Hi and welcome, or welcome back. You are listening to the Perio Patient Podcast, a podcast for my patients and anyone else who cares to listen. My name is Dr. Ben Young and I am a periodontist in private practice in San Antonio, Texas. This is Episode 101 and the title is How Much Does It Cost?
Today’s topic is broad and challenging. But if you stick with me through this presentation, I think I will be able to help you work through the issues and concerns you are facing right now. What treatment recommendations make sense, or are a good deal, and what treatments may not be in your best interest? What I cannot do — and I want to be upfront about this — is to give you some specific dollar amounts, because frankly there are too many variables for that to be helpful. However, I will give you a few ball-parks to help you understand cost in relative terms.
To begin with, the cost of care, and in my case, care for gum disease or the surgical management and placement of dental implants, impacts me as a provider as well as you, the patient. For this reason, I am going to give you my observations, both as a provider and a patient – and in this context, dealing with money – a customer. And even though there is a specific focus to this discussion having to do with my area of healthcare, because it is what I know best, I believe it might be helpful to all of us in a broader context both in the area healthcare as well as economics in a more general way.
Here is one of the biggest mistakes I find people making in attempting to determine what treatment option is best for them. They jump to wanting to know cost rather than first understanding what exactly the problem is and all the logical treatment options there are to correct it. Our health can’t be boiled down to a math problem and paying someone to fix something on or in our own bodies without insisting that it be explained to us clearly first can result in more unnecessary cost and problems later – which, incidentally, is a good reason why you might want to list to some of my earlier podcasts. The more information you obtain, the easier it is for you to be able to make good decisions with regards to your health.
I understand that it is not possible for a patient to have as much information about this topic as I do – even if they Google the topic – unless they themselves are a dentist or periodontist (and I have treated my share of both). But this is no excuse for us providers to not patiently answer questions until you are comfortable making your decisions as to what care you wish to receive. Certainly, this is a team effort, and I do rely on my office team to help me explain treatment options as I lay them out. But the buck stops with me, and if they can’t answer your questions, they will come to me to provide more information, if I can. In addition to this, you, as a patient, can certainly choose to obtain other opinions from dentists and periodontists. Does a treatment recommendation make sense to others who do the same or similar things?
In a moment I will lay out my reasons for why the initial treatment of most periodontal disease should be using LANAP — or Laser Assisted-New Attachment Procedure – and cost and affordability are two big ones – but first, let’s talk about dental insurance.
My experience with dental insurance – and I have discussed this on earlier podcasts, so go check them out – is that they are complicated and confusing on purpose. Unlike providers, they really prefer customers simply accept their behavior. And many do. To some extent, this is reasonable, especially if the insurance comes as part of an employment package. My personal default is to not want to get into the insurance weeds, however, we all need to understand a few things about insurance, as it relates to the cost of dental care.
• There usually is a co-pay. This is money you will pay on the front end before the insurance pays anything.
• You are paying for the insurance through hidden fees. Whether the policy comes from your workplace or you purchase it yourself, there are fees you will pay to the insurance company whether or not you ever use the insurance.
• The difference between insurance policies comes down to the money supporting the particular plan. Low funded, or cheap, insurance will not cover what better funded, more expensive, insurance will. Either way, the insurance company has designed their programs in such a way that the company will make money whether or not people obtain dental care. In fact, the insurance company is happy when they can make the process so difficult that you elect not to obtain dental care at all. Later, when you need more dental care because you have neglected yourself, you might think that your insurance, since you have not used it, or that you have many insurances, will cover the costs. This is likely not going to happen because every year the coverage starts over. And multiple insurances play off each other deciding who pays first and who then pays little. Dental insurance is not a dental savings plan.
• Because dental insurance is not a single policy known by all, they can put into the fine print what they will or will not cover. These are dental codes. Patients do not understand what the codes are which places them at a disadvantage. For example, here’s a good one. One dental policy did not cover the cost of a periodontal examination but did cover the cost of scaling and root planing – a non-surgical treatment for periodontal disease. The fact that they did not cover the cost of the examination meant that it would come out of the patient’s pocket. And if they did not have the examination they did not qualify for the treatment. To many patients, the fact that their policy would not cover the examination necessary to document the need for treatment kept them from obtaining the treatment they needed to stop the progression of the disease.
