5. Payment for Dental Care Flashcards
Advent of Health Insurance
u Pre-World War II
u Patient Provider
u ____
u Post-World War II uAdvent of \_\_\_\_ Party uPremium for protection against potential loss uUnion-employer negotiations u \_\_\_\_ benefit (Taft-Hartley Act)
• Pre WWII ○ Relationship bt patient and provider > FFS ○ Relatively modest fees ○ Not everyone could get to dentist; if couldn't afford > robin hood effect > the healthcare provider was a \_\_\_\_ based on the dentist's perception • Post WWII ○ Third parties > insurance that was similar to protect house, car, etc. § Premium against \_\_\_\_ ○ Came about > health benefits are offset of \_\_\_\_ § Started bc of wage and salary freezes > then THA allowed to pay with tax-free dollars
FFS
third
tax-free
social worker
loss
salary
Insurance Principles u Definable risk - yes u Catastrophic - no u Infrequent - no u Unwanted nature - yes u Outside person’s control - no u Without “moral hazard - no
insurable because utilization how can we have dental insurance?
○ Utilization is always less than 100%
○ Perceived need for care vs. the normative which is determined by the ____
100
catastrophic
professional
Control of Demand by Third Parties
- ____
- Deductibles
- ____ only coverage
- Limit range of services
- ____ periods
- Pre-authorization
- Annual ____ caps• Deductible
○ Pay certain amount before insurance kicks in
○ Makes you ____ about expenses and visits, etc.
• Co-payments
○ 10-20% range
§ In PPO’s can be smaller
○ Makes people ____ if they need to go
• Waiting periods
○ Wait 6 mo before you can have certain procedures
○ ____ is an example
• Pre-auth
○ Dentist has to submit treatment plan to insurance company
• Annual expenditure caps
○ $____/year is common for dentistry
○ Not a problem for normal recall - but for RC and crowns > will be way over the cap
co-payments
group
waiting
expenditure
think
think
crown and bridge
1500
• FFS
○ Receive care and ____ for that care
○ Or submit to insurance
• IPA
○ Independent practice association
○ Clusters of dentists that agree to provide service, under the umbrella of ____
§ PPO - orgs that take money from ____ and provide benefits to employees of the org
• POS
○ Won’t talk about
○ More on medical side (point of service)
○ If you have a plan that allows to go straight to ____; some plans allow, but most plans you have to go see your PP
• Par v nonpar
○ Participating v non-participating dentists
• UCR
• Fee percentiles
• Managed care
• Table of allowances
• Capitation
pay
PPO
employers
specialist
Types of Third Party Reimbursement
u Fee-for-Service uTable of \_\_\_\_ (\_\_\_\_ ok) u\_\_\_\_ Schedule u\_\_\_\_ fees u \_\_\_\_
u Capitation
u Value-based
• Table of allowances ○ Insurance establishes a fee schedule that syas we'll pay this much, and if your fee is higher than feel free to collect from \_\_\_\_ • Fee schedule ○ No \_\_\_\_ billing • Discounted fees ○ Not popular ○ But applies to \_\_\_\_ where a dentist may agree to disocunt fees to get more patients into a practice • Value-based ○ Beginning to make an impact in \_\_\_\_
allowances balance billing fee discounted UCR
patient
balance
PPO
medicine
UCR Fees
uUsual - dentist’s ____ fee for procedure
uCustomary- plan determined ____ fee
uReasonable – fee modified for ____
• Plan - that the employer and insurance company agreed to • Special conditions ○ Disability, etc. ○ Can negotiate with the company for a higher fee to cover the additional time needed to deal with patient
normal
maximum
special conditions
- Patient goes to dentist and ____ for care
- Employer pays employee a salary but also pays a premium benefit (that goes to insurance); dentist sends claim to insurance company, and the ____ pays the dentist
2A. Dentist accepts the assignment; bills the insurance company for the patient; also where dentist does not accept assignment from insurance company; will provide care, and patient will pay, and the patient will do the ____ and submit the claim to the insurance company, and receive ____ back from the insurance company
