Dental Dilemma

Dental Dilemma

iUniverse, Inc.

Chapter One

I retired from active practice on December 1, 1986. I must say that to this day I miss my old patients and their families. In fact, I was a great-grand dentist. I had fun doing dentistry. Today I would not have fun doing dentistry; it would be a job, not a profession. Most dental practices now are large with many general dentists and specialists working on tight schedules. The cost to run these practices is enormous. All the dentists have to have chair-side assistants, business managers, and front desk people. Malpractice insurance, comprehensive medical coverage, and student loans place a heavy financial burden on the owner dentist. Being able to spend time with your patients and their families, watching their kids grow, hearing about the up-coming weddings, the graduations from high school, college, etc., and laughing and smiling, doesn't seem to happen today. It seems that it's all basically about money.

So it was in March of 1987 that I first heard about the Dental Health Maintenance Organization (DHMO). For the next twenty years, I worked for four different DHMO companies.

Any names mentioned in this book are not the actual names of the companies involved or the names of the people with whom I worked.

In March 1987, my son, Bob, told me about a DHMO that was in the process of selling its business to a group of investors. Bob was and still is in the industrial real estate business. One of the principals in the selling company was a business acquaintance of Bob's, who had been talking to the CEO of the selling company regarding vacating their offices, which they were renting through Bob's firm. He suggested that I talk to the CEO who was working with a dentist who represented a group that was going to buy the company.

So the CEO introduced me to Anthony Amato, D.D.S., who was one of the men investing in the company, which was to be named Den-Cap (DC). Dr. Amato was going to be the CEO of the newly formed company. We instantly became good friends. Everyone knew him as Tony. He was the best salesman I'd ever seen. He should have been pitching patent medicine off the back of a horse-drawn surrey. His enthusiasm was infectious. Tony explained how "capitation" works, the Knox-Keene laws of California, the need for a quality management committee, and the managing of the provider dentists. He said that he would know by May or June if he had control of the company, and when he gained control, he would hire me immediately to start the quality assurance program for the company.

Most competing DHMO systems are very similar, and the competition is fierce. The marketing people go out into the commercial field and speak to the human resources department (HR) of a certain company. Once the various types of dental programs are accepted and rates established, an open enrollment takes place. At this time the benefits and options are explained to the enrollees This sets the tone of the quality assurance business. Most people never read the directions for anything. (How many times have you read your auto owner's manual? Ever?) Most enrollees go home with the idea that everything is free. The evil exclusions and limitations of the programs usually do not sink in. Thus, when they go to see a DC provider, they expect everything to be free. Up pops the supercilious office manager, who tries to explain what is a benefit and what is an optional treatment, which are billed at the dentist's usual customary fees. This makes the dentist the bad guy. Situations like this often lead to grievances.

Every company has a provider relations department that handles the provider dentists and their complaints, which are usually about compensation and the eligibility lists of patients.

The dentists' compensation is in the form of a capitation (per head). They are paid so much per month per enrolled patient, whether he or she makes an appointment or not. Most dental procedures also have patient co-payments. The dentist makes his money from the co-payments of the patient and the monthly capitation. The idea is to give the provider dentist a monthly list of eligible patients and pay him or her the monthly capitation rate. The number of patients accessing the office is the utilization for that office. An office that is underutilized makes a lot of capitation money, but the office that has a high utilization rate can lose money because the operating expenses will exceed the income from the payments of capitation and the patient co-payments. This system seems to work if the company can maintain and add to its line of business. When a business drops its contract with the DHMO, the provider dentist must start over again with a new list of patients, taking the initial financial hit before getting the patient into a maintenance position (all extensive work completed and the patient placed on recall). It is imperative that the DHMO retain its existing book of business while acquiring new groups and individuals; otherwise, the dentist takes it in the shorts.

This is what makes the DHMO unique. The provider dentist assumes all the risk. Hence, the DHMO is not an insurance company but is strictly a benefits' company. The schedules of benefits (SOB) are established by competition with other similar companies. These schedules list a series of dental procedures with notations indicating co-payments, if any. For example, x-rays and exams often have a "0" co-pay, while the co-pay for a porcelain-fused-to-metal crown (PFM) might be $100 plus an additional charge for a noble metal instead of the covered "base" metal. (Most dentists claim that base metal is too hard and unworkable, while noble metals are softer and easier to fit to the prepared tooth.)

