A Review of Dental Care Services for Adults in Receipt of Social Assistance in Ontario

August 2019

EVID

ENC

E R

EPORT

Integrating health, economic and equity evidence to inform policy

Aaron Burry, Ted Cohen, Carlos QuiñonezFaculty of Dentistry, University of Toronto

About this ReportConverge3 commissioned the Faculty of Dentistry at the University of Toronto to conduct a review of dental care services for adults in receipt of social assistance in Ontario. Converge3 receives funding from the Province of Ontario. The views expressed in this report are those of the authors and do not necessarily reflect those of Converge3 or the Province of Ontario.

Suggested CitationBurry A, Cohen T, Quiñonez C (Faculty of Dentistry, University of Toronto). A Review of Dental Care Services for Adults in Receipt of Social Assistance in Ontario. Converge3: Toronto, Canada. 30 August 2019. Available from: https://converge3.ca/publication/evidence-dental-care-services-adults-receipt-social-assistance-ontario.

About Converge3Converge3 is a policy research centre based in the Institute of Health Policy, Management and Evaluation at the University of Toronto that focuses on integrating health, economic and equity evidence to inform policy. The Centre is funded by the Province of Ontario and includes multiple partner organizations, including Li Ka Shing Knowledge Institute at St. Michael’s Hospital, McMaster University, Ottawa Hospital Research Institute, ICES, Health Quality Ontario, Public Health Ontario, and the Ontario Ministry of Health.

© Converge3 2019

Contact InformationConverge3 Institute of Health Policy, Management and EvaluationDalla Lana School of Public HealthUniversity of Toronto155 College Street – 4th FloorToronto, Ontario M5T 3M6 Canada

https://converge3.ca

info@converge3.ca

@converge3_ca

1

A Review of Dental Care Services for Adults in Receipt of Social Assistance in Ontario

Executive Summary ........................................................................................................................ 2

1.0 Introduction and Background .............................................................................................. 3

1.1 The Historical Perspective ............................................................................................................ 3

2.0 Methods .............................................................................................................................. 5

3.0 Findings ................................................................................................................................ 8

3.1 Descriptive Summary.................................................................................................................... 8

3.2 Program Transparency ............................................................................................................... 16

3.3 Program Administration: Approval of Covered Services, Adjudication and Payment of Claims . 17

3.4 Program Eligibility for Dental Benefits........................................................................................ 20

3.5 Supplemental Public Clinics and Access to Care for Adults Receiving OW .................................. 21

3.6 Assessment and Comparison of Benefits Offered to Adults Receiving OW................................. 23

3.7 MCCSS Fee Comparison .............................................................................................................. 28

Appendix A – Comparison of Dental Coverage ............................................................................. 31

Appendix B – Comparison of Select Fee Codes ............................................................................. 33

2

ExecutiveSummaryThisreportwascommissionedbyConverge3toaddressthefollowingquestion:WhatisthestatusofdentalcareservicesofferedtoadultsinreceiptofsocialassistanceinOntario?Assuch,thisreportdescribesandcomparesthediscretionarydentalbenefitsthatareavailabletoOntarioWorks(OW)recipientsandtheirspousewhoare18yearsofageorolder(adultsreceivingOW)acrossOntariomunicipalities.Inaddition,itexamineswhereadditionalsupportwithdentureservicesareofferedtoadultsreceivingOW.OWisalegislatedsocialassistanceprogramfundedbytheMinistryofChildren,CommunityandSocialServices(MCCSS)andislocallydeliveredacrossOntarioby47ConsolidatedMunicipalServicesManagers(CMSM)orDistrictServicesAdministrationBoards(DSAB).DentalcareforadultsreceivingOWisclassifiedasa“discretionaryhealthbenefit,”meaningthattheCMSM/DSAB(OWadministrators)determinethelevelofhealthbenefitanddeliveryaspartofpolicyandbudgetprocessesoflocalmunicipalcouncilsandadministrativeboards.Italsomeansthattheabilitytosupportdiscretionarybenefitsisimpactedbythefinancialcapacityofthelocalcommunity.Overthelast30years,howsocialassistanceisfundedhaschangedinOntario.Thischangehasresultedinshiftstofundingandcost-sharingformulasand,ingeneralterms,areductionindentalcarebenefitsforOWrecipientstowards“basic”and“emergency/urgent”careonly.Thesereductionshavealsobeencoupledtorestrictionsonservices(e.g.settingfrequencylimitsandincreasingpreapprovals)andthegradualeliminationofitemssuchasdentures.Fromacomparativeperspective,programsand/orbenefitsvaryconsiderablyacrosstheprovinceintermsof:

• Transparency,orhowreadilyaccessibletheinformationistoclientsandproviders• Policyandprocesselements,orthebroadadministrativeapproachtoprovidingandpayingfor

clientbenefits• Eligibility,orthebroadconsiderationsrelatedtoreceiptofdentalservices• Benefits,orthelevelofservicesofferedsuchas“emergencydentalplan,”“basicdentalplan,”

“dentureplan,”“reliefofpainonly,”and/orwhethercontactwiththeOWadministratororcase-workerisrequired

• Serviceplandetails,orwhetherthereisareadilyaccessibledescriptionorlistingoftheservicesthatarecoveredoroffered,and

• Pricing,orthedifferencesinfeesforthesameservicesacrossprogramsand/orwhencomparedtotheMCCSSserviceschedule.

Thecurrentstateofdentalprogramsand/orbenefitsforadultsreceivingOWacrosstheprovinceisdefinedbysubstantialvariationacrossalltheparametersinvestigated,includinghowbenefitsareaccessed,howtheyareadministered,whatservicesareincludedorexcluded,whatmaximumannuallimitsapply,andthelevelsofreimbursementincluded.Fromahealthequityperspective,suchvariationrepresentsatargetforhealthpolicyintervention.Ultimately,policyquestionsfordecision-makersinclude:Shouldtheseservicesremaindiscretionaryorbecomemandatory?Whatoutcomesaregovernmentstryingtoachievebyfundingsuchservices?Whatwaysoforganizing,financinganddeliveringtheseservicesarenecessary?Whatservicesshouldbefundedandforwhatreasons?AndwhatexpertiseisneededtodeliverefficientandequitabledentalcareforadultsreceivingOW?

3

1.0 IntroductionandBackgroundThisreportwascommissionedbyConverge3toaddressthefollowingquestion:WhatisthestatusofdentalcareservicesofferedtoadultsinreceiptofsocialassistanceinOntario?Assuch,thisreportdescribesandcomparesthediscretionarydentalbenefitsthatareavailabletoOntarioWorks(OW)recipientsandtheirspousewhoare18yearsofageorolder(adultsreceivingOW)acrossOntariomunicipalities.Inaddition,itexamineswhereadditionalsupportwithdentureservicesareofferedtoadultsreceivingOW,orrecipientsoftheOntarioDisabilitySupportProgram(ODSP)andtheirdependents.1OWisalegislatedsocialassistanceprogramfundedbytheMinistryofChildren,CommunityandSocialServices(MCCSS)andislocallydeliveredacrossOntarioby47ConsolidatedMunicipalServicesManagers(CMSM)orDistrictServicesAdministrationBoards(DSAB).TheOWprogramobjectivesare:

1. Providefinancialassistancetothosewhoareinneedofhelpwithbasicitemslikefood,shelterandclothing,aswellasassistancewithhealthbenefitsfortherecipientandtheirdependents.

2. Provideemploymentassistancetohelpclientsfind,prepareandkeepajob.Thisassistancemayinclude:resumewriting,interviewing,jobcounsellingworkshops,andjobspecifictrainingtoassistclientstoimprovetheirlanguageskillsorfinishhighschool.

3. Provideemergencyassistanceforpeoplewhoareincrisisoranemergencysituation.OntariansareeligibleforOWiftheyarelivinginahouseholdthatdoesnothavesufficientfinancialresourcestomeetbasiclivingexpensesandiftheyarewillingtomakereasonableeffortstofind,prepareforandkeepajob(unlessspecificcircumstancestemporarilypreventdoingso,suchasanillnessorcaregivingresponsibilities).ToqualifyforODSP,anindividualmustbeatleast18yearsold,anOntarioresident,infinancialneed,andmeettheprogram’sdefinitionofapersonwithadisabilityorbeamemberofaPrescribedClass.21.1 TheHistoricalPerspectiveSomehistoricalperspectiveisusefulforunderstandingthenatureofdentalbenefitsavailabletoadultsonsocialassistanceinOntario.DentalcareforadultsonOWisclassifiedasa“discretionaryhealthbenefit,”meaningthattheCMSM/DSAB(OWadministrators)determinethelevelofhealthbenefitanddeliveryaspartofpolicyandbudgetprocessesoflocalmunicipalcouncilsandadministrativeboards.Italsomeansthattheabilitytosupportdiscretionarybenefitsisimpactedbythefinancialcapacityofthelocalcommunity.Forthesereasons,variationinadultdentalservicesacrossjurisdictionsisexpected.Ontario’sapproachtofundingsocialassistanceisuniqueinCanadawhereinlocalpropertytaxoffsetsaportionofthecosts.Municipalitiesalsodeliversocialassistanceonbehalfoftheprovince.Importantly,howsocialassistanceisfundedhaschangedinOntarioacrosstime.31TheMCCSSprovidesabasicdentalplantoODSPrecipientsandtheirdependents,whichiscentrallyadministered.2AsperMCCSS,“[p]rescribedclassesarespecificcategoriesofpeoplewhodonothavetogothroughthedisabilityadjudicationprocesstoqualifyforODSPIncomeSupport.”See:EligibilityforODSPIncomeSupport.Availableat:https://www.mcss.gov.on.ca/en/mcss/programs/social/odsp/income_support/IS_Eligibility.aspx3See:OfficeoftheAuditorGeneralofOntario.AnnualReport2018.Chapter3.Section3.11OntarioWorks(pp.494-546).Toronto:OfficeoftheAuditorGeneralofOntario,2018;AssociationofMunicipalitiesofOntario(AMO).The2008UploadAgreement(Provincial-MunicipalFiscalandServiceDeliveryReview).Toronto:AMO,August2017;BélandD,DaigneaultPM,editors.WelfarereforminCanada:provincialsocialassistanceincomparativeperspective.UniversityofTorontoPress;2015Sep18;MunirS.ReportoftheCommissionfortheReviewofSocialAssistanceinOntario:TakingStockTwoYearsLater.SPPResearchPaper.2015Mar31;8(8);QuiñonezC,SherretL,GrootendorstP,ShimMS,AzarpazhoohA,

4

Priorto1995,theprovincefundedthefullcostofmonthlysocialassistance,50%of“discretionaryhealthbenefits”(includingdental),and50%ofthe“costofadministration”forsocialassistancelocally.After1995,municipalitiesbecameresponsiblefor20%ofthecostofmonthlysocialassistance;however,theprovinceincreasedtheportionofdiscretionarybenefitsitwouldcost-shareto80%.Municipalitieswereabletoleveragethecost-sharingwiththeprovincetoattractadditionalprovincialdollars(80centdollars)totheircommunitiesandthereforeoffermoreservicestothoseinneed.In1996,thefirstfundingcapsontotalexpendituresfordiscretionaryhealthbenefitsandchangestothecostofadministrationformulaswereintroducedbytheprovince.Thechangeinfundingformulascreatedlocalfinancialshortfalls.Asaresult,severalmajorjurisdictions,whichofferedabroadsuiteofbasicdentalcareservices,beganadjustingtheirprogramstoprovide“emergencydentalcareonly”foradultsocialassistancerecipients.Thechangesin1996wereapreludetothe1998majorrestructuringofsocialassistanceintowhatisknowntodayasOWandODSP.Aspartofthechangestolegislation,agreateremphasisonemploymentandtrainingwasaddedandaportionofthecostofsocialassistancewasdownloadedtothemunicipalities.Thismeantanincreasedportionofthepropertytaxrevenuefundedmonthlysocialassistancepayments.Municipaladministratorswerealsorequiredtocoveraportion(20%)ofthemonthlycostofODSP(eventhoughtheydidnotdeliverODSP)and20%ofthehealthbenefitsforODSP.Theyear2008markedanothersignificanttransition,withtheprovinceagreeingtoassumethecostofallsocialassistanceover10years.In2012,administrationofOWwaschangedtoapercaseformularatherthantheprevious50/50costsharingarrangement.OWadministratorswerealsonolongerrequiredtocost-sharediscretionarybenefits;however,theprovinceintroducedapercapitafundingmodelforalldiscretionaryhealthbenefitsataflatrateof$10perOW/ODSPrecipientperfiscalyear,basedonitstotalexpendituresin2010.Byfixingtheamountpercase,municipalitieswhowereinvestingmorethantheflatrateunderthe80/20formulatendedtoreceivelessprovincialfundingfordiscretionarybenefitsthantheywereaccustomedto,andthosewhoinvestedlesstendedtoreceivemore.Overall,thechangesdescribedabovehavetendedtoreducedentalcarebenefitsforOWrecipientsto“basic”or“emergency/urgentlevel.”Thesereductionshavealsobeencoupledtorestrictionsonservices(e.g.settingfrequencylimitsandincreasingpreapprovals)andthegradualeliminationofitemssuchasdentures.Importantly,whilespecificsocialassistancedentalcareexpendituresarenotavailable,overall,publiclyavailableinformationdemonstratesvariabilityinprovincialgovernmentfundeddentalcareexpendituresbasedonthechangesoutlinedabove(Figure1).

