Managed Care and Policy at Dental Health Maintenance Organization - Assignment Example

? Managed Care and Policy Papers Managed Care Paper Dental health maintenance organisation (DHMO) plans were established with the intention of providing an acceptable alternative to the fee-for-service payment system as well as assisting in restraining the cost of dental care. The various DHMO plans have influenced the dentist-patient relationship in different ways based on the terms that dictate the services provided under every plan. There are four basic organisational modes under which dental care can be provided. These modes impact how the dentists relate to their patients or clients. In the staff model, patients receive dental care services from dentists, dental hygienists and dental assistants salaried by HMO (Marya, 2011). HMO also contracts directly with a group practice, partnerships or corporations for the provision of dental services. The various HMO models contain numerous clauses, contractual limitations and bureaucratic processes which affect the relationship between the dentists and their clients. The HMO insurance plans have been significantly focused on the medical sector with limited investment in the dental sector. This has significantly undermined the motivation among dentists to service patients seeking dental care services. The financial compensation provided to dentists is significantly low compared to what other healthcare professionals receive from HMO (Gluck & Morganstein, 2002). This has really impacted negatively the motivation of dentists, especially those serving in community health facilities. Bureaucracies surrounding reimbursement of dentists and dental hygienists are dictated by the DHMO plan terms and contractual agreements. In some cases, dental hygienists need approval by other professionals within the organisation they are working for, including senior dentists. Delays associated with the DHMO reimbursement process has seen some dentists within the general health care setting avoid providing dental care services to patients seeking services under the DHMO insurance plan. As such, the majority of dentists prefer serving customers seeking dental care under the fee-for-service payment method. The dentist-patient relationship is at times limited by the DHMO contractual terms which dictate and limit dental care services provided by the dentists and dental hygienists. As such, DHMO undermines the individual consent of the patient as one of the key ethical principles of healthcare practice. In essence, patients are not given an opportunity to provide an informed consent to what should be done about their dental health. Dentists can only provide those services included in the DHMO plan rather than what the patients need done about their dental health. Dentists are compelled by the insurance plan terms and conditions to limit the extent of dental care services provided, with most patients only receiving essential dental services while they may be in need of advanced care. Therefore, DHMO to a great extent introduces limitations in the dentist-patient relationship in which the patient is required to discuss issues about their dental health and agree on the best intervention to diagnosed dental health problems. Unlike in the fee-for-service payment method where dentists rely on their requests to provided dental care, patients under the DHMO plan receive services outlined by the HMO insurance. The dentist-patient relationship is further undermined where the dentist is dealing with many patients seeking dental care under the DHMO insurance. Under such circumstances, dentists are forced to limit the time spent with patient to better understand their dental health problem and provide lasting solutions. In this case, the rapport between the dentists and the patients required to guarantee effective intervention does not develop as the dentist rushes to serve as many patients as possible in order to receive better financial reimbursement. DHMO raises quality issues which consequently undermine the dentist-patient relationship and that between the patients and dental care facilities (Gluck & Morganstein, 2002). Patients are sensitive about the quality of care provided by individual dentists and dental facilities, a phenomenon that may contribute to a poor reputation especially for dentists and dental facilities compelled by DHMO insurance terms to provide limited dental care services. Insurance companies have begun appreciating the increasing focus on dental care within the health care system as part of promoting general wellbeing of the society. In response to this, several private insurance companies have introduced dental insurance packages to tap on the growing demand for dental care services. Most of the insurance companies provide dental insurance packages ranging from basic to major insurance packages. Unlike DHMO insurance, patients are provided with adequate freedom to establish long-term relationships with their dentists as well as the freedom to change assigned dentists to their preferred choice dentist. Upon realisation of the limitations associated with DHMO insurance plans, an increased number of patients now prefer private dental insurance companies which provide them with significant freedom in their quest