Everything from a PPO, PMO, PTO, HMO or DHMO L, M, N, O, P, O—nothing is easy and dentists in the city will make you feel even dumber for asking. But as a child of learning things on my own, I had to ask around, peer-to-peer recommendations are always king in a city where spending $5 more on a latte is blasphemy. It even shocks me today that when you seek dental work, you’re put on the spot for not booking it sooner.
When flying through my email, I have chains on chains on chains with SF dentists who either rejected my insurance as a whole, don’t understand what insurance I have, will accept my insurance but is fully booked for nine months out of the year. “I do have a handful of patients who have HMO or DHMO insurance plans, but unfortunately our office cannot bill their insurance plans and they pay for my services completely out of pocket,” said one SF dentist in a reply back to my personal email.
He goes onto explain, “Dentists can form contracts with insurance companies to become “in-network” or “preferred” providers. In exchange for appearing on the insurance plan’s recommended list of dentists, dentists are required to provide services at a discounted fee. Unfortunately, due to this decrease, some offices are forced to see more patients per day, work more quickly, or use cheaper dental labs and dental materials to make up the difference,” he divulges.
“It’s important to me to have plenty of time to listen to my patients, and to provide safe, comfortable, and appropriate care. I also use amazing dental labs and the highest quality dental materials that help ensure that I provide great work to my patients. This, along with my strong focus on patient education, does not allow certain insurance companies discounted fees to be sustainable. Your insurance plan allows you the freedom to choose your own dentist, but unfortunately, it looks like your insurance company cuts your benefits in half when you see out of network providers. I have plenty of patients who still come to see me despite their insurance company’s limitations, but they do have a higher out of pocket costs.”
OUT. OF. POCKET. COSTS.
In the United States alone, the price of dental has skyrocketed since the early 2000’s. On a site, conveniently titled, dentist-prices.com—we got a run down of what the money really looks like.
Apiectomy—$797
Braces, Invisalign—$6000
Braces, Metal—$1033
Bridge—$687
Cancellation fee—$40
Combined Treatments—$440
Dental Bonding—$500
Dental Crown, Composite—$597
Dental Crown, Gold—$598
Dental Crown, Porcelain—$1188
Dental Examination—$49
Dentures, Full—$570
Dentures, Partial—$416
First Consultation—$53
Hygiene Clean—$126
Implants—$1901
Large tooth filling—$171
Large tooth filling, White—$197
Root canal—$695
Sedated tooth removal—$217
Small tooth filling—$175
Small tooth filling, White—$117
Tooth Extraction—$283
Tooth Scale and Polish—$42
Veneer—$874
Whitening—$444
Wisdom tooth extraction—$175
X-ray—$30
You get the picture. When I further researched why dental was so expensive in the United States, a very interesting Huffington Post article mentioned a very key component to dental coverage, “One of the reasons so many of us decide against dental insurance, even if our employers pay part of the premiums, is the relatively skimpy coverage it provides for anything other than routine checkups and cleanings,” says HuffPost writer Wendell Potter, “A typical dental plan requires a 50 percent copay for complicated procedures and high-ticket items like crowns and bridges. Many plans have a “missing tooth clause,” meaning they won’t pay for replacing a tooth if it was missing when you enrolled in the plan. And most dental plans limit coverage to just $1,500 a year. That’s hardly more than a down payment on your kid’s $6,000 braces.”
Even when diving deeper into this, we forget the initial forerunner, dentists are doctors too, “There are a number of reasons why dental procedures are so expensive. First, services are performed by trained professionals. Dentists are doctors who go through many years of college, dental school and specialized (read: expensive) training. Like many other professionals — lawyers, accountants, expert mechanics — dental services are priced accordingly.” At the same time, about 108 million Americans have no dental insurance coverage, typically meaning they either pay for dental services out-of-pocket or go without care.
And this is where I fall. Down a sticky and gum-ridden hole where I have to hope and pray that my teeth can withstand food. I know I’m only in my late 20’s but as wise words say, “don’t let it get bad,” I don’t want my wallet to suffer for years to come.
How does fear play out in this scenario?
Not only do I feel a hole in my wallet, the fear of being judged by a stranger is even greater. Sometimes it’s outright, other times it’s as subtle as a glare into my mouth. Dr. Bob Frazer, Jr., FACD, FICD, the founder of R.L. Frazer & Assoc. wrote an interesting essay about the nuisances of subtle fear. He writes about his case study, “A 64-year-old, civically prominent woman had come in for a case presentation with my client, a well-qualified restorative dentist. I was there to observe the new-patient experience for critical feedback and course correction. My client doctor, we’ll call him Dr. J.” He continues to write…
“At that moment, I asked Dr. J if he would mind if I intervened. He was surprised, but said no, that was OK. I asked him to turn off the slides, and then I asked Ann how she was feeling about seeing these pictures. She looked at me with disgust written on her face and said, “I hate it!” I nodded, leaned toward her, and said, “Can you tell us why?” Ann said, “Of course I can! I feel so guilty! I’m responsible for this and should not have let this happen.” Reflecting those feelings back with a gentle understanding, I said, “It sounds like you’re feeling ashamed of your mouth and in some way responsible.” (Note: My client resides in the British Isles, where many people Ann’s age are edentulous.) She concurred and reiterated how she hated to see those pictures. I told her I understood how she could feel that way. Then, I asked her how she would like Dr. J to present what can be done for her. She said the models would be fine, and maybe slides of a “before” and “after” full-face smile of a patient with similar problems. Clearly, the intensity of Ann’s nonverbal response—which my client missed—conveyed strong emotions, primarily of guilt and shame.”
