Dr. Kitchen’s suggestion that risk information not be made available to dental insurers stems from a concern that the profit motives of some insurance companies might lead to a loss of coverage for high-risk patients. Unfortunately, the suggestion itself would have the effect of disenfranchising large numbers of insured high-risk patients who might benefit from enhanced coverage for preventive treatment. Two assumptions underlying this paradox merit closer examination.
Dr. Kitchen suggests that the sole intent of the insurance industry’s risk assessment efforts is to limit procedures, thereby increasing profits. As I understand insurance companies’ interest in risk assessment, a reduction in reparative procedures is anticipated only through the long-term effects of an increase in preventive procedures to be provided to the high-risk population. The expected outcome of "healthier insureds" is viewed not only as cost-saving, but also as a competitive advantage as insurance companies market their plans to purchasers.
Insurers are being encouraged by purchasers to design plans that expand coverage for those most at risk without increasing overall costs. In so doing, however, dental insurance companies fear that expanded coverage will result in more services for everyone, not just for those with the greatest risk. Without risk assessment data, insurers have no way of knowing whether they are making expanded benefits available to those beneficiaries at greatest risk, thereby fulfilling the expectations of purchasers—public and private employers, unions and others—who ultimately pay the dental insurance bill.
Dr. Kitchen also states that dental insurers might limit or deny coverage to high-risk individuals. While there is evidence, both anecdotal and documented, that some medical insurance companies have excluded or limited coverage for certain pre-existing conditions, it seems to me that there are substantial differences between medical and dental insurance that make such a response less likely among dental insurance plans.
There are fewer incentives for dental plans to deny or limit coverage based on risk status. Dental insurance is more similar to a prepaid plan, with first-dollar coverage for preventive and diagnostic procedures and varying levels of coverage for other services. In addition, most dental plans have annual maximums, thereby establishing limits on loss. Unlike medical insurance plans, they are not designed to cover catastrophic loss.
Finally, I am unaware of exclusions for pre-existing conditions among most dental insurance plans despite the ease with which many such conditions can be identified through claims data alone.
Through analyses of their claims data, dental insurance companies are aware of the underutilization of risk-based provision of preventive services.1–4 Thus, the participation of an insurer in the risk-assessment project reported in our article is not surprising. The for-profit company that sponsored our study made a deliberate choice to support this public domain work. In doing so, I believe that it demonstrated a welcome level of openness in working with the dental community to improve patient treatment outcomes.
The volunteer dentists who participated in the project also understood the potential advantages of risk assessment for their patients and their practices. I hope that this and other such efforts to maximize the health of patients are evaluated based on their potential to do so, rather than on unsubstantiated assumptions.
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