Th 209678

Why Should a Hygienist Care about Insurance?

May 1, 2006
If anyone is aware that the rules of diagnosis are about to change in dentistry, it’s the insurance industry.
Click here to enlarge image

If anyone is aware that the rules of diagnosis are about to change in dentistry, it’s the insurance industry.

“Almost all dental benefits are based on procedures developed in the 1950s,” said Robert Compton, DDS, Chief Dental Officer for Delta Dental Massachusetts. We are moving beyond the drill into the threshold of a golden age of molecular diagnosis and biotech-therapy. Sound like your practice? Maybe not yet, but very soon there will be no choice. You or your practice might not be embracing this brave new world, but the insurance industry will take us there whether we want to go or not.

Insurance marketplace reality

Why should you care as a hygienist? Why do you need to understand anything about codes? The reason you need to care is - whether you like it or not, whether you want to be involved or not, whether your practice accepts insurance assignment, or is enrolled in any PPOs/HMOs - you are affected by the dental benefits industry. Dental insurance is a marketplace reality, yet many hygienists take a complete hands-off attitude to something affecting much of what we do.

Insurance carriers are often made the bad guy and inappropriately blamed. Before any discussion of how insurance affects hygiene, it is necessary to first clarify and remind practitioners that we are treating patients, not insurance policies. The treatment plan should be developed according to professional standards, not according to the provisions of the contract. We can commit fraud by “accident” or “ignorance.” As a hygienist, you are most often one of only two licensed professionals in the practice. The decisions made by others in the practice can put your license at risk. Fraud can be committed in your name, and ignorance is not an excuse. Hygienists need to understand the world of dental benefits not just to protect themselves, but also to be prepared for the future.

Why evidence-based dentistry?

Evidence-based dentistry (EBD) is a hot topic in articles, on the lecture circuit, and with purchasers and providers of dental benefits. For a majority of clinical practitioners, these discussions do not seem to have much connection to their everyday decision making. Without the connection to current research, practitioners can feel helpless, hopeless, and a victim to changes made by others. For hygienists, EBD can open doors that in the past seemed insurmountable. Dental hygiene clinicians need to understand this changing arena to prepare for the future.

The American Medical Association and the American Dental Association hosted a one-day conference titled Oral and Systemic Health: Exploring the Connection in February. Among the doctors attending were (left to right) Moise Desvarieux, MD, MPH, PhD; Steven Offenbacher, DDS, PhD, MMSc; Michael Glick, DMD; Robert Genco, DDS, PhD; Louis Rose, DDS, MD; Elizabeth Krall Kaye, PhD, PPH; James B. Bramson, DDS; and Foti Panagakos, DMD, PhD.
Click here to enlarge image

Because dentistry has remained essentially a cottage industry, solitary practitioners have been able to use bits and pieces of conveniently selected evidence to make decisions. Practitioners make decisions based on their dental or hygiene school education no matter how long ago they may have graduated - if no one was injured no one was the wiser. In an era of rapid changes, for graduates of 10 years ago or longer, up to 80 percent of what was taught has probaby changed or is just plain wrong.

For example, some practitioners are still using the pre-1960s thought that calculus is the cause of periodontal destruction. Advanced degree knowledge holds only for six to eight years. As many of us have experienced with our home computers or even cell phones, high tech is replaced every two to three years. Textbooks cannot always reflect the most current research findings. With the constant pressure educators are under, they can also stagnate in their learning.

“Eminence decision-making” can result when decisions are based only on the opinions of those recognized as “expert” leaders. Decisions are also based on traditions, with no memory or thought of the derivation of those traditions. Certified nurses aide training books still refer to periodontal disease as pyorrhea. Dental professionals also continue to perpetuate myths, such as the reason a patient has recession is based only on brushing too hard.

New technology and the constant information flow make day-to-day practice more complex and challenging. Busy or procrastinating practitioners do not have or take the time to read and understand all of the information available. Even those who try can easily find themselves in information overload. A practitioner can easily fall prey to using the same old diagnostic and treatment options because it can feel easier to function on automatic pilot. Yet, changing demographic patterns, more knowledgeable consumers, rapid technological advances, the information explosion, along with the litigious nature of our society and the increasing costs of health care all put greater demands on clinicians.

Use of computers and the Internet is rapidly becoming a necessity, not just a choice. Online research can produce a million hits in response to one simple query. Finding, deciphering, and then applying the information found is a learned skill - just like using any other instrument in our armamentarium. Yet the skill is not just another technique, it is a way of thinking, a philosophy, a paradigm. The ultimate goal of EBD is to aid in clinical judgment, minimize diagnostic errors, and ensure optimal decision-making about treatment and therapies.

Numerous courses and articles explain the integration of EBD into daily practice. This article is about why hygienists need to not only understand and utilize EBD, but how insurance carriers already are. This is the connection: EBD will lay out the statistical foundations for insurers to support new technologies and methods in dentistry.