One interesting aspect about these plans is that a dentist is rarely or never consulted before the company's final printing of a SOB. I wasn't. Lay employees confer to create these benefits by comparing them to those of the competitors. Many SOBs list procedures that are never done or are obsolete. Therefore, you, the patient, should always read your benefits and be dental savvy before you meet the employee with the clipboard.

The schism between the business end of the company and the quality side has always existed since the creation of the DHMO. Quality Management (QM), which is necessary in California in order to comply with the Knox-Keene law, is basically the non-productive enemy of a profit-making enterprise. QM is the same thing as QA, quality assurance, a title that is not being used currently.

However, QM does set the tone for the efficient and ethical delivery of dental services. According to most surveys conducted by the DHMOs, more than 80 percent of their patients are happy with their treatment and continue their recalls with those dentists. One major advantage with a capitation plan is that for dentists who have a small patient list and/or are just starting out, the DHMO provides an immediate source of patients. As Tony said, "An empty chair produces nothing." It is not a bad idea for the young dentist just starting out to sign up with the DHMOs to fill those empty chairs.

Tony lived up to his word, and in May 1987 I started working for a DHMO. The company already had a provider list of participating dentists, mostly in San Bernardino County, Riverside County, and Los Angeles County. The company had a CEO, many stockholders, a Knox-Keene license, and an office in a new ten-story Orange County office building. It had a marketing department, computer department, provider relations, grievances, billing and claims, and all the other departments necessary to the success of a DHMO. I invested in the company, along with at least six other investors.

Chapter Two

My first job for someone other than myself was to set up a program for Quality Management (QM), a necessity under Knox-Keene. I would go out to the various general dentists who were on the company's roster and evaluate their facilities and their chart documentation to ensure that they were in compliance with the quality standards established by the law. Our company was under the watchful eye of the California Department of Corporations (DOC), which administered the Knox-Keene criteria and would perform periodic audits of our company, both fiscally and quality-wise. The DOC also would check to see how QM handled grievances from the patients and the thoroughness of our audits.

In order to perform the required audits, some type of standardized form was going to be needed that would enable an evaluation of the facility itself and an evaluation of the patient files. But, at the beginning, I rated the offices on a scale of one to ten, ten being the highest. When I returned to corporate, I would complete my evaluation, adding comments and grades from one to ten. The grades were then put into the computer system, which also contained all the appropriate credentialing of the participating dentists. Provider Relations (which was also me) kept the files on all of the provider dentists. The customer service representative would call and ask about the quality of a certain dentist. I would recommend the provider with the highest number first if the facility were conveniently located. Lower scorers were recommended next with location being an important issue for the patient. Only offices that had scores above six were referred. Offices that scored below six were appointed for re-auditing and closed to new patients until they had a passing score.

Then I was introduced to one of the first shareholders of DC, an oral surgeon, Dr. John Schnell, from northern California. Tony wanted me to work with John to create an auditing tool that would produce a scoring percentage. The score would evaluate both the physical quality of the facility and the accuracy of its charting and diagnoses. The score would indicate when the office should be re-audited.

John and I went together to review an office and see if our form made sense. John was incredible. He was the most relaxed man I'd ever met. He would sleep while I drove to our appointed facility. The practice we visited was in the poorer part of town and housed in an antiquated building. We brought with us a notebook outlining the regulations the state had created and expected us to adhere to and enforce established criteria. It was a shock to us, and especially me, to see a facility with a business office occupied by an army of people who ignored the piles of records scattered about the room, the absolute chaos of a full waiting room, and very few English-speaking people jammed into worn, plastic-covered chairs. The office had ten operating rooms, a lab, a darkroom, two restrooms, and a large lunchroom.

We plowed through the clutter to a small room where we were seated and allowed to peruse the thick records, which contained bare-minimum x-rays and writing in the documentation that was for the most part illegible. As I said to John, "Such writing would make my personal physician feel vindicated for his lousy scribbles."

