Making prevention pay

oral health promotion

Changes to health insurance policies are encouraging practices to re-evaluate their billing system. By Chloe Warren

At Paradise Dentistry on the Gold Coast, Drs Troy Evans and Renee Heathcote have always worked to ensure that education is at the core of patient care. As one would expect, this encompasses oral hygiene instruction, as well as advice regarding diet and smoking cessation. Education is just not central to their clinical approach—it also affects their financial framework.

Or at least, it did—before changes to health insurance policies and software became so restrictive that Paradise Dentistry had to completely re-evaluate their billing system.

Over 20 years ago, Dr Evans was inspired by his late friend, Dr John Wells, to establish the first time-charging dentistry clinic in Australia. Having worked under the NHS system in the UK for a short period in the 1990s, Dr Evans became wary of what can happen when health care is completely motivated by item numbers.

“Fitting a patient with a single crown wasn’t profitable under the government rebate scheme so we were told by managers to always do at least two crowns, even if the patient only needed one. It was shocking,” remembers Dr Evans.

It was this experience that influenced his preventive healthcare philosophy that put education at the forefront of his clinical practice. “If I’m doing a crown or a filling, I feel like I’ve failed my patient in some way. Something must have gone wrong for that damage to have occurred in the first place. I refuse to believe dentists are most valuable when doing high-end restorative work.”

There are only a handful of insurers in Australia who can relate to this sentiment—those who offer any rebate amount for Item 141: oral hygiene instruction. This is what motivated Dr Evans to use a unique billing system—to charge patients for the time he spent with them, as opposed to the treatment he performed. He was tired of seeing patients who had received poor treatment based on the rebate value of the procedure they had undergone.

“A Class V filling is usually one of the easiest fillings to do so the cost and the rebate value is low. But some of those procedures can be quite difficult. If you’re going to get paid bugger all for your time, there’s just no incentive to get it right,” Dr Evans explains. “What we want to do is prevent the decay that causes the need for that filling in the first place. We want to incentivise the patient to stop it from happening. However, under the traditional billing system, if a dentist spends their day teaching patients how to clean their teeth, they’d make no money and the practise would fold. According to the vast majority of insurers, the value of education is literally zero.”

While some clinics leave oral health education to the hygienist, at Paradise Dentistry, it’s embedded in every step of patient care. “The education needs to be individualised—you need to be with patients to personalise the instruction,” he explains. “If they come into our clinic, we will brush their teeth with them.”

“When we first started out, it was awful. I didn’t know where to set my rates at so I set them low. Then each year we bumped them up. It got to the point where I felt like my rates sounded too high but I was still making less than every other dentist I knew.”—Dr Troy Evans, Paradise Dentistry

A lot of the education is not only individualised but confidential. Drs Evans and Heathcote will talk to their patients not just about brushing and flossing but diet, smoking, eating disorders and drug addiction.

When he initially established his clinic, Dr Evans was able to generate a list of item numbers for each treatment the patient received, then give the insurers a total cost amount. He would then request that the insurer allocate amounts to each item number so that the patient received the most benefit. He was effectively able to bill the patient for the time he had spent with them.

“When we first started out, it was awful. I didn’t know where to set my rates at so I set them low. Then each year we bumped them up. It got to the point where I felt like my rates sounded too high but I was still making less than every other dentist I knew,” says Dr Evans. “The only difference was that I was saying out loud to the patient, ‘This is going to cost you x amount per hour.”

“All dentists think in an hourly rate anyway,” agrees Dr Heathcote. “They just don’t charge that way. They always know how much they are earning per hour.”

In recent years, changes in insurance policy and software has majorly disrupted the clinic’s billing strategy. “We started getting the paperwork sent back, with insurers demanding that we itemise each item number exactly, and allocate specific costs,” he says. “With all the thousands of permutations of health insurance coverage, it was a nightmare. I’d have staff at the front desk spending all their time trying to figure out how to distribute the money and no-one could understand it. It just became intolerable.”

The patient response to time-charging was variable. One of Dr Evans’ friends and colleagues has told him that all he has managed to do is collect together a group of patients who were already preventive-minded. “Maybe if you are into golf, you get more golfing patients,” suggests Dr Evans. “But I know I have seen patients who were heading in a particular direction and they are no longer on that pathway because of our intervention. It just breaks my heart that we can’t work this way anymore.”

In December 2017, the Australian Dentistry Association News Bulletin included an opinion piece from Dr Andrew Howe, who is facing issues with a private health insurer, having called into question the nature of their auditing process. Stories like Dr Howe’s and those of Paradise Dentistry are becoming all too common—over 160 dentists came forward with submissions to the recent Senate Inquiry into Private Health Insurance.

While the Senate Committee did make several positive recommendations moving forward from the Inquiry, it’s important to note that there are many more issues surrounding the ethics of private health insurance companies aside from the widely acknowledged preferred provider controversy. “It’s all a case of the fox running the hen-house,” as Dr Evans summarised.

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