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DAY TWO
2
wwwdentaquestpartnershiporg
bull Click on Learn
bull Click on Resource library
3
4
5
bull $37 trillion
bull $10739 per
person
bull 179 of GDP
2017 National Health Expenditures
6
Mortality Rates Decreasing
httpswwwhealthsystemtrackerorgchart-collectionquality-u-s-healthcare-system-compare-countriesitem-overall-years-
life-lost-1990-2017
7
Early Detection amp Prevention Matters
One of our providers was able to diagnose a lesion the biopsy had some cancer
cells We were trying to get that patient into an oral surgeon We contacted several
of the private practice oral surgeons in the area It was anywhere from $300 to $400
to walk into their office for an evaluation and a diagnosis That doesnt mean even
treatment
We were able to get him to The University of Maryland Its about a two-hour trip for
this patient to get there His first appointment his car broke down and he couldnt
get there The next appointment we were able to get him he traveled the two hours
and waited for four and a half hours and then wasnt seen They had a backlog and
he was sent home and told they would give him another appointment and come
back He then left our area and came back three years later in 2017 and our dentist
that does pediatrics is actually the only one in the office
8
Early Detection amp Prevention Matters
When he came as an emergency she saw him He had just came out of the
hospital His ENT just diagnosed him with stage four head and neck cancer And
if we had been able to see him got him into care with that initial diagnosis
which was a very small lesion at the time we might have been able to prevent
that
9
Evaluation survey must be completed to receive 10 CE credits
bull httpswwwsurveymonkeycomrVBCTraining1
bull httpswwwsurveymonkeycomrVBCTraining2
10
Agenda
Highlights from Day One
Group Discussion
Laying the Groundwork for Oral Health Value-Based Care Readiness
Lunch
Breakout Exercise Oral Health Value-Based Care Readiness
A Dental Directorrsquos Experience in Risk-Based Oral Health Managed Care
Promising Practices from the Field
ClosingWrap Up
11
12
bull Outline the key components to prepare for oral health value-based care
delivery system
bull Understand measurement and principles in healthcare transformation
Todayrsquos Learning Objectives ndash Day Two
LAYING THE GROUNDWORKCLINICAL OPERATIONS IN A VBR ENVIRONMENTCarolyn Brown DDS Consultant
November 19th 2019
14
INTRODUCTION
15
Todayrsquos Agenda
bull Discuss value-based health and pay-for-performance approaches to health
systems and the integral building block of data
bull Dive deep into the emerging field of value-based care measurement and
data in oral health from national and statewide perspectives
bull Present oral health and clinical measurement approaches and relate to
oversight
16
bull Consultant working with DQP FQHCs Primary Care Associations and Foundations advancing oral health programs
bull DQPSNS Expert Advisor
bull IHI Improvement Coach
bull Former Dental Director
bull Research Marketing Finance
Carolyn Brown DDS
Consultant Acting Director of Value-Based Care
DentaQuest Partnership for Oral Health Advancement
bull DDS University of Maryland School of Dentistry
bull MAEd University of the Pacific
bull BS University of Maryland
bull Speaker researcher expert advisor review panel
17
Poll What do you measure
A Dental provider productivity per day
B Treatment plan completion
C Dental new patient exams
D Combination of A-C
E No Shows
F Sealants only
18
Population
Prevention
Healthy
Minimally Invasive
Health outcomes
MDI
EHR EDR
PCC
Risk Assessment
19
VALUE-BASED CAREPushing the impact quality and quantity of measurement
20
OHVBC Readiness
Leadership
Value of oral health and oral health transformation
Structure Systems and Operations
Efficiencies innovative care delivery
Care Pathways and Provider Buy-In
Risk-based care Training patient engagement
Data and Analytic Technology and Personnel
DataReports Interoperability
Financial Viability and Strength
Payerpatient mix billing infrastructure
httpswwwdentaquestpartnershiporglearnsafety-net-solutionsoral-health-value-based-careohvbc-readiness-
assessment
21
DentaQuest Partnership OHVBC Survey
Barriers to Value-based Transformation in Oral Health ndash
Most Common Responses
bull Patient engagement
bull EHREDR
bull Tracking outcomes lack of nationally-recognized and standardized quality
metrics in dental
22
How Can FQHC Dental Programs Prepare for Value-based
Transformation in Oral Health
bull Begin or continue focusing on prevention disease management and risk-based care
bull Hygienists will be key to success ndash We need primary dental care not just surgical
interventions
bull Start measuring outcomes instead of just processutilization metrics bull of initially high-risk patients with new caries lesions
bull of initially high-risk patients with decreased risk status
bull of initially low-risk patients with risk status maintained
bull Address patient engagement in a more meaningful way and invest in case
management
bull Invest in interprofessional practice including HIT interoperability
bull Evaluate how services are being delivered and determine if its reaching the patients
who need care the most
23
Value-Based Care
Care Coordination
ldquoClosing outrdquo referrals
Diagnostic coding
Risk Screenings
Care plans based on risk
Patient Engagement
Incentive payments
Quality metrics
Clinic Response
Case Management IT
Active timely records mngt
Mapping Dx codes to CDT
Time bill CPT codes Tx plan
IPP data tofrom PC MH
Recall window important
Attention to $ related metrics
Attention to assigned metrics
Direct and Indirect Effects of VBC on Dental Systems of Care
Utilization Impact
New workforce CDT codes
New or + workforce IT
ICD-CM-10 codes
+CDT codes
Modifiers (CPT ICD10)
+ recall adherence
in incentivized procedures
in sealant POC A1C
Counseling codes SD
24
MEASUREMENT IN ORAL HEALTH
25
Poll What percentage of your adult dental patients are diabetic
or pre-diabetic
A 50-80
B 20-50
C Less than 20
D Not sure
26
27
ldquoTrue Measures of Successrdquo
1 Define your governing objective
2 Develop a theory of cause and effect to assess presumed drivers of the
objective
3 Identify the specific activities that employees can do to help achieve the
governing objective
4 Evaluate your statistics
5 Communicate the story of your measurement
Adapted from HBR ldquoThe True Measures of Successrdquo httpshbrorg201210the-true-measures-of-success
28
1 Governing objective
2 Theory of cause and effect
3 Activities of team
4 Evaluate your statistics
5 Storycraft
Sustainability
Clinic revenuegt expenses= sustainability
Patient compliance Assets Clinic Mngt
Care team Operations Pt Support Billing
Of Prod on and type Patients on time
Daily weekly monthly quarterly
ldquoTrue Measures of Successrdquo
Adapted from HBR ldquoThe True Measures of Successrdquo httpshbrorg201210the-true-measures-of-success
29
Measuring Risk and Health
November is Diabetes Awareness Month- 2019Communication Plans are as
important as cold hard numbers
Patients
Care Team
Other Health Teams
Executive Team
Funders
Data on your dental patients are medical patients of record
Data on your medical + dental patients with DM2
30
Develop Diabetic Patient
Protocols
Review evidence and rationale with dental team
Partner with primary care team
bull Protocols Care mngt Tests and Recording
Quality Goals
Protocols for newly screened and existing patients
Educate and train dental team in reading AND
charting test results and PILOT
31
External Measurement in Oral Health Programs
httpswwwadaorg~mediaADADQA2019_DiabetesOralEvaluationpdfla=en
httpswwworegongovohaHPAANALYTICSCCOMetrics2019-Oral-Evaluation-Adults-Diabetespdf
32
Baseline for 2019 271
httpswwworegongovohaHPAANALYTICSCCOMetrics2019-Oral-Evaluation-Adults-Diabetespdf
33
Diabetes burden in your panel of dental patients
Baseline Medical-Dental Integrated panel of all patients
Dental patients with DM2 MDI
Dental patients with DM2
1000 or 10
600 or 60
300010000= 30
Population Health- Clinic Level
34
1 Governing objective
2 Theory of cause and effect
3 Activities of team
4 Evaluate your statistics
5 Storycraft
Discuss at meetings (Oct + Nov) Health education training
materials NP training CQI Note in Board report Clinical
measures
Care Pathways Hygiene Resources (ScheduleAvail)
ldquoTrue Measures of Successrdquo
Adapted from HBR ldquoThe True Measures of Successrdquo httpshbrorg201210the-true-measures-of-success
Diabetes Awareness Prevention Healthier Community
Prevention Awareness Care Pathway promotes health
MDI= 10 6 out of 10 adult patients with DM2
Goal set for integrated patient panels ndash PCMH
Pre-diabetes approach for executive team
Care Pathways
Care Coordination
35
MEASURING PATIENT ORAL HEALTHRisk assessments and Care Pathways
36
37
Risk Assessment and Care Pathways
Caries Risk Assessment
Multiple tools
EDREHR modules smart notes or dot phrases
CDT Codes
Decide frequency
D0601
Low Caries Risk
D0601
Moderate Caries Risk
D0601
High Caries Risk
38
The Disease Management DifferenceDisease Management Difference
Traditional Dental Care Disease Management
Approach
All patients return in 6 months
regardless of risk status
Recare interval is based on the
childrsquos caries risk
Caries Risk
Level
Recommended
Recare Interval
High Risk 1 ndash 3 months
Moderate Risk 3 ndash 6 months
Low Risk 6 ndash 12 months
Caries
Stabilizing
agents
Health Ed
Nutritional
Counseling
Anti-bacterial
and Fluoride
interventions
39
Disease Management Care Pathways
DentaQuest Partnership for Oral Health Advancement Disease Management Model
Caries
Stabilizing
agents
Whole
Person
Inter-
professional
Approaches
Anti-bacterial
and Fluoride
interventions
40
Disease Management and Risk Screening Training
DentaQuest Partnership for Oral Health Advancementrsquos
Online Learning Center
Disease Management Series
8 modules 40 CDE available
httpswwwdentaquestpartnershiporglearnonline-learning-centeronline-
coursewaredentaquest-disease-management-series
41
MEASUREMENT IN TEAMSSharing meaningful data with your dental clinical teams
42
rdquoDental Homerdquo = Health Home where WE can meet the patient
Oralhealthworkforceorg
43
POLL HOW OFTEN DO YOU SHARE YOUR S WITH YOUR DENTAL TEAM
A Yearly only
B Quarterly
C Monthly
D Weekly
E Daily
44
Clinical Measures ndash Dental Practice Perspective
Private Practice Office
New patients seen
Assigned vs seen if capitated
Treatment plans incomplete
$ produced amp per provider
$ collected amp monthly per provider
CDT 6000 codes completed
RecallHygiene maintenance
Based on this consultants experienced
FQHC
Unduplicated patients
patients seen per day
Treatment plans complete
$ gainedlost via accounting
Broken appointment rate
procedures
Sealant rate (annual)
45
bull HRSA Sealant Measure Compliance for FQHCs
bull Completion of phase 1 treatment plans
bull Children seen 0-5 years old
bull Children seen getting a preventive service
bull Fluoride Varnish applications
bull Pregnant women seen and treated
bull Diabetic patients with HbA1C gt 7 seen
bull Patients seen who have not been seen for 12 months
bull Patients seen getting a Risk Assessment
bull Patients with moderate or high risk who lower risk at recare
bull Sealants provided httpwwwnnohaorgnnoha-contentuploads201512Demystifying-HRSA-SEALANT-PRESENTATION_FINALpdf
Program Measures
46
HRSA Performance Measurement and Data Collection
bull FQHCs and look-alikes submit CY data to HRSA since 2008
bull UDS Uniform Data System
bull Require FTE for clinical staff patient demographics
bull Dental utilization s (UDCTPV)
bull Dental Clinical Measure dental sealants placed on 1st molars ages 6-9 yo
bull Health Center Quartile rankings (Clinical measure performance influences
HC rankings as does EHR adoption and other HC characteristics)
47
Low birth weight
Access to prenatal care
Childhood Immunization
Children (Ages 3-17) Receiving
Weight Assessment amp
Counseling
Children (Age 6-9) Receiving
