community ch 3-5

dental care delivery in the united states

• involves mostly private dental practices and some government entities

• oral health is a major unmet need but is integral to total health and well being

• impacted by many federal and state governmental entities

• trends are suggesting more public funding for dental care in future

lower income households and ethnic minorities

untreated dental disease is more prevalent in individuals from _

providers of dental care in united states

• dental hygienist

• dentist

• dental assistants

• denturists (some states)

• expanded function dental personnel

• dental lab technicians

federal providers of dental care in US

• department of federal government

• department of health and human services (HHS), National Instituites of Health (NIH), and Food and Drug administration (FDA), united states public health service (PHS), centers for disease control and prevention (CDC), indian health service (IHS), administration on aging, department of justice (DOJ), bureau of labor statistics, agencies

nongovernment provider of dental care in US

• private practice

• institutions

• schools

• insurance based models

state providers of dental care in united states

• department of state

• state prisons

• community clinics

• schools

department of health and human services (HHS)

• federal influence

• largest grant-making agency in the federal government

• works closely with state and local governments

• ex: school based sealant programs using federal grants to deliver services (state run but funded federally)

united states public health service (PHS)

• federal influence

• improve and advance the health of all Americans

• US surgeon general directs

• RDH can work as a commissioned officer

strategic goal 1 of HHS

• reform, strengthen, and modernize the nations healthcare system

strategic goal 2 of HHS

• protect the health of Americans where they live, learn, work, and play

strategic goal 3 of HHS

• strengthen the economic and social well being of americans across the lifespan

strategic goal 4 of HHS

• foster sound, sustained advances in sciences

strategic goal 5 of HHS

• promote effective and efficient management and stewardship

national institute of health (NIH)

• federal agencie

• the federal government’s medical research institution

• research conducted within bethesda, maryland facilities and coordinates other research projects across the US

• national instituites of dental and craniofacial research (NIDCR)

food and drug administration (FDA)

• federal agency

• established in 1906 and headquartered in Rockville, Maryland

• regulates

  • dental materials

  • dental equipment

  • dental medicine

  • over the counter dental care products

centers for disease control and prevention (CDC)

• federal agency

• health surveillance

• prevent and monitor outbreaks

• oral health division

  • focuses on prevention

  • community water fluoridation

indian health service (IHS)

• federal agency

• dental care for native americans

administration on aging

• federal agency

• older Americans act of 1965 (foundation and federal legislation for delivering social and nutritional services to Americans over the age of 60)

health resources and services administration (HRSA)

• federal agency

• national health service corps, ryan white act, organ transplants, infant and children health

agency for healthcare research and quality (AHRQ)

• federal agency

• researches quality, costs, access, and effectiveness

administration of children and families

• federal agency

• early head start and head start programs

medicare

• title XVIII

• federal agency - part of centers for medicare and medicaid (CMM)

• federal insurance programs from trust fund for senior citizens over 65

• generally does not fund dental care but may reimburse for hospital procedures in some instances. primarily pays medical bills

medicaid

• title XIX

• federal agency - part of centers for medicare and medicaid (CMM)

• publicly-funded insurance program for low income and populations with disabilities, aged, blind, and members with dependent children

• includes dental for children and adults in some states

CHIPS

• federal agency - part of centers for medicare and medicaid (CMM)

• the largest effort by congress since medicaid to provide health insurance to vulnerable children throughout US

• enacted as part of balanced budget act of 1997

• entitles states to allot federal funds to purchase child health assistance; 30% higher share of program cost than medicaid

department of justice (DOJ)

• federal agency

• responsible for the federal bureau of prisons and the dental care provided to inmates incarcerated in the system

department of veterans affairs (VA)

• federal agency

• dental care for veterans with service connected disabilities

bureau of labor statistics

• federal agency

• labor, economics and statistics, which impact dental care delivery

department of agriculture (WIC)

• federal agency

• women, infant and children program

• nutrition focused

department of treasury

• federal agency

• tobacco labeling

department of agriculture federal dental hygiene settings and positions

• women, infant, children (WIC) preventive educator

department of defense federal dental hygiene settings and positions

• military base dental clinican

department of justice federal dental hygiene settings and positions

• federal prison dental clinician

department of health and human services federal dental hygiene settings and positions

• public health service commissioned officer

• early head start and head start dental educator/provider

• CDC/HRSA/NIDCR researcher/ administrator

peace corps federal dental hygiene settings and positions

• developing country dental clinician/educator

state federal dental hygiene settings and positions

• civil service position with military, VA hospital, or other government agency

veterans affairs federal dental hygiene settings and positions

• VA hospital dental clinican

state influence

• dental departments work as dental consultants within the state enviornment and strive to promote dental health

