So, in my last blog, I dissected Humana's new individual dental insurance plan that "rewards" its enrolled members on year two and three. Well, I didn't dissect the WHOLE plan because I couldn't get past that the colossal fees for enrolling and using preventive services. In all fairness to Humana, and having presented the point of view of the patient and dentist, I will shed light on Humana's point of view. I can only speculate here, but providing all sides is what this blog is about, and since there are usually three sides to every story, I will illuminate the third side as best I can.
Here goes:
Humana: There is no shared risk for individual dental plans. "What the heck does that mean, Annelise??", you ask? Well, it basically means that unlike group dental policies, with many enrolled members, like the plans that employers purchase for their employees, individual plans have no shared risk pool. In a group plan, there is an assumption that while many people will use their benefits to the max because they have them (called Moral Hazard), many will only use some of the benefits, and some will use NONE of the benefits of the plan. If a dental insurance plan is paying out up to $1000.00 in annual benefits, but only charging $467.00 per year in premiums ($35 enrollment fee + approximately $36 per month premium), they will not be making money off of that policy (called a loss ratio). If EVERYONE in the group plan uses all $1000.00 in benefits and only pays $467 per year for premiums each, then the insurance company has lost a crap-ton of money on that group. Obviously, an insurance company can not survive by losing money on insurance plans, therefore, the risk of no profitability is shared in a group policy, and offset by those who will use only some of their benefits and those who will use none of their benefits. That's what a shared risk pool means.
On individual dental plans, it is highly likely that the insured will be using ALL of their benefits for the first year, since most people purchase individual plans when they are in desperate need of dental work all of a sudden. People are famous for doing this. They don't have any dental work, exams, or even cleanings for years on end, then wake up one day in pain and realize, "Oh Crap! I need dental work! I have no insurance! It's going to be expensive (because I waited so long and didn't have even routine cleanings done)! Let's see if I can find a "cheap" individual dental insurance plan so I can get this work done!" Yes, that's how it happens. Nothing like last minute emergency planning on compromised oral health....but I digress.
So, because dental insurance companies KNOW this, they usually do not pay out very much in the first year, which makes people upset since they are paying premiums for little benefits. USUALLY, however, the difference is that almost ALL preventive services are covered at 100% with zero deductible. THAT I understand AND support fully. That's not what Humana's dental plan is doing, though, as you know. And, while I DO see where collecting $467 in premiums from an enrolled member and paying out $1000 in benefits does NOT make good business sense, nor is it a viable/sustainable business model for insurance companies, I STILL believe that putting a $150 deductible on xrays is flirting with disaster on all ends. It just makes everyone cranky: the patient for having to pay out a whopping amount at the first visit, the dentist who gets an aggravated patient upset at having to pay for expensive/needed/required xrays on the first visit, and the insurance company who will have to deal with that upset patient when they call and complain. Three strikes on this one all the way around.
Humana really, really, really, should have put that deductible on basic and major work and NOT on preventive services that are critical to proper diagnosis. In fact, based on the statutes that relate to the actual duties of a dentist, it is not even possible for a dentist to diagnose what type of cleaning a patient needs, without first viewing the xrays to see if there is bone loss (from periodontal disease), debris under the gums (subgingival calculus/tartar), or infection brewing (like an abscess). Soooooooooooo, technically, and according to the statutes, the dentist must conduct a thorough exam and diagnose the cleaning type needed by using a diagnostic tool (called xrays!) along with other visual and manual methods, BEFORE a patient can get their teeth cleaned.
And, JUST so that you know, that INDEED I speak the truth, here is the actual statute on dental records (along with the link for you seriously Doubting Thomas types). Get ready to be impressed by my massive dental geekiness (I'm just a veritable LANDFILL of useless dental legal knowledge)!
CHAPTER 64B5-17
DENTAL PRACTICE AND PRINCIPLES
64B5-17.002 Written Dental Records; Minimum Content; Retention.
(1) For the purpose of implementing the provisions of subsection 466.028(1)(m), F.S., a dentist shall maintain written records
on each patient which written records shall contain, at a minimum, the following information about the patient:
(a) Appropriate medical history;
(b) Results of clinical examination and tests conducted, including the identification, or lack thereof, of any oral pathology or
diseases;
(c) Any radiographs used for the diagnosis or treatment of the patient;
(d) Treatment plan proposed by the dentist; and
(e) Treatment rendered to the patient.