for dental care services. Indeed, insurance companies have begun acknowledging the increasing demand for insurance packages to replace the traditional HMOs characterised by several contractual limitations and inefficiencies. Some of the insurance companies in the business of dental care include the DeltaCare, Aflac, and MetLife (Delta Dental, 2012). Insurance companies have embarked on the process of creating and offering a wide range of competitively priced dental insurance plans in order to compete effectively in the increasingly competitive dental insurance market. Although DHMO plans have been characterised by several limitations, the society cannot be better without them. This is because not all people are able to secure a private insurance package themselves. HMO has played a critical role in promoting access to essential dental care services especially among the middle and low socioeconomic population. Therefore, HMO remains crucial in the provision of dental care services as well as controlling the pricing of dental care services. The society needs HMO to put checks on the pricing of insurance packages offered by the private companies. However, there is a need to address limitations associated with HMO including bureaucracies involved in the reimbursement of dentists, and rationing of dental care services provided by dentists under the HMO plans. Improvement of the terms and standards in HMO plans and focus on quality would be better for the society than abolishing the plans. Indeed, DHMOs ration care by limiting the type of dental care services that can be provided to patients with the HMO insurance. Dentists are instructed on the level and extent of dental care services that they can provide to patients seeking services under the HMO plans. Patients and dentists are not given the opportunity to negotiate the best intervention, but the dentist is guided by the service guideline provided by the insurer. Patients are entitled to services outlined under the plan and the dentist can provide services beyond the limitations provided by the insurer. The patient’s autonomy is not recognised in this plan because dentists can only provide services that are outlined in an HMO insurance plan. Dentists are denied the freedom to decide what is best for the patient in negotiation with patient rather than following the insurer’s guidelines which have been constituted without consulting the dentist and the patients. Health Policy Children from disadvantaged families are the worst hit by dental health problems, especially tooth decay, which can be prevented through establishment of effective policies and programmes. In respect to such experiences, the Patient Protection and Affordable Care Act (P.L.111-148), Sec. 4102 (a), acknowledges the importance of establishing science-based strategies such as provision of fluoridated water and sealants to prevent tooth decay and related dental health problems (Wolters Kluwer, 2010). The bill mandates the secretary in the health sector to implement the Affordable Care Act in order to ensure promotion of general wellbeing of the society. The bill recognises the importance of school-based sealant dental programmes in enhancing better dental health for all children regardless of their socioeconomic backgrounds. However, formulation of science-based dental health promotion policy would play a great role in preventing dental health problems especially among the disadvantaged children who are highly likely to develop dental health complications. Sealants and fluoridation of water are some of the most cost effective strategies that could be effectively exploited to reduce the limitations in access to dental care among low-income, minority and disabled children (Kelly, Binkley, Neace & Gale, 2005). The policy should provide for inclusion of parents or involvement of communities in the school-based sealant and fluoridation programmes as a way of ensuring that the programmes are effective in addressing disparities in dental care access among these populations. The prevention policy will play a critical role in reducing the number of children in need of dental care services and cultivate a strong culture of good oral hygiene not only among the children but also in the communities where the children come from (Kelly, Binkley, Neace & Gale, 2005). Policy Statement The policy on the promoting scientific dental health prevention programmes such as provision of sealant and fluoridation of water is crucial in addressing the problem of tooth decay specifically among the low income, disabled and minority group children. These children face the greatest tooth decay challenges as well as limited access to dental care services. As such, this policy is aimed at addressing the problem of tooth decay and disparity in the access to dental care by emphasising preventive measures among the worst hit populations. The prevention measures are expected to reduce the number of children from these groups in need for dental care services (Kellogg, 2010). In addition, the policy will enhance the attention given to school-based dental programmes and provide avenues for funding such programmes in order to enhance their effectiveness in addressing the dental health challenges faced by the American children. The policy is in line with the