Imagine being employed for 15 years by an employer who is legally established as a not-for-profit organization that touts this distinction as a mark of their purpose to make health care accessible to more people. After fifteen years, you realize that you haven’t been given a raise. In fact, those employed for 30 years tell you that the wages paid by the employer have remained virtually stagnant for that entire time. When you raise this issue with your employee representative, you are told that if you aren’t making enough at your job, it was your fault. Even after a global pandemic that drove costs up the roof due to inflation, this employer that pays you as a contract worker, has not only neglected but refused to increase compensation to keep up with skyrocketing costs. The employer and their competitors actually have contracts with 75% of your industry in which you work. Despite a national organization, you realize that any unionization is poor. Even the professional association to which you pay dues every year to represent your interests, repeats the employer’s talking points to work faster, cut costs, and decrease quality control checks to increase profit margins.

It is health care, you muse to yourself. People deserve it. Except the employer has raised its fees to clients EVERY year. The CEO for their California chapter was paid a 15 million dollar salary. The not-for-profit could afford such a compensation  by raising premiums while simultaneously cutting benefits year after year! You’re repeatedly told that this not-for-profit employer can’t afford to pay you more and if you wanted to make more money, YOU needed to do more to gain marginal benefits from your work. They brazenly suggest you are lazy and that your colleagues have managed to work faster, seeing more and more clients every day. If that's not enough, YOU should cut some costs in who you subcontract with. If your porcelain and lab technician/artists are too expensive, just use a guy who charges less. Don't think about how he manages to charge less by buying lower quality materials, skipping critical quality control checks, and even ignoring steps in production that drastically increase the quality and longevity of the final product.

You've been at it long enough to know that your business is not in making things, it's in treating people. In fact, you knew that from the start and as a not-for-profit, they say that all the time except in salary negotiations! Helping people is a major reason why you spent eight years in school and amassing suffocating educational debt to become competent. Now you continue to spend hundreds of hours every couple of years with continued education to pursue excellence. The in-your-face (literally and figuratively) metaphor that two teeth that try to occupy the same space cause major problems is at the forefront of your view every day. You know that you can't be in more than one place at a time and you truly believe that your client's time means as much to them as your time means to you. Patients deserve your full attention while they are in your care. The employer, however, to save money literally expects you to either try to see three or four clients at a time or hire less-qualified people to provide the delicate services in which you take pride. You like helping people and working with the employer your patients pay to help pay for their health and benefit seems like the best way to help them until you realize that it's unsustainable. You cannot maintain a financial agreement with someone paying you what they paid 30 years ago for the same service.

According to the Consumer Price Index Inflation Calculator on the Bureau of Labor Statistics website, a service that cost $1000 in 1985 should cost over $3000 today. Compensation for services ought to have tripled since 1995. Dental labs, clinical suppliers, lessors, equipment manufacturers, educational institutions, insurance providers, and employees all got the memo. They shamelessly raise their prices because they have to.  Dental insurance also got the memo and raised their fees to patients or cut approved services. And then they pass along the message that a dental office that declines to contract with them is practicing without beneficence to their clients. Health care providers can be made to feel ashamed for thinking that a simple cost increase for them ought to be accompanied by a reimbursement increase from the patient’s insurer who is already charging the patient more. The people who hold your health in their hands have been asked to reduce the time they spend with you, try to treat as many as four people at once, or look for lower quality materials to make a profit. In those cases, the patient becomes the one who loses.

For the self employed, profits are what they get to pay themselves after all bills, payroll, and taxes are paid. We struggle to continue to deliver the highest level of care and still make ends-meet. On occasion, we know we are not making a profit. Take for example the last three times I provided veneers for patients with whom I contract with their insurance carrier--whether for cosmetic or purely functional reasons. We did the math. It cost us money to provide the service. Why? Because I wouldn't shorten the time necessary to deliver excellent care nor cut out a valuable member of my team who makes the veneers. I utilize two, world-class labs for such esthetically and functionally demanding treatment. An average lab may charge around $200 for the porcelain work. A low cost lab from China or who insurance asked me to "check out" charge from $50-$75. Like the dentist, labs have found ways to cut costs to meet the demands of their “employer.” They certainly cannot allocate the necessary time to perform excellent work at $50 per unit when the on-brand materials cost $50-100 alone...without labor costs. They are forced to shop for gray and black market materials to keep their overhead under control and turn a profit. I had another conversation with my insurance representative in which she said, yet again, that Delta Dental has been “talking” about increasing compensation to dentists. I can confidently report that they have been undertaking this conversation for at least 29 years with no end in sight. The result is a lot like some politicians healthcare plan promises: they have concepts of a plan but have no intention of revealing them or, if they have them, enacting them. After all, 75% of dentists have already accepted their terms.

Would you stay with an employer that refused to give you a raise for 30 years despite their increased profits? An employer that demanded that you find places to cut costs?

