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Dental care in public assistance programs
the Journal of the American Dental Association
D e n ta l care in p ublic a ss ista n c e p ro g ra m s
John M . F ran kel, D .D .S ., M .S ., San Francisco
Dental care in public assistance programs is an integral part o f the whole pattern of federal, state and local activity de veloped over the years to aid indigent citizens. A t the federal level, this activity has its roots in the Social Security Act. In the states and localities, it stems from welfare and assistance legislation which serves to complement and supplement the basic national Social Security legislation. Various forms of relief from economic stress have been a recognized function of government for centuries. T h e approach was more or less piecemeal, however, un til the 1930’s. O ut o f the depression there developed a broad public consciousness of the over-all problems presented by economic distress among various segments o f the population. Th e net result of this consciousness and subsequent planning to remedy the problem was the enactment of the Social Security A ct of 1935.
A d d ition a l fu nd s fo r m ed ical ( and d en tal ) serv ices in p u b lic assistance program s w ere m a d e available u n d er a 1956 a m en d m en t to th e S ocial S ecu rity A ct. S tate legislators an d adm inistrators look to organ ized d en tistry fo r aid in fo r m u lating d en ta l care p rogra m s fo r eligible n eed y persons. D en tists sh ou ld : ( 1 ) en sure that state w elfa re appropriation s are sufficien t fo r th e inclusion o f ad e q u a te d en ta l c a r e ; ( 2 ) establish e ffe c tiv e liaison w ith th e legisla tu re; ( 3 ) c o o p er a te w ith th e respon sible a g en cy in plan nin g details o f th e s e r v ic e ; ( 4 ) d evise m eth od s to p ro v id e d en tal services to those eligible, and ( 5 ) con tin u ou sly eva lu a te th e p r o gram . A “ f e e fo r serv ice” basis is ideal fo r p rog ra m s that are con trolled locally. T h e closed p a n el plan is a g o o d adm inis tra tive m ech an ism to p ro v id e serv ice w h ere ben eficiaries are co n c en tra te d in a rela tively sm all area. A p r ep a y m en t p r o gram has w ork ed w ell in th e state o f W a sh in gton . T h e k ey to success fo r any d en ta l care p rogra m is th e den tist and his
Presented before the Ninth N a tio n a l Dental Health C onference, C h ic a g o , A p r il, 1958. A ssista nt re gion a l _ dental consultant, U. S. Public H e alth Service, Re gion IX.
d en ta l society. 17
18 • T H E J O U R N A L O F T H E A M E R I C A N D E N T A L A S S O C I A T I O N
This basic body of laws is fundamental to the evolution o f public assistance pro grams. T h e First Annual Report o f the Social Security Board 1 expresses the phi losophy under which a democracy func tions on behalf of the welfare of its citizens: T h e quest of security is a task for the whole o f the people. It must be worked out within a system which is distinctly American. T h at system does not offer the individual a life o f security. It grants him an opportunity to find security for himself. . . . T h e citizens, the economic system, and the government are partners in this national provision. Th e Social Security Act was passed as a single measure to promote the realization of this broad aim. Its meaning and significance are to be discovered in its relationship to the society it serves. It does not usurp the role o f private enterprise. It recognizes work and a wage as the best security which the worker can find for himself. T h e Act provides not a com plete security in itself but a necessary comple ment to the security afforded by private enter prise and a complement to the other measures of government directed to the same end. . . . H ere is the key to the Social Security Act. It hedges the m ajor hazards o f life with safe guards which neither the individual alone nor industry unaided can provide. . . . A number of hazards which no one can control lie in 'the path o f every man and every woman— a de pendent childhood, blindness, disability, the need fo r maternity care, an indigent old age. This is the case for public assistance and special services for health and welfare. W e cannot achieve security for a nation without promoting the security of the groups which make it up. . . .
Responsibility for administration of the public assistance programs under the Social Security A ct rests with the Depart ment o f Health, Education and W elfare. Specific responsibility rests with the Bu reau o f Public Assistance under the So cial Security Administration. T h e whole public assistance program is described in four titles of the Social Security A c t : These titles provide for federal grantsin-aid to the states and territories in these categories: T itle I — O ld-A ge Assistance; T itle I V — A id to Dependent Children; T itle X — A id to the Blind; T itle X I V —
A id to the Permanently and Totally Dis abled. Th e primary purpose o f the public as sistance program is to provide needy per sons with income to supplement their own resources and enable them to secure the necessities of life, and to help them achieve the greatest economic and per sonal independence possible.2 This is ac complished in two ways— by money pay ments to recipients and, since 1950, by offering them medical and remedial care through payments to the vendors o f that care. T o finance the program, the federal government matches state expenditure up to specified maximums. Quarterly federal grants are made to the states for this purpose, based on the state’s estimate of expenditures. States can and do appro priate funds in excess of the federal maximums, but these cannot be met by federal funds. Th e federal government pays 50 per cent of administrative costs. Although the public assistance pro grams receive federal support, they are administered by states or by local sub divisions under the supervision of states. Each state develops a plan which is in compliance with federal requirements. T o be approved for the federal grant, the state plan for aid to any one of these groups o f needy persons must be state wide in scope. Am ong other requirements are that the state must share in the cost, and a single state agency must administer the plan or supervise administration. Th e aid must be given directly to the needy person, in money, except that the agency may pay other persons who have given medical care to the recipient. T h e state must provide safeguards against disclo sure of personal information about ap plicants and recipients except for pur-
1. First annual report of the S o cia l Secu rity Board, 1936, p. v. 2. U. S. Dep artm e n t of H ealth, Education, and W e lfa re . Pu b lic assistance under the S o cia l Security A ct. W a sh in gto n , D. C., G o v e rn m e n t Prin ting Office, A u g . 1957.
