Dr. Stephen Abrams and Dr. Ian McConnachie discuss the history and current format of the Canadian Dental Care Plan, and share what they would like to see from the program in the future as it evolves.
Read the audio transcript below:
Dr. Luisa Schuldt: Hey, everyone. Welcome to Brush Up, presented by Oral Health Group, the dental podcast where we speak with industry experts to discuss a variety of topics such as technology, finance and practice management. I’m Dr. Luisa Schuldt, a prosthodontist and periodontist based out of Font Hill, and I am pleased to introduce a special episode of Brush Up that will be all about a topic we have on hand, on our minds all the time. The Canadian Dental Care Plan, CDCP, with guests Dr. Stephen Abrams and Dr. Ian McConachie. With that, it is my pleasure to hand the conversation over to you, Stephen and Ian.
Dr. Stephen Abrams (SA): Good morning. My name is Stephen Abrams and I’m looking forward to this podcast this morning to talk about the Canadian Dental Care Program.
Dr. Ian McConachie (IM): Hi, I’m Ian McConachie. I’m a retired pediatric dentist in Ottawa and, likewise, looking forward to joining you and having you joining us. So, I guess off the beginning, who are we and why should you bother listening to us? Briefly, a 45 seconds or so summary of my career: when I first graduated from dentistry, I did a year of Flying Dentistry on First Nations communities in Northwestern Ontario, followed by two years working on inpatients at a psychiatric hospital. Following that, two years in Graduate School, University of Michigan for a Masters in pediatric dentistry. From there I set up practice in Ottawa and practiced for 37 years, of which 34 years was also on staff at the Children’s Hospital of Eastern Ontario. With respect to governance, I’ve been involved at the local, provincial, and national level and various organizations, including a year as President of the Ontario Dental Association, volunteer work outside of the Governance area, with some international volunteerism in the Caribbean, Central America and South America. And I’ve continued with other volunteer efforts leading up to my involvement with an independent working group that has been working on the Canada Dental Care Plan since its inception or since the announcement in the Spring of 2022.
SA: Well, I’m a general practitioner. Been in practice now over 44 years and in Scarborough, ON. And I’ve been involved in a number of aspects that relate to this particular program. I’ve been involved in the development of a device for carries detection, but in doing that involvement, it got me to meet with a lot of researchers internationally who are involved in carries research, carries management, and also the design and implementation of a variety of national programs to look at how to treat both carries and other diseases. I’ve also been active in the Ontario Dental Association for many, many years. I go back to being involved with the EDI committee that the Ontario Dental Association set up to establish that electronic data interchange that was set up in the early 90s. I’ve been involved in the government relations task force and then in 2000 became involved in the provincial task force that was set up by the Ontario Dental Association to deal with the Ontario Ministries of Community and Social Services and the Ministry of Health, on the design and implementation of the Ontario works program, the Ontario Disability Support Program and Healthy Smiles. Now I know all of you from Ontario that are listening, you’re saying, well, that really wasn’t all that successful. And what I can tell you is that there were elements of our dealings with government that were successful. And elements where we did meet resistance, but it also provided me with a perspective from their side of the table as to what the needs were and what the blockages were. And also, we were able to develop the Dental Special Care program for ODSP that allowed patients with higher needs to get access to more care. You could say it wasn’t enough, but it was a way around it. That finished in 2018 and I still remained involved within the Ontario Dental Association. I’m now on their governing Council again, but we’re also, Ian and I and a number of others, we’re monitoring other programs to see how we could improve them. The other thing that we were involved with is that back in 2000, we were the Ontario Dental Association – myself, Frank Bevilacqua, who’s now the CEO – developed a report that looked at the data from these programs and shared it with the Ontario government to show them, although there wasn’t as much interest as we’d hope, on how data can be used to manage and monitor the program outcomes. And finally, I’ve been involved in other research through colleagues of mine, the latest one being looking at how adverse childhood events can affect an animal formation. And also, we’ve looked at how fluoride varnish can really decrease the carries rates in a high-risk population. So that’s a bit about me.
