Nesconset Dental Takes on the Big Easy!

We just got back from “The Big Easy” for the American Dental Association Annual Session. I had a great time with my wife Melissa, while meeting up with some friends along the way.  I think the staff that came with me also had a great time, but honestly I did not see them that often, I think they were hiding from me. (Let’s just say I hope they bought all those beads they were wearing)

            MVP (most valuable partier) was definitely Christina. In the morning she looked like you are supposed to look after a night on Bourbon Street. The hygienists that came Kelly, Christine, Jody, Sue and Naomi were a tight group that made the most of their trip and managed to actually attend the meeting as well.

            Representing the front desk were Rita and Annie, mother daughter combo that work together, live together, play together and drank god knows what out of giant plastic sippy cups together, while perusing the gift shops of New Orleans looking for munchies.

            Only two assistants made the journey (I think the others were afraid), and Danielle and Christina were creatures of the night straight out of a Anne Rice novel. Dr Yarian and her husband attended the most courses at the meeting while still managing to soak in the best of the French Quarter.

            As for me, I was an angel, in bed by 9pm and studying dentistry the whole time!

            -Sal 

Part 5: Malpractice Insurance and Providing Healthcare in a litigious society

The cost of malpractice insurance is often cited as a major culprit in increasing fees and costs for providing healthcare. But the cost of the insurance itself is only a small factor, rather it is the culture malpractice lawsuits has created that has helped to create the modern health care economics we now have.

                The problem is in our current society if anything goes wrong in any aspect of life, someone has to pay. Personal responsibility is gone, someone, something is always to blame. If we go back to the turn of the century, the balance of rights of people vs. business and government agencies was probably to one sided for the business and government. In that era if you went to a business a bought a defective product and injured yourself with it, tough luck, next time don’t buy from that store.

                Obviously things needed to change, but now the pendulum has swung too far. The infamous McDonalds’ coffee burn lawsuit is probably the highlight of this new “someone has to pay” mentality. But numerous other examples of this attitude in all aspects of life drive prices and the cost of doing business up. McDonalds’ paid there settlement, but then they had to reprint billion of cups with the words “caution coffee is hot” on them. They had to put signs up in all their restaurants indicating it isn’t a good idea to pour hot coffee on your skin. That cost was passed on to all of us.

                Healthcare is no different. Every time a doctor gets sued for something even if the doctor believes he did the right thing he will change the way he practices. When a doctor loses a lawsuit because if by chance he had ordered a lab test for something that may have picked up some disease no matter how rare, he now will order that test for all his patients even if it is not in the best interest of the patient or the society in whole, because he will no longer take any chances he may miss something. The doctor has now taken his years of education and experience and will not use that knowledge to make a decision; rather he will play not to lose, even if better judgment would rule against such decision. The one person who doesn’t know that coffee is hot has made the vast majority of us who do, change the way everyone does things. Game changer!

                The cost of defensive practicing healthcare is probably mind blowing, when you consider every unnecessary drug prescribed, test ordered and procedure done to “cover your butt”. Dentistry is right there too. A great everyday example: you don’t need an antibiotic every time a root canal is done, but if you are the dentist that had a patient hospitalized after a root canal that became infected, guess what you are prescribing an antibiotic after every root canal. The reaction might be, well good, no one will ever be hospitalized after a root canal ever again. But you can’t live life nor practice medicine or run a government or business with that mentality. Number one, it will bankrupt any system that behaves like that and it is not in the best interest of individuals to be treated to avoid one in a million occurrences. When does it end? Either when the healthcare system is unsustainable or people understand that there are risks in living and not everything can or should be avoided to achieve a zero risk world.

Part 4: Insurance

“Meet the new boss, same as the old boss”

-          Pete Townsend

Insurance for dentistry doesn’t make sense. Why do you buy insurance? To protect yourself against an unforeseen event that could result in expenses you can’t afford.  Automobile insurance is important because in the event you get into an accident and total your car, you may not be able to buy a new car that you need.

The only insurance that works for dentistry or healthcare in general would be catastrophic coverage.  Catastrophic coverage in medicine insures you against an unforeseen illness that could be very expensive to treat, like a heart attack.

When people try to “insure” themselves against things that are likely to occur it becomes impossible for an insurance company to make a profit when they know eventually they will have to pay out it this scenario.  To make it work from a business perspective the premiums would have to be very high and pay outs would have to be monitored and limited to make sure that the amount of money the company takes in remains higher than what they pay out.

