financing dental care seminar

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Slide 1:

Financing Dental Care Dr. Deepthi Athuluru,II Post Graduate, Public HealthDentistry

Contents :

Contents Introduction Terminologies History Different payment mechanisms 1. Private fee - for services 2. Post payment plans 3. Private third party service plans 3a. Commercial insurance companies 3b. Non profit health service corporations

Contents :

Contents 3c. Prepaid group practice 3d. Capitation plans 4. Salary 5. Public programs Public Programmes Recommendations Strategies for health financing Conclusion References

Introduction :



Terminologies Coinsurance: is a fixed percentage of charges the insured has to pay in order to cover dental treatment services. Copayment: is the dollar amount of the fee the insured has to pay the dentist after the insurance company has paid a certain percentage stipulated in the contract. Deductible: is a fixed dollar amount that a policy holder is to pay each year before the dental plan begins to pay for basic, restorative and orthodontic benefits.

Slide 6:

Direct reimbursement plan: is a dental insurance plan that is usually entirely funded by the employer and allows the insured to see any dentist of his/her choice without any network restrictions.

Slide 7:

Indemnity plan: a dental plan where a third party payer provides payment of an amount for specific services, regardless of the actual charges made by the provider. Payment may be made either to enrollees or, by assignment, directly to dentists. Schedule of allowances, table of allowances, or reasonable and customary plans are examples of indemnity plans.

Slide 8:

Table of allowance: a list of covered services with an assigned dollar amount that represents the total obligation of the plan with respect to payment for such services, but does not necessarily represent the dentists full fee for that service. Fee schedule: is a list of fees a dentist is expected to charge for certain dental care procedures, which determines a specific amount your insurance provider reimburses you for your dental care expenditures. The fee schedule is stable and unrelated to a particular dentists fee.

Slide 9:

Participating dentist: (provider) is a dentist who signs a contract with the insurance company and agrees to provide dental services and supplies to eligible participants at a fixed price. Non participating dentist: is a dentist who has not signed any contract with a network of providers to accept participants of a certain dental plan under stipulated conditions. If you choose a network based plan, you will have to pay comparatively a lump sum applying to a non participating dentist.

Slide 10:

Premium: is the money amount one is to pay on a regular basis ( usually either every month or every year ) so that, the insurance company could fund your dental plan.

Slide 11:

Usual, customary, and reasonable fee: (USR fee) is a fee associated with each dental procedure which reflects the fee charged by the majority of dentists for the services in question in a given area. The "UCR" fee can help you determine whether your dentist is charging too much. Third party payment: an organisation other than the patient ( first party) or health care provider (second party) involved in the financing of personal health services.

Slide 12:

Prepaid dental plan: a method of financing the cost of dental care for a defined population, in advance of receipt of services. Preffered provider organisation : (PPO) a formal agreement between a purchaser of a dental benefit programming and a defined group of dentists for the delivery of dental services to a specific patient population, as an adjunct to a traditional plan, using discount fees for cost savings.

History :

History Traditionally insurance involves: group of people makes small payments the risk of any one suffering from catastrophic loss loss of home through fire, trauma etc

Slide 14:

Fee for service was the first mode of payment to the dentist with respect to the services received. 1945- the start of voluntary prepaid comprehensive dental care in St.Louis , U.S.A. 1948- Establishment in England of a National Insurance Scheme including Comprhensive Dental Service. 1948- Bisell.B.Palmer of New York City founded group health dental insurance as open panel pre-payment system. 1949- Group Health Association, consumers co-operative in Washington, established a clinic dental service, which soon changed from fee for service basis to prepayment. 

Slide 15:

1954- Washington State Dental Council organized Washington State Dental Services Corporation for helping administer prepayment dental care plan for children of International Longshoreman’s Union Pacific Maritime Association. This mechanism was soon found to be the best form of rendering dental care. 1966- Medicare brought medical care to the aged of the U.S without regard to the income. This did not include dentistry, but Medicaid did.

Slide 16:

1973- Health Maintenance Organization Act was passed which provided government support for organizations providing standardized comprehensive care to the individuals in enrolled groups. 1989- Delta Dental Plan and other agencies were covering about 107 million beneficiaries.

