February 17, 1999

To:Board of Health

From:Dr. Sheela Basrur, Medical Officer of Health

Subject:Options For The Delivery Of Public Health Dental Treatment Programs

Purpose:

This report provides a comparison of the costs and benefits of using community based clinics and/or a fee for service model for the delivery of Public Health Dental Treatment Programs.

Source of Funds:

Funding to be determined through the budget process.

Recommendations:

It is recommended that:

(1)that the Board of Health uses the results of the analysis of the cost effectiveness of different service delivery options to ensure that whatever service delivery option is chosen for the provision of dental services, the cost of that option is comparable to or less than the direct service delivery model, and the level and quality of care is the same or higher than the direct service delivery model.

(2)That this report be forwarded to Budget Committee for consideration.

Background:

At the Board of Health meeting of January 25, 1999, the Public Health Division was requested to report on a comparative analysis of the costs and benefits of using a community based clinic model vs. a fee-for-service model for the delivery of Public Health Dental Treatment Services. In addition the Medical Officer of Health was requested to explore other potential sites through co-operation with universities, colleges, technical schools, community health centers, hospitals and other health units, so that geographic access to dental services across the new City of Toronto would be optimized.

Comments:

Work Group Information

A project team consisting of an external consultant and staff from Public Health and Social Services were responsible for doing the research and analyses of the options available to the City for the delivery of dental services.

Detailed information on possible options for the provision of clinical dental services was obtained using a structured survey of the dental care delivery models currently operating in the province. In addition there was a search of the scientific and professional literature for examples of other dental care delivery models that might be considered. This research identified twelve examples or potential models of dental care that might operate in the province, and information was further collected on five of the main models, as outlined below. The methodology and the findings of the analysis were subjected to an external review by a health economist, a member of the Institute of Clinical Evaluative Studies and a consultant in health program evaluation, to ensure the approach and interpretations were valid.

Models

Direct Service Provision

This is the model used by the four former municipalities (North York, York, Etobicoke and Toronto) with treatment programs. Staff are hired to work in municipally owned or leased facilities and are accountable, usually in a line relationship to program Managers or Directors.

Clients' choice of service provider is limited to those staff employed by the municipality or agency. This model of service delivery is used by the Ottawa-Carleton Health Unit, The Children's Aid Society and Community Health Centers.

Children in Need of Treatment Model

This is a provincially mandated program model which builds on the existing infrastructure of Public Health screening programs in schools and service delivery by private practitioners and salaried dentists working in municipally funded dental programs.

Families with children who have dental needs consistent with the CINOT Program eligibility criteria i.e. large, open visible lesion on a tooth, pain and/or infection and whose families declare financial hardship, are issued a dental claim form, which allows them to take the child to the dentist of choice. The dentist bills Public Health, whose staff review the claims to ensure compliance with program requirements, and authorize payment to the dentists. Some services require predetermination and post treatment evaluation prior to reimbursement of the dentist for the services rendered.

It is also a requirement that program managers audit a minimum of 10% of the children receiving care to ensure that all needs were treated, and that the services claimed were actually provided.

Since its implementation in 1987, this program has consistently remained within its allocated budget across the province.

Service Contract for Identified Groups

Currently this model does not exist in its pure form in Canada. A variation of this model of care is used by the Hotel and Restaurant Employees Union.

In this model, the agency/municipality would develop a contract which defines the terms, conditions and method of remuneration for providing dental care for a defined group of individuals. Service providers would be invited to bid on the contract. The contract would be awarded on the basis of defined criteria. It would then be the responsibility of the agency/municipality (the health division) to ensure that the terms and conditions of the contract are met.

There is no support for this model of care from the organized profession. It is noteworthy that the organized profession actively discourages its members from participating in these kinds of contractual arrangements, as it is felt that this model of care is not in the best interest of the patient or service provider.

Insured Service Program

In this model, private dentists provide care on a fee for service basis in independently owned and operated facilities. The clients have the choice of service provider and may change provider at any time during the course of treatment. This could increase the cost of providing care.

The private dentist provides dental care, then bills the dental plan and is reimbursed by an administrator for the treatment provided on a fee-for-service basis from a defined schedule of benefits. Only those services itemized in the schedule of benefits are paid for by the plan administrator.

There is a wide variability in the services covered by different dental plans. In addition some plans provide partial payments for services. It is then the clients responsibility to pay for the rest of the cost of those services provided. Most plans use the Ontario Dental Association suggested fee guide as a basis for payment.

This is the model that is supported by the organized dental profession as it allows autonomy of independent dental practitioners and has the potential for maximizing profit.

Part-time Rental of Dental Office and Staff

This model was suggested in the 1998 Budget Review Process. The municipality would enter into a contractual agreement to rent a dental practice for specific periods (blocks) of time. Children or other groups in need of care would be referred to the identified dental practice to receive dental services during those specific time periods only. Estimates of daily costs to rent a practice are: $1,000 - $1,500. This includes rent for the office space, supplies and staff clinical time.

