Plan Types and Management - America's Health Insurance Plans€¦ · Dental Benefits Part B Study...

Dental Benefits Part B Study Manual

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America’s Health Insurance Plans

Dental Benefits, Part B:

A Closer Look at Plan Types and Management

Study Manual

For use in the AHIP course

Dental Benefits, Part B and to accompany the textbook

Dental Benefits: A Guide to Managed Plans (Third Edition) by Cathye L. Smithwick.

Previously authored by Donald S. Mayes.


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America’s Health Insurance Plans Washington, DC 20004

© 2013 by America’s Health Insurance Plans

All rights reserved. Published 2013.


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Contents

Note that the chapters of this study manual correspond to the chapters of the textbook covered in the course Dental Benefits Part B—chapters 14, 17-18, 19-21, 24-25, 30 and 34-41. The other textbook chapters are covered in Dental Benefits Part A and are included in the Part A study manual.

How to Use This Study Manual 4

Frequently Asked Questions About the AHIP Examination 5

America’s Health Insurance Plans (AHIP) 7

14 Understanding PPO Fee Schedules and Discounts 8

17 Dental PPOs: An Overview 17

18 Dental PPOs: Plan Design 23

19 Dental HMOs: An Overview 30

20 Dental HMOs: Plan Design Concepts 37

21 Dental HMOs: Copayment Schedule Basics 44

24 Selecting a Dental Administrator: The Procurement Process 50

25 Dental Policy—Translating Evidence Into Reality 57

30 The Dental Consultant: An Essential Resource 63

34 Gaining Value From Data Mining—The case for Data Warehousing in Dental Plans 70

35 Informatics and the Whole-Health/Dental Health Connection 77

36 Technology and the Active Consumer: Empowerment Through Information 82

37 Developing Direct-to-Consumer Markets 87

38 Using Evidence-Based Dentistry to Improve Plan Management, Clinical Outcomes and Consumer Satisfaction 94

39 The Oral Health-Systemic Health Connection: A Physician’s Perspective 102

40 Dental-Medical Coordination 105

41 Coordinating Dental and Medical Care—Issues and Challenges 110

AHIP’s Courses and Professional Designations 116

AHIP Insurance Education Books 121


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How to Use This Study Manual

This study manual accompanies the textbook Dental Benefits: A Guide to Managed Plans (Third Edition) by Cathye L. Smithwick. Previously authored by Donald S. Mayes, the text is published by the International Foundation of Employee Benefit Plans, Inc. It is intended to be used by those taking the course Dental Benefits, Part B (A Closer Look at Plan Types and Management), offered by the Center for Insurance Education and Professional Development of America’s Health Insurance Plans (AHIP). There is also a study manual for the course Dental Benefits, Part A (Dental Benefits: An Overview of Dental Benefits and Dental Plans), which is based on other chapters of the same textbook.

This manual is designed to help the student learn the material in the textbook more easily and to review and prepare for the course examination. It covers 17 chapters drawn from six sections of the textbook that make up Part B of the course (chapters 14, 17-18, 19-21, 24-25, 30 and 34-41). Each review lesson contains:

learning objectives,

a summary of the textbook chapter,

review questions,

answers to review questions, and

practice exam questions (multiple-choice questions in the format of the exam, with answers).

We recommend that the student take the following approach in studying each chapter:

First, read the learning objectives to find out the main points you should focus on in your reading and study.

Next, read the chapter summary for a preview of the most important concepts and information.

Read the chapter in the textbook. After you have finished, reread the chapter summary to reinforce the main points covered.

Answer the review questions and check your answers. If you do not understand an answer, reread the corresponding paragraph of the text. If you miss a lot of questions in a particular section, reread that section.

To gain familiarity with the format of the exam, answer the practice exam questions at the end of the chapter.

Before you take the exam, thoroughly review all questions to make sure you can answer them correctly.


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Frequently Asked Questions About the AHIP Examination

What is covered in the examination for the AHIP course Dental Benefits, Part B?

Chapters 14, 17-18, 19-21, 24-25, 30 and 34-41 of the textbook Dental Benefits: A Guide to Managed Plans (Third Edition) by Cathye L. Smithwick. (The remaining chapters are covered in the course Dental Benefits, Part A.)

What is the format of the exam questions?

All questions are four-part multiple choice. For examples, see the practice exam questions at the end of each chapter of this study manual.

Some questions may be multiple-option multiple choice.

EXAMPLE

Types of managed dental plans include

I. Dental HMOs.

II. Dental PPOs.

III. Health savings accounts.

a. I and II only.

b. I and III only.

c. II and III only.

d. I, II, and III.

(The correct answer is A.)

A few questions are application questions. These require you to determine which of the facts given in the question are relevant and then apply your knowledge to reach a conclusion.

EXAMPLE

James has a dental insurance policy with an annual deductible of $500. He incurs an expense of $1,100 which is covered by the policy at a 50 percent rate. This is his first covered expense of the plan year. How much will his insurance company reimburse him?

a. $200

b. $300

c. $400

d. $600

(The correct answer is B.)


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You should be able to answer the question by applying your knowledge of how a deductible works.

Are there any questions on the statistics and numbers in the textbook?

Yes, there are a few. For a few simple and important numbers, the exact figure must be known. For example, under dental managed care products, major services are generally covered at 50 percent, and the student would be expected to know this number. Usually, however, an approximate idea of a number is sufficient. For instance, students should know that under dental PPOs purchasers can usually obtain services at discounts of around 15 to 25 percent.

Is information from figures and tables covered in the exam?

Yes, the figures and tables found in the chapters of the book are covered, but exam questions focus on the main points, not details.

Is information from the appendices covered in the exam?

No. The appendices are provided as a resource for the student. Any information that appears only in the appendices (and not in the chapters of the text as well) is not tested.


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America’s Health Insurance Plans (AHIP)

America’s Health Insurance Plans (AHIP) is the national association representing nearly 1,300 member companies providing health insurance coverage to more than 200 million Americans. Our member companies offer medical expense insurance, long-term care insurance, disability income insurance, dental insurance, supplemental insurance, stop-loss insurance, and reinsurance to consumers, employers, and public purchasers.

Our goal is to provide a unified voice for the health care financing industry; to expand access to high-quality, cost-effective health care to all Americans; and to ensure Americans’ financial security through robust insurance markets, product flexibility, innovation, and an abundance of consumer choice.

The Center for Insurance Education and Professional Development of AHIP aims to be the leader in providing the highest-quality educational materials and services to the health insurance industry and related health care fields. To accomplish this mission, the program seeks to fulfill the following goals:

provide tools for member company personnel to use in enhancing the quality and efficiency of services to the public;

provide a career development vehicle for employees and other health care industry professionals; and

promote general understanding of the role and contribution of the health insurance industry in the financing, administration, and delivery of health care services.

The Center provides the following services:

a comprehensive course of study in health insurance fundamentals, medical expense insurance, supplemental health insurance, health care management, long-term care insurance, disability income insurance, employee health care benefits, health care fraud, and customer service in the health care environment;

certification of educational achievement by examination for all courses;

programs to recognize accomplishment in the industry and academic communities through course evaluation and certification, which enable participants to obtain academic or continuing education credits; and

development of educational, instructional, training, and informational materials related to the health insurance and health care industries.

America's Health Insurance Plans (AHIP) Center for Insurance Education and Professional Development 601 Pennsylvania Avenue, NW

South Building, Suite 500 Washington, DC 20004

800-509-4422 www.ahip.org/courses

Email:[email protected]


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14 Understanding PPO Fee Schedules and Discounts

Objectives

After reading this chapter in the textbook and completing the review lesson, the student will be able to:

Understand the basics of discount calculations for PPO plans and identify types of discounts;

Recognize the impact of plan design and incentives, such as passive versus active PPOs and maximum allowable charge plans;

Describe common ways to measure dentists’ charges and explain cost control methods; and

Discuss industry trends and regulatory activities regarding network discounts, contracting, and fee structures.

Chapter Summary

The primary topic under scrutiny here is the network discount, one of the most important and difficult components of a dental PPO plan to evaluate. While purchasers consider size and quality in their selection of managed dental care products, ultimately it is the potential for cost savings due to discounted fees negotiated with network dentists that seals the deal. A lot of energy goes into comparison shopping fee schedules, the list of procedure codes and associated fees paid for each service covered by the plan. Students will soon learn, however, that these schedules do not tell the whole savings story.

This chapter discusses the nuances of evaluating network discounts. It covers a variety of methods and terminologies used to help purchasers be more precise in determining the best analytics for comparing networks and cost savings across carriers. It also looks at various other factors that can influence network savings, as well as trends in contracting and regulations that have affected the industry over time.

It is important for students to understand the various ways of calculating discounts. Let’s review some basic terms. Discounts generally refer to the percentage difference between the fee actually allowed for a claim or claims, based on a mutually agreed-upon contract between network dentists and carriers, and some measure of the expected, non-discounted cost for those claims. The author defines two types:

The most commonly used measure is the average discount which is a weighted average discount for claims paid to network dentists. However, since a majority of dental PPO claims are still from non-participating dentists, the in-network discount is not the only metric insurers watch.

Even more revealing is the effective discount, or total percentage savings on claims from all dentists. It includes a factor to account for the level of network penetration and also reflects how company policies differ concerning fee limits to non-contracted


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dentists. This number is the best indication of how often the in-network discounts are being used and what overall savings the network provides.1

Network structure as it pertains to plan design can also have a significant impact on effective PPO discounts. The most common design used is the passive PPO. Under this plan, the member coinsurance, deductibles, and other cost-sharing elements are the same whether members use an in- or out-of-network dentist. On the other hand, active PPOs (also referred to as incentive PPOs) provide a much stronger incentive for members to choose a contracted dentist. One final type—maximum allowable charge (MAC) plans—pays non-contracted dentists only up to the network fee schedule.

In measuring dentists’ fees for calculating discounts, companies often compare discounted fees to the original charges. Keep in mind the importance of using “allowed charges” instead of “dollars paid” which vary widely across each plan, product, and individual member. One approach to adjusting for misleading comparisons between plans is to use average charges, defined as the average fee submitted across all claims for a given procedure.

Another common term that describes fee schedules or fee limits is usual and customary (U&C), also known as usual, customary and reasonable (UCR). Used interchangeably, they simply mean that the fees represent an attempt to determine charges typical for dentists in a given area. U&C is based on a statistically valid approach that uses market prices charged by dentists in a given region to make fee determinations. By far the most common method is to use a specified percentile of dentists’ charges. For example, to find the 90th percentile for an adult cleaning, all claims for this procedure would be collected from lowest to highest. The bottom 90 percent of those charges would be identified; the highest of those would be the 90th percentile. The 90th percentile charge is only exceeded by the top 10 percent in which the fees exceed the targeted 90th percentile. In other words, nine out of ten dentists charge at or below the 90th percentile.

Industry trends reflect overall annual increases in the fees allowed for network dentists. For most of the past decade, dentist fees increased about 3.5 percent to 4 percent each year, and carriers increased fees by about 2 percent. More recently, the 2007-2010 recession put downward pressure on prices making dentists and carriers more cautious about increasing fees.

Trends in contracting have also changed over the years. Originally, one fee schedule was used to pay all network dentists within a geographic area. Carriers moved away from the one-schedule-per-area model when it became too costly to add new dentists to the network without increasing the fees paid to existing dentists. Today, carriers focus more on effective discounts to track their progress, rather than measuring network size and average discounts.

Review Questions

Overview (pages 199-200)

1. What one topic affects all aspects of a carrier’s business?

2. From a recruiting perspective, there is an inverse relationship between the level of fees paid to dentists and the (size / quality) of the network.

1 Appendix F / Dental PPO Network Study 2009 Edition, p. 545.


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3. What tradeoff should purchasers, consultants, and dentists consider when network access is of the utmost importance?

4. When is it prudent to consider a smaller, deeper discounted network?

5. A larger network with smaller discount may result in greater cost savings overall when you account for the impact of __________.

6. True or False: Having a deeply discounted fee schedule is not a guarantee of network-based cost savings.

7. In selecting a PPO plan, what else does a purchaser need to consider besides the fee schedule?

Basic Discount Calculations (pages 200-202)

8. __________ refers to the percentage difference between the fee actually allowed for a claim, based on a mutually agreed-upon contract between network dentists and carriers.

9. If a fee of $80 is allowed for a service that generally costs $100, the discount is (10 percent / 20 percent).

Discount Types (pages 201-202)

10. A weighted average discount used for claims paid to network dentists is called __________.

11. Which type of discount includes a factor to account for the level of network penetration?

12. (Average discount / Effective discount) provides the best way to compare total savings potential across various dental plans.

13. True or False: Having higher network discounts but lower effective discounts would apply to where dentists are relative to plan members, especially how many network dentists are being accessed by employees.

14. According to the author’s experience, what is the correlation between type of network discount and network savings?

Impact of Plan Design and Incentives (pages 202-205)

Passive Versus Active PPOs (pages 202-203)

15. (Passive / Active) PPOs are the most commonly used network design structure.

16. Under passive PPOs, what is a good rule of thumb when estimating the possible level of in-network utilization?

17. What does an active PPO provide members that may make them more appealing during economic downturns?


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18. An active plan design with (more / less) prominent benefit differentials can be an effective way to encourage the use of network dentists.

Maximum Allowable Charge Plans (pages 204-205)

19. Which type of plan pays up to the network schedule regardless if the dentist is contracted or not?

20. Why do MAC plans appear to have the same plan design as a passive PPO?

21. The difference between MAC plans and passive PPOs is that (MAC / PPO) plans create significantly greater out-of-pocket cost for patients who go out of network.

22. MAC plans typically result in (more / less) claim dollars being paid at the discounted, network level than passive plans.

23. When comparing discounts across multiple dental plans, what is it important to ask?

Average Charge (page 206)

24. What are average charges?

25. Why use industry data that show average charges by region?

Usual and Customary (page 206-207)

26. What do the terms usual and customary (U&C), reasonable and customary (R&C), or usual, customary and reasonable (UCR) mean?

27. Most often, usual and customary fees are used (as a basis for discount calculations / to set limits on what a plan will pay for claims to noncontracted dentists).

Percentiles (pages 207-208)

28. On what basis is a fee determined to be usual and customary?

29. What is the most common method to make fee determinations?

30. What does the nth percentile of dentist fees mean?

Industry Trends Regarding Network Discounts (pages 208-209)

31. Similar to prices for all goods and services, fees allowed for network dentists have increased (one or two / three or four) percent annually.

32. For most of the past decade, dentists’ fees increased about __________ percent each year.

33. What effect did the 2007-2010 recession have on the dental market?

Contracting Philosophies (page 210)


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34. What was the original approach carriers developed to contract with dentists?

35. Why did carriers move away from the one-schedule-per-area model?

36. Today carriers focus more on __________ to track their progress, rather than measuring network size and average discounts.

37. Why is it prudent to add a dentist to the network at a smaller discount than fees used in the area?

Contracting With Specialists (pages 210-211)

38. Claims by specialists generally make up _____ percent of network charges.

39. What approach did some carriers take to address the issue of specialists charging higher fees than general dentists for the same procedures?

40. Why would a network with few or no contracted specialists have lower discounts than one with an extensive specialty panel?

Impact of Changes to Contracting Approaches (pages 211-212)

41. How can the problem of administrative complexity related to the maintenance of thousands of fee schedules be overcome?

42. What must be in place to avoid increasing fees too quickly and eroding discounts?

43. How do multiple schedules make it harder to calculate discounts and demonstrate their impact of costs savings to customers?

44. What is an advantage of contracting with some dentists at higher fees than others, particularly with active PPO and MAC plans?

45. Given the same scenario, what is the disadvantage for an active PPO when a dentist joins a network with higher than standard network fees?

46. True or False: Under a MAC plan, contracting with any dentist at fees higher than the standard automatically brings them into the network at a higher cost than that of an out-of-network dentist.

47. While contractual changes in a MAC plan involving higher fees can erode the cost advantage to plan sponsors, how will members benefit?

Evaluating Network Discounts for Benefit Managers, Brokers and Consultants (pages 213-214)

48. According to the text, what is the most important consideration for choosing a dental plan, especially when the plan is self-insured?

49. What is the metric that gives the best comparison of overall savings from the network, leading to a comparison of overall costs?


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Out-of-Network Cost (pages 214-215)

50. What is the most common approach plans can use to control out-of-network cost?

51. What is the most rigorous way to control out-of-network cost?

Other Cost-Control Methods (page 215)

52. How does subcontracting with another network, such as a PPO with similar discounts, improve network performance?

53. How can a carrier create a “safety net” that limits out-of-network cost on all claims that go to these dentists?

54. The type of network large enough that only a small percentage of claims remain from dentists where there is no contract is known as __________.

55. True or False: For administrative services only (ASO) plans, carriers usually allow the plan sponsor to choose how out-of-network claims will be paid.

Regulatory Activities (pages 216-217)

56. What is FAIR Health, Inc., tasked with?

57. How does the FAIR Health website help consumers?

58. True or False: Some industry professionals have expressed concern that too much information via the FAIR health website may lead to an overall increase in dentist charges.

Answers to Review Questions

1. Network discounts and the resulting cost savings. 2. Size. 3. Consider a larger network with smaller discounts. 4. If cost savings is the most important goal. 5. The effective discount. 6. True 7. The number and percent of claim dollars flowing to network dentists; the type and mix of

services they provide. 8. Discounts. 9. 20 percent. 10. Average network discount. 11. Effective discount. 12. Effective discount. 13. True 14. Networks with the highest effective discount in an area—and therefore the greatest

network savings—are usually the largest of the networks in that area. 15. Passive PPO. 16. Assume that the percent of members using network dentists will mirror, on average, the

degree of network penetration.


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17. Financial incentives to use network providers and greater cost-control features. 18. The More prominent benefit differentials. 19. Maximum allowable charge (MAC) plan. 20. The patient pays their coinsuance percentage of the network fee, plus the entire

difference between that fee and the amount actually billed by the dentist. 21. MAC plans. 22. More. 23. “Discount from what?” 24. The average fee submitted across all claims for a given procedure. 25. Industry data help ensure all discounts are calculated on the same basis. 26. Used interchangeably, these terms mean that the fees represent charges typical for

dentists in a given area. 27. To set limits on what a plan will pay for claims to noncontracted dentists. 28. On a statistically valid approach that uses market prices charged by dentists in a given

region to make fee determinations. 29. A specified percentile of dentists’ charges (e.g., the 80th or 90th percentile). 30. The nth percentile means that n percent of dentists charge a fee less than or equal to

that amount. 31. One or two percent. 32. 3.5 percent to 4 percent each year. 33. Put downward pressure on prices and made providers and carriers more cautious about

increasing fees. 34. One fee schedule was used to pay all network dentists within a geographic area. 35. It became too costly to add new dentists to the network without increasing the fees paid

to existing dentists. 36. Effective discounts. 37. If fees are lower than that dentist’s full retail fees, they still create savings for the plan

and customers. 38. 10 to 20 percent. 39. Some carriers used a separate standard fee schedule for each specialty., others

negotiated individual fees. 40. The latter network’s specialists receive higher fees. 41. Through the creation of flexible claim systems and the savvy use of technology. 42. Careful controls and well-trained staff must be in place—actuarial, network development,

and dentist consultants. 43. The management of multiple schedules requires looking at all claims to study how many

are based on each set of fees, and weighting each fee set to determine the overall discount.

44. Generally any discount saves money compared to no discount. 45. The plan now has an increase in costs not fully offset by higher benefits to that dentist’s

patients. 46. True 47. The savings to members are significant because they would have been responsible for

the full difference between the low MAC fees paid and the provider’s full fee were the dentist outside the network.

48. Minimizing overall claim cost. 49. Effective discounts. 50. Use some sort of usual and customary fees to limit plan reimbursement for out-of-

network claims with the patient responsible for any amount billed above this limit (called balance billing).

51. Use a MAC plan or very low usual and customary fees.


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52. It creates a larger network at a lower cost. 53. The carrier’s in-house PPO may be supplemented by another, larger network but at a

much smaller discount. 54. Managed indemnity. 55. True 56. Developing a new database of doctor and dentist fee percentiles. 57. Helps consumers understand what charges they might expect. 58. True

Practice Exam Questions

1. In evaluating network discounts, failure to understand nuances can result in: a. Erroneous assumptions. b. Flawed analysis. c. Error-ridden purchasing decisions. d. All of the above are correct.

2. What is the most commonly discussed and used measure for claims paid to network dentists?

a. Average network discount. b. Effective discount. c. Usual and customary. d. Specific percentile.

3. This discount includes a factor to account for the level of network penetration. a. Average discount. b. Effective discount. c. Percentage discount. d. Weighted discount.

4. Under a passive PPO plan, which of the following variables change if a member uses an out-of-network dentist?

a. Coinsurance. b. Deductibles. c. Dentist charges. d. None of the above.

5. What do active PPO plans include to push members toward in-network providers? a. Richer benefits. b. Financial incentives. c. Lower contracted fees. d. All of the above.

6. Jessie and Patricia are members of a passive PPO plan. Jessie sees an in-network dentist while Patricia continues to see a dentist outside the network. Both pay 20 percent of allowable charges. Which of the following accounts for Jessie paying less out of pocket than Patricia?

a. Jessie pays 20 percent of a lower contracted fee. b. Patricia pays 20 percent of the full charge for services. c. Patricia violates the rules of the dental benefits plan. d. Both “a” and “b” are correct.


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7. In this type of plan, the portion of an out-of-network claim reimbursed by the plan is

calculated as the coinsurance multiplied by the network fee only. a. Active PPO. b. Passive PPO. c. Maximum allowable charge. d. Managed indemnity.

8. What is a common term used to describe fee schedules or fee limits? a. Usual and customary. b. Average charges. c. Specified percentile. d. Effective discount.

9. Decreasing fees carriers pay to dentists may be one way to lower claims cost, but why would this action be imprudent?

a. Creates a threat to network stability. b. Makes dentists unhappy. c. Causes a decline in customer satisfaction. d. All of the above are correct.

10. For this type of plan, carriers usually allow the plan sponsor to choose how out-of-network claims will be paid.

a. Passive preferred provider organizations. b. Administrative services only (ASO) plans. c. Dental health maintenance organizations. d. Active preferred provider organizations.

Answers

1. d 2. a 3. b 4. d 5. d

6. d 7. c 8. a 9. d 10. b


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17 Dental PPOs: An Overview

Objectives


Understand the scope and basic contract conditions of dental preferred provider organizations (PPOs);

Discuss PPO enrollment growth and cite factors influencing dentist participation trends;

Explain the methodology used to develop PPO fee schedules; and

Recognize the types, changes, and characteristics of dental PPOs.

Chapter Summary

A preferred provider organization (PPO) is a network of dentists created through a contractual agreement between providers and a plan administrator. Dental PPOs have been in existence since the early 1960s. Today, with an enrollment share of 74 percent, this type plan and its hybrid products dominate the dental delivery system. Estimates of dentist participation rates vary widely by state and region—from a high of 100 percent in Arizona, Nevada, New Mexico, and Utah to a low of 22 percent in Wyoming.

In a dental PPO, the contracted dentist agrees to provide treatment to an enrolled population on a discounted fee-for-service basis. Dentists that choose to participate may be influenced by a number of factors, including:

Reimbursement level

Practice characteristics

Degree of market power

Steady cash flow

Increased visibility

Patient volume

New patient referrals

Dental needs of new patients

Additional revenue from elective services

Potential loss of patients to other dentists. This chapter2 provides students with a general overview of PPO reimbursement. To recap briefly, PPO schedules can be based on:

A discount off the community average (or the 50th percentile);

A discount off the average submitted fees, drawn from the claims database; and

A targeted percentile, such as the 50th, 60th or greater.

2 Chapter 14 provides an in-depth look at the various methods used in determining network discounts and

developing provider fee schedules.


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When developing fee schedules, it is important to determine the appropriate geographic zones (or communities) to use. In recruiting dentists for large, national networks, it may be better financially and otherwise to have more, rather than fewer fee schedule zones. Yet, in the current recruiting environment, it is not unusual for carriers to negotiate unique fee schedules with individual providers, resulting in thousands of schedules across the country. Types of PPO plans have morphed into an assortment of hybrid varieties that can be classified by distinguishing characteristics in the way they affect both access and cost. The chapter describes the two primary types—active and passive PPOs—that dominate the market today and other variations, including the exclusive provider organization (EPO) and the point-of-service (POS) plan.

Review Questions

Introduction (pages 231-232)

1. What is the definition of a dental preferred provider organization (PPO)?

2. Dental PPOs are now the dominant dental delivery system with a market share of (74 / 94) percent by enrollment.

3. True or False: A condition that contracted PPO dentists do not have to abide by is peer review and oversight processes established by the administrator.

4. True or False: Contracted PPO dentists must agree to maintain certain standards of practice and levels of malpractice insurance.

PPO Enrollment Growth (page 232)

5. Dental PPOs far exceed enrollment in (indemnity / discount / DHMO / all three) type plans.

6. What factors fueled PPO growth?

Dentist Participation Trends (pages 232-234)

7. In 2010, about _____ percent of actively practicing dentists in the U.S. participated in at least one PPO.

8. In 2011, PPO providers participated in an average of 8.8 networks, an increase of _____ percent from the 2008 average of 5.9 percent.

