12

CASE: JUST TAKE IT OUT, DOC!

Dr. Ed Witten’s receptionist, Mary Rawley, arrives a little early to open the office. Already waiting at the door is Jane Nelson, a twenty-six-year-old graduate student. Mary invites her into the waiting room and checks her daily morning text from the answering service. It says, “Call Mrs. Brown, needs to reschedule.”

“Are you Mrs. Brown?” asks Mary.

“No, Jane Nelson. I came to see if I could get an appointment. I’ve had a lot of pain on and off and it started up again last night. I’ve been looking for a dentist to help me—all I have is one of those state medical insurance cards. I saw your hours posted online and thought I’d just stop here real early rather than call.”

“Well, we’re both little early birds,” says Mary, “and you may be in luck. But I need to make a few quick calls first.”

Mrs. Brown had been the first patient, but Mary needs to check her list of patients who want to be called in case of a last-minute opening.

Within a few minutes Dr. Witten arrives. “Good morning! Mrs. Brown?”

“No, Jane Nelson. I don’t have an appointment.”

“That shouldn’t be a problem,” says Dr. Witten. “Mary, can we fit her in this morning?”

“She has some pain and is looking for a dentist. Mrs. Brown has had to cancel and none of the patients on the waiting list can come right now.”

“Well, you are way ahead of us this morning,” says Dr. Witten. “We need a few minutes to wake up our computers and flip some switches in the back room. Then I’ll come back to talk with you. Can I bring you a cup of coffee?”

“No, thank you,” replies Mrs. Nelson. “I’m OK.”

Mary catches up with Dr. Witten as he heads into the back. “Our first patient, Mrs. Brown, left a message saying she needed to reschedule. I’ve called the patients who are looking for a cancellation, but none of them is available. So we do have room for her.”

“Okay, thanks, Mary. I hope nothing serious happened with Mrs. Brown. Check with her when you have a minute. I’ll go talk with Mrs. Nelson in the waiting room to see what she needs. Would you finish getting things up and running?”

“Hello, again!” Dr. Witten greets Mrs. Nelson as he returns to the waiting room. “We do have a cancellation, and no one on our waiting list is available right now. Mary says you’re in a lot of pain and you’ve had trouble finding a dentist.”

“Yes, Doc, thanks for seeing me. You can’t believe the run around I’ve been getting, just trying to get these two teeth out. You’re the fifth dentist I’ve tried to see in the past two years.”

“Two years?” says Dr. Witten.

“Yes,” says Mrs. Nelson. “I only have a medical card.”

“Okay, we’ll talk about that in a minute. What I want to know is how bad your pain is right now.”

“It’s pretty bad right now. It started up again last night, that’s why I found your web page and office hours. They cut the class I registered for online, and then last night their site shut down and I was stuck. I was feeling pretty mad about it, and the last thing I needed was a tooth going bad. I was going to come this way anyway to see my adviser. I hope he can help me fix it. I need that class this semester to graduate on time.”

“Sorry about your computer woes and your registration problem. I hope your adviser can get it fixed,” says Dr. Witten. “But to help me judge the pain from your teeth, what would you say, on a scale of one to ten, is the worst pain you’ve ever felt?”

“A kidney stone—three years ago. It’s not like that—at least not yet,” says Mrs. Nelson. “About seven, I’d say. It’s been worse, but it’s pretty bad right now and I don’t want it getting worse. For the past month I’ve been pretty miserable, though it only hurts off and on. Sometimes it’s more when I lay down.”

“Does the pain keep you up at night?”

“Not really. I take some Tylenol and that helps. It’s the teeth in the back on the right side.”

“Top or bottom?”

“Bottom,” she says, pointing to her lower-right molars. “They don’t wake me up if I take the Tylenol, but they do make it slow to get to sleep sometimes. During the day it only hurts for ten or fifteen minutes, then goes away. I know I have other cavities. It makes it hard to eat though—hot, cold, sweets . . . anything like that sets them off.”

