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Delta Dental plan for employees limits cleanings for healthy adults to one per year

March 03, 2014

Kelly Soderlund, ADA News staff

Delta Dental unveiled a new risk-based dental insurance plan Jan. 1 for its employees in Michigan, Indiana and Ohio that reduces the number of cleanings each year for healthy adults.

Patients who complete an online risk assesment survey and document certain risk factors—diabetes, history of stroke or heart attack, renal failure/dialysis, a suppressed immune system, radiation treatments for head or neck because of cancer or pregnancy—are eligible to receive one additional cleaning up to a maximum of four in a year's time. People with a history of periodontal disease can receive three additional cleanings, up to a maximum of four per year.

All others who do not meet the conditions are limited to one cleaning per year. Participants in the plan, called RightSize Dental, will continue to be covered for two oral exams each year.

"The plan does not include several known risk factors that would possibly warrant additional cleaning benefits, especially smoking," said Dr. Andrew Vorrasi, chair of the ADA Council on Dental Benefit Programs.

The American Academy of Periodontology provides a list of known risk factors for periodontal disease at perio.org/consumer/risk-factors. Risk factors include age, smoking/tobacco use, genetics, stress, medication, clenching/grinding, systemic conditions, poor nutrition and obesity.

Both the AAP and a University of Michigan study cited by Delta, in a letter to its network dentists announcing this new design, recognize smoking as a risk factor for periodontal disease. According to the letter, Delta excluded smoking as a risk factor because it did not want to reward employees for "bad behaviors." Delta employees who smoke will not be eligible for the additional cleaning unless they develop the disease, the letter said.

"To say this argument is specious is not really strong enough," said Dr. Dave Preble, vice president of the ADA Practice Institute. "Does Delta really believe that including smoking as a risk factor would result in patients smoking just to get an additional prophy?"

"The ADA believes that risk-based plans, if designed properly, could be beneficial for plan purchasers," said Dr. Vorrasi, "However, there are concerns with the RightSize Dental plan. It is not clear how the decrease in prophylaxis coverage will affect plan participants in the future. Dentists should inform their patients that when planning treatment, dental benefits should not be the only consideration. You and your patient should determine the appropriate treatment."

In addition to the online risk assessment, the plan, which is available to adults 18 and older, incorporates a genetic test that assesses patients' risk for developing periodontitis. Patients who test positive for specific genetic markers identified by a cheek swab test for the Interleukin-1 gene are eligible for one additional cleaning up to a maximum of four per year, according to Delta.

Delta employees are under no obligation to complete the online risk assessment survey or to take the genetic periodontitis test. In addition, dentists are not required to administer the cheek swab test for the Interleukin-1 gene, but the eligibility for expanded benefits is dependent on these results.

Dr. Jed Jacobson, chief science officer and senior vice president for Delta Dental of Michigan, Ohio and Indiana, said the genetic test should not be confused with a diagnostic test.

"We're not trying to force a diagnosis," said Dr. Jacobson, who estimates that 400 Delta employees and their dependents are affected by this new plan. "We're trying to equip the dentist and the patients with some knowledge of their patients risk for periodontitis."

Dr. Vorrasi countered by saying, "If Delta honestly wanted to assess risk of periodontal disease, why would they exclude the most recognized factors in favor of a genetic test that is unproven?"

Patients who decide to opt out of taking the genetic test will receive only one cleaning per year, unless they document other risk factors, Dr. Jacobson said. Depending on the reception in the marketplace, the plan may extend beyond just Delta employees.

Because the majority of Delta employees reside in Michigan, the Michigan Dental Association is developing resources to help members be better prepared to communicate with patients.

"Although your patients may be tempted to make decisions about their dental care based on what insurance will cover, remember that your patient's health is the most important thing," Dr. Vorrasi said.

The ADA believes that personalized oral care is a necessity for good dental health, according to a 2013 ADA statement on regular dental visits. The ADA encourages people to work closely with their dentists to identify any potential risk factors that would determine the need for and frequency of follow up visits to enhance the outcomes of preventive care.