Rational Expectations II
Managed care has been advocated as the prime solution to containing costs of medical services, and its application to dentistry is increasing.
Orthodontics is usually an elective procedure. No one dies of malocclusion. Nevertheless, it is an attractive procedure to many people, and it is likely to become attractive to more people if it is routinely offered in man-aged-care programs. In common with other third-party systems, managed-care programs live and die by managing utilization and costs--specifically, by limiting utilization and costs. If utilization is restricted enough, the increased volume that the orthodontist might expect to counteract the decreased fees then dematerializes, and the orthodontist's income goes down. If fees are restricted enough, the orthodontist's income inevitably goes down, unless there is a balancing increase in the number of patients. If both utilization and fees are reduced, the orthodontist who is a captive of the managed-care program may be in an untenable position.
The JCO Orthodontic Practice Studies have shown that not many orthodontists are yet involved in managed-care programs. However, there have been instances in which a major employer in a community has elected to enter a managed-care program, such as a Health Maintenance Organization, to provide medical and dental services for its employees. An orthodontist in that community, the majority of whose patients were affected, has then been forced to make the decision of accepting the patients on the new managed-care basis or leaving town. In other words, an uninvited partner has joined the practice. Experiencing actual occurrences like that or fearing that they might, combined with an aversion to practice building and practice management, is pushing some orthodontists into individual contracts with managed-care programs.
Physicians have succumbed to managed-care arrangements in much greater numbers than dentists or orthodontists have. They only now seem to be catching on to the idea that they have permitted themselves to be victimized by health-care insurers who have overlaid medical costs with third-party administrative costs, and who have restricted procedures to maintain or increase their own profitability at the expense of the medical profession. Quality of care has been jeopardized, and the doctor/patient relationship has been severely damaged.
Having finally awakened to the thought that the price they have paid may be too high, physicians are showing signs of trying to retrieve some of what they have lost in professional prerogatives and in control of their own destinies. Physicians in many areas are forming large networks to add clout to their negotiations with third parties, or even to act as third parties themselves. It remains to be seen what the outcome of these efforts may be.
In another development, practice-management companies, usually with capital raised from public stock offerings, have entered into the health-care picture with various arrangements to relieve practitioners of the burden of practice promotion and management. In some instances, these companies run the business of a practice for a percentage of the income. They may also buy a practice and employ the doctor on a contract basis, guaranteeing a level of income and benefits for the term of the contract. The field is just developing, so it remains to be seen whether the doctors may be left out in the cold after their contracts expire, or whether the companies can continue to prosper if production declines. In any case, physicians, dentists, and orthodontists in small but increasing numbers are entering into yet another arrangement that is more concerned with third-party profits than with the quality of health care.
Today's practitioners often lament that the Golden Age of Orthodontics ended some time ago, but it is not so. We are still living in the Golden Age of Orthodontics. In the Golden Age, the orthodontist is an entrepreneur, free to make all the practice decisions, free to treat patients to his or her own standards, free to make arrangements for treatment and fee that are mutually acceptable to doctor and patient. "Golden" describes more than money.
Our age is golden not only for the orthodontist, but for the patient as well. When a patient can afford to pay for orthodontic treatment with or without an insurance benefit, the orthodontist can afford to give a best effort in terms of quality and quantity of treatment, with no restrictions that are irrelevant to the patient's orthodontic needs. The Golden Age of Orthodontics, then, is associated with the private, fee-for-service practice. If orthodontists, by choice or due to irresistible external forces, give up that mode of practice, that will mark the end of the Golden Age.