Digital technology changed dentistry in fee-for-service (FFS) and PPO offices. It's time for this change to happen in Medicaid and low-reimbursement offices, as well. Like many others, years ago I believed that this technology was only for the upscale offices of Fifth Avenue and Rodeo Drive.
The reasons dentists shared for not investing in the technology included the expense, poor return on investment, they didn’t think it worked, they didn’t like the crown margins, and they thought it was too complicated. I believe that this technology should not be used only in PPO and FFS practices, but also in Medicaid practices.
Back in the day
When I was young, I watched my father practice dentistry. It took him three visits over four to six weeks to deliver a porcelain-fused-to-metal (PFM) crown. Patients were exhausted from coming to the office so many times for one crown. I viewed my father as an old-school dentist since he scheduled a metal try-in appointment. He probably did this because of the inaccuracies of impression materials, stone, and human error. His dentistry was superb, and his patients loved him for this. Multiple visits for a crown were standard, no matter the reimbursement, even if a patient’s insurance was Medicaid.
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When I started to work for my father in midtown New York City and Brooklyn, I saw many Medicaid patients. There were a few things that didn't make sense. Three appointments on three separate days to deliver a crown with minimal reimbursement was not a financially prudent move in my mind. This gave the patient numerous chances not to show up, which led to drawers full of undelivered crowns. Even with a metal try-in, the crowns did not fit perfectly, and adjustments had to be made. Too much chair time was needed to deliver a crown. We were also experiencing far too many emergencies with broken or lost temporary crowns. Faced with so much unbillable wasted time coupled with the frustration from our patients, I knew the crown process had to be done better.
When I purchased my first practice in 2012, it was also a Medicaid practice. To drive production of the office, I cut out the metal try-in appointment to speed up the delivery process. However, this led to more crowns not fitting and insertion appointments taking 45 minutes. There is nothing more embarrassing than shaving away porcelain for 45 minutes and then having the metal show through the crown. Now I had another issue; with an associate now working with me, I needed a way to check his dentistry without being too invasive. I needed some form of quality control beyond a post-op radiograph.
The move that changed everything
These reasons pushed me to make a move that changed my world. The frustration of numerous undelivered, ill-fitting, and low reimbursed crowns pushed me into the world of digital dentistry. I purchased a Trios scanner in 2015 at the same time I purchased my second practice, and the impact was immediate. Crowns now fit with minimal adjustments. The crown process was smooth, predictable, and state-of-the-art. The turnaround time was usually less than a week, so the crown delivery process was shortened dramatically.
This is how I used the scanner for quality control. After a tooth was scanned, the operating dentist marked their margins on the design software. The associate had the ability to check their work and make sure there was enough clearance, no undercuts, and visible margins. I was able to use this tool to verify the quality of the associate’s work. Furthermore, the scan is a digital record of the patient's mouth that can be used as another source of documentation. Despite the increase in quality, I still had patients who didn't return for the delivery appointment. My drawer of undelivered crowns was fuller than I wanted.
Then, inspiration. Just two months after we bought the scanner, I was walking the exhibit floor of the Javits Center at the Greater New York Dental Meeting when it struck me. Why not mill these crowns ourselves so we could deliver them the same day? The only people I knew who were using this type of technology were FFS and high-end PPO practices. Why hadn’t any other Medicaid practice tried this?
Maybe the costs were too great and outweighed the benefits. A full scanning, design, and milling system exceeded $100,000 in 2015. Nevertheless, we bought an E4D mill and Romexis design software, and we created a Frankenstein-like machine. The Trios scanner was fast, accurate, and clear, and the addition of more technology seemed like the next step. This took a few months to develop, but after considerable time setting this up, it was more than worth it. In early 2016, we delivered our first same-day Medicaid crown.
Life was great. There was no need to make temporary crowns, and no emergency appointments to recement the temps. What was once four to six weeks for a crown to be delivered was now completed in one day. The crowns fit perfectly and fell in place. I had my quality assurance and a choice of materials. Patients were impressed with the scanner and their minds were blown when we told them to come back in an hour or two for delivery.
