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PREFACE This study was initiated by the Institute of Medicine because of interest by the Institute membership in analysis of issues that had received too little attention in the debates over national health insurance. In spite of the prevalence of dental disease and the ex- tensive resources directed to dental care, it has largely been ignored in the current public policy discussions, except for local flurries of concern about the fluoridation of public water supplies. Dental care has also been neglected by most private health insurance plans until recent times. The lack of analysis and discussion, even as private dental health insurance is experiencing rapid growth, seemed to justify an independent activity by the Institute to focus attention on the policy issues relating to the financing and provision of dental services. The W. K. Kellogg Foundation, which has a long-standing interest in dental care, was willing to provide financial support for the study. This support was part of a broader effort by the foundation to stimu- late analysis of dental health policy issues at the national and state levels. A committee representing the multiple disciplines and perspec- tives relevant to dental health policy was appointed by David Hamburg, president of the Institute, to direct the study. The charge to the committee was to consider alternatives for the inclusion of dental care, particularly dental care for children, under national health insurance plans. At the first meeting of the committee in May, 1977 the committee agreed with the suggestion by Julius Richmond, who was the chairman of the committee before his appointment as Assistant Secretary for Health and Surgeon General, that the committee regard benefits to dental health as the primary criterion for evaluating alternative dental health plans. The analysis of options also was to include consideration of economic implications, acceptability, and feasibility. But the ultimate assessment used in the study has been the improvement in quality of life through better oral health, as measured by the prevention and control of the two principal oral diseases--dental caries and periodontal disease. The committee also agreed that the scope of the study should not be limited to the traditional boundaries of health insurance-- third party payment of expenses incurred for a stated package of benefits--but should extend to consideration of alternative forms of provider payment and service delivery mechanisms which could be more effective for achieving the objectives of improved oral health than an insurance benefit alone. xiii

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In conjunction with the initial meeting of the committee, a conference was held at which invited speakers described the dental care systems of several industrialized nations and suggested lessons that might be learned from their approach to the prevention and con- trol of dental problems. The committee conducted a public hearing as part of its second meeting. A variety of dental care providers, as well as interested consumers, repeatedly emphasized the importance and feasibility of prevention measures in controlling dental disease. A school-based program of prevention care also was mentioned frequently, and this alternative was pursued in subsequent committee deliberations. The committee met seven times over the life of the study. The findings, conclusions, and recommendations were endorsed by the entire committee, with the exceptions noted in the additional com- ments by several committee members and printed at the end of the study text. The committee benefited greatly from comments and suggestions made during the review of the draft report by the Institute Council. Chapter 1 of this report contains the commmittee's conclusions and recommendations concerning dental health policy. Chapters 2 through 5 provide a review of the existing literature and data on need for dental services, utilization of those services, epidemiology of dental disease, evidence for the effectiveness of preventive ser- vices, expenditures for dental care, and the current characteristics of dental health insurance. Because of our intent to be concerned about the impact on oral health of dental policy alternatives, the committee believed that it was necessary to examine the nature and distribution of dental disease, the efficacy of interventions, and the current financing of dental services in order to make informed judgments about the changes that altered financing and organization of services would cause in oral health status. This approach contrasts with much of the history of the growth of insurance for the costs of medical care, which evolved largely in response to financial and income protection considerations. Chapter 6 displays cost estimates for each of the benefit packages for which priorities are recommended in Chapter 1. These cost estimates are based on estimates of need for dental services, and methods for arriving at those estimates are de- scribed. The needs-based estimates are then compared with current expenditure projections and with an actuarial (demand-based) estimate derived from actual experience under an existing dental insurance plan. The committee believed that the comparison of Cat estimates based on need and demand forms a useful context for consideration of x~v

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dental policy alternatives. A reasonable objective of such policy would be to recommend financial and service alternatives that would stimulate a pattern of utilization that is as closely matched as possible to needs. This intent contrasts with the history of medical care insurance, which has tended to reinforce a pattern of demand that emphasizes expensive services. ~u _ _, ~ . I enjoyed chairing this committee. I believe that the extent of agreement among this diverse group is a tribute to their willingness to learn from each other as well as a recognition of the compelling nature of the evidence that we reviewed. The work of the committee has been greatly facilitated by the work of the staff, especially Chester Douglass, who as staff director for the study assembled and analyzed a wide array of information and data on dental services. Dr. Douglass was able to draw upon the assistance of many others who are noted in the acknowledgments. The committee joins with Dr. Douglass in expressing our appreciation for all of their help, without which the study would not have been complete. I also want to acknowledge on behalf of the committee the help and support of Dr. Hamburg and the senior staff of the Institute, especially Linda Demlo, Carleton Evans, Wallace Waterfall, and Karl Yordy, all of whom helped the report achieve its final shape. Finally, the committee gratefully acknowledges the support pro- vided by the W. K. Kellogg Foundation. The Foundation's willingness to support this initiative and the understanding of Ben Barker, the program officer, made possible the committee's work. We also acknowledge support from the Initiatives Fund of the Institute which assisted in the completion of this study. Dorothy P. Rice xv

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ACKNOWLEDGEMENTS Several organizations, agencies, foundations, and universities have contributed to this study. Ben Barker, program director for the W. K. Kellogg Foundation, facilitated communication with other projects of the Foundation related to dental care issues. This coordination resulted in the sharing of data and background papers with concurrent projects being conducted by the Council of State Governments, the American Association of Dental Schools, and the Quality Assurance Programs of the American Fund for Dental Health. Three sources of unpublished data have been provided for use in the study. The National Center for Health Statistics provided its Health and Nutrition Examination Survey dental disease data, the California Dental Service Corporation provided cost estimates and certain requested actuarial data, and the Bureau of Health Manpower provided their continuing estimation of dental care providers and their information on productivity in dental practice. The National Institute of Dental Research, the Health Care Financing Administration, and the American Dental Association pro- vided documents, the scientific knowledge of their staffs, and their most current data. The National Preventive Dentistry Demonstration Project, funded by the Robert Wood Johnson Foundation, also furnished ideas and preliminary information generated by the project. An added thank-you is owed to the administration of the Harvard School of Dental Medicine for the time and extra staff support devoted to the study, and to many faculty colleagues who provided valuable ad- vice and technical information relating to specific scientific questions. Special recognition should go to John I. Ingle, who as a member of the IOM senior staff participated in the initiation of the study. Finally, and most important, I wish to express my appreciation for the opportunity to work with the committee under the leadership of Dorothy Rice, who assumed chairmanship of the committee after Julius Richmond's resignation. Chester W. Douglass Staff Director xvi