Tuesday, October 15, 2013

Obamacare - How will it affect dentistry?

I was recently asked by a friend how do I think that the Affordable Care Act (ACA or Obamacare) will affect dentistry.  This took some thinking on my part.

I have spent the past 5 years going to Washington DC to discuss dental care with our legislators. When the ACA was being discussed prior to becoming law, we did everything we could to get a seat at the discussion table to very little avail.

The year after the ACA was passed in Washington, we had a political pundit,  Dr. Frank Luntz ask us the question, "Are you happy with the results?"

No one could really answer because no one really knew or understood what was being thrust upon us as dental practitioners.

Frank's dad was a dentist.  As a child growing up, he recalled the animated stories his father would share about his patients. He was truly a caring practitioner. He loved the practice of dentistry, but he loved the relationship that he had with his patients even more.  Improving the health of the patients that he cherished is what he looked forward to every day that he practiced.  This is what I look forward to every day that I practice too.

Tragically, I see this style of practice on the decline.

From his personal experience, he went on to say that dentistry, as a profession, should be thrilled that it was basically left out of the ACA.  He reminded us that -

Dentistry is the last free market health care system that is working in this country.  

The reason - We keep the doctor patient relationship sacred. For more elaboration see my blog from July, 2011 The Sacred Cow.

In all aspects of health care there is trending consolidation of providers.  This means that private practices are joining up with hospitals or large groups called medical service organizations (MSO's). Included in these MSO's, hospitals are joining up with other hospitals and insurance companies to improve efficiency and improve access to information and resources.

As with any new paradigm, there will be some confusion from both sides of the fence as this takes affect.  All-in-all it should improve health care delivery as long as the doctor patient relationship is kept in the forefront. I hope that doctors are allowed to treat patients like they know best as opposed to management making decisions based on financial impact.

I expect many people to be upset at the changes from what they are used to with how they received health care in the past.  I also expect many people to be thrilled with the heath care that they are now eligible to receive.  The old adage comes to mind - "You can't please everyone, all the time".

There are many (including me) who are upset how the bill was passed and what was promised to the citizens.  I don't think that the legislators knew or could predict the extent of the problem at hand.  Therefore, they couldn't predictably fix the problem with the ACA bill.  What our legislators on both sides of the aisle knew was that our health care system needed to change.

The ACA is a start to solving the problems, it will evolve over time but it will never solve everyone's problems, expectations or needs.  We must accept this fact.  It will cost more and provide less than what we are used to.  We must accept this fact too.

I personally trust my physician to recommend the finest care to me.  Whatever he needs to do to evaluate my health, I expect him to recommend.  This should be in a "patient bill of rights".  I am cautiously optimistic that this style of practice will continue.

The insurance industry is the real winner in the ACA as they will have 48 million more people in the system that are now mandated to pay their premiums.  As a small business owner, I have seen my own health insurance premiums rise significantly over the last several years.  I predict that they will continue to rise as the ACA is implemented.

My predictions on how the ACA will affect the dental profession -
  Please note that these are my views and my views only.

In dentistry, we are seeing consolidation in a different form - through explosive growth in corporate dental service organizations (DSO's).  They seem to be sprouting up everywhere.  They provide a niche for people who are looking for low cost dentistry. This could be either good or bad depending on the perspective of the experience.  This practice model has been around for decades. They are a safety net -providing basic dental services (cleanings, fillings, crowns, dentures, partials, etc.)

I am hearing that these corporate dental organizations are recruiting heavily at the dental schools to attract new dentists to work for them.  Many new dentists are taking jobs with these firms as it is very difficult for them to find jobs elsewhere that satisfy their needs - such as make a decent living and paying off their student loans (average $250,000).

There will also be a rise in Federally Qualified Health Care facilities (FQHC's).  This is also a safety net capturing those patients that are lower income and have medicaid as a primary coverage.  These offices also provide basic dentistry similar to the DSO's.

Dental insurance - There are health insurance plans that offer dental benefits as an add on.  These plans are what I refer to as "skinny plans".  They offer the absolute basic dental services such as cleanings and exams.  I hope that these companies that are offering these plans are being honest to their clients about the limited extent of these plans.

If the reimbursement rates to the dentists are too low, dentists will not participate with these plans
- making it hard for patients to find dentists that take their insurance.

If the insurance companies drive the costs down through lower reimbursements, dentists will evolve their practice model to accommodate.  Please note that most dental offices are small businesses and provide dental care to the community that they serve while providing jobs to their support staff.  As with any small business, they must be profitable to remain viable.

I bring this up because there is a precedent of insurance companies cutting reimbursements to dentists in several states including: Washington, Missouri, Idaho, New Jersey, and Connecticut.  To show how volatile the relationship between dentists and insurance companies are see Washington Dentists vs. Delta Dental.  

Episodes like this don't make dentists happy.  Dentists want to provide a service to their community.  At the same time, we wish to keep our businesses viable with minimal third party interference and regulations that affect the "sacred cow" (doctor patient relationship).

With lower reimbursement rates, dentists must either see more patients per hour or cut costs. This could affect the practice in several ways including less time with the patient leading to a less personalized service. The dentist could also choose to use cheaper materials that may not last as long or be optimal for the situation as what he/she is currently using.  