Dental Sealant to First Molars
Diabetes Control
Hypertension Control
Pap Test
Depression Screening and
Follow-up (Age 12+)
Asthma Patients (Age 5-40)
Receiving Pharmacologic
Therapy
Colorectal Cancer
Screening (Ages 51-74)
HRSA UDS Clinical Measures
Adults (Age 18+) Receiving
Weight Screening amp Follow-up
Adults (Age 18+) Receiving
Tobacco Use Assessment and
Cessation Intervention
Coronary Artery Disease
Receiving Lipid Therapy (18+)
Ischemic Vascular Disease (IVD)
Receiving Aspirin Therapy (18+)
HIV Linkage to Care
48
Dashboards
Grants
Average
amp
Targets
Quality
Rev
Costs
Visits
Priority
Pop
Prevention
49
Dashboard- Provider Team Level
Patient
Compliance
Satisfaction
50
Case Study-
Incentives bonus round pools benchmark and improvement target goals risk-sharing possible later years
51
Qualitative Measurement
ldquoPatient engagement is the act of patients and providers working together
toward the end goal of improved patient wellnessrdquo
wwwpatientengagementhitcom
Access to Care
Patient Activation
Patient Satisfaction
Patient-Provider-Care Team Communication
Care Team Satisfaction
52
OHVBC Readiness
Leadership
bull Value of oral health and oral health transformation
Structure Systems and Operations
bull Operational efficiencies innovative care delivery methodologies
Care Pathways and Provider Buy-In
bull Training disease management risk-based care referrals IDC-10 coding patient engagement
Data and Analytic Technology and Personnel
bull Interoperability reporting
Financial Viability and Strength
bull Payerpatient mix billing infrastructure financial reports
httpswwwdentaquestpartnershiporglearnsafety-net-solutionsoral-health-value-based-careohvbc-readiness-
assessment
53
QUESTIONS COMMENTS
Carolyn Brown DDS
cbrownddsgmailcom
RISK BASED MANAGED CARE
Value Based Training Conference
Manchester New Hampshire
Mark Koday DDS
111919
5555
Objectives
bull Review current drivers of dental managed care
bull Understand the basics of risk-based dental managed care contracts
bull Learn the basics of managing costs in a riskndashbased contract
bull Gain an understanding in the potential advantage of risk-based contracting
56
What Is Dental Managed Care
Managed care is a health delivery system whose purpose is to manage both the
quality and cost of health care
Common types of managed care health insurance plans
bull HMOs
bull PPOs
bull POSs
bull Medicaid Managed Care
DIDNrsquoT WE ALREADY HAVE MANAGED CARE AND IT FAILED
57
What Has Happened Since the 90s
58
WHY THE FFS AND PPS DOESNrsquoT WORK FOR OUR POPULATIONS
bull Inefficient payment systems designed to produce encounters or procedures but not real health
bull No focus on population health
bull Does not incentivize innovation
bull Patients essentially on their own for accessing specialty care
59
Rule of 4
Source Kaiser Family Foundation analysis of National Health Expenditure (NHE) data from Centers for
Medicare and Medicaid Services Office of the Actuary National Health Statistics Group
60
Rule of 4
bull This helps explain why oral health has been relatively ignored so far by CMS
bull Explains why we have PCMH instead of PCHH
bull Where is the real value on a national level in preventing disease and
controlling costs
bull Beware- wersquove been found
61
Reasons Dental Managed Care is Spreading Across the States
NON-MANAGED CARE STATE DENTAL BUDGETS ARE
OPENED ENDED
STRAIN ON STATE BUDGETS
UPCOMING RECESSION WITH TRILLION DOLLAR
DEFICIT
SHIFTS FINANCIAL RISK FROM THE STATES TO THE
PLANS
6262
Types of Medicaid Managed Care
bull State Medicaid agency administrator lowest administrative
costs
bull Third Party Administrator Typically 15 administrative costs
bull Managed Care Organization Typically 15 administrative
costs
bull Carved-in
bull Carved-out
bull Risk Based Managed Care Administrative costs part of
contract negotiation
63
RISK CONTRACTS
6464
Components of a Risk-based Contract
Risk
Medical Loss Ratio
Quality withhold
Specialty withhold
Managed care payment (pmpm)
Covered services
Fee schedule Claims are paid as usual on a FFS basis
Credentialing
Quality Review process and Quality Metrics
65
Upside Risk
The possibility that the cost of
delivering dental care to an assigned
patient panel is less than the amount
of funding calculated for that care
The Plan pays the CHC additional
funds based on a predetermine
formula
Downside Risk
The possibility that the cost of
delivering dental care to an assigned
patient panel is more than the amount
of funding calculated for that care
The CHC pays the Plan additional
funds based on a predetermine
formula
Upside and Downside Risk
66
Taking On Risk 100 or Shared Risk
With 100 risk you receive 100 of the potential savings but are also at risk for
100 of the losses
Shared Risk MCO and health center share a percentage of the risk
Shared Risk leads to better cooperation since both organizations are
incentivized to save on costs
6767
Reports Needed
bull Enrollment reports lists of who is assigned on a monthly basis
bull Reconciliation reports insure appropriate payments
bull Specialty Referral reports
bull You will need your own reporting process so you donrsquot rely completely on
reports supplied by the Plan
6868
Medical Loss Ratio
Medical Loss Ratio (MLR) is proportion of premium revenues spent on clinical
services and quality improvement also known as the Medical Loss Ratio (MLR)
For CMS requires Medical Plans to spend at least 80 to 85 of the premiums
on actual medical care
69
Administrative Fees
bull Essentially the opposite of MLR
bull The State Medicaid Agency is funded by the Governorrsquos budget
bull The State Medicaid Agency will keep some of these funds for their
admin costs and give the remaining to the Managed Care Plans
bull Private Plan admin costs can be as high as 40 but most states
limit these cost for Medicaid Plans to between 15 and 20 (85-
80 MLR)
bull This may be negotiable depending on your program size of your
program
70
Quality Withhold
bull The state withholds a certain percent (typically 2-4 ) of the funds they give
to the Plans for Value Based Reimbursement
bull They choose quality metrics and set benchmarks and assign payments for
each metric based on an assigned priority for each metric
bull If a Plan meets the benchmark of every quality metric the state passes on
their full share of the quality withhold
bull The Plans may or may not withhold a percent of the funds for quality payment
to the dentists or manage care contractors
71
Quality Withhold
Either way the Plans may or may not pass the quality payments they receive to
the dentists or contractors
This should be spelled out in a risk-based contract
72
Percent of funds set aside
to cover specialty care
referrals
Typically 10-15
Goal Limit referral costs
to within or less than
Specialty set aside
Specialty Withhold
73
Per Member Per Month
bull Capitated Payment
bull Specific dollar amount paid for each enrolled member each month
bull Paid whether patient is accessed for care or not
bull States do set access benchmarks
bull In Oregon access for any dental procedure (adults and children combined)
was 267 in 2015
74
Payment Math Example
Premium per enrollee = $25
Administrative fee 15 = $375
Funds available per enrollee to the clinic = $2125
Management fee per enrollee = $175
Funds per enrollee that would undergo PPS reconciliation = $1950
For every 10000 enrollees the managed care income = $2340000
Specialty withhold (10) = $234000
YE Cost lt or gt $2340000
Upside Risk
CHC Gains $
Downside Risk
CHC Loses $
75
Covered Services and Fee Schedules
bull The state Medicaid agency spells out the minimum procedures and fees that
MCOs must cover
bull MCOs may add procedures or increase periodicity of procedures particularly
preventative services
bull MCOs may increase fees to entice rural providers and specialists to enroll in
their Plans
bull Access Rules
bull How many days it takes to access a patent
bull How many days it takes for a patent to access urgent care services
bull How many days it takes for a patent to access emergency care services
76
Credentialing
All MCOs are required to credential all Providers
All MCOs have their own credentialing process
Credentialing process is can be lengthy
Credentialing process may be negotiable
77
Quality Review Process and Quality Metrics
MCOs must have a Quality and Compliance Review Process
If you arenrsquot in compliance with both you likely wonrsquot get paid
Typical processes reviewed
bull Charting specifications
bull Incident report
bull Enrollee complaints quality rudeness and access issues
bull Medicaid compliance
78
Quality Payments
bull State Shared Incentive Withhold Typically quality metrics and benchmarks
are set by the state sets aside a certain percent (3-5) of the payments to
the Managed Care Plan (MCP)
bull If the benchmarks are achieved the MCP is then paid the a predetermine
amount
bull Benchmarks may not be the same as the states
bull Managed Care Plans do not have to pass all or any of the quality payments to
the health centers or providers
bull Managed Care contract- Metrics benchmarks should be selected and part of
the contract
7979
Achieving Quality Metric Payments
Dealing with under achievers
Process issues
Individual issues
Identifying workflows
Developing Best Practices through
PDSA process
Developing Best Practices through
PDSA process
CHC Metrics Committee
Clinicians Operations various key staff
Identify Best Practices
Spread Best Practices
80
New Team Needed Business Intelligence
Business Intelligence (BI) is critical for effective managed care business decisions
BI team inputs metrics into your EHR collects integrates analyses and displays all your managed care business and clinical information
Easy to say- hard to achieve
Build your own or outsource
Possible future role of Primary Care Associations
8181
Clinicianrsquos Dashboard
Expensive to build
Displayed on your screen when your computer is first turned on
Easy to read and understand
Data dumped from the day before
Can dialed down from Org-wide to clinic to each clinicianrsquos data
Operational and clinical metrics
bull Treatment Plan Completion
bull DQA quality measures
bull Caries at Recall
bull Re-care reports
bull Care Gap reports
82
CONTROLLING COSTS
8383
Controlling Costs- Current
bull Increasing efficiencies
bull Decreasing broken appointments
bull Controlling supplies equipment costs
bull Staff recruitment retention costs
84
Specialty Care
Training current CHC dentists in
specialty areas
Hiring general dentists with higher
specialty skill sets
Hiring in house specialists
Contract with outside specialists
Work with Managed Care Plan
specialists
Lowering Disease Rates
Community Dental Health
Coordinators case management
If your state law allows- embed
hygienists in medical and community
to provide primary and secondary
prevention procedures
In clinic Caries Classification and
Silver Diamine Fluoride
Effective recare programs
Controlling Costs- Additions in Risk-based Contracting
85
Specialty Care ndash Primary Referrals by Cost
Pediatric dentistry
Orthodontics
Oral surgery
Endodontics
86
In-clinic Pediatric Services
Encounters expected
of operatories available
State dental law and ability to have
expanded duties
General Anesthesia
GA in- house
Ability for a hospital or surgery center
to set aside regular OR time
Ability to hire or assign DAs to GA
days
Four GA cases day x PPS rate
Should You Hire a Pediatric Dentist- It Depends
8787
Solutions for Controlling Pediatric Costs
Hire a general dentist that is skilled in treating young children
Make the clinic child friendly nitrous oxide TVs in the operatory etc
Teach entire staff behavioral control techniques
Contract with a pediatric dentist for the GA care
88
Lowering Overall Disease Rates (and Costs)
You are responsible for both the patients you see in the chair and the ones
assigned to you
Breaking down the walls of the dental clinic
Community Dental Health Coordinators
Case Management
89
Cost Control Essentials
Diagnosis codes