“Let me take a look at them,” says Dr. Witten, escorting Mrs. Nelson into an operatory and getting her settled in the chair. He does a quick exam and finds a deep cavity in #30, which might be the culprit for Mrs. Nelson’s current pain, but he also sees another in #29 and a few others as well.

“Well, Mrs. Nelson, your pain is probably coming from the teeth you pointed to, the lower-right first molar in the back and the bicuspid right next to it. But you do have other cavities, quite a few of them. We will need to talk a bit more about them. But since we’re just fitting you in here and you only wanted to see if you could get an appointment for your pain, should we just deal with what’s bothering you most today and talk about the other issues later? Or I could do a complete exam and you could walk out of here with a long-range plan to deal with all of it. We could work together and get you on a path where you could still keep your teeth. The teeth you pointed to probably don’t need to come out, although I’ll need some X-rays to be sure of that.”

“Look, Doc, I don’t want a plan,” says Mrs. Nelson. “You’re the fifth dentist I’ve tried to see in the past two years. Two years ago I went to the dentist that I grew up with when I was on my mom and dad’s dental insurance that covered me for fillings and all kinds of stuff. But I graduated from high school and got married and all that stopped. My old dentist said he and some other dentists set up a clinic for people like me and he told me I should go there.”

“What do you mean, ‘people like you’?”

“You know what I mean, people that can’t afford regular care, people with a medical card. My old dentist didn’t say it that way. I liked him because he always tried to be nice. But he said to go to the clinic, so I went to the clinic. That was two years ago. At that time I couldn’t sleep at all because of the pain . . . and I wasn’t eating. I was really acting like a total jerk with everyone. The clinic said they couldn’t see me for two months, but the pain was terrible, so I went to the ER at the hospital. They gave me some pain meds and antibiotics, and it went away. They also told me I should see an oral surgeon, and they gave me the name of some. So I called them, but the people on the phone always said they didn’t take medical cards. But the pain had stopped so I didn’t bother going back to the clinic. Then, last year, when it was bothering me again, I started calling around to find another dentist and no one would take my card, or if they would they could only see me months later.”

“Well, Mrs. Nelson, I can’t say much about all that. I know it happens. But you’re here now and I’d like to help you, so can we just talk about that now?”

“I’d like that, Doc, but how much is that going to cost? Can we do payments?”

“Yes, we can work out something, but that depends on what you and I decide to do. Your lower-right first molar has a very large cavity in it and it’s probably near the pulp, the part that keeps the tooth alive, and it may even be into the pulp. There’s also a smaller cavity in the tooth right in front of it. Let me get a model to show what the problem might be.”

Dr. Witten goes back to his office and brings back a small education model. “Here’s what your tooth #30 might look like in 3-D.”

“Isn’t that cute. I didn’t know teeth had numbers.”

“Yes, all the teeth have numbers, though some people count them in different ways. But what you and I need to talk about is the big cavity in your #30—the lower-right molar that is probably what is hurting you—and what can be done about it. The other tooth there, #29, also needs a filling sometime soon. But for #30, from the way you’re talking about it and what I can see, I think we can try putting a sedative filling in it or paint a special silver fluoride coating on it. I think either treatment might work and solve your pain problem for a little while. But the tooth may need something more rather soon if the filling or coating doesn’t solve the problem. And I would like to take some X-rays before I do that to be sure the cavity hasn’t gone into the pulp.”

“When you say ‘something more,’ do you mean like a root canal? I’ve heard of those, people talk about them. But they hurt, don’t they?”

“It’s a way of saving a tooth rather than losing it, and no, they don’t have to hurt. They’re a way to save the tooth and keep it from hurting, that’s the point. But I really think temporarily filling the tooth or treating it the way I described will resolve your pain for now. I just have to say that eventually the tooth will likely need a root canal and probably a crown, but I think a filling will be enough for today. Your current medical card wouldn’t cover a root canal or crown. It would only cover an extraction, but we can work out a payment plan like you said to cover the filling. Later on, if it needs a root canal and crown, you may be working by then and may even have some kind of dental insurance.”

