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  #11  
Old 03-20-2019, 03:57 PM
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MayanActuary MayanActuary is offline
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Wouldn't a large filling make the tooth more at risk for fracturing down the road compared to a crown?

IANAD but my understanding is the crown not only lasts longer than a filling would, but the key feature of it is that it strengthens the tooth. If the tooth is too the point of needing a large filling / crown, it seems like in many cases that tooth is so weak that you would want to strengthen it and not leave the possibility for further fractures down the road. So yes you save money not doing crowns now, but in the long run how much is saved due to the lower quality of it all? What is the complication rate of your patients 5-10 years down the road?

See here for reference on tooth strength: https://www.biomimeticdentistryce.co...trength-teeth/

Other studies:
https://www.jendodon.com/article/S00...89)80191-8/pdf
https://www.ncbi.nlm.nih.gov/pubmed/12859085


So I understand the narrative you are pushing, trying to save money for your patients by doing a cheaper procedure, and there are probably more crowns done than needed, but your pictures included seem to go beyond what the research indicates is the best approach.

You are also charging much more for these procedures than is currently typical ("my per procedure fees are roughly 350% of the 'negotiated' rates typically offered by inscos"), so you are making a nice bang for your buck for the type of procedure done. And the patient is happy because you saved them money from the crown they would have gotten. But the patient doesn't understand that they are getting a suboptimal procedure done in many of these cases, and that this could result in further complications down the line. The patient also doesn't understand that if a standard dentist did the same procedure you are doing they could save an additional few hundred dollars based upon those negotiated rates.

So nice racket, but I would side with MetLife.

My $0.02.
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  #12  
Old 03-20-2019, 05:29 PM
BarG BarG is offline
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Originally Posted by MayanActuary View Post
Wouldn't a large filling make the tooth more at risk for fracturing down the road compared to a crown?
Actually the opposite. Are you familiar with the engineering concepts of moment of inertia? By decreasing the radius of a tooth (crown preparation) you are actually weakening the tooth catastrophically. Take a look at the attached image. For simplification crown preparations decrease both the web height, flange width.

I should have mentioned I also embed a kevlar type fiber into these teeth to protect from future fracture. I create a 'crumple' zone inside the tooth to protect from the future fracture down the road.

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Originally Posted by MayanActuary View Post
IANAD but my understanding is the crown not only lasts longer than a filling would, but the key feature of it is that it strengthens the tooth. If the tooth is too the point of needing a large filling / crown, it seems like in many cases that tooth is so weak that you would want to strengthen it and not leave the possibility for further fractures down the road. So yes you save money not doing crowns now, but in the long run how much is saved due to the lower quality of it all? What is the complication rate of your patients 5-10 years down the road?
The latest research shows no increased longevity of crown restorations than fillings when using a proper adhesive protocol. Without proper bonding crowns actually weaken teeth leading to increase failure rates.

I haven't been doing this long enough to know down the road. I can only quote multiple mentors which show regular 20-30 year old successful cases without the need for full cuspal coverage restorations. I have entire books showing this type of treatment.

https://www.ncbi.nlm.nih.gov/pubmed/26918928


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See here for reference on tooth strength: https://www.biomimeticdentistryce.co...trength-teeth/
I am now confused. The above link is to one of my mentors who doesn't believe in full coverage crowns either. The information you just posted completely contradicts your above comments that crowns strengthen teeth.

Take a look at these cases also on the same site. These are the types of restorations I referenced that aren't covered by insurance but lead to increased longevity.

https://www.biomimeticdentistryce.com/social-media/


Once again you have me confused. The first study you just sent also confirms my comments that endo treated tooth aren't actually weaker than non-treat teeth, therefore don't actually need crowns to 'strengthen' then. This follows my comments on moment of inertia earlier. The greatest loss of stiffness is due to a loss of marginal ridge integrity. The marginal ridge is equivalent to the flange width and web height.

