Posts tagged ‘san Francisco conebeam’

The delta between Delta and doctors

Most dentists view insurance as a necessary evil. For those eight who don’t, Delta is making it that much easier. Delta has quietly been changing its evil ways… and not at all for the better for doctors or patients.

 

A quick review: Delta Premier is/was/should be the best insurance for everybody. Dentists get reimbursed at or near their standard fees, meaning dentists can afford to take adequate time, hire well-trained staff, invest in technology, use premium materials, and send work to high quality labs. Employers get the widest network of dentists. Patients get the best possible care, through a wide selection of dentists who are compensated enough to provide high quality service.

 

By contrast, Delta PPO sucks. Dentists are typically reimbursed at 40 to 70% of their regular fees. Remember dental offices typically operate on average at 65-70% overhead. PPOs reimburse at less than the cost of running a business, or at best about break-even. This raises the prickly question of how a dentist can stay in business when each PPO patient actually costs the doctor money to treat. Wouldn’t it be cheaper to not see PPO patients and keep the office closed? There are a few things PPO doctors can do to keep their doors open, and a few things you may tell yourself so you can sleep at night:

  • Lower expenses by hiring less experienced staff, using cheaper materials, and not upgrading equipment or technology

You tell your patients “you get what you pay for,” but that doesn’t necessarily apply to a $10.25/hour assistant or discount composite with foreign-language instructions

  • See more patients per hour by working faster

Rushing through procedures; what could possibly go wrong?

  • Use cheaper labs and cheaper restorations

There’s no certainty that the patient will experience an adverse reaction to a $19 PFMM (porcelain fused to mystery metal) that was made in an overseas sweatshop suspiciously located next to an auto scrap yard

  • Up-sell elective procedures that aren’t covered/limited by the PPO

This creates an uncomfortable sell-or-starve atmosphere that is better suited to Time Share sales or an episode of The Dental Apprentice than to dental offices

  • Increase the fees for your nice non-PPO cash-paying patients

Which penalizes non-PPO patients and is just plain unethical in some US states and Puerto Rico

 

I don’t mean to single out Delta’s PPO. Almost all dental PPOs rate sub-sewage, so I don’t mean to imply that Delta’s PPO is uniquely bad. I mean to single out Delta Dental as a company, because Delta happens to be uniquely bad in other ways… which I’ll explain now.

 

First understand that Delta Dental is a business, and good businesses make money, and Delta is a very, very good business. Several years ago, to increase profits, counter emerging Metlife and Aetna, and remain the Walmart of dental insurance, Delta began promoting its PPO over its Premier plan. This was originally done by switching Premier patients/employers over to PPO. That’s bad for dentists but not necessarily shady business. Non-PPO dentists who were in the Premier program were still getting reimbursed at their contracted Premier rates.

 

Until now…

  • Delta wants to claim the highest number of in-network PPO dentists
  • Any dentist who wants to apply for Premier must also accept PPO
  • When an associate joins a Premier practice, the practice must accept PPO or lose its Premier status
  • Ditto for practices being sold to associates

 

Okay, you may shrug. So I have to accept PPOs as well as Premier. My Delta patients are all Premier so it won’t affect me… will it? The answer is a crushing YES.

 

Even IF the patient is a Premier partner, if the doctor accepts PPO as well as Premier (which doctors are being coerced to do), Delta will reimburse the doctor at the lower PPO rate.

 

Re-read that above statement 3 more times… Stings, doesn’t it? Even worse, Delta never announced this policy change. My dental friends suddenly and surprisingly found out, kind of like the Titanic captain found out there was an iceberg around. Some dentists are still blissfully cruising full speed ahead through treacherous waters.

 

How bad is the situation? Look at the ramifications.

  • If you’re accustomed to your Premier income, you’re heavily disincented to take on an associate and slash those reimbursements in half
  • If you’re buying a practice, the income and profitability projections under a Premier-only dentist will be much higher than you (as a new PPO dentist) can expect
  • Banks know the above point, so getting a loan for a highly profitable Premier practice will be more difficult and expensive
  • If you’re selling a Premier practice, it’s worth a lot less to a new dentist who can only collect PPO fees… which cuts the value of that heavy Delta Premier practice you were counting on for retirement

 

You can avoid this by dropping Delta, maybe, but Delta won’t go without a fight.

