The Insurance Dilemma: Who are we really working for?

The Insurance Dilemma:
Who are we really working for?

Originally Published in the Canadian Dental Association Journal
Vol 67, No. 4 – April  2001

Canadian Dentists face a dilemma on a daily basis. Approximately 70 % of their patients have some sort of private dental insurance (according to the CDA’s most recent figures). Many patients have been conditioned by Canada’s socialized medical system when they consider the financial consequences of any of their Health Care decisions. In most cases, they are not used to seeing a “bill” when they attend the hospital or consult their Physician.

Patients with Dental insurance often expect that dental benefits will work the same way. Patients present with an insurance form and claim that they are “covered”.  If the procedure recommended by the dentist is not a benefit of their plan, they often elect not to have the procedure performed.  That certainly is not the best way to decide on treatment, however for many patients and the dentists that treat them, this is a fact. Regardless of how well the treatment plan is presented or how extraction may adversely affect their oral health, that is the reality in many dental practices.  Work within the insurance benefit limits or lose the patient.

By choosing this method of Health Care planning, the patient is now in effect letting the Insurance Company decide which procedure they will receive.  Dentists know what is best for their patients, rather than some bureaucrat at an insurance agency who knows nothing about the patient’s oral condition and who does not have any personal relationship with the patient.

Furthermore, it is painfully obvious that Insurance companies have been unwilling to modify their plans to accommodate for the increased costs of dentistry.  Many plans with a $1500 limit have had the same dollar amounts for the past 35 years or more.  During that same period, dental fees have had to increase approximately 3-4% per year on average to accommodate increases in wages, technology, supplies, infection control and inflation. It is unrealistic to expect that insurance coverage amounts that were merely adequate a quarter century ago will be entirely adequate today.  Yet patients still do not seem to understand this concept and insurance companies are loathe to do anything about it unless severely pressured by their policyholders.  This situation underlines how dependent dentists have become on the whims of the insurance industry, an industry whose primary concern is focused on providing the maximum profits to its shareholders.

That is a failure of both Canadian Dentistry as a whole and the representatives of its professional membership, the CDA. Why ? Because, the CDA has been placed in the dilemma of officially endorsing a stand that discourages assignment of patient benefits to its members. At the same time it must acknowledge that a substantial portion of its membership relies directly on this method for its livelihood.

While Canadian dentists in most of the country have managed to hold the line against Capitation, this slow erosion of real buying power of dental insurance benefits threatens the oral health of their patients.  As insurance companies continue to make huge profits (based mainly on the fact that only half of their subscribers visit a dentist regularly) they continue to cut benefits, lengthen recognized time between check ups, lower scaling allowances, limit cosmetic, prosthetic and implant treatment and often deny retreatment due to frequency limitation. Yet their premiums either remain the same year after year or increase. Our greatest failing as health professionals has been our inability to convince our insured patients that by partnering with their Dentists, they are more likely to attain optimal oral health. The insurance carrier could care less about the specifics of their case and is interested in nothing more than satisfying the barest of requirements at the least cost. Still, patients continue to make critical oral health care decisions, based mostly on the level of coverage.

As fees increase, endodontic procedures in particular (per tooth) continue to consume higher and higher percentages of patient’s benefits.  With the average yearly benefit maximums in the $1500 CDN range, endodontic treatment and core buildup of one molar tooth in the General Dentists office can now come close to exhausting the patient’s benefits for an entire calendar year. Referral to an Endodontist for that same procedure leaves no benefits for any other routine treatment that may be necessary. This is a definite dissuasion for referral to an Endodontist and an encouragement of extraction. As a profession, this is something we cannot abide.

In areas of affluence or in certain provinces with a totally different attitude toward assignment of insurance benefits (such as Quebec), this does not seem to be a problem.  Dentists have made a decision to simply not take assignment of benefits and their practices may have not suffered.  But in many other areas, more and more patients (many of whom live from paycheck to paycheck) choose a dentist based upon whether the dentist takes direct assignment of their benefits. If the dentist does not, patients often threaten to move to an office that does take assignment.

In some cases, it has reached the point where dentists do not even pursue patients for the 10 or 20% co-payment.  This is not only damaging to patient’s perception of real fees, it is fraudulent and illegal under the insurance benefit guidelines. Nevertheless, some dentists find that “chasing” the patient for a relatively few dollars simply is not economical or they may carry these outstanding amounts on their books in the hope that the patient will pay during their next check up (if or when they ever do return to the office).

Even worse, some dentists attempt to “fudge” insurance claims by submitting for exaggerated covered restorative procedures when placing non-covered restorations of equal value. (e.g./ submitting a claim for a 5 surface composite when a porcelain veneer is placed)  This practice is deplorable but is much more common than we as a profession are willing to acknowledge.  It has occurred precisely because of this insurance “squeeze”.

There is no point discussing the merits or disadvantages of assignment of benefits.  The genie is out of the bottle and there will always be those who will cave into the pressure of the patient who threatens to leave a practice unless assignment is taken. With the advent of EDI, the problems of protracted delays in processing of claims or waiting for insurance monies (from some but not all insurers) may have lessened but have not entirely disappeared. The dental office remains a de facto unofficial extension of the insurer because it is the first place that the patient contacts when any problems occur with insurance claims. Most of us would prefer to deal directly with the patient and would like to eliminate dental insurers from the equation. However, it is unreasonable to expect every employer to dump the insurance company and move to direct reimbursement. We will have to live with this situation for the foreseeable future.

The time has come for organized Dentistry to exert as much pressure as possible and to at the very least demand that insurers increase the routine benefit maximums to a minimum of $2000 per covered individual per year as a start. We must convince our patients and their employers that their benefit maximums are not in step with modern dentistry. They must in turn make their concerns known to their underwriters and demand that increases in benefits be realistic and regularly reviewed.

In the same way that we as Dentists must be current with regards to techniques, training, equipment, wages and asepsis, the insurance companies and their subscribers must recognize their obligation to alter their coverage with the times.  Failure to make this accommodation will eventually 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 are at risk.

In the best case scenario, the continued irrational use of antibiotics as “do something” treatment, contributes to the proliferation of antibiotic resistance. The consequences will probably not be apparent to clinicians in their middle or late career years. The problem will no doubt escalate in the future, as bacteria become more resistant and we are left with fewer effective drugs. Those of us prescribing in a haphazard manner may well be responsible for a situation where our children and grandchildren have fewer and fewer alternatives for treating serious bacterial infection in other, more critical areas of the body.

In the worse case scenario, a patient may undergo an anaphylactic reaction, possibly resulting in death. The chances of this happening are remote. But should that happen to your patient, and you are required to justify your prescription in a court of law, do you want an Endodontist to be forced to tell the court that your prescription was not indicated, ineffective and unsupported by any of the literature?

Responsible use of antibiotic therapy is part of good dental practice. Clinicians who are unwilling to take the time to properly diagnose and treat a problem or who are not able to make a definitive diagnosis should opt for referral. The use of antibiotics as scattergun treatment for problems of unknown etiology is poor clinical practice. Antibiotics are not “chicken soup” and clinicians should not use them in this manner.  They should not be used as a “Do something – dismissal tool” when you are too busy or are unable to make a diagnosis. When in doubt, refer the case to a specialist.