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 By Dr. Mary Jennings, Editor, WSDA News

The Affordable Care Act’s Pediatric Dental Health Benefit is one of the poorest pieces of legislation ever drafted. It looks like an afterthought. I believe it was irresponsible, if not down right lazy, to send this weak and undefined benefit out to the world like a spring lamb to wolves. 
Only Washington and Nevada took the high road and mandated the benefit for children. Washington started early and invited stakeholders like the WSDA to participate in the process. They listened when we said that the dental plans within and without the exchanges must be competitive and did not allow insurance monopolies to control the exchange. Even still, there are wolves within the exchange who are causing problems for both dentists and our patients.
I recently received a letter sent from Delta Dental of Washington (DDoW, formerly known as Washington Dental Service, or WDS) to their member dentists regarding their “Washington Kids Plan,” a plan they developed expressly for the Affordable Health Care Dental Exchange. Among other things, it lays out the rules for extraction of third molars. With this policy, dentists can remove teeth that have obvious non-restorable damage or pathology. What dentists cannot do is anticipate impacted third molar damage and have them removed before it happens. 
The letter states under “Qualifying Conditions Specifically for Removal of Third Molars Only” that we can extract if there is “bone loss or caries in the adjacent second molar that cannot satisfactorily be treated without removal of the third molar.” It also allows extraction when there is periodontal disease that is unmanageable without extraction.
Evidently, I am supposed to let the damage that I knew was bound to happen actually happen before anyone can extract the offending tooth. We all know the development of periodontal disease and caries takes time and will most likely occur after a child has graduated from this plan. Still, we all knew it was coming. 
It gets worse. Patients must have “second or subsequent episodes of pericoronitis (unless the first episode is particularly severe), that cannot be resolved through the use of antibiotics, irrigation or other topical treatment.” Let’s tear into this statement. All my patients with pericoronitis feel that their pain is “particularly severe.” Exactly how am I to explain that they need to have more pain, miss school and take more drugs, in order get a service paid for? Oh, there’s a trust builder.
Most pericoronitis cases respond well to antibiotics. One has to have two that don’t? How sick is that? Ludwig’s angina sick? Hospitalization sick? Won’t that cost some insurance money? What about those superbugs we are not supposed to be breeding by the misuse of antibiotics? 
I like the American Association of Oral and Maxillofacial Surgeon’s catch phrase “asymptomatic does not mean healthy.” Take a look at their “Evidence Based Third Molar Surgery” white paper that states, “The presence of symptomatic or asymptomatic pericoronal infection is, of course, an absolute indication for removal of the third molar teeth.” 
All dentists know that microbial complexes found around third molars can cause periodontal disease and lead to other problems such as pre-term low birth weight pregnancies and cardiovascular disease. We find more cysts and cancers in retained third molars. We all know that extractions of third molars in older people cause more trauma, longer post surgery healing and complications. Throw bisphosphonates into the mix and even DDoW’s much-maligned prophylactic extraction looks rather attractive. 
Dentists often feel the confines of patient financing and insurance limiting our full ability to provide the very best care possible. We can usually work around those confines. Unfortunately, DDoW’s Washington Kids Plan rules allow sickness and damage to occur. Am I supposed to base my practice on prevention and evidence-based dentistry or insurance benefit rules? I can “document, document, document” the fact that I warned my patient of adverse outcomes, but I still feel that is just not enough. I know that without insurance coverage, most people cannot afford surgical third molar extractions. When adverse outcomes result from this who gets the blame? The patient for not being able to afford it, the dentist whose care was prohibited by DDoW’s policies, or DDoW, who reported $1.003 billion in premium revenue in 2011 and claims to be the advocate for the patient? 
I believe profit is the defining reason for the new rules. This plan needed to be affordable and competitive for the Exchange. With a $33.17 a month premium, surgical thirds must be too expensive to make a profit. One of DDoW’s core values from their website is accountability. They state: “Accountability: We achieve results at Delta Dental and hold ourselves and each other accountable for doing so. We are profit-oriented but in the interest of ensuring that we can continue to improve oral health, innovate and grow, and sustain us during tough times. At Delta Dental, we are committed to doing the right thing.”
Let’s get this straight. DDoW considers itself a profit oriented non-profit. Okay… but since when does “doing the right thing” include letting kids get sick?
 Helen Keller said that the only thing worse than being blind is to have sight but no vision. Oh DDoW, what profit do you really need to make besides the business expenses necessary to mediate fees between patients and dentists? Could this be the true definition of blood money? Why can you not simply give back to the people you promised to serve? 

Reader Comments (3)

This is getting to be ridiculous. No longer are we, the educated professionals, the diagnosticians looking out for the well being of our patients. The insurer is now the decision maker that the patient has to trust. When a patient has to experience pain to obtain coverage, it is us that suffers credibility, not the insurer. Recently had a case denied where the tooth was visibly cracked horizontally across the buccal cusp, had a large MOD alloy and WDS would not provide coverage unless the cusp actually broke away. Businesses would be financially ahead, and their employees more well cared for by self insuring thereby allowing their employees to regain trust in their health care provider and allowing them to decide how they want to spend their money. Insurance should be in place to cover the non anticipated "catastrophic" procedures that are more of a financial burden, rather than the affordable cleanings and exams. This is not what the insurers provide because it sucks out their profit. Where has the benefit in health care benefits gone? To the insurance company-not the patient.

03.13.2014 | Unregistered CommenterMCB

Dr. Jennings.
Your recent commentary regarding "Delta Dental; Doing the Right Thing?" although provocative, is missing one key element - that the enpowerment of WDS or DDofWA or whatever the latest corporate brand has been affixed to this for-profit "non-profit" (1.003 BILLION in 2011 remember?) - is our own fault. That is right my colleagues. I have yet to see a dental benefits company do a filling.
Your participation as a member of this company that has/is totally manipulating your care shows that you and your practice are an addicts. So does your denial. You are addicted to the foursome. The foursome used to be the pillar of the dental care delivery arrangement - Payer (usually employer)/Dental Insurance/Dentist/Patient.
My colleagues, create a more contemporary solution for delivering patient-centered care in your practice that does not involve a third party - whether it is a patient-direct in-house membership program or otherwise. Highlighting the continued absurdity of the insurance provisions mandated by WDS upon its members achieves NOTHING except to proclaim the depth of your addiction. John K. McGuill CPA,MBA,JD publisher of the respected dental management newsletter The McGuill Advisory puts it best...

”Once they dominate dental market, managed care plans often seek to manage the care itself”...The McGill Advisory 6.12

Let's face it though, you're not going to leave doctor, you're too much of an addict....So remember, antibiotics first because that's what's best...isn't it?

Gregory C. Yen DDS
Dental Wellness Club of Seattle

03.13.2014 | Unregistered CommenterGregory Yen DDS

Great piece Mary! I love our editor!

03.13.2014 | Unregistered Commentertheresa cheng

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