FRANKEL
poses related to the administration of the program. Plans must also provide for such methods of administration as are found necessary for proper and efficient opera tion .3 T h e public assistance program in any state is developed by that particular state. Beyond compliance with the federal re quirements (some o f which were cited in the preceding paragraph) the details of each state program for welfare recipients are left to the state and localities. Specific content, then, is the prerogative o f the state, and the state’s plan may or may not include dental care. Frequently the state legislation leaves most o f the detailed planning to the discretion o f state and local administrators. A ll medical services actively seek their share of the state’s public assistance budget. Dental services have not always fared well in obtaining a reasonable share of the total funds. Additional funds for medical services (including dental services) were made available under a 1956 amendment to the Social Security Act, which went into effect in July o f 1957. T h e amendment established formulas for medical and remedial care which provide that the federal government w ill match half o f the money expended by the state up to a six dollar per month maximum for each aged, blind or disabled recipient. T h e federal government will match half o f the money, again, with a six dollar maximum per month for each adult caretaker or needy relative in the A id to Dependent Children Program, and half of the amount, up to three dollars per month, fo r the depen dent children who are themselves recipi ents. W ith the new source o f funds made available by the 1956 amendment, state legislatures and administrators o f public assistance programs might re-examine their programs fo r initiation or expansion of medical or remedial services. Dental care is one area which particularly merits such re-examination. Some particularly alert state dental associations already have stepped forward
V O L U M E 58, F E B R U A R Y 1959 • 19
to guide the thinking of persons respon sible for their state’s public welfare pro grams. T h e Missouri State Dental Asso ciation, for instance, recently published the following recommendation 4 from a workshop sponsored by its Council on Dental H ealth: Because o f the great need for dental care of welfare recipients and because dental health is an integral part of total health of the pa tient, we recommend that the legislature utilize all the funds available to the state under the 1956 medical care amendments to the Social Security Act, and that a part of the funds be earmarked for dental services. W e are presently investigating methods through which such care can be furnished, statewide.
Since that recommendation was made, the dental service corporation has be come a fact in Missouri, and there is statewide provision for dental care. This kind of interest and activity by organized dentistry is seriously needed, and is generally welcomed by both legis lators and administrators. Th ey rightfully look to dentists for guidance in the den tal field. Dentists must be in the forefront in planning programs if such programs are to be acceptable to all parties con cerned— the w elfare agency, the recipient and the dental profession itself. T h e first thing that must be done is to ensure that state welfare appropriations are sufficient fo r the inclusion o f ade quate dental care within the framework o f the total medical services. Obtaining adequate appropriations calls fo r effec tive liaison with the legislature. Next, the details o f the service to be offered must be planned in cooperation with the agency responsible for the program. Simultaneously, methods must be devised to provide services to all eligible recipi ents throughout the community. Lastly, there must be continuous evaluation of
3. U. S. De p a rtm e n t^ o f H ealth, Education, and W e lfa re . S o c ia l security in the U nited States. W a s h in g ton, D. O., G o v e rn m e n t Printing Office, 1957, p. 29. 4. D e v e lo p m e n t of a dental care p ro g ra m for M is souri. J. M isso u ri D. A ., 28:21 M a rc h 1958'.
