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Washington State Dental Association

Old and Tired, I Worry About the Future of Dentistry - John Weaver, DDS

Reflections of an Olympia Dentist with 33 years of practice on WDS’ 15-22% fee cut!:

Having witnessed the events of the last few weeks and the reactions (fears) of the dentists around me, most of whom are of the younger generation, I am dismayed by the apparent lack of cohesiveness to the best interests of dentistry at large as a profession that has given so much to the betterment of our patients. I am also concerned about a perceived lack of resolve to our patient’s best interests as dental care trends becomes less professional & personal and more retail and “bottom line” oriented for the needs of the dental office or the needs of the insurance corporations to which we are increasingly being asked to tie much of our decision making. I am even more disheartened by the lack of loyalty to ourselves, our ideals, to the equality of the treatment and fees we provide to the patients who trust us so very much (read - equal treatment provided and not cost shifting to non WDS patients), and especially disheartened by the lack of insight as to what is being foisted on us, the sheep we are apparently expected to be? Who owns each of us and to whom do we owe our loyalty, responsibility, and self respect as the patient’s primary advocate for their dental health advice and treatment? If the WDS planned effort succeeds, it may very well not be ourselves or our trusting patients?

Does ANYONE feel that WDS has handled this in an above board and mutually respectful way? Did they consider any input from members on how to control costs? Did they consider eliminating or lowering some high end procedures or fees, which could aid in preserving the quality and emphasis on disease control as dentistry’s first responsibility, instead of an across the board rape of all of the fees? Does anyone feel that the “timing” was designed to push dentist’s hands and to not give them time to make informed decisions before the 60 day “drop out of WDS” clock started ticking? Does anyone feel that despite the fact that member dentist’s fees have been held at most to inflation increases for 16 years since 1995 (0% for the last 3 years despite the rise in all the precious metals dentistry uses), it is now equitable to unilaterally return my office to almost the exact fees that we functioned under 11 years ago in the year 2000?

While not discussing or making any reference to specific fees to keep the legal eagles happy, over the years in my consultations with patients who have come to see me for a second opinion on a treatment plan or brought in forms of predetermination for treatments, I have noted that the WDS’ “allowed” fees for treatment vary wildly across different dentists. Notably for full coverage restorations, I have been perplexed that “allowed” crown fees can vary seemingly by up to $400. In the days when you set your own fees that were accepted as long as they were at the 90th percentile or below, this wide variation resulted from the value each dentist placed on their own individual worth, skill, and expertise, and was hence part of a fair and acceptable system. Even after WDS’ 1995 unilaterally imposed ruling that future fee increases would be held to the State inflation CPI, WDS dentists could conceivably and did swallow this accommodation for the betterment of WDS without too much trouble or loss of a sense of independence assuming that the office was satisfied with the fees in place at that time. But please note however, that this first unilateral “top down” ruling locked the office permanently into its position in the historically accepted 90% and under bell shaped curve. New office, better service, more expertise or new services through increased training or postgraduate work was supposed to allow you a special appeal to increase your position within the ranks of your filed fee colleagues. I was never aware of anyone who succeeded in such an appeal, if any real accommodation in this way was ever made?

But with this latest “Central Planning” from WDS with fees that are “top down” reduced in this unilateral way and obviously to a dramatic degree, the once fair old system of fee filings appears corrupted beyond the point of fairness or a fair business practice. Allowed fees may rapidly approach a level at which many offices no longer are reimbursed at levels “they chose” that allows them to deliver their care in the best manner and in their pursuit of excellence of care, evidence based or otherwise. As these announced fee reductions have and as future ones certainly will cause many practices to approach an ever narrowing edge of profitability, does anyone out there feel that such variance, in this example for crowns of up to $400, in the fees “allowed” by WDS to different offices is in any way fair and equitable and does it further the mission of WDS or ourselves in providing optimal dental health to our patients?

And please note that offices such as mine that accommodated our patient’s needs by keeping our fees on the low end of the spectrum have been arbitrarily, unequally, and discriminatorily affected and locked in by BOTH the fee restriction to “inflation adjustments only” that began way back in 1995 and as well by the current unilateral moves by WDS to reduce fees by 15% or more. In other words, unlike the offices who were more aggressive in their fee fillings towards the 90th percentile in years past, the practices that did the best job at keeping their fees in the lower percentiles and hence keeping their profit margins smaller and thinner to begin with are exactly the ones who are now pushed closer to the edge when WDS now rewards these dentists by closing their already narrow profit margins to razor thin or beyond; these are same dentists who were as responsible as possible in their charges to patients to increase the access to affordable care.