LockerD.Anenvironmentalscanofprovincial/territorialdentalpublichealthprograms.Ottawa:OfficeoftheChiefDentalOfficer,HealthCanada,2007;HerdD,MitchellA,LightmanE.Ritualsofdegradation:AdministrationaspolicyintheOntarioWorksProgramme.SocialPolicy&Administration.2005Feb;39(1):65-79;HerdD.Rhetoricandretrenchment‘commonsense’welfarereforminOntario.Benefits.2002Jun1;10(2):105-10;GrahamKA,PhillipsSD.“WhoDoesWhat”inOntario:Theprocessofprovincial-municipaldisentanglement.CanadianPublicAdministration.1998Jun;41(2):175-209;MorrisonI,PearceG.Undertheaxe:socialassistanceinOntarioin1995.JournalofLawandSocialPolicy.1995;11:1.

5

Figure1.Provincialgovernmentfundeddentalcareexpenditures,Ontario,1975to2017($2017,‘000000).Source:NationalHealthExpenditureDatabase,CanadianInstituteforHealthInformation

2.0 MethodsThiswasadescriptivestudybasedonareviewofwebsites,documents,andinformationsourcedfromtheInternetandthroughrequeststoOWadministrators.Specifically,informationwasobtainedthroughanonlinesearchoftheCMSMorDSABwebsites/portalsorthird-partyorganizationswithwhichtheCMSMorDSABhaspartnered(i.e.PublicHealthUnit[PHU])orcontracted(i.e.AccertaClaimServicorpInc.[Accerta],TheGreat-WestLifeAssuranceCompany[Great-WestLife])toadministerdiscretionarydentalbenefitsforOWrecipients.Informationwassummarizedandcollatedinavarietyofways.Anoveralldescriptivesummarybyjurisdictionisprovidedforthefollowingelements:

• Transparency,orhowreadilyaccessibletheinformationistoclientsandproviders• Policyandprocesselements,orthebroadadministrativeapproachtoprovidingandpayingfor

clientbenefits• Eligibility,orthebroadconsiderationsrelatedtoreceiptofdentalservices• Benefits,orthelevelofservicesofferedsuchas“emergencydentalplan,”“basicdentalplan,”

“dentureplan,”“reliefofpainonly,”and/orwhethercontactwiththeOWadministratororcase-workerisrequiredandanyannuallimit

• Serviceplandetails,orwhetherthereisareadilyaccessibledescriptionorlistingoftheservicesthatarecoveredoroffered,and

• Notes,oradditionalrelevantdetails.

Amoredetailedanalysisbasedontheaboveelementsisprovidedbeyondjustsimpledescription.Areviewofthepublic(directdelivery)clinicsandapproachestakenintheseclinicsisincluded.A

$0

$10

$20

$30

$40

$50

$60

$70

$80

$90

$100

Prov

incia

l Gov

ernm

ent F

unde

d D

enta

l Car

e Ex

pend

iture

s ($

2017

, '00

0 00

0)

Year

6

conveniencesampleofdentalbenefitplansisreviewedtodetermineandcomparethelevelofservicesbeingofferedbymunicipaladministrators.Thebroadareasreviewedinclude:

• Theannuallevelofbenefitsavailable• Whetherpredeterminationorpreauthorizationforservicesisrequired• Whetherproceduresincommoncategoriesarecovered• Specificlimitationsforreimbursement(servicecodes,frequencyandotherlimitations),and• Thegeneralconstructionoftheplanandcoveragefordentures.

Andanassessmenttoolwasalsodevelopedthatconsiders30differentparameters,whichareusedtocomparejurisdictionsinAppendixA--ComparisonofDentalCoverage.Table1belowprovidesadescriptionforeachoftheparameters.

7

Table1.ParameterstocomparedetailsofaconveniencesampleofdentalbenefitplansofferedbymunicipaladministratorsParameter AssessmentparameterdescriptionDollarlimit Paymentlimitordollarlimitoftheplanina12-monthperiodPredetermination/preauthorization(PD)

Dentistsarerequiredtosubmitinformationforapprovalforspecificservicesorwhentreatmentcostsareexpectedtoexceedacertaindollarlimitlevel

MCCSSFees ArethereimbursementlevelsintheplanthesameasfoundJanuary2018MCCSSScheduleofDentalServicesandFees(yesorno)?

Amalgam&composite Doestheplanreimbursecompositerestorationstothesamerate?Complete Referstoacomprehensivedentalexamination,whichisdonewhenapatient

seestheirdentistforthefirsttimeorperiodically(generallyeveryfiveyears)Emergency Referstoanemergencyexaminationtoinvestigateanurgentdentalproblem

whenthepatientpresentswithpainorinfectionSpecific Likeanemergencyexamination,reimbursedatthesamelevel;someplans

placelimitationsonhowmanyspecificoremergencyexamscanbeclaimedwhileothersareopenended,forexample,aplanthatindicatesanycombinationofanemergencyexamandspecificexamsuptothreeduringasix-monthperiod(describedas3/6inthechart)

Recall Referstoreimbursementforaperiodicre-examinationofexistingpatient;notconsideredascomprehensiveasacompleteexam;usuallynotincludedinplanswherethefocusistheimmediatereliefofpainanddiscomfort(emergencydentalplan)

Film Referstoradiographs(x-rays),orthenumberthatwillbereimbursedinagivenperiod

Panoramic Generalfull-faceorsurvey(x-ray)oftheentireteethandjawsBiopsy Referstoassessinggrowthsorlesionsinthemouththataresuspiciousand

removingthesuspecttissueandsendingforanalysisPreventative Referstothreeelementsdefinedunderprevention:polishing,scalingand

topicalfluoridetreatments;emergencydentalplanstypicallydonotincludethiscomponent

Caries,TraumaandPainControl(CTPC)

Referstotheplacementofvariousdressingsintheteethandgumstostoppain

Amalgam Planreimbursesamalgam(silver)fillingsComp(A) Planreimburseswhite(compositeresin)fillingsinthefrontteeth(12front

teeth)Comp(P) Planreimbursesforwhite(compositeresin)fillingsinthebackteeth(12back

teeth)Pulpotomy ReferstoproceduresremovingpartofthenerveofapainfultoothPulpectomy ReferstoproceduresforremovingallthenervetissueofapainfultoothRootCanalTherapy Referstosealingthecanalspaceleftafterthenervetissuehasbeenremoved,

cleanedandshapedPerio42831 Referstotreatingapainfulinfectioninthegums(gumabscess)Basicremovals ReferstoremovingorextractingteethorotherdamagedtissuesinthemouthReplant Referstoputtingatoothbackintoplaceifitisknockedoutormovedbya

blowLimited8’s ReferstolimitationintheremovalofimpactedwisdomteethGeneralAnesthetic(GA) ReferstogeneralanestheticbeingacoveredserviceSedation ReferstotheadministrationofintravenousdrugstosedateapatientNitrousOxide(NO) Referstonitrousoxideor“laughinggas”Dentures ReferstocoverageforacrylicdentureseithercompleteorpartialCastRemovalPartialDenture(RPD) Referstopartialdenturesthathavecastmetalcomponents;usuallymore

expensivethancompletelyplasticdenturesRepairs ReferstorepairingofadentureReline Referstotheadditionofnewmaterialtoadenturetofillinareaswherethe

tissuehasshrunk;improvesfitofdenture

8

3.0 Findings3.1 DescriptiveSummaryTables2to4belowprovidedatakeysforinterpretinganoveralldescriptivesummaryofprogramsandbenefitsbyjurisdiction.ThissummaryisincludedinTable5,whichhighlightsprogramtransparency,policyandprocesselements,eligibility,benefits,availabledetailsoftheserviceplan,andanyadditionalrelevantinformation.ThedatapresentedinTable5(alsobelow)indicatesthatthereisvariationintheapproachtoprogramsandbenefits.Morespecifically,thereremaingeographicdifferencesinhowservicesareadministered,theservicesthatareoffered,andhowtheyareoffered.Forexample,somejurisdictionshavedevelopedlocalinitiativestoaddressaccesstodentalcarechallengesbyexpandingclinicseitherwithinCommunityHealthCentresoraspartofthelocalPHUinfrastructure.Theseclinicsarefundedthroughacombinationofprovincialgrants,localgrantsand/orcontributionsfromcharitableorganizations.Insomejurisdictions,thereisafixedandtransparentcommitmenttotheseprogramsandbenefitsavailabletoclientsforagivenperiodoftime,whichareclearlyoutlinedinofficialpoliciesandsupportedbybudgetallocationsandrelatedtenderingprocesses.However,forsomemunicipaladministrators,thereisadegreeofopacityrelatedtotheinformationavailableregardingwhatdentalcarebenefitsareoffered.Thisisarguablyduetosomejurisdictions’needtomanagethedemandforarangeofassistance,andforstafftomaintaindiscretionintheapprovalprocess.Thedatacollectedreflectsasnapshotintimethatcontinuestoevolveasjurisdictionsreviewtheirprogramsaspartoftheirpolicyandannualbudgetcycles.Table2.Datakey1:TransparencyA InformationavailableforclientsandprovidersaboutthebenefitsofferedontheOW

administrator’ssiteB InformationavailableforclientsaboutthebenefitsofferedontheOWadministrator’ssiteC Informationavailableforprovidersthroughthird-partybenefitsadministratorD Informationavailablethroughasecondarywebsiteinthelocaladministrativeareasuchasa

communityorPHUwebsiteE Noinformationavailableandclientsrequiredtospeakwiththeirworkertodeterminewhat

assistancemightbeavailableF Indicationthatassistancemaybeofferedbutnodetails

Table3.Datakey2:PolicyandprocesselementsDirectlyadministered

OWadministratordirectlyauthorizesandpaysforservices

Third-partyadministered

OWadministratorhascontractedwiththird-partytoadjudicateandpayforserviceclaims

PHUadministered

OWadministratorhaspartneredwithPHUtoprovidearangeofadministrativeservices,fromadjudicationandpaymentofserviceclaims,toprovidingcaredirectlyinPHUdentalclinics

9

Table4.Datakey3:Eligibility1 Assistancewiththecostofemergencydentalcare:Adultsanddependentsovertheageof18up

tothelastmonthadultisinreceiptofOW2 Assistancewiththecostofdentures:Adultsanddependentsovertheageof18uptothelast

monthadultisinreceiptofOW3 Reliefofpainonly:Adultsanddependentsovertheageof18uptothelastmonthadultisin

receiptofOW4 Pre-reviewbyOWadministratortoseeifassistancemaybeprovided:Adultsanddependentsover

theageof18uptothelastmonthadultisinreceiptofOW

10

Table5.SummaryofprogramsandbenefitsbyjurisdictionJurisdiction Transparency Policyandprocess

elementEligibility Benefits Service

plandetails

Notes

Toronto B/C Third-partyadministered,definedbenefitclaimsadjudicatedbyGreat-WestLife

1/2 Emergencydentalplananddentureplan,noannualdollarlimit

Yes Announcementin2016thatOWclientscouldattendTorontoPublicHealthdentalclinics

Cornwall E Directlyadministered

2 Reimburse,tothedentaloffice,$75dollarspertoothforemergencyrelatedwork

No EasternOntarioHealthUnitprovidingdentalservicestoOWclientsonaprobonobasisbeyondthe$75dollarsforanemergencyextraction

Durham A PHUadministered 1/2 Emergencydentalplananddentureplan,predeterminationforvariousotherservices

Yes

CountyofHastings

F Directlyadministered

4 GatewayCommunityHealthCentredentalclinicoffersservices,$50pervisit

No ClinicstartedatGatewayCommunityHealthCentredentalclinicstartedforOW/ODSPclientsaswellaslowincomeclients,$50pervisitirrespectiveofcostoftreatmentforthosewithoutcoverage

KawarthaLakes/Haliburton

C/F Third-partyadministered,definedbenefitclaimsadjudicatedbyAccerta

1/2 Emergencydentalanddentureplan

Yes

Kingston F Directlyadministered

1 Emergencydentalplan,upto$350annually

No ClinicstartedatKingstonCommunityHealthCentre.Staffdentistsprovidecare.Acceptthe$350annuallyandprovidecareoutsidethelimit.Additionalsourcesoffundingavailablethatsomeclientscanaccessfundedbythemunicipality,alocalcharity,aswellasblockfundingfromtheLocalHealth

11

Jurisdiction Transparency Policyandprocesselement

Eligibility Benefits Serviceplandetails

Notes

IntegrationNetwork.Programandservicescontinuetoevolve.

