I couldn’t resist responding to all the chatter on the Orthotown message boards and blogs these past two months. At the end of January, the one generating the most discussion was about a large insurance company restricting covered benefits for upgraded appliances like clear brackets and aligners, and other elective procedures. Doctors are now confused about their options.
Another trending topic in orthodontics is the new Invisalign storefront in San Francisco that’s bound to make its way to your local mall. The store functions as a brokerage for aligner patients; orthodontists might not be too thrilled about the options and terms offered to patients and doctors. From what I’ve gathered, patients are scanned and offered several options for treatment, very similar to Sears’ “good, better, best” arrangement. The jury is out on whether patients selecting “good” or “better” will be happy with their treatment or, more importantly, with their treating doctor. Doctors are stuck with explaining the lack of precision or finish on the less-than-ideal cases and also collecting payment on them. The inevitable has arrived, but I can’t say thumbs up or down on this new concept until I can digest how the options are presented.
Change is inescapable
It’s a confusing time in the rapidly changing profession of orthodontics. Some still say that if you treat patients well, you’ll thrive. I’m not so sure about that.
There are, of course, legacy practices that would be hard to kill off. Their scope, reach and patient base extend for years and miles, but they’ll continue to be under pressure to adapt to pricing and conveniences offered by the new arrivals.
I’ll go on record saying that orthodontics should have become its own specialty a long time ago. Delivery models, diagnosis and treatment rationale have stayed the same for many years. Treatment time has gradually crept downward, putting pressure on insurance reimbursement for what used to be a two-year treatment plan. Third-party and corporate interests have recognized that the area easiest to cut and increase the profit margin is the doctor’s earnings. Profit margins are in the 40 percent and up range for solo practices, so it’s easy to see why venture and private capital groups have inserted themselves to skim the excesses.
Since the government intervened in health care, the system is two-tiered. Health care costs have nothing to do with face-to-face, one-on-one business transactions anymore. (If you need more explanation, review my column from last month.) I remember being in the sixth grade and having my adenoids removed. My parents prepaid the doctor ($175) and we went to the hospital. Hospital insurance covered the big expenses.
In the ’80s we watched as doctors got swallowed up by HMOs and other entities and were thankful that we had not followed them down that path. I used to talk to my MD buddies about their need to differentiate and charge for magazines and paper filing reviewing charts. A couple of decades later, the concierge practice evolved. Now, we feel powerless because we’ve allowed ourselves to plead for insurance benefits for our services, only to be held hostage by the codes and restrictions placed on them. Is it time for a concierge dental or orthodontic practice? Should there be services billed to the patient for items we perform daily but have no code for?
Is it time to redefine the orthodontic practice? Our existence has been defined by the Angle’s classification, but we know it’s much more. Maybe that simple tooth-pushing should be what is “covered” by insurance. All other services, reception room reading materials, coffee and contests, should be lumped under concierge services with no attempt to bill the insurance company. In other words, we all get the same for braces or aligners, and are free to charge our concierge fee. Let the strong survive.
And finally, perhaps the definition of “orthodontist” needs to change so that the gray area lumping us in with general dentists no longer exists. Services such as soft tissue enhancement and modification, sleep diagnosis and treatment, and straightening teeth would all be part of the new specialty. Airway evaluation and management would be part of diagnosis and treatment. Absolutely no other specialty spends as much time on evaluation of growth, development and saving time as orthodontics does.
None of this is easy. The ADA, AAO and insurance companies all have vested interests in seeing things stay the same. But with Invisalign stores and short-term ortho becoming more common, it’s clear that things are going to change. Are you ready to roll with the punches?