Dental care in federally qualified HMOs. Council on Dental Care Programs.

A S S O C IA T IO N

REPORTS

D ental care in fe d e ra lly q u a lifie d H M O s C o u n c il o n D e n t a l C a r e P r o g r a m s The Council on Dental Care Programs has conducted a series of surveys of alter native delivery systems and benefit plan designs. In 1978-1979, the Council’s ac tivities in this regard centered on the role of federally qualified health mainte nance organizations in the delivery of dental care. In the course of this survey, the Council also collected information on the extent of government subsidiza tion of these organizations. Following are two special reports, detailing the re sults of these activities.

SPECIAL REPORT 1 OF THE COUNCIL ON DENTAL CARE PROGRAMS FEDERAL SUBSIDIES AWARDED TO HEALTH MAINTENANCE ORGANIZATIONS (HMOs) AS OF SEPTEMBER 30, 1978 During recent years, the federal government has de veloped increased interest in health maintenance or ganizations (HMOs) as a means of reducing or control ling health care c o s t s . The health maintenance organization concept has been defined as an organized system of health care that accepts the responsibility to provide or otherwise en sure the delivery of an agreed upon set of comprehen sive health maintenance and treatment services for a voluntarily enrolled group of persons in a geographic area and is reimbursed through a prenegotiated and fixed periodic payment made by or on behalf of each person or family unit enrolled in the plan. Dental care services are not presently included as one of the basic services required for an HMO to becom e federally qualified but may be offered as a supplemental benefit. The involvem ent of federally qualified HMOs in providing dental care services is detailed in Special Report 2 of the Council on Dental Care Programs (see page 680). While the American Dental Association does not op pose the concept of HMOs ( T r a n s . 1 9 7 1 : 501) it does maintain that HMOs or any one health care delivery system should not receive preferential treatment under the law. The 1978 House of Delegates defined preferen tial treatment as the awarding to HMOs of government subsidies not available to other delivery systems. As the continued developm ent of HMOs may have an impor tant impact on the delivery of dental care in the future, the 1978 ADA House of D elegates adopted the follow ing Resolution 127H ( T r a n s . 1 9 7 8 : 530):

672 ■ JADA, Vol. 99, October 1979

Resolved, that the ADA oppose government sub sid ies which give unfair advantage to selected health care delivery systems, such as HMOs, and be it further Resolved, that appropriate agencies of the Associa tion, in cooperation with constituent so cieties, gather, coordinate and dissem inate information relative to this subject to the appropriate leadership at the national and state levels. As an initial step, Council staff visited the Office of Health Maintenance Organizations, U.S. Department of Health, Education, and Welfare, to discuss and collect information detailing federal grants and loans awarded to HMOs. Additionally, in states where federally qual ified HMOs existed, the constituent dental societies were requested to provide data on state and local gov ernment subsidies awarded to the HMOs within their respective states. Based upon responses received from the constituent societies surveyed, there appears to be no significant state or local government subsidies, in the form of grants or loans, being awarded to HMOs. This report, therefore, will focus on federal govern ment subsidies available and awarded to HMOs and HMO prototypes since the passage of the original HMO Act, Decem ber 29, 1973, through September 30, 1978. This latter date corresponds to the federal government’s 1978 fiscal year reporting cycle and includes the latest statistics available at the time of this report. Although federal financial support is not specifically available for the developm ent or provision of dental services within

ASSO CIATION

HMOs, federal funds designated for the medical portion of the HMO may be used for planning dental services as a supplemental benefit. Prior to the passage of the Health Maintenance Act of 1973, Public Law 93-222, there were 89 HMO pro totypes in existence. According to T h e F o u r t h A n n u a l R e p o r t

t o

t h e

C o n g r e s s

o n

H

e a l t h

M

a i n t e n a n c e

O r g a n i

there w ere 203 prepaid health care plans (which includes the 69 federally qualified HMOs) in 36 states and the District of Columbia serving approxi mately 7.5 m illion Americans as of September 1978. A prepaid health care plan is defined as an entity that pro vides com prehensive health care services including, at a minimum, inpatient and ambulatory benefits to a volun tarily enrolled population on a prepaid capitated basis.

z a t i o n s ,

Highlights of the 1973 HMO Act and 1976 and 1978 Amend ments: From as early as 1929, prepaid medical treat ment, including services of specialists and, w hen neces sary, hospitalization, has been offered to select groups as an alternative to traditional health insurance plans. In 1971, the federal government began providing funds to stimulate and encourage the developm ent o f health maintenance organizations as an alternative to the tradi tional, fee-for-service system of medical delivery. The Health Maintenance Organization Act of 1973 es tablished guidelines for the initiation and developm ent of HMOs, provided funds for grants, loans and loan guarantees, developed enrollment guidelines, and spec ified basic health care services necessary to becom e federally qualified. As one of its basic health services, this Act as defined by federal regulations required pre ventive dental care services for children through age 11 and included oral prophylaxis, as necessary; topical ap plication of fluorides, as necessary; and prescription of systemic fluorides, as necessary. In an effort to further encourage HMO developm ent, the HMO Amendments of 1976 elim inated or modified certain basic service requirements and enrollment pro visions v ie w e d by som e as hindering the national growth of HMOs. The mandated preventive dental serv ices for children through age 11 were removed from the list of required basic health services. Instead, the offer ing of dental benefits became optional at the discretion of each HMO. The HMO Amendments of 1978 increased the amount of grant and loan awards, provided additional technical assistance to new and existing HMOs, and authorized a formal management program for the specific purpose of training current and potential administrators and medi cal directors for HMOs. Federal Qualification: Federal qualification is granted to an HMO which provides comprehensive basic health services to all its subscribers. These basic health care services must include: Physician Services Outpatient Services and Inpatient Hospital Serv ices

REPORTS

M edically Necessary Emergency Health Services Short-term Mental Health Services Medical Treatment and Referral Services for Abuse or Addiction to Alcohol and Drugs D ia g n o stic Laboratory and D ia g n o stic and Therapeutic Radiologic Services Home Health Services Preventive Health Services and shall be provided to the plan members without limit as to time, cost or health status. In addition, supplem en tal health services, including dentistry, may be offered on an optional basis for which the HMO may request additional payment. All federally qualified HMOs are required by regulation to submit periodic reports to the Office of Health Maintenance Organizations, Depart ment of Health, Education, and Welfare on their mem bership, utilization of services and financial condition. Becoming a federally qualified HMO has its advan tages. From a marketing standpoint, the HMO can profit from the dual choice option clause of the 1973 HMO Act. T his requires em p loyers w ith 25 or more em ployees within the HMO’s service area upon an HMO’s request to offer the option of HMO membership if the employer currently offers traditional health insur ance. This creates an almost instant market for HMO services. Also, once an HMO becom es federally qual ified, it may apply for a federal loan or loan guarantee, as w ill be detailed later in this report. As of September 30, 1978 there were 69 federally qualified HMOs operating in 27 states and the District of Columbia and covering approximately 4.7 million Americans. Exhibit I details total grants and loans award ed to these qualified HMOs. Grant Program: The grant program, available to public and nonprofit organizations, addresses itself to three stages o f HMO initiation and/or expansion: 1. F e a s i b i l i t y g r a n t s are provided to determine through surveys or canvasses whether an HMO could econom ically operate in a given geographical area. The 1973 HMO Act provided up to $50,000 for a period not to exceed 12 months for this activity. The 1976 Amendments increased this amount to $75,000. 2. P l a n n i n g g r a n t s are awarded once feasibility has been demonstrated. The 1973 HMO Act pro vided up to $125,000 for a period not to exceed 12 months for use in market analysis and preparing for initial development. This Act was amended in 1976 to provide up to $200,000 for such planning ac tivities. 3. I n i t i a l d e v e l o p m e n t g r a n t s are awarded for up to $1 m illion for a period not to exceed three years to cover administrative and organizational costs, re cruiting p erso n n el, launching m arketing cam paigns, purchasing equipm ent, and develop in g quality assurance programs. The major exception relates to individual practice associations (IPAs) and excludes expenses associated with recruitment

JAOA, Vol. 99, October 1979 ■ 673

A SSO CIATIO N

REPORTS

of personnel and equipm ent purchases. The 1978 Amendments raise this maximum to $2 million ef fective October 1, 1979. For-profit organizations are not eligib le for grants but are eligible under certain conditions to apply for loan guarantees for planning and initial developm ent ac tivities (see next section). The distinction betw een forprofit versus public or nonprofit HMOs is primarily one relating to the distribution of and taxation on profits realized. Profits represent the difference betw een total incom e and total costs. Shareholders usually invest in for-profit HMOs to share in expected profits through the payment of dividends or accumulated retained earnings. Since the passage of the HMO Act, Decem ber 29, 1973, through September 3 0 ,1 9 7 8 ,3 9 0 grants have been aw arded to 227 organizations for a total valu e of $74,558,790. T hese grants were awarded for developing and expanding HMOs through feasibility studies (190), planning activities (100), and initial developm ent ac tivities (100). Exhibit II summarizes the maximum federal grant dollars available to eligible applicants through the 1973 HMO Act and its 1976 and 1978 Amendments. Exhibit III summarizes federal grants awarded to HMOs by type of grant, fiscal year, number of awards and total dollars. Loan and Loan Guarantee Program: The loan program, like that of the grant program, was initially created by the 1973 HMO Act. It allows public and nonprofit federally qualified HMOs to apply for loans to help cover (1) defi cits incurred during the first five years o f operation and (2) operating deficits attributable to the expansion of an HMO during the first five years follow ing significant ex pansion of membership or service area. The Act pro vides up to $2.5 million to an HMO for such expenses with a maximum in any 12-month period of $1 million. On October 1, 1979, these limits increase to $4 million and $2 m illion, respectively, as a result of the 1978 Amendments. For-profit, federally qualified HMOs serving m edi cally underserved populations are eligible for guaran tees of loans from non-federal lenders on the same terms as public and nonprofit federally qualified HMOs. Addi tionally, nonprofit and for-profit entities are eligible for loan guarantees for planning activities relating to HMO establishm ent or expansion and for initial developm ent activities. The Act allows for support up.to $200,000 for planning activities and $1 m illion for initial develop m ent until October 1, 1979 and $2 m illion thereafter. As of September 30, 1978, six of the 69 federally qual ified HMOs were organized as for-profit. To date, none of these for-profit HMOs have received federal grant fu n d s. H o w ev er, tw o loan gu aran tees totalin g $2,282,000 have been awarded (refer to Exhibit I for details). These federally qualified, for-profit HMOs in clude: (1) ABC-HM O, Inc., P hoen ix, Arizona; (2) Arizona Health Plan, Inc., Phoenix, Arizona; (3) Califor nia Medical Group Health Plan, Los A ngeles, Califor


nia; (4) American Health Plan, North Miami Beach, Florida; (5) Av-Med Health Plan, Inc., Miami, Florida; and (6) Prudential Health Care, Inc., Houston, Texas. Loans and loan guarantees for the purpose of acquir ing and constructing ambulatory health care facilities and purchasing related equipm ent is a new section of the HMO Act established by the 1978 amendments. The amount of these loans may not exceed $2.5 million per facility. This provision is expected to alleviate some major capital financing problems of the past. Repayment of loans and guaranteed loans must occur within 22 years from the making of the loan; however, principal payments are deferred during the five-year eligibility period. The interest rate for direct loans by the federal government is determined by the current U.S. Treasury borrowing rate at the time of the loan. The interest rate for guaranteed loans is negotiated betw een the HMO and the lender; however, the interest rate may not exceed a ceiling im posed by DHEW based on the Federal National Mortgage Association average auction yield rate on four-month certificates. Interest rates may be two or three percentage points lower than the pre vailing market rate. During fiscal year 1977, this interest rate fell in the 7.25-9.21% range. In the event of default on a loan or loan guarantee, the Secretary of the Department of Health, Education, and Welfare is authorized to take whatever action he deems appropriate to protect the interest of the taxpayers, in cluding taking possession of, holding and using real property pledged as security for the loan or loan guaran tee. To date, one loan default of $2.5 million has oc curred. Presently, 53 HMOs have received loan assistance, totaling $96,041,000, under the auspices of the HMO Act. Of this figure, 50 HMOs received loan commit ments totaling $92,546,000, while three HMOs were awarded loan guarantees for a total of $3,495,000. Dur ing the 1978 fiscal year, 18 loans were awarded for $31,100,000 and two loan guarantees for $2,313,000. Five of the 1978 loans for $4,267,000 were to organizations which had previously received loan funds. Exhibit IV summarizes the maximum amount of loans and loan guarantees available through the 1973 HMO Act and its 1976 and 1978 Amendments. Exhibit V de tails the number and amount of loans and loan guaran tees awarded by fiscal year. Summary: The HMO Act of 1973 formally committed the federal government to encouraging the initiation, de velopm ent and expansion of health maintenance organi zations by providing grants, loans, technical assistance and promotional support. With various legislation having passed in Congress, the Administration has targeted its hopes for health care reforms in a push to persuade business and labor that it is in their best interest to sponsor or at least support HMOs. Joseph A. Califano, Jr.,-HEW secretary, recently stated, “We intend to help make it possible for every American citizen to have the option of joining a health maintenance organization.” With this goal in mind, fur-

j

ASSO CIATION

ther emphasis was made by Howard R. Veit, director of the Office of Health M aintenance Organizations, in another statement: “The federal government is mount ing a major promotional campaign to establish HMOs in every major urban center. T he federal governm ent would like to see at least 10% o f the population enrolled in HMOs by the late 1980's.” Federal grants and loans are not specifically available for the developm ent of dental services within HMOs. However, federal funds designated for the medical por tion of the HMO may be used for planning dental serv ices as a supplemental benefit. The Carter Administration is strongly behind HMO developm ent as reflected in its recent request to Con-

