Going to the dentist can be well scary. Americans have a lot of
reasons for not going to the dentist. They include fear of
actually going, inconvenience, and trouble finding a dentist
who's covered by insurance. But the top reason by far is cost
nearly 60% of Americans said cost was the main reason they
haven't visited a dentist within the past 12 months. That's the
case regardless of their age, income level or the type of
insurance they have. That's because dental insurance is
well, wonky. It functions differently than medical
insurance, and that can be confusing for patients.
Dental insurance is a mixed bag. It's a misnomer, it's called
dental insurance because in reality, it's really not
insurance. It's reimbursement.
It is frustrating for a consumer when they visit several
different offices and they find out that the fees are varying
widely.
People may question whether getting dental insurance or even
going to the dentist at all is worth it.
The public may look at dentistry as elective and that's where the
problem therein in lies.
That mindset can actually drive costs up in the long run, there
were roughly 2.2 million emergency room visits in 2016
for dental conditions. According to the American Dental
Association, the American Dental Association estimates that
diverting these emergency room visits could save $1.7 billion
per year.
Preventive care is the key to oral health care, and also a key
to systemic health care.
The system isn't easy to navigate with or without
insurance, but there are ways patients can save at the
dentist.
Access is frequently available, but people are unaware of how to
access the access.
Let's break down what it actually costs to go to the
dentist, whether dental insurance is worth investing in
and what patients and policymakers can do about it.
Dentistry and medicine have always been considered separate
fields in terms of the education system, medical records and
benefits. This separation can also cause some blind spots and
treatment.
My name is Dr. Marie Jackson. I'm a general dentist based out
of Montclair, New Jersey, and I'm the owner of Stellar Smile
Center. A lot of companies cut dental benefits, because the
mindset is that it is an elective care type of issue. So
when these issues come about, people have let it go because
they didn't think of it as essential to their well being.
There's a lot of emerging evidence that what happens in
the mouth can impact a lot of chronic disease management.
Your mouth's part of your body. That's the bottom line.
Dental insurance is a nearly $85 billion industry in the US.
Historically, there have been separate companies for dental
and health insurance but the industry landscape is shifting
more health insurance carriers are now offering dental benefit
options according to a 2020 survey conducted by the firm
West Monroe Partners.
Years ago when I went into practice, the big players were
Delta and Horizon. Now the big players are the commercial
carriers because they've been able to do the formulation to
figure out what they need to charge and premium provide a
quality service but at the same time assure high profitability.
According to West Monroe's data, dental insurers are making plans
to stay competitive with most of those surveyed planning to
either partner or bundle benefits with a health insurer
by 2025. Much of the dental insurance industry is run at the
state level, with some states being more competitive than
others. Now the big publicly traded health care companies
such as MetLife, Aetna and Cigna are offering consumers the
option to supplement their health insurance with separate
dental plans.
Dental insurance is extremely profitable to the insurance
companies, which is why many of the major carriers offer dental
insurance.
Putting the medical component aside when it comes to business,
dentistry and medicine are better off separate.
Think about when you go to the dentist and how that office is
set up versus the office when you go to a physician. When you
walk into a dental office, you sit in that operatory that
treatment room costs over $100,000 to set up and you have
to have more than one treatment. Well, what we provide requires
more specific equipment and supplies, and also hence the
cost. A dental office is operates at a 65% overhead where
a medical office will be considerably lower than that.
These challenges make it very unlikely that dental insurance
will combine with medical insurance because it could cause
problems for dental offices.
The billing systems are totally different. And so providers
would have to switch over to a medical model that's very
daunting to many offices, especially small offices.
Dental benefit plans can sometimes be unclear about
pricing, causing problems for both patients and dental
offices.
It's a lose lose all around when we don't have that transparency
that we can show to the patient. It's gonna be this much. And
that's really that's the bottom line. We always say it, we think
it's going to be this much and then we just cross our fingers
and hope that it's going to be true.
I think it's also important for the dental provider to be very
transparent and let a patient know costs upfront before the
work is done. So if there are any questions, you should be
able to get an answer from your provider. You don't want to be
hit with a surprise
In the area where Dr. Jackson works in New Jersey a dental
exam for a new or returning patient is estimated to be
around $130 without in Insurance according to
fairhealthconsumer.org. Dr. Jackson charges a little over
$100 for an exam for new patients, that's the out of
pocket price. But if a patient goes through insurance fair
health estimates the dental office would receive around $80
from the insurance company for that visit.
When insurance carrier takes 35 or 40% off of your usual fee, it
then becomes very difficult to meet your bottom line in your
practice.
Here are the estimated costs for some other common dental
services. X rays, which are crucial for diagnosis can cost
around $185 for a patient without insurance in Montclair,
New Jersey. A filling for just one surface can run $250, but if
three surfaces on the tooth need to be filled, it can go up to
$385. A root canal for a front tooth can cost around $1,100.
And a crown for a back tooth can range from 15 to $1,600.
Depending on what sort of material is used. It may seem
counterintuitive, but dentists say the best way to avoid high
prices is by going to the dentist more.
I think the solution to patients not having huge out of pocket
dental costs is to stay with the prevention side of it. So if we
can reach consumers, when they're younger college age 20s
they can, we can get the word out that you need to take care
of your teeth so that they don't necessarily break down on you
down the road.
Getting any type of insurance is about risk you're paying upfront
in the event that you're going to end up paying something more
in the future. So the question is whether a person feels like
that risk is warranted when it comes to dental insurance. Most
dental benefit plans have annual maximums or the amount of dental
care the plan will cover for the whole year.
