Most people would agree that designing an effective dental facility requires an intimate understanding of dentistry and a thoughtful identification of the design objectives for a specific practice. That statement alone involves a multitude of details and design decisions that can be quite overwhelming (assuming you want to attend to all the details and get it “right”). And while that is the primary part of the designing process, evolving factors outside of the control of practitioners will greatly impact the design and economics of current and future facilities.

What are some of those factors?

• Regulatory factors

In the early 1990s, the Occupational Safety and Health Administration (OSHA) regulations required appropriate labeling, storage, and inventory access to certain regulated dental materials and drugs. It also mandated protective eyewear, gloves, and gowns for the dental staff; appropriate disposal of biohazardous materials; and compliance with sterilization processes to protect the general public (your patients). In response, dental office design began to include appropriately sized and accessible storage and inventory areas, staff areas with changing rooms and storage for gowns, appropriately labeled and located disposal drops, and thoughtfully conceived central sterilization areas.

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A specific example of a design response to OSHA regulation is the placement of a “sharps” receptacle in each operatory and the sterilization area. Rather than transporting contaminated needles or scalpel blades to a centralized sterilization area, disposal now occurs in the room where the sharp was used. The rationale is to prevent contaminated “sharps” from being dropped or misplaced en route to sterilization. A needle on an operatory floor can conceivably puncture an exposed foot or puncture a retrieving hand (gloved or ungloved). A recessed sharps disposal on a countertop with a minimally visible grommet ring is an excellent solution to this requirement. Companies such as Greeno provide these solutions. Table 1 shows an example of the cost implications of this requirement.

Dental industry veterans understand that the evolution of these OSHA safeguards decreases the likelihood of disease transmission in dental facilities and the diseases associated with those promulgated regulations. Receiving periodical empirical evidence of the success of these regulations would also be meaningful to the dental community as a counterpoint to the increased costs absorbed by all participants in the delivery of dental treatment.

By the end of the 1990s, the ADA (the American with Disabilities Act) inserted regulations that addressed disabled patients and disabled staff members in the dental office. The generally understood handicap code plan configurations no longer met the expanded patient and staff accessibility requirements imposed by the ADA. This law has profoundly impacted the arrangement of space and the amount of square footage required to effectively design an ADA-compliant dental office. A four-operatory office that seemed spacious at 1,500 square feet now may require 1,800 to 2,000 square feet to comply with ADA accessibility regulations.

Dental office floor plans that are ADA-compliant are confusing because they seem to waste precious and costly space in unusual locations. ADA compliance requires any door within your facility to have an 18-inch clearance between the door opening side (not hinge side) and a wall if the door swings inward. This is considered the “pull” side of the door. On the other side of the door — the “push” side — ADA regulations require a 12-inch clearance. These clearances allow wheelchair-bound patients to position themselves to one side of the door and swing the door past without colliding with the wheelchair. This requirement is what drives the minimum size of compliant rooms; however, it can create the undesirable effect of doors swinging out into corridors because sizing does not allow an 18-inch door clearance inside a space. For example, the smallest room you can have in a dental facility and still swing the door into the room is 5 feet by 5 feet. This assumes there are no fixed objects in the room. As soon as you introduce a standard, 24-inch deep, fixed countertop to one end of this 5 feet by 5 feet space, ADA-compliance would dictate its size to increase to 5 feet by 7 feet or even larger, depending on spatial use and local ADA interpretation.

Regulatory compliance and you: Photos 1, 2, and 3 are (from above) HIPAA-compliant front-desk area; check-out station; consultation room. 4). This ADA-compliant restroom is both functional and elegant.

You can reasonably calculate the increased square footage assumptions of ADA-compliant dental facilities based on the number of doors within the facility. An ADA-compliant dental office door swing consumes approximately 45 sf compared with a non-ADA compliant door swing of approximately 25 sf. If a five-operatory facility has 15 doors, the square footage increase due to ADA compliant door swings is (15 sf x (45 sf – 25 sf) = 300 sf), an additional 300 square feet. If your existing five-operatory facility has 2,400 sf and was constructed pre-ADA, an exact duplication of your existing plan conceivably would require 2,700 sf to comply with today’s standards. If interior finish-out construction costs for well-designed dental facilities range from $80 to $140 per square foot, you can better appreciate the cost implications of your project from an ADA-compliance standpoint.

ADA compliance also mandates wheelchair ramps for elevation changes and elevator access to dental facilities located on multiple levels. A hydraulic elevator for most two- or three-story dental facilities typically costs around $50,000. Wheelchair ramps require 10 to 12 feet of ramp for every 12 inches of rise. A four-foot rise from your parking area to your patient entry door typically would require a 40-foot ramp with appropriate railing. This same ramp costs approximately $20,000 to $30,000.