LanarkCounty D Directlyadministered

1 Emergencydentalplan,upto$400annually

No

LeedsGrenville D Noonlineinformation

1 Basicdentalplan,upto$400annually

No

Northumberland A/C Third-partyadministered,definedbenefitclaimsadjudicatedbyAccerta

1/2 Emergencydentalanddentureplan

Yes

CityofOttawa A/C PHUadministeredanddirectadministrationofdentureprogram

1/2 Emergencydentalplanwithinclinicsanddentureplanwhichispreauthorizedaccordingtoclinicalneed

No DentalcareprovidedthroughtheOttawaPublicHealthclinics.Variableservicesavailableyear-over-yearpendingbudgetaryapprovalfromCityCouncil.

Peterborough A Third-partyadministered,definedbenefitclaimsadjudicatedbyAccertaanddirectadministrationofdentureservices

1/2 Accertabasicdentalplanupto$600pertreatmentplanandupto$1500fordenturesevery5years

Yes

Prescott-Russell F Directlyadministered

3 Emergencydentalplan,limitedto$75

No EasternOntarioHealthUnitoffersclinicsinCornwallandHawkesburywhereclientscanattendatnocharge.Clinicdoesacceptthelimitedpaymentbutbroaderdentalneedsmaybeaddressed.

PrinceEdward/LennoxandAddington

C/D Third-partyadministered,definedbenefit

1 Accertaemergencydentalplan

Yes

12

Jurisdiction Transparency Policyandprocesselement

Eligibility Benefits Serviceplandetails

Notes

claimsadjudicatedbyAccerta

CountyofRenfrew

C/D Third-partyadministered,definedbenefitclaimsadjudicatedbyAccerta

1 Accertaemergencyplanupto$500annually

Yes

CountyofDufferin

D Directlyadministered

1 Emergencyplan,$300per12months

No

HaltonRegion D PHUadministered 1/4 Upto$200thenpreauthorizationrequired

No

Peel A Third-partyadministered,definedbenefitclaimsadjudicatedbyGreat-WestLife

1/2 Emergencydentalplananddentureplan

Yes

SimcoeCounty C/D PHUadministered 1/2 Emergencydentalanddenturebenefitplan

Yes

Waterloo A PHUadministered 1/2 Emergencydentalanddenturebenefitplan

Yes

CountyofWellington

A Thirdpartyadministered,definedbenefitclaimsadjudicatedbyAccerta

1 Accertabasicdentalplan,upto$1000percalendaryear

Yes

YorkRegion A Third-partyadministered,definedbenefitclaimsadjudicatedbyAccerta

1/2 Accertaemergencydentalplananddentureplan

Yes

13

Jurisdiction Transparency Policyandprocesselement

Eligibility Benefits Serviceplandetails

Notes

Brantford E Directlyadministered

4 Reliefofpain,contactwithcaseworkerrequired

No

BruceCounty F Directlyadministered

4 Directfollow-uprequiredtoseehowOWadministratorwillassist

No

Chatham-Kent F Directlyadministered

4 Directfollow-uprequiredtoseehowOWadministratorwillassist

No

CountyofGrey C/F Third-partyadministered,definedbenefitclaimsadjudicatedbyAccerta

1 Accertabasicdentalplan,upto$1000percalendaryear

Yes

CityofHamilton A Directlyadministered

1/2 Emergencydentalplananddentureplan

Yes

HuronCounty B/C Third-partyadministered,definedbenefitclaimsadjudicatedbyAccerta

1 Accertabasicdentalplan,upto$1000percalendaryear

Yes

LambtonCounty B PHUadministered 1 Emergencydentalplan

No

CityofLondon A DirectlyAdministered

1 Emergencydentalplan

No Twoteethpersixmonths,fillingorextractionsonly

Niagara B Directlyadministered

1/4 Upto$135permonth,thenfollow-upwithcaseworker

No

NorfolkCounty F Directlyadministered

3 Directfollow-upwithOWcase

No

14

Jurisdiction Transparency Policyandprocesselement

Eligibility Benefits Serviceplandetails

Notes

worker,vouchersystem

OxfordCounty E Directlyadministered

3 Directfollow-uprequiredtoseehowOWadministratorwillassist

No

CityofSt.Thomas

F Directlyadministered

3 Directfollow-uprequiredtoseehowOWadministratorwillassist

No

CityofStratford C/F Third-partyadministered,definedbenefitclaimsadjudicatedbyAccerta

1 Accertaemergencydentalplan

Yes

CityofWindsor A Directlyadministered

1 Basicdentalplan,$300percalendaryear

Yes

Algoma C/E Third-partyadministered,definedbenefitclaimsadjudicatedbyAccerta

1/2 Accertaemergencydentalplananddentureplan

Yes

Cochrane C/E Third-partyadministered,definedbenefitclaimsadjudicatedbyAccerta

1/2 Accertaemergencydentalplananddentureplan

Yes

Kenora C/F PHUadministered 1 Basicdentalplan No Manitoulin-Sudbury

A Third-partyadministered,definedbenefitclaimsadjudicatedbyAccerta

1 Accertaemergencydentalplan

Yes

15

Jurisdiction Transparency Policyandprocesselement

Eligibility Benefits Serviceplandetails

Notes

Muskoka A PHUadministered 1/2 Emergencydentalplananddentureplan

Yes

Nipissing E Directlyadministered

3 OWadministratorprovidesvoucherforreliefofpain

No

ParrySound C PHUadministered 1/2 Emergencydentalplananddentureplan

Yes

RainyRiver C/F PHUadministered 1 Indicationthatbenefitsareavailable,butnodetails

No

SaultSte.Marie B/C Third-partyadministered,definedbenefitclaimsadjudicatedbyAccerta

1/2 Accertaemergencydentalanddentureplan

Yes

Sudbury E Directlyadministered

3 Contactwithcaseworkedforvoucher,limitedtopain

No

ThunderBay B/C Third-partyadministered,definedbenefitclaimsadjudicatedbyAccerta

1 Accertaemergencydentalplan

Yes

Timiskaming C/E Third-partyadministered,definedbenefitclaimsadjudicatedbyAccerta

1/2 Accertaemergencydentalplananddentureplan

Yes

16

3.2 ProgramTransparencyTable6belowsummarizesthedatarelatedtoprogramtransparency,ortheeaseoffindingprograminformationrelatedtothedentalprogram.Table6.ProgramtransparencyCategory Description CountofOWmunicipal

administratorsA Informationavailableforclientsandprovidersaboutthe

benefitsofferedontheOWadministrator’ssite131

B InformationavailableforclientsaboutthebenefitsofferedontheOWadministrator’ssite

62

C Informationavailableforprovidersthroughthird-partybenefitsadministrator

1

D InformationavailablethroughasecondarywebsiteinthelocaladministrativeareasuchasacommunityorPHUwebsite

73

E Noinformationavailableandclientsrequiredtospeakwiththeirworkertodeterminewhatassistancemightbeavailable

84

F Indicationthatassistancemaybeofferedbutnodetails 1251Two of the 13municipalities refer and direct dental providers to Accerta for information about thebenefitsplan.2FourofthesixmunicipalitiesreferanddirectdentalproviderstoAccerta.InthecaseofToronto,theinformationcanbeobtainedfromGreat-WestLife.3Forthreeofsevenmunicipalities,theplanswereavailableelectronicallyandtheinformationpostedfordentalofficesanddenturists.4Threeof theeightmunicipalitieshavecontractswithAccertaand the informationwas foundon theAccertawebsite.Theinformationwouldbemoretransparenttodentalofficesbutlesstoclientsinthesecases.5Forfiveofthe12municipalities,althoughthereisnopublicinformationeasilyaccessible,informationwasobtaineddirectlyfromtheAccertawebsite.Intermsoftransparency,an“A”ratingisthemostdesirable.Thismeansthatboththeclientandpotentialdentalproviderhaveaclearindicationofwhatwillbecoveredorpaidforbythemunicipaladministrator.Forthesurveyperiodin2017,thisrepresentedapproximatelyoneinfourmunicipaladministrators.Attheotherendofthespectrum,categoryF,therewasonlyanindicationthatdiscretionarydentalbenefitsmightbeavailable.Withineachprogram,therewasvariationintheleveloftransparency.Theareaofleasttransparency(withtheexceptionofthosewithpublishedplans)wasrelatedtodentureplans.Incomparisontoemergencyplans,fordentureplans,therewasoftennoinformationatallorastatementindicatingclientscouldspeakwiththeircaseworkertoseeifassistanceisavailable.Themajorityofprogramsdoprovideinformationonline;however,inanumberofcasesfindinginformationrelatedtoprogramswasdifficult.Fortheseprograms,municipaladministratorswerecontactedtoseekadditioninformation.Whileinformationrelatedtoseveralplanswasobtainedthroughtheirassistance,inmanycasesthemunicipaladministratorshadnoinformationavailableandindicatedthatclientswouldneedtospeakwithaninternalcaseworkertoobtaininformation.And

17

often,thecaseworkerwouldonlysupplyinformationtoindividualswhowereregisteredintheprogram.AsignificantsourceofadditionalinformationwasobtainedfromPHUsandisreflectedincategoryD,whereinformationrelatedtodentalservicesofferedbythemunicipaladministratorcouldbefoundthroughthePHUwebsite.Thesewebsitesfrequentlyofferedsummariesofalldentalprogramsandservicesbycategory(children,adults,lowincomeandseniors,includingadultsonOW)thatwereavailableinthatjurisdictionorsurroundingjurisdictions.Inthesejurisdictions,clientsseekingadditionalinformationarethusmorelikelytocallthePHU.Astheresultsdemonstrate,theextenttowhichassistanceisavailablevariesandinformationrelatedtotheprogramscanbeopaque.Althoughalladministratorsoffersomeassistance,thereisvariationinhoweasyitistoanswerabasicquestion:WhathelpisavailabletomeifIhaveatoothacheandamanadultonOntarioWorks?Itispossibletogetaclearanswertothisquestionfromsomemunicipaladministrators.Inothercases,adentalofficethatacceptsOWclientsintheirareawillhavetoprovidetheinformationandcanassistandexplaintheentitlements.Andinothercases,themunicipaladministratorstates“itdepends,”andclientsneedtospeakwithanOWcaseworkerdirectly,whereinsomecasestheclientisrequiredtoobtainestimatesfromdentalofficespriortoassistancebeingapproved.Ultimately,formanyOWclientsinOntario,itisdifficulttoknowiftheycanobtainassistancefortheirdentalproblemsorwhethertheywillberesponsibleforpayingforaportionorallofthecostsofcare.Thesetwofactorsarebarrierstoseekingandreceivingdentalcare.WhilePHUscanbeakeysourceofinformationandmayhelpclientsnavigatingthesystem,thisisnotconsistentacrossOntarioeither.Transparencyintermsofprocessisalsoimportanttoproviders.Indeed,aprovider’sdecisiontoparticipateinaprogramandacceptOWclientsarguablyrelatestotheeaseofofficestaffconfirmingaclientiseligiblefortheprogram,clarityaroundservicesthatarecoveredwithminimalrequirementforfollow-upwiththirdparties(predeterminationoradditionalrequests),availabilityofinformationdirectlyrelatedtothelevelsofreimbursement(feestobepaid),aswellasaclearindicationofthelimitationsinthescopeofprocedures,andpromptpaymentpreferablythroughanelectronicsubmissionandpaymentsystem.Whentheseelementsarenotinplaceorreadilyavailablethereisanincreasedlikelihoodthataproviderwilloptnottoparticipateinagovernmentplan.43.3 ProgramAdministration:ApprovalofCoveredServices,AdjudicationandPaymentofClaimsDiscretionarydentalbenefitshavebeenavailableforsocialassistancerecipientsinOntarioforatleastfivedecades.5Municipaladministratorsassessanindividual’slevelofeligibilityfordentalassistancetoaddresstheirdentalneedsandbalancetheneedtoprovideshort-termassistancewithavailablefunding.