REPORTS

gress calling for a major expansion in HMO funding to $74 million for fiscal year 1980. Subsequent Congres sional action authorized spending levels of $65 million for fiscal year 1980 and $68 million for 1981. Of the 69 federal qualified HMOs by September 30, 1978, 56 have obtained federal grants and/or loans total ing in excess of $134 million. Since the original 1973 HMO Act, 390 grants have been awarded to 227 prepaid health care plans for a total value of $74,558,790. Fourteen percent of these funds were awarded for feasibility studies, 18% for planning and 68% for initial developm ent grants. Fifty-three HMOs have received loan assistance totaling in excess of $96 million.

EXHIBIT I Total Federal Grants and Loans Awarded to F ed era lly Q u a lifie d HMOs as of September 30, 1978 Location

Name of HMO

T otal Loans

T otal Grants and Loans

$ 0

$ 0

$ 0

0

0

0

T otal Grants*

A rizona, Phoenix

ABC-HMO, Inc.

A rizona, Phoenix

Arizona H ealth Plan, Inc.

C a lifo r n ia , Hawthorne

Maxi-Care

C a lifo r n ia , Long Beach

Family H ealth Program

0

0

0

C a lifo r n ia , Los Angeles

C a lifo r n ia Medical Group H ealth Plan

0

0

0

C a lifo r n ia , Los Angeles

South Los A ngeles Community H ealth Plan

C a lifo r n ia , Oakland

0

0

C a lifo r n ia , Oakland

K aiser Foundation H ealth P la n , In c . Rockridge H ealth Care Plan

0

2 ,5 0 0 ,0 0 0

2 ,5 0 0 ,0 0 0

C a lifo r n ia , Orange

HMO C oncepts, Inc.

0

437,000

437,000

C a lifo r n ia , Pomona

Family H ealth S e r v ic e s , In c.

0

2 ,5 0 0 ,0 0 0

2 ,5 0 0 ,0 0 0

C a lifo r n ia , Sacramento

Foundation Health P lan, In c.

INDV-710,215

2 , 292,000

3,0 0 2 ,2 1 5

C a lifo r n ia , Santa Clara

H ealth A llia n c e of Northern C a lifo r n ia

PLAN-120, 486 INDV-601,738

2 ,3 4 2 ,0 0 0

3,0 6 4 ,2 2 4

C a lifo r n ia , San Luis Obispo

Los Padres Group Health

PLAN-125,000 INDV-598,508

PLAN-169, 592

PLAN-113,082 INDV-563,670

0

2 ,1 0 0 ,0 0 0

0

169,592

2 ,7 7 6 ,7 5 2 0

723,508

in c lu d e s t o t a l amount awarded whether for i n i t i a l and/or expansion purposes. Types of grants in clu d e: F E A S -F easib ility Grant PLAN-Planning Grant IN D V -Initial Development Grant

JADA, Vol. 99, October 1979 ■ 675

ASSO CIATION

REPORTS

Name of HMO

Total Grants

T otal Loans


Colorado, Denver

CompreCare, Inc.

FEAS-19,522 INDV-699,096

$ 1 ,4 1 3 ,0 0 0

$ 2,1 3 1 ,6 1 8

Colorado, Denver

K aiser Foundation Health Plan of Colorado, Inc.

0

0

Colorado, Fort C o llin s

ChoiceCare H ealth S e r v ic e s

FEAS-22,340 PLAN-68, 521 INDV-2 58,497

728,000

1 ,0 7 7 ,3 5 8

Colorado, Grand Junction

Rocky Mountain HMO

FEAS-14,7 06 INDV-192,937

332,000

539,643

C o n n ecticu t, Bridgeport

C onnecticut H ealth Plan

FEAS-7 5,000 PLAN-103,492 INDV-9 6 7 , 550 INDV-362 ,461

2,5 0 0 ,0 0 0

3 ,6 4 6 ,0 4 2

2,0 9 0 ,0 0 0

2,4 5 2 ,4 6 1

1 ,9 8 2 ,0 0 0

2,8 6 6 ,2 2 1

L ocation

C on n ecticu t, New Haven Community H ealth Care Center Plan, In c.

0

D is t r i c t of Columbia

Georgetown U n iv e r sity ' Community H ealth P lan, Inc.

INDV-884,221

D is t r i c t of Columbia

Group Health A s s o c ia tio n , Inc.

FEAS-50,000

F lo r id a , Clearwater

Prepaid H ealth Care, Inc.

FEAS-80,128 PLAN-123, 758 INDV-1,0 00,000

2,50 0 ,0 0 0

3 ,7 0 3 ,8 8 6

INDV-124,4 56

2,50 0 ,0 0 0

2,62 4 ,4 5 6

F lo r id a , Daytona Beach F lo rid a Health Care P lan, Inc.

0

50,000

F lo r id a , Miami

Av-Med H ealth P lan, Inc.

0

1,1 0 0 ,0 0 0

1 ,1 0 0 ,0 0 0

F lo r id a , North Miami Beach

American H ealth Plan

0

1,1 8 2 ,0 0 0

1 ,1 8 2 ,0 0 0

Hawaii, Honolulu (Oakland, CA)

K aiser Foundation Health Plan, Inc.

0

Idaho, B oise

GEM Health A s s o c ia tio n , Inc.

PLAN-124,634 INDV-1,000,000

I l l i n o i s , Chicago

Anchor O rganization for H ealth Maintenance

FEAS-34,005 INDV-704,723


HMO I l l i n o i s ,


Inc.

0 1 ,7 3 5 ,0 0 0 0

0 2,8 5 9 ,6 3 4 738,728

0

0

0

Intergroup Prepaid Health S e r v ic e s , In c.

0

0

0


Michael Reese Health P la n , Inc .

0

0

0

I l l i n o i s , Evanston

North Communities Health Plan

Indiana, In d ia n a p o lis

Metro Health Plan

Kentucky, L o u is v ille

H ealthcare of L o u is v ille , Inc.

L o u isia n a , Baton Rouge Health Maintenance Organiza tio n of Baton Rouge, Inc.


2 ,5 0 0 ,0 0 0

2,9 7 8 ,6 1 8

0

1 ,2 6 4 ,0 0 0

1 ,2 6 4 ,0 0 0

PLAN-120, 566 INDV-1,006,806

2 ,5 0 0 ,0 0 0

3,627,372

FEAS-49,260 PLAN-124, 997 INDV-9 90,918

2 ,5 0 0 ,0 0 0

3,665,175

FEAS-75,000 INDV-403,618

ASSO CIATIO N

REPORTS

Name of HMO

T otal Grants

T otal Loans


Maryland, Baltim ore

M etropolitan B altim ore Health Care, Inc .

PLAN-125,000 INDV-931,87 5

$ 2,5 0 0 ,0 0 0

$ 3,5 5 6 ,8 7 5

M assach usetts,

Harvard Community H ealth Plan

0

0

0

Location

A llsto n

M assach u setts, Amherst

V a lley Health Plan

PLAN-125,000 INDV-523,330

0

648,330

M ichigan, D e tr o it

Michigan Health Maintenance O rganization P lan, In c.

INDV-266,141

0

266,141

M ichigan, Lansing

H ealth C en tra l, In c.

FEAS-50,000 PLAN-121,084 INDV-1,0 00,000

2,5 0 0 ,0 0 0

3,671,084

M ichigan, Warren

Group Health Plan of Southeast Michigan

PLAN-227,129 INDV-996,371

2,5 0 0 ,0 0 0

3,7 2 3 ,5 0 0

M innesota, S t. Paul

SHARE H ealth Plan

FEAS-125,000 INDV-450,000

850,000

1,4 2 5 ,0 0 0

M issou ri, Kansas C ity

Prim: Health

PLAN-112,381 INDV-1,000,000

2,2 7 3 ,0 0 0

3,3 8 5 ,3 8 1

New Hampshire, Nashua

Matthew Thorton H ealth Plan, Inc.

FEAS-50,000 PLAN-125,000 INDV-857,621

859,000

1 ,8 9 1 ,6 2 1

New J er se y , East Orange

Crossroads H ealth Plan

FEAS-8 5 ,0 0 0 PLAN-122,121 INDV-4 93,800

2,50 0 ,0 0 0

3,200,921

New J er se y , Guttenberg

Group H ealth Plan of New Jersey

FEAS-119,9 78 PLAN-125,000 INDV-1,000,000

2,47 8 ,0 0 0

3,722,978

New J er se y , Moorestown

Health Care Plan of New Jersey FEAS-66,590 PLAN-199,995 INDV-7 21,174

1 ,7 7 1 ,0 0 0

2,758,759

New J er se y , New Brunswick

R utgers Community Health Plan

PLAN-125, 000 INDV-1,000,000

2 ,0 0 0 ,0 0 0

3 ,125,000

New J e rse y , Orange

C entral Essex H ealth Plan

PLAN-93,145 INDV-9 51, 462

2 ,1 7 8 ,0 0 0

3 ,222,607

New York, Latham

C ap ital Area Community Health Plan

PLAN-315, 464 INDV-1,070,409

1 ,8 3 2 ,0 0 0

3,217,873

New York, B uffalo

H ealth Care Plan, Inc.

PLAN-273,807 INDV-1,000,000

2 ,5 0 0 ,0 0 0

3,773,807

New York, New York

Manhattan Health P lan, Inc.

FEAS-4 9 , 876 PLAN-125,000 INDV-999,611

2 ,5 0 0 ,0 0 0

3,674,487

New York, Rochester

Genesee V a lley Group H ealth A sso c ia tio n

INDV-298,500

2 ,5 0 0 ,0 0 0

2,7 9 8 ,5 0 0

New York, White P la in s

W estchester Community Health Plan

PLAN-114,902 INDV-1,000,000

2 ,5 0 0 ,0 0 0

3 ,6 1 4 ,9 0 2

Ohio , Cleveland

K aiser Health Foundation of Ohio

Ohio, Marion

Marion H ealth Foundation

0 FEAS-74,936 INDV-344,179

0 0

0 419,115


ASSO CIATION

REPORTS

Location

Name of HMO

Total Grants

T otal Loans


Oregon, Portland

K aiser Foundation Health Plan of Oregon

0

Oregon, Portland

H ealth Maintenance of Oregon

0

Oregon, Portland

Portland Metro H ealth, Inc.

INDV-455,188

2 ,5 0 0 ,0 0 0

2,955,188

Oregon, Salem

C ap itol Health Care, Inc.