Do people in wheelchairs deserve equal access to dental facilities? Absolutely. Do participants in the delivery of dental care that share the increased costs associated with ADA compliance deserve to be thanked … yes!

Compliance with these regulations applies to all dental offices designed today. It is wise to engage design and construction professionals who understand these regulations. Otherwise, rejection, revision requirements for drawings, or worse, tagging (stopping construction) on a job site by an inspector for noncompliance is an unfortunate and costly possibility.

After you address these OSHA and ADA requirements in your dental office design, what other noteworthy changes in dental office design today should you address?

• HIPAA compliance

Understanding the compliance implications of this privacy act has fostered forums, articles, and fervent discussions within the dental community. The intent of this law and the subsequent compliance steps that dentists should take are still under development by the agencies assigned to regulate this act. The American Dental Association is pressing for these compliance determinations so that it can appropriately inform its membership. And, even now, consensus is developing on the specifics of patient file information compliances. However, compliance is not limited to the administration and exchange of patient file information. The visibility and auditory patient privacy directives of the HIPAA are affecting the dental office design criteria in a number of areas.

Sound and noise concerns that have plagued staff in front-desk areas will now become HIPAA noncompliance issues. The ability for patients to interact with front-desk personnel in greater privacy is now a HIPAA design consideration. Separation of the appointing activity from the waiting area and easy access to a private consultation room will effectively address this issue. Introducing a consultation room into the dental office has become a design compliance response that protects the dialogue between the dentist and the patient about procedural, medical, and financial issues. Computer monitors also must be positioned out-of-view (across a desk or across a room) in a such a way that personal information about one patient is not visible to another patient nearby.

Surprisingly, the cost implications of HIPAA on well-designed dental facilities are minimal. For years, we have advocated consultation rooms and semi-private areas to facilitate private conversations; architecture and finish materials to minimize sound transmission; and protecting the confidential patient information that is displayed on monitors. Not surprisingly, less well-conceived facilities are suffering the greatest increased costs to achieve HIPAA compliance.

• Amalgam separators

The most recent regulatory issue to influence design is the use of amalgam separators. As with any new issue, confusion abounds. The short explanation would recommend amalgam separators be plumbed at the confluence of all vacuum lines and before the holding tank (semi-dry units) or vacuum pump (water-driven impellers). This allows heavy metal separation based on weight and filters out any amalgam particles before they can enter the municipal sewer system. RamVac, the dental industry leader in vacuum pumps, provides an amalgam separator unit for approximately $700. Removable filters ($100) are changed two or three times a year and disposed through biohazardous protocols. Amalgam separators are not large and would consume approximately two cubic feet of space.

What nonregulatory factors are currently influencing design?

• Technology

Technology in the dental office is no longer an afterthought. Dealing with dental technology after the office is designed, or worse, after construction is completed, translates to offices with exposed cable runs, compromised operator access to technology, and / or technology purchases that either fall short or far exceed the needs of the practice.

For these reasons, planning for and installing the cabling “system” to support current or future technology should be a part of the facility design process. That said, a word of caution is warranted about which company you choose for your technology design and development. This design arena is still rife with technology companies that know a lot about “high tech” but little about its specific application to dentistry. In our observation, the result is system installations that far surpass dental application requirements and the abilities or objectives of the dental staff end users. Our recent review of submitted specifications and pricing to clients confirm that these circumstances still exist. Therefore, be sure to retain the services of a reputable firm that specializes in dental technology applications. By doing this, you are more assured of appropriate equipment specification and installations that support your dental objectives rather than straining the dental practice financially for the sake of “technology.”

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Wheelchair ramps mandatory under the Americans With Disabilities Act.

An industry rule of thumb for cost approximations of networked computers within a dental office is to assume $5000 for each networked computer in your facility, which includes all costs for computer hardware, software, networking, cabling, mounting solutions, and installation. However, this $5,000 assumption does not include dental specific technologies layered over the more generic computer infrastructure. If your new, five-operatory facility needs 12 computers, you can expect to invest approximately $60,000 for just the computer network infrastructure.

• Operatories — size and access

Considering our background, it is interesting to examine the changes occurring in the dental operatory, primarily because the 9’6″ x 10′ operatory has been a “mainstay” in dental design for a long time. We, too, have promoted this size as optimum for the general practitioner for many years and for valid reasons. However, the expansion into more complex dental procedures, the material requirements involved in these procedures, the increased size in dental chairs, the heightened demand by operators for mobility at the chair, and the need for access to technology that supports this treatment command a different design response.

This blueprint is an excellent illustration of ADA-compliant design.

