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Key words: dental insurance, dental benefits, caries, periodontal disease, restorative dentistry, evidence-based dentistry
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Abstract |
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World War II created a huge demand for labor in the United States. The labor force was significantly depleted by the Armed Forces as the United States fought in Europe and Asia. The posters of Rosie the Riveter were produced during this period as women moved into the wartime production economy to fulfill the needs of the war effort. At the same time, the United States had frozen wartime wages. This wage freeze was put in place to prevent individuals or groups from leveraging the shortage of labor to their economic advantage. To compete for labor in these wage-restricted markets, employers began to offer non-wage compensation, and health insurance was a popular total compensation enticement to work for an employer. The effects of this employment-based health insurance system are still in place today, although its relevance to today’s economy and health systems is increasingly debated.
Some progressive employers went so far as to open their own medical clinics. This was seen as useful from a number of perspectives. In some cases, workers did not need to leave their workplace to receive medical services, thereby reducing the amount of time lost to production. The cost of the health system was also under the control of the employer. The Kaiser Health system of today is the evolutionary prodigy of Henry Kaiser’s vision for the health care of the individuals employed in his shipyards.
Against this background, Washington Dental Service was born in 1954 as a cooperative agreement between the International Longshoreman and Warehouse Union (ILWU) and the Washington State Dental Association (WSDA) to insure the children of the longshoremen. The ILWU suggested to the WSDA that the association could help design a program for the ILWU children or, taking the Kaiser example to heart, the ILWU could open its own clinics. The WSDA decided to participate and late in 1954 opened the Washington State Dental Service Corporation. It was the first dental plan in the nation.
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Changes in the Penetration and Treatment of Dental Diseases |
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In the intervening fifty years, the penetration and distribution of dental diseases have changed dramatically. Dentistry’s two primary diseases are increasingly found in smaller and smaller portions of the population. An examination of the distribution of services in Washington Dental Service’s population of approximately two million individuals in 2004 showed that 10 percent of the population received 65 percent of restorative services while another 10 percent received 98 percent of periodontal services.
There has been a continuing sequestration of dental caries not only in selected portions of the population but also by location on the tooth/teeth. Children with caries have a high incidence of occlusal caries compared to adult populations. Much of the adults’ restorative services may be the result of the restoration/rerestoration cycle and represent cumulative damage rather than new disease. This sequestration of diseases is leading to new strategies for dentists, manufacturers, and third party payment systems.
Decreasing Disease Penetration
With the move from a pandemic disease pattern to an endemic and increasingly sequestered disease pattern, the opportunity for treating patients with best practices is changing. Risk assessment, once unnecessary because the majority of the population was at risk, is now emerging as a vital and necessary strategy. Many of the risk factors associated with dental caries and periodontal diseases are known, and models of the interaction of various factors have been and are being developed. (Many of these factors are discussed in other articles in this symposium proceedings.) Developing, validating, and deploying useful disease management models based on patient risk profiles are critical and emerging parts of our science.
The dental industry (patients, dentists, dental schools, insurance carriers, purchasers, etc.) is beginning to adapt to these predictive models to provide better health outcomes. Prior to these models, dentists could use only their experience and clinical judgment to plan preventive strategies for patients judged to be at risk for disease. Much of this judgment was based on dentists’ previous observation of the history of dental diseases. While this was and still is a powerful predictor, multifactorial analyses are developing that have high predictive accuracy. As these models mature, dentists, manufacturers, purchasers, and third party payment systems will leverage this knowledge to intercept high risk patients and prevent the onset of dental diseases.
Current risk prediction models use socioeconomic status, age, sex, and, if known, disease history, smoking status, and current pathologies. As these algorithms mature and are tested on larger populations, they will be continuously improved. As they reach an accuracy threshold of approximately 0.85 Positive Predictive Value (PPV) and 0.85 Negative Predictive Value (NPV), payers will move to change plan designs to benefit these systems.
Treatment Variation
One of the interesting aspects of all health care is the variation in health services given for the same presenting conditions. Both the medical and dental literature is resplendent with examples of this variation. One of the best references on this topic is Michael Millenson’s Demanding Medical Excellence.1 While the book does not address dentistry, the patterns and practices are identical. There are numerous examples of how noticing treatment variations can improve health outcomes. One of the first examples involved Dr. Ignaz Semmelweis in 1847. One of Semmelweis’s colleagues cut his finger while performing an autopsy. His colleague, Jakob Kolletschka, soon died of what was described as puerperal fever. Semmelweis sensed a connection to the maternity patients in his hospital. Thirteen percent of women giving birth in his hospital died of puerperal fever. A nearby obstetric hospital, run by midwives, lost only 2 percent of its patients to the fever. Importantly, Semmelweis noticed and investigated this variation in outcomes. It is useful to remember that germ theory did not reach the literature for another six years and it was eighteen years before Lister showed the scientific community how to kill germs.