Evaluation of Models

The different models for dental service delivery were evaluated using a five-point scale relative to the following criteria: client factors, management factors, economic factors, program quality factors.

Table 1 shows the results of the evaluation. The insured service model scores lowest, primarily because of its low management and program quality factors. The service contract model was rated higher than the office "rental" model primarily because it would need less day to day management. The advantage of the CINOT model lies in its ability to offer choice of provider and its low start up costs.

The Direct Service Model ranks highest primarily due to its manageability and program quality factors. Its main disadvantage is the high front end capital costs to establish new clinics. However these capital costs are low relative to operative costs even if amortized over a relatively short time period. Its main disadvantage is that eligible residents would have fewer sites to access dental services.

The advantage of the CINOT model are its gatekeeper approach to accessing care and flexibility for clients to choose their care provider. The main disadvantage is its relatively higher cost, as compared with direct service or insurance/indemnity. In the former City of Toronto, and to a lesser extent in North York, most parents of CINOT eligible children choose to receive care in City-owned clinics. This is also the current model being used for the Ontario Works (OW) dental program for dependent children 0-17 years.

The service contract model, if selected, could allow for the rapid implementation of a treatment program in areas not currently serviced. However, there is very little practical experience with this model in Canada with regard to utilization, cost and service quality. Also, there is little professional support for this model of service delivery.

The insurance/indemnity model of dental care builds on the existing private practice structure. However, the model is relatively open-ended and has the potential for inappropriate utilization by client and service providers. In particular the model is weak in such areas as controlling service volumes, the ability to determine relative need among clients and in the appropriateness of types and levels of services provided.

Relative Cost

The relative cost of providing dental services under the different service delivery options was also analyzed where data was available. The analysis is shown in Appendix 1. The unit used for comparison is the Relative Value Unit or R.V.U. This is a simple formula developed by the Ontario Dental Association (ODA) that permits calculation of the relative values of different services. The ODA assigns a relative time factor to complete each dental service. Services are then classified into groups, and a responsibility factor assigned to each group. The product of these two factors time and responsibility gives a relative value for each service. For example a simple filling on the chewing surface of a premolar tooth has a R.V.U. of 1 but a complicated crown on a molar tooth has a R.V.U. of 14. Using the ODA fee guide, the average cost of 1 R.V.U. is $29.65. This amount is the basis of comparison. Where known, services provided in a particular model were converted to R.V.U.'s and the cost per R.V.U. calculated using the total cost of the program.

As seen in Appendix 1 the cost of 1 R.V.U. is $15.42 in the direct service delivery model.

The cost of 1 R.V.U. is $19.47 in the insurance indeminity model used by Social Services for the delivery of their adult emergency dental program. The cost of 1 R.V.U. using the CINOT/OW model is $22.16.

Potential Sites and Partnerships

Staff have also done a preliminary exploration of potential sites and partnerships with universities, colleges, technical schools, community health centres and hospitals and other health units to optimize access to dental services across the new City of Toronto.

In the former City of Scarborough, the three major hospitals were contacted. None of them provide dental care. One chronic care and rehabilitation hospital has a dental clinic that is available to in-patients only and they do not accept any other patients. There are no teaching institutions in Scarborough with dental programs with which the municipality could partner for the provision of dental care.

In the former City of Etobicoke, the Etobicoke General Hospital was contacted. The Hospital is currently going through transition in co-operation with other hospitals. However, they are interested in pursuing the idea of the municipality leasing space to provide dental services.

The Lamp Community Health Centre was also contacted. Staff at the community health centre indicated that they could do changes to their existing facility to make available adequate space to lease to the municipality. Staff at the Rexdale Community Health Centre identified the surrounding community as a high need area for dental care and have indicated a willingness to accommodate the municipality's need.

The property manager for the Toronto Board of Education, for the former North York area was also contacted. He was receptive to the idea of having community clinics located in schools and felt that there was a real possibility that the Board may be able to provide suitable space that met the requirements of the municipality. However, the Board of Education was in the process of deciding which schools will be closing and where accessible space will be located. These decisions may be delayed for up to one year. If a formal request is made to the Board, it was the opinion of the property manager, that the request would be considered in the context of school closures. There are no teaching institutions in North York with dental programs/facilities that could provide dental services through a partnership with the municipality.

In the former City of Toronto, some hospitals have dental clinics. Staff held discussions with one of the staff dentists at one of the major hospitals. This dentist chairs a committee which is researching the relationship of hospital restructuring on hospital services, in particular hospital dental care, as well as access to dental care by the homeless, the working poor and seniors. This dentist presented a number of issues that would have to be dealt with for hospital dental clinics to become involved with providing care for a non-hospital based group of patients. In the opinion of this dentist, dental care in hospitals is expensive and could be provided in a more cost-effective way in the community.

