Managing managed care

May 1, 1998
Prevention is the key word for managed-care organizations and that`s why managed care and dental hygiene should be a match made in heaven. The primary focus of insurance coverage is preventive treatment. Managed-care programs are designed to meet the needs of the majority, not the individual, as with traditional systems. Managed-care organizations focus on a population average.

A little research will help you to determine your feelings about managed care.

Cat Schmidt, RDH

Prevention is the key word for managed-care organizations and that`s why managed care and dental hygiene should be a match made in heaven. The primary focus of insurance coverage is preventive treatment. Managed-care programs are designed to meet the needs of the majority, not the individual, as with traditional systems. Managed-care organizations focus on a population average.

The emphasis for managed-care insurance is cost-effective treatment for both the insured and the company. Managed care banks on keeping the population, as a whole, healthy through preventive measures. It pays for preventive services with the hope that fewer of the population base will get sick and have to undergo costly procedures. Fewer illnesses result in lower final costs to the company. Healthy individuals do not need expensive treatment.

Managed care here to stay

Managed care has its foot in the dental-office door. Managed care is cost-effective for at least three of the four entities involved: patient, patient`s employer and the insurance company. However, most dentists are not fond of managed care.

Why not? The ADA frets that managed-care organizations give the patient a reduced fee at the dentist`s expense. Some dentists feel that the plan exerts too much control over acceptable modes of treatment. Some worry about diminished quality of service for the patient. Still other dentists fear that dental offices will turn into "dental mills," or one we`re familiar with, "prophy mills." The ADA supports fee-for-service dental care over managed-care dentistry.

One of the benefits of managed care for dental hygiene is that it is prevention-oriented, just like hygiene. We understand the need for preventive therapy, and the foundation of managed care is prevention. It seems that managed care and dental hygiene should go hand-in-hand. As empathetic health-care practitioners, we appreciate the fact that managed care provides our patients with access to cost-effective preventive dentistry. With greater access to dental benefits through managed-care insurance systems, it is anticipated that more people will seek preventive dental care provided by dental hygienists.

The American Dental Hygienists` Association (ADHA) believes managed-care insurance in dentistry is here to stay and that prudent behavior dictates its acceptance. Simply wishing away managed care is unrealistic, believes the ADHA, so why not accept the changes in our profession so that we can more astutely deal with insurance realities. As the saying goes: denial is not a river in Egypt. The ADA appears to be in denial.

The ADHA does not endorse all managed-care plans, but the organization does believe that managed care will provide greater access to preventive dentistry for the general public and broader career opportunities for dental hygienists. In a press kit released by the ADHA regarding managed care, the organization states: "Managed care provides a framework in which to maximize and appropriately recognize the role of dental hygienists. Managed care and dental hygiene naturally complement one another because both emphasize prevention and cost-effectiveness. ADHA looks forward to a future in which Americans easily and affordably can access the quality, cost-effective oral-health services provided by dental hygienists."

If our goal as dental hygienists is to provide the highest quality of dental-hygiene care to the general public and to promote preventive measures of oral-health care, then managed care could aid us in the attainment of that goal.

On the flip side, a reduction in fees directly related to the managed-care model might indirectly affect the dental hygienist through loss of wages, production figures and/or benefits. The math is easy: if our employers make less, the office makes less and we don`t get raises. If our employers are financially strong, they`ll be able to provide us with the type of compensation to which we are entitled. Whether we like it or not, we are tied to the office-profit margin and we have to learn to accept that.

Difference of opinion

Dr. Richard Simms stated in an article in Dental Economics that no practitioner, whether dentist or dental hygienist, should willingly accept a 50-percent reduction in income that accompanies managed-care treatment. A 50- percent reduction in income for hygienists would correlate to income levels of the early 1980s. He also notes that if managed-care companies are so eager to save money, why would they not be just as eager to see auxiliary personnel performing the duties of dental hygienists? They also may push for legislative changes in auxiliary duties. Remember that it takes money to fight for changes in laws, and managed-care organizations have plenty of money for these battles. These are all valid points for hygienists to consider when contemplating the benefits of managed care.

