Differences Between Medicine and Dentistry Drive Plan Design

Medicine and dentistry have many differences, and sound dental plan design recognizes these. These differences include practice location, the nature of care, cost, and emphasis on prevention.

Location

The practice of the typical physician is hospital-based, while many dentists practice almost exclusively in individual offices. Partly because of these practice differences, physicians tend to associate with other physicians with greater frequency than dentists associate with other dentists. This isolation, along with the inherent differences in the nature of medical and dental care, tends to produce a greater variety of dental practice patterns than is the case in medicine. In addition, practicing in isolation does not afford the same opportunities for peer review and general quality control.

Nature of Care, Cost, and Prevention

Perhaps contributing more significantly to the differences in medicine and dentistry are the important differences between the nature of medical and dental care.

First and perhaps foremost, because of the importance of preventive dentistry, the need for dental care is almost universal to ensure sound oral hygiene. Many individuals sometimes require only preventive or no medical care for years. Individuals routinely visit their dentists for preventive dental care, but in medicine the patient typically visits a physician with certain symptoms—often pain or discomfort—and seeks relief.

Dental treatment, because of its emphasis on prevention, often is considered elective. Unless there is pain or trauma, dental care is sometimes postponed. The patient recognizes that life is not at risk and as a result has few reservations about postponing treatment. In fact, postponement may be preferable to some patients—perhaps because of an aversion to visiting the dentist, rooted many years in the past when dental technology was less developed.

Because major dental care is not life-threatening and time-critical, dentists' charges for major courses of treatment often are discussed in advance of the treatment when there is no pain or trauma. As with any number of other consumer decisions, the patient may opt to defer the treatment to a later time or spend the money elsewhere.

A second difference in the nature of care is that, while medical care is rarely cosmetic, dental care often is. A crown, for example, may be necessary to save a tooth, but it also may be used to improve the patient's appearance. Many people place orthodontics into the same category, although evidence exists that failure to obtain needed orthodontic care may result in problems ranging from major gum disease to temporomandibular joint (TMJ) disorders in later life.

A third major difference between the nature of medical and dental care is that dentistry often offers alternative procedures for treating disease and restoring teeth, many of which are equally effective. For example, a molar cavity might be treated by a two-surface gold onlay, which may cost 10 times as much as a simple amalgam filling. In these instances, the choice of the appropriate procedure is influenced by a number of factors, including the cost of the alternatives, the condition of the affected tooth and the teeth surrounding it, and the likelihood that a particular approach will be successful.

There are other significant differences in medical care and dentistry that will have an effect on plan design. These include the cost of the typical treatment and the emphasis on prevention.

Dental expenses generally are lower, more predictable, and budgetable. The average dental claim check is only about $139. Medical claims, on average, are much higher.

The last significant difference is the emphasis on prevention. The advantages of preventive dentistry are clearly documented. While certain medical diseases and injuries are self-healing, dental disease, once started, almost always gets progressively worse. Therefore, preventive care may be more productive in dentistry than in medicine. Certainly the value of preventive dentistry relative to its cost is acknowledged.

Evaluating Demand-Side Approaches

Demand-side approaches to improving quality of care can be considered under the broad heading of "demand management." Demand management has been defined as "the support of individuals so that they may make rational health and medical decisions based on a consideration of benefits and risks." Viewed in this way, traditional health promotion and disease prevention can be regarded as quality of care-related demand management. Much of the attention received by demand management has been directed at controlling utilization and cost of health care. Yet, there is intuitive appeal to the concept of modifying consumer behavior to improve quality of care. There is also some research evidence to suggest such an approach can be effective.

It has long been apparent that providing preventive services is an important element of quality health care. The U.S. Preventive Services Task Force, a panel of medical and health experts appointed by HHS, has published guidelines that have set the standard for quality in preventive care since 1989. Since that time, the NCQA has incorporated measures of delivery of selected preventive services into its HEDIS measures of MCO performance. Clearly, employers can improve the quality of care received by their employees by increasing employee demand for these preventive services.