- Employer pays employee a salary but also pays a premium benefit (that goes to insurance); dentist sends claim to insurance company, and the ____ pays the dentist
pays
insurance company
paperwork
money
• Fee at the 80th percetile: $68
○ 80% of dentit charge 68 or less
• 90th percentile: $72
○ Plan pays at 90th percentile > you ge tpaid ____ even if fee is 80/90
• What if fee is $40, and then in program that participates at 90th percentile > you get paid $____
○ If below the upper spot > you get your fee, those that won’t be happy are those above that percentile
• People above the ____
72
40
90th
Dental reimbursement - plan types
u Not-for-Profit
u Dental service
____ (Delta, BC/BS)
u 1954 – ____ Union & Seattle Dental Society
u Adapt private practice to ____ purchasing
u 42 M now covered
u For Profit \_\_\_\_ insurance Indemnity plans \_\_\_\_ not used Fee profiles by \_\_\_\_ Add-on to medical
* Add on to medical > exchanges with the \_\_\_\_ * Only have one insurance company > \_\_\_\_
corporations longshoremen group commercial UCR region ACA for-profits
Reimbursement under Delta Plans
Participating dentists u Sign \_\_\_\_ u \_\_\_\_ payment u Usually \_\_\_\_ Percentile u \_\_\_\_ common u Fee audits u QA of patient sample
NonParticipating
u____ percentile
u ____ billing ok
• Delta non-profit ○ Participating dentists > a large portion belong to deltas ○ Fee audits - to make sure that you're offering a dentists lowest price to someone; doesn't change non-Delta patients lower • Non-participating ○ Don't signt hese contracts; but can still take patients that are Delta ○ 50th percentiel - only 50% will be happy ○ Balance billing is ok - you try to collect the difference from the patient; you cnanot do this if you're a participating dentist
contracts UCR 80th-90th copayments 50th balance
Managed Care
- components:
- ____ health services package
- ____ providers
- ____ to use providers
- examples: ____, PPOs
- cost control
- ____ less affected than medicine• Selected providers - do not have ____; but in many plans, so many participate that it’s likely yours is in the plan
comprehensive selected incentives HMOs denistry POS
Health Maintenance Organizations (HMOs)
u Alternative to \_\_\_\_ u \_\_\_\_ (fixed payment per enrollee) u Enrolled population u \_\_\_\_ care u Goal: cost control u Promoted by \_\_\_\_ government
• Instead of paying for a service, pay \_\_\_\_ a capitation fee ○ Insurance company would agree for x amount of money from the employer to provide a certain array of benefits ○ The physicians responsible for the enroll population - paid a fixed fee • Low cost services > keep them healthy > won't have big costs overtime, but you'll be getting \_\_\_\_ reimbursements over time • Fixed amount up front > there will be \_\_\_\_ control
FFS capitation prevention/ambulatory federal perspectively consistent cost
Dentistry in HMOs
u Offered by relatively few \_\_\_\_ u Financed by: u \_\_\_\_ capitation Fee u \_\_\_\_ capitation fee u \_\_\_\_
u Models:
u Staff, ____, IPA, capitated network
u Separate DHMOs
• Primary - pays for the \_\_\_\_ • FFS, even though the health planw as capitated by the mployer • \_\_\_\_ model - most common ○ Clinic with x number of employees - the patients have to go to get service, and the service is part of the HMO • Group practice - combined > \_\_\_\_ (independent practice association, which collects the fee from the service company)
primary additional FFS group health plan staff IPA
Fee-for-service u \_\_\_\_ u Pay as \_\_\_\_ provided u Risk – \_\_\_\_ u Bias – \_\_\_\_ u 75 M in dental PPOs
Capitation u \_\_\_\_: Staff, Group, Independent Practice Associations, Capitated Networks u \_\_\_\_ monthly fee u Risk – \_\_\_\_ u Bias – \_\_\_\_ u 23 M in dental HMOs
