Will PPO Plans be relevant in 10 Years?

For dental practice owners working toward less insurance dependence, understanding the ideas in this article is essential. Here we break down key strategies and actionable steps you can start implementing in your practice today.

Today’s podcast is titled, Will PPO Plans Be Relevant in 10 Years? It’s a really interesting and provocative question. I think it’s making us think, okay, fast forward so many years into the future—would we have PPO plans and how would dentists practice dentistry? So, Gary, I’m really excited to explore this. I know lots of changes are happening. The

Evolution of Dental Insurance

Gary explains how dental insurance began in the 1960s as a dentist-friendly system.

Comparison of 1965 coverage versus today’s significantly diminished value.

Well, you know, Naren, I wish I did have a crystal ball. It’s a great question—will PPO plans even be relevant in 10 years? And I’d love to just confidently say, no. They are going the way of the dodo bird. PPO plans are going extinct. I would love to be able to say that, and I’d love to be able to back it up with data. However, I can’t do that, and I don’t have a crystal ball, but I do have a pretty good perspective on our profession, and I’ll share with you some thoughts that I have.

You know, it’s interesting—if you look at the evolution of dental insurance, the history of dental insurance only goes back to the mid-1960s, Naren. So think about that—the mid-1960s. It’s 50-plus years of history.

And in the beginning, dental insurance was created by dentists for dentists. Really, right? And look what it’s evolved to—look at the, you know, what-show it’s evolved to today, right? I’ll keep it G-rated to save our podcast rating. But it was literally started by dentists for dentists. And if you think about it, in the 1960s, the average annual benefit was $1,000 a year. Now, we have to go back in time to put that in perspective. Let’s say 1965—a thousand dollars. If someone got dental insurance benefits, dental insurance would pay up to $1,000 a year max.

What did it cover? A crown in 1965 was $150 on average. And how much does insurance pay for a crown?

$150. If it’s a thousand dollars, pretty much—

Half—50%. It’s always been covered at 50%. Yes. So if a crown’s $150, the patient pays $75, the insurance company pays $75. And if they have $1,000 of benefit, how many crowns can they get?

I’ll do the math for you. It’s between 13 and 14. Thirteen point something crowns. Let’s round down, call it 13 crowns. Thirteen crowns is not a full-mouth reconstruction, but in two years with the benefits, they could have a completely restored mouth.

Today, there are still some insurance policies that have a $1,000 max. What does a $1,000 max cover today with today’s fees?

If it doesn’t need a root canal. If it needs a root canal, we’re already out of the benefits by covering the root canal. So it’s really morphed into something that’s a joke—an absolute joke. Now, more and more patients are choosing not to have dental insurance because they realize it’s not really insurance at all.

Patient Awareness and PPO Limitations

How to help patients understand whether their plan is employer-funded or employee-paid.

Half of the Americans don’t have dental insurance.

It’s growing. That segment is growing. People are choosing—it’s very different than health insurance. We all need some health insurance coverage in case of some catastrophic event that would put us in the hospital. Exactly. If you’re in the hospital and it involves a multi-night stay, we could be talking about hundreds of thousands of dollars, if not millions of dollars, depending on what’s going on. So we need insurance to cover that.

Health insurance is very different. But what I see happening is that consumers are much wiser today than they were. We read food labels. Remember the time when we didn’t have food labels?

I mean, we had, what do you call it, corn syrup, right, in everything. But now people are very careful about what they put in their mouth.

And there are patients or employees who are realizing the benefit that the employer is hoisting on them is really no benefit at all. In terms of what it covers, it’s a free cleaning twice a year. Exactly. That’s it. But it doesn’t really cover any needs beyond that. It’s so limited in what it covers that it really isn’t a benefit at all.

One of the things to ask your patients in your practice is, "Is your dental insurance provided as a benefit of employment—meaning your employer is paying for it—or do you pay for it yourself in the form of a payroll deduction?" You know what most people say when you ask them that question? "I don’t know." Well, you could say, "Look at your pay stub and see if you are paying that in the form of a payroll deduction." If you are, tell your employer politely, "I don’t want that anymore," and encourage them to purchase your membership plan at your office.