Therefore, another change we promote in dental design is the development of an optimally sized operatory to meet the specific type of practice rather than assuming the “standard” operatory design solution. For example, in a high-volume general practice that emphasizes family dentistry or smaller cosmetic and restorative procedures, the demand for a larger operatory or additional storage cabinetry may not apply. However, for the practice focused on large-case, advanced restorative procedures, the operatory size, cabinetry storage, and access will be different. The addition of overhead side cabinets to accommodate infection control and restorative materials may generate additional costs of $1,500 to $2,000 per operatory.

• Central sterilization

Central sterilization still is an effective design solution for instrumentation delivery to the operatory. OSHA reinforced these concepts by mandating appropriate sterilization processes as a compliance requirement. Even so, the expansion of material requirements necessary to effectively complete advanced dental procedures have challenged the notion that everything procedural must be delivered via a tray from a central location.

We still maintain that all instruments and handpieces that require sterilization are stored, organized, and delivered most effectively via tray set up to the operatory. Basic consumables also can be stored and delivered effectively in tray set-ups as well. We also agree that to be effective, central sterilization areas still require an appropriate amount of linear feet of counter or cabinet space to support proper sterilization procedures.

The exception will be with the persistent premise that all materials utilized in dental procedures must be stored in the central sterilization area and delivered to the operatory in tubs or trays. A multitude of adhesive, restorative and impression materials, and “guns” are accessed in many practices regularly. But retrieving materials of considerable mass and/or number through central tubs can be inefficient and outdated. For example, you wouldn’t want to retrieve three tubs for every crown preparation. Design must respond with appropriate solutions to support the efficient access and utilization of these materials within the operatory.

Cabinetry in the sterilization area may actually decrease as we shift materials storage back to the operatory. Removing 10 linear feet of glass-front overhead cabinets can save approximately $3,500. This cost savings can help offset the increased costs of operatory expansion.

• Dental staffing

Management consultants predict significant changes in administrative staffing with the onset of computer scheduling and business systems. The type of dentistry produced affects the type and number of personnel required to execute it. In addition, the onset of computerization has also increased staff productivity, reducing the number of personnel needed to run a dental practice.

We find that working closely with management consultants and their clients is a great way to identify the spatial needs for the front desk and business areas. Anticipating current and future staff needs is an important design decision that must be made for practices to develop effective, efficient administrative space.

• Digital dentistry: Is the darkroom gone?

Our clients regularly pose the question of whether to incorporate a darkroom. The impulse is to respond in the affirmative and assume a darkroom will be used for something else when the office “goes digital,” or, conversely, to assume the office will be completely “digital” from the beginning, rendering a darkroom unnecessary. The better response might be “How committed are you to going digital and how soon?”

Creating a darkroom within your office means creating another ADA-compliant space where square footage is considered. And if this space is an anticipated dinosaur, then the more appropriate design response may be to locate an auto-processor with a daylight loader in an alcove (without a door and without an ADA- access issue) that also has been designed as a future digital scanning/workstation (CPU/keyboard) area.

Scanning technologies (DenOptix, Scan-X, and others) are emerging as a more affordable and reliable technology than the hard-wired sensors options originally introduced into the dental market place. This makes the above design solution the one of choice for those dentists who are still using film, but seriously contemplating the leap into digital radiography in their future.

• Consultation rooms

The consultation room has become an accepted design “concept” for the practitioner who understands the benefit of a space devoted to treatment presentation and consultation. Management consultants helped us understand this concept many years ago, and HIPAA’s privacy compliance edicts have reinforced it further. Space permitting, most dentists prefer this design solution.

Easy access to case presentation technology (a computer workstation) and a comfortable presentation environment are primary design criteria. Unfortunately, design solutions for the consultation room often fail to incorporate both considerations. The table-and-chairs-arrangement in the middle of the room reduces access to technology on the side counter, making it a less effective solution. Alternatively, built-in cabinetry with a table peninsula that gives both dentists and patient visual access to a computer workstation during treatment presentations addresses both issues optimally.

• The staff room

“Why in the world do we need a staff room?” has been a typical response to the idea of incorporating a separate area for staff use. Management consultants again deserve credit for convincing dentists that staff rooms are more than just a frivolous expense. This paradigm shift has been realized in many successful practices that understand that a supported staff is a supported practice.

Management consultants recommend providing a private area for staff respite.

When updating your staff room criteria, consider the technology available. Beyond lunch room and morning huddles, the practice can benefit from flexible furnishings that allow tables to be folded and removed, stacking chairs that can be arranged for workshops and then put away, and LCD projectors and pull down screens installed in cabinetry for presentations.

Whether looking within the practice, complying with outside regulatory factors, or integrating the latest in equipment and technology, the design of an effective dental facility responds to the criteria that is detailed and understood. For your part, be thoughtful about your practice objectives and expectations. Ultimately, the ideal office for you should be a direct response to you as a practitioner, to the type of practice you have now and want in the future, and to the community that it will serve. In this way, design helps to make your ideal office a reality.

