May 18, 2007, Los Angeles and Beverly Hills - Managed care has less to do with managing your dental care and a lot more to do with managing costs.
For a managed-care plan, your insurer has established an agreement with physicians, hospitals and any other involved health-care professionals to provide your treatment at a reduced cost.
More than 85 percent of insured patients are enrolled in some sort of managed-care plan; however the extent of coverage varies for each insurer. The advantage for dentists is that these insurers promise them exclusive access to their participants.
Types of managed care companies include preferred provider organizations (PPOs), health-maintenance organizations (HMOs) and the less common point-of-service plan (POS).
Most insurance companies offer one of two basic types of plans: the Preferred (or network) plan and the Capitated plan.
CAPITATED PLAN
Also known as HMOs or dental-health-maintenance organizes (DHMO), this type of plan establishes a pre-agreed upon monthly fee for each enrolled member, whether they visit the doctor or not.
In return, the doctor agrees to provide all treatment required by the patient, providing the plan covers that specific form of treatment.
Capitated-plan members may only see participating dentists, unless they desire to pay for outside treatment.
Some plans penalize dentists who refer patients to an outside specialist. Others offer indemnity options for a POS plan. This plan allows dentists to refer patients to other providers in the network. Patients also can refer themselves to dentists outside the plan and still receive some coverage.
PREFERRED OR NETWORK PLANS
Generally known as PPOs, these plans provide a list of preferred dentists, who have agreed to discount their normal fee.
In return, the insurance company promotes participating dentists to their subscribers by listing them as their preferred providers. Members are encouraged to use the preferred doctors by including a hefty financial penalty if they visit non-participating doctors.
As with HMOs, PPOs make arrangements with hospital, dentists and other care providers to provide service at a lower fee. If a member visits a dentist outside the network, they usually will pay more of the bill.
VOLUME DISCOUNT PRINCIPLE
All managed-care plans depend upon the volume discount principle for cost savings. By selling a larger volume of product units, it's possible to charge less for each unit yet still produce the same amount or more for greater profit.
This method may work well for WalMart or MacDonalds, but it tends to break down when applied to any form of health care, particularly dentistry.
The actual costs of dental care tend to be fixed so any discount comes from the profit segment of the fee. Thus, no amount of volume allows a dentist to make up for the financial loss associated with each case. Participating dentists then face an ethical dilemma: Should they cut corners to reduce their overhead, reducing the quality of care.
Despite these problems, many dentists have tried to use some form of managed care in their practices. These plans require a dentist accept the problems related to a two-tier practice. One level of patient receives the dentist's normal care and pays the standard fee, and the second level of patients receives only the treatment specified by their plan and, in return, receives a discounted fee.
LEARN MORE
Call cosmetic dentist Dr. Anthony Mobasser today at 1.310.550.0383 or email us to schedule an appointment and learn more about dealing with dry mouth.
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