After observing the standard birthing activities of both his residents and the midwives, Semmelweis, on a hunch, had his residents wash their hands as they moved between dissecting cadavers and the birthing arena. Immediately, the puerperal fever mortality rate dropped to 2 percent. Semmelweis published his work in 1861 and, as might be expected with any change to operating procedures, it was not well received nor well adopted. Tragically, in 1865 Semmelweis died of puerperal fever from a cut on his finger at the age of forty-seven. This was the same year that Lister began spraying carbolic acid on surgical instruments to kill germs. It was Lister who gave Semmelweis his due when he stated, "Without Semmelweis, my achievements would be nothing."
This is a narrative of how variation and observation can work to our advantage. This same strategy is now being employed in much more sophisticated ways. Health services researchers are engaged in observing the outcomes of the remarkable variation in treatment and assessing which interventions or noninterventions have superior outcomes, given the same presenting conditions. Demanding Medical Excellence cites a number of modern examples of these variations. These variations present both serious concerns for our health care delivery systems and enormous opportunities to improve our practices and the health of our patients.
Variation is also both a threat and an opportunity in dentistry. There is wide variation in diagnostic, preventive, and treatment strategies for the same presenting conditions/patients.2–4 When this is placed in the context of a declining and increasingly sequestered caries incidence, we should have serious concerns about the level of variation among dentists. Inherently, most of us recognize that some diagnostic, preventive, or treatment strategies outperform others. Most of us also believe that our practices and outcomes are equal to or superior to that of our colleagues treating similar populations. The reality is that some of us are outperforming the rest of us.
This is not different from our medical colleagues. Where differences in outcomes are perceived as important to consumers (patients and the purchasers of health benefits), quality tiered systems are evolving. A medical example is the risk adjusted rating system for cardiac surgeons.5 In several states, there are online outcomes-based evaluations of the performance of cardiac surgeons, risk adjusted, by specific procedure. As a patient, you can see the ranking of your cardiothoracic surgeon with his or her peers for your intended procedure. Initial attempts to perform these rankings suffered from a lack of risk adjustment. Those treating high risk patients had higher mortality and morbidity rates than those treating relatively low risk patients. In fact, one way to improve your score on these publicly available scales was to refrain from accepting higher risk patients. Risk adjustments based on a series of measures were then employed to normalize these outcomes data. As might be expected, the discussion on these adjustments was and is the focus of a great deal of debate. However, the result of this body of work is the emergence of consumer demand for quality-tiered networks. It is clear that if your cardiac surgeon’s risk adjusted performance is in the bottom quartile for your projected four vessel bypass surgery, you may have an interest in finding someone in the upper quartile.
While it is clear that dental services will not rise to the level of importance that cardiac surgery does for individuals, there is an emerging financial issue. Not only do those top-performing practitioners have better health outcomes, they often also have better economic outcomes. Lower morbidity equates to immediate and longer term reduction in costs. There are also those dentists and specific practices that exhibit better near- and long-term health outcomes for identical presenting problems and have lower costs. Quantification of this variation in health and cost outcomes is one of the important roles of health services researchers. Virtually all practitioners want to provide the best services to our patients. Identifying those best practices is part of the work of evidence-based dentistry.
Impact of Evidence-Based Dentistry
Evidence-based dentistry is beginning to systematically review research findings and evaluate them for how much confidence we can have in those findings. This article will not review the precepts of evidence-based dentistry (EBD) but will propose how these processes can and will be used by the dental benefits industry.
As individual practitioners, we use our clinical experience to routinely gather outcomes data on our treatment of our patients. As individuals, we tend to repeat our successes and not repeat our failures. This, in and of itself, leads to some of the variation noted above. What is missing from our individual clinical experience views is the systematic review of the literature that can tell us if we are performing at the best-practice level for any service in a particular population. For example, we know from the evidence-based literature that sealants are 71.36 percent effective in preventing caries compared to an untreated cohort across a variety of populations.6 Yet when we examine the treatment patterns of dentists treating WDS patients, only 64 percent of general practitioners use any sealants in any given year.
