Preceptorship + Managed care = Unemployment Line?

Nov. 1, 1999
Author states a bold case for why your job may be on shaky ground. If managed care drives the market, the economic solution is preceptorship. It`s up to you to advocate treatment based on quality of care. Your best ally is the dentist, who also abhors lowering standards of care.

Author states a bold case for why your job may be on shaky ground. If managed care drives the market, the economic solution is preceptorship. It`s up to you to advocate treatment based on quality of care. Your best ally is the dentist, who also abhors lowering standards of care.

Carol D. Tekavec, CDA, RDH

With the dentist acting as a teacher, many dental assistants are trained "on the job." Admittedly, it is hard to discredit the intelligence, effort, and skill required to master many of the tasks involved with dental assisting. However, most consumers would be shocked to discover that, in many states, clinical dental assistants may not be formally educated, certified, or licensed. Hairdressers must have a state license to cut a person`s hair, but a dental assistant may place a restoration without any formal training.

In addition, many consumers would be shocked to discover that, in Alabama, hygienists also may be trained "on the job." While traditionally educated and licensed hygienists are employed in Alabama, "on the job" or preceptor-trained hygienists enjoy great popularity with employers. Preceptor-trained hygienists do become licensed, but an obvious division exists in the requirements of traditional vs. preceptorship education.

Despite this, no distinction is required in the actual clinical setting in Alabama practices. Patients are unaware of the educational background of the hygienists treating them. Presumably, many are treated without their knowledge by "student" hygienists in their dentist`s office during the preceptor and prelicensure period. This, of course, prompts many to ask out of curiosity: Are fees for the student prophys different than fees for licensed hygienist prophys?

It is known that salaries for preceptor-trained hygienists in Alabama are much lower than hygienists` salaries in other states. It is not surprising that salaries for "traditional" hygienists in the state also are much lower. With the wide availability of preceptor-trained hygienists, pay scales for the entire profession have been driven down.

While preceptor-trained hygienists are not currently legal in Kansas, they soon may be. Many dental assistants are taking advantage of new rules and regulations that allow them to perform hygiene procedures. Dental assistants may probe gingival pockets to the depth, use ultrasonic scalers and air polishers, and scale dentition supragingivally. A weekend course must be attended before patients may be treated.

Dentists in Florida and other states also have been attempting to change educational requirements for dental hygienists. The emphasis is on preceptorship. This is being done with the full support of the American Dental Association. In fact, the ADA House of Delegates has passed several resolutions during the past few years that support alternate dental hygiene education. "The alternate pathway model of dental hygiene education as used in Alabama" is being recommended. State dental societies that seek changes in their states` practice acts receive assistance from organized dentistry. The goal is to allow alternatively trained dental hygienists to be licensed. The ADA also has called for a committee to author a workbook to help other state dental societies create a hygiene educational system modeled on the one in Alabama, and the Academy of General Dentistry has gone on record as supporting "alternative" educational methods of training dental hygienists.

Why is this happening now?

A perceived shortage of dental hygienists is sometimes blamed for fueling the rush to preceptorship. Dentists in some geographical areas find it difficult to employ hygienists.

In fact, in some parts of the country, it is difficult for communities to find dentists or hygienists. During the past several years, seven dental schools have closed in the United States. It seems logical to assume that, with fewer graduates, fewer dentists will be practicing. (If there is a shortage of dentists, will there be a push to lower educational and clinical requirements for dentists?)

Perceptions of a shortage of hygienists may be somewhat responsible for the widespread interest in preceptorship. More likely, what is happening is more a function of market economics.

Managed care has completely changed the way health care in general is viewed. Money matters have been forced to the forefront - ahead of patient care in some instances. Over the past several years, hospitals have been slowly reducing their numbers of registered nurses in favor of licensed practical nurses, certified nurses` assistants, and nurses` aides. Fewer visible distinctions are evident in many hospitals. Patients often have a difficult time identifying who is working with them. Delegation of duties to the least expensive health care worker has become the norm.

