MANAGED CARE ISSUES
The influence of “managed health care hat changed many aspects of dentistry. This In the doctor-patient relationship and the way decislonsatil . made regarding which treatment alternatives are most appropriate. Dentists are often .placed in the middle of a conflict between a desire to provide opti mal treatment and a health care plan’s, willingness to approve approriate, ‘needed care. , Traditionally; the patient chose whether to elect a compromised treatment plan or even no treatment. Under managed care, however, some patients are being forced to accept compromised tr’eatment or no treatment, based on administrative decislons that may be driven more by cost containment pressures than sound dental judgment.
. In some cases a “gag provision” is included in a dentist’s contract with a managed care organization. This prevents the dentist from criticizing managed care organizations and sometimes prevents a dentist from presenting an alternative for care not covered by the third party
provider. This obviously creates a conflict between a contractual agreement with the company and the ethical and
professional responsibility of the dentist to the patient. In 0some states this provision is illegal and unenforceable. In 1995 the American Dental Association (ADA) Council on Ethics, Bylaws, and Judicial Affairs issued the following statement underscoring dentists’ obligation to provide appropriate care: Dentists who enter into managed care agreements may be
called upon to reconcile the demands placed on them to contain costs with the needs of their patients. Dentists must not ‘allow these demands to interfere with the • patient’s right to -select a treatment option based on
informed consent. Nor should dentists allow anything to interfere with the free exercise of their professional judgment or their dutyto make appropriate referrals if indicated. Dentists are reminded that contract obligations do not excuse them from their ethical duty to put the patient’s welfare first.2 Dentists may have a responsibility to advise patients
that a “comproised” treatment plan has been approved by the managed care organization. The dentist should seek the patient’s’ consent to provide such treatment after the pertinent risks, complications, and limitations have been reviewed, along with an explanation of more optimal treatment options. Dentists should consider advising in written form both patients and third party payers of reasonably expected outcomes when the appropriate
treatment is not available because of improper decision by third providers.
Telemedicine, Electronic Records, and the Internet.
Recent technologic developments have induced changes associated with medical and dental practices. The increasing popularity of computers and the Internet has given birth to new potential duties and liability concerns. Digital imaging and radiology, combined with the Internet capabilities for communication and even video conferencing, has created situations where patients may receive advise without the traditional doctor-patient interaction. The conversion to electronic rather than paper charts is a growing technology, with many potential applications for a modern dental practice. A dentist’S legal duty to a patient is currently linked to the existence of a doctor-patient relationship. Determind Ing whether this relatlonship exists, however, is no longer a simple task. The advent of internet marketing, telemedicine and other modes of providing information
or advice through an electronic media, without the direct ability to examine, diagnose, and recommend treatment, has clouded the issue of whether a- doctor-patient relationship (and a legal duty owed to a particular patient) exists. Courts in several states are beginning to make decisions that may provide some guidance. related to these evolving issues, although controversy, still exists. For example, a recent court decision has determined that a physician who consults with a treating physician over the
telephone owes no legal duty to the treating physician’s patient when treatment options were relayed during a telephone call.’ However, another court recently ruled that a doctor-patient relationship could be ‘implied when an on-call physician is consulted by telephone by an emergency department physician who relied upon the consulting physician’s. advice.”
Defining clear rules that can be relied upon by practicing dentists who provide direct or indirect advice over the telephone, Internet, or through web sites, will not be an easy task. Many questions remain unanswered. Do the laws of the state in which the patient lives or those in , which the dentist practices actually.control this issue? Is the dentist practicing dentistry in another state without a license? Is the advice offered by electronic means intended for general information and not intended to be relied upon by patients or the treating dentist for specific care? Will the electronictransfer of the information such as the patient’s chart or billing information violate state or federal privacy laws?’ Can the dentist protect the information from manipulation or misuse if sent electronically? Over the coming-years it, will be extremely important for practitioners to monitor trends in dental care as the Internet, information storage and transfer, and doctor patient relationships are affected by advancing technology. Current federal rules governing the electronic maintenance and transfer of records are provided in detail in the Healthcare Insurance Portability & Accountability Act
(HIPPA). SUMMARY In addition to providing sound technical care, the dentist