Transcript Corporate Presentation Template

©UFS
Dental Benefits – U.S. Market
June 2010
Dr. Alan Vogel
MetLife, VP Dental Products
Today’s Topics
• US Dental Market – Statistics
•
Dental Plan Evolution – Design & Administration
– Initial approach - Cost Drivers
•
•
•
Plan Design and Contract Provisions
Plan Administration
Provider Networks
•
•
•
Research based / Evidenced Based Dentistry
Consumer Directed Plans
Tools – Employee
•
•
Wellness / Disease Management
Data management
– Current approach – Cost & Value Drivers
– Future
2
Size of U.S. Dental Market
Number of Covered Lives: Approx. 176 million (57% of
U.S. population)1
Total Dental Dollars: $46.5B in premium2, $101.2B spent
on dental in 20083
DPPO Lives1:
DHMO Lives1:
Indemnity Lives1:
Access Lives1:
101,504,708 / 101.5 million
12,644,357 / 12.6 million
22,116,711 / 22.1 million
15,222,239 / 15.2 million
(1) NAD/DPPA 2009 Dental Benefits Joint Report: Enrollment, June 2009 pg. 7, Dallas, Texas. Ordering information at www.nadp.org. (2) NADP 2009
State of the Dental Benefits Market, February 2009, pg. 6. Dallas, Texas. (3) Centers for Medicare & Medicaid Services, Office of the Actuary. National
Health Expenditures Amounts by Type of Expense an Source of Funds: Calendar Years 1965-2019, January 2010.
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Dental Plan Trends
DPPOs are the only segment with significant growth from 2000 - 20081
110
101.5
95.6
90
91.8
80.2
80.3
69.7
70
60.5
50
54.3
60.7
58.9
65
51
40.8
54.2
33.5
30
26.6
23.7
23.5
23.6
28.5
23.2
22.1
14.9
13.8
15.6
13.7
12.7
13.1
15.1
10
-10
13.2
2000
11.3
2001
Indemnity Plans
12
2002
11.6
2003
PPO Plans
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2004
2005
DHMO Plans
2006
2007
15.2
12.6
2008
Access/Discount Plans
(1) NAD/DPPA 2009 Dental Benefits Joint Report: Enrollment, June 2009 pg. 7, Dallas, Texas. Ordering information at www.nadp.org. Numbers in millions of covered lives.
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Types of Plans
•
•
•
DHMO
– Dentist paid on a per capita basis at a fixed rate for each individual or family
–
Indemnity
– Fee-for-service reimbursement generally based either on a schedule of
–
allowances or UCR
No network provider assigned or available
DPPO
– Fee-for-service reimbursement with in and out-of-network options
– Network of dentists agreeing to a discounted level of payment for covered
–
•
enrolled regardless of number of services performed. Co-payment may be
required for certain procedures
Referral required for specialist care
services
Patient may choose to go out-of-network and plan design/carrier will determine
out-of-network reimbursement level.
Access Plan
– Network Plan – no out of network access
– No Benefits Covered
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Plan Financials
• Insured
– Plan and Administration Defined by Carrier
– Regulated by State
• ASC (Administrative Services Contract)
– Plan and Administration Defined by Employer
– Exempt from State Regulation
• Employer Sponsored
– Majority of Costs picked up by Employer (50%+)
– Cost sharing with Employee and / or Dependent
• Voluntary
– Employee picks up majority of Costs or all the Costs (50-100%)
– Usually Insured
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©UFS
Evolution of Dental Plans
Examining the Present and Future
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Initial Plans Focused on Costs
•
Cost Drivers
– Plan Design
• Allocation of Services
• Age, Frequency & Dollar Limits
• Contract Provisions
–
–
–
–
Alternate Benefit
Pre-existing Space
Plan Administration
• Bundling Software
• Tooth Map History
Provider Networks
• Discounts
• Patterns of Care
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Costs -Plan Design Components DPPO / Indemnity
• Allocation of Services & Coinsurance percentages
– Preventive: Cleanings, Routine X-rays (100%)
– Basic Restorative: Fillings, Periodontics, Surgery, Endodontics (80%)
– Major Restorative: Crowns, Bridges/Dentures (50%)
• Plan maximums ($)
– Annual Max and Orthodontia Lifetime Max
• Deductibles (individual & Family)
• Reimbursement Design
• Age & Frequency Limitations
• Exclusions
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Potential Allocation of Services
— Type A, B, C & D covered services
Type A
Type B
Type C
Type D
Preventive & Diagnostic
Restorative
Prosthodontics
Orthodontics
 Oral exams
 Full mouth X-rays
 Bitewing X-rays,






periapicals
& other X-rays
Lab and other tests
Prophylaxis (cleaning)
Fluoride treatments
Space maintainers
Palliative care
Sealants