Does anyone feel that the once fair old fee filing system we had freely accepted since WDS’ inception is being bastardized by the WDS inflation restrictions of the past and by the accelerating top down fee manipulations we are currently being asked to accept? Does anyone feel that the allowable fee filing (setting) system as it now exists with WDS is “fair?” Though I do not agree with the PPO concept, existing PPO offices are another group similarly affected and even more so in this way because in their previous fee concessions, “they already gave at the office.” Does anyone feel that it is fair in any way that the more conservative fee filers among us come out even closer to the bottom while the more aggressive fee filers come out on top? I never have and still do not.

A large part of WDS’ original mission was to educate employers about quality dental coverage and to bring employers, the dental community at large, and patients together through a well engineered insurance product to serve that mission. Does anyone feel that this is still the primary reason for WDS’ existence or does it feel like this effort is more exclusively about the survival of the corporation at any cost?

In minutes of the WDS panel meeting of March 25, 2011, I read a few insightful comments:

“Last year was WDS’ most successful year.”

“Dollar impact to dentist revenue is estimated to be 2.25% for the premier dentist and 1.05% for the enrolled PPO dentist.”

“A fee reduction… has been accomplished by several other Deltas….. There was a lot of noise, but the Delta’s only lost 2-3% of providers in the short term.”

“…panel members may speak to other dentists about the fact that they brought this on themselves….”

In reflecting on the above points, remember that if WDS’ contention that “Big is Nice”, please keep in mind that “Better is in the details:”

And the CEO salary and benefits open for public inspection 2009 tax return was $1,098,333? 2010 compensation was even higher! Would he be willing to take a 50% pay cut as a percentage of take home income as many dentists are being asked to accept? Perhaps if the goal is to control costs for WDS and ensure its continued financial success, the President, Board, Provider Compensation Committee, management, and senior personnel would be willing to join the member dentists in this valiant cause by reducing their compensation to that which existed at WDS in 2001, again “for the cause” as we are being asked to accept?

What better time to entice the dentists to surrender even more financial control of the fees they need to run viable practices before the inflated money supply causes the accelerating inflation that is assuredly here and indeed worsening? How few now practicing dentistry remember the 14% inflation of the late 1970’s? With a money supply more inflated than those days, the inflation could be even worse than what I experienced then along with a 21% prime interest rate? Will WDS allow practices to adjust for such future inflation with more equity than their edict for the last 3 years of 0% fee increases has in not allowing us to adjust to the rise in the cost of the precious metals we all use? Can anyone spell “hypocrisy” or “lack of critical thinking!?”

Who are they kidding! Spread out across the Okanogan dental landscape maybe. Try being in a WDS dominate area like Olympia with 65-75% of your patients covered by WDS. What figures or new math textbook did WDS use to generate such an inaccurate and misleading estimate of the effect of this dramatic slash in reimbursements on practice viability? Perhaps the same new math that the Federal Government has been using to tell us that the country’s inflation rate is still -0-!? And perhaps for the same end… the divestiture of the individual and small businessperson in favor of the accelerating rise of the power of corporations over us all. As the other carriers cut fees to reinstate their competitive upper hand, are we going to continue to trust WDS and not expect additional future unilateral actions as we all “race to the bottom?” Ah, the corporation must survive, even if some dentists and patients do not.

Was this placed into the minutes as a bargaining tactic? And if this is a true statistic, is it applicable to our State and our individual practices? Is the WDS penetration (sexual reference is unintentional!) of our practices more comprehensive than in the other Delta’s referenced in these minute’s? Are those Delta’s and this State’s Delta different in ways that makes WDS more at risk of network degradation? Whatever the answers to these questions, was this factoid placed in the minutes to reassure or entice a skittish Board or more ominously directly aimed at scaring dentists into compliance against their own patient and self interests, particularly if the parallels between those Delta’s and WDS are not applicable? Can anyone not born in the 50’s and anyone among the younger dentists spell “DISINFORMATION?”

Is the corporate hope that dentists will stampede like lemmings off the edge of this “cliff?” And even if just the old skeptical dentists like myself, who are more financially independent, are the only ones that drop out of WDS, the corporation’s advantage is actually increased because the financial obligations, needs, and fears carried so heavily by the younger dentists in this community and the State may leave them little alternative but to play the game, even if unfortunately, the only way to win may be not to play.

I actually agree with this one and protested as such when during my 33 years in practice, dentists started caving into the PPO’s seeking to obtain a short term competitive advantage. Really proved worth it in the long run as everyone caves again. Since WDS is correct that dentists brought this on themselves, why not complete the process of corporate ownership of your practices, minds, and bodies? Hey, why don’t you just GIVE it away?