Mechanisms Of Payment :

Mechanisms Of Payment 1. Private fee - for services 2. Post payment plans 3. Private third party service plans 3a. Commercial insurance companies 3b. Non profit health service corporations E.g.: Delta dental plans : Blue cross \Blue shield 3c. Prepaid group practice 3d. Capitation plans 4. Salary 5. Public programs

Private fee for service:

Private fee for service The two party arrangement, traditional form of reimbursement for dental services. Integral part of private practice as a delivery method. Advantages: 1) Culturally acceptable 2) Flexibility 3) Administratively simple 4) Can be used in expensive situations Disadvantages: Major percent of the population cannot afford dental care

Indian scenario:

Indian scenario This is the payment method most commonly employed in India. India, though a socialist state and committed to providing health care for its citizens , has one of the lowest per capita public expenditures on health. The government spends just 4.9% of the GDP on health care. As 80% of this is on salaries, there is little for other medical conditions.

Slide 20:

This results in poor quality of care in most of these government institutions . This pushes the patients to use the private sector to meet their health needs. Estimates show that about 80% of all outpatients and about 40-60% of all inpatients use the private health care facilities . At these facilities, the patients pay user fees for each service received and this is met from out of pocket.

Slide 21:

As the cost of dental care continues to rise, the majority of the people are not able to afford dental treatment, especially when it is being provided on a fee for service basis. Very few people can afford to utilize this service regularly. This places a large burden on the households, especially the poor and indigent. They are forced to borrow or sell their assets to meet the expenses.

Slide 22:

Most of the people will visit dentist only for curative services occasionally. Preventive measures are not given importance due to high cost. Thus the current methods of financing the dental health care, the fee for private services, are clearly unsatisfactory.

Post payment plans or budget plans:

Post payment plans or budget plans First started in Late 1930's - local dental societies in Pennsylvania & Michigan The individual purchase of service Payments made at intervals over a period of time

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ADVANTAGES: 1) Helpful for middle income people. 2) Primarily used to Finance prosthetic and other costly Treatment DISADVANTAGES: Lower income people Cannot use to the full 2) Problem of defaulted loans This system is not in use in India and difficult to be implemented as we have majority of low income people

Private third party payment:

Private third party payment Definition: “as payment for service by some agency rather than directly by the beneficiary of those services”

Slide 27:

1 st Party- Dentist 2nd Party - Patient 3rd Party - Administrator Of Finances THIRD PARTY : Definition: “The party to a dental prepayment contract that may collect premiums , assume financial risk , pay claims and provide administrative services” The third party is also known as insurer, under writer or administrative agent.

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BASIC PRINCIPLES To Be Insurable , A Risk Must: Be Precisely definable Be of sufficient magnitude, if occurs ,should cause a major loss Be infrequent Be of unwanted nature ex: accidents , fire etc Beyond the control of individual Not constitute a moral hazard

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Dental insurance made feasible: Have patient share the cost Limit the range of services available Offering services only to group Include waiting period before benefits become payable Use pre authorisation and annual expenditure limits

Slide 30:

Different ways an insurance carrier works:- Payments either by Deductible (FRONT END PAYMENTS) – Flat sum paid Co-insurance, Paid in percentages “LIMITATION OF BENEFITS ” a) Group Insurance

Slide 31:


Reimbursement of Dentist in Third Party Plans :

Reimbursement of Dentist in Third Party Plans The major forms of third-party reimbursement currently in use are: Usual, customary and reasonable fee Table of allowances Fee schedules Discounted fee Capitation

Slide 33:

Usual fee: The fee that an individual dentist most frequently charges for a given dental service. Customary Fee: The fee level determined by the administrator of a dental benefit 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 the dentist for a specific dental procedure that has been modified by the nature and severity of the condition being treated and by any medical or dental complications may differ from the dentists usual fee or the benefit administrators customary fee 33

Slide 34:

A 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 that does not necessarily represent the dentists full fee for that service”. For example: 34

Slide 35:

Fee schedule: “ a fee schedule is defined as a list of charges established or agreed to by a dentist for specific dental services. A fee schedule is usually taken to represent payment in full, whereas a table of allowances, as just explained, may not. With a fee schedule, the dentist must accept the listed amount as payment in full and not charge the patient at all. ”.

Slide 36:

Capitation : “a capitation fee is usually a fixed monthly payment paid by a carrier to a dentist based on the number or patients assigned to the dentist for treatment. Capitation requires that patients be assigned to specific dentists or dental practices for care, so that the capitation payment can be paid to the appropriate dentist or practice.”

