Finance in dental care

1
FINANCE IN
DENTAL CARE
Check out ppt download link in description
Or
Download link : https://userupload.net/yk8shpcpwk19

Introduction
History
Mechanism of payment for dental care
 Private fee-for-service
 Post payment plans
 Private third party prepayment plans
Commercial insurance companies
Non profit health service corporations
Delta dental plans
Blue cross/Blue shield
Prepaid group practice
Capitation plans
 Salary
 Public programs
Indian Scenario
Conclusion
2

HEALTH
Fundamental Human Right
Healthcare services have been provided on a
FEE-FOR-SERVICE
Patient receives specific services / pays the
provider directly for services.
This is the two party system
where the contract exist between the
3

4
In most of the developed and developing countries….
Traditional system of payment has been progressed to Third
Party System
where in an employer, union, insurance carrier, or agency
pays for health services
behalf of the patients

CLICK HERE TO DOWNLOAD
THIS PPT
https://userupload.net/yk8shpcpwk19

6
In most of the developed and developing countries cost of the
health care services are rising sharply due to ……..
Public’s increasing demand for health services,
Ever growing technology of health care,
Lack of incentives in health care,
Higher quality of health care and
General inflation

7
ORAL
HEALTH
an integral part of general health
called as the GATEWAY OF THE
BODY.
The prohibitive cost of dentistry
which deprives people
availing the oral healthcare / Dental services

In the developing countries like India, Very few people can
afford to utilize oral health care services regularly.
Most of the people will visit dentist only for curative services
occasionally, not for preventive measures
As the costs of dental care continues to rise, the majority of
the people cannot afford dental treatment, especially when it is
being provided on a fee-for-service.
8

Dentists are often puzzled when patients and the public complain
about the high cost of dental care.
In response to the barriers faced as a result of not being able to
afford the cost of health care, various concepts and mechanisms
of financing are born.
Hence it is not surprising to see a continuous stream of proposals
and mechanisms being conceptualized to make…..
HEALTH CARE AMENABLE TO THE
9

Fee for service First mode of payment to the
dentist with respect to the services received.
Main type of payment for many years until other forms of
payment came into existence.
1945- Voluntary prepaid comprehensive dental care in
St Louis U.S.A.
1948- Establishment in England of National Insurance
Scheme including Comprehensive Dental Service.
11

1948- Bisell B. Palmer of Newyork city founded group dental
health insurance as open panel prepayment system
1949- Group Health Association, consumers cooperative in
Washington, established a clinic dental service, which soon
changed from fee for service basis to prepayment.
1954- Washington State Dental Council organized Washington
State Dental Services Corporation for helping administer
prepayment dental care plan for children.
12

1966- Medicare brought medical care to the aged of the U.S without
regard to the income. This did not include dentistry,but Medicaid did.
1973- Health Maintenance organizations providing standardized
comprehensive care to individuals in enrolled group
1989- Delta Dental Plan and other agencies were covering about 107
million beneficiaries.
However, fee for service continues to be the major mechanism
of payment in many developing countries
13

Two party arrangement
Traditional form of reimbursement for dental services.
It has been in existence since the evolution of dentistry, and it
still remains the main form of payment in many developing
countries.
16

Although alternative forms of payment for dental services are
growing rapidly, at present private fee for service arrangement
is still the method of payment in many developed countries.
ADA defends fee-for-service as the most efficient way of
providing dental care.
17

Patient decides
visit a dentist
Dentist suggest appropriate treatment / informs the patient of
the fee for the service.
If the patient follow the recommendation of the dentist and
receives services, the patient is then responsible for the fee.
18
Patient Dentist

Culturally acceptable- concept is accepted in many Countries
( American way of doing business)
Flexible system (Fees can be changed according to market conditions)
Dentist can also able to Practice- “Price Discrimination”
“Robin Hood Approach”
in which fees charged to wealthier patient can subsidize treatment provided
to poorer ones.
Administratively simple- dentist rarely keep a written list of fees for
procedures.
It is the only system under which some form of dental care likely will
ever be provide.
19