  • Delta typically refuses to tell out-of-network dentists how much they can expect for reimbursement of most procedures
  • Delta now refuses to pay out-of-network dentists directly, even if the patient signs the standard request that the money go to the dental office
  • This forces out-of-network dentists to bill patients up front, with no clear idea of reimbursement expectations

 

So you might have to stick it out with Delta after all, which is a lot worse than expected but not catastrophic. Or so you tell yourself. Actually, the catastrophe is on its way to a state near you. In addition to the above maneuvers, Delta has also been cutting reimbursements systematically (state-by-state) to reduce everybody to PPO levels. There’s less outrage if one state gets nailed. After a majority of states have converted, it’s easier to tell the big ones like California and New York they just have to follow the trend.

  • Delta reports they set the reimbursement fee at the 80th percentile of dentists “in the area,” which oddly seems to include rural Alaskan dentists-veterinarians-fishing guides, regardless of where you live
  • In June 2011 Delta cut back those reimbursements in Washington state by 15% (meaning Delta is now reimbursing at the 68th percentile, assuming they actually started at the 80th)
  • In November 2011 Delta cut the Idaho state reimbursements by 8%
  • Delta seems to be converging its Premier and PPO fees, so even if you’re Premier and haven’t succumbed to accepting PPO fees, soon there won’t be much of a difference

 

As I said earlier, these are pretty evil developments for doctors and patients alike. Before you take out your Delta Voodoo Dolls or organize Occupy Delta rallies, this could be indicative of all insurance to come (meaning you’ll at least need more voodoo dolls). Insurance companies are exempt from Federal Trade Commission anti-trust laws and are therefore allowed to collude and prices and services, even though they are competitors. This looks like the beginning of a large-scale squeeze on doctors and their patients. On the other hand, if you’re an executive or shareholder of Delta Dental, evil can be quite profitable.

 

What do these three have in common?

Coming soon: what you can do to fight the future, besides unleash the Occupy My Street protestors on them…

New Year, New Plan, Same Guy

I gathered our office together this week for a “New Plan for the New Year” brainstorming session. Lindsay, my way-too-comfortable office manager, started the discussion with: “let’s use the old plan, but this time actually stick to it.”

 

It was a really short meeting.

 

Lindsay was completely right (as well as completely annoying). I’d spent a lot of time putting together 3D imaging systems and plans… and not a lot of time implementing them and keeping them in place. Ditto for my plans on exercise, dieting, and helping with laundry. My only resolution for 2012 is to post and re-read and re-re-commit to my resolutions of 2011 (and 2006-2010, minus that resolution to become a competitive hotdog eater).

 

After some thought and less than a week of reading the 2012 news, I did add a few more do’s and dont’s to my resolution list:

  • Do Occupy something before the movement has moved on (I missed the 60′s)
  • Don’t shank an easy Bowl game-winning field goal (or two in Stanford’s case)
  • Do work hard for every vote (they count in Iowa, not so much in Russia)
  • Don’t carry a loaded gun through airport security
  • Do expand Reveal to three or four locations (had to slip some work CBCT in here)
  • Don’t marry a Kardashian (especially the skinny one)
  • Do treat 2012 like it’ll be the best year in your life (just in case the Mayans were right)

 

Happy 2012! I hope your resolutions get more attention than dust!

 

Marshall & The Reveal Diagnostics Team

 

 

 

If you could see what I see…

A patient came in today for a simple implant assessment. Take a 3D scan, determine bone thickness and density for implants on 5 and 12, and send the pictures and CD to the referring doctor. I glanced at the pano (first image below) and thought it would be easy. I thought wrong.

 

Click on one of the pictures below and use the arrow (far right side of the picture) to navigate your own cone beam slide show. I highlighted the more interesting pathologies and concern areas. When you’re done look at the pano and ask how much you would have seen originally.

           

This guy looked great and was completely asymptomatic. Just like most of the patients who walk in each day. My New Years Resolution (along with hide sharp objects from Aimee) is to take a long look outside of the prescribed implant areas, just in case.