9. What are two notable trends initiated by administrators?

10. True or False: The higher the fee schedule, the more dentists will be willing to participate and the greater the size of the network.

11. In reviewing the section on PPO participation trends, several points relate to patient volume. Identify those factors most likely to improve cash flow for PPO providers.


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PPO Reimbursement (pages 234 and 235)

12. Client base, geographic location of providers and customers, degree of market power possessed by the providers and the administrator are all factors that need to be considered in developing __________.

13. What are PPO schedules based on?

14. For large, national networks, a strategy considered financially sound, and often better for recruiting efforts, is to have (more / less) fee schedule zones.

15. True or False: Due to today’s economic uncertainty, it has become quite uncommon for carriers to negotiate unique fee schedules with individual providers.

Types of Dental PPOs (pages 235-237)

16. Basic dental PPO plans have propagated a profusion of hybrid varieties, distinguished by the way they affect __________.

17. What are the two primary types of PPOs that dominate the market today?

Passive PPOs (pages 235-236)

18. What is the key characteristic of a passive PPO?

19. True or False: Under a passive PPO agreement, participating dentists are not allowed to “balance bill” any amount over and above the fee schedule for covered services.

20. Why were passive PPOs considered a transitional product in the dental market?

21. What plan feature makes the passive PPO model popular and well received by participants and purchasers?

22. Why were purchasers incentivized to migrate to active PPO plans?

Active PPOs (pages 236-237)

23. What is the key characteristic of an active PPO plan?

24. What financial incentives help to steer participants to network dentists?

25. Why do many plan sponsors, dentists, and patients view the active PPO as a win-win scenario?

26. What pushes patients away from seeking treatment from out-of-network dentists?

Exclusive Provider Organization (EPO) (page 237)

27. True or False: In an exclusive provider organization (EPO) plan patients have access to benefits when they seek care from a dentist not in the network.

28. EPOs are created for which segment of the dental market?


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Point-of-Service (POS) Plan (page 237)

29. What is the most distinguishing feature of a POS plan?

30. The most common POS dental benefits program combines design features of __________ and __________.


1. A network of dentists created through a contractual agreement between a dental program administrator and providers, for the delivery of services to defined patient populations, where reimbursement is based on predetermined, discounted fees.

2. 74 percent of market share by enrollment. 3. False 4. True 5. All three plans. 6. Increased demand from purchasers; increased dedication of carrier recruiting efforts;

greater acceptance of PPOs among the dental community. 7. 64 percent. 8. 49 percent. 9. Administrators have (1) become more flexible in negotiating with providers and (2)

increased the use of tiered networks. 10. True 11. Steady cash flow; increased visibility; maintaining patient volume; new patient referrals;

greater needs of new patients; elective services. 12. PPO fee schedules and the level of network discounts. 13. Discounts off the community average and the average of submitted fees based on

claims; a targeted percentile. 14. More. 15. False 16. Access and cost. 17. Active and passive PPOs. 18. The benefit design is the same irrespective of whether or not the patient goes to a

participating dentist. 19. True 20. Passive PPOs were attractive to groups looking for a “gentle managed care step” in their

dental program. 21. Participants can go to any dentist they choose with no reduction in benefit design. 22. The desire to contain costs motivated purchasers to steer patients to network dentists. 23. The benefit differential between in- and out-of-network care. 24. Lower participant coinsurance and deductibles and/or higher annual and lifetime

maximums. 25. Sponsors can offer richer benefits at an affordable price; network dentists increase traffic

and patient loyalty; patients get more for their benefit dollar. 26. Reduced benefits and (possibly) higher fees. 27. False 28. A particular employer with a large or highly concentrated employee population. 29. Members do not have to choose any particular dentist or network during annual open

enrollment. They are free to switch at will with benefits available at point of service. 30. PPOs and DHMOs.


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1. What do dentists agree to accept under the terms of a PPO contract? a. A specified fee schedule as payment for covered services. b. A specific percentage discount off their usual charges. c. The administrator’s determination of covered services. d. All of the above are correct.

2. All of the following are credited with promoting PPO growth EXCEPT: a. Preferred per capita payment system. b. Increased demand from purchasers c. Expanded recruitment efforts. d. Widespread acceptance of providers.

3. The methodology used to develop PPO fee schedules is dependent on which of the following?

a. The education level and credentials of the provider network. b. The administrator’s corporate strategy and goals for its PPO product. c. Past trends that create the basis for current economic models. d. The influence of the American Dental Association’s CDT codes.

4. What problem may a dentist encounter when administrators do not permit patients to assign payment (known as assignment of benefits) to an out-of-network dentist?

a. Dentists have difficulty collecting from some patients. b. The patient may receive the check and find other uses for the money. c. Cheating dentists are commonplace in the PPO market. d. Both “a” and “b” are correct answers.

5. How did passive PPOs offer the best of both worlds in managed dental care? a. Offered a benefit differential between in- and out-of-network care. b. Prohibited balance billing for use of out-of-network dentists. c. Provided cost savings without the plan design differential. d. All of the above are correct.

6. In active PPOs, which of the following helps steer participants to network dentists? a. Lower participant coinsurance and deductibles. b. Higher annual and lifetime maximums. c. Benefit differential between in- and out-of-network care. d. All of the above are correct.

7. Besides the advantages of richer benefits for in-network care, patients also benefit from the __________ protection that active PPOs provide.

a. no balance billing b. anti-fraud c. over payment d. check overdraft

8. The combination of reduced benefits and higher fees are powerful disincentives for patients to seek treatment from __________.

a. in-network providers b. out-of-network providers


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c. point-of-service plans d. exclusive provider organizations

9. Exclusive provider organizations are much more common in __________. a. medical services b. cosmetic services c. dental benefits d. All of the above.

10. These features would identify a point-of-service (POS) plan. a. Combination of networks. b. Members can choose any dentist. c. Benefit level and provider reimbursement vary. d. All of the above are correct.

Answers

1. d 2. a 3. b 4. d 5. c

6. d 7. a 8. a 9. a 10. d


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18 Dental PPOs: Plan Design

Objectives


Understand the basic principles and applications of dental PPO plan design;

Distinguish the differences between passive and active PPOs regarding costs, benefit value, and network access;

Identify strategies, group characteristics, and trade-offs when adding benefits or changing from passive to active PPO plans; and

Recognize which approaches may work best in certain scenarios.

Chapter Summary

Plan design is the most critical element of a cost-effective and relatively problem-free dental program. Think of it as a basic blueprint for building a successful PPO plan, one that will ensure member satisfaction, network stability, and long-term financial success for the group and its sponsor. This chapter outlines the principles and applications of plan design under a third-party payer system. It serves as a practical guide to decision-making in determining the best approach for a particular group.

By now, you have become familiar with many of the core design elements of dental plans. The author suggests one way to organize various design options under similar delivery systems is to categorize the benefits as “low, medium or high” from the member perspective. For example, low benefit levels also mean low premiums, but higher out-of-pocket cost. This trade-off is preferred by some, while others prefer the opposite. This chapter helps you hone in on some of the finer details marking the difference between passive and active PPO plans. Let’s begin with brief descriptions:

Passive PPOs provide the same benefit for both in-network and out-of-network care.

Active PPOs have richer benefits for in-network services to steer members to contracted dentists.

Market trends and group characteristics are other factors that come into play when choosing PPO plans. You know from previous chapters that the PPO segment is growing rapidly. In addition, many purchasers are switching from passive to active PPOs because the latter offers more options for controlling cost and benefit design, including greater steerage to lower-cost network dentists, as mentioned above.

Keep in mind there is no one-size-fits-all dental plan that will work for every group. For example, when anticipating a change from a passive to an active PPO, a paternalistic plan sponsor may have concerns about how disruptive a change may be for users. In this case, a passive PPO or active PPO with nominal steerage may be the best options. Often the choice depends on the


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plan sponsor’s objectives. For obvious reasons, it is important to consider the unique characteristics of the purchaser and group, including:

Geographic location and group size. Is the group small and locally situated, or large and widely dispersed?

Familiarity with managed plans. What is the group’s prior experience with managed plans—either medical or dental?

Demographics. What is the demographic profile of the groups (e.g., age, family size, gender, education, etc.)

Cost-sharing structure. Who pays the majority of the premium—the sponsor or the members?

Group stability. Is the group stable (e.g., teachers or workers in collectively bargained groups) or does it have high employee turnover rates (e.g., fast-food workers)?

Budget constraints. What are the budget constraints and price sensitivity of both the sponsor and the members?

Benefits philosophy. What is the benefits philosophy of the plan sponsor? This issue is especially applicable for employer-sponsored plans.

Illustrations throughout the chapter enable students to compare various strategies, such as class shifting for passive PPOs, and advantages and disadvantages of different reimbursement methods for non-network providers. Also included are samples of plan designs for active PPOs along with scenarios that define assumptions and outcomes for groups that are adding PPO benefits for the first time or changing from passive to active PPOs.

Review Questions Introduction (page 239)

1. What is the most important element for creating a cost-effective and relatively problem-free dental plan?

2. What are well-designed dental plans configured to do?

PPO Plan Design: Common Approaches (pages 239-246)

Passive PPO Plan Design (page 240)

3. What are members free to do in passive PPOs?

4. Cost, utilization, and satisfaction among members and providers are greatly affected by how services are (evaluated and rated / classified and paid).

5. Moving procedures between classes is known as __________.


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6. Class shifting for diagnostic and preventive services is (less / more) common than other forms of class shifting.

7. Why is class shifting most widespread for basic restorative services?

Provider Reimbursement for Non-Network Care (pages 246-251)

8. Why is it especially important to know how non-network providers will be reimbursed under a passive PPO plan?

9. From the plan perspective, what is the impact of non-network reimbursement approaches?

10. What is the impact of non-network reimbursement on purchasers?

Reimbursement Methods for Non-Network Providers (page 247)

11. Payments to non-network dentists are based on the lesser of the_________ or the __________.

12. To collect the difference in their fee and what the plan pays, in most cases dentists are allowed to __________.

13. What metric is a usual, customary and reasonable (UCR) fee based on?

14. A separate fee schedule used for reimbursement to non-network dentists is called __________.

Choosing an Appropriate Active PPO Design (pages 252-254)

15. Along with the rapid growth in the number of enrollees and percent of market share, how else are PPOs changing today?

16. Active PPOs provide (greater / lesser) options for controlling cost and benefit design.

17. Which feature of active PPOs provides greater steerage to lower cost network dentists?

18. When designing or recommending a particular plan design and network, what is it important to consider?

19. Changing from a passive PPO to an active PPO can cause (disruption / interruption) for users of the current plan.

20. What trade-offs will sponsors and members face in the switch to an active PPO?

21. What does the text suggest very cost-sensitive groups would be willing to accept as a trade-off for a more limited choice of dentists?

22. When changing from a passive PPO to an active PPO, (small, locally clustered groups / large, widely dispersed groups) should have little problem with access issues.

23. Actuarial estimates of utilization and cost are highly dependent on __________.


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24. When budget constraints and price sensitivity are concerns for the sponsor and members, (passive PPOs / active PPOs) are especially effective for controlling cost.

25. (Teachers / Fast-food workers) may be more likely to choose a network provider.

26. In considering the benefits philosophy of a plan sponsor, paternalistic sponsors who are concerned about disrupting employees may prefer which type of plan?

27. What is a risk that occurs when members pay the majority of the premium cost?

Strategies for Adopting an Active PPO (pages 254-255)

28. What “incentive” would a plan sponsor use to achieve greater cost savings while keeping the current plan design in place?

29. What is the objective of the “disincentive” approach?

Steerage Elements (page 255)

30. What are the most effective plan design elements for incentivizing participants to see network dentists?

31. How is the term illusory benefits defined?

Considerations: What Is the Best Approach for Your Group? (pages 258-259)

32. Why would the incentive approach using the current benefit design for the out-of-network benefit and enhancing the design for in-network care be viewed as a benefit enhancement for members?

33. How would some members view the disincentive approach that keeps the current benefit design for the in-network benefit and reduces benefits for non-network care?

34. What are three plan considerations for adding PPO benefits for a group with no prior coverage?

Other Plan Design Elements (pages 259-260)

35. What does a maximum rollover allow enrollees to do?

36. __________ is a popular new design feature that exempts diagnostic and preventive services from counting against the annual maximum, freeing up dollars to be used elsewhere.

Riders (page 259)

37. True or False: A dental accident rider may cover certain necessary procedures at or near 100 percent, but the benefit usually includes a lifetime maximum.

38. True or False: Unlike medical services, cosmetic services will be subject to tax and thus are not typically covered under a rider.


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Evidence-Based Plans (page 259-260)

39. What is the targeted patient population for evidence-based plans?

40. Evidence-based plans often waive (cost sharing / frequency limits / both) for extra cleaning and/or periodontal treatments for pregnant women, those with Type II diabetes, history of cardio-vascular disease, stroke, and other conditions linked to oral health.


1. Plan design. 2. Ensure the efficient allocation of benefit dollars by creating incentives for patients and

providers to maintain oral health and treat dental disease. 3. Members are free to see any dentist they wish. 4. Classified and paid. 5. Class shifting. 6. Less common. 7. The restorative services category is more complex and useful in terms of class-shifting

opportunities, plus the potential for cost savings is greater. 8. Non-network reimbursement is a primary tool for encouraging greater use of network

dentists and holding beneficiaries financially accountable for going out of network. 9. Can affect cost, the plan’s reputation with providers, and network stability. 10. Affects cost and member satisfaction. 11. Dentist’s charge / PPO fee schedule. 12. Balance bill. 13. A specific percentile level determined by the administrator. 14. Maximum allowable charge or MAC schedule. 15. Many purchasers are switching from passive to active PPOs. 16. Greater options. 17. Benefit differentials between in- and out-of-network care. 18. The unique characteristics of the purchaser and group. 19. Disruption. 20. Active PPOs involve trade-offs among cost, benefit value, and access to network

dentists. 21. Better benefits at a lower price. 22. Small, locally clustered groups. 23. Demographics. 24. Active PPOs. 25. Fast-food workers. 26. A passive PPO or an active PPO with nominal steerage. 27. Adverse selection. 28. The “incentive” approach uses the current plan design as the out-of-network benefit and

enhances the in-network benefit. 29. The “disincentive” approach uses current plan design as the in-network benefit and

reduces benefits for out-of-network care. 30. Deductibles, annual and lifetime maximums and coinsurance. 31. Benefits that may look reasonable on paper but in practice are not available to some

beneficiaries. 32. No one would be worse off and all would have the option of obtaining better benefits by

seeing a network dentist.


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33. Some members would view this approach as a benefit takeaway, but it may be a necessary strategy to reduce costs.

34. Consider a plan that (1) has a low or medium benefit level; (2) includes waiting periods; and (3) does not include coverage for orthodontics.

35. Roll over a portion of their unused annual maximum benefit, up to a limit. 36. Diagnostic and preventive maximum waiver. 37. True 38. True 39. Patients with conditions that place them at greater risk for dental disease and/or

increased severity of existing medical conditions (due to untreated dental conditions). 40. Both cost sharing and frequency limits.


1. Configured to ensure the efficient allocation of benefit dollars, well-designed dental plans create incentives for patients to do all of the following EXCEPT:

a. Maintain oral health by receiving regular dental care. b. Treat disease at the earliest possible time. c. Hold dentists accountable for patient neglect. d. Be vigilant in daily oral health regimens.

2. Which of the following is an option passive PPO plan members have? a. Freedom to see any dentist they wish. b. Freedom to go to in- and out-of-network without incurring extra costs. c. Freedom from balance-billing for out-of-network care. d. All of the above are correct.

3. One of the most common cost-control methods used today involves moving procedures between classes. What is this practice called?

a. Benefit shuffling. b. Cost accounting. c. Class shifting. d. Shifted procedures.

4. What are the most commonly shifted procedures? a. Dental sealants. b. Space maintainers. c. Palliative treatment. d. All of the above.

5. Under a passive PPO plan, reimbursement to non-network dentists is based on __________.

a. An effective discount. b. A separate fee schedule called a MAC. c. A fee schedule similar to an active PPO. d. Whatever amount the provider bills.

6. Active PPOs involve trade-offs for sponsors and members involving __________. a. Cost. b. Benefit value. c. Access to network dentists.


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d. All of the above are correct.

7. Which of the following is one of the most effective design elements for incentivizing participants to see network dentists?

a. Deductibles, annual and lifetime maximums. b. Illusory benefits. c. Low out-of-network rates. d. Scarcity of specialists.

8. Popular with purchasers and beneficiaries alike, a __________ allows low-cost users to access some of their unused funds should the need arise.

a. maximum waiver b. dental plan rider c. maximum rollover d. cost sharing waiver

9. Why are riders sometimes used separate from the core plan design? a. To enrich the plan’s benefits while not adding to premium cost. b. To add features not normally covered under the majority of plans. c. To include popular cosmetic services without adding coinsurance. d. All of the above are correct.

10. Which of the following features and/or services do evidence-based benefit plans often waive?

a. Extra cleanings for pregnant women. b. Cost sharing and/or frequency limits. c. Topical fluoride for senior citizens. d. Out-of-network payment differentials.

Answers

1. c 2. a 3. c 4. d 5. b

6. d 7. a 8. c 9. b 10. b


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19 Dental HMOs: An Overview

Objectives


Describe the evolution of dental HMO plans;

Recognize basic differences between DHMO and PPO models;

Explain the decline in DHMO enrollment and cite reasons why employers shifted to PPOs; and

Grasp the implications of growth—the critical mass of bigger pools of available patients; large, sophisticated administrative structures creating economies of scale.

Chapter Summary

Dental HMOs (DHMOs) are prepaid dental plans where the dentist is paid on a per capita1 basis. Unlike PPOs that reimburse dentists on a fee-for-service schedule and allow members to seek care from in- or out-of-network providers, a DHMO plan pays a fixed monthly amount “per family” or “per person” regardless of the services provided, and enrollees must see a network provider to obtain benefits.

The DHMO model has transitioned over the years, fixed early aberrations such as rationing (delaying appointments, spreading care over several appointments) to manage cost and risk, and made adjustments to accommodate patient and provider needs. For example:

Administrators are now required to monitor utilization and appointment wait times to address the rationing concern;

Plans typically use a combination of monthly capitation payments and patient copayments to pay providers; and

Administrators pay providers a small nominal sum, referred to as an encounter form filing fee, which has improved the collection of utilization data.

In addition, a newer hybrid model, based on a combination of patient copayments and supplements by the administrator, has been designed to cover complex or specialty-type procedures.

At its inception, the DHMO seemed like the ideal plan because it linked the financing and delivery of dental care. Its original focus on preventive services and early treatment actually proved to be highly cost effective. During the early years, DHMOs experienced substantial growth, peaking in 1998 at 19 percent of the membership market. Today, market share has plummeted to 8 percent which begs the question: How could a dental plan with so much promise fall on hard times?

1 [heads] Equal to each individual.


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This chapter discusses the changing nature of DHMOs, pointing out that medical HMOs have charted a similar course. To escape some rather serious problems with HMO plans, many employers shifted to PPOs, seeking an alternative that would offer the best of both worlds—managed care savings and greater access to care. According to the authors, however, the HMO product continues to be a viable option for dental benefits, in spite of the industry’s growing pains. Employee enrollment lends support: When given the choice between a PPO (or indemnity plan) and a DHMO, experience shows that between 15 percent and 25 percent of employees in a large group situation will select the DHMO and be relatively satisfied over the long run. For these employees, the prospect of no deductibles, no annual maximums, lower premiums, zero copayments for exams and cleanings, and small copayments for routine services is just too good to pass up.

The authors conclude that the concept of a health maintenance organization delivery system may be too valid to disappear from the dental landscape. With the right combination of features and risk sharing, a well-designed DHMO has the potential to make everyone a winner—the purchaser, the patient, the dentist, and even the plan administrator.

Review Questions


1. What are three alternative names for dental HMOs?

2. How are dentists paid under DHMOs?

3. How is payment from administrators made for services rendered?

4. In a DHMO, enrollees must see a network provider to obtain benefits. What is this type of arrangement called?

5. What was an unintended consequence of transferring financial risk to providers?

6. How have administrators been required to address the rationing concern?

7. Today, reimbursement to the provider is typically in the form of (monthly capitation payments / patient copayments / a combination of both).

8. True or False: Under DHMO plans, low-cost, high frequency services may be fully capitated with no patient copayment, while higher-cost, lower-frequency services may carry increasingly high copayments.

9. What is the purpose of the encounter form filing fee?

10. How have administrators responded to patients needing extensive dental services that cannot be covered by the small monthly capitation amount?

11. What are the advantages of the hybrid model of reimbursement?

12. How is payment handled under the hybrid arrangement?


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13. The financial mechanism where the administrator pays the difference between a minimum amount and any patient copayment is called __________.

14. With the increasing growth of large group practices, how are referrals handled?

15. True or False: Group practices that refer a certain number of patients to specialists each month are paid a capitated referral fee.

16. True or False: Preventive services and early treatment have proven to be highly cost effective in dentistry.

DHMOs Growth Slows (pages 262-263)

17. What did the author of the first edition of this text, published in 1993, predict about DHMO growth?

18. When and at what percentage of market share did DHMOs peak?

19. By 2010, DHMO market share had fallen to (8 percent / 10 percent) of total dental plan enrollment.

20. Initially, purchasers liked the concept of DHMOs but only focused on __________ and __________.

The Changing Nature of DHMOs (pages 263-264)

21. What did many employers hope to achieve when they shifted their focus to preferred provider organizations (PPOs)?

22. True or False: The growth in medical and dental PPOs was at the expense of traditional fee-for-service/indemnity plans.

23. Why are so many employee/member beneficiaries willing to join PPOs?

24. What unrealistic expectation did purchasers have for DHMOs?

25. What expectations did DHMO patients have?

26. True or False: By design, DHMOs must have fewer offices to give providers sufficient patient volume to be profitable.

27. At least (200 / 300 / 400) members are needed in each dental office for the monthly total capitation to cover the cost of the services provided these members.

28. Why is DHMO penetration unlikely in less populated areas?

29. How did poor employee communications contribute to misconceptions about DHMOs?

30. True or False: Premium cost savings of 20 percent was not worth the employee dissatisfaction that resulted with some DHMOs.


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DHMOs Today (page 264)

31. Despite the growing pains, it appears that DHMOs continue to be a (best-buy / viable option) for dental benefits.

32. When employees in a large group situation are given a choice between a PPO or indemnity plan and a DHMO, what has industry experience shown?

33. True or False: A well-designed DHMO has the potential to provide a more efficient mix of services at less cost than a fee-for-service dental plan.

34. Under (PPO / DHMO) reimbursement models, dentists are financially incentivized to help patients maintain their oral health.

35. Under fee-for-service reimbursement, dentists are incentivized to provide treatment options offering the (highest profit margin / least invasive approach).

Closing Remarks (page 265)

36. With restructuring of DHMO plans, what can participating dentists hope to realize?

37. What have today’s more sophisticated data reporting mechanisms helped to achieve?

38. How has the risk to primary dentists been addressed under restructured plans?

39. Many newer DHMO models provide (a floor for reimbursement / fee-for-service supplements / both).

40. Larger, more sophisticated DHMO administrative structures will lead to __________.


1. DHMOs, prepaid dental plans, and dental capitation plans. 2. Dentists are paid a capitation or on a per capita basis. 3. Payment is rendered via a fixed monthly amount “per family” or “per person” regardless

of the services rendered. 4. A “closed panel” network. 5. It encouraged dentists to use various rationing methods. 6. Administrators must monitor utilization and appointment wait times. 7. A combination of monthly capitation payments and patient copayments. 8. True 9. A nominal sum administrators pay providers to encourage submission of encounter data

(e.g., information regarding services performed per patient treated) to capture actual utilization.

10. Through minimum financial thresholds for providers performing a higher level of major services.

11. Allows easy implementation (through the merger of DHMO reimbursement methods with varying copayment schedules) and encourages dentists to participate.

12. By a combination of patient copayments and additional supplements by the administrator.


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13. As a supplemental payment. 14. Many plans have delegated the referral approval to the primary care dental office. 15. False 16. True 17. That enrollment in DHMOs would ultimately grow to be 20 to 25 percent of the market. 18. In 1998 at approximately 19 percent of market share. 19. 8 percent. 20. Premium and sometimes the geographic coverage of the network. 21. That this alternative would offer the best of both worlds—managed care and greater

access to care. 22. True 23. Better benefits; modest savings for in-network care; freedom to choose the provider. 24. Purchasers wanted an office on every corner. 25. Their dentist in the network and DHMOs that functioned like medical HMOs. 26. True 27. 200 members. 28. It is difficult to find dentists willing to participate. 29. Without understanding the trade-offs, employees wanted to pay less and get more. 30. True 31. Viable option. 32. Between 15 and 25 percent of the employee group will select the DHMO. 33. True 34. DHMO. 35. Highest profit margin. 36. An adequate profit. 37. Better underwriting practices that can work for DHMO plan sponsors, patients, and

dentists. 38. Reimburses specialists on a fee-for-service basis. 39. Both a floor for reimbursement or fee-for-service supplements. 40. Economies of scale.


