The ink barely was dry on H.R. 3962, the House health reform bill, before dental industry leaders hunkered down to fight drastic changes to dental coverages and how dental plans were administered.
The battle continues into the new year, with opponents of the drastic reconstruction to the nation's dental delivery system clamoring that a large chunk of Americans could see their dental coverage evaporate or their children could be forced to visit a different dentist.
"The dental industry is in the midst of the potentially greatest change that I can recall in my 17 years in the industry. There's a lot at stake in the outcome of the Congressional debate on health care reform. There are problems in both bills for dentistry, but we have hope in the Senate bill," says Jeff Album, vice president,public and government affairs at Delta Dental of Calif., N.Y., Pa. & Affiliates.
The House bill requires pediatric dental coverage within the health care exchange to be bundled with medical coverage. After five years, the requirement extends to pediatric dental outside the exchange. Thus, under the House plan, stand-alone dental providers can't participate in the exchange for mandated children's benefits because the coverage must be bundled within medical coverage; nor can they participate with required children's dental outside the exchange after five years. This is a big problem when 97% of dental plans are stand-alone plans provided through specialized dental carriers.
By mandating and bundling dental coverage within medical coverage for children, many of them will be forced out of their family dentist, experts warn, signaling the end of uniform family benefits, Album says.
There's quite a bit of advantage and value that stand-alone dentistry and separate dental policies contribute in terms of dentist networks, quality care and quality coverage that dental and medical simply aren't the same and shouldn't be grouped together, explains Album. Just because they're both parts of the body doesn't mean they're a part of the same delivery system.
If the bill's provision is maintained in the final reform measure, large companies will shoulder most of the burden because carriers that don't offer competitive dental, which is quite a few, will have to subcontract out or implement their own dental plans, driving up their administrative costs, which will ultimately be passed on to employer groups.
Further, because there is no mandate for adult dental, it's possible that employers will increase copayments, lower annual maximums, decrease coverage or drop dental benefits altogether in order to not pay the excise tax. There is also a worry that many adults will forego their own dental care in the absence of a family plan when their kids are covered separately.
All of that has a negative impact on the oral health of the nation, because people without dental benefits are two-and-a-half times less likely to go to the dentist, says Evelyn Ireland, executive director of the National Association of Dental Plans.
In addition, because the mandate only applies to covering children under the age of 21, carriers may opt to provide minors with a bare-bones benefit in order to keep premiums down.
In order to compete, carriers may end up providing the absolute minimum for children's dental coverage - for instance, just an oral exam a year - in order to keep their premiums low. This would be a disservice to children, says Mitch McGlynn, president of Dominion Dental.
Of the 176 million Americans who have dental benefits, 153 million get dental benefits through the employer and group marketplace; 132 million of these have coverage under family policies. Of that 132 million with family coverage, 45 million kids are covered under policies with their parents. With this shift, over 40 million kids would be shifted to a medical plan, and as many as 22.3 million adults are expected to drop dental coverage from the general marketplace when their children are no longer on their policies.
"With the four words, 'pediatric oral health services,' included in the essential benefits package, the [dental] benefits system for employers in the United States ... is turned upside down," Ireland says.
Though there are problems with the way both chambers address dental benefits, industry leaders rest their hopes with the Senate bill, which carves out a place for stand-alone dental for individuals and small business as well as in the exchanges. An amendment authored by Senators Debbie Stabenow (D-Mich.) and Blanche Lincoln (D-Ark.) allows medical and dental to be unbundled.
Album encourages employers to write their legislators, explaining that they want the ability to maintain dental benefits from the best carrier they can find and they want to preserve relationships between employees and dentists.
Employers have as much at stake, maybe more so, in seeing stand-alone dental [retain its] flexibility in the new health care environment, he says.
Dental benefits are the second most common benefit offered by employers, according to the National Association of Dental Plans, and 50% to 70% of employees elect dental plan coverage even if it is 100% employee- paid.
And while most employers will not cut the benefit due to its popularity and cost-effectiveness, very few are adding dental. Instead, companies have begun cost-shifting to their employees by increasing copayments and employee premiums, or adding a premium for dependents. This trend has gradually gained traction over the past five years, but in a down economy these trends may pick up speed. In addition to basic coverages, some employers also have eliminated cosmetic coverage.
"Dental is an easier target than medical coverage [when an employer looks to cutting benefits] because it is not an employee's primary health care benefit," says McGlynn.
Meanwhile, more employees are taking advantage of the benefit. There has been an uptick in dental utilization. It reflects a phenomenon that in a difficult economy when there are layoffs, [and] people are worried about their jobs, they use their insurance more than they would under normal situations. It's almost a fear-based response, explains Delta Dental's Album.
A paradigm shift
"In 2010, I believe that we will see a continuing transformation of some of the dental value propositions. The industry is moving away from the old financial-exchange value proposition to more of a wellness-and-data- integration value proposition that delivers more than just payment for certain services. It's about risk assessment, prevention and better oral and overall health outcomes,' predicts Joseph Errante, vice president for dental, Blue Cross Blue Shield of Massachusetts.
He's noticed that this is especially true for many of his larger clients who are buying dental because of our value proposition in which we integrate all of the health and dental data and deliver interventions that help manage their employees' overall health better than is possible when the health and dental are separated, says Errante.
Historically, employers have offered dental to retain and attract employees. Errante has noticed that employers are building on this model by integrating data around health and dental - that is, identifying high-risk individuals and fixing overall health.
At BCBSMA, 32%-35% of individuals in their at-risk populations converted from noncompliance to compliance by receiving dental services that improve their overall health outcomes. This behavior change was influenced by the insurer's outreach programs.
Susan Fournier, executive director of the Massachusetts Public Employees Union, also sees some changes starting to surface in the realm of evidence-based dentistry.
"I think that the traditional form of dental plan design, where you get a cleaning and an exam every six months [no matter what], should be modified," she says. "You'll begin to see dentists that have individuals, especially children, at high risk [encourage their patients] to do more frequent interventions, so they can possibly prevent restorations down the road. Some of the costs upfront might increase, but on the other end, you hopefully will reduce the need for restorations and improve the patient's oral health."
She strongly believes in evidence-based dentistry, wherein the dentist provides appropriate care based on risk and a greater focus is aimed at prevention. There is no science for getting a cleaning every six months, she says, and those at risk may need more than two cleanings a year.
To change the system, Fournier insists that employers work with dentists in incentivizing prevention.
"There's more financial incentive [for a dentist] to do a crown than there is to do some interventions with extra fluorides or extra cleanings, especially if the plan doesn't pay for them. We want to change that model and pay dentists fairly and appropriately to do more of those preventive interventions," she says.
In this economy, dentists are seeing fewer patients, especially patients that have no dental insurance, she continues. Also, many patients are foregoing more extensive treatment, such as putting off having a crown, due to the costs. So, dentists are obviously concerned about declining revenues. Where they may have been willing to accept discounted-fee schedules, they are paying more attention to those discounts as they look at their bottom line.
In the Massachusetts Public Employees Fund's plan, which provides dental and vision for 35,000 employees in the Commonwealth of Massachusetts. and certain City of Boston employees, the fee schedule structure has shifted for two health centers to incentivize prevention with significant increased fees for dentists who practiced prevention services. This is 100% employer-paid.
"We want to make it profitable for the dentist office, and it's hopefully cost-neutral or eventually will be cost-neutral. It is all in the patient's best interest, because you're keeping them healthy," Fournier says.
