Finance in dentistry

About finance in dentistry

1. Government Dental College and Hospital

2. Department of public health dentistry

3. Finance in dental care Presented by, A.subba saranya Final year,Bds

4. Contents : Introduction Mechanism of payment for dental care Financing dental health services in india Reference Conclusion

5. Introduction Health care services Traditionally have been provided on a fee-for-service basis where by the patient receives specific services and pay the provider directly.  The cost of the health care continue to raise due: Public increase in demand for health service Even growing technology for health care Higher quality of health care As the cost is increasing many  people can’t effort the health care services So many methods have been developed so ease the cost of health services. 

6. Private fee-for-service Post payment plans Private third party prepayment plans  Commercial insurance companies Non profits health service corporations e.g Delta dental plans and blue Cross/blue shield Prepaid group practice Capitation plans Salary Public programs Mechanism of payment for dental care

7. Private Fee-For-Service/two party arrangement: Private Fee-For-Service, is a traditional forms Patient take the appointment and dentist suggest the appropriate treatment and informs the patient His fee for the service Patient is responsible to pay the fees

8. Advantages Culturally acceptable This system is flexible It is adminstratively simple Time saving Mode of patient can be finalized before the treatment is started Appointment can be made based on the convenience of dentist as well as patient Disadvantages Though it is flexible, due to the cost of treatment many people cannot afford dental care under this method of payment

9. Post payment plans/Budget payment plan First started by local dental societies in Pennsylvania and Michigan.

10. Private Third Party Prepayment Plans Defined as payment for service by some agency rather than directly by the beneficiary of those services. 1 party- Dentist 2 party- patient 3 party-administrator of finance The third party is also known as the carrier insurance,underwriter or administrative agent. Usually third party refers to a private carrier such as insurance company.

11. INSURANCE PRINCIPLES To Be Insurable, A Risk Must . Be Precisely definable . Be of sufficient magnitude, that if it occurs, constitute a majorloss . Be/ infrequent. Be of unwanted nature ex: accident, fire, etc. Beyond control of individual. Dental insurance can be made feasible by: Having patient pay a share of the cost. Limiting the range of services available. Offering services only to group. Include waiting period before benefits become payable. Use preauthorization and annual expenditure limits.

12. Different types of payments offered by the insurer: Deductible/front end payment: It is the sum that the patient must pay towards the cost of the treatment before the benefits of the program go into effect Group insurance: This is health insurance offered only to groups

13. Co-Insurance/co payment: It is an arrangement under which a carrier and the beneficiary are each liable for a share of the cost of the dental service provided

14. Reimbursement of dentists in pre payment plans: Usual fee: The fee that an individual dentist most frequently charges for a given dental service. Customary Fee : : A fee is customary when it is in the range of the usual fee charged by dentist of similar training and experience for the same service within the specific and limited geographic area. Reasonable fee: A fee is reasonable if it meets the above two criteria or if it is justifiable considering the special circumstances or the particular patient in question.

15. Table of allowance: it is defined as a list of covered services with an assigned amount that represents the total obligation of the plan with respect to payment for such services, but does not necessarily represent the dentists full fee for that service.

16. Companies operate for profit
Cash payment to the providers i.e., the companies pay the dentist directly for the provision of covered services and payment is quicker.
Carrier develops fee profile based on the prevailing fees in the given area and the dentist are paid at that rate. Commercial insurance companies Disadvantages They charge higher premiums They do not conduct fee audits and post treatment dental examination                

17. Inspite of disadvantages they can compete successfully because: They are expertise in promotion and marketing allows them to present attractive plans to purchasers.

18. Non profit health service corporations Delta Dental Plans It is a legally constituted non- profit organization incorporated on state by state basis and sponsored by a constituent dental society to negotiate and administer contracts for Dental care. started as National Association of Dental Service Plans(NADSP) In june 1966 with the help of ADA. Later changed it name into Delta Dental Plans Association in April 1969

19. Reimbursement of dentists in Delta plans: A participating dentist is defined as any duly licensed dentist with whom a delta plan has a contractual agreement. Participating dentist They should follow the following conditions Pre-filing of their usual and customary fees Acceptance of payment for their services at an agreed-on percentile. Fee audits by auditors from delta plan. Post treatment inspection Withholding of small amount of each fee to go into the delta capital reserve fund. Non participating dentist can also treat patients in delta plan and get reimbursed by deltaplan They need not follow any of conditions They are paid at 50th percentile of fees rater than at 80 of 90th percentile

20. The 90 th percentile

21. BLUE CROSS BLUE SHEILD ASSOCIATION (BCBSA) It is a federation of 38 separate health insurance organizations and companies in United states. Combined, they directly or indirectly provide health insurance to over 99 million Americans. Blue cross dates back to 1929 while Blue shield dates back to 1939,these two organizations merged in 1982. These non profit health service corporations have for years offered limited dental coverage as a part of medical policies.