Slide 37:

Commercial insurance companies in India 37

Slide 38:


Two Types :

Two Types Stand alone dental insurance plan: This type of plan covers the expenses related to general dental problems, such as periodontitis and extraction of permanent teeth due to ailments such as caries. This type of plan is generally provided by the popular dental care product companies in association with one of the insurance companies. Dental insurance cover as part of general health insurance plan: This type of dental insurance is provided by the general insurance companies as part of their own general health insurance schemes, such as health advantage policy or student medical policy. Through this scheme, one can claim dental expenses along with the other kinds of reimbursements, such as the cost of medicines or hospitalization. 39

Employees State Insurance Scheme (ESIS):

Employees State Insurance Scheme (ESIS) Established in 1948, ESIS is an insurance system which provides both the cash and medical benefits Managed by Employees State Insurance Corporation (ESIC) – a wholly Govt owned enterprises The scheme cover Non-power using factories employing 20 or more members Power using factories employing 10 or more persons Road transport establishments News paper establishments Cinema theatre, hotels and shops 40

Slide 41:

Only employees earning basic salaries of less than 3000 Rs (recently enhanced to 6500) are eligible Premiums are paid through pay roll tax of 4.75% by employer and 1.75% by employee BENEFITS 1. Sickness benefits (in cash) – 7/12 th of the rate of daily average pay for a maximum period of 56 days in a year 2. Maternity benefits (in cash) – at the rate of full wages for 12 weeks 3. Disablement benefits (in cash) – temporary disablement – 72% of the wages for the duration disablement ; permanent disablement – in the form of pension

Defense Medical Services:

Defense Medical Services Medical and dental care is provided through their own organization under the banner “ Armed Medical and Dental Services”. Health Care of Railway Employees Comprehensive health services including dental treatment through the agency of railway hospitals, health units and clinics

Central government health scheme (CGHS):

Central government health scheme (CGHS) Previously known as – “Contributory Health Service Scheme” Introduced in 1954 in New Delhi to provide comprehensive medical care to central government employees and their families 320 Separate dispensaries for the employees covered by the scheme Covers Central Govt employees Retired central Govt employees Widows receiving pension Members of parliament Ex-governors and Retired judges 43

Slide 44:

Facilities under the scheme Out patient care through network of dispensaries Supply of necessary drugs Laboratory and x-ray investigations Domiciliary visits Hospitalization facilities at Govt and private hospitals specialist consultation Pediatric consultation including immunization Emergency treatment Supply of optical and dental aids at reasonable rates Family welfare service 44

Mediclaim policy of the General Insurance Corporation (GIC):

Mediclaim policy of the General Insurance Corporation (GIC) GIC was set by Govt in 1973 as a public sector organization to market a range of insurance services Its four subsidiaries; National Insurance Company , Oriental Insurance Company , New India Assurance Company and United India Insurance Company It introduced Mediclaim insurance scheme in 1986, and became active in 1987 Policy was modified in 1996 to allow for differentials in premium for six age groups Policy was framed for both groups and individuals Mediclaim provides only reimbursement insurance – i.e..,enrollees are reimbursed for their medical claim only after the payments have been made out of the pocket to the provider 45

Slide 46:

SALIENT FEATURES 1. Provides cover, which takes care of medical expenses following hospitalization from sudden illness or accident 2. Cover extends to pre-hospitalization and post-hospitalization for periods of 30 days and 60 days respectively 3. Domiciliary hospitalization is also covered Dental treatment except arising out of accident. Major weaknesses of Mediclaim 1.It covers only hospitalization, leaving out , out-patient care 2. The coverage is subjected to various exclusions, limits and restrictions on eligibility 3. Premiums are high in relation to claim payments which are only 58% of the premiums

Apollo Munich Health Insurance :

Apollo Munich Health Insurance Maxima Plan Upto 65 years Dental treatment is covered for Rs. 1,000/- in a year, subject to treatment taken in a network hospital.  OPD is covered for Rs.10,000/- to Rs.15,000/- Approx. including consultation fees & Annual health checkup Out-patient Dental Treatment within specified Network - Any necessary dental treatment taken by an Insured Person from a Network Dentist provided that company will not pay for any dental treatment that comprises cosmetic treatment.

Munich Health Insurance ICICI Lombard :

Munich Health Insurance ICICI Lombard Health Advantage Plus Upto 65 years This Policy Covers Outpatient Department (OPD) expenses, such as diagnostics tests, dental treatment, medical bills, ambulance charges, etc. The outpatient treatment expenses can be claimed only once a year within a period of 90 days from the start of cover and 30 days from the end of cover. 

