Health care – Beyond the Bite

Opinion: Dental Insurance Next Industry That Badly Needs Reform

by Florida Dental AssociationAugust 10, 2021August 10, 20211 Comment

By Yaël Ossowski, Consumer Choice Center Deputy Director

In the last decade, most debate and discussion on reforms related to health care have focused on Americans’ general health insurance plans and costs. And for good reason.

And though our health system is convoluted and complicated, it gets even more complex when we examine what is happening with dental care.

The intersection of hefty insurance premiums, confusing government benefits and a red tape bonanza keep many Americans from ever visiting a dentist’s office.

Even though 80% of Americans have access to dental benefits, nearly 35% of American adults didn’t visit a dentist in 2019, according to the National Association of Dental Plans.

The reason so many neglect getting their teeth checked is clear in the data: the mounting cost. And modern dental insurance, coupled with myriad various government programs, is a big reason for that.

Unlike most health care plans, dental plans have low caps on the number of benefits they will pay out, anywhere between $1,000-$1,500 a year. Premiums average $30-$50 per month depending on the plan and the number of people covered.

Because patients use dental insurance to cover all aspects of their care, rather than emergencies, this adds to an inflation of the price of rudimentary care, a phenomenon dubbed the “social consequences problem” by economists.

That problem gets even more complicated considering that nearly all dental patients don’t choose their plans themselves.

At present, 93% of privately insured dental patients receive coverage from their employers, meaning there is little incentive to innovate direct-to-consumer options that would offer competition.

This incentive problem, along with a relatively opaque dental insurance market, means costs will continue to rise unless we can agree on simple reforms to increase competition and transparency in the dental insurance market.

To do so, state legislatures and Congress should first look to encourage patients who choose membership programs as dental plans, rather than traditional insurance. Using health savings accounts to buy these memberships, as well as pay for care, would be a huge improvement that would empower patients to contract their own care.

This would be similar to the movement of direct primary care doctors, who offer direct monthly subscriptions to patients and don’t accept insurance. Removing the insurance middleman means less bureaucracy, less red tape and more time with patients. As a plus, prices are transparent and fair. That alone would provide better competition and prices for patients in need.

This would lead to a larger decoupling of health and dental insurance from employers, allowing patients and consumers to choose the plan that works best for them and their families.

On the note of transparency, state legislatures should hold the dental insurance industry accountable with simple reforms that empower patients when choosing their dentists.

Assignment of benefits laws, already passed in states like Colorado and Illinois, allow patients to choose whether they want insurance companies to directly pay dental clinics, freeing patients from having to pay upfront and negotiate with insurance companies for reimbursement.

Similarly, network leasing regulations, allowing dental clinics to revise and opt-in to insurance networks rather than being automatically forced into them, would keep prices low and transparent, not to mention predictable before you even step into the dentist’s chair.

As legislatures look to reform health care, we should also keep in mind the growing dental bills facing Americans every day, and hope lawmakers understand the need for more competition and transparency to better improve dental care in our country.

Encouraging competition to traditional dental insurance, while promoting simple regulations to promote financial transparency, will serve to empower consumers and lower the costs of care.

That would be bold and revolutionary for patients and would help encourage innovation in a sector where it has not always been the most welcome.

Reprinted with permission from the Boston Herald. This op-ed was originally posted on July 14, 2021 at bit.ly/3CzGRfI.

The FDA thanks the Consumer Choice Center for bringing attention to these important issues. The dental insurance industry needs important reforms to protect transparency and competition for patients. We’re glad to see this additional momentum behind the work of the National Council of Insurance Legislators to reform dental insurance and protect patients.

Funding Donated Dental Services will help Florida’s most vulnerable get life-saving care

by Florida Dental AssociationDecember 30, 2019December 30, 20192 Comments

By Dr. Cesar Sabates

“The mouth is the window into the health of the body” is a well-known phrase in the health care community.

As a dentist who has practiced for 30 years, I know that this statement is true.

I’ve treated patients who could not undergo transplants until the infections in their mouths were treated, and I’ve treated patients who couldn’t eat or sleep properly because of the pain of gum infection and decayed teeth, which can be associated with medical conditions such as diabetes.

