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THE EDITOR'S CORNER

Can We Manage Without Managed Health Care?

Proponents of national universal health-care schemes point out that the United States is the only nation in the Western world that does not have such a program. By some curious twist of logic, it is assumed that because everyone else has one, we are somehow shortchanging our citizenry by not having one.

The article on "Managed Care in Europe" in this issue asks whether the experiences in managed health care in the nine countries listed may be a mirror of what we would experience in this country if we ventured into similar arrangements. The article is admittedly anecdotal, with one orthodontist in each country describing the program as he or she sees it. There are probably practitioners in each country who approve of their system as well as practitioners who disapprove of it.

It is doubtful that U.S. orthodontists would favor any of the programs described in the article, and not entirely because of self-serving financial concerns. The reason is that none of these programs is an orthodontic program. They are all attempts to devise insurance programs for uninsurable risks. The same is true of the so-called health insurance programs in this country. The only real difference is that we have apparently stopped short of having a majority of our patients covered by insurance, and we do not have the government controlling a universal system. With numerous insurance companies entering into contracts with numerous consumer groups, our insurance industry is not yet a monolith equivalent to a central government.

A theme that emerges over and over from the managed care article is the inevitability of programs that intend to do no harm, but wind up with more quantity and less quality in health care. In country after country, it appears that the programs grow beyond the expectations of the planners and produce deficits that need to be addressed. The only ways a deficit can be reduced are to place a cap on the amount of money allocated to the program, reduce fees, reduce the number of people eligible for care, set up some index of priority for various treatments to control the volume, set limitations on the kinds of treatment made available, or adopt restrictions that reduce or eliminate the patient's freedom to choose a doctor.

The result of placing a cap on health-care expenditures and lowering fees is that practitioners scramble to treat more cases at lower fees, trying to maintain their pieces of the pie. Each year, the treadmill moves faster and faster, but the orthodontist remains in place or, more likely, loses ground. The most advanced techniques are abandoned as unaffordable. The doctor-patient relationship is another casualty of the program. The profession is fundamentally changed, and not for the better. It does not serve the best interests of a country or its citizens to mismanage health care on a grand scale.

The only way a country could possibly offer its citizens a high-quality program of universal health care would be if that country had unlimited resources to spend on the program. There is such a country. It is called Brunei. It is a small country with huge oil income. To its credit, it uses its huge income to carry the concept of a welfare state to the level of Nirvana. Until less fortunate countries also find Nirvana, their attempts to be mega-Bruneis will fail. No one yet has been clever enough to make a dollar out of 50 cents.

The United States currently has welfare programs that pay for a certain amount of orthodontic treatment for the underprivileged, and many orthodontists cooperate with such programs by accepting lower fees. I must confess a certain ambivalence toward publicly funded welfare programs. On the one hand, they do extend orthodontic treatment to many who would not ordinarily have it; on the other hand, welfare patients were among the most uncooperative in my practice in following instructions, in keeping appointments, and in maintaining a decent level of oral hygiene. I could not put my finger on why this was so, because these patients were handled in my office in the same manner as full-fee, self-paying patients were. It may be that "if it costs nothing, it is worth nothing". The catch-22 here is that it probably improves patients' performance if they have to pay something toward the cost of treatment, but those on welfare cannot make the contribution.

In addition--and this could easily be a problem with private health insurance coverage as well--the government welfare agency that I dealt with made a commitment for one year at a time. It would not accept the idea that orthodontic treatment must be undertaken with an obligation to carrying the case through to a correction that would achieve orthodontic goals, including a reasonable chance of stability. The need for orthodontic treatment was based on an index of malocclusion that was principally concerned with the protrusion of the upper anterior teeth. Once the amount of overjet was reduced to less than the prescribed amount, the case no longer qualified for treatment under the program.

My value system required me to finish those cases for free. My sense of social justice compelled me to drop out of the program and offer free service to people of my choosing and not the government's. Unless there were a better way to motivate those patients and a better understanding of the nature of orthodontic treatment on the part of government agencies, a welfare system such as I encountered is likely to be unsatisfactory for the orthodontist, the patient, and the taxpayer.

An ideal plan for universal orthodontic care would include a great deal of patient education before, during, and after treatment; prevention as best we know it; research into prevention, including gene therapy as that science develops; patient selection based on physical and psychological needs and on patient commitment to achieving a desirable result; and acceptance by the program of orthodontic goals.

It seems unlikely that our government can afford to take on such an open-ended orthodontic program for people of all ages at any fee level in the near future, but it would be folly not to recognize that pressure groups are critical in shaping our system of government, and that government does not pay attention to small groups, especially when it considers them to be self-serving. It would also be folly to overlook the traditional pecking order. What applies to medicine is made to apply to dentistry, and what applies to dentistry applies to orthodontics. We could be well advised to break that chain and spend some time thinking about the future in connection with those who are thus far orthodontically unserved, and devising an effective program to deal with their orthodontic needs.

EUGENE L. GOTTLIEB, DDS

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