Providing creative waiting rooms and play spaces for children is an important consideration in today`s competitive marketplace. Given the current high U.S. birth rate, the census forecasts a total of over 40 million children under the age of 10 during the next decade. With a much stronger focus on the benefits of preventative dental care and early treatment, odds are that a significant portion of them will be in your waiting rooms. With some forethought and professional advice, designing space and providing the appropriate products to engage children can offer benefits beyond occupying them while in your office.

James Barnard is president of Playscapes Children`s Environments, a company that designs and manufactures children`s furniture and activities with emphasis on its use in the medical environment. “When you design for children in a health-care environment,” Barnard says, “you`re really designing for four separate clients – children, their parents, staff, and the facility owner. They all have separate needs which should be taken into account.”

Jay Levitt, DDS, is the owner of four Dentistry for Children PC practices outside Atlanta, Ga. Dr. Levitt worked with professionals to help him create waiting areas that function as more than just a place to sit and wait.

“Our waiting area is designed to communicate how important our patients are to us,” Dr. Levitt emphasized. “I not only want everything to look terrific, [but] I want an environment that makes our patients feel comfortable. We used to have staff bring in old books, puzzles, and games, but small pieces were lost and the game or puzzle became worthless. We now select more durable equipment without small pieces that can be lost or swallowed.”

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Barbara Balongue, IIDA and president of Balongue Design, Villanova, Pa., works with health-care staff members. “Our clients come to us for the assurance that, as professionals, we have designed an environment for children that frees them from liability-related issues,” she explains. “Safety is always a big concern.”

Barnard agreed. “All of our customers are very concerned with installing and purchasing equipment which not only engages children in interactive play, but also pays close attention to safety issues. We design our products to avoid concerns such as pieces which can be put in the mouth, choked on, tripped over, or used to hit another child.”

Parents appreciate having activities for their children, as well. Lynn Pawlak, Waunakee, Wis., and a mother of two young children, points out, “The biggest challenge in any waiting room is occupying the kids. There is always an added value when the dentist has thought about the strong possibility that parents need to keep their children engaged in activities that keep them from climbing over and under chairs while waiting for an appointment. The whole experience is more relaxing for everyone.”

“Paying attention to designing an environment for children within the waiting area frees up the balance of the space from being disrupted by young children,” Balongue adds, “and can enhance the overall environment of the office.”

Since front-office staff members often assume the responsibility for maintaining the appearance of the waiting area, their concerns also should be addressed. According to Barnard, some key points to consider are:

> Keep clean-up simple by purchasing equipment with laminate surfaces that can be maintained easily with the usual disinfectants.

> Avoid loose pieces which staff may need to keep picking up to avoid a cluttered look in the area.

> Keep in mind the amount of noise an activity will make and, on a similar note, avoid toys that require battery replacement.

“Finally, keep in mind that your staff has to look at the office all day, every day,” Barnard says. “I always recommend selecting equipment and décor that bring out the child in anyone – child-like, not childish.”

Arguably, when designing for young children, the most important customers are the kids themselves. Young children are divided into three age groups – infants, toddlers, and preschoolers, each with their own play-area requirements. Learning through exploration is important at every stage. Infants tend to stay on the caregiver`s lap, while toddlers and preschoolers are more likely to play independently … and potentially wreak havoc in a waiting area!

When designing for young children, Barnard recommends having a well-defined area that encourages interactive and dramatic play. The defined area always should be in the sight-line of adult supervision. Focusing on activities that encourage fine motor exploration (i.e., a play island) versus gross-motor activities (such as running and jumping) can help keep noise and chaos to a minimum. Wall-mounted units, such as an engaging finger maze, can keep young children busy, quiet, and much easier to supervise. Self-contained play stations also keep kids busy and have minimal clean-up responsibilities for staff. In fact, many units currently on the market have nonremovable pieces.

“Waiting rooms, when well thought out and properly designed, can serve as an important marketing tool,” Dr. Levitt notes. “For us, they are part of our daily focus on creating a positive, professional experience for our patients, parents, and siblings.”

Tips on designing for children

James Barnard, president of Playscapes Children`s Environments and author of Children in the Built Environment, gave the following tips for designing spaces with the young child in mind. While this list serves as a good starting point, Barnard advises consultation with a professional when it comes time for final decisions.

1. Make sure the space is developmentally appropriate.

* Is the area well-defined?

* Is the area scaled to the size of young children?

* Is the space visually engaging – i.e., child-like, but not childish?

* Are there possibilities for self-directed discovery, as well as interactive and dramatic play?

* Are the activities developmentally appropriate?

2. Pay close attention to safety factors.

* Does the space afford easy supervision in the sight line of adults?

* Is the equipment easy to sanitize for infection control?

* Is the space free of equipment that can be choked on or tripped on?