FEAS-4 9,922 PLAN-125, 000

1 ,2 1 3 ,0 0 0

1,38 7 ,9 2 2

P en n sy lv a n ia , P h ila d elp h ia

H ealth S erv ice Plan of Pennsylvania

INDV-2 2 7, 610

2 ,2 1 3 ,0 0 0

2 ,4 4 0 ,6 1 0

P en n sy lv a n ia , P ittsb u rg h

Penn Group H ealth Plan

INDV-1,4 9 8 ,7 81

2 ,0 5 0 ,0 0 0

3,54 8 ,7 8 1

P en n sy lv a n ia , Willow Grove

HMO of Pennsylvania

FEAS-42,906 PLAN-108, 235 INDV-663,965

2 ,5 0 0 ,0 0 0

3,31 5 ,1 0 6

Rhode Isla n d , Providence

Rhode Islan d Group H ealth A sso c ia tio n

FEAS-5 0,000 INDV-1,492,255

2 ,5 0 0 ,0 0 0

4,04 2 ,2 5 5

South C arolin a, G r e e n v ille

Piedmont H ealth Care Corp .

FEAS-70,860

Texas, El Paso

Group Health of El Paso, Inc.

PLAN-123,963 INDV-763,528

Texas, Houston

P ru d en tial Health Care P lan, Inc.

Utah, S a lt Lake C ity

Family Health Program

IN DV.-211,716

Washington, Spokane

C ooperative Health Plan o f Greater Spokane

FEAS-50,000 PLAN-122,500 INDV-9 9 9,980

2 .5 0 0 ,0 0 0

3,6 7 2 ,4 8 0

Washington, Tacoma

Sound H ealth A sso c ia tio n

INDV-304,738

2 ,5 0 0 ,0 0 0

2,8 0 4 ,7 3 8

W isconsin, Madison

Group H ealth C ooperative of South C entral W isconsin

PLAN-250,000 INDV-1,000,000

2 ,5 0 0 ,0 0 0

3,7 5 0 ,0 0 0

$ 94.8 5 9 .0 0 0

$134,009,531

o

$

0

0

0

70,860 1 ,1 4 5 ,0 0 0 0

2 ,0 3 2 ,4 9 1 0 211,716

FEAS- 1 ,3 0 5 ,0 2 9 PLAN- 4 ,2 5 3 ,8 5 4 INDV-3 3,591,648

SUMMARY:

GRAND TOTALS


0

$

$39,150,531

A SSO CIATION

REPORTS

EXHIBIT II Maximum F ederal Grant Awards A v a ila b le Through the 1973 HMO Act and 1976 and 1978 Amendments

1973 HMO Act

Type o f Grant

$

F e a s i b i li t y

50,000

$

1978 Amendments

75,000

$

75,000

125,000

200,000

200,000

1 ,0 0 0 ,0 0 0

1,0.00,000

2,0 0 0 ,0 0 0

Planning I n i t i a l Development

1976 Amendments

E XH IB IT I I I F e d e r a l G ra n ts Awarded by T y p e , F i s c a l Y e a r , Number and T o t a l Amount Type o f G ra n t

F i s c a l Y ear 1975

F i s c a l Y e a r 1976

F e a s ib ility

108

5 0 9 ,3 7 0 )



T o ta l

($ 5 ,1 9 6 ,2 8 1 )

11

($

2 0 8 ,6 8 6 )

66

($ 4 ,5 4 3 ,1 9 3 )

190

($ 1 0 ,4 5 7 ,5 3 0 )

P la n n in g

31 ($ 3 ,7 5 8 ,7 4 5 )

41

($ 5 ,0 8 0 ,6 0 2 )

15 ($ 2 ,2 2 3 ,1 3 3 )

13

($ 2 ,0 6 8 ,4 3 3 )

100

($ 1 3 ,1 3 0 ,9 1 3 )

I n i t i a l Developm ent

33

($ 1 3 ,5 0 7 ,2 7 4 )

20

($ 1 2 ,5 8 0 ,3 6 8 )

26 ($ 1 4 ,5 1 5 ,5 1 0 )

21

($ 1 0 ,3 6 7 ,1 9 5 )

100

($ 5 0 ,9 7 0 ,3 4 7 )

172 ($ 2 2 ,4 6 2 ,3 0 0 )

72

($ 1 8 ,1 7 0 ,3 4 0 )

46 ($ 1 6 ,9 4 7 ,3 2 9 )

100

($ 1 6 ,9 7 8 ,8 2 1 )

390

($ 7 4 ,5 5 8 ,7 9 0 )

5 ($

EXHIBIT IV Maximum Federal Loans and Loan Guarantees A v a ila b le Through the 1973 HMO Act A n d 1976 and 1978 Amendments Purpose of Loan

1973 HMO Act

1976 Amendments

1978 Amendments

Operating Loans and Loan Guarantees

$ 2 ,5 0 0 ,0 0 0

$ 2 ,5 0 0 ,0 0 0

$ 4 ,0 0 0 ,0 0 0

Loans and Loan Guarantees for A c q u isitio n and C onstruction o f Ambulatory Health Care F a c ilitie s

NA

NA

2 ,5 0 0 ,0 0 0

EXH IB IT V F e d e r a l Loans and Loan G u arantees by Number Awarded Ty p e , F i s c a l Y e a r , and Amount

Type

Loans

F i s c a l Y ear 1975




2 ($ 2 ,4 4 6 ,0 0 0 )

13 ($ 2 5 ,8 2 1 ,0 0 0 )

17 ($ 3 3 ,1 7 9 ,0 0 0 )

18 ($ 3 1 ,1 0 0 ,0 0 0 )

1 ($ 1 ,1 8 2 ,0 0 0 )

2 ($ 2 ,3 1 3 ,0 0 0 )

Loan G u ara n te es

T o ta l

2 ($ 2 ,4 4 6 ,0 0 0 )

13 ($ 2 5 ,8 2 1 ,0 0 0 )

18 ($ 3 4 ,3 6 1 ,0 0 0 )

20

($ 3 3 ,4 1 3 ,0 0 0 )

T o ta l

50

($ 9 2 ,5 4 6 ,0 0 0

3 ($ 3 ,4 9 5 ,0 0 0

53 ($ 9 6 ,0 4 1 ,0 0 0 )


ASSO CIATION

REPORTS

SPECIAL REPORT 2 OF THE COUNCIL ON DENTAL CARE PROGRAMS INVOLVEMENT OF FEDERALLY QUALIFIED HEALTH MAINTENANCE ORGANIZATIONS (HMOs) IN PROVIDING DENTAL CARE SERVICES The Council on Dental Care Programs is charged with monitoring alternate dental care delivery systems and reporting to the profession on its findings. In that health maintenance organizations represent a consumer alter native to traditional, fee-for-service health care, they are monitored under the Council’s mandate. This report fo cuses on the involvem ent of the 69 federally qualified HMOs as of September 30, 1978 in providing dental care services. The health maintenance organization concept has been defined as an organized system of health care that accepts the responsibility to provide or otherwise en sure the delivery of an agreed upon set of comprehen sive health maintenance and treatment services for a voluntarily enrolled group of persons in a geographic area and is reimbursed through a prenegotiated and fixed periodic payment made by or on behalf of each person or family unit enrolled in the plan. Largely be cause of escalating health care costs, HMOs are receiv ing considerable attention from government, business, labor and the general public as a possible method of reducing or controlling overall expenditures while still providing comprehensive, quality health care services. The term “health m aintenance organization” was coined in the early 1970’s. The concept of prepaid health care, however, is not new. In 1929, the first pre payment group practice was opened in Los Angeles by Donald Ross, M.D., and H. Clifford Loos, M.D., to pro v id e m ed ica l se r v ic e s to city w ater departm ent em ployees. In 1942, the Kaiser Foundation Health Plan, Inc., often cited as the model upon which the closedpanel HMO is based, began its operations in Oakland, California. Other major plans developed have included Group H ealth Association, Inc., W ashington, D.C., 1937; Group Health Cooperative of Puget Sound, Se attle, Washington, 1947; Health Insurance Plan of Great er N ew York, 1947; and Group Health Plan, Inc., Min neapolis, Minnesota, 1957. T h e

F o u r t h

A n n u a l

R e p o r t

t o

t h e

C o n g r e s s

o n

H

e a l t h

reported a total of 203 pre paid health care plans as of September, 1978 in 36 states, the D istrict of Colum bia and Guam. T w enty-seven states have two or more prepaid plans. Six states have 10 or more. The com bined enrollm ents are 7,470,963 members, an 18% increase over 1977 figures.

M

a i n t e n a n c e

O r g a n i z a t i o n s

Dentistry Under The HMO Act: Regulations accompanying the original HMO Act of 1973 divided dental benefits into three categories: (1) basic dental health services, (2) supplemental dental health services, and (3) any other services related to dentistry. With regard to basic dental health services, federal regulations pertaining to the Act stated:


Each health m aintenance organization shall have the capac ity and the capability to deliver or arrange for the delivery . . . (of) preventive dental care to protect and maintain the dental health o f children through age 11 and provided by a licensed dentist or other qualified p e rso n n e l. . . T he preventive dental care shall include: (1) Oral prophylaxis, as necessary, and (2) Topical application o f fluorides and the prescription of fluorides for system ic use when not available in the community water supply.

The American Dental Association opposed the dental provision of the 1973 HMO Act relating to the preven tive dental services for children through age 11 as in adequate to safeguard the dental health of children. The Association maintained that an HMO should provide a full spectrum of dental care services including diagnos tic, preventive, restorative and emergency treatment. The HMO Amendments of 1976 elim inated the re quired preventive dental services for children through age 11, but many HMOs voluntarily retained this bene fit. (Prior to the 1976 Am endm ents, the 28 HMOs which were federally qualified provided the mandatory preventive dental services by em ploying salaried den tists or by contracting with private practitioners in the community on either a capitation or fee-for-service basis.) Study Population: The 69 HMOs federally qualified by the U.S. Department of Health, Education, and Welfare as of September 30, 1978 w ere surveyed by the Council. Covering 4,704,465 members, these HMOs were lo cated in 27 states and the District of Columbia. (Exhibit I lists all HMOs surveyed by name, address, model and date of qualification. Exhibit II details membership and the number of federally qualified HMOs within each state.) The purpose of this effort was to ascertain the in volvem ent of federally qualified HMOs in providing dental care services. Questionnaires, review of market ing brochures, site-visits, and telephone conversations comprise the data for this report. Responses, either di rectly or indirectly via review of marketing brochures, were received from all 69 HMOs surveyed. (Exhibit III summarizes dental services offered by these HMOs.) Thirty of the HMOs surveyed were staff models, i.e., the HMO em ploys its own physicians, usually on a salaried basis, to provide the contractual medical serv ices to its subscribers. E ighteen w ere organized as group practice models with the HMO, as a legal entity, contracting directly with a medical group, partnership or corporation. Typically, the physicians in a group prac tice model are located in a central facility and are com p en sated on eith er a salaried or capitation basis. Twenty-one of the HMOs were individual practice as

ASSO CIATION

sociations (IPAs). U nder the IPA arrangement, the HMO contracts with a partnership, corporation or as sociation to provide the necessary m edical services through existing health care facilities. Physicians are thus allow ed to work directly from their own private offices and are compensated on either a fee-for-service or capitation basis. It should be noted that both the group practice and the IPA m odel places the physicians at risk in the event of over-utilization of services. In other words, the physicians must continue to provide contractual services even though the common fund pay ing their fees no longer has any financial resources. Twenty-nine of the HMOs surveyed were organized by consum ers; 19 by ph ysician groups; 7 by com munities; 4 by insurance carriers; 3 by hospitals, and 7 by m iscellaneous sponsors. Six of the 69 HMOs were incorporated as for-profit organizations. These were: ABC-HMO, Inc., Phoenix, Arizona; Arizona Health Plan, Inc., Phoenix, Arizona; California Medical Group Health Plan, Los Angeles, California; American Health Plan, North Miami Beach, Florida; Av-Med Health Plan, Inc., Miami, Florida; and Prudential Health Care, Inc., Houston, Texas. As of September 30, 1978, 51 of these HMOs had re ceived grants from the U.S. Department of Health, Edu cation, and Welfare totaling $39.1 m illion and 47 had received loans totaling $94.8 million. Site Visits: Council members and staff conducted on-site interviews with eight of the 21 HMOs identified as of fering com prehensive dental care services (defined as restorative as w ell as preventive and diagnostic serv ices) within an HMO environment. The HMOs visited were: (1) ABC-HMO, Phoenix, Arizona (2) Maxi-Care, Hawthorne, California (3) Family Health Program, Long Beach, California (4) Group Health Association, Inc., Washington, D.C. (5) Capital Area Community Health Plan, Latham, N ew York (6) Manhattan Health Plan, N ew York, N ew York (7) W estchester Com m unity Health Plan, White Plains, N ew York and (8) Kaiser Foundation Health Plan, Portland, Oregon. The eight HMOs visited were informed at the outset that the purpose of the survey was not to approve or disapprove a particular program, but, rather, to obtain sufficient background materials for an informational re port to the Association and other interested parties. Ex hibit IV provides a brief overview of those HMOs vis ited. Summaries of these visits conducted in April 1978 follow: 1. A B C - H M O , I n c . , is a for-profit, carrier-sponsored h ealth m a in ten a n ce organ ization e sta b lish e d in Novem ber 1972 to provide com prehensive prepaid health care services to subscribers in the Phoenix, Arizona area. F ed era lly qualified in A ugust 1978, ABC-HMO now serves over 51,000 members including em p lo y ees o f the U .S. C ivil S ervice, the State of Arizona, the City of Phoenix and numerous private businesses. ABC-HMO maintains four primary health care centers

