The Insurance Game — Who Are We Really Working For?

Canadians are not used to seeing a “bill” when they go to the hospital or consult their physician. Our patients often expect that dental benefits will work the same way. They fail to understand the distinction between “dental insurance” and “dental benefits.” If a procedure recommended by the dentist is not covered by the benefits plan, the patient frequently elects not to have the procedure performed. That certainly is not the best way to decide on treatment; however, for many patients and the dentists who treat them, this is a fact. Work within the benefit limits or lose the patient.

By choosing this method of health care planning, some patients are now allowing insurance companies to decide which procedures they will receive. Our greatest failing as health professionals has been our inability to convince these patients that by partnering with us rather than with their insurer, they are more likely to attain optimal oral health.

The Erosion of Real Dollar Values of Dental Benefits

Most benefit plans with a $1,200-$1,500 annual limit have had the same dollar amounts for the past 15 or 20 years. During that same period, dental fees have had to increase approximately 3 to 4% per year on average to accommodate increases in wages, new technology, supplies, changes to infection control and pollution control procedures, and inflation. It is unrealistic to expect that insurance benefit limits which may have been merely adequate a quarter century ago will be entirely adequate today. This phenomenon, which I call “creeping capitation,” is merely managed care in disguise. The result is a steady erosion of the real buying power of benefits. Insurers continue to lengthen recognized time between checkups, lower scaling allowances, limit cosmetic, prosthetic and implant treatment, and often deny retreatment due to frequency limitations. Yet their premiums have either remained fixed or increased, while their claims processing costs have dramatically decreased (thanks to the efficiency of electronic data interchange).

The Fight Against Capitation

CDA representatives have said that their first priority is to combat capitation and preserve “the freedom of choice and the integrity of the dentist-patient relationship” (personal correspondence from Dr. Louis Dubé, chair of CDA’s steering committee on dental benefits issues, January 7, 2001). The dentist-patient relationship means nothing if the patient’s treatment choices are first and foremost determined by the financial limitations imposed by the benefits plan. Insurers are accomplishing the goals of capitation right under our noses by just holding firm on benefit levels. At the same time, dentists squirm as they try to attend to patients’ increasingly costly treatment needs while their overheads increase each year. Whether treatment is performed by a specific group of dentists who work for a fixed fee per patient (capitation) or by a dentist of the patient’s choosing who works under a strict benefits limit, the end result is the same: carriers control their costs while dentists’ costs continue to increase.

Consequences of the Current Situation

Certain endodontic and periodontal procedures will continue to consume higher percentages of patients’ overall benefits. Rehabilitation or retreatment of one molar tooth (endodontic treatment and crown) will virtually exhaust a patient’s benefits for an entire calendar year, leaving no benefits for any other routine treatment. The clinician is therefore faced with the prospect of:

• referring the case to a specialist and having no benefits to work with for the rest of the year;

• extracting the tooth to preserve the remaining benefits in case other treatment is needed; or

• attempting to perform a complicated treatment that may normally have been referred because of its level of difficulty.

The overall result will be fewer referrals, more extractions and a greater number of treatment failures requiring complicated, expensive retreatment. This is a situation our profession cannot abide.

It is interesting to note that some provinces with the lowest fee guides still have the highest levels of dentist production and incomes.² This occurs even though the vast majority of dentists charge at the fee guide level and accept direct assignment of benefits. The dentists in these provinces have learned to “play the game” well after decades of practice. If fee guide increases are kept low, insurers will keep benefit levels close to 100% of the guide for most routine dental procedures. The idea behind this philosophy is “Don’t get greedy and the status quo can be maintained.” Unfortunately, in these provinces one is much more likely to have 2 virgin anterior teeth prepared for abutments than to have a single implant, simply because the former is a benefit while the latter isn’t. This way of doing things can’t be very good for dentistry or for patients.

Rather than perform comprehensive treatment plans, clinicians begin to treat patients on a crisis-to-crisis basis. Dentists will consider a treatment that is covered rather than the treatment that is best for the patient. In extreme cases, some clinicians may perform one procedure but submit a claim for a different procedure of equal dollar value that is a benefit. Or they may alter dates of service to enable a patient to receive reimbursement. This is fraud, and it is a symptom of a problem that will not go away any time soon. Clinicians who are compelled to work within these limitations feel justified in stretching the rules. It is the insurance game.

Each individual dentist must educate his or her patients about the limitations of benefits. Unfortunately, in these days of high overheads, there is little incentive to do this. Most dentists see this effort as an unproductive waste of valuable chair time. Many would rather replace restorations that are covered by the benefits plan than discuss such difficult, complicated and unpopular topics with their patients, especially if these discussions are not claimable as an insured benefit. Dentists will need leadership, support and assistance from national and provincial dental bodies if they hope to convince Canadians to change their attitude.

If we are content to deal with patients who only choose treatments covered by their plan, then we will have surrendered our independence. If benefits are insufficient, then we will be placed in a position of having to convince patients to buy more “insurance.” At that point our transformation will be complete! Dentists will have become salespeople for insurers because that is the only way patients will accept treatment. Who will we really be working for then?

In the same way that dentists must remain current with regard to techniques, training, equipment, wages and asepsis, insurance companies and their subscribers must recognize their obligation to alter coverage with the times. Should they not accept this, then dentists will have to convince patients to increase their out-of-pocket expenses. That will be a bitter pill to swallow, especially for those who for years have been used to handing a form to the receptionist and having their assigned benefits pay for 75-100% of their treatment costs. Dentists will need the courage and right tools to convince patients to make this transition. Failure will result in an untenable situation where dentists will be asked to work within financial limitations so confining that the best interests and health of their patients will be at risk. Creeping capitation will have won.

Conclusion

Our first mistake was accepting assignment of benefits. Our second and last mistake will be failing to acknowledge that creeping capitation is actually occurring through the dual pressures of ever-increasing overhead and intransigent benefit limits. We must find a way out of this problem or face the unpleasant realization that our future mode of practice will be determined by what insurers (and their clients, our patients) will allow us to do rather than what we believe our patients truly need. Our independence will have been lost as creeping capitation slowly chokes us into submission. Are we prepared to live with that?

Dr. Kaufmann maintains a practice limited to endodontics in Winnipeg, Manitoba. E-mail: rmk@endoexperience.com.

The views expressed are those of the author and do not necessarily reflect the opinions or official policies of the Canadian Dental Association.

References

1. Manifest Survey on Managed Care. 1999. Commissioned by CDA.