Link: http://www.doh.state.fl.us/mqa/dentistry/rule_64B5-17Dental_Prac-Princ.pdf
I highlighted the brilliant, supporting parts--you don't have to thank me, I'm happy to help.
Anywhoooo, as you can see, those stinking xrays are a thorn in the side of this dental insurance policy that Humana created. While I have presented all three sides now, and you now fully understand the financial loss potential Humana faces with individual dental insurance plans, that does NOT change the fact that, no matter what "loyalty" rewards this policy provides for enrolled members over the first 3 years, it STILL gets a hearty, finger-wagging "tisk, tisk" for subjecting a basic required diagnostic tool to a whopping $150 deductible. Not cool, Humana. It's a disservice to patients and dentists alike, and opens up the door for conflict between the two, which is 100% avoidable and preventable had you placed that deductible on basic and major services only.
Go ahead, Humana. Redo the plan and shift the deductible to basic (fillings) and major (root canals/crowns) services, so there is no fuel for further debate. I can wait. I'm right here. It needs to be done. It's the right thing. Just let me know when it's done so I can reassess this plan and hopefully, recommend it to everyone I know who does not have dental insurance. No pressure or anything, but I'm waiting here. :)
Wow, I'm exhausted! Did I burn calories on this one, or what? Am I thin yet? That was a workout.
That's it for me for today. Thanks for stopping by and remember; you only have to brush and floss the teeth that you ABSOLUTELY, POSITIVELY want to keep.
Dr. Driscoll
Wednesday, May 23, 2012
Monday, May 21, 2012
Oh Humana....I had such high hopes for you...tisk, tisk.
So, recently I came upon an article in an Orlando business paper announcing that the insurance company Humana was getting ready to offer a dental insurance plan for those who don't have dental insurance, that would "reward its members" for their "loyalty" to the plan. What this means, bottom line, is that they will increase benefit levels in the second and third year of (having) the plan. At first, I thought, hmmm...well that sounds pretty good, especially since there are few, if any, "good" individual dental plans out there. Most cost more then what they provide in limited benefits. In other words, its "slim pickin's" out there for dental insurance if your employer does not provide you with a decent plan. A decent individual plan with little or no co-pays,and increasing coverage after the second and third years? Rewarding my loyalty? Well, alrighty then! Sounds good to me (finally)! I was almost excited! Almost........
Upon further review of this HumanaOne Loyalty Plus Plan, I will let you know what I have found. Before I tell you about their reasonable premiums, let me just say that there is an enrollment fee, and administration fee, and a PBA member monthly association fee ON TOP OF the monthly premium. What is this PBA group that enrollees must subscribe to? Is it something fantastically beneficial to help mankind improve on their dental status? Um. No. It is not. The small writing at the bottom of the page states it is a (and I quote the Humana ad here) "a not-for-profit membership organization that provides health, travel, consumer and business-related discounts to its members". Hmmmm...you mean, I HAVE to join this group to purchase the dental insurance and then I have to PAY money every month to get "travel discounts"? Huh?? Why is this sending off a red flag in my head? Ok, well, as it turns out it is a small fee, which when combined with the other small fees, for other "stuff", you get a monthly premium of $35.74, after an enrollment fee of $35.00. Really. Hmmm...Ok.
Driving on, I realize that they pay 100% for preventive services (exam and healthy mouth cleanings) in all three years, so that's good. That should be a savings right there, no? Oh wait a minute! They don't pay for x-rays at the first appointment or anytime after that until I've met my deductible of $150.00? Holy moly. So, after paying the premiums, and enrollment fees, I have to pay for the x-rays out of pocket, which cost more than $100 for the first visit to a dentist's office. I'm not feeling the "loyalty" being "rewarded here. In fact, if I'm not mistaken, this now will likely become a bigger issue....possibly....
And, here is where we get to the BIG red flag:
Every new patient visit at a dental office requires a full series of xrays to be taken in order for the dentist to view your whole mouth, teeth, roots, bones, etc. Without that full series of xrays, the dentist is not able to see your whole mouth and its total oral health status, nor is he/she able to properly and thoroughly diagnose any conditions that are evident on the xrays, but maybe not by the naked eye's visual exam only. That is a significant issue. But, in all fairness, let's look at this from both sides, shall we?