 

 

2011 Year in Verbatim

As we’re wrapping up 2011 and our first calendar year in the 3D dental imaging business, Aimee and I began collecting our favorite quotes of the year. None of the embarrassing ones were uttered by you, I promise.

 

“Seriously, you two are doing what?” – almost everybody at Patterson

 

“When you’ve gotten that out of your system, give us a call.” – everybody at Schein

 

“I’ll ask you for decorating advice when I want that men’s locker room feel.” – Aimee to Marshall

 

“I don’t usually take on fashion projects, but for you I’ll make a huge exception.” – Aimee to Marshall

 

“If I wanted this much abuse I’d stay home with my wife and kids.” – Marshall to Aimee

 

“You two ever consider couples counseling?” – Our CRT Darin to Marshall and Aimee

 

“I use my cone beam only after placing implants, mainly to see how well I did.” – Doctor who uses his cone beam only after placing implants

 

“Can you tell me how bad it is before you show me the picture?” – Doctor who had bad news coming

 

“What can I say about this case that hasn’t already been said about Somalia?” – Marshall delivering bad news

 

“Wow, 3rd world dentistry looks a lot worse in 3D.” – Doctor fixing work done overseas

 

“I’m putting an end to country music in the office. I think I’ve grown dumber for having listened to it.” – Marshall to our office manager Lindsay

 

“You’re right on the dumber part, wrong on the cause.” – Lindsay’s reply

 

“Our software is so much better… because… well, everybody just says it is.” – Sales person for software we didn’t buy

 

“The power’s out in the office. I plugged in both space heaters and was using the microwave. You know, this also happened the last time I plugged in both space heaters and used the microwave.” – Aimee

 

“And you thought this time would be different because…” – Marshall’s reply

 

“I got divorced for a reason.” – Aimee’s reply to Marshall’s reply

 

“You guys can say on your blog what doctors can’t for fear offending of the insurance mafia and the stingy patient!” – the one doctor who reads our blog

 

“I’m so glad I can stop by here and tell jokes that would get me sued in my own office.” – Doctor with great jokes

 

“Your face is beautiful… with all the flesh gone and just the bones left.” – Marshall trying to compliment patient

 

“Every dentist I’ve every worked with graduated in the top 1% of their class and truly the best in the city. It’s statistically amazing.” – Oral surgeon, who also graduated in top 1% of the class

 

“The closest I’ve gotten to dental school is the mandatory biology class in high school, but I did get an A.” – Marshall’s disclaimer when offering an opinion

 

“There’s almost no difference between screwing and implant into bone and a wood screw into wood.” – Doctor/carpenter on screwing

 

“I swear I’ll delete your calendar so you’ll have time to get that done!” – our office manager Lindsay to Marshall

 

“Actually I’ve had plenty of opportunities to get that done. I just chose to ignore them all, like ghosts or drunken relatives.” – Marshall on prioritization

 

“Would you mind stopping by for a quick CEREC question? The patient’s in the chair right now.” – Doctor in my building with a not-so-quick CEREC question

 

Patients’ comments when viewing their 3D skull and images:

  • “Why can’t I see my brain?”
  • “So that’s what I’ll look like when I’m dead!”
  • “Is that really me?”
  • “Yuck! Can you photoshop that?”
  • “Can I have this for my Facebook profile?”
  • “If insurance doesn’t cover this it must be good for me.”
  • “Can somebody buy a cone beam for personal use?”
  • “Can I have that for my fourth grade science project?”
  • “I felt my pineal gland move during the scan!”
  • “This office has really great psychic vibes.”
  • “You guys do CBT? No way!” (google CBT; it’s not Cogitative Behavioral Therapy)
  • “Am I in the right place? You guys seem way too happy to be in dental.”
  • “You four could be your own sit-com.”

 

We hope you make the most out of the last few days of 2011, and we look forward to seeing and helping you in 2012.

