2.  At the end of the lecture students should be able to –  Explain non profitable health services.  Discuss HMO.  Explain capitation plan and salary programs.  Discuss some public programs.

3. 3b) Non profit health services i) Delta dental plans – (Dental Service Corporation)  A dental service corporation is a legally constituted non profit organization run by each state and sponsored by dental society.  They are usually subjected to insurance law of the state.  The plan has a board of directors (dentists), members from finance, insurance, and consumer groups.

4. Reimbursement of dentist in dental plan  The payment is through UCR (usual, customary, reasonable) concept.  Dentist in this plan can be Participating or non participating dentist  A participating dentist is any duly licensed dentist with whom delta dental plan has a contract/agreement to provide care to covered subscribers.

5.  Dentist participating in the plan have to agree to the following conditions – 1) Dentist has to pre file his usual fees. 2) Acceptance of the payment is in 90 th percentile, some amount is withheld and goes to delta reserve fund. 3) Auditors check the records from time to time. 4) Post treatment inspection is done randomly on some patients.  Non participating dentists can also treat patients covered under delta dental plan.  They are paid usually 50 th percentile, and need not file fees and are not subjected to fee audits.

6. What is 90 th percentile ?  Suppose in an area there are 200 participating dentists, their fees range from 50-90 SAR for filling.  Then we plot graph with fees on x-axis, and percentile on y-axis.  The 90 th percentile is that value below which 90% observation fall.  The figure shows 1) about 10% of dentists charge 60 SAR or less 2) about 50% of dentists charge 65 SAR or less 3) about 80% of dentists charge 70 SAR or less 4) about 90% of dentists charge 78 SAR or less  When payment is made at 90 th percentile, a payment of 78 SAR or their actual fees (which ever is less) is paid to participating dentist.

7. ii) Blue cross/ Blue shield  These non profit health service corporations offered limited dental services for years as a part of medical policies.  Dental coverage was limited only in the hospitals.  Has similar cost control features pioneered by delta plans

8. 3c) Pre paid Group practice  It is a group practice that provide dental services on a prepaid basis, also called open panels. Types of group practice  A) all are general practitioners, B) all are specialists of same specialty, C) Multi specialty. Advantages for dentists in this plan  Provides better way of organization  Less disruption of practice  Quality of care is improved  Many other benefits like sick leave, pension plans are also entitled.

9. Closed panel practice  Public or private program can receive these services only at specified facilities from a limited number of dentists.  It has been charged as unethical practice and that they deliver care of inadequate quality.

10. HMO (Health Maintenance Organization)  It is a legal entity which provides a prescribed range of health services to each individual who has enrolled in this organization.  They need to pay a prepaid, fixed and uniform payment.  The four principles that characterize an HMO are – 1) An organized system of health care 2) An agreed set of comprehensive health and treatment services 3) Voluntarily enrolled group of people. 4) A pre negotiated, fixed periodic payment plan.

11.  Dental personal in HMO 1) The staff model (dentist, hygienist, assistants are all salaries employees). 2) The group model (contract/partnership with a group practice, where group receives regular capitation). 3) The Independent Practice Association (IPA) – contract is similar to open panels. 4) The primary care capitated network or direct contract model. (network is similar to IPA except HMO contracts individual provider for provision of services).

12. 3d) Capitation plans  Here the dentist receives a negotiated sum on a monthly or yearly basis from the patient.  The money is paid regardless the patient utilizes the services or not.  In return, patient is entitled to receive a prescribed set of services over a specified period

13. 4) Salary  Dentist is some group practices, those in the armed forces and those employed by the public agencies are salaried. Advantages  Allows dentist to be free from business concern of running his private practice.  Benefits are also often attractive. Disadvantage  There could be lack of financial incentives.

14. 5) Public programs  Private practice alone, is not able to meet dental demands of all people.  Therefore there are many public programs to meet the needs of the people.  These programs are sponsored by the government.  Public financing of dental care are - A) Medicare B) Medicaid C) National health insurance

15. A) Medicare  This program was introduced in USA  It removed all financial barriers for hospital and physician services for all persons aged 65 and above.  The dental segment of Medicare is limited to services requiring hospitalization for treatment. B) Medicaid  It was also started in USA to provide funds to meet health care needs of all needy and poor people.  It’s a joint program of central and state governments to cover at least basic services.

16. C) National Health Insurance (NHI)  NHI was introduced in Germany and Britain as a basis of humanitarian and development.  They thought that healthy and secure society would lead to political stability and greater economic and individual strength.  NHI is primarily a financing mechanism by which health care services are paid by a publicly organized fund.