Free Dental Care for Kids in Maccabi Health Plan

• Abstract
• Purpose of health policy or idea
• Characteristics of this policy
• Political and economic background
• Purpose and process analysis
• Expected outcome
• References

Abstract

Maccabi Healthcare Service added free dental care for young children to its supplemental insurance program; this service is not covered by the NHI law. An evaluation conducted in 2008 showed an increase of 400% in dental treatments for children under age six in Maccabi. The main objectives of this policy were to raise parents' awareness to the need to treat young children and increase access to dental care in order to improve children's oral health and prevent future deterioration.

Purpose of health policy or idea

In Israel, the basket of services mandated by the National Health Insurance law does not include coverage for dental care.

Since 2007, Maccabi Healthcare Services, (the second largest health plan in Israel, which provides care for 25% of the Israeli  population and insures 220,000 children under the age of six) has provided free dental care for children under the age of six who have supplemental insurance (95% of this agegroup). This includes: checkup, x-rays and treatment plans; oral hygiene, fluoride treatments, pit & fissure sealants; fillings, extractions, crowns, root canal procedures and trauma treatment.

Objectives of this policy

The objective of the new policy was to increase access to dental care for children under the age of six in Maccabi and consequently improve their oral health and prevent future deterioration. Another objective was to raise parents' awareness to the need to provide dental treatments to young children (with primary teeth), and encourage them to get care.

Maccabi also intended to lead a national change in policy regarding the oral health of children, as other organizations follow suit.

A secondary positive gain from the program would be strengthening Maccabi's image as an innovative leading organization providing comprehensive care for its members (which is the organizational mission). This potentially can contribute to attracting new members, young families in particular. 

Oral care is provided through Maccabi's dental care company (Maccabi-Dent) which operates as an independent company. The care for children is provided free of charge; Maccabi-Dent receives payment from Maccabi's supplemental insurance company.   

The main incentive in this program for parents to provide oral care for their young children is providing it free of charge for children who have supplemental insurance. Before, co-payments for oral care for children could reach hundreds of NIS. 

Expected outcomes

The expected outcomes of this policy are an increase in dental treatments for children under the age of six and an increase in purchase of supplemental insurance by young families. Indeed, an evaluation conducted in 2008, one year after implementing the policy, showed an increase of 400% in dental treatments for children in Maccabi (from 10,250 children treated in 2006 to 41,000 treated in 2007). 

Nationally, we could expect other healthcare organizations to provide similar coverage, for competitive considerations. Indeed Clalit health Services anounced provision of similar coverage as of May 2008. We could also expect that the Ministry of Health would advocate for adding this coverage to the mandatory basket of services in order to promote equality. Indeed, recently they have prepared and submitted a proposition on this issue.

Main points

Main objectives

• To increase access to dental care for children under the age of six;
• to raise parent's awareness of the need to provide dental care for young children;
• to lead a national change in policy regarding childrens' oral health. 

Type of incentives

High quality dental care is provided free of charge creating a financial incentive for parents to provide oral care for their children. The incentive for Maccabi healthcare organization is the opportunity to strengthen its image as an innovative leading organization providing comprehensive health care. This can potentially contribute to attracting new members, young families in particular. 

Groups affected

Children under the age of six with supplemental insurance will receive comprehensive oral care and consequently will improve their dental health, Maccabi will allocate funds for oral care, attract new members ( young families in particular), receive good publicity and reinforce its position as a leader in the field., Other healthcare organizations and the Ministry of Health will be pressured to provide similar services

Degree of Innovation	traditional		innovative
Degree of Controversy	consensual		highly controversial
Structural or Systemic Impact	marginal		fundamental
Public Visibility	very low		very high
Transferability	strongly system-dependent		system-neutral

Innovation - the program was the first of its kind in Israel. The Maccabi sick fund added free dental coverage for young childrent to its supplemental insurance program without a raise in premium.  

Controversy - most actors involved supported the program with some opposition from private dentists who stood to lose patients.

