Nothing Will Ever Be the Same Again … For Dental Plans and Dentistry

A new payment system would shift the balance of power back to the patient and dentist

Daniel Hinkle

The vast majority of dentists in the United States participate in at least one insurance network, and many of them are frustrated by a perception that third-party payers are squeezing their practices with reduced reimbursement rates and claim denials.¹

Entrepreneur Qadeer Ahmed says dentists become emotional when discussing this subject with him. Some show him bills for procedures that were supposed to be 50% covered and tell him they were paid only 5%. Others talk about predeterminations whereby patients were compelled to return several times for routine and medically obvious procedures.

“The system is broken,” Ahmed says. “It is broken from the perspective of employers who pay 6% to 12% more each year with the claim caps staying the same. It is broken from the perspective of patients who face a disparity between what they need and what is covered. And it is broken from the perspective of dentists who are being forced to incorporate various creative adjustments to their practices just to make ends meet with the plan designs that are being provided.”

Ahmed is not alone in this assessment. In a 2016 Inside Dental Technology interview, Clinicians Report co-founder Gordon Christensen, DDS, MSD, PhD, said surveys he has conducted and published indicate that third-party payment organizations were the singular most disagreeable aspect in all of dental practice.²

“The challenge is only getting worse with frequent reductions in payments for oral procedures. Third parties are now dictating fees, treatment plans, and fees for treatment they do not even fund,” Christensen said in the interview. “The profession is ready to rise up with a major anti-third-party payment revolution. All that is needed is a leader of that revolution, and that will happen. The profession needs to abolish the current dental payment concept and form a new system that is equitable for patients, dentists, and any business or company that will be involved.”

Ahmed and his company ProCare Dental Services plan to be that leader by revolutionizing oral healthcare with the design of a new payment model for dental coverage. He expects the transformation this delivers in dentistry to be similar to that of online retailers replacing brick-and-mortar bookstores or websites such as Expedia replacing travel agencies.

“We are at one of those ‘nothing will ever be the same again’ moments in dentistry,” Ahmed says. “For the longest time, in medicine and particularly dentistry, we have lived in a world in which the people who collect the money for healthcare have dictated how medicine was provided, rather than the people who actually paid for it or the people who provided the medical services and had the expertise to determine their necessity. It is a strange, unnatural process by which, if you want to be healed, then the entity collecting the money—not the healer or yourself —is allowed to define what you can and cannot have happen to you.”

ProCare’s goal is to create a system in which decisions about health and dental care are made by the patient and the provider. In order for that to happen, Ahmed says, the provider’s economics must change.

“In the old days, companies made money selling coverage, and dentists earned money by trying to survive and provide services underneath that coverage. The business of providing coverage, and the business of providing care were almost two separate industries,” he says. “In the world we see, providing care will be the dominant business. The traditional coverage business will be effectively leaned out to its natural economic role and its actual value, and much of that revenue will shift to the people who provide care. The providers in this new world will have groups of patients they select and revenue streams they define, as well as control and influence.”

Leaning out the traditional coverage business will mean eliminating inefficiencies, which Ahmed notes is commonplace in sophisticated negotiations between those who pay and those who provide in other industries.

“In modern business, suppose a soda company wants to sell a bottle of its latest beverage for $1, and a retailer wants to buy that bottle for $0.90 instead. They work together to discover money that neither wants to pay,” he says. “The retailer might decide to pick up the product from the factory to save money on shipping, and the soda company might then agree to reduce the price charged by most of the amount saved. In this way, the soda company can keep making the same profit while the retailer gets a lower price. Both sides win. There is a negotiation whereby people find shared solutions to a common problem so the pricing becomes sustainable. Yesterday’s healthcare plans are like a retailer who just yells “90 cents! 90 cents!” and changes nothing to actually fix the reasons why the bottle is sold for this price—they do not solve problems for providers.”

The problem in dentistry has become pronounced in part because of other pressures such as labor rates, the increasing use of technology and capital equipment, and the rising costs of dental school. While dentists should be focused primarily on providing optimal care, Ahmed says, often they are not.

“Fixing the healthcare problem in the United States and around the world starts with having healthcare providers who are economically powerful because they are willing to be accountable and willing to have their work measured,” he says.

ProCare’s vision for the future includes dentists who do not need to wait for insurance reimbursements to cover their overhead, and subsequently, the quality of care will increase.

“Dentists will have the freedom, dignity, and respect to do their jobs as they imagined, as healers,” Ahmed says.

“Patients will be able to get the care they want at a fraction of the cost they paid previously. Employers will finally be able to bend the cost curve and have a permanent solution to their dental coverage needs, which will set the stage for this to occur in the rest of the healthcare industry. All of this will create a multibillion-dollar value shift toward the people who are running today’s and tomorrow’s dental practices.”

References

1. DeWyze J. Dental Reimbursement. Inside Dentistry. 2016;12(3):92-99

2. Industry Ripe for Transformation. Inside Dental Technology. 2016;7(8):8-9.

About the Author

Daniel Hinkle is the founder of Practice Performance Inc. and a consultant for ProCare Dental Services.

“The system is broken from the perspective of employers who pay 6% to 12% more each year with the claim caps staying the same.”

“Dentists will have the freedom, dignity, and respect to do their jobs as they imagined, as healers.”