Editorial

The Conglomerate/Consumer Transaction v. The Dentist/Patient Relationship

Large corporate entities force themselves into the lineup between dentists and patients in a high stakes game for the conscience of oral healthcare delivery.

Dentistry steps up to the plate. As practitioners, we fight off daily deceptive pitches from managed care organizations (MCOs), product manufacturers and non-dentist-owned practice management organizations. Pitches in the form of onerous contracts, misleading marketing and aggressive business tactics intended to defeat the dentist/patient relationship and replace it with a conglomerate/ consumer transaction. These intrusions corrupt the professional norms and legal standards that currently govern the relationship between dentist and patient with marketplace greed. Dentistry must come to bat to defend our ethical and legal commitments to patients in the face of these powerbrokers’ profit-driven assault on the rights and duties inherent in the dentist/patient relationship to protect our professional status and strengthen society’s trust in our oral healthcare leadership.

Managed Care’s Knuckleball in the Dirt

MCOs’ game plan seeks to replace dentists as the primary decision-makers in oral healthcare treatment planning. MCOs sell the bogus myth of bargain basement quality dentistry and need dentists on the sidelines when they design their self-serving strategies. Their cost-containment schemes result in limited benefit plans that attract patient populations that either cannot afford or elect not to routinely pursue optimal oral health. Insidiously, MCOs create an implied MCO/patient relationship that portends to protect patients from what MCOs falsely portray as over-treating dentists otherwise incentivized to provide high-cost, complex procedures.

MCOs lead off and broker deals between these prospective patients, their unions and their employers. They wield their newfound power over these patients’ future choice of dentists as leverage against the dentists available to serve these populations.

Under pressure to retain and attract patients in this market, many dentists succumb to one-sided provider agreements with MCOs. These onerous contracts force dentists into the roles of obedient subcontractors who abdicate their authority in the treatment planning process to MCOs. Here, MCOs deliver their knuckleball in the dirt: fee schedules set intentionally below the costs necessary to deliver services within the legal standard of care and ethically. MCOs toss this erratic pitch with no intent for the ultimate treatment to hit the legal and ethical strike zones. They base these arbitrary fee structures upon aggregate cost calculations that bear no relationship to the actual costs necessary to properly treat individual patients, and are set solely to protect the MCOs’ profit margin.

Regretfully, many dentists swing and sign these provider agreements. However, when dentists act as mere subcontractors bound to follow the MCO business plan, they can miss meeting the legal standard of care and their ethical duty to act in their patients’ best interests. In the best case scenario, dentists do not swing and refuse to agree to terms that hinder or preclude them from achieving these standards.

Product Manufacturers’ Curveballs off the Corner of the Plate

The manufacturers’ game plan strives to replace dental researchers and practitioners as patients’ primary sources of scientific information. Manufacturers utilize two curveballs to commercialize the dental literature and promote their products. The first curveball, aimed at dentists, initially appears as a legitimate research publication headed into the strike zone when, in fact, this pitch misses the zone of reliability because the manufacturer bought and paid for the results. When the dental profession fails to expose these conflicts of interest and question the veracity of such studies, we facilitate the flow of misinformation to our patients. As a profession, we must keep our eye on this ball, monitor the commercialization of the dental literature and expose manufacturers’ bias and conflicts of interest whenever appropriate.

The second curveball, misleading online marketing aimed directly at patients, exploits patients’ desire for quick cosmetic fixes, and encourages them to demand procedures that utilize manufacturers’ products from their dentist. These pitches create manufacturer/patient relationships in which manufacturers supply biased information directly to patients and dentists act as mere facilitators to give patients what the manufacturers tell patients they should want. Practitioners must drive this hittable pitch for extra bases and maintain collaborative relationships with our patients, correct misconceptions, dispel any myths falsely created in the exploitive advertising and refuse to treat when patients’ demands would lead to substandard care.

Non-Dentist-Owned Management Organizations’ Fastball Down the Middle

Non-dentist-owned management organizations’ game plan aims to commodify dental services and reduce long-term dentist/patient relationships into a series of independent transactions. This commercialized environment works synergistically to enable MCOs to supersede dentists as primary decision-makers and manufacturers to replace dentists and dental researchers as the patients’ primary source of scientific information.

The non-dentist management organizations’ fastball moves quickly and deliberately and overpowers every aspect of the process. Professionally administered oral healthcare delivery involves uniquely qualified doctors rendering services to patients as part of long-term collaborative relationships and making decisions in the best interests of the patient. The fastball transforms the process to fungible providers selling a commodity to consumers in isolated business transactions making decisions in the best interests of the conglomerate.

Dentists swing and miss when they commercialize their services and place the profit margin of the practice entity above their patients’ best interests. We hit home runs when we, as a profession, advocate against non-dentist practice ownership and management of clinical decision-making. As individual practitioners, we must take the time to maintain an ongoing dialogue with patients, understand what serves their best interests and then deliver it.

The Business-Profession Squeeze Play

These conglomerates implement a squeeze play when they, as business entities, insert themselves into professional relationships but continue to operate under the lower legal standards of the marketplace, devoid of ethical constraints. They squeeze dentists to do the right thing and treat patients ethically and within the standard of care, for less remuneration, in the form of reduced fees in a managed care plan or lose patients for refusing to contract with MCOs in the first place. Although, these business entities legally must, like everyone in the marketplace, including dentists, avoid misrepresentation and fraud in their activities, unlike dentists, they bear no liability for patient injuries that may result from their business decisions.

Furthermore, conglomerates embrace no obligation to act in the best interests of patients or with a conscience that distinguishes right from wrong. In this maneuver, the conglomerates actually use dentists’ elevated standards and principles against dentists.

Conversely, we, as dentists, cannot, without liability, contract away or abdicate, in any form, our legal duty to treat to the standard of care. No contract provision, manufacturers’ marketing claim or non-dentist management groups’ tactic can provide dentists with a defense to malpractice allegations for patient injuries related to dentists’ substandard care. Most importantly, we damage our own professional status every time we ignore our conscience and its directives to place the best interests of our patients above corporate and self-interest.

Dentistry’s Conscience Grand Slam

We have all heard the voice. It sends signals to guide our decisionmaking and distinguish right from wrong. It coaches us on meeting our ethical obligations. Sometimes we listen; other times, we ignore its advice. The voice represents dentistry’s collective conscience. Society bestowed upon dentistry the privilege of self-regulation in return for our ethical commitment to our patients. Society’s trust that dentistry will do the right thing to protect society from conglomerate attacks on our professional commitments stands as our most valuable asset. When we disregard our conscience, we dissipate this trust.

Dentistry steps into the batter’s box late in the game of today’s competitive practice environment with the bases loaded with opportunities to drive home our professional promises. We must listen to our conscience and hit a grand slam or become one of the conglomerates we oppose.

Chester J. Gary, D.D.S., J.D.