Impact - the impact is rather fundamental since a very important additional service was made available for children in Maccabi (covering 25% of the population). Consequently Clalit (covering 55% of the population), a competing sick fund, has come out with a similar program. Therefore, the program initiated by Maccabi has had a fundamental impact on dental services for children in Israel

Visibility - high, the program and it's success in increasing access to care was presented in the Media. It was also presented in internal communication channels to Maccabi members.

Transferability - Rather system neutral, other countries can adopt increasing coverage for dental care in a similar way.

Political and economic background

Not relevant

Purpose and process analysis

Current Process Stages

	Idea	Pilot	Policy Paper	Legislation	Implementation	Evaluation	Change
Implemented in this survey?

Origins of health policy idea

High private expenditure on dental care 

The basket of services mandated by the National Health Insurance law to be provided by the healthcare organizations does not include coverage for dental care. The third addendum to the law stipulates that the Ministry of Health is responsible for providing some dental care for school children. Care is provided through public dental clinics belonging to the municiplities, and the services provided include mainly preventive and emergency care (funded by the MOH, municiplities and a yearly dental fee per pupil collected from families with no exemptions or reductions for the poor). 95% of the expenditure on dental care is funded privately via out-of-pocket payments or private dental care insurance; 8% of the populaiton have a dental insurance policy.  Consequently, dental care is the largest out-of-pocket expenditure on health, constituting 28% of the family's expenditure on health. The issue of funding dental care has been raised in a parliamentary health committee (2000); policy committee (2003) and in the State General Comptroller's report in 2004. However there was no efffort to change the current situation and include dental care in the National Health Insurance basket of services (Horev and Man, 2007).

Poor oral health, especially among low-income households

Data on the oral health of the population is partial. The existing data indicate that among children aged 0-12, 54% had caries which is a high rate compared to other western countries. The number of cavities is also relatively high - 1.66 teeth. Data also indicate that there is inequality in oral health and dental services, with more problems among families residing in low SES areas (Horev and Man 2007). A population survey conducted in 2005 indicated that 30% of families have foregone dental care because of the cost, reaching 50% among the lowest income quintile families (Gross, Brammli-Greenberg Matzliach 2007). 

Window of opportunity: Review of supplemental insurance policy in Maccabi

The Director General of Maccabi-Dent (Maccabi's oral health company),  who is a pediatric dentist, has advocated for some time the need to improve dental coverage for young children. He percieved this as an integral part of  Maccabi's commitment to provide comprehensive health care to it's members. He also saw this as an opportunity for growth and development of Maccabi-Dent. Towards January 2007, he saw a window of opportunity when Maccabi's supplemental insurance policy was reviewed with the objective of adding new services. His suggestion to include free of charge dental care for young children was accepted by Maccabi's Director General and this coverage was added to the supplemental insurance policy without an increase in premiums. 

Initiators of idea/main actors

• Government

• Providers

• Payers

• Patients, Consumers

• Civil Society

• Media

Approach of idea

The approach of the idea is described as:
new:

Innovation or pilot project

Stakeholder positions

MaccabiDent initiated the idea and therefore was very supportive. As Maccabi's dental company, providing dental care is their core business and organizational mission.  They have advocated for free-of-charge treatment for children as a way to encourage parents to provide comprehensive care for their young children. In addition, they stood to gain from providing free of charge coverage to children, funded by supplemental insurance, as their number of patients, and consequently their income, will increase, enabling the company to grow.

Maccabi Healthcare Services - supported this program which promotes the organizational mission of providing comprehensive health care and reducing inequality. Maccabi also saw this as an opportunity to strengthen its image as an innovative organization which is willing to fund important extra services that are not included in the mandatory basket of services. (In the past they funded the Herceptin medication before it was included in the mandatory basket). Another potential benefit from the program may be increasing Maccabi's memebership by attracting young families to join the healthcare organization.

The media supported this program and publicized it, probably because news related to children have a high profile in Israel.

Private dentists opposed the program because of financial considerations - they stood to lose clients if high quality dental care is provided through Maccabi-dent offices. They tried to persuade specialist dentists to refuse working at the clincis but with no success.

Maccabi Dentists had an ambigous attitude - they could not oppose the policy of their organization (Macabi-dent) and stood to increase their income if the turnover grew. On the other hand, most of them have private clinics as well and they were concerned that the demand for private dental care for children will decrease.