Click here to read the full article in the Miami Herald published on Dec. 26, 2019.

Dr. Cesar Sabates is president of Florida Donated Dental Services, a past president of the Florida Dental Association, a Trustee of the American Dental Association and a practicing dentist in Coral Gables.

Florida Donated Dental Services program, which gives dental care to patients unable to pay, is seeking full funding from the state. Getty Images

Case Study: Unethical Treatment Leads to Lawsuit and Dental Board Action

by Florida Dental AssociationAugust 11, 2016May 30, 2017Leave a comment

By Kim Hathaway, MSN, CPHRM, CPHQ, Patient Safety Risk Manager, Department of Patient Safety and Risk Management, The Doctors Company

A celebrity dentist performed excessive treatment and committed ethical violations.

A 46-year-old male was evaluated by a general dentist, who conducted an examination with X-rays. The dentist determined that two dental surfaces were decayed and one tooth had a possible fracture. Excessive wear to the teeth was not indicated, and pretreatment photographs revealed good stippling of the gums.

Five days later the patient presented to a celebrated dentist who practiced general dentistry with advanced training in cosmetic procedures. The dentist was widely known through appearances in multiple television commercials, coverage on reputable news channels and his website. This media exposure created an assumption by the patient that the dentist’s professional qualifications were undeniable.

According to the patient, this publicity was a determining factor for his selection of the celebrated dentist to continue his treatment. During the initial evaluation, the patient complained of a “gummy” smile, as well as chipped and discolored teeth. The dentist performed restorative procedures that resulted in patient fees of $47,000.

A review of the dental record indicated that medical history, initial examination, X-rays and photographs had been repeated by the celebrated dentist prior to treatment. According to the second assessment, the patient had decay on 45 dental surfaces, tooth fractures on 77 surfaces and 31 teeth worn down by one-third to one-half. Gingival recession and tetracycline staining also were noted.

Although the diagnosis and treatment plan were vastly different from those of the original dentist, the patient agreed to undergo the procedures. Following the restoration, the patient remained unhappy with his appearance and experienced unrelenting pain. The pain led to gum surgeries, multiple root canals and significant weight loss. As a result, the patient was ultimately examined by five additional dentists. All of these dentists agreed the procedures performed by the celebrated dentist were below the standard of care. The estimated cost of the examinations by the additional dentists totaled $63,000.

The patient pursued a claim against the celebrated dentist, resulting in an indemnity payment.

A complaint also was issued by the state’s dental board. According to the complaint, the dental record indicated a recommendation of crowns to nine teeth, veneer treatment on 11 teeth, laser treatment on six teeth, a bridge on three teeth and one implant. Other procedures also were performed, including laser treatments to restore the patient’s smile.

Diagnostic imaging and other pretreatment photos did not support the need for restorations. Some teeth that had been diagnosed with decay and/or fractures were not treated. There were other accusations of ill-fitting restorations on multiple teeth.

The complaint contained ethical declarations, including that the dentist failed to address the patient’s concerns appropriately when he complained of pain. The dentist incurred charges of unprofessional conduct, excessive treatment and repeated acts of negligence. The dental board determined that the dentist provided substandard care that was indefensible, unnecessary and incomplete. The allegations were compounded because it appeared the dentist had rewritten a portion of the chart and that critical evidence had been destroyed. This rendered the dentist unreliable in his own defense.

Risk Management Discussion
According to the American Dental Association’s Principles of Ethics and Code of Professional Conduct (ADA Code), “The dental profession holds a position of trust within society.” The celebrity status of the dentist and the media coverage displayed on the dentist’s website indicated to the patient that he could rely on this dentist and trust him more than other dentists. The dentist violated each of the five fundamental principles of the ADA Code: patient autonomy, non-maleficence, beneficence, justice and veracity.