When Bravo et al.7 compared sealants to fluoride varnish, they saw the traditional reduction in pit and fissure caries when sealants were applied over a twenty-four-month period. However, they also found an 87 percent reduction in smooth surface caries in those children receiving sealants compared to a 66 percent reduction in smooth surface caries for fluoride varnishes.5 This was a very interesting and unexpected finding. We expect sealants to demonstrate some efficacy at reducing pit and fissure caries. Most of us don’t expect that sealants will have a material effect on smooth surface caries.
In an effort to determine if this outcome was repeatable and therefore important to dental plan structure, the Delta Data Analysis Center undertook a study of 239,443 seven- to fifteen-year-old children who had received sealants compared with an age-matched group of 272,872 children who had not received sealants. The outcome measured was restorative services on all surfaces over a four-year period. The results emulated Bravo et al. in that there was an 85 percent reduction in all restorative services provided to the sealed children compared to their untreated cohort. Of the 272,872 children who did not receive sealants, 198,565 received restorations.
Projecting an identical restorative reduction in the untreated cohort (which may or may not be a valid projection) would lead to 168,780 "prevented patients" in the 272,872 untreated children. The restored children had an average restorative cost during this time frame of $364 per child. This number argues for the reduction in more than pit and fissure caries in the untreated cohort. Preventing 85 percent of these costs would equate to a savings of $61,434,002. Take from this raw savings the cost of sealants in all 272,872 children, and you get a final cost savings of $31,599,975 or a savings of $115.66 per child. Add to this the improved quality of life and satisfaction with noninvasive care, as well as the longer term issues of rerestoration costs, and both the purchasers of health services and dental plans will begin to evaluate how to entice dentists to place sealants on at-risk children or to advantage those dentists who place sealants and hence have better outcomes.
This example is used to demonstrate the use of EBD that is validated with outcomes data from non-academic sources—in this case, insurance claims data. This will become increasingly prevalent in setting risk-adjusted plan design parameters. If, as in this case, an intervention is superior to a nonintervention across half a million children age seven to fifteen, those practitioners who use the procedure and obtain the projected outcomes will be at an advantage. That advantage will, in all likelihood, be economic. That is, dentists will be placed in "preferred provider" categories for specific procedures and patient risk profiles, or all practitioners will receive the incentive to perform sealants because the unit cost is increased to an attractive level when compared on a time and effort basis to the subsequent restorative procedures.
There may be advantages for dental insurance companies to integrate their data with other health plans providing services to the same populations. These entities will have access to more information about their patients and hence will be able to leverage that knowledge in potentially useful, health-promoting ways. An example might be the use of periodontal diseases claims data. Setting aside the competing arguments on whether there is a true causal relationship, assume that there is a valid association between periodontal diseases in women of child-bearing age and pre-term, low birthweight babies in those that conceive. A full line carrier will note the treatment/diagnosis of periodontal diseases and, in all likelihood, flag that woman’s health record, and her obstetric visits will have a different series of predelivery protocols than her nonperiodontal diseased peers. The reality is that the cause and effect relationship is secondary to the fact that periodontal diseases are, in this hypothetical model, a marker that may be leveraged to lower medical costs for the health plan. Given the costs associated with premature, low birthweight babies, both initially and over these children’s life spans, this could be highly cost-effective. Purchasers and health plans are interested in their total health care costs. If information can be used to lower any costs while maintaining quality, they will move in that direction.
Unfortunately, there is a lack of the highest level of evidence for much of what we do in dentistry. However, that does not preclude us from using the evidence we have until more appropriate studies answer the questions of importance to us. Third party payment systems will help fill the void through the use of their data sets and the outcomes derived therefrom.
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Likely Changes |
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Demographics
A number of concurrent changes are projected to occur in the demographics of the U.S. population during the next twenty years. Our aging population is an important and increasingly discussed factor to consider. The baby-boomers begin turning sixty-five years old in 2011. They will be doing so at the rate of 10,000 per day, and they will have a projected average of twenty-six teeth per person, many of them heavily restored. Based on our current data, the population from sixty-five to eighty-nine years old has treatment needs that do not vary markedly from the population that is forty-five years old. That is, their treatment needs and patterns of services are almost identical to individuals at ages forty-five, fifty, fifty-five, and sixty. This holds true through age eighty-four. The dental profession has never seen this population in the numbers that will be present, and we are guessing what their needs will be. Based on current data, we know that root caries is a major factor in the elderly with a penetration of 64 percent, and 23 percent have untreated root caries at the time of examination at age eighty-five.8 If the incidence of root caries holds at the current rate, which is doubtful as better therapies are developed, there would be approximately 235 million teeth at risk in 2025 and 50 million teeth that have experienced root caries. This will invite the development of new dental prepayment programs and new materials that we can use to diagnose, prevent, and treat this population and their needs.