Fillings
Repairs
Periapicals
Pulp capping/
pulpal therapy
Endodontics/root canal
Periodontal maintenance
Periodontics
Rebases/relines
Simple extractions
Surgical extractions
Oral surgery
General anesthesia
Consultations




Inlays/onlays
Crowns
Dentures
Bridges
 Orthodontic
diagnostics
 Orthodontic
treatment
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Limitations and Exclusions
Standard
Up to age 19
Up to age 19
2 per year
Fluoride age
Once per 12 months
Space maintainer age
Once per lifetime
Periodontal maintenance
Combined with cleaning
1 in 5 years
Prosthodontic services
Up to age 16
Sealant age
Molars only
90th
Not covered
One per 60 months
R&C Percentile
Implants
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Costs - Plan Administration - PPO / Indemnity
• Unbundling software
•
Claim Review
•
Reimbursement amounts
•
Alternate benefits
•
Pre existing conditions
• Prior History (Tooth Map History)
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Costs - Networks - PPO
• Provider Selection & Credentialing
–
Practice Patterns
• Contract
–
–
Defines Relationship to Carrier
Defines Relationship to Plans
• Fee Schedule
–
–
Creates maximum reimbursement amounts
Defines many plan requirements
• Access to Providers
–
Geo-Access reports – Generalist & Specialist
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Current Plans Focus on Value & Costs
•
Value Drivers (Evidence Based Benefits)
– Researched Based Plan Design
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•
Build Research into Age, Frequency Limits
Build Research into Guidelines & Covered Services
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•
Cover Services That Treat Disease at Higher Levels
Patient makes “Bad Choice” = Higher Costs
•
•
Oral Health Library
Decision Support
– Consumer Based Plan Ideas
– Employee Tools
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Value- Covered Services – Researched based
• Implants
•
White Fillings on Molars
•
Bruxing Appliances
Add These Services Without Increasing Costs, How?
•
Evidenced Based Dentistry - Modify
– Age & frequency limits
– Allocation of Services
– Replacement Limits
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Adjusted Allocation of Services
— Type A, B, C & D covered services
Type A
Type B
Type C
Type D
Preventive & Diagnostic
Restorative
Prosthodontics
Orthodontics
 Oral exams
 Bitewing X-rays,




periapicals
& other X-rays
Lab and other tests
Prophylaxis (cleaning)
Fluoride treatments
Sealants