Despite of flexibility and price discrimination - many
potential patients who cannot afford for dental services.
These persons would thus be unable to receive dental care if
private fee for service were the only financing mechanism for
dental care.
Thus other forms of payment like budget payment, dental
insurance came into existence in order to ease the financial
burden on the patient in many developed countries.
21

It was first introduced in the late 1930’s by local dental
practitioners in Pennsylvania and Michigan USA.
It is also known as budget payment plans
Mechanism for Individual purchase of services
Dentists have frequently arranged to allow payment for dental
care to be made at intervals over a period of time.
22

Patients borrows money from bank
or finance company to pay the
dentists fee at the time that the
agreement to receive care is made.
After the application is approved
by the lending institution, the
dentist is paid the entire fee.
The patient then repays the loan
with specified interest amount to
the bank in budgeted amounts.
23

This post payment/Budget plan was developed with the idea of
providing dental care to large segment of population, but it was not
done so.
Studies of this plan show that it was primarily utilized by the people
of middle-income rather than low-income group and it was used
primarily to finance prosthetic treatment.
Although some dentist found post payment plans as a successful
mechanism there were still problems associated with defaulted loans
and low-income patients would also have more difficulty being
accepted as credit worthy by the lending institutions.
24

Most recent methods of credit payment for services have tended to
bypass post payment plans.
By the late 1970’s many dentists were accepting credit cards in the
developed countries
Many patients now use this mechanism for purchasing their dental
care in much the same way as they use them for purchasing goods
and other services.
Because of widespread use of credit cards, it is unlikely that post
payment plans will develop any further
25

 No charge by the dentist for broken appointments
 Instances of uncompleted work- dentist must refund entire
amount due to uncompleted services.
 Minimum entrance fee
 Members dropped out from dental society for non payment
of dues – dropped from treatment plan
 Members going into military service should maintain their
status, no entrance fee for returning
 Uncompleted work of deceased dentist should be paid for
by his estate.
26

for the plan to be successful-
Simple and yet a proper presentation of plan by the dentist to
the patient.
Note should be explained to the patient
Credit information should be obtained
Total amount of the note should be stated
Amount of interest to be charged should be discussed
Length of time in processing the notes is important
Operating Give acceptance or rejection within 2 days
27

No one is in a position to state definitely the value of the services
performed and the cost may vary – 2 times to 10 times for the
same treatment depending upon the skill, experience and
reputation of the dentist
Bank can establish value for automobiles, appliances or units of
furniture but it is impossible to determine the definite value of
services performed.
28

Payment for dental services by some agency rather than directly
by the beneficiary of those services.
payment for dental services are paid directly to dentist by an
agency rather than by the patient.
Here, the third party defined as the party to a dental prepayment
contract that may collect premiums, assume financial risk, pay
claims and provide cost of administrative services.
29

In the language of contract………
It is also known as the carrier, insurer, underwriter or
administrative agent.
31

32
The purchaser of the plan can be an organized private group such as
a union, or an employer, a union-employer welfare fund, or a
governmental agency
Usually the term Third party refers to a

Periodic premiums are collected to meet the costs of providing
care as well as the administrative costs of the third party.
It has been argued that this arrangement should most properly
be called prepayment rather than insurance because it does not
fulfill the classic definition of insurance.
Periodic premiums are collected to meet the costs of providing
care as well as the administrative costs of the third party.
It has been argued that this arrangement should most properly
be called prepayment rather than insurance because it does not
fulfill the classic definition of insurance.
33

Earlier dental care was considered uninsurable by carriers……
based on the assumption………….
Nature of Dental Need violated the basic principles of Insurance.
To be insurable, a risk must be the fallowing……
Be precisely definable
Be of a sufficient magnitude that if it occurs, it constitutes a
major loss
Be infrequent
Be of an unwanted nature, such as destruction of a home
through fire.
Be beyond the control of individual
Not constitute a “moral Hazard (means that the presence of
insurance itself should not lead to additional claims)
34

All health insurance violates these principles
Illness is not predictable for the individual
health care is usually a wanted service.
To get around these problems Insurance carriers came up with
different types of payments like ………….
Deductible .
Coinsurance.
Range of health care services.
Health insurance only to groups.
Using preauthorization and annual expenditure limits
35