Two hundred fifty-three dollars, $300, $350—it’s—

It’s peanuts. Your membership plan is so much better, without the rules, without the games, without the restrictions. And if they’re paying for it themselves, they’re getting a much better value by buying your membership plan. The other thing you could tell the patient, if they really have a lousy plan—and most of them are really horrible—is talk to your benefits supervisor at work. This is assuming it’s provided as an employer benefit. Let them know you’re not the least bit happy with this dental plan.

Imagine a group of employees bringing that message to the benefits supervisor. And by the way, if you’re an office that happens to know of a good plan—because there are some good insurance plans that pay good benefits—have them switch to this plan. Encourage your benefits supervisor to switch to one that’s actually better.

Speaking Up Against Bad Plans

Right. But you can create a lobby in the form of your patients by telling your patients, “Let your benefits supervisor know that this lousy Delta plan—wait, did I say Delta? Yeah, I did.”

Yeah, I did. That wasn’t an accident. The Delta plans are horrible—absolutely horrible. They’re paying less and less and less. Their reimbursement is going down, not going up, in the face of ever-rising inflation and wage inflation in particular. Yes, Delta has the nerve to lower your fees.

Exactly. And as a result of that, Naren, there is a groundswell effort afoot—a groundswell, individual effort of dentists just saying, “Enough’s enough, I can’t make this work.” If you do the accounting in your office—if you actually do cost accounting—you may discover on many of those really bad Delta plans…

Financial Reality for Dentists

Current system benefits insurance companies most, leaving dentists and patients at a disadvantage.

It’s costing you money to provide your patients’ care. If it’s costing you money to provide your patients’ care, does it make any sense to have that plan in your practice?

No, not at all. So my crystal ball—I’ll come back to the question at hand—says that we’re going to see some changes coming up because this current system doesn’t work. It doesn’t work for the dentist.

Think about the entities that are involved in the dental insurance game, Naren. There’s the dental insurance company, the patient policy, the dentist or dental office that provides the care, the patient that receives the care, and the company that buys the policy. That’s it—the four entities. The only one that wins today is the dental insurance company.

And by the way, this has sort of been disclosed—that the insurance companies are the only ones that win. How has that been disclosed? Now, think about some recent events. What are some recent events that have disclosed the dirty secret that insurance only works for the insurance company? What are some events that have occurred?

Public Backlash Against Insurance Companies

High-profile example: UnitedHealthcare CEO’s assassination highlights public frustration.

AI-based claim denials eroding trust in insurers.

You mean the murder in New York? The person who was shot—

Assassination, yeah. The CEO of one of their top dental insurance companies, right?

Health insurance, sorry. Health insurance company, yeah. And of course, the public outcry—there were a lot of people who were, quote-unquote, you know, even though I’m not a fan of this, kind of on the side of the vigilante.

You know, you can’t be a fan of vigilante justice. But when they discovered that it was—look it up on Google, but I believe it was UnitedHealthcare—

I think you’re right, Gary. I’m pretty sure—

I’d like to confirm it for sure for our listeners.

But I believe it was UnitedHealthcare, and they discovered that in the previous year, hundreds of millions of dollars of claims were denied because of the use of AI. And what kind of light does that shine on the insurance company?

The gentleman who was killed was Brian Thompson.

There are three NFL stadiums that are named after an insurance company. Now, why do insurance companies want to name a stadium?

No, for the companies—because they want to give them the box. So the CEOs of these employers show up, they can give them a box at the game.

So they pay hundreds of millions of dollars in naming rights instead of benefits to the people that are insured. And the public has gotten—you know, you’re not in good hands. Do you remember that slogan? "You’re in good hands."

What does that say—State Farm? You’re in good hands with State Farm. You know what? You’re not in good hands with State Farm. The public is becoming more savvy, and I think there’s an effort afoot to really make PPOs become obsolete, at least in the way they’re designed today. It’s not a win-win—it’s a win-lose.

And when insurance companies are making hundreds of millions of dollars of profit on insurance—I mean, I am a capitalist. I’m in favor of profit, Naren.

