- Email: [email protected]
INSURERS AND MARKET POWER
L E T T E R S
consulting business is not intentional, this is an oversight that needs to be corrected. If intentional, perhaps Dr. Levin’s columns should be confined to the paid advertising section of JADA. Robert K. Thompson Jr., DMD Cohasset, Mass. 1. Reynolds G. An Army of Davids: How Markets and Technology Empower Ordinary People to Beat Big Media, Big Government, and Other Goliaths. Nashville, Tenn.: Nelson Current; 2006. 2. Levin R. The phenomenon of the “cashpoor” practice. JADA 2009;140(1):105-106.
Author’s response: I wholeheartedly agree with Dr. Thompson’s point about the importance of dentists being able to determine their own path and their own destiny. In fact, my whole concept of Level III and Level IV dentists is based on the idea of putting the right management systems in place so that dentists have control over everything that goes on in the practice. If this is accomplished, they absolutely can determine their own path and their own destiny. My article was not meant, in any way, to advocate for the same shift of power that physicians experienced during the last several decades. Rather, being able to move from a Level III leader to a Level IV leader means the dentist has a firm grasp of the business end of running his or her practice and has created an efficient business model. Creating a Level IV practice actually empowers the dentist to utilize staff members to their highest potential and enables the dentist to spend the majority of his or her time providing the highest quality of care possible to every patient. Once a dentist becomes a Level IV leader, which takes 832
JADA, Vol. 140
http://jada.ada.org
time and commitment, he or she is better positioned to enjoy his or her career, to provide excellent care to patients, to continue to grow the practice with much less stress and to achieve personal and professional goals. It is not about relinquishing control and power to anyone, including insurance companies and the government. It simply is an approach that I have seen work for hundreds of dentists during the past 24 years. My article was intended to help dentists better understand the opportunity for them to improve their practices and, ultimately, their career satisfaction. I thank Dr. Thompson for his passionate response and agree with him that dentists should control their own destinies. Roger P. Levin, DDS Chairman and CEO Levin Group Owing Mills, Md.
INSURERS AND MARKET POWER
Regarding Dr. L. Jackson Brown and colleagues’ January JADA article, “The Effects of Insurance Carrier Market Power on Dentists and Patients” (Jackson LJ, Guay AH, House DR. JADA 2009;150 [1]:90-97), it is my opinion that the authors captured the essence of the issue in their discussion of the concept of “market power.” If there is an abundance of dentists vying for shares within the marketplace, insurance companies have more leverage in their negotiations with practitioners. When dental insurance came into vogue in the 1970s and 1980s, this clearly was the situation. There were large numbers of dentists who were will-
ing to try nearly anything to get more patients into their chairs. This put the insurance companies into a strong negotiating position. On the other hand, dentists have the leverage when there is a relative shortage of practitioners. That is quickly becoming the case today. I will use my home state of Georgia as an example. When Emory University’s School of Dentistry closed its doors in 1988, the state was left with just one dental school, the Medical College of Georgia (MCG) in Augusta. MCG’s dental school graduates just 60 students per year to service a growing state of approximately 10 million people. Clearly, the relatively shrinking population of dentists will be in an ever-improving position to dictate terms to the insurance industry rather than having terms dictated to them. If we’re smart, the negotiated fee portion of the problem will self-correct. The portion of the problem that will not self-correct is the effect that the insurance industry has on the actual treatment decisions that we make. In my opinion, there is one glaring example that requires strong action on our part. When a patient is missing a tooth, the question becomes how, and if, we should replace it. If the teeth adjacent to the edentulous space are virgin or have conservative restorations (in other words, not in need of a crown), then it is my firm belief that a bridge is a disservice to the patient. I believe this to be true owing to the amount of natural and otherwise healthy tooth structure that must be removed from the abutment teeth. Continued on page 835
July 2009
Copyright © 2009 American Dental Association. All rights reserved. Reprinted by permission.