It is stipulated flat sum that the patient must pay toward the cost of
treatment before benefits of the program go into effect.
It is sometime called a front-end-payment.
Familiar example for this type is automobile insurance where a
deductable of rupees 10,000 means ----------
if damage is sustained, the 10,000 of repairs must be paid by the owner
whether the total cost of repairs comes to 15,000 or 1,00,000.
36

It means that both the carrier and the beneficiary are liable for a
share of the cost of dental services provided.
Eg -if a patient is to pay 20% of the daily cost of hospital care, the
absolute amount will vary depending on the actual hospital
charges, and type of room chosen. But in any case will be 20% of
those charges, remaining 80% will be from the carrier.
37

Some services are available and some are not as per the plan.
This range is termed coverage, covered charges, or schedule of
benefits.
For Eg, services such as dental implants,cosmietic restorations and
extensive temporomandibular joint disorders, are rarely covered.
38

cost control mechanism, widely used by insurers, also known
as pre determination/prior authorization.
Means that treatment plans for more than a specified sum must
be reviewed by the carrier's dental consultants to ensure that
the proposed treatment is reasonable and that the same quality
of care could not be achieved at less expense
39

When the cost of treatment are expected to exceed some limit,
the dentist are required to submit the treatment plan to the insurer
for review before the treatment begins.
These reviews reduce the cost of care either directly or
indirectly by the carrier’s dental consultants to ensure that the
proposed treatment is reasonable and that same quality of care
could not be achieved at less expense.
40

Health insurance first offered only to groups because illness
experience is reasonably predictable for a group, though not for
an individual.
Insurance covering a group of persons , usually employees of a
single employer or members of a union, under one contact for
the benefit of the members of the group.
41

The major forms of third-party reimbursement currently in use
are
Usual, customary, and reasonable fee (UCR) .
Table of allowances.
Fee schedules.
Capitation.
Direct Reimbursement
42

It usually provides the highest levels of reimbursement for the
dentist’s charges.
Frequently provides least cost sharing responsibilities for the
covered member – patient
The perception is that UCR approach intrudes minimally on the
dentist patient relationship
The covered member has the widest choice of providers.
Benefits may be “weighed” to encourage use of certain
procedures
Responsive to inflationary charges and allows for the best
relationship to current charges and economic development.
Allows dentists to receive their usual fee from covered
members benefit program
44

To receive the maximum percentile reimbursement, dentists must
agree to participate with other plans. --result in delaying their fee
increases in order to maintain a participating relationship with
these administrators.
Most costly reimbursement methodology for purchasers of
benefits, because it is based on dentist charge data, It may reflect
their wishes and not the actual needs of the covered members
45

Significantly contribute to an increase in dental benefit
program costs.
Plan design - more complex and difficult to understand,
explain and to compare with other reimbursement
methodology
Complexity results in higher administrative costs to the
purchaser.
46

It is defined as the list of covered services with an assigned
amount to each service that represents the total obligation of
the plan with respect to payment for such service, but that does
not necessarily represent a dentist full fee for that service.
47

If the dentist’s fee becomes more than that assigned to that service
by the carrier, the remainder will be collected by the dentist from
the patient.
This method of reimbursement is not entirely satisfactory because
the patients are often unaware that the plan may not cover them in
full for dental care.
For example,
if a dentist's usual fee – Rs. 100
Plan lists for that service a fee of – Rs.80
Dentist will provide the service, collect Rs.80 from the carrier, and
may charge the patient Rs.20 to make up the difference.
48

 Fixed stated benefit for each covered procedure is usually easily
understood by patient, dentist and purchaser of benefits.
 Fixed costs for each procedure allow for better prediction of
total plan costs and establishing of premium rates.
 Lower administrative costs - result form the less complex
program designs.
49

is also called a service plan
is defined as a list of the charges established or agreed by a
dentist for specific dental services
A program in which the payment is meant to represent full
payment, with no additional charge to the patient
A dentist participating in a schedule of benefits program
agrees to charge no more than the listed fees as payment in
full and will not ask the covered member to make any
additional payments for covered services, even if the dentists
usual fees are higher.
50

