THE READERS' CORNER

Topics are surgical-orthodontic cases and HMO/PPO patients.

1. What percentage of your patients are surgical-orthodontic cases?

Most of the respondents reported that between 4% and 5% of their active cases were surgical-orthodontic patients. The range was from less than 1% to 15%.

What do you see as the major indications for orthognathic surgery?

The most commonly used general indication was a significant skeletal discrepancy, usually in a non-growing patient, where the malocclusion was too severe to allow for a successful orthodontic solution. Skeletal mandibular deficiency and skeletal mandibular prognathism were the most frequently mentioned specific discrepancies, closely followed by anterior open bite. Other general indications included the patient's desire to achieve a facial change beyond the scope of conventional orthodontics, functional requirements, and craniofacial deformities such as cleft lip and palate.

What age or developmental considerations do you have for any of the surgeries you use?

The clinicians were almost universally agreed that surgical-orthodontic patients should be non-growing, particularly in Class III cases. Many suggested taking serial cephalometric radiographs until a full year of no growth was evident. Several orthodontists recommended waiting until at least 16 years of age in females and 18 in males for Class II cases, and even longer for Class III cases.

Do you have a surgeon who will perform segmental two-jaw surgery in one operation, or do your surgeons need to carry out procedures in two stages?

Ninety-seven percent of the respondents reported having surgeons who would do segmental two-jaw surgery in one operation.

On a scale from 1 to 5, with 1 being very happy and 5 being very unhappy, how pleased have you been with the results of: surgical cases in general, mandibular advancements, maxillary impactions, two-jaw surgeries?

For surgical outcomes in general, 70% of the clinicians were either very happy or happy with their results, 15% were fairly happy, 15% were unhappy, and none was very unhappy. Responses for one-jaw mandibular advancements and maxillary impactions were similar, with 66-70% very happy or happy and only 5-6% unhappy. The level of satisfaction with two-jaw surgeries was lower: 58% of the respondents were very happy or happy, 15% were unhappy, and 2% were very unhappy.

What are the major problems you have encountered in your surgical-orthodontic cases?

The most common problem--mentioned by 25% of the clinicians--was post-surgical relapse, particularly of mandibular advancements and anterior open-bite correction. Also listed were postoperative paresthesia and TMD symptoms.

What are the best methods you have found to improve the results of surgical cases?

The most frequently mentioned solution was detailed, comprehensive treatment planning by the orthodontist and the surgeon together--both prior to starting the case and immediately after surgery. The importance of communication between the professionals as well as with the patient was emphasized repeatedly. A close second in importance was meticulous presurgical orthodontic preparation, including arch coordination and, if necessary, a setup. The third most common recommendation was to "find a good surgeon", reflecting the orthodontists' concern about a reliable surgical outcome.

Specific suggestions included:

"Having a pre-ortho consult with the patient and a surgeon who will spend the time needed in pre-op. Then having a realistic presurgical orthodontic time schedule and not rushing the presurgical orthodontics to meet the patient?s desired time to have surgery."

"1. Choose your surgeon carefully. 2. Do meticulous presurgical orthodontics. 3. Don't remove the appliances too soon. 4. Don't let the surgeon talk you into doing one jaw when the diagnosis calls for two-jaw surgery."

"I see my patients every one to two weeks after the surgery, even though the surgeon is the "captain of the ship" until he releases the patient back to me. This way I stay on top of any potential complications and can communicate this to the surgeon immediately."

2. What percentage of your patients come from an HMO or PPO?

Of the entire sample, an average of 2.1% of their patients came from HMOs or PPOs. Only 32% of the respondents had any such patients; of these, an average of 6.5% of their cases were from managed-care plans, with a range from 1% to 25%.

Do you have a contract or agreement with an HMO or PPO? If so, for how long have you had this agreement? Please describe your arrangement.

Twenty percent of the practices had had managed-care contracts for an average of four years. Many offices had only signed on within the last one or two years. There was no consensus form of agreement. Although fees ranged from "my UCR" to "30% off", most of the orthodontists reported lowering their fees to meet the plan requirements.

What were your reasons for signing up with the HMO or PPO?

There was a wide variety of responses. Mention was made of the need to join a plan when a referring dentist signed up, so as to be able to continue receiving referrals. Some clinicians signed on to attract new patients, particularly when just starting a practice. Others were located in towns where principal employers joined HMOs or PPOs, and they felt obliged to follow suit to stay in business.

In what ways have your expectations been met or not met? What do you see as the major advantages of an HMO or PPO?

About 80% of the practitioners who had contracted with HMOs or PPOs felt their expectations had been met, but could see no particular advantages to working with such plans. Several respondents thought it gave them access to a greater number of referring dentists and improved the availability of care for some patients.

Specific comments included:

"My expectations were met. The patients refer their neighbors who are not on the plan."

"My expectations were met, except that they recently changed from monthly to quarterly payments, so they keep my money two extra months."

"The advantage is that there is less 'selling' the need for treatment."

Please describe any problems you have encountered with the HMO or PPO.