The Ministry of Health supported the program and saw it as a kind of "pilot" which will provide actuarial data on the demand for care and the cost of care. They received these data from MaccabiDent after a year of operation - and the data was used for preparing a program for including dental coverage in the mandatory basket of services.

The Council for Children's Welfare strongly supported the program as it saw the benefits it will bring for all children with particular benefits for children of low-income families. Low income children were particularly affected by financial barriers for receiving dental care, and the Council supported the program for reducing these disparities. They gave wide publicity to the program in the media, in conferences and in a parliamentary committees.

Actors and positions

Government
Ministry of Health	very supportive		strongly opposed
Providers
MaccabiDent	very supportive		strongly opposed
Private dentists	very supportive		strongly opposed
Maccabi dentists	very supportive		strongly opposed
Payers
Maccabi Healthcare Service	very supportive		strongly opposed
Patients, Consumers
Maccabi members	very supportive		strongly opposed
Civil Society
The Council for Children's Welfare	very supportive		strongly opposed
Media
Media	very supportive		strongly opposed

Influences in policy making and legislation

Not relevant, no need for legislation.

Actors and influence

Government
Ministry of Health	very strong		none
Providers
MaccabiDent	very strong		none
Private dentists	very strong		none
Maccabi dentists	very strong		none
Payers
Maccabi Healthcare Service	very strong		none
Patients, Consumers
Maccabi members	very strong		none
Civil Society
The Council for Children's Welfare	very strong		none
Media
Media	very strong		none

Positions and Influences at a glance

Adoption and implementation

Providing free of charge care for children entailed some necessary steps to enlarge the infrastructure so as to provide care for more children. Maccabi-dent recruited additional general practitioners who limit their scope to children's dentistry as well as specialists in pediatric dentistry. They have contracted with anesthetic services in Maccabi's hospital (Assuta) as well as in branches in the north and south of Israel; appointed a dentist in charge of manpower management, training and supervision. Maccabi-dent had launched an inter-organizational publicity campaign for the new service, and a marketing campaign to Maccabi members via internal channels such as the Maccabi paper, internet site etc.

In order to provide care for more children the opening hours were increased as well as the turnover of dental facilities. Four new clinics were opened in areas with a high demand for children's dental care (Moddiin Ilit, Netivot, Elad and Zichron), with an overall of 47 clinics operating in 2007.

Monitoring and evaluation

The evaluation of this policy consists of outcome measures: the change in the  number of children receiving care comapred to 2006; the number of treatments provided (by age-group); type of treatment, and the cost of treatments per age-group.

Another parameter for success is leading system-wide change - which is measured by adoption of similar programs by other sick funds and government.

Review mechanisms

Final evaluation (internal)

Dimensions of evaluation

Outcome

Results of evaluation

Increased number of children treated

The number of children treated in Maccabi-dent clinics has risen from 10,250 in 2006 to 41,000 in 2007. The number of treatments provided to children under the age of 6 in 2007 was 210,000.

Data collected as of January 1st, 2007, indicate that over 6000 children a month have used the services, 5 times more than the monthly average a year before the plan started. The heaviest usage is in areas of the country where the families are of low socio-economic level. 42% of children receiving treatment are aged 5-6; and 31% are aged 4-5; 27% are younger.

The rates of visits per age group are depicted in table 1.

Table 1: Visit rate per age group, 2007

age	no. children who have visited	% visitors from all age group
0	94	0%
1	1,265	3%
2	4,313	11%
3	9,133	25%
4	12,705	35%
5	17,248	50%
Total	40,854	100%

 

The main procedures conducted in 2007 included: 39, 856 Amalgam fillings; 21,887 pit and fissure sealants; 11,524  crowns, 40,670 checkups.

The distribution of type of procedure is depicted in Table 2, and presented by age group in Table 3.