 It is dental benefit program in which a dentist or dentists
contract with the programs sponsor or administrator to provide
all or most of all services covered under a program to
subscriber in return for a payment on a per capita basis.
51

 It is fixed monthly or yearly payment paid by a carrier to dentist
in closed panel, based on the number of patient assigned to the
dentist for treatment regardless of whether the patients
participate in the plan, receive no care, a little care or great deal
of care.
52

This program involves an agreement between the employer and
the employees in which the employer agrees to reimburse the
employees for some part of their expense for dental care.
Reimbursement is usually on a percentage basis and annual
limits are customary.
Covered member directly pays to dentists, Collects bill from
the dentist, Submits it to his or her employer to be reimbursed.
53

1. Commercial insurance companies
2. Non profit health service corporations
(delta dental plans & blue cross/blue shield).
3. Prepaid group practice
(health maintenance organizations and independent practice
association)
4. Capitation plans
54

1. COMMERCIAL INSURANCE COMPANIES
Companies operate for profit
Cash payment to the providers i.e., the companies pay the dentist
directly for the provision of covered services and payment is
quicker.
Carrier develops fee profile based on the prevailing fees in the
given area and the dentist are paid at that rate.
There is no Fee audits , post treatment evaluations to assess the
quality of dental care delivered.
55

Delta Dental plans
Blue Cross/ Blue Shield dental plans
56

Dental service corporation was born with the purpose of providing
comprehensive dental care programme for children up to 14 years
age after the acceptance of the proposal of international
longshoremen's and warehouse men’s union by seattle district
dental society of Washington in June 1954.
This corporation was legally constituted, not for profit
organization, incorporated on a state by-state basis that negotiates
and administers contracts for dental care.
57

The original dental service corporation now known as delta dental
plans in most states
sponsored by the constituents dental societies in each state where
they were initially formed usually subjected to insurance laws of
that particular state where they are constituted
Characteristics of a dental service corporation are…….
Professional sponsorship
Non-profit operation
Participation permitted by all licensed dentists with the state
Benefits provided on a service basis
Freedom of choice is allowed for both patient and dentist.
58

As the number of corporations increases in the state , there was a
need for a national organization, thus leading to the formation
National Association of Dental Services Plans (NADSP)
in June 1966 , supported and funded by ADA
DELTA DENTAL PLANS ASSOCIATION
in APRIL 1969
Delta plans cover about 20 million people in US
account for about 25% of total claims paid annually by all the
dental care givers.
59

Delta dental plan uses UCR concept exclusively
Reimbursement depends on
Participating dentist
Non participating dentist
Participating dentist is defined as duly licensed dentist with
whom a delta plan has a contractual agreement to render care
to cover subscribers
60

These participating dentists should agree to some conditions
1. Pre filing of their usual and customary fees
2. Acceptance of payment for their services at the 90th
percentile
3. Fee audits by auditors from delta, who may check their office
records from time to time mainly to ensure that the dentists are
charging their delta plan patients the same fees as they charge
their other patients.
61

4. Post treatment inspection of randomly chosen patients to
monitor the quality of care
5. With holding of a small amount of each fee, usually less
than 5%, to go into delta capital reserve fund
62

Non participating dentists
can also treat patients in delta plan and get reimbursed by delta
plan
They need not follow any of conditions
They are paid at 50th
percentile of fees rater than at 80th
of 90th
percentile
50th
percentile
63

Cost control mechanism incorporated in delta plan
The percentiles of a set of data divide the total
frequency in to hundredths, so that the 90th
percentile
is that value below which 90% of the observations
lie.
64

Delta plans though small – have given successful and high competition in
comparison to giant commercial insurance world.
Delta’s attractiveness basically rest on………..
 Control of cost - preauthorization, free audits and percentile payment
 Quality assurance procedures by post treatment clinical examinations of
treated patients
 Individual patients know that they don’t have to pay anything extra
66

In addition, delta’s attractiveness to potential purchasers
depends on its wide support from dental practitioners.
financial incentives in this plans seek regular care and maintain
dental health by fulfilling dentistry’s aims using improved
access to dental care to improve the dental health of the public.
67