20 • T H E J O U R N A L O F T H E A M E R I C A N D E N T A L A S S O C I A T I O N
the program in order to modify it as cir cumstances warrant. State health departments, through their dental divisions, are invaluable re sources for organized dentistry in these matters. T h ey are willing and anxious to work with dental associations and their constituent societies in the development of all phases of organized care programs. Th e dental division also is the natural liaison between organized dentistry and the welfare agency. Th e state dental as sociation, the state dental division and the state w elfare agency have areas of mutual interest where close cooperation among them would be both logical and profit able. Some o f these areas a re: 1. Determination o f the needs of re cipient groups by means o f dental surveys of adequate samples o f each category to receive service. 2. Determination, through fee surveys or other means, of an adequate fee sched ule for the program. 3. Estimation o f program costs based on the results o f the needs survey and the fee schedule. 4. Determination, within the resources available, o f the most suitable types o f dental services to be provided for the various categories o f recipients, and the methods by which those services may be offered. O f greatest interest to the dental profes sion are the types o f services offered in public assistance programs. Availability o f funds w ill be a major factor in deter mining what services can be allowed, and availability of funds w ill govern to a large extent the scope of the program. T h e con tent o f three general types o f dental pro grams might well be as follows: ( 1 ) a minimum program which can be planned with limited funds; ( 2 ) an intermediate program requiring somewhat greater funds; (3 ) an adequate program which would be more costly, but well within the capacities of many states. A minimum program for either adults or children would be limited to emer
gency services and would include only: ( 1 ) alleviation o f pain, usually by ex traction o f the offending tooth or teeth; ( 2 ) treatment of acute infection; (3 ) diagnosis and treatment o f oral neo plasm; (4 ) elimination o f oral infection retarding the treatment o f acute systemic disease (usually on referral from a phy sician) . This kind o f program is commonly found in public assistance programs and. o f course, meets only the immediate and most pressing needs of recipients. Care under an intermediate program would include the services o f a minimum program and, in addition, for children: ( 1 ) all needed extractions; ( 2 ) all neces sary amalgam and silicate restorations; (3 ) all necessary treatment o f soft tissue disease. For adults, the intermediate program would provid e: ( 1 ) all services included for children; ( 2 ) construction o f com plete dentures where indicated for eden tulous patients or patients having insuffi cient masticating teeth for adequate nutrition. In the process o f rehabilitating the recipient and making him a productive citizen, it is sometimes necessary to have teeth replaced for esthetic reasons or to improve his speech. However, partial dentures and fixed bridgework do not easily fit into a program of this nature for adults. Construction costs o f such appliances would rapidly deplete avail able funds in an intermediate program. A more nearly adequate program from a professional point of view would in clude the follow ing services fo r children, in addition to those listed in an inter mediate program: ( 1 ) topical applica tion o f fluoride where there is no water fluoridation; ( 2 ) space maintenance for prematurely extracted deciduous teeth. For adults, there would be provided partial dentures and fixed bridgework for a limited number o f carefully selected recipients reflecting the greatest need.
F R A N K E L . . . V O L U M E 58, F E B R U A R Y 1959 • 21
T h e most rigid criteria would be used in this selection. Whereas available funds must be a factor in selecting services to be offered, priorities can be set for the provision of one type o f program for one category or age group and provision o f a completely different type of program for another group. In some communities it may be practical, for instance, to provide an adequate type of program for children and a minimum program for adults. Dental care administration is a dis cipline unto itself, and although dentists zealously safeguard all dental professional determinations, they should call on others with special training and skills to aid in operating broad programs under organ ized dentistry. In the provision o f public assistance, including medical services, there are many methods of administration and numerous methods o f payment to the vendors o f care. State laws may specify in detail the method of administration and payment; but more often than not, the state legislature gives the responsibil ity to the appropriate state agency, leav ing to that agency the determination of how to operate the program. T h e law may provide that the state assistance agency administer the program itself, or administration may be delegated to coun ties under state agency supervision. G ov ernment agencies may elect to certify eligibility o f recipients, leaving the actual provision o f care to outside organizations. Th e organization may be the dental asso ciation, the dental association service cor poration or another administrative entity specifically designed to provide such serv ice to groups (Blue Cross, for exam ple). Th e most common method of payment for dental service is “ fee for service,” a method similar to that which the dentist uses in his private practice. This method, to be successful, presupposes an adequate fee schedule which is fair to both the purchaser o f the service (ultimately the taxpayer) and the vendor o f the service
(the dentist). U nder a state plan, pay ment may be m a d e ,to the recipient as part of his money payment, and he in turn pays the dentist; or the payment may be made directly to the dentist, under the separate provision for vendor payments. American Dental Association policy is in support of payment being made directly from the administrative agency to the provider o f care .5 Another method of payment is an hourly fee for services rendered. This method is often used in closed panel clinics where dentists are hired on a part time basis. However, it has been used successfully in public programs purchas ing services o f private dentists in their own offices. Prepaid dental care is new to the field o f dentistry. Under this method of pay ment, the vendor or contractor agrees to furnish specified services for a fixed pre mium payment per recipient. This meth od is still in an experimental stage, but a body of actuarial information is being gathered which should encourage its use. A given program may utilize a number of different methods of providing care and more than one method of payment. Whatever methods or combinations of methods are employed, the program must be statewide and there are certain prin ciples of good administration and ac counting which must be followed. M ech anisms must be set up t o : 1. Certify recipient eligibility fo r den tal care. 2. Get the eligible recipient into the office o f the participating dentist. 3. Estimate the care needed by the recipient (except under emergency situa tions where frequently no prior author ization is required). 4. Submit an estimate to the admin istrative agency for authorization to pro ceed with the treatment plan. This may include a preaudit by a screening dentist.
5. A m e ric a n d. 156.
Dental
A sso cia tio n .
T ran sactions
1951.
22 • T H E J O U R N A L O F T H E A M E R I C A N Ü E N T A I A S S O C I A T I O N
5. Submit a voucher for work com pleted and certify the voucher for pay ment. 6 . M ake actual payment to the dentist-vendor. 7. Audit procedures, which may in clude spot-checking by a screening den tist. A county dental program which has a long history of fruitful operation is the one in Racine, Wise. This depressionborn program began in 1932 and has been successfully operated ever since. It is ad ministered by the Racine County Depart ment o f Public W elfare, and services are provided by all members of the Racine County Dental Society. This wide par ticipation of dentists is particularly sig nificant because the program gives eligi ble recipients complete freedom of choice of the practicing dentists in the county. It is financed through the County W el fare Department, which receives a por tion of its funds from the State o f Wiscon sin. T h e state, in turn, receives federal funds through the plan o f matching funds. A fee schedule was originally worked out by a committee consisting o f three members o f the Racine County Dental Society, two members of which were ap pointed by the society and one by the County W elfare Department. Th e fee schedule has been revised and updated periodically. Th e same committee has screening and auditing functions in mat ters pertaining to dental services under the plan. Th e committee spot-checks completed work and has full authority to act for the Department o f Public W elfare in disputes with dentists, thus keeping such matters in professional dental hands. This simple type of “ fee for service” program seems ideal for locally con trolled programs— even those o f a fairly large scale. Its success depends, however, on wholehearted official support o f the local dental society, as well as enthusias tic participation of a large segment of the community’s practicing dentists.