The office flunked the audit. However, the owner/doctor was very pleasant, mainly because our approach to the audit was not the least bit punitive in nature. We collected copies of the participating dentists' licenses, their evidence of malpractice insurance, their DEA (prescription drugs and narcotics) licenses, and a copy of their diplomas. After almost four hours, the review was complete, with the doctor signing off and agreeing to have a six-month re-audit.

Completed audits were entered into the computer system, which would set a date for the next audit of that facility. When an office scored low, the company would have the peer committee (made up of select provider dentists, Tony, and me) review that office in order to determine whether it should be terminated from its contract with DC. Terminating an office for quality was a difficult process involving the State Board of Dentistry and the DOC. Normally a poor performer could be terminated for failure to comply with the provider contract.

One of the office personnel, Betty, was designated to help me with the scheduling of offices to be reviewed. She would call the offices and assign my appointments for me. One time she sent me to Banning, California, for a 9:00 am appointment. I knocked on the door to what appeared be a dental office even though there was no sign. When the door opened, I soon realized I had been appointed to audit a whorehouse! That incident has been rehashed through the years, with lots of smart remarks from my colleagues. They were either skeptical or jealous.

Another memorable encounter with a new provider review occurred in Hemet. I drove there to audit the office of Dr. Jerome O'Kelly, who I assumed was an Irishman. When I got there, I found an office in a single house that appeared to have been built in the 1920s. It had a front porch and heavy, partial glass front door. I went into the large waiting room, which was the former living room of this old house. There was nobody in sight. I looked around the room, which was carpeted with ugly "high-low" deep pile carpeting. The room was lined with folding chairs except for one area near the former fireplace. There stood a large aviary with all sorts of birds and parrots squawking and tweeting. The room stunk so bad that I gagged.

I looked around and saw a little homemade alcove with a countertop; I saw no one. Then I heard a high-pitched voice from behind the counter. I looked over the top of the counter and saw a very small, dark-skinned lady. She asked, "What do you want?"

I said, "I'm Dr. Pedersen from Den-Cap, and I have an appointment with Dr. O'Kelly to review his office to see if it is up to state standards in order for him to continue as a provider."

Just then in walks Dr. O'Kelly, a very short Hindu dentist with a high-pitched voice. He was definitely not an Irishman. He walked me through the office, showing me his two dingy operating rooms and a cluttered, filthy lab. Then in another larger room, he showed me several up-right pianos in various stages of repair. This was his hobby, and he was very proud of the pianos. He never once talked about dentistry. I'm thinking, Where am I? Am I crazy? What is this?

Then Jerome said, "I have been receiving many Den-Cap patients, but after I examine them, they don't come back." No kidding! This was my only experience with an Irish-named Hindu dentist in a smelly bird guano laced, filthy dental office. Needless to say, he was terminated from the plan. How he got on the plan in the first place is still a mystery. The only possible explanation is that the former DHMO was desperate for provider dentists and accepted any office without having a provider-relations representative at least look at the office.

When brokers and agents work to sell the DHMO plans, the Human Resources (HR) people look for two things: benefits and the number of providers. The longer the list of providers, the better the impression on the HR person. That's why many plans sign on dentists without performing thorough office reviews. When a bad dentist signs on as a provider, it is incumbent on the patient to immediately call the plan and change providers.

Chapter Three

After the incident with the whorehouse in Banning, I did my own scheduling of panel providers. I made the necessary phone calls, schmoozing the office managers and establishing a good rapport with the staff. The auditing was going well in the quest for timely compliance with the DOC requirements. I was feeling pretty good about myself.

Then the need for audits waned for a while. So early in my career with DC, Tony decided the company should have a presence in northern California. At this time, the company had providers in the counties of San Bernardino, Riverside, Los Angeles, San Diego, Kern, Fresno, and Ventura. DC was not a big player in northern California. Thus, I became a recruiter and embarked on a recruiting tour of northern California, hoping to increase the provider panel.

DC had a small marketing office located in Walnut Creek. One of my arrangements with Tony was that I could on most occasions have my wife, Gloria, come along with me on the trips, which made it much more pleasant for both of us. The company did not expense my wife, so I was very careful watching expenses, never taking advantage of the company.

(Continues...)

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Excerpted from Dental Dilemma by James Pedersen Copyright © 2010 by James Pedersen DDS. Excerpted by permission.
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