Dental Managed Care in the Context of Ethics

The Officers and Regents of the American College of Dentists

Reprinted from

Journal of the American College of Dentists
Winter 1996, Volume 63(4), pages 19-21

Definitions

Managed care is a market mechanism for distributing oral health care resources. There are four essential features which together define managed care:

1. It is a secondary market; dental health care opportunity, not care itself, is brokered in the managed care market. In this fashion it might best be termed "brokered care" since future dental visits are actually bought and sold rather than oral health itself
2. It is a four-party system; there are (a) patients, (b) dentists [together comprising the primary market], (c) brokers, and (d) purchasers [the latter two comprising the secondary market].
3. Costs and benefits are calculated in the aggregate; not on an individual basis. Plan purchasers buy a package of benefits. Third parties work on an actuarial basis. Dentists cannot use conventional per-procedure accounting to figure their return; only aggregate marginal analysis works.
4. Some of the dental health care dollars are shifted from providing care to managing the market.

There are eight characteristics of managed dental care that seem to be emerging, which although they do not define managed care, are usually the focus of discussion:

1. Income of providers tends to be lowered
2. Income of brokers tends to rise
3. Cost to purchasers tends to be lowered
4. Risk is spread more evenly across the four parties
5. Access to care among the marginally served tends to be increased
6. There are pressures for standardizing dental care
7. Large databases on care delivery are being assembled by third parties
8. More opportunities for ethically based decisions are created for dentists

The aspirational statements of the American College of Dentists are a voluntary set of ethical guidelines that all Fellows of the College hold as goals in their professional lives.

A Fellow of the College will ...

1. Value truthfulness as the basis for trust in the dentist-patient relationship (Veracity)
2. Treat all individuals and groups in a fair and equitable manner (Justice)
3. Recognize the dignity and intrinsic worth of individuals and their rights to make choices (Autonomy)
4. Respect the rights of individuals to hold disparate views in ethics discourse and dialogue as these views arise from diverse personal, ethnic, or cultural norms (Tolerance)
5. Be sensitive to and empathizes with individual and societal needs for comfort and help (Compassion)
6. Strive to achieve the highest level of knowledge, skills, and ability within his or her capacity (Competence)
7. Be committed to involvement in professional endeavors that enhance knowledge, skills, judgment, and intellectual development for the benefit of society (Professionalism)
8. Act in the best interests of patients and society even when there are conflicts with the dentist's personal self interest (Beneficence)
9. Incorporate core values as the basis for ethical practice and the foundation for honorable character (Integrity)

It is the position of the American College of Dentists that ethical practice takes precedence over features of any particular system of delivering or paying for care. Managed care can be viewed in the context of ethics; the opposite is not meaningful. The core aspirational values of the College are identified in bold in the following analysis of managed care.

Managed Care per se

Managed care is a market mechanism. Dentists and patients participate out of the same motivation as purchasers and carriers–economic advantage. Although ethical abuses might be caused by participants in such a system, in theory, the system is neither good nor bad. However, to protect against moral risk, the following principles are considered primary:

A. The ethical and professional aspects of dentistry must always take precedence over its economic ones. The market nature of managed dental care must always be evaluated in an ethical and professional context; whereas the reverse is not meaningful.

Although managed care per se might be regarded as ethically neutral, it does confront the profession with increased levels of ethical risk. Increased vigilance is necessary in order to avoid the ethical compromises associated with maintaining different standards of care for patients on different payment systems, passing the costs of bad business decisions on to patients, and failing to fully disclose pertinent information to patients, for example. The principle of justice would be violated if it were found that managed care distributed oral health care in an inappropriate manner or that it lowered the overall level of care provided (as would be the case if chronically low levels of compensation undermined the research foundation or reduced the number of care providers).

The most serious of the ethical risks to which managed care exposes the profession concerns autonomy of the patient, the dentists, and to some extent the purchaser. Autonomy encompasses individuals' free choice of their own futures, subject to not causing harm to others. It remains to be determined by ethical analysis whether the restructuring of large segments of the health care system based on aggregate patient characteristics is in conflict with the ethical principle of autonomy. Coercion–forced choices between avoidable undesirable alternatives–and withholding or distorting information are factors contributing to limited autonomy. Veracity is also a related ethical risk.

B. It is unethical to participate in care programs that require the dentist to knowingly coerce patients or limit the information available to them for making informed decisions about their care.

Obligations of Dentists Who Participate in Managed Care Systems

The dentist-patient relationship is often altered in managed care arrangements, and incidents have been reported of attempts to Justify substandard dentistry based on terms imposed by managed care contracts. At this time there is no conclusive evidence that dental care delivered in managed care settings is different in quality from care delivered in traditional systems. The potential for under treatment represented by selection of care based on coverage rather than need, failure to diagnose, use of inferior materials or performing careless work, rationing access to care, or delegating to unqualified support staff is real. But this risk is not inevitable—it is always mediated through the dentist's personal choice of standards of care. Economic self-interest should not be placed higher than the aspirational goals of compassion, justice, and beneficence.

C. The standard of care must be the same for all patients regardless of the means of reimbursement available to patients.