• FFS ○ FFS preferred in PPO § Dentists discount fees and agree to provide services for those fees to patients who are covered by that plan ○ Risk: with the third party § The third party has been paid; they're paying you on a service basis > but they don't know how many services you provide □ They spend a lot more potentially if dentists treat too much • Capitation ○ Fixed monthly fee § Capitated networks - can also be solo's under this network ○ Risk is now on the dentist § Responsible for the care, but will only get a certain amount per month ○ Undertreatment ○ Need to have a capitation fee that will support the program § May need help from the outside
PPO
service
third party
overtreatment
HMOs
fixed
dentist
undertreatment
Direct Reimbursement
u \_\_\_\_ promotes strongly u Dentist and patient decide \_\_\_\_ u Patient pays dentist u Patient submits claim to \_\_\_\_ u Employer reimburses patient per agreement u DR not embraced by \_\_\_\_
ADA
treatment
employer
employers
Public financing
u 1798 – merchant seamen, military, American Indians, Federal prisoners
u 1935 – SSA – grants-in-aid to states
u 1965 SSA Amendments
uTitle XVIII ____ (federal)
uTitle XIX ____ (federal-state) • 1997 Amendment:
– Title XXI ____
u 2010 ____ (Dental in 2014)
• Merchant seaman are no longer covered ○ They were covered bc they traveled all over the world; and infectious diseases were more rampant back in the 1800s > didn't want any outbreaks • SSA ○ Grants-in-aid to states § Some states spent on healthcare • Federal pays 50-80% of medicaid (depending on the per capita income is per state - the lower the income, the more they pay)
medicare
medicaid
SCHIP
affordable care act
Medicaid
u \_\_\_\_ cost share u Health care needs of indigent u EPSDT (1968 amendments) u Dental < \_\_\_\_% of expenditures u 20% of US \_\_\_\_ eligible (21 M) u Receive dental care u2000 – 29% (~ 4M children) u2012 – \_\_\_\_% (~ 10M children)*
federal-state
1
children
48
State Children’s Health Insurance Program (S-CHIP)
u Title XXI of Social Security Act
u Children of families w/ income too ____ for Medicaid, but too low to afford ____
u Dental originally optional but included in most ____
u SCHIP reauthorization in FY 2009 included coverage of preventive, restorative and emergency services for oral health.
• Too high for medicaid, but too low for health insurance
high
health insurance
states
(Patient Protection and) Affordable Care Act of 2010 – Dental related provisions (PEW)
u \_\_\_\_ Medicaid coverage u Extended CHIP thru 2015 u \_\_\_\_ dental under exchanges (2014)* u Expand \_\_\_\_ to tribal lands u Demo prgm for new types of providers u Increase CDC \_\_\_\_ to states u Sealant prgms and fluoridation education u Funds for CHC, residency trng, school health ctrs and OH monitoring
• Expanded Medicaid coverage has made the difference to access to care • \_\_\_\_ have continued to see money from the government, but the other aspects have not been fulfilled ○ We've been having authorization, but \_\_\_\_ has not been appropriating
expanded
pediatric
DHAT
grants
FQHC
congress
Accountable Care Organizations (ACOs)
u Authorized by ____
u ____ of physicians and/or hospitals
u ____ payment models
u Aim: improve patient health and reduce health care costs
u Commercial, Medicare, Medicaid
u About 10% of the U.S. population covered by ACOs (Health Affairs, 2018)
ACA
groups
innovative
Medical
Managed care models
uIndemnity (FFS): < 10% of commercial enrollees
uHealth maintenance organizations (HMOs) rise and fall (20%)
u____ dominate (60%)
uBut … Expenditures continue to ____! (~18% GDP)
uACA > delivery system change (coordinated care & health outcomes > ____ > ACO
uSet patient pool plus financial incentives for improving patient ____
PPO
rise
value-based payment
health
Eliminating waste in US healthcare
• By 2020 - 20% of GDP ○ If limit all wedges, in theory, growth of national health care expenditures the same as GDP - save the growth of GDP and money ○ Categories §\_\_\_\_ § \_\_\_\_ failures □ MRI § \_\_\_\_ § Failure of \_\_\_\_ □ Have a patient - diabetic crisis - the hospital stabilizes the patient > the patient is discharged within a week, and then they're back in the hospital in a few months □ Not addressing factors in their living situations § Failures of \_\_\_\_ • Infection rates have plummeted because of implementation of simple checklists