I think back to when I started practice 38 years ago, the
average dental plan covered 1000 to $1,500 for a patient and back
then that provided the patient with a decent amount of
dentistry and it really increased access to care for
many patients. So they really look forward to having that
dental insurance. Well now if you fast forward 38 years that
insurance maximum is still the same. It's still $1,000 or
$1,500, which has not changed while the premiums have gone up.
A typical plan works like this, patients pay into the plan in
several ways. There are monthly premiums which are typically 25
to $30. According to the data from the National Association of
Dental Plans or the NADP. There can also be deductibles, which
is the amount of money a patient has to pay out of pocket before
their plan starts to cover any care those typically run from 50
to $99. So $360 in premiums per year if you're paying at the
high end of the typical rate, another $100. Again, worst case
scenario totals $460. Most plans cover preventative care, such as
one or two cleanings a year and one set of x rays with no out of
pocket cost to the patient. But the plans vary in coverage when
it comes to major services like crowns or surgery. If a person
decided not to get insurance, had no other issues with their
teeth and just focused on preventative care, such as
getting two cleanings a year and one set of x rays, it would cost
them around $485 out of pocket compared to the $460 a year a
hypothetical dental plan may cost they would essentially
break even if they did get insurance. According to the NADP
95% of Americans do not hit the annual benefit maximum.
It all depends on the patient and what their needs are. So if
someone's getting a lot of work done, it is a benefit to them.
It does give them a break. It works rather much like a coupon
rather than insurance.
According to a study that was put out by the National
Association of Dental Plans, 68% of people that don't have dental
benefits, they'll actually go and get dental care but it's a
whopping 88% that have dental benefits are actually going to
use those benefits.
When it comes to preventive measures, dental insurance is
definitely worth it so you can have some type of method of
getting you in so that you're encouraged to make sure your
dental health is in check.
Patients have this perception that they need dental insurance
to go to the dentist. For many individuals having access to
dental insurance, it does assist them, does it assist them at the
level that it should? It does not. When you're talking about
the maximums that these policies have it does not assist
individuals that truly need it.
It's not just patients who question whether insurance is
worth it, dental offices can sometimes struggle to make ends
meet if they decide to accept insurance.
So when we take on insurance plans, we're taking a break on
fees. So for a small office that has majority insurance patients,
if you're in network, you are literally taking a cut of
hundreds of 1000s of dollars within a year. I've seen figures
went up as much as $600,000 of insurance breaks that colleagues
of mine have taken in one calendar year you'll find a lot
of offices will take insurance plans because if they're a
smaller office or new to an area to bring patients in patients
will often look for an in network provider on their
benefit website. So they'll log in see who's a provider in the
area and it'll draw them to the office.
Dental offices have found ways to help patients who choose to
opt out of insurance.
Typically a membership plan will be a fixed cost per year and
you'll get a certain percentage off of the practice's fees. So
for example, you could end up paying $450 for the year, and
then you would get 10 to 15% off of the practice's fees. There's
no limitations. There's no deductibles, it's just a
straight buy into the practice. They're huge in the dental
marketplace now, because there is such consumer demand for an
insurance alternative.
There's this misnomer that you need dental insurance to go to
the dentist. You really don't, dental insurance is not the
panacea that most people think it is.
There are ways people can access lower cost care without policy
changes. Another option for low cost care is to tap into dental
education programs.
If a patient is able to travel to a dental school, most of the
time, you'll see dental schools accept Medicaid. And if a person
doesn't have Medicaid or Medicare plan, they are able to
usually pay out of pocket at a much lower rate than you would
at a private office.
There's also the option of going to a community health center
which could provide patients with affordable care. These are
federally qualified health centers spread across the
country that mainly provide medical services but some of
them also offer dental care.
There is access to dental services through that community
health center. Primary care associations are agencies that
oversee the function and the efficiencies of health centers
and they help with the very smooth running of health centers
who are needed in a particular area, they help with needs
assessment and patient access to care.
Policy changes can also be used to help those who struggle to
pay dentist frequently say that Medicaid, the government funded
health insurance program for low income Americans, needs to be
overhauled in order to help patients.
Medicaid is a wonderful concept and many offices are able to
work with it. However, there's a lot of changes in the Medicaid
programs. In some years, you'll have adult Medicaid benefits
approved and they're given out. And then when administration's
change or midterms come along, sometimes those adult benefits
are yanked out or the child benefits are pared down. So it's
a very fluid program in most states. And so dentists struggle
with that and they struggle with keeping on top of it.
We know that children do better with their dental appointments
and their preventive visits when parents have coverage. And the
American Dental Association's collaborated with other agencies
to advocate for predictable adult dental benefits and an
opportunity to change some of the administrative burdens so
that it is easier for dentists to participate in a program that
they know is here today and will be here tomorrow. And not here
today and gone tomorrow.
Another issue with Medicaid that I hear very often from dentists
is that the reimbursement is just too low. It's not enough
for them to even recoup their overhead. There's a huge risk to
the livelihood of your practice. If you make that a huge chunk of
your practice.
If I were to take Medicaid, I wouldn't be able to call, cover
my costs of operations and I wouldn't be able to stay open.
Ultimately, the best way to save at the dentist is by putting in
the long term investment and care into your teeth.
I'll see patients who may not come in for years at a time
because nothing hurt but the problem is when a patient does
come in, we hope to catch things well before something is painful
or before something is broken. Preventive care is essential in
keeping costs more reasonable in the dentist.