Delta: "The Dentist's Dental Plan", What went wrong?

 

By: Lawrence F. Emmott, DDS

"Good Dentists" When I became a dentist back in the seventies there were certain things all "good" dentists did. For example you belonged to the dental society, you didn't advertise and you belonged to Delta Dental. Delta was perceived as the "Dentist's Insurance Company". Now, thirty years later, that has changed completely. In fact as I travel the country speaking to dentists I find one of the sure signs of a quality practice providing the best dental care possible is that they have dropped Delta. Being "Delta Free" is the new status symbol of the elite dental practice.

What happened? For many Dentists Delta was seen as a way to fight managed care and the other incursions of the insurance industry into our profession. And even today many dentists think that Delta is different, that Delta is on our side. Many dentists still think that Delta represents quality care and fee for service as opposed to managed care. However in my experience and opinion if that was ever true is certainly isn't any more.

Is Delta to blame? Has Delta done anything wrong? Not really, Delta and all the other dental insurance companies have done a tremendous job. They are very successful in what they attempt to do. The real question now is should all "good" dentists belong to and support Delta Dental. Does Delta participation improve dentistry and help dentists and our patients?

Some dentists continue to support Delta because they see it as an alternative to managed care. The problem with this thinking is that Delta is managed care. Delta is a PPO. It always has been but they have chosen to call themselves by other names. By the ADA definition a managed care PPO is a plan which contracts with dentists to provide dental services and restrict fees. That is exactly what Delta does. As all dentists know PPO stands for Preferred Provider Organization. Who prefers them?  A more accurate description than PPO would be contracted discount dental group.

 In all relevant matters Delta is set up and runs as a PPO and they are now establishing HMOs as well. Delta contracts with dentists, restricts fees and restricts how and what contracted dentists can bill for. It is little different from Blue Cross PPO, Prudential PPO or the others. In fact Delta is much more restrictive that many other PPOs and is significantly more hostile to non-participating dentists that other PPO plans. In their defense Delta uses a slightly higher maximum fee schedule but when the withhold and other restrictions are included this is not very significant. In my office we were writing off over $60,000 dollars a year in profit to Delta withholds.

Are you a managed care dentist? Most national surveys indicate less than 50% of dentists say that they participate in managed care. At the same time they indicate 80% are Delta contracted dentists. What that indicates is that most dentists are still fooled into thinking that Delta is different, they just don't realize that as a Delta contracted dentist they are a managed care dentist. I know many dentists only consider prepaid HMO cap plans to be managed care, however the ADA and others define PPOs as managed care.  I have always found it baffling that most dentists don't recognize Delta as a PPO and I have always found it dishonest on the part of Delta that they represent themselves to dentists as some how different than a PPO and an alternative to managed care. My experience tells me that many if not most Delta dentists are passionately anti managed care. However at the same time they are contracted with the biggest PPO of all, Delta Dental.

What's wrong with being a contract dentist? As any dentist knows, Delta (and all the rest) place all kinds of restrictions on what they will cover. The best example of this is the annual limit.

Most insurance plans limit the annual benefit to $1,000 a year. In the 1960s the annual limit was also $1,000. There has been no change for over thirty years. You know what inflation has done for the past thirty years. Think about the cost of cars and houses. In fact think about dental insurance premiums. $1,000 today is worth $138 in 1960 dollars. How does this limit improve dental care and help dentists, or our patients?

In addition Delta (and the others) pay little or nothing toward the finest and most up to date care. For example the best way to replace a missing tooth is with an implant. Insurance pays nothing. Bonded esthetic posterior restorations such as Targis or Empress onlays are much better than previous metal options, more esthetic, more conservative and stronger. Insurance pays little or nothing. Non surgical periodontal therapies that employ multiple therapies and meicaments such as perio chip or laser are far superior to old-fashioned perio surgeries. Insurance will pay little or nothing. How do these arbitrary restrictions on the best modern dentistry has to offer improve dental care and help dentists, or our patients?

What's the point? The point here is not to say Delta needs to cover these services. Delta will make coverage decisions based on what the market wants and is willing to pay for. The point is that as a contract dentist you agree to their rules. For example many plans will not pay for a base under a filling or a crown build up. These are just two obvious examples but there are many others involving x-rays, exams, perio therapy and more. With a non contract plan the dentist could simply provide the service he/she and the patient believed was best and then charge the patient for the non covered service.  As a contract Delta dentist you are forced to write them off.  You can either provide a service and not get paid or not provide the service. The contract limitations could effect the quality of service by limiting coverage and the patient is the ultimate loser. Faced with this ethical dilemma, that is to fail to provide the service you believe is the best for the patient or provide it but not get paid I believe the only proper course is not to participate as a contracted dentist.

