Dental is Different from Medical

Dentistry is an important part of healthcare. Dental care, though, is different from medical care. These differences must be reflected in plan design, benefits and legislation so that costly, inappropriate regulation does not result in employers dropping dental benefits.

  • Dental disease is limited in scope in comparison to medical, primarily involving tooth decay and gum disease.

  • Dental disease is generally not acute or life-threatening. Hospitalization is rarely needed, usually only in response to a patient's medical condition. Emergencies are rarely treated in the hospital, except for accidental injuries, which are generally covered under medical plans.

  • Many dental procedures are elective, reflecting equally effective alternatives between more or less expensive treatment options. For example, a crown is optional where a filling would be a satisfactory treatment.

  • General dentists provide 85% of dental care and account for 80% of total dental costs. Just the opposite is true for medical, where secondary and tertiary care are most common, and primary care represents the smallest component and cost.

  • The American Dental Association recognizes only eight specialties with no sub-specialties. The American Medical Association recognizes 150 specialties and sub-specialties. While 82% of dentists are general dentists, less than 15% of physicians are primary care physicians.

  • Over 70% of dentists are in solo practice, compared to less than 10% of physicians.

  • Many dental services may be repeated if a satisfactory result is not achieved. For example, a crown can be redone, while many medical procedures are irreversible.

  • Fewer dental claims are reviewed prospectively or denied for appropriateness for necessity. Professional review is simpler. Dental radiographs provide clear evidence of both treatment and need.

  • HCFA, HEDIS and Milliman and Robertson provide objective, science-based medical standards and measurements. For dental, there are limited parameters of care but no widely accepted measurable benchmarks at present.

  • Consumers report no significant problems with dental benefits. Satisfaction with dental plans is high across the dental product spectrum as reported in studies by the American Dental Association, William Mercer, Inc., and carrier surveys.

  • Dental benefits provide a significant benefit for employees at premiums about 1/10th to 1/15th of medical premiums. Surveys show even modest increases in costs result in employers dropping dental benefits. Approximately 37 million Americans don't have medical coverage. About 150 million don't have dental coverage.

  • Imposing medically-oriented administrative requirements on dental plans to solve problems that don't exist within the dental arena will eventually cause an increase in premiums, resulting in fewer covered individuals.

Underlying Principles of Successful Dental Benefit Programs

To understand the industry's view of healthcare legislation, it's important to understand a few facts about dental benefits, based on years of actuarial and administrative experience in the dental benefits arena.

Five points underlie our "dental perspective" on proposed legislation:

  1. Dental health is an integral part of overall health, and dental benefits are an integral part of dental health. Oral health has improved dramatically over the last three decades due largely to better access to affordable dental care.

  2. Better access to affordable dental care is primarily due to the tremendous growth of both employer-and government-sponsored dental programs. Such programs -- including UCR, HMO and PPO dental delivery models -- are already cost-efficient, consumer-oriented and effectively administered under current regulations.

  3. Despite the success of dental benefits in promoting oral health, there are still many Californians who lack coverage because their employers do not offer it. Many Californians only recently obtained such benefits due to the recent availability of lower cost, dental HMO and PPO programs and enrollee-paid voluntary programs.

  4. Legislative proposals that significantly increase the cost to administer dental programs have the unintended effect of reducing the number of Californians with dental coverage, thereby limiting access to affordable dental care and diminishing oral health throughout the state.

  5. Free market forces properly dictate the fee and reimbursement arrangements negotiated under various delivery models between dental carriers and dental professionals. Dental carriers must be encouraged -- not hindered -- in their efforts to define and enforce their fee arrangements and dental policies to ensure necessary and appropriate care is delivered in accordance with group contracts and high professional standards.

