A focus on systemic conditions prompts insurer to expand coverage
When I visited the Yankee Dental Congress in Boston in January 2018, it was thrilling to learn that Blue Cross Blue Shield of Massachusetts (BCBSMA) has come up with a novel approach that considers the impact of untreated dental disease on the systemic health of patients. But before I share what I learned, let’s review the structure of traditional dental plans.
Both patients and clinicians grumble about poor dental insurance coverage. When dental benefit plans were first conceived, they were never intended to simulate traditional medical insurance models. Plans are simply a business contract between the benefit provider and the patient that are typically purchased by a company for their employees. Most dental plans feature a defined list of covered procedures that usually cap out at $1,500 to $2,000 per year—a figure that has sadly remained unchanged for 50 years. Specific benefits can be loaded with lots of rules defining how often a procedure can be performed, the dollar amount of reimbursement, a potential co-pay, etc.
To further complicate the situation, patients often think that if treatment is not covered, then it is not necessary. Or, if the reimbursement is not 100% of the fee, then the office is overprescribing or overpriced. In most cases, nothing could be further from the truth. These misconceptions create unnecessary tension between the patient and the provider. In addition, many patients do not realize their dental benefits package reflects the benefit plan the employer was willing to purchase for their workers.
Just like a dental practice, insurance companies are in the business to remain profitable. Like all other businesses today, insurance companies are looking for ways to reduce costs. Imagine, though, if there were a way to lower costs while incentivizing people to seek out and receive appropriate treatment that could end up lowering the overall cost of their medical care and improving their health at the same time.
This is exactly the approach now being taken by Blue Cross Blue Shield Massachusetts (BCBSMA).
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Dental Blue’s plan
According to Robert Lewando, DDS, MBA, executive director of Dental Blue at BCBSMA, 80% of all medical costs are incurred in the management of chronic disease. Since it is also known that inflammation plays a role in the management of chronic disease, there is mounting evidence that oral inflammation contributes to the overall inflammatory burden affecting the management of these diseases. Dental Blue has created a unique program for individuals who are covered under BCBS medical and dental plans.
Those who are eligible under this innovative approach can have additional services covered outside of a traditional dental benefit plan. Patients who are at a higher risk for medical problems are now eligible for these enhanced benefits—preventive and periodontal services that help reduce inflammation.
At this point, the list includes those with coronary heart disease, diabetes, oral cancer, and pregnant women. According to Dr. Lewando, additional health conditions are expected to be included for enhanced benefits later in 2019.
The enhanced benefits for eligible patients includes coverage for periodontal scaling and root planing, quarterly dental hygiene visits for either a prophylaxis or periodontal maintenance therapy, and fluoride therapy for those with a history of oral cancer. Fees for the enhanced benefits for designated high-risk patients are covered by BCBS and not counted against a patient’s traditional benefit plan. The enhanced coverage eliminates the financial barrier for receiving treatment that has been shown to reduce oral inflammation. A more stable oral health status reduces the body’s total inflammatory burden and supports overall reduction in medical costs.
This integrated system works because the patient’s health-care record is housed under one common carrier, BCBS. Patients with these medical conditions are automatically notified of their enhanced benefits when they are identified from the medical claim system. The health-care costs of individuals with these conditions can be tracked, and differences can be seen between those using their dental benefits to reduce inflammation compared to those who do not. Outreach is also done to members with these conditions who are not using their benefits to encourage their use.
Members with dental benefits through BCBS but who are also covered by a different medical carrier are still entitled to these enhanced benefits. However, since BCBS does not know in advance the medical history of these members, they must self-enroll.
The benefit to Uncle Dan
So let’s put a real-life picture together. Your favorite uncle, Dan, is 48 years old and lives in Framingham, Massachusetts. He’s overweight, a longtime smoker, and has just been diagnosed with type 2 diabetes. His periodontal condition is always unstable, No. 30 has a huge amalgam and a dark fracture over the distal marginal ridge.
He’s a mess and has never been willing to deal with his oral issues, always citing money as the obstacle. If Dan’s dental coverage is with BCBS, then the cost of his nonsurgical periodontal therapy and subsequent maintenance visits is now a moot point. These procedures are covered by this new integrative plan, and he can still use the coverage in his traditional plan to get a crown on No. 30.
Kudos to BCBSMA for creating a plan, back by current research, that supports both the health of the patient and the health of the business.
1. Heart disease fact sheet. CDC website. https://www.cdc.gov/dhdsp/data_statistics/fact_sheets/fs_heart_disease.htm. Updated August 23, 2017. Accessed February 18, 2018.
2. Sanchis-Gomar F, Perez-Quilis C, Leischik R, Lucia A. Epidemiology of coronary heart disease and acute coronary syndrome. Anns Transl Med. 2016;4(13):256.
3. New CDC report: More than 100 million Americans have diabetes or prediabetes. CDC website. https://www.cdc.gov/media/releases/2017/p0718-diabetes-report.html. Published July 18, 2017. Accessed February 18, 2018.
4. The staggering cost of diabetes. American Diabetes Association website. http://www.diabetes.org diabetes- basics/statistics/infographics/adv-staggering-cost-of-diabetes.html. Accessed February 18, 2018.
5. Preterm birth. CDC website. https://www.cdc.gov/reproductivehealth/maternalinfanthealth/pretermbirth.htm. Accessed February 18, 2018.
6. Oral cancer facts. Oral Cancer Foundation website. https://oralcancerfoundation.org/facts/. Accessed February 18, 2018.
ANNE NUGENT GUIGNON, MPH, RDH, CSP, provides popular programs, including topics on biofilms, power-
driven scaling, ergonomics, hypersensitivity, and
remineralization. Recipient of the 2004 Mentor of the Year Award and the 2009 ADHA Irene Newman Award, Anne has practiced clinical dental hygiene in Houston since 1971. You may contact her at [email protected].
High-risk conditions: Prevalence and financial impact
Coronary heart disease1,2
• Major cause of death and disability
• One in four deaths annually
• Leading cause of death for men and women
• Most common type of heart disease
• $200 billion per year in health-care services, medications, lost productivity
• Seventh leading cause of death
• 30.3 million adults and children with diabetes
• 7.2 million unaware of their diabetes
• $322 billion in direct medical costs, reduced productivity
• 2.3 times higher health-care costs
• 84 million have prediabetes
• 90% unaware of their prediabetes
Preterm Birth/low birth weight5
• 10% all US births
• Rates increasing since 2015
• Higher risks of breathing and feeding issues, developmental delays, vision and hearing issues, cerebral palsy
• In 2015, caused 7% all infant deaths
• $26.2 billion in medical costs for mothers and infants, intervention services, special education
• Estimated 50,000 new cases annually
• Two times the risk in males
• Rise in HPV-related oropharyngeal cancer
• Five-year survival rate is 57%
• 20 times the risk for developing a second cancer
• $3.2 billion in head and neck cancer treatment