fraud/abuse pricing overtreatment care coordination care delivery
Dental
Managed care models
uIndemnity (FFS): 23% - 6% (2005-14) of commercial enrollees
uDental ____: not popular, little growth
u____
dominate (56%- 82%)
uLimited growth of dental within ____ so far
uFew current studies on perceptions, cost & quality
u____ will be key and facilitate shift to group practice/DSOs
• A lot of the studies for EB-principles are weak
HMOs
PPO
ACOs
IT
- Direct reimbursement has never been more than ____%
- Discount ____ is similar
- Indemnity have shrunk
- ____ have grown
1
dental
PPOs
Fate of Standalone Dental
West Monroe survey of 125 dental & health plan Executives (2018)
u Now: 99% of commercial dental insur is ____
u Future: Integration of med and de insur is inevitable
(96%)
u 98% of medical payers are or will ____ dental & medical
u Primary drivers of change
u Better ____ integration (62%) u Shift to ____ system (39%) u ____(23%)
u Dental payers planning for future
u Strategic ____, diversify/merge, strong differentiation
• VBP - value based payment systems • IT is the largest driver of change • \_\_\_\_ ○ Take on other functions, or merge with other groups • Strong differentiation ○ Something you're known for - you pay claims very \_\_\_\_, etc.
standalone bundle IT VBP profit/savings alliances diversify quickly
Calls for reform of health care
reimbursement in U.S.
u High expenditures / poor relative health outcomes
u 2012: National Commission on Physician Payment
Reform
uMain culprit: ____ reimbursement
uMore ____, higher cost, low coordination
u CMS framework
uMove FFS > modified FFS: reward____ and
efficiency (P4P) >
uGoal: ____-based payments for sustained health maintenance (____)
• Spending too much money and no results • More per capita (2-3x) • CMS - center for medicaid and medicare services ○ Move from FFS to a modified § Still a service fee, but part of old fee may be related to \_\_\_\_ > pay for performance § Reimbursing for treamtent condition vs procedures related to a position
FFS services quality population P4P or VBP
quality
Value-based Payment System
uReimburse for treatment of a disease ____ vs procedure(s)
uUtilize ____ for subgroups of patients with same diagnosis
condition
teams
Quality & Performance
u Is Pay 4 Performance new to dentistry?
u Pre & Post treatment reviews > denial of
payment or denied plan participation
u Prepaid health care focus should be on the ____ and the ____
u ____ of population examined
u ____ oral care needs met
u Patient ____
u Efficiency, effectiveness and appropriateness
u Combined evaluation of above > ____ of a plan
• Not \_\_\_\_ to dentistry
individual population percent basic satisfaction value new
Barriers to Quality Assessment in Dentistry (Bader, 2009)
u No ____ measures for treatment selection or outcomes. Why?
u ____ development of dental profession
u ____ methods in education and licensure
u Absence of evidence re: treatment selection or outcome
u Lack of ____
• No standardized - related to how dentistry developed historically - largely based on the \_\_\_\_ ○ Dental societies were set up to tackle this - but not effective • Not looking at eligible individuals in west Philly and tracking if improving their health • Lack of diagnostic codes ○ Proxy: treatment needs ○ Don't diagnose caries based on the amount of caries; only says what's needed; nothing standardized in the chart, no diagnostic codes
standardized historical evaluation diagnostic codes individual
Important Recent developments
u Diagnostic ____
u Dental ____ changes
u Dental practice ____
codes
workforce
evolution
Diagnostic Codes
u Important for measuring ____ outcomes
u Help focus on patients’ ____ vs clinician’s skill
u Lacking in dentistry until very recently
u SNODENT released (finally!)
