CHANDNI SETIA IV YEAR 11

INTRODUCTION

In most of the countries ,cost of the health care services is rising sharply due to which people are unable to afford the cost of health care. As a result various concepts and mechanism of financing were born. Ever since, health care service has been a two party system where the patient pays the provider directly for services. Over a period of time there has been emergence of third parties in financing of health care.

MECHANISM OF PAYMENT FOR DENTAL CARE

1. 2. 3.

4. 5.

Private fee for service. Post payment plans. Private third party plansa) commercial insurance companies. b) non profit health service corporations. c) prepaid group practice. d) capitation plans. Salary. Public programmes.

Private fee for service

Two party arrangement system and traditional form of reimbursement for dental services. Advantages1. Culturally acceptable. 2. Flexible. 3. Administratively simple. Disadvantages1. some patients are unable to afford the dental care offered.

POST PAYMENT PLANS

First introduced by local dental practitioners in Pennysylvania and Michigan in 1930s. Also called budget payment plans. Patient borrows money from a bank or finance company to pay the dentists fee and the patient then repays the loan to the bank in budgeted amounts with specified interest.

PRIVATE THIRD PARTY PREPAYMENT PLANS

Defined as payment for services by some agency rather than directly by the beneficiary of those services. The dentist and the patient are the first and the second parties and the administrator of finance is the third party. Third party is also called carrier, insurer, underwriter or administrative agent. Different types of payments offered by the insurer are1. Deductible 2. Co-insurance 3. Group insurance.

Reimbursement of dentists in prepayment plans

The ADA supports the concept of (UCR) usual, customary and reasonable fee as preferred method . Apart from UCR fees the only other form of payment plan is table allowances. Usual fee-the fee that an individual dentist frequently charges for a given dental service. Customary fee-The fee level determined by the administrator of a dental benefits plan from actual submitted fees for a specific dental procedure to establish the maximum benefit payable under a given plan for that specific procedure.

Reasonable fee-the fee charged by a dental professional for a specific dental procedure modified by the nature and severity of the condition and by any medical or dental complications; therefore may differ from the dental professional's usual fee or customary fee Table of allowances- a list of covered services with an assigned dollar amount that represents the total obligation of the plan with respect to payment for such service but does not represent the dental professional's full fee for that service. if fee becomes more than assigned to that service, remainder will be collected from the patient.

COMMERCIAL INSURANCE COMPANIES

a) b) 1. 2. 3.

1.
2.

These operate for profit by charging higher premiums. They are competitive through a variety of mechanismsThey can be more selective about a group to which it offers dental insurance. They present attractive total health package to potential purchasers. AdvantagesThey directly pay the dentist for provision of covered services. Payment is quicker and hassles free. Fee audits and post t/m examinations are not conducted. DisadvantagesDo not encourage utilization of professional services. They charge higher premiums.

NON PROFIT HEALTH SERVICE CORPORATIONS

Delta dental plans 2. Blue cross and blue shield. DELTA DENTAL PLANS It was born with purpose of providing comprehensive dental care program for children upto 14 yrs age. It is a legally constituted, not for profit organization, incorporated on a state by state basis that negiotates and administers contracts for dental care. The NADSP was formed in June 1966 and changed to delta dental plans in April 1969. DDP help the dental practitioners to adapt their traditional patterns of practice to meet the group purchase demand care.
1.

Blue cross and blue shield

These for years have provided limited dental coverage i.e. services provided in a hospital, as a part of medical policies. Once dental prepayment was shown to be viable, they have adopted many of the cost control features pioneered by delta plans.

PREPAID GROUP PRACTICE

It is a term given to a group practice that provides dental services on a prepaid basis. Generally regarded as open panels. ADA has defined group practice as group practice is that type of dental practice in which dentists, sometimes in association with members of other health professions agree formally between themselves on certain central arrangements designed to provide efficient

Types1. General-consists of general practitioners. 2. Single specialty-all members of the group are of same specialty. 3. Multi-specialty groups-practitioners in two or more specialty fields of practice. Advantages1. Better way of organizing ones life i.e. vacations or continuing education. 2. Less disruption in practice caused by illness to a dentist. 3. Quality of care improved. 4. Financial fringe benefits such as sick leave and pension plans can be built more readily.

CAPITATION PLANS

A capitation fee is usually a fixed monthly payment paid by a carrier to a dentist based on the number of patients assigned to dentist for treatment. The dentist receives a fixed sum of money per enrolled person per month, regardless of whether the patient utilizes care or not. Many of these plans offer only limited services such as examination, prophylaxis, radiographs and treatment plan.

SALARY

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2.
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A defined amount is paid to the dentist whatever treatment may b assigned to him, regardless of whether the patient utilizes or not. Dentists in some group practices, those in armed forces and those employed by public agencies are salaried. AdvantagesDentist is free of business concerns of running a practice and can concentrate on clinical matters. Fringe benefits are often attractive. DisadvantagesLack of financial incentive that some dentists need to be highly productive.

PUBLIC PROGRAMS
Private practice is usually not able to meet the dental demands of all the people. Therefore public programs are sponsored by the govt. and also include community health centers. Public financing of dental care1. Medicare. 2. Medicaid. 3. National health insurance.

Medicare In U.S.A, title XVIII of social security Amendments of 1965 is the program known as Medicare. It removed all financial barriers for hospital and physician services for all persons aged 65 or over, regardless of their financial means. It has 2 parts1. Hospital insurance. 2. Supplemental medical insurance. It is limited to those services requiring hospitalization for treatment usually surgical

MEDICAID Name given to the title XIX of social security Amendments of 1965. It provides medical and health related services to poor people. Covers following services1. Inpatient and outpatient hospital care. 2. Lab and X ray services. 3. Nursing home care 4. Home health services for individuals of 21 yrs or more. 5. Early and periodic scanning, diagnosis and treatment programe (EPSDT) for individuals under 21 yrs of age. 6. Family planning services. 7. Physician services.

NATIONAL HEALTH INSURANCE Introduced by Bismarck in Germany in 1880s and in Britain in 1910 by Lloyd George. It is a financing mechanism by which health care services are paid for from a publically organized fund.

INDIAN SCENARIO
Diff. forms of payment for dental health services 1. Fee for service. 2. Dental insurance-covers dental check ups, oral prophylaxis, restorations, extractions and treatment requiring hospitalization. 3. Government schemes- various government schemes provide medical/dental services to govt. employees.

EMPLOYEE STATE INSURANCE SCHEME Introduced by act of parliament in 1948 for health insurance of factory workers whose salary does not exceed Rs 3000 per month. Provides benefits for sickness, maternity, employment injury, and death due to employment injury.

CENTRAL GOVT. HEALTH SCHEME Introduced in 1954 for comprehensive medical care of central govt. employees. Benefits central Govt. employees and families. central govt. pensioners. member of parliament. general public living in vicinity of CGHS dispensaries.

CONCLUSION

Financing of dental care is well practiced in developed countries like U.S. However in India fee for service basis is still the most prevalent form of availing dental services. Dental personnel and health care service organizations can be certain that financing of dental care is a very important dynamic area and there could be further expansion and evolution with new concepts that might emerge.