Dentists being afraid and with VERY short sightedness hope to claim some individual safety and benefit, albeit temporary:

“I don’t like confrontation. I don’t want to make waves or take any risks to stand up for myself and my patients. Just leave me alone in my practice so I can somehow make enough money to pay the bills, the staff, and have enough left over to make all the hardship we went and still go through worth it. Just let me be please, and I will go quietly….. Where do I sign?”

This whole scenario reminds me of the best 100 seconds in movie film history!

“I don’t have to tell you things are bad. Everybody knows things are bad. It’s a depression! Everybody’s out of work or scared of losing their job. The dollar buys a nickel’s worth; banks are going bust…….”

“……We know things are bad, worse than bad. They’re crazy! It’s like everything everywhere is going crazy. So we don’t go out anymore. We sit in the house and slowly the world we’re living in is getting smaller and all we say, Please at least leave us alone in our living rooms and let me have my toaster and my TV and my steel belted radials and I won’t say anything. Just leave us alone. Well I am not going to leave you alone. I want you to get mad. … … “

“……All I know is that first you’ve got to get mad. You’ve got to say I am a human being G** dammit! My life has value! So, I want you to get up now. I want all of you to get up out of your chairs. I want you to get up right now, and go to the window, open it, and stick your head out, and yell, “I ‘m as mad as HELL and I AM NOT GOING TO TAKE THIS ANYMORE!!!”

Threats such as this, though not this barefaced, occurred twice earlier in my career in Olympia and both were rebuffed and failed because INDIVIDUAL dentists stood up for themselves, their ethics, their pride in themselves, their self worth, their care, and their patients. Washington State dentists and the historical standard of care here are acknowledged to be among the best in the country. The UW Dental School has been rated #1 and is universally in the top 10 of annual ratings producing a well rounded oral medicine specialist whose training is second to none. Our training is not just as a “tooth mechanic” but geared towards being a partner in the patient’s overall medical health, not just their dental health.

I have personally found and diagnosed 5 intraoral malignancies and 5 extra-oral additional melanomas. All 10 of these patients are alive and well 1 to 25 years later. In support of their unilateral and dramatic fee reduction, WDS’ minute’s note, “In a national comparison……..Washington State has either the highest or among the highest fees.” If our training and skills are second to none, why is the insinuation being drawn that our skill, caring, and expertise are not worthy of the fees that have allowed us to provide the level of care that has become the standard of excellence to emulate?

I do not think my 10 patients who are alive and well because I practiced under fee levels that allowed me to take the necessary time required for their diagnosis feel that my training, my careful, paced exams and my treatment were not worth the fee. I doubt they would feel my service to them warranted being asked to return to my filed fees for the year 2000, which is strikingly similar to the one WDS “filed for me” on their website notification of their “adjustments” to my filed fee list. And remember, in another unilateral decision, my fees have been held to only the Seattle inflation rate since 1995 and the last 3 years we have been allowed NO fee increase at all despite having the costs of managing our office, especially the lab work and precious metals, escalating considerably.

Dentists, like myself, raised in the 50-60’s were the “protest generation” and learned to not trust big government and corporations, but rather to respect and trust ourselves and our own self reliance. From what I am hearing about the resolve of our children’s generation of dentists, it appears maybe that WDS’ high stakes poker bet may succeed if (1) the new generation of dentists do not have enough faith in themselves to stand up against a barefaced effort to corrupt their wellbeing and futures in order that “WDS remains sustainable,” if (2) the new crop of dentists are more sheep than militants; and if (3) they are easily led to march to the government or corporate drumbeat. Remembering that 2010 was “ WDS’ most successful year” ever, by imposing these fee reductions that they hope will insure that their successful years continue, I hope that WDS does not also insure that 2010 will in return be your most successful year…. Ever again!

It clearly does not have to be that future. Twice in my 33 years of practice in Olympia, as individual dentists pursuing individual self interest, success was achieved in folding up 2 other insurer’s plans for co-opting dentistry’s control of its own destiny and not becoming mirror images of our medical brethren. The power is in your own hands and only you can give it up. And make no mistake; if you give it up, you do so willingly of your own free will – fully supporting WDS’ bet that you have no backbone, driven by fear, not insight.

Remembering the WDS that I knew throughout my 33 years serving my patients, their current behavior, methods, goals, and expectations eerily reminds me of the drug cartel’s admonition:

“Silver or Lead” Take the money we are offering or Death!”

The only real difference is that the “Death” will be in our practices and the “Lead” will be in the gold crowns we all “choose” to have made in China.

With respect,

John (aka Dream) Weaver, DDS
Olympia, WA

Dedicated to the memory of Dr. Frederick L. Gonzales - my friend and one of the finest endodontists to grace the planet – who when I asked why his endodontic cases were so exceptional told me, “because I will crawl across a bed of hot coals naked, to get the case right!”

“Energy and persistence conquer all things!”
-Benjamin Franklin

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