THE EDITOR'S CORNER
We may be approaching a confrontation between the profession and the insurance industry over administrative control and over who will make the professional decisions with regard to who will be treated, when they will be treated, by whom they will be treated, with what appliances they will be treated, for how long they will be treated, and what the plan of treatment will be.
One does not have to go any further than the unequal treatment of the health professions under the recent Phase IV regulations of the Economic Stabilization Act to perceive a public dissatisfaction with the cost of health care and a movement toward consumer control. It is significant that under Phase IV regulations, insurance companies were appointed monitors of professional fee increases. It is significant that insurance companies are forming HMOs and therefore are experimenting in owning and operating health care facilities.
Insurance companies have been involved in health care insurance for many years. The indifferent success of such programs has caused the insurance companies to look for additional roles in the health field.
There is no need to argue whether health insurance is good or bad. As far as orthodontics is concerned, the question is whether the changes that will occur if insurance companies assume control are either necessary or desirable. If private practice were to remain the way it is and insurance company costs and profits superimposed, the cost of orthodontic care would have to rise or fees would have to go down. If you were to guess that orthodontic fees would go down under these circumstances, you are probably correct. This is what has happened when insurance companies have developed panels of participating dentists. The chief way that the insurance companies can justify their intrusion into orthodontics, apart from supplying a plan of prepayment, is that they can reduce fees.
Another role that the insurance companies would like to fill is to offer the public a service of quality and performance control of the profession. This, incidentally, is why peer review is of vital importance. We are going to have review. Of that there can be no doubt. If we do not provide meaningful peer review and convince the public that it works, they will provide civilian review and the insurance companies would be pleased to be their agent.
Another role that the insurance companies would like to fill is that of authorizing agency, deciding which treatment is covered under the program, when it will be performed and how much of it will be performed. The treatment program varies with the contract and the contract is generally drawn for one year. Thus, the orthodontist may be limited to the treatment defined in a contract to which he was not a party and to a term of one year on a treatment program which almost always must exceed that time.
The alternatives to keeping private practice in the form that we know it and succumbing to insurance company dominance are either to refuse any relationship with insurance companies, or to change the mode of private practice, or to somehow manage an accommodation with the insurance companies. None of these will be possible if we continue the unequal contest of the individual practitioner against the giant corporation, the huge industry, or the state and federal governments. We have reached a point at which the coming changes will affect the life and professional and economic well-being of a majority of orthodontists presently in practice. If enough orthodontists realize this, they should be impelled to develop an organized approach to the problem, before it becomes too late even for group action.
Changes are occurring in the mode of private practice. They need some organizational direction and some guidance. For example, we have had a widespread change in the functions of auxiliary personnel. There are indications that this has the potential to permit one orthodontist to treat more patients. It should also be explored from the point of view of lowering the cost of treatment. The insurance company could have an administrative role, a fiscal intermediary role, and be the source of the increased case load. Other modes should also be explored, but without the bias with which insurance companies are now sponsoring HMOs.
Orthodontists should avoid becoming hirelings of insurance companies. They should preserve their professional prerogatives of case selection, diagnosis, treatment planning, and actual treatment. They should jealously guard their initiatives in patient care and practice administration. They should accept their responsibilities to furnish peer review. They should not become so disoriented in the presence of change that the high levels and standards of orthodontic treatment of which we are capable become victims of administrative or political expediency.