1. Dental health maintenance organizations are also called: a. Prepaid dental plans. b. Capitation plans c. DHMOs. d. All of the above.

2. During the 1980s and early 1990s, DHMOs experienced substantial growth, peaking in

1998 at approximately what percentage market share? a. 16 percent b. 19 percent c. 23 percent d. 26 percent

3. According to the Joint Dental Benefits Report on enrollment, in 2010 DHMOs had _____

percent enrollment, while _____ percent were enrolled in some type of dental PPO. a. 10 percent / 75 percent b. 19 percent / 80 percent


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c. 8 percent / 74 percent d. 5 percent / 70 percent

4. Which of the following is NOT a true statement with regard to how DHMO plans have changed reimbursement relative to specialists?

a. Referrals require pre-authorization by the administrator. b. Specialists are paid on a discounted fee-for-service basis. c. Primary dentists are never delegated with referral approvals. d. Reimbursement may be included in the capitation payment.

5. Members left DHMO plans to join PPOs because of:

a. Premium savings. b. Larger networks and fewer complaints. c. Higher cost of dental services. d. None of the above is correct.

6. According to the text, all of the following make DHMO plans attractive EXCEPT: a. Smaller networks. b. No deductibles. c. No annual maximums. d. Lower premiums.

7. Which of the following explains why employees prefer PPOs?

a. Larger size and number of networks offered. b. The option to see non-network dentists. c. Easier to change dentists or see specialists. d. All of the above are correct.

8. Market dynamics have produced a demand for __________ that combine the best aspects of DHMOs, PPOs, and fee-for-service plans.

a. combo dental plans b. hybrid dental plans c. package dental plans d. All of the above.

9. Which of the following is NOT a projection concerning the evolution of more and larger group dental practices?

a. Provider participation in DHMOs will grow as a steady revenue stream. b. Growth will come in urban and suburban areas with large pools of patients. c. Dental HMOs as a delivery system may fade from the health care landscape. d. Expansion of administrative structures will lead to economies of scale.

10. The DHMO concept will continue to attract purchasers and fill an important niche

because of its __________. a. Low cost, high-benefit design. b. Larger network of providers. c. Newer hybrid arrangements. d. All of the above are correct.


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Answers 1. d 2. b 3. c 4. c 5. b

6. a 7. d 8. b 9. c 10. a


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20 Dental HMOs: Plan Design Concepts

Objectives


Understand key rules for designing plans for DHMO programs,

Name and describe the main treatment classifications,

Explain how patient cost-sharing occurs, and

Identify approaches to limitations and exclusions unique to DHMOs.

Chapter Summary

There are four key rules to follow when designing DHMO plans. Let’s review these realistic guidelines for creating sustainable patient-centered programs:

Rule Number One—Incentives help patients maintain good oral health. Patients should share in the cost of expensive major services and services needed due to poor oral hygiene.

Rule Number Two—Patients should have access to dental care within 30 to 45 minutes based on regional geographic factors (i.e., urban, suburban or rural).

Rule Number Three—Basic services (i.e., diagnostic, preventive, and in some cases, routine fillings) should be available at little or no cost to the patient, with no dentist-induced barriers to necessary care.

Rule Number Four—A dental plan (the plan’s sponsor) cannot afford to pay for everything. DHMOs, in particular, are designed to be low-cost “no frills” dental plans.

Recommended DHMO models contain three main treatment classifications: basic, intermediate, and major, along with orthodontics, if covered. Here’s a rundown of common services provided under each classification:

Basic services (Class A/Class 1) are diagnostic (including examinations, x-rays, and others) and preventive (including prophylaxis4, sealants, space maintainers, and others).

Common intermediate services (Class B/Class II) include restorative, endodontic, nonsurgical periodontal, oral surgery, and adjunctive services.

Common major services (Class C/Class III) include lab-processed restorations, endodontic, surgical periodontal, oral surgery, removable prosthodontic and fixed prosthodontic services.

4 Teeth cleaning.


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Orthodontic services (Class D/Class IV) are usually offered as a rider with a high, fixed copayment and a limit of one course of treatment per patient per lifetime.

Today’s DHMOs can provide nearly any level of plan richness desired by purchasers and beneficiaries. The chapter stresses that cost sharing occurs via patient copayments and that deductibles and maximums are rare and do not belong in a DHMO. However, nearly all DHMOs now include limitations and exclusions based on the same or similar approaches used by indemnity and PPO plans. The authors emphasize that financial simplicity and transparency are essential in DHMOs for two primary reasons:

Limited choice. DHMOs are closed panel networks that limit the patient’s choice of providers.

Price-sensitive patients. Some individuals who choose DHMOs over other alternatives are those with less disposable income and greater sensitivity to price.

Review Questions

Key Rules to Follow When Designing DHMO Dental Plans (pages 267-269)

Rule Number One (pages 267-268)

1. Why should DHMOs establish patient incentives?

2. In addition to incentives, what other objective is stated in Rule One?

3. What is the most critical element of good dental health?

4. What occurs within hours of a prophylaxis (teeth cleaning)?

5. What does the success of dental treatment require?

6. True or False: If a patient shares in the cost of treatment, they are more likely to have a greater interest in assuring the success of the care provided.

Rule Number Two (page 268)

7. _____ percent of people should have access to dental care within _____ minutes based on regional geographic factors.

8. In large urban areas where high numbers of beneficiaries reside, one or two dental office facilities should be within _____ miles of _____ percent of patients.

Rule Number Three (page 268-269)

9. What is the rule regarding basic services?

10. How should plans be structured so as not to impede patient access to care?

11. What did a Rand study conclude about cost related to patient demand?


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12. What does the text suggest about barriers to Class I services?

Rule Number Four (page 269)

13. What are dental benefits designed to provide?

14. DHMOs, in particular, are designed to be __________ dental plans.

15. How does the text define “heroic dentistry”?

16. High cost solutions to treat low-frequency dental conditions with poor prognosis are usually (excluded / limited) under DHMO plans.

Dental HMO Models (pages 269-270)

17. What are the main treatment classifications in DHMO model plans?

18. The treatment classifications generally correlate with __________ plans.

Basic Services (Class A/Class I) (pages 269-270)

19. The least costly and the most critical element for good oral health, __________ services represent the essential components of any dental plan.

20. What do common basic services include?

Intermediate Services (Class B/Class II) (pages 270-271)

21. Also important to oral health, intermediate services carry a (major / modest) patient copayment.

22. What is a low-cost substitute for periodontal scaling and root planning?

23. What does patient neglect of oral health contribute to?

24. What common services are covered under the intermediate classification?

25. Fillings are covered under __________ services.

26. Pulp capping is covered under which service grouping?

27. Oral surgery services cover (simple / complex) extractions that do not involve bony impactions.

28. How are adjunctive services defined?

Major Services (Class C/Class III) (pages 271-272)

29. How do major services differ from basic and intermediate services?

30. Unlike basic and intermediate procedures, major services tend to have a __________ ratio.


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31. Major services may represent a significant portion of plan cost; therefore, they should carry the (lowest / highest) patient copayments.

32. What common services are covered under the major classification?

33. True or False: Removable full and partial dentures are almost always a far less costly method of replacing missing teeth.

34. True or False: Fixed partial dentures are usually considerably more expensive than removable partial dentures.

35. (Removable dentures / Fixed partial dentures) have become the standard of care if the prognosis is good and there are only one or two teeth to replace.

36. What has become a costly but effective long-term solution for replacing missing teeth?

Orthodontic Services (Class D/Class IV) (page 272)

37. How does a DHMO plan cover orthodontic services?

38. For children and adults, orthodontic benefits remain one of the (most / least) popular of all dental benefits.

39. What do orthodontic services cover?

40. When covered, adult orthodontics usually has a (higher / lower) copayment than orthodontics for children.

Copayments, Deductibles, and Maximums (pages 271-273)

41. (Deductibles / Copayments) do not belong in a DHMO.

42. (Coinsurance / Copayments) are expressed in dollar terms by procedure code.

43. With the variety of copayment levels and combinations available for DHMO plans, what is probably the best design approach to take, according to the text?

Limitations, Exclusions, and Other Matters (pages 273-274)

44. What plan feature, once limited to fee-for-service plans, is now in nearly all DHMOs?

45. Who do limitations and exclusions protect and from what?

46. True or False: Many DHMOs have modified their plans to allow dentists to charge additional lab fees for material upgrades, while placing a ceiling on the maximum fee that can be assessed.

47. Why is it more important than ever for purchasers to ensure their DHMO program includes a fair policy for handling lab fees?

48. What are the two primary reasons transparency and financial simplicity are essentials in DHMOs versus fee-for-service plans?


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49. How does limited choice apply to DHMO plans?

50. What responsibilities do good DHMO administrators have to price-sensitive patients?


1. To encourage patients to maintain good oral health. 2. Patients should share in the cost of expensive major services and services needed due

to poor oral hygiene. 3. Maintaining good oral hygiene. 4. Plaque recolonizes on the teeth, bacteria multiply and begin the process that leads to

infection and damage of the teeth and supporting structures. 5. A partnership between the patient and the dentist. 6. True 7. 80 percent / 30 to 45 minutes. 8. 10 miles / 80 percent. 9. Basic services should be available at little or no cost to the patient. 10. To avoid dentist-induced barriers to necessary care. 11. Reducing the level of cost sharing increases the demand for dental services. 12. Barriers should be eliminated or drastically reduced. 13. Financial assistance in a way that allows affordable coverage for the most essential

services for the greatest numbers of eligibles. 14. Low cost “no frills” dental plans. 15. Extensive and expensive dental treatment performed to save teeth in very bad condition. 16. Excluded. 17. Basic, intermediate, major, and orthodontics. 18. Fee-for-service plans. 19. Basic services (Class A/Class I). 20. Diagnostic and preventive services. 21. Modest copayment. 22. Routine cleaning. 23. The need for additional and more expensive services. 24. Restorative, endodontic, nonsurgical periodontal, oral surgery, and adjunctive services. 25. Restorative services. 26. Endodontic services. 27. Simple extractions. 28. Emergency and other treatments not classified elsewhere. 29. Major services are more expensive, more invasive and more likely to fail if the patient

does not maintain good oral hygiene. 30. A high-cost and low-benefit ratio. 31. Highest copayments. 32. Lab-processed restorations, oral surgery, and endodontic, surgical periodontal,

removable prosthodontic, and fixed prosthodontic services. 33. True 34. True 35. Fixed partial dentures. 36. Implants. 37. As a rider with a high, fixed copayment and a limit of one course of treatment per patient

per lifetime. 38. Most popular. 39. Repositioning of teeth and malalignment corrections between the upper and lower jaw.


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40. Higher copayment. 41. Deductibles. 42. Copayments. 43. Stay somewhere in the middle where there are some incentives for patients to follow

treatment protocols, yet still have access to basic care at no or low out-of-pocket cost. 44. Limitations and exclusions. 45. Ls&Es protect providers, patients, and plan sponsors from risk that is inherent in the

capitation reimbursement structure. 46. True 47. Because of the aging population and increased use of lab-processed restorations. 48. The two primary reasons relate to limited choice and price-sensitive patients. 49. DHMOs are closed panel networks that limit the patient’s choice of providers. Limited

choice increases the responsibility for full disclosure of cost, risk, and treatment options prior to any service being rendered.

50. Good administrators will ensure that financial variables such as lab fees and copays are disclosed and/or controlled and not left entirely up to the provider.


1. Which of the following is a subtle barrier used by dentists to ration services? a. Long waiting times for appointments. b. Long waiting times at the office. c. Few services per visit. d. All of the above are correct.

2. What type of services in the intermediate category should be an exception and require a more substantial copayment?

a. Endodontic services. b. Periodontal scaling and root planing. c. Emergency treatment. d. Restorative services.

3. Coverage of which of these services is generally offered as a rider to dental plans? a. Orthodontics. b. Oral surgery. c. Inlays and crowns. d. Endodontic services.

4. Success of orthodontic treatment depends largely on:

a. Patient cooperation. b. Not wearing the appliance. c. Teeth moving on their own. d. All of the above are correct.

5. What cost-sharing measure applies to intermediate, major, and orthodontic services under a DHMO?

a. Deductibles. b. Annual maximums. c. Copayments. d. Lifetime maximums.


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6. All of these limitations and exclusions now apply to DHMOs EXCEPT: a. Upgrades from least expensive service. b. Extra cleanings. c. Cosmetic services. d. Additional lab fees for restorations.

7. Which of these is classified as a preventive service? a. Fluoride treatment. b. Endodontic services. c. Nonsurgical scaling and planing. d. Emergency treatment.

8. Which of the following is included under intermediate services?

a. Prophylaxis. b. Sealants. c. Amalgam restoration. d. Space maintainers.

9. What prompts plans to have a fair policy for handling lab fees? a. Increased use of lab-processed restorations. b. Decreased use of lower-cost materials. c. Volatility of the current economy. d. All of the above are correct.

10. According to the text, financial simplicity and transparency are essential in DHMOs for these reasons:

a. Less disposable income and better oversight. b. Limited choice and price-sensitive patients. c. Consumer preferences and cost constraints. d. Limited choice and greater responsibility.

Answers

1. d 2. b 3. a 4. a 5. c

6. d 7. a 8. c 9. a 10. b

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21 Dental HMOs: Copayment Schedule Basics

Objectives


Define what a copayment schedule is and how it differs from coinsurance,

Recognize basic concepts that apply in a DHMO environment,

Identify trade-offs purchasers and beneficiaries must consider in choosing a plan, and

Understand the characteristics that make DHMO copayment schedules unique.

Chapter Summary

This chapter gets down to basics in its focus on the core component of DHMO plan designs—the copayment schedule. The copayment or copay is a flat fee paid by a beneficiary each time a dental service is provided, with some exceptions for diagnostic and preventive procedures, which may have a zero copayment. Unlike coinsurance in fee-for-service plans, DHMO copayment schedules represent the fixed dollar amount members must pay when visiting the dentist. Most DHMO copayment schedules are as comprehensive as possible in the way codes and procedures are listed. If a procedure isn’t listed, assume it’s not covered.

Selecting a DHMO plan for yourself or your group often comes down to a comparison of trade-offs. For example, from the beneficiary’s perspective, it is important to balance the monthly premium that must be paid (regardless of whether or not you use the plan) with the out-of-pocket cost to pay the dentist. If you select a low premium plan, you may have zero or nominal copayments for routine services, but you will have high copayments for intermediate and major services. On the other hand, if you desire the lowest out-of-pocket expense, then you must absorb the cost of higher monthly premiums. Let’s check out some plan sponsor and user profiles for premium and copayment trade-offs:

Plan A—High premium/Low copayments

Plan A Profile Paternalistic sponsor; may contribute to premium. User has ability to pay higher monthly rate. Group may be bargained (union). User prefers “rich” benefits and expects to use them; good for families needing

orthodontic care. User has aversion to risk.

Plan B—Midrange premium/Midrange copayments

Plan B Profile Sponsor wants to offer rich benefits as a choice; may contribute to premiums. User prefers lower monthly cost, willing to pay moderately high copayments when

treatment is needed.


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User expects to use routine, zero copay services, but does not expect to need high-cost services.

Plan C—Low premium/High copayments

Plan C Profile Sponsor wants lowest premium possible and may pay 100 percent of premium cost. Sponsor may offer users to buy up to a richer plan, usually a PPO (dual choice). User very sensitive to premium cost (if contributions are required) and does not want to

pay until services are used; willing to accept higher copayments as the trade-off. User does not expect to need or use expensive restorative care.

The chapter provides a series of sample copayment schedules in condensed form that illustrate how the balance between premium levels and copayment schedules might look. It also identifies and describes key features that need to be understood for grasping the uniqueness of DHMO copayment schedules. For example:

allowing for more frequent services,

listing integral services separately,

listing services that are rarely done,

lab fees, and

treatment by specialists. The author explains the significance of each item—noting some differences between DHMOs and fee-for-service plans, commenting on the attractiveness of some features, and cautioning patients and purchasers about others. The author also describes how plans and dentists are protected by limitations and exclusions:

Limitations apply to frequencies and are placed on services that may be appropriate but can be subject to abuse and overtreatment, or are very costly. For example, crowns, bridges, and dentures.

Exclusions are specific services and items not covered by the plan, usually because they are very expensive (e.g., implants), cosmetic, experimental treatments, services with a poor prognosis, not needed to treat disease caused by patient neglect, or typically covered under a medical plan.

Review Questions


1. True or False: A DHMO copayment schedule is similar to coinsurance in a fee-for-service plan.

2. What do copayment schedules represent?

3. How are patient copays expressed on the plan schedule?

4. What makes DHMOs appealing to a specific market niche?

5. What trade-offs do purchasers and patients have to consider?


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6. How are dentists compensated under DHMO plans?

7. How have administrators addressed the incentive dentists have for rationing care, inherent in DHMOs?

8. What factor makes DHMOs a target for state regulators?

9. What innovation addresses some of the weaknesses in the original DHMO model?

DHMO Options—Premium and Copayment Trade-Offs (pages 276-286)

10. What does choosing the right DHMO plan often come down to?

11. Aversion to risk would appear in the profile of users who select the (high premium-low copayments / low premium-high copayments) DHMO plan.

12. A sponsor that wants the lowest premium possible and who may be willing to pay 100 percent of the cost would fit into the (midrange premium-midrange copayments / low premium-high copayments) profile.

13. Those who desire the lowest out-of-pocket cost for care will be charged the __________ monthly premium.

Allowing for More Frequent Services (page 282-283)

14. According to the text, __________ is an entirely appropriate feature that can make DHMOs attractive to members.

Listing Integral Services Separately (page 283)

15. Which services may be listed on DHMO copayment schedules with a zero copayment?

16. What is the purpose of listing integral components of other procedures as separate items on the copayment schedule?

17. Why do purchasers need to be aware of the unbundling practice when evaluating dental plans?

Listing Services That Are Rarely Done (page 283)

18. What is the likely perception of DHMOs that list all covered services on the plan’s copayment schedule?

19. How should purchasers evaluate the actual nature of the benefits listed on the DHMO copayment schedule?

20. True or False: The list of rarely done procedures tends to give the impression that DHMOs cover many more procedures than fee-for-service plans.

Lab Fees (page 284)


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21. What is the market response to the increased demand for lab-processed, tooth-colored restorations?

22. Who currently feels the greatest impact due to the increase in lab fees?

23. From the patient’s perspective, what is one solution that can be put in place to address the issue of lab fees?

24. How do overly frequent copayment revisions impact carriers?

Treatment by Specialists (pages 284-285)

25. What are the protocols under a DHMO plan for treatment by specialists?

26. What should patients and purchasers consider regarding specialty care provided by specialists?

27. What do some carriers do to simplify copayment schedules—especially for lab-processed restorations?

28. To be fair to both purchasers and patients, what should copayment schedules reflect regarding direct placement fillings?

Limitations and Exclusions (page 285-286)

29. What additional benefit do dentists get, thanks to a plan’s limitations?

30. Why are specific services or items likely to be excluded from a plan?


1. False 2. The fixed dollar amount members must pay when visiting the dentist. 3. By the name and code for each covered procedure. 4. Better benefits at lower cost. 5. Fewer providers and lack of out-of-network benefits, except in special cases. 6. Through a combination of capitation and copayments). 7. Through proper monitoring. 8. Closed panel networks. 9. Hybrid models. 10. Trade-offs involving higher premium/lower copayments versus lower premium/higher

copayments and everything in-between. 11. High premium-low copayments. 12. Low premium-high copayments. 13. Highest monthly premium. 14. Allowing more frequent services, such as additional cleanings for a smaller or even zero

copayment. 15. Oral hygiene instruction, nutritional counseling, and local anesthesia. 16. To make the benefit appear more generous than it really is. 17. This practice can make a DHMO appear far more comprehensive than PPOs and other

plans that do not involve schedules.


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18. That DHMOs cover many more services than they actually do. 19. In terms of what’s most important to patients. 20. True 21. Manufacturers have stepped up efforts to develop new technologies and materials for

fabricating superior products that also push costs higher. 22. Higher lab fees in DHMOs must often be borne by the dentist. 23. Revise copayment schedules to keep pace with rapidly changing lab fees. 24. Revisions are costly and disruptive, causing increased administrative and compliance

expense and the potential for higher premium trend rates. 25. Depending on the contractual arrangement with the general dentist, the patient may be

charged the same copayment as shown on the schedule with the plan making up the difference, or the patient may be charged a higher copayment.

26. The financial impact in terms of patient out-of-pocket cost and premium rates. 27. Some carriers will show the same dollar amount for a series of related procedures. 28. One-surface fillings that involve amalgam and composite-resin materials are less

expensive to do and do not involve lab fees. 29. Dentist can offer noncovered or optional benefits and get paid at their full fee. 30. Services may be excluded because they are either very expensive, cosmetic,

experimental, unnecessary, or have a poor prognosis.


1. Which of the following design features typically apply to DHMO plans? a. Better benefits at lower cost. b. Smaller networks. c. Limited out-of-network services. d. All of the above are correct.

2. What do well-managed DHMO plans offer that make them competitive with fee-for-service plans?

a. Larger networks and more providers. b. Greater access to specialists. c. Better benefits at a lower cost. d. Larger percent of market share.

3. Under a high premium/low copayment arrangement, the user profile would indicate all of the following characteristics EXCEPT:

a. Aversion to risk. b. Ability to pay higher monthly rate. c. Little need for expensive care. d. Preference for rich benefits.

4. Which of the following rarely appears on plan documents for fee-for-service programs such as PPOs?

a. Oral hygiene instruction. b. Scaling and root planing. c. Extraction of primary tooth. d. Metallic crowns.

5. Gold foil restorations and apically positioned flaps are two examples of the following:


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a. Practices that were discontinued decades ago. b. Procedures that appear on copayment schedules. c. Both “a” and “b” are correct. d. Neither “a” nor “b” is correct.

6. Like most folks, Lilly wants a movie-star smile. She’s asked her dentist for a tooth-colored restoration, an upgrade of the crown she’s having replaced. Her copayment schedule included a footnote concerning lab-processed services. If Lilly read the fine print on her plan document, she may be aware of the following:

a. The dentist may have to absorb the extra cost. b. The dentist may charge Lilly an additional fee. c. The plan will supplement the dentist’s added fee. d. None of the above is correct.

7. What is the effect of the increased demand and market response for lab-processed, tooth-colored restorations?

a. Over production. b. Shortage of materials. c. Higher costs. d. Decreased sales.

8. How do some carriers simplify the copayment schedule to reflect the variability of lab fees today?

a. Show the same copay for a series of related procedures. b. Show the cost of the most expensive procedures only. c. Bury the costs in fine print on an annotated schedule. d. Hold providers responsible for covering increased costs.

9. Which of the following explains why limitations may be placed on services that are appropriate?

a. Service may be too expensive. b. Service may be subject to abuse and overtreatment. c. Limits usually apply to frequencies (exams and teeth cleanings). d. All of the above are correct.

10. Under which category would a popular service, such as bleaching teeth to make them whiter, be excluded by a dental plan?

a. Cosmetic. b. Unnecessary. c. Too expensive. d. Experimental.

Answers

1. d 2. c 3. c 4. a 5. c

6. b 7. c 8. a 9. d 10. a


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24 Selecting a Dental Administrator: The Procurement Process

Objectives


Understand why plan sponsors elect to go through a competitive bidding process,

Explain the seven steps in the vendor procurement process,

Know what to include and how to organize a request for proposal (RFP), and

Recognize common mistakes made by sponsors and vendors.

Chapter Summary

Why do benefit managers put a current dental program through a competitive bidding process? There are many reasons: cost concerns, employer or employee dissatisfaction, legal mandates, corporate restructuring, to name a few. Before you embark on what could be a costly and time-consuming endeavor for your organization, it is wise to prepare yourself with a thorough understanding of the procurement process. When selecting a dental administrator, doing it right the first time pays off not only for creating long-lasting relationships but also for producing cost-savings and service quality.

This chapter walks you through seven steps in the selection process: (1) gaining consensus from decision makers, (2) determining the search intensity, (3) identifying potential vendors, (4) designing the instrument, (5) evaluating the response, (6) making the selection, and (7) debriefing. At the onset, you’ll need to consider the actual reasons for bidding the plan and establish goals you want to achieve for stakeholders. You must decide on the structure and content of your bidding instrument and understand why size and complexity matter. For example, do you want to issue a full request for proposal (RFP) or merely a request for information (RFI)? When preparing an RFP, keep the instrument simple because poorly written or complex terminology makes the evaluation process more difficult.

RFPs typically contain the following elements:

Table of contents and clear organization. Whether printed or electronic, a clear table of contents and good organization produce a better response.

Introduction. This section explains the reason for the bid, gives history and information about the current program, the sponsor, and the type of plan desired.

Demographics, plan specifics, and other pertinent information. This section includes all the necessary detail needed by responders to assess risk and required performance.


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Questionnaire. This section allows sponsors to find out about the history and experience of the bidders.

Knowing how to avoid some of the common mistakes that occur during the bidding process can certainly make finding or changing dental administrators a lot less onerous.

