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Up the Down Escalator

Up the Down Escalator

There is an ambivalence in the dental profession that, at times, may place the needs of the individual practitioner at odds with the needs of Dentistry with a big "D". Dentistry has a need to sustain its position as one of the learned health-care professions and demand its inclusion in any program that professes to deal with a national crisis in health care. The dental practitioner, on the other hand, has a stake in maintaining private practice as we know it. A prominent public health official once said to me, "When I die, I want to be reincarnated as a private practicing U.S. orthodontist".

Are there problems in the U.S. health-care system? Yes, there are. Do those problems amount to a crisis? That depends on how you define a crisis. If one is desperately ill with nowhere to turn for health care, that individual has a crisis. Almost everyone would agree that that individual needs help. But do you overhaul the most effective health-care system in the world to solve such a problem?

A "crisis" has been evoked on the basis that there may be 37 million Americans at any one time who have no health insurance coverage. However, some have whittled away at the numbers to reduce the actual number of uncovered Americans to a fraction of that. There is not a constant group of 37 million people who are uninsured. One large portion includes those who are between jobs. If insurance coverage were portable from job to job, a good portion of the 37 million would evaporate. Another substantial portion comprises young people with adequate incomes who choose to roll the dice and not purchase insurance coverage. These two items alone suggest that a large part of the uninsured problem could be alleviated without changing an entire system and without handing another one-seventh of our economy over to a bureaucracy that has shown time and again how ill-equipped it is to handle such a task. One has only to look at Medicaid and Medicare as they are administered today to be frightened at the prospect of government control of health care.

Whether there is a crisis need not be the centerpiece of a discussion of health care. There are legitimate concerns about our present system that can be identified and addressed.

A major complaint about health care in the United States is that it costs too much. To some extent, this problem is treatable without resorting to Draconian measures. The cost of private health insurance is bloated with administrative expenses, which have been reported to account for 25-40% of total insurance costs. Public health-care programs are also inundated in a blizzard of paper work, the storage of which alone boggles the mind. Direct reimbursement has been demonstrated to be an effective alternative that reduces administrative costs, and it was recently reported that 600,000 individuals are so insured. With no significant program of support for the concept, that is an impressive number.

Another important aspect of the high cost of health care is a lack of restraint because the insurance company, or Medicare, or Medicaid, or some other government program, is paying the bill. Also, it is fair to say that the system encourages overtreatment and overbilling. Both of these problems could be alleviated if the patient were required to pay some amount of out-of-pocket expense.

The cost of health care is also greatly increased by the threat of malpractice suits, which virtually compel defensive practice. Millions of dollars in health-care charges result from defensive tests and x-rays, and from the extra time required to cover one's rear.

The public has a high degree of trust in health professionals, but the government bureaucracy does not. The adversarial attitude of those who promulgate and enforce health-care regulations, with little or no input from the professions, produces nitpicking and, at times, inappropriate regulations that increase costs. So there are a number of causes of the high cost of health care today that can be addressed without replacing an effective health-care system with one that is likely to be worse and cost more. Show me a program that our government runs that is as universally admired as our present health-care system and that would be cost-effective. These are, after all, the people who have brought you the U.S. Postal Service.

I would remind you that once before, in the formation of the Delta Dental plans, organized dentistry bought into an insurance scheme that included just about every bad concept imaginable--participating dentists or closed panels, diminished doctor/patient relationships, pre-authorization, fee schedules, coinsurance, and community-based rather than experience-based coverage. This type of restrictive approach seems akin to what the government has in mind today. Some of the proposals on the table provide that a substantial part of the program will be paid for by the health-care provider, a substantial part by the employer, and a substantial part through taxation. Keep your eye on the word "substantial". In these days of "three strikes and you're out", how about a triple play? You are a health-care provider, you are an employer, and you are a taxpayer.

If orthodontics were to be included in the plan as presently outlined, I can foresee an attempt to shape a system that includes indexes of malocclusion to determine eligibility, no freedom of choice, and low fixed fees within a fixed allocation of dollars to the program. With a cap on the amount of money allocated to dentistry, every dentist would be scrambling to get a bigger piece of it. It conjures up images of hamsters racing on their wheels, or humans running up the down escalator.


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