Most state public assistance agencies which conduct dental' programs do so in very much the same manner as was de scribed for the Racine County program. Th ey handle all phases of administration within the agency and contract directly with individual dentists, paying on a “ fee for service” basis. T w o notable exceptions w ill be described in some detail because they illustrate a variety of administrative methods, types of services and methods of payment. Th e State of Washington Department of Public Assistance purchases dental care for its public assistance recipients from the Washington State Dental Service Corporation which was created by the Washington State Dental Association in October, 1954, to study and carry out dental care programs for groups. It is the first such corporation formed in the United States and is similar in structure and purpose to the Blue Cross and M ed i cal Service Bureau. It now has 15 thirdparty payment contracts in addition to that with the state o f Washington. The corporation contracts with licensed den tists in the state of Waashington to pro vide dental treatment for recipients. A detailed description of the Washington State Dental Service Corporation, espe cially in relation to its programs o f den tal care for a labor-management welfare fund, (the International Longshoremen’s and Warehousemen’s Union-Pacific M aritim e Association W elfare Fund) can be found in a recent publication 6 of the Division of Dental Resources of the U.S. Public Health Service. A t present, the Washington program has 110,000 recipients o f public assist ance eligible for treatment of their acute and emergent dental problems. About 22,000 persons per year, or 20 per cent of the eligible recipients, use this service.
6. U. S. D epartm ent of H ealth, Education, and W e lfa re . The dental service corp o ra tion, a new a p proach to dental care. W a sh in gto n , D. C., G o ve rnm e n t Printing Office, Public H e alth S e rvice P ub lica tion No. 570, 1958.
F R A N K E L . . . V O L U M E 58, F E B R U A R Y 1959 • 23
Service is provided in three different ways. Th e first is a “ fee for service” pro gram operating in all but nine counties o f the state. U nder this program a recipi ent takes proof o f his eligibility to a par ticipating dentist who may be any li censed dentist in Washington. Th e dentist makes an examination, treats acute conditions and sends his treatment plan to the corporation for approval. The corporation audits the treatment plan to determine if it is in accord with the established rules and priorities and au thorizes treatment, if possible. A fter treatment, the dentist submits his voucher to the corporation for payment. Th e corporation, in turn, bills the Washington State Department o f Public Assistance for the dentist’s fees and, separately, for administrative costs. A t present, the ad ministrative costs are approximately 6.5 per cent o f the fees for treatment. T h e second program is a closed panel clinic in Pierce County, Washington. This clinic hires local dentists for a fixed daily fee to serve in the clinic. This legal and ethical closed panel (at one time operated by the Pierce County Dental So ciety) is an excellent administrative mechanism for the provision o f service where beneficiaries of the program are concentrated in a relatively small area and, o f course, where there is active and enthusiastic support from the local dental society. T h e third program operated by the Washington State Dental Service Corpo ration is a true prepayment (premium) p rogram . U nder its agreement with the State Department o f Public Assistance, the corporation agrees to furnish all necessary acute and emergent dental care for recipients, for the fixed sum o f 50 cents per month per eligible recipient. This program has proved extremely satis factory from all points o f view and, after having been used in only eight counties, was recently extended to include all the counties in the state. Whereas service under the Washing
ton Public Assistance program is limited to “ acute and emergent” conditions, the widest interpretation has been given to these terms. Only limitation o f funds has prevented widening the scope of the serv ices offered. Administratively, it is with out doubt one of the best-conceived and best-operated programs in the country. Th e California Department o f Social W elfare began a program in October, 1957, which is the largest in size and, for children, the widest in scope o f any public assistance dental plan now in operation. T h e department earmarked $2,225,000 o f state funds which are being matched by the same amount o f federal funds under the 1956 amendments to the Social Security Act. Most o f the funds were to be spent fo r the complete dental care o f 77,000 children aged 5 through 12 years in the California program, “ A id to Needy Children,” (federal category, A id to Dependent C h ild ren ). Recipients in all other categories and outside this age group receive only acute and emergent care. In California, public assistance is ad ministered by counties under state super vision. Thirty-eight counties elected to purchase dental services under the pro gram through the California Dental Asso ciation Service, a corporation sponsored by the California State Dental Associa tion. O ther counties elected to handle the administration themselves and contracted directly with local dentists. Because o f the short time which elapsed between the legislative authorization and the time set for the program to go into actual opera tion, the California Dental Association Service decided to subcontract the physi cal accounting operations. T h e subcon tractor is the California Physicians Serv ice, which has been operating for many years and has the necessary mechanical equipment for a program of this scale. W hether services are handled through the California Dental Association Service or individually by counties, the dentists are recompensed on a “ fee-for-service”
D e n ta l care in p ublic a ss ista n c e p ro g ra m s
John M . F ran kel, D .D .S ., M .S ., San Francisco
Dental care in public assistance programs is an integral part o f the whole pattern of federal, state and local activity de veloped over the years to aid indigent citizens. A t the federal level, this activity has its roots in the Social Security Act. In the states and localities, it stems from welfare and assistance legislation which serves to complement and supplement the basic national Social Security legislation. Various forms of relief from economic stress have been a recognized function of government for centuries. T h e approach was more or less piecemeal, however, un til the 1930’s. O ut o f the depression there developed a broad public consciousness of the over-all problems presented by economic distress among various segments o f the population. Th e net result of this consciousness and subsequent planning to remedy the problem was the enactment of the Social Security A ct of 1935.
