Milliman Markt Monitor Nederland – juni 2020
Maandelijkse publicatie van Milliman met een overzicht van de ontwikkelingen op de markten die relevant zijn voor pensioenfondsen.
New trends in dental care and insurance coverage are aimed at improving the patient experience as Milliman’s Joanne Fontana discusses.
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Lesley Pink: Hello and welcome to Critical Point, brought to you by Milliman. I'm Lesley Pink and I'll be your host today. In this episode of Critical Point, we're going to be talking about dental insurance and some of the latest trends in both care and coverage. According to the American Dental Association, one-third of adults in the U.S. lack dental insurance, but there are some new options on the way for those who don't have dental insurance and need it. Joining us today is Joanne Fontana, a Milliman healthcare consultant who has written extensively about dental insurance. Hi, Joanne. Thanks for coming from Connecticut to talk to us today.
Joanne Fontana: Thank you for having me.
Lesley Pink: Well, let's talk a little bit about dental insurance in general. One thing I've always wondered about is why it is separate from medical insurance when oral health is linked to overall health.
Joanne Fontana: Yeah, that's a very good question, and I don't think there's one specific reason that dental insurance is separate from health insurance. I think it’s how things have just historically evolved over time. A couple of factors might be, first of all, the way the different types of healthcare providers are educated. If you think about dental schools, they're separate from medical school programs and also the doctors and dentists generally practice separately. If you think about when you go to a dentist office, it's not usually co-located with a doctor's office. I also think that healthcare insurance is generally thought of as helping people protect themselves from catastrophic events. You know, if you think about the cost of healthcare, if you have a severe health problem, the cost can go into the hundreds of thousands of dollars. Whereas for dental care it's not really that same level of cost. So because of that, dental insurance really is not geared towards catastrophic coverage; it's more geared towards helping people get into the dentist for their preventive care, getting their cleanings, getting their oral exams at a lower cost or even potentially no cost as long as they're paying their insurance premiums.
Lesley Pink: And how many people in the U.S. now have commercial dental coverage?
Joanne Fontana: Yep. Yeah, about a third of adults have no dental coverage at all. And also about 10% of children have no coverage at all. If you're getting dental insurance through your job, that type of insurance coverage is covering about 59% of working age adults, and roughly half of the children in the United States are covered by that private dental insurance coming through your employer. And then the remainder that we haven't talked about yet are generally covered under public programs, like state Medicaid programs. So under Medicaid or CHIP, children are covered for dental care across all the states in the U.S. And it's pretty comprehensive dental care. It's not just going in for cleanings. It covers higher order care as well, usually even including things like orthodontia if there's a true medical need for something like that.
On the flip side for adults, the coverage for adult dental care under Medicaid is not a federal requirement. So it's an optional benefit that states can choose to offer and because of that, it takes various forms depending on the state that you live in. So if you're an adult in a particular state, you might have no dental benefits at all under Medicaid except for the true emergency. You know, you show up an emergency room, you have a severe dental issue, you might get admitted to the hospital and then it kind of ends up falling under the medical side of things. But anything that we would traditionally consider as dental care may not be covered at all for your state. So that's kind of the bottom end of the spectrum, and it ranges all the way up to some states that have very comprehensive adult dental coverage for-- under the Medicaid program-- you know, up to and including things like dentures, which can be very important especially for older adults, things like oral surgery. So it really does depend on the state you live in, which can be hard for people that have particular needs. The other thing that's interesting is even within a state you will see changes in the adult Medicaid dental benefit over time. Because it's an optional benefit, whenever there is any sort of budget concerns at a state level, if there are Medicaid dollars that need to be cut out of the program, oftentimes adult dental coverage is the first thing to get slashed. And it can be just a reduction in the benefit level or it can be entirely eliminated. So even if you are in a state that has dental coverage today, that's no guarantee that tomorrow or next year you'll still be able to go in and get that dental care.
Lesley Pink: Is there a state in particular recently that's been affected by cuts?
Joanne Fontana: There is. I try to track it and it's really interesting to see over time. You really do see this ebb and flow as budgets are bigger or smaller and need to be adjusted. Alaska is in the news right now because just recently in the last couple of weeks, they reduced their Medicaid budget and adult dental has been cut. And Alaska, prior to this, had been one of the states that covered very comprehensive dental care for its Medicaid adult population. So I was just reading an article on the way over here that talked about, you know, there's people that are in the process of care that maybe were preparing to get dentures that now may not be able to complete their treatment because of the cost of them.
Lesley Pink: What about Medicare? Medicare covers 59 million people in the U.S. And again dental benefits are not included in standard benefits.