u Better ____ communication
u Data ____ for oral health outcomes assessment
u Improved support for ____practice
u ____ culture well received in one large medical-dental system
• SNODENT - systematic nomenclature of dentistry
appropriateness/tx health interprofessional retrieval evidence-based diagnostic-centric
Dental Workforce
u ____ accepted
u EFDA (reversible procedures) – mixed prof
support
u Dental therapists – strong ____
u Evidence-base supports competence
u Auxiliaries well accepted in ____ (PAs, NPs)
u Liaisons between medical and dental practices > better care coordination, potential to reduce costs and improved outcomes (IOM 2015, Guyton et al 2018)
u Future
u Integrate medical and dental ____ (Nash 2012)
u ____ in dentistry (Harris 1972)
• Ensure patient gets to see the dentist via a physician • Ladder ○ Community health work, hygienest, EFDA, therapist to dentist ○ People who go up the ladder are fully capable, but also fully acceptable to exit along at any point route ○ Trying to contorl classes associated with educational system
DA and RDH resistance medicine education career ladder
Dental Practice
u Major reform needed to: (Vujicic 2018)
u address the lack of ____
u improve measurement of ____
u reform reimbursement to reflect what is done for vs. to ____
u explore models to deliver OH at lowest cost
u Solo practice slowly giving way to ____ groups
u ____ a problem for new graduates
u ~8% of dentists practice in ____
u Pressure on commercial carriers to reduce ____
u Value for expenditures critical
u ____ practices better positioned
* Dentistry at crossroads and needs major reform in order to deal with a ccess * OH = oral health * Larger groups - driven by debt
coverage oral health patients larger debt DSOs premiums larger
Percentage of total dental receipts accounted for by establishment size (number of paid employees), 1992 and 2007.
• Growth from 92 to 2007 > largest colelctions has been in \_\_\_\_ practices with 10+ employees
large
Models of Success
- Tribal programs
- ____
- ____
• Apple Tree Dental (MN) • \_\_\_\_ teams & community collaborations • OH maintenance in LT care pop • \_\_\_\_ & EHRs
- Sarrell (AL) – good oral health care at lower cost
- Financially stable despite low ____
- Revenue/patient down but new ____ up• Tribal programs
○ Dental therapists
○ VBP can start here
• Sarrell
○ Maintained financial stability in regards to low medicaid rates
○ Increasing access to maintain a viable model
DHAT VBP diagnostic codes medicaid visits
Looking Ahead
• Rapid changes continue in medical • Gradual in dentistry • solo > group > \_\_\_\_ • FFS > \_\_\_\_ > \_\_\_\_ payment • More salaried providers? • Diagnostic codes? • Dental schools as models? • working with all types of \_\_\_\_ • focus on \_\_\_\_ health outcomes \_\_\_\_ training • Need \_\_\_\_ changes • office interventions limited • outreach: community health workers • Leadership
• Don't know how fast transition into group will go ○ Integration with specialists and medical care? • Bundled payment ○ Not done in \_\_\_\_ ○ One situation where med does do it > medicare will reimburse for knee replacement surgery ○ Rehab - they should be fully active within 90 days - can be the health outcome standard ○ If had bundled payment > depends on patient being in ambulatory in 90 days > you'd want them to go to the best one there is so they achieve health outcome in \_\_\_\_ days • Dental schools ○ No exposure to preschool kids > can we have experience with DA's? • Office interventions can only go so far; need behavioral change and need work in the \_\_\_\_
integration capitation bundled DAs patient interprofessional behavioral medicine 90 community
Evolution of Dental Payment Delivery
• Solo through groups, networks and outreach ○ \_\_\_\_ with medicine is the holy grail • \_\_\_\_ is the goal ○ We're at FFS surgical and prevention now; but soon we'll see \_\_\_\_ that pay for outcomes • \_\_\_\_; dental nearby medical • Dental ACOs ○ Share \_\_\_\_, but have separate \_\_\_\_ from medicine ○ Handling the business side of practice, and delivery is separate • Health ACOs ○ Dental and medicine combined ○ Full integration ○ Striving for this to get \_\_\_\_ under control
integration VBP carveouts co-location finance delivery systems cost
