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Strap Him Down.

Joey, a three-year-old with severely decayed and abscessed teeth caused by prolonged bottle feedings, was in great pain. He was not sleeping, and his upper lip was swollen due to infection. The treatment recommended by the family's dentist included extractions, root canals, and fillings, to be performed immediately under general anesthesia in the hospital. In consultation with the family's dentist, Joey's pediatrician referred Joey to Pauline Jones, chief of pediatric dentistry at the areas major medical center.

Dr. Jones examined a screaming, kicking Joey and confirmed that he needed to receive the recommended care under general anesthesia in the hospital. The procedure would be scheduled as soon as possible as an outpatient case in the ambulatory surgery center. Authorization for hospital coverage from the family's medical insurance company would be required, and as was the usual practice, Dr. Jones' staff contacted both the dental insurance company and the medical insurance company to obtain prior approval of benefits. The dental insurance carrier authorized reimbursment to the family for the dentist's charges. The medical carrier, however, refused to cover the hospital charges and the administration of anesthesia by an anesthesiologist, claiming that they were not responsible for treatment involving the mouth or teeth.

Dr. Jones explained that this complex procedure would take approximately two and a half hours to complete even under ideal conditions, with Joey asleep. If the procedure were performed outside the hospital, in an office setting, on a child who was petrified, screaming and resisting violently, it could take twice as long. Joey would have to be held down or strapped to a papoose board and might suffer lasting psychological damage. The high-speed cutting instruments used in the treatment could cause severe injury. Alternatively, if ambulatory sedation was utilized in an office not equipped with the proper monitoring devices and life support equipment, there was a potential for catastrophe. The insurance company, however, still refused to cover the procedure.

Should Dr. Jones agree to practice dentistry according to the dictates of the insurance company and compromise both her standards and the health of her patient?


by Frederic R. Kunken

Sadly, cases like this have become all too common. In an effort to control costs and maximize their profits, untrained and frequently uncaring employees of health insurance companies have been denying coverage to their insureds for procedures that had recently been covered. In this case the company is attempting to limit its liability by claiming that they are not responsible for the hospital charges because treatment involves the teeth. This is both ridiculous and unconscionable. Left untreated, an infection involving the teeth is just as dangerous and potentially threatening to one's health as an infection elsewhere in the body. It is the responsibility of the health insurance company to cover the related costs associated with the treatment of these problems in the safest possible environment.

Dr. Jones is faced with a most difficult decision. She must provide immediate care to a patient suffering from both pain and infection with no time to debate the issue. The insurance company is telling her to do something that is contrary to her best professional judgment and ethical standards. To strap a child to a board for the time required to complete the treatment, even if successful, often leaves psychological scars which can last a lifetime. Performing this care in an office with heavy doses of sedative drugs can be dangerous. Cases of coma and death have been reported all too frequently.

Dr. Jones' primary responsibility is to insure that the best possible care is provided to her patient. After the family was denied hospital coverage, she must now consider all of the possible options available and then present them to Joey's parents, explaining the risks and benefits of each.

One approach could be to go ahead with the hospital admission, with the understanding that the family will have to pay the hospital charges up front. They could then contest the denial of coverage with the insurance company upon completion of the case. The family must understand that they would be reimbursed only if the insurance company were to reverse its decision. If they do not, however, the issue could be taken to the state insurance commission for review.

If the family is unable to accept the financial burden that might result, Dr. Jones might offer another alternative. Understanding that nontreatment places Joey at great risk, she must decide either to treat him or to refer him elsewhere. If she decides to treat Joey she must come to grips with all of her misgivings and provide care as diligently as possible. If she decides to refer him, it must be to someone in whom she has confidence and who has the skills and ability to provide the required care. If she finds such a referral impossible then referral to a hospital dental clinic is another alternative. Care, however, would most likely be provided by a dental resident.

In the long run, the best approach to resolving these problems is legislative reform. Health insurance disagreements between the doctor and patient on one side and the insurance company on the other must be regulated differently from the way they have been. An impartial panel should be created to review disputes and adjudicate them expeditiously. Physicians, dentists, and representatives of insurance companies should be appointed to these panels, and the decisions should be blind and based solely on the specifics of each case.


by Ellen N. McGee

It is difficult not to see this as a case of proposed child abuse. The image of a screaming, terrified child, pinned to a board for several hours of work on his mouth, or subjected to the risks of general anesthesia in an office setting, certainly warrants the indignation toward insurance companies that has prompted calls for legislative mandates requiring independent review panels. The case could serve as an advertisement for reform of a health care system that is capricious and unjust in its coverage of both individuals and services. Because of the vagaries of our present health care system, a different company or a different person at the end of the phone line might choose to cover this type of care, and ironically if the child were totally uninsured and financially eligible, his treatment would be through the hospital clinic. Clearly, the procedure should not be treated as a nonessential form of health care. Faced with an immoral directive from the insurance company, what is the dentist's ethical obligation?