4See:QuiñonezCR,FigueiredoR,LockerD.Canadiandentists'opinionsonpubliclyfinanceddentalcare.Journalofpublichealthdentistry.2009Mar;69(2):64-73; Quiñonez C, Figueiredo R, Azarpazhooh A, Locker D. Public preferences for seeking publicly financed dental care andprofessionalpreferencesforstructuringit.Communitydentistryandoralepidemiology.2010Apr;38(2):152-8.5See:QuiñonezC,SherretL,GrootendorstP,ShimMS,AzarpazhoohA,LockerD.Anenvironmentalscanofprovincial/territorialdentalpublichealthprograms.OfficeoftheChiefDentalOfficer,HealthCanada;2007.

18

TherearespecificmandatorybenefitsorentitlementsforeligibleOWrecipients(e.g.adefinedmonthlyallowance),andOWclientshavearighttoappealthedecisionsofmunicipaladministrators(generallywhentheadministratorhasdeniedbenefits)totheSocialBenefitsTribunal(SBT).Importantly,municipaladministratorssetpolicieswithrespecttoeligibilityfordiscretionarybenefits,whichcannotbeappealedtotheSBT.Municipaladministratorsdeterminethescopeofbenefitstobeofferedandgenerallyadministerthesebenefitsdirectly(issueavoucherorrequisitionforthespecifiedservice);however,arrangementswithathird-partyclaims-payeroraPHU(departmentorBoardofHealth)alsoexist.Beyondtheadministrativearrangementstherearealsovariationsinprogramdelivery.Table7belowsummarizestheadministrativeapproachestoadjudicatingandreimbursingprovidersforcoveredservices.Asdescribed,approximately40%ofdiscretionarydentalbenefitsareadministereddirectlybyOWadministrators.Thepercentageishigherfordentureplans,assomeOWadministratorsthathavethird-partyarrangementsstillretainadministrationofthedentureplancomponent.ThesearenotedinthedetailedsummaryinformationrelatedtoplansfoundinAppendixA–ComparisonofDentalCoverage.Approximately33%areusingthirty-partyclaimadjudicationarrangements,primarilyAccertaorintwocasesGreat-WestLife.Approximately24%havearrangementwithaPHUstooverseetheirprograms.Theapproachvaries,includingadjudicatingspecificdentalbenefitsandreimbursingclaims,assessingandauthorizingspecifictreatment,and/orprovidingcaredirectlythroughpublicclinics.Table7.AdministrativeapproachestoadjudicatingandreimbursingprovidersApproach Description

CountofOWmunicipal

administrators

Directlyadministered

OWadministratordirectlyauthorizesandpaysforservices 21

Third-partyadministered

OWadministratorhascontractedwiththird-partytoadjudicateandpayforserviceclaims

15

PHUadministered

OWadministratorhaspartneredwithPHUtoprovidearangeofadministrativeservices,fromadjudicationandpaymentofserviceclaims,toprovidingcaredirectlyinPHUdentalclinics

11

Ingeneralterms,thefollowingaretheprogrambenefitadministrationapproaches:

1. Definedbenefitandpayment.Thedentalproviderandpatientdeterminethecourseoftreatmentandthemunicipaladministratoragreestoreimburseeligibleproceduresundertermsofthecontract.Theentitlementsavailablemayormaynotaddressalltreatmentneeds.Noadditionalconsiderationforcareexitsoutsideoftheprogramlimitations.Themajorityofmunicipaladministratorspayfordiscretionarydentalservicesdirectly.One-thirdhasengagedathird-partycarriertoadjudicateandpayclaims.

2. Definedbenefitandpaymentwithconsiderationtoadditionalexpenses.Similarto1;however,

themunicipaladministratormayapproveadditionalassistanceonacase-by-casebasis.Third-partyadministratorsarenotinvolvedinthisprocessandOWadministratorsauthorizetheadditionalexpensesdirectly.

19

3. Caseworkerrequest/approval.Theclientrequestsassistancewithdentalcareandtheircaseworkerprovidesa“requisition”tocoversomeportionofthevisit.Thiscantakeavarietyofformsfromarequisitionthatwillcoveramaximumcostforthevisitproblemtoapprovingaspecificestimateforservicesthatissubmittedbytheproviderorclient.

4. Pre-assessmentandauthorization.Clientsrequestassistanceandarescreenedorasubmission

reviewedbyadentalprofessionalandaspecificauthorizationforcareisprovidedtotheclientthattheclientcanthentaketoadentist.Insomeinstances,theassessmentisbeingdoneinpublichealthclinicsthatoffer“preventive”and“cleanings”butdonotprovidefillingsandextractions,whichtheyauthorizeandtheclientcanthenseeaprivatedentist.

5. Directdelivery.OWclientsattendpublicclinicsandseeastaffdentist.Thedentistassessesthe

clientandprovidescare.Programslikethishaveadegreeofflexibilitytoexpandwhatisofferedbasedontheclient’sneedsthatmaybebeyondadefinedschedulewhilestillconsistentwithstabilizinganindividual’sdentalcondition.Theseclinicsoperateonacost-recoverybasisandmayormaynothaveadditionalgovernmentcontributions.Forexample,theCityofOttawahasusedthisapproachforover30yearsandhasfourclinicstoserveadultsreceivingOWamongitspatientgroup.

6. Mixeddelivery.OWclientsareprovidedemergencylevelcoverageorbenefitsbutcanalso

attendpublicclinicsthatmayofferadditionalbasiccare.Forexample,theCityofTorontohasopeneditpublicclinicstoOWrecipientsspecificallyforthisreason.

Giventheabove,itisclearthatmunicipaladministratorshaveconsiderableflexibilityinhowprogramsaredesignedanddelivered,particularlybecausethesearecompletelydiscretionarybenefits.Thisisreflectedintheadministrativeapproaches,variationinprogramdelivery,andthebenefitsoffered.Cost-sharingwasanimportantincentivetoprovidingtheseserviceswhentheprovincepaid80%ofthecostofdiscretionaryhealthbenefits(includingdentalcare).Withtheintroductionofper-capitafundingfordiscretionarybenefits,thereareindicationsthatthedesignanddeliveryoftheseprogramsisevolving.Forexample,third-partyadministrationisincreasinglycommon-place,whetherselectedthroughaformaltenderingprocess(Toronto),sole-sourcedtoaspecificprovider(Renfrew),orareacontinuationofarrangementsthathavebeeninplaceformanyyears(Ottawa,Waterloo,Hamilton).Engagingathird-partygenerallysignalsthatthemunicipaladministratorhasmovedawayfrommakingdeterminationsinternallyonacase-by-casebasistoadoptingadefinedbenefitwithuniformclaimsprocessing.Thistendstoprovidegreaterclaritytoprovidersandtoclientsaboutwhatcareiscovered,andissuggestedtoachievecostcontainmentthroughplandesignthatlimitstherangeandfrequencyofservices.Accerta,forinstance,claimsthattheyhelp“provide[municipal]clientswithacomprehensive,high-qualityoralhealthcaresocialservicesprogramwhilecurtailingcosts,reducingfraudulentclaims,andincreasingoverallefficiency.”6PHUsalsoactasthird-partyprocessorsforsomemunicipaladministrators.TheyperformthesamefunctionsasclaimprocessingandpaymentcompaniessuchasAccertaandGreat-WestLife.Someincorporateadditionalreviewandauthorizationfunctionsandtakemoreofaprogrammaticapproachthatincorporatesplandesign,assessmentofclinicalcircumstancesandauthorizationofadditionalcarethatisoutsideofadefinedplan.Plans/programsadministeredbyPHUshavehigherlevelsofpreandpostdeterminationsincorporatedintotheadministrationingeneralbasedonthereviewofthe

6See:Accerta.DentalCarePlanManagement.Availableat:https://www.accerta.ca/dental

20

documentedplans,policiesandproceduresherein.Theseaddedaccountabilitymeasuresaredesignedtoarguablycontaincostsbylimitedreimbursementbutalsohaveprovisionstoapproveadditionalcareundercertaincircumstancestoaddressaspecificclient’shealthneeds.Basedonproviderdiscussionsconductedbytheauthorsofthisreport,thisdoesresultinaddedeffort,timedelaysandhasthepotentialforproviderstofeeltheyhavetounnecessarilyjustifythecaretheyareproviding.Additionaladministrativeburdenisafactorinproviderselectingnottoacceptgovernmentplans.73.4 ProgramEligibilityforDentalBenefitsAllmunicipaladministratorsoffersomeformofassistancewithemergencydentalneedstoadultclients,between18and65yearsofage,whiletheyareeligibleforOW.Table8belowsummarizesthetypicallevelofdiscretionarybenefitsofferedandarereflectiveoflocalpolicyrelatedtoreliefofpainonly,tobroaderemergencydentalcare,andwhetherdenturebenefitsareoffered.Table8.LevelofdiscretionarybenefitsofferedDescription CountofOW

municipaladministrators

Assistancewiththecostofemergencydentalcare:Adultsanddependentsovertheageof18uptothelastmonthadultisinreceiptofOW

14

Assistancewiththecostofemergencydentalcareanddentures:Adultsanddependentsovertheageof18uptothelastmonthadultisinreceiptofOW

20

Assistancewiththecostofemergencydentalcareandwithapre-reviewforassistancewithdentures:Adultsanddependentsovertheageof18uptothelastmonthadultisinreceiptofOW

5

Reliefofpainonly:Adultsanddependentsovertheageof18uptothelastmonthadultisinreceiptofOW

7

Pre-reviewbyOWadministratortoseeifassistancemaybeprovided:Adultsanddependentsovertheageof18uptothelastmonthadultisinreceiptofOW

1

TheOWclientstatementofbenefitsservesasproofofeligibilityinmostjurisdictions.Theclientpresentsthisstatementatthetimeofavisittoadentalofficeasproofofeligibility.Themaindifferenceineligibilityiswhetheraprovidercanproceedandprovidecarewithinthescopeofbenefitsavailable(automaticallyeligible)orwhetheraspecificrequesthastobemadebytheclientorthedentalprovideronbehalfoftheclientbeforetreatmentcanproceed.Forsomemunicipaladministratorsbothemergencydentalanddenturesbenefitsareautomaticallyprovidedtoeligiblerecipients.Forothermunicipaladministrators,clientsareautomaticallyeligiblefortheemergencydentalplanhoweverdentureplanassistancemustbepreauthorized.Sevenmunicipaladministratorsprovidecoveragethataddressesreliefofpainonlywhereremovingatoothbutarelessclearastowhetherafillingofatoothmightbecovered.Caseworkersaremoredirectlyinvolvedinapprovingthebenefitinsuchcases.Itisdifficulttoaccesswritteninternalmunicipaladministrativeguidelines;however,anelectroniccopywasprovidedbyManitoulin-Sudbury.Manitoulin-Sudburyisanexampleofamunicipaladministratorthathasathird-partyprocessercontractedtoadjudicateandpayclaimstodentaloffices(Accerta).Their

7See:QuiñonezCR,FigueiredoR,LockerD.Canadiandentists'opinionsonpubliclyfinanceddentalcare.Journalofpublichealthdentistry.2009Mar;69(2):64-73; Quiñonez C, Figueiredo R, Azarpazhooh A, Locker D. Public preferences for seeking publicly financed dental care andprofessionalpreferencesforstructuringit.Communitydentistryandoralepidemiology.2010Apr;38(2):152-8.

