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2009 House acts on risk assessment

Honolulu—The dental benefits industry is discussing adding its assessment of the risk of disease in beneficiaries as a part of benefits determination. In anticipation of that possibility, the Council on Dental Benefit Programs' Office of Quality Assessment and Improvement, in consultation with other Association agencies, recommended the establishment by the ADA of risk assessment principles when risk assessment is used in dental benefit plans.

"The important factor that drives these principles is the need to maintain the integrity of the patient-dentist relationship," said Dr. Albert Guay, ADA chief policy advisor. "Other parties, especially those that have only financial interests, should not interfere with that relationship."

In Resolution 14 H-2009, the House approved principles for the Application of Risk Assessments in Dental Benefit Plans, which read as follows:

(1) The assessment of the risk for the development of oral diseases, the progress of existing disease or the adverse outcomes of treatment of oral disease for an individual patient is a professional matter that is the sole responsibility of the attending dentist.

(2) Individual risk assessment is an important consideration in developing a complete diagnosis and treatment recommendations for each patient, the complexity of which is determined by the oral health status, goals and desires of the individual patient. The assessment should be scientifically based, clinically relevant and continually refined through outcomes studies.

(3) There should be no interference by outside parties in the patient-doctor relationship by injecting factors unrelated to the patient's needs in any aspect of the diagnosis of the patient's oral health status or the attending dentist's treatment recommendations.

(4) Risk assessments should not limit access to care for patients, including individuals who require extraordinary levels or type of care, nor provide a disincentive for practitioners to treat complex or difficult cases because of concern about performance ratings. There should be a system of risk adjustments for difficult or complex cases.

(5) Risk assessments should be conducted periodically on a schedule determined by the attending dentist based upon the needs and medical status of the individual patient, since risk can change over time due to application of preventive measures, changes in science, the effects of therapy and changes in patient behaviors.

(6) Self-administered patient questionnaires provided by third-party payers used for risk assessment purposes should contain the admonition that they are not to be considered as a substitute for a clinical evaluation performed by a dentist.

(7) Risk assessment for communities or groups within a community is a science separate from individual patient risk assessment, one that requires different skills and techniques than those used in the assessment of individual patients.

(8) When a disease is present in a community and its prevalence is low because of the effectiveness of preventive efforts, third-party payers should continue those preventive services as benefits of a dental plan.