The PPO: All I Needed to Know with Just One Patient

The PPO: All I Needed to Know with Just One Patient

By: Dr. Ron Wilkins, DDS.

Have you ever felt like the whole world is going crazy around you? The older I get, the more often I seem to be having that feeling. I want to share a true story that illustrates this point.  Warning: This could turn into a rant. There are things happening in dentistry that no one seems to be talking about. I feel that someone needs to speak up, and it might as well be me.

I am a Kois trained general dentist who has been practicing for 32 years. For 29 of those years, my practice grew a little bit each year. I was never a participating provider on any plans during that time. In 2010 and 2011, my practice had a significant downturn due to many factors that I will not bore you with at this time. I reluctantly decided to join three PPO plans in an attempt to increase new patients and busyness. (Please stop laughing at me…We all have to learn lessons in our own way).

TRUE STORY

Prior to joining the plans in 2012, I did an implant, custom abutment, and crown for a very nice lady. The implant was well placed by my periodontist. The abutment and crown were done by my premier lab. The work was impeccable. The fit, contacts, occlusion, and esthetics were outstanding. The fee for this dentistry reflected the fact that it was performed by a world-class lab. The patient and I were both very pleased with the result.

About two months later, the plans we joined became active. The same patient called and said, “This is great!  You are on my plan now, and I can do the crown on the other side.”  I initially thought this was a good thing. A patient was going to do some dentistry she wasn’t planning on doing, simply because it would be less out of pocket for her. Wasn’t this the reason I joined the plan? Wasn’t being busier a good thing?

So, we did the crown. Due to the meager reimbursement, I used my local lab. Our fee and the lab fee are less using this lab. The crown turned out fine. It wasn’t as nice as the implant crown. However, the fit, margins, contacts, occlusion, and esthetics were all acceptable.  It will be a functional crown for the patient for many years.

When we got the insurance payment, and did the adjustments, we had written off 33% of our standard crown fee. This of course wiped out all the profit on the procedure. I wasn’t happy about this, but, I had made the decision to give this my best effort. I know practices on multiple plans and they find a way to make it work. I would just have to be more efficient, right?

THE REVELATION

Something kept bugging me. It wasn’t just the huge write-off of my already more than reasonable fee. Something just kept nagging at me, it just didn’t feel right. Then it hit me…as long as the patient and I are on the same plan, she can never again have the level of care she received on her implant crown. I can’t offer it to her even if she wants to pay for it herself. The contract states member dentists cannot charge over and above the plan fee schedule, even if the yearly limit has been met!

One of the things I have been taught is that as a doctor it is my duty to help the patient determine the level of care they desire. What the plans are in effect doing is determining both the level and type of care a patient can receive by restricting reimbursement, and contractually tying the doctor’s hands. I don’t think most people realize that they are trading away freedom of choice for the promise of less out of pocket expense.

While writing this story I read an article that addresses this issue. (Wentworth 310).  “What are the Ethical Considerations in Accepting Lower Reimbursement?”  I quote the final lines:

            “…If you feel that a third-party contract prevents you from caring for your patients fairly or limits your ability to treat them in the same way you treat your other patients, you may want to consider opting out of the contract.”

“The ethical bottom line is that all patients should be offered the same treatment options and given the same quality of care, regardless of level of  reimbursement.”

This makes absolute sense to me.  But I feel like I am in the minority.

THE RANT

(Here are some of the reasons I feel everything is going crazy.)  We have everyone from the President of the United States to the ADA telling us that managed care is a good thing for dentistry because it increases “access to care”.  No one seems to address the quality of that insurance modulated care.  Here are several other things no one seems to want to bring up:

1.  Dental insurance is nothing like medical insurance. Dental insurance is more like a coupon that is good for $1000-1500 per year. (Thanks to Mac Lee for this analogy).  It is a coupon with many restrictions: Yearly limits, deductibles, co-pays, waiting periods, restrictions on where you can spend your coupon, and even how much the doctor can charge for treatment. None of these restrictions increase “access to care”. They do, however, increase the profit for the insurance companies.
2. We now have a system that encourages third parties to run our health care system.  The insurance companies have done a masterful job of convincing people they can’t do any level of dentistry without insurance. The plans continue to work very hard to make sure that this actually becomes the truth. They want their cut.
3. PPOs collect the premium (paid by the employer in most cases); the co-pay is paid by the patient, the plan sets the fees to their own advantage, and offers the patient a “discount” taken directly from the dentist. What a sweet deal for the insurance companies!  They make the rules, and have no skin in the game. And yet, most people think they are the good guys because they “provide” dental insurance… While we scramble around trying to do a good job with diminishing reimbursement…CRAZY!
4. Many of the so called studies about access equate the presence of insurance with access to care. They are not the same thing. One would think our esteemed organized dental leaders could come up with a system that really did increase access to care, while at the same time not taking away choice of care. I guess there is just too much money in this game for truly creative thinking.

I realize that most of what I have said is already too little too late. I don’t think we are really going to have much of a chance to change the direction of the tsunami of managed care.  However, for myself, I am going to try to keep practicing in the way I have been trained.  I may go broke doing it, but I am getting off the plans and I will continue to recommend the treatment to patients that I feel is in their best interest. I realize the market for this type of dentistry is shrinking, but I will attempt to eke out a living on my own terms.

This diatribe has not been about returning to “the good old days”, whatever they were. Presently, there is a monumental effort being made to drive all patients into the world of PPOs. That side will garner the most dentists and patients. However, I believe there will still be a smaller group of people who need or want a level of dental care PPOs cannot provide. Regardless of the side you end up serving, it will be hard work to make a living.  On the managed care side you will face increased competition and decreasing reimbursement. On the fee for service side, you will see a shrinking patient base as managed care grows.

Thank you for letting me vent my feelings about some of the changes being imposed upon our profession. Each of us will have to deal with these issues in our own way. We will also need to develop the wisdom to recognize the things we need to change; while preserving the things we shouldn’t change…like our core values.

“Convert change from enemy to ally by understanding when to enjoy the exhilaration of change and when to fight it and steadfastly defend the unchangeable.”  Rabbi Daniel Lapin

References:

Wentworth, Rod B. “What are the Ethical Considerations in Accepting Lower Reimbursement?” The Journal of the American Dental Association. March 2013 144(3): 310. Print

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