As I follow the debates about Obamacare: about rising health care costs, about insurance, about coverage and denials and debt, I've often found myself drawn into the side questions and stories about dental care. I've followed these with interest, because of my experiences working the "front desk" at a small dental office several years back, and the privilege I had of working for an outstanding dentist who was truly dedicated to patient-based care. I'm hoping my story can add a helpful perspective. Please follow me past the fancy orange grille into our office for more...
Several years ago, I worked for a while at a small-town dental office. There were two dental offices in town. The other one, run by a father-son team, took everyone: they were on everyone's PPO list, they took all the emergencies, they ran orthodontia, periodontia, dentures, anything you needed in your mouth. The word in town was that patient care was not exactly a guiding value at their office; they depended on volume instead. Let's just say we got a lot of their botched cases and angry clients.
My dentist viewed things differently. Above all, he was dedicated to the true care of his clients, as patients and as people. He embraced a holistic approach to dentistry that knew the teeth were integral to the body. He ran an interdisciplinary study group with a wide variety of dental and medical providers. He specialized in the treatment of TMJ, refusing to accept that jaw surgery or a lifetime mouth guard was the only answer, and networking with a wide variety of medical peers to restore the clients to positive overall health. His work was beautiful, but he was not a cosmetic dentist: form simply followed function. As the teeth, bones, and muscles of a pained and twisted mouth relaxed and gained normal function, the client's smile and face transformed. It was a true joy.
Primarily a family dentist, my dentist emphasized continual care and overall good health. He worked hard to educate his patients. Those who repeatedly refused to care for their teeth, expecting he could fix their neglect, he might gently refer to the other dentists' office. For trusted patients, though, he'd drive over in the middle of the night if he needed to, to respond to a dental emergency. He wanted to build relationships, not just fix teeth.
One important though often uncomfortable part of patient education, which fell mostly to me, was dental insurance and the cost of care. Because he was patient-focused, my dentist refused to be controlled by any fee schedules associated with being "in-network", though he accepted assignment of benefits from any insurance company willing to pay. Dental insurance rarely paid the full cost of dental care, not even routine cleanings; as a result, my dentist wanted every client to pay up front, and then later, receive (partial) reimbursement from their insurance. As this would cause significant financial strain for many of our middle- and working-class patients, we made reasonable estimates of what their effective "co-pay" would be (the part we calculated the insurance wouldn't cover), and allowed them to pay just that portion up front. This greatly reduced our accounts receivable from the previous years, when clients were not asked for their co-pay until after the insurance had paid (or not), the balance was due, and unsuspecting patients were furious their insurance hadn't paid as advertised.
Why didn't insurance fully cover even preventive care? Was the dentist simply enriching himself? Is this an example of why health care costs are skyrocketing?
Let me first explain a bit of the ongoing struggle we faced with the insurance companies as we sought to provide true patient-based care, and the Orwellian language the companies used. Insurance companies make fee schedules, based on the codes for all the different dental procedures. These schedules show what the companies accept as the base price for each procedure, and the percentage of that price they will pay. Depending on the plan, some or, perhaps, many of the procedure codes may not be covered, regardless of what the plan language claims. The insurance company calls their accepted prices "customary" or "necessary and reasonable". What does that mean? It doesn't mean that those prices are actually necessary or reasonable, or that other prices are unnecessary or unreasonable. It certainly doesn't mean they are really customary, because each company has its own fee schedule, and they often vary widely. (Some companies claim they survey dentists to get average fees, but despite knowing all the providers within a wide radius, we knew nobody who charged so little.) No: it simply means that those prices are what the insurance company has determined are the minimum they can pay and still get away with convincing people to buy their insurance. Even better, insurance companies almost never publish their fee schedules. It's a guessing game. We aggregated claim payment data and used it to forecast what each company might pay for current or future treatment. However, there was no telling when a company might change their fee schedule, or even change what procedure codes they considered "eligible". Furthermore, procedures lumped under the same code are not one-size-fits-all: a filling may be quick, or it may become incredibly complicated and time-consuming (say if a person generates a lot of saliva, or if his/her teeth are somewhat unusually shaped) - yet the insurance company insists there is only one "allowable" price to pay for each code. Adhering to a fee schedule makes it very difficult to customize care to a patient's true needs.
Insurance companies also determined how often they would pay for certain procedures or codes. This sounds reasonable, but in reality it had nothing to do with billing fraud or clients' health and everything to do with trying to avoid paying for needed care. Most dental insurance plans cover two cleanings per twelve months, or one every six months. If a patient has periodontal (gum) disease, or a very dry mouth caused by certain medications, most dentists will recommend cleanings on a 3- or 4-month cycle to prevent gumline cavities or infections. When the insurance company refuses to pay, the company says these "extra cleanings" are not "necessary and reasonable" - even though they are preventing the patient from incurring gumline damage and costly follow-on treatment of fillings, root canals, implants, dentures, etc. (not to mention medical impacts such as heart disease). For another example, many plans limit the number of office visits with the dentist him/herself. While one or two visits a year may be sufficient for most patients (in conjunction with cleanings, typically), what if the patient gets a tooth knocked out in a basketball game, or starts clenching at night, or simply has a question about his/her oral health? The insurance company says such consultations with the dentist are not "necessary and reasonable", but surely they are, from a patient care perspective: really the company is just saying it doesn't want to pay. I spent a lot of time on the phone arguing with insurance companies. I knew their policies backwards and forwards. It was tiresome.
