The need for changes in our countries health care and insurance systems have been in the news now for years & probably will be for years to come. Currently the trend is towards more HMO style of plans for our medical and dental care instead of private insurance because of rising costs of care. Change may be the solution to our systems problems, but are we moving in the right direction?
An HMO is an organization where you only have the choice to choose your dental or medical provider from a list of doctors. The dentist or physician have signed a contract to see these patients at a reduced rate. With this type of plan, you do not have freedom of choice to go to whomever you wish. With a PPO (preferred provider organization) you may choose the doctor that you see, but you may pay less if you go to a provider on the list.
With each change in insurance there is a direct correlation with the way we are "handled" by the insurance companies and health care systems. Most dentists and physicians add HMO's strictly as a supplement to their practices' which allows them to maintain an excellent standard of care for their patients. As the number of plans accepted in an office increase, certain changes need to be implemented to maintain that practice. The reason for restructuring is because the method and amount of reimbursement from the insurance companies to the offices. With many HMO's, the patient may have no or little co-payment and the doctor may receive half or less of his/her normal fee. For dentistry, HMO's pay very poorly, for example the plans in HMO's called capitation. Here is an example of an actual capitation plan presented to me by an insurance company; the insurance company would pay the doctor 6 dollars a month per single patient or 11 dollars a month per family(any size) for which the patient would have no co-pay for all of the following procedures: all exams, all X-rays, fluoride, all fillings, any diagnostic procedures, study models, a small co-pay for crowns etc.... Considering the average over head in a general dentists office is approximately 70%, reimbursement paid at this rate would not even pay their rent. Some offices can manage accepting many of these plans by having a production line style of treatment (increase in volume of patients per day) or by "other methods". Dental office patient flow is different than physicians considering the average appointment length at the dental office is around 45 minutes to 1 ½ hours verses the 5 to 20 minute appointments at the physicians. Therefore, fewer patients can be seen during office hours. Typical concerns aired about the "other methods" are the tendency to over or under treat the patients. HMO's put limitations not only on the income of the provider, but also on the type of treatment that may be done. If a patient is in need of a specialists services, the insurance company may have incentives to prevent the referral of the patient to the needed specialist causing an under experienced provider to perform treatment. The patient must see the general practitioner first to obtain a referral and then get approval from the insurance company before seeing the needed specialist. The number of specialists is usually limited. Since many dentists accept these plans to supplement their practices, it is common for them to stop accepting your HMO after a few years which leaves the patient a choice of paying cash, changing dentists or insurance companies. In the past, it was the patient that evaluated a dentist's performance. With HMO's a dentist is judged by the volume of patients he can see and by how much he can reduce his fees.
How managed care reduces costs
Managed care reduces costs by keeping a pool of dentists and dental specialists to a minimum and by keeping the volume of patients high which means that you may not receive the same amount of attention and care to which you may be accustomed.
Choosing an HMO may save you money, but it limits your freedom of choice. Ask your employer to change your insurance so that you may have the freedom to choose your provider. If your current provider accepts a HMO plan that you are considering ask them if they plan on staying with the plan long term.