It is possible that dentists may discover themselves in contractual arrangements that force a choice between compromised patient care and personal economic loss to the dentist. If this situation arises because the dentist was mislead or defrauded by a carrier, appropriate legal action against the carrier should be followed, always with the help of competent legal advise and the support of the profession (professionalism). If the unsound contractual arrangement resulted from the dentist making a decision that was not fully informed, both the dentist and his or her patents have been put at risk by the dentist's negligence. The concept of competence in dentistry extends to the safety, personnel, financial, and other areas of dental practice, as well as to technical matters. Because the dentist assumes personal responsibility for providing care under the terms of all reimbursement systems accepted in the office, diligence in selecting such programs is also the dentist's responsibility.

D. It is an ethical obligation to fully explore and understand all terms of contractual arrangements and their implications for practice prior to committing to them.

Managed care cannot be used in any way to shift responsibility for patient care from the dentist. The basic tenants of veracity should prevent one from justifying substandard care by pointing to other's rules. Especially disturbing would be any attempt to involve or use others in such a system.

E. Employing or directing underqualified individuals in order to profit from a lower standard of-care offered to patients in a managed care system is inherently unethical.

Obligations of Dentists Who Do Not Participate in Managed Care Systems

The emergence of managed care has created division within the profession. Differences in the relative importance of values intrinsic to the profession, actual and perceived competition among practitioners, and uncertainty about how the profession should respond collectively have caused undesirable tensions among dentists. While the choice to participate, the nature of participation, or the choice of not participating in managed care systems is a personal matter, there are some ethical obligations that apply to dentists not involved with managed care.

Professionalism and tolerance are clearly established principles in dentistry. The American Dental Association Principles of Ethics and Code of Professional Conduct lays out guidelines for criticizing the work of colleagues. The aspirational principle of tolerance applies in such cases as well.

F. Dentists shall be obliged to report to the appropriate reviewing agency as determined by the local component or constituent society instances of gross or continual faulty treatment by other dentists. Action is required because the patient’s oral health is being threatened and not because of the nature of the reimbursement system.

Patients have a right to know why their dentists choose not to participate in managed care systems. It is as important to carefully think through one's position to avoid managed care as it is to evaluate offered contracts. This is the essence of integrity. It may even be appropriate to present this professional position in writing. A personalized variant of the following position would convey a professional respect for patients' health and dignity without maligning managed care.

G. I believe in providing the highest level of care possible to my patients. After carefully studying the plans available as supplements for patients’ responsibility for their own health, I have not found any which permit me to offer the level of care I believe my patients are entitled to. I would be pleased to discuss various plans and alternatives with you.

Obligations of the Profession

Managed care is an issue facing the profession as well as individual dentists. While single practitioners cannot be relieved of their personal responsibility in patient care, there are several aspects of an altered economic system for allocating oral health care that can only be addressed at a larger level. In fact, one of the characteristics of managed care is its emphasis on aggregate rather than individual markets. Another feature of managed care is the involvement of four parties in place of the customary dentist-patient dyad.

The economic interest of carriers and purchasers call for one kind of regulation of quality while health concerns of dentists and patients call for a different type. The principles of integrity and competence require that dentists retain full responsibility for defining, monitoring, and enforcing technical dental standards of care. Professionalism can be used to justify the obligation that the profession as a whole engage in cooperative evaluation of the economic and patient satisfaction aspects of care.

H. Organized dentistry and other groups concerned with oral health should actively engage managed care carriers and purchasers to create systems for ensuring appropriate economic and patient satisfaction outcomes and develop or enforce existing regulations to protect the quality of oral health of patients.

Managed care is based on a number of assumptions about the relationship between oral health and cost factors that have not so far been supported with adequate data. Specifically, the following hypotheses stand in need of verification (veracity):

1. The cost of introducing a market intermediary is less than the improvement in overall oral health that such an intermediary introduces.
2. It is possible to reduce variation around the least expensive acceptable alternative sufficiently to avoid the damage caused by random undercare.
3. Market-driven reimbursement patterns across the range of service, including diagnosis and prevention, match the optimal allocation of care.
4. The benefit of aggregate decrease in overall level of excellence of care to acceptable levels will be offset by greater aggregate utilization rates.

I. The profession should both focus issues critical to the evaluation of managed care and gather, interpret, and disseminate research bearing on these questions.

The emergence of managed care is heightening the importance of several issues already recognized as being especially important to the profession and the patients it serves. There is a history of progress in each of the following areas:

1. Valid and interpretable information about the outcomes of treatment.
2. Standards of care that are uniform enough to provide guidance and flexible enough to accommodate patient individuality.
3. Training of dentists in business and interpersonal skills sufficient to support practices based on quality dental care for patients.
4. Advocacy for patient oral health at the individual and group levels.
5. Training of dentists in the ethics of the dental profession.
6. Forums for the presentation and debate of issues critical to the oral health of America.

J. The profession should refocus on the traditionally important roles of serving dentists through treatment outcomes data, standards of care, business training, advocacy for patient oral health, training in ethics, and forums for policy issues in order to improve oral health of patients.

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