This plays out in more significant ways as well. Sometimes a tooth doesn't need a buildup and a crown - a large and well-constructed filling is best for the patient's needs. Many companies will say that, if that tooth has had a filling in the recent past (varies by company - one to five years was standard), it is "not medically necessary" to put a new filling on that tooth. My dentist used to get very angry when the insurance companies would deny claims by stating the work was "not medically necessary". My dentist called it practicing without a license. I spent a lot of time explaining to patients that "not medically necessary" had no bearing on whether or not the procedure was truly medically necessary, and that such a statement of denial from their insurance company did not mean the dentist was lying to them in his recommended treatment plan. It simply meant their insurance company didn't want to pay. Dental insurance companies also play the same cap game as their medical counterparts. Most dental insurance has an absurdly low annual cap. Back then, a single root canal/buildup/crown could cost around $2000 all together. Even with the insurance companies' lowball fee schedules and 50% payment on "major" dental work, a single crown and a couple of cleanings could max out a person's dental insurance for an entire year. Need another filling? Dental emergency? It's on you.
Finally, I mentioned earlier that my dentist specialized in treatment of TMJ and other challenging myofascial pain. The "standard" remedy for severe TMJ is jaw surgery, which can be invasive, harsh on the body, very expensive, and have a limited success rate. However, most insurance companies considered surgery the "accepted" treatment. TMJ falls in that horrific black hole between medical and dental insurance. Most dental insurance considered it a medical issue no matter what, and nearly all medical insurance considered anything mouth-related, other than full-fledged jaw surgery, to be dental. In addition to causing chronic pain, headaches, affected vision, and problems eating, speaking, or even sleeping, TMJ can ruin a person's teeth over time, with clenching, grinding, and an uneven bite wearing away the occlusal surfaces in ways the teeth weren't designed to protect against, or causing cracks and pain in the teeth leading to root canals and other major dental work.
My dentist coordinated with his network of specialists to develop a comprehensive, patient-based treatment plan for serious TMJ sufferers that could involve massage therapy, osteopathy, an orthotic (special bite guard designed to protect teeth and restore proper jaw function), orthodontia, periodontia, oral surgery, implants, and traditional restorative dentistry. This sounds expensive, and sometimes it was - but it was far less expensive than jaw surgery, nowhere near as invasive, and nearly always successful - it was the best patient-based care in many circumstances. It restored function and often created the "side effect" of a beautiful new smile. However, the insurance companies refused to pay. Dental said it was medical. Medical said it was dental. They both said there wasn't proper "evidence" for the procedures being performed - for example, if no decay was present on a tooth, insurance claimed there was no need to work on it - even if the work helped restore proper jaw position and function, obviating the need for surgery. As a result, most of these comprehensive cases were paid in cash, sometimes with payment plans over time (the work often took years anyway, as after each step we waited for the body to adjust and recover). One patient, a lawyer, went so far as to sue her medical insurance company for refusing to cover such alternate, less-costly treatment when they insisted again and again they would cover jaw surgery. Their official denial letters kept telling her that the treatment she was receiving was "not medically necessary".
It is probably not surprising that a number of our patients dropped their dental insurance or spoke with their employers about obtaining a better plan. We turned many of them into health advocates, inspired by their dentist's devotion to them and their overall health.
So why was our dental care so expensive? And - was it really so expensive? My dentist was a well-educated man, but by this point he had no college loans, his children were grown, and he owned the small property where his office was located. Yet: he was what we would call now a progressive business owner, and he believed that good employees fostered better patient care. First off, and perhaps most importantly, he ensured that all of us received a living wage - the dental assistants, the hygienist (who worked on commission), me, and even his wife, who would help out during busy periods. Additionally, we received benefits including an HSA, paid vacation time that increased (up to several weeks total) based on years worked, and 401(k) matching funds. We also received overtime when we deserved it, no questions asked. In fact, often, if we wanted to work more, we could. Because the dentist knew that better-trained and educated employees would provide better patient care, he paid us to attend his peers' study-group training and other professional development. We also received a nearly inexhaustible amount of free dental care for ourselves and our families each year. Remember - this was a very small town in a rural area. If I had to guess now, I'd say there was a dwindling old guard of union Democrats, going quickly as the union plants closed; and a growing new guard of rural low-income Republicans. Against these headwinds, my dentist treated us with respect, because he cared about us as people and wanted us to give the best care to his patients.