Slide 49:

Under this scheme, along with other reimbursements of costs of medicines, hospitalization, and other charges dental expenses are also reimbursed. For student medical insurance gold plan includes expenses of dental treatment

Star health insurance:

Star health insurance Health Star Gain 5 months to 60 Years. Treatment costs covered even for pre-existing conditions/diseases, dental expenses, prenatal and post-natal care

Max Bupa Health Insurance :

Max Bupa Health Insurance Heartbeat Platinum Policy At any age this policy covers cost of treatment incurred as an outpatient in any hospital or nursing home. put a natural tooth back into a jaw bone after it is knocked out or dislodged in an Accident 

Slide 52:

treat irreversible bone disease involving the jaw which cannot be treated in any other way surgically remove a complicated, buried or impacted tooth root, for example in the case of an impacted wisdom tooth Exception: oral condition, which includes Surgical Operations for the treatment of bone disease when related to gum disease or damage, treatment arising from, disorders of the tempromandibular joint.

Bajaj Allianz General Insurance :

Bajaj Allianz General Insurance Tax Gain Plan 56 - 75 yrs for Senior Citizen Plan Insured can claim for dental procedures & treatment under OPD section, Cost of dentures, can also be claimed under OPD Section 53

HLL launches Pepsodent Dental Insurance:

HLL launches Pepsodent Dental Insurance Hindustan Lever announced the launch of Pepsodent Dental Insurance, in partnership with New India Assurance, wherein every purchase of a Pepsodent toothpaste will enable the customer to get Rs 1,000 worth of free dental insurance. 54

Slide 55:

Under this initiative, Pepsodent offered consumers insurance cover against expenses for the extraction of a permanent tooth due to severe caries and periodontitis, including cost of medication. The insurance cover would be valid for one year and would take effect six months after the purchase of the toothpaste. 55

Dental Coverage under various policies Life Insurance Companies:

Dental Coverage under various policies Life Insurance Companies Birla Sun Life Insurance- BSLI Saral Health Plan ICICI Prudential Life Insurance- Health Saver Life Insurance Corporation - Health Protection Plus Entry 56

Employee health scheme:

Employee health scheme Employee health scheme is like governmental commercial insurance scheme in India. In this government deduct particular amount of money from the insurer per every month and the government pays back money to the doctor. The Govt. of the State of Andhra Pradesh with its vide G.O. Ms. No.134 dated 29-10-2014 has issued this Scheme with few modifications.

Slide 58:

the Trust is set up for providing health care services to the families living below poverty line and the families covered under the Journalist scheme, CMCO, destitute living in old age homes under Rajiv Aarogyasri scheme, and the families of Government employees, pensioners and their dependent family members in surgeries / therapeutic procedures as mentioned in annexure-C for which purpose Trust has created a network of Service Providers. The Trust is a non-profitable institution which is providing the health care services under the scheme to the respective States of Telangana and Andhra Pradesh.

Slide 59:

All the network hospitals including the corporate and government hospitals located in the states of A.P under the respective Employees Health Scheme shall empanel itself and implement the total of 1885 procedures, without fail.

Slide 61:

Non Profitable Health Service Corporation

Slide 62:

Dental Service Corporation Legally constituted Non –profitable organization incorporated on a state by state basis It's the subject to the insurance laws thereby negotiates, allowing to grow Started as National association of dental service plans (NADSP) JUNE 1966 Name changed to DELTA DENTAL PLANS ASSOCIATION, APRIL 1969

Slide 63:

The purpose of delta dental plan was to provide comprehensive dental care programme for children up to 14 years age. Characteristics of dental service corporation: Professional sponsor ship Non profit operation Participation permitted by all licensed dentists Benefit provided on a service basis Freedom of choice allowed for both patient and dentist

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MEMBERS: board of directors (dentists) representatives of world of finance, insurance, labour and consumer groups reimbursement of dentists by ucr fee.

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FUNCTIONS Ensures quality and care provided Keeps the cost within limits

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90th Percentile :

90 th Percentile

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Advantages of delta plans - Control of cost - Quality assurance procedure - No need to pay extra There by encourages regular attendance maintains good dental health of the society by various services

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Commercial v/s delta dental plans: Commercial companies are better because Expertise in Promotion and Marketing Presents attractive total health packages Take the risk to offer reduced dental premiums

Slide 70:

Health Service Corporation: Blue cross/ Blue shield Offers limited dental coverage as apart of medical/ surgical/ and hospital polices Has similar cost control features pioneered by delta plans Dental coverage are limited to services provided in the hospital (constituting minor proportion) It does not put its hand into dental prepayments

Slide 71:

Non profit health service corporation in India

Karuna Trust:

