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MARCH / APRIL 2012 :: 73(2)
Oral Health

This issue's policy forum focuses on initiatives that promote oral health and on challenges the state currently faces. Commentaries discuss new practice models and trends in dental practice, dentist workforce numbers, the East Carolina University School of Dental Medicine education model, and insurance innovation in dental coverage. Several articles focus on access to oral health care in specific populations including children, adult Medicaid recipients, and people with special needs. Original articles examine reasons for tanning bed use among community college students and evaluate the effectiveness of mailed interventions to increase colon cancer screening.

INVITED COMMENTARY

Innovations in Oral Health Insurance

Linda Moore

N C Med J. 2012;73(2):131-132.PDF | TABLE OF CONTENTS



Dental disease can impact a person’s ability to eat and speak, and increases absenteeism at work and school. Dental insurance plays an important role in the oral health care of North Carolinians as children and adults with dental insurance are more likely to get routine dental care, which can prevent dental disease.

Blue Cross and Blue Shield of North Carolina (BCBSNC) has offered dental insurance to its clients for over 20 years, offering a variety of plan designs to meet the demands of our customers. We are proud to cover dental insurance needs for over 4,000 employer groups in North Carolina and for our 380,000 members. We process over 1.5 million dental service claims annually but, with the current economic climate, we’ve seen a decline in utilization. People are putting off going to the dentist now more than ever. Many North Carolinians are making tough decisions about where they spend their disposable income and are choosing to forgo dental care.

Medical professionals and insurance companies recognize that oral health is an important part of a person’s overall health and well-being. However, the insurance industry and employer groups have been slow to consider dental insurance beyond an ancillary benefit. In the end, it all comes down to cost.

The Cost Problem
“Cost” is often too narrowly defined. We need to recognize that the cost of dental insurance not only covers dental services, but also has downstream impacts on costs that can relate to a person’s overall health status. As indicated in a National Association of Dental Plans survey [1], people without dental insurance are more likely to forgo routine care and potentially neglect dental problems until they end up at the emergency room. Costs for a single emergency room visit are 10 times more costly than the cost of preventive dental treatment for a year [2]. Due to economic concerns and rising costs of health plan premiums, employers struggle to continue offering dental and other ancillary benefits. Some employers are moving toward voluntary benefits offered through the employer, but the employee pays all of the cost. Some are eliminating ancillary benefits altogether.

In general, the insurance industry has yet to connect all of the dots in terms of costs, partly due to the disparate systems used for claims processing. Often, employer groups use a different carrier for health and dental insurance coverage. Even when both health and dental insurance are with the same carrier, the carrier may use different systems for processing the claims. This is the case with BCBSNC.

BCBSNC is taking steps to further integrate information from its two claims processing systems to deliver a more complete solution for our clients. For members with certain diseases that link to oral disease, dental care history is embedded into our case management system and captured as a part of their background information. This allows BCBSNC to better manage the care of our members. For example, when a case manager identifies a member with diabetes, the case manager asks the member about the date of their last dental visit, how regularly they visit the dentist, and their home care regimen.

We want to encourage our members to take advantage of their dental preventive care visits. If a member with both health and dental coverage hasn’t visited the dentist during the past year, we now send reminders to them to do so. To further encourage visits, employer groups have the option to include additional cleaning visits in their dental policy for employees with qualifying conditions such as diabetes, heart conditions, and pregnancy.

Until recently, dental insurance benefits have been very static. The typical employer plan included 100% coverage for preventive and diagnostic services, 80% for minor restorative services, and 50% for major services with an annual maximum benefit of $1,000. While costs have risen due to normal inflation, dental insurance plan maximums have not risen. A few new options have hit the market in the last several years. BCBSNC now offers rollover plans that reward members by rolling over a portion of their unused benefits if they have had a preventive visit and low utilization. This rollover benefit will accumulate from year to year (limits do apply depending on the benefit plan) and is available for the member to use to help offset the costs of expensive dental services at a later date. We also offer a plan where preventive and diagnostic costs do not count toward the annual maximum. Other plan options are available with higher annual maximums.

The Road Ahead
Preventive oral health care is important to lifelong oral health, and oral health care should begin early. Studies have shown that every $1 of preventive dental care results in a savings of $8 in medical costs downstream [3], not to mention dividends in healthy living. The old adage of an ounce of prevention is worth a pound of cure certainly is true for oral health. However, access to care continues to be a roadblock for those who live rurally and for many children statewide. Many rural areas lack a sufficient number of dentists, and pediatric dentists can only be found in the more urban areas of our state. Dental schools in North Carolina are at capacity and cannot meet the growing demands of an increasing population. Furthermore, by not allowing reciprocity for dental licenses from other states, it can be difficult for dental professionals to relocate to North Carolina. Recently there has been a push in other states to allow a mid-level dental professional license. By addressing these issues, there is potential to significantly improve access to affordable preventive dental services.

In addition, the Affordable Care Act may have a considerable impact on access to dental providers. As currently written, the “essential benefits” includes pediatric oral health care. However, what this means has yet to be defined. What is the age range for pediatric? What does the oral health benefit include? How do we incorporate this benefit into the health contract and keep health benefits as affordable as possible? Are the pediatric oral health benefits administered by the health carrier or a separate dental carrier? If routine preventive care (exam, cleanings, x-rays, fluoride treatments, sealants) is now covered for all children below the age of 18, will there be enough dentists in our state to meet the increased demand? This could lead to an increase in costs as demand exceeds supply, further stretching the affordability band.

BCBSNC recognizes that good oral health is an essential component of an individual’s overall health and self-esteem, and also plays a key role in managing total health care costs. We will continue to look for innovative ways to control costs and provide excellent coverage so that we can see healthy smiles on the faces of as many North Carolinians as possible.

Acknowledgment
Potential conflicts of interest. L.M. has no relevant conflicts of interest.

References
1. National Association of Dental Plans. The Haves and the Have-nots: Consumers With and Without Dental Benefits. Dallas, TX: National Association of Dental Plans; 2009. http://www.nadp.org/researchpublications/reportvault.aspx. Accessed March 26, 2012.

2. Bertolami CN. Health care reform must include dental care. Roll Call. April 23, 2009. http://www.rollcall.com/news/-34231-1.html. Accessed March 26, 2012.

3. American Dental Hygienists’ Association. Access to Care Position Paper, 2001. http://www.adha.org/profissues/access_to_care.htm. Accessed March 26, 2012.


Linda Moore director, Dental Markets, Blue Cross and Blue Shield of North Carolina, Durham, North Carolina.

Address correspondence to Ms. Linda Moore, Blue Cross and Blue Shield of North Carolina, PO Box 2291, Durham, NC 27702 (linda.moore@bcbsnc.com).