ADA rebukes insurers interpretation of EBD

Driven by the commitment to help dentists provide quality oral health care to their patients, the ADA is challenging the insurance industry’s usage of the term evidence based in its communications to the profession.

It appears to the Association that insurers are distorting the terms “evidence,” “evidence-based” and “EBD” to lend credibility to plan design, dental coverage and cost containment strategies, without employing a truly science-based approach.

Imploring the insurance industry not to underestimate the need for correct methodology when using the term “evidence,” the Division of Dental Practice, in collaboration with the Council on Scientific Affairs, last month rejected America’s Health Insurance Plans’ report to its dental plan members entitled “Guiding Principles for the Development of Quality Affordable Dental Coverage Based on Evidence.” AHIP is a national association representing some 1,300 member insurance companies.

While stating that guidelines on incorporating evidence in plan design and dental coverage is a much needed and worthwhile effort, Dr. John Luther, ADA senior vice president, dental practice/professional affairs, specified ADA concerns to AHIP in a Dec. 20, 2007, letter.

“Developing evidence-based guidelines without correct methodology may lead to the conclusion that the guidelines are evidence based in name only, and that would be a disservice to patients and plan purchasers alike,” he included in remarks accompanying a six-point outline explaining key differences in the way the ADA and AHIP view evidence-based dentistry.

Those key differences are:

• The ADA wants to see the ADA definition of EBD used appropriately.
• The AHIP guiding principles for benefit design are not based on a transparent and reproducible evidence-based approach.
• Using the term “evidence based” to support cost containment strategies may mislead dental plan purchasers, the dental community and patients.
• The AHIP document doesn’t clearly define how cost benefit decisions should be made.
• The ADA believes that the types of evidence considered in the AHIP document are not broad enough to be considered best available evidence.
• The AHIP workgroup did not include scientific experts or evidence-based dentistry experts necessary to develop correct methodology for EBD guidelines.

(The entire letter is available online in PDF format at ADA.org. Future issues of ADA News will report on the contested areas.)

“The ADA is working very hard to develop sound evidence-based approaches for the prevention and treatment of oral diseases, and, at the same time diligently watching use by the insurance industry and third-party payers of EBD as a reason to deny coverage of appropriate care to our patients,” said Dr. Jeffrey B. Sameroff. He serves on the 2008 ADA EBD Advisory Committee, as well as the ADA Council on Dental Practice. “When insurers do this, patients and employer purchasers may be led into believing that because clinical services are not covered by a dental plan policy they are not supported by scientific evidence.”

The ADA response is in accordance with Executive Director James B. Bramson’s message in “Facing the Future: ADA’s Challenges and Opportunities.”

“Our value to the profession and members is through the creation and dissemination of current science and in ensuring that this information is neither over nor understated,” Dr. Bramson said in his report.

The ADA has a formal EBD policy statement, which includes the following definition of evidence-based dentistry: “An approach to oral health care that requires the judicious integration of systemic assessments of clinically relevant scientific evidence, relating to the patient’s oral and medical condition and history, with the dentist’s clinical expertise and the patient’s treatment needs and preferences.”

The ADA policy also includes the four primary steps of the evidence-based review process: defining a clinically relevant question; synthesizing the available evidence that is relevant to the clinical question; translating that synthesis to the professional community; and evaluating health outcomes in clinical practice (based on the findings of the previous steps).

The entire process aims to minimize the influence of individual bias in the systematic review and to develop justified clinical recommendations that address specific questions, said Dr. Daniel Meyer, senior vice president, ADA Division of Science.

“Aggregate claims data and published studies offer wide variations not only in methodologies and outcome measurements, but more importantly, in assessing useful clinical information,” said Dr. Meyer. “Insurers are developing benefits in their policies and saying they’re based on evidence, instead of the more transparent, evidence-based systematic reviews. Proprietary, aggregate data from insurance claims cannot compare to the quality of evidence gathered from randomized, controlled, scientific studies in recognized, peer-reviewed professional publications.”

Dr. Meyer continued, “Third party payers often use aggregate claims data to adjust patient benefits instead of supporting comprehensive care that is based on clinically relevant, objective information from comprehensive systematic reviews of published clinical studies.”

Dr. William Calnon, ADA 2nd District trustee, a member of the ADA 2008 EBD Advisory Committee, told ADA News, “The interpretation and representation of the term evidence based may be confusing and places the eventual end-users of any product or service at a distinct disadvantage.” Dr. Calnon, who also serves as trustee liaison for the Council on Dental Benefit Programs, said, “A true application of the evidence-based concept must comply with basic principles of discovery, transparency and reproducibility.”

That insurers are using proprietary data in studies that aren’t subjected to the peer review process is inconsistent with the evidence-based approach most widely used by scientific, medical and dental communities and can be used as a means to deny appropriate care for the benefits of a third-party payers bottom line, EBD experts say. “The addition of items that do not fall under the scrutiny of accepted criteria may greatly distort the correct use of this valuable tool as well,” said Dr. Calnon.

Dr. Luther agrees. “We’re all in favor of enhanced benefits,” he said. “But we’re not in favor of miscommunication about scientific evidence. The terminology linked with some benefits defined as ‘evidence based’ may be simple sales talk.”