TMJsurgeon.com….Difficulties in obtaining TMJ surgical care in the United States, Part II

When President Clinton was running for election, his campaign adviser, James Carville, always reminded him to focus on what the public was most interested in, always reminding him: “It’s the economy, stupid!”  That was nearly 20 years ago and things have intensified to be sure.  Let’s look at some basic economic facts about why a patient may have  trouble finding an oral and maxillofacial  surgeon  (OMS)  if they have a problem that has gotten worse and they feel they require surgery because non surgical treatment has run its course.

There are two words that summarize the practice and economic state of affairs in oral and maxillofacial surgery (OMS)….”dental implants”. 

 These are remarkable devices capable of solving many difficult dental problems or tooth replacement issues that  people have had …with few options for improved function….through the years.   For those who argue the US leads the world in medical technologic creativity and advances…..well they have missed the boat on this one…..as the prototype R&D and development goes to …..well…….that honor goes to Sweden and to an orthopedic surgeon no less,….not a dental researcher. …..that’s right…..something that has revolutionized a major aspect of American healthcare came from…..yes…….another country.  Inventive American manufacturing changes have simplified various dental implant systems to the degree that they are so excellent now that today’s systems can also be placed by generalists and other dental surgical specialists in a dental office setting.  Think of it…..a major advancement in this country that was created out of a country with socialized health care….@#%&   !!!  Wow, how could that have happened ??!!

If one looks at what  current basic free market supply/demand forces (and complimentary insurance company set fee rates ) will compensate a contracted dental provider to surgically place a single dental implant….one that replaces a single tooth ….those fees for compensation range from $1704   to $2010..(cost of the implant the provider pays is roughly 1/4 to 1/3 of the cost).depending on the insurance company( and the regional marketplace….these ranges are for the writer’s  market).   This is a procedure in skilled hands that can take 30-60 minutes tops depending on the tooth being replaced  and other factors that impact degree of difficulty to perform.  It can be done conveniently in a private office setting with minimal bureacracy compared to a hospital setting. It is generally fee for service which at best means the office will as a courtesy file a dental insurance claim, but the patient will pay the fee and be reimbursed by the insurer or doctor when the insurance portion is paid.  There are some but very minimal risks compared to….let’s say performing a total jaw joint replacement,  skeletal jaw or orthognathic surgery,  or other major maxillofacial surgical hospital based procedure and paid for as a “medical” expense.  Removal of a set of  impacted teeth, the bread and butter procedure of an OMS (like tonsils, adenoids and ear tube placement for an Ear, Nose, Throat physician) can parallel the insurance compensation for placement of a single dental implant.  These are services that are not paid by Medicare or other federal services…..entrepreneurs with ideas of improvement and a competitive capitalist model among manufacturers of dental implants have now made a product that the public has benefited from….and now actively seeks……particulary when dental esthetics/and functional improvement for people compared to removable dentures replacing teeth,  etc.

On the other hand, medical/surgical fees for services for physicians/providers are set in one way, shape, or form by the US government.  The government, through Medicare sets base rates.  Insurance companies  borrow from these Medicare base rates and base  their medical fee payments to doctors on  this system that is called a relative value system…..that is to say, groups of people in a think tank once got together, created a point system that scored things such as degree of work anticipated that would be required, technical difficulty, time to accomplish the task, risk of procedure, need of a specialist to perform , and a host of  factors…..starting an IV and administering medications carries a relative value…..performing open heart surgery has a relative value number…..  A number is created and multiplied by a standard dollar amount  multiplying  factor….and presto, a magical number/fee is produced that reflects what a bureacracy (non active patient managing human beings …or someone like an actuary) thinks a procedure is worth.  Insurance companies, borrow this data from Medicare, and increase the fee by a percentage, say 20-35%….to determine their fees to be paid for care.    The increase is necessary to lure doctors into participating in a “network”  so as to allow insurance companies to sell their products in each of the states or to employers providing healthcare benefits…..a “network” has to be created to assure governmental regulators that the insurance company has the manpower to deliver the health care that they….as a profit motivated stock company…..can sell to employers or individuals.  Currently, one of the  suggested solutions to pay for healthcare in this country is to decrease payments to doctors by 20%…..and this is a fundamental aspect of the solution that Obamacare offers the country for healthcare cost containment…..so an artificial system is always vulnerable to continued manipulation in order to control costs….this represents a socialized concept of health care delivery…..there is no free market….and hence, no competition…..it is impossible to implement otherwise…..because the government is the originator of the logistics of the system in the first place. 

The Medicare relative value for a basic arthroplasty  (procedure to correct a TM joint which is painful and chronically locks to where the patient can not open the mouth to eat….or it gets locked in the full open mouth position ) of the human jaw joint is approximately $1120.  This is a procedure generally done under general anesthesia, in a hospital or surgery center . Depending on degree of difficulty, the procedure can take up to 1.5-2 hours to perform, the doctor will be away from his/her office for at least 3 hours.  These procedures are not covered under dental insurance, as dental insurance is restricted to tooth related work of some sort. ….and payment for such services is paid by the government or an employer out of medical insurance funds.

For a total joint replacement of the human jaw joint, the Medicare limit (For Medicare payment) that a doctor can charge is $1704.  This is an extremely complicated and precise surgery, it involves two separate external to the mouth incisions, is a hospital procedure…..and few surgeons have the desire or assumption of the responsibilty to perform…..it is a much longer and more difficult procedure than an arthroplasty as well….and the government “rewards” this complexity on a par with placement of a single dental implant placed by any dental provider…..in a dental office.

It is no secret why patients have trouble finding a  provider willing to perform TMJ surgery…..During the past 10-15 years, OMSs have been leaving the hospital environment because of these reasons……when the government deems that performance of surgeries such as this is on a compensation par with placement of a single dental implant for replacement of a single tooth…..it does not take a PhD graduate from Harvard Business school to connect the dots relative to choice of business/surgical risk model in decisions concerning agreement to perform certain procedures….or how that doctor would choose to make his or her living.    Plus, with the anesthesia training that OMSs receive in residency….it is the only  surgical specialty where the surgeon himself has had anesthesiology training in residency….hence, there is no need for a hospital based practice when the doctor takes a financial hit to perform procedures there…..the logical and rational choice is to make his/her living in what the  insurance and government controlled  marketplace  forces he or she to do.  

The OMS, in the majority,  is the  only surgical specialty with  surgical training for management of orthopedic disease or dysfunction of the jaw joint.  With such discrepancies and lack of logic relative to reasonable compensation performed by the few providers who do this work….it is no secret why an experienced provider is hard to find.

This is a crash course in healthcare economics 101 for American Society…and we have talked about only one situation impacting a small area of healthcare…..every medical  surgical specialty has comparable situations in its field that mirrors issues like this that have evolved in American healthcare……so multiply this many times over and presto…one has the chaos that is known as the American medical  healthcare economic system.  Is it any wonder that skilled specialist providers of all types are no longer willing to perform very specialized work, leaving their surgical specialties, retiring or changing or modifying their careers and choosing to simplify their personal and professional lives?

For US citizens, consult the web site of the American Society of Temporomandibular Joint Surgeons…ASTMJS.org for a list of providers who welcome patients with these needs.  These members are a mix of institutional (University)  and private providers who continue to welcome patients and who can be assured that they are seeing a provider with significant experience in this field.  They are also individuals who are committed to this area and providing these hard to find services.

Tags: Healthcare in US, TMJ Surgery