Oral health has improved dramatically in the United States between 1970, when fewer than six million Americans had dental coverage, and today, when more than 161 million Americans are covered. The National Institute of Dental Research (NIDR), in a joint 1992study with the University of Connecticut, reported the number of cavities found in children ages 5 to 17 decreased from seven in the early 1970s to three by 1987. The same study reported significant reductions in tooth loss among working adults, with increased access to preventive services cited as one of the major factors for these improvements, along with wider use of fluorides and better oral hygiene practices.1 These findings echo those of many other studies, including one by the Institute of Medicine, which found that regular dental care has resulted in a dramatic reduction in dental diseases, saving patients an estimated $4 billion a year.2

Total dental expenditures climbed from $2 billion in 1960 to an estimated $61 billion by 2000, according to the U.S. Health Care Financing Administration (HCFA).3 Yet even as utilization of dental services grew over this period, a shift in the kinds of services provided -- from major restorative to more preventive-oriented services -- bears testament to the progress made by the dental profession in controlling oral disease, promoting oral hygiene and encouraging routine, professional dental care. The American Dental Association estimates that periodic oral exams increased by 12.1 percent just since 1979, while the number of metal fillings decreased by 51.7 %, plastic restorations by 5.7 %, and simple extractions by 41.2 %.4

The importance of access to dental care to oral health as provided by dental benefits is further documented in a Rand study, which concluded that Americans in poor oral health are less likely to have used dental services in the past or to have access to them in the future. Conversely, the Rand study showed those in good oral health are more likely to have had previous dental care and good access to future care.5

Having dental coverage is the single greatest factor in determining whether a person sees a dentist, according to statistics compiled by the Nation Health Center for Statistics. The Center's National Health Interview Survey revealed that people with dental benefits coverage are almost twice as likely to visit a dentist in any given year (2.6 vs. 1.7 visits per year), are far more likely to have multiple dental visits in a year (45% vs. 28%), and are more likely to have had a checkup during their last visit rather than require treatment for a specific problem (48% vs. 30%).6

The motivational effect of dental coverage on encouraging utilization of dental services is most evident when looking at the behavior of older Americans and lower income Americans. Covered adults over 75, for instance, average 4.3 dental visits annually, while those without coverage average only 1.4. Similarly, Americans with dental coverage earning under $10,000 annually average 2.9 dental visits a year compared with only 1.2 for those without.

All of these increased dental office visits translate to better oral health for millions of Americans as they gain access to a host of preventive and basic restorative services. Dental expenditures paid for by private insurance programs grew from $10 million in 1960 (10% of all expenditures), to $24 billion in 1997 (50%).7

Despite the tremendous growth in dental coverage and insurer-paid dental expenditures, overall spending on dental services actually declined as a percentage of total healthcare spending, from 7.4% in 1960 to a projected 4.7% in 2000.8 Many researchers attribute this to the success of dental benefits in improving oral health. As more Americans gained access to dental care , a corresponding improvement in oral health greatly limited the number of expensive, more costly procedures performed on Americans.9

Bibliography

  1. HHS News, Public Health Service, National Institutes of Health, July 1992.
  2. Soto, MA, Behrens, R, and Rosemont, C, eds., "Healthy People 2000: National Health Promotion ad Disease Prevention Objectives," Institute of Medicine, Washington, 1987.
  3. Data from Health Care Financing Administration, Office of the Actuary, Office of National Health Statistics Group.
  4. American Dental Association, Bureau of Economic and Behavioral Research. "Survey of Dental Fees," 1990.
  5. Davies AR et al. "Explaining dental utilization behavior." Santa Monica, CA: Rand, publ. no. R3528-NCHSR, Aug. 1987.
  6. Waldman, HB, "Who is Paying for Dental Care?" Compendium of Continuing Education, Vol. 13, No. 7.
  7. Waldman, HB, "Who is Paying for Dental Care?" Compendium of Continuing Education, Vol. 13, No. 7.
  8. Office of National Cost Estimates, Office of the Actuary, Health Care Financing Administration, US Department of Health and Human Services, US Public Health Service.
  9. Levit, KR, Lazenby, HC, Cowan, CA, and Letsch, SW, "National Health Expenditures, 1990," Health Care Financing Review Fall, Fall 1990 Vol. 13, No. 1. 1991 Data from Health Care Financing Administration, Office of the Actuary, based on data from Office of National Health Statistics.
  10. Survey conducted by Market Facts, Inc., conducted Feb. 5-7, 1993 for Delta Dental Plans Association.
  11. Alexander Consulting Group, July 1993 National Survey of Employer Groups
  12. Cooper, H, staff reporter for Wall Street Journal, quoting Frank McArdle, consultant from Hewitt Associates. "Employees' Cherished Dental Plans Will Feel the Bite," WSJ, 9/23/93, page B 11.
  13. Calculations from Delta Dental and HCFA Office of the Actuary data.
  14. Foster & Higgins Annual Benefit Survey, 1989, 1992.