In today's Wall Street Journal (5/9/96), there is an article dealing with
the slings and arrows that EVERYONE from providers and employers to
patients and IPAs have to pass through.  It is an excellent read because
of its insights into the impact of managed care.

My medical consultant friends believe that the IPAs are the only way
physicians have been able to hold onto any reasonable negociating position
at all.  I am making a public call to organized dentistry to take action.
I worked for the California Dental Association for several years so I know
their limitations.  But the time has come to act on behalf of the
profession.

I believe than rather than fight for direct reimbur{*filter*}t (which is a
great theory) that they FACILITATE the formulation of IPAs among dentists.
 Low cost or free legal work can be done in their formulation.  They
should NOT be owned by the non-profit associations because they would lose
their tax exempt status.  Instead, they should help spin-off these
for-profit, doctor run organizations ASAP.  I believe they might even set
up competing IPAs in the same market.  My concern is not to have organized
dentistry run them, just help them happen as a natural market response to
influences which I think COULD hurt patients, the dental consumer, and
ethical dental practice.

Unless organized dentistry steps up to the plate, the vacuum will be
filled by others with less pure motives.  I am interested in hearing your
response.

Scott McDonald & Associates, Dental Marketing Services and Demographic
Research, (800) 424-6222

     IPA's ARE managed care.  In my opinion, they are a result of Dentists
"running scared" in the face of managed care, and doing the same thing to
themselves that the big insurance companies are trying to do.  Dentists
have a choice that physicians do not have--they can individually insulate
themselves against these managed care forces by offering good, honest,
quality service and by educating their patients.
     Is there a place for them?  Sure.  But's it's not a necessity, as
managed care acceptance is not a necessity for the dental practitioner,
since dental treatment does not involve "catastrophic" expenses to the
average patient.  Most treatment, even in case of an emergency, is
elective or has options.  The profession has also always kept fee
increases below inflation, and most dentists are happy to work out payment
arrangements for desired treatment.
     Managed care will NEVER overtake dentistry, only those practitioners
who let it.

                                                            Eliot

I think  Dr. Eliot D. Guerin's opinion that managed care will never
overtake fee-for-service dentistry may be correct from a certain
geographical perspective. But as I have the chance to see so many parts of
the country, I can testify that it IS and HAS overtaken many markets.  And
it is only ignorance to suggest that it was all the fault of the local
dentists for not having the GUTS to fight it.  Market conditions are often
like gravity, we may not like the results but you had better not ignore
them.

Short of a dentist union or IPAs, I find little hope for SOME geographic
markets to fight against non-dentist controlled managed care (I am bowing
to your point that IPAs are a kind of managed care).

I have always contended that when anyone gets between the patient and the
dentist is treatment, something valuable will be lost.  What many of us
are searching for is a way to keep that relationship in tact (if
possible).

Scott McDonald & Associates, Dental Marketing Services and Demographic
Research, (800) 424-6222

All the points Scott MacDonald made in his response are well taken and
valid, and I do not disagree.  But he mistakenly assumes something I said
as saying that managed care overtakes and area because the local area's
dentists don't have the GUTS to fight it, or that it won't overtake
dentistry in general, at least in some areas.

My point was that an INDIVIDUAL can prevent being overtaken by managed
care contracts and even the necessity to enroll in an IPA by the way
he/she runs his practice, even if the whole area is inundated with only
these kinds of plans.  Go into any of your markets where these plans have
taken over, and you'll find some of the most successful offices not even
accepting assignment of benefits on regular insurance plans.  

So Mr. Mcdonald is right in his statement that certain areas cannot fight
non-dentist controlled managed care, and I commend him in his fight to
prevent a third entity from coming between the dentist and patient.  But
those same areas will always have successful dentists who have
individually molded their offices so that these factors have little
influence.  Where there's a K-Mart, there's also room for Neiman Marcus!

                                                            Eliot

I agree with Eliot.  There will always be a significant group of dental
patients who choose not to pay fee for service dentistry, don't value it,
or simply can not afford it.  However, there will always be a small but
loyal population of health-conscious people who value a quality fee for
service practice and who will always be philosophically diametrically
opposed to any form of managed care.  For the individual dentist, it
requires a firm philosophical and ethical stance to reject the temptation
to take the easy route.  Remember, managed care neither is well-managed
nor provides optimal care.

Grant Ritchey

writes:

You are correct in your theory, but, I believe, incorrect in the
practicality of the dynamics of a free-market society.  Of course
there's room for Neiman Marcus...but just how many NM's do you think
each region can support?  Have you noticed an increase in the number of
outlet stores in your state?

I think you should also take into account the changes in all
socio-economic levels and the trickle-down effect of corporate
down-sizing.  You are INCORRECTLY stereotyping all managed-care
practices as K-Marts.  While I would be the first to agree that there
are some terrible dental practices out there, many of them are
full-fee-for-service practices that have never been on an HMO plan.
Yes, some of the bad practices are HMO practices, but I think it is
unwise of you to make the assumption.

I also think you are probably smart enough to realize that there are in
fact, some similar items that can be purchased at K-Mart & NM.  Paying
the higher price does not always guarantee quaility.  And as we
approach the 21st century, I think you will find that much more of the
population is concerned about value and conserving cash than they are
about seeking out the difference between a "plan" crown vs. a
"non-plan" crown.

Robert Markoff, DDS  TX

Dr. Markoff,

Thanks for the confidence in my intelligence!  Your response sounds pretty
defensive to me--believeme, I was not attacking your office!  All these
"economic" quotes look to me like a pretty pessimistic view of the way
society is affecting your practice.  All I said was that what I do in my
office (offer quality service and dentistry, treat people nicely, spend
more time with them than the average dentist does, and more time than the
average HMO dentist can afford to) allows me to work and be happier.

Nowhere did I say I do better crowns than every HMO dentist, or that all
HMO dentists are bad dentists, but this seems to be the message you got.
I can't deny that the segment of the population "price shopping" for
crowns or dentistry in general is growing, but my office is geared to the
people who will always appreciate that something extra they get in my
office and don't only rely on price.  I've had many patients come back to
me after trying their "plan dentist".  

And fee-wise, no, I'm not cheap, but I'm not the most expensive either.
Read again the last post from Grant Richey--he words it perfectly.

So am I saying that this is the only way dentists should practice--No!
Only that this works for me and my patients.  Good luck with whatever
management style works for you.

                                                            Eliot

Well, I don't know what it's like in the States, but here in the U.K.,
in three areas where I have experience, there have always been more
people wiling to pay a fair fee for the highest quality dentistry than
there are dentists wiling to provide that service.

So until that disparity disappears, I shan't worry about the
intellectual niceties.

Stephen

Dr. Todd makes an interesting observation about the UK.

If there are people in the UK who are willing to pay for quality service,
why are there insufficient numbers of dentists willing to provide it?  I
would propose from my work in the UK and on the continent that government
regulation has a very chilling effect.

If there is a "holy fight" in the managed care issue, it is to keep
government regulators (the 900 pound gorilla) out of the fight.
Unfortunately, I believe we may see Washington attempt to get its hands on
even more regulation in the name of protecting the public's best interest.

Back to the point, there is certainly a "balance level" which market
forces will reach IF they are permitted to reach it without interference.
I am doing everything I can to predict that point of balance so I can
share the information with my dentist friends.  To put it another way,
when will there be enough NM vs. K-Marts?  It's out there somewhere (the
number, I mean.)

Scott McDonald & Associates, Dental Marketing Services and Demographic
Research, (800) 424-6222