A d d ition a l fu nd s fo r m ed ical ( and d en tal ) serv ices in p u b lic assistance program s w ere m a d e available u n d er a 1956 a m en d m en t to th e S ocial S ecu rity A ct. S tate legislators an d adm inistrators look to organ ized d en tistry fo r aid in fo r m u lating d en ta l care p rogra m s fo r eligible n eed y persons. D en tists sh ou ld : ( 1 ) en sure that state w elfa re appropriation s are sufficien t fo r th e inclusion o f ad e q u a te d en ta l c a r e ; ( 2 ) establish e ffe c tiv e liaison w ith th e legisla tu re; ( 3 ) c o o p er a te w ith th e respon sible a g en cy in plan nin g details o f th e s e r v ic e ; ( 4 ) d evise m eth od s to p ro v id e d en tal services to those eligible, and ( 5 ) con tin u ou sly eva lu a te th e p r o gram . A “ f e e fo r serv ice” basis is ideal fo r p rog ra m s that are con trolled locally. T h e closed p a n el plan is a g o o d adm inis tra tive m ech an ism to p ro v id e serv ice w h ere ben eficiaries are co n c en tra te d in a rela tively sm all area. A p r ep a y m en t p r o gram has w ork ed w ell in th e state o f W a sh in gton . T h e k ey to success fo r any d en ta l care p rogra m is th e den tist and his
Presented before the Ninth N a tio n a l Dental Health C onference, C h ic a g o , A p r il, 1958. A ssista nt re gion a l _ dental consultant, U. S. Public H e alth Service, Re gion IX.
d en ta l society. 17
18 • T H E J O U R N A L O F T H E A M E R I C A N D E N T A L A S S O C I A T I O N
This basic body of laws is fundamental to the evolution o f public assistance pro grams. T h e First Annual Report o f the Social Security Board 1 expresses the phi losophy under which a democracy func tions on behalf of the welfare of its citizens: T h e quest of security is a task for the whole o f the people. It must be worked out within a system which is distinctly American. T h at system does not offer the individual a life o f security. It grants him an opportunity to find security for himself. . . . T h e citizens, the economic system, and the government are partners in this national provision. Th e Social Security Act was passed as a single measure to promote the realization of this broad aim. Its meaning and significance are to be discovered in its relationship to the society it serves. It does not usurp the role o f private enterprise. It recognizes work and a wage as the best security which the worker can find for himself. T h e Act provides not a com plete security in itself but a necessary comple ment to the security afforded by private enter prise and a complement to the other measures of government directed to the same end. . . . H ere is the key to the Social Security Act. It hedges the m ajor hazards o f life with safe guards which neither the individual alone nor industry unaided can provide. . . . A number of hazards which no one can control lie in 'the path o f every man and every woman— a de pendent childhood, blindness, disability, the need fo r maternity care, an indigent old age. This is the case for public assistance and special services for health and welfare. W e cannot achieve security for a nation without promoting the security of the groups which make it up. . . .
Responsibility for administration of the public assistance programs under the Social Security A ct rests with the Depart ment o f Health, Education and W elfare. Specific responsibility rests with the Bu reau o f Public Assistance under the So cial Security Administration. T h e whole public assistance program is described in four titles of the Social Security A c t : These titles provide for federal grantsin-aid to the states and territories in these categories: T itle I — O ld-A ge Assistance; T itle I V — A id to Dependent Children; T itle X — A id to the Blind; T itle X I V —
A id to the Permanently and Totally Dis abled. Th e primary purpose o f the public as sistance program is to provide needy per sons with income to supplement their own resources and enable them to secure the necessities of life, and to help them achieve the greatest economic and per sonal independence possible.2 This is ac complished in two ways— by money pay ments to recipients and, since 1950, by offering them medical and remedial care through payments to the vendors o f that care. T o finance the program, the federal government matches state expenditure up to specified maximums. Quarterly federal grants are made to the states for this purpose, based on the state’s estimate of expenditures. States can and do appro priate funds in excess of the federal maximums, but these cannot be met by federal funds. Th e federal government pays 50 per cent of administrative costs. Although the public assistance pro grams receive federal support, they are administered by states or by local sub divisions under the supervision of states. Each state develops a plan which is in compliance with federal requirements. T o be approved for the federal grant, the state plan for aid to any one of these groups o f needy persons must be state wide in scope. Am ong other requirements are that the state must share in the cost, and a single state agency must administer the plan or supervise administration. Th e aid must be given directly to the needy person, in money, except that the agency may pay other persons who have given medical care to the recipient. T h e state must provide safeguards against disclo sure of personal information about ap plicants and recipients except for pur-
1. First annual report of the S o cia l Secu rity Board, 1936, p. v. 2. U. S. Dep artm e n t of H ealth, Education, and W e lfa re . Pu b lic assistance under the S o cia l Security A ct. W a sh in gto n , D. C., G o v e rn m e n t Prin ting Office, A u g . 1957.