They offered only limited dental coverage for longer periods of
-time as a part of their hospital –surgical-medical policies
Blues showed little enthusiasm for going any further into dental
prepayment on the grounds that it was a poor insurance risk.
Their Attitude changed………
once dental prepayment was shown to be feasible.
68

Have adapted many of the cost control features and mode of
reimbursement pioneered by Delta plans.
Many now use UCR fees to reimburse the dentists
Active in developing alternative reimbursement methods, such
as capitation, including independent practice associations and
preferred provider organizations to meet the demand of cost
control from purchasers.
69

It is a group practice that provides dental services on a prepaid
basis. Such groups are often regarded as open panels.
According to ADA (1969) Group practice is that type of dental
practice in which dentists, sometimes in association with the
members of other health professions agree formally between
themselves on certain central arrangements designed to provide
efficient dental health service.
70

Code of Ethics of the Dental Society of state of New York states “
type of dental practice in which ethical, licensed dentists
sometimes in association with members of other health professions
agree formally among themselves on certain central arrangements
designed to advance the economical and efficient conduct of a
dental practice in order to render an improved health service to the
patient”
71

According to U.S. Public Health Service (1971) A group practice
is defined as a practice formally organized to provide dental care
through the services of three or more dentists, using office space,
equipment and or personnel jointly.
72

It can be of different types
General Group practice—composed entirely of general
practitioners
Single specialty group—composed entirely of same specialty
practitioners
Multi-specialty groups—composed of practitioners in two or
more specialty fields of practice.
73

Net income in a group practice can be divided equally or
distributed according to
Patient load
Years of Service
Specialty dentist
Some group practices
All these make their dentists salaried.
74

Better way of organizing one’s life, i.e., one practitioner can plan readily
for vacation or for continuing educational leave because the colleagues
in the practice can temporarily care that dentist’s patients during his
absence
Less disruption in the practice caused by the illness to a dentist
Improved quality of care because of the built in peer review.
Sick leave and pension plans can be built into a group organization more
readily, thus easing the economic concerns of dental practice.
MOST OF THE GROUP PRACTICES TREAT PATIENTS ON THE TRADITIONAL
FEE-FOR-SERVICE BASIS.
75

Was defined in the act 1973 as “a legal entity which provides a
prescribed range of health services to each individual who has
enrolled in the organization in return for a prepaid, fixed and
uniform payments
Started essentially as a method to provide health care services to
workers, Served 13 states with a total enrollment of close to 5
million
76

1. A managing organization
2. A delivery system
3. An enrolled population
4. A benefit package
5. A system of financing and prepayment.
77

HMO use prepaid capitation system of financing medical services.
One of the main advantages of HMO’s lies in their claim to reduce
costs of care for those enrolled.
The emphasis is on ambulatory care, and unnecessary
hospitalization, e.g. for diagnostic tests or minor surgery is
curtailed
78

Dental care limited to preventive services was originally part of
basic services and later become a supplementary service.
In 1990 only small proportion of HMO’s offered dental services
where the care was financed through primary capitation premium,
a separate premium or on fee-for-service basis
79

80
The Staff model
The Group model
The Independent Practice association
The Primary care capitated network or direct contract model

81
STAFF MODEL
Dentists dental hygienists and dental assistants are salaried
employees of HMO
May or may not have a dental director
Only model that affects the auxiliary personnel directly
because of direct employment

82
HMO contracts directly with a group practice, partnership or
corporation for the provision of dental services.
The group concerned receives a regular capitation from HMO
The individual dentists usually receive the income as in group
practice , it is not affected by HMO contract.

83
IPA is an association of independent dentists that develops its own
management and fiscal structure for the treatment of patients enrolled
in HMO
IPA acts as link between the HMO and providers.
IPA can also contract with other prepaid agencies
ADA considers IPA as a “Open Panel” – any dentist is free to join
Dentists remain in their own offices- continue to treat their patients
IPA receive capitation premium from HMO and in turn reimburses the
individual dentists on either a modified fee for service basis or
capitation basis

84
Similar to IPA except that HMO contracts directly with
individual provider for provision of services
Most common form of capitation arrangement in dentistry
Dental insurers who wish to offer a capitation product recruit
and contract with dental offices that are willing to have
patients assigned to them.

