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
No comments:
Post a Comment