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Medical Forum / General / Dentistry / December 2004Quality of Service vs. Insuarance Plans
Both dentists who I have gone to had excellent reputations. Neither accepted any kind of dental insurance. I was told by both that if they contracted with cigna or aetna etc. that they could not afford to provide the quality of skill or lab work. The insurance companies would only reimburse them for a fraction of what the would charge and they would need to wait for payments (hassles) for a long time. My question is this.. Do you agree that a good dentist cannot survive if he accepts any of these insurance contracts. Is the lab work as professional as it would be if the dentist was collecting full payment from the patient instead of getting paid maybe half from the insurance company? I'm sure you have some comments on this touchy subject. Personally, I pay alot more because I am self insured as a patient. There are plans that I could have joined where everything was covered but I would have to use one of "their" dentists. My bills are high and I often question if I made the correct decision. Regards, Ken >Both dentists who I have gone to had excellent reputations. Neither >accepted any kind of dental insurance. I was told by both that if they >contracted with cigna or aetna etc. that they could not afford to provide >the quality of skill or lab work. This is known as INSURANCE INDEPENENT DENTIST in the business. I'd say this is 10% of dentists (a guess). How come all dentists are not insurance-independent? In many practices, the patients do not have the cash flow to pay the dentist first and then get reimbursed. Others have very poor credit and are not to be trusted with the insurance check without payment to the dentist. Sorry. So many dentists must accept assignment (redirect the check to the dentist) and in addition, some are participants which is a different category. Participants must adhere to "a fee." Is it a fair fee? It depends on the insurance and it depends on the type of practice. For example, you can send me Connecticut General patients CIGNA all day long. >The insurance companies would only reimburse them for a fraction of what the >would charge and they would need to wait for payments (hassles) for a long >time. > >My question is this.. Do you agree that a good dentist cannot survive if he >accepts any of these insurance contracts. Depends on his overhead and his type of practice. There are good dentists in all categories, perhaps more bad dentists under the El in Kensington. But then again, a colleague is a very excellent dentist is that setting. > Is the lab work as professional >as it would be if the dentist was collecting full payment from the patient >instead of getting paid maybe half from the insurance company? Hah! Paying more is no guarantee of quality! Far from it! >I'm sure you have some comments on this touchy subject. Personally, I pay >alot more because I am self insured as a patient. There are plans that I >could have joined where everything was covered but I would have to use one >of "their" dentists. My bills are high and I often question if I made the >correct decision. YUP and it keeps changing. I always spoke against the controlling of fees until things got so out of hand! Joel >Regards, Ken > Both dentists who I have gone to had excellent reputations. Neither > accepted any kind of dental insurance. I was told by both that if they [quoted text clipped - 6 lines] > My question is this.. Do you agree that a good dentist cannot survive if he > accepts any of these insurance contracts. Disagree strongly. Steve Is the lab work as professional > as it would be if the dentist was collecting full payment from the patient > instead of getting paid maybe half from the insurance company? [quoted text clipped - 6 lines] > > Regards, Ken >> My question is this.. Do you agree that a good dentist cannot survive if he >> accepts any of these insurance contracts. > > Disagree strongly. > >Steve I agree with Steve. Joel > Both dentists who I have gone to had excellent reputations. Neither > accepted any kind of dental insurance. I was told by both that if they [quoted text clipped - 6 lines] > My question is this.. Do you agree that a good dentist cannot survive if he > accepts any of these insurance contracts. A good and honest dentist can survive and thrive, but as you may guess, the profit margin is lower. The problem is that when there is a lower fee, too many dentist's are tempted to cut corners, take shortcuts, add on services that you may or may not need. They want the same profit from the lower fees, and this means the patient suffers. Does this mean everyone who accepts a policy or plan does so? No. Keep in mind that many of the doctors who will tell you their high fees are an indicator of the quality work are selling you a bill of goods. Their skill may be in marketing rather than dentistry. I practice in a large city, and have seen a handful of patients formerly cared for by a dentist who charges what I feel are obscene fees. He is always lecturing on how to run a high fee, high quality practice, yet the work I have seem from his office is average at best...certainly not worth what people have paid. Bottom line is that yoiu can get good and bad under both systems > Is the lab work as professional > as it would be if the dentist was collecting full payment from the patient > instead of getting paid maybe half from the insurance company? Not always. > I'm sure you have some comments on this touchy subject. Personally, I pay > alot more because I am self insured as a patient. There are plans that I > could have joined where everything was covered but I