Dental Benefits in the United States. Fay Donohue

Transcription

1 Dental Benefits in the United States Fay Donohue President & CEO 1

2 Agenda Dental Insurance Market Coverage Types Plans Price Cost Management Case Study The DentaQuest Story 2

3 Nearly 166 million Americans, 54% of the population, were covered by some form of dental benefit in 2009 Population with Dental Benefits % Population with Dental Benefits 57% 57% 57% 54% 55% 54% 54% 54% 173,6 175,8 169,6 165,71 162,5 159,3 154,5 155, Source: 2010 NADP State of Dental Benefits Market, April 2011 (Population in Millions) 3

4 Common Types of Dental Plans Indemnity Dental Preferred Provider Organization (DPPO) Dental Health Maintenance Organization (DHMO) Discount Dental Card All Dentists Group of Dentists for best coverage Less paymentto other dentist Benefits available only at HMO dentist Not Insurance 4

5 Total Dental Insurance Market, $36.7 Billion in 2010 DPPO Dental Indemity DHMO Discount Card Source: 2010 NADP State of Dental Benefits Market, April

6 Distribution of Enrollment in Dental Benefits Individual 1% Smallest Group (<50 Employees) 6% Small Group (50-99 Employees) 30% Large Group (100 + Employees) 56% Public 16% Source: 2010 NADP State of Dental Benefits Market, April 2011 Notes: Add to more than 100% 6

7 Funding of Dental Benefits Employer Paid Shared Employee Paid 5% 20% 17% 21% 56% 71% 58% 67% 61% 22% 16% 39% 27% 2% 18% DHMO DPPO Dental Indemity Discount Dental Total Source: 2010 NADP / DDPA Enrollment Report 7

8 Voluntary Benefits Employees feel like life, disability and dental insurance through the workplace are important even if they have to pay 100% of the cost. 60% 50% 40% 54% 58% 59% 30% 20% 10% 0% Interested in life insurance Interested in disability Insurance Interested in dental insurance 8

9 Preventive & Diagnostic Services (100%) Oral exams, 2x per year Full mouth x-ray, once 60 months Bi-wing x-rays, every 6 months Single tooth x-ray Cleaning, 2x per year Periodontal cleans, every 3 months Fluoride treatment, up age 19 /every 6 months Typical Benefit Plan Basic Restorative (80 %) Silver fillings, once every 24 months White fillings, front teeth / single surface back teeth Temporary fillings Endodontic Root canal Oral surgery Simple and surgical extractions Periodontal Periodontal surgery Scaling and root planning, once every 24 months Major Restorative (50 %) Prosthodontics Dentures, once within 60 months Fixed bridges and crowns $1,500 per year maximum 9

10 Top 10- Most Expensive Disease (2008, MEPS) Hyperlipidemia; $39 Diabetes; $46 Hypertension; $47 COPA, Asthma; $54 Osteoathrithis; $57 Mental; $72 Cancer; $72 Trama; $74 Dental; $85 Heart conditions; $96 $100 $80 $60 $40 $ in Billions 10 $20 $0

11 Top 10 Out-of Pocket Expenses for Americans $ $ $ $ $ $ $ $ $5.000 $- $ $ $9.700 $9.300 $ in Millions $8.000 $8.000 $7.000 $6.500 $6.000 $

12 Uninsured Adults Are Less Likely to Have a Regular Source of Care: Adults % 95% 84% 69% 59% 69% 47% 29% Regular source of care Dental exam in past year Total Insured all Year Insured now, time uninsured in past year Uninsured now Source: The Commonwealth Fund Biennial Health Insurance Survey (2010) 12

13 % Visited Dentist in the Past Year 65% 64% 65% 73% 77% 78% 64% 60% 62% 55% 58% 60% Years of Age and Older Children: 2-17 Years Old Adults: Adults: 65 and Older Source: Health, United States

14 Cost Management Tools Benefit Design Utilization Review Utilization Management Provider Reimbursement 14

15 Utilization Review The post-payment review of dentist treatment patterns: To detect patterns of over or under utilization To detect fraud and abuse To Increase cost effectiveness and improve care 15

16 Utilization Management The pre-payment review of claims or requests Either through pre-approval process or systems edits 16

17 Reimbursement Methodologies Fee schedule Capitation Incentive pay for performance / pay for quality 17

18 Case Study 1 One Plan - 600,000 Members 18

19 One Case Study-One Plan= 600 K Members Cost Management of Claims - % of Services Denied due to System Edits Covered Services $160,00 $120,00 Reduction to the average claim cost due to system edits $157,49 $126,07 15,8% $80,00 $40,00 $31,42 $- Average amount would have been paid Savings Actual paid claim 19

20 Total Dollar Amounts of Prior Authorizations 8,0 6.8 Million 6,0 4,0 3.5 Million 3.3 Million 2,0 0,0 Submitted Denied Approved 20

21 Number of Prior Authorizations Submitted Denied Approved 21

22 Case Study 2 Plan For High Risk Children 22

23 Today s Path to Quality Improvement Basic Systematic Clinical Quality Research Reviews Guidelines Measures 23

24 Health Care Delivery System Metrics & Domains Quality Outcome Process Access Structure Patient Experience Related Measures Use of Services Cost of Care Health Status of Patient Management of Care Efficiency Units of Care per resource Source for Slides: 24

25 Data Driven Decisions What s Driving Cost? Milhões $5,5 $5,0 $4,5 $4,0 $3,5 $3,0 P = Permanent or adult teeth D= Deciduous or baby teeth D 2nd Molar D 1st Molar D Canine D Lateral Incisor D Central Incisor $2,5 P 3rd Molars $2,0 P 2nd Molars $1,5 $1,0 $0,5 P 1st Molars P 2nd Premolars $0,0 P 1st Premolars P Canines Age of Beneficiaries 25

26 Restorations per Patient by Tooth Type 26

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28 Evidence - Based Decisions Evidence from ADA Dental Sealant Recommendation Reduction of caries incidence in children after placement of resin-based sealants ranges from 86 percent at one year 78.6 percent at two years 58.6 percent at four years Sealants are effective in reducing occlusal caries incidence in permanent first molars of children by 76.3 percent at four years Caries reduction was 65 percent at nine years with no reapplication during the last five years 28 Evidence-based clinical recommendations for the use of pit-and-fissure sealants. A report of the American Dental Association Council on Scientific Affairs. JADA, Vol March 2008

29 Provider Performance - Sealants 100% Percent of 6 and 7 Year Olds Receiving Dental Sealant on First Molars % Count of Ages 5, 6 & 7 Percent 5-7 w/ Seal % % % % % % % % 100 0% 0 29

30 The DentaQuest Story 30

31 Mission To Improve Oral Health 31

32 How? Dental Benefits Philanthropy Knowledge 32

33 Give Grants to: DentaQuest Foundation US Oral Health Alliance Community Health Centers State Coalitions Demonstration Grants 33

34 DentaQuest Institute To provide clinical care and practice management solutions to clinical partners across the country to develop and implement more effective approaches to prevent and manage oral disease. 34

35 DentaQuest Oral Health Center Multispecialty group practice Disease management Model of Best Practice Evidence based 13,000 patients a year 35

36 DentaQuest Dental Plans 17 Million Members: Different Products DHMO, PPO, Indemnity Different Markets Government, Employer, Individual 36

37 Questions 37