CHAPTER 4 Managed Care Programs in Dentistry
Over the past several years there has been a major effort by business organizations to become involved with the administration and funding of health care. You are undoubtedly familiar with these programs as administered for your medical plans. Overall, there has been only fair to poor acceptance of the influence of these plans on the access and quality of health care. Some of these programs are now active in dentistry, but they are not nearly as dominant as they are in the other parts of medicine. This chapter provides a candid view of the various types of dental care plans that are now available in the United States as viewed through the eyes of the author, a dental practitioner, teacher, and researcher who has practiced high-quality oral care for more than 40 years. Although these opinions are those of the author, they represent the majority of opinions of the thousands of dentists to whom the author speaks each year.
This is the type of payment for dental services many readers will remember as a child, when it was the only form of payment that was available to dental patients. You had an oral need, and you consulted with the dentist of your choice relative to that need. The dentist provided a professional opinion to you. You accepted or rejected the treatment plan. The treatment was accomplished, and just as you pay for groceries or clothing, you paid for the treatment, and went home. Dental benefit plans were not available, and patients did not expect any third party to pay for their oral therapy. You selected the dentist of your choice and the quality level you could afford, and you received the treatment of your choice.
This type of oral care is still available. It is called fee-for-service dentistry. In fact, it is the only form of payment that many dentists will accept. In fee-for-service dentistry, you are in control of your oral health care. You select the dentist. You save the money for the service, and you pay for it. You receive the therapy of your choice that meets with your treatment preference and budget availability. However, this type of payment now constitutes only a portion of payments for oral therapy.
Some dentists who have fee-for-service practices accept so-called dental insurance funding as a part of the payment for services. However, some insurance plans will not allow the patient to receive treatment from fee-for-service dentists. In such plans, you must seek the service of so-called preferred providers who have contracts with the third-party payer.
Most high-quality dental practitioners practice fee-for-service dentistry. They cannot afford to meet the requirements for the discounted plans and still provide the quality level, and type of services they desire. Although there are many excellent dentists who are involved with dental insurance or dental benefit plans, you, the consumer, must be careful to analyze the potential reasons for a specific practitioner’s participation in an insurance plan.
These plans are patterned after the other medical HMO plans. A dental insurance company contracts with your employer to provide discounted oral care services for the employees of your company. The services provided by these plans are usually very minimal in nature. They provide emergency services and a few of the more rudimentary oral therapies. Almost always, they do not provide the more advanced or elective oral care services, including dental implants, veneers, orthodontics, complex crowns (caps) and bridges (prostheses) required in oral rehabilitation, major surgical services, and many other cosmetic or esthetic services. You will find that if you are involved with a dental HMO you will have some difficulty obtaining many of the services that you desire. You may find difficulty in obtaining an appointment at a time of your choice. You may find that in many offices accepting such plans the level of care you receive is different than the care you would receive from the same practitioner if you were paying a normal fee. Why do dentists become involved in DHMOs? These plans provide a specific amount of payment to the dentist for a certain time period. On many procedures, if the dentist sees the patient and provides services, he or she does not receive any additional payment. If the dentist does not see the patient, he or she receives the same amount. Is there a motivation to treat the patient? The likelihood of the patient receiving optimal dental care in a dental HMO may not be good, unless the patient has nothing to do />