Four years ago, twelve-year old Deamonte Driver died of a toothache. Extreme neglect had led to an abscess that spread to his brain and killed him. The Drivers were a desperately poor family in Maryland that had trouble locating an oral surgeon who would work for Medicaid rates.
But rich, poor, or somewhere in between, regular dental care has declined as out-of- pocket costs have risen during the Great Recession. But few people know that good dental care can be the key to good overall health. According to the Mayo Clinic, a full menu of diseases can result from poor dental care, including endocarditis (an infection of the inner lining of the heart), cardiovascular disease (clogged arteries and stroke may be linked to oral bacteria), and premature birth and low birth weight babies, to name a few.
In the months after the Wall Street crash of 2008, Dr. Aziza Askari faced her own financial crisis. Patients in her the Farmington Hills, Michigan, dental practice began to ask for refunds on pre- payments for planned dental work. Askari honored their requests but wondered what was going to happen to her practice. “It was hitting us from everywhere,” she said.
To save the practice, she focused on holistic treatments and expanded into sedation dentistry – in which anxious patients are relaxed before the drill begins to whirr. Along with a hefty investment in laser technology and digital X-rays, this appealing change broadened her client base. She advertised her new services, which grew to 10 percent of her practice’s costs. Despite the expense, offering this mix of services without raising prices for customers was necessary to survive, she said. “It kept us afloat. If not, we could be down 50 percent or close to it.”
There's no doubt that fewer Americans are choosing to go under the drill. A recent poll of 1,000 Americans conducted by Empirica Research for Brighter.com, a dental discounter, found that 74 percent of respondents said they only go to the dentist when there is a problem; nearly one-third who did not have dental coverage said they’d been to the dentist “only once” or “not at all” in the last 10 years; 73 percent without coverage said they had delayed care due to fear of costs.
For those who skip regular dental visits, like Deamonte, the long-term costs can be alarming. In his case, after two operations and six weeks in the hospital, the bill was more than $250,000. But even less dramatic dental neglect can cost a bundle: a $125 cavity filling can result in the need for a root canal or crown down the road, or even a dental implant, which can costs thousands.
benefit has remained capped
at around $1,000-$1,500
for the last four decades.
Americans spent a total of $102.2 billion on dental care in 2009, down slightly from 2008 as patients pulled back. For those who do visit the dentist, costs are continuing to rise. Annual spending for dental care is expected to increase 58 percent in the next seven years, according to a 2010 Pew Center on the States report.
While dental care is only 4.3 percent of total health costs, consumers are paying more dental bills themselves.
A 2009 report in the New York State Dental Journal showed that while 10.3 percent of physician costs, 3.3 percent of hospital care, and 26.8 percent of nursing care expenses were paid out-of-pocket in 2007, 44.2 percent of dental bills were paid out-of-pocket.
In addition, the cost of dental insurance has risen annually over the last decade at a rate of 4 percent to 7 percent, depending on the level of coverage, according to consultancy Aon Hewitt. Yet the average annual dental benefit has remained capped at around $1,000-$1,500 for the last four decades. This is also causing fewer Americans to buy dental insurance. The most recent report by the National Association of Dental Plans reveals that 166 million Americans were covered by some sort of dental plan at the end of 2009, down 10 million from the year before.
Even for Americans that are covered, many dentists have stopped taking state-provided insurance like Medicaid and some have stopped accepting insurance altogether. Dr. Robert Minch, a dentist in Lutherville, Maryland, said he does not take dental insurance to avoid dealing with low reimbursements. Instead, he said he’s offering more elective procedures such as Invisalign braces and veneers because they are not covered by insurance and therefore more profitable.
is a crown is a crown, but they’re not...
It’s like comparing the Ritz-Carlton
or the Hilton to the Motel 6.”
An American Dental Association survey released in August underlines a struggling industry: nearly 39 percent of dentists saw their patient billings decrease in the first quarter of 2011. In addition, only 16 percent of dentists added to their patient base, while the rest stayed the same or had a decline.
There is also a huge variation in dental costs and access in the country. People in rural areas, the poor, and minority communities are suffering from a severe lack of dentists, said Cathy Dunham, the executive director of the Children’s Dental Health Project, an advocacy organization. Costs for many procedures also vary greatly. The cost of a dental crown can be anywhere from $600 to $1,800, depending on the type of material, where it’s made, and the experience of the dentist. “We’re talking apples and oranges,” says Dan King, the marketing director of the Atlanta Center for Cosmetic Dentistry. “A lot of people think ‘a crown is a crown is a crown,’ but they’re not...It’s like comparing the Ritz-Carlton or the Hilton to the Motel 6.”
to his Atlanta practice had gone
from a 'fire hose' to a 'garden hose.'
To cope with the changing industry, many dentists are offering cosmetic procedures, but in the past few years, cosmetic dentists have been some of the hardest hit. “A few years ago, you had people taking second mortgages or using their credit cards to pay for procedures. That easy credit has dried up,” said Dr. John Sullivan, president of the American Academy of Cosmetic Dentistry. King said the flow of customers to his Atlanta practice had gone from a “fire hose” to a “garden hose,” but that the practice held up its bottom line by halving its staff.
Askari faced the choice that confronts dentists around the country: either invest in expensive new equipment to expand the procedures offered or risk a “race to the bottom” on price for basic services such as teeth cleaning and cavity filling, which could lower the quality of service.
“It really is a tale of two cities,” said Bassim Michael, a CPA who works with more than 30 dental practices across the country. “The practices that are doing well are the ones that are very growth oriented,” Michael said. “They’ve put more money in marketing, and they’re investing in new technology.”
The low end of the dental market is served by discounters such as Brighter.com, a website that includes 25,000 dentists who offer reduced price services, such as crown work that would normally cost $1,340 for $595. Aziza Askari, the dentist from Michigan, said such “rock bottom” prices make it extremely hard to remain profitable and requires a practice to have very little overhead.
Robert Minch, the dentist in Maryland, said discounter services fill a niche, but it’s also important to keep in mind that dentists are running businesses and have fixed costs they need to meet. The cheaper the care, the more likely some corners will be cut.
“Dentistry is a labor-intensive operation,” he said. “It’s hard to do it on a heavily discounted basis. You’ll likely get heavily discounted work.”