Except for the rarity, people have to have dental treatment eventually, even if only a cleaning or a filling. And regular checkups are important to prevent bigger problems from occurring. But insuring yourself for these services that you will need on a regular basis becomes a conundrum economically. Back to the automobile insurance analogy, let’s say you were concerned about the high cost of tires, so you went to your insurer and said in addition to accident coverage, I want you to pay for new tires every 20,000 miles. Well the insurance company knows at 20,000 miles they will have to pay for new tires, so they would have to charge you at least the same as the cost of the tires to break even, and actually more if they want to make a profit (which they are in business to do). Makes no sense! To make it work basically you would be paying the insurance company to get tires for you and somehow they can make money and you can still get your tires. What usually happens is the middleman (the insurance company) makes money, the consumer (you) get an inferior tire or service and the seller (the tire company or garage) has to cut corners all so the middleman gets paid. For more on this see my previous blog about Dental insurance.

How does insurance raise the cost of dental care? Well, we added a middleman who needs to get paid. So now patients have dental bills and insurance bills. And even if your company is paying for a portion of the premium or for that matter the entire premium, money is being funneled out to the middleman resulting in less for you or the healthcare provider.  MetLife’s gross revenues last year were in excess of $70,000,000,000.00 (70 billion dollars). That’s some middleman!

On the level of the dental practice the costs are driven up by insurance because of the added administration necessary to process and get claims paid. Most offices now have a full time person (insurance coordinator) who spends all their time dealing with the insurance company. This additional salary, as well as the mailing, phone and computer costs is a completely new expense category created by insurance that impacts the fees healthcare providers must charge.  The Center for Information and Technology, a non-profit healthcare research group estimates the cost of just fighting denied claims is as much as 10 billion dollars a year in administrative expenses.

Part 3: The Cosmetic Revolution! “You say you want a revolution, well, we all want to change the world” – John Lennon

Since the advent of predictable dental bonding and tooth colored restorations the game, the rules and the field changed overnight. The ability to provide esthetic, as well as, functional changes for patients was a boon to dentistry. Gone would be the days of big silver fillings or full metal crowns, patient now expected and were entitled to fillings, crowns, and veneers that could mimic tooth structure so well that when properly done, were indistinguishable from the adjacent natural teeth.

                Like any business, competition drove the market and dentists who were behind the educational curve regarding cosmetic dentistry would become obsolete dinosaurs until that learned and developed the ability to provide quality cosmetics. Where would they learn these new technologies and techniques that haven’t even been invented yet while they were in dental school?

                Continuing education in the form of new “institutes” for higher learning was born. The need for dentists to acquire the skills to do comprehensive cosmetic dentistry was fueling an industry led by the manufacturers of these new products, encouraging us to use their products. The continuing education advantage was great for dentistry; more educators were sharing their knowledge and lifting the level of dentistry a patient could expect.

                But once again there was a cost. The typical “institute” charged thousands of dollars to learn their techniques for this or that. Required dentist to take time out of their practice, travel to their facilities, book flights hotels etc… Great opportunities to learn and hone your skills but this tremendous cost had to be absorbed somewhere. The fees for these procedures would go up.

                In the fifties through the seventies, a typical dentist may go to his local society meeting or study club. Occasionally they would go to the ADA convention. Now, I and many other progressive minded dentists I know go to meetings, seminars, and training classes as much as once a month. And it is not unusual for quality dentist to log 200+ hours of CE a year. That is a lot of time away from the office and expenses that have to be made up. Yes it allows dentists to stay current and provide patients with the best possible care, but there is a price.

                Cosmetic dentistry is not cheap. Prior to “white fillings”, nearly every filling was done with dental amalgam, which is 1/10, the cost of composites and related materials. Crowns made of all ceramic materials that can match natural teeth, or porcelain veneers used in many smile makeovers are very time consuming and lab technicians whom are qualified to deliver the results patients are expecting have to charge larger fees for the demands placed on their work. The lab costs go up, the fee goes up.

                The dental laboratories have evolved. In the days of yore, the dentist worked with a one man lab that was down the block. Now large labs are the only ones who are able to afford the extremely expensive CAD CAM milling machines for the modern ceramics we now use and they must make large investments in technology year after year. This cost rolls down to the dentist and subsequently down to the patient.

                Modern dental patients have high expectations for cosmetic dental procedures and we are obligated to meet them. But this high level of esthetics is very expensive to deliver, and when dentist cut costs by using “cheap labs” and inferior materials, or simply they have not gone out and invested in the right technology or education to improve their skills patient become disillusioned with the promise of cosmetic dentistry they see in magazines and in the media. So those of us who want to deliver the quality results that patient are so happy for, we know our fees need to reflect the costs we have incurred so we can remain profitable to continue doing so. Thomas Edison once said he was interested in making a lot of money with his inventions, so he could afford to continue creating more inventions.