would have to use one > of "their" dentists. My bills are high and I often question if I made the > correct decision. As my earlier comments indicate, that is hard to tell. High cost does not always equal high quality, nor does lower cost universally mean low quality. T > . > > [quoted text clipped - 4 lines] > profit margin is lower. The problem is that when there is a lower fee, too many > dentist's are tempted to cut corners, take shortcuts, add on What kind of shortcuts? I'd really be curios to know what those shorcuts are. How many ways can you place a filling given the same level of manual dexterity. Ad on tests I could imagine, such as testing the patient for "vitamin C deficency". >What kind of shortcuts? I'd really be curios to know what >those shorcuts are. How many ways can you place a filling >given the same level of manual dexterity. Ad on tests I could imagine, >such as testing the patient for "vitamin C deficency". HAH! Shortcuts? 1,000 ways ...... of just placing the matrix band! Joel You tell me the procedure and I will give examples of shortcuts .... Well, I suppose there is cleaning or drilling out the decay before placement then setting the matrix as you call it and then carving and condensing the amalgam before placement. I'd be most interested in shortcuts that would affect the material composition of thel amalgam or cause it to crack. But I guess if there where gaps between the amalgam and the tooth that would invite decay also. I've got a copy of my old x-rays somewhere. When I get the chance I'll scan them in and you can tell what shortcuts may have been taken. >Well, I suppose there is cleaning or drilling out the decay before >placement [quoted text clipped - 4 lines] >crack. But I guess if there where gaps between the amalgam and the >tooth that would invite decay also. Very very simple. Excellent condensation of amalgam restorations is very important. Sophisticated patients are aware. If one "pats in" the amalgam, FORGET IT. I personally use a vibrato (think violin player) technique to vibrate in and FIRMLY condense the pliable amalgam. Upper is easier as the head is stationary while the lower requires my supporting of the jaw. Yes, the pressure is almost firm enough to UNSEAT the patient. Now patients know and appreciate that these amalgam restorations are in there for 30+ years. YES this takes more time (2 minutes) and not doing it is quicker, but it mainly comes from the dentist not understanding HOW rather than any malicious intent. If someone watches me once or twice, they got it! About cracking ....... next ... if I am on the right track here..... Joel >I've got a copy of my old x-rays somewhere. When I get the chance I'll >scan them >in and you can tell what shortcuts may have been taken. > Excellent condensation of amalgam restorations is very important. > Sophisticated patients are aware. [quoted text clipped - 12 lines] > it mainly comes from the dentist not understanding HOW rather than any > malicious intent. If someone watches me once or twice, they got it! Interesting. I'm surprised that they wouldn't teach those techniques in dental school. >From my understanding when you do condense (apply pressure to) the amalgam Hg rises to the surface so I assume you remove the filling and carve the excess off. But, wouldn't that destroy any good fit you had achieved using that method unless you repeat the process many times. Well, obviously this is a complicated issue. > About cracking ....... next ... if I am on the right track here..... Yeah, how on earth could a dentist place an amalgam that would be more likely to crack?...seems impossible.. >>From my understanding when you do condense (apply pressure to) the >amalgam Hg rises to the surface so I assume you remove the filling and >carve the excess off. But, wouldn't that destroy any good fit you had >achieved using that method unless you repeat the process >many times. Well, obviously this is a complicated issue. Precisely. As you work the amalgam, the mercury "puddles" up to the top. This is good. I want to suck out excess mercury. As I am doing this I am using a squeeze cloth to create drier and drier increments ........ that absorb the mercury! Joel Yes, this is done incrementally ......... it literally takes 3 minutes though. >>>From my understanding when you do condense (apply pressure to) the >>amalgam Hg rises to the surface so I assume you remove the filling and [quoted text clipped - 9 lines] > As I am doing this I am using a squeeze cloth to create drier and > drier increments ........ that absorb the mercury! We now return from the year 1958 >>>>From my understanding when you do condense (apply pressure to) the >>>amalgam Hg rises to the surface so I assume you remove the filling and [quoted text clipped - 11 lines] > >We now return from the year 1958 TRUE! This is from a bygone era. Joel You don't use that procedure with capsules or the cheesecloth. You still have to condense the amalgam after it is mixed don't you? >You don't use that procedure with capsules or the cheesecloth. You >still have >to condense the amalgam after it is mixed don't you? ALWAYS ... so that it crunches into the cavity. It makes a cool crunching sound. Joel >ALWAYS ... so that it crunches into the cavity. > >It makes a cool crunching sound. > >Joel Except if you use a sperical alloy. -- W_B wubbabubbazG@RBAGEyahoo.com Take out the G'RBAGE >>ALWAYS ... so that it crunches into the cavity. >> [quoted text clipped - 3 lines] > >Except if you use a sperical alloy. RIGHT. Then it makes a cool bouncing sound ..... >>>It makes a cool crunching sound. >>> [quoted text clipped - 3 lines] > >RIGHT. Then it makes a cool bouncing sound ..... <spherical> -- W_B