Most of the hospitals with dental treatment facilities are in the former City of Toronto. This is the area of the new City that is already serviced by nine community based, municipally funded clinics.

From the foregoing, it is apparent that in areas of the new City where there are vulnerable groups (e.g. children, adolescents, high-risk mothers and seniors), who do not have access to dental services due to financial hardship there are no hospitals, community health centres or teaching institutions that currently have the facility and/or capacity to treat these client groups. There is a potential to develop partnership arrangements with Community Health Centres in south Etobicoke and Rexdale, which would increase access and continuity of dental care for individuals seeking other primary health care services in these Community Health Centres.

Conclusions:

Based on the analysis of cost, effectiveness and different service delivery options, it is apparent that the direct service delivery option is the most cost-effective, flexible, quality assured mode of care delivery. One must take into account the front end capital costs to establish new clinics. If clinics are located in municipally owned buildings, then these costs can be minimized. In addition, if the City harmonizes dental services over a period of time, then the financial impact could be spread over a number of years.

It is recommended that the Board of Health uses the results of the analysis of the cost effectiveness of different service delivery options to ensure that whatever service delivery option is chosen for the provision of dental services, the cost of that option is comparable to or less than the direct service delivery model and the level and quality of care is the same or higher than the direct service delivery model.

Contact Name:

Dr. Hazel Stewart, Regional Director, Toronto Public Health

Tel: (416) 392-0442

Fax: (416) 392-0713

Dr. Sheela V. Basrur

Medical Officer of Health

Table 1:Evaluation of Models

Scoring system0 =does not meet the criteria at all

1 =meets very little of the criteria

2 =meets some parts of the criteria

3 =meets the criteria fairly well

4 =meets the criteria strongly

Appendix 1:Description of Alternative Service Delivery Models

1. Direct Service

This is the current model used by some of the former municipalities for the provision of dental and oral health services. Staff are hired to work in municipally-owned facilities and are accountable in a line relationship to managers/directors.

Rate of utilization - approximately 40 per cent of eligible persons

Cost per RVU* - Best practice - $15.42 (1997)

(Services - exam, x-rays, fillings, extractions, root canal, dentures cleaning)

2. Insurance/Indemnity

This model is used by Social Services for the delivery of their adult emergency dental program. Treatment facilities owned and operated by private practice dentists are the site of care for clients who elect to utilize services. The dentists bill the plan administrator for the treatment provided.

Rate of utilization - approximately 20 per cent of eligible persons

Cost per RVU* - $19.47 (1997)

(Services - relief of pain and infection - may include extractions, fillings, x-rays, exam)

3. Service Contracts

Currently there is very limited experience with this model in Canada, but it is based on the preferred-provider relationship with selected private sector clinics which is a common model of service delivery in the U.S. It could also involve contracting for specific types and levels of service with community health centres, out-patient clinics of hospitals, or with private practitioners. Under this model, the municipality would tender for the care of groups of individuals (e.g. 10,000 low-income children living in a defined area of the city), and invite dentists or agencies such as community health centres, to bid on the provision of care. Contracts with successful candidates would be developed to include terms such as accessibility standards, language facility, services, waiting times for regular and emergency appointments, and other performance criteria. Toronto Public Health Department would be the purchaser and conduct quality assurance monitoring of the services.

Rate of utilization} Not established; targets would be set through

Cost per RVU*} public tendering process.

4. OW/CINOT

This model uses both private practice dentists and publicly-owned dental clinics as the delivery sites. Provision of service involves preauthorization and predetermination of services to be provided to individual clients. Dentists provide the services and bill Toronto Public Health Department according to a provincially-defined schedule of benefits. Toronto Public Health staff review claims and authorize payment to the dentists. Approximately 10 per cent of cases are audited to ensure that all needs were treated and the services claimed were provided.

While there are differences in the eligibility criteria and list of services covered between OW and CINOT, the management of both programs is the same. It builds on the existing infrastructure of programming since children can gain access to the services by having needs identified at a screening in the schools or at a nearby clinic.

Rate of utilization - approximately 50 percent of eligible persons (CINOT only, 1997)

Cost per RVU* - $22.16 (CINOT, 1997)

Cost per RVU* - $22.95 (OW, 1998)

(Services - exams, x-rays, fillings, extractions, dentures, cleanings, root canal)

* The Ontario Dental Association (ODA) assigns relative time and degree of difficulty requirements for each procedure. The product of these two factors (i.e. time and difficulty) is the relative value unit (RVU). For example, a simple filling on a premolor tooth has an RVU of 1 but a complicated crown on a posterior molar has an RVU of 14. Using the ODA fee schedule, the average cost of RVU is $29.65. This amount is the basis for comparison.