Increased ability to identify
disease by risk
Motivational
Interviewing
Developing Polices and
Procedures design to treat
disease according to risk
ie Silver Diamine Fluoride
Treating by Risk
Effective Recare
Process
Critical to continual disease
controlPrevention education that is
meaningful and designed to
change behaviors
90
Social Determinants of Health Aunt Bertha
httpswwwauntberthacom
91
REASON TO CONSIDER RISK- BASED CONTRACTING
9292
PPS Reconciliation and Federal Code 42 CFR sect4052469(a)(2)
42 CFR sect4052469(a)(2)
ldquoAny financial incentives provided to Federally Qualified Health Centers
under their Medicare Advantage Contracts such as risk pool payments
bonuses or withholds are prohibited from being included in the
calculation of supplemental payments due to the Federally Qualified
Health Centerrdquo
9393
Why Risk Based Contract in Times of PPS Reconciliation
bull Not all Risk- based Contract funds are reconciled
bull Risk is the key word- you can come out with less money than your normal
PPS reconciliation payment
bull Can lead to better patient care
bull May improve manage care enrollment for your medical plan
bull Promotes integrated care increases health for your CHC patients
9494
Not Included in the Reconciliation
Enrollment management pmpm
Quality Payments
Upside risk payments
Downside risk losses
9595
Determinants of Financial Success in Risk-Based Contracting
bull Most critical- State pmpm payment to the Managed Care Plan
bull Reporting capabilities
bull Specialty service capabilities
bull Access numbers count
bull Ability to move metric numbers
9696
What About the Non- Medicaid Poor We Serve
bull Numbers are king in a managed care contract and the more access you have
the better contract terms you can negotiate
bull We will potentially have a steady supply of Medicaid patients
bull As managed care spreads states this may be compromising the ability of
health centers to serve the non-Medicaid poor and others lacking dental
insurance
97
Mark Koday DDS
(509) 949-2278
Dental Quality Consultants
of WA
httpdentalqualityconsultin
gcom
dentalqualityconsultantsg
mailcom
Contact Information
LUNCH
BREAKOUT EXERCISEORAL HEALTH VALUE-BASED CARE READINESS ASSESSMENT
Danielle Apostolon
PROMISING PRACTICES FROM THE FIELD STRATEGIES FOR INCREASING VALUE IN ORAL HEALTH
Dr Carolyn Brown
Dr Kelly Perry
Dr Rachel Rivard
Dr Adeloye
Commitment Compassion Community
m i d s t a t e h e a l t h o r g
Promising Practices from the
Field Strategies for Increasing
Value in Oral Health Care
Kelly Perry DMD
Better Health
Outcomes
Improved Staff
Experience
Reduced Cost
Improved Patient
Experience
Better Health
Outcomes
Improved Staff
Experience
Reduced Cost
Improved Patient
Experience
Better Health
Outcomes
Improved Staff
Experience
Reduced Cost
Improved Patient
Experience
Better Health
Outcomes
Improved Staff
Experience
Reduced Cost
Improved Patient
Experience
Commitment Compassion Community
kpe r r ymids t a tehea l t h o rg
Thank you
Completion of Disease Control Phase
Pelumi Adeloye DMD MPH
HEALTH ACCESS NETWORK (HAN) FAMILY DENTAL
Introduction
⧫1 Dentist I Hygienist 3 EFDArsquos1 Receptionist
⧫ 6 Chairs= 4 (dentist) + 2 (hygienist)
⧫ Slide ⥶80 off
⧫ Service areas Northern Penobscot Southern Aroostook Western
Washington Counties amp more
Completion of Phase I Treatment
⧫LimitedLack of Access to dental care
⧫Difficulty completing the disease control phase
Caries amp periodontal disease
⧫Attaining stable restorative state
Goal
Increase the completion of Disease Control Phase
Current practice
⧫Education
Assess level of dental literacy
Incremental strategy
⧫Increase access to dental care
Generous sliding scale (⥸$40 per visit)
Incorporate Expanded Function Dental Assistants
⧫Schedule modification
Incorporate more restorative blocks to allow
for follow-up visit and completion of restorative phase
httpswwwglasbergencomdentist-cartoons
Schedule
⧫Piggybacking technique
Increased allotted restorative blocks
⧫Sustainability of current schedule is
contingent on cooperation amp skills of HAN
Dental staff
Note
Strategies mentioned today is personalized to HAN Dental clinic
Current implemented strategies might be modified or changed in the
future as required in order to accommodate the need of our pts
THANK YOU
DAY TWOCLOSINGWRAP-UP
End of Day Two ndash Survey
Day Two Creating a Value-Based Oral Health Care Delivery
System
129
Payment Reform in Oral Health Online Learning Module
Oral Health Value-based Care Online Learning Module
Value-based Care Keys to Success Article
Readiness Assessment
Competency Development Guide
Oral Health Value-based Care Training
Dental Caries Management Practicum
Clinicians Companion Guide
Interprofessional Network Referral Process
Traditional Dental Care Vs Value-Based Care
Resources
131
wwwDentaQuestPartnershiporg
wwwfacebookcomDentaQuest
DentaQuest
wwwlinkedincomcompanyDentaQuest
Inside_DentaQuest
QUESTIONS
2
wwwdentaquestpartnershiporg
bull Click on Learn
bull Click on Resource library
3
4
5
bull $37 trillion
bull $10739 per
person
bull 179 of GDP
2017 National Health Expenditures
6
Mortality Rates Decreasing
httpswwwhealthsystemtrackerorgchart-collectionquality-u-s-healthcare-system-compare-countriesitem-overall-years-
life-lost-1990-2017
7
Early Detection amp Prevention Matters
One of our providers was able to diagnose a lesion the biopsy had some cancer
cells We were trying to get that patient into an oral surgeon We contacted several
of the private practice oral surgeons in the area It was anywhere from $300 to $400
to walk into their office for an evaluation and a diagnosis That doesnt mean even
treatment
We were able to get him to The University of Maryland Its about a two-hour trip for
this patient to get there His first appointment his car broke down and he couldnt
get there The next appointment we were able to get him he traveled the two hours
and waited for four and a half hours and then wasnt seen They had a backlog and
he was sent home and told they would give him another appointment and come
back He then left our area and came back three years later in 2017 and our dentist
that does pediatrics is actually the only one in the office
8
Early Detection amp Prevention Matters
When he came as an emergency she saw him He had just came out of the
hospital His ENT just diagnosed him with stage four head and neck cancer And
if we had been able to see him got him into care with that initial diagnosis
which was a very small lesion at the time we might have been able to prevent
that
9
Evaluation survey must be completed to receive 10 CE credits
bull httpswwwsurveymonkeycomrVBCTraining1
bull httpswwwsurveymonkeycomrVBCTraining2
10
Agenda
Highlights from Day One
Group Discussion
Laying the Groundwork for Oral Health Value-Based Care Readiness
Lunch
Breakout Exercise Oral Health Value-Based Care Readiness
A Dental Directorrsquos Experience in Risk-Based Oral Health Managed Care
Promising Practices from the Field
ClosingWrap Up
11
12
bull Outline the key components to prepare for oral health value-based care
delivery system
bull Understand measurement and principles in healthcare transformation
Todayrsquos Learning Objectives ndash Day Two
LAYING THE GROUNDWORKCLINICAL OPERATIONS IN A VBR ENVIRONMENTCarolyn Brown DDS Consultant
November 19th 2019
14
INTRODUCTION
15
Todayrsquos Agenda
bull Discuss value-based health and pay-for-performance approaches to health
systems and the integral building block of data
bull Dive deep into the emerging field of value-based care measurement and
data in oral health from national and statewide perspectives
bull Present oral health and clinical measurement approaches and relate to
oversight
16
bull Consultant working with DQP FQHCs Primary Care Associations and Foundations advancing oral health programs
bull DQPSNS Expert Advisor
bull IHI Improvement Coach
bull Former Dental Director
bull Research Marketing Finance
Carolyn Brown DDS
Consultant Acting Director of Value-Based Care
DentaQuest Partnership for Oral Health Advancement
bull DDS University of Maryland School of Dentistry
bull MAEd University of the Pacific
bull BS University of Maryland
bull Speaker researcher expert advisor review panel
17
Poll What do you measure
A Dental provider productivity per day
B Treatment plan completion
C Dental new patient exams
D Combination of A-C
E No Shows
F Sealants only
18
Population
Prevention
Healthy
Minimally Invasive
Health outcomes
MDI
EHR EDR
PCC
Risk Assessment
19
VALUE-BASED CAREPushing the impact quality and quantity of measurement
20
OHVBC Readiness
Leadership
Value of oral health and oral health transformation
Structure Systems and Operations
Efficiencies innovative care delivery
Care Pathways and Provider Buy-In
Risk-based care Training patient engagement
Data and Analytic Technology and Personnel
DataReports Interoperability
Financial Viability and Strength
Payerpatient mix billing infrastructure
httpswwwdentaquestpartnershiporglearnsafety-net-solutionsoral-health-value-based-careohvbc-readiness-
assessment
21
DentaQuest Partnership OHVBC Survey
Barriers to Value-based Transformation in Oral Health ndash
Most Common Responses
bull Patient engagement
bull EHREDR
bull Tracking outcomes lack of nationally-recognized and standardized quality
metrics in dental
22
How Can FQHC Dental Programs Prepare for Value-based
Transformation in Oral Health
bull Begin or continue focusing on prevention disease management and risk-based care
bull Hygienists will be key to success ndash We need primary dental care not just surgical
interventions
bull Start measuring outcomes instead of just processutilization metrics bull of initially high-risk patients with new caries lesions
bull of initially high-risk patients with decreased risk status
bull of initially low-risk patients with risk status maintained
bull Address patient engagement in a more meaningful way and invest in case
management
bull Invest in interprofessional practice including HIT interoperability
bull Evaluate how services are being delivered and determine if its reaching the patients
who need care the most
23
Value-Based Care
Care Coordination
ldquoClosing outrdquo referrals
Diagnostic coding
Risk Screenings
Care plans based on risk
Patient Engagement
Incentive payments
Quality metrics
Clinic Response
Case Management IT
Active timely records mngt
Mapping Dx codes to CDT
Time bill CPT codes Tx plan
IPP data tofrom PC MH
Recall window important
Attention to $ related metrics
Attention to assigned metrics
Direct and Indirect Effects of VBC on Dental Systems of Care
Utilization Impact
New workforce CDT codes
New or + workforce IT
ICD-CM-10 codes
+CDT codes
Modifiers (CPT ICD10)
+ recall adherence
in incentivized procedures
in sealant POC A1C
Counseling codes SD
24
MEASUREMENT IN ORAL HEALTH
25
Poll What percentage of your adult dental patients are diabetic
or pre-diabetic
A 50-80
B 20-50
C Less than 20
D Not sure
26
27
ldquoTrue Measures of Successrdquo
1 Define your governing objective
2 Develop a theory of cause and effect to assess presumed drivers of the
objective
3 Identify the specific activities that employees can do to help achieve the
governing objective
4 Evaluate your statistics
5 Communicate the story of your measurement
Adapted from HBR ldquoThe True Measures of Successrdquo httpshbrorg201210the-true-measures-of-success
28
1 Governing objective
2 Theory of cause and effect
3 Activities of team
4 Evaluate your statistics
5 Storycraft
Sustainability
Clinic revenuegt expenses= sustainability
Patient compliance Assets Clinic Mngt
Care team Operations Pt Support Billing
Of Prod on and type Patients on time
Daily weekly monthly quarterly
ldquoTrue Measures of Successrdquo
Adapted from HBR ldquoThe True Measures of Successrdquo httpshbrorg201210the-true-measures-of-success
29
Measuring Risk and Health
November is Diabetes Awareness Month- 2019Communication Plans are as
important as cold hard numbers
Patients
Care Team
Other Health Teams
Executive Team
Funders