Review Questions

Introduction (page 305)

1. Why are plan sponsors reluctant to make changes to existing dental programs?

2. What is another reason for not changing existing dental benefit plans?

Step 1: Gaining Consensus From Decision Makers (pages 305-307)

3. Why do plan sponsors go to bid in the first place?

4. What is another part of the discussion concerning reasons for going to bid?

Step 2: Determine the Search Intensity (page 307)

5. Why does the sponsor need to determine search intensity?

6. What may a less formal request for information (RFI) entail?

Step 3: Identify Potential Vendors

7. In identifying potential vendors, what services would a self-funded indemnity dental plan require?

8. What attributes should a sponsor seek in an insured product that leverages network discounts to enhance plan benefits?

9. What are three resources for obtaining information about dental plans in a given area?

Step 4: The RFP Instrument (pages 308-312)

10. What is the historical description of a request for proposal (RFP)?

11. The data requested via an RFP is (public / proprietary) information.

12. RFPs are moving toward (written / electronic) instruments.

13. True or False: If an instrument is not on a secure platform, vendors are not likely to submit bids

14. What may result from a poorly written or complex RFP?

15. What are the four main elements of a written or electronic RFP?

16. Who needs data on demographics and plan specifics and for what purpose?


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17. The questionnaire requires information from bidders concerning what categories?

Step 5: Evaluation (pages 312-313)

18. How do sponsors typically array answers and for what purpose?

19. Who gets the job of displaying answers and what is the downside of this assignment?

20. Sponsors and vendors should insist that (dental benefit specialists / medical or dental specialists) are directly involved in the evaluation process.

21. Why are electronic instruments especially helpful?

22. What do electronic formats force vendors to do?

23. What is the flip side of electronic instruments?

24. When multiple choices do not apply to a bidder, what allowances can be made?

25. What is the caution concerning use of a spreadsheet to report answers?

Step 6: Selection—Making the Cut (page 313-314)

26. Which element gets special consideration for vendors making the final cut?

27. How are unusually low vendor quotes viewed?

28. What should low bidders be prepared to do?

29. A set of screening processes weeds out bidders that do not meet certain (minimum standards / minimum requirements).

30. In lieu of site visits, what may some finalists in the bidding process be invited to do?

31. Typically, (consultants / sponsors) do not select the winning bidder.

Step 7: Debriefing (pages 314-315)

32. During the debriefing process, what opportunity should be given to vendors?

33. In providing feedback to vendors, what needs to be protected?

34. In seeking information from vendors and/or sponsors about the RFP, what was the author’s favorite question?

Common Errors (pages 315-316)

Common Sponsor Errors (page 315)

35. Lack of clarity in the desired outcome produces (complex / confused) responses.


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36. Assigning the task of summarizing and reviewing answers to an inexperienced person causes information to be __________.

37. What action can result in a ludicrous RFP instrument having little to do with dental benefits and produce an impossible outcome?

Common Vendor Errors (page 315-316)

38. What happens when marketing personnel are tasked to respond to an RFP and manager-level individuals from each functional area fail to review the drafts?

39. True or False: Relying on boiler-plate responses that don’t fit the question asked would lessen a vendor’s opportunity to make the cut.

40. Why is it imprudent for a vendor to reference redundant answers on an RFP questionnaire?


1. Economic uncertainty, mostly due to increased regulation and government intrusion into the health care industry, makes plan sponsors cautious about the future.

2. Dental premium trend has been stable. 3. Cost concerns, mergers and acquisitions, dissatisfaction with the current plan, due

diligence, legal mandates, changes in corporate structure, or new HR director seeks a full review.

4. Changing the delivery system (e.g., moving from an indemnity to a PPO plan). 5. Search intensity refers to the size, scope, and cost of the project. The search for a new

vender can be costly and time consuming. An employer who is relatively happy with an existing plan may not need a full RFP when a request for information may suffice.

6. Contact vendors in writing to ask if costs can be reduced or network access increased. Each vendor is required to provide the same information and go through the same process.

7. A third-party administrator (TPA) with efficient claims processing skills and customer service.

8. Good network penetration where employees live and the best possible working relationships with dentists.

9. Consultants, state registration of insured products, and the National Association of Dental Plans (NADP).

10. A large written document that required evaluators to summarize and compare all answers.

11. Proprietary information. 12. Electronic. 13. True 14. Cumbersome and confusing proposals make the scoring process especially difficult. 15. Table of contents, introduction, description of demographics and plan specifics,

questionnaire. 16. Responders need the detailed information on demographics and plan specifics to assess

risk and required performance. 17. Information from bidders about their organizational governance and experience, financial

operations, plan transfer, customer service, network management, and clinical management.


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18. Answers are arrayed in a grid to facilitate comparisons. 19. An entry-level employee who lacks experience. 20. Dental benefit specialists. 21. Because they permit single or multiple-choice answers and can limit the length of

allotted free-text. 22. Clearly and consistently state answers. 23. Lack of flexibility and choices available may not apply to some bidders. 24. Submit an attachment to support a response. 25. Spreadsheets do not capture qualitative information. 26. Competitive pricing. 27. With skepticism. 28. Justify the validity of their pricing methodology. 29. Minimum requirements. 30. Make a presentation to the sponsor at the sponsor’s or consultant’s location. 31. Consultants. 32. To receive feedback on what they did well, where they fell short, and how they can

improve in the future. 33. Confidential information of the other bidders. 34. If you were in charge of the responding/issuing company, what changes would you

make? 35. Confused. 36. Misinterpreted. 37. Using a medical RFP by replacing the word medical with dental. 38. Can lead to inappropriate or inaccurate answers. 39. True 40. Analysts hate to hunt for information; the vendor may receive zero points for that area.


1. What is the first step in putting a current dental plan through a competitive bidding process?

a. Gaining consensus from decision makers. b. Identifying potential vendors. c. Determining the search intensity. d. Preparing the RFP instrument.

2. Going to bid is an ideal time for a plan sponsor to consider which of these other options? a. Plan funding. b. Type of delivery system. c. Network access. d. All of the above.

3. An employer that is relatively satisfied with an existing plan may informally contact several vendors to determine if cost can be reduced or network access increased. This process is usually referred to as a __________.

a. request for service b. request for estimate c. request for information d. request for proposal


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4. Finding vendors can be relatively easy if you can locate the right resources. Which of the following is NOT a likely resource for procuring a TPA?

a. Consultant’s list. b. State regulators. c. NADP. d. Mayo Clinic.

5. A request for proposal (RFP) may include all of the following elements EXCEPT: a. Table of contents. b. Introduction. c. Ls & Es. d. Questionnaire.

6. Which section of the RFP allows sponsors to find out about the history and experience of bidders?

a. Questionnaire. b. Plan summary. c. Introduction. d. All of the above.

7. Which of the following best describes the kind of response a poorly written or overly complex RFP will generate?

a. You get what you pay for. b. Garbage in, garbage out. c. Honesty is the best policy. d. Always read the small print.

8. How do sponsors or their consultants typically array answers generated from an RFP questionnaire?

a. In a table to compare comments. b. In a grid to facilitate comparisons. c. In a matrix to evaluate answers. d. All of the above are correct.

9. Unusually low vendor quotes are likely to be viewed with __________. a. discernment b. discretion c. skepticism d. uncertainty

10. Vendors should be given an opportunity to receive feedback on: a. What they did well. b. Where they fell short. c. How they can improve in the future. d. All of the above are correct.


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Answers 1. a 2. d 3. c 4. d 5. c

6. a 7. b 8. b 9. c 10. d


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25 Dental Policy—Translating Evidence Into Reality

Objectives


Define dental policy, from administrative and clinical perspectives;

Describe the primary administrative elements common to well-run dental programs;

Understand the objective of clinical policy to provide dental coverage for evidence-based dental benefits;

Recognize clinical policy standards for dealing with experimental treatments, dental necessity, cosmetic dentistry, and dental technology.

Chapter Summary

Students who have completed Part A of the Dental Benefits course understand how dental plans are structured and recognize the differences between medical and dental coverage. Unlike medical plans, dental benefits cover low-cost (non-catastrophic), high-frequency services. The nature and scope of dental policy are also a result of how dental benefits differ from medical benefits. Dental benefits are not true insurance, as this chapter notes, but designed to provide financial assistance for plan members to seek dental care.

The author suggests we think of dental benefits as the “what” in dental plan coverage, and view plan policy as the “why,” “how,” “when,” and “where.” The more common use of the term policy refers to a contract between an insurance company and a person or organization, while dental policy refers to a specific set of principles and rules to administer dental benefits. There are two main types of plan policy: (1) administrative and (2) clinical.

Administrative policy primarily addresses the process of reporting on services that were rendered and the payment for them. It focuses on several of the how, when, and where aspects of dental services and benefits.

Clinical policy provides benefit coverage and reimbursement for services in accordance with accepted dental practice that meet the standard of care, are known to be effective, and are supported by science. Perhaps it’s safe to say clinical policy deals with the “why” aspect of patient care.

It is dental policy that controls and specifies the availability of coverage, and under what conditions benefits exist. In this chapter, you’ll study the primary administrative elements common to well-run dental programs. Claim documentation requirements, review policies, claim system edits, specialty referral guidelines, provider network considerations, and reimbursement rules are the essential components of plan administrative policy. You’ll also examine the components of sound clinical policy, including standards for dealing with experimental treatments, dental necessity, cosmetic dentistry, and dental technology.

Review Questions



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1. __________ refers to the set of principles and rules used to administer dental benefits.

2. What is the other, more common use of the term policy?

3. What do a dental plan’s policy guidelines provide?

4. True or False: Essentially, dental benefits are designed to provide financial assistance for plan members to seek dental care.

5. What are the two main types of plan policy?

Administrative Policy (pages 318-321)

Administrative Policy Checklist (pages 318-321)

6. What requirements should be made publicly available and communicated to network providers as applicable?

7. What is the policy specified for professional review criteria?

8. (Utilization review / Professional review criteria) policy defines which providers and corresponding claim types and procedures should go to professional review.

9. __________ refers to which procedure codes the policy claims system will disallow for separate reimbursement if rendered on the same date of service.

10. Integral logic is the processing policy that identifies what?

11. How is the policy regarding the alternate benefit provision clarified in the text?

12. True or False: Policy exclusions always disallow providers (and patients) the freedom to choose a more expensive treatment than the one covered.

13. What criteria are alternate benefit provisions based on?

14. What does the reimbursement policy establish?

15. According to the text, carriers, plans sponsors, and beneficiaries would prefer that maximums be applied to (every procedure code on the fee schedule / those covered under the applicable plan).

16. Which items should be ineligible for reimbursement?

Clinical Policy, Evidence-Based Dentistry and the Dental Consultant (pages 321-329)

17. What is the objective of clinical policy?

18. True or False: A main reason carriers do not automatically pay claims as submitted is due to the wide variation in dental treatment decisions and procedures performed by different dentists when treating the same problem.

19. Whenever possible, a dental plan should endeavor to provide dental coverage for only __________.

20. Through the integration of good science with plan benefit language and utilization review programs, what can dental plans hope to achieve?

Experimental Policy (pages 329-330)

21. What should be the goal of any dental plan, according to the text?

22. How are determinations made concerning proven therapies?


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23. What are three underlying factors in designating procedures or treatments experimental or investigational?

Experimental Policy Checklist (pages 329-330)

24. True or False: A new therapy is presumed to be experimental until proven otherwise.

25. Which government agency may assist in your evaluation of a new therapy?

26. What is the concern about FDA approval?

Dental Necessity (pages 330-331)

27. One study of 1,187 teeth in 43 patients showed unanimity at only _____ percent of which teeth required treatment.

28. An example of targeted high-cost/abuse-prone claims for professional review might include (all anterior crowns and veneers / implants / fixed prostheses / all of these procedures).

29. What does a company’s clinical necessity policy define?

30. What is as important as defining dental necessity?

31. How do most dental plans address treatment upgrades and elective services?

32. What is the rationale for excluding upgrades and elective dental services?

Cosmetic and Technology Policy (pages 332-333)

33. Elective procedures such as cosmetics cannot be funded through (pretax benefit dollars / health savings accounts).

34. According to Dr. Gordon Christensen, elective/cosmetic procedures can generate as much as _____ percent of a typical dentist’s income.

35. Services that are aesthetic upgrades or that represent technique variations of performing a traditional procedure are (included in / excluded from) most well-run, financially stable plans.

36. Give two examples of conventional dental applications that have evolved due to technological advances.

Product Specific Policy for DHMOs (page 333)

37. What should a DHMO policy include concerning specialty referral guidelines?

The Lifecycle of Dental Policy (pages 333-334)

38. To ensure that administrative policy is updated with respect to policies governing mutual exclusivity, integral logic, utilization and professional review criteria, this action is necessary.

39. What position is recommended for some larger national plans to oversee administrative and clinical policies?


1. Dental policy 2. A contract between an insurance company and a person or organization. 3. The specificity of when dental procedures (codes or descriptors listed in the plan)

become covered and payable. 4. True


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5. Administrative and clinical. 6. Requirements for “clean claims” and associated attachments. 7. It covers which claim types and submitted dental procedures should be reviewed by a

dental consultant. 8. Utilization review. 9. Mutual exclusivity. 10. Integral logic identifies procedures that are a conjunctive part of another more global

procedure. 11. It is strictly an administrative policy and not a clinical one. 12. False 13. Accepted dental practice that meet basic standards of care. 14. The level of the maximum allowed fee amounts, the specific methodology, and how

periodic adjustments will occur. 15. Every procedure code on the fee schedule. 16. Charges for completing claim forms, annual patient administration, infection control, and,

in some cases, broken appointments. 17. To provide benefit coverage and reimbursement for services that are accepted dental

practice, meet the standard of care, are known to be effective and are supported by science.

18. True 19. Evidence-based dental benefits. 20. Maximize the potential for aligning plan structure and benefits with successful patient

outcomes. 21. To benefit only proven therapies supported by science. 22. The determination is based on peer-reviewed dental and scientific literature and the

practice of the national dental community. 23. The procedure or treatment: (1) is not recognized as conforming to accepted dental

practice; (2) the scientific assessment of the technique, or its application for a particular clinical condition is incomplete and/or its effectiveness has not been established; (3) the required approval of a governmental agency has not been granted at the time the services are rendered as applicable.

24. True 25. The FDA. 26. It is based on safety concerns, not efficacy. 27. 22 percent. 28. All of these procedures. 29. Under what conditions a specific dental procedure is a covered benefit. 30. Defining services that are deemed elective. 31. Upgrades and elective are left out of the scope of services. 32. Ensures plans remain affordable for employers and employees. 33. Pretax benefit dollars. 34. 50 percent. 35. Excluded from most well-run plans. 36. Laser applications replacing the handpiece or scalpel to accomplish a standard

procedure; taking radiographs conventionally or using digital technology. 37. A DHMO policy should include any process instructions, documentation requirements

and charge backs to the provider as may be applicable. 38. A review of the Current Dental Terminology (CDT) codes. 39. A dedicated policy position such as a dental policy officer.


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1. What are the two main types of plan policy? a. Claims and reimbursement. b. Administrative and clinical. c. PPOs and DHMOs. d. Limitations and exclusions.

2. Which of the following states what administrative policy addresses? a. The provision of benefit coverage and reimbursement for evidence-based dental

care. b. The designation of which providers and corresponding claim types should be

reviewed. c. The process of reporting what dental services were rendered and the payment

for them. d. The integration of good science with plan benefit language and utilization review

programs.

3. If the dental benefit available is based on an alternative, but is a professionally acceptable procedure, beneficiaries should not interpret it as:

a. Dictating what treatment should be done. b. Questioning the value of alternative care. c. Promoting one procedure over another. d. Pushing consumers to accept the policy.

4. Why is a reimbursement policy necessary? a. To establish the level of the maximum allowed fee amounts. b. To specify the methodology. c. To denote how periodic adjustments will occur. d. All of the above are correct.

5. This function can only be performed by a licensed dentist well-versed in the nuances of dental science:

a. Provide health care patient education. b. Provide evidence-based dental care. c. Provide cosmetic and specialty services. d. Provide services to a diverse population.

6. In the effort to identify evidence-based dental benefits and create policy accordingly, the following professional would be a key resource:

a. Medical doctor. b. Benefits specialist. c. Dental consultant. d. Health educator.

7. A new therapy is presumed experimental until proven otherwise. Which of the following questions can be used as a guide for assessing whether a treatment is experimental or not?

a. What are the study types and are they repeatable? b. Are the levels of clinical evidence high or low? c. What is the size of the population studied?


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8. Examples of high-cost/abuse-prone claims targeted for professional review would include all of the following EXCEPT:

a. Implants b. Fixed prostheses. c. Periodontal surgical procedures. d. Restoration of a cracked tooth.

9. Which of the following is a true statement regarding the need for plan policy covering the use of technology in current dental practice?

a. Good policy will identify clinical situations in which technology is strictly a variation of process.

b. Disseminating policy about standalone procedures will generate patient and provider complaints.

c. A plan’s policy should cover informed consent procedures by the dentist and instructions for filing claims.

d. Dentistry is a cottage industry with little demand for laser applications and digital technology.

10. What irritates dentists more, or lessens the stature of the carrier in their minds? a. Using antiquated clinical policies. b. Denying benefits based on antiquated policies. c. Basing clinical policies on evidence-based practice. d. Both “a” and “b” are correct.

Answers

1. b 2. c 3. a 4. d 5. b

6. c 7. d 8. d 9. a 10. d


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30 The Dental Consultant: An Essential Resource

Objectives


Recognize the need for competent clinical oversight in the design and evaluation of dental programs,

Discuss the broad array of valuable functions performed by dental consultants, and

Understand how the dentist consultant brings a unique integration of clinical experience and business skills into the benefits marketplace.

Chapter Summary

The demand for dental benefits grew in the 1970s along with awareness that there was a dearth of knowledge about plan design and evaluation. Initially, medical plan structures were used as templates for dental plans, but it didn’t work. The differences between medicine and dentistry soon became apparent, creating opportunities for pioneer dental consultants who took on the task of forming a workable environment for dental benefits.

Today, purchasers and carriers recognize the need for competent clinical oversight in the design and evaluation of dental programs, and dental consultants perform a broad array of valuable functions. To quote the author: “A dental plan that does not have dental consultants with the functional skills described in this chapter is like a plane without a navigator.”

Starting out as CEOs of their own practices, dentists are acknowledged for their integration of clinical experience with successful business skills. Clinical training, skilled patient care, and educational credentials, backed by the American Association of Dental Consultants (AADC), make these professionals ideally qualified for the vital roles they play in the current benefit marketplace. Let’s begin with a quick overview of what the job entails:

Dental policy development. The consultant uses information from current evidence-based research to ensure that policies provide acceptable care at reasonable costs, and also monitors the field, including the American Dental Association’s (ADA) code revision cycle, to determine when policy changes are needed to maintain appropriate care.

Utilization review. The consultant reviews and analyzes coding practices and radiograph ordering patterns to detect inappropriate use and possible abuse of Food and Drug Administration (FDA) and ADA guidelines. Effective utilization review results in cost savings and improved quality of care.

Prepayment claims review. Some procedures require a review prior to payment to ensure benefits are being paid appropriately. Today’s carriers use off-site dental consultants for utilization and claims review and for input on advancing information technology and for employee training.

Communications with the professional community. The need for effective corporate communications calls for a clinician-consultant on staff who can relate peer-to-peer with network dentists. Without such a liaison, an administrator may foster an “us versus them” environment that can lead to contentious relationships with providers.


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Plan design. In responding to a potential purchaser’s request for proposal (RFP), letting an experienced dentist answer the clinical and technical questions can make a difference in gaining or losing a client.

Grievances. When a grievance is against a dentist regarding the quality of care received, only another dentist can technically adjudicate the complaint. This protects the administrator from liability and other concerns.

Research. Larger, leading-edge carriers often collaborate with dental academia to conduct studies. For such projects, having a skilled dentist consultant with training in evidence-based dentistry take the lead in working with research teams is a plus.

Training. Keeping the frontline trained and up-to-date is a proven strategy for winning and retaining customers. Knowledgeable dental consultants can share their insight with non-dentist personnel in how to interact effectively with network dentists and patients.

Community outreach. Dental consultants and other dental health professionals can visit schools and other public facilities to educate consumers on the prevention of tooth decay. It’s an effective way for a carrier to get the message out and demonstrate a commitment to oral health.

Review Questions


1. What became obvious when the market for dental benefits began to expand in the 1970s?

2. How did early dental consultants contribute to the development of plan designs?

Dental Consultants in the 21st Century (pages 369-377)

Dental Policy Development (page 370)

3. With regard to policy development, the consultant gathers information from current research to achieve what purpose?

4. Why do dental consultants monitor changes in dental practice, technology, and the ADA coding system?

5. What analogy did the author make concerning decision-making without proper oversight?

Utilization Review (pages 370-372)

6. What do plan administrators often fail to grasp when they focus on fee schedules and maximum allowable charges as the hallmark of cost management?

7. Although diagnostic and preventive procedures are just as likely to be abused or misreported as higher cost procedures, they fly under the radar because of __________.

8. Defined as “problem-focused” the __________ code is frequently abused.

9. What action would a dental consultant take regarding a dentist who demonstrates a significantly higher utilization of the exam code?

10. What is the end result of effective utilization review?

11. According to the text, another significant reduction in cost of care that is difficult to quantify is the __________ effect of consultant review.


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Prepayment Claims Review (pages 372-373)

12. (Crowns / Bridges / both) are examples of high-cost or highly abused procedures that should be reviewed prior to payment.

13. What must a dental consultant be prepared to do once a clinical determination concerning plan limitations is made?

14. With effective prepayment review, plans can realize a (20-40 percent / 40-60 percent) reduction in payout for scaling and root planing.

15. What is required for prepayment review of crowns?

16. A dental consultant determines if a crown is the (least affordable method of restoration / only acceptable method of restoration).

17. An important role of the dental consultant with regard to IT is to provide information that is __________, not garbage.

Communications With the Professional Community (pages 373-374)

18. Cite a reason why dentists prefer to talk to other dentists.

19. Like all professions, dentistry has its own __________.

20. True or False: A customer service representative can confirm the company’s dental policies but generally does not have the professional expertise to explain why such policies exist.

21. True or False: Even if members of a group disagree with the clinical rationale, there is far greater understanding of the policy if it is explained by a respected dental colleague.

22. The carrier must have a dentist who is respected as a (consultant / clinician).

Plan Design (pages 374-375)

23. When it comes to plan design, firms are increasingly turning to dental consultants to help separate the __________ from the __________.

24. What does an experienced and respected dental clinician have to offer in responding to RFPs?

25. What was the outcome of this real-world example cited in the text? A dental consultant met with the administrator and the client’s benefits committee to discuss the current best evidence regarding office fluoride applications.

Grievances (pages 375-376)

26. Who can technically adjudicate a complaint when the grievance is against a dentist regarding quality of care?

27. Why is it prudent to have a dentist address a client’s complaint?

28. What does a dental consultant need to know to make a justifiable determination?

29. What is the consultant’s role in a breach of standards of care?

Research (page 376)

30. Who is best suited to take the lead when a corporate carrier links up with dental academia to conduct studies?


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31. What does having a dental professional involved in research signify from the carrier’s perspective?

Training (pages 376-377)

32. What makes employees who are involved in claims review, credentialing, and utilization review more effective in their work?

33. What advantage does a claims reviewer with a good dental background have?

34. What objectives should a dental consultant have for training claims reviewers?

Community Outreach (page 377)

35. Describe two approaches cited in the text that would involve dental consultants, carriers, and providers in community outreach.

36. From the carrier’s perspective, why get involved in community outreach?

The American Association of Dental Consultants (AADC)

37. What is a common trait among dental consultants?

38. What route do many dentists who desire a career change take?

39. This organization emerged out of the frustration of the early “lone wolf” dental consultants.

40. What does the AADC confer to members who participate in educational workshops and pass an exam?


1. The realization that few in the commercial world were knowledgeable in the design and evaluation of dental plans.

2. They developed clinically appropriate plan designs, including covered benefits, exclusions and limitations.

3. To ensure policies provide acceptable care at reasonable prices. 4. To determine what changes are needed to maintain appropriate care while avoiding

payment for services that have little or no health benefit. 5. Making plan design decisions without professional input is akin to establishing premium

rates without the help of actuaries. 6. The nuance that cost of care has more to do with the frequency, mix, and intensity of

services provided than the cost per procedure. 7. The low cost per unit. 8. Exam code. 9. Conduct an analysis and raise questions if records do not support the code definition. 10. Significant cost of care savings and improved quality with minimal administrative costs. 11. Sentinel effect. 12. Both crowns and bridges. 13. Discuss results with the network provider in case there is an appeal. 14. 40 to 60 percent reduction. 15. A periapical film. 16. Only acceptable method of restoration. 17. Relevant. 18. Only a dentist can effectively communicate with other dentists. 19. Jargon. 20. True


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21. True 22. Clinician. 23. “Chaff from the grain.” 24. Far more veracity. 25. Office fluoride for adults was dropped from the plan design. The group was satisfied with

the cost savings and clinical rationale—and retained as a client. 26. A dentist. 27. It protects the administrator from liability and other concerns. 28. Clinical experience as well as knowledge of the benefit program’s contractual and policy

limitations. 29. Review all the available information and make a determination. 30. The skilled dental consultant. 31. The carrier’s commitment to improve clinical quality and outcomes, not just pay claims. 32. A workable knowledge of dentistry. 33. The knowledge to identify unusual claim submissions and forward these claims for

professional review. 34. The consultant can train claims reviewers on the basics of dental x-rays to determine

which are clearly payable and which need to be reviewed by a dentist. 35. Locate a dental facility in an area of need and recruit volunteer dentists, hygienists, and

assistants to provide direct patient care for a day. Have the dental consultant visit schools to give children and parents information on preventing tooth decay.