IM: So, over the course of the next half hour or so, we’re breaking this down into three sections. The first section how did we get here? Here being May of 2024. What does that look like? And the bulk of the time spent on what we have now and going forward over the next six months towards the government’s anticipated announcements in the Fall for other elements of the basket of services. And then finally, we’ll spend a bit of time talking about where we believe that we can and should be going as we move forward into a more mature plan further down the road. So back to Stephen with some of the critical components of the national plan.
SA: So, as we think about designing a national dental program, and this is one thing we shared with, well, first with the Ontario government now with the Canadian government, there’s really what we feel are five critical components. The first critical component for designing any type of national dental plan is to find the diseases that you’re treating and the diseases that we said to them are that you need to be treating carries, periodontal disease, temperamental or joint diseases, and, if you’re interested in getting into it, orthodontics. It’s very, very severe. So that’s the disease definition. Once you define those diseases, then you can then begin to develop a basket of services that will treat these diseases. And the plan needs to facilitate developing what we call a “dental home.” So, we’re not going to have the patient run into an office and have a tooth filled and say, oh, we’ve treated the disease; the dental home allows you to develop a treatment plan, engage the patient, engage the family and treat the disease and monitor it long-term. The third part to this is what we call population engagement and population education. What that means is that we need to have people out in the community, particularly dental public health, that are out there providing the education on the value of oral health. How one can improve their oral health and also the impact that oral health has on their overall health. And there are a number of examples internationally that show that doing this properly not only gets the patients and the families engaged in seeking care, but it also lowers the disease rates. Then the fourth thing is data. Because what we’re doing is we’re submitting billing data and in Canada it’s one set of billing codes. So, we’re submitting data and then that can give us a lot of information about, first off, the age, the gender, the postal code. But it also will tell you the mix of services that are being provided by age, gender and postal code. And this is one of the things that we showed the Ontario government going forward with the ODSP program and Dental Special Care, how these programs will perform. And finally, there needs to be a production of an annual report so that annual report will show them how things are doing. So, the five pieces are to find the diseases, put the basket of services together to treat the diseases, find out ways to engage and educate the population, get the data, which is going to be from the billing data. You can try an oral health survey, but we’ll discuss that in a couple of minutes, and then create annual reports that can be shared with government, but also share it with us the profession so we know how things are doing. The next thing I wanted to share with you is these government funded programs and the question I always ask here in Ontario is who do you think developed the first funded program? Well, the first funded program was developed by the Ontario Dental Association. They went out and raised money back in the late 60s, early 70s. And then allocated those funds to practices that were providing care to low-income Ontarians. And this went on until one of the governments came into power and realized that really, this isn’t something that the dental association should be doing. They should be doing it. And the Family Benefits Act was established, and the Ontario Dental Association was established as administrator for this program, the FBA program. And it was set up so that the government was getting a 5% reduction in fees. Actually, ODA was getting a 5% administration cost, and we were taking a 10% reduction in fees, and this ran for a number of years. There’s more history about it, but the reason for sharing this with you is that the dental profession and the associations do have an idea as to how to run a dental program.
