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CHAPTER 1 CONCLUS IONS AND RECOMMENDATIONS Americans have a substantial unmet need for dental care, as is indicated by surveys employing objective professional examinations of persons to determine their dental health. At the same time, proved methods exist for preventing and reducing dental diseases, which if untreated, are important causes of pain, discomfort, and disfigurement and can contribute to nutritional deficits or impaired social function. The coexistence of these circumstances provides an opportunity for improving dental health through direct support of an efficacious prevention program and implementation of an insurance plan to cover costs of dental services that can help control dental disease, reduce the backlog of need for care, and improve the quality of life for most Americans. The national program to improve dental health described in this report proposes that dental care resources be allocated to meet more closely the population's need for dental care. Included as the highest priority is a proposed public program of preventive services for children, ranging from fluoridation of water supplies to professional- ly administered preventive agents and oral hygiene education. Pro- phylaxis and preventive and education services are proposed to be initiated through school systems in a manner that would be more timely for prevention, more equitable for access by the poor, and less costly than the existing majority of fee-for-service care. In addition to this public program of preventive services, priorities are recommended for a national program of dental insurance leading to the availability of comprehensive dental service to all Americans. These priorities are intended to introduce a set of in- centives to improve the oral health of the population by fostering an emphasis on prevention and early treatment rather than expensive dental repair and reconstruction. These priorities should also serve as a guide for the design of private health insurance plans. The committee felt that the national goal for dental care should be the eventual availability of comprehensive dental services to all Americans through a combination of public and private financing 1

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arrangements and administrative mechanisms that will emerge over time. Only if that goal is met, can the dental health of the nation be maxi- mized. The overall approach proposed implies that an increased investment in preventive measures for new generations of Americans will result in a population that has better dental health and a noticeable improvement in quality of life. This improvement would result not only from the re- duction of acute and often disabling incidents of pain and discomfort, but also from the longer-term beneficial effects--less disfigurement, clearer speech, improved ability to eat healthful food--all of which can contribute to physical health and social well being. Chapter 2 contains the data that describe the unmet need for dental care in the United States and itemizes the lower utilization of dental services along the lines of lower socio-economic status. The existing measures of proved efficacy in preventing and reducing the most common dental diseases are discussed in Chapter 3. The projected adequacy of supply of dental care personnel, with or without the inclusion of dental benefits in a national health insurance plan, is discussed in Chapter 4. Also discussed are possible modifications of the dental care delivery system--including a greater role for dental hygienists and other auxiliary personnel--to promote more cost-effective service methods, particularly in the area of preven- tion. The rise of dental care expenditures over the past decade--at a rate slightly greater than expenditures for all health care--is de- scribed in Chapter 5. That section also reviews the experience of private programs of third-party payment for dental care and public programs for direct services, all of which together have accounted for a proportion of dental care expenditures that rose from about 9 percent to 23 percent in the past decade. The increase, however, is almost all due to the growth in private insurance plans; public expenditures have decreased as a proportion of the total. Still, 75 percent of all expenditures for dental care are out-of-pocket outlays. In addition, Chapter 5 describes various approaches to containing the costs of dental care and redirect- ing limited resources toward the goal of better oral health through better disease control. The Rationale for Insuring Dental Services A fundamental question for this study committee was whether health insurance, either public or private, should be extended to cover dental care, either now under existing plans or under an eventual national health insurance program. 2

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During the course of this study, the likelihood has decreased that any national health insurance plan will be enacted in the near future. Enactment of a broad plan including dental benefits seems even more unlikely. However, the priorities developed by the committee for den- tal services should provide guidance to any future actions concerning dental benefits under national health insurance. Meanwhile, the recommendations should prove useful in assuring that additional funds committed to the extension of private dental insurance benefits will have a greater impact on oral health. The issues in dental insurance differ from those in medical in- surance because the services they cover differ. Hospital care, which is the biggest item of coverage by medical insurance, is needed by only a minority of people and at a reasonably predictable rate among a popu- lation with known characteristics, and is very expensive. Hospitaliza- tion meets the three major criteria for casualty insurance: the event or expense insured against (1) is relatively rare for the individual person but occurs at known rates for groups, (2) is very costly, and (3) cannot generally be controlled by the insured. Dental care typically lacks all three of these characteristics. Most persons have or need some dental care each year. The services usually are not as expensive as other types of health care; it usually is the patient's decision to use dental services; and the patient's desires are an important factor in determining what kind of dental ser- vices are received, the dentist's suggestions notwithstanding. Control of the use of dental services by patients seems to be borne out by the experience of existing insurance plans. For example, when dental insurance was extended to a group, a relatively few more people began using dental services--perhaps an increase in individual utilization from 50 percent to 60 percent. However, there was a marked increase in expenditures because of increases in the number and expense of services received by those who were already receiving some services. These basic differences between dental and other health services might lead traditional insurers to conclude that dental services should not be insured. However, additional factors in dental services are important to a consideration of their insurability. First, utili- zation of services is highly correlated with income, education and occupational status (Chapter 2~. Second, much more is known about the etiology of dental disease than of many medical diseases, and effective preventive measures are already developed, proved, and available (Chapter 3~. Third, patterns of current use and provision of dental services indicate that many consumers are not receiving the mix of services that could be most cost-effective for the individual and the nation. Fourth, although private dental insurance is growing rapidly and includes some preventive services, the committee finds that the current pattern of benefit coverage encourages treatment late in the disease process, such as more expensive reconstructive services, rather than prevention or early treatment. 3