36. The company gains a positive press and a caring image by developing free clinics for underserved populations, and providing screenings and preventive care for school children.

37. The integration of clinical experience and expertise with successful business skills. 38. Return to school and obtain business-related degrees, such as an MBA or MPH or a

similar concentration. 39. The American Association of Dental Consultants (AADC). 40. Certification to members who demonstrate core knowledge of the dental benefits

industry.


1. Using current evidence-based research to ensure quality care and monitoring ADA updates to CDT codes are part of the dental consultant’s role in the following area:

a. Dental policy development. b. Utilization review. c. Claims review. d. Professional communications.

2. Plans frequently focus utilization review on high-cost procedures, but the largest total dollar payout goes to diagnostic and preventive services which would include all of the following EXCEPT:

a. Radiographs. b. Fluoride treatment. c. Crowns. d. Examination codes.

3. Modern technology has expanded the availability of dentists to:

a. Review claims. b. Conduct utilization reviews.


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c. Provide consultations regarding policies. d. All of the above are correct.

4. In the realm of information technology, the dental consultant can help ensure that input is relevant, evidence-based, and __________.

a. based on the latest scientific data b. peer-reviewed by acknowledged experts c. invaluable to the success of safeguarding benefits d. directly related to the dental business model

5. A network dentist may become frustrated when he or she attempts to explain a clinical situation to:

a. A non-dentist who does not understand the procedure or terminology. b. A respected dental colleague who spoke at the recent AADC meeting. c. A valued office assistant who specializes in dental practice management. d. A network dentist who has experience with a similar patient problem.

6. An experienced dental consultant has far more veracity in responding to this type of inquiry from a potential purchaser:

a. FBI investigation. b. RFP questionnaire. c. CMS patient survey. d. Political opinion poll.

7. To make a justifiable determination concerning a grievance, a dental consultant must have both clinical experience as well as benefit program knowledge related to the following:

a. Contractual and policy limitations. b. Financial and legal liabilities. c. Common patient complaints. d. Adverse determinations.

8. Which of the following explains the rationale for a carrier putting a dental consultant in charge of a research project coordinated by the carrier and a prestigious university?

a. Involving a dental professional signifies the carrier’s commitment to improve clinical quality and outcomes.

b. Allowing the doctor to take the public lead attests to the carrier’s ability to attract the top professional talent in the marketplace.

c. Attracting publicity gives the carrier an advantage, particularly among sophisticated clients, brokers, and benefits consulting firms.

d. Both “a” and “c” are correct.

9. Why have the dental consultant train claims reviewers on the basics of dental x-rays? a. To increase the reviewer’s confidence. b. To determine if the x-ray is payable. c. To determine if a dentist should review. d. All of the above are correct.

10. According to the text, this is an inexpensive yet very effective approach to community outreach:


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a. Asking a dental consultant to write an article promoting oral health for publication in a local newspaper.

b. Having a dental consultant visit schools to provide information to children and parents on oral health care.

c. Launching a public relations campaign in conjunction with a well-known dental school to ban sugary sodas.

d. Buying time on a local TV station to promote a one-day free dental clinic in an inner city neighborhood.

Answers

1. a 2. c 3. d 4. c 5. a

6. b 7. a 8. d 9. d 10. b


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34 Gaining Value From Data Mining—The Case for Data Warehousing in Dental Plans

Objectives


Define data warehousing and describe its conceptual platform,

Understand strategies for building data warehouses and using business intelligence tools,

Discuss key issues in dental plan data warehousing,

Know how to plan for future changes in dental plans, and

Identify areas to target for data-mining opportunities.

Chapter Summary

Data warehousing is the art and science of turning transaction data into business intelligence that can be used to drive new initiatives. Internal data generated by the typical dental health plan is a key corporate asset that should be mined like precious ore. It should be judiciously collected, scrubbed, transformed, and delivered to users in an easy-to-understand fashion. Nurturing enterprise data can pay huge dividends to a dental plan.

This chapter takes you on an expedition into analytical technology where you’ll learn how organizations can become transformational by adopting data warehousing. It will help you understand the conceptual framework of data warehousing and the tools, such as dashboard tracking and data-mining analysis with the power to change paradigms in today’s business world. You’ll grasp ideas for making the leap from information to knowledge to evidence-based decision-making. You’ll also drill down even further to discover five functional areas, including sales and marketing, provider analysis, and actuarial and underwriting assessments, that a dental plan should consider for data-mining opportunities. To develop a data warehousing capability, a company would proceed as follows:

Replace existing transactional system reports or department-based Excel and Access reports with a standardized enterprise-reporting repository.

Create ad hoc query generation capabilities.

Develop Web-based dashboard delivery of key corporate metrics.

Introduce predictive analytic tools.

Review Questions

What Is Data Warehousing (pages 415-417)

1. What does the term data warehousing mean in its broadest sense?

2. What must industries that rely on transactional business processes as core functions do to stay competitive?

3. How is knowledge gained and deployed in the data warehouse environment?


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4. What does the data warehousing environment encompass?

5. What is the simple (but operationally complex) concept that defines data warehousing?

6. What is the data warehousing platform based on?

7. Why should an organization, including dental plan administrators, view their internal data as a key corporate asset?

Insurance Companies or Claims Factories (pages 417-418)

8. How do many insurance organizations envision their primary function?

9. What’s the matter with having a strong focus on claims processing?

10. What is sacrificed when a company has a claims factory mentality?

11. What is the problem with compartmentalizing information and computer technologies into standalone, siloed systems?

Data Warehousing Data Versus Transactional Operational Data (pages 418-421)

12. What is the outcome of an inability to share an organization’s transactional data?

13. In the 1990s, an emerging discipline called __________ addressed the need to aggregate transactional data for easier access and use.

14. What is the main focus of data warehousing?

15. What is the purpose of business intelligence tools?

16. True or False: With data warehousing as opposed to transactional systems development, the task is always completed quickly.

17. Within the business intelligence community, it is accepted that data warehousing is best accomplished in a/an __________ fashion.

18. What’s the outlook on how management will react once an organization becomes reliant on data-driven information and process metrics to conduct business?

19. Why hasn’t data warehousing been fully embraced by businesses?

Strategies for Building Data Warehouses and Business Intelligence Tools (pages 422-424)

20. One of the best ways to maintain integrity of data and information being generated from the corporate information factory is to create a __________ also known as a __________.

21. What does the term “maintaining metadata” refer to?

22. What does the acronym “ETL” stand for?

23. What is one of the primary goals of data-driven organizations, according to the text?

24. True or False: Everyone within an organization needs access to all of the various BI tools, all of the data an organization may employ and collect, all of the time.

Key Issues in Dental Plan Data Warehousing (pages 424-427)

25. What are the four key issues that need special consideration for data warehousing projects?

Individual Identifiers (pages 424-425)


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26. What individual identifier replaced the Social Security number and why was the change made?

27. What is a common event that can trigger an identifier mix-up?

Identifying Providers (pages 425-426)

28. What is the first step in establishing the identity of a provider?

29. What are barriers to tracking individuals over time?

30. What system solution helps overcome difficulties in linking patients and providers through multiple identifiers?

Dental HMO Treatment Data (pages 426-427)

31. What is the core function of evidence-based dentistry?

32. Why is it more challenging to capture data for DHMO plans versus fee-for-service plans?

33. Why does the movement of patients between claims-based and capitation-based plans raise special considerations for data warehousing?

34. What measure is used to analyze aggregate dentist income versus treatment utilization under an HMO plan?

Slowly Changing Dimensions: Planning for the Future (pages 427-430)

35. In the parlance of data warehousing, what must one plan for when the business rules of an organization change?

Changes to the Codes (pages 427-428)

36. What is the most frequently encountered issue faced by dental plans?

37. How has the ADA helped minimize potential disruption to systems that capture procedure-level data?

Participation Status of Network Dentists (page 428)

38. The common churning of network membership is a thorny issue to handle in a ________.

39. To define the participation status of network dentists, __________ are key pieces of information to store in the data warehouse.

Benefit Structure and Plan Design (pages 428-429)

40. Why are elements in plan design/benefit structure important to the process data analysis?

41. When studying treatment utilization over time, what elements would you want to capture?

Medical/Dental Coordination (pages 429-430)

42. What is the rationale for the movement toward a coordinated integration of medical and dental disciplines and its implications for data warehousing?

43. A critical factor in transforming medical/dental science into evidence-based analysis is the ability to link patient outcomes from (both disciplines / multi disciplines).

Areas Rich for Data-Mining Opportunities (pages 430-435)


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44. What are the five functional areas a dental plan should seriously consider for a data warehouse initiative?

Sales and Marketing (pages 430-431)

45. Why is the dental plan business referred to as a zero-sum game?

46. What does data-mining analysis entail?

47. What does data warehousing provide a dental plan that enhances the marketing function?

Provider Analysis (pages 431-432)

48. If the future of dental plans looks anything like medical plans, what looms ahead with regard to government mandates?

49. How might data warehousing initiatives help dental plan administrators prepare for improving patient outcomes and lowering costs?

50. Why should administrators have reservations about using data analysis as “the” definitive source for making network participation and other provider-related decisions?

Treatment Outcome Analysis (pages 432-433)

51. An example of how policy is set by factors of questionable scientific influence is __________.

52. With an effective data warehousing initiative, the plan’s own data can reveal (what works in the real world / what works in the scientific literature).

Patient Cohort Studies (pages 433-434)

53. According to the text, a well-constructed and well-populated dental data warehouse could deliver results similar to the Framingham Study. How so?

54. How might a study of claims history contribute to the actual treatment of a patient with periodontal disease?

Actuarial and Underwriting Assessments (pages 434-435)

55. What could greater predictive power in underwriting lead to?

56. Why is the actuarial group often an excellent place to support and deploy the efforts of a data warehousing initiative?


1. It encompasses the practice of using corporate data to drive new initiatives essential for success of the firm.

2. Move toward more meaningful, value-added services. 3. It is gained through robust data sources and deployed to support strategic decision

making. 4. Building business intelligence systems and fostering a corporate mindset to use data-

driven metrics for directing business performance. 5. Using data to drive evidence-based business decisions. 6. Data that has been judiciously collected, scrubbed, transformed, and delivered to

business users in an easy and understandable fashion. 7. Substantive data enables an organization to generate reliable information, promote

informed knowledge, gain insight, and ultimately make sound business decisions.


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8. As a factory processing thousands of claims. 9. It is shortsighted and financially unsustainable in today’s competitive market. 10. Weakens financial commitments to developing IT systems and providing operational

support for the benefit plan enterprise. 11. Vast quantities of data cannot be shared, integrated, or used for other purposes, such as

decision-making. 12. The opportunity to use one of the organization’s key assets—its internal data—is lost. 13. Data warehousing. 14. To build a repository of transactional data from multiple functional system sources. 15. To provide an interface between nontechnical data users and the data warehouse. 16. False 17. Incremental. 18. Management will become enlightened and seek ever-increasing sophisticated

technologies. 19. It requires a huge investment and complete commitment to long-term objectives. 20. Centralized repository, also known as a data warehouse. 21. The endeavor of creating common names and definitions of key business terms and

elements used in data analysis. 22. Extracting data (E), translating it to common definitions and values (T), and loading it to

the data warehouse (L). 23. Place the function of gaining information away from specialized IT staff and into the

hands of the data user. 24. False 25. Individual identifiers, DHMO treatment data, slowly changing dimensions, and

medical/dental coordination. 26. The SS# was replaced with group-assigned or plan-assigned identifiers to protect

privacy and security. 27. Jane Doe gets married and changes her name. 28. Determine if he or she is a billing dentist or a rendering dentist. 29. HIPAA, electronic identifiers, and other regulatory requirements. 30. Crosswalk lookup tables. 31. Analyzing treatment patterns. 32. DHMO plans are not claims-based; providers are asked to submit “encounter forms” for

tracking services, but do not always comply, thus compromising data integrity. 33. Treatment pattern analysis can be seriously compromised if the records are incomplete. 34. Relative value scores (RVS) that measure the intensity of treatment. 35. Slowly changing dimensions related to codes, participation status of network dentists,

enrollee benefit structure, and plan design. 36. Periodic changes made to procedure codes and their descriptions. 37. The ADA recognizes the need to maintain uniformity and continuity in its codification

scheme. 38. Data warehousing. 39. Panel start and stop dates. 40. For forecasting, pricing, and analyzing the utilization and cost of dental services. 41. As many as possible benefit design elements common to the study population. 42. Overall improvement in health outcomes. Dental and medical plans operating under the

same corporate umbrella should plan for an integrated medical/dental data warehouse. 43. Both disciplines. 44. Sales and marketing; provider analysis; treatment outcome analysis; patient cohort

studies; actuarial and underwriting assessments.


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45. The term refers to the fact that the number of insured mouths and teeth is fairly static, increasing only by the general population growth rate.

46. Studying patterns of provider, treatment, and patient complaints within clients groups. 47. The opportunity to partner with one’s clients in all aspects of enrollee satisfaction and

support. 48. The need for transparency and accountability in provider billings and fees. 49. Give them a jump ahead in the ability to mine their rich claim and provider information. 50. Pure data analysis has its limitations when evaluating provider performance. 51. The two-in-12-month allowance for prophylaxis. 52. What works in the real world. 53. Through patient cohort claims analyses, the study could enhance understanding of the

epidemiology of dental disease. 54. The plan could initiate a number of patient interventions based on evidence supplied by

patient cohort studies. 55. Greater precision in the rate-setting process for both renewing clients and the pricing of

client prospects. 56. Actuarial staff are inherently “data friendly” and generally early adopters of technology.


1. Which of the following is a component of data warehousing? a. Building business intelligence systems. b. Fostering a corporate mindset to use data-driven metrics. c. Promoting the image of data factory. d. Both “a” and “b” are correct.

2. According to the text, dental plan administrators should view their internal plan data as: a. A key corporate asset. b. A management resource. c. An expensive necessity. d. An element IT manages.

3. Ask most insurance companies what their major area of competence is and the answer is likely to reflect pride in their enormous ability to:

a. Pay claims. b. Maintain eligibility files. c. Provide members with call center support. d. All of the above are correct.

4. Any data warehousing program will likely yield suboptimal results if management takes

any of the following away EXCEPT: a. Systems development. b. Short-term objectives. c. Human capital. d. Management focus.

5. Why must care be taken in the data warehouse environment to preserve historical data integrity?

a. To ensure accurate analysis when data is viewed over time. b. To crosscheck code set changes against previous revisions. c. To ensure that codes match dental treatment procedures.


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6. What are the choices data warehouse developers have for addressing slowly changing dimensions?

a. Doing nothing. b. Overwriting data. c. Date stamping changes. d. All of the above are correct.

7. According to the text, this methodology has limitations when evaluating provider performance.

a. Data repository. b. Pure data analysis. c. Data mining tools. d. Metadata.

8. The most significant aspect of a dental plan’s business is customer retention. Which of the following could provide a big boost in this endeavor?

a. Data warehousing and business intelligence (BI) tools. b. Customer service metrics. c. Sales and marketing metrics. d. Database marketing.

9. Why be cautious when performing patient cohort studies based on a dental claim-based data warehouse?

a. It is based on medical codes. b. It contains inherent limitations. c. The technology is not robust. d. All of the above are correct.

10. Known to be data friendly and early adopters of technology, the actuarial group may be an excellent place to find support for a data warehousing initiative, especially because of the following:

a. New paradigms. b. New platforms. c. Useful business intelligence tools. d. All of the above.

Answers

1. d 2. a 3. d 4. b 5. a

6. d 7. b 8. a 9. b 10. c


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35 Informatics and the Whole-Health/Dental Health

Connection

Objectives


Understand how sound research and unbiased analytics can lead to better employee health outcomes and a reduction in costs,

Describe the whole-health approach and the importance of employee engagement,

Define characteristics of employee population groups and identify the first goal of any health care program, and

Recognize the four critical steps in applying health care analytics.

Chapter Summary

Making the right connections is important to business success and, as you’ll see from this chapter, in areas of employee health management as well. Students get a unique opportunity here not only to explore the challenges confronting employers who sponsor employee health care programs but to examine proposed solutions through the lenses of two disciplines.

Informatics is a science that deals with the processes of storing and transferring information. It gathers data from varied disciplines—in this case dental and medical— to uncover trends and find potential solutions to current health care problems. Analytics is a system of reasoning that delves into elemental parts or basic principles to search for meaningful patterns in data. It is a method of logical analysis that is especially useful in efforts to quantify performance.

In its discussion of the whole-health approach to oral health, this chapter brings the two disciplines together to focus on the ways that informatics and dental analytics in particular can best be used to improve health outcomes and ultimately reduce costs.

Review Questions


1. What is one of the most important, yet costly elements of maintaining a productive workforce?

2. How have organizations attempted to offset rising health care costs?

3. What suggestions does the author make for addressing issues related to health care benefits?

4. Which population needs to be engaged in making improvements?

Why Dental Matters (pages 437-438)

5. What does the state of a person’s oral health reveal? 6. Gum disease might be an early predictor of what other kinds of diseases?


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7. Diseases not normally associated with the mouth are often first observed by the (patient / dentist / physician).

8. Aside from the low-cost, high value coverage offered by dental plans, what is another

value-added benefit?

The Whole-Health Approach (page 438)

9. How does the benefits manager receive health care information on employees and what problem does it cause?

10. How does the text describe the whole-health approach? 11. What would be the expected outcomes of applying whole-health concepts?

Employee Engagement: The Essential Element (page 439)

12. A critical ingredient in achieving health improvement objectives is involving and motivating (management / employees).

13. What is the qualitative dimension that is absolutely essential for achieving health

improvement objectives? 14. Successful employee engagement begins with what fundamental notion? 15. For a manager, having employee health information presented in __________ makes it

impossible to understand.

Understanding Your Employee Population (pages 439-440)

16. In the process of employee engagement, what is the first step for the benefits manager? 17. Name the four segments that identify the health status of employee populations. 18. What is the first goal of any health care program? 19. What are the two aspects of the second immediate goal? 20. (Seventy / Eighty) percent of total health care costs are attributed to the chronically ill

population. 21. What is the most startling trait of the chronically ill population group, according to the

text? 22. What is required before you implement a wellness measurement platform?

Employee Engagement and Health Care Analytics (page 440)

23. How can you get the greatest return on investment through health care analytics?

Validating Employee Engagement Programs (pages 440-442)

24. What are the four critical steps for applying health care analytics to validate your company’s employee engagement programs?


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25. The first step in gauging the effectiveness of employee engagement programs is to establish (a threshold / a baseline) of your employees’ overall health.

26. How can you know how well your company is doing in improving employee health? 27. How can you determine which health initiatives will be cost effective for your group? 28. What will you gain by using the data from your own employee population and applying

the principles from proven engagement programs? 29. After you have applied your employee engagement initiatives, what is your next step?

Case Study: Apply Informatics to Dental Plans (Page 442)

30. What metrics were tracked in the end-to-end approach described in the case study?

The Future of Health Care Analytics (page 443)

31. How is the “shotgun” approach to health improvement initiatives changing? 32. What is the future focus of health care analytics?


1. Employer-sponsored health care. 2. Changing plan design and cost shifting. 3. Leverage data-driven methods and informatics to facilitate change, let go of long-held

beliefs and practices, and recalibrate expectations. 4. Employees. 5. Insight into his or her overall health. 6. Diabetes, kidney disease, adverse pregnancy outcomes, osteoporosis, Alzheimer’s

disease, and certain types of cancer. 7. Dentist. 8. It’s a vital predictor of overall health. 9. Information is disaggregated and based on multiple, separate data feeds on conditions,

treatment, cost, and sometimes outcomes. It causes information overload. 10. Compile unbiased information and apply the knowledge gained to addressing the

individual employee’s health care needs while the conditions are still manageable. 11. Improvement in employee health and reduction in health care costs. 12. Employees. 13. Employee engagement. 14. Whole-health measurement. 15. Silos. 16. Understanding the employee population. 17. Healthy population, at risk, chronically ill, catastrophically ill. 18. To care for the catastrophically ill. 19. To keep the healthy population as healthy as possible; to reduce the risk factors for

those in the at-risk segment. 20. Seventy percent. 21. For the most part their conditions are preventable. 22. Establishing a baseline of the current situation. 23. By using unbiased data to either prove or disprove the effectiveness of a wellness

initiative. 24. Measure, plan, change, and track.


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25. A baseline. 26. By comparing your own company’s health score against similar industries. 27. Identify the specific at-risk groups and determine from research which employee

engagement measures would have the greatest impact. 28. You should achieve better results than by simply applying a blanket solution to your

entire employee base. 29. Track the results to prove or disprove the effectiveness of each initiative. 30. Activity, engagement, and outcome metrics were tracked for 28 initiatives that included

dental, dental/medical, and medical-only. 31. It is becoming more focused and individualized. 32. Continual improvement based on accurate data and constant feedback to reduce costs

plus timely treatment coupled with positive lifestyle changes for at-risk groups.


1. People with periodontal disease may be at risk for which of the following: a. Obesity. b. Hypertension. c. Diabetes. d. All of the above.

2. The whole health approach to wellness and prevention advocates all of the following methods EXCEPT:

a. Compile unbiased information. b. Apply knowledge based on individual health needs. c. Pay employees to participate in studies on oral health care. d. Use informatics and analytics to improve outcomes and reduce costs.

3. The first goal of any health care program is to care for the __________ population. a. catastrophically ill b. healthy c. at-risk d. chronically ill

4. The following is NOT a critical step in the application of health care analytics in the workplace:

a. Determining an overall health baseline. b. Applying research from generic scientific studies. c. Establishing initiatives based on employee health needs. d. Tracking results.

5. Which of the following is a contributing factor in reducing health care costs? a. Denying patient care. b. Making lifestyle changes. c. Encouraging timely treatment. d. Both “b” and “c” are correct.


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Answers

1. d 2. c 3. a 4. b 5. d


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36 Technology and the Active Consumer: Empowerment Through Information

Objectives


Explain why health plans are shifting responsibility to the employee/beneficiary;

Define consumerism and describe products that fall under the umbrella of consumer-directed health care;

Account for changes in consumer behavior and know how the Internet has influenced buying patterns and decision-making;

Discuss the impact of technical advances, such as member portals, online directories, and Websites that provide credible health information for consumers; and

Identify what’s in the pipeline for dental benefits, technology, and the future.

Chapter Summary

As health care costs escalate and employees are pressured to assume more responsibility for paying their share, many are feeling the pinch. What if these new health care initiatives lead to a consumer-centric system? Would consumers use the wealth of resources on the Internet to become more informed? Will they comparison shop for providers and dental services as they now do for deals and discounts on eBay and Expedia?

It’s already happening. This chapter confirms that many support tools are in place to turn passive, sometimes reluctant consumers of dental and other health care services into energized, informed decision-makers. It focuses on early technology applications used to help consumers make informed decisions, and addresses how technology has improved the dental experience by guiding patients through the many dental care choices they face. It also contains some predictions on what future applications might look like.

Review Questions


1. Why have employees in the past been less conscious of the price of health care services?

2. What might patients expect to know in advance in a pay-as-you-go, cash-based health care system?

3. The concept of shopping for the best value in health care products and/or providers is now referred to as __________.

4. The consumer-directed approach to health care shifts responsibility of decision-making to (employer/sponsors / employee/beneficiaries).

5. What do beneficiaries need to make better health care decisions?

6. Why does the electronic approach have an advantage in the delivery of health care information to consumers?


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Exploding Health Care Costs (page 446)

7. Health care costs are escalating at a rate that is typically (two to three / four to five) times the Consumer Price Index (CPI) for all other goods and services.

8. What are the two primary paths employers have followed to reduce the rising cost of health care?

Consumerism Efforts (pages 446-450)

9. Which groups pushed the move toward health care consumerism and why?

10. What did the Internet facilitate for consumers?

11. What is the additional challenge faced by consumers in making informed health care decisions versus purchasing typical consumer products like cars or appliances?

Consumerism in Health Care (pages 448-450)

12. How is the role of consumers changing with regard to health care?

13. What was missing from the traditional health care scenario?

14. What types of consumer-directed health plans put the employee in control of their health care services and expenses?

15. Enrollees of CDHPs receive a set dollar amount from their employer, sometimes through a __________.

16. To become good consumers of health care, what must employees be willing to do?

17. How can employers help employees make wise health care choices?

18. Who were some of the early innovators that provided credible information on the Internet to help health care consumers?

19. (Health Grades / FAIR Health) is an independent source of health care reimbursement data for consumers, insurers, health care providers, and others.