The biggest problem reported was that many patients did not understand the plan. They often thought it covered all dental and orthodontic care and that there would be no charge to them for orthodontics.

What do you see as the major disadvantages?

"Lower fees" was the primary drawback, closely followed by the orthodontists' distaste for having a managed-care plan dictate the quality of care they could provide. Difficulty in obtaining preauthorizations and payments and general bureaucratic delays were other sources of dissatisfaction.

Some specific comments:

"A service becomes a commodity. It is highly detrimental to what we should believe is in the best interest of our patients. Would we want this kind of treatment of our families?"

"Having to request preauthorization and payment. The HMO dictates the quality of care by the procedures it covers. The fees generally are 20-40% less than the usual and customary fees."

"The insurance companies have no risk or financial obligation. They take a middleman position--providing no service, just making a profit."

Do you plan to continue, discontinue, increase, or decrease your activity with the HMO or PPO?

All the offices that currently had agreements with managed-care plans reported that they intended to continue. About half said they would increase their activity; the other half planned to remain at their current level.

If you do not belong to an HMO or PPO, what are your reasons?

"I do not belong to an HMO because I would not want to lower my fees or my standards. I hate being at the mercy of someone else who does not care about good orthodontic treatment, but is only interested in the bottom line."

"I cannot accept the concept of treating some people at a lower fee than my regular patients. We treat all patients to the same standard of care and incur the same overhead for each. Dental suppliers, utilities, landlords, and employees don't take a 30% reduction on HMO patients."

"I do not want to lose the ability to control my own practice. I do not want to end up working for insurance companies."

"Due to the high overhead of an orthodontic practice, the fees are not compatible with rendering high-quality care. Either the profit level or the quality level will be squeezed. These alternatives sound stressful to me."

"We need only look at Medicare to know we should not join--quality declines, and the future ramifications are unknown at this time."

"I will pursue each and every new HMO so as to be No. 1 in patient choices. Many times patients elect full service over discounted services due to the special attention they receive in our office."

"I left [a plan] after four years because:

"1. The fees were outrageously low.

"2. There was too much paper work for approval of two-phase treatments, exposure of impacted teeth--i.e., anything that wasn't a straightforward case.

"3. The contracts were mute on the issues of non-compliance and transfer cases, and therefore the decisions were always favorable for the PPO and not the patient or orthodontist."

JCO would like to thank the following contributors to this month's column:

Dr. Christopher M. Biety, Broomfield, CO

Dr. David H. Crowder, Memphis, TN

Dr. John C. Daire, Opelousas, LA

Dr. Robert Davis, Columbus, OH

Dr. James R. Dee, Jr., Munhall, PA

Dr. Kerwin V. Donaldson, Jr., New Iberia, LA

Dr. John D. Doucet, Niagara Falls, Ontario

Dr. David L. Drake, Tiffin, OH

Dr. Norman Farley, The Woodlands, TX

Dr. Bruce M. Field, Auburn, MA

Dr. Craig W. Fischer, Pittsfield, MA

Dr. Ronald L. Gallerano, Houston, TX

Drs. Bryce C. Gochnour, Stephen A. Morris, Edward J. Mulick, and Glen A. Smith, Boise, ID

Drs. Alfred C. Griffin, Jr., and Scott C. Berman, Warrenton, VA

Dr. Terry V. Gruelle, Fort Thomas, KY

Dr. Anthony L. Harwell, Amarillo, TX

Dr. Rowland U. Haryett, Edmonton, Alberta

Dr. Dennis C. Hiller, Conway, NH

Dr. Stuart J. Hoffman, Calabasas, CA

Dr. Earl T. Holdsworth, Yarmouth, ME

Dr. Gordon C. Honig, Newark, DE

Dr. David R. Hunter, Glendale, AZ

Dr. James B. Kendrick, Sebring, FL

Drs. Charles W. Kenney and Edward F. Tipton, Lexington, KY

Dr. Samuel G. Koonce, Whiteville, NC

Dr. Robert J. Kuhn, Santa Barbara, CA

Drs. Franklin D. Lo and Robert W. Elliot, Prince George, B.C.

Dr. James I. Lopez, Columbus, GA

Dr. Robert W. Magness, Houston, TX

Dr. Richard T. McDaniel and Myron M. Sternstein, Springfield, IL

Dr. James E. Meeks, Jr., Florence, AL

Drs. William A. Mitchell, Richard F. Hewitt, and Karen S. Rogers, Greenville, SC

Dr. Edwin L. Morris, Kingsville, MD

Dr. Edward S. Orenstein, Chester, NJ

Dr. Mitchell W. Pelsue, Janesville, WI

Dr. Carmine N. Petrarca, Bethesda, MD

Dr. Timothy D. Poppell, Orange City, FL

Dr. J. Robinson Prewitt, Fayetteville, NC

Dr. Denton R. Rogers, Chandler, AZ

Dr. Michael L. Runey III, Charleston, SC

Dr. David M. Schneeweiss, Suffern, NY

Dr. Joseph J. Shadeed, Bucyrus, OH

Dr. Leon Strohecker, Lansdale, PA

Dr. Jim E. Williams, Fort Wayne, IN