Before leaving the age topic in demographics, access to care should be mentioned. As aging progresses, mobility and therefore access to traditional dental resources can wane. Dental carriers or other enterprising groups with sufficient resources may move to fill this void by establishing in-home dental services. This is a largely unexplored and untested market that may be able to be insured or may be reimbursed through other mechanisms. The good news is that in the American culture, if a market exists, someone will fill it.
There are also major ethnic changes occurring in the United States. There will be major shifts in the ethnicity of the U.S. population and in specific geographic areas that may have an impact on dental needs. Disease rates in ethnic groups that modify their native diets to Westernized foods are an unknown wild card in looking at future disease burdens and, hence, ways of assessing risk and insuring these populations.
Economic
Financing dental services for the elder population appears to be problematic for a portion of the population. It is currently estimated that one-third of the elder population will have adequate resources to pay their dental and medical bills during their "second-half" of life. One-third will be marginal and will need to make significant choices about their health care needs, and one-third will have no resources for dental care unless entitlement programs are extended to oral health care. Given the significant shortfall in funds for the medical component of these entitlement programs, entitlement coverage for dental programs seems less than a certainty. It is instructive to note that while Congress has had a fair amount of dialogue and debate about medical care, Medicaid, and the emerging funding crisis, there have been almost no discussions about dental services for this population or about their projected needs. There are a myriad of reasons for this. Primarily, in the face of life-threatening and debilitating acute and chronic diseases, dentistry doesn’t rise to the level of consciousness of legislators or other public policymakers. Dental services will be in competition for scarce resources, and dentistry may or may not win its fair share of these diminishing resources.
What is clear is that there is an impending constriction of funding. Our entitlement programs have been designed to be paid by the contributions of the existing workforce. We have not, as a system, put our health taxes into accounts to be spent in the second half of our lives. The funds have gone to the general funds of the United States and have paid for all general fund items including current health entitlement programs.
One way of dealing with this problem is to pre-buy benefits. New governmentally allowed programs like the Medical Savings Accounts (MSA) in modified forms may meet the needs of some. If their structure remains as it is currently configured, the high deductible amount may make them unsuitable for dental programs. Alternatively, a dental annuity that invests relatively small sums on a monthly basis for a predefined period would allow a portion of society to prepare for their future dental needs. If specific elements of the previously examined association between dental health and specific disease conditions can be validated and if it can be demonstrated that an investment in dental health has a positive return on investment for medical programs, there will be a potential for medical plan investment in dental services.
Traditional, albeit modified, dental funding programs will likely continue during the next ten to twenty years. The modifications that are most likely will be discussed at the end of this article and will be influenced by a number of economic issues. In growing economies, with what has been termed "full employment," dental benefits are extended to more workers than in recession or depression economies. The competition for skilled workers is still active today, and dental is, at the time of this writing, the second most requested benefit after the medical benefit by the employed workforce. It has supplanted pharmacy as the second most desirable benefit. In times of underemployment, cost shifting to the employee should be anticipated. That is, purchasers of health services will require the employee to pay more of their health care costs. This will take many forms and includes the introduction of basic programs that cover only rudimentary services. In dentistry, this could be diagnostic, preventive, and basic restorative services. Patients might upgrade to a richer benefits design for a payroll deduction. Alternatively, a group dental benefit plan that covers only higher cost services can be designed where the patient is responsible for the routine diagnostic, preventive, and basic restorative costs on an out-of-pocket basis. The insurance plan would cover only those expenses that are defined as major expenses, such as implants, crown and bridge, etc. This would be more like traditional insurance where you insure against high cost events but is sold to groups, thereby removing much of the selection bias that individual programs introduce. Mixes and variations on these and many other themes will be tried as the cost of health care continues to consume our finite resources.
Decreasing Disease
It also appears that the decrease in dental diseases and the sequestration of the diseases discussed earlier in this article will continue. It is also likely that our ability to identify those at risk for future disease will continue to improve. This has significant implications for future dental programs.