The ADA vehemently does not endorse managed care and has voiced opinion against the ADHA for supporting managed care. Some are quick to point out that the ADA`s position results from both political and economic concerns. That`s also true of the ADHA`s position. All debate regarding such explosive issues is inherently politically and financially loaded. Each organization battles for causes benefiting its own profession and for membership base. Our job, as intelligent hygienists, is to sift through the chaff to understand the true issue.

A scenario worth considering is that, in practices where both fee-for-service and capitation patients exist, the fee-for-service patients may end up picking up the slack. If managed care cannot properly compensate the dental office for its members, then fee-for-service patients would have to foot the bill by paying higher fees for each service rendered.

Some dentists and dental hygienists have voiced their concerns over procedural guidelines and tight scheduling pressures that accompany managed care. A managed-care patient can come to be seen as a nonproductive patient, as a problem and not a solution. This is the antithesis to the ADHA`s wishes for access to preventive-care treatment for many people. If these patients become burdens, preventive care will take on a whole new meaning (read: prophy mill).

Another problem with managed care is that a practitioner?s judgments could be taking a back seat to profitability. If the dentist desires full-mouth root-planing and a crown, and the company negates the diagnosis, opting instead for two scalings and a four surface amalgam, who benefits? Certainly not the patient, who receives below-par treatment. Definitely not the dental practice, which receives far less compensation for treatment. The managed-care insurance organization benefits. Its profits increase. Hygienists? Perhaps the only route left for them would be to establish independent practices, if their practices can survive on the lower managed-care fees.

If you?re in a typical practice, you probably experience a fee-for-service environment. Perhaps you work in a managed-care setting or maybe you have a mixture of insurance plans. Whatever your current position, it?s in your best interests to do a little investigating and research on your own to determine your feelings about managed care and its effects on the future of hygiene and, most importantly, your own future. Managed care is a hot issue and it?s in our best interest as hygienists to understand both the ADA?s viewpoint, as well as the ADHA?s position, on the subject. When we blindly accept a viewpoint handed to us by a group or organization, we rob ourselves of self-discovery and a chance to use our intellect. There?s something wasteful and empty about a mind unused.

Since 1992, Catherine Anne Schmidt, RDH, has been a full-time hygienist, exposure control manager, office coordinator, and CPR instructor at Gentle Dental in Cedar Rapids, Iowa. Schmidt holds a bachelor of arts degree in communications from Southern Methodist University. This article is an excerpt from her book, ONot Just the Cleaning Lady: A Hygienist?s Guide to Survival.O The book is available from PennWell Publishing for $29.95. To purchase the book, call (800) 752-9764. Or fax to (918) 831-9555.

Managed-Care Organizations

* Exclusive Provider Organization (EPO): The EPO is used by employers to keep costs down while providing employees with an insurance program. The employer will contract with a provider for services at a reduced-fee rate. The insured must use only providers and clinics that have agreed to this plan.

* Health Maintenance Organization (HMO): The HMO is probably the most widely known of the managed-care organizations. A prepayment for services is expected before the patient is seen for treatment. The patient chooses from a network of specified providers or a group practice owned by the HMO. Payment is made through capitation (set amount paid yearly or monthly) to the practice.

* Individual Practice Association (IPA): Sixty-five percent of HMOs are IPAs, groups of providers that negotiate with HMOs. They contract with HMOs, yet retain their autonomy. These providers will be reimbursed by capitation or fee-for-service.

* Physician-Hospital Organization (PHO): PHOs consist of physicians and hospitals. This organization then contracts with HMOs and other managed-care organizations to provide services in a managed-care manner.

* Preferred Provider Organization (PPO): PPOs are established when insurance companies create contracts with providers. There is a fee schedule involved for the provider and the patient must pay a portion of the fee at the time services are rendered.

* Point-Of-Service plan (POS): This plan affords the patient a choice of using either a PPO or a compensation plan. The patient has a broader range of choices as far as choosing a provider, but the reimbursement may be diminished.