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If private dental insurance continues its present rate of growth and its present patterns in coverage, and if other public programs to improve dental health remain unchanged, the result may be that some of the most cost-effective preventive measures to improve dental health will be underutilized, while some of the less cost-effective reconstructive procedures will likely increase in use because they are covered (Chapter 6~. A drift by much of the population into an emphasis on reconstructive over preventive services would parallel the pattern the country has followed in acute medical care services and would fail to obtain the maximum in oral health benefits for the costs incurred. The committee concluded that well-designed public and private dental health insurance would be useful for achieving important ob- jectives in dental health and that this advantage outweighs the inapplicability of some of the traditional insurance principles to dental care benefits. Specifically, the committee concluded that properly designed dental insurance could (1) permit budgeting of family dental expenses over time and over differing needs of family members; (2) avoid financial hardship; (3) encourage and expand, by covering under insurance, those services that clearly are needed and cost-effective, but that may be under-used without insurance coverage; (4) create incentives to restrain growth in expenditures over time; and (5) improve the effectiveness and accessibility to various dental care delivery systems. Recommendations To help achieve the purposes stated above and thus improve the quality of life for Americans, the committee recommends that properly designed health insurance covering dental care services be considered an appropriate component of a national health insurance plan. The committee also recommends that these purposes be supported by appro- priate design of existing public and private dental insurance coverage. A Basic Public Plan for Preventive Services A major issue in the design of insurance plans for dental ser- vices is whether certain services, primarily preventive, should be pro- vided through public financing to the entire population as a foundation upon which services covered under dental health insurance (public and private) should be built. Important subsidiary questions are how such basic preventive services should be delivered, and what relationship should be established between the basic services and the services covered by public or private insurance systems. 4

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The evidence in Chapters 2 and 3 justifies a foundation of communi- ty fluoridation and preventive care as essential to improvement of dental health. The committee further believes that some preventive services might best be provided in or through the nation's school systems based on existing experience described in Chapter 4. The private dental office was considered by the committee as an alternative to school-based settings for delivering the preventive services that are recommended. Because many preventive services can be delivered by auxiliary personnel in a group or classroom setting, there are many efficiencies and economies to be gained in a school-based setting. In addition, a school-based setting provides greater access to the individual services (e.g., screening examination) for children from lower income families, who tend to underutilize private office dental services. Therefore, because certain basic preventive services are necessary to improving the dental health of the nation, the committee recommends that a basic system assure the delivery of preventive services to all children, whether or not dental health insurance is included in national health insurance or there is continued growth in private dental in- surance. The committee suggests further that the most efficient way to accomplish this objective may be to encourage and enlarge school-based preventive dentistry services that have been initiated in many school districts throughout the nation, and to initiate such services where they do not now exist. This program constitutes the committee's first priority. The committee did not recommend the specific details of the financ- ing and operation of such a program, which would require detailed consideration of mechanisms for encouraging and funding these services through schools. However, the following is an outline of how such a program might work. Financial support on a capitation basis might be provided to cover the reasonable full costs of providing a basic set of educational and preventive services in the schools to all children and adolescents. All children in the grades covered would receive two types of services as part of the school curriculum. The first type would be solely educational and could be integrated with the general physical and health education methods appropriate to each grade level that have been found to improve physical awareness and general health behavior most effectively. The second type would be a set of preventive services furnished directly to each child, either individual or within class- room groups, with continuing emphasis on children of greatest need and the development of personal responsibility of child and family. Services to be considered for inclusion would be a screening exam- ination, prophylaxis (cleaning) and, if needed, sealants and topical fluoride applications. The specific set of services in this second 5