Karuna Trust It was initiated in September 2002 by a partnership between Karuna Trust, the Govt. of Karnataka, the Govt. of India, the United Nations Development Programme (UNDP), the National Insurance Corporation (NIC) and the Centre for Population Dynamis (CFPD). Initially operational in T. Narsipur Taluk , it has been subsequently expanded to Yelandur Taluk also Karuna Trust organises the collection of premium and reinsures with the National Insurance Company (NIC). The NIC (a para-statal insurance company) reimburses the claims submitted by Karuna Trust. 72

Slide 73:

Premium The premium varies according to the socio-economic status. The premium for the households below the poverty line is Rs 30 per individual per year. UNDP fully subsidises the premium for the households that are below the poverty line (BPL) and belong to the SC / ST category. So in reality, for these families, it is free.

Slide 74:


Naandi foundation :

Naandi foundation Naandi Foundation is an autonomous, not-for-profit trust dedicated to changing lives of the underserved populations in India through public-private Partnerships Since 2002 and under the banner of Child Rights,Naandi , in partnership with the state government of Andhra Pradesh Young children in the age group of 6 to 14 years enlisted in public schools

Slide 76:

The insurance plan provides “whole care” coverage without any limitation or service cap while operating at all levels: primary, secondary and tertiary level. Surgical interventions extend to corrective, cosmetic and dental surgery.

Trinity Care Foundation:

Trinity Care Foundation Non-Profit Organization based in Bangalore dedicated to School Health Programs, Facial Deformity Programs and Oral Cancer Programs, working with community organizations, educational Institutions and involving Government, Industry and the Medical Profession. 77

Prepaid group practice:

Prepaid group practice There is no relation between group practice and any form of financing. Payment to the dentist is by fee for service or capitation plans.

Slide 79:

Definition: “as a practice formally organized to provide dental care through the services of three or more dentists using office space, equipment and /or personnel jointly”. Net income in a group is divided equally and paid according to Patient load, Years of service, Specialty status.

Slide 80:

General practice groups composed Entirely of general practitioners. Single speciality groups - all members of the group are of the same specialty. Multi- speciality groups certain practitioners in two or more speciality fields of practice ADVANTAGE: Multispeciality Can enjoy vacation leaves In case of illness Quality will improve because of built-in peer review Financial benefits like sick leave and pension plans….

In India:

In India Smile Stone Dental Clinic Started in delhi Team six consultants (specializing in each branch of Dentistry). Together they provide Comprehensive Dental Treatment for the entire family. opened in the first phase in places like Kerala, Tamil Nadu, Andhra Pradesh. The first Vasan Dental Care Centre hospital in India was started at Trichy

Slide 82:

Vasan dental care hospital With the beginning of Vasan Dental Care , the concept of Multi speciality Dental hospitals in India


HEALTH MAINTENANCE ORGANIZATIONS (HMO) Definition: “a legal entity which provides a prescribed range of health services to each individual who has enrolled in the organization in return for a prepaid, fixed and uniform payments.

Slide 84:

Provides comprehensive health maintenance and treatment service Primary care Emergency care Hospital care Rehabilitation

Slide 85:

An Enrolled Group : Members of the HMO are those people who voluntarily join the HMO through a contact arrangement in which the enrolled agrees to pay the fixed monthly or other periodic payment to the HMO. Enrollees agree to use the HMO as their principal source of health care if they become ill or need care.

Different types of dental personal in HMO:

Different types of dental personal in HMO Staff model – in this dentist, dental assistants are salaried employees. Group models – HMO contracts directly with a group practice, partnership or corporations for the provision of dental services. Independent Practice Association – the IPA is an association of independent dentist that develops its own management and fiscal structures for the treatment of patients enrolled in an HMO.

Slide 87:

Primary Care Capitated Network Or Direct Contract Model – network is similar to IPA except HMO contracts individual provider for provision of services.

HMO in India :

HMO in India Hurdles In Implementing HMOs In India Experts fear that Indian HMOs would repeat the functioning of their counterparts in the US, which in the pursuit of controlling costs and maximising profits, often become very inflexible, thus defeating the purpose for which they were set up. "For both insurance and HMOs to function, the medical profession and practice has to be regulated“

Suggestions For Developing HMOs:

Suggestions For Developing HMOs Considering the government’s inability to increase the required financial inputs for improving rural healthcare, both preventive and curative, Public Private Partnership is the need of the hour. “Private partners may adopt primary health centres and community health centres. By innovative approaches such as micro-financing and micro-health insurance, we can provide them cost-effective healthcare,” insurance companies can also adopt HMO models, which would in turn control the way care is given or accessed. The other side of the coin is that most Third Party Administrators are focussed on corporate clients. Therefore, if TPAs in India transform themselves into HMOs in collaboration with a network of family physicians specialists and hospitals, the expertise of TPAs can be better utilised.