21

policyallowsforadditionalcareoutsidethatplantobeauthorizedandpaidfordirectlybythemunicipaladministrator.ThefollowingisanexcerptfromtheManitoulin-SudburyDistrictServicesBoard,policyandproceduremanuallastrevisedJanuary2009:

Emergencyisdefinedasbeinganunscheduledeventwhereanindividualappearsinimmediatedistressandrequirescare,andimmediateappropriatetreatmentisneededtocorrecttheproblem.TheDirectorofIntegratedSocialServicesmayapprovecostsfordentalservicesprovidedtoadultmembersofthebenefitunitfor:Emergencydentalcare(dentalserviceswhicharenecessarytorelievepainorformedicalortherapeuticreasons);Dentalcarewhichsupportstheperson’semployabilityorparticipationrequirements(e.g.orthodonticanddentureservices);AnyexceptionalcircumstanceswheredeemedmedicallynecessaryatthediscretionoftheDirectorofIntegratedSocialServicestakingintoconsiderationtheHealthandWelfareoftheindividual.Thisserviceisavailabletoparticipantsandbeneficiarieswhoarenotdependentchildren.DentalcoveragefordependentchildrenisamandatoryitemofassistanceunderOW.

Basedonanumberofconversationswithmunicipaladministrators,aswellastwooftheauthors’(AB,CQ)experiencetreatingpatientsorconsultingfordifferentpublicdentalprogramsacrossOntario,manymunicipaladministratorshavesimilarinternalprocedurestoapproveadditionalassistanceoutsideofprescribedbenefitplans.Thenumberofprogramsthatprovideadditionalassistanceisnotpossibletodetermineandwouldrequiresignificantfollow-upanddiscussionwithmunicipaladministrators.Giventheabove,itisclearthatallmunicipaladministratorsoffersomeformofemergencydentalbenefitorassistance.Municipaladministrators,withformalplansforbothemergencydentalanddenturebenefits,haveinessencecreatedaquasi-mandatorybenefit.Clientscanaccesscareasneededandreceivetreatmentanddentalofficesarereimbursedinaccordancewithspecificserviceandfrequencylimitations.Theprimaryobjectiveofthisapproachisarguablytoachieveclarityofbenefitsreimbursedandtoadministerplansthataredesignedtoensuresomelevelofcost-containment.Othermunicipaladministratorssee“dental”asacompletelydiscretionarybenefitwiththedeterminationmadebycaseworkers.Minimalpainrelief(forexamplecostofanextraction)arereimbursedaspartofasingleemergencyappointmentwithadditionalservicesbeyondthefirstappointmentrequiringpre-approval.Thisresultsinuncertaintyforboththeclientsanddentaloffices.Basedonthereviewofmunicipaladministrators’websitematerials,factorsrelatedtoqualityoflife,health,andemployabilityarepartoftheoverallgoalsforprovidingdiscretionaryassistance,whichsupportoralhealthgoalsandobjectiveslessdirectly.Onlyafterpre-approvalisreceivedwillclientsknowwhatserviceswillbeprovided.Dentalofficesarerequiredtoprepareestimatesandwaitfornotificationofauthorizationpriortoproceedingwithcare.Thecriteriausedtodeterminewhatwillbeauthorizedornotauthorizedbymunicipaladministrativestaffisgenerallynotpubliclyavailable.Importantly,somejurisdictions(Ottawa)havesystematicassessmenttoolsandpoliciesthatareusedbystaffdentiststoreview,performandapprovereferralforcare.3.5 SupplementalPublicClinicsandAccesstoCareforAdultsReceivingOWThemajorityofmunicipalitiesuseadefinedbenefitplanwhereprivateprovidersdelivercareandarereimbursedforservicesprovidedthroughaclaimsadjudicationandpaymentprocess.Adjudicationandclaimspaymentprocessesareincreasinglyrapidandprovidedbyanumberofthird-partyadministratorsandinsurancecarriers.TherehasbeenatrendtowardscentralizationofclaimspaymentforsocialassistanceinOntario(HealthySmilesOntario(HSO)andODSP).Theapproachreliesonaclearsetof

22

proceduresthatdefinewhichproceduresareeligibleforreimbursement.Themajorlimitationisthat,bydesign,claimsadjudicatingandpaymentprocessesmustmeetfinancialparameterswhilenotnecessarilyaddressingthecareneedsofallclients.ThereareagrowingnumberofOntariocommunitieswhere,inadditiontothedefinedbenefitsplans,fixedpublicclinicshavebeenestablished(Toronto,Kingston,Hawkesbury,Tweed,NorthBay,Cornwallasexamples),ashavemobilepublicclinics(NiagaraRegion,HamiltonandPeel),withtheinitialcapitalcostssupportedbyprovincialandlocalinitiativesandoperatingfundsderivedfromvarioussources.Theseclinicshaveprogramsthatserveprimarilylow-incomeOntarianswhohavedifficultyaccessingprivatecare(somealsoincluderecipientsoftheFederalNon-InsuredHealthBenefits(NIHB),ODSPandOWprograms).Theseclinicalprogramsweredevelopedindependentlyofoneanotherandthereisconsiderablevariationintheiroperationsandservicesoffered.Thelevelofintegrationwiththelocalmunicipaladministratorandothernot-for-profitorganizationslikecommunityhealthcentresandPHUsalsovaries.Insomeinstances,thehostnot-for-profitorganizationhasaspecificcontractualandfundingarrangementinplacewithmunicipaladministrators.Inothercases,OWclientsareacceptedbytheclinicandtheclinicisreimbursedforservicessimilartootherprovidersorreceivesblockfundingthattheclinicshadow-billsagainst.Dependingonfunding,clinicsofferservicesfromonetofivedaysormoreperweek.Theclinicsgenerallyofferthesamelevelofcaretoallclientswhoseekservicesandfunctionasadirectaccessclinicalprogram.Demandforservicesishighandthereforeeffectivemanagementoftheservicesofferediscriticaltoensureurgentproblemsareprioritized.TheCityofOttawaistheonlymunicipaladministratorthatprovidesdirectcaretoalladultsreceivingOW.Themunicipaladministrator(abranchofcitygovernment)hasenteredintoanagreementwithOttawaPublicHealth.Underthisagreement,OttawaPublicHealthisresponsibleforalldental-relatedmattersforOWclients.OWprogramstaffarenotabletogeneraterequisitionsrelatedtodentalservicesanddirecttheirclientsforalldental-relatedmatterstotheclosestclinic.Throughtheclinics,clientsareoffereddentalserviceswithreferralstospecialistsarrangedasrequired.OttawaoperatesthreeclinicscurrentlyspecificallydedicatedtoadultsreceivingOWandlow-incomeindividuals,aswellaschildrenthroughtheHSOprogram.8Thefinancialeligibilityfortheprogramisconfirmedbythemunicipaladministratorthroughacentralizedfinancialassessmentprocess.AllOWclientsareeligibletoreceiveservicesatanyofthethreeclinics.DentalcardsorproofofeligibilityforOWarenotrequiredbecausedentalclinicsarepartofthecity’sintegratedinformationsystem.Theprogramhaswell-developedpolicyandassessmentparametersforthecaretobeprovided.Theprogramprioritizesurgentproblems,offerssame-dayornext-dayappointmentsandfocusesonmeasurestohelppreventfurtherproblems.TheprogramencouragesadultsreceivingOWtotakeadvantageofthetwodentalhygienetrainingprogramsatthetwocommunitycollegestohelpmaintaintheiroralhealthoncetheurgentproblemorproblemshavebeenaddressed.DenturesareofferedthroughaspecificpartnershipprogramwiththeOttawaDentalandDenturistSocieties.Staffdentistsassessandauthorizingspecificdentureservices.Thisapproachwasintroduced

8OttawaPublicHealthoperatesadentalclinicattheWabanoCentreandprovidesdentalservicestoIndigenousadultsincludingthosewhoareinreceiptofOW.

23

inthelate1990’sandresultedinbetteroutcomesbecauseitensuredthatclientshadallthenecessarypre-workcompletedpriortothepatientshavingtheirpartialorfulldenturesmade.Staffdentistscanpreauthorizeadditionalserviceswhererequiredtoimproveoutcomesandworkdirectlywithexternalproviders.Overallthough,basedonareviewoftheplansobtainedforthisstudy,themajorityofmunicipaladministratorsareusingadefineddentalbenefitplanthatfunctionsinasimilarmannertoemployer-sponsoredplans,butoffermorelimitedcoveragewhencomparedtoemployer-sponsoredplans(whichincludemorecoveredproceduresandopportunityforregularvisitsandmaintenance).Importantly,inmanycommunitiestheOWadultplanswillpayforurgentcarethatotherlow-incomeOntarianscannotafford.Andoneofthekeyissuesrelatedtothisistheissueutilization,meaningdentalplansforlow-incomeOntarianshavehigherutilizationratesthannon-insuredpopulationsyetlowerutilizationratesthanemployer-sponsoredplans.9Giventhis,alimitednumberofmunicipaladministratorsfundlocalprogramswhichallowlow-incomeadultstoaccessthesamediscretionarybenefitsasadultsreceivingOW.Inaddition,OWadministratorsincommunitiesincludingKingston,Cornwall,andTweed,forexample,reportedtotheresearchersthattheyopenedpublicclinicstoassistagrowingnumberofindividualswhocannotaffordtoaccesscareandthatarenotcoveredbypublicprograms.Theclinicsoperatebasedonacombinationoffee-for-service,grants,localfundingandorlocalcharitablecontributions.Althoughtheseapproachesappeartohaveincreasedinrecentyears,theyremaintheexceptionratherthanthenorm.3.6 AssessmentandComparisonofBenefitsOfferedtoAdultsReceivingOWInOntario,servicesperformedbydentists(examination,diagnosis,fillingsetc.)havespecificdescriptionsandareassignedaspecificfive-digitnumericcode.TheseservicedescriptionsandtheircorrespondingcodesarereferredtoastheUniformSystemofCodingandListofServices(USC&LS).TheUSC&LSisproducedandownedbytheCanadianDentalAssociation.InOntario,theOntarioDentalAssociation(ODA)producestheODASuggestedFeeGuideforGeneralPractitioners,whichassignsasuggestedfeetospecificcodesfromtheUSC&LS.SpecialityassociationsinOntarioalsoproducetheirownschedulesfortheirmembers.Aruleofthumbisthatspecialistfeesare20%higherthangeneralpractitionerfees.Governmentdentalplans,likeOW,HSOorODSP,usetheUSC&LSunderlicense.ThesepublicplanscontainaselectionorpartiallistofcodesthatappearintheODAsuggestedfeeguideandarereimbursedunderthetermsofthepublicplan(totalfeeandfrequency).TheHSOandODSPplansarecommonlyreferredtoas“basicdentalplans”.Asanexample,takingandinterpretingapanoramicradiographicisdescribedbycode02601,iscoveredonceeveryfiveyears,isreimbursedat$31.54forageneraldentistor$37.85foraregistereddentalspecialistlicensedbytheRoyalCollegeofDentistsofOntario(RCDSO).OWadultplans(withacoupleofexceptions)coverfewerservices(codes)orlowerallowancesorfrequencyandarecommonlyreferredtoas“emergencydentalplans”.Wheremunicipaladministrators

9See:QuiñonezC,SherretL,GrootendorstP,ShimMS,AzarpazhoohA,LockerD.Anenvironmentalscanofprovincial/territorialdentalpublichealthprograms.OfficeoftheChiefDentalOfficer,HealthCanada;2007;QuiñonezC,FigueiredoR.Sorrydoctor,Ican’taffordtherootcanal,Ihaveajob:Canadiandentalcarepolicyandtheworkingpoor.CanadianJournalofPublicHealth.2010Nov1;101(6):481-5;RamrajC,SadeghiL,LawrenceHP,DempsterL,QuiñonezC.Isaccessingdentalcarebecomingmoredifficult?EvidencefromCanada'smiddle-incomepopulation.PloSone.2013Feb20;8(2):e57377.

