Mark Vitale, DMD, has been a practicing dentist in New Jersey for the past 40 years. He is also the past chair of the ADA council on government affairs, past president of the New Jersey Dental Association, and president of Dental Lifeline Network of New Jersey.
He recently connected with Becker's about dental insurance carriers, reform taking place and the impact the networks have on dental offices and patient care.
Note: Responses were lightly edited for clarity and length.
Question: Why are dentists deciding to drop their current insurance networks?
Dr. Mark Vitale: I think there could be a couple of possibilities. The first thing is, back when I went into practice, the average maximum for a dental plan was $1,500. Fast forward 40 years, and that maximum hasn't changed at all. Is the consumer really being treated fairly? The other thing that is a problem is there are a number of restrictive clauses in many insurance plans such as non-coverage service clauses and disallowed service clauses. These clauses that are introduced create a lot of frustration for the doctor and the patient. At the end of the day, it interferes with the doctor-patient relationship and the consumers end up not getting what they are paying for. The abundance of the clauses has discouraged doctors tremendously and created a communication problem. Thirdly, the cost to run a dental office has gone up tremendously since the workforce issue caused by COVID-19. While the cost has gone up to maintain our offices, the fees for many of the carriers has gone down substantially.
Q: When dentists leave insurance networks, what impact does that have on oral health and dental care?
MV: When dental offices start dropping out of plans, you have a decrease in access. Unfortunately, there is this misconception that you have to have dental insurance to go to the dentist, so when dental offices start dropping plans, fewer patients will go to the dentist because of that misconception. It creates a perceived access-to-care issue, not a true access-to-care issue. It will also result in loss of patients for some offices, potentially resulting in a loss of revenue. Overall, I think it will drive up costs for patients and carriers, because they then have to do something to boost up their network. On the good side, it gives the dentists the opportunity to promote in-office loyalty plans and the opportunity to spend more time educating patients. The other good thing that could come out of this is that the carriers might reconsider their fee schedules and have a discussion with the dental association and come to an alignment and agreement on the actual costs that are incurred in operating an office. That would be the ideal situation.
Q: What do you think are some potential fixes or solutions to the insurance reimbursement problem?
MV: In reality, I don't see the insurance carriers finding common ground with private practice dentists. It would be nice to find common ground and develop the best scenario that would benefit the dental practices, the insurance carriers and the patients. I would love to see that, but I just don't see that being reality. The insurance carriers have a lot more money and a stronger lobby. We are creating dental insurance reform that looks at the clauses and we have been successful state to state to outlaw the use of these clauses in dental insurance policies. As we go through this dental insurance reform, we've run into this dilemma where we have passed the regulations at the state level — they don't apply to self-insured plans governed at the federal level. Right now, we are working on reform at the federal level to bring parity between the self-insured and fully-insured plans. The Medical Loss Ratio issue in Massachusetts brought to light what the insurance carriers were doing with the premium dollar. It forces the insurance carriers to incentivize the patients to go to the dentist because, if they don't, the insurance carrier has to refund the premium. So now the insurance carrier and the dentist are working side-by-side in getting the patients into the dental office and getting the oral healthcare they need. That is a win-win situation. What should be taking place is what is taking place, and that is promoting quality oral healthcare.
Q: How should dentists approach the decision to keep, add or drop insurance networks?
MV: The first thing they need to do is understand their own business. They need to look at the cost benefit of keeping a plan or dropping a plan. Once you examine the financials, you need a marketing plan. You don't want to just drop a dental insurance company and not tell your patients. I always tell my patients, dental insurance isn't insurance, because nothing is being insured. Dental insurance is dental reimbursement. The other thing a dentist needs to do is understand the demographics of their office. If you have the majority of your patients coming from one insurance carrier, then you obviously have a much more difficult decision. If you have very few patients from the carrier, then it is an easy decision. The last thing you need to do is ask yourself the question: Does an office need more patients or just operate more efficiently? Many dentists have this misconception that having more patients means they have a more profitable practice and that can be the furthest thing from the truth.