I've often wondered why we dentists aren't as squeezed by the health care crisis as physicians seem to feel. I figure it has something to do with our model of practice and reimbursement. We generally have a fee-for-service relationship with our patients, and for the most part, we don't have relationships with the insurance companies.

This leads to two things: First, we charge what we need to charge, and what seems fair to us, for our various services. Second, we treat patients without regard to a contract signed with a third party, meaning that we concern ourselves with their best interests.

An interesting article in my Illinois State Dental Journal - an editorial, really, by Dr. Trucia Drummond, pointed out another result of our practice model, and that is that patients know what things cost and don't do things they can't afford. Dr. Drummond points out that in dentistry we can earn a good living, and we use very few public dollars. Our patients may depend on insurance companies to help them pay their bills, but we don't have any obligations to insurance companies to do anything less than, or more than (for that matter), what is best for our patient.

Dr. Drummond says, in the middle of her editorial, that she, like many self-insured individuals with a health insurance plan with a large deductible, was used to paying for her own care, since no catastrophes had occurred in her personal health. But someone in the medical field pointed out to her that if she let the medical practice or hospital process the services through her insurance company, she would be billed for a lesser amount than the original bill. Cost saving?

Then she asked an MD how she felt about this, and was told that "in order to maintain her hospital privileges, the hospital includes her in the overall insurance agreement with the various companies, and she takes what they give her. According to her, she does not even know what the agreement is and does not negotiate on her own. Ergo, the hospital holds the physicians hostage and makes the deals with the insurance companies. Who knows if the costs would be less or more if the individual docs could set their own fees and collect them?"

This is interesting to me, because I get a ton of PPO agreements to look over, and often their fees for certain procedures are higher than mine are. (Many are lower, too.) And except for cleanings and exams and x-rays, I rarely get my full fee for anything from the insurance company - the patient is responsible for a portion, maybe 20% for a fillng or a root canal, or 50% for a crown or a partial.

The salient point is that the patient has to come up with that money out of pocket, they have to make arrangements to pay for this stuff. If they can't afford a crown, they might choose a cheaper option. Or they might look into creative ways (like the 0% financing options we provide) to be able to afford their part of that crown.

I think it holds our fees in check. Much as I'd like to, I can't charge 4000 dollars for a crown. I have to charge something affordable to the patient, and something where I can earn a decent living when it's paid. There's a balance there that the medical profession does not have to consider, with insurance covering everything.

Fee-for-service might not be the total answer to our medical problems, but it might be a part of it, and in fact, be a good first step.