3. Kids require tough long-lasting equipment.

* What materials and processes are used to make the equipment tough and justify cost?

* Are there loose pieces that might easily be removed from the environment?

* After the equipment is purchased and installed, what kind of warranty and ongoing service does the company provide?

by David J. Ahearn, DDS

In every practitioner’s life there comes a time when it is clear that a physical office change must occur. For some doctors, this happens early in practice; for others, a reawakening occurs later in the practice life that makes this transition desirable. Nevertheless, it is a point through which every dedicated caregiver crosses at some time.

Because office redesign is such a rare event, we do not gain enough knowledge or experience to do justice to this critical task. For example, we place composites every day, and, as a result, our trade journals have hundreds of articles about them each month. Our knowledge is great in such areas — not so regarding future office planning.

Dental supply companies frequently will supply you with a floor plan at no up-front cost. Unfortunately, they can’t be expected to spend a great deal of time on productivity enhancements that only an actual practitioner would understand, nor can they be expected to labor long and hard to save you money. These plans tend to be simple to draw and very expensive to equip. It isn’t the supplier’s fault. Everything costs money and there is no such thing as a free lunch. This is a reasonable choice for practices that are relocating but not expanding, or for offices that are simply purchasing new equipment to replace outdated hardware rather than re-engineering or re-invigorating their practices.

High-end office designers offer great service and have the benefit of prior dental practice experience. They are noted for creating “image” practices for those dentists who desire them. Design costs alone for such offices can run into the tens of thousands of dollars as each step in the design process is individually handled. Moreover, due to the one-of-a-kind nature of the design, it is common for a project to take up to two years to complete.

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A larger number of practices are actually designed by local architects rather than by high-end dental designers for two reasons. First, doctors often hire professional architects who they are familiar with (through patient contact or social activity). Secondly, doctors often feel that they must use a local professional because of what might be unique code requirements in their geographical area. Unfortunately, in most situations, this is the least-desirable method of office design. Perhaps one practice in 25 should pursue this design alternative.

We find that it is virtually impossible for an architect without vast knowledge and experience in dentistry to lead you beyond your existing vantage point. Even architects who have successfully worked out the physical requirements (plumbing, etc.) have little actual knowledge regarding what makes a practice highly productive. It would be like designing tomorrow’s most advanced car without having a driver’s license!

All dental offices today must comply with national standards such as the Building Officials and Code Administrators (BOCA) and the International Mechanical Code (IMC). While it may be possible to get something accepted by a local building inspector at a lower local standard, it seems rather shortsighted to risk potential liabilities associated with the Americans with Disabilities Act, which holds the owner liable for oversights despite the issuance of local building permits. Figure 1 shows the pros and cons of each choice of office design supplier.

I won’t go into further detail here about these choices. This series is about dental office design for the rest of us. It’s about taking charge of the process — about establishing a method for going where you have never been before in a safe, sure, and successful manner — and only spending those dollars that provide a significant return on your investment. As we progress in these discussions, you should become able to specify a design plan in a straightforward manner. This will allow you to save a significant amount of time and expense, and often permit the purchase of a pre-engineered office plan or even the acquisition of an entire prefabricated office that is the practice of your dreams (see Figure 2).

Figure 2: Three-section, 2,600 square foot office under construction.

To take your practice into the future with maximum success and minimal risk, we first should establish some conceptual foundations to build upon and accept some of the constraints within which we must work.

Conceptual vs. physical design
Let’s break your design endeavor down into two major categories:

1. The physical aspects — the design, construction, equipment, lighting, etc.

2. The conceptual aspects — the sort of technology people will want in the future, what staffing may be like in five years, how a dental office should feel to a new patient, etc.

Most dentists hate to think about the intangible elements of office design and, as a result, will do anything they can to rush into the physical aspects of the project. Please don’t do that! You should build your physical infrastructure around your carefully evaluated plans.

Figure 3 (see next page) outlines the conceptual aspects of office planning. Note that not all of these items will relate to your specific goals. Clearly, how you rank the importance of these trends will have a strong influence on where and how you create your new practice — how the design becomes uniquely yours.

Practices that plan to focus on perio/hygiene need to make a strong commitment to more treatment rooms. Practices developing a cosmetic future must plan space for an optimal consultation area and create a scheduling system that permits privacy. For practices that are suffering from manpower shortages, a design that enables uncompromising two-handed function is requisite.

You need to clearly outline what you want your practice to be long before committing to a design. You should have a good sense of how your specific objectives will influence your design, and then carefully communicate them to your designer. This will allow you to assess the ability of your designer more accurately. If he or she is unable to quickly translate your conceptual needs into an outline for your future, it is best to extend your search for help, perhaps to another category of designer.