Why the Cost of Dentistry is so Expensive: “The rise of the machines” (I know I used this chapter title in the previous article, but it is perfect for the next segment)

As a society we are now dependent on technology and the machines that it has given rise to. We love our technology so much so that people who may not have money to spend on things necessary will spend money on the newest cell phone, iPad etc… But technology is not free, the latest profit making business models are all based on selling a product, then selling the services associated with it. The services are the hidden money makers for these technologies. So much so, manufactures will sell the product (hardware) for cheap or often give it away.         

The cell phone is the classic example, money is made on the phone itself, but the apps you purchase, the service plans, and all the accessories are the hidden costs. If you compare the expenses of a typical family in 1970   to a modern typical family you will see how the small but ubiquitous charges for a technology have raised the cost of living. The following is a off the cuff list of things we need to pay for yearly or monthly in our personal lives that the previous generation did not:

                Service or Revolving Monthly or Yearly Expenses

Cable

                                Internet Access

                                Cell phone

                                Netflix

                                Anti Virus plans

                                SiriusXM

               

                               

                Products that require constant upgrades and replacement to keep up with changes

                                Cell phones

                                Video Games

                                iPad, iPod

                                Computers, lap tops, wifi,

                                Software, upgrades (some require yearly contracts such as Quicken)

                               

 

Back to the cost of Dentistry…

 

                Even more so than in our personal lives, technology brings many added expenses to a dental practice. And, furthermore, unlike personal items where you can make a choice to indulge or not, in our field if you don’t keep up with technology you are considered (and probably so) an out-of-date dentist, and who wants to go to a dentist who is still practicing like it is 1970. Lets touch on some of the larger technology expense categories, keep in mind, I love most of these new products and what they can do, but I am demonstrating in this article why the cost of delivering dentistry (or medicine) has become so inflated in recent years.

                Digital X-rays:  a tremendous technology that improves diagnostic capabilities while reducing radiation exposure. We were one of the first practices to go completely paperless and digital x-rays were the icing on the cake. But the salesman marketed it as a cost saver when compared to traditional film x-rays. The argument was you didn’t have buy film x-rays, and the cost of developing them was gone. I’ve crunched the numbers and that just isn’t factual. First of all, the initial cost of a digital x-ray system includes upgrading your current computer system and expanding it to include coverage in each operatory that x-rays are needed. Then the costs of the sensors are about $6,000 each and they break occasionally. Of course there is a monthly service contract needed in case something goes wrong, because there is no way you can repair or figure out anything yourself on these products.   Digital x-rays take up a ton of memory so you need to large capacity servers to house all the files. And lastly they all need to be backed up, and when the backup file is so large you have to use an offsite back up company to ensure all your records are safe.$$$

Why the cost of Dentisty is so expensive: Chapter One “In Quest of Knowing”

               Humans want to know. Whatever the topic, we want more and more knowledge of it. This has been from the beginning of our time. The satisfaction of answering a question leads to an insatiable desire for more questions and answers. It feels good to learn. If you have young children in your house, the never ending “why, why, why..?” will usually result in the highly irritated response of “because it is” by the beleaguered parent. This is our nature.

              

In medicine and dentistry alike (you thought I may have forgotten the topic of this diatribe) the quest of knowing is no different and, in fact, its ostensibly moral and benevolent nature in seeking this information for the good of mankind does provide ample motivation for its continuance. In the hunt for cures and treatments to limit the suffering and death of our fellow men, we must make sure we leave no stone unturned and realize the potential of our intellect and abilities to solve the mysteries of biology, disease and health.

 

To start this journey sometime, during high school, someone with aspirations of becoming a doctor (from  here out I will focus on dentistry since that is the path I know well, but it is a similar one for a physician and other healthcare providers as well)  must start considering colleges. In order to get into a good dental school it helps to go to a good college, usually with a strong science curriculum.  All colleges are expensive and the better ones even more so. $$$ (every time you see  dollar signs I am trying to indicate without being overly repetitive the impact on the eventual cost on health care delivery our current system).

 

Ok, you are in your undergraduate school of choice and with the help of mom and dad, uncle Sam, banks, and loans $$$ you spend four years hard at work studying and graduate with excellent grades. Then you start looking into applying to dental schools. There are applications, entrance tests, visiting schools, buying a suit and going on interviews. $.

