Why are hygienists in the tug of war between dentists and managed care?

A potential alliance between managed care organizations and hygienists represents a real threat to the hygiene profession. Hygienists should read the fine print before leaping into the partnership.

Richard A. Simms, DDS, MS

The position paper of the American Dental Hygienists` Association (ADHA) on managed care sounds good but "there is naiveté in conception and expectation, and devil in the details."

The expressed position of the ADHA is to embrace managed care as a perfect complement to the hygiene profession. As stated, "91.9 percent of the leadership of the ADHA see managed care as providing and supporting increased emphasis on prevention and cost control, increased recognition of hygienists ... increased access for patients, independent practice, self-regulation in education, licensure and practice, increase in the variety of methods of compensation, and ... increased career opportunities for hygienists in managed care."

The position paper will be read by policy-makers, health-care delivery planners, legislators, managed-care companies and practicing dentists. These groups will perceive the statement to be the position of all (or a significant majority) of the 100,000 practicing dental hygienists in the United States - rather than all (or a significant majority) of the 23,000-plus members of the ADHA. It is critically important that all hygienists carefully examine and understand the details of what is being proposed in their name on their behalf.

The leadership of the ADHA should realize that many of the components of such a wish list are, for the most part, highly unlikely. It also reveals a basic misunderstanding of what managed care really has to offer.

Given what is known to date about managed care, this writer sees such an alliance as offering little more than an opportunity to voluntarily self-destruct a fine profession. The alliance with managed care inflicts a major change in the professional status of all dental hygienists, along with accompanying major economic losses from which the entire profession - but particularly practicing hygienists - may never recover.

The position paper provides a short list of 13 career opportunities available under managed care. Twelve of them have little, if anything, to do with the practice of dental hygiene. One does not need to be trained as a dental hygienist to have the prerequisites to be successful in these non-dental occupations. In addition, dental hygienists who wish to avail themselves of career opportunities outside of the practice of dentistry are free to do so now.

The position paper gives no specific details and makes no reference to the amount of payment for hygiene services (or compensation of hygienists) in the managed care environment. However, previous position statements, voluntarily presented to the federal government by the ADHA and its coalition partners, supported and recommended amounts that the ADHA was willing to accept as compensation or oral health services provided by hygienists.

The 1993 ADHA position statement preceded the actual national debate in Congress on health care reform, recommended that a dental component be included in the reform. It said the cost of their "recommended package of basic preventive and primary oral health services" (including non-hygiene services) be based upon the "50th percentile level" of then current private-practice fees. The recommended premium cost (what is charged to the purchaser, not what the practitioner ultimately receives) was "$9 per month per person."

In the position statement published in 1994, "the premium cost was raised to $10 to adjust for inflation." While all verbal reference to the 50th percentile has been dropped from the 1994 document, the derivation of the rate is exactly the same as in the 1993 document.

The leadership of the ADHA is again publicly offering the services of the nation`s 100,000 dental hygienists to the managed-care industry. This offer accepts the same financial underpinning as that of their 1993 and 1994 proposals (voluntary acceptance of reduced compensation to at least the 45th to 50th percentile of usual, customary and reasonable fees). These percentiles are, coincidentally, exactly the level of reduced total compensation quite commonly received today by dentists who participate in managed-care plans.

The realities that RDHs need to know

What does the dental profession know about the details and realities of participation in managed-care programs that all dental hygienists need to know?

- For most for-profit managed-care companies, practitioner`s judgments with respect to dental treatment often is secondary to the financial goals of the companies.

- Many managed-care companies do not use all of the costs incurred by the dentist in calculating the fees or capitation payment. They expect dentists to charge the fixed costs of running an office to other categories of patients (fee-for-service patients, for example) and have their patients under managed care treated during unfilled appointment time, thus justifying not paying a fair share of overhead costs.

- In the currently prevailing dental delivery system, compensation for preventive oral-health services are included along with all fillings, X-rays, diagnosis and routine extractions in the single. Total capitation payment for these services often range between $3 and $6 per month per person ($10 and $13 per month per family of two or three or more individuals) - that`s $36 to $72 per person per year ($120 to $156 per family per year). Compensation for preventive oral-health services often is between the 50th and 65th percentile of UCR fees.

- As previously mentioned, compensation to dentists for the total of all services rendered under managed care is most frequently between the 45th and 50th percentile of UCR compensation.

- What portion of the above amounts would be appropriate reimbursement for the limited range of services that hygienists would provide under managed care? What portion of the discounted fees would managed-care companies be willing to pay hygienists who practice independent of dentists for the provision of these limited services?