Dr. Jones's first obligation is to prevent harm to Joey. After she has initiated pain treatment, she must do whatever she can to get the health plan to reconsider. Obviously, she must fully inform the parents of the dangers raised by the insurance company's intransigence and explore with them the possibility of paying personally for the treatment and attempting afterwards to recover from the insurance company. Additionally, the parents and dentist could seek media publicity regarding the child's plight, recognizing that such pressure might influence the medical insurance company. Dr. Jones needs to forcefully advocate for appropriate care for this vulnerable toddler.

However, dealing with the immediate problem is but one part of what is required of Dr. Jones. She should bring the issue to the ethics committee of the hospital where she is Chief of Pediatric Dentistry. Since 1995 the Joint Commission for Accreditation of Health Care Organizations has included a section on "Organization Ethics" in its Standards for Patient Rights and Ethics. One area of concern is the relationship of the hospital to the managed care organizations with which it contracts. Conflicts inevitably arise in situations where underlying values are at odds. For the managed care organization the main objective is to control costs, while for the health care professional and institution it is to provide quality care. Since this is not an isolated case, explicit discussion about whether or not medical plans provide coverage for in-hospital or outpatient treatment for dental work should be part of contractual negotiations. As an issue in organizational ethics, hospital policies should include principles for allocating resources. Surely, as in this case, where the costs are so relatively low, and where the potential medical and psychological outcomes are so clear, it may be that, as an interim measure, the hospital itself should offer care, as well as pursue the issue with the insurers whose denial of benefits impacts patients so severely. Hospitals have an obligation to contract only with insurance providers whose packages offer reasonable care. It is not reasonable for there to be a gap in coverage because the teeth rather than another body part are diseased. The fragmentation of medical care illustrated here is symptomatic of a failed system.

Moreover, since Dr. Jones is so highly respected in the dental community, and serves in a position of leadership, she should consider that she has an obligation to raise these issues through her professional organizations, which may be instrumental in alerting managed care organizations to its failure to properly consider dental health in its allocation of medical resources and the formation of healthcare policy. Certainly it should be as unthinkable to suggest this type of dental care as to suggest tying shildren down in doctor's offices to set their fractured bones. Cases such as this demonstrate that decisionmaking for medical treatment plans should be based on an objective standard of care, and that inconsistencies in coverage for necessary treatments are unethical. Decision-making should be returned to the true experts (in this case the dentist and parents of Joey), and that the power of corporate bodies such as insurance companies and HMOs must be countered by effective professional and institutional organizations.


by Lance K. Stell

This case is remarkable for its multiple conflicts of interest.

The first conflict is as old as the Aesklepian/Hippocratic tradition itself. It results from that tradition's nonmendicant self-understanding, namely: (a) that the physician should visit his patients primarily for their benefit, not for his own; (b) that the physician should be compensated for his services; but (c) that the latter should never have priority over the former. Thus the idea of making service conditional on the outcome of a "wallet biopsy" has always been regarded as corrupt. Yet, the inherent conflict between serving the patient and securing compensation dogs every case the doctor has: how long should each patient encounter last? how many visits does the patient need? when to tell the patient that her illness has run its course, that she is "well" and may now discontinue regular visits?

In a nutshell, Dr. Jones' question asks whether it is permissible to give priority to reimbursement (here, of the hospital charges, since she is guaranteed of having her own fee covered) over patient care. According to traditional medical ethics, this is a no-brainer.

However, let's assume that Dr. Jones has signed a contract with a managed care plan obligating her to do just what now bothers her. Suppose the managed care contract says that if Dr. Jones wants assurance of reimbursement for any nonemergent care plan she proposes, then she must submit to pretreatment review. If she refuses to comply with the review process, she risks a denial of reimbursement. And, in fact, the insurance company now disputes whether the plan she proposes is "medically necessary," a criterion of uncertain relationship to "medically indicated" or "medically appropriate."