Data on your dental patients are medical patients of record
Data on your medical + dental patients with DM2
30
Develop Diabetic Patient
Protocols
Review evidence and rationale with dental team
Partner with primary care team
bull Protocols Care mngt Tests and Recording
Quality Goals
Protocols for newly screened and existing patients
Educate and train dental team in reading AND
charting test results and PILOT
31
External Measurement in Oral Health Programs
httpswwwadaorg~mediaADADQA2019_DiabetesOralEvaluationpdfla=en
httpswwworegongovohaHPAANALYTICSCCOMetrics2019-Oral-Evaluation-Adults-Diabetespdf
32
Baseline for 2019 271
httpswwworegongovohaHPAANALYTICSCCOMetrics2019-Oral-Evaluation-Adults-Diabetespdf
33
Diabetes burden in your panel of dental patients
Baseline Medical-Dental Integrated panel of all patients
Dental patients with DM2 MDI
Dental patients with DM2
1000 or 10
600 or 60
300010000= 30
Population Health- Clinic Level
34
1 Governing objective
2 Theory of cause and effect
3 Activities of team
4 Evaluate your statistics
5 Storycraft
Discuss at meetings (Oct + Nov) Health education training
materials NP training CQI Note in Board report Clinical
measures
Care Pathways Hygiene Resources (ScheduleAvail)
ldquoTrue Measures of Successrdquo
Adapted from HBR ldquoThe True Measures of Successrdquo httpshbrorg201210the-true-measures-of-success
Diabetes Awareness Prevention Healthier Community
Prevention Awareness Care Pathway promotes health
MDI= 10 6 out of 10 adult patients with DM2
Goal set for integrated patient panels ndash PCMH
Pre-diabetes approach for executive team
Care Pathways
Care Coordination
35
MEASURING PATIENT ORAL HEALTHRisk assessments and Care Pathways
36
37
Risk Assessment and Care Pathways
Caries Risk Assessment
Multiple tools
EDREHR modules smart notes or dot phrases
CDT Codes
Decide frequency
D0601
Low Caries Risk
D0601
Moderate Caries Risk
D0601
High Caries Risk
38
The Disease Management DifferenceDisease Management Difference
Traditional Dental Care Disease Management
Approach
All patients return in 6 months
regardless of risk status
Recare interval is based on the
childrsquos caries risk
Caries Risk
Level
Recommended
Recare Interval
High Risk 1 ndash 3 months
Moderate Risk 3 ndash 6 months
Low Risk 6 ndash 12 months
Caries
Stabilizing
agents
Health Ed
Nutritional
Counseling
Anti-bacterial
and Fluoride
interventions
39
Disease Management Care Pathways
DentaQuest Partnership for Oral Health Advancement Disease Management Model
Caries
Stabilizing
agents
Whole
Person
Inter-
professional
Approaches
Anti-bacterial
and Fluoride
interventions
40
Disease Management and Risk Screening Training
DentaQuest Partnership for Oral Health Advancementrsquos
Online Learning Center
Disease Management Series
8 modules 40 CDE available
httpswwwdentaquestpartnershiporglearnonline-learning-centeronline-
coursewaredentaquest-disease-management-series
41
MEASUREMENT IN TEAMSSharing meaningful data with your dental clinical teams
42
rdquoDental Homerdquo = Health Home where WE can meet the patient
Oralhealthworkforceorg
43
POLL HOW OFTEN DO YOU SHARE YOUR S WITH YOUR DENTAL TEAM
A Yearly only
B Quarterly
C Monthly
D Weekly
E Daily
44
Clinical Measures ndash Dental Practice Perspective
Private Practice Office
New patients seen
Assigned vs seen if capitated
Treatment plans incomplete
$ produced amp per provider
$ collected amp monthly per provider
CDT 6000 codes completed
RecallHygiene maintenance
Based on this consultants experienced
FQHC
Unduplicated patients
patients seen per day
Treatment plans complete
$ gainedlost via accounting
Broken appointment rate
procedures
Sealant rate (annual)
45
bull HRSA Sealant Measure Compliance for FQHCs
bull Completion of phase 1 treatment plans
bull Children seen 0-5 years old
bull Children seen getting a preventive service
bull Fluoride Varnish applications
bull Pregnant women seen and treated
bull Diabetic patients with HbA1C gt 7 seen
bull Patients seen who have not been seen for 12 months
bull Patients seen getting a Risk Assessment
bull Patients with moderate or high risk who lower risk at recare
bull Sealants provided httpwwwnnohaorgnnoha-contentuploads201512Demystifying-HRSA-SEALANT-PRESENTATION_FINALpdf
Program Measures
46
HRSA Performance Measurement and Data Collection
bull FQHCs and look-alikes submit CY data to HRSA since 2008
bull UDS Uniform Data System
bull Require FTE for clinical staff patient demographics
bull Dental utilization s (UDCTPV)
bull Dental Clinical Measure dental sealants placed on 1st molars ages 6-9 yo
bull Health Center Quartile rankings (Clinical measure performance influences
HC rankings as does EHR adoption and other HC characteristics)
47
Low birth weight
Access to prenatal care
Childhood Immunization
Children (Ages 3-17) Receiving
Weight Assessment amp
Counseling
Children (Age 6-9) Receiving
Dental Sealant to First Molars
Diabetes Control
Hypertension Control
Pap Test
Depression Screening and
Follow-up (Age 12+)
Asthma Patients (Age 5-40)
Receiving Pharmacologic
Therapy
Colorectal Cancer
Screening (Ages 51-74)
HRSA UDS Clinical Measures
Adults (Age 18+) Receiving
Weight Screening amp Follow-up
Adults (Age 18+) Receiving
Tobacco Use Assessment and
Cessation Intervention
Coronary Artery Disease
Receiving Lipid Therapy (18+)
Ischemic Vascular Disease (IVD)
Receiving Aspirin Therapy (18+)
HIV Linkage to Care
48
Dashboards
Grants
Average
amp
Targets
Quality
Rev
Costs
Visits
Priority
Pop
Prevention
49
Dashboard- Provider Team Level
Patient
Compliance
Satisfaction
50
Case Study-
Incentives bonus round pools benchmark and improvement target goals risk-sharing possible later years
51
Qualitative Measurement
ldquoPatient engagement is the act of patients and providers working together
toward the end goal of improved patient wellnessrdquo
wwwpatientengagementhitcom
Access to Care
Patient Activation
Patient Satisfaction
Patient-Provider-Care Team Communication
Care Team Satisfaction
52
OHVBC Readiness
Leadership
bull Value of oral health and oral health transformation
Structure Systems and Operations
bull Operational efficiencies innovative care delivery methodologies
Care Pathways and Provider Buy-In
bull Training disease management risk-based care referrals IDC-10 coding patient engagement
Data and Analytic Technology and Personnel
bull Interoperability reporting
Financial Viability and Strength
bull Payerpatient mix billing infrastructure financial reports
httpswwwdentaquestpartnershiporglearnsafety-net-solutionsoral-health-value-based-careohvbc-readiness-
assessment
53
QUESTIONS COMMENTS
Carolyn Brown DDS
cbrownddsgmailcom
RISK BASED MANAGED CARE
Value Based Training Conference
Manchester New Hampshire
Mark Koday DDS
111919
5555
Objectives
bull Review current drivers of dental managed care
bull Understand the basics of risk-based dental managed care contracts
bull Learn the basics of managing costs in a riskndashbased contract
bull Gain an understanding in the potential advantage of risk-based contracting
56
What Is Dental Managed Care
Managed care is a health delivery system whose purpose is to manage both the
quality and cost of health care
Common types of managed care health insurance plans
bull HMOs
bull PPOs
bull POSs
bull Medicaid Managed Care
DIDNrsquoT WE ALREADY HAVE MANAGED CARE AND IT FAILED
57
What Has Happened Since the 90s
58
WHY THE FFS AND PPS DOESNrsquoT WORK FOR OUR POPULATIONS
bull Inefficient payment systems designed to produce encounters or procedures but not real health
bull No focus on population health
bull Does not incentivize innovation
bull Patients essentially on their own for accessing specialty care
59
Rule of 4
Source Kaiser Family Foundation analysis of National Health Expenditure (NHE) data from Centers for
Medicare and Medicaid Services Office of the Actuary National Health Statistics Group
60
Rule of 4
bull This helps explain why oral health has been relatively ignored so far by CMS
bull Explains why we have PCMH instead of PCHH
bull Where is the real value on a national level in preventing disease and
controlling costs
bull Beware- wersquove been found
61
Reasons Dental Managed Care is Spreading Across the States
NON-MANAGED CARE STATE DENTAL BUDGETS ARE
OPENED ENDED
STRAIN ON STATE BUDGETS
UPCOMING RECESSION WITH TRILLION DOLLAR
DEFICIT
SHIFTS FINANCIAL RISK FROM THE STATES TO THE
PLANS
6262
Types of Medicaid Managed Care
bull State Medicaid agency administrator lowest administrative
costs
bull Third Party Administrator Typically 15 administrative costs
bull Managed Care Organization Typically 15 administrative
costs
bull Carved-in
bull Carved-out
bull Risk Based Managed Care Administrative costs part of
contract negotiation
63
RISK CONTRACTS
6464
Components of a Risk-based Contract
Risk
Medical Loss Ratio
Quality withhold
Specialty withhold
Managed care payment (pmpm)
Covered services
Fee schedule Claims are paid as usual on a FFS basis
Credentialing
Quality Review process and Quality Metrics
65
Upside Risk
The possibility that the cost of
delivering dental care to an assigned
patient panel is less than the amount
of funding calculated for that care
The Plan pays the CHC additional
funds based on a predetermine
formula
Downside Risk
The possibility that the cost of
delivering dental care to an assigned
patient panel is more than the amount
of funding calculated for that care
The CHC pays the Plan additional
funds based on a predetermine
formula
Upside and Downside Risk
66
Taking On Risk 100 or Shared Risk
With 100 risk you receive 100 of the potential savings but are also at risk for
100 of the losses
Shared Risk MCO and health center share a percentage of the risk
Shared Risk leads to better cooperation since both organizations are
incentivized to save on costs
6767
Reports Needed
bull Enrollment reports lists of who is assigned on a monthly basis
bull Reconciliation reports insure appropriate payments
bull Specialty Referral reports
bull You will need your own reporting process so you donrsquot rely completely on
reports supplied by the Plan
6868
Medical Loss Ratio
Medical Loss Ratio (MLR) is proportion of premium revenues spent on clinical
services and quality improvement also known as the Medical Loss Ratio (MLR)
For CMS requires Medical Plans to spend at least 80 to 85 of the premiums
on actual medical care
69
Administrative Fees
bull Essentially the opposite of MLR
bull The State Medicaid Agency is funded by the Governorrsquos budget
bull The State Medicaid Agency will keep some of these funds for their
admin costs and give the remaining to the Managed Care Plans
bull Private Plan admin costs can be as high as 40 but most states
limit these cost for Medicaid Plans to between 15 and 20 (85-
80 MLR)
bull This may be negotiable depending on your program size of your
program
70
Quality Withhold
bull The state withholds a certain percent (typically 2-4 ) of the funds they give
to the Plans for Value Based Reimbursement
bull They choose quality metrics and set benchmarks and assign payments for
each metric based on an assigned priority for each metric
bull If a Plan meets the benchmark of every quality metric the state passes on
their full share of the quality withhold
bull The Plans may or may not withhold a percent of the funds for quality payment
to the dentists or manage care contractors
71
Quality Withhold
Either way the Plans may or may not pass the quality payments they receive to
the dentists or contractors
This should be spelled out in a risk-based contract
72
Percent of funds set aside
to cover specialty care
referrals
Typically 10-15
Goal Limit referral costs
to within or less than
Specialty set aside
Specialty Withhold
73
Per Member Per Month
bull Capitated Payment
bull Specific dollar amount paid for each enrolled member each month
bull Paid whether patient is accessed for care or not
bull States do set access benchmarks
bull In Oregon access for any dental procedure (adults and children combined)
was 267 in 2015
74
Payment Math Example
Premium per enrollee = $25