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segment would be modified periodically on the basis of recommenda- tions from a continuing body of experts established for this purpose. Targeting of selected preventive procedures would be desirable for particular age groups and persons with particular dental disease risks. The school system might provide the services directly or contract for their provision, or the school-based services might be provided by a public health agency. Parents and any family dentist identified for each child would receive a report of the results of the examinations, including need for fillings or other dental care. Parents would be allowed to exempt their children from the second type of services. However, no payment would be provided by public insurance programs for such services outside the school-based program.* The committee believes that the particulars of such an approach deserve full discussion as the preferred alternative to including such services under either national health insurance plans or a com- prehensive national health policy. Because children would not be eligible for a school-based pro- gram before the age of five or six, it is recognized and expected that children should have earlier encounters with professional dental care from their family dentist, pedodontist, or community-based child care program. In order to ease the financial barrier to this initial dental care for children of low income families a recommenda- tion regarding the priority of this special population group is under the following outlined insurance priorities. Dental Insurance Priorities With the highest priority given to a school-based preventive education and services program described above and assuming its adoption whether or not a national health insurance program is enacted the committee grouped other dental services into three broad cate- gories in decreasing order of their long-range cost-effectiveness in improving oral health (Chapter 6~. If economic or other con- straints limit an eventual national health insurance program initially to less than comprehensive medical and dental benefits, the committee recommends that benefits be phased in according to the priorities indicated by their long-range cost-effectiveness. The committee recommends the following priorities for coverage of dental care under a national health insurance program: *See additional comments by committee members, Appendix 2. 6

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Priority One: Prevention for children and adolescents (to be provided through the basic public plan described above) a) Integration of dental health education and plaque control into general education program b) Screening examination, prophylaxis (age 12-17 years only), an appropriate type of fluoride application, and sealants where applicable Priority Two: Comprehensive services (other than prevention) for children and adolescents from birth to 17 years a) Examination b) Radiographs c) Space maintainers d) Extractions e) Restorations f) Crowns g) Endodontic treatment h) Treatment of handicapping malocclusion Priority Three: Prevention for adults - 18 years and over a) Screening examination and prophylaxis b) Prophylaxis Priority Four: Comprehensive services (other than prevention) for adults a) Examination b) Radiographs c) Extractions d) Periodontal treatment e) Restorations f) Crowns g) Endodontic treatment h) Replacement services 1. bridges 2. full and partial dentures If these priorities are followed as a basis for phasing in dental insurance coverage, some committee members believe that emergency services for everyone should be included in Priority One. The rationale for such inclusion would be the inappropriateness of any financial barrier to obtaining services that would relieve the intense discomfort of dental emergencies. ~- ~ ~ ~ ~ ~ - ~ ~ . . . . . . , . , . . . However, it is the judgment of the majority or the committee, Why le appreciating the concern about alleviation of suffering, that this benefit in the absence of comprehensive benefits would prove unworkable. There would be strong pressures to define many dental visits as emergencies to make them eligible for insurance

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payments. In addition, greater incentive might be provided to extract teeth as an emergency procedure, particularly for low income patients, unless the backup of reconstructive services was available.* Special Population Group Priority The committee believes that private dental insurance can play an important role in assuring access to dental care. It also wishes to stress that private insurance is unlikely to lead to the most cost- effective dental care for the nation as a whole. The current patterns of private insurance coverage would tend to provide comprehensive cover- age, including preventive and basic as well as the less cost-effective reconstructive procedures, for one segment of the population, primarily the employed who obtain insurance coverage through their employment, but leave large groups of the population without any coverage of dental services. If national health insurance with universal coverage for dental benefits is not enacted, the question remains regarding the public role in assuring access to dental care for the poor. As stated in Chapter 4, the present Medicaid program is inadequate in covering dental services for the poor. Many states do not cover dental ser- vices at all; and many of those that do have severe limitations on coverage. Such unevenness in a program funded in substantial part by federal tax dollars seems to the committee to be inequitable. Evidence is presented in Chapter 2 to suggest that the markedly lower utilization of these basic services would be expected to persist if such financial aid were not made available to this special population group. The committee believes that achievement of better equity in access to improved dental health status requires that the child from a poor family who has been found to need such basic preventive, emergency, and restorative dental services under the school-based program recom- mended above should have the opportunity to receive these services. Therefore, the committee recommends that at a minimum, and even if national health insurance is not enacted, steps should be taken to assure that the children of low-income familes have access to . the basic dental services described in Priorities One and Two above. Cost Sharing for Dental Benefits The literature on medical care includes studies and analyses on the effects of cost-sharing by the individual on utilization, costs, and accessibility of health care services. If dental coverage is part of national health insurance, the committee assumes that the basic decisions on cost-sharing alternatives for medical care will likely apply in the same fashion to dental care benefits. . .. *See additional comments by committee members, Appendix 2. 8