A hundred percent. So are our listeners. Hopefully, they’re running a profitable enterprise in their dental practice.So we’re all in favor of profit.

But I think the difference between a dentist in favor of profit and an insurance company in favor of profit is that ours is beneficial profit—we profit by actually providing good and taking care of people. The insurance company profits by taking advantage of people.

You know the Medical Loss Ratio—MLR—do you remember that initiative, Naren?

MLR—it was 2022. It was a ballot measure in the state of Massachusetts that the Massachusetts Dental Association got enough signatures to put on the ballot.

Legislative Wins for Fairer Coverage

Massachusetts Medical Loss Ratio law requires insurers to pay 82–84% of premiums in benefits.

Potential for similar laws in other states to reform the system.

And the ballot—if it passed, and of course it did pass—would require dental insurance companies to also have a loss ratio, meaning that they’d have to pay a certain percentage of dollars taken in from premiums directly for patient benefits. Before this existed, they were only obligated to pay around 50%. So, in other words, 50% of the revenue they took in from premiums had to be paid directly to policyholders—to patients.

Now, because of the Medical Loss Ratio getting passed—by the way, it was an overwhelming landslide win for the Medical Loss Ratio—they now have to pay 80, I believe it’s 84%, it’s either 82 or 84%, of every dollar that’s taken in on premiums. And I think we’re going to see more of that, and when we see more of that, it’s going to change the face of insurance.

So I think the future is going to change. I think it’s going to get better. I see this as kind of the low-water mark. I guess it can’t get any worse—until Delta cuts the fees again, which they’re going to do. So there, it gets worse.

But what can you do now, if you don’t want to wait around for 10 years and see what happens? What you can do now is successfully resign from PPO plans. That’s what you can do to be in control of this. And there are more and more dentists that are doing that individually—they’re just saying, “Enough is enough.”

It’s getting harder for patients to find offices that accept their PPO plan. And when that happens, things will have to change. Because if you can’t find anywhere to go that will take this bad plan that your employer is foisting on you, that’s going to force some change.

Post-COVID Health Awareness

Naren, I’ll let you have the closing comments. What do you think about my prediction? My prediction is that it’s going to change, and it’s going to be forced to change, because what we have right now doesn’t work.

I agree with you, Gary. I mean, already we know the number of doctors who are literally saying, “Enough is enough,” and leaving insurance PPO plans. There’s a huge groundswell of interest in reducing insurance dependence, and every week we see people getting on this journey. Some have dropped one plan, some have dropped 15 plans. We are also noticing, like you said, patients saying, “Enough is enough,” and half of Americans don’t even have dental insurance.

So I think these trends have been going on for the last 10, 20 years—they’re just getting faster and faster and faster.

Everything’s accelerating. Peter Diamandis talks about the rapid acceleration of change, and this is another example of it. The PPO heyday—when the PPO plans were in control—we’re already past that. I think we’re already past that.

I think the last thing that’s driving this trend is, especially after COVID, people are taking health a lot more seriously. And the relationship—especially with a good, relationship-driven dental practice—has grown exponentially because that’s the closest healthcare relationship they have. Everyone is starting to understand the oral-systemic connection and how important oral health is for all kinds of reasons.

So I do think these are not reversible trends. Are people going to be less knowledgeable and less interested in their health in the future? I don’t think so. These are all trends that are accelerating. So I agree with you, Gary.

How Dentists Can Take Control Now

Steps for successfully resigning from PPO plans without going fully fee-for-service.

There’s no reason to wait. I don’t like to be passive in this. There’s no reason to wait with things that are outside of your control. What’s in your control is your practice format. We’ve worked with practices in all 50 states—over 400 practices—successfully resigning from PPO plans in every locational environment.

Every time you successfully resign from a PPO plan, you strengthen and improve your practice.

The only one who wins in today’s dental insurance game is the insurance company and that has to change.

Half of Americans don’t even have dental insurance, and that number is growing.

These are not reversible trends,people are becoming more informed and more committed to their health every day.

With over 2,200 coaching clients, Gary has first-hand experience transforming insurance-dependent practices into thriving and profitable practices.

Through his Personalized Coaching Program, Gary