Taking a Tailored Approach to Dental Benefits

Dental coverage, traditionally a one-size-fits-all benefit, is becoming more complex. For interested employers, though, the more nuanced options may provide better prevention and related cost savings than does the cookie-cutter approach.

The plan designs, which range from new covered services to better coverage of existing treatments, have emerged from an evolving body of research called evidence-based dentistry. As the field develops, one of its central tenets is risk stratification.

Rather than offer the same dental services to everyone, the plans more closely align coverage not only with the individual’s cavity and gum history but even with other non-dental conditions, such as diabetes or heart disease. By providing broader coverage upfront, the goal is to forestall or prevent more costly dental work later, according to the providers and dental consultants interviewed.

Frequently, though, employers haven’t caught up with the new world of dental coverage, says Doyle Williams, DDS, chief dental officer at Delta Dental of Massachusetts. “I give about 150 lectures a year to employers,” he says. “To watch their eyes pop open tells me that they don’t know this, they don’t get it. They have no idea that dentistry can be tailored—that there is a risk status. That some people are at higher risk.”

Tailoring coverage
The specifics of tailored coverage vary depending on the plan involved, as well as what the employer has negotiated. Along with providing more stratified coverage options, insurance providers also are striving to better educate employees about their own dental risk and the related benefits available to them.

Employees with a cavity track record, for example, might get more than two covered cleanings annually. Other plans might pay for deep cleanings of diseased gums (also known as scaling and root planing), rather than asking the employee to pick up part of the tab. Depending on the employee’s risk, other products might be offered, including fluoride varnish or a special prescription mouth rinse.

In recent years, the Massachusetts Public Employees Fund has expanded preventive coverage for the approximately 76,000 enrollees, including dependents, who are covered by the fund’s dental and vision plans. The fund, which is self-insured, uses Delta Dental of Massachusetts to administer its dental coverage but has designed its own network of affiliated dentists and related benefits.

In recent years, the fund has started paying for a prescription antimicrobial mouth rinse after deep gum cleaning treatments. It also covers 100 percent of the cost of fluoride varnish—a sticky coat of fluoride applied to the tooth’s surface—for both children and adults who are considered to be at moderate to high risk of tooth decay.

Susan Fournier, the fund’s executive director, can’t point to any precise cost-savings data. But she remains hopeful, based on some early indications of improved dental health. “It just makes sense that if you can move them [enrollees] out of that higher risk status and get them into a low risk status, it will be less expensive,” she says. “But we also know it will take a lot [of care] upfront.”

Weighing risk
By 2008, 176 million Americans—slightly more than half the U.S. population—carried some type of dental insurance, a 1.3 percent increase from the prior year, according to a survey published this summer by the National Association of Dental Plans and the Delta Dental Plan Association.

Employers are becoming more aware of dental care’s value, says Evelyn Ireland, executive director of the National Association of Dental Plans, a trade group. In 2008, 62 percent of employers surveyed described dental as essential to their benefits package, compared with 53 percent three years earlier. That’s a nearly 10-point jump, Ireland points out. “The message about the connection between dental benefits and overall health is really getting through.”

Still, providing coverage doesn’t guarantee that employees will use the benefits, whether the underlying reason is dental-chair nerves or simply an overbooked schedule. Just three-fourths of those with dental insurance (and half of those without) have gotten at least one checkup in the prior year, according to a 2007 consumer survey conducted by National Association of Dental Plans. “There’s a real hard core of patients who will not seek dental care no matter what,” says Marv Zatz, DDS, a senior dental consultant at Towers Perrin.

In truth, though, not all patients face the same dental risk. Risk can be altered by the patients’ history of cavities and gum disease, whether they smoke or drink, and even vulnerability to conditions like dry mouth. Cigna is among those insurers that offer online risk assessments, such as this cavity risk tool.

Emerging research also indicates that untreated gum disease may be associated with other medical conditions, including heart disease and diabetes. As a result, some plans have made it easier for those at-risk groups to get scaling and root planing, when needed, by covering it at 100 percent, Ireland says.

Cigna offers that option for at-risk individuals who are enrolled in both their medical and dental plans. “I’ll be very frank: The studies that are out there show a strong association,” says Miles Hall, DDS, chief clinical director for Cigna Dental. “At this point, they do not necessarily show a causal relationship. But it’s significant enough that we took a step to be proactive about it.”

But to capitalize on the latest research, employers need to regularly re-evaluate their dental coverage, says Vincent Graziano, a Boston-based vice president and dental expert at Segal Co., a human resources consulting firm. “I see a lot of dental plans that are out of date,” he says. Plans left on autopilot, he says, run the risk of incorporating deductibles and co-pays that discourage employees from preventive steps that could save money later.

Educating employees
It’s not just employers that can give dental benefits short shift. A MetLife survey found that employees spend just 25 minutes on average on dental coverage during initial enrollment. During re-enrollment, that average drops to just five minutes, according to the 2009 online survey of 500 employees.

It may be that they spent so little time because they weren’t offered much plan detail. Only one-third felt they had sufficient information about their coverage or to select a plan. And comprehension did drive satisfaction, the MetLife analysis found. Those employees who reported an excellent understanding of their benefits reported a threefold higher overall satisfaction level; 53 percent were very satisfied, while 17 percent said they had a fair to poor understanding of their dental plan benefits. Early this year, MetLife launched an online dental resource to help employers better communicate dental benefits.

While it’s not uncommon for medical plans to cover 80 percent of an expensive procedure or surgery, dental insurance may only cover half the cost of such care. To guard against sticker shock, some dental plans offer online calculators so employees can estimate the out-of-pocket cost of that looming root canal. Employees also can use online tools to calculate the relative tax benefits of flexible spending accounts.

Employees who don’t bank enough in advance may set themselves up for bigger—and more painful—bills later, says Alan Vogel, DMD, national dental director for MetLife. For example, an employee might invest in a root canal, but postpone the crown that protects the tooth involved from fracturing. “I think a lot of people think that dental care can be delayed ad infinitum,” Vogel says. “Sometimes that delay can be problematic.”

The cost-savings question
As insurers take steps to redesign their plans, they can outpace the dentists themselves, as Fournier of the Massachusetts Public Employees Fund discovered. The fund, for example, covers fluoride varnish for enrollees who are at moderate to high risk. But there are no universally accepted criteria for determining risk, she says. And not all dentists are accustomed to making the assessment.

Even so, Fourier is intrigued by the progress made by some fund enrollees, who use a designated oral health center that provides additional preventive coverage. “We’ve seen over the years, as we get into the data, that there is definitely a reduction in the risk status of those patients,” she says.

And that reduction can translate to dollars and cents. The annual claims cost for a low-risk dental patient is $175, according to fund data provided by Fournier. The cost for a high-risk patient—someone who has undergone at least three procedures in as many years—runs about four times higher, roughly $800 annually.