Dental Benefits, Technology and the Future (pages 450-454)

Dental Benefits as a Part of the Benefits Spectrum (pages 450-451)

20. True or False: While dental premiums represent only a fraction of the cost employer-sponsored plans pay for medical benefits, employees highly value their dental benefits.

21. True or False: Because of the link between a person’s oral health and their overall health, dental has new importance in the health care spectrum.

Dental Benefit Costs (pages 451)

22. The basic cost elements for dental plans fall into _________ and _________ cost buckets.

23. The cost of managing eligibility, adjudicating claims, customer service, etc., comes out of which bucket?

24. The cost of dental care services comes from the __________ bucket.

25. What are claims costs directly attributable to?

Technology Adds Value and Reduces Cost (pages 452-454)


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26. The proliferation of home computers has helped plans (accelerate investment in online support tools / improve customer satisfaction / both) for members.

27. What is the before and after scenario of open enrollment meetings now that dental plans have member portals?

28. What is the most obvious benefit of having an online provider directory?

29. What is the impact of insurance companies having specific portals for constituents on their Website?

Future Predictions for the Dental Benefits Industry (page 455)

30. What are some technical advances already employed in the medical industry that may have applications for the dental benefits industry?


1. Health care benefit plans were structured in a way that shielded employees from the true cost.

2. Consumers would expect to know the price of each non-emergency service in advance. 3. Consumer-directed health care or “consumerism” for short. 4. Employee/beneficiaries. 5. The right combination of information and motivation (e.g., accurate, easy-to-access

objective information and decision-support tools). 6. It is the most cost-effective method for delivering large amounts of up-to-date complex

information. 7. Two to three times the CPI. 8. (1) reducing benefits and/or (2) requiring employees to pay a greater share of “up-front”

costs. 9. Employers, patients, providers, and administrators frustrated because of the

unsustainably rapid rise in health care cost. 10. Opportunity to compare similar products/services, evaluate reviews by other users, and

become more informed. 11. Providers have the ability to influence demand for their services by determining how

much and what kind of procedures they recommend. 12. Consumers are being encouraged to take more responsibility in spending health care

dollars and more active in making treatment decisions. 13. Incentives for patients to shop wisely or ask questions or for providers to concern

themselves with the cost-effectiveness of the treatment provided. 14. Health savings accounts (HSAs) and health reimbursement accounts (HRAs). 15. Debit card. 16. To take responsibility for their lifestyle, shop effectively for the best care, and be

engaged and knowledgeable with the provider’s recommendations for treatment. 17. Provide employees with information and decision support tools. 18. WebMD, NCQA, HealthGrades, to name just a few. 19. Fair Health. 20. True 21. True 22. Administrative and claims cost buckets. 23. The first bucket for plan administration. 24. The second bucket for claims cost. 25. The care decisions patients make and the dentist they select.


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26. Both online support and customer satisfaction. 27. Before there were only minutes allotted to the dental program, now employees and

family members can look up information on the member portal. 28. Provider directories are online within the member portal of the insurance company’s

Website and constantly updated. 29. Fewer staff and equipment are needed to support customer service centers. Most

questions are answered via self-service. Both changes reduce administrative costs. 30. Employer-customized Web interfaces, provider rankings and reviews, tiered networks,

mobile applications, patient bartering, social networks and corporate intranets that link people to resources that help them understand and resolve health problems.


1. The underlying concept of the consumer-directed approach to health care is based on: a. Comparison shopping for the best products and services. b. Incentives designed to shift decision-making to the beneficiary. c. Reduction in the complexity of plan administration and service. d. Reduced costs in employer-sponsored health care for employees.

2. Which tool for delivery of health care information to consumers may have the greatest advantage?

a. Verbal. b. Written. c. Electronic. d. All of the above.

3. What do consumers need to be aware of when becoming active health care participants?

a. The true cost of care. b. Their personal stake. c. Future predictions. d. Both “a” and “b” are correct.

4. Which of the following is NOT a factor that is shaping the evolution of CDHPs? a. Consumers will design their own health plans. b. Consumers will spend their own money. c. Consumers will make their own buying decisions. d. All of the above are correct.

5. In practice philosophy and fees, dentists can vary a lot. According to the text, these differences can be attributed to:

a. Training and education. b. Patient population demographics. c. Marketplace factors. d. All of the above are correct.

6. Considering the two different approaches to health care decision-making, a patient that

is consumer-centric would be: a. A passive user. b. Active and engaged. c. Neglectful of oral health. d. None of the above.


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7. What relevance do online models such as eBay and Expedia have for today’s health

care consumers? a. Tell consumers how to find best buys. b. Guide consumers to alternative care. c. Help consumers make informed decisions. d. Provide quick-look self-help advice.

8. All of the following predictions for the dental benefits industry are based on trends

showing up on the medical side EXCEPT: a. Patient demand for boutique services. b. Web interfaces that deliver self-help. c. Provider rankings and reviews. d. Proliferation of mobile applications.

9. How have technological advances improved open enrollment meetings? a. Meetings last the same amount of time, typically 60 minutes. b. Employees learn about portals and tools for acquiring more information. c. Employees learn about changes in member benefits that may affect them. d. Dental programs are usually explained in 3 to 5 minutes.

10. On FAIR Health’s consumer portal, users can access data that helps them: a. Find information on conditions, symptoms, and dental terminology. b. Get directions to local dental facilities and provider phone numbers. c. Evaluate fees charged by procedure code and zip code location. d. Review scientific literature on new developments in dental care.

Answers

1. b 2. c 3. d 4. a 5. d

6. b 7. c 8. a 9. b 10. c


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37 Developing Direct-to-Consumer Markets

Objectives


Understand the current approaches carriers are taking to reach consumers who do not have group dental coverage,

Identify some of the barriers to growth in a potentially huge market segment,

Recognize the importance of developing the right sales and marketing approaches, and

Know how operations can be honed in a phased approach to developing and marketing a direct-to-consumer dental product.

Chapter Summary

An estimated 43 percent of Americans have no dental health coverage. Considering the popularity of group dental benefits, you would think individual policies would also be a must-have. Yet, according to the National Association of Dental Plans (NADP), less than 4 percent of the population is covered. Why aren’t individual consumers buying dental insurance? Is it due to a lack of awareness? Is it a rational, informed financial decision, for whatever reason? Or do carriers simply misunderstand the demographics and motivations of these potential buyers?

This chapter addresses these questions and more in an in-depth focus on the direct-to-consumer market. It begins by carefully dissecting and explaining the approaches that carriers are currently using to reach the consumer who does not have group coverage. Here’s a brief rundown of eight main points:

Carriers are looking at a variety of markets and approaches to the direct-to-consumer market.

Carriers have approached this market from a product perspective with offerings that rely heavily on traditional group plan designs and features.

Many of the inherent product advantages of a group plan do not apply to an individual product.

Consumers will carefully consider the expected benefits and the true cost of a plan before purchasing.

The key to creating a viable individual product is to develop a provider network that is specific to the direct-to-consumer market.

Successful direct-to-consumer offerings require significantly different operational capabilities than for traditional group policies.

Developing the appropriate sales and marketing approach is vitally important.

Creating a phased approach to developing and marketing a direct-to-consumer dental product may be best.

For starters, to be successful with a consumer product, a carrier must have a well-thought-out plan that is mindful of the organization’s overall objectives, financial tolerance, product development resources, market segmentation, messaging, and measurement capabilities. In a four-part template, the author details steps carriers should take in creating direct-to-consumer marketing efforts and administering individual dental offerings:

Phase 1: Formulate a strategic plan with business intelligence.


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Phase 2: Build consumer-focused technology and revenue foundation.

Phase 3: Engage prospects to convert to customers.

Phase 4: Nurture best customers to create “staying power.”

Review Questions


1. What percent of dental benefit plans are currently sold to single employers and multiemployer trusts?

2. Now that the group market has become mature, what are dental vendors considering to pursue growth?

3. In offering dental products to individuals, what have carriers discovered?

Variety of Markets and Approaches to the Direct-to-Consumer Market (pages 458-459)

4. From what perspective does the direct-to-consumer market offer carriers an opportunity for growth?

5. Mass marketing individual products to the general public gives carriers the ability to reach a targeted population of people who currently (have / do not have) dental coverage.

6. How can carriers reach targeted populations in the individual consumer market?

7. What is an example of an affinity group that offers value-added services to its members as a way to increase membership?

8. How does the affinity group or association benefit from the sponsorship?

9. What strategy has emerged for employers who want to eliminate retiree group benefits?

10. From the carrier’s perspective, individuals who have had continuous dental coverage are likely to be a better (marketing prospect / underwriting risk).

11. Direct-to-consumer plans are similar to __________ in which there is no cost to the employer.

12. In what ways do voluntary group plans differ from individual plans offered directly to consumers?

Carrier Approaches from a Product Perspective (pages 459-460)

13. What is the typical pattern of plan design for individual dental benefit plans?

Insured Plans (pages 459-460)

14. What are the three models of insured plans discussed in the chapter?

15. What provisions make direct-to-consumer products using the fee-for-service design affordable?

16. How are DHMOs attractive to carriers offering coverage in the individual market?

17. What is a disadvantage of using DHMOs in the individual market?

18. How do hybrid plans work in the individual market?

Access Only Plans (page 460)

19. What advantage do access only plans offer the consumer?


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20. How do access only plans work?

Advantages of a Group Plan Do Not Apply to an Individual Product (pages 460-462)

21. True or False: An individual insured product with the same plan design as a traditional group plan will cost more than the group plan.

22. Why are claims cost higher with individual dental plans?

23. What accounts for the higher administrative expenses for individual plans?

24. Unlike employer premium payments and employee contributions which are (paid before / exempt from) taxes, individual plan premiums are paid by the consumer with (pre- / after-) tax dollars.

25. True or False: The additional cost factors that affect individual dental plans have a significantly greater impact on access only plans.

Consumer Considerations of Expected Benefits Versus Plan Cost (pages 462-463)

26. Before purchasing an individual plan, what would consumers carefully compare?

27. How have carriers attempted to make the cost of individual plans more affordable?

28. Validating discounts has been an issue for consumers who have individual __________ plans.

Creating a Provider Network Specific to the Direct-to-Consumer Market (page 463)

29. What is the critical component to offering a dental product with consumer value?

30. What must the network offer consumers?

31. What are two main considerations for carriers building dental networks for individual consumers?

Direct-to-Consumer Offerings Require Different Operational Capabilities (pages 463-464)

32. How will a carrier’s existing technological systems need to be modified to offer direct-to-consumer products?

33. What staff and system modifications will be needed in the customer service area?

34. What other area may come under increased scrutiny with the addition of individual policies and discount-only plans?

Developing the Appropriate Sales and Marketing Approach (pages 464-465)

35. What are many carriers concerned about with regard to marketing through well-established group delivery systems?

36. What must carriers do to be successful in the direct-to-consumer market?

37. Carriers have cultivated a (catchy slogan / brand image) unique to the consumer market.

38. Some additional approaches carriers will need to consider in reaching the consumer market are (TV and radio advertising / the use of social media / both).

Creating a Phased Approach in Direct-to-Consumer Marketing (pages 465-468)

39. On the carrier side, what’s missing with regard to marketing dental plans to consumers?

40. Where do you start in the development of direct-to-consumer marketing efforts?


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41. Statistical procedures that model choices made by people among a finite set of alternatives are referred to as __________.

42. What instrument may be used within the framework of the discrete choice model to test various product offerings?

43. The findings from discrete choice model research help the carrier to determine (effectiveness of buy messages / influences of purchasing decisions / both).

44. In a __________ study, survey respondents have the opportunity to select the benefits and features of a dental benefit offering that are most important to them.

45. Research findings from a correlation study help carriers develop a _________ scheme.

46. After the needs of the various segments are identified, what’s the next step?

47. In brief, what is the three-prong approach outlined in phase two for marketing a direct-to-consumer product?

48. In phase three, the objective is to convert prospects into __________.

49. How do you accomplish customer conversions using tactics outlined in phase three?

50. What is the objective of phase four in the template for marketing and administering direct-to-consumer plans?


1. Well over 90 percent. 2. Non-traditional, direct-to-consumer product offerings. 3. Consumer uptake has been minimal. 4. From the perspective of market size of the population eligible to purchase. 5. Do not have dental coverage. 6. By partnering with affinity groups and associations that offer products to their members. 7. AARP. 8. The partnership is a way to increase membership and loyalty to the group. 9. Provide retiree with access to individual dental benefits. 10. Underwriting risk. 11. Voluntary group dental plans. 12. As opposed to individual policies, voluntary plans have a master policy with certificates

issued to covered employees; employers collect premiums through payroll deductions; and participants may pay premiums with pretax contributions.

13. Typically the design and features are patterned after traditional group products but issued as insured plans or access only plans.

14. Fee-for-service comprehensive plan design; dental HMO products; and hybrid plan design.

15. Longer wait periods and incentives to see a network provider. 16. The cost control mechanisms of DHMOs reduce the risk of an underwriting loss. 17. Carriers have had difficulty developing robust provider networks. 18. Hybrid plans reimburse the consumer for a portion of preventive services but provide

only access to the network discounts for restorative and major expenses. 19. The consumer gains access to a discounted fee schedule the carrier has negotiated with

network dentists without providing any insurance reimbursement. 20. The consumer pays an access fee on a quarterly or annual basis and receives the

discounted rate for services performed by a network dentist. 21. True


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22. Individuals that purchase plans are much more likely to use the plan benefits, resulting in higher claim cost and higher premium rate.

23. Unlike group plans, there are no economies of scale for individual dental policies. 24. Exempt from taxes; after-tax dollars. 25. False 26. The cost versus expected benefits of the individual plan. 27. By including plan design restrictions such as higher deductibles and waiting periods. 28. Access only plans. 29. Access to network dentists through either a dental insurance policy or an access only

product. 30. Meaningful discounts for a wide range of procedures; sufficient access to quality

dentists. 31. First, achieving the financial result that makes the product competitive; second, providing

access to a large number of quality dentists. 32. New billing/eligibility protocols will need to be created. 33. Modifications to claims and customer services systems including direct and online

servicing; possibly additional staff training and new protocols for handling a different demographic segment.

34. State licensing requirements and regulatory compliance. 35. That benefit brokers and consultants will be alienated. 36. Develop cost effective, efficient sales approaches tailored to specific market needs. 37. Brand image. 38. Both TV and radio advertising and the use of social media. 39. Lack of experience in marketing, selling, and administering benefits that are sold directly

to consumers. 40. With a strategic plan based on robust business intelligence. 41. Discrete choice models. 42. An online survey. 43. Both the effectiveness of buy messages and the influences of purchasing decisions. 44. Correlation study. 45. Segmentation scheme. 46. Relevant packages and messaging by segment can be developed based on the

attributes of the “best customer” of each segment. 47. Build a cost effective prospect and customer marketing data mart; prioritize transactional

technology and customer service needs; create or adapt financial models tailored to consumer-based business.

48. Customers. 49. Build a multi-media communications strategy; create an Internet marketing plan; tailor

communications to a one-to-one strategy for key targets; develop early “wins” by testing marketing content and audience.

50. Nurture best customers with ongoing communications, relevant messaging, and retention offers to create staying power.


1. Mass marketing individual products directly to the general population presents dental plan carriers and vendors with the opportunity to accomplish which of the following?

a. To carve a new niche in a saturated market. b. To reach anyone without dental coverage. c. To develop less costly marketing methods. d. To test new products in uncharted territory.


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2. Individual plans differ from voluntary plans in all of the following ways EXCEPT?

a. Offer payroll deductions. b. Provide individual policies. c. Paid directly by consumers. d. Are paid with after-tax dollars.

3. Carriers offering individual dental benefit plans typically pattern the design for insured

plans on which of the following traditional models? a. Fee-for-service comprehensive plan designs. b. Dental HMO products. c. Hybrid plan designs. d. All of the above are correct.

4. A direct-to-consumer marketing plan includes all of the following steps EXCEPT:

a. Build technology and revenue foundation. b. Advertise on TV in prime time. c. Formulate a strategic plan. d. Nurture best customers.

5. Which of the following product advantages of a group plan apply to an individual product?

a. Claims cost will be lower. b. Administrative expenses are lower. c. Premiums are tax exempt. d. None of the above would apply.

6. Carriers have cultivated a brand image unique to the consumer market that they project to a targeted audience consisting of these groups:

a. Health benefit purchasers. b. Benefit brokers. c. Dental consultants. d. All of the above.

7. To be successful with a consumer product offering, a carrier must have:

a. Unlimited resources. b. A well-thought-out plan. c. Analytical technology. d. All of the above.

8. According to the text, consumers often deal with the cost of dental treatment by taking this action.

a. Self-insuring. b. Cutting back on treatment. c. Ripping off the system. d. Both “a” and “b” are correct.


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9. Building a “marketing pyramid” using “discrete choice” analysis and research is part of

which phase of developing a consumer dental product? a. Phase 1 b. Phase 2 c. Phase 3 d. Phase 4

10. How can a carrier create early “wins” in Phase 3 (converting prospects into customers)? a. Provide “freebies” as incentives. b. Track marketing results. c. Test market content and audience. d. Both “b” and “c” are correct.

Answers

1. b 2. a 3. d 4. b 5. d

6. d 7. b 8. d 9. a 10. d


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38 Using Evidence-Based Dentistry to Improve Plan Management, Clinical Outcomes and Consumer Satisfaction

Objectives


Define what is and is not evidence-based (EB) practice,

Identify the technical steps involved in EB practice,

Explain why EB practice has an important role in dental benefits, and

Describe how EB practice can be applied to dentistry and plan management.

Chapter Summary

This chapter provides an overview and explanation of evidence-based (EB) practice and its role in enhancing dental care and quality. The author uses the current definition, describing EB practice as the integration of best research evidence with clinical expertise and patient values. Best research evidence refers to clinically relevant, patient-centered outcomes data. Clinical expertise means applying clinical skills and past experience to address each patient’s unique health state and diagnosis. Patient values are unique preferences, concerns, and expectations each patient brings to a clinical encounter. The major steps of EB practice are as follows:

Ask an answerable question.

Gather the best evidence.

Appraise the evidence critically.

Apply the results of the critical appraisal.

Evaluate the results and make appropriate changes.

EB practice is important because it provides an assurance that care is of high quality, taking into account both the patient’s values and the best practices in the industry. This is particularly essential in an age of increased consumer awareness and demand for value. With its focus on the treatment of two primary diseases (tooth decay and periodontal disease), dentistry should find the concept of EB care easy to adopt. At its core, disease management is about using evidence-based processes to improve health, so it is a natural fit. In addition, in our increasingly litigious and regulated society, an evidence-based approach may enable providers to avoid legal entanglements.

Review Questions

What Is Evidence-Based (EB) Practice? (pages 469-475)

1. What is the current definition of evidence-based practice?

2. What is meant by best research evidence?

3. What does the term patient values refer to?


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4. Managed care and insurance plan designs are focused on the effective and efficient management of (populations / individuals).

5. What two elements are integrated in a practitioner’s evidence-based approach? 6. Decision support for health care systems (has / has not) made significant strides in

dentistry.

7. Some dental professionals fear that (regulators / insurance companies / both) will take over health care and limit professional judgment.

8. The evidence-based approach is about __________ by the practitioner and the tools to

make better decisions.

9. What are the three aspects of choice in evidence-based practice?

10. What is the goal of evidence-based care?

11. A major challenge in the practice of evidence-based dentistry is obtaining solid (clinical experience / outcomes data).

12. As a profession, dentists (have / have not) systematically collected and analyzed the

outcomes of care.

13. What are the five steps of the evidence-based approach?

14. What is the easiest-to-use Internet resource on dental and medical issues?

15. The best research questions are not general, but rather __________.

16. Name two organizations that are supportive of evidence-based dentistry.

17. What are randomized controlled trials (RCTs)?

18. Name two journals that have researched and analyzed evidence-based dentistry.

19. What is the Cochrane Collaboration?

20. What is the most reliable type of study?

Why Is EB Practice Important? (pages 475-479)

21. What are two significant barriers to the practice of evidence-based dentistry?

22. What are two primary drivers of evidence-based practice?

23. What are consumers of medical and dental care now using increased access to computer technology to do?

24. In the United States, the insured population consumes (50 percent / 65 percent) of

dental services.


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25. Health care consumers are increasingly seeking choice in (providers / treatments / both).

26. Consumers increasingly want their providers (to make / to be involved in) most decisions

related to their health care.

27. Health care consumers are increasingly influenced by (branding and marketing / referrals from friends and relatives).

28. What are two barriers to consumerism in dentistry?

29. The knowledge gap between dentists and their patients is currently (narrowing /

widening).

30. In his book Demanding Medical Excellence: Doctors and Accountability in the Information Age, what does Michael Millenson say is behind the demand for evidence-based practice?

31. Over the years, variations in the treatment plans of different dentists for the same dental

condition have led to questions of ___________.

32. The application of (evidence-based dentistry / office reviews) goes a long way toward narrowing the range of variation in dentistry.

33. What is the value equation?

34. Identify the three dimensions of quality put forth by Avedis Donabedian.

35. In dentistry, most structural elements, such as x-ray equipment and sterilization

procedures, are monitored by (regulatory and licensing agencies / the office review process).

36. Process addresses the (providers’ / patients’) values and how they will be met in health

plans and the health care system.

37. In which of the three dimensions of quality can dental providers significantly improve the health delivery system?

38. What two elements are required to improve health plan quality through a continuous

improvement process? Applications to Plan Management (pages 479-481)

39. The difficulty keeping up in dentistry relates to the explosion in scientific literature. There are currently more than 50 reviewed journals that cover (endodontic / restorative) dentistry.

40. Dentistry is primarily concerned with the treatment of dental caries and periodontal

diseases, both of which (are bacterial infections / result from TMJ).


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41. Both dental caries and periodontal diseases were (rare / pandemic) in the United States for most of the 20th century.

42. During the first half of the 20th century, the incidence of _________ was high and it often

occurred at a very young age.

43. A study by the National Health and Nutrition Examination Survey showed that (20 percent / 35 percent) of the population manifests 60 percent of dental disease.

44. In the area of restorative services, (10 percent / 25 percent) of the population receives

65 percent of services.

45. In the area of periodontal services, 10 percent of the population receives (70 percent / 98 percent) of the services.

46. The application of evidence-based practice is most salient in the provision of

(prosthodontic services / disease management).

47. What are the goals of disease management?

48. The core concept of disease management involves avoiding the acquisition of (decay / infection).

49. Dental caries account for approximately (45 percent / 60 percent) of the direct costs of

dental care.

50. Periodontal disease accounts for approximately (17 percent / 7 percent) of the direct costs of dental care.

51. In disease management, a key in risk assessment involves assessing what individuals?

52. What is a useful tool in managing risk because it can be used to help improve oral health

for an entire population at a very low cost per person?

53. Dental caries require the presence of what three elements to have the clinical manifestations of the disease?

54. What has been patented and made available to identify three of the most virulent forms

of the bacteria streptococcus mutans?

55. Evidence-based practice requires that (dentists / plan administrators / both) constantly monitor the developing science of dental treatment.

56. What type of economic modeling provides a hedge against adverse outcomes, but does

not absolutely protect against unanticipated outcomes?

57. When there is a high correlation between (provider satisfaction / plan changes) and patient satisfaction, this can be used in the sale and marketing of the plan.

58. (Redesigning data / Analysis of data) is simply the application of a feedback loop to plan

design and delivery.


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Legal Implications (pages 483-484)

59. The purpose of EB clinical guidelines is to improve the (effectiveness / quality) of clinical care as measured by quantifiable outcomes.

60. Those who explicitly review or follow EB clinical guidelines that are professionally

accepted are less exposed to (pressures from patients for experimental treatment / legal actions for inappropriate care).

61. With increasing legislation and regulations, it is likely that EB practice will be (more

accepted / less questioned) as a standard for assessing providers and/or plans.


1. The integration of best research evidence with clinical expertise and patient values. 2. Clinically relevant research, particularly patient-centered clinical research. 3. The unique preferences, concerns, and expectations that each patient brings to a clinical

encounter. 4. Populations. 5. Clinical expertise and current best external evidence. 6. Has not. 7. Both. 8. Informed choice. 9. Accountability, efficiency, and effectiveness. 10. Improve the clinical outcome of patients. 11. Outcome data. 12. Have not. 13. Ask an answerable question; gather the best evidence; appraise the evidence critically;

apply the results of the critical appraisal; evaluate the results and make appropriate changes.

14. The Library of Medicine’s PubMed. 15. Outcome-focused. 16. The Agency for Health Care Research and Quality; the Cochrane Collaboration. 17. Studies involving subjects that are randomly assigned to either the experimental or the

control group. 18. The Journal of Evidence-Based Dental Practice and Evidence-Based Dentistry. 19. A multinational group of individuals who systematically find, appraise, and review the

available evidence from randomized controlled trials. 20. Randomized controlled trials. 21. Time and keeping up-to-date with changes in dental practice. 22. Consumerism and the development of a knowledge-based economy. 23. Comparison shop. 24. 65 percent. 25. Both. 26. To be involved in. 27. Branding and marketing. 28. The perceived authority of the dentist and the knowledge gap between the dentist and

the patient. 29. Narrowing. 30. The extreme geographic variation in the delivery of health care. 31. Honesty.