Quote:
Originally Posted by from J. Endo you posted
The largest losses in stiffness were related to the loss of marginal ridge integrity. MOD cavity preparation resulted in an average of a 63% loss in relative cuspal stiffness. The results indicate that endodontic procedures do not weaken teeth with intact marginal ridges.
I also have a case series showing the commonly accepted diagnosis of 'cracked tooth syndrome' is more likely due to 'partially bonded syndrome' due to the inadequate bond between a restoration and a tooth which presents in the same clinical manner. I have even developed an entire technique which helps to differentiate the two.

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Originally Posted by MayanActuary View Post
So I understand the narrative you are pushing, trying to save money for your patients by doing a cheaper procedure, and there are probably more crowns done than needed, but your pictures included seem to go beyond what the research indicates is the best approach.

You are also charging much more for these procedures than is currently typical ("my per procedure fees are roughly 350% of the 'negotiated' rates typically offered by inscos"), so you are making a nice bang for your buck for the type of procedure done. And the patient is happy because you saved them money from the crown they would have gotten. But the patient doesn't understand that they are getting a suboptimal procedure done in many of these cases, and that this could result in further complications down the line. The patient also doesn't understand that if a standard dentist did the same procedure you are doing they could save an additional few hundred dollars based upon those negotiated rates.

So nice racket, but I would side with MetLife.

My $0.02.
I actually have 100s of peer reviewed journal articles which back up this method of practice. The problem is a majority of those articles are from outside this country.

I like where you are going with 'suboptimal' procedure. In your opinion which are some of the key metrics which indicate a 'suboptimal' procedure? Remember I have all the data you need to prove this since I did 'standard' dentistry for 5 years before I realized there was a better way to treat teeth. You can easily compare the data before and after I went beyond what the research indicates.

Keep in mind MetLife never said my pattern of practice led to an increase in total cost of claims, just that I deliver this type of service much more than in an insurance based dental practice. MetLife wouldn't give me my overall utilization profile. I actually approached MetLife with my 'restoration dissection' technique as way for them to help detect inadequate protocols.

I enjoy your commentary and hope you keep picking at me. I need this type of scrutiny from someone on your side of the equation.
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  #13  
Old 03-21-2019, 07:41 AM
WhosOnFirst WhosOnFirst is offline
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I think what you are doing is really cool. I think if you could hook up with someone who does dental actuarial consulting they could help you. However, that's probably not feasible as actuarial consulting is really expensive.

You need good benchmark data. Without a basis of comparison, you are going to have a tough time. I didn't review what you all supplied above so I can't comment on whether it is sufficient.

I'm curious what you are trying to achieve in a broader sense. Are you trying to prove you are cheaper? That you provide higher quality care? Once you (presumably) prove that, what do you do with it?


JohnLocke is right here. It sounds like you might have some of the data you need to start building some metrics. However, it sounds like you are trying to create metrics that aren't in common use. Hiring a professional is a good idea. It doesn't need to be an actuary specifically but someone who does solid data analysis. This assumes that you data is available in electronic form. The type of analysis you are looking for is ... involved, if done properly.

I do this type of thing on the medical side but we have some pretty established metrics to review. We also deal with it on a population basis so we have a much larger sample to look at. As I recommended before, I'd develop metrics that measure your practice on a per patient basis. This creates metrics that examine the average number of procedures patients receive. So, if you saw 1,000 patients in a year and performed 1,500 cleanings you performed 1.5 cleanings per patient per year (PYPY). This can be done with all of your procedures over multiple years. You can then compare the results from year 1 to year 2 and this will show the reduction or increase in the service level. You should expect to see that as large fillings have increase, the rate of crowns and root canals has decreased.

To look at the financial picture, I would assign a cost to each of the services provided. Since you have the average number of those types of services performed you can now calculate the average cost in year 1 and compare that with the average cost in year 2. The difference is the savings or cost increase as the case may be.

