Dental Insurance: Do You or Don't You?

By Dana C. Ackley, Ph.D. (Originally published in Dentistry Today, March 2001)

Contrary to widespread belief, dentists do not need to be involved with dental insurance unless they want to be. I know this from personal experience and from working with dentists from around the country.

In dentistry, as in psychology, there are three camps when it comes to insurance:

  1. Dentists in the first group find themselves comfortable working with insurance. Their philosophy of practice is consistent with what dental insurance companies require.

  2. Dentists in the second group are uncomfortable working with insurance. Because their philosophy of practice is discrepant from insurance requirements, they find ways to practice without it.

  3. Dentists in the third group, although highly uncomfortable working with dental insurance, do so anyway, because they believe that they have no choice.

The first two groups sometimes snipe indignantly at each other. However, holier-than-thou moral indignation does not help settle the issue. Instead, it implies that there is no room for differences in professional judgment. That is a dangerous position. Further, such sniping directs attention away from the real questions. The real question is not whether insurance is right or wrong for everyone. The real question is whether participation fits with your individual beliefs about what constitutes appropriate care and with the level of compensation that feels right to you.

Unfortunately, the third group, perhaps the largest group of dentists, seems to have opted to practice within insurance in spite of extreme discomfort with it. They do not like the intrusions, having their judgment questioned, nor knowing that insurance companies create economic incentives for care that is different from what the dentist might recommend. They feel poorly compensated for doing what they can for their patients. Going to work everyday may be a nightmare. If this describes you, know that you can awaken and find joy in dentistry again. You can transition your practice to one where you are in charge again.

The transition process is not simple, but it is entirely possible, if you follow a series of orderly steps. If you can successfully complete dental training, then you have the intelligence and courage required to make a successful transition. Those dentists who have failed in their attempts to become insurance-free typically have not understood all of the necessary steps. They may have impulsively resigned from their PPO memberships, for example, only to be deluged with requests for transfer of records. So read, study, and plan before you start.

You may wonder how a psychologist can tell dentists that they don’t have to work with insurance. The answer is that when my own practice in clinical psychology was threatened by managed care, I made it my business to discover how healthcare practitioners could operate outside of insurance. I developed a conceptual model that now has been used by thousands of health care professionals. While my original audiences primarily consisted of mental health professionals, in recent years I have had the good fortune to work with a growing number of dentists who also are breaking free of insurance dependency. What I have noticed is that while psychologists and dentists face some different issues, the areas of overlap are so large that the model works in dentistry as well as it does in psychology.

In the early 1990's, when managed care began to replace indemnity insurance in my area, I thought that it would take over my practice. Yet, I knew that if I practiced according to their guidelines, I would hate myself. I felt helpless, out of control, frightened, and depressed. These are the same feelings dentists report who occupy the insurance-dependent-but-hating-it camp. They tell me that they take Prozac, detest their jobs, and feel angry, unhappy, and trapped. “What else can I do?” they ask, not expecting an answer. Feeling trapped helps them justify making compromises with the care they provide. In the middle of the night, however, the justifications ring hollow in their heads.

My salvation came in an unexpected way. I decided that, if I had to, I could quit psychology. Suddenly, the anxiety and despair that comes when outsiders control your life, which had been distorting my thinking more than I realized, evaporated. Recognizing that I could find a way to make a decent living, even if it was outside psychology, put me in control of my life again. That gave me a clear enough head to figure out how to stay in psychology, which is what I really wanted to do.

If you have what it takes to complete dental school, you also have what it takes to be successful in many other fields. Noticing this will help you be able to take the risks inherent in moving from insurance-dependency to insurance independence. This does not mean that you will never feel anxious and confused during your transition. You will. However, notice that, maybe for the first time in a long while, you will also feel hope.

So, first understand that you could leave dentistry if you had to. Then, take the following steps, so that you can stay and prosper in the profession to which you have devoted so much time and effort:

  • Recommit to Your Practice Standards: Go through what Bob Barkley, DDS, called an “agonizing reappraisal”. In my case, I had to admit that my reliance even on indemnity insurance had, little by little, led me to make decisions about how to work with people that were inconsistent with what I believe to be effective. Contrasting insurance demands with my own professional values gave me the chance to rediscover and rededicate myself to my own judgments about good care. The goal of your agonizing reappraisal is to become clear in your own mind what your practice values are. Agonizing reappraisals can hurt a bit in the beginning. However, when you give yourself permission to grow as a dentist and as a person, the pain will ebb and the excitement will grow. This will put you back in charge of your professional life.

  • Learn Basic Business Skills: Most health care professionals know very little about the business part of practice. The result is that, by default, we let insurance companies make our business decisions. Since their interests do not overlap with ours, that turns out not to be a good idea. Take control of your business decisions. Even if you have a highly skilled office manager and a great CPA, you need to be the final decision maker. Recognize that you are a person of good intelligence. Many people have learned what they need to learn to run a business responsibly. You can too. Learn how to write a business plan. Establish a reasonable fee structure. Figure out what it really costs you to practice.