 

Sincerely,

The Reveal Team

Top Ten Reasons Your Dentist Hates You Back

A friend sent me a semi-hilarious list entitled Top Ten Reasons You Hate Your Dentist. I’m no dentist; I own a San Francisco 3D dental imaging center. However, I spend enough time with dentists (huddled around cone beam x-ray images or around bottles of wine) to empathize with their plight. So I wrote a response for that small 90% of patients who might not get it…

Top 10 Reasons Your Dentist Hates You Too

10. I’m a lot sorrier than you that you’re late. You’re upset there was a red light, dirty diaper, chatty boss, or trivial errand that prevented you from showing up on time. I’m upset I have an expensive staff and half million dollar office and equipment loan that I need to pay for, and we’re looking at an empty chair while you check Facebook one last time before leaving home. Now I have the ethical choice of treating you in half the time (with twice the chance of sacrificing quality) or giving you the full treatment and inconveniencing all of my patients and staff for the rest of the day. It’s a tough choice.

9. I am sincerely sorry you’ve been sitting in the waiting room for 30 minutes. You have a right to be upset. Direct that anger at the patient who showed up late (see above Reason 10) and take it out on him in the parking lot. Next time if you’re late and a patient punches you in the parking lot, you’ll know why. If you miss an appointment I may punch you myself.

8. No, you can’t pay me later when you have the money. You can’t buy a venti carmel frappachino without first surrendering $4.65 plus tax. I know you know this; I just scraped six months of Starbucks film off your teeth. By the way, a daily Starbucks adds up to $1,300 per year and causes tooth decay. You somehow found the money to cause the double-shot non-fat extra-whip problem; you can find the money to fix it.

7. I know you’re in extreme pain and you feel it’s a do-it-right-now emergency. In your mind this probably has nothing to do with my recommendation last month of “do it right now or you’ll be in extreme pain.” In my mind it’s a lesson, and at 10pm on a Friday it’s also annoying. Did you think I was joking when I showed you the ginormous cavity on the x-ray, or did you think I’d rather miss my kid’s ballgame and see you on a Saturday? Go medicate yourself and pray my kid wins the game so I’ll be in a good enough mood to come in early Monday morning.

6. I didn’t break it, and I don’t really care who did. If your tooth is broken it’s hard to claim it’s not your fault with a straight face. If you try I may leave your face crooked. More to the point, I don’t care unless I ask (and I won’t). If it’s your tooth in your head then it’s your responsibility and you’re paying to get it fixed. Don’t think that because I placed the crown twelve years ago or put in a filling two teeth over that suddenly I’ve insured your whole mouth for life. Or if you think it, don’t every say it. I’m the guy holding very sharp things near very sensitive places.

5. Yes I know you can get this service cheaper somewhere else. You didn’t think I knew about the 19-year-old down the street with the semi-legal dental license who offers $195 crowns? I pay my lab more than that for the crown. The cheaper guy pays $19 for crowns that were used car parts in a Chinese junk yard last week. He also spends 12 minutes on the total procedure; I spend an hour and a half. I’m sure my quality and his are comparable to apples and asphalt, but since that doesn’t matter I suggest you call him on your iPhone 4Gs then hop in your Mercedes SL and go see him to save a buck. In addition to tattoos, car seats, and airport security, your health is a fine thing to bid out to the lowest bidder.

4. Of course there’s another, better treatment to what I suggested. I based my opinion solely on a long and ongoing education and lifetime of experience, but I understand you’re looking for something faster or cheaper or less detailed. Let’s extract the tooth. Yes, Plan B is to yank the whole tooth out of your mouth and it will never bother you again. That’s dentistry in most of the world and you seem like a worldly person. Would you like me to do it, or do you have pliers at home?

3. You treat my bill like it’s the decaying filth I just spent an hour scraping out of your mouth.  Do you really think I’m stealing your retirement savings so I can buy a third vacation home on the French Riviera. I’m lucky I can afford a croissant. I came out of dental school with $300,000 in debt and then paid another $500,000 to buy and modernize my practice. My staff refuses to work for free, the landlord demands rent, and I have foolishly decided to buy thousands of dollars in brand new disposable items for each operation–when recycling cotton rolls and gloves and needles would lower the cost for everybody. You’re paying a very fair price so smile with those teeth I just fixed.