Brave new world

One key piece of evidence emerging from research is the connection between dental and overall health. On February 23, the Oral and Systemic Health: Exploring the Connection meeting was hosted by the American Medical Association and the American Dental Association (sponsored by the Colgate-Palmolive Company). Several press releases were published following this historic meeting to further establish this connection. (See Figure 1 for references.)

Less than 50 percent of the U.S. population have dental benefits. Dental benefits often play second fiddle to medical. Yet with this new research, that equation is changing. In the years ahead, purchasers of insurance will have increasing expectations as to our understanding of dental disease and its connections. The walls separating medicine, dentistry, and public health are beginning to crumble. EBD is establishing a new standard of care. Robert Klaus of Oral Health America said, “Having a standard diagnostic procedure and treatment recommendations are critical steps toward improving a patient’s overall oral and systemic health.”

The alliance between EBD and the insurance industry is already being established. CIGNA uses data integrated between the dental and medical sides of their business for its disease management programs. CIGNA will give providers the same literature references they use in adjudicating claims. Dr. Alan Vogel of MetLife said he hopes its evidence-based outcomes study will give practitioners more solid proof to guide their care rather than the anecdotal information relied on now.

Click here to enlarge image

One of the nation’s largest dental insurers, Delta Dental of Massachusetts, and Forsyth Center for Evidence-Based Dentistry established an alliance in 2004. In April 2005, Delta announced what it termed three new evidence-based benefits to its dental plans. The benefits are coverage for:

• Dental sealants beyond age 15

• Prescription fluoride toothpaste

• Chlorhexidine antimicrobial mouthrinse

In November 2005, Delta announced another evidence-based benefit - single tooth implants - stating they would be providing this scientifically-proven treatment at no additional cost of their clients. Blue Cross/Blue Shield Association’s Technology Evaluation Center (TEC) employs many evidence-based criteria when evaluating health-care interventions. TEC determines whether available scientific evidence permits the conclusion of whether a technology improves the net health outcome. Though TEC does not make insurance decisions, the important part to grasp is that insurers are embracing EBD methodologies.

Concerns about insurers and EBD

A 1999 article in the Journal of the American Dental Association expressed concerns about how insurers might use EBD: “Denial of necessary treatment by benefit managers continues to be a major criticism of health plans by patients and health-care practitioners. Under these circumstances, it isn’t difficult to visualize payers selecting only (evidence-based dentistry) that supports the cheapest treatments.”

Dr. Richard Niederman of Forsyth’s Center for Evidence-Based Dentistry responds, “Evidence-based dentistry is not a set of cookbook methods. It is not a method for insurers to dominate dentists. It’s not a pre-ordained, biased set of rules that people apply to other people. It is the integrating of the best evidence with clinical experience and patient needs and values in making clinical decisions.”

Thomas Deahl, DMD, PhD, adjunct associate professor, University of Texas, said, “Finding appropriate evidence to a specific problem can be like finding a needle in a haystack. Evidence-based care should be a relief to clinicians.”

Rather than fearing change and insurance carrier intrusion into practice, we need to realize dental disease patterns are changing. Employee dental plans have remained practically unchanged since the 1960s. The one-size-fits-all mentality stems from the early days of creating dental policies. Dental insurance isn’t and never was true insurance. Dental benefits can be better tailored to our current understanding of EBD, which offers a more scientific and thereby potentially more effective basis for dental benefit management. Reliable risk assessment can enable benefits to take into account individual response to disease and prevention.

Hygienists as the future leaders

With the connection between oral and total health becoming more widely understood, dental policies based on procedures developed in the 1950s are no longer appropriate. Dental professionals have an influence on this process. Carriers reply to organized dentistry, specifically specialty organizations through their position papers that create policies and criteria based on the evidence.

This is one important reason for practitioners to be members of the professional organizations representing their interests. In June 2005, the American Dental Hygienists’ Association, the largest national organization representing the professional interests of the more than 120,000 registered dental hygienists nationwide, released the Dental Hygiene Diagnosis Position Paper (, adding to the body of position papers and other influential documents.

Molecular-based dental care will soon begin to replace the need for restorative-based care. This biotech approach to dentistry will focus more on prevention than drill, fill, and bill that has been the long time norm of most dentists. Insurance carriers are also more accustomed to paying for procedures rather than prevention. EBD is changing this.

The preventive role of the hygienist has long been considered a loss leader or just a necessary evil, perhaps a way for a dentist without people skills to attract patients to the dental practice. At worst, it has been considered a role that can be easily performed by an individual trained on-the-job using a preceptorship model.

The heart of dental hygiene education is prevention and its value is shown by EBD. Insurers and policy-makers are beginning to understand this. At the same time, the number of dentists is decreasing while the number of hygienists is increasing. These factors can position hygienists as the future leaders of the oral health profession. Can you see why hygienists need to embrace insurance and evidence-based dentistry? Are you preparing for that future?