摘要：Objectives. We explored insurers’ perceptions regarding barriers to reimbursement for oral rapid HIV testing and other preventive screenings during dental care. Methods. We conducted semistructured interviews between April and October 2010 with a targeted sample of 13 dental insurance company executives and consultants, whose firms’ cumulative market share exceeded 50% of US employer-based dental insurance markets. Participants represented viewpoints from a significant share of the dental insurance industry. Results. Some preventive screenings, such as for oral cancer, received widespread insurer support and reimbursement. Others, such as population-based HIV screening, appeared to face many barriers to insurance reimbursement. The principal barriers were minimal employer demand, limited evidence of effectiveness and return on investment specific to dental settings, implementation and organizational constraints, lack of provider training, and perceived lack of patient acceptance. Conclusions. The dental setting is a promising venue for preventive screenings, and addressing barriers to insurance reimbursement for such services is a key challenge for public health policy. Health care providers, the public health community, payers, and health services researchers are increasingly recognizing oral health as a crucial component of the medical home, as well as the potential role of dentists as partners to perform public health screening and to engage patients who may not be receiving regular preventive health services. 1–7 Previous research demonstrated high dental care utilization among key populations such as smokers, individuals at elevated risk for HIV, and individuals at risk for diabetes; many at-risk individuals use dental services even when they do not regularly receive primary medical care services. 8–11 Furthermore, rapid advances have been made in salivary diagnostics for early disease detection and routine health monitoring. Emergence of the oral rapid HIV and hepatitis C tests has prompted calls for more aggressive screening in the dental setting. 12,13 Increased attention is also focusing on the use of clinical periodontal markers and self-reported risk factors to detect undiagnosed diabetes. 5,9,14 The dental venue has been identified as an untapped resource for the provision of oral rapid HIV screening. 8 The Centers for Disease Control and Prevention’s revised 2006 guidelines advocated routine opt-out HIV screening and near-universal screening in diverse settings. 15 The oral health component of the Healthy People 2020 initiative includes the aim to “increase the proportion of adults who receive preventive interventions in dental offices [OH-14],” specifically, smoking cessation services [OH-14.1], oral cancer screenings [OH-14.2], and tests and referrals for glycemic control [OH-14.3]. 16 In a survey of dentists, the majority of respondents endorsed the importance of dental screening for specified systemic conditions, such as cardiovascular disease, hypertension, diabetes, and HIV; almost all respondents highly valued chairside medical screening in dental settings. 4 Despite this broadening view of dentists’ professional role, actual provision of preventive screenings, including cardiovascular and HIV screenings, is low. 17 Low provision of routine tobacco cessation service delivery has also been documented, despite high perceived importance as part of the dentist’s professional responsibility. 11 Furthermore, research has shown that dentists are not fully assuming the responsibility of conducting thorough oral cancer screenings, although this screening has been characterized as the single most essential service a dentist can offer and is one of the few dental services that can save a patient’s life when routinely performed. 18 Dentists’ reluctance to perform medical screenings in their clinical practice is multifactorial; cited barriers to performing HIV oral rapid screening, oral cancer examinations, and tobacco cessation services are lack of training and expertise, time constraints, scope of practice, confidentiality, low perceived disease prevalence, and low index of suspicion. 4,19–23 Limited insurance reimbursement is another major barrier to broad implementation of comprehensive public health screening in the dental setting. 24 From a payer perspective, the feasibility and cost-effectiveness of broad dental chairside screenings remain unclear. 8 Insurer perspectives regarding such questions are rarely explored. We investigated attitudes of dental insurers toward expanding routine screening, including oral rapid HIV testing, in the dental setting to promote early diagnosis and treatment of prevalent systemic diseases.