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32. Evidence-based dentistry. 33. Value = Quality / Cost. 34. Structure, process, and outcomes. 35. Regulatory and licensing agencies. 36. Patients’. 37. Outcomes. 38. Appropriate data and rigorous analysis. 39. Restorative. 40. Are bacterial infections. 41. Pandemic. 42. Edentulism. 43. 20 percent. 44. 10 percent. 45. 98 percent. 46. Disease management. 47. To improve the patient’s, the purchaser’s, and the treating dentist’s satisfaction with

care; improve health; and lower both near- and long-term costs. 48. Infection. 49. 45 percent. 50. 7 percent. 51. Those who are at risk for the specific disease. 52. Water fluoridation. 53. Bacterium, a susceptible host, and a suitable metabolic substrate on which the

bacterium can act. 54. Monoclonal antibody diagnostic test. 55. Both. 56. Pharmacoeconomic modeling. 57. Plan changes. 58. Redesigning data. 59. Effectiveness. 60. Legal actions for inappropriate care. 61. More accepted.


1. In the current definition, the practice of evidence-based dentistry implicitly includes the integration of the individual practitioner’s __________.

a. clinical experience b. research studies c. clinical credentials d. human values

2. Informed choices in EB practice are about:

a. Accountability. b. Efficiency. c. Effectiveness. d. All of the above.


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3. Which of the following is NOT one of the technical steps involved in EB practice cited in

the text: a. Ask an answerable question. b. Gather the best evidence. c. Study communication barriers. d. Appraise the evidence critically.

4. Which statement best explains why EB practice in the form of disease management is

especially relevant to dentistry? a. A growing segment of the aging population in the United States suffers from

endemic oral health problems. b. Both dental caries and periodontal diseases are sequestered in an increasingly

smaller segment of the population. c. The prolonged economic downturn and loss of jobs have left many American

workers without dental benefits. d. Many people living in rural communities are without fluoridated water and access

to quality dental care.

5. Which of the following is considered to be the most reliable type of study for gathering clinically important data?

a. Systemic reviews. b. Cohort study. c. Randomized controlled trials. d. All of the above.

6. Applying best practices can be described as:

a. Relying on the best research to know what really works. b. Consulting with colleagues to gain conventional wisdom. c. Figuring out what an at-risk patient needs and then doing it. d. Using professional instincts to find out what a patient wants.

7. In gathering data for analysis, what is a significant and sometimes costly error in EB

practice and disease management? a. Inadequate preparation. b. Outdated technology. c. Unqualified technicians. d. Poor metric systems.

8. The state of risk assessment for either of dentistry’s primary diseases is somewhat

limited, but we do know about certain elements that are clinically manifested in caries. Which of the following fit the disease spectrum?

a. A specific bacterium. b. A susceptible host. c. A suitable metabolic substrate. d. All of the above.

9. What is the significance for clinicians and health plans of the monoclonal antibody

diagnostic test? a. Possibly other improvements in the treatment, prevention, or cure for periodontal

disease.


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b. Major improvements in therapies targeted to those who are actually at risk for future caries.

c. More diagnostic tools and predictive models for use in the detection and treatment of diseases.

d. New pharmacological approaches to the prevention and treatment of caries and periodontal disease.

10. From a legal perspective, practitioners who know and follow EB clinical guidelines that

are peer-reviewed and professionally accepted are less exposed to: a. Patient complaints about standard treatment. b. Legal action based on the appropriateness of care. c. Disputes with plan administrators regarding claims. d. All of the above are correct.

Answers

1. a 2. d 3. c 4. b 5. c

6. c 7. a 8. d 9. b 10. b


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39 The Oral Health-Systemic Health Connection: A Physician’s Perspective

Objectives


Explain the connection between gum disease and systemic health,

Understand how sustained inflammation, a characteristic of atherosclerosis, is linked to cardiovascular disease and may be a risk for Type II diabetes, and

Recognize what physicians and dentists can do to address health risks related to caries and periodontal disease.

Chapter Summary

The dentist is the first line of defense against some serious health threats—for example, heart disease and Type II diabetes. This chapter provides a wake-up call from the physician’s perspective in a brief but intense look at the oral health-systemic health connection. It’s a keeper for understanding how inflammatory processes associated with gum disease can signal the need for further intervention.

Review Questions


1. Why has the treatment of gum disease and its impact on wellness moved beyond the mouth?

2. Define atherosclerosis and identify a characteristic feature related to oral health.

3. Plaque deposited in arterial walls increases __________, weakening the wall and the inner lining.

4. True or False: Serious health risks associated with atherosclerosis include heart attacks and strokes.

5. What is another link between inflammation and a serious health risk?

6. How is hardening of the arteries differentiated from atherosclerosis?

7. What role can dental health professionals play in managing a patient’s systemic health?

8. How are insurance companies being proactive in the coordination of care between the two disciplines?

9. What emerging field is also playing a supporting role?

What Are Physicians Doing? (page 486)

10. How are physicians working with patients to address risks related to oral health?

11. What are two noninvasive tests physicians are using that are helpful?

What Can Dentists Do? (page 486)

12. What’s a good place to begin when patients present with unresolved gingival inflammation or periodontal disease?


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13. When a patient is about to undergo an invasive dental procedure, what should a dentist do to determine potential health risks?


1. It is now known that inflammatory processes in the gums and surrounding oral tissues can spread to other parts of the body.

2. Atherosclerosis is a buildup of cholesterol and calcified inflammatory tissue known as plaque in the innermost lining of the arteries. Sustained inflammation is a characteristic feature of the disease.

3. Inflammation. 4. True 5. Risk for or ability to manage Type II diabetes through glycemic control. 6. Hardening of the arteries is a vascular aging process, probably not related to

atherosclerosis. 7. Coordinating patient care between dental and medical. 8. Developing new types of products and processes for coordinating care and measuring

results. 9. Health informatics. 10. Work with patients to measure the risk and treat it. 11. C-Reactive Protein, or CRP and CVPProfiler®. 12. Educate patients and encourage them to see their physician for follow up. 13. Employ the Framingham Risk Scoring System to determine the patient’s health risk

status; then provide guidance about what is needed to avoid complications.


1. What do we now know about inflammatory processes related to oral health? a. Bacteria can travel throughout the body and lodge on heart valves. b. Inflammation can spread systemically and cause serious consequences. c. Inflammation from gum tissues can accelerate posits of arterial plaque. d. All of the above are correct.

2. Which of the following is a true statement relating to the difference between atherosclerosis and hardening of the arteries?

a. Both terms relate to the same condition. b. Sustained inflammation is not related to atherosclerosis. c. Hardening of the arteries is related to vascular aging. d. Both conditions are connected to oral health.

3. How are various sectors working toward a coordinated approach to managing the oral health-systemic health connection?

a. The research community continues to investigate. b. Insurance companies are developing new products. c. Health informatics is playing a supporting role. d. All of the above are correct.

4. Which of the following is a noninvasive test physicians use in identifying patients at risk for atherosclerosis?

a. Endoscopy. b. CVProfiler®.


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c. CT scan. d. All of the above.

5. When a patient presents with unresolved gingival inflammation, what should a dentist do?

a. Educate the patient. b. Use the Framingham Risk Scoring System. c. Encourage the patient to see a physician. d. Both “a” and “c” are correct.

Answers

1. d 2. c 3. d 4. b 5. d


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40 Dental-Medical Coordination

Objectives


Recognize how research has exposed links between oral health and chronic disease,

Advance the discussion and make the case for dental-medical coordination of patient care, and

Plan ahead as research continues to prove associations between oral and systemic health.

Chapter Summary

With the spotlight on new developments in the oral health/systemic health connection, there is increased awareness of the need to coordinate dental-medical patient care. In this chapter, students get a closer look at the correlation between oral and chronic health conditions from a scientific perspective. Here’s some good news:

A study conducted by Aetna and Columbia University College of Dental Medicine (2006) found a reduction in risk for individuals with coronary disease and diabetes who had been treated for periodontal disease.

From a second study published in the New England Journal of Medicine (2007) we learned that intensive treatment of periodontitis resulted in an improvement in circulatory system function.

In addition to cardiovascular disease and diabetes, the chapter examines research that links poor gum health to other conditions like cancer, osteoporosis, and the association between dental care and pregnancy complications. Students will also learn about the negative impact related to oral health on an individual’s work attendance and performance. It is estimated that employed adults lose more than 164 million hours of work each year due to oral health problems or dental visits, according to an HHS report.

Clearly there is a need to coordinate dental and medical care and treat patients holistically, as the chapter suggests. The author draws on contributions from the wellness community and industry sources, explaining how insurance companies possess the technology to integrate members’ medical and dental information with disease management programs to promote the coordination of care effort.

Moving ahead, health plans have already begun to integrate medical and dental features in policy design and employers are becoming comfortable with new offerings that include enhanced dental benefits and targeted outreach to at-risk members at no extra cost. In addition, new and perhaps better models of care are surfacing, such as medical and dental homes, which provide coordinated preventive, continuous and emergency care to patients all within one facility.

And finally, judging by the proliferation of seminars where clinicians from both disciplines meet and learn more about the coordination of dental-medical care, collaboration is already underway. In the meantime, other groups in public and human service sectors are pooling resources to educate people about oral health and chronic diseases.


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Review Questions


1. Research has become a greater priority to the medical, dental, and scientific communities, as the ________ model of care management becomes more popular.

2. What have technological advancements given the health care community with regard to the management of chronic conditions?

3. Scientists and clinicians indicate that improving oral health, especially (restorative dental care / preventive dental care) could possibly aid in the treatment of chronic conditions.

The Value of Coordination Is Supported by Research (pages 487-492)

4. What did the 2006 study conducted by Aetna and Columbia University College of Dental Medicine report?

5. Intensive treatment of periodontitis resulted in an improvement in circulatory system function, according to a study published by __________ in 2007.

6. In its 2004 study, the American Academy of Periodontology found that _____ percent of patients with cardiovascular disease suffered from moderate to severe periodontitis, while only _____ percent of non-cardiac patients did.

Oral Health and Diabetes (pages 488-489)

7. What do newer studies on the correlation between diabetes and oral health indicate?

8. The ADA published a report on the University of Michigan School of Public Health’s investigation of bacteria associated with periodontal disease. What were the conclusions of this study concerning medical costs?

Oral Health and Pregnancy (pages 489-490)

9. Research findings suggest that women with medical and dental insurance, the provision of dental treatment, particularly __________, was associated with lower incidence of adverse birth outcomes.

10. What combination of treatments did researchers recommend for women before they get pregnant to lower risks?

11. Women in good health who become pregnant can sometimes develop __________, swollen, tender gums due to a change in hormonal levels.

Oral Health and Cardiovascular Disease (pages 490-491)

12. What is a symptom that is seen both in periodontitis and cardiovascular disease?

13. What did the 2004 study by the American Academy of Periodontology find relative to periodontitis and coronary artery disease?

14. Within 60 days after treatment for periodontitis, (an increase / a decrease) in inflammation was seen in both gums and arteries, according to Academy researchers.

Oral Health and Links to Other Conditions (pages 491-492)

15. What did Harvard researchers discover in a 2007 study of more than 52,000 male doctors?

16. One theory scientists have suggests that chronic infection in the gums triggers __________ which can fuel the growth of cancer.


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17. Another condition thought to be linked to the health of the mouth is __________, which is characterized by bone loss and density.

18. What class of drugs is used to prevent the loss of bone mass for patients at risk for osteoporosis?

19. Medications to treat osteoporosis have been associated with a condition known as __________ that occurs as a result of reduced blood supply to the jaw area.

Dental-Medical Coordination Contributes to Overall Wellness/Improved Health Outcomes (pages 492-493)

20. Besides the connections to chronic diseases, what other problems are associated with poor oral health?

21. Employees with tooth pain who may be distracted by their condition are likely to perform poorly at work, a condition known as __________.

22. In what ways have health plans responded to wellness challenges facing today’s employers and workers?

23. What do insurance companies possess that could enhance the effectiveness of disease management programs?

24. Besides improved employee health, what else have employers who adopted integrated medical and dental programs discovered?

What’s Next for Dental-Medical Coordination? (pages 493-495)

25. Name two noninvasive oral diagnostic procedures that assist in the early detection and surveillance of both systemic and oral conditions.

26. What did a review of the scientific literature by Cochrane Collaboration reveal?

Medical and Dental Homes (page 494)

27. Supporters of the _________ model believe patients achieve the best health care outcomes when all of their health care services are integrated under one roof.

28. Similarly, __________ provide coordinated preventive, continuous, and emergency oral health care in one facility.

29. What do proponents of the medical and dental home models say about these facilities?

Collaboration Between the Physician and Dentist Communities (494-495)

30. How have physician and dentist communities responded in collaboration efforts to integrate medical and oral health care?

31. What steps have been taken by human service and public health groups?


1. Holistic model. 2. A more efficient way to track and integrate the medical and dental health care needs of

patients and coordinate member outreach and education. 3. Preventive dental care. 4. A significant reduction in risk scores for individual with coronary artery disease and

diabetes who had also received treatment for periodontal disease. 5. The New England Journal of Medicine.


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6. 91 percent versus 66 percent. 7. That periodontitis may be present well before the development of Type II diabetes. 8. Insured adults who received routine periodontal treatment had significantly lower

medical costs that those who did not receive preventive care. 9. Dental prophylaxis. 10. A regimen of periodontal and prophylaxis treatments. 11. Pregnancy gingivitis. 12. Inflammation. 13. That periodontitis appeared to influence the occurrence and severity of coronary artery

disease and increased the risk of heart attack or stroke. 14. A decrease. 15. A strong link between poor gum health and pancreatic cancer. 16. Inflammation throughout the body. 17. Osteoporosis. 18. Bisphosphonates. 19. Osteonecrosis of the jaw (ONJ). 20. Employee work attendance and performance. 21. Presenteeism. 22. Insurers are designing more plans with integrated medical and dental features and have

begun to offer Web-based health educational materials. 23. The technological capability to integrate members’ medical and dental information with

disease management programs. 24. A significant cost savings. 25. Salivary and oral fluid diagnostic tests. 26. That the treatment of periodontal disease helped lower the blood sugar of patients with

Type II diabetes. 27. Medical home model. 28. Dental homes. 29. That these facilities provide better care at lower costs because they are more

accessible, promote prevention, and proactively support patients with chronic conditions. 30. More seminars are underway where clinicians from both disciplines meet and learn more

about dental-medical coordination. 31. Various human service organizations and public health groups have started to pool

resources and develop educational materials and campaigns to create public awareness.


1. Scientists and clinicians say that improving oral health could possibly aid in the treatment of chronic conditions, especially by administering the following:

a. More noninvasive tests. b. More preventive care. c. More drug therapies. d. All of the above.

2. Which study found that 91 percent of patients with cardiovascular disease suffered from moderate to severe periodontitis?

a. A study released by the American Academy of Periodontology in 2004. b. A study published in 2007 by the New England Journal of Medicine. c. Research done in 2006 at the Columbia University College of Dental Medicine. d. A pilot intervention study published in 2003 by the Journal of Periodontology.


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3. Insurers have begun to design more health plans with which of the following elements: a. Integrated medical and dental features. b. Enhanced dental benefits. c. Targeted outreach to at-risk members. d. All of the above are correct.

4. Proponents of the medical and dental home models think these facilities provide better

care at lower costs because in addition to proactively supporting patients with chronic conditions and promoting prevention, they are:

a. More accessible. b. Technically advanced. c. Customer oriented. d. More up-to-date.

5. It is estimated that employees lose more than _____ million hours of work each year due

to oral health problems or dental visits. a. 360 b. 260 c. 160 d. 60

Answers

1. b 2. a 3. d 4. a 5. c


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41 Coordinating Dental and Medical Care— Issues and Challenges

Objectives


Define medical-dental coordination and explain the process;

Understand how proactive programs can educate, motivate, and improve oral and overall health of an employee population; and

Describe some of the issues and challenges faced by health plan administrators (HPAs) in coordinating medical and dental care.

Chapter Summary

What is medical-dental coordination? The text describes the process as looking at medical conditions that might be adversely affected by the presence of dental disease, or dental disease that might be affected by medical conditions. Thanks to scientific research, including case reports, cross-sectional, longitudinal, and intervention studies, there is a strong professional awareness and support for coordinating dental and medical care to treat those at risk for diabetes, adverse pregnancy outcomes, and cardiovascular disease associated with poor oral health.

This chapter examines the issues and challenges facing today’s providers, and health plan administrators (HPAs) in particular who are not only expected to coordinate medical and dental care but to collect information regarding individual health and risk. The objective of medical-dental coordination is to create a program or system that includes:

Choosing the associated medical conditions;

Identifying the patient (member) at risk, or with an associated medical condition;

Engaging the member through education and outreach (verbal and/or written);

Changing behavior to ensure good daily oral habits and that the member is receiving needed dental treatment;

Improving health and productivity, and potentially lowering medical and dental costs.

The author describes features of an enhanced dental benefit that an HPA may offer at-risk members. For example, enhancements for expectant mothers should focus not only on periodontal disease but also address pregnancy gingivitis. Typically dental benefit enhancements for diabetes, stroke, and cardiovascular disease would focus on periodontal disease, including scaling and root planing.

As incentives, the HPA may consider relaxing or waiving limits on periodontal procedures. HPAs may also require at-risk members to enroll in a disease management program to be eligible for the enhanced benefit. Outreach programs are another model that integrates medical and dental care and promotes participation. Potential savings in future medical or dental claims costs can be viewed as the “icing on the cake,” the author adds in a concluding statement about this positive new trend in employee health care.

Review Questions



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1. What did the Surgeon General’s May 2000 report on oral health in America call for?

2. The present mindset of professionals and the public is shifting toward a more (invasive / holistic) philosophy.

Level of Evidence (pages 497-498)

3. What type of research studies the characteristics in individuals or groups of patients with a particular disease?

4. Research that examines hundreds of patients and finds a pattern that suggests smokers may have a higher rate of periodontal disease than nonsmokers is called __________.

5. Provide an example of a longitudinal study.

6. (Intervention / Longitudinal) studies strengthen the evidence of the cause or exposure to a risk factor to find a cause and effect.

What General Levels of Evidence Have Been Attained? (pages 498-499)

7. For diabetes, what does research indicate about periodontal treatment?

8. Studies show that performing periodontal treatment on pregnant women may reduce the risk of __________.

9. What does research on cardiovascular disease indicate with regard to periodontal disease?

What Is Medical-Dental Coordination? (pages 499-500)

10. With the concept of wellness becoming more important, what is a related emphasis for health plan administrators (HPAs)?

11. Many employers now require employees to complete a/an __________ to be eligible for health care benefits.

12. What other section needs to be incorporated into a health risk assessment (HRA)?

13. How may HPAs use the data collected from HRAs and other risk assessment tools?

14. What is a typical next step once an individual is identified as being at risk for a health condition or chronic disease?

15. What issue arises due to dentistry’s lack of diagnostic codes?

16. Without diagnostic codes, it is even more important to incorporate __________.

17. What do many HPAs and providers use to identify individuals at risk for dental disease?

18. How does the text define medical-dental coordination?

19. Many medical conditions can lead to increased tooth decay, primarily due to __________, or dry mouth syndrome.

Why Coordinate Medical and Dental? (pages 501-505)

20. In the coordination of medical and dental, what is the twofold objective for HPAs?

21. According to the Surgeon General’s report on oral health in America (2000), how many work hours are lost due to dental disease or treatment?

22. One published study indicated that every dollar spent on preventive dental care saved between ($4 to $25 / $8 to $50) in restorative and emergency treatments.


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Diabetes (page 501)

23. Diabetic patients may be at increased risk for __________ disease.

24. Gum disease may make it more difficult for people with diabetes to control __________.

Heart Disease (page 502)

25. What cardiovascular conditions and risks are associated with periodontal disease and its associated bacteria?

Pregnancy (page 502)

26. True or False: Pregnant women who have periodontal disease may be more likely to gain too much weight and have a difficult delivery.

27. What other dental condition may occur during pregnancy?

Medical-Dental Coordination Models (pages 502-505)

28. HPAs have responded to health risks associated with periodontal disease by offering dental benefit _________ to __________.

Maternity (page 503)

29. What provisions do dental enhancements offer expectant mothers?

30. What other procedures are considered for an enhanced dental benefit plan for expectant mothers?

31. How do members usually share in the cost of procedures covered under the enhanced dental benefit plan?

32. One mechanism for payment is to have the member (pay their share at the time of the visit / pay online and apply for reimbursement at the same time).

33. True or False: It is becoming more frequent for dental HPAs to offer incentives that encourage expectant mothers to get preventive and periodontal treatments.

Diabetes, Stroke and Cardiovascular Disease (pages 503-504)

34. Dental benefit enhancements for diabetes, stroke and cardiovascular disease most commonly focus on __________.

35. Which enhanced options would an HPA consider for individuals at risk for diabetes, stroke, or cardiovascular disease?

36. What other provisions might an HPA offer individuals with or at risk for cardiovascular diseases and diabetes?

Outreach Models (pages 504-505)

37. How do HPAs with both medical and dental reach out to those members identified with at-risk medical health conditions associated with oral health?

38. What is an important feature of a truly integrated medical-dental outreach program?

39. Engaging __________ programs for diabetes and cardiovascular disease is another outreach activity.

40. A medical-dental HPA should consider integrating the dental message and track the dental educational interventions with what other kind of programs?


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How Does a Coordinated Program Benefit Clients and Members (page 505)

41. Identify at least two potential member benefits that have evolved as a result of a coordinated medical-dental program offering incentives.

42. How would an employer/plan sponsor benefit from a coordinated medical-dental program effort?

How Does Coordinated Care Impact Administrative and Claims Cost? (pages 505-506)

43. What is the obvious investment an HPA must make to establish an automated system?

44. With an automated system, (population trends / prevalence numbers) for diagnosed and undiagnosed diabetes and heart disease can be used to estimate the number of individuals with associated medical conditions.

45. Based on how well consumer rebates on computers work, what could an HPA expect when actually providing financial incentives to members?

46. How can employers boost the level of employee participation in a coordinated, enhanced dental benefit program?

Challenges and Barriers (pages 506-507)

47. Lack of access to medical information for identifying individuals with associated medical conditions is a/an __________ to coordinating medical and dental benefits.

48. Another obstacle to coordinating medical and dental benefits may be an employer’s reluctance to invest in (information systems / analytical technology).

49. What does the text recommend as a way to allay fears and validate program assumptions related to utilization and cost of a coordinated medical-dental benefit?

Cooperation of Health Care Professionals (page 507)

50. While most dentists and physicians support educating patients about the connection between oral and systemic health, more of __________ studies may strengthen acceptance of health care professionals.


1. Action to help promote access to oral health care for all Americans, particularly minority children and the disadvantaged.

2. Holistic. 3. Case reports/series. 4. A cross-sectional study. 5. Assess the existence of periodontal disease of 250 smokers and 250 nonsmokers to

establish a baseline, and then track the subjects for several years to determine the outcome.

6. Intervention. 7. Treatment for diabetic patients may help glycemic control. 8. Preterm birth. 9. An associative risk, increasing the risk of cardiovascular disease and stroke. 10. Identifying the “ticking time bombs,” individuals with specific diagnoses or prediagnoses

that have not received associated needed dental treatment. 11. Health risk assessment (HRA). 12. Dental risk assessment questions. 13. To identify gaps in care systematically.


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14. An outreach effort is established with the patient or provider to encourage follow-through preventive care.

15. An inability to use claims data for determining whether an individual has periodontal disease or tooth decay, and the extent to which the disease has progressed.

16. Risk assessment tools. 17. Caries and periodontal risk assessment tools. 18. The process of looking at medical conditions affected by dental diseases and vice versa. 19. Xerostomia. 20. (1) To improve oral health identifying those at risk and conducting education and

outreach; and (2) achieve cost savings by improving employee productivity and lowering health care costs and claims for both dental and medical.

21. Approximately 164 million work hours per year. 22. $8 to $50. 23. Periodontal disease. 24. Blood sugar. 25. Blood clots that, in turn, increase the risk of a heart attack or stroke. 26. False. Have a baby that is born too early and too small. 27. Dental gingivitis. 28. Enhancements to at-risk members. 29. Relaxation or elimination of frequency limits for preventive procedures. 30. Early intervention and treatment of periodontal treatment, including scaling and root

planing, periodontal maintenance, and services for treating inflammation of the gums around wisdom teeth.

31. Through coinsurance or a copayment. 32. Pay their share at the time of the visit. 33. True 34. Periodontal disease. 35. Relax or waive limits on periodontal treatment and reimburse the member for out-of-

pocket cost. 36. Provide incentives for individuals at risk to seek treatment by removing financial barriers;

require enrollment in a diabetes or cardiovascular disease management program to qualify.