IM: Just taking it forward to what happened at the leadership level, first of all for the profession. When you see the announcement May of 2022, it comes as a general shock because it wasn’t anticipated that this was coming, but in fact, the leadership in Canadian dentistry had been looking at and beginning the knowledge growth for the previous decade. So, in the early teens, the Canadian Dental Association began understanding that at some point there was going to be discussion around a national dental plan. And what would that look like? What were the best international practices on this and how could the profession plan for this and anticipate and begin the dialogues in preparation? Well, healthcare got interacted with politics and things happen a whole lot faster than planned. But in the late stages of it, the CDA had a delivery of care task force, of which Stephen was one of the expert panel on that. I was one of the Members on that. It was from 2018 to 2020. Roll forward then to 2022. Ultimately, what happens with the CDA, they put forward in ’23, a document that we would strongly encourage that you take a look at called Bridging the Financial Gap in Dental Care. And this was the 1000-foot level look from the profession about what a national plan could and should look like. It’s a worthwhile read on that. So, then we get to the government and then what happens with them? You have to realize as well that every government funded dental plan in the country, all the provinces, all the territories and the federal government, all these plans are benefits plans. They’re not healthcare plans. The federal government, quickly to use the old cliché, they didn’t know what they didn’t know. So, when they first came into this, they anticipated being able to roll out a fully designed program within a year or so. The reality was they were also fortunate that their Health Minister at the time, Jean-Yves Duclos, PhD in Economics. He was a number cruncher. And then they rapidly discovered that we didn’t have good numbers or data available in Canadian dentistry. This changed things and that’s why at the end of that year they roll out the Child Dental Benefit, a flat fee or check of $650 going to every family for every child in the family. This was a placeholder. This was something that complied with the agreement with the he NDP, but at the same time, bought them time to do a whole lot more. And you see happening in the early stages of the government actions, particularly with the budget of 2023. Three funds are established. One is the data fund, second is the Oral Health Access Fund, which will roll out next year, and the third is the National Dental Plan itself. And even there, the preliminary information had been it would cost about $5 billion over 5 years. They then shift that to the more updated budget for that of $13 billion.
SA: I wanted to add in now, where did the 5 billion come from? And when we take a look at the NDP’s proposal, they went to the Parliamentary Budget Office in 2020 and took with them the last oral health survey done in Canada, which was 2007 to 2009, and data was published in 2011, 2012. And that was then used by the parliamentary budget officer to establish the budget for this plan. Now there are a couple of problems. Number one: it’s old data. Number two: there’s a debate, at least within the tooth decay research community, as to whether or not the data was gathered properly and whether or not they were including or ranking early areas of tooth decay or white spot lesions, which would then tell you that it’s not just the big hole we found, but the early stuff. And how can we control the early areas of tooth decay? So, this is one of the major problems. This is where the 5 billion started from and it’s now gotten, as Ian said, up to 13 billion over 5 years. Which also may not be an adequate amount because if we look at that 13 billion and we’re told that it’s for approximately 9,000,000 Canadians that sign up, we’re looking at it will work out to about $1,444 over a five-year period if all those people sign up or $289.89 per year. Now, you can say, well, not everybody’s going to sign up, but we don’t have a sense as to what’s the disease rate when we go back to the five core principles. You need to define the diseases and have a sense as to what the disease rates are in order for you to establish a budget.
IM: So now we get to where we are, Spring 2024. What do we have? What’s coming in the short term? What is the government anticipating for longer term? So, let’s talk about the schedule. The basket of services that you have is broken down into two sections, Schedule A, Schedule B. And then there is to be a third component with that Schedule B, which is the pre-authorization process. A lot of the dialogue that’s going on around this and, in particular, the dialogue with the provincial and territorial dental associations, gets to the minutiae of how the plan should be working or how the plan is rolled out. And there’s lots of noise out there and you have to get away from the noise and just deal with the actual core of the basket. If you look at Schedule B, schedule A rather, there is a significant number of core services, but there are also deficiencies or absences from that core that in and of itself is potentially problematic. But a lot of the answers will also be solved in the Schedule B that become in force in November of this year. Ones where you would have to get, for instance, if you have a child you want to put them to sleep under general anesthesia, general anesthesia needs to be authorized and the authorization process won’t happen until November of this year. So that’s problematic. Dealing with this, our independent group as well as others, have been saying you need to fix the basket. Either the content of specific codes or frequencies of procedures that can be done, the ones commonly talked about is scaling maximum of four units of time in a calendar year. Which, remember who the people are that we’re serving here, the 25 to 30% of the population that hasn’t had a regular dental home, many of whom have not been for years. So, their needs at the beginning, in particular, for the first few years until you get to a stability of health, is going to be much beyond what the basket is. Will they capture it enough through the frequency limits and being able to expand on that? We don’t know that. That’s things to be arranged and that’s an important piece of your thought process as you’re deciding whether or not to register.