Patient’s can’t always tell that one crown is superior to another. They often see money and speed--often mistaken for efficiency--as the predictors of a legitimate dentist. I don’t blame them. Efficiency is the courtesy of the highly skilled but not always a predictor of good care. I can’t claim that giving more time per patient makes a dentist a good provider, but I know I need it. In dental school a clinician boasted that he had pioneered and promoted the 15 minute crown preparation. At that time, I thought such efficiency marked him as exceptional until I stood in the office of a dentist performing truly exceptional work by a standard few non-dental professionals could comprehend. He always booked at least 90 minutes for a single crown and often more. He paid his lab more—a lot more. He gave more of himself by never double-booking patients and by paying attention to details I believed it was not cost-effective to care about. After disappointing employment early in my practice, attempting to provide fast and "inexpensive" dentistry, I wanted to quit. I started to believe I’d made a life-enslaving mistake in my choice of career. I found some solace in treating patients over teeth in the way that colleague patiently showed me. He also told me that I wouldn’t be able to do it under the insurance dictated model. After 15 year of trying to prove him wrong, I must admit he was right. I can’t trade my exceptional quality crowns that cost two to three times the generic crown price. That would mean trading quality for cost. But he was right in that I would still lose sleep because I would struggle to pay my inflation-rising bills with an insurance carrier that refused to acknowledge rising costs for providers despite raising their premiums on customers every year.

My wife asked me to really determine what sets me apart from other practices. While there are doctors who can do everything and see multiple patients at every minute through the day, it’s not me. So I’ll tell you what a new patient told me recently after an exam: “I’ve never had a dentist sit down with me for ninety minutes on the first visit, look at every single thing in my mouth, jaw, and joints, and talk to me about what they were seeing and want to hear what I knew about it, too. You never left to go do a filling or something with another patient.” (To be fair, when my assistant was taking x-rays, I did excuse myself to perform routine examinations on our regular patients in for a cleaning.)

Beyond taking advantage of providers, insurance behaves the way an abusive partner works. Right now Delta Dental is purchasing clinics in Minnesota to create their own managed care organization. That’s their right to do so, but the dentist can no longer look at them as a reliable member of the patient-care team when they blatantly position themselves as a direct competitor. They are literally pushing private practice dental offices away and then saying to them, “Where will you go? Without us you are going to fail.” All-the-while with one hand picking our pocket of simple cost-of-living increases for three decades as with the other hand they direct patients to large, corporate dental chains that have bought into the insurance-managed platform or to clinics owned by their own not-for-profit company. If the trends continue, which recent history seems to indicate they will, decisions about dental care will be the province of insurance carriers and the boards of dental service organizations and their strings of clinics in every state. This board is made up of people beholden to shareholders who don’t ask “are we delivering exceptional care to the people we charge premiums every month” but “are we delivering acceptable care while maximizing our profits for shareholders?” Also consider that in 2008, Delta Dental cut reimbursement rates across the board by 30%. Like a good employer/partner, Delta Dental graciously let dentists know about this cut when dentist looked at their Explanation of Benefits and found the cuts. They seemed to be taunting: "What are you gonna do about it?" I came into practice just after this cut. Since then, they have not increased reimbursements in a meaningful way. We're not only making less than they did 30 years ago, we're making 30% less.

Many dentists are opting out of insurance altogether as the American Dental Association barters away its members’ professional autonomy for a mess of pottage. When questioned, the ADA admits on its website that "third party payer insurance issues are a top rated concern" from dentists who are ADA members. On the same page, "Understanding Dental Insurance Issues" they hide behind the statement that "It is important [for dentists who pay their dues] to understand that when it comes to interactions with dental insurance, federal antitrust laws may limit the scope of what the ADA can do." John Glenn famously observed that he was rocketed into space by a machine, the components of which were each supplied by the lowest bidder. I’ve placed a few crowns and bridges in my day that were supplied by the lowest bidder and I’ll not continue. Unfortunately, insurance companies, cozying up to DSO’s, don’t have to offer us any more than they did 30 years ago. Recall the esthetic, veneer cases I mentioned a moment ago: in one case, we submitted the accurate procedures performed and awaited payment. Weeks later, we received an EOB (Explanation of Benefits) that was also sent to the patient. The insurance had the right to do what we did not without facing a lawsuit from their well-paid lawyers. They “downgraded” the procedure to something less expensive. This, I regret to have to say, is quite common. They paid less by calling the procedure something adjacent though imprecise enough that they could have sued me for fraud had I submitted the same to them to try to increase my profit.

The choice seems forced upon us. If I want to continue to see one patient at a time, I won’t be able to do it with insurance dictating the terms of treatment. The only play I have is to simply fold and find a game where the deck isn’t stacked against me by the dealer and condoned by gaming commission that should be protecting my rights rather than cozying up to the insurance giants. The level of care I provide won’t change, and patients will still make decisions about their care based on what their insurance tells them is necessary. But it’s no deception to say that I couldn’t afford to continue practice when 40-60% of our usual fee was being dismissed. I’d go the way of the DSO’s in my area that closed their doors. In that case, I’m not helping anyone.