That's the high level approach, the devil is in the details. You want to be certain that you pick an appropriate population. For example, you may only want to include established patients and not those requiring emergency treatment. I'd recommend building a total cost of care view (which is what I describe above) but it may be more appropriate to use just select services and only include patients who use those services. 80-90% of the time spent doing the analysis is the data prep work which is why we recommend paying a professional to help. The actual calculations are easy. You may run into some credibility issues as the number of procedures you have performed is relatively low. By comparison, I'm currently working on a savings estimate where my population size is around 150,000 people and for parts of my analysis the results are sketchy because the number of people gets pretty small.
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  #14  
Old 03-21-2019, 11:15 AM
nonactuarialactuary nonactuarialactuary is offline
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BarG, what are you hoping to get out of posting here? The vast majority of people on this board are actuaries, actuarial recruiters, or actuarial candidates taking exams. Iíll be the first to admit that I donít know the first thing about the science behind dentistry, and I suspect the majority of posters on this board are the same. The pictures of teeth and discussion around moments of inertia donít really mean anything to this audience. It might mean a lot on DentistryOutpost.com, but people here simply havenít studied this stuff (including folks that have worked in dental insurance).

At a 30,000 foot level though, it sounds like youíve adopted a new procedure for fixing teeth. You believe this new procedure (1) is more cost effective, and (2) takes less time to complete, and (3) doesnít sacrifice quality of care for patients. An automated MetLife fraud program likely saw that you were an outlier in that one particular metric, prompting the letter. Your current office requires upfront cash payments, while you used to run a more traditional office relying on patientís dental insurance for funding. Do I have that right? Are you looking for help marketing the advantages of your new procedure? Trying to justify the new procedure to MetLife? Something else entirely? Iím a little confused as to what youíre hoping to get out of this post. Before diving into the detail, maybe define what youíre trying to do first, and people can take it from there.
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  #15  
Old 03-21-2019, 11:51 AM
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I wish I had access to dental data. I would have done some pro-bono work with you just to get some more dental actuarial experience on my resume. I think my Healthcare background/experience would run circles around the dental arena, however the dental actuaries disagree with me most the time unfortunately.
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  #16  
Old 03-21-2019, 12:24 PM
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<dental stuff>
Like I said, I am not a dentist, my understanding of crown strength over fillings was based off of what I had been told awhile back and some quick google searches when I saw this thread that confirmed my prior understanding. If this is a new way of doing it (with new bonding techniques to prevent fractures), that is neat and I was unaware.

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I like where you are going with 'suboptimal' procedure. In your opinion which are some of the key metrics which indicate a 'suboptimal' procedure? Remember I have all the data you need to prove this since I did 'standard' dentistry for 5 years before I realized there was a better way to treat teeth. You can easily compare the data before and after I went beyond what the research indicates.
By suboptimal I would be interested in seeing the following metrics comparing crowns to large fillings-
What is the distribution on length until failure?
Upon failure, what is the expected next step?
What other potential complications occur under both procedures, and what is the difference in complication rates?

Basically I would be trying to get at this: Does a large filling fail after 6 years and then a root canal / crown is needed? Whereas a crown would last 12 years, and then just need recementing or something like that? (length of times completely made up).

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I enjoy your commentary and hope you keep picking at me. I need this type of scrutiny from someone on your side of the equation.


Some additional unsolicited thoughts on value-based payments-

Dental insurance has been pretty far behind health insurance in terms of innovation. So I haven't seen any big pushes for value-based arrangements in that area, unlike health. But if you were interested in doing something, I would think you would need to band together with a group of dentists, enough to make the insurance companies interested. Then you approach them with a proposition to reduce their costs, reduce patient costs, and increase your bottom line, while keeping quality high.