However what bothers me most about Delta and the other dental insurance companies is what seems to be a deliberate and malicious attempt to destroy the trust and the relationship between dentists and the people we serve. The dental plans do this by implying that treatment they choose not to cover is unneeded, inappropriate or excessive.

"A good portion of the claims that we deny is for care that we agree is needed and should be provided."

Who said this? Jeff Album, a top manager at San Francisco based Delta Dental Plan of California quoted in a recent Wall Street Journal. I wish they'd just tell the patients this. Instead they imply any non covered service is unneeded or excessive.

For example Karen Johnson, Vice President of Operations with Delta Dental of Wisconsin was quoted in a newspaper article, she said.

"With dental insurance a company knows that money spent on dentistry goes for standard care not inappropriate treatment"

"Patient's don't know if the treatments they are getting from their dentist are sound or not."

"Patient's in a direct reimbursement plan are hostage to what the dentist wants to charge"

What an insult! Does Delta really believe that dentists are holding patients hostage and providing inappropriate treatment? How does this attitude improve dental care and help dentists, or our patients?

My argument here is not that Delta, or any plan, should be paying for implants and all the rest. I don't really care what they cover. I object when they imply that non covered services are "inappropriate, non standard or unsound". Just tell the truth, dental insurance only pays for basic services using the cheapest materials. That is called the "least expensive clinically acceptable alternative" and it is a feature of virtually every dental insurance plan. But it gets worse.

Bill Blatchford reports that on February 1, 1999, Delta Dental of Minnesota informed 464 dentists that they did not fit the statistical average of dentists. The 464 “above average” dentists had their fees frozen by Delta for 1999. Two thousand other dentists were declared by Delta to be  “average.”

Delta Dental wrote to patients of the 464 dentists to share that their dentist was not in the PRIME group, meaning he/she was statistically out of the norm. The areas of statistical difference for the 464 “above average” dentists sighted by Delta are:

   1. Too many sealants.
   2. Not enough multi-surface alloys.
   3. Referring too many specialty items.

Delta Dental of Minnesota claims in a press clipping that this division of dentists was not based on economics but rather was “done to save patients from over treatment.” How does this action, including contacting active patients of record to tell them that their dentist is "Non Prime" and that the insurance company is "saving the patients from over treatment" improve dental care and help dentists, or our patients?

Evidence based care: A frightening aspect to this is that Delta is attempting to claim these changes are based on "Evidence based care" In other words that there is a scientific basis for what they are doing. In a recent newsletter Jim Pride of "The Pride Institute" wrote, " According to Dr. Richard Hastreiter, Delta's assistant vice president, the PRIME program is not a ranking of technical skill levels, but rather an inter-peer comparison that is economically based. So the standard is not whether the dentist gives quality care, but how the dentist's costs to Delta compare to those of other dentists in the program. While every conscientious professional in any field of human endeavor from sports to business to the arts and sciences strives to be exceptional, not mediocre, Delta's PRIME program will be rewarding the average for being average and financially penalizing those dentists with superior abilities in gaining the patient's trust, enhancing case acceptance, effectively recalling hygiene patients, offering preventative services such as sealants, and providing a greater level of care."

The point of all this is not to be Anti Delta but to be Pro Dentistry. Personally I love being a dentist and I love my profession. What I see Delta and the others doing is I believe very dangerous to the dental profession. And what makes it even worse is that so many dentists still support Delta without realizing Delta is just another managed care PPO.

At one time I was heavily involved with managed care. I now have no affiliation with any managed care plan, prepaid, HMO or PPO. Delta was the last managed care plan I was contracted with and I am happy to say I am now Delta free. It hasn't been easy. Delta is highly discriminatory toward non participating dentists. But I would never go back.

It's your choice: What can individual dentists do to change things? You could try and change Delta, work with them, go to meetings and become positively involved. I urge you to do something else. Something I believe all "good" dentists should do. Evaluate your personal situation, make any changes needed, get professional consulting help if needed and then quit, Delta is not on our side!y