Dr. Jones is then boxed in. The dental insurance carrier has authorized reimbursement for the plan she has outlined, namely, surgery and other procedures to be performed in the ambulatory care center, under general anesthesia. However, the dental insurance policy excludes anesthesia care, probably because that part of the care plan would involve an MD anesthesiologist, rather than a DDS.

Dr. Jones has argued that her plan has no reasonable alternative. Thus if the medical insurer sticks to its guns, refusing to cooperate, Dr. Jones cannot simply pursue the sedation-using "alternative" instead. She might appeal to the dental insurance carrier to authorize reimbursement for the anesthesiologist. But she cannot in good conscience merely reapproach the dental carrier for approval of a nonanesthesia plan. Doing so would show either that she had been gaming the medical insurance carrier, or that at the end of the day, she's more interested in collecting her fee than in doing the job right.

The case also displays a routine conflict of interest between an insurance policy beneficiary and the insurance company. Insurance companies seek to limit their liability by specifying exclusions and limitations in the contract. Policy beneficiaries have an obvious incentive to seek reimbursement. Each party must rely on the other's truthfulness and good faith. Each party has reason to distrust the other and to take precautions against being had.

Since insurance contracts for medical care commonly exclude reimbursement for dental services, the scope of the disclaimer "we don't cover teeth" would have to be interpreted in light of specific contract language. In practice, the disclaimer will not be absolute. Suppose, for example, a policy beneficiary is in a car wreck. He sustains traumatic injuries to his face and mouth, including several teeth broken or knocked out and with severe resulting gum injuries. Several specialists might be consulted in the case, including a plastic surgeon and an oral surgeon (who might be either a DDS or an MD). The insurance company might try to deny reimbursement to the oral surgeon if he were a DDS rather than an MD, reasoning, "DDSs are dentists, dentists take care of teeth, we don't cover teeth." More likely, the insurer would try to limit reimbursement to "medically necessary" care rather than deny reimbursement to the DDS outright. The company will be more likely to reimburse for services directed at "repair" but to dcny "enhancement." Thus the company may be willing to reimburse for dental bridge-work to replace teeth knocked out ill the wreck, but not for dental implants.

Finally, there is a conflict, also routine, between the care provider and the insurance company. Care providers have an incentive to overutilize--to please patients and to maximize provider income. However, maintaining credibility with insurers is a countervailing consideration. When it's lost, providers face increased costs, resulting from demands for additional justification and in delayed reimbursement (effectively, a "loan" floated to the company). Too, what counts as "indicated" care exists partly in the eye of the beholder. Care providers can influence the patient's attitude about what is "necessary," most notably at the margin. Painstakingly reviewing claims for marginally necessary care is costly. Insurance companies have an incentive to shift those costs to providers.

So what ought Dr. Jones do? I assume she has had her legal department review the contract with the dental insurer and her legal eagles have found that the MD exclusions support its refusal to reimburse for the anesthesia. Also, I assume that Dr. Jones has tried to pressure the medical insurer: she has enlisted colleagues from other prestigious centers to call the carrier's medical director and explain that Dr. Jones's plan is the only reasonable one and that they are prepared to sign affidavits to that effect; she's said she may contact the state's insurance commissioner over the case; maybe she's even agreed to appear on the evening news to describe the case and how it indicates that more stringent oversight of the insurance company may be necessary. Assume further that all is for naught (which in my experience is unlikely). Dr. Jones has to follow the plan she's proposed, irrespective of the medical insurer's demurrer. She mustn't abandon her patient. She mustn't follow a plan that's inhumane and risky.

Her institution will and should support her going ahead. The institution also retains the option of submitting the bill to the medical insurer after service has been delivered. Big centers can be relentless, obnoxious, and effective in pursuing open accounts.

Frederic R. Kunken is chair of the department of dentistry and chief of pediatric dentistry at North Shore University Hospital in Manhasset, New York. He teaches dental students, residents, and fellows and maintain a private practice in pediatric dentistry.

Ellen M. McGee is director of the Long Island Center for Ethics at Long Island University, C.W. Post campus. She teaches ethics and philosophy. Her research interests include end of life care, suicide intervention and human rights.

Lance K. Stell is professor of philosophy and director of the Program in Medical Humanities at Davidson College. He also teaches regularly for the departments of pediatrics and general surgery.
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Author:Kunken, Frederic R.; McGee, Ellen M.; Stell, Lance K.
Publication:The Hastings Center Report
Date:Jan 1, 2001
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