Finance in

dentistry
Guided By :- Presented By:-
Dr. C. L. Dileep Dr.Hansika Popli
PG 3rd year
Dr. Manu Batra
Department of public
Dr. Deeksha Gijwani health dentistry
 CONTENTS
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
 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

 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

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
 an integral part of general health
ORAL
called as the GATEWAY OF THE
HEALTH
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.

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

 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.
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.
 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

 1. PRIVATE FEE FOR SERVICE

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.
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.

 Patient 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.
Advantages

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.
Disadvantages

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.
 2. Post Payment Plans/ BUDGET PAYMENT PLANS

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.

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.
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.
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

Basic Principles- bank should adhere to bring a workable relationship
between the dentist,the patient and the bank………………………

 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.
 ESSENTIAL FEATURES

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
Problems in Financing

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.
 3. Third Party/ Pre Payment Plans

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.
Routing of funds for dental care
In the language of contract………

It is also known as the carrier, insurer, underwriter or

administrative agent.
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

 Private THIRD PARTY PAYMENT IN DENTISTRY

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.

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)
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

 Deductible:

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.

Co-insurance/ co-payment.

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.

Range of health care services

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.
 Preauthorization

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

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.

Group insurance

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.

REIMBURSEMENT OF DENTISTS IN PREPAYMENT
PLANS

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
Advantages of UCR approach

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
Disadvantages of UCR approach

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
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.
Table of Allowances( or schedule)

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.

 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.
Advantages OF TABLE OF
ALLOWANCE
• 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.
Fee schedules

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.
Capitation

 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.

 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.
DIRECT REIMBURSEMENT

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.

 PRIVATE THIRD Party prepayment plans

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
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.
2. Non Profit Health Service Corporations

Delta Dental plans

Blue Cross/ Blue Shield dental plans

 2 a. Delta Dental Plans

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.
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.
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.
Reimbursement of Dentists in Delta Dental Plan
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
 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.

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

 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
90th percentile

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.
 Commentary of Delta Dental Plans
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
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.

2b. Blue Cross/ Blue Shield Dental Plans

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.

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.
3. PREPAID GROUP PRACTICE

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.

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”

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.
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.

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.
 ADVANTAGE OF GROUP PRACTICE:

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.
3a. HEALTH MAINTENANCEORGANIZATION (HMO)

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

Hmo’ s have 5 essential element are…….

1. A managing organization

2. A delivery system

3. An enrolled population

4. A benefit package

5. A system of financing and prepayment.

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
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
Dental Personnel in HMO’s: the models are………..

The Staff model

The Group model

The Independent Practice association

The Primary care capitated network or direct contract

model
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
Group model

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.

Independent Practice Association (IPA)

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
PRIMARY CARE CAPITATED NETWORK OR
DIRECT CONTRACT MODEL

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.

PREFERRED PROVIDER ORGANISATION (PPO’S)

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.
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
4. CAPITATION PLANS

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

 4. SALARY

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.

 ADVANTAGE

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

DISADVANTAGE

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.
 5. PUBLIC PROGRAMS

 MEDICARE

 MEDICAID

 VETERANS ADMINISTRATION

 NATIONAL HEALTH INSURANCE

 PUBLIC FINANCING OF DENTAL CARE

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.

 MEDICARE:

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.

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.

Hospital Insurance

Provides substantial coverage of the costs of

Inpatient Hospital services

Skilled nursing care

Post institutional home health care

Supplementary Medical Insurance : covers

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.

MEDICAID

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.
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.
• 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.

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.

early and periodic screening, diagnosis and treatment services

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
Dental Services in Medicaid

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.
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.
• 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
• 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
 STATE CHILDREN'S HEALTH INSURANCE PROGRAM
(SCHIP)

• 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.
 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.
National Health Insurance

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
OTHER PROGRAMS OF PUBLIC FINANCING
OF DENTAL CARE

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.

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.

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.
 indian scenario

> 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

 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%
 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.

 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.

 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)

 EMPLOYEES STATE INSURANCE SCHEME(ESI)

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.

SCOPE OF ESI
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

 FINANCE IN ESI SCHEME
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 7/8 th

of the medical expenditure.

BENEFITS TO THE EMPLOYEES in esi scheme

Medical benefit

Sickness benefit

Maternity benefits

Disablement benefit

Dependant's benefit

Funeral expenses

Rehabilitation allowance.
 CENTRAL GOVERNMENT HEALTH SCHEME(CGHS)

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.

 DEFENCE MEDICAL SERVICES
Defence services have their own organization for medical care to

their personnel under the banner "Armed Medical and Dental

Service.”
 HEALTH CARE OF RAILWAY EMPLOYEES

The railways provide comprehensive health services including

dental treatment through the agency of railway hospitals, health

unit and clinics.

 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

Life Insurance General Insurance

Government Corporation Corporation
(LIC) (GIC)

United Indian
Employees’ Central Insurance
State Government National
Corporation
Insurance Health Insurance
(UIIC),
Scheme Scheme Corporation
(ESIS) (CGHS) (NIC)

Oriental
Insurance
New India Company
Assurance (OIC).
(NIA)
 Conclusions
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.

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.

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.

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