Insuring your smile
Clinical studies bolster push for more dental health services

by Marjolijn Bijlefeld
for Virginia Business
September 2007

Laura Lafayette found that negotiating health-care benefits for a professional association can be a lot like pulling teeth. By contrast, signing up for a dental plan turned out to be as routine as a simple cleaning.

That’s how things played out for Lafayette, senior vice president of the Richmond Association of Realtors, which serves 6,000 members and 750 real estate brokerages. In late winter, the association began offering members dental coverage through Dominion Dental Services’ eDental program — a Web-based approach that allows membership organizations to provide easy access to dental programs at negotiated rates. “We have tried to sign up for medical plans, but those usually require more true group participation than we’ve been able to generate,” says Lafayette. “And we’ve offered insurance discount programs, but Dominion Dental’s program has been the most full-fledged program, extending group-level benefits to independent contractors. It also required so little work from me.”

In the first four months or so, about 150 of the association’s members enrolled in the program by going through a dedicated Web site created by Dominion Dental. “That’s a significant response rate, and that Web site is seeing about 100 visitors a month,” Lafayette says, noting she expects the enrollment rate to climb as members learn more about the program.

Dominion Dental, an Alexandria-based, dental-only benefits company, is not the only Virginia insurer looking for new ways to tap into the dental market. Nationwide, about 55 percent of the U.S. population is enrolled in a dental benefit plan — a percentage that holds steady even as the population grows.

The National Association of Dental Plans (NADP), based in Dallas, says that 71 percent of employers offered dental benefits in 2005. Still, that leaves a huge opportunity to expand the market with this desirable and comparatively inexpensive benefit. The NADP reports that average annual premiums for an individual are about $183 for a dental HMO, $341 for a dental PPO and $350 for an indemnity, or fee-for-service, plan that requires little or no out-of-pocket spending for the employee. Those rates are typically less than monthly health insurance premiums. And premium increases tend to mirror the rate of inflation — averaging between $5 and $11 a year, the NADP report says.

This year, the federal government added dental and vision benefits as an option for its employees, bringing another potential 8 million workers into the market. Among large employers, then, the market is nearly saturated. So the trends there reflect what’s happening in medical care — choice of providers, a variety of plans and shifting more of the premium costs to the employee.

Yet continued growth is likely for a variety of reasons — particularly among smaller businesses and individuals. Web-based programs and a sophisticated infrastructure make it possible to track and offer different levels of benefits to more people. And recent clinical studies have found strong correlations between overall health and oral health because the bacteria that grows in the mouth can have an effect on the whole body. Studies show the risk of fatal heart disease doubles in people with severe periodontal disease and that people with diabetes can have a more difficult time controlling their glucose levels, for example.

As a result, dental-only insurers and major medical insurers that package dental and other ancillary benefits are adding products and services.
Anthem Blue Cross/Blue Shield of Virginia, for example, will roll out several pilot programs on Jan. 1 that it hopes will encourage people with Anthem medical insurance to use their dental benefits. Dr. Carl Gong, the national dental director for Anthem’s parent company, Indianapolis-based Wellpoint Inc. explains two of these initiatives. In one, the company will encourage diabetic patients to visit the dentist. Studies show that poor oral health and periodontal disease make it more difficult for diabetics to control their glucose levels. Research reveals that medical costs for patients with diabetes decline from 9 to 15 percent with good oral hygiene. “If you look at the prevalence of diabetes, that’s a major opportunity to save health-care dollars and improve the health of our members. The diabetic population is 4 percent to 7 percent of the typical medical population, so [those savings] can be a tremendous benefit,” Gong says.

Another pilot program will encourage pregnant women to use their dental benefits. “Pregnant women with periodontal disease have a seven times higher incidence of low-birth weight, pre-term babies. The neonatal costs and other medical disadvantages for the lifetime of a premature baby are significant,” he says. In the pilot program, Wellpoint enrollees who are pregnant will be urged to go to the dentist for routine periodontal care.

“That’s a shift from how it used to be. The old-school way was when a woman is pregnant, leave her alone.” Recent studies have also shown a correlation between advanced gum disease and heart attacks and strokes.