The Consumer: Having to pay out over $100 for xrays on the first visit, after paying the premiums and other "fees", may seem like a lot. In fact, that consumer may very well say to the dental practice, "Hey, I don't have that kind of money, so can I just get the exam and cleaning at least?" I certainly understand where the consumer is coming from. I really do. I would be annoyed to have to find out that the xrays were subject to a $150 deductible. In most other group dental insurance plans, that is part of the preventive services that are USUALLY covered at 100% by the insurance company. I can see where the consumer might want to just get what is covered. I get it. It feels like the consumer is getting "nickled and dimed to death", as they say, and they will likely be annoyed and request no xrays be taken.
The Dentist: Knowing what their protocols are for a new patient exam, which includes taking a full series of xrays, to "see" everything and assess the true condition of the patient's mouth, this presents a liability issue. The difference between conducting a new patient exam with only the naked eye, and one which includes a full series of xrays, is the difference between looking through a keyhole into a room to see what is in it, and opening the door to get the whole view of what is in that room. They don't compare. It would be a disservice to a patient to not fully view and diagnose the condition of that patient's mouth. In fact, it could very easily lead to a lawsuit if something is "brewing" that was not visible with the naked eye and then did not get addressed. Major Liability Risk: "Danger, Will Robinson, Danger Will Robinson"! Plus, the dentist may very well get cited by the Board of Dentistry for negligence for NOT taking the appropriate and needed/required xrays on a new patient. That dentist's license may now be at risk.
And all because Humana 'rewarded' its enrollees by putting a $150 deductible on xrays.....Oh boy. Hot mess. Not good. Both sides of this equation have merit and can be clearly seen and understood. Both sides have issues that are real and valid. Unfortunately, what I REALLY fear happening here, in this very troubled time, and in this tough economy, is PERHAPS a dentist accepting that patient anyway, because they threatened to see someone else, and waiving the xrays until "next time". Meanwhile, under the gums, 'something wicked this way comes'....like a looming infection, bone loss, resorption, an abscess, a cyst, you name it...I was almost excited about this plan...I really, really was...
But really, Humana, all you have done here, is create a difficult situation for everyone involved; except you. Having a customer pay 3 extra fees plus a premium is enough. It could be overlooked if indeed you rewarded your customers. I see where your benefits for basic and major services increase at year 2 and 3 and I think that's ok; not great, but ok. But do I feel you did the right thing by penalizing both the patient and the dentist by creating the conflict associated with attaching a high deductible to needed/required xrays on the VERY FIRST VISIT??? Nope. I do not. Not only do I NOT think it was the right thing, I fear it will place both parties involved at great risk; both clinically, and ethically/legally.
Sure, there may be many patients who can pay the $70 plus for the enrollment fees and first month's premium, but then another $150 to get an exam, xrays and cleaning after that? Over $200 for the first visit? Unless I'm mistaken, that's pretty comparable to what the patient would have paid without any insurance at all, isn't it? Oh Humana, you were SO CLOSE to being a good policy...SO CLOSE...but not close enough. Based on all of that (and I couldn't even really get to the rest of the plan "benefits"), I would have to give this policy a big "tisk, tisk"....Buyer beware...and dentists beware too!
That's it for me today. Thanks for stopping by. And, remember, you only have to brush and floss the teeth that you ABSOLUTELY, POSITIVELY want to keep. That's it. Nothing more.
Dr. Driscoll
Upon further review of this HumanaOne Loyalty Plus Plan, I will let you know what I have found. Before I tell you about their reasonable premiums, let me just say that there is an enrollment fee, and administration fee, and a PBA member monthly association fee ON TOP OF the monthly premium. What is this PBA group that enrollees must subscribe to? Is it something fantastically beneficial to help mankind improve on their dental status? Um. No. It is not. The small writing at the bottom of the page states it is a (and I quote the Humana ad here) "a not-for-profit membership organization that provides health, travel, consumer and business-related discounts to its members". Hmmmm...you mean, I HAVE to join this group to purchase the dental insurance and then I have to PAY money every month to get "travel discounts"? Huh?? Why is this sending off a red flag in my head? Ok, well, as it turns out it is a small fee, which when combined with the other small fees, for other "stuff", you get a monthly premium of $35.74, after an enrollment fee of $35.00. Really. Hmmm...Ok.