22. . According to ADA (1969) Group practice is that type of dental practice in which dentists, sometimes in association with the members of other health professions agree formally between themselves on certain central arrangements designed to provide efficient dental health service. It is a group practice that provides dental services on a prepaid basis. Such groups are often regarded as open panels. Prepaid group practice:

23. Types of group practice: • General Group practice-c omposed entirely of general practitioners Single specialty group- composed entirely of same specialty practitioners Multi-specialty groups- composed of practitioners in two or more specialty fields of practice.

24. Better way of organizing one's life, i.e., one practitioner can plan readily for vacation Less disruption in the practice caused by the illness to a dentist Improved quality of care because of the built in peer review. S ick leave and pension plans can be built into a group organization more readily, thus easing the economic concerns of dental practice. MOST OF THE GROUP PRACTICES TREAT PATIENTS ON THE TRADITIONAL FEE-FOR-SERVICE BASIS. Advantages:

25. HEALTH MAINTENANCE ORGANIZATION (HMO) It is a legal entity which provides a prescribed range of health service to each individual who has enrolled in the organization, in return for a prepaid, fixed and uniform payment. It must be capable of Providing or organizing for the provision of the health services that a population might require including primary care and rehabilitation. services will be purchased from the HMO in return for the prepayment figure.

26. An enrolled group: People who voluntarily join the HMO through a contract arrangement in which the enrolled agrees to pay the fixed monthly or periodic payment to HMO Reimbursement : HMO use a prepaid capitation system of financing medical services. Only an small amount of HMO offers dental services

27. Dental Personnel in HMO Staff model- Dentists, dental hygienists, and dental assistants are salaried employees of the HM Ο. Group models - HMO contracts directly with a group practice, partnership or corporations for the provision of dental services. Independent Practice Association (IPA) - IPA is an association of independent dentist that develops its own management and fiscal structures for the treatment of patients enrolled in an HMO. Primary Care Capitated Network Or Direct Contract Model-network S imilar to IPA except that the HMO contracts directly the individual provider for provision of services.

28. Capitation plans: The basis of capitation is that the contracting provider, whether an HMO or individual dentist receives an established, negotiated sum on a monthly or yearly basis for each eligible patient. The money is paid regardless of whether the patients utilize care or/not. In return, patient is entitled to receive a prescribed set of services over a specified period

29. Salary: Dentists in some group practices, those in the armed forces and those employed by public agencies are salaried.

30. Advantages: It allows a dentist to be largely free of the business concerns of running a practice, thereby allowing the dentist to concentrate on clinical matters. Fringe benefits are attractive. Disadvantages : There could be a lack of financial incentive that some dentists need to be highly productive.

31. Public programs: Private practice is usually not able to meet the dental demands of public. Therefore a number of public programs aimed at meeting the needs of society. The public programs are sponsored by the government and also include community health centres.

32. Public financing of dental care:

33. I n the USA, title XVIII of the Social Security Amendments of 1965 is the program known as "Medicare". This program removed all financial barriers for hospital and physician services for all persons aged 65 and over, regardless of their financial means. Because the income of persons aged 65 and older is considerably less, they have limited funds to spend on health care. The dental segment of Medicare is limited to those services requiring hospitalization for treatment .

34. It is the name given to title XIX of the United States Social Security Amendments of 1965. The original intent of the program was to provide funds to meet the health care needs of all indigent and medically indigent persons. Medicaid is a joint federal state program covering at least these basic services

35. National health insurance (NHI) Introduced by Bismarck in Germany in the 1880's and in Britain by Lloyd George in 1910. While humanitarianism was a factor in their development, a more powerful stimulus was probably the awareness that a healthy and secure society led to political stability and greater economical and industrial strength. The NHI is primarily a financing mechanism by which health care services are paid for from a public organiz ation .

36. FINANCING DENTAL HEALTH SERVICES IN INDIA Fee-for service A majority of dentists in india provide dental services on a fee for service basis.other facilities providing fee for service are, Private hospitals Private doctors Facilities of private firms/enterprises Medical education/research and training in the private sector.

37. Dental insurance Insurance companies have now started offering dental insurance,whichcovers not only those dental treatments which require hospitalization, but also covers dental checkup,oral prophylaxis, restorations and dental extractions. The premium however,varies with the coverage.