L E T T E R S
Continued from page 832 Assuming that there is an adequate amount of bone, or that osseous augmentation can provide an adequate amount of bone, an implant is a much better option in that situation. However, most insurance companies will not cover implants. Therefore, both the patient and the practitioner are put into a position of having to give more consideration to a bridge than they otherwise should. I find it regrettable, to put it mildly, that the insurance industry has almost unilaterally taken a superior option off the table. It is particularly confusing given that implants end up costing about the same as does a three-unit bridge. Furthermore, the success rates of implants are such that one can expect an implant to last longer than does a bridge, and absolutely no damage is done to any neighboring teeth in the process. This begs the question, what is the American Dental Association doing to influence the insurance industry to start covering implants in the same fashion as it covers bridges? What are state dental associations doing to lobby their insurance commissioners to mandate that implants be covered in their states? Matthew H. Folan, DMD
However, our experience has been that the efficacy of any given treatment is not necessarily the determining factor in benefit design for insurers. The ADA can use evidence-based dentistry or best practices to advocate for benefit design, as Dr. Folan suggests, but what drives coverage is a business model based on cost. The most likely impetus for more widespread implant coverage would be patient and employer demand for the service that gives those carriers who provide it a market
position superior to that of those who don’t. The National Association of Dental Plans’ March 2009 report, “The State of the Dental Benefits Market, 2008,”1 states that 72 percent of employers are looking for dental implant coverage in their dental plans. As long as employers are willing to pay for the coverage they want, we may see an increase in dental implant coverage. 1. National Association of Dental Plans. The State of the Dental Benefits Market, 2008. Dallas: National Association of Dental Plans; 2009.
Savannah, Ga.
Response from the ADA Council on Dental Benefit Programs: In response to Dr. Folan’s questions about influencing the insurance industry to provide coverage for implants, the ADA supports efforts to encourage insurance carriers to cover treatment that best serves the interests of the covered patients. JADA, Vol. 140
http://jada.ada.org
Copyright © 2009 American Dental Association. All rights reserved. Reprinted by permission.
July 2009
835
consulting business is not intentional, this is an oversight that needs to be corrected. If intentional, perhaps Dr. Levin’s columns should be confined to the paid advertising section of JADA. Robert K. Thompson Jr., DMD Cohasset, Mass. 1. Reynolds G. An Army of Davids: How Markets and Technology Empower Ordinary People to Beat Big Media, Big Government, and Other Goliaths. Nashville, Tenn.: Nelson Current; 2006. 2. Levin R. The phenomenon of the “cashpoor” practice. JADA 2009;140(1):105-106.
Author’s response: I wholeheartedly agree with Dr. Thompson’s point about the importance of dentists being able to determine their own path and their own destiny. In fact, my whole concept of Level III and Level IV dentists is based on the idea of putting the right management systems in place so that dentists have control over everything that goes on in the practice. If this is accomplished, they absolutely can determine their own path and their own destiny. My article was not meant, in any way, to advocate for the same shift of power that physicians experienced during the last several decades. Rather, being able to move from a Level III leader to a Level IV leader means the dentist has a firm grasp of the business end of running his or her practice and has created an efficient business model. Creating a Level IV practice actually empowers the dentist to utilize staff members to their highest potential and enables the dentist to spend the majority of his or her time providing the highest quality of care possible to every patient. Once a dentist becomes a Level IV leader, which takes 832
JADA, Vol. 140
http://jada.ada.org
time and commitment, he or she is better positioned to enjoy his or her career, to provide excellent care to patients, to continue to grow the practice with much less stress and to achieve personal and professional goals. It is not about relinquishing control and power to anyone, including insurance companies and the government. It simply is an approach that I have seen work for hundreds of dentists during the past 24 years. My article was intended to help dentists better understand the opportunity for them to improve their practices and, ultimately, their career satisfaction. I thank Dr. Thompson for his passionate response and agree with him that dentists should control their own destinies. Roger P. Levin, DDS Chairman and CEO Levin Group Owing Mills, Md.