The future is in your hands. The practice of your dreams does not have to become a nightmare of overbudget or overtime woes. Clear, written design goals are the first step in creating that future.

A growing number of dentists who have left the NHS are setting up lucrative sidelines in beauty treatment, offering Botox injections alongside fillings and check-ups.

The article below states that the AMA “has been considered the largest barrier to enacting e-prescribing legislation” because of the group’s “concerns over the cost of adopting and implementing the technology”

 What does the ADA say?  They are all for e-prescribing, no questions asked.  Darrell

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Kaiser Daily Health Policy Report

AMA Officials Outline Provisions Physicians Would Accept in Electronic Prescribing Legislation

The American Medical Association on Friday discussed a set of standards that physicians would accept for any electronic prescribing requirement under Medicare, CongressDaily reports. According to CongressDaily, AMA “has been considered the largest barrier to enacting e-prescribing legislation” because of the group’s “concerns over the cost of adopting and implementing the technology” (Edney, CongressDaily, 5/9).

Some consumer, labor, insurer and business groups have said that the Medicare package that the Senate Finance Committee is drafting should include language to require physicians participating in Medicare to e-prescribe, CQ HealthBeat reports. In addition, separate legislation (S 2408, HR 4296) would require e-prescribing in Medicare and would offer payment incentives to encourage e-prescribing adoption. AMA officials announced the proposal at a forum sponsored by the Brookings Institution’s Engelberg Center for Health Care Reform (Carey, CQ HealthBeat, 5/9).

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Andrew M. Cuomo, New York State attorney general, announced an inquiry into health insurance

New York Times-By REED ABELSON

It is a common medical puzzler. The benefits statement arrives from the insurance company, saying that although the doctor has charged, say, $200 for that recent office visit, only $80 is covered — and the consumer is obliged to pick up the balance.

That gap may be too big, according to critics of the health insurance industry, whose ranks were joined Wednesday by the New York State attorney general, Andrew M. Cuomo.

Mr. Cuomo announced a sweeping investigation into whether health insurance companies have systematically forced patients to pay more than they should when using doctors and hospitals outside their insurer’s networks.
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As part of the investigation, Mr. Cuomo said he intended to sue UnitedHealth Group, the state’s largest medical insurer and one of the nation’s biggest.

“We believe there was an industrywide scheme perpetuated by some of the nation’s largest health insurers to deceive and defraud consumers,” Mr. Cuomo said at a news conference on Wednesday.

Mr. Cuomo, who has conducted a number of recent inquiries aimed at health insurers, said that the practice had gone on for about a decade, potentially adding hundreds of millions of dollars to the out-of-pocket medical expenses of insured consumers nationwide.

UnitedHealth said it had done nothing wrong and was cooperating with the attorney general’s inquiry.

The investigation, which raises issues that doctors’ groups and some other critics have brought up, is likely to place greater scrutiny on health insurers. And it comes at a time when the industry is reporting big profits but the rising cost of medical insurance has left an estimated 47 million people uninsured in the United States.

“The larger issue is health plans make an awful lot of money,” said Sheryl R. Skolnick, a health care analyst for CRT Capital Holdings in Stamford, Conn. If insurers are found to have underpaid, she said, they could end up having to make big restitutions to consumers.

The inquiry by Mr. Cuomo focuses on a fundamental industry practice: how insurers determine what portion of a doctor or hospital bill they will pay if a patient receives care from a provider not under contract to the insurer.

Individuals who use doctors outside the insurer’s networks are generally required to pay a certain percentage, typically 20 percent, of “reasonable and customary” charges — a calculation that is supposed to reflect the prevailing market rate in a given geographic area for a doctor visit or other services.

But Mr. Cuomo contends that the industry has consistently underestimated the prevailing market rates, forcing insured patients to pay a greater portion of their own medical bills than their insurance policies are supposed to require.

Individuals generally pay higher premiums for the privilege of being able to select doctors or hospitals outside the network, Mr. Cuomo said.

“You could have paid less and be limited to the in-network doctors,” he said.

Among those with employer-provided health benefits, about three out of four workers, or 54.2 million people, were covered by insurance plans offering out-of-network options, according to a 2007 survey by the Kaiser Family Foundation, a health care research group.

From the insurance industry’s standpoint, the out-of-network rate system is meant to make sure an insurer is not responsible for paying high medical bills generated by extremely expensive doctors.

The attorney general said he planned to sue UnitedHealth and some of its subsidiaries, accusing them of deceptive practices and consumer fraud. United Health owns Ingenix, the company used by the industry to calculate reasonable and customary rates.

He said he had also issued subpoenas to 16 insurers, including Aetna, Cigna and Empire Blue Cross and Blue Shield; all of them, like UnitedHealth, do business in New York State.

“We believe Ingenix systemically reduced the amount of money consumers should have been reimbursed,” Mr. Cuomo said.

