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Letters: Apprehensive about the future

January 20, 2015 I am a dentist in New Jersey with 30 years of private practice experience. I am concerned about the future of our profession. My concern is both the less than subtle influence of dental insurance as well as the lack of lessons learned by many of our colleagues. Medical professionals are virtually out of the loop in many health care decisions that are controlled by health insurance companies, the government and now hospital networks, in my opinion. This is partially the result of allowing health insurance companies to dictate terms of their reimbursement for care.

In what is the perfect storm of high tuition costs for graduating dentists, large costs to set up and operate a dental office with up-to-date equipment, a slow economy and a health care environment where patients feel they either need to or benefit by going to a participating dentist. There is lack of some or all freedom in choosing dental insurance, which is almost always determined by the employer.  

Historically, dental insurance has been a double-edged sword for dentists. By paying a substantial portion of dental costs for patients, our patients have been willing and able to achieve a higher level of oral health, and dental care has been more affordable. Over the years, dental insurance companies have found many ways to reduce their costs to both lower premiums and increase profits by lowering reimbursement to dentists. Initially, most dental insurance plans were of the now obsolete UCR variety. UCR was short for usual, customary and reasonable fee and originally this was a fair description. By the time I graduated dental school in 1983, while this term was still used, the fees set were often arbitrary and this evolved into the preferred provider organization model of dental insurance. Insurance companies were still not happy with the risk vs. profit ratio, so the next model was the dental maintenance organization model (the dental version of a health maintenance organization), which essentially shares the risk between insurance companies and dentists while still cutting dental insurance company costs. I particularly disliked the DMO model, since a dental office would be most financially successful with this type of patient by never treating them or encouraging a minimal level of dental care and oral health.

Dentists and patients share in the choices made, and I cannot fault insurance companies for their desire to be profitable. Patients are often not educated and unaware of the issues involved in dental choice and reimbursement. I am concerned that may no longer be the case for many dentists and both these dentists and their patients will suffer. A private dental office must operate as a for-profit model, and I see the future as the growth of group if not corporate dental practice at the expense of solo practice, which will be a natural evolution to control costs. As a dentist, I am both a small business owner and a dental professional. I have always had the luxury of making my clinical decisions without regard to my bottom line. I am concerned that may no longer be the case for many dentists and both these dentists and their patients will suffer. As an organization the dental association should do everything possible to preserve an environment to allow dental choice for quality dentistry.

I am aware of the antitrust laws that exist and how this gives insurance companies an advantage over dentists. I do think the time has come for the ADA to start rating insurance policies to both guide and inform patients, and their employers. My suggestion would be a zero to five star rating system based on the coverage offered and the reimbursement rate for patients and to dentists, including the maximum paid. No judgment needs to be made, and this will educate patients and employers to a degree. Dental insurance choices can be intelligently made. A precedence for this exists in the rating of health insurance plans in the Affordable Care Act. This will no doubt require work on the part of the organization, but the benefit would be enormous for our profession, organized dentistry overall and our patients.

Jeffrey Mermelstein, D.M.D
Livingston, New Jersey