Research also suggests that consumer-directed decision support, in the form of interactive video, can be effective in improving the appropriateness of medical treatment. This approach, referred to as shared decision-making programs, has produced dramatic changes in patient preferences for treatment of benign prostatic hypertrophy (BPH) or benign enlargement of the prostate gland. Patients with BPH participating in early shared decision-making programs showed a 44 percent to 60 percent reduction in surgery rates, opting more frequently for "watchful waiting" as an alternative. These results suggest the tremendous potential for targeted and well-designed demand management programs to improve quality. For more information on shared decision-making programs contact the Foundation for Informed Medical Decision-Making, Hanover, NH, atwww.healthdialog.com.

Another approach attempting to modify consumer care-seeking behavior has been the dissemination of information about provider quality. This approach has been used by the Minnesota Health Data Institute, the Cleveland Health Quality Choice program, the Foundation for Accountability (FAACT), the Pennsylvania Health Care Cost Containment Council, and others. Schneider and Epstein studied the impact of this approach, as implemented by the Pennsylvania Health Care Cost Containment Council in its Consumer Guide to Coronary Artery Bypass Graft (CABG) surgery. The Guide provided CABG mortality ratings of all cardiac surgeons and hospitals in the state. A telephone survey of patients who had undergone CABG in one of four hospitals included in the Guide revealed that only 12 percent of patients were aware of the Guide, and fewer than 1 percent knew the correct rating of their surgeon or hospital and reported that it had a moderate or major impact on their selection of provider. The authors concluded: "Efforts to aid patient decision-making with performance reports are unlikely to succeed without a tailored and intensive program for dissemination and patient education."

Despite the proliferation of physician report cards, there are few studies indicating that they influence consumer behavior. In a survey of employees in firms participating in the Minneapolis-based Buyers Health Care Action Group, health care consumers reported they were using employer-provided information on satisfaction and service-quality for physicians. A more recent survey of individuals with employer-sponsored health benefits reported that patients remain largely passive consumers of physician services.

More general approaches to demand management have produced suggestive, though less well-documented results. One such approach is telephonic nurse counseling. These services offer telephone access to nurses to discuss health issues in general and answer clinical questions in particular. Vendors of these services purport to be effective in reducing costs and improving appropriateness of health care, and they appear to have convinced a growing number of employers and health plans.

Telephonic nurse case management is also being targeted to patients with specific medical conditions, such as congestive heart failure, diabetes, and asthma. A variety of organizations offer this type of service, including pharmacy benefit management firms, MCOs, hospitals, and others. This approach appears to hold promise for improving compliance with state-of-the-art treatment through improved self-care and patient-provider communication.

The explosive growth of the Internet and its widespread use in the arena of health, suggests that it may be a medium that can contribute to health care quality improvement. Yet, its growth and use have raised a number of new quality-related issues. One study of Internet-derived information on clinical questions found that:

• Eighty-nine percent of retrieved pages were not applicable to the question that prompted the search.
• Fewer than 1 percent of pages consisted of original research or systematic reviews.
• Sixty-nine percent of pages did not indicate an author.
• Only 1 percent of pages provided information on financial or other conflicts of interest.
• Fewer than 18 percent of pages gave the date they were posted or most recently updated.

While the Internet represents a tool with great promise for health care quality improvement, consumers, purchasers and providers should employ the same rigor in evaluating its application as we do for other quality improvement interventions.

The U.S. Department of Health and Human Services, Agency for Health Care Research and Quality has useful resources for consumer decision-making about health care quality. These resources and internet links can be found at www.ahcpr.gov. Another source—NCQA—has developed a suite of tools for employers to assist employees in accessing information on quality of care and using the information to make more informed patient choices. HealthChoices^TM offers an Internet portal, data on quality ratings, custom report cards, and other employee communication tools. These tools can be found at the NCQA web site at www.ncqa.org.

Demand management represents a wide variety of concepts and products with potential application to quality improvement. The most cost-effective of these are likely to be focused on well-defined, measurable target behaviors, and to include education and skill-building, monitoring, and reinforcement of target behaviors. Effective integration of such demand-management programs with supply-management programs will likely bring about the greatest impact on quality improvement.