Dental treatment should not be free.


I was listening to the Adam and Drew Podcast the other day, as I often do, and during that episode Adam brought to light an important economic concept.  I’m not sure if it was intentional or not on his part, but the concept he alluded to is something that would apply to many areas of life.  And one of those areas happens to be government dental insurance.

“Skin in the game” economics
During the podcast episode he and Drew were reminiscing about their MTV Loveline days, which included many, many performances at colleges and universities across the U.S.  Adam mentioned a specific incident during that particular episode that stuck in my mind.  I don’t remember the exact details, but this is the gist of it.  The person coordinating the performance at one of the colleges told Adam, with excitement, that the college was not going to charge the students anything to watch the show so as to maximize attendance.  Adam did not respond with the same excitement.  He highly encouraged that person to charge something, anything, even $1.  Adam did not care about the money.  He just cared about the transaction and how it affected the experience for everyone.  Adam had learned over those years that when entrance was free, the engagement of the crowds was significantly lower than the crowds that had paid to get in.  He also made it very clear that the actual ticket price didn’t really matter.  All that mattered was that there was an actual ticket price.  The point is this.  When people have skin in the game, it tends to positively increase their engagement.  That’s the concept.  So how does this concept apply to government dental insurance?

Medicaid – All or nothing
Back in 2010, MassHealth (Massachusetts’ version of Medicaid) cut adult dental benefits across the board.  The state left a few benefits; exams, radiographs, prophies, and extractions, but that’s it.  Before the cut, MassHealth had pretty comprehensive coverage of general dental procedures (FYI, as of 2016 most coverage has returned).  This all or nothing approach never made sense to me.  From the state’s point of view, the state either pays 100% for you or they pay nothing at all.  But if the state’s goal at the time was to cut the budget then why not just share the cost with the beneficiary instead?  Studies show that cost sharing will reduce spending.  Any percentage is better than 0% from the beneficiary’s perspective.  When cutting state budgets in relation to basic services like healthcare the benefits should be reduced like you were turning down a dimmer switch, not like an on/off switch, which leaves the beneficiaries completely in the dark.  Sharing the cost would both cut the budget and maintain the same benefits with only a slightly higher cost to the beneficiary.  It’s the win, win option.

Cost sharing changes the conversation
I work in a clinic that sees both MassHealth and commercial insurance patients with the majority being MassHealth (~70%).  MassHealth patients pay 0% for all covered procedures.  Commercial patients (e.g. Delta Dental), on the other hand, pay different cost sharing percentages.  Generally speaking, the percentages are typically 0% for preventive procedures (e.g. sealants), 20% for basic treatments (e.g. restorations, a.k.a. “fillings”), and 50% for more advance treatments (e.g. orthodontics, a.k.a. “braces”).  When the cost goes from 0% to anything above 0% the conversation, in my experience, changes.  Patients ask more questions.  What will this cost me?  Do I really need this?  What are the alternatives?  What are the risks of delaying this?  This change in conversation is no doubt one of the reasons why cost sharing reduces overall spending by all parties (government, private insurance, and patients).

Prices are very important
Too many people underestimate the role of prices in healthcare, and the economy in general.  Prices provide vital pieces of information.  Prices tell us the relative value of each product and service in the economy.  Prices are created, and this is key, by the trillions of daily transactions that happen everyday among people.  Without these transactions, accurate prices (a.k.a. information about value) could not exist.  Prices cannot be created from the top down.  They can only be created from the ground up.  This is one of the major problems I see with the concept of large third party payers (especially in very regulated industries like healthcare and insurance).  You have a large third party, more often than not, deciding what the price will be for the first and second parties even though the first and second parties are the ones making the actual value exchange (e.g. dentist and patient).  The more you move away from first party and second party only transactions and more towards large third party transactions, the less accurate prices become.  That in turn will make healthcare decisions much less informed about the real market value of dental services.  That is a problem.  Adding cost sharing to MassHealth is not perfect in this sense, since large third parties are still involved, but having the second party (the patient) pay a percentage of the price is a good way to embed, to some extent, beneficial market forces into a government program.