wubbabubbazG@RBAGEyahoo.com Take out the G'RBAGE >Interesting. I'm surprised that they wouldn't teach those >techniques in dental school. They most certainly do ... or DID! You know, if its not a complete makeover, its hard to catch the attention of many dentists ...... Joel Every single procedure is a learned skill, including how to mix and then vary the concentration of mercury within the mix AS you fill the tooth. Too much mercury and its a lousy filling. We dentists can spot a poor mix twenty years later! > We dentists can spot a poor mix twenty years later! Sometimes the patients can tell too, after 10 years, without even looking at the filling. > Do you agree that a good dentist cannot survive if he > > accepts any of these insurance contracts. [quoted text clipped - 4 lines] > may or may not need. They want the same profit from the lower fees, and this > means the patient suffers. That doesn't seem right. The patient has to evaluate the dentist AND the insurance company contract. Why accept a contract at all if you can't do good work. In fact if a large number of a dentists patients where under cheap insurance contracts and received cheap work that would in my mind constitute fraud. On the other hand if a small percentage had such coverage it would take a pretty greedy person to give those patients poor treatment for a few extra bucks, considering that many patients would be unaware of the differences. >That doesn't seem right. The patient has to evaluate the dentist >AND the insurance company contract. Why accept a contract at all if >you can't do good work. This is the conundrum in which many dentists find themselves. There is a ridiculous discount dental plan around here with 616 providers signed up for it. So you get a couple of patients and then, they think they need the $43 filling but you tell them they need the $4,000 crown, root canal, crown lengthening etc. Now the dentist is not lying ... WELL NOT in most cases anyway. If you do not accept the plan, you MISS the referral altogether. That's a crummy system isn't it? Its partially the dentists' fault, partially the business guys' fault. Joel > received cheap work >that would in my mind constitute fraud. Fraud is extremely tricky unless you sell corporate bonds and there is no corporation or something like that. Malpractice? That is tough too. Dentists will mostly PERFORM well. That's accountable. If someone does not have the skills or the desire, the State Board will catch up with him or her eventually ..... Joel > That doesn't seem right. The patient has to evaluate the dentist > AND the insurance company contract. Truth is that very few dental patients can evaluate dental treatment for QUALITY. Is the dentist pleasant? Is the staff helpful and polite? Is the office clean? Is treatment rough or painful? Are teeth painful after treatment? Are esthetics acceptable? Those questions can be answered honestly by a lay person. For the stuff that really counts, you haven't got a clue. Judging decay removal, tooth preparation, diagnostic skills, material selection, bonding techniques, sterilization procedures, honesty in treatment recommendations, selection of labs, impressions, root canal cleaning, shaping, and obturation, legal delegation of treatment to assistants, etc. are way beyond the patient's abilities to assess. There are some excellent dentists that have a hard time developing a successful practice. There are some lesser skilled dentists raking in the dough. It would take another fairly long post to deal with some of the insurance issues, and we have been over those several times in the last year already. Fawks That's obviously a lose/lose proposition for the public and those dentists who are higher quality but have problems developing a practice. I know I wasn't aware of many of these issues. I always figured the tooth itself was basically inert (wrong) and that it couldn't make too much of a difference how the stainless steel filling was put in as long as it didn't fall out or too much of the tooth wasn't taken off. I will say that the dentist I went to was brought in by an owner with an excellent reputation himself and he (my dentist) actually graduated from Georgetown so quality of care was never an issue in my mind. However these issues are obviously always present. >That's obviously a lose/lose proposition for the public and those >dentists who >are higher quality but have problems developing a practice. I know I >wasn't >aware of many of these issues. YES younger dentists have trouble competing, unless they have street smarts, or are not within a competitive area. Joel >There are plans that I > could have joined where everything was covered but I would have to use one > of "their" dentists. My bills are high and I often question if I made the > correct decision. (I have told this story several times here, so the regulars will just have to bear with me for a moment) It is virtually impossible for the average dental consumer to evaluate the quality of work that their dentist does. So you have to base your decision on other factors, like a "gut feeling" or the quality of the magazines in the waiting room, or the Yani background music. I am an exception to that rule because my wife works in a dental lab and sees the work done by a variety of local dentists. Some are consistantly better than others. Like you, my employer gives us dental insurance which comes with a little booklet of providers. Every time, I send that little booklet to the lab with the request that they circle all the good dentists, and every time it comes back to me with no marks on it! Does that tell you something? Vaughn > Regards, Ken >>There are plans that I >>could have joined