Materials
Materials of the future are discussed here for their likely impact on the payment systems. The areas covered will be predictive diagnostics, non-shrinking polymers, and anti-infectives that are capable of eradicating the primary etiologic agents of dentistry’s primary diseases.
Predictive diagnostics or more properly "prognostic programs" are addressed by Drs. Kornman and Page in other articles in this issue. There are clear implications for sophisticated chemical diagnostics and artificial intelligence systems and their application to dental prepayment systems. Predictive diagnostics will facilitate the application of disease management strategies. Disease management, in this context, suggests the application of additional benefits to those at increased risk for disease and disease progression. This will initially be an investigative process and will systematically evaluate the health and cost outcomes of specific interventions. The goal will be to find the best intervention for a presenting risk profile and to reduce the treatment and outcomes variability. This will not be prescriptive or "cookbook" dentistry. Rather, it will be a series of preferred choices for which clinicians will be paid a premium. These preferred treatment choices will also be preadjudicated for the patient. That is, the payment system will have risk information and will preapprove the preferred treatments based on that risk. This will speed the processing of these claims and will facilitate real-time claims transactions.
Artificial intelligence predictive diagnostics will be augmented with chemical and microbial diagnostics if they add sufficiently to predictive accuracy. Most infectious diseases today have monoclonal antibodies or similar molecular diagnostic tools to identify the pathogens or suspected pathogens. These tests are now reaching a level of maturity that makes them available to the clinician at the dental chair and are no longer laboratory curiosities. As cost-effective therapeutics are developed to address these specific infectious agents, these tests will start to be covered by insurance entities.
In the area of dental caries, the development of highly effective topically applied therapeutics is almost a certainty. Whether the strategy employed is a substitution strategy like that being employed by Hillman,9 targeted antimicrobial strategies,10 or proposed vaccines,11 some research group will achieve a breakthrough within the time frame being considered here. There is sustained progress by many researchers in these and other areas, and it will likely culminate in a cure for dental caries. A cure will initially not be a cure for all forms of caries. For example, a cure for Streptococcus mutans and Streptococcus sobrinus will not be a cure for actinomyces infections that may initiate root caries. Lactobacillus, now considered a secondary organism in the caries process, may take on a new role. Still, the penetration of caries will continue to decline in treated populations. This will lead to significant health improvements and may, depending on the price of a successful therapeutic, lead to significant cost savings for the purchasers of health care.
Cures for periodontal diseases will also likely occur within a twenty-year time horizon. The mechanisms will probably be different but, nevertheless, there will be far more effective strategies to assess risk and diagnose and treat these diseases. There are important questions for third party payments systems embedded in this research. It is very likely that some of these therapeutic modalities will be systemic in nature.
Given the probable ease with which diagnostics, preventives, and therapeutics can be applied, how will health systems deal with these strategies? I suggest that a minimum of two different paths may be followed. The first involves the application of diagnostics, preventives, and therapeutics by physicians’ offices rather than dental offices. The rationale is as follows. If any dental diseases are shown to be causative or significantly associated with any costly medical conditions or events, it may be in the medical system’s self-interest to manage dental diseases. Even in the case of a strong association and not cause, if the presence of dental diseases is sufficiently predictive for an expensive medical condition or disease, it may be in the medical system’s best interest to diagnose those at risk for specific dental diseases. This makes the assumption that the health economics work for the health plan. This would require an effective intervention that would prevent or reduce the cost of the medical condition or event. The likelihood of this scenario hinges on the connection of dental diseases to costly medical conditions.
The second scenario involves dental prepayment systems changing from payment for piecework, our current system, to an internal medicine type payment model. If the cures or treatments for dental diseases are more medicinal than mechanical, payment systems will need to learn to pay for diagnosis, prevention, and treatment in ways that are different from what they do today. This again will require health economists’ assistance. These strategies will be adopted if they improve overall health outcomes at equivalent costs, have equivalent health overall outcomes with lower costs, or improve health outcomes and save dental costs. We are just beginning to experience the development of diagnostic and therapeutic systems that will force these kinds of systems to develop.