Table 2: Distribution of procedures, 2007

Procedure	% of total procedures
Sealants	10.4%
Amalgam fillings	19.1%
Crowns	5.5%
Tartar removal	4.7%
Pulpotomy	5.4%
Nitrous oxide	17.0%
Check ups	19.4%
X-ray	11.2%
Other	7.3%

 

Table 3: Type of procedure by age group in percent, 2007

	0	1	2	3	4	5
Sealants	0	1	4	9	10	11
Amalgam fill	0	1	4	14	19	21
Crown	0	1	4	5	6	6
Tartar removal	0	2	3	4	4	5
Pulpotomy	0	0	2	4	5	6
Check up	84	75	60	32	19	3
X-ray	0	7	7	10	12	12
Nitrous oxide	2	0	3	13	18	19
Other	10	13	12	9	7	7
Total	100	100	100	100	100	100

Leading system-wide change

Following  Maccabi's initiative and successful implementation, Clalit health services has anounced recently (30/3/08) that they will follow suit: From May 1st 2008 children under the age of six who have supplemental insurance will be entitled to free dental care including: fillings, pit and fissure sealants, root canal treatments and extractions  provided in Clalit Dental Clinics. The premium collected for children age 0-17 will rise from 1.18 NIS to 4.0 NIS per month. 

Furthermore, the Minister of Health has anounced a program to include dental care to children under 18 and the elderly free of charge in the National Health Insurance benefits package. The benefits are similar to those covered by the Maccabi program (check ups, fillings, extractions, dental hygien treatments, fluoride treatments, counselling, root canat treatment). The estimated cost of 410 million NIS is to be covered by an increase of 0.2% in the health tax collected from all residents. This program has not yet been approved by the Ministry of Finance and therefore a bill has not yet been prepared. 

Expected outcome

The policy has ncreased parents' awareness of the need to treat as well as to increase access to dental care among young children, which was the main objective. This is expected to result in better oral health in the short term (less cavities; more awareness of preventive procedures, knowledge about oral hygiene). Many studies have shown that appropriate dental care at a young age prevents the need for complicated and expensive procedures when older. Regular dental care at a young age also teaches life-long dental care habits and raises parents' and childrens' awareness of the need to maintain oral hygiene. This leads to the development of strong preventive behaviors re oral hygiene. Therefore, regular dental care at an early age has been found to result also in better oral health in older age.

Impact of this policy

Quality of Health Care Services	marginal		fundamental
Level of Equity	system less equitable		system more equitable
Cost Efficiency	very low		very high

Quality of care - will be enhanced because the program provides more comprehensive care and free access to young children resulting in better care in the short term with life-long affects on oral health when older. 

Equity - the program increases equity because of the free dental care provided. Before, financial considerations were a barrier mainly to families of low Social Economic Status. Therefore the program reduces disparities in access to dental care for young children. 

Cost-efficiency - research data indicates that overall, dental related illness accounts for 5.7 DALYS (Disability adjusted life years) in western countries, similar to the effect of Glaukoma (Horev and Man, 2007). Therefore, prevention and treatment at a young age is expected to be cost-effective in the long term as it will reduce serious dental illness at an older age.  

References

Sources of Information

• MaccabiDent Ltd. Company Profile 2007
• Horev T. and Man J. Dental care: a responsibility of the state to the citizens. Taub Center for Research of Social Policy in Israel. Jerusalem, 2007.
• Gross R. Brammli-Greenberg S., Matzliach R. Publich opinion on the level of service and functioning of the health care system 2003 and comparison to past years. Myers-JDC-Brookdale RR-455-05. Jerusalem, 2005.
• Linder-Gantz R. Following Maccabi's success Clalit will provide free dental care for children aged 6 or under in its supplemental insurance. The Marker, 30.3.2008
• Yasor Beit-Or M. Ministry of Health: Children and elderly will receive free dental care. Ynet 11.2.08

Author/s and/or contributors to this survey

Moti, Seifan, Friedman Nurit and Revital Gross

Dr. Seifan is the Director of Maccabi-Dent, Dr. Friedman is the Director of the Research and Evaluation Department of Maccabi, Prof. Gross is a Senior Researcher at Myers-JDC-Brookdale Institute and Bar-Ilan University

Suggested citation for this online article

Moti, Seifan, Friedman Nurit and Revital Gross. "Free Dental Care for Kids in Maccabi Health Plan". Health Policy Monitor, April 2008. Available at http://www.hpm.org/survey/is/a11/4