You could negotiate an arrangement where as a group of dentists your target crown rate per patient is based on average crowns per patient across the block of business. As you reduce this crown rate, you and your fellow dentists would share in a portion (say 50% or so) of the savings that the insurance company is seeing from this reduction in costs. You would propose some quality metrics that would have to be met to see these savings. During this negotiation you could also see about the fees for this alternative large filling and make sure it meets your needs there. A little wrinkle in this might be what class large fillings are in compared to crowns, and the coinsurance amounts on each of those.

I'm not sure on the desire from the dental insurance side of it, but that's how it would work with health.
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  #17  
Old 03-21-2019, 12:47 PM
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Originally Posted by MayanActuary View Post
Some additional unsolicited thoughts on value-based payments-

Dental insurance has been pretty far behind health insurance in terms of innovation. So I haven't seen any big pushes for value-based arrangements in that area, unlike health. But if you were interested in doing something, I would think you would need to band together with a group of dentists, enough to make the insurance companies interested. Then you approach them with a proposition to reduce their costs, reduce patient costs, and increase your bottom line, while keeping quality high.

You could negotiate an arrangement where as a group of dentists your target crown rate per patient is based on average crowns per patient across the block of business. As you reduce this crown rate, you and your fellow dentists would share in a portion (say 50% or so) of the savings that the insurance company is seeing from this reduction in costs. You would propose some quality metrics that would have to be met to see these savings. During this negotiation you could also see about the fees for this alternative large filling and make sure it meets your needs there. A little wrinkle in this might be what class large fillings are in compared to crowns, and the coinsurance amounts on each of those.

I'm not sure on the desire from the dental insurance side of it, but that's how it would work with health.
This is kind of where my mind went. BarG, my work is in value-based care for oncology, prior to that I was in population health management (asthma, diabetes, COPD, etc). I generally find payers don't really know what's going on clinically, so we have to educate them, more or less. It's a slog. Payers will talk to you but then they can't get resources to see a value-based deal through, that happens all the time. Data is messy. You'll get halfway through negotiating a deal and someone on their side quits, and you have to start all over.

Consolidating with other providers makes sense, more providers means more dollars, so they pay more attention. Two other thoughts based on what we've had some success with. One, capitation. To make it work you need steerage, and if you're out-of-network now this may not be the best play. MayanActuary is talking about case rates / bundles, and we've done those with great success for tx that is episodic, I quite like that idea. Two, are you tracking patient satisfaction? We've gotten good traction on that with several payers, we mail or email surveys, it's a bit of manual work but hasn't been horrible.

I wish I had more free time, I'd love to learn more about the dental landscape. BarG, a gigantic tip of the hat, I'm encouraged to see a provider really trying to improve on cost and quality. Keep fighting the good fight.
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Old 03-21-2019, 03:18 PM
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I think what you are doing is really cool. I think if you could hook up with someone who does dental actuarial consulting they could help you. However, that's probably not feasible as actuarial consulting is really expensive.

You need good benchmark data. Without a basis of comparison, you are going to have a tough time. I didn't review what you all supplied above so I can't comment on whether it is sufficient.

I'm curious what you are trying to achieve in a broader sense. Are you trying to prove you are cheaper? That you provide higher quality care? Once you (presumably) prove that, what do you do with it?
John, the profit propositions are vastly different for a provider that gets paid on a 'fee for service' basis versus a doctor who will be forced to adapt to the upcoming shift toward a 'value based system'.

I have been studying the differences in compensation systems and how this would theoretically affect a dentist. This has been a hobby for me over the past 7 years. After studying the financial incentives for both providers and payers and how insurances can increase their profits through lower claims submissions, I then set out and looked for doctors across the world who claimed 'ultra-longevity' in their restorations, theoretically increasing the length of time between replacements, thus driving down the cost of claims submissions.

I then spent another year or so going to specific continuing education and learning what made this group of doctors different. I spend a week in Sardinia, studied under a dentist in New Zealand, and learned how the concept began in Japan. I then implemented this group of procedures and watched the change in treatment pattern versus the 'accepted' norm.