 

               With some luck you get into a great dental school. $$$. Spend four years studying and learning, yada, yada, yada.  You get the idea- education is expensive! But the knowledge our profession (as well as other fields of study i.e. physics, computer science, engineering) has grown to the point where even a four year graduate education is merely scratching the surface of what the collective information there exists. The student has the responsibility of learning and retaining this information to bring into the real world and use it to improve the life of our patients.

              

What a dentist needed to know in 1955 is probably 10 % of what a dentist graduating from dentals school in 2013 must know. For medicine it’s probably even more dramatic. Just think of what is available now just in the small subset of healthcare that is dentistry. Since 1955 we now have implants, cone beam (3D scans), rotary files for root canals, myriad of bonding adhesives, microscopes, cements and composite materials, Cad Cam (milling crowns and inlays by computer), bleaching, veneers, Invisalign, numerous types modern ceramics, computer records, digital x-rays, bone grafting, gum grafting, non surgical periodontal treatments (Arestin), Lasers for surgery, lasers for tooth preparation and periodontal treatment, digital imaging. I could probably fill a full page, so what does this mean? – Specialization $$$, Continuing Education beyond dental school $$$, staff and doctor training to use specialized equipment $$$.

 

Specialization was inevitable when the breadth our knowledge grew. But to be a specialist means additional years of schooling. $$$. When specialists do finally get out, they want to treat patients with all the latest and greatest things that they have learned. $$$. Even general dentists upon graduating are no longer really prepared to practice modern dentistry. What is taught in dental school provides the foundation for practicing dentistry. It is then the responsibility of young graduates to seek out post graduate training to really learn how to do procedures that patients want since they were unable to master in dental school. Implants are the perfect example; in most dental schools undergrads get very little practical experience with implants. Enrolling in an implant course $$, is just the beginning. To fully be proficient you must continually educate yourself and join groups or academies $$ that provide further information and support. The days of a dentist graduating from dental school and “hanging the shingle” are over. In fact now to get your license, graduating from an accredited dental school is not enough you must pass licensing tests and  do a one year post dental school program $$ before you can practice.

              

               All of the progress our profession has made in the advent of new technologies and understanding of pathology and the best ways to treat our patients requires a significant investment in time and money to fully grasp and integrate into our practices.  The end result is extraordinary advances in the profession that have the potential to change people’s lives. If you have ever seen a child with cleft lip, you know there is no way we cannot use every advancement we have to try and correct these malformations.  There are so many ways that all those technologies listed previously have made a difference in our quality of care, and there is no going back. But once again the progress trap comes into play, are we creating doctors that spend so much of their lives educating and training, and mounting huge financial debts, that when they come out to practice, the fees they need to charge for these advanced treatments are out of reach for the average person.  I’ll leave you with a dialogue I had not too long ago:

 

Patient- “you would think by now, you dentists would have come up with a way of giving someone back       their tooth by now”

              

Dentist –“we have – they’re called implants”

 

Patient- “I mean something that I can afford”

Why is Dentistry so Expensive?

“A long, long time ago,
I can still remember how that music used to make me smile.” – D. Mclean

                The first three questions I usually get asked when telling a patient they need some type of treatment or another are in order:

1.       Is it going to hurt?

2.       How much does it cost?

3.       Is it covered by my insurance?

Sometimes in the mix of question and answer is “Why is dentistry so expensive?” My point is - cost isa always a factor (as it should be!). But how did dentistry or healthcare costs, for that matter, rise at such a rate over the latter half of this past century?

                Society may be headed for a progress trap. Our dependence on technology grows at an overwhelming pace and the very benefits we seek from this technology could ultimately be our downfall. Just as a vast supply of inexpensive food made in part abundant by advances in farming, food preservation and mass production has led ironically to many problems they meant to solve those being obesity, nutritional issues and causal links disease related to some of the chemicals used in modern food production. This is just one example of a progress trap. Because the natural tendency to correct a progress is to solve it with more technology and so it goes around and around like the famous Penrose steps illustration.

                What does this have to do with the cost of dentistry? Well healthcare (dentistry included) is falling into a progress trap. The very goals of education, advances in treatment, advances in technology, advances in administration, the development of pharmaceuticals, insuring patients safety, protecting patients against malpractice and third party systems all directed toward improving the health of our patients is actually driving the cost up to such a degree that we can’t afford to be healthy. Hence a progress trap.

               

                In the next series of articles I will attempt to discuss how some of these technologies and progressions in how we administer health and dental care have evolved into the current conditions and the impact these have had on the economics we are now challenged with.