The following strategies can help you avoid unethical allegations:

Understand and practice under the ADA Code.
Provide only tests and treatments that are reasonable and necessary, with documentation to support the necessity of services provided.
Research and follow state regulations related to advertising as well as regulations regarding all aspects of a dental practice.
Exercise caution in advertising to avoid false or misleading claims about treatments, experience, certification or credentials that might misinform patients about the qualifications of a provider.
Display your credentials clearly and accurately. General dentists who perform complex prosthodontic or periodontal treatments, or practice as experts or specialists may be held to a higher standard of care than general practitioners.
Do not alter or destroy the patient record. In the event of a claim or litigation, the alteration will likely be perceived as a deliberate act to deceptively reflect care or explain a less than perfect outcome. Altering the patient record also may result in a regulatory agency disciplinary action and create lasting reputational damage. Concealing damaging evidence will render a case indefensible.

The guidelines suggested here are not rules, do not constitute legal advice, and do not ensure a successful outcome. The ultimate decision regarding the appropriateness of any treatment must be made by each health care provider in light of all circumstances prevailing in the individual situation and in accordance with the laws of the jurisdiction in which the care is rendered.

HIPAA Audits: Why Dental Organizations Shouldn’t Ignore the Audits

by Florida Dental AssociationMay 5, 2016May 30, 20171 Comment

By Dr. Danika Brinda, CEO, Planet HIPAA

2016 is going to be a monumental year for HIPAA compliance. The Phase 2 HIPAA audits will be starting, and increased HIPAA enforcement is a guarantee. So far in 2016, we have seen multiple fines and HIPAA compliance enforcement that are setting the stage for the remainder of 2016. For many years, HIPAA compliance has been pushed off and ignored; however, if the first 2 months of 2016 is telling the story, now is the time to ensure your dental practice has established proper policies, procedures and practices for HIPAA compliance. Don’t get tangled up in a HIPAA audit with no confidence in your dental practice’s compliance with HIPAA!

It is easy to think that your practice is too small to get selected for a HIPAA audit or that audits will focus on large, integrated health care systems. However, looking at the findings from the pilot audits indicate that dental practices are just as desirable for a HIPAA audit as any other type of organization.

Some key findings from the HIPAA Pilot Audits are:

Smaller organizations tended to struggle with HIPAA compliance more than larger organizations.
The most common finding was that the entity was “unaware of the requirement.”
Of the total health care providers audited, NONE of them were 100 percent HIPAA compliant.
Incomplete implementation of the regulations was cited as a top finding from the audits.

We are at a stage with HIPAA compliance that the “I didn’t know” or “I was unaware” is no longer going to be an acceptable reason for non-compliance. In the past year, numerous data breaches were reported to the Department of Health and Human Services. In some of the dental data breaches reported, more than 500 individuals were impacted!

2,000 individuals impacted when an unencrypted portable device was stolen from a dental provider.
3,200 individuals impacted after an unencrypted server was stolen during a burglary of a dental office.
7,400 individuals impacted when dental records at an off-site storage were released by the storage company to unauthorized individuals.

With proper oversight of HIPAA and appropriate physical, technical and administrative safeguards, these data breaches could have been avoided.

Another common finding is false security that the vendor of your practice management system or electronic health record has all aspects of HIPAA compliance covered. Even when a third-party solution manages a system, not all aspects of HIPAA compliance are met. Additionally, you may find that some functionality of your systems does not actually meet HIPAA compliance. For example, your systems should be able to automatically log out after a specified time of inactivity. Your vendor may be the group responsible for creating the functionality, but you are responsible for the implementation in your dental organization. If your software system doesn’t have the functionality to automatically log out of the system with inactivity, you may be out of compliance with HIPAA. Don’t assume that compliance is met — verify it!

Don’t wait until a HIPAA audit comes to your dental practice to know that you are out of compliance. Immediate action is needed if you are not confident in your HIPAA compliance. HIPAA takes more than just putting a HIPAA manual on the shelf in your dental practice. Make sure your organization takes the steps NOW and prevents a bad outcome from a HIPAA audit or showing up on the HIPAA Wall of Shame.

Dr. Danika Brinda is the CEO of Planet HIPAA and has more than 12 years of experience in health care privacy and security practices. She also is a nationally recognized speaker on a variety of health care privacy and security topics, and specializes in helping dental organizations implement a HIPAA-compliance program.

This article was first published on Planet HIPAA on April 18, 2016.