“I think I just want the tooth out,” says Mrs. Nelson. “My husband and I are both full-time students, and we really haven’t got much money. I don’t think I could get my parents to pay for it either, even if it was just for a small down payment. If the medical card covers for extractions, then I think I would rather have it out, so I won’t have to worry about the money or payments right now. I know I have other cavities and some are in front. I’d rather spend money on that whenever we get enough together—we’re waiting for tax refunds in the spring. I’m only twenty-six, and I don’t want to lose my front teeth. My husband and I could only scrape up $100 this morning between us before I left, and that really needs to go for food and gas this week.”

After further conversation, with Mrs. Nelson acknowledging that she would prefer to keep her teeth if she thought they could afford it, Mrs. Nelson asks Dr. Witten again if he will take the tooth out. He agrees, explaining that extraction may be within the standard of care for her situation but that he would need to get her history and take some X-rays before he knows it is appropriate to do it. He adds that she should consider what might be causing her to get cavities and briefly mentions proper nutrition, avoiding sipping and snacking, using fluoride toothpaste, and other preventive dentistry measures. He then says she should make a point of seeing a dentist regularly because the tooth next to it and a few others could also be causing problems—or soon will be if nothing more is done. He reminds her again that even if she decided to take one or two teeth out, she would still need a complete exam and treatment for the other concerns if she wants to keep her teeth, including the ones in front.

“I understand all that,” says Mrs. Nelson. “Just take the tooth out so it stops hurting and my medical card will pay for that much. I need to stop thinking and fretting about tooth pain every time I eat or do anything else, and I will try to come back whenever we have some money for it. Are you upset with me for asking you to take it out?”

“Mrs. Nelson, I am a dentist and a professional. I’ve made a commitment to put my patient’s health first whenever I can, and I think it’s terrible that your medical card only covers extractions in a case like yours. You’re young, you have many years ahead of you, and keeping your teeth and taking care of them is the best way to protect your health over the long run. The people who manage the medical card that is paid for by our taxes know this; but they’re given only a certain amount of money and not enough to cover anything but extractions in a case like yours. It really bothers me—mostly because I see how it changes our thinking about what could be done.”

“I’m sorry to make you feel bad,” says Mrs. Nelson, “but this really is the best thing for me to do right now. Maybe you should send them a letter or something.”

“I and thousands of other dentists have sent many letters to lots of people, Mrs. Nelson, as have our many dental organizations. But we’re not telling them anything they don’t already know. There are lots of wheels turning in dentistry and society and the messages get very complex. It makes being a dentist very hard when our world isn’t set up to work with people and offer the dental care they really need.”

THIRD-PARTY PAYERS AND OTHER DISTANT BUREAUCRACIES

There was a time not too many years ago when almost all dental care was paid for solely and directly by the person receiving it. The conversation about costs and payments was a two-party conversation, as was the conversation that preceded it about the patient’s oral health needs and the ways in which the dentist might address them. Dentists and their patients together worked out what the dentist would do for the patient and what it would cost the patient, including payment plans and other ways in which the dentist could help when patients’ resources were stretched thin.

Beginning in the 1970s, some employers began including some form of dental insurance in the health insurance benefits package offered to their employees, and over time this became a common pattern. Various government programs then began to appear that included limited coverage for the oral health needs of some groups of participants. The conversation about what the dentist would do for the patient and how much the patient would need to pay for became a three-party conversation, with the third party far away and impersonal. Nevertheless, at least for a while, these “third-party payers” transferred funds collected by employers from the labor of their employees or from taxes paid by the public to dentists (or else to patients to reimburse them). Payments to dentists were made on the basis of “usual and ordinary” charges for each service; in this way, “third-party payers” simply accepted the providers’ internal mechanisms for determining their charges to patients. For a while, then, the third-party payers’ participation in the dentist-patient conversation was often not very intrusive.