• work to implement water fluoridation within communities, school-based prevention programs, school sealant programs, and fluoride mouth rinse programs

dental healthcare workforce

• mixture of organizations practitioners, financing mechanisms, and innovative approaches to health services planning

  • need

  • demand

  • utilization

  • supply

need

• can be defined as a normative, professional judgement as to the amount and kind of health care services required to attain or maintain health

demand

• the particular or desired frequency of dental care utilized by a population

supply

• amount of dental care services available

utilization

• is the number of dental care services actually consumed not just desired

• important when speculating on the available supply of personnel to meet the demand/need

denturists

• are trained to provide complete oral examinations and evaluation of patients

• directly provide them with removeable dentures and fit them accordingly

• legally allowed to practice in only a few states

dental therapists

• beginning in 200, alaska native tribal health organizations developed the alaska dental health therapist initiative

• new solution to address rural alaska’s dental needs

• DHAT student completes two year program and focuses on providing restorative care in patients located at remote areas under supervision of dentist

• delivery of health services use telecommunications

advanced dental hygiene practitioner (ADHP)

• proposed

• developed by american dental hygienist’s association

• masters degree

• no physical presence of dentist required for clinical care

• prevention and primary restorative focus

• state license required

alaska dental therapist (DHAT)

• currently practiced in alaska indian health service clinics

• developed by united states public health service

• no degree required

• no physical presence of dentist required

• restorative focus

• no state license required

community dental health coordinator (CDHC)

• proposed

• developed by american dental association

• no degree required

• physical presence of dentist is required

• preventative focus

• no state license required

political, cultural, and socioeconomic factors

• globally, dental public health is affected by political, cultural, and socioeconomic factors

• many do not place oral health as priority

• preventive strategies include fluoridation of toothpastes, community water systems, milk products, table salt, and education about oral health risk factors

world health organization

• has identified profound oral health disparities that may relate to socioeconomic status, race, ethnicity, gender, or general health status

• underserved population groups are found in both develops and developing countries

• maintains statistics on prevalence of dental disease from more than 170 countries in their global oral data bank

• data on both periodontal disease and dental caries is accessible

DMFT indices

• dental caries is commonly measured by

• significant caries index replaces this

dental caries and periodontal disease

• are the most widespread of all human diseases

federation dentair internationale (FDI)

• organization that represents the international community of dentists

• data bank that gathers epidemiological data and contains information about dentistry and dental team

council of european chief dental officers (CECDO)

• maintains another databank

• oral health workforce, dental education, costs, and oral health indicators including the epidemiological data on decayed, missing, and filled teeth (DMFT)

• may also include information on the numbers of registered and active dental hygienists in europe

• dentists; dental diseases

the highest number of dental hygienists are found in countries with the highest _ population rations and the greatest reduction of __ __

Canada, Japan, United states

• a survey of the dental hygiene workforce in 1998 concluded that __ __ and __had more than fifteen times as many dental hygienists as the former eighteen member states of the european economic area

trends in professional regulation

• primary purpose is to ensure the quality and safety of patient care

• national differences in legislative practices affecting dental hygienists tend to reflect the impact of an organized lobby of dental profession trying to stay in control of dental hygiene care

portability of licensure

• at this point in time, US requires state qualifications in addition to national qualifications

• European countries are closer to attaining more portable options

direct supervision

• dentist not only decide and authorize dental hygiene treatment but must be physically on site during the delivery and, in some cases, may have to be in the room or examine patient after treatment

general supervision

• dentists prescribe and authorize dental hygiene care but do not need to by physically present on site while treatment is rendered

• generally, care is provided at a facility owned or managed by dentists or at public health clinics managed by them

98%

• approximatly _ % of dental hygienists are women

• gender bias has impaired equal access to education and equal occupational opportunities

dental therapists

• provide restorative care under the general supervision of dentists

• mostly found in united kingdom and in former countries of the British commonwealth such as autralia, canada, and nigeria

• referred to as school dental nurses in new zealand

dental nurses

• services include dental hygiene care but primary focuse is on childrens restorative needs

• may restor both the primary and permanent dentition of children and extract primary teeth

3% were spent on dental care

• of the total health care expenditures in the united states in 2020, only …

• approximately 50% of the population had at least one dental visit in 2017

private funding

• includes patient out of pocket fees or funding by private insurance companies

• forty four percent of the population had at least on dental visit throughout the year