Being a dentist means that you will have to be a critical and yet gentle therapist, when you see an actual therapist, you’re working through your bodies responses to emotions and how the brain (which you can’t control) distributes those emotions. With your teeth, that’s all you all the time. At the end of the day, it’s your sole responsibility. Dr. Frazer, Jr goes on to say, “what I discovered was that shame as a healthy human emotion can be transformed into shame as a state of being. To have shame as an identity is to believe that one’s being is flawed, that one is defective as a human being … it becomes toxic and dehumanizing.”
Another journal in my research of fear and embarrassment brought me to Moore et al, 2004, which stated that, “The psychology of embarrassment is pretty interesting. Studies, for example by sociologist Andre Modigliani, have shown that shy people with high levels of empathy—the ability to imagine how others may be feeling – can be more easily embarrassed. Easy-to-embarrass people also have a tendency to believe that others see them as somehow inadequate.”
I feel inadequate. My oral health was my responsibility and when it’s mentioned in conversation, I divert all attention away from it. But one thing that keeps me from the office, from tackling out-of-pocket costs is the dreaded lecture. The feeling and being of scolding in the office—it’s all too real, happened before, and makes me visually angry. I’ve told myself multiple times that if a dentist ever gave me lip or made me feel inadequate that I would fully walk-out of their office. I don’t need to sit their and be berated for hours on end.
In the terms of services at most SF dental care facilities, a “No Lecture Guarentee” is now stated for those who don’t want to feel like their in trouble. Does this help with potentially bringing in more “clients, customers, patients?” Possibly. But some even fear the dentist farther more than I do.
Extreme Dentist Anxiety:
From the American Journal of Modern Dentistry, “Between 9% and 20% of Americans avoid going to the dentist because of anxiety or fear. Indeed, it is a universal phenomenon. Dental phobia is a more serious condition than anxiety. It leaves people panic-stricken and terrified. People with dental phobia have an awareness that the fear is totally irrational, but are unable to do much about it. They exhibit classic avoidance behavior; that is, they will do everything possible to avoid going to the dentist. People with dental phobia usually go to the dentist only when forced to do so by extreme pain. Pathologic anxiety or phobia may require psychiatric consultation in some cases.” It’s incredibly real and somedays, I feel as I may have this. But what actually compels myself and others to feels this? My research turned up studies that say that most patients are afraid of three things at the dental office—fear of loss of control, fear of embarrassment, or fear of pain. Loss of control is when patients can’t see what dentists are doing to them, can’t help the physician to do it, or can’t anticipate what will happen next. Patients have fear of embarrassment because dentists work inches away from patients faces and are in their personal space. Some people lack self-confidence or are ashamed of how their teeth look, and they’re afraid they’ll be judged or ridiculed.
It’s a cycle that knows itself all too well.
What can SF do to make dentistry more affordable, approachable, or even applicable?
When I had a full time job, I ran around my office asking my co-workers about our incredibly flawed dental insurance. What it meant? How could I use it? How they used it? Etc and so on. From the Bay Area’s Consumer Checkbook, they suggest a second opinion. “Probably the most underused consumer tool in dentistry, obtaining a second opinion before agreeing to costly treatment can make sure you get appropriate, reasonably priced care,” they report, “It can also be useful leverage if a dispute arises later. Consult a dentist who is independent of your own dentist, telling this dentist in advance that you will not be using him or her for the treatment or procedure.”
But Anthony, what if I’m a freelancer and insurance is not an option? I’m right there with you. When I was laid off in August, I feared what would happen to me, when in my research of finding affordable to free procedures, the SF Dental Implant Center came up with a small but resourceful lists of starting points. Though the list of resources are scarce—Bob Cut couldn’t even come up with our own list due to the fleeting services many low-income practices offer.
But is dental insurance worth it? Dentalplans.com believes that either or is the way to go. “Dental insurance only covers you up to a specific limit. Typically that limit is $1,000-$1,500 annually. When your reimbursable dental costs go over that limit, you are responsible for paying your dental care costs for the rest of the year. The policy caps on dental insurance have remained the same for the past forty years. Meanwhile, expenditures for dental services continue to rise, at an average rate of 5.5 percent annually. Given that the average cost for a crown is $750-1200, and the cost of a single implant starts at $1500, you can exhaust your annual dental allowance fairly quickly.” All in all, you will be paying SOMETHING out-of-pocket.
So Bay Area, I’ve plead my case. The United States dental workforce is unfortunately unfixable but could we see a brighter tomorrow? Maybe? Am I going to continue brushing? You bet your ass. My dental plan is a good toothpaste and a brush I can trust. Ce la vie.
// Art created by Anthony Rogers & Tin Dinh, quotes sourced from various journals hyperlinked in the story. Have something to chip in or weigh in on this discussion? Let us know; we’d love to hear.