We ran a lot of the office on a shoestring - though spotless and fully functional, it had not been remodeled in years and years. The dentist did not have the latest fancy tools. He made his own models and orthotics. And he took time with the patients. He was constantly busy, but he never rushed. He was not afraid to ask me to reschedule appointments if he needed extra time with a patient to ensure they received the best, most appropriate care. He met personally with just about everyone who came through the door, ensuring he fully understood their circumstances and often, by listening, coming to a much more accurate diagnosis. Many providers order a stack of tests. My dentist simply listened.
The dentist was, of course, fully licensed. He used a very talented local lab (actually a guy who had turned his garage into a lab) to prepare his crowns, bridges, and other dental work. He carried insurance, and he paid all the requisite taxes for us, and for his business (no treating employees like "independent contractors"). He had taken a number of charity cases for years when he was younger and more idealistic; but the state dental plan (long gone) and other government dental coverage had completely dwindled away, and he found to his chagrin that it was far too expensive to continue working for free. Still, he never turned down an established patient in need for lack of his/her ability to pay. For example, he created beautiful, highly complicated partial dentures and bridges for an elderly client with an incredibly complex bite - and never charged her a dime more than she could afford. The dentist always paid himself last: we employees were first, then business expenses, then a savings fund for future renovation of the office (note: he was not planning to take on debt and then pay interest on it, ultimately saving quite a bit of money), and finally himself. If money ran short in a month, he took the hit.
Our clients were very loyal, though a few of them - often the most well-off - would conduct dental tourism to obtain work in Mexico, or other countries, at a fraction of our prices. The work sometimes was very beautiful and durable. Although their dental tourism challenged our continuity of care, we understood why some people chose to go elsewhere. We knew there were solid reasons why comparable dental work is more expensive in the US, even when the dentist is being very fair - or perhaps, because the dentist is being fair. The cost of living is higher here, by far. Wages, benefits, insurance (liability, fire, etc), licensing, lab work, utilities, equipment, rent/property taxes, education (dental/hygienist/assistant training) - as well as roads, streetlights, running water, stable electricity. Even something as simple as hiring someone to come clean the offices is a fraction of the cost in other countries as it was at our office - in small town America. I'm sure in large US cities the costs are far greater. And it is more expensive to provide patient-based care than to run people through a dental assembly line.
With such inequality in standard of living, the only way we could "compete" with medical tourism in developing countries would be to run our dental office like it were in a developing country. But do we really want to deal with the effects of deregulation? Lack of licensing? Minimum wage and no benefits for the staff? Should we tear up the streets and push half the city into slums? Certainly, some big-government programs such as health care, infrastructure investments, and education credits will help reduce the cost of dental care at the provider level. Getting as far away as we can from the for-profit insurance agencies would lower costs, too, as (for one) we wouldn't be constantly arguing with them to get them to pay up. And equally, I am sure there are plenty of profit-driven or profit-influenced offices out there that are trying to beat the insurance companies at their own game by overbilling or fleecing clients.
But I believe that as we engage in these national discussions about managing health costs, we must remember first that dental care is integral to holistic medical care; second, that insurance companies are always out to make a profit; third, that the costs of doing business in a first-world country are unavoidably higher than in less-developed nations; and finally, that true patient-focused care takes time, and is never "one size fits all". Above all, in our efforts to extend health care nationwide, we must avoid a race to the bottom that unfairly punishes our fellow Americans working in the "blue collar" jobs of the medical profession by slashing their wages and benefits as the low-hanging fruit of cost-cutting.
UPDATE: terjeanderson makes a great point in the comments about federally funded community health centers, many of which provide dental care. Here is a link to find one near you: Find A Health Center
I have been out of the dental world for years, but another option for lower-cost dental care may include a dental school or hygienist/assistant training school nearby. If you know of a nearby place of worship that sends mobile dental clinics to developing countries, it might be worth asking if they can host a local clinic as well. If you know of other options, please add them in the comments.
It may seem silly to say, but diligent home care (regular flossing and brushing) can help keep the dentist away, too :) For far less than the cost of a filling, your dentist can prescribe prescription-level fluoride toothpaste - which is a real lifesaver for those with dry mouths, perhaps due to medications. Electric or ultrasonic toothbrushes may be very helpful for those with limited manual dexterity. Placing sealants on kids' teeth (as chimene points out) can help prevent cavities for years to come.
Finally, ask questions at the dental office. It can be uncomfortable to speak up, but make sure you understand what care you're getting, why, and what it will cost. Ask to see the X-rays and have the dentist or a staff member explain the treatment they recommend. Get a second opinion before committing to large treatment plans. Ask the front desk to calculate your co-pay or obtain a predetermination from insurance. If you have insurance, read the policy/plan language carefully and negotiate with the insurance provider if necessary - as the insured, you have a much stronger bargaining chip than the dental office does. If things don't feel right after the treatment, tell your dentist - searing pain, for example, may be as simple as a new filling with a slightly new surface shape that threw off your bite, and often can be fixed very simply without additional cost. If your dental office resists you being an informed patient/consumer, it may be time to look for other options - trust and good care go both directions.