where everything was covered but I would have to use one [quoted text clipped - 18 lines] > > Vaughn I have some patients that are consistently nicer, cleaner and more pleasant to treat. I'm not telling you their names either. ;-) Steve >>Regards, Ken > I have some patients that are consistently nicer, cleaner and more > pleasant to treat. I am sure that is true. It is the nature of humans and the 'ole bell curve. I'm not telling you their names either. ;-) I get your implication, but in this case they *would* tell me. The simple fact is that some dentists do technically better work than others, same as any other profession, same as any other group of humans. I have tried it both ways, and I am now a "fee for service" dental customer who ignores the HMO dental insurance I get for "free" at work. I go to one of those known "good" dentists. In the long run, I am convinced it is both the cheapest and best option. Vaughn > Steve > > >>Regards, Ken Wow, looking at the posting times you got a mouthful of great advice! What does self insured mean as you stated? Are you taking advantage of pre-tax $ to pay for dental/medical care? If so, you are probably money ahead assuming your dentist is even half honorable. I practice orthodontics exclusively as a specialist and do participate in most of the ins. co. *plans*. The financial scenario is a little different for me compared to those in general practice. Some of the economic dynamics have to be similiar though. Basically the decision has to be made to either work faster and not sacrifice quality, resign yourself to making less money, or work faster and perform subpar work. Fortunately, I can work a little faster and not sacrifice the quality. Not all can, need to, or are willing to try. A lot depends on the locale they practice in, and/or how good they are at selling themselves to the public (ie. not participating and making patients feel that both they and the dentist they see are special). Some can do this successfully with sincerity others do it successfully with selfish motives. How this relates to your original question of can you survive and participate is yes. What it means from my standpoint is I treat my patients and parents with respect. Try to keep them informed and do my best. What it does not mean is I spend the extra time I would have in a total fee for service practice out in the waitng room giving my patients mothers a virtual pat on the butt and telling them how smart their D student is. There is a distinct difference between treating you patients with informative respect compared to making them think they had nothing to do with paying for the water fountain in the reception area. carabelli >>There are plans that I >> could have joined where everything was covered but I would have to use one [quoted text clipped - 8 lines] >other factors, like a "gut feeling" or the quality of the magazines in the >waiting room, or the Yani background music. We agree Vaughn, except for the Yanni music of course! Joel > I am an exception to that rule >because my wife works in a dental lab and sees the work done by a variety of [quoted text clipped - 9 lines] > >> Regards, Ken If you are discussing HMO, DMO or PPO type insurance schemes, then you are right. Very few dental offices will participate in those plans and be able to stay in business while providing quality care. Most other plans allow the dental office to set their fees at a level representative of what it costs that office to actually provide quality care. The carrier may refuse to pay over a certain amount per procedure, but that is due to artificial limits set to insurance reimbursements designed to maintain the premium cost below a certain level.  Signature~+--~+--~+--~+--~+-- Stephen Mancuso, D.D.S. Troy, Michigan, USA .................................................... This posting is intended for informational or conversational purposes only. Always seek the opinion of a licensed dental professional before acting on the advice or opinion expressed here. Only a dentist who has examined you in person can diagnose your problems and make decisions which will affect your health. ...................... > Both dentists who I have gone to had excellent reputations. Neither > accepted any kind of dental insurance. I was told by both that if they [quoted text clipped - 18 lines] > > Regards, Ken > If you are discussing HMO, DMO or PPO type insurance schemes, then you are > right. Very few dental offices will participate in those plans and be able [quoted text clipped - 9 lines] > Stephen Mancuso, D.D.S. > Troy, Michigan, USA I think Mr. Mancuso addressed the question very correctly... When a dentist signs with a cigna, aetna etc he receives a fixed fee for certain services. I believe some insurance companies pay a "capitation" fee whereby they pay a fixed amount each month for each subscribed patient. They do not get reimbursed for exams/fillings etc. but do get compensation for crowns, RC etc. Here's an example.. I used to go to a Dentist in Norwalk Ct. who was an excellent dentist (by rep) of other practitioners. He never accepted insurance. Then one day I look in my corporate insurance program for the following year and I find his name under Cigna. I call him and ask what's the story. He responds that all the companies are into managed dental health and that he lost too many patients so he decided to sign up with the program. I go to see him (under the new plan) and he finds a cavity. I ask him to fill and he says it's better that he do a crown. He would not do a filling. Need I say more... that was my last visit. He would not have been compensated for the filling. Ken |
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