Managed care also has affected dentistry along these same lines, although to a lesser degree. Dentists who have become involved in plans that include "free" prophys, "free" examinations, and "free" radiographs (for a typical monthly capitation payment of $5 to $10 per person) can find themselves scrambling for funds to pay quality staff. Rent, electricity, and supplies will usually rate higher in importance than staff in order for the office to survive.

Hygienists may find their jobs in jeopardy in offices that participate in too many low-fee plans. While working for $18 to $25 per hour, many hygienists are simply too expensive for managed care.

Despite these facts, many hygienists, including organized hygiene in the form of the American Dental Hygienists` Association, embrace managed care. They do not seem to understand the impact that these plans can have upon dental practices. Hygienists who have worked in underfunded managed-care plans have witnessed the decline in the quality of care patients receive. Rather than promoting preventive care, many plans discourage preventive procedures, since they are not adequately paid for by monthly capitation fees.

Dental hygienists may find themselves providing fewer, not more, preventive services because of expenses and overhead. Some hygiene procedures may even become shortened or delegated to a less expensive (preceptor trained?) staff member. If a dentist is economically pressured to sign up for an excessive number of these plans - such as in an area with a single, large employer who has opted for a DMO plan - hygienists may even lose their positions altogether.

Looking at the actual economics of managed care helps illustrate the problem. With a managed care payment of $5 to $10 per month per person, a dental office will collect at most $120 per year. Most managed care plans specify that subscriber patients may come in for preventive procedures as necessary at no extra charge. These procedures include prophys and diagnostic services.

If a standard recall exam, prophy, and a half set of bitewings (where recall radiographs are taken only one time per year) are $78 (taken from Dental Economics` national survey), funds are insufficient for paying even two such visits per year. Patients who require only two simple prophy/recall visits will exceed the compensation provided for their total yearly care. No funds will be available for restorations, crowns, or endos if needed. If these procedures are necessary, the dental office absorbs the costs.

While managed care plans stress preventive therapy on paper, reality is somewhat different. Many plans point to the fact that most managed care patients will be in "maintenance" and actually require few restorative or preventive services. While this may or may not be true, it has already been shown that two simple prophy/recalls can exceed allowed compensation. If a patient requires multiple visits for periodontal maintenance, as many as necessary are allowed under managed care when the dentist and hygienist are at risk. Under standard indemnity, when the insurance company is at risk, only two per year are a benefit, after the deductible is met.

Regardless of statements to the contrary, "maintenance" is expensive. Managed care plans recognize this. Under these conditions, it is unrealistic to expect equitable hygiene salaries to exist side-by-side with inadequate compensation from managed care companies.

The demand for hygienists

Managed care plans do offer other opportunities for hygienists - aside from clinical practice where their jobs are undermined. Hygienists may be employed to perform office site visits, record reviews, audits, dental case management, and credentialing of dental practices. In fact, hygienists are in demand as insurance company employees. Following current trends, it is possible in the future that hygienists who are preceptor-trained might require lower salaries than traditionally trained hygienists and be even more in demand.

What can we do?

A relationship between managed care and preceptorship can definitely be seen. Market factors, such as employers who want to pay less and less for health care services for their employees, are fueling the trend. Dentists and hygienists should have a common goal of providing excellent or, at the very least, adequate dental care for consumers. They also should have a common goal of receiving adequate compensation for providing such care.

Hygienists should speak to employers, local hygiene societies, community meetings, and to each of their patients during the course of a day, highlighting the positive aspects of having educated, licensed hygienists in dental practices. Hygienists also can become members of the American Dental Hygienists` Association and voice their opinions openly and often.

Dentists and hygienists are natural allies for their patients and for the practice of dentistry. Communication and common cause can alter the current landscape of managed care and preceptorship.

Carol D. Tekavec, CDA, RDH, is a well-known author and lecturer on practice management and insurance issues. She has presented programs nationally, internationally, and on videotape. She is the developer of a dental chart, an informed consent booklet of forms, and has written two manuals on dental insurance, all of which are available from Stepping Stones to Success, (800) 548-2164. Still practicing clinically, she is the monthly columnist on insurance for Dental Economics magazine.