Administrative fee 15 = $375
Funds available per enrollee to the clinic = $2125
Management fee per enrollee = $175
Funds per enrollee that would undergo PPS reconciliation = $1950
For every 10000 enrollees the managed care income = $2340000
Specialty withhold (10) = $234000
YE Cost lt or gt $2340000
Upside Risk
CHC Gains $
Downside Risk
CHC Loses $
75
Covered Services and Fee Schedules
bull The state Medicaid agency spells out the minimum procedures and fees that
MCOs must cover
bull MCOs may add procedures or increase periodicity of procedures particularly
preventative services
bull MCOs may increase fees to entice rural providers and specialists to enroll in
their Plans
bull Access Rules
bull How many days it takes to access a patent
bull How many days it takes for a patent to access urgent care services
bull How many days it takes for a patent to access emergency care services
76
Credentialing
All MCOs are required to credential all Providers
All MCOs have their own credentialing process
Credentialing process is can be lengthy
Credentialing process may be negotiable
77
Quality Review Process and Quality Metrics
MCOs must have a Quality and Compliance Review Process
If you arenrsquot in compliance with both you likely wonrsquot get paid
Typical processes reviewed
bull Charting specifications
bull Incident report
bull Enrollee complaints quality rudeness and access issues
bull Medicaid compliance
78
Quality Payments
bull State Shared Incentive Withhold Typically quality metrics and benchmarks
are set by the state sets aside a certain percent (3-5) of the payments to
the Managed Care Plan (MCP)
bull If the benchmarks are achieved the MCP is then paid the a predetermine
amount
bull Benchmarks may not be the same as the states
bull Managed Care Plans do not have to pass all or any of the quality payments to
the health centers or providers
bull Managed Care contract- Metrics benchmarks should be selected and part of
the contract
7979
Achieving Quality Metric Payments
Dealing with under achievers
Process issues
Individual issues
Identifying workflows
Developing Best Practices through
PDSA process
Developing Best Practices through
PDSA process
CHC Metrics Committee
Clinicians Operations various key staff
Identify Best Practices
Spread Best Practices
80
New Team Needed Business Intelligence
Business Intelligence (BI) is critical for effective managed care business decisions
BI team inputs metrics into your EHR collects integrates analyses and displays all your managed care business and clinical information
Easy to say- hard to achieve
Build your own or outsource
Possible future role of Primary Care Associations
8181
Clinicianrsquos Dashboard
Expensive to build
Displayed on your screen when your computer is first turned on
Easy to read and understand
Data dumped from the day before
Can dialed down from Org-wide to clinic to each clinicianrsquos data
Operational and clinical metrics
bull Treatment Plan Completion
bull DQA quality measures
bull Caries at Recall
bull Re-care reports
bull Care Gap reports
82
CONTROLLING COSTS
8383
Controlling Costs- Current
bull Increasing efficiencies
bull Decreasing broken appointments
bull Controlling supplies equipment costs
bull Staff recruitment retention costs
84
Specialty Care
Training current CHC dentists in
specialty areas
Hiring general dentists with higher
specialty skill sets
Hiring in house specialists
Contract with outside specialists
Work with Managed Care Plan
specialists
Lowering Disease Rates
Community Dental Health
Coordinators case management
If your state law allows- embed
hygienists in medical and community
to provide primary and secondary
prevention procedures
In clinic Caries Classification and
Silver Diamine Fluoride
Effective recare programs
Controlling Costs- Additions in Risk-based Contracting
85
Specialty Care ndash Primary Referrals by Cost
Pediatric dentistry
Orthodontics
Oral surgery
Endodontics
86
In-clinic Pediatric Services
Encounters expected
of operatories available
State dental law and ability to have
expanded duties
General Anesthesia
GA in- house
Ability for a hospital or surgery center
to set aside regular OR time
Ability to hire or assign DAs to GA
days
Four GA cases day x PPS rate
Should You Hire a Pediatric Dentist- It Depends
8787
Solutions for Controlling Pediatric Costs
Hire a general dentist that is skilled in treating young children
Make the clinic child friendly nitrous oxide TVs in the operatory etc
Teach entire staff behavioral control techniques
Contract with a pediatric dentist for the GA care
88
Lowering Overall Disease Rates (and Costs)
You are responsible for both the patients you see in the chair and the ones
assigned to you
Breaking down the walls of the dental clinic
Community Dental Health Coordinators
Case Management
89
Cost Control Essentials
Diagnosis codes
Increased ability to identify
disease by risk
Motivational
Interviewing
Developing Polices and
Procedures design to treat
disease according to risk
ie Silver Diamine Fluoride
Treating by Risk
Effective Recare
Process
Critical to continual disease
controlPrevention education that is
meaningful and designed to
change behaviors
90
Social Determinants of Health Aunt Bertha
httpswwwauntberthacom
91
REASON TO CONSIDER RISK- BASED CONTRACTING
9292
PPS Reconciliation and Federal Code 42 CFR sect4052469(a)(2)
42 CFR sect4052469(a)(2)
ldquoAny financial incentives provided to Federally Qualified Health Centers
under their Medicare Advantage Contracts such as risk pool payments
bonuses or withholds are prohibited from being included in the
calculation of supplemental payments due to the Federally Qualified
Health Centerrdquo
9393
Why Risk Based Contract in Times of PPS Reconciliation
bull Not all Risk- based Contract funds are reconciled
bull Risk is the key word- you can come out with less money than your normal
PPS reconciliation payment
bull Can lead to better patient care
bull May improve manage care enrollment for your medical plan
bull Promotes integrated care increases health for your CHC patients
9494
Not Included in the Reconciliation
Enrollment management pmpm
Quality Payments
Upside risk payments
Downside risk losses
9595
Determinants of Financial Success in Risk-Based Contracting
bull Most critical- State pmpm payment to the Managed Care Plan
bull Reporting capabilities
bull Specialty service capabilities
bull Access numbers count
bull Ability to move metric numbers
9696
What About the Non- Medicaid Poor We Serve
bull Numbers are king in a managed care contract and the more access you have
the better contract terms you can negotiate
bull We will potentially have a steady supply of Medicaid patients
bull As managed care spreads states this may be compromising the ability of
health centers to serve the non-Medicaid poor and others lacking dental
insurance
97
Mark Koday DDS
(509) 949-2278
Dental Quality Consultants
of WA
httpdentalqualityconsultin
gcom
dentalqualityconsultantsg
mailcom
Contact Information
LUNCH
BREAKOUT EXERCISEORAL HEALTH VALUE-BASED CARE READINESS ASSESSMENT
Danielle Apostolon
PROMISING PRACTICES FROM THE FIELD STRATEGIES FOR INCREASING VALUE IN ORAL HEALTH
Dr Carolyn Brown
Dr Kelly Perry
Dr Rachel Rivard
Dr Adeloye
Commitment Compassion Community
m i d s t a t e h e a l t h o r g
Promising Practices from the
Field Strategies for Increasing
Value in Oral Health Care
Kelly Perry DMD
Better Health
Outcomes
Improved Staff
Experience
Reduced Cost
Improved Patient
Experience
Better Health
Outcomes
Improved Staff
Experience
Reduced Cost
Improved Patient
Experience
Better Health
Outcomes
Improved Staff
Experience
Reduced Cost
Improved Patient
Experience
Better Health
Outcomes
Improved Staff
Experience
Reduced Cost
Improved Patient
Experience
Commitment Compassion Community
kpe r r ymids t a tehea l t h o rg
Thank you
Completion of Disease Control Phase
Pelumi Adeloye DMD MPH
HEALTH ACCESS NETWORK (HAN) FAMILY DENTAL
Introduction
⧫1 Dentist I Hygienist 3 EFDArsquos1 Receptionist
⧫ 6 Chairs= 4 (dentist) + 2 (hygienist)
⧫ Slide ⥶80 off
⧫ Service areas Northern Penobscot Southern Aroostook Western
Washington Counties amp more
Completion of Phase I Treatment
⧫LimitedLack of Access to dental care
⧫Difficulty completing the disease control phase
Caries amp periodontal disease
⧫Attaining stable restorative state
Goal
Increase the completion of Disease Control Phase
Current practice
⧫Education
Assess level of dental literacy
Incremental strategy
⧫Increase access to dental care
Generous sliding scale (⥸$40 per visit)
Incorporate Expanded Function Dental Assistants
⧫Schedule modification
Incorporate more restorative blocks to allow
for follow-up visit and completion of restorative phase
httpswwwglasbergencomdentist-cartoons
Schedule
⧫Piggybacking technique
Increased allotted restorative blocks
⧫Sustainability of current schedule is
contingent on cooperation amp skills of HAN
Dental staff
Note
Strategies mentioned today is personalized to HAN Dental clinic
Current implemented strategies might be modified or changed in the
future as required in order to accommodate the need of our pts
THANK YOU
DAY TWOCLOSINGWRAP-UP
End of Day Two ndash Survey
Day Two Creating a Value-Based Oral Health Care Delivery
System
129
Payment Reform in Oral Health Online Learning Module
Oral Health Value-based Care Online Learning Module
Value-based Care Keys to Success Article
Readiness Assessment
Competency Development Guide
Oral Health Value-based Care Training
Dental Caries Management Practicum
Clinicians Companion Guide
Interprofessional Network Referral Process
Traditional Dental Care Vs Value-Based Care
Resources
131
wwwDentaQuestPartnershiporg
wwwfacebookcomDentaQuest
DentaQuest
wwwlinkedincomcompanyDentaQuest
Inside_DentaQuest
QUESTIONS
3
4
5
bull $37 trillion
bull $10739 per
person
bull 179 of GDP
2017 National Health Expenditures
6
Mortality Rates Decreasing
httpswwwhealthsystemtrackerorgchart-collectionquality-u-s-healthcare-system-compare-countriesitem-overall-years-
life-lost-1990-2017
7
Early Detection amp Prevention Matters
One of our providers was able to diagnose a lesion the biopsy had some cancer
cells We were trying to get that patient into an oral surgeon We contacted several
of the private practice oral surgeons in the area It was anywhere from $300 to $400
to walk into their office for an evaluation and a diagnosis That doesnt mean even
treatment
We were able to get him to The University of Maryland Its about a two-hour trip for
this patient to get there His first appointment his car broke down and he couldnt
get there The next appointment we were able to get him he traveled the two hours
and waited for four and a half hours and then wasnt seen They had a backlog and
he was sent home and told they would give him another appointment and come
back He then left our area and came back three years later in 2017 and our dentist
that does pediatrics is actually the only one in the office
8
Early Detection amp Prevention Matters
When he came as an emergency she saw him He had just came out of the
hospital His ENT just diagnosed him with stage four head and neck cancer And
if we had been able to see him got him into care with that initial diagnosis
which was a very small lesion at the time we might have been able to prevent
that
9
Evaluation survey must be completed to receive 10 CE credits
bull httpswwwsurveymonkeycomrVBCTraining1
bull httpswwwsurveymonkeycomrVBCTraining2
10
Agenda
Highlights from Day One
Group Discussion
Laying the Groundwork for Oral Health Value-Based Care Readiness
Lunch
Breakout Exercise Oral Health Value-Based Care Readiness
A Dental Directorrsquos Experience in Risk-Based Oral Health Managed Care
Promising Practices from the Field
ClosingWrap Up
11
12
bull Outline the key components to prepare for oral health value-based care
delivery system
bull Understand measurement and principles in healthcare transformation
Todayrsquos Learning Objectives ndash Day Two
LAYING THE GROUNDWORKCLINICAL OPERATIONS IN A VBR ENVIRONMENTCarolyn Brown DDS Consultant