38. Free or discounted rat e Free or discounted health services are provided under publicly funded Government schemes like Hospitals of the State government Dispensaries of the State government; Health-centers Rural and urban family welfare centers of the State government Facilities of various Central ministries(such as defence or railways) Facilities of Employees state Insurance scheme 1948 ( ESIS) Facilities of Central government t Health Scheme 1954 (CHS) Facilities of autonomous institutions and societi es .

39. Ayushman Bharat Yojana: Ayushman Bharat is a universal health insurance scheme of the Ministry of Health and Family Welfare, Government of India. PMJAY was launched to provide free healthcare services to more than 40% population of the country. The scheme offers a health cover of Rs 5 Lakh.In this scheme, it covers medicines, diagnostic expenses, medical treatment, and pre- hospitalization costs. The poorest families of India can benefit from this healthcare scheme.

40. Aam Aadmi Bima Yojana (AABY): This is one of the latest National Health Insurance schemes having been established in the year 2007, October. It basically covers individuals from the age of 18 years-59 years. AABY insurance scheme is for all those citizens living in the upcountry and in the rural areas and covers the landless citizens who are tenants living both in urban and rural areas. Basically, the head of the family or the earning member is the one protected by this sch eme. Upon a natural death, the family is compensated at 30000 rupees. However, upon death caused by a permanent disability, the family is compensated at 75,000 rupees.

41. Janshree Bima Yojana: Janshree Bima Yojana is designed for individuals in the poor category who are within the age group of 18-59 years. The scheme includes special features like Women SHG Groups and Shiksha Sahyog Yojana. At present there are 45 occupational groups under this scheme.

42. Mahatma Jyotiba Phule Jan Arogya Yojana The scheme is going to be helpful for below the poverty line and was targeted at the farmers in Maharashtra. The policy offers a family health cover of up to Rs 1.5 lakh for specified illnesses. The best part about this policy is that there is no waiting period, and it is claimable after the first day itself . Pradhan Mantri Suraksha Bima Yojana: Pradhan Mantri Suraksha Bima Yojana aims to provide accident insurance cover to the people of India. People in the age group of 18 years to 70 years who have an account in a bank can avail benefit from this scheme. This policy provides an annual cover of Rs 2 lakh for total disability and death cover and Rs 1 lakh for partial disability.

43. Dr YSR Aarogyasri is a Health Insurance Plan that was launched in 2007 by the then Chief Minister of Andhra Pradesh, Dr Y. S Rajasekhar Reddy. The aim of the scheme is to enable low income-group families to access good quality healthcare. Some of the advantages that it offers are: • Hospitalization • Out-Patient Care: • Cashless Services • Pre-existing Condition Coverage • Coverage for Additional Operations • Family-floater health insurance coverage . The benefits of Dr YSR Aarogyasri Health Care Trust are : • Per family, annual coverage of Rs. 5 lakhs. • Free medical care is provided by public hospitals. • Cashless care from the first day through 10 days after discharge. • Cashless care for patients receiving therapies for up to 30 days after discharge. • The patient's costs for transportation and food are covered by this program. Dr.YSR Aarogyasri scheme

44. 8. Universal Health Insurance Scheme (UHIS): To help the families who live below the poverty line . It covers the medical expenses of each and every member of the family. Once a family member is hospitalized, this scheme may facilitate the medical expenses of up to 30,000 rupees. However, when the earning head of the family is admitted to the hospital, the scheme compensates a total of 50 rupees daily for a maximum of 15 da ys .

45. Employment State Insurance Scheme: This is a multidimensional National Health insurance scheme due to the fact that it provides social security as well as socio-economic protection to all workers in India. This insurance scheme commences upon the first day of insurable employment to each and every worker. They are provided with full medical care insurance for themselves and their families as well. On the other hand, those covered under this scheme are also entitled to a wide range of cash benefits. They include cash in times of physical distress such as sickness . In addition, for any woman who would lose the capacity to earn or dependents of persons injured during occupational accidents, they are entitled to a monthly pension commonly referred to as dependents benefits. It is only applicable to all permanent factories employing more than ten employees.

46. The financing of dental care is well developed and well practiced in developed countries like the U.S however in India Fee-for-service is still the most prevalent form of availing dental services. Although free dental services are provided by the government at some of the health centers,it is scarce and inefficient Dental insurance is in its infancy and with the very high premiums, dental service is still very far from the reaches of the indigent. Conclusion

47. Reference Essentials of public Health Dentistry- Soben Peter(7 th edition)