REPORTS

located in Phoenix, Glendale* Mesa and Sun City. All centers are open Monday through Friday from 8:00 AM until 5:00 pm . Emergency services are available at all times. C om prehensive dental services for children only were first offered in January 1978. These dental serv ices, for a charge of $2.00 per visit, are available to chil dren under 14 years of age as a supplemental benefit to the existing plan, without a separate premium for the dental benefits nor an increase in the existing medical p rem iu m s. S ervices in c lu d e exam in ation , X -rays, prophylaxis, space maintainers, basic restorations, endodontics, and oral surgical services. Approximately 8,500 children are now covered and utilization ap proaches the 85-90% level. Within the next year, all other plan members, regardless of age, w ill becom e eli gible to receive preventive dental services as part of their basic contract. These services include examina tion, X-rays and prophylaxis. At the present time, the ABC-HMO management does not foresee the addition of a comprehensive prepaid dental plan available to the membership. Currently, 15 dental operatories are located at the Phoenix Center and 12 at Mesa. With the exception of orthodontics and certain oral surgical procedures view ed as too complex for in-house personnel, most dental services are available to both members and the general public on a fee-for-service basis, utilizing a fee schedule. According to the dental director, the fees are competitive with dental fees in the community. Plan members enjoy a 20% discount from the fee schedule. Nonmembers now account for about 20% of all dental services rendered. The ABC-HMO dental staff (5 full-time and 5 parttime general practitioners, 4 full-time hygienists and 12 full-time assistants) serves approximately 125 patients per working day. Dentists earn a fixed salary with fringe benefits including a retirement plan, vacation and sick leave, as w ell as disability and malpractice insurance. Dentists are also provided time off and an allowance for continuing education. Patients at ABC-HMO are offered the opportunity to select a particular dentist, but few patients do so. Patient opinions as to the quality of care received are not routinely solicited. Each center does, however, employ a consumer health representative. This individual re ceives and responds to patient complaints. 2. M a x i - C a r e ( M A X ) , headquartered in Hawthorne, California, becam e federally qualified in 1976 and was the first health maintenance organization to receive such certification in the Southern California area. MAX is a physician-sponsored, not-for-profit, IPA model HMO. Membership totals 44,000 members, serviced from three locations in the Los Angeles county and Orange county areas. MAX began offering prepaid dental benefits to its en tire health plan membership in September of 1978. The decision to do so was the result of its experience in serv ing as a prototype prepaid health plan (PHP) for the state’s Denti-Cal program. The initial enrollment con


ASSO CIATION

REPORTS

sisted of participants in the prototype. Currently, MAX contracts with one full-time dentist, who also serves as the dental director, and three parttime dentists to provide services to its 4,000 enrollees. The dental facilities are located in the administration building in Hawthorne where there are ten operatories. Contractual relationships betw een MAX and the pro vider dentists are in the formative stage as the entire dental program is seven months old. Data were unavail able to determine dental utilization. The dental program is marketed on an optional basis to members of Maxi-Care’s hospital/medical program. No individual membership is available due to the possi ble effects of adverse selection. The program is only sold to groups of 50 or more em ployees. The dentists are free to treat private patients, including those who have other dental insurance coverage. Treating nonmember patients is highly encouraged at this point in the life of the program . A ccording to the d en ta l d irector, a community-competitive fee schedule is used in these instances. Approximately 22% of office visits are on a nonmember basis. 3. F a m i l y H e a l t h P r o g r a m ( F H P ) , headquartered in Long Beach, California began providing prepaid m edi cal care services in 1960. In 1977, FHP received federal qualification as a not-for-profit, staff m odel health maintenance organization. FHP has seven centers in California, three in Utah and one in Guam, serving over 100,000 members. Dental benefits were first introduced in 1978 and are currently provided in four of the seven California cen ters. Total enrollment in the dental program is 18,000. The four dental care centers are strategically located in Orange County and southern Los A ngeles County. Expansion is currently in process at FH P’s Anaheim and Fountain Valley centers. Upon completion of the construction in progress, the Anaheim center w ill have 19 operatories and the Fountain Valley center will have 15. Further expansion is projected for the next ten years which will more than double the dental department’s current size. The centers are open from 9:00 A M to 6:00 P M five days a week. Two of the centers are open Satur days, one of which is open late two evenings a week and the other is open late three evenings. In California, FHP'employs 14 full-time general prac titioners, 2 oral surgeons, 2 periodontists, 5 hygienists and 30 auxiliary personnel. The dentists are salaried and have b en efits w h ich in clu d e: m em b ersh ip in the hospital/m edical plan, life and disability insurance, postgraduate education allowance, dental association dues allowance, vacation and sick leave and a retire ment program. The dental director described the dental staff as characteristically being com posed of recent den tal school graduates predominantly from the West Coast. FHPs dental program is marketed as a separate entity or in addition to the hospital/medical plan for an extra premium. School districts compose 60% of membership in the dental program with Medicare, Medicaid, government em ployees, and commercial groups making up the rest.


The programs are sold to groups of no less than 50 em ployees. Patients may select their dentist. If no preference is indicated they are assigned with freedom to change. An average of 175 patients per day are seen by FHP den tists, and approximately 1% of them are private fee-forservice patients. FHPs comprehensive prepaid dental plan offers the following: Services D ia g n o s tic E m e rg e n c y C a re at F H P D e n ta l C en ters P re v e n tiv e R esto rativ e O ra l S urgery E n d o d o n tic s P erio d o n tics Prosthetics

O u t o f A re a E m e rg e n c y C are

P la n M a x im u m A d m in is tra tiv e Fee

Patient Copayments

$0 P a tie n t pays 4 0 % o f charges in itia lly ; a fte r 1 y e a r in p la n and a ll p re s c rib e d d e n ta l tre a tm e n t is c o m p le te d , pays 100% . P la n co v e rs u s u a l, c u s to m a ry a n d re a s o n a b le ch arg es u p to $5 0 each o c c u rre n c e . F H P m u s t b e n o t if ie d w i t h i n 3 0 days. U n lim ite d S h o u ld th e p a tie n t fa il to k e e p an a p p o in tm e n t o r fa il to n o tify th e d e n ta l office o f a c a n c e lla tio n 2 4 ho urs in a d v a n c e , th e p a t ie n t m a y b e a s s e s s e d a $ 1 0 .0 0 service ch arg e.*

* T h e d e n ta l d ire c to r e x p la in e d th e m issed a p p o in tm e n t fe e as p e rta in in g to those w h o have m issed a p p o in tm e n ts fo r a second tim e , th e first tim e b e in g a w a rn in g at no charge.

The charge for m issed and uncancelled appointments has greatly reduced the monthly average from 20-30% to

10%. FHP has developed a formalized system of quality assurance involving both dental record and clinical evaluations. 4. G r o u p H e a l t h A s s o c i a t i o n , I n c . , ( G H A ) , Washington, D.C., a not-for-profit consumer-owned cor poration, was founded in 1937 to provide comprehen sive medical care on a prepaid basis. Today, GHA serv ices approximately 110,000 subscribers in its five health centers located throughout the greater Washington area. GHA membership comprises mainly people of the mid dle and lower-middle economic classes, including sub stantial numbers of government employees. GHA has offered dental services to its members through various mechanisms since 1949. The provision of dental care, however, has not been em phasized dur ing this time. In the past three years, the GHA dental department has received increased attention and sig nificant expansion has resulted. For example, expendi tures for dental care in 1978 increased by 22% over 1977 and are projected to increase by an additional 25% in 1979. Dental expenditures for 1978 ($1,880,000) repre sented 4.5% of GHA’s total annual expenditures. Ap

ASSO CIATION

proximately 22,000 of GHA’s subscribers, or 20%, avail th em selves of dental services, mainly on a fee-forservice basis with a published fee schedule. Dental services are available to GHA health plan members only. Total expenditures for dental care are distributed over the various categories of treatment as follows: D iag no sis X -rays O ra l H y g ie n e R esto rativ e E n d o d o n tic P e rio d o n tic R e m o v a b le Prosthesis F ix e d Prosthesis O ra l S u rg ery O rth o d o n tic s

12% 13% 16% 19% 3% 4% 7% 18% 5% 3%

100% L i m i t e d p r e p a i d d e n t a l p r o g r a m s a r e a v a ila b le to m e m b e rs a n d t h e i r f a m ili e s o n a n i n d i v i d u a l b a s is . E l i g i b i l i t y f o r e n r o l l m e n t i n th e s e p r o g r a m s is c o n t i n g e n t u p o n c o m p l e t i o n o f s u c h d e n t a l t r e a t m e n t as t h e d e n t a l d i r e c t o r d e t e r m i n e s is r e q u i r e d f o r a n “ a c c e p t a b le h e a lt h c o n d i t i o n . ” A d d i t i o n a l l y , e n r o lle e s i n th e s e p r o g r a m s m a y b e d i s e n r o lle d u p o n r e c o m m e n d a t i o n o f t h e d e n t a l d i r e c t o r , i f t h e y d o n o t r e a s o n a b ly c o m p ly w i t h r e c o m m e n d a t io n s r e g a r d in g c a r e o f t e e t h , i n c l u d i n g r e g u la r p r o p h y la c t ic c a r e . T h e d e n t a l d i r e c t o r a d v is e d t h a t e l i m i n a t i o n o f d e n ta l d is e a s e , b u t n o t r e p l a c e m e n t o f m is s in g t e e t h , is p r e r e q u is it e fo r e n r o llm e n t . B r i e f ly , th e s e b a s ic p r e p a i d p la n s a r e d e s c r ib e d as f o l lo w s : 1. A p la n fo r ad ults (1 3 years a n d o ld er) a t a m o n th ly p re m iu m 2. A p la n fo r c h ild r e n ag ed 6 - 1 2 at a m o n th ly p re m iu m 3. A p la n fo r c h ild re n e n ro lle d b e fo re age 6 a t a m o n th ly p re m iu m In

th e th r e e p la n s , th e f o llo w i n g

s e r v ic e s a r e i n

c lu d e d : 1. P re v e n tiv e care a. b. c. d. e.

p ro p h y laxis X-rays ex am in atio n s to p ic al a p p lic a tio n o f flu o rid e oral h y g ie n e co u n selin g

2. T r e a tm e n t services a. e m e rg e n c y care for r e lie f o f p a in b. am alg am , re s in o r s y n th e tic p o rc e la in restorations c. s im p le extractions an d m in o r oral surgery T h e t w o c h i l d r e n ’s p la n s i n c l u d e t h e f o l l o w i n g a d d i t io n a l s e rv ic e s : 1. 2. 3. 4. 5. 6. six

D e n ta l h e a lth e d u c a tio n a n d co u n selin g Space m ain tain ers C ro w n s T e m p o ra ry re m o v a b le p a rtia l dentu res P e rio d o n ta l tre a tm e n t 2 5 % d isco u n t on o rth o d o n tic services fo r c h ild re n u n d e r

