Thursday, October 4, 2012

Dental Pirate

I joke to my Dentist that I am going to open up a traveling dental truck similar to the food truck one sees throughout America. Having had a myriad of dental problems all my life I have been with this same Dentist for what seems a lifetime. Well in all honesty its been the majority of my life and oddly his as well as he was just out of Dental School at the time. Unlike today's Dental School grads he had the GI Bill and it was a different time when it came to saddling people with debt upon graduation.

I also joke he has no apprentice which means he will force me into the free market upon his retirement. Which he also jokes won't be happening as well many men (Dentists no exception) he entered into having a family late. Clearly after what happened to me at Harborview and the desperate search for next of kin I should have done the same. Oh que sera sera.

But because of that long term relationship, I have no problem negotiating my Dental needs. The office Manager jokes that I got my start and practice with them. She may be right. But she also is right about the fact that Dental Insurance is the biggest rip off of all. Unless its paid for by an Employer (which actually means that the premium benefit is removed from actual salary but hey that is another blog) its utterly absurd for anyone to purchase private coverage. For approximately $50/month you get 2 cleanings a year and that is about it. And given that its simply cleanings you could easily shop on the free market for a Hygienist who could accomplish that depending on your needs. But as in all medical situations this person is front line in being part of your long term health. Dental like vision can often mask underlying health problems so in some ways that individual is as essential in maintaining your well being. Many many ER visits are because of dental problems gone untreated and led to major other more critical health problems.

The Affordable Care Act did nothing about either Vision or Dental. That is one of my many complaints with the act. It does nothing about the rising costs of all Medical care, including Dental. And once again why is Dental care so outrageous? The check comes due at the end of school. Its exactly the same as the Medical profession. A limited number of students, limited schools equals monopoly and in turn price setting. Its a nice gig if you can get it.

Here in Seattle we have one Dental School at the University of Washington. Ironically the same school that runs Harborview Medical School, with such illustrious med students who simply come into a patient room ask "why was she intubated?" then add that inquiry to the billing. You can see Houston we have a problem here. That is why all Medicine is outrageous in more ways that one.

And just like Medical care, Dental care is also ripping off Medicaid/Medicare. Why they got bills to pay!! An investigation by ProPublica found that Dental clinics are doing just what the big boys do. Ripping off the Government while simultaneously putting kids through unnecessary treatments. Good prep for later when Doctors do it! Get em while they are young!

A couple of years ago Washington Dental limited the payments for many treatments to their insured clients because they found that Dentists in Washington state billed at higher rates than around the country. This was mostly based on annual average income. And because balance billing is not illegal you receive that difference billed to you as very rarely does the Dentist write off that cost. They constantly threaten they will go out of business! Utter nonsense. They should just simply lower rates and market themselves. Imagine having cash paying customers. But that is not part of their equation. Their rates are not set in stone. I negotiate. This is that free market you keep hearing about and yes Virginia you can do that (unless you are being wheeled into an ER). Try it you might like it. Trust me I have over the years bought my Dentist a Porsche so we are even.

Are High-Volume Dental Chains Exploiting Kids on Medicaid?
by Olga Pierce

David Heath of the Center for Public Integrity recently investigated a new breed of corporate dental care chains that cater to low-income adults and children. Heath collaborated with Jill Rosenbaum of PBS FRONTLINE on “Dollars and Dentists.” They found a high-volume business model that scored dentists on production and offered bonuses based on the revenue they brought in. Heath and Rosenbaum reported that Georgia-based Kool Smiles, the biggest Medicaid dental provider, has been accused by state regulators of giving shoddy or unnecessary care to some of America’s poorest kids.

As part of our ongoing look at patient safety, we occasionally interview other journalists who’ve examined health care quality.

PP: What did you find in your reporting?

Heath: I looked at what impact corporate dentistry is having on the care being provided. We looked at two of the larger chains, and found evidence that these companies were putting pressure on their dentists to produce at certain revenue targets, thus encouraging them to do procedures that may have been unnecessary.

PP: Can you say a bit more about the harm or overtreatment to patients that you saw?

Heath: One of the chains focused on kids on Medicaid, and the reimbursement rates for Medicaid are pretty low. So in order to get a lot of revenue from these patients they were doing things like taking x-rays that were not needed, or putting stainless steel crowns instead of fillings on their teeth. They could make twice as much money from Medicaid on these crowns versus just putting a filling on a tooth. Kids were getting treatments that they really didn’t need.