Preferred Provider Organizations:

Preferred Provider Organizations Managed care arrangement system It involves contract between insurer and a number of practitioners who agree to provide specific services for fees that are lower than average for that area. Competition for patients is the driving force behind the willingness to discount their fee


CAPITATION PLANS The dentist receives an established, negotiated sum on a monthly or yearly basis for each liable patient. The money is paid regardless of whether the patients utilize care or not In return, patient is entitled to receive a prescribed set of services over a specified period

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CAPITATION FEES Fixed monthly or yearly payments Paid by a carrier to the dentist for treatment DISADVATAGE: 1) Fear of over utilization 2) Demand for expensive treatment


SALARY Dentists in some group practices, those in the armed forces and those employed by public agencies are salaried. 93

Slide 94:

Advantages: It allows a dentist to be largely free of the business concerns of running a practice, thereby allowing the dentist to concentrate on clinical matters. Fringe benefits are also often attractive. Disadvantages: There could be lack of financial incentive Some dentists need to be highly productive.

In india :

In india Dentists are appointed in insurance companies and hospitals on salary basis

Public programs :

Public programs

Slide 97:

97 Monitoring and evaluation

National health insurance:

National health insurance The National Health Insurance Scheme was launched in 2007 by the Indian government. It aims to protect unorganized sector workers below the poverty line from major health expenses associated with hospitalization. The scheme is sponsored by the central and state governments. The state governments contract with insurance companies to manage financial risk and run the schemes (each state government goes through its own procurement process to select an insurance company). The benefits package is limited to hospitalization and surgical services. Outpatient procedures, pre- and post-hospitalization expenses, and a transport allowance are also included, as are maternity expenses. A provider network consisting mainly of private hospitals may be accessed for no fee by the beneficiaries.

Slide 99:

The network of hospitals is established by an insurer-appointed TPA, which evaluates them on a set of quality of care standards. The central government contributes significant resources to subsidize premiums. State governments are also responsible for a portion of the premium. Beneficiaries pay a nominal registration fee (Rs.30, or $0.63) per annum. Additional administrative costs not covered by premiums are borne by the state

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Slide 101:

The basic fact is that any scheme of health insurance to be introduced on large-scale in this country, requires a tremendous attention for developing organisational capacity on the part of the Insurers and the regulators to bring together the disparate elements that largely constitute the 'Health Marketing'. Health insurance today which exists in whatever little form that we have, mostly is a 'reimbursement policy' which the General Insurance Corporation's subsidiaries, have been extending to people. It does not take care of fundamental requirements of the people.

Slide 102:

Insurance Regulatory and Development Authority should be more effective and should concentrate on accessibility, quality and affordability dimensions of the health insurance sector. Agencies such as State Health System, Indian Medical Association and Administrators from Third Parties (TPAs) should form a composite monitoring network for professional regulation of health insurance in India. The statistical system is a lifeline for health insurance. India lacks appropriate data and information system for planning and management of health insurance schemes. Efforts are required for developing a holistic Health Insurance Information System.



Slide 104:

Need for participation of government funded public health institutions The challenge of risk pooling for remote rural households can only be met when public health systems are also a part of such innovative health financing mechanisms. The example of Karuna Trust’s work in Karnataka showed how by compensating poor households for loss of wages and other indirect expenses and reimbursing hospitals a certain amount for drugs and medicines in every case of hospitalization, result in increasing access to health care One possibility therefore is to have a number of pilots undertaken on risk pooling for poor households through NGOs, Self Help Groups, other community organizations covering the indirect expenditures that are incurred in seeking health care.

Slide 105:

Any kind of Health Insurance Scheme, which does not involve the public medical facilities, would not succeed because, in majority of states, these are the only facilities available in rural areas. The involvement of the States could be worked out by designing a Plan Scheme by the Ministry of Health and Family Welfare with subsidy being passed on to the hospitals through the State Governments. In such a situation, the State Governments can invite bids on ‘premium to the charged’ at their level from all the insurance companies, both public and private. For availing of the subsidy from the Central Government, the minimum features of the Scheme could be decided a priori and informed to the State Governments

Slide 106:

Innovative financing for efficiency Innovative mechanisms of health financing can be used to improve accountability of the health system, be it in the public or private sector. For example if a CHC were to receive resources directly on the basis of their case load, it would contribute to a more effective service delivery. the work of the National Commission on Macroeconomics and Health on unit costs for core, basic and secondary health care package alongside the facility survey of the public and private sectors in districts could be a useful starting point for developing standard costs and treatment protocols and a basis for public private partnerships in health service delivery.