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The committee considered the positive effects of cost sharing on containing expenditures as well as the negative consequences re- sulting from inhibiting or discouraging the use of services. It seems especially important in dental care to encourage the individual to utilize those preventive services essential to future dental health. Any impediment to the use of appropriate preventive services, financial or other, should be avoided. Therefore, the committee recommends that cost-sharing not be applied to preventive dental services. Financing and Delivery Systems In considering the types of delivery systems that should be covered under a dental component of a national health insurance pro- gram, a variety of payment methods, reimbursement systems, and practice setting organizations seem to show some promise. Several such delivery systems are either in place or could be created and appear to have the potential for containing expenditures while assuring quality care (Chapter 4~. Dental practice organizations along the general lines of health maintenance organizations, or with other risk-sharing characteristics, reflect certain cost-effective features. The California Dental Service Corporation administers such an HMO-like program, along with a number of private dental insurance plans. Private dentists of that state have made arrangements with the corporation to provide dental services to Medicaid patients under a risk arrangement, which has proved success- ful in constraining costs of the service benefits provided by Medicaid. The dentists agree to provide all the covered services at a capitation rate, and the individual dentists participating in the plan receive a fee-for-service payment for services provided to Medicaid patients. Two important results came out of this experience. First, many more Medicaid patients have had access to dental care, because a very large proportion of dentists participated in the organization's plan; and second, costs were held substantially below what they would have been had there not been an organized plan to provide the benefits. A similar experiment is under way in Massachusetts. Such direct experience with dental care and the positive results of a variety of forms of medical care organizations along the general lines of health maintenance organizations (HMOs) have shown to be efficient and effective in providing ambulatory health services and have contributed to a substantial body of experience supporting development of alternative dental care delivery systems. The committee recommends that alternative prepaid delivery systems and capitation reimbursement systems be made an integral part of a den- tal health program under national health insurance and that a substantial 9

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research and development effort to establish, improve, and refine alter- native methods of prepaid delivery of dental care be included in a national health insurance program. Dental Auxiliaries in the Recommended Prevention Program The data and analysis support the finding that dental auxiliaries are competent to provide a series of preventive services that meet desirable standards of quality (Chapter 4~. The use of dental hygienists and expanded function dental auxiliaries in providing preventive ser- vices in a school-based preventive program for children and adolescents, such as that recommended by the committee, would have two important effects. First, program expenditures can be better contained because the limited scope of services provided by such dental auxiliaries do not require the extensive training provided to a dentist and thus the labor costs of their services are substantially less. Second, the availability of dental auxiliaries for preventive services would help assure that an adequate number of dentists will be available to meet the increasing demand for treatment services as dental in- surance continues to grow. Legal constraints on the use of auxiliaries for the direct provision of preventive services purport to protect the public from inadequately trained personnel. However, the results of many demon- strations do not support this assertion. Even if dentists are available to perform these services, the use of dental auxiliaries will be more economical and will restrain the cost of a universal school-based program (Chapter 4~. Therefore, the committee recommends that dental hygienists and dental assistants with appropriate training be used to provide preventive care in the recommended school-based system and that those - few state lezal restrictions to carryin~ out this recommendation be negated. Quality Assurance and Utilization Review Restorative dental services include of procedures that range from the removal of plaque and maintenance care, to an optimal level of extensive occlusal reconstruction. Although the decision to seek dental care is predominately determined by the patient, the kind of procedures and services actually delivered are heavily influenced by the dentist. Of importance, then, is the level (preventive, basic, or reconstructive) of restorative services that dental insurance should cover and that should be delivered to each patient. Therefore, mechanisms to assure the appropriate fit between provider resources and patient needs are necessary. 10

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various kinds of dental services and intended levels of dental health require different types of review mechanisms in order to assure the quality of care and the appropriateness of the services provided. Preventive measures such as topical fluorides, plaque removal, and teeth sealants will require one type of quality assurance mechanism, while restorative procedures may require other mechanisms such as preauthorization and record reviews. However, in order to evaluate the quality and level of the services actually provided, some system must be instituted so that there is a continuing assurance that the insured benefits are being appropriately utilized and delivered. The committee recommends that Roland mechanism Of ad irv ~nr1 utilization review for ambulatory dental care be demonstrated and analyzed and that an effective system be included in any national health insurance system. Information System The administration of a national health insurance plan will require a population-based information system in order to provide several kinds of data. For example, it will be necessary to have accurate current information on the persons enrolled, services received, provider identification, and resulting treatment patterns. In addition, program management will require data on expenditures and uses of various types of resources. Continuing analysis will be required of the effect of the dental services provided on the entire dental care system and the oral health of the nation. Thus, data are needed to provide information necessary for management of operations, policy analysis, and overall program evaluation. toted as an initial component of a national health insurance program. Funds to support these management, analysis, and evaluation activities should be allocated as part of the operating budget of national health insurance as an integral component of annual administrative The committee recommends that an information system be insti- expenses. 11

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