Carol Tekavec, RDH
Evidence-based dentistry is the new hot-button of controversy in the world of dental care and reimbursement. While basing the need for treatment on "evidence" seems both logical and sensible, it can be far more complicated.
If all dental treatment is to be based on evidence, whose evidence will be used for treatment decisions? Who decides what the best evidence is and whether or not the evidence is valid? If a treatment outcome is to be predicted, what factors will be included in the outcome evidence? With our current information overload, the quantity of "evidence" is daunting. Whose opinion will determine the quality?
Some suggest that dentists whose practices embody the ideal of "best practices" combine their own clinical expertise with the best available scientific studies. Without scientific studies, treatment that is useless or harmful might be performed. Without clinical expertise, "one size fits all" treatment might be used, without regard to a patient`s specific needs.
The problem with evidence-based dentistry is that the identification of "best practices" often can depend simply on who is compiling the evidence. Where insurance plans are involved, another problem is that the listing of "best practices" may be compiled using undisclosed mechanisms under the guise of "statistical and proprietary" information.
In my September 1999 column, I discussed Delta Dental Plan of Minnesota using its utilization-review information to rank its participating dentists on a profile system of practice patterns. Dentists who fit a "good" profile were being compensated at a higher fee rate than participating dentists who deviated from the profile. In fact, "deviant" dentists had their fees frozen in 1999.
Delta Dental Plan of Minnesota still is making news. An article in the March 6 issue of the ADA News reported on a complaint by Minnesota dentists. They are protesting the fact that Delta is making reimbursement decisions based on secret compilations of utilization data that it is defining as evidence of "good practices." According to the article, participating Delta dentists are scored on "their orientation to provide economic value in treatment approaches ... in relation to Delta`s statistical model, utilizing current research and clinical standards."
Dentists who fall outside this "statistical model" still can be a part of the Delta network, but their reimbursement levels are frozen. These dentists are unable to find out what put them "outside" of the model. Delta of Minnesota will not explain or provide information as to what criteria actually is being used to rank plan dentists.
It can be postulated that Delta`s efforts to freeze certain dentists` fees are directly related to pressure from dental-plan purchasers (your patient`s employers) to reduce premium costs. When an employer purchases a plan on behalf of its employees, benefits are considered. But the primary factor in the purchasing decision typically is premium cost. In that respect Delta is not reacting in a manner any different than any other business.
The conflict revolves around the nature of divided loyalties involved in a health-care process. The dentist must be concerned primarily with the patient, with the maintenance of a viable practice being a secondary concern. Patients want to receive the maximum benefits for the least possible cost. Delta`s priority is keeping its share of the insurance market, and employers are primarily concerned with corporate profits.
While utilization review has long been a measurement of the numbers and types of services provided by dentists participating in a dental plan, bringing in a model that uses "current research and clinical standards" adds "evidence" to the mix.
The Minnesota legislature currently is considering a bill called the "Dental Benefits Disclosure Act." This bill would compel insurance companies to reveal their methods of profiling dentists and lift the veil of secrecy. Dentists should watch the outcome of this proposed legislation with great interest.
Carol Tekavec, RDH, is the author of a new insurance-coding manual, co-designer of a dental chart, and a national lecturer with the ADA Seminar Series. Contact her at (800) 548-2164 or visit her Web site at www.steppingstonetosuccess.com.