SA: I would encourage everybody to go to the website on the Health Canada website because what it lays out for you is it actually lays out all the limitations for every one of the procedure codes in this plan. So, it’s not just the thing that you’ve downloaded, the documents you downloaded from the Sun Life site. If you move to this, you begin to see a much clearer definition as to what procedures are covered, what are the limitations, what’s the frequency? And I would encourage you to read this because it will provide you with more information on what to do now in terms of, Ian, you’d asked me about the fees. Well, the fees themselves, we’re not sure how they were established. The plan mirrors a little bit of the FNIHB program. But we know that when Ian and I have done a review of the fee guide and then when we’ve heard at an ODA meeting to RK House review this or Ron House review this, the fees are somewhere around 80% for general practitioners on average and for when you move into specialists then the percentage of fees is much less. Ian, what were you seeing in your analysis?
IM: Yeah, and we looked, we didn’t look at all of them across all the provinces and territories, but specifically for the specialists being a pediatric dentist in Ontario, we looked at the fees that we’re going to be paid for them and for them the discount is significantly higher. And you see they talk about the 100 most commonly used procedures in the basket. That’s a useful parameters under which to look at the discounts. And again, with the pediatric dentist as well as the other specialists, there will be a significant discount beyond the 15% or so that’s happening with the general practitioner’s fees. To that point, the idea of the 100 most commonly used codes, you can do this in your own practice with your software company. You can have an analysis done or you may know it already yourself. What are the most common procedures that you use in your practice and how many times do you use them? And you can do your own analysis of what the discounts would be for your practice based on the procedures that you’ve been doing. That’s a useful exercise for you to be doing. People such as Stephen, who participate in the cost of practice monitor in Ontario, he already gets a report from Dr. House and his economics firm about what his most commonly used codes are for his practice, so it’s easier for him to do the analysis. Frankly, we’ve suggested to the Dental Association, this would be a useful service to their members if they were to assist their members on this aspect of what this looks like for their individual practice, but that’s going to be important for you as well going forward. Regardless of what happens with the fees, regardless of what happens with the evolution there, you need to be able to do the analysis for yourself now. To the specialist, it’s a different problem. Because Health Canada, remember, we’re all taxpayers, we want the $13 billion or however much money is being spent. We want it to be spent wisely as taxpayers and as dentists we also want it to be spent wisely. So, Health Canada would like to have a good understanding of how our fee guides are structured, how they’re created. That data, that information, rests with the provincial and territorial dental associations, and they’re not sharing that with Health Canada. That becomes a problem. Now, the association say there are reasons why we can’t do that. Okay, but your member dentists who are specialists, justifiably, should be asking the associations. Well, given the information, if that’s going to make a difference as to how much they’re actually going to be reimbursing us for the care that we’re providing as specialists. Because we don’t want to take a 40% discount in our fees when the general practitioners are taking a 15% discount. So, this is an ongoing issue for ongoing discussion, but that is frankly an Achilles heel for the associations that they still haven’t answered. So that one remains an issue. The Dental Benefits Guide, that also remains an issue because there are things within the guide that don’t meet your own personal standard of care. You talk about, for instance, root canal treatments and the exclusions or the restrictions on that that are problematic. That would say, okay, somebody’s come in here and has a mouthful of work that needs doing, but they’re in pain. So, I want to get the root canal done by time while I get the rest of the mouth into a better level of health and get more comprehensive care going. According to their exclusions, you can’t do the root canal because their decay situation isn’t under control.
SA: Or the perio was not under control, so that’s the other thing.
IM: Or the perio is not under control, so there are things that need to be continued in the dialogue with the government and there is a dialogue. It’s not, kind of, like we’ve rolled this out, that’s it. Full stop. We’re running forward with this plan. There’s an evolution that’s going on over the next period of time. The critical time is going to be November because that’s when the rollout of the pre-authorizations and all the issues with respect to frequencies will get clarified.