Encourage Co-operative insurance :

Encourage Co-operative insurance Promote health insurance schemes by Involving network of co-operatives as in Karnataka. Constitute risk pools around professional or occupational groups like self help groups or micro credit groups, weavers, fishermen, farmers, agricultural laborers and other informal groups (as in Kozhikod , Kerala)

Slide 108:

Appoint a body that will take the responsibility of organising the insurance programme – could be an independent Health Insurance Corporation, or a cell in the Dept. of H & FW, a separate trust, or a NGO. Arrive at a basic package that would address the medical, surgical and other health needs of the poor to be provided as inpatient or outpatient. The proportionate share between the three key stake holders will need to be finalized : the Central Governemnt , the State Government and the individual households. An independent body should be appointed to administer the scheme having the requisite technical and managerial capacity. A cell should be established to closely monitor specific indicators to ensure that the programme is on track.


DENTAL INSURANCE MANAGEMENT PROGRAMME  Patient’s responsibity : Although the patient is responsible for ascertaining the benefits of his or her policy, the office should be able to clarify what the benefits are available to the patient, so that there is no misunderstanding as to the patient’s responsibility.

Slide 110:

Because major dental carriers have many different types of plans, one of the essential ingredients for a management system to work smoothly and effectively is the “Insurance Bible”. At first contact with the patient (which is often by telephone), the patient should be requested to: 1) Bring several insurance forms into the office and 2) Bring in their insurance policy, which gives a description of service benefits.

Slide 111:

The parts of the plan that explain the benefits, deductibles, and the expiration date of the policy should be highlighted. In this way the staff can determine while the patient is there, the dentist’s fee, what services the insurance company covers, the amount they will pay, and whether the patient is responsible for the differential. Highlight the expiration date so that there will be no confusion as to when the policy expires.


SUPERBILL FORM Reduces work load and increases efficiency It has prewritten codes for all procedures routinely used Special slots for tooth number and dentist fee It is in triplicate Once these sections are filled super bill is stapled with patient’s insurance form and send to company

Marking of patient chart:

Marking of patient chart Receptionist places white piece of tape or colour codes on the side of patient’s chart to denote that he has insurance. The dentist who will mark PE (preestimate) in green ink if prior authorization is required Likewise when a claim is mailed to the insurance company for payment the claim number and date the claim was mailed to the insurance should be in red ink

Insured patient claim forms files with colour coding:

Insured patient claim forms files with colour coding

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Slide 116:


Strategies for health financing:

Strategies for health financing Currently India’s health financing mechanism as mentioned earlier is largely out-of-pocket and a declining trend in public finance. First, within the existing public finance of healthcare, macro policy changes in the way funds are allocated can bring about substantial equity in reducing geographical inequities between rural and urban areas. Presently, the central and state governments together spend Rs.250 per capita at the national level, but this is inequitably allocated between urban and rural areas.

Slide 119:

If allocations are made using the mechanism of global budgeting, as is done in Canada for instance, that is on a per capita basis then rural and urban areas will both get Rs.250 per capita. This will be a major gain, over two times, for rural healthcare and this can help fill gaps in both human and material resources in the rural healthcare system. ratios) are adequately provided The highly centralized planning and programming in the public health sector will have to be done away with and greater faith will have to be placed in local capacities.

Slide 120:

Third, the governments can raise additional resources through levying “sin taxes” - compulsory cesses and levies on products such as cigarettes,beedis , alcohol, pann masalas and guthka , personal vehicles etc For instance tobacco, which kills 670,000 people in India each year, is a Rs.350 billion industry and a 2% health cess would generate Rs.7 billion annually for the public health budget.

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Likewise to reduce out - of-pocket financing of the healthcare system, policies need to be quickly put in place for a system of health financing that will be a combination of public finance and private contribution by establishing various collective financing options such as social ,collectives/common interest groups etc. At another level the healthcare system needs to be organized into a regulated system that is ethical and accountable and is governed by a statutory mandate, which pools together the various sources of financing and manages it for ensuring all the members access to comprehensive healthcare. This will happen only if the entire healthcare system, public and private, is organized under a common umbrella, ideally through a single-payer mechanism that operates in a decentralized way.