• of the 7.4% of dental care expenditures, nearly 92% were paid for by private funding

$560

• the average expense for dental treatment is _ per year (2.5 visits)

payment methods

• generally there are four

  • fee for service

  • capitation plans

  • encounter fee plans

  • barter system

fee for service

• based on a fee scale for all covered services, and bills the patient for the services rendered by dental hygienist, dentist, or denturist

• most commonly used payemt method in US

• patient or insurance may pay fee

• increases office production

usual, customary, and reasonable (UCR) fee

• are the average dentist fee per service in the immediate local region

• what is most often charged by dental providers for a given dental or dental hygiene service

usual

• what is most often charged by dental providers for a given dental or dental hygiene service

reasonable

• indicates that the fee meets the usual and customary definition and is therefore justifiable

customary

• refers to a schedule of maximum fees charges by dental providers with similar training and service within a specific and limited geographic area as determined by the administrator of a dental plan based on submitted fees

capitation

• dental provider contracts with a program to provide all or most dental services to the programs subscribers in return for payment on a per capita basis

• receives fixed monthly payment whether the patients use care or not

  • health maintenance organization

• decreases production due to less of an incentive to provide preventative treatment

• decreases control of providers recommended treatment

barter system

• dental provider and patient negotiate payment by exchanging goods or services without utilizing money

• used in private sector

• less common payment method, used more often in rural settings

encounter

• payment is based on an office visit and is always the same regardless of the services rendered

• may decrease productivity of office

• some clinics only provide one service per dental visit

• may lead to decrease in comprehensive care

dental insurance plans

• legally constituted nonprofit organizations incorporated on a state basis and sponsored by a dental society to negotiate and administer programs

  • UCR

  • contractual agreement

types of insurance plans

• dental service corporations

• health service corporations

• preferred providers organization (PPO)

• individual practice association (IPA)

• commercial dental insurance

• prepaid group practice

• health maintenance organization (HMO)

• capitation plan

dental service corporation

• not-for-profit organization that negotiates and provides dental care contracts

• corporate on a state by state basis and sponsored by a constituent dental society

  • delta dental

health service corporation

• offers limited dental coverage as part of its hospital-surgical/medical policy

  • blue Cross and Blue Shield

preferred providers organization

• Dental providers and third-party contract with employer of dental benefits to offer services at reduced prices

  • Aetna U.S. Healthcare Dental P P O

individual practice associations

• legal entities organized for dental providers to enter into contracts collectively to provide prepaid dental services to enrolled groups

commercial insurance plans

• operate for profit and designed as indemnity plan

prepaid group practice

• large group practice that contracts with groups of subscribers

health maintenance organization (HMO)

• Developed in 1973 by the H M O act, organization provides comprehensive health care to enrolled individuals and families in a specified region by participating providers, financed by fixed periodic payments; initially designed to decrease health care costs

capitation plan

• offers per capita payment for a defined population provided by specific dental providers; payment made to provider regardless of use

dental billing

• bill for dental procedures utilizing a dental claim form

• use dental procedure codes (CDT codes)

• patients payment is expected after services are rendered

benefit

• amount that the insurance entity will pay for covered dental services described in its policy

children health insurance program (CHIP)

• federal program created to cover medical care for children whose families have incomes too high to qualify for state medical assistance by cannot obtain private insurance

  • all states participate, but some do not cover dental

claims processing

• entering procedures rendered and determining whether payment will be approved or denied

commercial insurance plan

• plan that operates for profit

contract

• legal agreement between an insurance entity and a group or individual

copayment

• portion of the cost of each service a patient pays

deductible

• amount an individual enrolled in an insurance plan must pay for covered services before the insurance entity begins paying

dental claims

• patient's formal request for insurance payment for a dental procedure that was rendered

dental claim form

• standard dental document used to file a claim or request authorization for a procedure

dental necessity

• service provided by a dental provider that has been determined as a generally acceptable dental practice for a specific diagnosis and treatment

early and periodic screening, diagnosis, and treatment (EPSDT)

• service for persons under twenty-one years of age for medical, dental, and vision care paid for by Medicaid

exclusive provider arrangement (EPA)

• contract between dental care providers and an employer (which eliminates the third party) stating the negotiated fees for services offered to the employer's employees

explanation of benefits

• form sent to the patient and provider explaining the approval or denial of payment for procedures rendered

fee slip

• form a dental practice uses to detail the services rendered a patient

managed care

• integration of health care delivery and financing