2. You’re really upset insurance isn’t paying for all of it? What about my feelings? I’m King-Kong-with-dandruff furious that insurance is forcing my fees down to those of a semi-retired dentist/goat herder in North Dakota, while forcing me to hire an employee just to decrypt the codes for submitting eighty-one forms to get my meager insurance reimbursement four months from now. You suspect insurance is short-changing you, but I know it’s fleecing me. Yet somehow you believe the shoddy contract between your employer and a multi-billion insurance company is my fault.

1. Wow, I hurt you. I did it intentionally because I became a doctor to hurt patients rather than help them. I only blew a puff of air on your diseased gums and  exposed tooth roots… and I’m the one causing the pain? That’s like blaming the nasty hard telephone pole for ruining your car, as you were driving 20 mph and 1.2 blood-alcohol over the limit. Introduce your mouth to 1870s technology: brush and floss. Then I won’t hurt you as I try to repair years of oral neglect.

I know you hate your dentist. It’s mutual. I’ll see you next week for your appointment. And thanks again for your referrals.

 

 

Monday Morning Mystery Case (priceless)

When this patient called to reserve a 3D scan, I thought it was a creative joke. When the patient arrived, I thought it was just creative. Actually the patient didn’t phone. The patient wasn’t alive.

 

A representative from the international auction agency Bonhams arrived with a 12″ x 12″ x 4″ sealed wooden box that hopefully contained a rare and snazzy Winston Churchill edition Montblanc pen. How snazzy? The barrel is crafted of 18 karat pink gold, inlaid with black and brown tortoise shell lacquer bands. The captop is ringed with 53 diamonds (to commemorate the year in which Churchill was both knighted and bestowed the Nobel Prize for Literature), and the Montblanc star is of mother-of-pearl. Really similar to the Reveal Diagnostics pens I give away to 3D dental imaging clients…

   

 

The pen is valued at $25,000 if it’s still in the sealed box. However, Bonhams needed to confirm the right pen was actually inside the box to ensure their seller was honest and their buyer would remain honest after taking the box home.

 

We tied the box to the chin rest of our CBCT and took a 3D x-ray scan. The cone beam image revealed a mint condition Winston Churchill Montblanc. The Bonhams agent was happy.

 

I wasn’t.

 

The 3D scan showed a pen that looked a lot different than the dozen Montblanc pen collection I’d purchased for three monthly installments of $19.95, plus shipping and handling. Still, the rare Montblanc pales (in utility and value) in comparison to my James Bond pen!

 

Monday Morning Mystery Case

Even before the 3d cone beam scan, this problem wasn’t much of a mystery… but treatment options were.

 

If you guessed the patient has a periapical lesion on ECT #2, you’re a winner! The bonus question is whether to retreat and keep the tooth, or extract it. The patient really wanted to keep her tooth and the doctor really wanted to see what he was dealing with, so they both showed up at Reveal Diagnostics. After a quick 15-second 3D dental imaging scan we had the below sagital (buccal) view.

 

This view only shows one dimension of the area of interest. True, the CBCT image bisected the buccal roots and allowed a better view of the abscess, and the cone beam image revealed previously hidden pathology in the maxillary sinus. We have more data than when we started with a 2D pano. However, one plane does not tell the whole story or answer the main question. Namely, can this ECT tooth be re-treated with a reasonable expectation of success? Before you pounce on the slippery definition of “success,” look at the 3D image from all three angles below.

 

The coronal (cross-section) and axial (top-down) views show the patient has no cortical bone on the buccal side of #2, not even at the root apex. In addition, only about 1mm of bone remains lingually and to the maxillary sinus cavity. Upon seeing these 3D cone beam images, the referring doctor decided to extract the infected tooth. I won’t judge if it was the right or wrong decision, but I will say the doctor’s judgement was based on as much 3D diagnostic information as possible.