Designated by ADA as Contract Provider Organization (CPO’s)
Involve contracts between insurance companies and number of
practitioners who agree to provide specific services for fees that
are lower then average for that area.
85

the mode of payment is fee-for-service unlike HMO.
The contracting dentists often agree to participate at the lower
than usual fees in order to attract additional patients to their
practice.
However this approach has not found many advocates and it's
future is questioned by many.
The financial incentive in PPOs
86

A capitation fee is defined as affixed monthly or early payment
paid by a carrier to a dentist in a closed panel, based on the
number of patients assigned to the dentist for treatment.
ADA defines capitation as dental benefit program in which a
dentist/ s contract with the program sponsor or administrator to
provide all or most of the services covered under the program to
subscribers in return for a payment on per capita basis.
Dentists receive fixed amount – irrespective of patients
treatment
87

Dentists participating in the specific program will be salaried as
those in the government agencies.
Dentist receives a fixed amount of money on a monthly basis for
the services he renders. For example, those in armed forces, those
employed by public agencies are salaried monthly.
For this purpose, he could participate in any form of programs,
either prepayment or post payment.
88

Under a salaried system of payment
Predetermined amount of money is paid by the plan to each
participating dentist
It allows a dentist to be largely free of the business concerns of
running a practice thereby allowing the dentist to concentrate on
clinical matters.
Salaried group practice combined with prepayment plan could
provide good dental care in a community
89

Lack of financial incentives to the participating dentist need
highly productive.
It rarely permits the accumulation of the kind of wealth that a
dentist with a flair of management can achieve in private
practice.
90

91
 MEDICARE
 MEDICAID
 VETERANS ADMINISTRATION
 NATIONAL HEALTH INSURANCE

92
Private practice is usually not able to meet the dental demands of
all people. Therefore a number of public programs aimed at
meeting the needs of specific groups of recipients in this divers
society. The public programs are sponsored by the government
and also include community health centers.

Title XVIII of the Social Security amendments of 1965 is the
program known as Medicare was started. Federal health insurance
program for aged and disabled Americans with the main intention
was to provide health care to above 65 years, usually they have
twin problems i.e. High health needs and low income.
- Provide free health services for all persons above the age of 65
years, regardless of their financial means.
93

Some financial constraints were introduced in the program.
By the mid of 1970s, it has two parts.
Part A: Hospital Insurance
Part B: Supplemental Medical Insurance.
- Both parts contain highly complex series of service benefits
available, both parts require some payment by the patients.
94

Provides substantial coverage of the costs of
Inpatient Hospital services
Skilled nursing care
Post institutional home health care
95

Outpatient hospital care
Physician services
Durable medical equipment
Diagnostic tests
Other medical services
Dental care is limited to only those services which needs
hospitalization, usually surgical treatment for fractures and cancer.
Denture service is not included.
96

The title XIX of the Social Security Amendments of 1965 is the
Medicaid
Federally assisted State program, With the intention to provide
funds to meet the health care needs of all indigent and medically
indigent persons.
97

Where the Federal government with the state governments
sharing the costs. The Federal government providing about 55-
83% of the finances, depending upon the percapita income of
states population,
Within the broad federal guidelines the states determine the
eligibility of the recipients, scope of services and amount paid to
providers.
98

• Every state Medicaid program must cover these basic services.
Like
- Inpatient hospital care.
- Outpatient hospital care.
- Laboratory and X- ray services.
- Skilled nursing facilities.
- Home health services for individuals aged 21 years and older
- EPSDT [Early and periodic screening, diagnosis and treatment]
for individuals under 21. 99

Family planning services and physician services.
Dental care is not mandatory except for persons under 21years.
Eligibility for Medicaid was complicated and confusing to many people.
Certain groups such as widows under 65 and families without children
have been identified as not being eligible for the benefits of Medicaid
Due to various loopholes in the program, it was not so successful.
100

EPSDT
Enacted into law in the year 1967,amended in the year1989 .
Provides for periodic screening,vision,dental, hearing and
necessary and follow-up services for Medicaid recipients under
age of 21
Supported by ADA- 1st
time –federal program mandated dental
care for the indigent children
101