November 19th 2019
14
INTRODUCTION
15
Todayrsquos Agenda
bull Discuss value-based health and pay-for-performance approaches to health
systems and the integral building block of data
bull Dive deep into the emerging field of value-based care measurement and
data in oral health from national and statewide perspectives
bull Present oral health and clinical measurement approaches and relate to
oversight
16
bull Consultant working with DQP FQHCs Primary Care Associations and Foundations advancing oral health programs
bull DQPSNS Expert Advisor
bull IHI Improvement Coach
bull Former Dental Director
bull Research Marketing Finance
Carolyn Brown DDS
Consultant Acting Director of Value-Based Care
DentaQuest Partnership for Oral Health Advancement
bull DDS University of Maryland School of Dentistry
bull MAEd University of the Pacific
bull BS University of Maryland
bull Speaker researcher expert advisor review panel
17
Poll What do you measure
A Dental provider productivity per day
B Treatment plan completion
C Dental new patient exams
D Combination of A-C
E No Shows
F Sealants only
18
Population
Prevention
Healthy
Minimally Invasive
Health outcomes
MDI
EHR EDR
PCC
Risk Assessment
19
VALUE-BASED CAREPushing the impact quality and quantity of measurement
20
OHVBC Readiness
Leadership
Value of oral health and oral health transformation
Structure Systems and Operations
Efficiencies innovative care delivery
Care Pathways and Provider Buy-In
Risk-based care Training patient engagement
Data and Analytic Technology and Personnel
DataReports Interoperability
Financial Viability and Strength
Payerpatient mix billing infrastructure
httpswwwdentaquestpartnershiporglearnsafety-net-solutionsoral-health-value-based-careohvbc-readiness-
assessment
21
DentaQuest Partnership OHVBC Survey
Barriers to Value-based Transformation in Oral Health ndash
Most Common Responses
bull Patient engagement
bull EHREDR
bull Tracking outcomes lack of nationally-recognized and standardized quality
metrics in dental
22
How Can FQHC Dental Programs Prepare for Value-based
Transformation in Oral Health
bull Begin or continue focusing on prevention disease management and risk-based care
bull Hygienists will be key to success ndash We need primary dental care not just surgical
interventions
bull Start measuring outcomes instead of just processutilization metrics bull of initially high-risk patients with new caries lesions
bull of initially high-risk patients with decreased risk status
bull of initially low-risk patients with risk status maintained
bull Address patient engagement in a more meaningful way and invest in case
management
bull Invest in interprofessional practice including HIT interoperability
bull Evaluate how services are being delivered and determine if its reaching the patients
who need care the most
23
Value-Based Care
Care Coordination
ldquoClosing outrdquo referrals
Diagnostic coding
Risk Screenings
Care plans based on risk
Patient Engagement
Incentive payments
Quality metrics
Clinic Response
Case Management IT
Active timely records mngt
Mapping Dx codes to CDT
Time bill CPT codes Tx plan
IPP data tofrom PC MH
Recall window important
Attention to $ related metrics
Attention to assigned metrics
Direct and Indirect Effects of VBC on Dental Systems of Care
Utilization Impact
New workforce CDT codes
New or + workforce IT
ICD-CM-10 codes
+CDT codes
Modifiers (CPT ICD10)
+ recall adherence
in incentivized procedures
in sealant POC A1C
Counseling codes SD
24
MEASUREMENT IN ORAL HEALTH
25
Poll What percentage of your adult dental patients are diabetic
or pre-diabetic
A 50-80
B 20-50
C Less than 20
D Not sure
26
27
ldquoTrue Measures of Successrdquo
1 Define your governing objective
2 Develop a theory of cause and effect to assess presumed drivers of the
objective
3 Identify the specific activities that employees can do to help achieve the
governing objective
4 Evaluate your statistics
5 Communicate the story of your measurement
Adapted from HBR ldquoThe True Measures of Successrdquo httpshbrorg201210the-true-measures-of-success
28
1 Governing objective
2 Theory of cause and effect
3 Activities of team
4 Evaluate your statistics
5 Storycraft
Sustainability
Clinic revenuegt expenses= sustainability
Patient compliance Assets Clinic Mngt
Care team Operations Pt Support Billing
Of Prod on and type Patients on time
Daily weekly monthly quarterly
ldquoTrue Measures of Successrdquo
Adapted from HBR ldquoThe True Measures of Successrdquo httpshbrorg201210the-true-measures-of-success
29
Measuring Risk and Health
November is Diabetes Awareness Month- 2019Communication Plans are as
important as cold hard numbers
Patients
Care Team
Other Health Teams
Executive Team
Funders
Data on your dental patients are medical patients of record
Data on your medical + dental patients with DM2
30
Develop Diabetic Patient
Protocols
Review evidence and rationale with dental team
Partner with primary care team
bull Protocols Care mngt Tests and Recording
Quality Goals
Protocols for newly screened and existing patients
Educate and train dental team in reading AND
charting test results and PILOT
31
External Measurement in Oral Health Programs
httpswwwadaorg~mediaADADQA2019_DiabetesOralEvaluationpdfla=en
httpswwworegongovohaHPAANALYTICSCCOMetrics2019-Oral-Evaluation-Adults-Diabetespdf
32
Baseline for 2019 271
httpswwworegongovohaHPAANALYTICSCCOMetrics2019-Oral-Evaluation-Adults-Diabetespdf
33
Diabetes burden in your panel of dental patients
Baseline Medical-Dental Integrated panel of all patients
Dental patients with DM2 MDI
Dental patients with DM2
1000 or 10
600 or 60
300010000= 30
Population Health- Clinic Level
34
1 Governing objective
2 Theory of cause and effect
3 Activities of team
4 Evaluate your statistics
5 Storycraft
Discuss at meetings (Oct + Nov) Health education training
materials NP training CQI Note in Board report Clinical
measures
Care Pathways Hygiene Resources (ScheduleAvail)
ldquoTrue Measures of Successrdquo
Adapted from HBR ldquoThe True Measures of Successrdquo httpshbrorg201210the-true-measures-of-success
Diabetes Awareness Prevention Healthier Community
Prevention Awareness Care Pathway promotes health
MDI= 10 6 out of 10 adult patients with DM2
Goal set for integrated patient panels ndash PCMH
Pre-diabetes approach for executive team
Care Pathways
Care Coordination
35
MEASURING PATIENT ORAL HEALTHRisk assessments and Care Pathways
36
37
Risk Assessment and Care Pathways
Caries Risk Assessment
Multiple tools
EDREHR modules smart notes or dot phrases
CDT Codes
Decide frequency
D0601
Low Caries Risk
D0601
Moderate Caries Risk
D0601
High Caries Risk
38
The Disease Management DifferenceDisease Management Difference
Traditional Dental Care Disease Management
Approach
All patients return in 6 months
regardless of risk status
Recare interval is based on the
childrsquos caries risk
Caries Risk
Level
Recommended
Recare Interval
High Risk 1 ndash 3 months
Moderate Risk 3 ndash 6 months
Low Risk 6 ndash 12 months
Caries
Stabilizing
agents
Health Ed
Nutritional
Counseling
Anti-bacterial
and Fluoride
interventions
39
Disease Management Care Pathways
DentaQuest Partnership for Oral Health Advancement Disease Management Model
Caries
Stabilizing
agents
Whole
Person
Inter-
professional
Approaches
Anti-bacterial
and Fluoride
interventions
40
Disease Management and Risk Screening Training
DentaQuest Partnership for Oral Health Advancementrsquos
Online Learning Center
Disease Management Series
8 modules 40 CDE available
httpswwwdentaquestpartnershiporglearnonline-learning-centeronline-
coursewaredentaquest-disease-management-series
41
MEASUREMENT IN TEAMSSharing meaningful data with your dental clinical teams
42
rdquoDental Homerdquo = Health Home where WE can meet the patient
Oralhealthworkforceorg
43
POLL HOW OFTEN DO YOU SHARE YOUR S WITH YOUR DENTAL TEAM
A Yearly only
B Quarterly
C Monthly
D Weekly
E Daily
44
Clinical Measures ndash Dental Practice Perspective
Private Practice Office
New patients seen
Assigned vs seen if capitated
Treatment plans incomplete
$ produced amp per provider
$ collected amp monthly per provider
CDT 6000 codes completed
RecallHygiene maintenance
Based on this consultants experienced
FQHC
Unduplicated patients
patients seen per day
Treatment plans complete
$ gainedlost via accounting
Broken appointment rate
procedures
Sealant rate (annual)
45
bull HRSA Sealant Measure Compliance for FQHCs
bull Completion of phase 1 treatment plans
bull Children seen 0-5 years old
bull Children seen getting a preventive service
bull Fluoride Varnish applications
bull Pregnant women seen and treated
bull Diabetic patients with HbA1C gt 7 seen
bull Patients seen who have not been seen for 12 months
bull Patients seen getting a Risk Assessment
bull Patients with moderate or high risk who lower risk at recare
bull Sealants provided httpwwwnnohaorgnnoha-contentuploads201512Demystifying-HRSA-SEALANT-PRESENTATION_FINALpdf
Program Measures
46
HRSA Performance Measurement and Data Collection
bull FQHCs and look-alikes submit CY data to HRSA since 2008
bull UDS Uniform Data System
bull Require FTE for clinical staff patient demographics
bull Dental utilization s (UDCTPV)
bull Dental Clinical Measure dental sealants placed on 1st molars ages 6-9 yo
bull Health Center Quartile rankings (Clinical measure performance influences
HC rankings as does EHR adoption and other HC characteristics)
47
Low birth weight
Access to prenatal care
Childhood Immunization
Children (Ages 3-17) Receiving
Weight Assessment amp
Counseling
Children (Age 6-9) Receiving
Dental Sealant to First Molars
Diabetes Control
Hypertension Control
Pap Test
Depression Screening and
Follow-up (Age 12+)
Asthma Patients (Age 5-40)
Receiving Pharmacologic
Therapy
Colorectal Cancer
Screening (Ages 51-74)
HRSA UDS Clinical Measures
Adults (Age 18+) Receiving
Weight Screening amp Follow-up
Adults (Age 18+) Receiving
Tobacco Use Assessment and
Cessation Intervention
Coronary Artery Disease
Receiving Lipid Therapy (18+)
Ischemic Vascular Disease (IVD)
Receiving Aspirin Therapy (18+)
HIV Linkage to Care
48
Dashboards
Grants
Average
amp
Targets
Quality
Rev
Costs
Visits
Priority
Pop
Prevention
49
Dashboard- Provider Team Level
Patient
Compliance
Satisfaction
50
Case Study-
Incentives bonus round pools benchmark and improvement target goals risk-sharing possible later years
51
Qualitative Measurement
ldquoPatient engagement is the act of patients and providers working together
toward the end goal of improved patient wellnessrdquo
wwwpatientengagementhitcom
Access to Care
Patient Activation
Patient Satisfaction
Patient-Provider-Care Team Communication
Care Team Satisfaction
52
OHVBC Readiness
Leadership
bull Value of oral health and oral health transformation
Structure Systems and Operations
bull Operational efficiencies innovative care delivery methodologies
Care Pathways and Provider Buy-In
bull Training disease management risk-based care referrals IDC-10 coding patient engagement
Data and Analytic Technology and Personnel
bull Interoperability reporting
Financial Viability and Strength
bull Payerpatient mix billing infrastructure financial reports
httpswwwdentaquestpartnershiporglearnsafety-net-solutionsoral-health-value-based-careohvbc-readiness-
assessment
53
QUESTIONS COMMENTS
Carolyn Brown DDS
cbrownddsgmailcom
RISK BASED MANAGED CARE
Value Based Training Conference
Manchester New Hampshire
Mark Koday DDS
111919
5555
Objectives
bull Review current drivers of dental managed care
bull Understand the basics of risk-based dental managed care contracts
bull Learn the basics of managing costs in a riskndashbased contract
bull Gain an understanding in the potential advantage of risk-based contracting
56
What Is Dental Managed Care
Managed care is a health delivery system whose purpose is to manage both the
quality and cost of health care
Common types of managed care health insurance plans
bull HMOs
bull PPOs
bull POSs
bull Medicaid Managed Care