• Insurance policies have maximums that, when reached, result in the patient having to pay the rest out of pocket. This is important to understand as I describe the cost of LANAP.
• Finally, when many insurance companies issue reports to patients, they use terminology intended to imply that the dental care someone is receiving is too expensive or even inappropriate. The most popular phrase to imply this is “Usual and Customary.” This was made up by the insurance industry and has nothing to do with quality care. It only has to do with cost tables that they keep themselves and can manipulate to imply anything they wish to imply. Here is a way to understand this. If it has to do with your health, rely on those in healthcare, not insurance. If you have a legal problem, rely on those in the legal profession, not healthcare or insurance. In other words, don’t cross over to using a company involved with covering expenses to give you advise on what is best for your health.
Now let’s talk about the cost of LANAP. To begin with, insurance companies do not cover it because there is no dental code for this particular procedure. For years, I followed the recommendations of my LANAP instructors to write my treatment entries avoiding the word “laser” and then taking the periodontal surgery code. This tells you that this problem with LANAP and insurance predates my involvement. The problem with this is that the periodontal surgery code, also known as osseous (meaning bone) surgery requires that a surgical incision be accomplished followed by moving the soft tissues away from the bone. This is unnecessary when using a laser. The justification I was given at the time was that the laser went down to the level of bone making it osseous sort of, but again, this is an interpretation of a very clear definition that states scalpel incision, flap to expose the bone, and then closing with sutures.
There is nothing worse than having a patient accept care believing their insurance company will cover the procedure only to have the insurance reject coverage. The implication, when this occurred was that I had done something wrong. I chose to treat the patient in a way that the insurance company did not approve – when, in fact, I had chosen a better, easier, simpler, less painful, faster way to treat patients than what the insurance company would cover. Remember, I told you the insurance companies like complicated. This is a great example. People who wish to have their periodontal disease “covered” by dental insurance, often end up either not completing care, because the insurance money runs out – which also means the disease processes that result losing bone around teeth continue – or they pay more out of pocket than they would have if they had paid my discounted fee upfront for LANAP.
One day I was talking with an Oral Surgeon friend who was describing what he was doing in order to avoid using dental insurance. He was simply posting his fees on his website. This then enabled patients to look at his fees and compare them with the cost elsewhere even when using dental insurance. The result was and still is that his fees were much lower because his administrative costs were lower. He didn’t have to have employees working full-time trying to get paid by the insurance companies, and he passed these savings on to the patients.
I have modified his plan. If I am a provider for a particular dental insurance company, and they cover the codes, I will work with them. This is because I understand that people are on dental insurance and would like to, therefore, use the insurance as much as possible. This is fair. However, on the one procedure, LANAP, where they do not cover it, I lower my fees to be less than osseous surgery codes. Now, once in a while, someone will call back and say they spoke with their insurance company and they say they will cover the cost. Wonderful. We routinely submit the treatment I provided. If it turns out that in this particular case, the insurance company will cover the cost, we will certainly make the appropriate adjustments. I’m not sure this has ever happened but will be happy for you if it does.
Another reason the LANAP approach to care is more affordable compared to osseous surgery, is that often these other procedures involve additional surgical enhancements, like bone grafting and membranes placed in attempts to improve outcomes. The problem is often they run up cost but do not result in any better outcomes. The use of the soft tissue BioLase Laser (NdYAG) that I use kills the bacteria causing the problem – and I use it throughout the mouth regardless pocket depth, and then in the deeper pockets, following mechanical removal of deposits produced by bacteria on the roots, the bone in the area is stimulated by the laser to begin to regenerate and repair. This is done specifically where the problems exist. Every osseous surgery involves more tissue than just the problem area. Healthy soft tissue are a part of the surgical field and will be subjected to wound healing even though they were healthy to begin with. In other words, the stimulation of the laser in the specific problem area, avoids the needs for bigger surgeries that take longer to recover and also the need for additional surgical codes for surgical enhancements like bone grafts and membranes that run the costs up.
