Orthodontists have participated in managed-care programs for a great many years, as participating dentists in insurance programs, in HMOs, in capitation programs, and in closed-panel relationships with unions and companies. Respondents to the JCO Orthodontic Practice Studies have consistently given these forms only fair ratings as practice-building methods.
In managed care, orthodontists sign an employment contract with the third party. The orthodontist is working for the third party and plays by its rules. The patient or the patient's employer has also made a contract with the third party. The third party agrees to provide orthodontic services as stipulated in the contract, to be delivered by the orthodontists with whom it has contracted for their services. The main attraction to the patient is lower fees. The main attraction to the orthodontist is the acquisition of patients without a need for internal or external practice building. The main attraction for the managed-care company is profit.
Some orthodontists are signing up with managed-care companies voluntarily, but some are being coopted by managed care. The simplest example is the practitioner in a town dominated by one employer, where the employer signs up for managed care. Virtually all the patients in the orthodontic practice may be covered by this managed-care contract. At that point, the orthodontist has three options: have a mixed practice of managed-care patients and full-fee patients, try to get along without managed-care patients, or leave town. None of this could happen if third parties were not able to control the demand side of orthodontics--the patients--or if orthodontists were able to control the supply side--the orthodontists who deliver the services. As it stands, it can be an unequal contest: the individual practitioner vs. the outsider who moves in and gains control of the patients.
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It would be incorrect to say that third-party involvement in dentistry and orthodontics has been all bad. It has quite likely enabled some people to have orthodontic treatment who might otherwise not have, although we cannot tell how many insured patients would have paid for their own treatment. The problem with the managed-care arrangement, however, is that it intrudes into a practice to a greater and more harmful extent than indemnity insurance programs have, and that the doctor, rather than the patient, is paying for the administrative costs of the program.
Private, fee-for-service orthodontic practices have traditionally accepted a responsibility for providing excellent treatment. Working for fixed fees, they have pursued that goal to the best of their abilities, without regard to the amount of time or number of visits required, or whether these exceeded the original estimation. The standard in managed care is not the quality of treatment. Basically, managed-care companies are in orthodontics to balance what they can receive in insurance payments with what they can pay out for the covered care, optimizing their profit in the bargain. They are not looking for the best care, but for the level of care they can get for what they are willing to spend. Because the value systems of traditional orthodontics and of managed care are at variance, the specialty would change fundamentally if managed care were to intrude too deeply. Will orthodontists be able to continue to do their best if they are paid for something less?
The managed-care issue is not entirely a matter of money. It is a question of integrity--integrity of the individual and integrity of the specialty. One definition of "integrity" (from Webster's Unabridged Dictionary) that might be applied to the individual orthodontist is "an uncompromising adherence to a code of moral, artistic, or other values; utter sincerity, honesty, and candor; avoidance of deception, expediency, artificiality, or shallowness of any kind". Another definition that might be applied to the entire specialty reads: "the quality or state of being complete or undivided". For the specialty, managed care divides orthodontists and threatens the doctor/patient relationship and the quality of treatment. For the individual orthodontist, managed care will severely test a system of high moral, artistic, or other values.
It remains to be seen whether orthodontists are making a Faustian bargain. Shakespeare said it best: "he that filches from me my good name robs me of that which enriches him not and makes me poor indeed".
ELG