G HA

a ls o p r o v i d e s

p r e s e n t , a p p r o x i m a t e ly

p r e p a id

g ro u p

4,600 p e r s o n s

c o v e ra g e . A t

a r e c o v e r e d in f iv e

REPORTS

plans. Basically, benefits in these plans are calculated as percentages of the GHA fee schedule, from 50% to 100% with annual maximums varying from $300 to $800 per covered individual. One plan contains the feature of covering initial treatment under the plan at 50% with subsequent treat ment, after a maintenance level of health has been at tained, being covered at 80%. Generally, these plans cover small groups, ranging in size from 11 to 110. The one exception is the plan of fered on a dual-choice basis with a Blue Cross/Blue Shield indemnity plan to the Transit E m ployee’s Union Health and Welfare Fund. Approximately 4,300 mem bers have opted for the GHA plan. The plan offers a lim ited set of covered services on a mainly prepaidwith-surcharge basis. Surcharges range from $.50 for a caries susceptibility test to $10.00 for a three (or more) surface amalgam restoration. Oral surgery, other than sim p le extractions, en d od on tic, p eriod on tic, prosthodontic, and orthodontic services are excluded. According to the dental director, none of the prepaid group plans has been in operation for sufficient time to evaluate the plans’ utilization. The dental director advised that all GHA dental pa tients are entitled to select their own dentist from among the general practitioners em ployed by GHA, and, upon request, may change from one GHA dentist to another. Patients are expected, how ever, to remain over the course of their treatment, within the facility in which they are enrolled. The GHA Dental Department employs the following persons who are assigned to its five health facilities (and one separate dental facility) comprising a total of 40 operatories and averaging 500 square feet per dentist: G e n e ra l P ra c titio n e r E n d o d o n tis t O ra l S urgeo n P e rio d o n tis t P ro sth od ontist O rth o d o n tis t H y g ie n is t A ssistant L a b o ra to ry T e c h n ic ia n S ecre ta ry /R e c e p ti on i st A d m in is tra to r

Full-Time 3 1 1 0 4 0 8 23 4 4 3

Part-Tii 12 1 0 4 2 1 1 0 1 0 0

All full-time personnel are em ployed on a salaried basis. Part-time dentists average $15 to $20 per hour. Some part-time dentists are em ployed under contract calling for retention of 40% of revenue which they gen erate. Additionally, the dental director explained, all GHA em ployees receive substantial fringe benefits, in cluding normal and early retirem ent, disability as sistance, life insurance, vacation and professional leave and participation in the GHA health plan. Quality assurance of dentists’ services within GHA largely constitutes supervision of the staff dentists by the dental director, as w ell as his serving as mediator of patient complaints. Unresolved complaints, he advised, could be referred to the Executive Director, Claims Committee, GHA Board of Trustees or the appropriate


ASSO CIATION

REPORTS

dental society. The treating dentists su p ervise the hygienists and other personnel assisting them. The dental director personally supervises the per formance of the GHA dental laboratory, which provides all laboratory services for the dental department other than castings for partial dentures which are referred to a commercial laboratory. 5. T h e C a p i t a l A r e a C o m m u n i t y H e a l t h P l a n ( C H P ) , Latham, N ew York, is a community-sponsored, not-forprofit health maintenance organization providing com prehensive health care services to its membership on a predominantly prepaid basis. Since becom ing federally qualified in D ecem ber 1976, CHP has experienced a steady rate of growth and now services approximately 20,000 subscribers through formal contracts with over 355 area employers. The physical facilities measure about 28,000 square feet. CHP does not own its own hospital, but, rather, is affiliated with four area hospitals to m eet its needs. Con struction is near completion on a separate building of 22,550 square feet with occupancy scheduled for July 1979. In addition to the main center in Latham, a re gional health center, consisting of a primary care physi cian, a physician’s assistant or nurse practitioner, lab and X-ray services, opened in April 1979 in the rural area of Canaan, N ew York. A similar satellite facility will begin operations in July 1979 in Hoosick Falls, N ew York. Being a staff m odel HMO, Capital Area Community Health Plan employs all its health care professionals on a salary basis. Patient visits are on an appointment basis. Individual practitioner schedules are arranged to in clude available times for same day appointments on an as needed basis. A $2.00 visit fee is charged and covers all services required by a patient on the same day. This $2.00 unit fee is not charged if the patient uses only the pharmacy, optical or dental facilities. The one exception is that the $2.00 fee is charged for the preventive dental services for children through age 11. In fulfilling its goals of offering comprehensive health care services, CHP maintains that dentistry is an essen tial service which must be readily available to the mem bership. The basic contract provides preventive dental services for children through age 11 and covers exami nation, prophylaxis, X-rays and fluoride treatment as necessary. Approximately 2,400 children are eligible to receive these yearly preventive dental services and w hile no exact figures are available, the utilization rate approaches 85-90%. All other dental care services are excluded. An optional dental care rider covering children under 19 for com prehensive dental care, excluding orthodon tics, is available to groups of 300 or more em ployees. This rider permits patients to pay 50% of CHP’s estab lished charges for the follow ing covered benefits: 1. P r e v e n t iv e a n d D ia g n o s tic D e n t a l C a r e — in c lu d in g scree n in g , diagn osis, p ro p h y la x is , X -ra y s , space m a in ta in e rs , d e n ta l h e a lth e d u c a tio n a n d co un selin g. 2. R esto rativ e D e n ta l C a re — in c lu d in g resto ra tio n o f in d i v id u a l te e th a n d ro u tin e ro o t canal tre a tm e n t.


3 . M in o r O ra l S u rg ery— in c lu d in g ro u tin e extractio ns. 4. E m e rg e n c y S ervices W h e n T e m p o r a r ily O u t o f th e C H P S e rv ic e A re a — services are lim ite d to th ose r e q u ire d to re lie v e p a in .

Comprehensive dental care services, excluding or thodontics, are readily available to both members and nonm em bers on a fee-for-service basis at rates ap proximating the 50th percentile in the area. Roughly 92% of all dental services provided are on a fee-forservice basis with 25% of this amount attributable to nonmember utilization. Three full-time dentists, including a dental director, are em ployed by CHP on a full-time basis. Prior to join ing the plan, the dental director had practiced in the vicinity as a private practitioner for 15 years. The other two dentists are also from the area and, to date, the plan has experienced no difficulty in attracting dentists. The starting salary for a dentist with no practice experience is $23,000. Starting salaries may be as high as $40,000 depending upon postgraduate training, board certifica tion and experience. Fringe benefits include health, malpractice, life and disability insurance, education al lowance to $500 per year, retirement plan, sick leave and three weeks vacation after one year of employment. The dental component w ill relocate to new facilities in July 1979 and will occupy about 3,500 of the 22,500 square foot addition. From its present four operatories, the dental facility w ill be expanded to in clu d e 12 operatories for dentists, 4 for hygienists, X-ray facilities, a preventive education room and a separate consultation room. The dental director is currently d eveloping com prehensive prepaid dental programs to be offered as an option to subscribers. As patient load increases, up to a total of six full-time dentists may be employed. Out-ofplan members will continue to be eligible to utilize the dental facilities on a fee-for-service basis. 6. M a n h a t t a n H e a l t h P l a n ( M H P ) , a private, not-forprofit organization, chartered by the State of N ew York, began operation on November 1, 1977 and has enrolled approximately 6,700 subscribers as o f March 1979. The health plan is offered on a group basis only. However, it should be noted.that one of the contracting groups, die Northeast Business Association, accepts as members a w ide variety of small businesses and self-em ployed in dividuals. In order to limit the potential for adverse selection by Northeast Business Association member firms, MHP has introduced special eligibility require ments for the organization’s members, to wit, that one must be a member of the Association for at least 30 days at the tim e of a sch ed u led health plan enrollm ent period, which occurs once every three months. In addi tion, in all groups, only residents of the Borough of Manhattan are eligible to join MHP. It was explained that, to date, subscribers have been mainly single per sons and, consequently, enrollment does not generate the patient volume experienced in other plans. In an interview with the medical director and dental coor dinator (referred to internally as the C hief of Dentistry), it was determined that they expect to enroll in the health

A SSO CIATION

plan approximately 6,000 new subscribers per year for the next three years and to expand availability to some other boroughs of N ew York. Originally, the medical director advised, MHP did not plan to offer a prepaid dental plan during its first several years of operation. Consideration is now being given to such an offering for the near future, however, because of the interest expressed by health plan subscribers. At present, MHP offers dental care on a fee-for-service (schedule) basis in a new ly constructed five-operatory treatment area within the MHP facility. Dental services are provided by two general dentists who are part-time MHP em ployees collectively comprising the equivalent of one half-time dentist. The dental coordinator stated that MHP expects to engage an oral surgeon on a parttime basis by mid-April 1979. Dental services at the MHP facility are available to the general public, although no public advertising of their availability is accomplished. At the tim e of the visit, dental services had been offered for less than one week so no utilization data were available. The medical director and dental coordinator voiced the expectation that dental patients w ill b e drawn largely from the health plan subscriber population. They stated that the dental fee schedule would be considered reasonable compared to fees charged on Manhattan’s upper east side (the location of MHP’s single facility) but probably would be considered average for all of Manhattan. Regarding quality assurance, the dental coordinator advised that he is developing a system based on record review through the application of quality indicators, chart audits, and, where necessary, clinical audits con d u cted by o u tsid e d en tists p racticin g in sim ilar facilities. H e gave, as examples of quality indicators, the ratios of endodontics to extractions, initial examinations to prophylaxes and initial examinations to recall exami nations. The quality assurance system is based on the MHP’s Management Information System. Patient complaints are addressed initially by the den tal coordinator. A second level of review is provided by the medical director. Ultimately, unresolved complaints would be referred to the local dental society’s peer re view committee. 7. W e s t c h e s t e r C o m m u n i t y H e a l t h P l a n , ( W C H P ) , White Plains, N ew York, is a consumer-sponsored, notfor-profit health m aintenance organization providing comprehensive health care services on a prepaid basis. Federally qualified in D ecem ber 1976* WCHP now serves approximately 16,500 members at its Health Cen ter and in selected community and specialty hospitals. The Health Center is a facility comprising 29,000 square feet. Both group and non-group contracts are available on an individual and family membership basis. Non-group contracts are offered only after examination and ap proval by the medical director. Additionally, WCHP is under contract with the U.S. Department o f Health, Education, and Welfare to provide com prehensive serv ices to Medicare patients.

REPORTS

Over the last 18 months, WCHP personnel have been actively involved in establishing a separate HMO in southern C onnecticut, about 20 m iles from WCHP. Federal qualification and opening of this new HMO, Southern Connecticut Community Health Plan, is an ticipated in July 1979. Being near the border of New York and Connecticut, WCHP initially sought to open a satellite facility in Connecticut. However, legal con straints prevented this and, hence, a separate HMO be came necessary. Annual preventive dental services for children under 12 are included as part of the basic contract. These serv ices include examination, prophylaxis, X-rays, topical fluoride application w hen necessary and instruction in plaque control. A $2.00 registration fee is charged for each visit. Oral surgical procedures resulting directly from accident or injury are also covered as part of the basic contract. All dental services other than orthodontics are avail able to both m em bers and nonm em bers at p osted WCHP rates. Nonmembers approximate 5% of dental services rendered. About 85% of all services are fee-forservice. The remaining 15% pertain to the covered pre ventive services for children under 12. Currently, one full-time and one part-time dentist are em ployed on a salary basis. Other dental department personnel include three part-time hygienists, one full time assistant and one full-time secretary/receptionist. The full-time dentist, a 1975 graduate of N ew York Col lege of Dentistry, was in private practice for two years prior to joining WCHP. The dental department is Under the supervision of the medical director. No formal dental quality assurance system exists, primarily because of the lim ited number of dentists employed. WCHP is considering major expansion of its dental department. If this occurs, the dental facilities w ill relo cate to new quarters in a separate building convenient to the main Center. In the next few months, plans call for extending hours into the evening to accommodate an increased patient load and as a convenience to the members. With this in mind, the part-time dentist posi tion will be increased to full-time. WCHP is also inves tigating the possibility of offering comprehensive pre paid dental plans as an optional rider to its basic policy. 8. K a i s e r F o u n d a t i o n H e a l t h P l a n o f O r e g o n ( K F H P ) , a nonprofit p rep aid group practice m od el health m aintenance organization (HMO), becam e federally qualified in 1977 as did its five regional counterparts in California, Colorado, Hawaii, Ohio and Washington. Kaiser-Permanente, the largest and among the oldest of the HMOs, has more than 3.5 million enrolled members of which the Oregon region serves more than 225,000 in the states of Oregon and Washington. This task of pro viding an organized delivery system of health services depends on four inter-related units—physician groups, hospitals, health plan organizations and one dental group. In 1969 as part o f a federally funded demonstration


