Risk management in dentistry: An ethical 'fork in the road'

A brief and personal take on the evolution of “risk” in dentistry

Famed New York Yankee Hall of Famer, the late and beloved Yogi Berra, once said, “When you come to the fork in the road, take it!”

Once upon a time there was only the dentist and the patient. No one came between the dentist and patient and the relationship was unencumbered by any third parties. Then, in the mid 1950s, California introduced the first actual dental insurance plans. Then into the '70s, dentists were becoming compelled to sign contracts and become “preferred providers.” Dentists now had to deal with dental plan administrators and consultants, who emerged as among the first intermediaries between doctors and patients.

Some called these times "the golden age of dentistry."

But with this boom came the realization that dentists no longer had the same control over the doctor/patient relationship. Someone was looking over their shoulder. Submissions for “preauthorization” had to be made. Right or wrong, dentists were being judged, but perhaps more importantly, dental insurers were collecting claims data.

It's safe to say that dental insurers started to know more about our practices than we did. They use their claims data to determine if our patterns of billing fit the “bell curve” of all general practices enrolled. Practice audits are conducted and consequences might be conveyed in a certified letter. The concept of dental insurance is a good one, but the execution was becoming more challenging.

Couple this with a heightened consumer awareness via "extreme” treatment and the “Hollywood smile.” Dentists were being courted by “practice philosophers” aimed at capitalizing on the public’s desire to create smiles that resembled the cover girl or guy on the trending magazines. Dentists bought into it and still do, with all the best intentions. The rub comes when promises are not kept, at least in the eyes of consumers/patients.

Whatever the motivation, dentists should not guarantee anything. I maintain that the four most dangerous words we can utter to patients is, “I can do that.” (It’s a great song from a great Broadway play.) If you say it, you better deliver, and if you don’t deliver to the patient’s sense of expectation and the accepted standard of care, the consequences and ramifications can be very costly in terms of time, dollars, and reputation.

Into the '80s, the US faced the HIV/AIDS scare, and societal and regulatory pressures altered the landscape of how dental practices prepared for safeguarding the delivery of clinical care. Patients became aware and asked, “Was that used before, and how was it cleaned?” Dentists were required to fulfill infection control expectations ranging from the public to the courts to state board regulators.

Another significant piece of the risk management picture was the introduction of HIPAA, the Health Insurance Portability and Accountability Act, in 1996. The Privacy Rule component came into effect on April 14, 2003. It defined Protected Health Information (PHI) as, “Any information held by a covered entity that concerns health status, the provision of health care, or payment for health care that can be linked to an individual.”(1) Dentists were deemed to be “covered entities,” and vulnerable to OCR investigation and potential fines. We’ve seen five-, six-, and even seven-figure fines, and we're seeing advanced notice of audits being conducted that should concern every dentist, wherever they practice.

Now in 2016, we're in the age of more complex and more restrictive dental benefits. Yet the scope of available services has expanded to the delivery of high risk procedures, such as dental implants and retained prostheses, clear orthodontic trays and appliances, Botox, endo without rubber dams, and treating patients with complex medical histories and medication lists, all in a far more litigious society. This is all done with office overheads reaching or exceeding 65% of revenue, under the pressures of increased production, with six-figure student debt, more competition, fewer patients, and more open chair time. Is this not the perfect storm for a professional crisis?

Outstanding dentistry is performed every day, preserving dentistry’s reputation as a noble profession. But it’s not getting any easier. Proactive risk management and a return to sound ethical thinking must be in place to protect patients and doctors from the harms that lurk in everyday practice. The degree to which we honor our ethical oath can be reflected in the amount of risk we encounter in our practice and how we manage that risk. Can you protect your own self-interests and still act ethically?

A friend and respected colleague recently wrote in a Letter to the Editor in the ADA NEWS in the context of an oversupply of dentists. He wrote, “… in our very competitive industry, unethical overtreatment will be, if it isn't already, a necessity to survive economically.”

How do we stay true to our oath yet make the decisions that will advance the health of our patients while advancing the viability and profitability of our practices? This may be the quintessential question of our time and the challenge is put to us—we must strive to elevate our practices and our decision making to do the right things at the right times for the right reasons.

We are at Yogi’s ethical “fork in the road.” Will you take it?

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[1] HIPAA Journal; HIPPA History