Mississippi Gulf Coast dentists are just like other dentists across the country. We are busy providing patient care, running a small business, attracting and keeping competent staff, coping with shortages of dental hygienists, keeping up with emerging technologies, and fighting increasing overhead costs. Like most of you, we spend lots of time and effort trying to figure out how to respond to patientis dental insurance concerns. In the early 1970s when dental insurance was just being introduced many of us were just beginning dental school. There were those in our profession who saw dental insurance as a wonderful opportunity to provide services that many of their patients had previously been unable to pay for out of their own pockets. Others were skeptical at the outset, and saw this as an early intrusion of third parties into the doctor-patient relationship. It seems now that the skeptics may have been right.
Dentists in this area have recently had their eyes opened to the true nature of their friends in the managed care dental insurance industry. A few years ago, because of the relatively large military presence here on the Mississippi Gulf Coast, community leaders, leaders in organized dentistry, and representatives of state and federal congressional delegations led an informal campaign to encourage dentists to do their part in helping take care of the dental needs of the families of our servicemen. We were encouraged to join the reduced fee military dependent network during the initial recruitment phase. Our leaderis explanation was that participation by large numbers of local dentists would make dental care accessible and affordable for these families. The picture that was painted for us in the proposal of this plan was that we would each be doing our civic duty by agreeing to accept reduced PPO fees while spreading the military dependent patient base among large numbers of providers, doing our civic duty, and giving a little back to our community.
Many dentists who had never considered becoming a part of a reduced fee managed care plan listened to the proposal because it was presented with an image of being civic minded and charitable in an effort to help our military families. No doubt, many dentists were concerned that the insurance carrier might automatically leverage this "benevolent" reduced fee network and in some way make our participation apply to other plans that might be marketed to private employers in the area and that question indeed was asked. In individual discussions and in iexplanation meetingsi that were held up and down the coast, dentists were reassured by insurance company representatives that this would not happen. We were told that the only plan that we would be signing up for was the network that was being established for military dependents and that our participation in this reduced fee plan in no way would make us part of any other reduced fee managed care plan. All of the dentists present at these meetings and all that had individual discussions with insurance company representatives remember the discussions and promises exactly the same way.
In spite of their assurances to the practicing dentists that were hoodwinked into joining their network, the next year the insurance carrier went to a number of local employers, including some of the largest employers in the area, extolling the exceptionally high local participation rate of their wonderful low cost network. They proceeded to sell their network plan and to convert existing freedom of choice traditional dental insurance plans to the lower cost network plan originally promised to the practicing dentists as only for military dependents. In trying to do their civic duty, dentists had been duped into joining this network and then shifted involuntarily by virtue of their participation to other reduced fee plans. Naturally, many dentists felt manipulated by this "bait and switch" approach, were outraged, and vehemently resigned. Most wrote letters to their existing patients explaining what had happened and why they would be dropping their participation. I'm sure that there were more than a few unhappy and confused patients.
This group of Mississippi Coast dentists was encouraged to iconspirei in attending explanation meetings sponsored by the insurance companies and then joining the network of providers as a group for a purported civic purpose. When most resigned as a group because they felt that they had been betrayed, the carrier then yelled "conspiracy." It was very easy to get "in" as a group but antitrust issues were raised upon getting "out" as a group.
I think that most dentists would be in favor of special programs for the support of military dependents when appropriate, but could never support insurance companies leveraging the goodwill of local dentists to then take advantage of them. Dentists and dental societies should be particularly sensitive to these "Trojan Horses." Also, managed care network contract language should not be tolerated if it allows a carrier to extend a network automatically, with the dentist opting out of the extended network only if they give written notice. I just doesnit seem fair.
Another interesting insurance situation seems to be developing on a statewide basis with a state-supported "CHIPS" plan developed to be affordable dental insurance coverage for iin-betweeni children not eligible for Medicaid but not covered by typical employer sponsored coverage. It has been operating pretty much as a traditional fee for service, freedom of choice plan for needy families for the first few years of the plan. Now, however, it appears that a closed network of providers is being established, with the only requirement of participation in the network being acceptance of the networkis reduced fee schedule. The interesting part of the set up is, however, that if you are not a participant in the network, you will not be able to provide care for these patients. They will be instructed that they are only to seek care from network participants. I don't think that in my 22 years in dentistry I have ever been told that I "would not be allowed" to treat a patient -- especially by an insurance company.
There are important lessons to be learned from these perhaps not too unusual occurrences involving managed care in dentistry. We must realize that there are long-term, lasting implications to our allowing insurance companies to be part of the relationship that dentists have always had with their patients. Our acceptance of managed care in any form and fees that are set by an insurance company while perhaps acceptable in the short term, can only lead to serious problems for our profession. We must never allow managed care in dentistry to become the universally accepted standard coverage that it has become in medicine even though it appears that this may be the ultimate goal of the insurance companies. For a look at what it could be, just review the cover article of the August 6, 2001 New York magazine. The article title is "Doctor Rage" and the cover summary states "Think you are sick of managed care hassles? Just talk to your doctor. It used to be that everyone wanted to be a doctor or marry one but now with managed care in control, even the doctors are not encouraging their children to consider medicine as a career. With their incomes slipping and their status shrinking, MDs are mad as hell. And there is no cure in sight."
Medicine's example has proven to us that administrators and insurance carriers with bottom-line leaders at the helm cannot be trusted. Smooth-talking insurance executives promote high-sounding ideology and put their "spin" on explanations of plan participation. The deception of some of these plans that often attracts dentists is that many times the fees offered are the same, or close to what the dentist is currently charging. What do they have to lose? This is the insurance company's way of getting their foot in the door. They do it on purpose. Later, the carrier does what ever they please with the fee schedule once enough providers are on board and they have large numbers of providers dependent upon them. Or perhaps they sell lots of plans and all of a sudden they are the only game in town. The only recourse the provider then has is to simply complain. If things get bad enough, of course they could always resign their participation and risk a significant loss of their patient base.
The moral of the story is that if promises made by an insurance company are not in writing, they do not exist; don't assume anything, be skeptical when insurance companies are involved. Always be charitable and help to improve access to care whenever possible. But let the profession beware!
Jay Willis, DMD
Pascagoula, Miss.
