Some readers say that volume = less quality for patients covered by managed care plans

Dec. 1, 1996
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.

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. For more information, please note that the ADHA published related articles about managed care in its September/October 1996 issue of Access.

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. RDH published other responses about this topic in the November 1996 issue.

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 are participating in a few managed care programs. We are seeing at least one new patient a day with this type of insurance. The doctor`s level of care with these patients has changed dramatically. They do not receive the care they would if they had regular insurance."

- 5-year veteran from Pennsylvania

-"I work for a father/son dental practice. The father, who has worked for 30-plus years, is not on any managed care programs. However, the son, who has worked four years, is on some plans - to `build up` his practice. We treat all the patients the same. But it is difficult sometimes because the `plan` patients usually always let their insurance dictate their treatment. They usually do what is `cheaper` rather than what`s best. They are often argumentative about what is covered under their plan. I find a lot of these patients don`t show up for appointments or are late. We have to refer some work that we could do, but the plans won`t let us."

- 11-year veteran from Texas

-"I have worked at a dental office for 41/2 years that takes many capitation plans. Advantages: I get to work full-time at one office and my employer doesn`t get upset if I take time off because he gets paid the same by the insurance company whether I work or not. I used to think my care was less than if I worked at an office that didn`t take managed care. But I worked temporarily at an office that wanted me to do the same thing in the same amount of time. Currently, we are booked four months ahead - even if you need root planing. I don`t recommend this office to any of my friends or acquaintances. I stay at my job because of the pay and benefits."

- 5-year veteran from Arizona

-"I work two jobs - one with managed care and one without. The one with managed care has less quality of care and less patient compliance. The other office`s quality of care is much better, and patients are willing to pay outside of insurance limits."

- 2-year veteran from Pennsylvania

-"Having just left an office that accepted all capitation plans, I realize that the only way they can be profitable is by sheer volume. Appointments are shorter, less done on each patient, and the patient doesn`t receive the `best` treatment - but gets what is the least costly to the office."

- 26-year veteran from Michigan

-"My boss is very much opposed to managed care, and so am I. He does not want a third party dictating to him his fees or the types of treatments he gives patients. We have had patients go to the dentists on their closed plans and come back to us because they saw the difference in the quality of their care."

- 14-year veteran from Nevada

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?

-"Yes and no. There will always be people who never seek dental care even if it is free. Some managed care patients see their dental care as free and still don`t utilize it. Method of payment should not affect the doctor`s treatment plan."

- 14-year veteran from Wisconsin

-"To me, managed care means rationed care, both in dentistry and medicine."

- 10-year veteran from California

-"The preventive aspect of managed care is closely aligned with the profession of dental hygiene. Hygienists practicing in states where the profession has been threatened legislatively - lowering educational standards or implementing on-the-job training - can understand and appreciate the need for dental hygiene to move forward as a viable and respected profession in the next century. In today`s environment, stagnation could lead to the demise of a profession, business, or career. Moving forward occurs as a result of change and progress."

- 23-year veteran from Florida

-"I strongly disagree. When you take away a person`s ability to earn a decent income, you will drive the high-quality people from the profession."

- 14-year veteran from Arizona

-"I disagree. The standard of dental care has been lowered for some dentists that are doing even less than the standard set before managed care. For example, crowns of non-precious metals are acceptable to `cap` insurance, but have a low quality margin of acceptable adaptability compared to the crown margins attained from gold. In the end, the patient will pay for quality dental care. Most will choose lower quality work."

- 10-year veteran from California

-"I agree in that the hygienist will become a primary care provider in the dental office. Because well care and education are important in patient education, it will be the hygienist`s responsibility to perform these services."

- 36-year veteran from Massachusetts

-"Agree in part. However, I do not believe that prevention is a large part of most managed care programs and often it is just shuffling of patients from one plan to another and delaying treatment due to smaller reimbursement."

- 16-year veteran from California

Question #3: Do you see managed care changing the way dental hygienists are accessing or treating patients? Why or why not?

-"Yes. I feel periodontal disease becomes overly diagnosed for dollars. I also think that staff attitudes suffer. It becomes `herd them in, herd them out.` I left managed care three months ago. It`s nice to find people who appreciate your service and don`t mind paying for it (with or without insurance)."

- 20-year veteran from Colorado

-"Yes. If dentists receive a flat fee, will our compensation be adjusted down accordingly? An anesthesia nurse and a OB/GYN nurse told me recently they see unhappy doctors who are less caring! Will this happen in dentistry?"

- 21-year veteran from Pennsylvania

-"It puts limitations on treatment plans. It also turns hygiene into a clinical situation giving patients poorer health care. It takes away from the one-on-one of traditional plans."

- 9-year veteran from Michigan

-"Dental hygienists tend to be new and green and burn out very quickly. So far managed care is a very sad situation. People need less expensive health care so that everyone can be cared for; but how much better is bad care than no care?"

- 19-year veteran from Arizona

-"Managed care will mandate 15-minute `prophys` and the `get them in - get them out` philosophy. And recalls under managed care? Who cares? Under capitation, it`s better if patients do not seek treatment. Preventive care will be a thing of the past."

- 30-year veteran from Rhode Island

A Reader`s Opinion

-"The office where I am currently working no longer takes managed care patients - except for a couple of fee schedule plans. For eight years, this practice did see managed care patients. But it had reached the point where the dentist was losing money on seeing these patients.

