(THIS ARTICLE EARNED “EDITORIAL OF THE YEAR” HONORS FOR 2001 IN THE CDA UPDATE)
Evidence-Based Dentistry and Insurance Independence
by Michael Perry, D.D.S.
I receive a remarkable volume of journals, newsletters, and other mailings.Like many of you, I’ve learned to skim through most of these, only slowing down when something seems salient to my practice. The July/August 2000 issue of the Insurance Solutions newsletter (American Dental Support) stopped me cold with its lead article entitled “Brace Yourself . . .” This article discussed the author’s opinions about the growing use by dental insurance carriers of “evidence-based care processing policies” that require dental teams to prove that patients need even the most basic services prior to granting benefits. Another article in the following September/October issue entitled “United Concordia Now Auditing for Bitewings” described how this insurance carrier was demanding chart audits from some of their contracted doctors to determine if documentation showed “that the dentist requested the bitewings for a specific reason.” If not, the dentist was ordered to refund money to the carrier.
I knew from various sources that evidence-based care had become a standard in medicine and that the powers-that-be were evaluating it for possible use in dentistry.
I was surprised to read, however, that the insurance industry was the one introducing the idea--not dental educators nor organized dentistry. Calling CDA to get more information, I was referred to Marjorie Powell, the manager of the Dental Care Division. She was happy to help me, but thought it best to arrange a conference call with CDA’s Dental Care Committee Chairman, Dr. James Van Sicklen. The 3 of us spoke on November 7, 2000. I learned from this conversation and the back-up material sent by the 2 of them that evidence-based dentistry (EBD) is an approach where the practitioner makes clinical decisions based on the dental literature. This follows an epidemiological model developed for medicine. The old method of decision making described to me as “anecdotal” or “empirical” is seen by some as less scientifically sound.
I also learned that the March, 1999 issue of the Academy of General Dentistry’s Impact news magazine described how Delta Dental Of CA granted UCSF Dental School $60,000 “to develop a means for dental plans to underwrite benefit plans using this approach” and that “HealthPartners Dental Clinics, a staff-model dental clinic was gathering data using EBD to create guidelines for dental care.” Ms. Powell supplied me with a copy of UCSF’s first year report to Delta which described the study’s progress toward the goal of developing and testing new dental delivery systems that will be more cost effective.
All of this information was available to our representatives at the CDA 1999-House of Delegates. Resolution 50 from the 1999-House would have directed the Council on Dental Care to review and evaluate current research and trends in the area of EBD and submit its recommendations for action to the CDA Board of Trustees. This resolution was defeated. It may have been that the delegates were worried that any evaluation of this new scientific method might give it greater credibility and lead to some misuse of EBD by the dental insurance industry. I waited with interest to hear if the 2000-House generated any action on the issue of EBD. It did not.
A supplement to the British Dental Journal (volume 185, #10) states that “Evidence-based dentistry is the conscientious, explicit and judicious use of current best evidence in making decisions about the care of individual patients.” I have not been able to think of any reason why this approach, allowed to develop in an unbiased and scientific manner, would not benefit our patients. Some might say that this approach is not new to dentistry. It is apparent to me, however, from the information I've received that the methodology for testing followed by the collation and dissemination of studies under a formal EBD system would be superior to what has been available in the past.
Who should be in control of this formal system? Who would you choose?:
1) organized dentistry
2) the government
3) insurance companies
Regardless if we are making a decision affecting millions or an individual person in our own practice, I have grown to believe that if we as dentists always give the greatest consideration to patients’ interests, we will also win in the process. One reason I feel this way is because of the high level of trust and confidence the general public has in us. Another is that, unlike our physician colleagues, most of what we do is not “needed” by our patients. Most of them “want” to save their teeth not because it will help them live any longer, but because it will give them a better quality of life. If we are insurance independent, our credibility with patients allows us to communicate what we feel is in their interest regardless of what their insurance carrier communicates. On the other hand, if we are contractually bound to the company that insures our patients, our communication with them can be significantly more challenging.
I sense that many dentists have a love/hate relationship with dental insurance companies. They feel they can’t live without them because they are dependent upon them for much of their livelihood. On the other hand they despise them because they exert control over much of their livelihood. In my opinion its not the insurance companies nor organized dentistry that have created this dichotomy. I think its simply the evolution of the marketplace. Insurance companies are in business to make an honest profit and are obligated to their stockholders to do so. We dentists are in business to provide the best care we can and are obligated to the public to do so. We, however, can only provide consistent quality care if we are adequately rewarded for our efforts.
EBD creates opportunities for both insurance companies and dentists. Marjorie Powell stated that she felt insurance companies were interested in EBD because it would help with “cost containment.” Dr. Van Sicklen sees EBD in part, as a means of creating databases of objective/unbiased studies that will help dentists make better clinical decisions. I agree with both of them.
Delta Dental of Minnesota has launched a pilot insurance program that utilizes their version of evidence-based review of claims. Other companies have taken similar action. What should organized dentistry’s response be? In my opinion, our response should not continue to be no-response. Since the creation of an objective form of EBD, unbiased by the interests of dental materials manufacturers, suppliers, and dental insurance companies, is certainly in the public interest, we need to do our part to develop and promote one. Its the right thing for us to do both ethically and strategically, and will help us maintain as a profession the high level of credibility we currently enjoy.
As individual practitioners, we need to carefully evaluate our contractual relationships with third party carriers. With the implementation of internally created evidence-based processing systems by insurance companies, the level of encumbrance placed upon contracting dentists will almost certainly rise. CDA provides a “Contract Analysis Service” to help members with these decisions.
The greatest challenge may be for those dentists who decide that their existing contracts with insurance companies are no longer in the best interests of their patients nor themselves. Terminating these contractual relationships for some will require strategic planning as the effect of such changes will certainly be significant to them and many of their patients as well. I am one of a significant number of CDA members who have proven that insurance independence can work and that viable strategies exist for obtaining it. As Dr. Omer Reed once said “if its been done before, its probably possible.”
I would like to thank Ms. Powell and Dr. Van Sicklen for taking the time to speak with me and supply me with background material for this article. I believe we all agreed that, like it or not, evidence-based dentistry is one of many current changes that are contributing to the evolution of the dental marketplace. For the benefit of our patients and ourselves, we must continue to evolve with it.
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