thegrumpydentist.com

Medicaid makes an end run

The Grumpy Dentist — Thu, 23 Jul 2009 13:02:00 GMT

I recently became a Medicaid provider for children's dentistry.

So you filled out a bunch of forms, right? You contacted the State of Michigan and asked to apply to be a Medicaid provider?

Ummmm...no. It's called an "implied contract." If I'm a premier provider for Delta Dental in Michigan then it's implied that I'll take "Healthy Kids" which is administered by Delta Dental of Michigan.

Does that mean that I have to take Medicaid for kids in Michigan if I want to keep my Delta Premier status? Actually, no. You just have to write to Delta Dental of Michigan to opt out. However, I take exception to the implied contract. I'm guessing that most "providers" for the Healthy Kids program don't realize that they are now providers for Medicaid. I'm pretty sure that most don't realize that they can opt out.

I'll give a little bit of credit to Healthy Kids. The fee schedule is closer to acceptable than "Medicaid" ever was. However they require NO co-payment whatsoever which pretty much kills any chance that this low income family will take any responsibility for their own oral health. They just pay whatever you do at the level of their fee schedule with no action on the part of the patient. The catch is that they don't allow a lot of treatments that I see are just plain necessary. The "Healthy Kids" that I've been seeing are adults (19-21 year olds) with bombed out mouths. They'll cover endo, but they won't cover a PFG crown to restore the tooth. Am I really going to put a stainless steel crown on a 21 year old's upper premolar?

There might be some steps in the right direction here, but I really resent the end run. One day I started seeing "Healthy Kids" patients showing up on my schedule and it took some research to find out that "the Michigan Department of Community Health contracts with Delta Dentalto provide dental benefits to Medicaid-eligible residents under the ageof 21 who live in 61 Michigan counties."

So why not ask Michigan dentists to accept this plan on it's merits alone? Why the end run?

"I haven't been to the dentist in a long time. I didn't have insurance."

The Grumpy Dentist — Wed, 18 Feb 2009 13:44:00 GMT

The second statement is meant to be the justification for the first.

Justification usually works for the person justifying, but not so much for the person they justify to.

When I hear "I haven't been to the dentist because I don't have insurance" I usually smile and say nothing. What I'm thinking is, "but you still have teeth, right?"

If so, those teeth are still the responsibility of the owner. Often the owner has a diet full of high fructose corn syrup and carbonated beverages and personal habits that rarely include brushing and never include flossing.

Dentistry is expensive (mostly because of dental insurance, but that's a probably another day's tirade) but the least expensive thing you can do in my office is come in every six months for us to get a look at your teeth. If you're a low risk due to habits, diet and genetics then God bless you and you probably don't need to be seen even that often.

But your teeth are still your responsibility (or your problem, depending on how you feel about them)...even if you don't have insurance.

To whom it may concern:

The Grumpy Dentist — Fri, 01 Aug 2008 00:15:00 GMT

Shorter line for cosmetics

The Grumpy Dentist — Mon, 28 Jul 2008 14:25:00 GMT

Kevin MD excerpted a NY Times article that reported wait times to see a dermatologist were shorter if your need was cosmetic. Just so you know, I'm way to cheap to pay to read the whole article. I quote from what Kevin quoted:

"Like airlines that offer first-class and coach sections, dermatology is fast becoming a two-tier business in which higher-paying customers often receive greater pampering. In some dermatologists’ offices, freer-spending cosmetic patients are given appointments more quickly than medical patients for whom health insurance pays fixed reimbursement fees."

Since I didn't read the article I cannot judge the tone that it was written in. I wonder if it was critical of this? The assumption that is made is: cosmetic = elective = no worrying about insurance reimbursement. My practice is admittedly insurance driven but we see occasional patients wanting cosmetic/big reconstructive work done and they're willing to pay for it. Do we treat these patients extra special? Yeah, I guess we do. But we don't make anyone wait to get in because our capacity is such that we can see an emergency same day.

There's an "insurance-free-every-patient-pays-for-and-appreciates-the-wonderful-service-that-we-give" dream that most dentists aspire to on certain days. It's a pipe dream for two reasons:

Most people still associate the dentist with pain and misery (not saying it's right, just being realistic)
There's an overwhelming belief that "I can't go to the dentist, I don't have insurance." (definitely

I know there are dentists out there who claim to be wildly successful doing "wants-based" dentistry and bully for them. Most patients are firmly grounded in "needs based" (my face is swollen out to here and I NEED to have this tooth taken out) dentistry.

Bottom line...if someone comes into my office wanting pretty teeth and they want to give me cash dollars for it they're a VIP. Maybe that makes me an evil, money-grubbing dentist but I think it makes me a realist.

the best of technology

The Grumpy Dentist — Mon, 28 Jul 2008 13:12:00 GMT

So, you know what didn't work for me. So what do I like?

I like stuff that truly makes things easier or faster than I used to. Also, I like things that allow me to do procedures that I couldn't do before.