Beginning in the late 1980s, however, health insurance organizations and government health coverage programs increasingly began to pressure health care providers, both institutional and individual, to bring the charges for health care down. They employed a variety of legal, economic, and contractual strategies to achieve this end, and by these means, as this process has continued and in fact increased in intensity in the intervening decades, they have profoundly changed not only the economics but also the social landscape of health care in American society. The principal impact of these changes on oral health care has been a transformation of the dentist-patient conversation about what the dentist will provide and what the patient must pay. More and more dental care is chosen in conformity with terms set by third-party payer organizations committed to pressuring providers to keep costs down.

In addition, this industry—the “managed care” industry—has come to be made up of many different kinds of organizations, not only insurers but also a wide range of support industries whose research and advice significantly affect how the third-party payers manage their businesses. It doesn’t matter much whether the third-party payer is a not-for-profit or a for-profit business or whether it is a government agency or a private organization. Each has its own systems and priorities and its own bureaucracy and rules, and all the administrative costs that go with them. To complicate matters still further, many government programs are actually run by—that is, “outsourced to”—private, for-profit or not-for-profit organizations with these organizations’ own systems, rules, and bureaucracies. This process, and its additional costs, has transferred the management of the fiscal side of oral health care to bureaucracies that are increasingly distant from the patient who needs the care. More important than this, the policies of these distant bureaucracies also have a significant effect on the treatments that patients actually receive. Their cost-limiting policies—especially policies that will cover the costs of only the least expensive treatments within the standard of care for a presenting condition—have the effect of limiting the kinds of care that patients actually choose, for choosing any other treatment recommended by the dentist for their condition will mean having to pay “out of pocket” to receive it.

In addition to the financial burden of such “out of pocket” payments for many patients, such payments seem to patients to be excessive because they have already paid out money (directly or indirectly, for example, by accepting a benefits package rather than higher salaries) to have dental care coverage in the first place or because, if their dental coverage is part of an entitlement program, they believe they are justly entitled to the dental care they need. For many patients, having to pay out of pocket to receive the treatments that their dentists recommend rather than those the insurers will pay for feels like a form of financial coercion and a violation of their autonomy.

Of course, patients have always brought their financial constraints to their conversations with dentists. It therefore might be argued that the insertion of the third-party payer into the dentist-patient conversation was not essentially anything new. Moreover, it might be argued that the patient has freely chosen the particular insurance contract that he or she brings to the dental office, including its limits on coverage, and the limitations are all in the contract the patient receives. As for the limits built into government oral health programs, they are all matters of public record. Patients who do not understand these limits, the argument goes, have no sound basis for complaints. If they want better coverage, they should do their homework, find better coverage, and pay for it.

In practice, of course, the contracts and policies that limit coverage of dental care are written by and for lawyers and health care administrators, not patients. Unfortunately, it is typically left to the dentist and the dentist’s staff to try to translate these policies and identify their implications for their patients. But this again means that the one-on-one relationship between dentist and patient that aims at their collaborating in judging and choosing what ought to be done is not only interfered with but also significantly controlled by the distant third party. The significant costs of all this for the dental office—what it takes to handle the complexity and unpredictability of the processes that determine patients’ eligibility: frequent, unilaterally initiated changes in patients’ policies; time limits; coinsurance requirements; inadequate or misleading forms; and so forth—are not just financial. There are also significant costs to relationships with patients for both dentists and office staff, and patients experience their contact with the dental office to be more impersonal as a result.

