Feeding the Monster

by Charles B. Clark, M.D.

Christmas day. The telephone rang. "Hello, Charles. This is Ray," the conversation began. "I hate to bother you on a holiday but I just crushed two fingers loading a trailer." It was my friendly dentist calling.

"Meet me at my office as soon as you can," I replied. The poor fellow had crushing injuries of the soft tissue and middle phalangeal fractures of his right long and ring fingers. His dental practice was hanging in the balance. After a trial of closed reduction, the fractures proved to be unstable. We had to perform further reduction with internal fixation using Kirschner wires as an operating room procedure. He responded well to treatment. The fingers regained full mobility and he resumed his dental practice. The surgical fee was $759.

Later one of my teeth needed a crown. I went to my faithful dentist. He spent ten minutes removing the enamel from the tooth and his assistant placed a temporary crown. When I went back for the permanent crown, he spent another five minutes putting that in place. My bill was $810.

Sometime later he put a crown on another tooth. Another fifteen minutes. That time it was $887.

Following an episode of severe pain in one of my teeth, another dentist performed a root canal procedure. That took about forty minutes counting the time he was off doing something else. The bill was $860.

Undeterred I decided to have a dental implant to replace a missing molar. I went to yet another dentist for that procedure. Everything was handled by the dental assistants up until the moment of truth. Then the dentist wheeled in. Placing the implant took exactly twenty minutes and then - out the door. That bill was $2,108.

The final stage was having the new tooth (dental crown) placed on the implant. The fee for that was $1,300.

So it seems that saving an individual’s dental career isn’t worth as much as saving just one of my teeth. How is this possible? It is called managed care. Some people call it mangled care. Apparently it hasn’t caught up with the dentists.

My own experience with managed care was brief. I contracted with a company who offered to pay 85% of the amount billed. That sounded O.K. so I signed up. Soon one of their providers was having difficulty with one of his patients. The provider requested a second opinion and the company sent him to me. For the consultation they paid 50% of the amount we billed. I told them I would not accept 50% since I was contracted for 85%. They declined to make any further payment and I cancelled my contract. So much for managed care.

In our office we are finding that the overhead is gradually increasing. The insurance fee for medical malpractice, the fee for Workers’ Compensation insurance, the fees for waste removal, the linen laundry service, changing the solutions in the dark room, the janitorial service and everything else keeps going up. The only thing that hasn’t increased is the medical fee schedule. Some of the payments have actually gone down. It should be clear that this can’t continue indefinitely without some rather undesirable consequences. A universal government delivery of health care may be just around the corner.

With the overhead relentlessly increasing and the fees remaining unchanged or decreasing, we are caught in a downward spiral. Where will it end? It will end when the doctors are government employees. Those who deliver health care will be getting salaries equal to those who deliver mail. That hardly does justice to the years we have devoted to acquiring our professional skills. Having practiced my specialty in a country that has government provided socialized medicine, I can tell you it isn’t a pretty picture.

How do we find ourselves in this quandary? We have embraced managed care with passion. We are sleeping with this monster that threatens to destroy us. We join groups so we are in a better position to negotiate for managed care contracts. But who are we competing against? We are competing against each other as we watch our fees decline. Aren’t we feeding the monster that is consuming us?

What can we do about it? Make a list of the managed care plans you are contracted with. Determine who compensates you at the lowest rate. Cancel your contract. See if that doesn’t make you feel better. Perhaps in another four to six months you will be considering the idea of dropping another one. Now you are on the way! Maybe we will all be on the way.