A SSO CIATION

REPORTS

project providing health care to indigent families, the Kaiser Foundation Health Plan of Oregon was awarded a grant to provide dental services to a population of 6,700 within the Portland inter-city area. Largely based on the knowledge gained from this project, the KaiserPermanente dental care program was formed in 1974 offering com prehensive prepaid dental coverage to en rolled members. Other regions of Kaiser-Permanente offer preventive dental coverage as a supplem ental benefit under their medical plan coverage. Kaiser-Permanente Dental Care Program of Oregon has three centers offering dental services, with 10 operatories in one center, 12 in the second and 5 in the third. The dental staff consists of: Full-Time

General Practitioner Endodontist Oral Surgeon Orthodontist Periodontist Hygienist Assistant/Preventive Therapist Office Manager/Receptionist Administrator Director

Part-Time

11 1 1 1 6 20 12 1 1

Enrollm ent in the dental program has greatly in creased from the original total of 2,000 in 1974 to 22,500 in March 1979. KFHP of Oregon is a group model HMO that contracts with the Permanente Dental Associates to provide serv ices to members having dental coverage. The dentists are reimbursed on a capitation basis which provides them with an income that is competitive with the other dentists in the community. They also receive fringe benefits including membership in the medical care pro gram, vacations, sick leave, postgraduate education al lowance and disability and life insurance. The majority of staff members were in private practice before joining Permanente Dental Associates. The dental program is offered on a dual choice basis to members enrolled in the medical care program who are eligible to enroll in the dental plan at an additional cost. An average of 245 patients per day are seen by the den tal staff, with 5% of them being private, fee-for-service patients. Dental program members are free to select a dentist of their choice and can change dentists upon request. Membership service representatives are located at the central offices where grievances may be presented and resolved. The peer review system is informal; dentists are review ed periodically. A specially designed chart review system is currently being developed to ensure quality assurance. One basic dental program is offered with four options available, each differing only in the extent to which reg istration charges and copayments for selected services are prepaid as part of the monthly premium. Should the employer wish to include orthodontics as a copayment benefit, a supplemental amount would be added to the monthly premium rate.


Services and charges included in the comprehensive dental plan are: D i a g n o s t i c

S e r v i c e s

1. O ra l ex a m in a tio n s

2.

X -rays

P r e v e n t i v e

C a r e

1. P ro p h ylax is

2.

Charge

$0 $0

T o p ic a l a p p lic a tio n o f flu o rid e as a p p ro p ria te

$0 $0

3. P re s c rib e d space m a in ta in e rs a n d h a b it a p p lia n ce s

4.

In s tru c tio n in care o f te e th an d gums

R e s t o r a t i v e

$0

$0

S e r v i c e s

$0 $0

1. F illin g s

2.

Stainless steel or p lastic crow ns

3. G o ld a n d /o r p o rc e la in cro w n s, in lays o r b rid g e p o n tics O r a l

1. R e m o v a l o f te e th

2.

$45 each

S u r g e r y

$0

M in o r su rg ical p re p a ra tio n o f th e m o u th fo r in s e rtio n o f d en tu res

$0

3. S urgical tre a tm e n t n o rm a lly p e rfo rm e d fo r m in o r p a th o lo g ic a l co n d itio n s

$0

P e r i o d o n t i c s

1.

T r e a tm e n t o f diseases o f tissues s u p p o rtin g th e te e th

$0

E n d o d o n t i c s

1. R oot canal th e ra p y

2.

P u lp a l th e ra p y

P r o s t h e t i c

D e v i c e s

1. F u ll d en tu res (u p p e r or lo w e r)

2.

P a rtia l d e n tu re s (u p p e r o r lo w e r)

3. R e lin e s , rebases

4.

$0 $0

O rth o d o n tic space m a in ta in e rs

$65 each $95 each $25 each $20 each

Orthodontic coverage is available to plan members under 18 for a supplemental premium. There is no dol lar limit to the value of orthodontic services provided; however, the members pay the first $100 plus 30% of additional charges up to a m aximum of $300 per member. The plan w ill also reimburse members up to $100 per occurrence for emergency dental care rendered more than 30 miles from a Kaiser-Permanente medical or den tal facility and covers dental services for relief of pain, acute infection or hemorrhage, or necessary treatment due to an injury. The dental director works with the dental adminis trator and as appropriate the regional manager o f the health plan in considering options for growth and policy-making procedures. Currently, there are no im mediate plans to im plem ent dental programs in the other five Kaiser regions. However, Oregon’s program is likely to be the model for such future development, should it occur. Dental Care Services Provided: Of the 69 HMOs sur veyed, 21 of the plans offer comprehensive dental serv

ASSO CIATION

ices (restorative, as w ell as preventive and diagnostic treatment), either on a fee-for-service, prepaid or com bination basis; 31 offer preventive services for children, under 12 (or older in a few cases) and commonly include exam ination, X-rays, prophylaxis and instruction in plaque control; 13 of the plans offer only the children’s preventive services as described above; 34 offer no dental care services other than oral surgical services commonly offered through major health insurance con tracts and resulting from accidental injury to sound and natural teeth. (Refer to Exhibit III for a breakdown of dental services provided by each of these HMOs.) Of the 21 HMOs offering com prehensive dental care services, 16 provide children’s preventive services as a basic contract benefit; 10 offer comprehensive prepaid plans to all or selected members; and 14 provide dental services on a fee-for-service basis generally to both plan members and the community-at-large. (Two o f the plans indicated that dental services were available to plan members only.) In all but one case, the com prehensive prepaid dental plans are offered as a supplem ental benefit for which additional premiums are required. When offered as a basic contract benefit, the preven tive services for children appear to be heavily utilized, reportedly in the 60% to 90% range. Several reasons were given for offering comprehen sive dental care services: (1) competitive advantage in the marketplace, (2) financially feasible and profitable, (3) demand by purchasers or consumers and (4) com mitment by the HMO to provide com prehensive health care services which include dentistry. Typical reasons for not offering such services included the lack of space, lack of consumer demand, uncertainty of demand, and the high initial cost in establishing a com plete dental facility. Plans offering comprehensive dental services gener ally em ploy dentists on a salary basis. In one case, an additional bonus equal to 5% of gross salary is given to the dentist based on a merit evaluation consisting of performance in patient relations, continuing education, administrative responsibilities, peer review and pro ductivity. In another, the dentists are compensated on a capita tion basis. One HMO employs dentists both on a salary and capitation basis. To date, the HMOs offering com prehensive dentistry have recruited dentists almost ex clusively from their immediate vicinity and have not experienced any significant problems in attracting ap plicants, particularly new graduates. N onm em ber utilization of dental services varies greatly. Two of the plans specifically prohibit nonmem bers’ utilization. Typically, in the early stages of offering comprehensive dentistry within an HMO, nonmember participation is encouraged in an effort to occupy the dentist’s tim e. As member utilization increases, the nonmember segm ent of the practice is reduced. In most cases, the fee-for-service charge is the same regardless of membership status. However, in one case, members enjoy a 20% discount of the scheduled fees.

REPORTS

None of the plans has a fully prepaid comprehensive dental care program. Many HMOs institute office visit charges ranging from $2 to $5. While preventive and diagnostic services are normally covered by a prepaid plan, surcharges are generally assessed on the other dental services. Summary: As was the case with the two previous admin istrations, the Carter Administration is committed to strengthening competition in the health care industry and is encouraging HMOs and other organizational modes which give providers an economic incentive to reduce or control costs. Evidence appears to confirm lower rates of hospitalization within an HMO environ ment versus fee-for-service medical care. As hospital costs generally account for 40% to 50% of all health care expenditures, such reductions offer significant cost savings. Whether reduction in hospital usage results from elim inating unnecessary hospital utilization or underutilizing these services at the ex pense of some members is subject to debate. In many respects, the delivery of dental care is dif ferent from the provision of other health care. Because hospitalization is not a major factor in the cost of dental services, the HMO approach has not proven to offer sig nificant econom ies in the delivery of dental care. Also, the emphasis on the preventive aspects of HMOs does not appear to offer any additional advantages as far as dental care is concerned. Dentists have been emphasiz ing preventive techniques in their private practices for many years and most dental prepayment plans also are structured to promote prevention. In the A ssociation’s view , dental care should be view ed as an integral part of any comprehensive health care benefit package. As HMOs becom e financially sta ble and secure adequate membership, the addition of comprehensive dental care services appears justifiable both on a cost basis and as a service and convenience to the membership. Also, the addition of comprehensive dental care services can provide an HMO a significant competitive advantage in its marketplace. The number of HMOs in the United States is likely to increase in the next few years as a result of continued financial support in the form of grants, loans and loan guarantees by the federal government, as w ell as in creased interest and participation in HMO developm ent by major labor and business groups. In order to remain competitive, most of the HMOs will eventually seek and obtain federal qualification. The Council on D ental Care Programs w ishes to thank the following individuals for their cooperation in compiling this information: F r e d N . Jones, D .D .S ., v ic e -p re s id e n t o f D e n ta l A ffa irs , A B C H M O , In c ., P h o e n ix , A rizo n a M r . M a rk M o s e r, d e n ta l ad m in is tra to r, M a x i-C a re , H a w th o rn e , C a lifo rn ia . R a y m o n d P in g le , D D S . , v ic e -p re s id e n t o f A sso ciated Services F a m ily H e a lth P ro g ram , L o n g B each, C a lifo rn ia . W illia m J. V la h o v , D .D .S ., d e n ta l d ire c to r, G ro u p H e a lth A s sociation, In c ., W a s h in g to n , D .C .


ASSO CIATION

REPORTS

Jo hn F . P rin c ip e , D .D .S ., d e n ta l d ire c to r, a n d W illia m A . S chlag, H e a lth C e n te r ad m in is tra to r, C a p ita l A re a C o m m u n ity H e a lth P lan , L a th a m , N e w Y ork M r . S tu a rt F rie d m a n , e x e c u tiv e d ire c to r, M a n h a tta n H e a lth P la n , N e w Y o rk , N e w Y o rk

M a ry A n n D o g g e tt, ad m in is tra to r, an d Joseph F . M a n z i, D .D .S ., W e s tc h e s te r C o m m u n ity H e a lth P la n , W h ite P lain s, N e w Y o rk James E . P in a rd i, D . M . D . , d e n ta l d ire c to r, a n d M r . G e o rg e R o b in s o n , d e n ta l a d m in is tra to r, K ais er F o u n d a tio n H e a lth P la n o f O re g o n , P o rtla n d , O re g o n

E X H IB IT I F e d e r a lly Q u a l i f i e d HMOs as o f Septem ber 3 0 , 1978 b y S t a t e , Name and Address o f HMO, M o d e l, and D ate o f Q u a l i f i c a t i o n

A riz o n a ABC-HMO, In c . 4747 N o rth 22nd S t r e e t P h o e n ix , A riz o n a 85016 Group - 8 /3 /7 8 A riz o n a H e a lth P la n , In c . 4811 N o rth 7 th S t r e e t P h o e n ix , A riz o n a 85006 Group - 8 /2 4 /7 8

R o c krid g e H e a lth C are P la n 420 4 9 th S t r e e t O a k la n d , C a l i f o r n i a 94609 IP A - 3 /3 1 /7 8

Group H e a lth A s s o c ia tio n , In c . 2121 P e n n s y lv a n ia A venue, N.W. W ash in g to n , D .C . 20037 S t a f f - 7 /1 8 /7 7

South Los A ng eles Community H e a lth P la n 1731 W est B a rb a ra Avenue Los A n g e le s , C a l i f o r n i a 90062 IP A - 2 /1 0 /7 8

F l o r id a A m erican H e a lth P la n 1701 N o r th e a s t 1 6 4 th N o rth M iam i B each, F l o r id a Group - 7 /2 9 /7 7

33162

C o lo ra d o C a lif o r n ia C a l i f o r n i a M e d ic a l Group H è a lth P la n 1880 C e n tu ry P ark E a s t , S u it e 1500 Los A n g e le s , C a l i f o r n i a 90067 S t a f f - 7 /1 9 /7 7 F a m ily H e a lth Program 2925 N o rth P a lo V erde Avenue Long B each, C a l i f o r n i a 90815 S t a f f - 7 /2 9 /7 7

F o u n d a tio n H e a lth P la n , In c . 650 U n iv e r s it y Avenue S acram ento, C a l i f o r n i a 95825 IPA - 1 2 /2 2 /7 7 H e a lth A llia n c e o f N o rth e rn C a l i f o r n i a 3000 S c o t t B lv d . S anta C la r a , C a l i f o r n i a 95050 Group - 1 1 /2 9 /7 6 HMO C o n cep ts, In c . 1110 E a s t Chapman Avenue O ran g e, C a l i f o r n i a 92666 IPA - 3 /1 7 /7 8

H a w a ii* K a is e r F o u n d a tio n H e a lth P la n , In c . (H a w a ii) 677 A la Moana B lv d . H o n o lu lu , H a w a ii 96813 Group - 1 0 /2 7 /7 7

C o n n e c tic u t

Id ah o

Community H e a lth C are C e n te r P la n , In c . 150 S a rg e n t D riv e New H aven, C o n n e c tic u t 06511 Group - 1 0 /3 1 /7 5

Gem H e a lth A s s o c ia tio n , 6565 E m erald S t r e e t B o is e , Id a h o 83704 Group - 6 /2 7 /7 7

In c .