Occupy My Street

We’re now two months into the nationwide Occupy Wall Street-palooza! Although there’s only the Wall Street in New York, and most of the greedy million-dollar-bonus firms have long since moved away, people from Santa Rosa to Salt Lake want a piece of the action. That includes me. I wasn’t alive during Woodstock and Burning Man is too far of a drive. Plus I love s’mores. So Saturday afternoon I packed my Eddie Bauer and North Face camping gear, grabbed plenty of Evian (at $6.90 a gallon), and hopped in the Prius to drive 1.2 miles to Occupy Palo Alto. I was most concerned about parking, as the campout probably coincided with another art and wine festival. Hopefully there would be valet nearby…

Then my wife caught me. Ashley knows I only clean the garage when looking for Christmas presents, so any pre-December rummaging signaled something bad. She stopped me in the driveway and verbally thrashed me.

Ashley: Hey, sweetie. Where are you going?

Me: To Occupy Palo Alto!

Why?

Because… it’s time to occupy!

Storm the castle, that sort of thing?

Exactly!

And what do you hope to accomplish after you take the castle?

I tried to envision a castle on University Avenue; I suspected she was being allegorical… or just female. Few women I know appreciate a good castle storming (or movies about it), and my wife obviously enjoyed mucking it up with questions about motive and purpose.

Ashley (laughing): You know this movement is about economic inequity.

Me: Exactly! And thanks for the prompt.

And about lack of a political voice.

Exactly again! You’re good at this.

So why don’t you work harder on your 3D x-ray business to earn more money, and vote to change the politics you don’t like?

I waited for a moment, hoping this was a rhetorical question and wouldn’t require much thought or response. It was a long wait. I finally answered in a very un-castle-storming voice.

But I like camping and s’mores and protesting…

Then invite your fraternity friends over and pitch tents in the back yard. That will be easier on everybody.

So I did. And it was much easier! At s’mores time my daughters even joined the protest, which devolved into a protest over limiting their chocolate intake. At the end I appreciated Ashley’s helpful protesting suggestions. We didn’t actually storm a physical castle, but I also didn’t have to worry about parking.

Monday Morning Mystery Case

This Frankenstein of a patient is near and dear to me; she is my business partner Aimee. She suffered late mandibular bone growth in her mid-20′s, especially on her right side. Her surgery included, among other procedures, the filing down of her right mandible to reach better symmetry.

 

Post surgery she experienced periodic numbness and shooting pain down the right side of her neck. The above left photo shows Aimee’s post-op 3D scan. The above right photo shows that her beauty isn’t just bone-deep.

Now for the cause of that recurrent pain… if you clicked on the above 3D image to enlarge it, you probably saw the culprit. However, we prefer to show these cases from different angles to make it obvious and for patient education.

 

In reshaping the right mandible (done before 3D cone beam scans were invented), the alveolar nerve canal was actually bisected and the nerve is now exposed. When this nerve rolls outside of the remaining half-canal, the stretching/pinching effect causes the numbness and pain.

I told Aimee that she’ll be pain-free if she just stops talking. Now instead of verbally abusing me she throws things!

Goblins, Ghosts, Ghouls, and Dentists

Tonight my four-year-old Riley will dress up as Little Bo Peep and my two-year-old Jordan will be a sheep. Riley has been practicing with her hooked staff for weeks. I expect Riley-Peep to professionally herd Jordan away from all dangers seen and imagined. Yet the biggest dangers will remain unseen and both girls–along with all kids nationwide–will fall victim to their twisted group scheme.

 

These sinister Halloween horrors are dentists. The diabolic scheme is Halloween itself.

 

Years ago I was exploring a secret underground passage that connects UOP and UCSF; I was looking for a lost treasure of CEREC blocks, hidden by the Templar dentists. I discovered a crumbling parchment written in Aramaic. (UOP’s restorative department still uses Aramaic in its treatment planning; they’re slow to change.) This document detailed an ongoing plot to boost dental production by promoting dental decay. For centuries dentists have been in league with bacteria! These supposed health care providers give unsuspecting children (and their chocoholic dads) ridiculous quantities of candy one night each year. Sticky caramel, pocket-producing tootsie rolls… dentists even sadistically named one brand of production-boosters “jaw-breakers.” Evil!

 

Tonight as I watch the beginning of the end of my daughters’ enamel, know that I’ll be looking for you dentists responsible for this. And I’ll be wearing a mask.

 

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