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Creation of separate budget head for all donor grants In India, foreign grant is received for combating specific diseases like HIV/AIDS, TB, leprosy, malaria etc. Such grants are disease specific which often do not take into account the disease burden or the priority of the Government. The funds from donor agencies should therefore be pooled under a single budget head so that government may prioritize the spending according to the disease burden of the population. This may well make all the difference. 122


CONCLUSION Private fee for service will likely to remain the predominant method of financing the dental care in foreseeable future. Developing countries like India are in transition period during which alternative feasible modes of financing and delivery services will evolve Dental personnel and health care service organization can be certain that financing of dental care is very important dynamic area, and there could be further expansion and evolution with new concepts that might emerge ………

Other publications:

Other publications

The private/public mix in health care in India RAMESH BHAT Health Policy Plan. (1993) 8 (1):43-56. :

The private/public mix in health care in India RAMESH BHAT Health Policy Plan. (1993) 8 (1):43-56. Private hospitals and private medical practitioners play a significant part in delivering health care services in India. As the demand for health care has increased, institutions in this sector have expanded widely in both urban and rural areas. The relationship between patient and private practitioner considerably influences the perceived and actual needs about health care. This relationship is expected to play an important role in the control of disease patterns and management. However, the developments in this sector have prompted concern about the efficiency of resources, equity and access to facilities, and the availability of financing mechanisms to support private health care. Also, the efficiency with which the resources are used in this sector has direct bearing on the cost and quality of services. The existence of these health care institutions therefore has profound implications for the present character of the Indian health care system, and its future course. The objectives of the present study are to review the role of the private health care sector in India and the policy concerns it engenders. The discussion suggests that policy makers in India should take serious note of the growing influence of the private sector in providing health care in India. Policy interventions in health should not ignore their existence and this sector should be explicitly involved in the health management process. It is argued that regulatory and supportive policy interventions are inevitable to promote this sector's viable and appropriate 

People's Choice of Health Care Provider: Policy Options for Rural Karnataka in India Journal of Health Management January/June 2003 5: 111-137,:

People's Choice of Health Care Provider: Policy Options for Rural Karnataka in India Journal of Health Management January/June 2003 5: 111-137, The main objective of this paper is to examine the people's choice of health care provider in rural India and the policy concerns in engenders. This is estimated through the Logit Model by using the rural household survey on health in Karnataka state in India. The study also explores the heuristic approach through observation and informal discussion with rural people about their opinion on existing health care services. The analysis shows that the private health care provider has emerged as the people's choice. However, the choice is significantly linked with socio-economic conditions of the rural people. The discussion suggests that policy makers in India should take serious note of the growing popularity of the private sector in providing health care services, and that it would be advisable to opt for a private-public mix for regulatory and supportive policy interventions. This would inevitably promote this sector's viable and appropriate development.

References :

References Report of the Working group on Health care financing including Health insurance For the 11th five year plan Ministry of health & family welfare The feasibility of a Community Based Health Insurance (CBHI) at Wayanad , Kerala. Dr. N Devadasan MBBS, MPH Poverty & health: Criticality of public financing Ravi Duggal Indian J Med Res 126, October 2007, pp 309-317

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SERIES: SOCIAL SECURITY EXTENSION INITIATIVES IN SOUTH ASIA COMMUNITY HEALTH INSURANCE – Karuna Trust. N. Devadasan , Karuna Trust Financing healthcare in India - prospects for health insurance, Ravi Duggal , Issue,15th March 2004 LORRAINE S.MASHIOFF. Management of dental insurance in dental office. DCNA 1987; 179-192

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James Morse Dunning. Principles of Dental Public Health.4 th edi . Burt B, Eklund S: Dentistry, dental practice, and the community, 6 th Ed, Elsevier publications 2005 : p 81-110 Daly, Watt: Essential Dental Public Health, Oxford university press 2002, p270-75 Cynthia pine, Rebecca Harris, Community Oral Health, 2 nd Ed.2007: p1-11 Jong : Community Dental Health, 5 th Ed, Mosby Publications, 2002 : p 91-104

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Hiremath S: Textbook Of Preventive And Community Dentistry, Elsevier Publication, 2007 : p 207-218 http://www. dental insurance\The Tribune, Chandigarh, India - Business.htm,last updated 10/10/2005: 5.45pm 17/08/09 ICICI Lombard launches 'Health Advantage Plus' First Health Insurance Plan in India that offers cover for OPD and Dental Treatment, New Delhi, IND, 2007-08-30 16:06:17 ( 6.30 pm 28/08/09 Health insurance handbook how to make it work

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