The recent article by Dr. Marko Yujicic in the ADA Journal suggests that dentistry is stuck with an outdated paradigm. Our assessment is that educators and politicians are trying to push dentistry to follow the failing model of medical care delivery. As a long term provider of care under a fee for service approach, I find his emphasis on moving dental care into the realm of the medical model unsuitable. I agree with Dr. Vujicic that dental health is an essential element in overall good health. I even agree in principle that covering preventive services under Medicaid/Medicare would be a good idea. However, those of us who have tried to be good Samaritans and serve those on Medicaid have found the system is as badly broken as the VA system. Our contention is that no one practicing comprehensive care can serve the Medicaid population, operate a business like office and make a profit under the current system.
In the article we note the continued use of words that come from the medical model of care such as “what patients need” vs. what outcomes patients want and are willing to pay for. The end users – patients – should be the final arbiter of what they need. We, trained professionals, may understand what might be in the patient’s clinical best interest. However, telling patients what they “need” does not lead to patient accountability or buy in. One key element in improving our care system is improving our dental education system to include training in the behavioral aspects of care and in emotional intelligence. Patients with low dental IQ’s may make choices that we might deem not ideal. However our role is not to “fix” people. Our role is to help patients understand the outcome of those choices and most important help them understand that they own the outcome. Then, and only then, we should strive to help them find an affordable path to care.
The value proposition, if we focus on outcomes based care, comes from patients choosing the outcomes that matter to them relative to cost of achieving those outcomes. The profession should focus on trying to make sure that no one is denied care based on economics. However, the profession should not and cannot be put in the position of providing care for those who are unwilling to be accountable for their own health. In my area we address a portion of this problem with local dentists working together to provide care under the umbrella of a community wide free clinic.
Among my peers who are small town, middle America, outcomes based, fee for service providers, demand for paid care continues to be stable or on an uptrend while free clinic care is trending down.
There is no question that the impact of the insurance based medical model has caused us to need to spend more time to develop relationship based care and an understanding that all parties involved in the relationship must be accountable in order to achieve success. For our elderly population that may mean forgoing discretionary restorative care so that available funds can be used for preventive services to prevent the need for further care. Just because “it is covered by your insurance” does not guarantee that a procedure is in the patient’s long-term best interest.
True fee for service care is not based on the number of procedures completed. That concept was developed by the insurance reimbursement model. Fee for service care is based on reaching outcomes that the patient defines, and the patient and provider agree is achievable clinically and economically.
We do not agree with the article mentioned by Dr Vujicic by Porter and Lee which treats healthcare as a risk management proposition. We do agree with Dr. Vujicic that systematically measuring oral health outcomes in ways that are relevant to patients is an important step needed to move away from a procedures based mentality prevalent in the profession today. Provider reimbursement when insurance is involved should move away from counting surfaces restored and allow freedom for the patient to allocate their allotted benefit funds for the outcomes that best suit them. Patients can be incentivized to be more proactive when they make choices that measurably improve their oral health (reduced decay rates, better periodontal health) and dis-incentivized when they fail to be accountable (not utilizing sealants, failing preventive care visits).
Dentistry is finally being recognized by the medical profession as a part of the family of the healing arts. As such it is critical that dentists develop patient management systems and communication systems that make it easy for an interdisciplinary team to work together on the patient’s behalf. Far too many dentists do not make the effort to develop relationships with their medical or specialist peers.
Finding others with similar practice philosophy is a strong motivator to remain a continuous student throughout your career. One easy and enjoyable way to do this is through quality CE providers such as the Pankey Institute and membership in some form of study club like the Seattle Study Club. Every member of the office team should feel empowered to speak up and reach out to, and for, the best interest of the patient.
There is a segment of the population that, for numerous reasons, is not seeking or receiving dental care. Our experience is that low dental IQ is more of a factor in not seeking care than economics. Like Dr. Vujicic, we believe, our senior population would benefit from the inclusion of basic preventive services under the Medicare umbrella. However, even if that entitlement is put in place it is not likely to be fully utilized. Until individuals take ownership of their own health, no system of “free” benefits will resolve the matter of people making poor choices in health care.
The worst thing dentistry can do is to try to model future care based on medical practice. The medical system is broken and has been moving the wrong way for a generation. Medicine is now an industry that is controlled by insurance companies, hospitals, the government and large group practices. The care delivery model in most medical offices and hospitals is little different than the process control utilized in the average manufacturing plant. Until we move medicine into a model that recognizes the importance of defining what the patient sees as ideal health and holds them accountable, while working together, to meet those goals we will continue to over prescribe drugs, over order diagnostics and strive to “fix” patients because they “need” care.
Practicing the profession of medicine or dentistry is not simple. However, the core elements of delivering care in a manner that is patient centered and economically feasible have been well defined. In John Torinus’ book “The Company That Solved Healthcare” he outlines proven methods that work in our current environment and can be implemented with relative ease if we have the will to do so. However, moving from the current model of medical care delivery will be difficult, if not impossible. Politically we continue to move toward a system that teaches patients that they are “entitled” to care no matter what behaviors they exhibit.
Nowhere in our system of care are we realistically addressing the epidemic of obesity, continued smoking, lack of exercise, excess use of drugs and sugar. These are all elements that our patients can control if they choose to do so. If we do not understand the behaviors our patients choose, how can we rationally expect to help them achieve the outcomes they express to us?
Moving to a single payers system will only exacerbate the situation; drive costs higher and penalize those who practice a healthy lifestyle. Would we agree to begin significant restorative treatment on a patient who continues to consume six Mountain Dew sodas a day? Our medical colleagues feel pressured to provide treatment no matter what choices their patients make. Thankfully, most dentists have the common sense and moral strength to say no in a situation like this.
Dentistry should not be a “fix it” profession. We are, or should be, driven to help patients determine what they want as an outcome for their oral health. After thorough diagnosis and open discussion of the patient’s situation we can offer the means to achieve their goals. We should understand and respect that economics will be a factor in people’s choices. Only when we have mutual agreement about the patient’s desired outcomes, the means necessary to achieve them and the prices (time, money, effort, stress) involved should we consider moving on to treatment.
Those in dentistry who are practicing outcomes based, patient centered fee for service care are not stuck. They are thriving. Those who see delivery of care as best provided under the corporate model or single payer system are not paying attention to the continued disintegration of relationship based care under our current medical model. The forces of politics and economics are deeply embedded in the systems in place today. It is unlikely that radical correction will take place any time soon. Dentistry would be wise, especially at the level of our national associations and educational institutions to refuse to allow our medical colleagues to guide us into the morass of the current medical model.
 Vujicic, Marko Phd, ADA Journal 201801.006
 Porter, Michael; Lee, Thomas; Harvard Business Review, I The Strategy the will Fix Healthcare, Oct 2013
 Torinus, John Jr, The Company That Solved Healthcare, Benbella Books, 2010
 Roth, Sandy, Personal correspondence, 1994