The dentist’s professional commitment to the Central Practice Values of the patient’s Oral Health and the patient’s Life and General Health require the dentist to do what is needed to care for the patient. So, in addition, it frequently falls to the dentist or the dentist’s staff members to intercede with the insurer as the patient’s advocate and attempt to persuade the insurer’s staff members—who must follow the rules and limits established by the actuarial teams—that the proposed treatment is indeed the cheapest acceptable intervention. In any society as dependent on third-party payment systems as ours is, every dentist is surely required to employ some amount of time and energy to advocate in this way for treatment the dentist judges the patient genuinely needs. But the extent of this obligation and the dentist’s practical ability to carry it out is limited by the dentist’s similar obligation to every other patient he or she serves. Dental professionals are constantly rationing time and energy among their patients: those in operatories and those in waiting rooms, those presently on the telephone and those waiting to receive a call. The emergence of third-party payers, however, has multiplied the time and energy a dentist needs to expend in order to deal with them and has required dentists to develop an additional set of skills unrelated to providing competent care in order to provide aggressive advocacy on behalf of their patients to the bureaucracies of third-party payers.

Moreover, the dentist-patient relationship as well as patient trust in the dentist can be affected adversely in another way if the dentist’s best professional judgment is rejected by a distant, nameless dentist or nondentist aid who has not seen the patient. Many patients find it difficult to understand how fully qualified dentists can disagree about what is the best treatment in a given case without either of them being mistaken; nor is it easy to express in any readable formula that, in dentistry, the standard of care often includes a range of treatments for each particular case and matter at hand, not only the very best or ideal one.

Moreover, whenever the third-party payer, speaking through its oral health professional, appears to give higher priority to cost over better care, patients can easily question whether their Oral and General Health really are the guiding values of the dental profession. In addition, explaining such things to patients is especially difficult in societies like ours where a large segment of the public believes that the only adequate treatment is the one best treatment and no other. Moreover, some third-party payers are for-profit corporations and may well be limiting covered treatments to the least expensive precisely for the sake of market success for the corporation rather than, as for government programs and some not-for-profits, from a conscientious effort to ration limited resources equitably across a whole population of oral health patients. In other words, with some insurers, the patient may be quite correct to see the limitation of treatments as an intrusion of marketplace values into the dentist-patient relationship that ought to be focused primarily on the patient’s Oral and General Health.

An even subtler form of intrusion occurs when a practice signs a contract with a corporation to allow them to audit all patient charts within their practice, not simply to assure accurate record keeping and claims reporting but to compare fees accepted by the practice from other third-party contracts. If evidence shows that one third-party is paying more than another, that party can invoke favorite nation clauses in their contracts to recover funds from the practice, thus placing an additional unexpected financial burden on a practice and all patients within the practice that are not insured by the insurance company that benefits from this maneuver.

Finally, the fact that the treatment covered by the third-party payer frequently is not the treatment that the dentist—who is actually dealing with the patient—judges to be the best treatment for the patient’s presenting condition is viewed by many dental professionals as unethical in itself. For all these reasons, this insertion of a distant third party—or at least the actual ways in which third-party payers currently do impact dental care—into what once was and ideally ought to remain a two-party relationship between dentist and patient is viewed by many dentists and patients as a severe and ethically questionable intrusion into the dentist-patient relationship. Despite the hope that progress, technology, patience, common sense, and a shared commitment to respond to patients’ oral health needs will eventually resolve these intrusions, the continuing experience of most dentists is that no clear resolution and no reassertion of the primacy of the dentist-patient relationship in oral health care is in sight.

MORAL DISTRESS

A sizable body of literature has recently emerged about what is called “moral distress” on the part of health professionals. A health professional is said to experience moral distress when he or she (1) believes that a certain course of action is the ethically correct action to be taken in a given situation but (2) is prevented in some way from following that course of action or must in fact do otherwise or cooperate in doing otherwise (3) due to external constraints so that (4) the person experiences this not acting or acting otherwise than his or her values direct as an undermining of personal integrity, a weakening or even a violation of important personal and ethical commitments.

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