Joanne Fontana: Medicare has never covered dental from its inception. I would point out that until 2006, Medicare did not even cover prescription drugs. So there's kind of this slow progression of potentially covering additional benefits. You know, if it took that long to cover something as important as prescription drugs, you can imagine that any sort of lobbying efforts to cover dental would be even harder. So dental has been excluded from Medicare since its inception and it's a statutory exclusion-- so essentially that means that legislation would have to be passed in order for dental to be added as a standard benefit. And over the years, there have been many bills, time and time again, that have been introduced to try to in some way cover dental for the Medicare population. But obviously none of those have made its way-- made their way through the process yet. There's actually a bill right now that has been introduced. It's called the Medicare and Medicaid Dental, Vision, and Hearing Benefit Act of 2019. And in part that would act to add a dental benefit to the standard Medicare program. It was introduced earlier this year, but no action has been taken yet. And as you can imagine, with elections coming up, you're not likely to see anything major like this happening in the very short term.
Lesley Pink: So what are people who are in that population who don't get that dental insurance- what do they do? How can they get it?
Joanne Fontana: Right. So for Medicare, we're talking about seniors. Some of them pay out-of-pocket for dental care. You know, they're walking in and basically paying full price. Some of them cannot afford to do that or they might not be mobile enough to do that. Or they might not have the transportation to do that. So there's lots of other ways that they can try to get affordable access to dental care.
The biggest product that I've seen that targets the senior population are these Medicare Advantage Plans. Medicare Part C is Medicare Advantage, which is essentially a managed care program that covers all the standard Medicare benefits, but allows private managed care companies to administer them. So dental is a very common supplemental benefit under Medicare Advantage programs. And because the, you know, these are just private insurance companies offering these benefits, like I was describing before, under Medicaid versus Medicare Advantage, dental benefits can vary widely depending on the plan that's running it, depending on the state you're in, etc. I mean, it can range from very low benefit levels that just say, "Hey, you can get a cleaning a year for free." Or it may go all the way up to covering X-rays, covering dentures, covering filings, all those things you think of that you need, for dental care especially as you age.
Lesley Pink: And what are some other options besides those supplemental benefits for seniors who need dental care?
Joanne Fontana: Yeah, so I think broadly, access to dental care can be an issue especially in certain geographic locations. There's places where there're, frankly, just aren't enough dentists, especially in rural areas, to service the population. You know, you might have to drive really far to get to a dentist. So it really expands beyond just seniors accessing care. But really for anybody who for whatever reason does not have dental insurance, there are some other ways that they can try to get care at a more affordable cost.
The first thing I would point to are dental discount plans. Those are-- you may have heard of prescription drug cards, which is basically like a discount card. So you can go in and get drugs at a discounted rate. You pay for access to this card but then the prescriptions that you get are at a reduced cost. There is the same type of product for dental insurance, so it's not really an insurance plan. It's just a discount card, but if you go to particular dentists, they will see you at a discounted rate. So that doesn't solve the access issue in terms of just being far away from somebody who can give you care, but it can help with the cost issue.
Another thing that's being explored more on the medical side and the dental side is telemedicine or teledentistry. So that's just what it sounds like. It's using technology to find innovative ways to help people get the dental care they need. So again, that can help with people that live in rural areas that might not have access to a dentist right down the street. It can also help people, going back to the senior population, people that might be in nursing homes or in long-term care facilities who may not be able to get out to go to the dentist on a regular basis. So teledentistry can be a real-time type of visit where, you know, imagine yourself having like a video conference with a dentist and there might be special cameras where they can look into your mouth. I mean, there's all kinds of neat technology that's being developed to help in these types of situations. That type of technology can be used in a rural health center as well. They can also be like non-real time interactions where you have somebody on site, maybe a hygienist, maybe some other type of healthcare provider, that can do enough of the groundwork to send information to some dentist who's working remotely somewhere, and who later on can review the information and help make a diagnosis. There's even things now that are like apps on your iPhone where you can pay for some app, you-- it allows you to take a picture of the inside your mouth. You can have that picture submitted to a dentist, the dentist is sitting on the other side looking at your pictures and giving you some sort of treatment recommendation-- which may be to go in and see a dentist at an actual dental office, but it may be to just do some at home care, which can help people again access care in kind of innovative ways.
Lesley Pink: So you could just snap a picture--
Joanne Fontana: Yes.
Lesley Pink: -- with their phone. I don't think you're using these apps for something that is… something minor.
Joanne Fontana: --a severe, you know, you're not using it for something where you would obviously need to go in and have somebody looking way, way back in your mouth. But for sort of a routine, "I think this tooth might be cracked. Can you look at it if I zoom in on it,"-- things like that, you may be able to get the advice you need without actually going into the office.
Lesley Pink: Another thing that I read about recently was the use of dental therapists. Can you talk a bit about that?