Illin o is

06606

D i s t r i c t o f Colum bia

93406

Anchor O r g a n iz a tio n f o r H e a lth M a in te n an ce 1725 W est H a r ris o n S t r e e t C h ic a g o , I l l i n o i s 60612 S t a f f 1 2 /2 0 /7 7

Georgetown U n iv e r s it y Community HMO I l l i n o i s , In c . H e a lth P la n , In c . 233 N o rth M ic h ig a n Avenue 5125 M acA rth u r B l v d . , N.W. C h ic a g o , I l l i n o i s 60601 W ash in g to n , D .C . 20016 IPA - 6 /1 5 /7 7 S ta ff 5 /2 6 /7 6 In te r g r o u p P re p a id H e a lth S e r v ic e s , In c . CNA P la z a C h ic a g o , I l l i n o i s 60685 IPA - 4 /1 8 /7 7

*T h e C a l i f o r n i a and H a w â ii lo c a t io n s o f th e K a is e r F o u n d a tio n H e a lth P ia n , In c . q u a l i f i e d to g e t h e r as one HMO.


p r e p a id H e a lth C a r e , In c . 1417 South B e lc h e r Road C le a r w a te r , F l o r id a 33516 S t a f f - 8 /3 /7 8

Rocky M o u n tain HMO 2231 N o rth S eventh S t r e e t Grand J u n c t io n , C o lo ra d o 81501 IP A - 1 2 /2 9 /7 5

C o n n e c tic u t H e a lth P la n 4000 P ark Avenue B r id g e p o r t, C o n n e c tic u t S t a f f - 3 /1 5 /7 7

K a is e r F o u n d a tio n H e a lth P la n , In c . K a is e r C e n te r O a k la n d , C a l i f o r n i a 94666 Group - 1 0 /2 7 /7 7

M a x i-C a re 4455 W est 1 1 7 th S t r e e t H aw th o rn e , C a l i f o r n i a 90250 IP A - 3 /2 5 /7 6

Av-Med H e a lth P la n , In c . 3300 South D ad elan d B lv d . M ia m i, F l o r id a 33156 IPA - 9 /9 /7 7 F l o r id a H e a lth C are P la n , In c . 350 N o rth C lyd e M o rr is B lv d . D aytona B each, F l o r id a 32014 S ta ff 5 /7 5

Com preCare, In c . 2040 South O neida S t r e e t , P .O . Box 22047 D e n v e r, C o lo ra d o 80222 IP A - 8 /2 0 /7 6 K a is e r F o u n d a tio n H e a lth P la n o f C o lo ra d o , In c . 2005 F r a n k lin S t r e e t D e n v e r, C o lo ra d o 80205 Group - 1 0 /2 7 /7 7

F a m ily H e a lth S e r v ic e s , In c . 300 South P a rk'A ven u e Pomona, C a l i f o r n i a 91766 IPA - 1 2 /1 4 /7 6

Los P ad res Group H e a lth P .O . Box 1767 San L u is O b is p o , C a l i f o r n i a IP A - 9 /2 1 /7 8

C ho iceC a re H e a lth S e r v ic e s 12 35 R iv e r s id e F o r t C o l l i n s , C olo rado 80525 IP A - 8 /1 2 /7 6

ASSO CIATIO N

M ic h a e l Reese H e a lth P la n , In c . 3055 South C o tta g e Grove A ve. C h ic a g o , I l l i n o i s 60616 S t a f f - 4 /1 7 /7 8

P rim e H e a lth 373 W est 1 0 1 s t T e rra c e Kansas C i t y , M is s o u ri 64114 S t a f f - 1 1 /2 6 /7 6

K a is e r Community H e a lth F o u n d a tio n o f Ohio Bond C o u rt B u ild in g 1300 E a s t 9 th S t r e e t C le v e la n d , Ohio 44114 Group - 1 0 /2 7 /7 7

N o rth Com m unities H e a lth P la n 1718 Sherman Avenue E v a n s to n , I l l i n o i s 60201 Group 5 /7 5

New Ham pshire

Oregon

Illin o is

M is s o u ri

(c o n tin u e d )

In d ia n a

M atthew T h o rn to n H e a lth P la n , 591 W est H o l l i s S t r e e t N ashua, New H am pshire 03060 S t a f f - 8 /1 5 /7 8

In c .

New J e rs e y

M e tro H e a lth P la n 3000 Meadows Parkway I n d ia n a p o lis , In d ia n a S t a f f - 1 /3 1 /7 7

C a p it o l H e a lth C a re , In c . 960 Broadway, N .E . S alem , Oregon 97301 IPA - 3 /1 /7 8 H e a lth M a in te n an ce o f Oregon P. 0 . Box 8471 P o r tla n d , Oregon 97207 IPA - 6 /9 /7 8

K en tucky

C e n t r a l Essex H e a lth P la n P. 0 . Box 371 O ran g e, New J e rs e y 07051 S t a f f - 1 2 /2 8 /7 6

H e a lth c a r e o f L o u i s v i l l e , In c . 1330 South T h ir d S t r e e t L o u i s v i l l e , K en tucky 40208 S t a f f - 4 /2 /7 6

C ro ssroads H e a lth P la n 141 South H a r ris o n S t r e e t E a s t O ran g e, New J e rs e y 07018 IPA - 3 /1 7 /7 8

K a is e r F o u n d a tio n H e a lth P la n o f Oregon Crown P la z a 1500 S.W. F i r s t Avenue P o r tla n d , Oregon 97201 Group - 1 0 /2 7 /7 7

L o u is ia n a

Group H e a lth P la n o f New J e rs e y 501 7 0 th S t r e e t G u tte n b e rg , New J e rs e y 07093 S t a f f - 6 /2 7 /7 7

P o r tla n d M e tro H e a lt h , In c . 5201 S.W. W estgate D r iv e P o r tla n d , Oregon 97221 IPA 7 /7 5

H e a lth C are P la n o f New J e rs e y 123 N o rth Church S t r e e t M oorestow n, New J e rs e y 08057 IPA - 5 /2 7 /7 6

P e n n s y lv a n ia

46205

H e a lth M a in te n an ce O r g a n iz a t io n o f B aton Rouge, In c . 9151 I n t e r l i n e Avenue B aton Rouge, L o u is ia n a 70809 Group - 3 /1 3 /7 8 M a ry la n d M e t r o p o lit a n B a ltim o re H e a lth C a r e , In c . 1005 N o rth P o in t B lv d : B a lt im o r e , M a ry la n d 21224 S t a f f - 4 /3 /7 8

REPORTS

R u tg ers Community H e a lth P la n 57 U .S . Highway 1 New B ru n s w ic k , New J e rs e y 08901 S t a f f - 7 /1 /7 6

H e a lth S e r v ic e P la n o f P e n n s y lv a n ia 917 S c h a ff B u ild in g 1505 Race S t r e e t P h ila d e lp h ia , P e n n s y lv a n ia Group - 4 /2 6 /7 6

HMO o f P e n n s y lv a n ia 2500 M a ry la n d Road W illo w G ro ve , P e n n s y lv a n ia 19090 C a p it a l A rea Community H e a lth P la n IP A - 6 /1 7 /7 7 1201 T ro y -S c h e n e c ta d y Road Latham , New Y ork 12110 Penn Group H e a lth P la n S t a f f - 1 2 /6 /7 6 IBM B u ild in g P it t s b u r g h , P e n n s y lv a n ia Genesee V a lle y Group H e a lth Group - 1 1 /2 8 /7 5 A s s o c ia tio n 41 C h e s tn u t S t r e e t Rhode Is la n d R o c h e s te r, New Y ork 14647 Group - 1 /3 0 /7 6 Rhode Is la n d Group H e a lth A s s o c ia tio n H e a lth C are P la n , In c . 530 N. M ain S t r e e t 664 E l l i c o t t Square B u ild in g P ro v id e n c e , Rhode Is l a n d B u f f a lo , New York 14203 S t a f f - 1 0 /3 0 /7 5 S t a f f - 8 /3 1 /7 8

19102

New York M a ssac h u setts H a rv a rd Community H e a lth P la n 80 B rig h to n Avenue A l l s t o n , M a ssac h u setts 02134 S t a f f - 9 /1 /7 7 V a lle y H e a lth P la n 441 W est S t r e e t A m h erst, M a ssac h u setts Group - 5 /1 0 /7 8

01002

M ic h ig a n Group H e a lth P la n o f S o u th e a s t M ic h ig a n 21000 Mound Road W a rre n , M ic h ig a n 48091 S t a f f - 9 /1 / 7 7 H e a lth C e n t r a l, In c . 2316 South C edar S t r e e t L a n s in g , M ic h ig a n 48910 S t a f f - 1 2 /6 /7 7 M ic h ig a n H e a lth M a in te n an ce O r g a n iz a t io n P la n , In c . 2200 E d is o n P la z a 600 P la z a D r iv e D e t r o i t , M ic h ig a n 48226 IP A - 4 /1 3 /7 8 M in n e s o ta SHARE H e a lth P la n 1515 C h a rle s Avenue S t . P a u l, M in n e so ta S t a f f - 6 /3 0 /7 6

W e s tc h e s te r Community H e a lth P la n 145 W e s tc h e s te r Avenue W h ite P la in s , New Y ork 10601 S t a f f - 9 /2 8 /7 6 • Ohio

IP A -

1 1 /3 0 /7 6

02904

South C a r o lin a

M a n h a tta n H e a lth P la n , In c . 425 E a s t 6 1 s t S t r e e t New Y o rk , New Y ork 10021 S t a f f - 1 0 /3 1 /7 7

M a rio n H e a lth F o u n d a tio n 125 E x e c u tiv e D r iv e , P. 0 . M a rio n , Ohio 43302

15222

P iedm ont H e a lth C are C o rp . P. 0 . Box 6967 G r e e n v ille , SoOth C a r o lin a S ta ff 6 /7 5

29606

Texas Group H e a lth o f E l P aso , In c . Eastwood M e d ic a l C e n te r 10301 Gateway West E l Paso, Texas 79925 Group - 2 /2 7 /7 8

Box 1085 P r u d e n t ia l H e a lth C are P la n , P. 0 . Box 2884 H ou sto n, Texas 77001 Group - 6 /2 /7 6

In c .