Driving on, I realize that they pay 100% for preventive services (exam and healthy mouth cleanings) in all three years, so that's good. That should be a savings right there, no? Oh wait a minute! They don't pay for x-rays at the first appointment or anytime after that until I've met my deductible of $150.00? Holy moly. So, after paying the premiums, and enrollment fees, I have to pay for the x-rays out of pocket, which cost more than $100 for the first visit to a dentist's office. I'm not feeling the "loyalty" being "rewarded here. In fact, if I'm not mistaken, this now will likely become a bigger issue....possibly....
And, here is where we get to the BIG red flag:
Every new patient visit at a dental office requires a full series of xrays to be taken in order for the dentist to view your whole mouth, teeth, roots, bones, etc. Without that full series of xrays, the dentist is not able to see your whole mouth and its total oral health status, nor is he/she able to properly and thoroughly diagnose any conditions that are evident on the xrays, but maybe not by the naked eye's visual exam only. That is a significant issue. But, in all fairness, let's look at this from both sides, shall we?
The Consumer: Having to pay out over $100 for xrays on the first visit, after paying the premiums and other "fees", may seem like a lot. In fact, that consumer may very well say to the dental practice, "Hey, I don't have that kind of money, so can I just get the exam and cleaning at least?" I certainly understand where the consumer is coming from. I really do. I would be annoyed to have to find out that the xrays were subject to a $150 deductible. In most other group dental insurance plans, that is part of the preventive services that are USUALLY covered at 100% by the insurance company. I can see where the consumer might want to just get what is covered. I get it. It feels like the consumer is getting "nickled and dimed to death", as they say, and they will likely be annoyed and request no xrays be taken.
The Dentist: Knowing what their protocols are for a new patient exam, which includes taking a full series of xrays, to "see" everything and assess the true condition of the patient's mouth, this presents a liability issue. The difference between conducting a new patient exam with only the naked eye, and one which includes a full series of xrays, is the difference between looking through a keyhole into a room to see what is in it, and opening the door to get the whole view of what is in that room. They don't compare. It would be a disservice to a patient to not fully view and diagnose the condition of that patient's mouth. In fact, it could very easily lead to a lawsuit if something is "brewing" that was not visible with the naked eye and then did not get addressed. Major Liability Risk: "Danger, Will Robinson, Danger Will Robinson"! Plus, the dentist may very well get cited by the Board of Dentistry for negligence for NOT taking the appropriate and needed/required xrays on a new patient. That dentist's license may now be at risk.
And all because Humana 'rewarded' its enrollees by putting a $150 deductible on xrays.....Oh boy. Hot mess. Not good. Both sides of this equation have merit and can be clearly seen and understood. Both sides have issues that are real and valid. Unfortunately, what I REALLY fear happening here, in this very troubled time, and in this tough economy, is PERHAPS a dentist accepting that patient anyway, because they threatened to see someone else, and waiving the xrays until "next time". Meanwhile, under the gums, 'something wicked this way comes'....like a looming infection, bone loss, resorption, an abscess, a cyst, you name it...I was almost excited about this plan...I really, really was...
But really, Humana, all you have done here, is create a difficult situation for everyone involved; except you. Having a customer pay 3 extra fees plus a premium is enough. It could be overlooked if indeed you rewarded your customers. I see where your benefits for basic and major services increase at year 2 and 3 and I think that's ok; not great, but ok. But do I feel you did the right thing by penalizing both the patient and the dentist by creating the conflict associated with attaching a high deductible to needed/required xrays on the VERY FIRST VISIT??? Nope. I do not. Not only do I NOT think it was the right thing, I fear it will place both parties involved at great risk; both clinically, and ethically/legally.
Sure, there may be many patients who can pay the $70 plus for the enrollment fees and first month's premium, but then another $150 to get an exam, xrays and cleaning after that? Over $200 for the first visit? Unless I'm mistaken, that's pretty comparable to what the patient would have paid without any insurance at all, isn't it? Oh Humana, you were SO CLOSE to being a good policy...SO CLOSE...but not close enough. Based on all of that (and I couldn't even really get to the rest of the plan "benefits"), I would have to give this policy a big "tisk, tisk"....Buyer beware...and dentists beware too!
That's it for me today. Thanks for stopping by. And, remember, you only have to brush and floss the teeth that you ABSOLUTELY, POSITIVELY want to keep. That's it. Nothing more.
Dr. Driscoll
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