by Richard Mounce, DDS
I believe in one standard of endodontics for everyoneacross the globe. I believe there is one best set of principles that should guide the delivery of endodontic care, whether it is in the first world or the developing (third) world. I believe that certain instruments, methods, and materials reflect the best of what we can offer patients at this time. I believe there are less desirable methods and materials that vary (at times shockingly) from this gold standard. Saving time to economize and create profitability by cutting corners is not a part of this belief.
I believe it is not possible to provide the same standard of care when comparing managed care plans in the United States to fee-for-service care. I believe managed care fee levels, and the limits that these plans place on patients and doctors alike, limit quality and make it a challenge to attain the standard of care with any semblance of profitability.
My experience with managed care has been negative. A representative for one of the managed care plans to whom my office spoke refused our request to place coronal buildups because the service was being done by a general practitioner. Endodontic literature shows that the success of endodontic treatment is directly tied to the quality of the coronal seal placed over the root canal. In addition, some of the reimbursement levels offered were barely more than when I began my practice in 1991. On average, the discount for a first-time treatment was approximately 30 percent to 40 percent less than the fee-for-service price.
To achieve anything remotely close to these reimbursement levels, I do not think it is possible to be able to use the following instruments that are needed to perform endodontics at the highest level:
- Rotary Nickel Titanium or K3 files (SybronEndo, Orange, Calif.) powered by reliable electric motor sources, such as the TCM III (SybronEndo) and the ELECTROtorque TLC (KaVo, Lake Zurich, Ill.)
- Surgical operating microscopes (Global Surgical, St. Louis, Mo.)
- Digital radiography (DEXIS, Alpharetta, Ga.)
- Warm obturation techniques and equipment, such as The Elements obturation unit (SybronEndo) that uses RealSeal bonded obturation (SybronEndo)
- Ancillary equipment that makes the nuances of treatment far more predictable by placing sealer with a Skini syringe and Navi Tip (Ultradent, South Jordan, Utah)
Aside from these equipment needs, I do not think it is possible to easily attain the additional education needed to learn how to use this and even more advanced equipment (e.g., ultrasonic tips and units) at the reimbursement rates offered.
In the interest of keeping costs down, I think managed care has restricted the creativity and productivity of dentists. This has provided dentists with a false sense of providing for patients at a rate that promotes speed and care that is not about either the clinician or the patient. I think the only way to make an adequate living with managed care is by volume, which implies speed. To me, speed and quality in endodontics are mutually exclusive.
If speed matters, how can a dentist develop a relationship with patients? I know doctors who work in solely managed care environments. They speak of treating 20 or more patients in an eight-hour period. How can this environment create trust and help dentistry overcome fears and become more available to people? Should we be proud of this American system? Is this what we seek to export to the world as a model of American efficiency?
My critics will argue that they cannot get enough patients or build their practices without resorting to managed care. Managed care insurance administrators will say they are only selling what the marketplace will purchase.
My response is that something needs to be fundamentally improved or is out of alignment if a clinician must resort to managed care for “survival.” We did not become dentists to survive or get rich but rather to care for people and use our God-given talents to enrich their lives. I think most managed care administrators have root canals performed by microscopic clinicians and not in the managed care settings at which they preside.
Quitting managed care as a profession and finding alternative practice arrangements that allow us to be all we can be in practice is the answer. We should not use dentistry and endodontics as a commodity that only profits insurance companies but offers little else in return.
