absorbs the costs of these plans, the staff is happy. But if everyone is affected by accepting the managed care plans, I think a lot of offices wouldn`t accept them."
- 17-year veteran from Virginia
-"If you like short appointments, backed-up patients because of time constraints, less service, no perio treatment, rushed doctors, cheaper materials, stressed staff, burnout, no profitability, no time to discuss patient-centered prevention and health, and doctors discovering that they can make more profit without us, then managed care is for you!"
- 15-year veteran from Nebraska
-"I disagree with this position. Dental hygiene and managed care do not complement each other, due to the fact that most dentists and dental hygienists feel that they don`t get adequately compensated for their treatments and schedule patients for 20 to 30 minute cleaning appointments. In my opinion, managed care is not conducive to prevention."
- 16-year veteran from Arizona
-"What I want to know is who is the ADHA trying to impress, and what do they think most of their member`s positions are. No one I have spoken to individually is in support of being a `sheep` to a managed care system."
- 13-year veteran from California
-"I strongly disagree with the position of the ADHA. I discontinued my membership in the ADHA in 1993 because I felt that the organization was out of touch with my needs as a practicing dental hygienist.
"I am currently a practicing dental hygienist. I also hold a master`s degree in public health/health education. Most certainly, we should all applaud managed care`s emphasis on prevention because it saves them money and increases their profit margin. Is managed care really cost-effective? For who? Granted, the patient is paying a lower monthly premium and they are entitled to certain services at no or reduced cost, but do the patients always receive these services in a timely fashion? I know of patients who belong to HMOs that provide two cleanings every year at no charge. These same patients tell me that they are unable to get an appointment twice a year because their dentist is too busy. I would like to see some unbiased research describing what is truly happening to the patients that enter the managed care arena. I think that it is too early to be taking a stance on either side of this issue. Can we state with complete certainty that the majority of managed care patients are benefiting from this type of delivery? I wonder if the ADHA would be so quick to take a stance if they were in the "real" world? We have patients that leave our practice because we are not on their provider list, only to return a year later because they did not think that they were being well taken care of.
"I also know that it is the dental hygienist working in the managed care setting that is being forced to see their patients on a 30-minute recall schedule. I think most professionals would agree that this is not an adequate amount of time to provide proper clinical care, much less to include any patient education. It is the hygienists who stand to lose the most if managed care becomes the wave of the future."
- 6-year veteran from Florida
-"I disagree. I have substituted in offices that offer managed care. The patients are treated like cattle, and the staff is overworked. The dental care is below standard because of the large number of patients that are seen on a daily basis. The hygiene schedule provides only 30 to 40 minutes per patient. After a medical history update, oral cancer screening, decay screening, taking and developing X-rays, check out by doctor, oral hygiene instructions, asepsis cleaning between patients, that leaves 10 minutes to scale and polish teeth. This does not complement oral health care. Several of the managed care offices employ assistants to scale teeth side-by-side with one registered dental hygienist. Patients are unaware and do not ask to see the RDH license."
- 30-year veteran from Pennsylvania
Question #3: Do you see managed care changing the way dental hygienists are accessing or treating patients? Why or why not?
-"It will change to assembly line, like a factory. There will be less time with patients. Production and quantity over quality."
- 12-year veteran from Wisconsin
-"Yes. There will be delays in treatment due to all the paperwork, etc. I get so discouraged with all this `managed care` talk! Why did we get degrees or why did the dentist get a degree? To let someone in the insurance business tell them how to practice? Do you want your chiropractor to do your bypass surgery? Think about it ADHA!"
- 20-year veteran from Virginia
-"Yes. We will be allowed insufficient time and given inferior supplies to complete the job. One positive point is that we will probably be allowed more general supervision eventually."
- 18-year veteran from Missouri
-"I do think managed care is changing the way some hygienists treat patients. I see it with many of our capitation patients. They come in with advanced perio and claim they have had their teeth cleaned every six months and the hygienist never used scalers. Some patients claim the hygienist only polished and was done with the patient in 20 minutes. I have worked in three states, and I have found the response by capitation patients to be the same in each state.O
? 6-year veteran from Colorado
-OYes, since reimbursement will probably decrease. Time spent with patients will be less as doctors desire increased patient load. Also, hygienists could begin to fade as assistants begin to increase their duties! Doctors may not want to pay higher hygiene salaries.O
? 4-year veteran from Arkansas
One Reader`s Opinion
-"Some areas will not be able to prevent managed care from growing - small towns with one or two major employers who can dictate insurance benefits, for example. The poor population will also find managed care as their only affordable option. Government will also use managed care vehicles for some of their programs.
"Our country boasts several levels of people. Some will either want or need to be K-Mart/Dollar Bill Store shoppers and others can and want to pay for Nieman Marcus and Saks Fifth Avenue. Those options may or may not be dictated by the amount of money a person has.
"Dentistry will also have levels. Patients` dental care shopping is driven by their dental IQ and/or financial status. Some patients will remain private payers. Others will have indemnity insurance with the remainder opting for managed care. A vast number of Americans will choose the middle of the road or PPO plans."
"It is a shame it took managed care to force dentistry to look at the cost effectiveness attached to the use of dental hygienists. Any good business delegates tasks to the lowest paid person possible who can accomplish the task properly, legally, and efficiently. Dental hygienists have been under-utilized for years.
"Dentists should have realized years ago that hygienists can help them better serve more patients. With that philosophy, they would have had the foresight to develop the dental practice acts to facilitate dental hygienist utilization and ultimately increase their income and business success."
"A good hygienist would not compromise patient care just because the patient is in a managed care plan. Neither should the hygienist allow a managing dentist dictate changes in patient care because of a patient`s insurance plan. Ethical hygienists will remain ethical, and others will cut corners for managed care patients."
- Diane M. Smith, RDH, MBA
Northwestern University Oral Health Center