Easier/faster:

digital x-rays: I use Sigma Biomedics intraoral sensors. There a relative unknown but I've found their prices to be good and they're receptive to problems. We've actually had a sensor or two with troubles and they're replaced them without the ridiculous maintenance schedules of most digital x-ray purveyors.
rotary endo: I say this with a note of caution because doing endo well has everything to do with attention to detail and very little to do with what file you use. Using rotary endo doesn't mean you can throw out the principles of endo. Rotary endo doesn't allow you to do molar endo in 30 minutes. Endo can't be rushed. You're trying to remove living and dead tissue while also removing microscopic bugs, not putting a white stripe down the tooth. Rotary endo increases efficiency, but isn't a magic wand.
digital cameras: This falls under the "new procedures" heading, too. I didn't use to take photos because the development/knowledge gap was impractical for me. I've been using a Canon 10D with a macro lens and ring flash for some years and it's made a difference for me. It's point and shoot, even though it looks really intimidating. I recently added usb intraoral cameras to each operatory. After years of dogging intraoral cameras I finally started using them. It's a great thing to have available. The photos aren't as good as a digital SLR, but they're much easier for "show and tell" in an exam. Worth every penny IMO
networked computers with practice management software in each operatory: This is where technology starts in my opinion. If you can't access your information throughout the office you're missing out on the advantage of having a computerized office.

Procedures you couldn't do otherwise:

digital pano: We added this recently. This is probably the greatest ROI I've had in dentistry. I'm seeing better stuff, explaining conditions to patients better and charging for a pano (which I haven't ever had before). Probably the best technology decision I've ever made. If you're on the fence about a digital pan my only advice is DO IT!
digital cameras/USB intraoral cameras: I don't charge for the photos I take, but being able to show the patient their teeth up close in real time has been very valuable for treatment planning. It isn't hard for a patient to see a failing restoration when it's well lighted and as big as their head on a monitor right in front of their face!

There's a lot of other "new procedure" type technology out there that I haven't experienced. One appointment crowns and onlays with a CEREC is a very popular one and "new attachment" perio procedures with a laser are too. The only concern that I have about them is that once you have this new hammer everything starts looking like a nail. Base your purchases on sound science and realistic procedures and you'll do O.K.

The worst of dental technology

The Grumpy Dentist — Fri, 25 Jul 2008 12:39:00 GMT

I'm a sucker for gadgets. I always have been. Dentistry is a great profession if you're into gadgets. The corollary to that statement is that dentists are great subjects to market to. If you design some thing to look cool and tell us it's going to boost our profits and put a hot chick in the ad it's money in the bank.

I want to believe that some shiny high-tech looking thingy is going to make my job easier and impress my patients. In fact, sometimes it happens just like that. Adding technology is a bittersweet deal. The sales folks will make lofty proclamations about what it will do for your bottom line. Remember that they make $$$ when you buy, not when your production and collections skyrocket.

So, what technology is good and what's not? I suppose that it's different for each office but prior to purchasing you should take a look at a few things.

Does the technology allow you to perform a service that you can't already perform?
Does the technology allow you to perform a service faster than you can right now?
Can the technology do what it says it can do? (two words: Zoom light)
Will you use it?
Does it make work more fun? Does in make work $x more fun if it isn't adding to your arsenal of worthwhile and helpful services? (that's the real question, isn't it?)

I've developed a couple of rules that I've tried to follow that has kept that shelf in the back of the closet with a bunch of expensive but unused crap (hereby referred to as "the shelf of doom") from growing too much in the last few years.

Never buy something at a convention that you weren't planning on buying before you got there
Always research the product online. If possible, search for "reviews" of trusted contributors to DentalTown. If you saw it at a show or in a magazine you've only seen what the manufacturers/marketers want you to see.
Whenever possible try the product in your office on regular patients. (e.g.--Designs for Vision gives a 45 day money back guarantee and the 45 days starts the day you receive your loupes. They REALLY believe in their product!)
Don't take cold calls from sales people.
Don't impulse buy, particularly at a big meeting like the Chicago Midwinter or the ADA. This is where new (read: barely tested) products are introduced and you might be paying for the privilege of beta testing something awful. If you feel like you REALLY want/need something you saw at a show give it a couple days. A stand up company will give you the show special a couple days after and that way you know you didn't just fall in lust.