55104


ASSO CIATIO N REPORTS

U ta h *

W ashington

F a m ily H e a lth Program 119 E . 2100 South S a l t Lake C i t y , U tah 84115 S t a f f - 7 /2 9 /7 7

C o o p e ra tiv e H e a lth P la n o f G r e a te r Spokane N o rth 120 S tevens Spokane, W ashington 99201 Group - 8 /3 0 /7 7

W isco n s in South H e a lth A s s o c ia tio n 622 Tacoma Avenue South Tacoma, W ashington 98402 S t a f f - 1 1 /7 4

Group H e a lth C o o p e ra tiv e o f South C e n tr a l W isco nsin One South P ark S t r e e t M a d iso n , W isco n s in 53715 S t a f f - 6 /2 7 /7 7

*T h e C a l i f o r n i a and Utah lo c a tio n s o f th e F a m ily H e a lth Program q u a lifie d

to g e th e r as one HMO.

E X H IB IT M e m b e r s h ip

an d Num ber o f

HMOs b y

S ta te

as

of

Num ber o f S ta te

1978

HMOs

M e m b e r s h ip 91,976 3,242,766 138,019 29 , 1 9 5 152,689

11 4 2 2 4

C o lu m b ia

H a w a ii

1

Id a h o Illin o is In d ia n a K e n tu c k y L o u is ia n a

1 5

18,444 110,365 5,674 78,229 15,214 13,209 3,553 719

1 1 1 1 2

M a ry la n d M a s s a c h u s e tts M ic h ig a n

87,346 36,456 19,099 16,204 2,828 47,964

3 1

M in n e s o ta M is s o u r i N ew H a m p s h ir e N ew J e r s e y

1 1 5 5 2

N ew Y o r k O h io O re g o n P e n n s y lv a n ia

Texas

4 3 1 1 2

U ta h W a s h in g to n

1 2

W is c o n s in Guam

1

Is la n d C a r o lin a

65,276 124,261 242,144 46,555 26,970 4,764 18,714 18,000 22,168 .4,664 21,000

------

P la n s

*A 1 th o u g h

Q u a lifie d

S e p te m b e r

2

C o lo r a d o C o n n e c tic u t D is tr ic t o f F lo r id a

A ll

F e d e r a lly

F e d e r a lly

Q u a lifie d

A riz o n a C a lifo r n ia

Rhode S o u th

II

69*

th is

c o lu m n

to ta ls

72,

th e

4,704,465

a c tu a l

num ber o f

fe d e r a lly

q u a lifie d

HMOs a s o f S e p t e m b e r 1 9 7 8 i s 6 9 f o r t h e f o l l o w i n g r e a s o n s : 1 ) T h e C a l i f o r n i a , U t a h a n d Guam l o c a t i o n s o f t h e F a m i l y H e a l t h P r o g r a m q u a l i f i e d t o g e t h e r a s o n e H M O, a n d 2 ) t h e C a l i f o r n i a a n d H a w a i i l o c a t i o n s o f t h e K a i s e r F o u n d a t i o n H e a l t h P l a n , I n c . q u a l i f i e d t o g e t h e r a s o n e HMO.


ASSO CIATIO N

REPORTS

E X H IB IT I I I D E N T A L S E R V IC E S O FFER ED BY F E D E R A L LY Q U A L IF IE D HMOs AS OF S EPTEM BER 3 0 , 1 9 7 8

NAME AND LOCATION OF HMO

DENTAL SERVICES AVAILABLE*

ABC-HMO, Inc. Phoenix, Arizona

prepaid comprehensive services** and fillings for children through age 13 as basic contract benefit comprehensive services on a fee-for-service basis to both plan members and the community at large

Arizona Health Plan, Inc. Phoenix, Arizona

none

California Medical Group Health Plan Los Angeles, California

optional comprehensive prepaid plans with copayments

Family Health Program Long Beach, California

optional comprehensive prepaid plans with copayments orthodontics offered

Family Health Services, Inc. Pomona, California

prepaid preventive services*** for child ren through age 11 as basic contract bene fit optional comprehensive prepaid plans with copayments

Foundation Health Plan, Inc. Sacramento, California

none

Health Alliance of Northern California Santa Clara, California

none

HMO Concepts, Inc. Orange, California

prepaid preventive services for children through age 11 as basic contract benefit optional comprehensive prepaid plans with copayments comprehensive services on a fee-for-services basis

Kaiser Foundation Health Plan, Inc. Oakland, California

none

Los Padres Group Health San Luis Obispo, California

none

*As described in these briefs, oral surgical services commonly offered through major insurance contracts and resulting from accidental injury to sound and natural teeth are not listed. In almost all cases, such oral surgical benefits are included as part of the basic contract benefits to all members. **Comprehensive services include, at a minimum, diagnostic and preventive as well as restorative dental services. ***Preventive dental services commonly include an examination, X-rays, cleaning, topical fluoride treatment as necessary and instruction in plaque control.


ASSO CIATIO N

REPORTS

Maxi-Care Hawthorne, California

prepaid preventive services for children through age 11 as basic contract benefit optional comprehensive prepaid plan with copayments comprehensive services on a fee-for-service basis to plan members and the com munity at large

Rockridge Health Care Plan Oakland, California

prepaid preventive services for children through age 11 as basic contract benefit optional comprehensive services on a feefor-service basis

South Los Angeles Community Health Plan Los Angeles, California

optional comprehensive prepaid plans with copayments

ChoiceCare Health Services Fort Collins, Colorado

prepaid preventive services for children through age 20 as basic contract benefit

CompreCare, Inc. Denver, Colorado

none

Kaiser Foundation Health Plan of Colorado, Inc, Denver, Colorado

none

Rocky Mountain HMO Grand Junction, Colorado


Community Health Care Center Plan, Inc. New Haven, Connecticut

prepaid preventive services for children through age 11 as basic contract benefit optional comprehensive prepaid plans with copayments

Connecticut Health Plan Bridgeport, Connecticut

none

Georgetown University Community Health Plan, Inc. Washington, D.C.

none

Health Association, Inc. Washington, D.C.

optional preventive and comprehensive prepaid plans with copayments

G ro u p

comprehensive services on a fee-forservice basis orthodontics offered American Health Plan North Miami Beach, Florida

none

Av-Med Health Plan, Inc. Miami, Florida

none

Florida Health Care Plan, Inc. Daytona Beach, Florida

prepaid preventive services with copayments for all plan members. comprehensive services on a fee-for-service basis

Prepaid Health Care, Inc. Clearwater, Florida


none

A SSO CIATION

Kaiser Foundation Health Plan, Inc. Honolulu, Hawaii

none

Gem Health Association, Inc. Boise, Idaho

none

Anchor Organization for Health Maintenance Chicago, Illinois

none

HMO Illinois, Inc. Chicago, Illinois

none

Intergroup Prepaid Health Services, Inc. Chicago, Illinois

none

Michael Reese Health Plan, Inc. Chicago, Illinois

none

North Communities Health Plan Evanston, Illinois

none

Metro Health Plan Indianapolis, Indiana

prepaid preventive services to children through age 11 as basic contract benefit

REPORTS

comprehensive services on a fee-for-service basis Healthcare of Louisville, Inc. Louisville, Kentucky

prepaid preventive services to children through age 11 as basic contract benefit comprehensive services on a fee-for-service basis

Health Maintenance Organization of Baton Rouge, Inc. Baton Rouge, Louisiana

none

Metropolitan Baltimore Health Care, Inc.

prepaid p. rìventive services to children through age 11 as a basic contract benefit

Harvard Community Health Plan Allston, Massachusetts

prepaid preventive services to children through age 11 as basic contract benefit comprehensive services on a fee-for-service basis

Valley Health Plan Amherst, Massachusetts

prepaid preventive services to children through age 11 as basic contract benefit

Group Health Plan of Southeast Michigan Warren, Michigan

none

Health Central, Inc. Lansing, Michigan

none

Michigan Health Maintenance Organization Plan, Inc. Detroit, Michigan

none

Share Health Plan St. Paul, Minnesota

prepaid preventive services for children through age 11 as basic contract benefit optional comprehensive prepaid plans with copayments


ASSO CIATION

REPORTS

Prime Health Kansas City, Missouri

hone

Matthew Thornton Health Plan, Inc. Nashua, New Hampshire

none

Central Essex Health Plan Orange, New Jersey

not applicable (will terminate operations as of May 31, 1979)

Crossroads Health Plan East Orange, New Jersey

none

Group Health Plan of New Jersey Guttenberg, New Jersey

none

Health Care Plan of New Jersey Moorestown, New Jersey

prepaid preventive Services for children and adults as basic contract benefit comprehensive services on a fee-for-service basis

Rutgers Community Health Plan New Brunswick, New Jersey

none

Capital Area Community Health Plan Latham, New York

prepaid preventive service for children through age 11 as basic contract benefit dental rider option for dependents to age 19 with a 50% copayment comprehensive services on a fee-for-service basis

Genesee Valley Group Health Association Rochester, New York

prepaid preventive services for children through age 11 as basic contract benefit comprehensive services on a fee-for-service basis

Health Care Plan, Inc. Buffalo, New York

none

Manhattan Health Plan, Inc. New York, New York

comprehensive services on a fee-for-service basis to plan members and the community at large

Westchester Community Health Plan White Plains, New York

prepaid preventive services for children through age 11 as basic contract benefit comprehensive services on a fee-for-service basis to plan members and community at large

Marioh Health Foundation Marion, Ohio


Kaiser Community Health Foundation of Ohio Cleveland, Ohio

none

Capitol Health Care, Inc. Salem, Oregon

none

Health Maintenance of Oregon Portland, Oregon

none


ASSO CIATION

Kaiser Foundation Health Plan of Oregon Portland, Oregon

REPORTS

prepaid preventive services for children through age 11 as basic contract benefit optional comprehensive prepaid plans with copayments orthodontics offered

Portland Metro Health, Inc. Portland, Oregon


Health Service Plan of Pennsylvania Philadelphia, Pennsylvania

none

HMO of Pennsylvania Willow Grove, Pennsylvania


Penn Group Health Plan Pittsburgh, Pennsylvania


Rhode Island Group Health Association Providence, Rhode Island


Piedmont Health Care Corp. Greenville, South Carolina


Group Health of El Paso, Inc. El Paso, Texas


Prudential Health Care Plan, Inc. Houston, Texas


Family Health Program Salt Lake City, Utah

prepaid preventive services for children through age 11 as basic contract benefit optional comprehensive prepaid plans with copayments orthodontics offered

Cooperative Health Plan of Greater Spokane Spokane, Washington

none

Sound Health Association Tacoma, Washington

not applicable (terminated operations as of December 31, 1978)

Group Health Cooperative of South Central Wisconsin Madison, Wisconsin

prepaid preventive services for children through age 11 as part of basic contract benefit (note: Preventive dental services are obtained from area dentists of the enrollee's choice and GHC pays $9.00 o r 50% of the charge, whichever is greater, for oral prophylaxis and $5.00 or 50% of the charge, whichever is greater, for topical application of fluorides) optional preventive services for enrollees 12 or older including up to $12.00 per treatment for oral prophylaxis, limited to 2 visits per year, and up to $5.00 for topic al application of fluorides

JADA, Vol. 99, October 1979

695

A SSO CIATION

REPORTS

'S O *: o

w v¡

Glossary of dental prepayment terms. Council on Dental Care Programs.

Dental care in pregnancy.

Dental care in leukemia.

Dental care in corrections.

The general dental council.

Council accepts Macleans Fluoride dentifrice. Council on Dental Therapeutics.

School dental care costs.

Obesity and dental care.

Dental care in emergency departments.

Prescribing in primary dental care.

Audit in primary dental care.

Course listing for December 1977 through June 1978. Council on Dental Education. Continuing education programs.

Dental Fear and Delayed Dental Care in Appalachia-West Virginia.

Certification and classification programs for dental materials and devices. List of certified dental materials and devices revised to Jan 1, 1977. Council on Dental Materials and Devices.

Using Quality Improvement to Increase Access to Behavioral Health Care in Federally Qualified Health Centers.

What proportion of dental care in care homes could be met by direct access to dental therapists or dental hygienists?

Health Care Use and Spending for Medicaid Enrollees in Federally Qualified Health Centers Versus Other Primary Care Settings.

Lists of products evaluated by the Council on Dental Materials and Devices and the Council on Dental Therapeutics.

Dental care of the child.

Time until first dental caries for young children first seen in Federally Qualified Health Centers: a retrospective cohort study.

Dental care for the handicapped.

Reasons preventing regular dental care.

'Preventive dental care for toddlers'.

Dental auxiliaries for dental care traditionally provided by dentists.