DIDNrsquoT WE ALREADY HAVE MANAGED CARE AND IT FAILED
57
What Has Happened Since the 90s
58
WHY THE FFS AND PPS DOESNrsquoT WORK FOR OUR POPULATIONS
bull Inefficient payment systems designed to produce encounters or procedures but not real health
bull No focus on population health
bull Does not incentivize innovation
bull Patients essentially on their own for accessing specialty care
59
Rule of 4
Source Kaiser Family Foundation analysis of National Health Expenditure (NHE) data from Centers for
Medicare and Medicaid Services Office of the Actuary National Health Statistics Group
60
Rule of 4
bull This helps explain why oral health has been relatively ignored so far by CMS
bull Explains why we have PCMH instead of PCHH
bull Where is the real value on a national level in preventing disease and
controlling costs
bull Beware- wersquove been found
61
Reasons Dental Managed Care is Spreading Across the States
NON-MANAGED CARE STATE DENTAL BUDGETS ARE
OPENED ENDED
STRAIN ON STATE BUDGETS
UPCOMING RECESSION WITH TRILLION DOLLAR
DEFICIT
SHIFTS FINANCIAL RISK FROM THE STATES TO THE
PLANS
6262
Types of Medicaid Managed Care
bull State Medicaid agency administrator lowest administrative
costs
bull Third Party Administrator Typically 15 administrative costs
bull Managed Care Organization Typically 15 administrative
costs
bull Carved-in
bull Carved-out
bull Risk Based Managed Care Administrative costs part of
contract negotiation
63
RISK CONTRACTS
6464
Components of a Risk-based Contract
Risk
Medical Loss Ratio
Quality withhold
Specialty withhold
Managed care payment (pmpm)
Covered services
Fee schedule Claims are paid as usual on a FFS basis
Credentialing
Quality Review process and Quality Metrics
65
Upside Risk
The possibility that the cost of
delivering dental care to an assigned
patient panel is less than the amount
of funding calculated for that care
The Plan pays the CHC additional
funds based on a predetermine
formula
Downside Risk
The possibility that the cost of
delivering dental care to an assigned
patient panel is more than the amount
of funding calculated for that care
The CHC pays the Plan additional
funds based on a predetermine
formula
Upside and Downside Risk
66
Taking On Risk 100 or Shared Risk
With 100 risk you receive 100 of the potential savings but are also at risk for
100 of the losses
Shared Risk MCO and health center share a percentage of the risk
Shared Risk leads to better cooperation since both organizations are
incentivized to save on costs
6767
Reports Needed
bull Enrollment reports lists of who is assigned on a monthly basis
bull Reconciliation reports insure appropriate payments
bull Specialty Referral reports
bull You will need your own reporting process so you donrsquot rely completely on
reports supplied by the Plan
6868
Medical Loss Ratio
Medical Loss Ratio (MLR) is proportion of premium revenues spent on clinical
services and quality improvement also known as the Medical Loss Ratio (MLR)
For CMS requires Medical Plans to spend at least 80 to 85 of the premiums
on actual medical care
69
Administrative Fees
bull Essentially the opposite of MLR
bull The State Medicaid Agency is funded by the Governorrsquos budget
bull The State Medicaid Agency will keep some of these funds for their
admin costs and give the remaining to the Managed Care Plans
bull Private Plan admin costs can be as high as 40 but most states
limit these cost for Medicaid Plans to between 15 and 20 (85-
80 MLR)
bull This may be negotiable depending on your program size of your
program
70
Quality Withhold
bull The state withholds a certain percent (typically 2-4 ) of the funds they give
to the Plans for Value Based Reimbursement
bull They choose quality metrics and set benchmarks and assign payments for
each metric based on an assigned priority for each metric
bull If a Plan meets the benchmark of every quality metric the state passes on
their full share of the quality withhold
bull The Plans may or may not withhold a percent of the funds for quality payment
to the dentists or manage care contractors
71
Quality Withhold
Either way the Plans may or may not pass the quality payments they receive to
the dentists or contractors
This should be spelled out in a risk-based contract
72
Percent of funds set aside
to cover specialty care
referrals
Typically 10-15
Goal Limit referral costs
to within or less than
Specialty set aside
Specialty Withhold
73
Per Member Per Month
bull Capitated Payment
bull Specific dollar amount paid for each enrolled member each month
bull Paid whether patient is accessed for care or not
bull States do set access benchmarks
bull In Oregon access for any dental procedure (adults and children combined)
was 267 in 2015
74
Payment Math Example
Premium per enrollee = $25
Administrative fee 15 = $375
Funds available per enrollee to the clinic = $2125
Management fee per enrollee = $175
Funds per enrollee that would undergo PPS reconciliation = $1950
For every 10000 enrollees the managed care income = $2340000
Specialty withhold (10) = $234000
YE Cost lt or gt $2340000
Upside Risk
CHC Gains $
Downside Risk
CHC Loses $
75
Covered Services and Fee Schedules
bull The state Medicaid agency spells out the minimum procedures and fees that
MCOs must cover
bull MCOs may add procedures or increase periodicity of procedures particularly
preventative services
bull MCOs may increase fees to entice rural providers and specialists to enroll in
their Plans
bull Access Rules
bull How many days it takes to access a patent
bull How many days it takes for a patent to access urgent care services
bull How many days it takes for a patent to access emergency care services
76
Credentialing
All MCOs are required to credential all Providers
All MCOs have their own credentialing process
Credentialing process is can be lengthy
Credentialing process may be negotiable
77
Quality Review Process and Quality Metrics
MCOs must have a Quality and Compliance Review Process
If you arenrsquot in compliance with both you likely wonrsquot get paid
Typical processes reviewed
bull Charting specifications
bull Incident report
bull Enrollee complaints quality rudeness and access issues
bull Medicaid compliance
78
Quality Payments
bull State Shared Incentive Withhold Typically quality metrics and benchmarks
are set by the state sets aside a certain percent (3-5) of the payments to
the Managed Care Plan (MCP)
bull If the benchmarks are achieved the MCP is then paid the a predetermine
amount
bull Benchmarks may not be the same as the states
bull Managed Care Plans do not have to pass all or any of the quality payments to
the health centers or providers
bull Managed Care contract- Metrics benchmarks should be selected and part of
the contract
7979
Achieving Quality Metric Payments
Dealing with under achievers
Process issues
Individual issues
Identifying workflows
Developing Best Practices through
PDSA process
Developing Best Practices through
PDSA process
CHC Metrics Committee
Clinicians Operations various key staff
Identify Best Practices
Spread Best Practices
80
New Team Needed Business Intelligence
Business Intelligence (BI) is critical for effective managed care business decisions
BI team inputs metrics into your EHR collects integrates analyses and displays all your managed care business and clinical information
Easy to say- hard to achieve
Build your own or outsource
Possible future role of Primary Care Associations
8181
Clinicianrsquos Dashboard
Expensive to build
Displayed on your screen when your computer is first turned on
Easy to read and understand
Data dumped from the day before
Can dialed down from Org-wide to clinic to each clinicianrsquos data
Operational and clinical metrics
bull Treatment Plan Completion
bull DQA quality measures
bull Caries at Recall
bull Re-care reports
bull Care Gap reports
82
CONTROLLING COSTS
8383
Controlling Costs- Current
bull Increasing efficiencies
bull Decreasing broken appointments
bull Controlling supplies equipment costs
bull Staff recruitment retention costs
84
Specialty Care
Training current CHC dentists in
specialty areas
Hiring general dentists with higher
specialty skill sets
Hiring in house specialists
Contract with outside specialists
Work with Managed Care Plan
specialists
Lowering Disease Rates
Community Dental Health
Coordinators case management
If your state law allows- embed
hygienists in medical and community
to provide primary and secondary
prevention procedures
In clinic Caries Classification and
Silver Diamine Fluoride
Effective recare programs
Controlling Costs- Additions in Risk-based Contracting
85
Specialty Care ndash Primary Referrals by Cost
Pediatric dentistry
Orthodontics
Oral surgery
Endodontics
86
In-clinic Pediatric Services
Encounters expected
of operatories available
State dental law and ability to have
expanded duties
General Anesthesia
GA in- house
Ability for a hospital or surgery center
to set aside regular OR time
Ability to hire or assign DAs to GA
days
Four GA cases day x PPS rate
Should You Hire a Pediatric Dentist- It Depends
8787
Solutions for Controlling Pediatric Costs
Hire a general dentist that is skilled in treating young children
Make the clinic child friendly nitrous oxide TVs in the operatory etc
Teach entire staff behavioral control techniques
Contract with a pediatric dentist for the GA care
88
Lowering Overall Disease Rates (and Costs)
You are responsible for both the patients you see in the chair and the ones
assigned to you
Breaking down the walls of the dental clinic
Community Dental Health Coordinators
Case Management
89
Cost Control Essentials
Diagnosis codes
Increased ability to identify
disease by risk
Motivational
Interviewing
Developing Polices and
Procedures design to treat
disease according to risk
ie Silver Diamine Fluoride
Treating by Risk
Effective Recare
Process
Critical to continual disease
controlPrevention education that is
meaningful and designed to
change behaviors
90
Social Determinants of Health Aunt Bertha
httpswwwauntberthacom
91
REASON TO CONSIDER RISK- BASED CONTRACTING
9292
PPS Reconciliation and Federal Code 42 CFR sect4052469(a)(2)
42 CFR sect4052469(a)(2)
ldquoAny financial incentives provided to Federally Qualified Health Centers
under their Medicare Advantage Contracts such as risk pool payments
bonuses or withholds are prohibited from being included in the
calculation of supplemental payments due to the Federally Qualified
Health Centerrdquo
9393
Why Risk Based Contract in Times of PPS Reconciliation
bull Not all Risk- based Contract funds are reconciled
bull Risk is the key word- you can come out with less money than your normal
PPS reconciliation payment
bull Can lead to better patient care
bull May improve manage care enrollment for your medical plan
bull Promotes integrated care increases health for your CHC patients
9494
Not Included in the Reconciliation
Enrollment management pmpm
Quality Payments
Upside risk payments
Downside risk losses
9595
Determinants of Financial Success in Risk-Based Contracting
bull Most critical- State pmpm payment to the Managed Care Plan
bull Reporting capabilities
bull Specialty service capabilities
bull Access numbers count
bull Ability to move metric numbers
9696
What About the Non- Medicaid Poor We Serve
bull Numbers are king in a managed care contract and the more access you have
the better contract terms you can negotiate
bull We will potentially have a steady supply of Medicaid patients
bull As managed care spreads states this may be compromising the ability of
health centers to serve the non-Medicaid poor and others lacking dental
insurance
97
Mark Koday DDS
(509) 949-2278
Dental Quality Consultants
of WA
httpdentalqualityconsultin
gcom
dentalqualityconsultantsg
mailcom
Contact Information
LUNCH
BREAKOUT EXERCISEORAL HEALTH VALUE-BASED CARE READINESS ASSESSMENT
Danielle Apostolon
PROMISING PRACTICES FROM THE FIELD STRATEGIES FOR INCREASING VALUE IN ORAL HEALTH
Dr Carolyn Brown
Dr Kelly Perry
Dr Rachel Rivard
Dr Adeloye
Commitment Compassion Community
