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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.
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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
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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
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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
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