24

coverservicesbyissuingarequisitioninresponsetoanestimatesuppliedbytheclientfromadentaloffice,theactualservicescovered,feesassessedandwhatisactuallyreimbursedislessclear.Thisreviewwasabletoobtain26publishedplansrepresenting56%ofmunicipaladministratorsacrossOntario.Theremainingadministratorsdonothavepublishedplansorschedulesthatcanbereferenced.TherearenotwoplansinOntariothatareexactlyalike,butanattempthasbeenmadetocomparethembasedonaseriesofparameters(seemethodssection).AppendixA–ComparisonofDentalCoverageprovidesadetaileddescriptionoftheuniquefeaturesofeachofthe26benefitplans,butingeneralterms,itcanbesaidthatthereisvariationbasedon:

• Specificservicesbeingcovered• Frequencywithwhichcertainservicesarecovered• Inclusionofcertaintreatmentsforallteeth• Exclusionofcertaintreatmentsforcertainteeth• Amountoftimereimbursedforservicesthatarebilledbasedonatimebasis• Limitstothetotalamountthatcanbereimbursedina12-monthperiodorotherperiod• ReimbursementoffeesasoutlinedintheMCCSSfeeguide,and• Otherspecificfeaturessuchaswhenexceptionscanbecoveredorarespecificallynot

considered.Itcannotbeoverstatedthatthevariationacrossandwithintheparametersmakesitdifficulttoestablishandidentifycommonalitiesamongstplans.Table9belowisadescriptivesummarythatillustrateswherethereiscommonality(likelypointingtothediversity)inthediscretionarydentalbenefitsofferedbyOWadministratorsthroughtheadultdentalplans.Table9.Commonality(diversity)indiscretionarydentalbenefitsParameter Descriptionofcommonality(diversity)Annualreimbursementlevels

Eightof26planshavea12-monthtotalreimbursementmaximum:Wellington$1,000,Grey$1000,Huron$1000,Peterborough$600,Renfrew$500,ParrySound$425,SimcoeCo.$400,andWindsor$300.Allremainingplansdonothaveanannuallimit.

Reimbursementperdentistorperclient

Thelimitationsaregenerallyperpatientpertimeframe.Insomeplansandforsomeservicesthewordingisperdentist.

Fullexaminations Threemunicipaladministrators,Peterborough(1/60months),YorkRegion(1/60months),andSaultSt.Marie(1/36months),coveracompleteexaminationatdifferentfrequencies.PeterboroughwillprovidecoverageforarecallexaminationafterninemonthsandYorkwillmatchthesamelevelofbenefitasODSPadultrecipients.Noneoftheotherplansincludearecallexamination.

Radiographs Coveragevariessignificantlybetweenplans.Forexample,ParrySoundwillreimbursethreeperiapicalradiographs(PA)peremergencyvisit,whileThunderBayorNorthumberlandreimbursethreePAevery12months.Thereisvariationaswhetherbitewing(BW)radiographsareincludedinthecountswithPA,inadditiontoPA,ornotincludedatall.ParrySoundcoverstwoBWeveryninemonths,TorontoreimbursessixPAorBWina12-monthperiod,whereasPeterborough,YorkandThunderBayallowforeightPAin12monthsandtwoBW.Durhamwillreimburseforthreefilmsclaimedinathree-monthperiodincludingBW.Incontrast,SaultSt.Marieprovidesforfivefilmsina12-monthperiod.Torontoexcludespanoramicradiographs(PAN),whileThunderBay,WellingtonandGreyCountyincludeaPANaspartofthetotalcountofthreeradiographsper12-months,whereasSaultSt.MariewillreimburseforaPANonceevery36monthsandPeterboroughonceevery24months.

25

Preventiveservices Scaling,polishingandfluoridetreatmentsareincludedinPeterborough’splan($600totalplanreimbursementlimitper12months).YorkRegion’splancoversscalingandfluoridetreatmentbutnotpolishing.NorthumberlandincludesuptofourunitsofscalingforOWadultwomenduringpregnancy.

Posteriorcomposites

Thesefillingsinthemolarteethareincludedasabenefitinallplans,exceptforToronto,wheretheyarenotanincludedbenefit.Torontowillreimburseforsilveramalgamfillingsinthemolarteeth.YorkandHamiltonincludeposteriorcompositesbutonlyreimbursethesamefeeasforanamalgamrestoration(feesarelower).PlansadministeredthroughAccertacontainageneraldisclaimerrelatedtoonlyreimbursingsilveramalgamfeesifatoothisfilledwithtwoseparatematerialsatthesametimebutdoreimbursehigherfeesforcompositerestorations.

Rootcanaltherapy(RCT)

PeterboroughwillcoverRCT.Yorkwillcoveroneortwocanaledteeth,SaultSt.MariewillreimburseforRCTonthefrontteeth(nocoverageforpremolarormolarteeth),Durhamrequirespredeterminationandcoversonlythefrontteethandlimitsthereimbursementtothefeeforonecanal.ParrySound,Simcoecoverone-canaledteeth.Fortheremainderofmunicipalities,includingToronto,ThunderBay,Wellington,GreyCounty,Windsor,Stratford,partialRCT(pulpectomy)iscovered.

Basicanddifficultextractions

Allplanscoverbasicandcomplexextractions.Durhamrequirespredeterminationforremovalofwisdomteeththatareimpacted.Allplans,withtheexceptionofToronto,paytore-implantatooththathasbeendislodgedorknockedout.TheMuskokaandSimcoeOWareaplansrequiretheprovidertosubmitanexplanationanddetailsoftheproceduresusedwhensubmittingforcomplexextractions.

Sedation Mostadministratorsdonotofferreimbursementprovidinggeneralanesthesia,deepsedationorconscioussedation.Peterborough,HuronandPeelcoveruptoeightunits(1.5hours)ofsedationpervisit.Torontowillreimburseforconscioussedationuptoeightunitsperyear.SaultSt.Mariereimbursesuptosixunits(75minutes)ofanycombinationofgeneralanesthesia,deepsedationorconscioussedationina12-monthperiod,whereasHamiltonwillreimbursefourunitsina12-monthperiod.TheSimcoeandMuskokaareaplanshaveprovisionstoconsidersedationunderverylimitedcircumstancesandrequireanexpertletterjustifyingthemedicalneedpriortobeingconsideredandauthorised

Intermsofdentureplans,ofthe46municipalities,13(25%)havepublisheddentureplans.Thisdoesnotnecessarilymeanthatothermunicipalitiesdonotprovidesuchassistance,astheymaybeofferedonacase-by-casebasisdirectlythroughcontactwithacaseworker.Liketheplansdescribedabove,therearenotwoplansthatarethesame.AnassessmentofeachplanisalsoincludedinAppendixA–ComparisonofDentalCoverage.Thedatahighlightsthefollowing:someplansaremoregenerousandwillprovidefornewdentures(onceeveryfiveyears),allowformorefrequentrepairsandmaintenance,periodicreliningorrebasingtoaddressmanydenture-relatedneedsand/orextendthelifeofanexistingdenture;otherscontainfewerservices(relinesorrebasesnotcovered),havelongerreplacementfrequencies,excludecastpartialdenturesandcaptotalreimbursementindifferentways.

Toillustratethevariation,Northumberlandwillcoveranewpairofdenturesevery60monthsbutnotrelinesorrepairstoexistingdenturesorthoseconstructedundertheplan.Torontocoversasetofdenturesorpartialseveryfiveyears(coversonlyacrylictypepartials),arelineonceevery36monthsand$88dollarsreimbursementina12-monthperiodforrepair.Haltonincontrastcoversanewfullorpartialdentureseveryfiveyears,uptofourrepairsperyearandcoverstissueconditioning,whichmostplansdonotinclude.SaultSt.Mariecoversanewdenturebenefitonceinalifetime,onerepairandarelineeverytwoyears.

26

Therewasalsonoconsistencyintermsoffeespaidfordenture-relatedservices.Forexample,Durhamwillreimburseamaximumfeeof$580.27perdentureandSaultSt.Marie$495.00.Theoppositeistrueforrelines/rebases,whereDurhamreimburses$163.86andSaultSt.Mariereimbursesamaximumfeeof$180.Fromthepointofviewofpolicy,thefollowingstatementfromWellingtonisreflectiveofthegeneralpolicyintentofmostplans:

Theintentofcoverage-PlansponsorsdoNOTintendtoprovideon-going,regulardentalcarefortheirclients.Theintentofthisplanistoprovideemergencycareonlywiththeconstraintsofthisprogram.Anemergencyinvolvesbleeding,pain,infectionortrauma.Itrequirestreatmentofasymptomaticpatientwhenthepatientappearsindistressandappropriatetreatmentisinstitutedforthatspecificemergencyproblem(s).Resolutionoftheproblemmayrequiremorethanoneappointment.

Whilemostoftheplandesignsemphasizeprovidingalimitedcourseoftreatment,allgenerallyreimbursethecostofabasicexam,aradiograph(s)andassistancetoremoveatooth,ortoplaceaverybasicfilling,whichisinconsistentwiththestatedintentofthepolicies.AnotherkeyissueisthelackofclarityforanOWadultclientintermsofthelevelofassistancetheycanreceiverelatedtoaparticulardentalproblem.Theinformationinplansisdesignedandtargetedtodentalprofessionalsandthelimitationsandservicescoveredarecomplexforthegeneralreaderorsomeonethatisnotfamiliarwithdentalterminology.AndincontrasttootherdiscretionarybenefitswhereanOWcaseworkercan,inrelativeterms,accuratelydescribethebenefit(assistancewitheyeglassesforexample),dentalcarerequiresexaminationanddiscussionwithaprovider.Afurtherandrelatedconsiderationisthat,whileextrabillingisnotpermittedforserviceswithintheplan,dentistsarepermittedtochargeforservicesoutsidetheplan.Thus,thereisthepotentialforclientstobeunsureaboutthelevelofassistanceavailableandconcernedaboutthepotentialofhavingtopayforsomeservices.Basedontheexperienceoftwooftheauthors(AB,CQ)inmanagingandadjudicatingdentalservicesforsocialservicesadultrecipients,thiscanresultinOWclientseitherdelayingornotseekingcare.ThediversityinplansalsomeansthatinsomeareasofOntario,theassistanceofferedcanhelpOWclientsmaintainorpotentiallyimprovetheiroralhealthduringthetimetheyareonassistance(Peterborough,YorkandtoalesserextentOttawa),whereasinotherareasofOntario(suchasWindsor),offersofassistancecoveronlyonedentalproblemorpossiblyasecondinstanceiftherearefundsremainingwithintheirannualdollarvaluelimit.ThisisconsistentwiththenotionthatOWis“shorttermassistance”andverybasicsupportsareprovidedtoclientstoachieveself-sufficiencyintheshortesttimepossible.Thisalsomeansthatplansdonotconsideranindividual’sbaselineoralhealthor“timeonassistance,”specificallycaseswhereindividualsreturntosocialassistancerepeatedly,orwhereassistanceisongoingandintergenerational,whichasindicatorsofpoverty,alsolikelymeansthatoralhealthstatusispoorerthanmoresocioeconomicallystableOntarians.10Sedation(specificallynitrousoxide,intravenoussedationandgeneralanesthesia)isapolicyareawhichrequirescarefulconsiderationwhendesigningpublicprograms.Therehasbeenconsiderableexpansion

10See:SadeghiL,MansonH,QuiñonezC.ReportonaccesstodentalcareandoralhealthinequalitiesinOntario.PublicHealthOntario;2013.