The final consideration is for nonshrinking polymers with thermal coefficients of expansion that match or nearly match tooth structure and that have color matching and wear characteristics of our best current polymers. Dr. Bayne’s article in this issue covers the materials aspects of this topic. Such nonshrinking polymers will not stress bonding materials during their weakest moments or at times of thermocycling. This will allow different design criteria for adhesives and eventually a more durable restoration. However, the bigger impact may be on the delivery system itself. There is a significant body of evidence that sealing in carious tooth structure does not lead to progression of caries.12 A form of this strategy is taught in most dental schools today as "indirect pulp capping without complete caries removal." The clinical conditions that surround this decision are rigorous, but, when appropriately applied, caries does not progress even though the organisms within the carious tooth structure are "alive."13 Following this logic, if we could affect a complete and permanent seal with a nonshrinking polymer and its bonding systems, in many conditions there would be no need for complete caries removal. Only modest caries removal would be required, and no cavity form would be required since these restorations rely on adhesion for retention. The intriguing system question is: what level of training is required to deliver effective restorative services using these materials? Having taught dental anatomy, I believe that technicians can be trained to do this in a matter of months. Perhaps this is heresy. However, with increasing health costs there will be economic drivers for this kind of service delivered by nondentists. These models are developing in other countries, and public policymakers will watch the successes and failures of these alternative delivery systems. When matched with more mechanical diagnostics/prognostics, these systems may present a viable alternative to traditional programs and may meet the emerging geographic access issues.
The predictions in this section are my own and require the development, application, and refinement of a number of systems or technologies. One has only to attend the International Association for Dental Research or review the research ongoing at the National Institute for Dental and Craniofacial Research or read any number of our professional journals to see the pattern of steady progression on all these fronts. The business term for these kinds of developments is "disruptive technology." While the specific technologies listed here may not be accurately predicted, the fact is that disruptive technologies will occur and the payment and practice systems will adapt.
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Future Plan Designs |
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First, there will be a continued reduction in disease penetration and increasing disease sequestration, mandating that health systems be risk-based at the level of the individual. Given the increasing financial pressure on health care, we cannot afford to treat all patients for diseases that many will never have. This will mean that the health services provider will use and be paid for validated diagnostics and their own deductive and intuitive skills that assess the patient’s current conditions and their risk of future diseases. In all likelihood, this diagnosis will include many other parameters besides those associated with dental caries, periodontal diseases, and oral cancer. Saliva, for example, is a rich diagnostic fluid that will find many uses by health care systems.
A range of treatments will be preadjudicated and paid for based on the patient’s risk profile and the known therapeutic successes of preadjudicated interventions when applied to that risk profile. Treatment outside this range of treatments will either not be reimbursed or will require separate approvals. This reflects the health and cost-driven need to limit treatment variation and the subsequent reduction of ineffective strategies. This will be likely facilitated by an expansion of the recent U.S. Supreme Court ruling that draws the distinction between payment decisions and treatment decisions. If extended beyond the current narrow interpretation, this decision will limit the liability of the payers who design and implement these strategies.
Diagnosis and treatments for dentistry’s two primary diseases will be delivered in a medical model of care with fewer mechanical interventions. When simple mechanical interventions are necessary, they will be provided by service providers with less training than dentists, leveraging the improvements in materials. Complex treatments, including implants, placement of their prostheses, trauma repair, oral surgery, endodontics, and a number of other treatments will still be performed by the dentist. Note that dentists will be involved in a number of diagnostic decisions.
Increasingly, there will be over-the-counter (OTC) diagnostics and therapeutics. Today we can test for pregnancy by using monoclonal antibodies that detect specific hormones in a woman’s urine with an OTC device. Similar devices, although currently only sold to dentists outside the United States, are available for detection of caries pathogens. Additional tests for periodontal disease organisms or specific cytokines have been developed and sold, while still others are emerging. Within twenty years, I believe these will reach the OTC markets along with their associated therapeutics.
Payment systems will likely change as well. Medical savings accounts (MSAs) require that a person pay a high "first dollar" amount, in essence forcing the patient to pay for routine examinations before accessing their MSA funds. True dental insurance could insure against only major oral care costs. Patients would be insured for high cost items but would bear the cost of diagnosis, prevention, and routine treatments up to some predetermined threshold. With the advent of effective and inexpensive OTC products to diagnose and treat dental diseases, this will become increasingly likely.
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Footnotes |
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REFERENCES |
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TopAbstractChanges in the penetration...Likely changesFuture plan designsReferences |
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This article has been cited by other articles:
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  L. A. Cohen, A. J. Bonito, D. R. Akin, R. J. Manski, M. D. Macek, R. R. Edwards, and L. J. Cornelius Toothache Pain: A Comparison of Visits to Physicians, Emergency Departments and Dentists J Am Dent Assoc, September 1, 2008; 139(9): 1205 - 1216. [Abstract] [Full Text] [PDF]
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