Medicaid EPSDT coverage includes all dental services deemed
"medically necessary" meaning services that in the opinion of a
qualified provider are required to relieve pain and infections,
restore teeth and maintain dental health; or correct or ameliorate
defects, illness and conditions discovered by screening services.
Orthodontic services are generally limited to cases to which the
malocclusion is deemed to be "handicapping" or more severe
using various classifying indices.
102

However this program seems to be a long way from fulfilling its
promise due to
 Slowness of Federal Government in publishing regulations
governing the administration of the program
 Unwillingness of some states to add rapidly growing
Medicaid costs.
103

• Increasing in number of people eligible for Medicaid and economic
recessions of 1970’s and 1980’s ----health costs were high– many
states cut back on
• Eligibility
• Reducing the availability of services
• Level of payment to providers
104

• Unfortunately dental services were on the cut back
• Frustrated dentist- have refused to treat new patients under
Medicaid
• Rapidly changing eligibility standards for prospective
standards
• Reductions in available services
• Changes in percentile fees paid
• Delays in payment for services rendered
105

 This program was developed in USA to provide coverage for
children in low to moderate-income families who do not qualify
for Medicaid.
 The overwhelming majority of newly covered children are from
"working poor" families in which one or both parents are
employed but earn little to afford health insurance.
106

 Dental coverage is not a requirement under Title.
 But 49 out of 50 states in US have chosen to offer dental coverage as
part of their SCHI programmes and to provide relatively comprehensive
benefits.
 It includes preventive, diagnostic and restorative services.
 although the coverage is not as broad as Medicaid's EPSDT programme.
 The relative success of dental service delivery through SCHIP,
supported by higher payment and improved provider participation, may
provide a model for Medicaid programmes to consider in their efforts to
improve access.
107

Was introduced by…….
Bismarck in Germany in 1880’s
Lloyd George in Britain in 1910
NHI is primarily a financing mechanism by which health care
services are paid for from a publicly organized fund
Bases for development was HUMANITARIANISM
They thought that healthy and secure society would led to
POLITICAL STABILITY AND GREATER ECONOMIC AND
INDIVIDUAL STRENGTH
108

In addition to Medicaid and Medicare – number of other small
programmes in the dept of health and human services that either
directly or indirectly finance the dental services for certain
population in the U.S.
109

Federal government provides financing for dental treatment of
children in pre-kindergarten , kindergarten with the deprived
background.
here private dental practitioners provide care to enrollees and are
paid by local administrators of the programs
Rehabilitative care for children born with cleft lips and palates
have long been financed cooperatively by state funds and grants in
aid from federal government.
110

US public health service provides dental care to US coast guard
personnel and inmates of federal prisons
The Indian Health Service is responsible for medical and dental
care for American Indians and Alaska natives
Community and migrant health centres for the benefit of rural
and high poverty urban areas
Various schemes for military personnel in service and after
treatment.
111

112
> ¾ of population reside in rural areas- depending on agriculture for
their livelihood.
Most of them are poor - no fixed income due to unpredictable
monsoons.
Hence purchasing insurance for health care, paying regular
premiums become out of question

113
In urban areas some population residing in the slums, called urban
poor who have migrated to cities in search of manual jobs and
working poor class people who are unable to purchase health care.
Population Eligible for insurance
2%

114
when it comes to purchase of care –
General health receives the first priority where oral health is
neglected
Thus collective organized efforts required to bring about a sea
change……………..
not only in the attitudes of the recipients of care,
also in the administrators, policy makers and like minded people
such as NGOs in the private sector.

115
Funds to set up an insurance corporation should be raised in the local
area , supported by Gram Panchayats and NGOs.
Government should provide boost for such endeavor by adding the
matching amount to the premium collected every month.
Coverage should be provided to the households rather than individual.
Priority
school children, expectant mothers , handicapped and for the aged.

116
There is no universal health scheme in India.
At present limited to some industrial workers or specified
group of employees.
The central government employees -- covered by health
insurance under the central government health scheme(CGHS)

117
It was introduced by an act of parliament in 1948 amended in
1975,1984 and 1989.
It provides benefits for sickness , maternity , employment injury and
death due to employment injury.