Thus far my predictions of what would happen in such as system has occurred exactly as I expected. I saw a huge shift in claims patterns, and on a case by case basis a decrease in the total cost of care needed. I have been flagged as the current system doesn't know what to make of it since it isn't the norm.

For your last question...What would you do if you believed you had developed a propriety system that could reduce the value of claims submissions by 50%?... Probably, the same as me, and look for ways 'sell' the concept to people who would greatly profit from my findings.
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Old 03-21-2019, 03:33 PM
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I have been studying the differences in compensation systems and how this would theoretically affect a dentist. … looked for doctors across the world who claimed 'ultra-longevity' in their restorations, theoretically increasing the length of time between replacements, thus driving down the cost of claims submissions.

what made this group of doctors different. I spend a week in Sardinia, studied under a dentist in New Zealand, and learned how the concept began in Japan. I then implemented this group of procedures and watched the change in treatment pattern versus the 'accepted' norm.

...saw a huge shift in claims patterns, and on a case by case basis a decrease in the total cost of care needed.
If you could put this into a few 20 minute presentations you'd be a hit at our continuing education forums. At least the dental Actuaries would appreciate most of it.
I think the Value Based Payment scheme would be a lot easier in the Dental field due to the high freq and low categories as compared to the high freq and VERY high categories of medical/drug.


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For your last question...What would you do if you believed you had developed a propriety system that could reduce the value of claims submissions by 50%?... Probably, the same as me, and look for ways 'sell' the concept to people who would greatly profit from my findings.

This is sort of not allowed in our forums, buuut… we'd get the "hint"
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Old 03-21-2019, 03:48 PM
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BarG, what are you hoping to get out of posting here? The vast majority of people on this board are actuaries, actuarial recruiters, or actuarial candidates taking exams. Iíll be the first to admit that I donít know the first thing about the science behind dentistry, and I suspect the majority of posters on this board are the same. The pictures of teeth and discussion around moments of inertia donít really mean anything to this audience. It might mean a lot on DentistryOutpost.com, but people here simply havenít studied this stuff (including folks that have worked in dental insurance).

At a 30,000 foot level though, it sounds like youíve adopted a new procedure for fixing teeth. You believe this new procedure (1) is more cost effective, and (2) takes less time to complete, and (3) doesnít sacrifice quality of care for patients. An automated MetLife fraud program likely saw that you were an outlier in that one particular metric, prompting the letter. Your current office requires upfront cash payments, while you used to run a more traditional office relying on patientís dental insurance for funding. Do I have that right? Are you looking for help marketing the advantages of your new procedure? Trying to justify the new procedure to MetLife? Something else entirely? Iím a little confused as to what youíre hoping to get out of this post. Before diving into the detail, maybe define what youíre trying to do first, and people can take it from there.
But a majority of claims decisions I have to understand are made by people with your limited clinical knowledge, which adds complexity to the equation.

On the same token dentists have no clue of the type of work actuaries do. This is a massive disconnect in the system, which I believe, is evidenced in many of the fee scheduled offered by insurers.

Look at Mayan's initial post. This person disagreed with me, then quoted peer reviewed research articles which actually agreed with my stance while contradicting the first assumption by the poster. Yet this wasn't even realized due to the lack of understanding of the fundamental science which drives the clinical decisions, and thus the claims.

How could we ever expect such a disconnect to ever lead to improved outcomes in our currently configured 'health'care system?

I came here to mingle with the guys on the opposite side of the equation who have inside knowledge of the payer's systems. I need a different perspective as I have reached a dead end in talking with dental professionals.

First let me say that this isn't 'my' procedure and isn't a 'new' procedure. All of the mentors I have studied under are in their late 60s to mid 80s. All of those I have found will gladly open up their records if anyone in the industry approached them.

Read my post on Risk Bearing Provider Entities, it provides insight into my long term vision.
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