Should MassHeath implement cost sharing?  Absolutely.  What should the cost sharing percentage be?  I don’t know, but as Adam Carolla said about ticket prices, it should be something, anything.  I say, let’s start from there.

Adam and Drew Podcast
The RAND Health Insurance Experiment
The Role of Consumer Copayments for Health Care: Lessons from the RAND Health Insurance Experiment and Beyond

3 thoughts on “Dental treatment should not be free.

  1. Prices are important. And in health care in general, they’re meaningless. Insurance has seen to that.

    How much does an MRI cost? It’s a completely different question than “how much is an MRI worth?” I find this endlessly irritating. It would make sense to charge for the difficulty of a procedure as well as the cost of its materials, but we don’t really do this. Honestly, crowns are probably too expensive and direct restoration aren’t expensive enough.

    Michigan does have Medicaid for children and adults, too. They don’t call it that, though. They call it “Healthy Michigan” and they act as if it’s insurance. Except there are no premiums. There is a $0 copay. They cover about 40% of a regular fee. Or as Adam would say, “no skin in the game.”

    It’s broken. I’m not hopeful that it can be fixed.

  2. Great points, Mark : this explores a significant dilemma. While I wholeheartedly agree that people in need should never be denied dental care if they cannot pay, I have worked in the UK National Health Service, and seen a lack of appreciation among many: I have seen patients who did not show up for appointments, and not call because “they can’t be bothered”(especially if it was raining, or if the weather was really nice-I’m serious!). This was frustrating when there was a waiting list for specialist appointments.

    Many patients did not return for their crown after a crown prep appointment; they did not care about the cost of the crown because they did not pay for it, and they thought the temp crown looked OK. Then they would return months later when the temp broke. I knew several dentists who would use stainless steel temp crowns for anterior teeth, to ensure they return for their permanent crown.

    What is the answer? I think everyone should pay what they can, and get some of the fee subsidised, according to their means, so that those in dire need won’t have to pay. It might be impossible to eliminate the lack of appreciation, and actions of those I have described, but if it helps someone with no $$ to get the care that they need, perhaps it is still worthwhile.

  3. Great post Mark, I couldn’t agree more.

    This thought process is what got me started as an oral health coach.

    Typically OHI is done during the hygiene appointment, and is included in the overall fee (to the point that there is a billiable code for OHI, but rarely a fee attached).

    Yet, OHI is one of the few things that can be utilized by a patient to control the disease process at home. Whether it be products, tools or techniques, most professionals would agree that IF someone is successful with their home care efforts a large portion of the disease process could be controlled or mitigated.

    Yet time and time again OHI is given for “free”, and is often given at a time the patient is least likely to absorb the information (at the end of an appointment).

    Clinically I started noticing a huge difference in patient outcomes when I started charging for OHI, which led me to leave clinical practice and create an online program that breaks down OHI into bite size pieces for the consumer population.

    The results that my clients get from the program continue to amaze even me. By now, I have hundreds of people who I have never seen clinically utilize their own dental provider to confirm the results they are getting, with astonishment from the professional each time.

    When someone invests in themselves, the outcome is personal to them. When we give things away for free the value goes way down and the person being given free advice does very little (if nothing at all) in regards to behavior modification. Seeing that both decay and perio are 100% preventable, it seems that behavior modification can make a huge impact in the disease process itself if and when we help the patient with relevant information that they are willing to invest in.

    Now getting the professional to feel comfortable charging for their time is another big issue, but that’s a discussion for a different post.

    Great insight, I hope this sparks some discussion. If I can get someone to pay $250 for OHI outside the dental walls, surely people are willing to pay for it, they just have to have a better understanding of WIIFT (what’s in it for them).

    Sell the benefits, not the features and you will see patients accepting your recommendations much easier. Attach a fee to your recommendations and you will see them own the information much more intensely.

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