37. With a postcard or follow-up phone call. 38. Ensuring that all activities are tracked, including subsequent dental visits to demonstrate

the value of the outreach intervention. 39. Disease management programs. 40. Wellness programs. 41. Individuals not likely to seek dental care are motivated to start seeing a dentist;

improvement in medical condition because of periodontal treatment. 42. Through medical claim cost savings for those individuals who would not have sought

needed care without the incentive. 43. Information systems that identify claimants with associated medical conditions. Also

costs associated with member incentives. 44. Prevalence numbers. 45. Market research indicates that about 60 percent of buyers never redeem their rebate. 46. Specific campaigns to promote employee awareness. 47. Barrier. 48. Information systems. 49. Pilot program. 50. Intervention studies.


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1. What type of research studies the characteristics in an individual patient or group of patients with a particular disease or condition?

a. Case reports. b. Cross-sectional. c. Longitudinal. d. Intervention.

2. What is missing from dentistry that makes it more important for health plan administrators (HPAs) to incorporate risk assessment tools to identify individuals at risk for dental disease?

a. Treatment protocols. b. Diagnostic codes. c. Evidence-based care. d. Scientific research.

3. In coordinating medical and dental care, the primary objective for HPAs is to:

a. Improve oral health by identifying those at risk, conducting education and outreach, and changing behavior.

b. Achieve savings through productivity and in claims cost for both medical and dental.

c. Both “a” and “b” are correct. d. None of the above is correct.

4. HPAs offering both medical and dental plans can create increased awareness and

engage members through which of the following? a. Education. b. Enhanced benefits c. Outcome activities. d. All of the above.

5. The author suggested that more research, particularly __________, was needed to

strengthen the associations between oral health and diabetes, heart disease, and adverse pregnancy outcomes.

a. cross-sectional studies b. longitudinal studies c. intervention studies d. case studies

Answers

1. a 2. b 3. c 4. d 5. c


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AHIP Courses and Professional Designations

AHIP has offered educational programs to hundreds of thousands of health care professionals throughout the world for more than 50 years. Our conferences, self-study courses (most online), multimedia, white papers, and designation programs provide the flexibility to meet the diverse educational needs of professionals at all levels—from those starting out to the most seasoned in our industry. Many are employees of health insurance plans, but consultants, third-party administrators, agents, brokers, and other health insurance professionals also study with us. In addition, many noninsurance professionals, including health care providers, economists, consumer advocates, and government officials, take AHIP courses to learn more about the operations of our industry and advance their careers in their own fields. Courses include:

Affordable Care Act (four courses)

Annuities and Retirement Planning (four courses)

Customer Service

Dental Benefits (two courses)

Disability Income Insurance (three courses)

Fundamentals of Health Insurance (two courses)

Governance and Regulation

Health Care Fraud (three courses)

Health Care Management

Health Insurance 101

Health Insurance Advanced Studies (two courses)

Health Plan Finance and Risk Management

ICD-10 and 5010 Mandate—A Technological View

Long-Term Care Insurance (six courses)

Managed Care (five courses)

Medicare (two courses)

Network Management

Supplemental Health Insurance

Wellness (two courses)

The completion of AHIP courses leads to widely respected professional designations:

Annuity Planning Professional (APP)

Dental Benefits Associate (DBA)

Disability Healthcare Professional (DHP)


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Disability Income Associate (DIA)

Fellow, Academy for Healthcare Management (FAHM®)

Fellow, Health Insurance Advanced Studies (FHIAS)

Health Care Anti-Fraud Associate (HCAFA)

Health Insurance Associate (HIA®)

Healthcare Compliance Professional™ (HCP)

Healthcare Customer Service Associate (HCSA)

IT Fellow (ITF)

IT Professional (ITP)

Long-Term Care Professional (LTCP)

Managed Healthcare Professional (MHP)

Professional, Academy for Healthcare Management (PAHM®)

Professional, Health Insurance Advanced Studies (PHIAS)

Health Insurance Associate (HIA®)

The HIA® designation, offered since 1990, is held by more than 20,000 professionals. It signifies that the holder has acquired a broad knowledge of health insurance products and health plan operations. Designees have a solid understanding of insurance principles and terminology, contracts, underwriting and pricing, sales and marketing, policy administration, claims administration, cost management, regulation, and health care fraud and abuse. They are familiar with a variety of health coverages, including medical expense insurance, disability income insurance, long-term care insurance, and supplemental products such as hospital indemnity coverage, specified disease insurance, Medicare supplements, accident coverage, and dental plans.

Managed Healthcare Professional (MHP)

The MHP designation was established in 1996, and there are now more than 7,000 designees. Professionals with the MHP are knowledgeable about the latest developments in health care management as well as the operations of traditional health insurance. They have acquired an understanding of the structure and operation of managed care organizations, provider contracting and provider relations, network administration, member services, claims administration, and quality assurance, as well as marketing, rating, financing, and budgeting. They are also familiar with regulatory policies and processes, the accreditation of managed care organizations, and the role of health care management in government health benefit programs.

Disability Income Associate (DIA)

Holders of the DIA designation have an in-depth understanding of how an injury or illness can lead to a substantial financial loss and how disability income (DI) insurance can protect against this risk. Designees are knowledgeable about employer-sponsored disability programs, ranging from sick leave benefits to long-term disability income plans, and about federal and state government disability programs, including Social Security Disability Insurance, workers’ compensation, and state temporary disability income programs. They also understand how


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individuals can supplement these employer- and government-sponsored programs with private DI insurance. Finally, DIA designees are familiar with the role DI insurance plays in retirement, estate, and long-term care planning.

Disability Healthcare Professional (DHP)

In the DHP designation program, students move beyond the specialized course of study of the DIA program to expand their understanding of the health insurance industry. DHP designees have the same in-depth knowledge of disability income (DI) insurance as DIA holders, including employer-sponsored benefits, government programs, individual DI policies, and retirement, estate, and long-term care planning. But they also have a familiarity with the principles of insurance, other health coverages, and the role DI insurance plays in the larger health insurance field.

Long-Term Care Professional (LTCP)

The LTCP program is an exciting opportunity for insurance professionals who want to learn about the increasing need for long-term care, the various ways of financing it, and the growing role of long-term care insurance. Students in the program learn about long-term care services, settings, and providers; they explore financing options such as personal savings, government programs, reverse mortgages, and annuities, discovering the limitations of each; and they examine in detail long-term care insurance, including policy provisions, underwriting and pricing, sales and marketing, policy administration, claims administration, and regulation. LTCP designees have the expertise they need to succeed in this expanding field.

Health Care Anti-Fraud Associate (HCAFA)

The HCAFA program provides those working in health insurance plan anti-fraud units and others with the information and skills they need to detect and prevent health care fraud and abuse. HCAFA designees understand how common fraudulent schemes work and how they can be discovered and investigated. They are familiar with many types of fraudulent activity, including fraud perpetrated by providers, consumers, agents, and health plan employees, as well as fraud involving a wide variety of health coverages, including medical expense insurance, managed care, disability income insurance, long-term care insurance, and others. Finally, holders of the HCAFA designation are knowledgeable about the laws and enforcement tools that can be used to stop fraud.

Dental Benefits Associate (DBA)

The DBA program is for health insurance professionals, plan administrators, purchasers of dental benefits, employee benefits specialists, dentists and dental students, public policy makers, members of the academic community, and others who need an understanding of dental insurance. Program participants learn the similarities and differences between dental insurance and medical insurance as they acquire detailed knowledge of the various types of dental benefits plans. The emphasis is on the two principal types—the dental preferred provider organization (dental PPO) and the dental health maintenance organization (DHMO), but other types of plans are also covered. The two course program covers plan design and structure; cost issues; plan management and evaluation; technology, consumer engagement, and data-driven management; and new developments on evidence-based dentistry, the oral-systemic connection, and coordination of dental and medical care.


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Healthcare Compliance Professional (HCP)

AHIP has created the Healthcare Compliance Professional (HCP) designation specifically for individuals who need a thorough understanding of the Affordable Care Act (ACA) to ensure that their companies meet the parameters of all of the new rules, regulations, and deadlines. From market conduct reviews, MLR, and audits to setting up a compliance program, the educational activities leading to the HCP designation helps the compliance professional manage job functions on a daily basis and plan for long-term ACA implementation. Anyone whose job is impacted by the ACA or who is responsible for any aspect of compliance could benefit from this program.

Healthcare Customer Service Associate (HCSA)

To stay competitive in today’s business environment, providers of health care services and products must offer outstanding customer service. The HCSA program is designed for those working on the front line throughout the industry who want to improve their relationships with internal and external customers and enhance the overall performance of their organizations. Students in the HCSA program acquire strategies for solving customer service problems; learn the basics of training, hiring, and managing customer service staff; and discover ways to achieve quality service and create customer-driven organizations.

Professional, Academy for Healthcare Management (PAHM®)

Students who complete the Academy for Healthcare Management’s PAHM program and earn the designation will have a thorough grasp of the fundamental building blocks of health insurance plans and their functions. Students gain a solid understanding of types of health insurance providers; types of products—including consumer-choice products; operational issues; legislative, regulatory and ethical issues; and Medicare Advantage plans.

Fellow, Academy for Healthcare Management (FAHM®)

For individuals who seek advancement as health care management professionals, the Academy for Healthcare Management’s FAHM program offers in-depth coursework focusing on specific operational areas. Advanced level students gain a thorough orientation to current industry trends, governance and leadership issues, financial management techniques, network development and maintenance strategies, as well as medical policies and technologies.

Annuity Planning Professional (APP) By completing the program requirements for the APP designation, students acquire a broad-based, client-relevant background on annuities. The program is designed for agents, brokers, financial planners, and other professionals who work in financial services or annuity planning. The four-course series imparts a thorough understanding of the various objectives of annuities, such as funding long-term care needs, equity-indexed annuities, variable annuities, and more. Professional, Health Insurance Advanced Studies (PHIAS) This learning path covers a wide range of health insurance reform topics, such as plan structures and alternatives; prescription drugs and pharmacy benefits; Medicare, Medicare Part D, and Medicaid; and tax treatment of medical expenses. The program is designed for


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experienced industry professionals who seek a deeper knowledge of health care reform, its impact on employee benefits and current plan structures, new tax rules in a post-reform environment, and the implications for consumer-driven health plans. Fellow, Health Insurance Advanced Studies (FHIAS) The FHIAS designation expands on the course of study offered in the PHIAS program. Offering an in-depth look at individual products like disability, long-term care, dental, and Medicare, this program is designed to enhance students’ knowledge of these important health insurance topics. IT Professional (ITP)

With increased emphasis on business intelligence, integration, patient relationship management software, ICD-10 conversions, and many other innovations resulting from health care reform, health care providers and insurers are facing a huge need for professionals with both IT and health insurance knowledge. To help fill the need, AHIP has developed an IT Series that combines mobile-friendly courses, webinars, workshops, and more. The program is designed to provide the skills required from IT employees working throughout this changing health care environment. The curriculum includes topics such as health care basics, regulation, self-service portals and apps, membership management, claims processing, health and wellness, administration, and risk management.

IT Fellow (ITF) As an expansion of the IT Professional program, the IT Fellow (ITF) designation is earned through a combination of online courses, and in-person and online event participation.

For more information visit our website (www.ahip.org/courses)

or call 800-509-4422.


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AHIP Insurance Education Books

Health Insurance

The Health Insurance Primer: An Introduction to How Health Insurance Works

This book, together with Health Insurance Nuts and Bolts (below), serves as a complete introduction to the health insurance field. The authors assume no prior knowledge and begin by explaining basic concepts and terminology, but they progress to an in-depth examination of such topics as the various kinds of health insurance, health insurance contracts, underwriting, and sales and marketing. The Health Insurance Primer is an excellent choice for beginners in the industry and those from other fields who need a basic understanding of health insurance. (Study manual included.)

Health Insurance Nuts and Bolts: An Introduction to Health Insurance Operations

The introduction to the fundamentals of group and individual health insurance begun in The Health Insurance Primer continues in Health Insurance Nuts and Bolts. Topics include policy issue, renewal, and service; claims administration; pricing health insurance products; managing the cost of health care; government regulation; and fraud and abuse. (Study manual included.)

Medical Expense Insurance

For those who have a basic grounding in the principles and functioning of health insurance, this book provides a more detailed look at the most common kind of health insurance in America—medical expense insurance. The text begins by describing the two coverages that provide health benefits to most Americans: group major medical insurance and individual hospital-surgical insurance. Subsequent chapters discuss contract provisions, underwriting and pricing, sales and marketing, policy administration, claims administration, and industry issues. (Study manual included.)

Supplemental Health Insurance

This book provides those with a basic understanding of health insurance and supplemental health insurance with more detailed information about the major supplemental products in the marketplace. These include hospital indemnity coverage, specified disease insurance, Medicare supplements, accident coverage, dental plans, and prescription drug plans. For each product, the text points out gaps in basic health insurance that create the need for additional coverage and explains how the product meets that need and protects the individual from financial risk. (Study manual included.)

Managed Care

Managed Care: What It Is and How It Works (Second Edition)

Completely updated and expanded by Peter R. Kongstvedt, MD, the foremost authority in the field, this book provides readers with a clear and easy-to-follow introduction to the fundamental concepts and basic functioning of health care management. It covers the origins and evolution of managed care, the various types of managed care organizations, network management, medical management, regulation, accreditation, and other topics. An extensive glossary of


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managed care terms is included. This book serves as the text for the AHIP course Managed Care, Part A. (Study materials available online.)

Managed Care: Integrating the Delivery and Financing of Health Care, Part B

The second book in AHIP’s health care management series builds on the basic knowledge the student acquired in the introductory course, with a focus on operational issues and problems. It discusses in greater depth the governance and management structure of managed care organizations; selective medical provider contracting; network administration and provider relations; marketing and member services; claims administration; financing, budgeting, and rating; legal issues; accreditation; and regulation. (Study manual included.)

Managed Care: Integrating the Delivery and Financing of Health Care, Part C

Part C of this series explores a variety of topics. It describes the continued evolution of health care management, including the impact of regulation and consumer attitudes. It examines the role managed care plays in government health benefit programs, such as Medicare, Medicaid, and health benefit plans for federal employees and military personnel. The functioning of managed care in specialty areas, such as pharmacy, dental, behavioral health, and vision benefits, is discussed. Finally, ideas are offered on how the operations of managed care organizations can be improved. (Study manual included.)

Dental Benefits

Dental Benefits: A Guide to Managed Plans (Third Edition)

This updated edition by Cathye L. Smithwick and an esteemed panel of co-contributors expands the comprehensive reference to dental benefits originally authored by Donald S. Mayes. It provides a wide-ranging overview of dental benefits in the 21st century, marking technological and clinical milestones. Preferred provider organization (PPO) plans, the dominant dental delivery system, are examined in-depth, as are dental HMOs, dental networks, voluntary and discount products, cost issues, and pricing. A new section has been added covering technology, consumer engagement, and data-driven management. The book also updates readers on scientific research related to the oral health/systemic health connection and on practice trends, including evidence-based dentistry. This is the textbook for two courses in the DBA program, Dental Benefits Part A (An Overview of Dental Benefits and Dental Plans) and Dental Benefits Part B (A Closer Look at Plan Types and Management). There is a study manual for each course developed by AHIP.

Disability Income Insurance

Disability Income Insurance: A Primer

Many people are unaware of the major financial loss that can result from a long-term disability, or they mistakenly believe that government programs will cover this loss. This book analyzes the financial risk of disability; it describes Social Security disability insurance, workers’ compensation, and other government programs and makes clear why they do not provide adequate benefits for most people; and it explains how disability income (DI) insurance can provide sufficient benefits. Employer-sponsored group DI coverage is briefly described (it is fully covered in the third book of this series), while individual DI insurance is examined in detail, with


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a focus on underwriting, contract provisions, and claims administration. (Study materials incorporated into text.)

Disability Income Insurance: Advanced Issues

The second book in the AHIP disability series explores more complex issues, including structuring DI benefit programs to meet the needs of lower-, mid-, and higher-level employees; combining group and individual DI coverage; implementing executive bonus and salary continuation plans; and coordinating DI insurance with both tax-qualified and nonqualified retirement plans. Specialty products, such as disability overhead expense insurance, key-person DI insurance, and disability buyout insurance, are described. Students also learn about the important role of DI insurance in planning for retirement, long-term care needs, and estate protection. (Study materials incorporated into text.)

Disability Income Insurance: Group and Worksite Issues

Many people look to their employers as the source of disability benefits, and many employers choose group disability income insurance as the best means of providing these benefits. In this book, the reader finds comprehensive and up-to-date information on all aspects of group DI insurance, including product design and policy features, underwriting and pricing, sales and marketing, and claims administration. A related product, voluntary worksite plans, is also examined, and regulatory and tax considerations are discussed. (Study materials incorporated into text.)

Long-Term Care Insurance

Long-Term Care: Understanding Needs and Options (Second Edition)

As people live longer and the population ages, there is an increasing need for home health care, assisted living, nursing home care, and other forms of long-term care. This book provides an introduction to the field of long-term care and long-term care insurance (LTCI). It begins with an explanation of what long-term care is, who needs it, and how and where it is provided. It then looks at several ways of paying for long-term care and the limitations of each. It examines long-term care insurance, describing how it works and explaining why it is often the best solution to the problem. Finally, it discusses the ways salespeople and insurance company personnel can bring this solution to the people who need it. (Study materials incorporated into text.)

Financing Long-Term Care Needs: Exploring Options and Reaching Solutions (Second Edition)

Long-term care services can be very expensive, and if they are required for more than a few months the total cost can represent a significant financial burden. But by planning ahead, the average person can provide for his or her long-term care needs. This second volume of AHIP’s long-term care series examines in greater detail the various ways of meeting the need for long-term care. It looks at personal savings and assets, family support, Medicaid, reverse mortgages, commercial and private annuities, life insurance, and both individual and group long-term care insurance. The advantages and disadvantages of each of these are discussed, giving the reader a clear understanding of the role each can play in long-term care planning. (Study materials incorporated into text.)


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The Long-Term Care Insurance Product: Policy Design, Pricing, and Regulation (Second Edition)

Long-term care insurance (LTCI) is a relatively new and still evolving product. This book looks at this evolution, focusing on the innovations insurers have made to better meet consumer needs and on the impact of regulation, especially HIPAA. It also provides a comprehensive look at LTCI policies, covering benefit eligibility, benefit amounts, inflation protection, elimination periods, policy maximums, nonforfeiture, renewal, lapse, and other features. Other topics include premium calculation, group long-term care insurance, and the combination of long-term care coverage with other insurance products. (Study materials incorporated into text.)

Long-Term Care Insurance: Administration, Claims, and the Impact of HIPAA (Second Edition)

The administration of long-term care insurance continues to evolve as the product itself develops. This book looks at practices and procedures in several administrative areas, including underwriting, issuance, premiums, policy maintenance, policyholder services, and reporting. It describes the long-term care claim process and the steps insurers take to control claim costs and hold down premium prices. In addition, the impact of the Health Insurance Portability and Accountability Act of 1996 (HIPAA) is discussed. (Study materials incorporated into text.)

The New Long-Term Care Partnership Programs: Understanding Needs, Solutions, and Ethical Considerations

As a result of the Deficit Reduction Act of 2005, state long-term care partnership programs are currently undergoing a major expansion. These programs give individuals incentives to provide for their own long-term care needs by purchasing a qualified long-term care insurance policy, and by doing so, they reduce the number of people who, because they have made no other provisions, must rely on Medicaid benefits to pay for their care. This book explains how these programs work and what advantages they offer, as well as providing the necessary background information on long-term care, long-term care funding sources, long-term care insurance, and ethical issues. The book offers insurance sales professionals, financial advisors, insurance company personnel, and consumers the opportunity to become knowledgeable about this growing field. (Study materials incorporated into text.)

Long-Term Care Suitability

This book discusses the issue of suitability in long-term care insurance, including the concerns of consumers, agents, financial planners, insurers, and regulators. It examines consumer education, fact-finding and analysis, benefit options and tailoring policies, suitability standards, and the application process. Concepts and information are illustrated in case studies. (Includes a study manual developed by AHIP.)

Health Care Fraud

Health Care Fraud: An Introduction to Detection, Investigation, and Prevention

Every year, fraud and abuse add billions of dollars to our country’s health care expenditures. This book describes how health care fraud is perpetrated and what is being done to combat it. It explains how some of the most common fraudulent schemes operate, how these schemes can be detected and investigated, and the laws that can be brought to bear against them. Fraud


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perpetrated by health care providers, consumers, and others is covered, and although medical expense insurance fraud is emphasized, fraud involving managed care and disability income insurance is also included. (Study materials incorporated into text.)

Insurance Fraud in Key Products: Disability, Long-Term Care, MedSupp, Drug Coverage, & Others

While the first book in AHIP’s fraud series focuses on medical expense insurance, the second looks at a range of health insurance products: disability income insurance; long-term care insurance; dental, behavioral health, and prescription drug benefits; and Medicare supplement insurance. Fraud in two nonhealth coverages, life insurance and property/casualty insurance, is also discussed. For all of these products, common fraudulent schemes are examined, and legal and investigative issues are explored. (Study materials incorporated into text.)

Legal Issues in Healthcare Fraud and Abuse: Navigating the Uncertainties (Third Edition)

This book, written by David E. Matyas and Carrie Valiant and published by the American Health Lawyers Association, provides those working to combat health care fraud with the legal background relevant to investigations, civil actions, and criminal prosecutions. It surveys the major players in anti-fraud enforcement and examines in detail the most important laws and regulations. Topics include anti-kickback legislation, restrictions on physician self-referrals, false claims and fraudulent billing, exclusion from federal health benefits programs, fraud and abuse in managed care, state anti-fraud laws, legal representation issues, and many others. (Study materials available online.)

Medical Management

Medical Management: An Overview

The introductory text of this six-part series provides readers with a background in the development of managed care and an overview of its latest phase—medical management. Early models of managed care, current practice, and emerging trends are discussed. Readers learn why and how health care benefit plans are developed, how legislative and regulatory requirements affect the industry, and how accreditation and certification function to promote quality. (Study materials incorporated into text.)

Medical Management: Utilization Management

The purpose of utilization management is to determine whether health care services are medically necessary and appropriate. It seeks to ensure that the treatment, provider, and facility that best meet a patient’s needs are chosen. This book describes utilization management’s evolution and explores its future. The reader acquires an understanding of the goals of utilization management, the programs and organizations that have adopted it, the professionals who are responsible for it, the processes they use to implement it, and the tools and resources they need to support it. (Study materials incorporated into text.)

Medical Management: Call Centers

This book presents an overview of the “telehealth” industry—from standard call centers that serve health plan members to more sophisticated systems that provide access to registered nurses who can assist patients with specific health problems. Readers are given practical


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pointers on how to establish a call center, select vendors, hire and train employees, and maintain quality in customer service. They learn about legal and regulatory requirements and look at trends in the use of electronic communications in health care. (Study materials incorporated into text.)

Medical Management: Case Management

Case managers help patients and their families navigate health care delivery systems and manage their own health care needs. Practitioners come from many disciplines—they are nurses, social workers, rehabilitation counselors, and physicians—and they collaborate with other stakeholders to achieve quality, cost-effective outcomes. This book gives the reader a clear understanding of the basic concepts, goals, and processes of case management; the professionals and organizations in the field and the services they provide; legal, ethical, and risk management concerns; and emerging trends. (Study materials incorporated into text.)

Medical Management: Disease Management

Disease management is a system of coordinated health care interventions for a medical condition in which patient education and self-care are key components. This book takes a practical approach to the subject and offers plenty of substance to readers at all levels, from beginners seeking a basic understanding to managers of disease management programs. Topics include the history of disease management, current challenges, and future projections; model programs for specific diseases; the tools and techniques used in these programs; regulatory and legislative issues; and accreditation and certification programs. (Study materials incorporated into text.)

Medical Management: Quality Management

Providing the right health care at the right time in a way that produces the most favorable patient outcomes is the objective of quality management. This book covers the essentials, helping students understand why quality management is important, how programs are implemented, and who the key stakeholders are. It introduces students to the fundamental framework of quality management, providing an overview of the programs, processes, and procedures used by health care organizations to ensure the delivery of quality services. (Study materials incorporated into text.)

HIPAA

HIPAA Primer: An Introduction to HIPAA Rules, Requirements, and Compliance (Second Edition)

Who must comply with HIPAA? What does “protected health information” mean? What types of information must be protected? This practical guide to the Privacy Rule of the Health Insurance Portability and Accountability Act of 1996 (HIPAA) provides the answers to these questions and many more. It explains what the rule is, what its key components are, and whom it affects. It discusses key concepts such as covered entities, business associates, and the minimum necessary standard and offers examples of their real-life application. A glossary of HIPAA terminology is also included.


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Customer Service

Customer Service Strategies for the Health Care Environment

In an easy-to-read style, this book offers strategies, tools, and exercises designed to make industry employees more aware of service issues and ways to create a customer-driven organization. Its wide range of coverage guides readers in removing the barriers to excellent customer service; improving communication; assessing quality issues; analyzing service cycles; hiring, training, and managing personnel; and handling complaints. Many valuable resources are included, such as 50 expert tips for achieving quality service and provocative self-study quizzes in each chapter. (Study materials available online.)

These books may be ordered by calling 800-828-0111.

Plan Types and Management - America's Health Insurance Plans€¦ · Dental Benefits Part B Study...

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