On June 14, 2023, Dentistry in General (DIG) hosted a powerful discussion moderated by Bob Dee, DDS, the founder of this “dentists only” website. Participants included Raymond Cohlmia, DDS, the executive director of the American Dental Association (ADA); Marko Vujicic, PhD, the ADA chief economist; Mouhab Rizkallah, DDS, the author of Massachusetts Question #2 on dental insurance medical loss ratios (MLRs); and David Leader, DDS, an associate professor at Tufts University School of Dental Medicine.
The fiery debate lasted nearly two hours and covered the ADA’s role in advocating for MLRs, the recent article co-authored by Vujicic on value-based dentistry (VBD) in the Journal of the American Dental Association (JADA) (June 2023), as well as a myriad of subjects concerning the dental insurance industry. The discussion also included Medicaid managed care organizations (MCOs). Dentists and viewers witnessed a welcome change from the standard fare of a panel discussion, with all voices mostly speaking in lockstep.
In fact, at times the discourse became so rousing that the moderator, Dee, injected his perspectives into the dialogue. Although on all occasions, the arguments presented remained within professional decorum, the ADA leadership was clearly unprepared for the level of fervency and frustration generated by alleged abuses by the insurance industry.
Rizkallah and Leader advocated that the ADA’s first priority should be to counter the exploitation of the public by insurance companies and MCOs. They also made a strong case that VBD is actually capitation masquerading under a new title.
Cohlmia countered that he must juggle multiple interests for different dental groups. Dental insurance matters are but a single issue. Vujicic held that VBD was the inevitable payment model for providers, either in the short term or long term. He believed that he had a responsibility to present reality.
Rizkallah came to the online symposium well-prepared with multiple graphic illustrations to help make his claims.
- Payments to providers must be sufficient to enlist adequate providers, such that care is equal to the general population.
- Minimal care must include relief of pain and infection, restoration of teeth, and maintenance of dental health.
- Render other necessary care, diagnostic services, and treatments to ameliorate or correct physical and mental illnesses, whether or not covered by a particular state’s plan.
- Reasonable promptness of dental care is delivered.
- Discrimination by diagnosis is not allowed. Medical (dental) assistance shall not be less in amount, duration, or scope, than any other individual served.
Obviously, most states (all?), including Rizkallah’s state of Massachusetts, are failing to meet the required federal Medicaid rules. Rizkallah tacitly but forcibly implied that the states’ failure to comply with federal Medicaid mandates was a driving force towards VBD, or capitation as he sees it. More insight on Rizkallah’s views is available in this interview conducted by Dentistry Today’s editor-in-chief, Dr. Paul Feuerstein.
Vujicic stated that there were significant differences between VBD and capitation. However, that was disputed by other panelists.
The discussion reached a particular apex of tension when Rizkallah highlighted the ADA’s participation in the April 2023 Dental Quality Alliance Conference (DQAC). Invited speakers not only included the ADA’s chief economist, Vujicic, lecturing on VBD, but also Mike Adelberg, the executive director of the National Association of Dental Plans; Mary Lee Concicella, DMD, the chief dental officer for Aetna Insurance; Julie Frantsve-Hawley, executive director for the TAG (The Aspen Group- Aspen Dental) Oral Center of Excellence; Betty Gilbert, RDH, vice president of Value-Based Care Programs at Liberty Dental; Cyrus J. Lee, DMD, executive director and CEO of Permanente Dental Associates; Daniel J. Pihlstrom, DDS, chief dental officer of Permanente Dental Associates; and Cherag Sarkari, DDS, the California dental director for Liberty Dental Plan, among others.
Meeting sponsors included Delta Dental, DentaQuest and its nonprofit affiliate CareQuest, Permanente Dentistry, Smiles to Go, LLC (an alleged faith-based dental Medicaid provider based in Mississippi and primarily focused on school programs), and the American Dental Education Association, a nonprofit.
Several presenters at the DQAC specifically focused on advocating for VBD. Representation from the insurance industry, Medicaid MCO companies, and the dental support organization (DSO) industry was well-represented in attendance.
Conspicuously absent as lecturers at the DQAC were clinical dentist speakers or small business dentists from the ADA, Academy of General Dentistry, American Academy of Pediatric Dentistry, Alliance of Independent Dentists, the American Association of Orthodontists, or other similar small business clinical stakeholders.
One would be hard-pressed not to respect Cohlmia and Vujicic for walking into a virtual lion’s den of wet-gloved clinicians who hold the US insurance industry in utter contempt for their perceived abuses. In historical context, earlier ADA leaders were allegedly “joined at the hip” with the insurance industry. Former ADA leaders never attended such an event as held by DIG.
In past years, ADA leadership too often admonished member dentists and their component societies that desired to bring reform to the insurance industry. Too often, apparent conflicts of interest were in play with ADA senior executives and directors. These organizational heads continually cited problematic violations of US Federal Trade Commission rules related to antitrust, which were, in fact, talking points of the insurance industry.
Today, a modernized ADA says it is willing and able to take on corporate behemoths. A revised edition of “The Antitrust Laws in Dentistry” offers “dos and don’ts.”
“We recognize that due to marketplace realities, the examples of sound ADA advocacy mentioned in this book have not yet produced all of the desired outcomes. At the very least, therefore, it is important that dentists know enough about the antitrust laws to avoid needlessly getting into harm’s way while trying to achieve their legitimate goals. Playing on an unlevel field is hard enough; trying to do so without knowing the rules of the game can make it orders of magnitude worse. So, let’s get started. The antitrust laws are sometimes called the rules of the game of competition. Let’s learn how to play!”
A common theme resonated throughout the DIG debate. All participants continually advocated for the value of ADA membership and the merit in the organization.
Consensus was repeatedly reached on the significance of open discussions to help counter declining ADA membership.
ABOUT THE AUTHOR
Dr. Michael W. Davis practices general dentistry in Santa Fe, NM. He also provides attorney clients with legal expert witness work and consultation.
Davis also currently chairs the Santa Fe District Dental Society Peer Review Committee.
He can be reached at MWDavisDDS@Comcast.net.
FEATURED IMAGE CREDIT: Rawpixel.com/Shutterstock.com.