We also looked at a chain that focuses on adults who haven’t been to the dentist in years. What were found there is again, patients would come in and everyone was given the same treatments. They were given these deep cleanings and a lot of people would get dentures and we were finding that in some cases maybe they didn’t need those services.

We had one example of an 87-year-old woman who had already been to the dentist and she went in to have two teeth pulled, thinking it would be cheaper at [New York-based] Aspen Dental. Instead they looked at her mouth and they came up with a treatment plan that was going to cost $8,000. They convinced her though hard-sell tactics to borrow that money through a credit card, and something like $2,000 of that was just to clean her teeth. (Aspen Dental’s response is here.)

PP: So, in some cases, you’re talking about pulling someone’s teeth unnecessarily?

Heath: There was a case where a woman went in who needed to have some teeth pulled, but they pulled all of her upper teeth, and several dentists told us she didn’t need that.

PP: What are the market forces that have resulted in private equity-owned chains providing dentistry?

Heath: These days, when dentists get out of dental school, they often owe anywhere between $200,000 and $300,000 dollars. Dental school is actually more expensive than medical school. So they come out with these huge debts, in a lot of cases they can’t really afford to start their own practice.

These dental chains hire people, a lot of the time right out of dental school, and they pay fairly decent salaries and they have a bonus system where the more work you do on a patient the more you get paid. That’s true for a private dentist as well, but the difference is that these companies are owned by private equity firms, and they’re managed in a different way. You have people who are not dentists coming up with a business plan that’s based on metrics. They try to get new patients in who haven’t been to the dentist in a while, and they’ve already calculated how much revenue the average new patient should generate.

If you happen to go in and you don’t really have anything wrong with your mouth and you’re a new patient you’re not fitting the model. That creates pressure for the dentists to find things that are ‘wrong.’

PP: Is dentistry particularly ripe for these kinds of abuses?

Heath: In dentistry there’s not really any peer review or oversight. So there’s really not anyone to challenge dentists. And patients almost never challenge that kind of thing either. For somebody who’s not ethical, there’s a lot you can do and get away with in dentistry.

PP: How is it that so many kids in Medicaid have ended up relying on corporate chains for their dental care?

Heath: Not that many dentists actually accept Medicaid. There are some states where the reimbursement rates are so low that even the chains don’t go there. Like in Florida, for example, the Medicaid rates are so low there that chains don’t really even bother. So children end up going to the emergency room because they have a toothache and there’s nothing else they can do. They end up in hospitals to treat a tooth.

There was a famous case in Maryland where a 10-year-old boy had a toothache and it was abscessed and he ended up dying because he didn’t have a dentist.

[Note: According to a recent study, only about a third of children in Medicaid-- which covers more than 30 million American children -- will see a dentist in a given year. In Florida, where reimbursements are particularly low, only a quarter of the children in Medicaid see a dentist.]

In other states, like Connecticut, Texas and Virginia, they have dramatically increased reimbursement rates. You have more options there, but not the same options a someone who can afford it.

Dentistry is a little unusual from doctors because a lot of people don’t have dental insurance, and even if you do have dental insurance it often doesn’t cover a lot, and a lot of dentists don’t take insurance any more because of low reimbursement rates. So even if you have dental insurance, finding a dentist can be a challenge. So there is a real problem, especially for children, to find a dentist if they don’t have money.

PP: Are changes under way as a result of your story? Are there solutions on the table?

Heath: There is a [U.S.] Senate investigation still ongoing, I don’t know what will come of that. There are investigations in some of the states, Texas being one, looking at this issue. I think there are things in the works we really won’t really know the full impact of for a while yet.

We definitely got the attention of the dental community; we got a lot of feedback from them. This whole issue of accepting patients who have limited resources is a real issue in dentistry and something I think the dental community has to sort out.


  1. The result looks like the ones at dental plans new york; darn obamacare.

  2. I agree with you that people often visit ER because of dental problems. Whenever I experience something bad with my teeth, I make it sure that my dentist have dental supplies in stock so we won’t waste each other’s time.

  3. Obamacare should have the public option that they had been pushing for initially. I hope with the Affordable Care Act being effective next year, the government will provide exchanges that would cover dental care.

    -Amber Clarey

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