FRANKEL
poses related to the administration of the program. Plans must also provide for such methods of administration as are found necessary for proper and efficient opera tion .3 T h e public assistance program in any state is developed by that particular state. Beyond compliance with the federal re quirements (some o f which were cited in the preceding paragraph) the details of each state program for welfare recipients are left to the state and localities. Specific content, then, is the prerogative o f the state, and the state’s plan may or may not include dental care. Frequently the state legislation leaves most o f the detailed planning to the discretion o f state and local administrators. A ll medical services actively seek their share of the state’s public assistance budget. Dental services have not always fared well in obtaining a reasonable share of the total funds. Additional funds for medical services (including dental services) were made available under a 1956 amendment to the Social Security Act, which went into effect in July o f 1957. T h e amendment established formulas for medical and remedial care which provide that the federal government w ill match half o f the money expended by the state up to a six dollar per month maximum for each aged, blind or disabled recipient. T h e federal government will match half o f the money, again, with a six dollar maximum per month for each adult caretaker or needy relative in the A id to Dependent Children Program, and half of the amount, up to three dollars per month, fo r the depen dent children who are themselves recipi ents. W ith the new source o f funds made available by the 1956 amendment, state legislatures and administrators o f public assistance programs might re-examine their programs fo r initiation or expansion of medical or remedial services. Dental care is one area which particularly merits such re-examination. Some particularly alert state dental associations already have stepped forward
V O L U M E 58, F E B R U A R Y 1959 • 19
to guide the thinking of persons respon sible for their state’s public welfare pro grams. T h e Missouri State Dental Asso ciation, for instance, recently published the following recommendation 4 from a workshop sponsored by its Council on Dental H ealth: Because o f the great need for dental care of welfare recipients and because dental health is an integral part of total health of the pa tient, we recommend that the legislature utilize all the funds available to the state under the 1956 medical care amendments to the Social Security Act, and that a part of the funds be earmarked for dental services. W e are presently investigating methods through which such care can be furnished, statewide.
Since that recommendation was made, the dental service corporation has be come a fact in Missouri, and there is statewide provision for dental care. This kind of interest and activity by organized dentistry is seriously needed, and is generally welcomed by both legis lators and administrators. Th ey rightfully look to dentists for guidance in the den tal field. Dentists must be in the forefront in planning programs if such programs are to be acceptable to all parties con cerned— the w elfare agency, the recipient and the dental profession itself. T h e first thing that must be done is to ensure that state welfare appropriations are sufficient fo r the inclusion o f ade quate dental care within the framework o f the total medical services. Obtaining adequate appropriations calls fo r effec tive liaison with the legislature. Next, the details o f the service to be offered must be planned in cooperation with the agency responsible for the program. Simultaneously, methods must be devised to provide services to all eligible recipi ents throughout the community. Lastly, there must be continuous evaluation of
3. U. S. De p a rtm e n t^ o f H ealth, Education, and W e lfa re . S o c ia l security in the U nited States. W a s h in g ton, D. O., G o v e rn m e n t Printing Office, 1957, p. 29. 4. D e v e lo p m e n t of a dental care p ro g ra m for M is souri. J. M isso u ri D. A ., 28:21 M a rc h 1958'.
