Structured Decay
Built With Good Intentions. Hollowed by Incentives.
I used to think burnout was the cost of caring too much. Turns out, it was the cost of caring inside a system that no longer does.
Like so many origin stories, my belief is that the people who created dental insurance were not evil. I think they were trying to solve a real problem. To help patients pay for the care they needed, and help dentists provide it without having to play debt collector. For a little while, maybe it worked. Unfortunately, over time, as happens with most human-led systems, something shifted. Not suddenly. Not overtly. Perhaps not even with a willful disregard for dignity. Not with a bang. But with a budget.
The benefits essentially stayed the same. The cost of care didn’t. The difference? That was called “margin.” At first, maybe it looked like discipline. Keep premiums low. Keep networks tight. Keep the system sustainable. But that logic calcified, until protection became the mission, and coverage stopped covering.
The system didn’t break all at once. It evolved. Quietly, almost invisibly. And it was shaped, like any living system, by the behaviors it rewarded. Deny just enough claims to protect the bottom line. Keep annual maximums frozen to avoid paying for more care, while slowly raising premiums to increase profit. Compete on price, not value. Avoid innovations that might reduce gatekeeping. Treat dentists like vendors, not partners. Equate stagnation with sustainability.
So even though the bones of the original model remained, the mission got eaten alive by the incentives it fed on. And the people left inside that structure, patients, providers, office teams…
we’re the ones holding it up while it hollows. What was originally built to connect patients and providers now rewards those who can delay, defer, and deny just long enough to win the quarterly report. To whose benefit? Not the patient missing work just to be denied. Not the provider navigating a maze of codes and conditions. The only ones who win are the administrators and executives who built careers on enforcing bureaucratic compliance… not care.
Most patients think they’re the only ones being denied. But providers have a deeper knowledge and an ongoing, disturbing perspective… We’re not just trying to give care. We’re now spending hours trying to justify it. The forms. The pre-approvals. The faxes. The phone calls. The quiet shame of explaining to someone why they can’t afford to fix the tooth that’s keeping them up at night, not because the treatment isn’t available, but because their benefits already maxed out… in February.
Somewhere along the line, dental professionals stopped being advocates and became bureaucrats, tasked with enforcing unwritten but fixed rules. And it happens slowly… until one day you realize you’re spending more time arguing with payers than talking with patients.
And yes, I’ve tried everything the system told me to try. Hired consultants to “close” more cases. Took CE courses to sell higher-ticket procedures. Considered offering treatments I didn’t even want to do, because they “were covered”, and I was underwater. But no matter how much I played their game, the friction never went away.
Because the people who decide what gets paid for aren’t the ones sitting across from the patient. And when that’s true, you don’t get a healthcare system. You get a system where proving you deserve treatment matters more than needing it.
You get structured decay.
No, I don’t think the people who built this system were evil... But eventually, the incentives stopped rewarding their better angels, and discouraged anyone who tried to prioritize care over what the system rewarded. And what started as a bridge between patients and providers now mostly just stands in the way. But it still collects the toll… in both directions.
So no, this isn’t a whitepaper… It’s just what happens when you stay inside a structure long enough to realize it forgot what it was for… A system that still operates, but no longer serves. A system that forgot the patient was ever the point. And everyone inside it feels it, even if no one’s allowed to say it out loud.
That’s structured decay: the quiet outcome of a system no longer calibrated to correct itself.
“Constant Decay Requires Correction” ~ Rusty Madison DDS
