Dental Insurance

Considering The Future: A Look At Public Dental Care
by Karen M. Gustin, LLIF

The current healthcare reform debates and the consideration of public healthcare options have focused primarily on the impact on medical care with little attention to changes that may occur with dental care.

Americans have enjoyed high quality dental care during the past 50 years. Approximately two-thirds of employees participate in dental care benefits available through their employers. Dental care is available through private dentists, public clinics, and at dental colleges. Will the quality of dental care remain the same if the U.S. adopts a public health plan? What is the possible impact on dental? Although it is impossible to predict the future, it is helpful to review dental care in the United Kingdom -- a country where public dental care has been available since 1948.

Dental Care as a Public Care Option

Dental care in the U.K. is offered through a public health plan, called the National Health System (NHS), private pay, or personal dental insurance available through dental offices or employers. For cost reasons, the majority of Britons register for dental care through the NHS.
During the first six decades of public dental care, thousands of Britons have reported problems with the NHS dental care, including the following:

• Lack of information on how to access dentists.
• Long waiting lines to register for dental care. (Many residents would delay dental care until oral pain became intolerable and then seek emergency dental care.)
• A complex cost system with 400 possible dental charges.
• Dentists focused on “drilling and filling” and not on preventive care. According to BBC news, many Britons believed that dentists preferred to perform complex procedures, such as crowns and root canals, for which they received higher fees, since they were paid according to the treatment they provided.

U.K. Dental Care Reform in 2006

In 2006, the U.K. government made a massive investment in overhauling the NHS dental system. The goal was to make it possible for all Britons who wanted a dentist, to register for one in their community. Under NHS, people registered for dental services and were charged a specific amount for care. Those with lower income levels typically paid little or nothing for dental services.

The government gave Primary Care Trusts (PCT) responsibility for overseeing dental care, including contracting with dentists to provide services in specific areas throughout the country. The government provided a minimal operating budget, expecting PCTs to use dental fees collected to pay dentists and run the organization.

The government also reduced the 400 charge options for dental services to three bands of care, each assigned specific rates. Fees for some procedures combined costs from more than one band.

U.K. dentists are self-employed. They contract with the NHS to provide care to residents in each community registered for dental services. Dentists are paid set amounts when meeting monthly quotas for services, instead of for care provided. The 2006 reform also restricted the amount dentists could charge for dental services. For example, if a patient needed dentist procedures within a two-month period for the same band of service, such as fillings for two different teeth, the patient only paid for one restoration.

A Look Back on Reform

Three years later, many in the U.K. consider the 2006 reform a failure. Consider the following issues:
• In many areas of the county, thousands of residents remain on NHS waiting lists for a dentist. Patients have reported waiting several years to see a dentist because one was not available in their area. Recently when residents in Wales heard that a new NHS dentist was accepting NHS patients, 600 people lined up outside the door to register.
• Frustrated by the waiting lists, some Britons travel long distances to a larger city in the U.K., or go outside the country to see a dentist. For others, it is easier to visit an urgent care center for painful dental needs than to find a regular dentist. In several areas of the country, NHS has opened emergency dental care centers because it cannot secure enough dentists to meet residents’ needs.
• Some dentists limit the number of NHS patients they accept while others take only full-pay patients with certain types of dental needs. NHS dentists may also turn away patients after meeting the monthly requirements of their contract, telling them to return next month. There is usually a waiting list for NHS patients needing assistance the following month.
• The British Dental Association (BDA) reports a significant decline in the number of dentists working for the NHS, in the past few years, because of the payment structure. The BDA believes the system also discourages dentists from working in some areas of the country where patients who do not have healthy teeth need more time for dental care, which reduces the number of patients the dentist can see each day.
• Britons concerned about dental costs typically avoid expensive procedures, preferring to have a tooth extracted instead of having a crown put on. Since the 2006 reform, dental procedures for crowns and root canals have declined substantially, according to the BDA.
• People with dental needs have reported taking painkillers until they can find a dentist or can find time to visit an emergency dental care center.
• Britons have discovered that it costs the same for a routine visit and one filling as it does for a routine visit and five fillings. So many wait until they have cavities in several teeth before seeking dental care.

According to BBC news, adult hospital visits for tooth abscesses have doubled since 2000 to about 1,500 each year. During the past nine years, the number of children going to the hospital for dental problems has increased 66%, with tooth extraction the most common procedure performed.

Some PCTs have contacted retired dentists, especially specialists, to practice part-time to reduce the waiting-list crisis. Some British families have reported waiting nearly three years for orthodontic work for their kids. Many of the primary care trusts responsible for overseeing dental care practices, throughout the U.K., have minimal dental knowledge or experience, but are expected to make dental care decisions, reports the BDA.

In December 2007, the London Assembly Health and Public Services Committee reported that 3.5% of adult Londoners had never visited a dentist (approximately 205,000 people) and 17% had not been to the dentist in the past two years -- equivalent to one million residents.

U.K. Explores New Reforms

U.K. government officials, along with the BDA, are exploring ways to overhaul the system to improve the care and services available through the NHS. They have identified several needs: increasing the number of dentists, providing more preventive care services, restructuring the fees and services, and improving communications with Britons on preventive dental care, stressing the importance of regular tooth brushing and flossing, and maintaining healthy diets. Officials hope to introduce changes to the system in 2010.

Consider the Future of U.S. Dental

Most Americans understand that the U.S. dental care system is not perfect. There are delivery and education issues and not everyone has access to the quality of care or services they need.
It is important to analyze reform options carefully to determine whether the proposed changes would result in the quality of dental care, access to services and treatments, and freedom of choice we need and expect. These questions deserve an investment of time to ensure plans are crafted thoughtfully and are in the best interests of all Americans.
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Karen M. Gustin, LLIF, is senior vice president – Group Marketing, Managed Care, and National Accounts for Ameritas Group, a division of Ameritas Life Insurance Corp. (a UNIFI Company), with headquarters in Lincoln, Neb. A provider of dental and eye care products and services, Ameritas Group added hearing care to its product portfolio in 2008. Gustin joined Ameritas Group in 1983. She is vice chair of the National Association of Dental Plans’ board of directors and its statistical task force, and also serves on NADP’s executive committee.