  • Understand the Psychology of Buying Decisions: If you know what motivates people to make buying decisions, you can help them to decide to buy your services. People make buying decisions based on two factors - high value and low cost. When I offered services through insurance, my strategy was based on low cost. In those days, I did not recognize that value is a more powerful factor in determining what people buy. If your service has no value to someone, then your cost cannot be low enough to convince them to buy it. If your services have sufficiently high value, people often will reorder their spending priorities in order to buy them. To make your transition to insurance-independency, recognize the value of your own services. Do so by figuring out the value that they hold for the people you serve. If your services cost more than those of an insurance-based practice, you will need to identify how your services can have higher value than what people can get for less money. Do not be modest. There are times for modesty, but this is not one of them.

  • Know Who You Want to Serve: Patients who hold our services in low value will be over-represented in practices which attract patients on the basis of low cost. I recognized that I did not want to work with those people. This helped me to know who I did want to work with. In your case, let go of the idea that you have to serve all people in all ways. We feel pressure to “never say no” when we are building a practice. It turns out, however, that when we realize that there is business that we don’t want, we do a better job getting focused on serving those whom we can really help.

  • Learn Ethical Marketing: At one time, most healthcare professionals felt that marketing was pretty scummy. That was because we did not understand what marketing, at its ethical best, can be. Marketing is merely a two step educational process. The first step of marketing is to educate ourselves about what people want and need. Second, after you determine which of those wants and needs fit the kind of practice you want to have, let people know how your services fit their wants and needs. This allows potential patients to make an informed decision about whether to buy your services.

  • Help Patients Overcome Insurance Hypnosis: People in our country have essentially been hypnotized by insurance. Hypnosis, actually one of my specialties, is not magic. A hypnotic trance is nothing more than highly focused attention. It is a natural process. In fact, all of us become “entranced” many times a day. When we are entranced by something, other aspects of reality seem to not exist. An exciting movie might entrance you so that you forget, for the moment, that it is just a movie. Or you may get so focused on something while driving that you “forget” how you got to your destination. People in our country have become so focused on insurance that other possibilities have fallen outside of their awareness. Those of us who want to be insurance-independent must help people remember that alternatives exist. When I began educating my patients about the pros and cons of using their insurance, I was stunned at the overwhelming percentage who opted to pay out of pocket. You need to develop a strategy to educate your patients about the pros and cons of using dental insurance. You may be the only source of information they will ever have about what they will lose if they let dental insurance companies decide the future of their teeth. Do not, repeat, do not, simply send out letters to your patients about these pros and cons, unless you are trying to pare down your case load. This is a process that has to be done, usually by the doctor, one on one.

  • Be Creative: When I let go of insurance and its constraints, I discovered many unexpected ways to use my training that had not previously occurred to me. Opportunities were everywhere. Maybe there are dental-based services, unrelated to insurance, that people in your community would love to have if only someone would offer them. Let yourself dream a bit. Look through Dentistry Today to get sparks of inspiration.

  • Let Go of “Money Guilt”: It is important to resolve the seeming conflict of wanting to help others, many of whom are in pain, while apparently increasing their pain by requiring them to pay for services. (See “Overcoming the Money Taboo”, Dentistry Today, September, 2000) It may seem surprising, but business relationships are far more satisfying to most patients when insurance is not involved, if they have been properly educated.

  • Find Emotional Support: Making the transition to an insurance independent practice requires courage. To maintain your resolve in the dark and frightening moments, you will need people who believe in what you are doing. Avoid nay-sayers. Their thinking will infect you. Do allow yourself to be asked hard questions, however. Such questions will help you to anticipate problems. Just be sure you know the difference between people who ask hard questions as a way of helping you to think through difficult problems and people who ask questions from a position of preconceived judgments. Nay-sayers need you to fail so that your success does not create anxiety for them.

If you are like most insurance-dependent-but-hating-it professionals, you have a healthy dose of skepticism about this model. You may be tempted to offer excuses about why it “can’t work for me.” I’ve heard them all. People in Manhattan tell me why it can work in smaller cities but not where they live, overlooking the fact that there are many professionals in Manhattan who are making this work just fine. Others have told me that this can work in big cities but not in rural areas. The model can work anywhere, regardless of size and regardless of the degree to which dental insurance may have “penetrated” your market.

My favorite quote comes from a psychologist in rural Pennsylvania: “I live in a very rural area where there is a huge stigma about mental health care - I have very poor, very blue-collar, very rural, very uneducated, very non-mobile, very horse-shoe-throwing, Budweiser-drinking, pregnant-by-17, gun rack-in-every-pickup, ultra-conservative bigoted, red-necked population and they still choose this model!” If this guy can make it work, so can you.

Dana C. Ackley, Ph.D. is a Consulting Psychologist in Roanoke, Virginia. He has been a guest presenter at the Pankey Institute. He and Paul Henny, DDS, provide seminars and consultation to dentists who are insurance-dependent-and-hating-it. He is the author of Breaking Free of Managed Care: A Step-by-Step Guide to Regaining Control of Your Practice (Guilford Press, 1997 - also available in paperback as of 1999). He can be reached by email at; by phone at 540-774-1927; and by mail at EQ Leader, Inc., 2840 Electric Rd., Suite 208, Roanoke, Virginia 24018

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