UnitedHealth, based in Minneapolis, said it believed that the Ingenix data was accurate. The company said in a statement that it was “committed to fair and appropriate payment for physicians, the state’s other health care providers and consumers.”

UnitedHealth said the data produced by Ingenix is used by insurers to help determine what they will pay when customers go out of network. The company said the unit analyzes 1.3 billion charges billed, collected from more than 100 health plans, to come up with its figures.

The company rejects charges that seem far from the norm and subjects the information to a “strong validation process,” according to a UnitedHealth spokesman, Don Nathan. The information gives insurers “a snapshot of current charges in a geographic area” that they can use to determine what is a reasonable and customary fee for a service, he said.

Aetna, Cigna and Empire said they were cooperating with the investigation.

Empire, a unit of WellPoint, also said that if the information was inaccurate or miscalculated, the company “would consider any and all remedies available to protect the interests of our members, their families, our group customers and providers in the New York marketplace.”

Mr. Cuomo said his office had compared the prevailing market rate for a routine doctor’s visit with the amount Ingenix had calculated as reasonable and customary. While doctors in the metropolitan New York City area typically charged $200 for an office visit, he said, Ingenix calculated the rate at only $77. Under a typical plan, the insurer would pay 8o percent of the $77, or only $62. The patient would be responsible for covering the remaining $138 balance.

UnitedHealth disputes the numbers Mr. Cuomo provided, saying Ingenix calculates the range of prices for those office visits as $125 to $300. The company said it did not know how Mr. Cuomo’s office came up with its figures. Members of Mr. Cuomo’s staff declined to describe the method.

Mr. Cuomo contends that Ingenix and some of the insurers manipulate the information to arrive at artificially low rates. He said the insurers had an inherent conflicted because it was in their interest to understate the true rates.

“There is no disclosure; there’s no transparency; there’s no accountability,” said Mr. Cuomo, saying his office began investigating the matter after receiving complaints from consumers.

He also said patients who belonged to a UnitedHealth plan were also not told that the company generating the rate data was a unit of the insurer.

Mr. Nathan, the UnitedHealth spokesman, said, “We don’t think there is a conflict of interest,” because the data is supplied to Ingenix by various insurers.

The way that insurers determine the prevailing market rates for medical services has long been a subject of controversy. The American Medical Association, for example, has a pending eight-year-old lawsuit that makes similar claims.

The practice “is primarily unfair to consumers,” said Dr. Nancy H. Nielsen, the president-elect of the medical association, who was present at the attorney general’s news conference. Consumer advocacy groups were also present.

Peter V. Lee, a health policy expert at the Pacific Business Group on Health, an employers’ group, said, “The whole mythology that there is a usual and customary charge has been part of what has made insurance hard to understand for patients as well as doctors.”

The concept of “customary and reasonable fees” as a way to pay doctors began more than three decades ago, recalled Robert Laszewski, an industry consultant in Washington and former insurance executive.

Back then, the figures were based on the median of what doctors in a local area were actually charging, Mr. Laszewski said, but insurers realized the system gave doctors an incentive to raise their fees to drive up the median numbers. “It was very ineffective in controlling health care costs,” he said.

Insurers generally turned to other payment systems, like negotiating prices with groups of doctors. But the industry, through a health insurance trade association, continued to calculate the reasonable and customary data, until UnitedHealth acquired the operation in 1998.

In recent years, as consumer dissatisfaction with many health maintenance organizations has helped make out-of-network options popular, the data has been important in determining the portion of medical bills that insured patients pay.

The main question now is what patients are told about what their health plans will pay when they go out of network, said William S. Custer, an associate professor at Georgia State University, who studies health insurance. “What did you think you were buying is exactly the issue,” he said.

Some of the stocks of insurers fell on the news, with UnitedHealth closing at $46.97, down $1.30, or 2.7 percent.

Acknowledging what he called the headline risk, Doug Simpson, a Merrill Lynch analyst, predicted in a research report Wednesday that consumers would end up paying more, no matter the end result of the investigation.

“We believe to the extent that regulators wish to raise provider payments for out-of-network care,” Mr. Simpson wrote, “there will be a corresponding increase in the cost of coverage.”

OTTAWA -A substance used to make chewing gum could soon be declared toxic by the federal government after an international agency found that it might cause cancer in lab rats.

On May 17, the government will publish a list of 17 substances that may be labeled as toxic in a draft report on risk assessment. Acetic acid ethenyl ester, or vinyl acetate – commonly used as a base in some chewing gums – could be on that list, Health Canada said Monday.

The substance is a colourless liquid with a strong, sweet scent that can be used as a flavouring agent. When made into a polymer, it becomes useful in the production of chewing gum.

However, tests completed by the International Agency for Research on Cancer found evidence that vinyl acetate could be linked to instances of cancer in rats. No similar results have been found in humans.