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the program in order to modify it as cir cumstances warrant. State health departments, through their dental divisions, are invaluable re sources for organized dentistry in these matters. T h ey are willing and anxious to work with dental associations and their constituent societies in the development of all phases of organized care programs. Th e dental division also is the natural liaison between organized dentistry and the welfare agency. Th e state dental as sociation, the state dental division and the state w elfare agency have areas of mutual interest where close cooperation among them would be both logical and profit able. Some o f these areas a re: 1. Determination o f the needs of re cipient groups by means o f dental surveys of adequate samples o f each category to receive service. 2. Determination, through fee surveys or other means, of an adequate fee sched ule for the program. 3. Estimation o f program costs based on the results o f the needs survey and the fee schedule. 4. Determination, within the resources available, o f the most suitable types o f dental services to be provided for the various categories o f recipients, and the methods by which those services may be offered. O f greatest interest to the dental profes sion are the types o f services offered in public assistance programs. Availability o f funds w ill be a major factor in deter mining what services can be allowed, and availability of funds w ill govern to a large extent the scope of the program. T h e con tent o f three general types o f dental pro grams might well be as follows: ( 1 ) a minimum program which can be planned with limited funds; ( 2 ) an intermediate program requiring somewhat greater funds; (3 ) an adequate program which would be more costly, but well within the capacities of many states. A minimum program for either adults or children would be limited to emer
gency services and would include only: ( 1 ) alleviation o f pain, usually by ex traction o f the offending tooth or teeth; ( 2 ) treatment of acute infection; (3 ) diagnosis and treatment o f oral neo plasm; (4 ) elimination o f oral infection retarding the treatment o f acute systemic disease (usually on referral from a phy sician) . This kind o f program is commonly found in public assistance programs and. o f course, meets only the immediate and most pressing needs of recipients. Care under an intermediate program would include the services o f a minimum program and, in addition, for children: ( 1 ) all needed extractions; ( 2 ) all neces sary amalgam and silicate restorations; (3 ) all necessary treatment o f soft tissue disease. For adults, the intermediate program would provid e: ( 1 ) all services included for children; ( 2 ) construction o f com plete dentures where indicated for eden tulous patients or patients having insuffi cient masticating teeth for adequate nutrition. In the process o f rehabilitating the recipient and making him a productive citizen, it is sometimes necessary to have teeth replaced for esthetic reasons or to improve his speech. However, partial dentures and fixed bridgework do not easily fit into a program of this nature for adults. Construction costs o f such appliances would rapidly deplete avail able funds in an intermediate program. A more nearly adequate program from a professional point of view would in clude the follow ing services fo r children, in addition to those listed in an inter mediate program: ( 1 ) topical applica tion o f fluoride where there is no water fluoridation; ( 2 ) space maintenance for prematurely extracted deciduous teeth. For adults, there would be provided partial dentures and fixed bridgework for a limited number o f carefully selected recipients reflecting the greatest need.
F R A N K E L . . . V O L U M E 58, F E B R U A R Y 1959 • 21
T h e most rigid criteria would be used in this selection. Whereas available funds must be a factor in selecting services to be offered, priorities can be set for the provision of one type o f program for one category or age group and provision o f a completely different type of program for another group. In some communities it may be practical, for instance, to provide an adequate type of program for children and a minimum program for adults. Dental care administration is a dis cipline unto itself, and although dentists zealously safeguard all dental professional determinations, they should call on others with special training and skills to aid in operating broad programs under organ ized dentistry. In the provision o f public assistance, including medical services, there are many methods of administration and numerous methods o f payment to the vendors o f care. State laws may specify in detail the method of administration and payment; but more often than not, the state legislature gives the responsibil ity to the appropriate state agency, leav ing to that agency the determination of how to operate the program. T h e law may provide that the state assistance agency administer the program itself, or administration may be delegated to coun ties under state agency supervision. G ov ernment agencies may elect to certify eligibility o f recipients, leaving the actual provision o f care to outside organizations. Th e organization may be the dental asso ciation, the dental association service cor poration or another administrative entity specifically designed to provide such serv ice to groups (Blue Cross, for exam ple). Th e most common method of payment for dental service is “ fee for service,” a method similar to that which the dentist uses in his private practice. This method, to be successful, presupposes an adequate fee schedule which is fair to both the purchaser o f the service (ultimately the taxpayer) and the vendor o f the service
(the dentist). U nder a state plan, pay ment may be m a d e ,to the recipient as part of his money payment, and he in turn pays the dentist; or the payment may be made directly to the dentist, under the separate provision for vendor payments. American Dental Association policy is in support of payment being made directly from the administrative agency to the provider o f care .5 Another method of payment is an hourly fee for services rendered. This method is often used in closed panel clinics where dentists are hired on a part time basis. However, it has been used successfully in public programs purchas ing services o f private dentists in their own offices. Prepaid dental care is new to the field o f dentistry. Under this method of pay ment, the vendor or contractor agrees to furnish specified services for a fixed pre mium payment per recipient. This meth od is still in an experimental stage, but a body of actuarial information is being gathered which should encourage its use. A given program may utilize a number of different methods of providing care and more than one method of payment. Whatever methods or combinations of methods are employed, the program must be statewide and there are certain prin ciples of good administration and ac counting which must be followed. M ech anisms must be set up t o : 1. Certify recipient eligibility fo r den tal care. 2. Get the eligible recipient into the office o f the participating dentist. 3. Estimate the care needed by the recipient (except under emergency situa tions where frequently no prior author ization is required). 4. Submit an estimate to the admin istrative agency for authorization to pro ceed with the treatment plan. This may include a preaudit by a screening dentist.
5. A m e ric a n d. 156.
Dental
A sso cia tio n .
T ran sactions
1951.
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5. Submit a voucher for work com pleted and certify the voucher for pay ment. 6 . M ake actual payment to the dentist-vendor. 7. Audit procedures, which may in clude spot-checking by a screening den tist. A county dental program which has a long history of fruitful operation is the one in Racine, Wise. This depressionborn program began in 1932 and has been successfully operated ever since. It is ad ministered by the Racine County Depart ment o f Public W elfare, and services are provided by all members of the Racine County Dental Society. This wide par ticipation of dentists is particularly sig nificant because the program gives eligi ble recipients complete freedom of choice of the practicing dentists in the county. It is financed through the County W el fare Department, which receives a por tion of its funds from the State o f Wiscon sin. T h e state, in turn, receives federal funds through the plan o f matching funds. A fee schedule was originally worked out by a committee consisting o f three members o f the Racine County Dental Society, two members of which were ap pointed by the society and one by the County W elfare Department. Th e fee schedule has been revised and updated periodically. Th e same committee has screening and auditing functions in mat ters pertaining to dental services under the plan. Th e committee spot-checks completed work and has full authority to act for the Department o f Public W elfare in disputes with dentists, thus keeping such matters in professional dental hands. This simple type of “ fee for service” program seems ideal for locally con trolled programs— even those o f a fairly large scale. Its success depends, however, on wholehearted official support o f the local dental society, as well as enthusias tic participation of a large segment of the community’s practicing dentists.