Can RDHs get a better deal?

Can hygienists as employees, or independent contractors, expect more favorable business practices from managed-care companies than that currently experienced by dentists? This writer does not think so. To date, the pleas of dentists in this area has fallen on deaf ears since managed-care companies believe that reimbursement for dental services is appropriate under their existing system.

All dental hygienists should question why and how they would expect to be more successful in achieving more appropriate reimbursement than dentists have been.

To support the charge made in position paper that the ADA`s only view of managed care is economically-driven, the ADHA quotes a recent past-president of the ADA on the subject: "Managed-care plans generally want quality service at a reduced premium while the dentist`s costs remain the same ... such plans manage care through cost ... usually a cost to the dentist."

The statement that the ADA`s only view of managed care is economically-driven is misrepresentation by an oversimplification of the ADA`s view. What the ADA and dentists believe is that dental plans and programs should be equitably funded to encourage the unrationed delivery of quality care.

Schoen, writing in the Journal of Public Health Policy in 1991, observed, "It is common for for-profit capitation-type plans using networks of providers to compensate them for marginal costs rather than average costs." He cites several large plans and reports "that only 54.9 to 73 percent of premium dollars was spent on dental care and 27 to 45.1 percent of premium dollars was spent on administration, marketing and profit."

The position of the ADHA seems to ignore any concern with adequate compensation of professional health-care providers, including dental hygienists.

The glass is really half empty

Let us now examine the concept of the 50th percentile when applied to real numbers - weekly, per diem and hourly compensation:

In 1994, the average weekly salary of full-time (32 hours or more per week) hygienists was:

- $693.90 among all independent dentists.

- $694.40 among independent general practitioners

- $687.60 among independent specialists.

The per diem compensation of dental hygienists in the practices of dentists of the author`s acquaintance in the Los Angeles area is $230 to $250. Some practices are in "service benefit-plan participation agreements (managed care)" as are an ever-increasing number of practices nationally, receiving reduced compensation for their services.

Recognizing the value, quality and longevity of the services provided by hygienists, these dentists have not asked hygienists to accept lower compensation or shorter appointment times. The offices treat the lower income as a business expense and look to increased efficiency of the entire practice, increases in patient volume or fees, and cost control as means to deal with the problem of declining revenue.

In 1994, independent dentists reported an average hourly compensation to hygienists of $22.20. Full-time hygienists earned slightly less, $19.80, while part-time hygienists made slightly more, $23.70.

The average fees charged by general practitioners (nationwide) in 1993 for a adult prophylaxis was $40.37. The same fee for children was $29.64.

In 1994, the average fees for pit and fissure sealants was $23.48 and $29.32 for topical fluoride.

The ADA Survey of Dental Practice and other surveys over the years reflect long-term recognition of the value of hygiene services. The dental hygienist is recognized as a most necessary, and much appreciated, professional member of the dental team.

The 50-percent or more reduction in hygiene fees and income stated as acceptable to the ADHA (and which would be acceptable to the managed-care industry) would set the income of hygienists back to levels prevailing in the years 1981-1982. No hygienist should be ready to voluntarily accept the great probability of up to a 50-percent reduction in income to accommodate the managed-care industry. One can also be certain the managed-care companies, as a further cost-cutting measure, will delegate duties currently performed by hygienists, wherever possible to even lesser-paid auxiliaries.

Dental hygienists must understand and see managed care for what it is. First, it is not a panacea capable of solving or eliminating all of the relationship problems that the leaders of the ADHA perceive to exist between hygienists and others in dentistry.

Managed-care companies have only one thing for certain to sell to purchasers, at least in the short term, and that is reduction in costs for the purchaser. Though these companies entered the health-care field with the promise of cost-cutting through better administration and management, better administration and management has yet to be demonstrated and delivered.

The only noticeable changes are sharply-increased administrative and management costs and profits resulting in sharply-decreased funds provided for patient care, resulting in cuts in services and decreased compensation to providers. For hygienists to enter an alliance with the managed-care industry with the expectation that it will deliver to them professionalism, recognition or higher status as professionals, and independence is fraught with presumption and risk.

Dr. Simms is a Diplomate of the American Board of Orthodontics, a former president of the California Society of Orthodontists and professor of orthodontics at Loma Linda University. His additional interests and expertise are in the area of contemporary practice and state and federal governmental affairs as they relate to the practice of dentistry. Dr. Simms can be reached at P.O. Box 185, Harbor City, 90710.