The future of dental insurance?
Delta Dental of Michigan just began offering a new kind of dental insurance to its employees. The insurance plan is being sold as “personalized care.” What a great service! They care about you as an individual! They actually test your genetic code to determine the best treatment for you, right? Well…sort of. Here’s a short version of how it works.
Adults will be given a baseline level of preventive coverage. This baseline includes one “cleaning” and two exams covered by insurance per year. Additional “cleanings” will be covered (a maximum of four) if you have one or more risk factors. The new program includes the following risk factors:
- history of heart attack/stroke
- renal failure/dialysis
- suppressed immune system
- history of radiation of the head and neck due to cancer
- a history of a periodontal disease/past periodontal disease treatment
Furthermore, a subscriber to this insurance policy may choose to have a genetic test done for the “periodontal disease gene.” If they test positive for this gene, they may qualify for more “cleanings.”
You may be wondering why I’m putting quotes around the word cleaning in the previous paragraphs. It’s because I kind of hate the term “cleaning.” It means different things depending on the patient’s gum (periodontal) health. So let me clarify. If you’re a healthy adult patient with no periodontal disease, you’ll most likely get a dental prophylaxis. This consists of a hygienist or dentist removing plaque and tartar that his harder to reach by regular home care as well as the crowns of your teeth polished. That’s the smooth and minty feeling you get after they finish up. If you have periodontal disease, which is to say that you’ve lost some supporting bone around your teeth, your cleaning is actually considered periodontal maintenance. This assumes you’ve had periodontal therapy (deep cleanings, aka: scaling and root planing). This is a much more in depth removal of tartar which may include local anesthesia and localized deep cleanings on the roots of the teeth. However, both of these things are (erroneously) being referred to as a cleaning, even though there are very specific insurance codes for each type.
At first glance, this really does seem like dental insurance providing true personalized care. Delta Dental of Michigan designed the plan based on some recent research from the University of Michigan that may indicate that 2 preventive visits to the dentist each year are no better than one at preventing disease.
Delta Dental seems to be indicating that this new, evidence based plan that treats patients based on their risk factors for disease is the way to go. I am very interested in letting good scientific evidence help guide the way we treat patients. I think this is in everyone’s best interest. That said, I think this plan is premature at best and disingenuous at worst. I think Dental Dental’s foray into personalized care is heading in the wrong direction for several reasons.
- Weird Science: The new insurance policy is based on a University of Michigan study called “Patient Stratification for Preventive Care in Dentistry.” The study was designed to see if two recall appointments (“cleanings”) were better than one. The results would lead one to believe that two cleanings are no better than one. From what I can tell, this is the entire basis for reducing the number of baseline “cleanings” the patients with this insurance policy would receive. But there is a problem with this research. The outcome that the study measured was “tooth loss.” Which is to say, two cleanings is no better than one cleaning if your only concern is losing teeth to periodontal disease. Losing teeth due to gum disease is clearly a huge concern, but there’s a lot of other concerns (gingivitis, tooth decay, crooked teeth, tooth wear and dry mouth to name a few) that this research doesn’t address. “Tooth loss from periodontal disease” is a pretty blunt measure of whether 1 or 2 cleanings per year is better. It seems to me that most patients aim higher than just not losing teeth to gum disease.
- No smoking?: Delta Dental listed many risk factors that they take into consideration when allowing for added “cleanings.” Diabetes, history of stroke/heart attack, suppressed immune system and even a genetic predilection toward gum disease. What didn’t they list? Smoking. Many believe that smoking is perhaps the most relevant risk factor of all when it comes to gum disease. Yet Delta Dental doesn’t list this as one factor that might qualify a patient for more covered recalls? What is that all about? Is it a moral stand against smoking? Whatever it is, they’re ignoring perhaps the most important factor in the development of gum disease. Since the new policy is based on research that judges tooth loss by gum disease, it seems that Delta Dental is picking the risk factors that benefit their bottom line more than the patients they serve.
- What about tooth decay?: As I mentioned before, this research measured tooth loss due to gum disease. The elephant in the living room is the fact that they didn’t mention risk for tooth decay. Gum disease is common, but not nearly as common as tooth decay. For people with a lot of risk factors for decay (dry mouth, lots of medications, diet, soda consumption, poor home care), 6 months is probably too long to go without being seen by a dentist. For these folks, a year is practically a lifetime! Tooth decay can proceed very quickly in a high risk patient, yet they may not test as high risk for gum disease, which means that under a plain like this, they would likely only have one “cleaning” per year. While cleanings may not directly affect tooth decay, the fact that the patient is presenting to the dental office means that the dental team is much more likely to catch problems (e.g–cavities) while they are small and easier to treat.
You might be thinking, “O.K. Doc. I hear you. But you’re missing the point. The insurance policies still pay for two exams per year. I can come in to see you twice and you’ll still get a chance to evaluate my teeth. Even though they won’t be as smooth and minty as before, I’m still getting all that preventive benefit. I think this is really about dentists losing all that revenue from cleaning teeth. So just pipe down.”
Honestly, this is a semi-reasonable argument. The insidious part is what the insurance companies know that regular folks don’t think of. Whether you want to believe it or not, we human beings are driven by incentives. As much as I like to think that I can teach all patients about their needs, I’m still almost always limited in my treatment options by what the insurance will cover. Patients with insurance like to use their insurance benefits and they take seriously the limits that insurance policies place on them. If a patient has been used to coming every 6 months for a cleaning ever since they were a child, how likely are they going to set up for that second examination if they don’t get a cleaning? I can see it now: “So you want me to miss work so I can come over here and have you look at me for 15 minutes? I don’t get to spend quality time with April or Tanna gently polishing the plaque off my teeth? All I get is Doc shining that bright light in my eyes? Well, thanks but no thanks. I’ll pass until my next cleaning is covered.”
I’ve written previously that cleanings are overrated. Apparently the insurance companies are beginning to agree with me. I hope I’m wrong.
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