Most state public assistance agencies which conduct dental' programs do so in very much the same manner as was de scribed for the Racine County program. Th ey handle all phases of administration within the agency and contract directly with individual dentists, paying on a “ fee for service” basis. T w o notable exceptions w ill be described in some detail because they illustrate a variety of administrative methods, types of services and methods of payment. Th e State of Washington Department of Public Assistance purchases dental care for its public assistance recipients from the Washington State Dental Service Corporation which was created by the Washington State Dental Association in October, 1954, to study and carry out dental care programs for groups. It is the first such corporation formed in the United States and is similar in structure and purpose to the Blue Cross and M ed i cal Service Bureau. It now has 15 thirdparty payment contracts in addition to that with the state o f Washington. The corporation contracts with licensed den tists in the state of Waashington to pro vide dental treatment for recipients. A detailed description of the Washington State Dental Service Corporation, espe cially in relation to its programs o f den tal care for a labor-management welfare fund, (the International Longshoremen’s and Warehousemen’s Union-Pacific M aritim e Association W elfare Fund) can be found in a recent publication 6 of the Division of Dental Resources of the U.S. Public Health Service. A t present, the Washington program has 110,000 recipients o f public assist ance eligible for treatment of their acute and emergent dental problems. About 22,000 persons per year, or 20 per cent of the eligible recipients, use this service.
6. U. S. D epartm ent of H ealth, Education, and W e lfa re . The dental service corp o ra tion, a new a p proach to dental care. W a sh in gto n , D. C., G o ve rnm e n t Printing Office, Public H e alth S e rvice P ub lica tion No. 570, 1958.
F R A N K E L . . . V O L U M E 58, F E B R U A R Y 1959 • 23
Service is provided in three different ways. Th e first is a “ fee for service” pro gram operating in all but nine counties o f the state. U nder this program a recipi ent takes proof o f his eligibility to a par ticipating dentist who may be any li censed dentist in Washington. Th e dentist makes an examination, treats acute conditions and sends his treatment plan to the corporation for approval. The corporation audits the treatment plan to determine if it is in accord with the established rules and priorities and au thorizes treatment, if possible. A fter treatment, the dentist submits his voucher to the corporation for payment. Th e corporation, in turn, bills the Washington State Department o f Public Assistance for the dentist’s fees and, separately, for administrative costs. A t present, the ad ministrative costs are approximately 6.5 per cent o f the fees for treatment. T h e second program is a closed panel clinic in Pierce County, Washington. This clinic hires local dentists for a fixed daily fee to serve in the clinic. This legal and ethical closed panel (at one time operated by the Pierce County Dental So ciety) is an excellent administrative mechanism for the provision o f service where beneficiaries of the program are concentrated in a relatively small area and, o f course, where there is active and enthusiastic support from the local dental society. T h e third program operated by the Washington State Dental Service Corpo ration is a true prepayment (premium) p rogram . U nder its agreement with the State Department o f Public Assistance, the corporation agrees to furnish all necessary acute and emergent dental care for recipients, for the fixed sum o f 50 cents per month per eligible recipient. This program has proved extremely satis factory from all points o f view and, after having been used in only eight counties, was recently extended to include all the counties in the state. Whereas service under the Washing
ton Public Assistance program is limited to “ acute and emergent” conditions, the widest interpretation has been given to these terms. Only limitation o f funds has prevented widening the scope of the serv ices offered. Administratively, it is with out doubt one of the best-conceived and best-operated programs in the country. Th e California Department o f Social W elfare began a program in October, 1957, which is the largest in size and, for children, the widest in scope o f any public assistance dental plan now in operation. T h e department earmarked $2,225,000 o f state funds which are being matched by the same amount o f federal funds under the 1956 amendments to the Social Security Act. Most o f the funds were to be spent fo r the complete dental care o f 77,000 children aged 5 through 12 years in the California program, “ A id to Needy Children,” (federal category, A id to Dependent C h ild ren ). Recipients in all other categories and outside this age group receive only acute and emergent care. In California, public assistance is ad ministered by counties under state super vision. Thirty-eight counties elected to purchase dental services under the pro gram through the California Dental Asso ciation Service, a corporation sponsored by the California State Dental Associa tion. O ther counties elected to handle the administration themselves and contracted directly with local dentists. Because o f the short time which elapsed between the legislative authorization and the time set for the program to go into actual opera tion, the California Dental Association Service decided to subcontract the physi cal accounting operations. T h e subcon tractor is the California Physicians Serv ice, which has been operating for many years and has the necessary mechanical equipment for a program of this scale. W hether services are handled through the California Dental Association Service or individually by counties, the dentists are recompensed on a “ fee-for-service”