I know what's going through your mind right now. You're thinking, "so Dr. Grumpy, were you just born brilliant (and handsome) or were you blessed with incredible wisdom (and looks) over time?" Well, the simple answer is I have a relatively extensive shelf of doom in my humble office and some pretty sweet Visa statements (and loan payments) to boot. Here, for the first time in one shameful place is Dr. Grumpy's three worst "new, fancy, high-tech, life-changing" purchases.

air abrasion: This is an AWESOME technology! In the lab. In a box. With suction. It's just not that good in someones mouth. I can do exactly the same thing with a $1.20 fissurotomy bur in 1/4 of the time without turning my operatory into the "Saraha Room." Also, the claims of "no anesthesia" because of air abrasion are greatly exaggerated. I heard Tim Rainey go on and on about how he hadn't numbed a patient with air abrasion in 40 years or something. A few years ago when I had first bought the thing I was trying to make it work (loan payments will do that to you) I would tell patients that we were going to do a painless filling with the wonders of air abrasion (parallel air/water abrasion, even). They were pretty excited until I hurt them. And they had had to wipe the sand off of their tongue. and face. and eyes. Maybe I just suck and there's a special way of cutting a hole in a tooth with a sandblaster that doesn't hurt, but I couldn't figure it out. Yeay air abrasion! What, only $12K? Sign me up!
Carifree: The concept is great. The execution is a nightmare. The concept is to assess a patient's individual risk for tooth decay. Those with low risk you don't medicate, but if they're high risk, you treat them with medicated mouth rinses. Sounds good. The problem: you "test" them for caries risk with very expensive Q-tips in a very expensive machine. It give a number on a scale that allows you to quantify risk. I tried it on lots of different patients. We closely followed the instructions. My numbers never really matched up with any of the other criteria I would measure. The kid who gargles with Mountain Dew and has giant craters in his teeth would measure a near pristine 210 while my completely cavity and plaque free appointment coordinator measured in at a whopping 6000 or something. Again, maybe I just suck, but until the testing is a bit more idiot-proof you might save your $$$. Once you've determined that a patient is high risk you treat them with the Carifree treatment rinses. You mix the "ingredients" (full strength lye and kerosene, I think) in a very clinical looking measurement tube and rinse for the longest minute of your life. The sales rep said "it tastes like minty pool water." After using the product (once...I survived, dammit!) myself I would describe the taste more like "minty liquid death." I completely lost my shirt on Carifree. I do love the caries management by risk assessment concept (CAMBRA )and I wanted to love Carifree, but each time I think about the actual product I find myself under my desk curled up in a ball and crying.
StatusBlue alginate replacement: Hey, why don't we use an impression material that is 10 times more expensive than alginate, yet takes worse impressions? Hey, sounds great! Sign me up! Honestly, I still use the stuff because it is much less messy than alginate and can be repoured. They're really accurate, too. Except since it's a polyvinyl it has pulls all over place. My assistant loves the convenience and cleanliness of it but there's going to come a time when I move back to alginate because my study models will be much better! Also, it's dispensed out of a cool looking MixStar machine which is very high tech looking.

So that's my hall of shame for the last 5 years or so. I'll write about what I'm glad I bought or what I'm indifferent to in another post.

What else have you bought that just plain sucked?

translation

The Grumpy Dentist — Thu, 24 Jul 2008 12:01:00 GMT

I recently received this email:

"Dear Dr. Grumpy,

I hope you are doing fine. As you know my family is due for our cleanings and I've got some other tooth problems that I want to have taken care of.

The problem is it looks like you are not participating in our Delta prefferred plan because of that we have to pay a lot out our pockets. I know I feel sad but there is no other way other than going to a Delta preferred plan participating dentist.

Please let me know if there is any other way out.

Thank you

Sincerely

Peter P. Oppenheimer"

I feel for this guy. He has chosen to pay for dental insurance that his employer picked because it was the cheapest. It limits his choice to a list of dentists who are O.K. with a capped fee schedule. This particular plan doesn't cover my overhead so I don't participate with it.

The problem that I have with the email is what it says about the patient's beliefs. What we (and by we, I mean "we the people") seem to believe about health care has really devalued the doctor/patient relationship. Also, we seem to hope that our employer or government makes better choices about our health than we do.

I've run the email through my patented "common sense translator" and came up with this:

"Dear Dr. Grumpy,

I hope you are doing fine. As you know my family is due for our cleanings and I've got some other tooth problems that I want to have taken care of.

The problem is that I care less about having a dentist that I know and trust than I do about paying as little as possible for my care. Since all dentists and doctors are the same I might as well pay as little as possible. It looks like you are not participating in our Delta prefferred plan and since I'm only interested in services my insurance covers completely I'm happy to throw you under the bus. I want you to think it troubles me so that maybe you'll join up and take the hit so all of my dental care is "free" but there is no other way that I'm willing to consider other than going to a Delta preferred plan participating dentist.

Please let me know if you'll take it in the shorts for me since you care more about my health than I do.

Thank you

Sincerely

Peter P. Oppenheimer"

Now what am I really going to say to this email? I'm going to thank him for his candor, explain that I understand his position and that I can recommend a dentist off of the list for him if he would like.

A system which involves a third party payor has complicated an already complicated system. "Health care as a right" has damaged the way people view their health and how health care is delivered to a point where they cannot see reality.

Anyone who needs to use my "common sense translator" needs only to email me at grumpy@thegrumpydentist.com. The cost is nominal, as long as I take your plan.

The tirade begins

The Grumpy Dentist — Tue, 22 Jul 2008 17:25:44 GMT

Welcome. Soon the grumpiness will begin.