Protection and Affordable Care Act which aimed at promoting improved health among the Americans. Affected Population This policy targets low income children, children from the minority groups, disabled children and the communities where these children come from. This population is worst hit by the disparity in dental care access. The population faces significant dental health challenges with tooth decay as one of the major challenges. Support for the Policy The policy on science based dental health prevention programmes such as the sealant and fluoridation programmeme is crucial in address the problem of tooth decay as well as reducing disparities in dental access among the low income, minority and disabled children. According to (Kellogg, 2010), about 17 million from low income children face the problem of simple cavity which triggers increased dental health challenges for lack of access to dental care services. Although the government has made significant efforts in addressing this problem, such challenges can be addressed through relatively low cost strategies such as the school-based sealant and provision of fluoridation of water services to communities and schools where children are at a great risk of suffering from tooth decay. Studies have shown that about $106 billion were spent in 2010 to cater for dental care services ranging from filling to root canals (Kellogg, 2010). This can be partially attributed to lack of basic dental care capable of preventing dental cavities that lead to the high cost of treatment in later days in the child’s life. In addition, the national dental health crisis has been attributed to limited access to proven preventive measures such as sealants and fluoridation among children, lack of enough dentists to provide dental care at the community level, and a limited number of dentists willing to provide dental care to Medicaid-enrolled children. In this case, such challenges can be circumvented by putting increased effort in cost effective measures such as sealant and fluoridation programmes. Sealants have been shown to prevent about 60 percent of decay in molars. Another advantage that could be used to support the application of sealants is that such services can be provided by dental hygienists through the school-based sealant programmes (Kellogg, 2010). Therefore, implementation of the policy to promote the sealant and fluoridation programmes could play a critical role in addressing challenges in the access of dental care among targeted populations. The process is not only cost effective but also guarantees provision of preventive dental care services to the majority of disadvantaged children. The CDC has suggested that for every $1 invested in water fluoridation about $38 is saved on dental treatments (Kellogg, 2010). Therefore, community water fluoridation has emerged as one of the most effective strategies that could drastically reduce dental problems currently experienced among the disadvantages populations. If the public health sector is willing to win the war against the dental health problems experienced by the identified populations, then it must consider investing heavily in preventive rather than treatment measures. Medicaid is currently experiencing increased pressure from increasing demand for dental care services among the children. It is, therefore, important to look for alternative and cost effective ways to reduce the burden on such programmes. Preventive measures are essential in assisting the government in reducing the providing of dental care to children and people with disabilities (Kelly, Binkley, Neace, & Gale, 2005). As discussed earlier, these populations are worst hit by dental health problems as well as limited access to dental care services. The proposed policy will play a critical role in increasing the public health commitment to reducing the dental health problems among children through the use of cost effective scientific measures such as the school-based sealant programme and the community water fluoridation. Effective limitation of tooth decay among these groups will significantly reduce the number of children in need of dental care services. In conclusion, the implementation of this policy will enhance public health efforts to promote the wellbeing of the public in line with the Protection and Affordable Care Act. The policy will also reduce the burden on the Medicaid programme. References Delta Dental. (2012). DeltaCare USA. Retrieved from http://www.deltadentalins.com/business/deltacare-usa.html. Gluck, G., & Morganstein, M. (2002). Jong's community dental health (2nd ed.). New York, NJ: Elsevier Health Sciences. Kellogg, K. (2010). The cost of delay: State dental policies fail one in five children. The PEW Center on the States. Retrieved from www.wkkf.org/.../the%20pew%20center%20on%20the%20states%20the...? Kelly, S., Binkley, C., Neace, W., & Gale, B. (2005). Barriers to care-seeking for children’s oral health among low-income caregivers. American Journal Public Health, 95(8), 1345- 1351. Marya, J. (2011). Textbook of public health dentistry Pb. London: JP Medical Ltd. Wolters Kluwer. (2010). Law, explanation and analysis of the Patient Protection and Affordable Care Act: Including Reconciliation Act Impact, Volume 1. New York, NY: CCH Incorporated. Read More