I can’t stress how much this system changed the patient experience in my office. Medicaid patients are used to inefficiencies and long waiting times for care. My patients definitely noticed the change, and we started to get many referrals. Most importantly, every crown that was scanned was also delivered because we do not make temporaries. This made financial sense.
As my business expanded, I had to keep investing in digital technology. By 2017, I had four Trios scanners for four offices, one E4D mill, one Roland mill, and Romexis design software. We scanned and sent the scan to another office where the mill was located. We set up a delivery service that allowed our crowns to be delivered the same day in every office. We had one Medicaid office and three PPO offices, and the same digital workflow for all offices.
From problems to a new system
Then, we started to have issues with our Frankenstein-like process and each company of my digital workflow pointed fingers at the other. It's hard to integrate multiple technology companies, and maybe our problems were inevitable. Crowns didn’t fit right and often the mill didn't work. After six to nine months of problems, we made the most important switch of my career. We switched to CEREC, and we haven't looked back. It’s one company for all scanning, design, and milling needs.
The CEREC experience has been invaluable. There are volumes of lectures, Facebook groups, CEREC doctor clubs, and continuing education that supports our learning. We received our level 2 training in Scottsdale at their training center. We brought our team members and have been to many of their courses. It’s the best clinical CE I’ve ever taken. We use CEREC to make crowns, inlays, onlays, veneers, bridges, and implant crowns on a daily basis. A part of the onboarding process for our new dentists is to have them train with the CEREC courses presented in Scottsdale and Charlotte. CEREC is now the cornerstone of our business.
From a clinical standpoint, the transition to digital dentistry has been fantastic. It’s a win-win-win. It's a win for our doctors because it has elevated the level of our dentistry, increased production, and given us an advantage over our competition. It’s a win for our patients because they’re getting the best dentistry has to offer. Lastly, it's been a win for my team because they’re involved in the process. But has this transition been a financially responsible move?
I may need another article to go through some of the finances, but I would like to illustrate what we’ve accomplished despite the poor reimbursement. When we insert an all-porcelain crown, we bill code D2740 as opposed to D2750, which is for a PFM crown. This is significant because Dentaquest, a third-party administrator for Medicaid in New York, has a different fee attached to those codes. A D2750 is reimbursed 15% more than a D2740 in the county where I'm located. I find this backward because Dentaquest rewards dentists for doing inferior treatment.
Could you imagine a heart surgeon using an inferior stent because the reimbursement was better than for the superior stent? Some associates have been upset about this because of the perceived loss of revenue. I’ve tried to negotiate with the company over the last seven years, with no success. Over the last seven years I’ve lost out on over $500,000 worth of revenue on this code change. Despite this perceived loss of revenue, I would still make the change to CEREC.
The reason why CEREC works in a Medicaid office is because of its efficiencies. On average, we’ve found that we save at least 25 minutes of chair time for every same-day CEREC crown. There is only a prepping appointment and a delivery appointment. We don't have to make a temp, cement a temp, and remove a temp and cement. Also, the crowns need minimal adjustments because the scan is a true impression. Traditional impressions are prone to distortion and human error.
If a Medicaid office does 250 same-day CEREC crowns in a year, 104 hours of free chair time would be created. I think I'm being conservative with the 25 minutes of saved chair time, but 104 hours is more than two-and-a-half weeks of open chair time. An average Medicaid office averages approximately $500 per chair per hour. That equals almost $52,000 of potential revenue or another two-and-a-half-week vacation. Let’s not forget how much chair time is wasted on recementing temporaries if you must wait two weeks for the crown. There is no better way to increase the revenue, income, and value of a practice than implementing clinical efficiencies.
There are more arguments to be made for why CEREC works in Medicaid offices, and hopefully I will illustrate them in the future. However, the greater patient experience, the quality assurance, and the clinical efficiencies of CEREC more than pay for the cost of the technology, even in a Medicaid situation. There is no reason why the underserved and underprivileged should not have access to the best dentistry has to offer.
Editor's note: This article appeared in the October 2022 print edition of Dental Economics magazine. Dentists in North America are eligible for a complimentary print subscription. Sign up here.