118
Small power using factories employing 10-19 persons, and
non power using factories employing 20 or more persons.
Shops
Hotels and restaurants
Cinemas and theaters
Road motor transport establishments
News paper establishments

119
The scheme is run by employee's contribution and grants from
central governments. The employer contributes 4.75% of the total
wage bill, the employee contributes 1.75% of the wages.
Employees getting wages below 15 rupees are exempted from the
payment contribution. State government shares 1/8th
of the total
cost of the medical expenditure and ESI corporation's share 7/8th
of the medical expenditure.

120
Medical benefit
Sickness benefit
Maternity benefits
Disablement benefit
Dependant's benefit
Funeral expenses
Rehabilitation allowance.

121
Central government health scheme was introduced in
1954 for comprehensive medical care of central government
employees.
The dental health aspect is covered through the dental
welfare facilities available in dispensaries.

122
Defence services have their own organization for medical care to
their personnel under the banner "Armed Medical and Dental
Service.”

123
The railways provide comprehensive health services including
dental treatment through the agency of railway hospitals, health
unit and clinics.

124
on the whole very limited percentage of population in India is
having the facilities either getting treatment postpaid or to make
payment in any other way.
Unfortunately within this category payment for dental treatment or
provisions for payment through any other means is very Negligible.
Hence the concept and utilization of financing for dental care in
Indian scenario is far from the reality and it is not possible to
practice.

Third parties in India
Government
General Insurance
Corporation
(GIC)
Life Insurance
Corporation
(LIC)
Employees’
State
Insurance
Scheme
(ESIS)
Central
Government
Health
Scheme
(CGHS)
National
Insurance
Corporation
(NIC)
United Indian
Insurance
Corporation
(UIIC),
New India
Assurance
(NIA)
Oriental
Insurance
Company
(OIC).

Private fee for service was the first form of payment which
existed from the beginning and likely to remain the
predominant method of financing dental care in the foreseeable
future.
however due to the problems faced by the patients other forms
of payment came into existence.
126

Different forms of the payment have their own set of rules and
regulations which the member has to strictly adhere to , if he
was to receive the benefits of the programme
Insurance has come of ages and has become the main stay of
payment in many developed countries.
However fee for service is still the major form of payment in
many developing countries like India.
127

128
Financing dental care helps people in many ways such as in their
range of economy , government has made several schemes for
providing health care for government employees and general
population in term of health insurance companies. These
companies helps them by providing financial support which are
beneficial for both the dentist and the patient

Ultimately it was entirely up to the dentist and his patients to
work out the most suitable form of the payment in which each
could be happy and satisfied.
Dental professionals and other health care service organizations
must adapt to the changing environment. Our responsibilities
will not diminish; instead we must remain involved to ensure the
public of the highest standards of care and professionalism.
129

Young and striffler: Dentistry, dental practice and the
community,3rd
edition. page no: 378-418.
Burt and Eklund : Dentistry, Dental practice and the
community, 4th
edition
Soben peter: essentials of preventive and community
dentistry, 3rd
edition, June 2006, page no:645-653.
Anthony Jong: Community Dental Health 5th
edition
Dr. SS. Hiremath: Text book of preventive and community
dentistry, 2007, page no: 207-218.
131

Dental Benefits and Reimbursements
Dental clinics of North America 1987: 31(2): 193-07
Dental Components in prepaid health plans
JADA 1980 vol 101:817-20
National Health Insurance for the United States
Public Health Reports 1977 Vol 92 (5) :399-451
Organization of group practice
Dental Clinics of North America 1967 Vol 32; 399-351
Financing dental care : Trends in public and private expenditure
for dental services
Dental clinics of North America 1987: 31(2): 193-07
132

Finance in dental care

Recommended

Recommended

More Related Content

What's hot

What's hot (20)

Similar to Finance in dental care

Similar to Finance in dental care (20)

More from Dr Medical

More from Dr Medical (18)

Recently uploaded

Recently uploaded (20)

Finance in dental care

Editor's Notes