For this reason, the substance is classified as a “potentially high hazard substance” by Health Canada.

“The problem with cancer-causing things is we don’t always know that there is a safe dose. Certainly, less is better,” says Dr. Kapil Khatter, an adviser with Enivironmental Defence. His organization will likely push for the government to encourage alternatives, which Khatter says are available.

The federal government is conducting the study on vinyl acetate as part of a larger review of 200 substances called the Chemicals Management Plan to determine what actions, if any, are necessary to protect human health. Vinyl acetate is classified as a “potentially high hazard substance” because of the findings related to its carcinogenic nature.

Following the publication of the report, the public will have 60 days to comment before a final report is issued, at which point Ottawa is required to implement control measures. This could include further study.

Last month, retailers across Canada voluntarily pulled baby bottles containing bisphenol A off the shelves when that substance was part of a similar assessment.

Vinyl acetate is also used in the production of perfumes, deodorizers and paints and sealants, among other things.

“Watchful monitoring” of asymptomatic wisdom teeth may be a more appropriate strategy, suggest review authors led by Dr. Dirk Mettes of Radboud University Medical Centre Nijmegen in the Netherlands. Furthermore, they add, health risks and cost-effectiveness of surgery deserve greater consideration.

“Prudent decision-making, with adherence to specified indicators for removal, may reduce the number of surgical procedures by 60 percent or more,” the authors say.

The review appears in the most recent issue of The Cochrane Library, a publication of The Cochrane Collaboration, an international organization that evaluates medical research. Systematic reviews draw evidence-based conclusions about medical practice after considering both the content and quality of existing medical trials on a topic.

…..

The studies focused only on whether removal of wisdom teeth prevents crowding in the lower jaw within five years, and neither study revealed a significant benefit. “The conclusion drawn from [the larger] study was that the removal of impacted third molars to reduce or prevent late incisor crowding cannot be justified,” say the review authors.

However, crowding is not the problem, according to Dr. Richard Haug, of the American Association of Oral and Maxillofacial Surgeons, and coinvestigator on two current studies on wisdom teeth.

Haug, executive associate dean of the University of Kentucky College of Dentistry, says wisdom teeth that are not pulled can cause decay and inflammation of the gums.

“ Getting these teeth out earlier makes sense.”

In 24 years of practice, Haug says he has found that the best time to remove impacted wisdom teeth with the lowest rate of complication is between the ages of 17 to 21. “Roots may not be fully formed and are softer, and you have a young, healthy population that heals better than an older population.”

Noting that only two studies were involved in the systematic review, he says, “It was a very elegant review with very high standards; the parameters for inclusion were wonderful but could hardly be replicated by the vast majority of studies that have appeared in the literature.”

Mettes attributes the dearth of studies to two factors: the difficulty and expense of monitoring dental changes over the requisite 10 to 20 years and the lack of adults with impacted wisdom teeth, due to the prevalence of routine removal in recent decades.

NEW YORK (Reuters) - Solobacterium moorei is the organism largely responsible for chronic bad breath, or halitosis, biologists reported Saturday at the annual meeting of the American Association for Dental Research in Dallas.

In a previous study of eight patients with halitosis and five without, S. moorei was “always found in patients with halitosis and never in patients who did not have this problem,” Dr. Violet I. Haraszthy, who was involved in both studies, noted in a telephone interview with Reuters Health. “A number of other studies have also found this bacterium in halitosis patients.”

Haraszthy points out that, at present, “not much is known about this particular organism.”

“As we identify and find out more about the bacteria that cause bad breath, we can develop treatments to reduce their numbers in the mouth,” Clark added in a university-issued statement.

As reported Friday on Reuters Health, the same team of investigators has found that brushing twice a day with antibacterial toothpaste and using a toothbrush with a built-in tongue scraper can eliminate chronic bad breath.

Candies containing a novel formula of arginine bicarbonate and calcium carbonate reduced decayed, missing, and filled surfaces by two thirds in a new study on children’s molars.

In the study — published in the March issue of the Journal of Clinical Dentistry — 96 Venezuelan children aged 10 and 11 sucked four mints fortified with CaviStat per day. A control group of 99 children sucked on sugarless mints without CaviStat. At the end of a year, the CaviStat group had 61.7 percent fewer decayed, missing, or filled surfaces in molars than the placebo group, the researchers reported.

Arginine is an amino acid that causes bacteria to produce base, counteracting the acid that demineralizes teeth, the researchers write. The bicarbonate produces an additional buffering effect, while the calcium carbonate provides a source of calcium to replace any that is dissolved in acid.

The study was funded by Ortek, where lead researcher Israel Kleinberg, D.D.S., Ph.D., a SUNY professor of oral biology, serves on the board of directors.