27

inthepromotionandavailabilityofsedationindentalpracticeinOntario;whileatthesametime,thereisdeclineinthenumberofpractitionerswhotreatveryanxiouspatientsbecauseoftheadditionaldemands(timeandemotion)onthedentalteamtoproperlysupportaclientwithdentalanxiety,whichisarguablymadeworsewhencoupledwithlowerreimbursementrates.11Aswasnotedinthefindingsonlyfivemunicipaladministratorsincludeassistancewiththecostsofsedationandthereisvariationintheamountcovered(twoothersofferlimitedreimbursementunderexceptionalmedicalcircumstances).Sedationcostsoftenequalorexceedthecostoftreatmentprovidedduringanappointmentandarethereforenotinsignificant.Someofthefiveplanshavelanguagethatspecificallyexcludessedationrelatedtoanxietyorfearofthedentist,andrequireanothermedically-relatedjustificationforittobereimbursed.Duringthegatheringofinformationrelatedtocase-by-caseauthorizations,itwasevidentthatinsomeinstances,municipaladministratorswereapprovingsedationinexceptionalcircumstances(removalofanimpactedtoothorwherethereareconcurrentmedicalproblemsmakingsedationcriticaltoprovidingtreatmentsafely).TheextenttowhichadultsreceivingOWareavoidingcarebecausetheycannotaccesssedationorarepayingforsedationservicesaspartofemergencydentalcareisunclear.Municipaladministratorsworkwithinspecificfinancialconstraintsandpolicyframeworksthatareapprovedlocally.TheplansreviewedforthisreportarguablyreflectarangeoflocalpolicyoutcomesthatbalancefinancialconstraintswiththelocalrealitiesofthecompositionofOWcaseloadsandthechallengesofgeography(ruralversusurbanforexample).Theapproachtoaddressingtheseconstraintsdiffers.PlansadministeredthroughPHUssuchasSimcoeandParrySoundhavecarecoveredannually($400/$425peryearandincludebothpre-treatmentandpost-treatmentadjudicationrequirements,suchassupplementalinformationandradiographswhenclaimingforthehigherfeeassociatedwiththeextractionofatoothorpreauthorizationforremovalofmorethanonewisdomtooth).Inthisapproach,andwhencomparedtothoseplansthatareadjudicatedbyotherthird-parties,therecanbeabroaderrangeofservicescoveredwithinasimilarfinanciallimitlikelybecauseofthehigherlevelofaccountabilityforexpenditures.Low-incomeadultsandadultsonsocialassistancehavehigherdentalneeds(poororalhealth)thanthegeneralpopulation.12Publicdentalplansforadultsonsocialassistancehavealsochangedlittleoverthelast30yearsintermsofthescopeofcoveredprocedures,andgenerallyonlyaddressanurgentdentalproblems.13MunicipaladministratorsthathaveplansthatareclosertotheODSPlevelofbenefithaveagreaterpotentialtoassistclientsmaintainorimprovetheiroralhealthwhileonassistancebecausetheplanincludesabroaderrangeofcoverageforroutinepreventivecare,restorative,endodonticcare,surgicalservicesandanesthesia.ProvidinganODSPlevelofbenefittoallOWadultclientswouldentailasignificantincreaseinexpendituresovercurrentlevelsinOntario.ItisalsoimportanttonotethatevenanODSPbenefitlevelwouldnotallowallOWadultclients’oralhealthtobemaintainedand/orrestored

11See:ChanpongB,HaasDA,LockerD.Needanddemandforsedationorgeneralanesthesiaindentistry:anationalsurveyoftheCanadianpopulation.Anesthesiaprogress.2005Mar;52(1):3-11;AdamsA,YarascavitchC,QuiñonezC.UseofandAccesstoDeepSedationandGeneralAnesthesiaforDentalPatients:ASurveyofOntarioDentists.JCanDentAssoc.2017;83(h4):1488-2159.12See:QuiñonezC,FigueiredoR.Sorrydoctor, Ican’taffordtherootcanal, Ihavea job:Canadiandentalcarepolicyandtheworkingpoor.CanadianJournalofPublicHealth.2010Nov1;101(6):481-5;HealthCanada.SummaryreportonthefindingsoftheoralhealthcomponentoftheCanadianHealthMeasuresSurvey,2007-2009.Ottawa:HealthCanada,2010;CanadianAcademyofHealthSciences.ImprovingaccesstooralhealthcareforvulnerablepeoplelivinginCanada.Ottawa:CanadianAcademyofHealthSciences,2014.13See:QuiñonezC,SherretL,GrootendorstP,ShimMS,AzarpazhoohA,LockerD.Anenvironmentalscanofprovincial/territorialdentalpublichealthprograms.OfficeoftheChiefDentalOfficer,HealthCanada;2007;ShawJ,FarmerJ.AnenvironmentalscanofpubliclyfinanceddentalcareinCanada:2015update.Toronto:FacultyofDentistry,UniversityofToronto,2016.

28

tofullfunction.Manylow-incomepatientsgowithoutdentalcareforsignificantperiodsoftimeandneedmoreadvancedtreatment,14whichisoutsidethescopeoftheODSPormostpublicplansinCanada.Finally,clinicslikethoseinEasternOntario,Kingston,NorthBay,andOttawaoftenhelpclosesomeofthegapinaccesstocareandservicesbyofferingcarethatresemblesthecarereceivedthroughHSOorODSPforadefinedperiod.ThistypeofextendedaccessisnotavailableineverycommunityinOntario,ornotpromotedopenlyduetothecommunity’slimitedcapacity.ThisreflectsthediversityanddisparityofapproachesofaccesstocareacrossOntario.3.7 MCCSSFeeComparisonAspresentedintheprevioussection,mostOWadultdentalbenefitplansfollowtheMCCSSscheduleofbenefits(levelofreimbursement).Thisreviewfoundthat:

• 17ofthe26plansreimbursethesamefeesforthesamecodesasfoundastheMCCSSschedule• SevenplanshavepaymentschedulesthatexceededtheMCCSSschedule,and• ThecurrentversionoftheplanfortheCityofTorontoprovidedbyGreat-WestLifeshowfees

thatarebelowthoseoftheMCCSSschedulewhilethoseintheRegionofPeelschedulewereverymarginallylower.

AppendixB–ComparisonofSelectFeeCodescontainsasummaryofthedifferentialinfeesforsevencommonlyusedcodesinemergencytreatment:

1. 01204,specificexamination2. 01205,emergencyexamination3. 02112,twoPAradiographs4. 20111,caries,painandtraumacontrol5. 21243,largesilveramalgamfillinginbacktooth6. 23323,largecompositeresinfillinginbacktooth7. 71201,complicatedextraction(removal)ofatooth

ForthesevenplansthatexceededtheMCCSSschedule,thedifferenceinfeesforthevariouscodesassessedwerebetween23.2and244%greater.Withinthesevenplans,therewerenotwofeestructuresthatmatched.Code20111showedthegreatestrangecomparedtotheMCCSSschedule,114.6to244%greater.Whereas01205variedfrom23.2to100%greater(doublethefeeintheMCCSSschedule).TheMCCSSscheduleofbenefitshasremainedlargelyunchangedformanyyears.Thesevenof26publiclyavailableplansthatarepayinginexcessoftheapprovedschedulesareoutsideofthemajorurbanareasoftheprovinceandareadministeredbyAccerta.Anassessmentoftherationalandvariationoflocalplansisbeyondthescopeofthisproject,butmaywarrantfurtherdiscussionswiththe

14See:LockerD,MaggiriasJ,QuiñonezC.Income,dentalinsurancecoverage,andfinancialbarrierstodentalcareamongCanadianadults.Journalofpublichealthdentistry.2011Sep;71(4):327-34;ThompsonB,CooneyP,LawrenceH,RavaghiV,QuiñonezC.Thepotentialoralhealthimpactofcostbarrierstodentalcare:findingsfromaCanadianpopulation-basedstudy.BMCOralHealth.2014Dec;14(1):78;ThompsonB,CooneyP,LawrenceH,RavaghiV,QuiñonezC.Costasabarriertoaccessingdentalcare:findingsfromaCanadianpopulation-basedstudy.Journalofpublichealthdentistry.2014Aug;74(3):210-8;RamrajC,AzarpazhoohA,DempsterL,RavaghiV,QuiñonezC.DentaltreatmentneedsintheCanadianpopulation:analysisofanationwidecross-sectionalsurvey.BMCoralhealth.2012Dec;12(1):46.

29

specificadministratorstoverifythemethodologyusedtodeterminereimbursementlevelsforspecificfeesandthebasisofthedecisiontodeviatefromtheMCCSSschedule.Ultimately,itisagoodworkingassumptionthattheclosergovernmentplansresembleemployer-sponsoredplans,themorelikelytheseplansaretobeacceptedbydentists.15Also,thereiscurrentlynoclearlydefinedsocialcontractwiththedentistsinOntario.Dentistsareundernoobligationtoacceptgovernmentplansandcanlimithowmanyclientstheywillacceptintheirpractice.ThecurrentdiscourseamongdentistsisthatthecurrentMCCSSschedulerepresentsonly“30centsonthedollar”foradentalpracticeandthereforedentistsarepersonallysubsidizingthegovernmentplans.16Indeed,beforethemostrecentelection,theOntarioDentalAssociation(ODA)hadapubliccampaignarguingforincreasestotheprovincialgovernment’sinvestmentinexistingpublicdentalplans.4.0 ConclusionsThisreportprovidedadescriptiveanalysisofthecurrentstateofdentalprogramsand/orbenefitsforadultsreceivingOWacrosstheprovince.Itdemonstratedsubstantialvariationacrossallparameterscompared,includinghowbenefitsareaccessed,howtheyareadministered,whateligibleservicesareincludedorexcluded,whatmaximumannuallimitsapplyandthelevelsofreimbursementincluded.Thesefindingssuggestseveralpolicyoptions.Thewidevariationpresentamongmunicipalitiesislikelyrelatedtothediscretionarynatureoforalhealthcaredeliveryforadultsreceivingsocialassistance.Thisvariationcouldbeaddressedbyguidancefromtheprovinceregardinghowtheseservicesaretobeorganized(managed),financed,anddelivered.Alternatively,governmentscouldsetorganizational,financing,anddeliverystandardsforthedeliveryoforalhealthcaretosocialassistancepopulationsbymakingclearwhatservicesaremandatorytodeliver.TheobjectivesofprovidingoralhealthcaretoadultsreceivingOWinOntariohavenotbeenclearlyarticulated.Identifyingspecificgoalscanindicatepolicyoptions.Forexample,ifthegoalistoincentivizeandincreasethechancesofemploymentamongadultsreceivingOW,approachestocarecouldincludecoordinationbetweencaseworkersandothersocialservicesorPHUstaffthatisfocusedonemploymentoutcomes.Alternatively,ifthegoalistoachieveimprovedhealth,approachescouldincludecoordinationbetweencaseworkersandothersocialservicesorPHUstaffthatisfocusedonhealthoutcomes.Importantly,thesearenotmutuallyexclusivestrategies.Notably,theevidenceofanassociationbetweenreceivingdentalservicesandleavingsocialassistanceforemploymentisweak,17yetindividualsdoreportimprovementstoemployment-relatedfactorswhensurveyedpreandpostdentaltreatment,includingimprovementstosubjectivemeasuresoforalhealth.18

15See:QuiñonezCR,FigueiredoR,LockerD.Canadiandentists'opinionsonpubliclyfinanceddentalcare.Journalofpublichealthdentistry.2009Mar;69(2):64-73; Quiñonez C, Figueiredo R, Azarpazhooh A, Locker D. Public preferences for seeking publicly financed dental care andprofessionalpreferencesforstructuringit.Communitydentistryandoralepidemiology.2010Apr;38(2):152-8.16 See:CBCNews. 'Ugly,awful secret:'Ontariodentistsareduckingsomepatients—and theysay theyhavenochoice.Deburary08,2018.Availableat:https://www.cbc.ca/news/canada/sudbury/healthy-smile-cost-money-1.4525204;TheAgendawithStevePaikin.Ontario’sDentalCare:BitingOffMyths.May14,2018.Availableat:https://www.tvo.org/video/ontarios-dental-care-biting-off-myths.17SeeSinghalS,CorreaR,QuinonezC.Theimpactofdentaltreatmentonemploymentoutcomes:asystematicreview.Healthpolicy.2013Jan1;109(1):88-96andSinghalS,MamdaniM,MitchellA,TenenbaumH,LebovicG,QuiñonezC.DentaltreatmentandemploymentoutcomesamongsocialassistancerecipientsinOntario,Canada.HealthPolicy.2016Oct1;120(10):1202-8.18SeeSinghalS,MamdaniM,MitchellA,TenenbaumH,QuiñonezC.Anexploratorypilotstudytoassessself-perceivedchangesamongsocialassistancerecipientsregardingemploymentprospectsafterreceivingdentaltreatment.BMCoralhealth.2015Dec;15(1):138.