INSURERS AND MARKET POWER
Regarding Dr. L. Jackson Brown and colleagues’ January JADA article, “The Effects of Insurance Carrier Market Power on Dentists and Patients” (Jackson LJ, Guay AH, House DR. JADA 2009;150 [1]:90-97), it is my opinion that the authors captured the essence of the issue in their discussion of the concept of “market power.” If there is an abundance of dentists vying for shares within the marketplace, insurance companies have more leverage in their negotiations with practitioners. When dental insurance came into vogue in the 1970s and 1980s, this clearly was the situation. There were large numbers of dentists who were will-
ing to try nearly anything to get more patients into their chairs. This put the insurance companies into a strong negotiating position. On the other hand, dentists have the leverage when there is a relative shortage of practitioners. That is quickly becoming the case today. I will use my home state of Georgia as an example. When Emory University’s School of Dentistry closed its doors in 1988, the state was left with just one dental school, the Medical College of Georgia (MCG) in Augusta. MCG’s dental school graduates just 60 students per year to service a growing state of approximately 10 million people. Clearly, the relatively shrinking population of dentists will be in an ever-improving position to dictate terms to the insurance industry rather than having terms dictated to them. If we’re smart, the negotiated fee portion of the problem will self-correct. The portion of the problem that will not self-correct is the effect that the insurance industry has on the actual treatment decisions that we make. In my opinion, there is one glaring example that requires strong action on our part. When a patient is missing a tooth, the question becomes how, and if, we should replace it. If the teeth adjacent to the edentulous space are virgin or have conservative restorations (in other words, not in need of a crown), then it is my firm belief that a bridge is a disservice to the patient. I believe this to be true owing to the amount of natural and otherwise healthy tooth structure that must be removed from the abutment teeth. Continued on page 835
July 2009
Copyright © 2009 American Dental Association. All rights reserved. Reprinted by permission.
L E T T E R S
Continued from page 832 Assuming that there is an adequate amount of bone, or that osseous augmentation can provide an adequate amount of bone, an implant is a much better option in that situation. However, most insurance companies will not cover implants. Therefore, both the patient and the practitioner are put into a position of having to give more consideration to a bridge than they otherwise should. I find it regrettable, to put it mildly, that the insurance industry has almost unilaterally taken a superior option off the table. It is particularly confusing given that implants end up costing about the same as does a three-unit bridge. Furthermore, the success rates of implants are such that one can expect an implant to last longer than does a bridge, and absolutely no damage is done to any neighboring teeth in the process. This begs the question, what is the American Dental Association doing to influence the insurance industry to start covering implants in the same fashion as it covers bridges? What are state dental associations doing to lobby their insurance commissioners to mandate that implants be covered in their states? Matthew H. Folan, DMD
However, our experience has been that the efficacy of any given treatment is not necessarily the determining factor in benefit design for insurers. The ADA can use evidence-based dentistry or best practices to advocate for benefit design, as Dr. Folan suggests, but what drives coverage is a business model based on cost. The most likely impetus for more widespread implant coverage would be patient and employer demand for the service that gives those carriers who provide it a market
position superior to that of those who don’t. The National Association of Dental Plans’ March 2009 report, “The State of the Dental Benefits Market, 2008,”1 states that 72 percent of employers are looking for dental implant coverage in their dental plans. As long as employers are willing to pay for the coverage they want, we may see an increase in dental implant coverage. 1. National Association of Dental Plans. The State of the Dental Benefits Market, 2008. Dallas: National Association of Dental Plans; 2009.
Savannah, Ga.
Response from the ADA Council on Dental Benefit Programs: In response to Dr. Folan’s questions about influencing the insurance industry to provide coverage for implants, the ADA supports efforts to encourage insurance carriers to cover treatment that best serves the interests of the covered patients. JADA, Vol. 140
http://jada.ada.org
Copyright © 2009 American Dental Association. All rights reserved. Reprinted by permission.
July 2009
835