So, once again, back to the original question. How much does it cost? If someone is attempting to recover from untreated periodontal disease, the LANAP method is the least expensive, most predictable option I have found for the following reasons.
• The LANAP procedure in my hands can usually be accomplished in one appointment. The total number of visits in the first six months for the treatment of full mouth chronic periodontitis will be a total of five. The first is the examination visit. The second is treatment. The third is a follow-up check, the fourth is a light cleaning in three months – often with the dental hygienist in the general dentist’s office, and the fifth visit at six months will be to remeasure the pockets and determine results. The question at that point will be, how can we best manage care going forward? Hopefully we will be able to minimize active treatment like this in the future. General health and the extent of the disease at the start will play a role in how much on-going care will be necessary.
• Now, let’s compare treating generalized periodontal disease in the classic conventional manner. How many visits can someone expect? The number of examination visits will change from two for LANAP to three. Treatment visits both non-surgical and surgical will increase from one for LANAP to around 4-6. Following each surgery there will be some 1-3 post-surgical visits as well. So, for the five standard dental visits common under LANAP over six months, conventional care will run longer, possibly a year or more, and likely involve between 10-15 visits. And let me add, somewhere along the line the insurance reimbursements usually run out. This means it is very likely, even with insurance paying a part of it, the patient will pay more out of pocket for conventional care compared to LANAP as I provide it.
• Now some ball-park numbers. I am generally hearing that conventional periodontal active therapy is running around 4-6 thousand dollars. This is the same for LANAP when insurance codes are being used. My fees for LANAP are half this.
Now let’s switch for just a moment and talk about dental implants. What do they cost?
• First, check your insurance policy. Do they even cover dental implants?
• Remember that the cost of a dental implant includes a surgical phase as well as a restorative phase. Make sure you get the treatment costs for both.
• Obtaining a Cone Beam Computer Tomography or CBCT before placing any dental implants is critical in my opinion. Also, make sure there is a dentist ready to restore the dental implant before permitting a surgeon to place one. There needs to be coordination between the two providers. There is a cost to obtaining this CBCT study, but it is well worth it because it reduces the risk of implant failure. From the CBCT data a surgical guide can be 3D printed that makes sure the implant goes exactly where planned.
• When moving in to implant therapy don’t be in a hurry. Cutting corners and doing more per visit might work, but there are risks. Personally, I want to place dental implants into healthy bone over extraction sockets whenever possible. It takes more time but the result is usually better bone around the implants. Can the other work – extracting teeth and placing dental implants? Absolutely, but again, understand that rushing increases risks.
• Ballpark cost for dental implants. I use $4500 as the medium cost for a single implant with crown. The range is probably $3500 to $5500. If you are wanting to calculate the cost of a large case of multiple implants then multiply the number of implants by $4500 and that will put you in the general area of costs. Don’t forget to take into account any teeth to be removed. This is not considered a part of my calculation.
And finally, I have to talk about the cost of preventing disease recurrence. Routine check-ups and cleanings are the best overall value compared with all other dental treatment options because they reduce the need to do other more expensive forms of care. To put this into context, and I have mentioned this before, dental treatment can be broken down into three categories of care. The first is emergency care. This is the most expensive and is often due to neglecting preventive care. The second is restorative care. This can be expensive, but again, if the preventive care is being accomplished, often the restorative care can be spread over a longer period of time because nothing is breaking down. New periodontal disease outbreaks and new decay are prevented.
And what if, in your particular case, you need more preventive care in a year than insurance will cover?
You should by now know my answer but let me say it anyway. Be wise and willing to spend the money necessary to keep yourself as healthy as possible.
Well, that’s it for today. I hope you have found this helpful. Feel free to pass this podcast on to friends and family. And one more thing. If you have friends or family members with dental questions, please have them call my office and give us your name as the reference. We will schedule them for a visit with me for just a few minutes to answer their questions. Sometimes they don’t need my services but are looking for a good dentist near them. I work with many all over the city and South Texas and am happy to give them a referral.
You have been listening to the Perio Patient Podcast and I am still Dr. Ben Young. Thank you, as always for listening. Bye for now.
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