"Almost all of the city of Dallas is on Safeguard `insurance.` So the dentist was taking a big risk by dropping the plan and others like it. He had his hygienist on commission and did not want to compensate her for cleaning these patients` teeth. Regular prophy time was 30 minutes.

"At this time, I was working for Monarch Dental in Dallas. Monarch did (and still does) treat Safeguard and other capitation patients. I was there for more than 11/2 years. It is a grueling, back-breaking pace for hygienists.

"There is a patient scheduled every 30 minutes - with one hour for deep scaling apppointments (which consists of two quads with perio probe and with anesthesia. In 30 minutes, you are supposed to go to the reception area, get your patient, greet them, seat them, check their current medical history, clean their teeth, do PSR, educate them, write in their chart, move them to the next chair for their exam, and then clean your room to OSHA standards and get ready to do it all over again. At some point, you must clean, bag, and sterilize your instruments. No-shows are almost unheard of because the places taking these patients are few and far between.

"One of the main problems I had with these patients was that they were generally very rude to the hygienist. They generally have the attitude that this is a free service, and you have very little value. We constantly had scenes with patients who would arrive ten minutes late for appointments. They wanted the hygienist to still see the patient and still stay on schedule. When the patient would be told to reschedule because they were late -- all heck would break loose.

"Frankly, the dentist just wanted the obvious calculus `flicked off` - polish over the rest and move them on. Since this is a conflict with my ethics, I quit.

"I took my present job because he offered me a good salary and was dropping Safeguard and his capitation plans. This dentist had been unable to fill his hygiene job for many months prior to my saying yes - because he only allowed 30 minutes for prophys and so on.

"The main difference is that my patients are generally great. They, or their insurance, pays for my services. They listen to what I say.

"I constantly hear the stories from patients about how they`ve never had their teeth cleaned like `this` before. For the first time, this practice is really seeing the results of a recall system and good preventive care."

- Sandra Zacek, RDH, BS, is from Rockwall, Texas

A Reader`s Opinion

-"I have been a hygienist for 19 years and have recently earned my degree in health care administration. Currently, I am working part-time as a hygienist in a busy, suburban solo dentist`s practice, and I am also his office manager. Managed care is a concept I have wrestled with for several years because of the courses I took in pursuing my degree.

"I believe that there is a place for managed care in the dental field. However, it is of limited value. For those who have not been able to seek preventive care in the past, PPOs and DMOs offer great benefits. For those who have had good fee-for-service dental care, there are surprises in store for them.

"In our practice, about 60 percent of the patients have some form of dental insurance. Of that 60 percent, 5 percent are from a PPO in which we are a participating practice. Over the past several years, as DMOs are making inroads in this metropolitan area, we have lost many patients.

Interestingly enough, a lot of them - after being part of the DMO for a year - have returned to our office, willing to pay cash for good care and service, something they do not feel they received at the DMO.

"Their complaints are: being treated as a number, not a person; being rushed through care; rarely seeing the same practitioner twice; only being allowed one preventive visit a year; obvious carious lesions that have been left unrepaired; and being unable to receive dental sealants.

"For some people, they would settle for this type of care, because in the past they have not been able to afford any treatment other than emergency visits. But, for others, it`s a big step down to poorer quality dental care.

"I am acquainted with hygienists who have worked for DMOs. They are rushed and feel like they`re working in a factory. They see more patients in a given day than those who work in a fee-for-service environment, and they also `burn out` faster. Often, they cannot provide ongoing care.

"One of the hygienists I currently work with came from such an office. She has had to retrain herself to take time with patients, personalize her services, and be thorough in her procedures.

"There is a very big difference between medical health care and dental health care. Without the benefit of insurance, medical illnesses can easily lead to financial ruin. Years ago, medical insurance was meant to provide families with coverage for catastrophic events. Only in recent years have large companies offered more benefits for routine and preventive care. There is an entire generation of people who are accustomed to having insurance pick up the costs of most of their medical care.

"Dental insurance on the other hand, is a fairly recent benefit. Differing from medical insurances, dental insurance has always helped people with the routine, preventive types of care, but the more costly expenses were only partially covered. In other words, it is the opposite of medical insurance. Yet patients expect to realize the same coverage benefits from each one.

"Let`s face it. Many of the people I see professionally spend more on their hair each year than they do on their teeth. If preventive dentistry is as successful as it seems to be, two preventive visits, perhaps a set of films, and maybe a restoration each year is all the average patient needs. In the scheme of things, dentistry is still a very good bargain.

"We have a number of patients who have decided that the premiums for dental insurance offered through their employers are simply not worth it. They`d rather pay cash. For the average middle income family, there may need to be a reprioritization of their spending habits. If they want good, personalized dental care, they are going to be willing to pay for it. This is definitely a case of "you get what you pay for."

"Society will always have those members who are too poor to be able to afford medical and dental care. In these cases, I do feel that some form of government plan needs to be in effect to help them.

"However, I am very concerned that, at the present time in America, there are people who choose to take advantage of governmental programs and feel no responsibility to give anything back. If health care is seen as a right, where is the line drawn on how much health care to provide and what about the individual responsibility that comes along with those rights?

"Managed care may provide technically sound dentistry. But it does not address the intangibles that are a part of good health care - the trusting relationship that is built up over time between practitioners and their patients is sorely lacking in managed care facilities."

- Marcia Bueschel, RDH, BA is from Menomonee Falls, Wisconsin