SA: There are a couple of other examples of concerns with the plan design. So, for example, well, with the prevention, as Ian mentioned earlier, there’s only four units of scalings in the seniors’ population, which is a concern over a 12-month period because we’re finding seniors that are coming into our practice…and I’m not on the plan yet. I haven’t signed the contract. I’m going to wait until July hopefully. They need more than that because they haven’t been in a long time. There’s also fluoride varnish; its limitations are two applications or one application, whereas this research shows us that more, actually three to four times through a year in a high tooth decay risk population, makes sense. We also have the issue of bite splints and we’ve spoken with Health Canada about this. They’re not covered yet. Everybody has been seeing a huge increase in patients coming into practice with fractured or broken teeth since COVID because of the stresses and strains that COVID has caused on families. And so there needs to be a bite splint placed into here. There’s also a limitation on you can’t place a crown on a tooth that’s showing sensitivity due to a crack. Well, how do you restore it then? What type of restorations would you recommend? That is one option.
IM: In certain age categories, including adults, but also adolescents, they are wanting pre-authorizations on the nitrous oxide, and they’ll not be giving approvals unless you have tried care without using nitrous oxide or minimal level of sedation. They want you to try that first before going to a moderate sedation or going to a general anesthesia. Well, as care providers, we are experienced at being able to diagnose as well as determining what our best course of action is for the care of the patient. So that having an artificial barrier there is, frankly, a bureaucratic block in my opinion, versus what is needed from a health perspective. They are not at the level of understanding that and they’re more at the cost containment side of things in my opinion.
SA: We also have issues with regards to the treatment of periodontal disease. Remember the core diseases we need to treat. And in speaking with our periodontal community, there are no periodontal surgery procedures in this plan. So besides scaling and root planning, how do you treat periodontal disease? And if we’re thinking that this plan has been rolled out into seniors now 65 and older…Yeah, you need to look at including surgical procedures in order to treat periodontal disease. They also have issues about bonded amalgams, and now most of us aren’t placing bonded amalgams, but they’re only being paid at non-bonded fees, so they need to rethink this piece as well too. So, these are just a couple of examples of where the limitations in the plan are limiting access to care. And the endodontic limitations, the nitrous oxide approach, the no bite splints, no perio. Those are just a couple of examples. And as you read through the health benefits, you’ll begin to find more. So there needs to be a rethink on the plan.
IM: So, I want to talk briefly as well. Ultimately, you’re going to know what the basket is, both now as well as evolving to schedule B in the pre-authorizations, and you’re going to have to come to a decision of what you are doing that’s in the best interest for your practice, best interest for your patients, as well as conscious of the needs of the population out there that doesn’t have a dental home. So, these are difficult decisions, but those are all part of the decisions that we take as healthcare providers and every one of those three words is important. I want to shift now for a little bit on the data piece. One of the key things that, as we’ve talked about, are not in the current government funded plans across the country, is enough good data collection and data analytics. For this plan to be a living, evolving plan based on the data, they have to have good data analytics, and this is a current effort that Stephen and I, in particular, but others as well, are pushing to say, okay, you’ve started the process here from the beginning with Statistics Canada and we’re helping them to consider other things, with the hope that we can create a living, evolving document that’s going to provide healthcare that’s for the future. We’re not there yet, but that’s something that is possible here to actually create a 21st century plan, not a 20th century plan. So that’s to come. That’s for the future here. Other message here – really important that you’re doing your homework for yourself and your people. What’s going to work for you going forward here? And that gets into the analysis, the work that you do yourself as well as the other efforts that are going on from the dental associations, from Health Canada as well. They want this to succeed. And frankly, forget the politics. Push the politics out of the way, put the politics out of the way, focus on yourself, understand the plan, understand what’s there and what’s not there. Can this work for you and your patients? Because that’s the goal here.
SA: I’m going to go back to the data piece just for half a second there, for a couple of seconds, just to say that even something as simple as taking a look at the number of root canal procedures and fillings or restorations per patients will give you a sense of, if you’re looking at the global data, what the disease rate is across a particular population by postal code and by age band, and this will then say the government what we need to bring in other resources to help improve the oral health. Those resources would be more population engagement and education. They would be looking at maybe a variety of different programs that are used internationally and a couple that are used internationally to help improve oral health. But simply just saying here’s how much we paid doesn’t tell us anything. We need to know how we’re doing, that’s government and us. And how we can improve things and how we can get the messaging into the population on the value of good oral health.