Joanne Fontana: So dental therapists are similar to on the medical side what you think of-- you've heard of physician's assistants. So they can do a lot of the same things that the dentist can do, not all of them, but they're kind of a mid-level dental provider. So they can do more than a hygienist, for example. They can also help fill gaps where there are just not enough dentists in an area to serve a particular population. Or when there's not enough dentists in an area that are willing to accept Medicaid patients. So even if there's enough dentists around, some of them are not willing to participate or not able to participate in the Medicaid program. So dental therapists, if they are allowed to practice in that way, can help fill that gap. And, again, they act just like dentists. There are certain things they can't do. But oftentimes they can have people come in for routine care and do those cleanings. And, you know, do those oral exams and see people who otherwise might not be able to be seen by somebody who's knowledgeable about dental issues. Dental therapists have to be allowed to practice in that way. States have different licensing rules and different kinds of scope of practice rules that explain what dental therapists are and are not allowed to do. And there are some states that have been leading edge in really helping dental therapists to practice to the full scope of their abilities and help fill those gaps for people that do need better access to healthcare. So Alaska comes to mind, Minnesota, Arizona, New Mexico. And it's an active thing where every couple months, I'll see information about a new state really trying to explore this. Again, it can really help in rural areas. It can help when you have tribal populations located somewhere that might need care and don't have ready access to a dentist right down the road.
Lesley Pink: What do you see for the future of dental coverage? Is there something coming down the pike on the insurtech side?
Joanne Fontana: In terms of insurtech, I would say that there are innovators in the dental insurance space. It's funny because dental insurance has been kind of a very slow moving industry. So, you know, there's a lot of well-established dental insurers that are doing their thing. And for a long time, we weren't seeing a lot of movement in terms of, what does your dental benefit look like that comes from your employer. Things like that have stayed fairly constant really for decades at this point.
But there are some innovative startup types of companies that are trying to really transform the whole experience of buying dental insurance. You know, much more consumer driven, much more personalized on your phone through apps things, like that. There are also companies that are using devices in new ways. So, for example, there's a company that like, you know, how Geico has the good driver device that you can stick in your car and it monitors your driving habits? There's a few companies that have toothbrushes like that. So you have your toothbrush and you're brushing your teeth, and it is tracking your brushing habits. And on the one hand, it's a toothbrush delivery service so you can subscribe to get a new toothbrush, maybe some toothpaste, maybe a battery every three months or whatever it is and you get supplies in the mail. And you can also allow them to track your data and then you can purchase insurance through this same company. And because they understand your brushing habits, in theory, if you are taking better care of yourself, you might get a lower insurance rate than somebody who is not-- who does not have the same good brushing habits. So there are definitely creative things like that happening that we will see, you know, how many of them end up taking off.
Lesley Pink: Well, that’s incredible that your brushing habits can be tracked. Now I wonder is flossing going to get involved? Is chocolate consumption going to get involved? Where does that end? So that is…
Joanne Fontana: Who knows?
Lesley Pink: So that is a whole new world?
Joanne Fontana: That is a good question.
Lesley Pink: Besides the insurtech side, what else do you see as the future of dental insurance in the U.S.?
Joanne Fontana: Yeah, one of the things that I’ve been hearing a lot about in my consulting work is the connection between your oral health and the health of your whole body. And really that should not be a surprise to any of us. You know, if you're taking good care of your teeth and reducing bacteria in your mouth, that it stands to reason that that would have some kind of effect on your overall body health. And there've been a lot of articles published, as well as a lot of clinical studies done in the last several years, on the connections between your oral health and your oral health maintenance. So how well you're brushing and how often you're going to the dentist and the connection with chronic diseases. So things like diabetes, things like heart disease, lung disease, stroke, preterm labor, preterm pregnancies, and other chronic medical conditions where if you take better care of your mouth, you can better manage those conditions or potentially even prevent them.
So the jury is still out on all of that. A lot of studies show that there's a connection, which makes sense. What I think the industry would really love to see is a cause and effect relationship. So if I take really good care of my mouth, can I prevent the progression of diabetes? We're definitely not to that point yet at least in the research that I’ve seen. But at the same time, all of those chronic diseases. They cost a lot of money. So insurance companies spend a ton of money on diabetics and on people with heart issues, etc. And so in any way that you can try to reduce the cost of that, try to reduce the severity of those diseases, is worth exploring. And the ones that you’ve seen probably even in your own insurance policies today, there will be disease management programs for things like diabetes. So your health benefit might allow you to go in and get extra dental cleanings if you are an identified diabetic. Oftentimes, pregnant women are able to go in and get extra dental cleanings because it's been shown that there are some correlation between healthy mouth and full-term pregnancy. So those are things that are kind of already incorporated into healthcare benefits today, and I think you'll see that expand well beyond what it is now. And I also think you could see more of a marrying of-- we talked about at the beginning how medical insurance and dental insurance are generally separate. If you truly believe that there's this total body connection, you might start seeing some of those separate companies kind of re-converge, so that you really are considering total body health and not separating your mouth from the rest of your body.
Lesley Pink: I'll try not to separate my mouth from my body in the near future.
Thanks for joining us, Joanne. You've been listening to Critical Point, presented by Milliman. To listen to other episodes of our podcast, please visit us at milliman.com. Or find us on iTunes, Google Play, Spotify, and Stitcher. See you next time.