Because Anthem covers medical and dental care, these programs reflect “the true value of the integration,” says Gong. Under a new program called 360o Health, Anthem is making comprehensive personal health records (PHR) available to its members. “Currently, members can input information into their PHR. In the future, the company plans to automatically populate member PHRs with claims data [including dental, medical and pharmacy] received by Anthem,” says Scott Golden, regional director of corporate communications.
Greater integration of medical records is one trend involving dental services.

On the other end is the growth of stand-alone dental insurance companies. For example, the revenues of Roanoke-based Delta Dental of Virginia have soared from about $30 million in 1996 to nearly $280 million in 2005. Membership has climbed from about 200,000 to nearly 1.2 million during that time.

Dental-only insurers claim that because dental is their only business, they can be more responsive to market changes. Dominion Dental holds out its eDental program as an example. “The demand for group-caliber dental coverage for associations and other member-based organizations has always existed,” says Mitch McGlynn, the company’s CEO. “Until now, most of these organizations were unable to offer plans with the same level of coverage or savings as employer groups.”

He adds that the appeal to this program is the extension of true group coverage sold on an individual basis with the convenience of being able to apply, check benefits and find a dentist online. “We offer a plan that is completely free of employer administrative responsibility. Dominion also provides a series of custom e-mails, newsletter articles, mailing pieces and other informational material for the group to distribute to its membership.”

For some businesses, bundling dental benefits with medical insurance isn’t practical. Linda Satlin is benefits manager for Prince William County, which self-insures its medical insurance and has been with Delta Dental for several years. About three-quarters of the county government’s 3,800 employees are enrolled in the dental program — more than participate in the medical plan. County workers typically have no need for medical insurance if their spouses work for the federal government or a high-tech firm in the area offering robust benefits packages. “But our employees have been anxious and vociferous about wanting richer dental benefits,” Satlin says.

As a result, in July the county began offering an enhanced Delta Dental program, which doubles the benefits at a slight premium increase. More than 1,000 people signed up for the new program. County employees staying with the basic program pay $12.50 for their monthly dental premium. Employees moving to the enhanced program pay $19.40, and the county’s contribution stays the same. In the enhanced program, the annual cap for coverage is doubled — from $1,000 to $2,000 — and routine cleanings require no co-payments, for example. Satlin says that, because administering the county’s health insurance and obtaining dental plan premium bids are such different processes, there is no synergy in bundling them.

Dental benefits remain stable, in part, because “there are no million-dollar teeth,” says Dr. George Koumaras, Delta Dental’s dental director. “Unlike medical, where million-dollar babies or million-dollar traumas are possible, dental is one of the most predictable benefits.” Koumaras says by focusing on one benefit, “it allows us to use all our resources toward developing the benefit most appropriate for any given population.” For example, most dental plans cover two cleanings a year. “But there are people whose oral hygiene is wonderful. One cleaning a year might be fine for them. And there are others who may need more frequent cleanings,” he says. By examining its data, the company may be able to create benefits directed to specific socioeconomic or other factors.

Or in broader initiatives, “we may start seeing benefits that include sealants for children extended into their later teens instead of age 12. By looking at the data, we see that those children who develop cavities in their baby teeth are predisposed to developing cavities in their permanent teeth,” he says. The Virginia company and the 38 other not-for-profits that make up the Delta Dental Association are eyeing the same clinical studies connecting oral health to overall wellness and crafting policies as a result.

Indeed, all companies that offer dental insurance are working to tweak benefits to patients and dentists alike — because without dentists’ participation, the network falters. For example, Wellpoint is rolling out its Dental Blue tiered program across the country in January. Dentists can sign up to participate on one or each of the three panels. The 100-level panel pays the lowest reimbursement, while the 200-level panel commands mid-level fees and the 300-level panel has the highest fees. It’s a step away from the one-size-fits-all reimbursement model. Enrollees get a list of participating dentists at the level they’ve selected. And 100-level dentists, who also are listed in the 200- and 300-level directories, will be paid according to the patient’s plan. So a new dentist, for example, might sign up as a 100-level provider to gain some patient volume. But any claims for 200-level or 300-level patients who come in will be paid at that higher level. “It’s a more fair system of compensation. We view dentists as our partners,” Gong says.