Fillings – resin on molars 
Repairs

Periapicals

Pulp capping/

pulpal therapy

Full mouth X-rays

Space maintainers
Palliative care

Periodontal maintenance

Periodontics – non surgical

Rebases/relines
Simple extractions
Surgical extractions
General anesthesia
Consultations
Inlays/onlays
Crowns
Dentures
Bridges
Implants
Endodontics/
root canal
Periodontics–surgery
Oral surgery
Bruxing Appliance
 Orthodontic
diagnostics
 Orthodontic
treatment
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Adjusted- Limitations and Exclusions
Research based
Alternatives
Standard
Up to age 19
Up to age 19
2 per year
Fluoride age
Once per 12 months
Space maintainer age
Once per lifetime
Periodontal maintenance
Up to age 14
Up to age 14
4 per year
Combined with cleaning
1 in 5 years
Prosthodontic services
1 in 10 years
Up to age 16
Sealant age
Up to age 19
Molars only
90th
Not covered
One per 60 months
R&C Percentile
Implants
Molars only
70th or 80th
Covered
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Value- Employee Tools
• Self Service
– Claim information
– Plan information
– Network Providers
•
Oral Health Library
– Educational on Services
– Educational on Risks
•
Fee Estimator
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What’s Driving Dental Plan Design Evolution?
Dental Benefits
Environment
Research
& Risk
Dental Plan Design
Changing
Benefits
Objectives &
Demands
Dental Standards
& Market Practice
Do the dental plans you recommend recognize and incorporate these trends?
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Changing
Benefits
Objectives &
Demands
Benefits Objectives and Demands
Employers Creating a Culture of Health and Responsibility
 While companies remain concerned with the rising cost of healthcare
coverage, at a broader, more holistic level, they are also focusing on how to
encourage employees to behave in ways that help them lead healthier lives.
WELLNESS PROGRAMS
Employers offer
wellness programs
2005
2008
2005 Programs
27%
33%
2008 Programs
More Employees Seek Advice and Guidance at the Workplace
 43% of employees want access to benefits advisors at the workplace, and
are interested in professional advice regarding critical decisions about their
benefits (up from 33% of employees in 2006).
Source: 7th Annual MetLife Study of Employee Benefits Trends
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Risk Is Playing a More Important Role inResearch
& Risk
Dental Plan Design
 Research has suggested a relationship between oral and overall health, and
has associated periodontal disease with conditions such as preterm births1,
diabetes2, and coronary heart disease3.
 However, studies have suggested additional relationships between oral and
overall health for which further research is underway:
People taking Antidepressants or Cancer Patients undergoing radiation —
In some cases antidepressants and radiation may cause Xerostomia (dry mouth),
which can compromise oral health.4,5
Women taking Bisphosphonates for Osteoporosis (Injectable) —
Bisphosphonates may contribute to osteonecrosis of the jaw in some cases6
People in need of organ transplants — One study suggests they may have a better
chance for success of the transplant if their oral health is good7 (a link between chronic
periodontitis and the risk for rejection)
(1) Khader YS, Ta’ani Q. Periodontal diseases and the risk of preterm birth and low birth weight: a meta-analysis. Evid Based Dent 2005 Feb; 76(2):161-5. (2) Mealey B.L. Oates T.V. Diabetes Mellitus and
Periodontal Diseases. AAP-Commissioned Review. J Periodontal 2006;77:1289-1303.. (3) Humphrey LL, Fu R Buckley DI, Freeman M, Helfand M. J Gen Intern Med. 2008;23(12):2079-86; (4) Keene,
Joseph J. Jr., et al. “Antidepressant use in psychiatry and medicine — Importance for dental practice,” Journal of the American Dental Association, Vol. 134, January 2003; (5) Dirix, Piet, et al. “RadiationInduced Xerostomia in Patients with Head and Neck Cancer,” Cancer, Vol. 107, number 11, December 2006; (6) Migliorati et al. “Managing the care of patients with bisphosphonate-associated
osteonecrosis: An American Academy of Oral Medicine Position Paper.” Journal of the American Dental Association. Vol. 136, December 2005; (7) Ioannidou et al. Elevated Serum Interleukin-6 (IL-6) in
Solid-Organ Transplant Recipients Is Positively Associated With Tissue Destruction and IL-6 Gene Expression in the Periodontium.” Journal of Periodontology, 2006, Vol. 77, No. 1, pg 1871-1878.
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Do you know?
It’s estimated 35% of adults have periodontal disease1,
and up to 13% have moderate or severe periodontal
disease2.
Q: and what percent is attributed to smoking?
A: Half2,3
(1) Quality Resource Guide, “Assessing Risk for Chronic Periodontitis in Adults, Dr. Ray Williams, DMD, Chair
Department of Periodontology, University of North Carolina School of Dentistry. (2) Center for Disease
Control, Oral Health at a Glance, 2010 (3) Journal of the American Dental Association, “Risk assessment and
management of periodontal disease”, Douglass, 2006 (4) Tobacco and healthy teeth don’t mix. Canadian
Dental Association website. www.healthyteeth.org/tobacco. Accessed October 2, 2009.
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Do you know?
So what?
Research suggests there is a two-way connection
between diabetes and periodontal disease – not only are
diabetics more susceptible (to periodontal disease), but
the presence (of perio disease) may also make glycemic
control more difficult.2
(1) Center for Disease Control, National Diabetes Fact Sheet, 2007
(2) Department of Health and Human Services, “Working Together to Manage Diabetes”, 2007
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Do you know?
Q:
Among the 50 most prescribed medications, this
percent had the capacity to cause xerostomia1, or
dry mouth, as a side effect?
A:
Half
(1) Quality Resource Guide, “Recognition and Management of Patients with Xerostomia”, James
Guggenheimer, DDS, University of Pittsburgh School of Dental Medicine
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Future Plan Focus
•
Disease Management / Wellness
– Medical / Dental Integration – Patient Information
– Education – To Risks for Disease
– Variable Benefits – Based on Individual Risk
•
Data Mining
– Outcome Measures – Network Selection Process
– Provider (Dentist) Profiles – Focused Claim Review
– Utilization Statistics – Show Value of Program to:
•
•
•
Patients
Dentists
Payor
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WHY???
So A Carrier Can:
 Analyze and challenge plan designs
– Look deeper than 100/80/50 and question where services are allocated
– Understand limitations, exclusions, contract language — and ask
questions!
 Understand what adds value to a plan and what is questionable
 Educate your clients on “why change plans”
 Present the best plans and alternatives to meet your customers’
unique needs
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Questions?
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