IM: Now going forward beyond November. How can this work? What other things are in play here right now? We’ve talked about the fact that in 2025, the Oral Health Access Fund comes into play. That’s a much smaller fund. It’s $250 million ober 5 years. The government plan for this is filling some of the gaps, knowing that in that 25 to 30% of the people who they’re trying to capture in this, there is a significant percentage of them that will not be able to receive care in private practices. Whether it’s mobile clinics that are happening, whether there are other sorts of facilities, you’ve got long-term care facilities and there’s a sad story in the history of Canadian dental literature. There are only two articles that have been done on dental care for people in long-term care facilities. Two articles (2012, 2018) and the current standards just recently updated last year. Canadian Standards Association. There is nothing in there about oral health diagnosis, examination, ongoing care. It’s absent. These are works that need to happen from the profession in trying to get the embracing of that in healthcare for this population. There’s currently now, through the Canadian Institute for Health Research, as an effort underway towards oral health research strategy, there’s a draft document out that will be finalized, I believe, in June. And that helps to populate research happening in Canada that hopefully the research community utilizing data through the data that comes out of the national dental plan and help in the evolution of the profession going forward here. Other things that are happening, there’s a significant percentage of the population of dentists who do not feel comfortable providing care for persons living with disabilities, and some of that is because it hasn’t been in the curriculum for the dental schools. It hasn’t been required as part of the curriculum before you walk out the door with your DDS or your DMD. So, there are efforts underway and largely led by the Association of Canadian Faculties of Dentistry as well as the Canadian Society for Disabilities and Oral Health in trying to have conversations about can a curriculum be created that would be appropriate for all of the dental schools in the country, and probably similarly on a curriculum for dental hygiene, that gives the practitioner comfort to provide care. These are some of the things that the profession could get into the 21st century instead of a lot of what’s happening, which is very much 20th century and concepts here. The other piece on this healthcare and politics media, again, we do have an election coming up in the Fall of 2025. Our focus is let’s get the best we can with what we have now and what is underway now and we’re ignoring what’s going to happen following that. We do believe that we have the potential here, when we look at what has been proposed, what is underway now, what can happen, this is the largest, most significant oral health initiative in the history of this country. We have to seize that opportunity as a profession, through our organizations, but we as clinicians, what is the best that we can do with this opportunity to get the best possible outcomes? That’s the future. So, you have to seize that opportunity to decide how you can make this work for yourself. And then hopefully we’ll get there in terms of the opportunities being presented.
SA: We also have to make sure that, and Ian mentioned this, that you know, sometimes we’ll have to deliver care in a in a nursing home, but we need to make sure that we’re establishing and maintaining what we call the dental home. And that concept needs to be delivered to the politicians, and in an appropriate way to your patients, and the dental home means that you’re seeing the same group of clinicians, the same group of oral health providers, so they can monitor the improvements or lack of improvements that the patient has, and also can establish a trusting relationship so that you can share information with the patient to help them to improve their oral health. And the final pieces is that if you’re seeing them fairly frequently, you can also monitor other health related conditions. So, providing care in a government program is not on a bus that pulls into a parking lot and sees six or eight patients and then moves on. It’s establishing the dental home, doing the right diagnostics, monitoring and treating and continuing to monitor and engage that patient going forward. So those are really the key pieces in a program.
IM: So just to wrap up then, hopefully you have found enough here to be of interest and of value for you. As we say, this is an evolving situation and, hopefully, perhaps we’ll get the chance in the Fall, once the November rollout is coming around, to update and see where things are then. But we wish you all the best on this. Do your homework. You got work to do to inform yourself and your staff about just what’s possible and how this can work for you and for the people we all know need the care. Thank you very much for joining us.
SA: Yep. Thank you.
LS: Thank you, Dr. Ian McConaughey and Dr. Stephen Abrams, for those valuable insights. Thank you to our listeners. Thanks so much for listening. Be sure to subscribe on Spotify and follow us on social media to be notified every time we post a new episode. Keep brushing up!