If there are not enough providers to fill this void, a new dental provider model has been making dental headlines over the past few years.  This "Midlevel" provider will be able to do irreversible dental surgical procedures with minimal training - usually 2 years after high school.  This scares me, but as with anything, survival of the fittest.  If this provider model can provide the care that dentists and hygienists currently provide, they will stay, if not they won't.

Again, this is a slippery slope that will create a potential two tiered dental system with a significant percentage of the population receiving care that is from a provider that is seriously under-qualified to perform.

There is a 2.1% medical device tax. It hasn't been defined yet on what is going to be taxed.  My prediction is that anything fabricated by a lab (crown, denture, veneer, etc) will be subject to this tax.  I also predict that this cost will be passed along to the patient in some way.  When we brought this up to our legislators, they weren't sure yet on what was going to be taxed.  The term medical device is not spelled out in the bill.  As much as we tried, this tax isn't going away.

Expansion of medicaid coverage to children.  All plans must include dental benefits for children up to the age of 19 (including medicaid).  This will put millions more children in line to have access to dental care.  I predict there will initially be a shortage of dentists that can provide proper care for these kids.

Expansion of medicaid benefits to adults.  The ACA is encouraging the states to expand dental services to adults.  I predict again that there will initially be a dearth of dentists that take medicaid.  Medicaid reimburses at around 30% of what the dentist's usual fees are.  Plus, medicaid creates a plethora of extra paper work and reporting to get reimbursement.  Again, not an incentive for dentists to participate.  Some corporate models have already stepped into this niche and I expect several more to adapt into this niche as well.

One potentially good thing the ACA incorporated is an increased focus on healthy lifestyle, and prevention strategies.  We dentists have been doing this for the past 50 years.  Dentistry can help lead the charge here. The goal of dentistry involves optimization of health and function.  The removal of infection that could potentially spread to other parts or systems of the body is imperative for optimal health.  The ultimate function of teeth is to chew food.  The best way to maintain optimal health is to have proper nutrition and lead a healthy lifestyle.  If you have no teeth, it is very difficult to get good nutrition.

Odds and Ends.  I hope that the ACA also consolidates the respect of all health care providers.  We all have an interdependent essential pieces of health care.  All health providers must learn to communicate better with each other and with our patients for the best interest to improve the delivery of healthcare to those that we serve.

Patient's responsibility. The ultimate responsibility of health lies on the citizen patient.  He/she must live a healthy lifestyle to remain healthy.  Many health problems are preventable. Many health problems are not preventable.  If the system is clogged with the health care problems of the preventable kind, there are not enough resources available to help those with the non-preventable kind.

With respect to dentistry - 
Clean teeth do not decay, most gum disease can be prevented with brushing and flossing! 

I welcome comments and perspectives on this.  I am no expert and would love to hear other opinions - especially if I am off base here.

If you like this blog post, I would love to hear about it.  Please comment or share it on Google+, Facebook, Linked in, Twitter, etc.  If you are looking for a dentist in the Denver area, we are always looking for new patients.  Please visit our website http://www.tcdodenver.com/ or like our facebook page,  https://www.facebook.com/TCDOdenver.  Or you can do it the old fashion way - call us at 303-321-4445.

Thanks for reading!  BK

Monday, October 7, 2013

Veneers, Veneers and More Veneers

A smile is the window to the soul.  
As a dentist, I do everything I can to help my patient's soul shine through.  

Smiles communicate happiness, pleasure and confidence.  Many of my patients who come to me for smile improvements, are happy people but self conscious and may not project their inner happiness as effectively as they would like.  This could affect any relationship that they are in whether it be personal or professional.

93% of all communications are non-verbal - of which body language including facial expressions are a large part of that.

A new improved smile is life-changing!

I'd like to share an example with you:

One of my patients moved to a new neighborhood.. She was slow to make new friends/acquaintances with her new neighbors.  She was perplexed by this as she had never had difficulty with making friends in the past. She had some dental issues that allowed us to have a conversation about her smile.  Once we improved her smile, she mentioned to me that people seemed more friendly to her.  A close friend told her that she didn't smile very much before and perhaps her new neighbors judged her as unfriendly. This brought tears to her eyes as she explained this to me.  She had no idea that she was hiding her smile.  Her new smile outwardly projects her inner beauty, happiness and confidence.

Here are some examples of  what can be done to improve smiles with veneers.

 Case 1: Before: Stained old restorations

After- Veneers and teethwhitening.
Case 2: Before - Worn front teeth from grinding

After - Four veneers, teeth whitening, and bite therapy to protect her new smile


Case 3: Before - stained, yellow teeth

After - Four veneers, whitening


Case 4: Before - Old restorations, improve smile

After: Four veneers, teeth whitening


Each case is carefully crafted to match the patient's facial structures, personality and function.  Before we start we have a discussion dedicated to help the patient identify their goals with their smiles.  The better we can identify these goals, the better we can create the smiles that he/she desires.

For more examples of smiles that we have created and lives that have changed, click on the link - Smiles

If you like this blog post, I would love to hear about it.  Please comment or share it on Google+, Facebook, Linked in, Twitter, etc.  If you are looking for a dentist in the Denver area, we are always looking for new patients.  Please visit our website http://www.tcdodenver.com/ or like our facebook page, https://www.facebook.com/TCDOdenver.  Or you can do it the old fashion way - call us at 303-321-4445.

Thanks for reading!  BK