30

Animportantpolicyquestionistheappropriatemixofpublicdeliveryofservices,privatedelivery,orboth(mixeddelivery).Almostalldevelopednationsworkonamixeddeliverymodel,19giventhatnotallservicedeliverycontextsareappropriateforallpopulations.20Economicevaluationsmayhelptodeterminetheefficiencyofblockfundingtheorganization,management,anddeliveryofpublicservices(PHUclinics,communityhealthsectorclinics),whileorganizing,financing,anddeliveringprivateservicesthroughtheuseofacentralizedclaimsprocessor,ascurrentlydonewiththeHSOprogram.Inonesense,theabovedecisionsarestructuralinnature.Theyinvolvequestionsastowhichlevelofgovernmentwillassumethefundingofsuchcare,whetheralocalsafetynetapproachwillbeprioritizedorsimplythepaymentofservices,whetherthegoalistocreatestrongpublicandprivatesystemsaroundtheoralhealthcaredeliveredtosocialassistancepopulations,andwhetherthefocuswillbearoundthosewithteethorthosewithout.Theseareobviouslyfalsedichotomies,buttheydopaintapictureofthetypesofdecisionsthatarerequired.AnotherimportantquestionforOntarioisthelevelofflexibilitythatisoptimalatthelocallevel.Forexample,localadministratorsareoftenfacedwiththechallengeofwhattodoforapersonwho,fromexperience,willlikelyonlybeonOWforaveryshorttime,versusapersonwho,againfromexperience,maybeheadedtowardsODSP.Flexibilityisparticularlyimportantintheformercase,assomeonemaynotneedtobeonOW,butsimplyneedssupportforatoothextractionorsomeotherbasicdentalcare.Blockfundingoftheseservicesprovidesforthistypeofflexibility,especiallyinlocationswherepublicclinicsareavailable,orwhereprivateclinicsaretheonlyoption.Fromanequityperspective,thewidevariationinwhatisavailabletowhomandthroughwhatprocessesmaybeparticularlyconcerning.Thisreporthashighlightedsuchvariation,whichhasimplicationsforfairaccesstoservicesandoutcomesacrosstheprovince,forachievingpositiveoutcomesinthesepopulationsingeneral,andforappropriateandeffectiveuseofscarceresources.Fromaneconomicperspective,rationalizingoralhealthcarecanhelpindecidingwhatservicesshouldbecoveredandatwhatcost.Dentistry,forgoodorbad,isarguablyuniqueinthatdifferenttreatmentregimens—oftenwithlargelyvaryingprices—canachieverelativelysimilaroutcomes(e.g.implantsvs.denturesinthetreatmentofmissingteeth,rootcanalsandfillingstodealwithaspecificlevelofdiseasevs.combiningextractionswithdenturestodealwiththesamelevelofdisease).Clinicalandvaluejudgmentsareimportantfordetermininghowservicesfundedbypublicprogramsarebestused(e.g.payingforarootcanalandcrownorpayingforextractionforapatientwithgivenprognosticfactors).Finally,formalizingdentalpublichealthexpertiseandleadershipcentrallymayimprovedecisionmakingprocesses(currently,thereisnoprovincialchiefdentalpublichealthofficer),andattheregional/locallevel(manymunicipalitieshavenosuchexpertiseavailable).Thiscanhelptoaddressconcernsaboutinequityinoralhealthservicesandmaximizethepotentialforefficientuseofresourcesinpublicdentalcareprogramming.

19SeeVujicicM,BernabéE,GarbinNeumannD,QuiñonezC,MertzE.(2016)DentalCare.WorldScientificHandbookofGlobalHealthEconomicsand Public Policy, Volume 2 – Health Determinants and Outcomes, Edited by Richard M. Scheffler. Singapore: World Scientific PublishingCompany,pp.83-121.20 See Quiñonez C, Figueiredo R, Azarpazhooh A, Locker D. Public preferences for seeking publicly financed dental care and professionalpreferencesforstructuringit.Communitydentistryandoralepidemiology.2010Apr;38(2):152-8.

31

AppendixA–ComparisonofDentalCoverageAbbreviation DescriptionGWL Great-WestLifeAssuranceCompanyAccerta AccertaClaimServicorpInc.NC NotcoveredX IncludedintheplanPD Pre-determinationR 3periapicalradiographs(PA)or1panoramicradiographper12months- Noplan

Toronto Durham ThunderBay

S.StMarie

Wellington GreyCounty Peterborough Windsori Stratford Waterlooii Haltoniii

Admin GWL PHU Accerta Accerta Accerta Accerta Accerta&OWadminiv

Accerta&OWadminv

Accerta PHUvi PHU

$limit none none none none $1000 $1000 $600 $300 none PD4teeth/yearvii

none

PD NO YESviii NO NO NO NO NO YES(Dentures) NO DenturesandRCT

Screeningfornonemergix

MCCSSFees

NO YES YES NO NO YES YES YES YES YES YES

Amalgam&composite

NO NO NO NO NO NO NO NO NOx NO NO

Complete NC NC NC 1/36 NC NC Xxi NC NC NC PD1per60mo

Emergency Xxii 3/12 3/6 3/12 3/6 3/6 X 2exams/year 3/12mocombined

X Unlimited

Specific X X X NI X X X 2exams/yr 3/12mocombinedxiii

X 1/12mo

Recall NC NC NC NC NC NC X NC NC NC NC

Film 6/12 3/12 3/12 5/12 3/12 3/12 8/12+2BW/9 3PA/3yrs 3PA/12mocombinedxiv

X 5/12mo

32

Toronto Durham ThunderBay

S.StMarie

Wellington GreyCounty Peterborough Windsori Stratford Waterlooii Haltoniii

Panoramic NC X Rxv 1/36 R R 1/24 1/3yrsxvi R X 1/24mo

Biopsy X X X X X X X X X X X

Prevention NC NC NC NC NC NC YESxvii NC NC NC PDupto4unitsscalingxviii

CTPC NCxix X X X X X X X X X X

Amalgam X X X X X X X X X X X

Comp(A) X X X X X X X X X X X

Comp(P) NC X X X X X X X X X X

Pulpotomy NC NC NC 13to43 NC NC YES X - SeeRCT SeeRCT

Pulpectomy X PD X 13to43 X X YES X X SeeRCT SeeRCT

RCT NC PDxx NC 13to43 NC NC YES NC NC PDxxi PD3per5years

Perio42831

NC X X X X X X NC X X 4unitsincludingscaling

Basicremovals

X X/PD8’s X X X X X X X X X

Replant X X X X X X X X X X X

GA NC NC NC Xxxii NC NC 8units/appt NC X NC NC

Sedation NC NC NC X NC NC 8units/visit NC X NC NC

NO X NC NC X NC NC 8units/visit NC NC NC NC

Denturesxxiii 1/5yrs PDxxiv - ONCE - - YES 1/10yrs - 1/5yrsxxv 1/5yrs

CastRDP NC NC - ONCE - - YES 1/10yrs - 1/5yrs 1/5yrs

Repairs $88/12mo

PD - 1/2yrs - - yes 1perappliance/year

- 1/3years 4/year

Reline 1/36xxvi PD - ½yrs - - yes 1perappliance/year

- 1/3yrsxxvii 1/3yrsxxviii

33

AppendixB–ComparisonofSelectFeeCodesFeecode 01204 01205 02112 20111 21243 23323 71201

MCCSSGP $19.00 $19.00 $16.33 $31.68 $79.32 $102.88 $88.69

Toronto$13.29(-30.1%)

$13.29(-30.1%)

$11.88(-27.3%)

N/A$55.40(-30.2%)

N/A$62.04(-30.0%)

Algoma$28.08(+51.6%)

$28.08(+51.6%)

$24.00(+47.0%)

$68.00(+114.6%)

$128.80(+62.4%)

$171.20(+66.4%)

$161.60(+82.2%)

KawarthaLakes$38.00

(+100.0%)$38.00

(+100.0%)$34.00

(+108.2%)$109.00(+244.1%)

$128.80(+62.4%)

$171.20(+66.4%)

$217.00(+144.7%)

Northumberland$29.60(+55.8%)

$29.60(+55.8%)

$26.40(+61.7%)

$83.20(+162.6%)

$152.80(+92.6%)

$152.80(+48.5%)

$167.20(+88.5%)

Peel$18.93(-0.4%)

$18.93(-0.4%)

$16.27(-0.4%)

$31.56(-0.4%)

$79.02(-0.4%)

$102.50(-0.4%)

$88.36(-0.4%)

SaultStMarie N/A$23.40(+23.2%)

$19.50(+19.4%)

$55.25(+74.4%)

$125.45(+58.2%)

$128.70(+25.1%)

$131.30(+48.0%)

ManitoulinSudbury

$38.00(+100.0%)

$38.00(+100.00)

$33.00(+100.00)

$108.00(+240.9%)

$208.00(+162.2%)

$239.00(+132.3%)

$210.00(+136.8%)

Huron$33.30(+75.3%)

$33.30(+75.3%)

$29.70(+81.9%)

$93.60(+195.5%)

$171.90(+116.7%)

$202.50(+96.8%)

$188.10(+112.1%)

Wellington$32.40(+70.5%)

$32.40(+70.5%)

$27.00(+65.3%)

$76.50(+141.5%)

$144.90(+82.7%)

$192,60(+87.2%)

$181.80(+105.0%)

iPlaninthepreambleindicatesreliefofpainonlyforthedentalplanandspecificallyindicatedthatnoextrabillingispermitted.

iiTheWaterlooplancoversupto4extractionsor3fillingspertheschedule.Treatmentbeyondthatlevelhastobepreauthorized.

iii“HaltonRegiondoesnotintendtoprovideon-goingregulardentalcaretoadultsintheOWprogram.TheOWAdultsdentalprogramisnotaninsuranceplan.Thisprogramprovidesthreetypesofcare:Emergencycareforconditionsinvolvingpain,infection,ortrauma.Denturecaretorestorechewingabilityand/orspeech.Non-emergencydentalserviceswillonlybecoveredunderspecialcircumstances.”ivDenturesare$750forupper/$750foralowerper5years;caseworkerdetermined.

vThemunicipaladministratorprocessesclaimsfordenturesinternallybuttheDiscretionaryDentalBenefitsProgramclaimsprocessingisdonebyAccerta.

viAdultsandtheirdependentchildren,18yearsandolder,canreceiveemergencycare.AsanOntarioWorksclient,youwillreceiveadentalcardwithyourstatementeachmonth.Ifyouhaveaspecificdentalproblemyoucangotoadentalcareproviderandhaveitchecked.Youcanhaveanexam,limitednumberofx-raysanduptothreeteethfilledoruptofourteethremoved.

viiPreamblefortheplanindicateswheredentistcansendtheirauthorizationsforcareandprovidesanumberfordentalofficestocall.

viii“PredeterminationofBenefitsifrequiredforanytreatmentotherthanthatprovidedatthetimeoftheinitialappointmenttorelievepainorbeyondthetwoteethtreatable[…].”

ixNon-emergencies;adultswithnon-emergencydentalconditionsmustfirstbescreenedbyHaltonRegionOralHealthstaff.� xThepreambleindicatesthatifatoothisrestoredwithmorethanonematerialthantheamalgamrateapplies.

xiIncludesany2examinationsper12monthsforemergency.Acompleteexamevery60monthsandarecallexaminationevery9monthsor9monthsafteracompleteexam.

34

xiiForeitheremergencyorspecificexamcoversonly1unitoftime(feeadjustedaccordingly).

xiiiPlanallowsforanycombinationof3exams(specificoremergencyper12-monthperiod).

xivTheplanallowsforeither3PA’sor1panorexper12months.

xvThebenefitiseither3filmsper12monthsor1panorex(BW’sexcluded).

xviPlanlimitseither3PA’sor1panorexper3years.

xviiIncludespolishing1per9months,scaling4unitsper12months,fluoridetreatment.

xviiiPlanalsohas1unitofsmokingcounselingasacoveredbenefit.

xixTheplanlists20131/9,whicharefortraumacontrol.

xxSetmaximumfeeof$253.39anteriorteethonly.

xxiWaterlooplan:1timepertooth:3teethperpatientsper60monthsexcludingtheanteriorteeth1-2to2-3.

xxii6unitsperdentistperyearforallthreecombinedGA,SedationorNO.

xxiiiInformationforthosemunicipaladministratorswithpublicplans.Thosenotindicatingaplandoesnotmeantthatitmaynotbeavailableandtypicallyclientshavetorequestassistance.

xxivAlldentureservicesarePD.Theplanreimbursesfeethatincludesprofessionalandlabcomponents.

xxvPlanalsocoversimmediatedentures.

xxviRelinesarelimitedtoonceevery36months,arenotcovereduntilafter3monthsifanewdenturehasbeenpaidforanddentureswillnotbereplacedifarelinefeehasbeenpainwithin6months.Repairsarelimitedto$88perdentureper12consecutivemonths

xxviiAlsocoversasoftrelineonceperdenture.

xxviiiPlanalsocoversupto4timesperyeartissueconditioning.

Integrating health, economic and equity evidence to inform policy

Institute of Health Policy, Management and EvaluationDalla Lana School of Public HealthUniversity of Toronto155 College Street – 4th FloorToronto, Ontario M5T 3M6 Canada

https://converge3.ca

info@converge3.ca

@converge3_ca