m i d s t a t e h e a l t h o r g
Promising Practices from the
Field Strategies for Increasing
Value in Oral Health Care
Kelly Perry DMD
Better Health
Outcomes
Improved Staff
Experience
Reduced Cost
Improved Patient
Experience
Better Health
Outcomes
Improved Staff
Experience
Reduced Cost
Improved Patient
Experience
Better Health
Outcomes
Improved Staff
Experience
Reduced Cost
Improved Patient
Experience
Better Health
Outcomes
Improved Staff
Experience
Reduced Cost
Improved Patient
Experience
Commitment Compassion Community
kpe r r ymids t a tehea l t h o rg
Thank you
Completion of Disease Control Phase
Pelumi Adeloye DMD MPH
HEALTH ACCESS NETWORK (HAN) FAMILY DENTAL
Introduction
⧫1 Dentist I Hygienist 3 EFDArsquos1 Receptionist
⧫ 6 Chairs= 4 (dentist) + 2 (hygienist)
⧫ Slide ⥶80 off
⧫ Service areas Northern Penobscot Southern Aroostook Western
Washington Counties amp more
Completion of Phase I Treatment
⧫LimitedLack of Access to dental care
⧫Difficulty completing the disease control phase
Caries amp periodontal disease
⧫Attaining stable restorative state
Goal
Increase the completion of Disease Control Phase
Current practice
⧫Education
Assess level of dental literacy
Incremental strategy
⧫Increase access to dental care
Generous sliding scale (⥸$40 per visit)
Incorporate Expanded Function Dental Assistants
⧫Schedule modification
Incorporate more restorative blocks to allow
for follow-up visit and completion of restorative phase
httpswwwglasbergencomdentist-cartoons
Schedule
⧫Piggybacking technique
Increased allotted restorative blocks
⧫Sustainability of current schedule is
contingent on cooperation amp skills of HAN
Dental staff
Note
Strategies mentioned today is personalized to HAN Dental clinic
Current implemented strategies might be modified or changed in the
future as required in order to accommodate the need of our pts
THANK YOU
DAY TWOCLOSINGWRAP-UP
End of Day Two ndash Survey
Day Two Creating a Value-Based Oral Health Care Delivery
System
129
Payment Reform in Oral Health Online Learning Module
Oral Health Value-based Care Online Learning Module
Value-based Care Keys to Success Article
Readiness Assessment
Competency Development Guide
Oral Health Value-based Care Training
Dental Caries Management Practicum
Clinicians Companion Guide
Interprofessional Network Referral Process
Traditional Dental Care Vs Value-Based Care
Resources
131
wwwDentaQuestPartnershiporg
wwwfacebookcomDentaQuest
DentaQuest
wwwlinkedincomcompanyDentaQuest
Inside_DentaQuest
QUESTIONS
4
5
bull $37 trillion
bull $10739 per
person
bull 179 of GDP
2017 National Health Expenditures
6
Mortality Rates Decreasing
httpswwwhealthsystemtrackerorgchart-collectionquality-u-s-healthcare-system-compare-countriesitem-overall-years-
life-lost-1990-2017
7
Early Detection amp Prevention Matters
One of our providers was able to diagnose a lesion the biopsy had some cancer
cells We were trying to get that patient into an oral surgeon We contacted several
of the private practice oral surgeons in the area It was anywhere from $300 to $400
to walk into their office for an evaluation and a diagnosis That doesnt mean even
treatment
We were able to get him to The University of Maryland Its about a two-hour trip for
this patient to get there His first appointment his car broke down and he couldnt
get there The next appointment we were able to get him he traveled the two hours
and waited for four and a half hours and then wasnt seen They had a backlog and
he was sent home and told they would give him another appointment and come
back He then left our area and came back three years later in 2017 and our dentist
that does pediatrics is actually the only one in the office
8
Early Detection amp Prevention Matters
When he came as an emergency she saw him He had just came out of the
hospital His ENT just diagnosed him with stage four head and neck cancer And
if we had been able to see him got him into care with that initial diagnosis
which was a very small lesion at the time we might have been able to prevent
that
9
Evaluation survey must be completed to receive 10 CE credits
bull httpswwwsurveymonkeycomrVBCTraining1
bull httpswwwsurveymonkeycomrVBCTraining2
10
Agenda
Highlights from Day One
Group Discussion
Laying the Groundwork for Oral Health Value-Based Care Readiness
Lunch
Breakout Exercise Oral Health Value-Based Care Readiness
A Dental Directorrsquos Experience in Risk-Based Oral Health Managed Care
Promising Practices from the Field
ClosingWrap Up
11
12
bull Outline the key components to prepare for oral health value-based care
delivery system
bull Understand measurement and principles in healthcare transformation
Todayrsquos Learning Objectives ndash Day Two
LAYING THE GROUNDWORKCLINICAL OPERATIONS IN A VBR ENVIRONMENTCarolyn Brown DDS Consultant
November 19th 2019
14
INTRODUCTION
15
Todayrsquos Agenda
bull Discuss value-based health and pay-for-performance approaches to health
systems and the integral building block of data
bull Dive deep into the emerging field of value-based care measurement and
data in oral health from national and statewide perspectives
bull Present oral health and clinical measurement approaches and relate to
oversight
16
bull Consultant working with DQP FQHCs Primary Care Associations and Foundations advancing oral health programs
bull DQPSNS Expert Advisor
bull IHI Improvement Coach
bull Former Dental Director
bull Research Marketing Finance
Carolyn Brown DDS
Consultant Acting Director of Value-Based Care
DentaQuest Partnership for Oral Health Advancement
bull DDS University of Maryland School of Dentistry
bull MAEd University of the Pacific
bull BS University of Maryland
bull Speaker researcher expert advisor review panel
17
Poll What do you measure
A Dental provider productivity per day
B Treatment plan completion
C Dental new patient exams
D Combination of A-C
E No Shows
F Sealants only
18
Population
Prevention
Healthy
Minimally Invasive
Health outcomes
MDI
EHR EDR
PCC
Risk Assessment
19
VALUE-BASED CAREPushing the impact quality and quantity of measurement
20
OHVBC Readiness
Leadership
Value of oral health and oral health transformation
Structure Systems and Operations
Efficiencies innovative care delivery
Care Pathways and Provider Buy-In
Risk-based care Training patient engagement
Data and Analytic Technology and Personnel
DataReports Interoperability
Financial Viability and Strength
Payerpatient mix billing infrastructure
httpswwwdentaquestpartnershiporglearnsafety-net-solutionsoral-health-value-based-careohvbc-readiness-
assessment
21
DentaQuest Partnership OHVBC Survey
Barriers to Value-based Transformation in Oral Health ndash
Most Common Responses
bull Patient engagement
bull EHREDR
bull Tracking outcomes lack of nationally-recognized and standardized quality
metrics in dental
22
How Can FQHC Dental Programs Prepare for Value-based
Transformation in Oral Health
bull Begin or continue focusing on prevention disease management and risk-based care
bull Hygienists will be key to success ndash We need primary dental care not just surgical
interventions
bull Start measuring outcomes instead of just processutilization metrics bull of initially high-risk patients with new caries lesions
bull of initially high-risk patients with decreased risk status
bull of initially low-risk patients with risk status maintained
bull Address patient engagement in a more meaningful way and invest in case
management
bull Invest in interprofessional practice including HIT interoperability
bull Evaluate how services are being delivered and determine if its reaching the patients
who need care the most
23
Value-Based Care
Care Coordination
ldquoClosing outrdquo referrals
Diagnostic coding
Risk Screenings
Care plans based on risk
Patient Engagement
Incentive payments
Quality metrics
Clinic Response
Case Management IT
Active timely records mngt
Mapping Dx codes to CDT
Time bill CPT codes Tx plan
IPP data tofrom PC MH
Recall window important
Attention to $ related metrics
Attention to assigned metrics
Direct and Indirect Effects of VBC on Dental Systems of Care
Utilization Impact
New workforce CDT codes
New or + workforce IT
ICD-CM-10 codes
+CDT codes
Modifiers (CPT ICD10)
+ recall adherence
in incentivized procedures
in sealant POC A1C
Counseling codes SD
24
MEASUREMENT IN ORAL HEALTH
25
Poll What percentage of your adult dental patients are diabetic
or pre-diabetic
A 50-80
B 20-50
C Less than 20
D Not sure
26
27
ldquoTrue Measures of Successrdquo
1 Define your governing objective
2 Develop a theory of cause and effect to assess presumed drivers of the
objective
3 Identify the specific activities that employees can do to help achieve the
governing objective
4 Evaluate your statistics
5 Communicate the story of your measurement
Adapted from HBR ldquoThe True Measures of Successrdquo httpshbrorg201210the-true-measures-of-success
28
1 Governing objective
2 Theory of cause and effect
3 Activities of team
4 Evaluate your statistics
5 Storycraft
Sustainability
Clinic revenuegt expenses= sustainability
Patient compliance Assets Clinic Mngt
Care team Operations Pt Support Billing
Of Prod on and type Patients on time
Daily weekly monthly quarterly
ldquoTrue Measures of Successrdquo
Adapted from HBR ldquoThe True Measures of Successrdquo httpshbrorg201210the-true-measures-of-success
29
Measuring Risk and Health
November is Diabetes Awareness Month- 2019Communication Plans are as
important as cold hard numbers
Patients
Care Team
Other Health Teams
Executive Team
Funders
Data on your dental patients are medical patients of record
Data on your medical + dental patients with DM2
30
Develop Diabetic Patient
Protocols
Review evidence and rationale with dental team
Partner with primary care team
bull Protocols Care mngt Tests and Recording
Quality Goals
Protocols for newly screened and existing patients
Educate and train dental team in reading AND
charting test results and PILOT
31
External Measurement in Oral Health Programs
httpswwwadaorg~mediaADADQA2019_DiabetesOralEvaluationpdfla=en
httpswwworegongovohaHPAANALYTICSCCOMetrics2019-Oral-Evaluation-Adults-Diabetespdf
32
Baseline for 2019 271
httpswwworegongovohaHPAANALYTICSCCOMetrics2019-Oral-Evaluation-Adults-Diabetespdf
33
Diabetes burden in your panel of dental patients
Baseline Medical-Dental Integrated panel of all patients
Dental patients with DM2 MDI
Dental patients with DM2
1000 or 10
600 or 60
300010000= 30
Population Health- Clinic Level
34
1 Governing objective
2 Theory of cause and effect
3 Activities of team
4 Evaluate your statistics
5 Storycraft
Discuss at meetings (Oct + Nov) Health education training
materials NP training CQI Note in Board report Clinical
measures
Care Pathways Hygiene Resources (ScheduleAvail)
ldquoTrue Measures of Successrdquo
Adapted from HBR ldquoThe True Measures of Successrdquo httpshbrorg201210the-true-measures-of-success
Diabetes Awareness Prevention Healthier Community
Prevention Awareness Care Pathway promotes health
MDI= 10 6 out of 10 adult patients with DM2
Goal set for integrated patient panels ndash PCMH
Pre-diabetes approach for executive team
Care Pathways
Care Coordination
35
MEASURING PATIENT ORAL HEALTHRisk assessments and Care Pathways
36
37
Risk Assessment and Care Pathways
Caries Risk Assessment
Multiple tools
EDREHR modules smart notes or dot phrases
CDT Codes
Decide frequency
D0601
Low Caries Risk
D0601
Moderate Caries Risk
D0601
High Caries Risk
38
The Disease Management DifferenceDisease Management Difference
Traditional Dental Care Disease Management
Approach
All patients return in 6 months
regardless of risk status
Recare interval is based on the
childrsquos caries risk
Caries Risk
Level
Recommended
Recare Interval
High Risk 1 ndash 3 months
Moderate Risk 3 ndash 6 months
Low Risk 6 ndash 12 months
Caries
Stabilizing
agents
Health Ed
Nutritional
Counseling
Anti-bacterial
and Fluoride
interventions
39
Disease Management Care Pathways
DentaQuest Partnership for Oral Health Advancement Disease Management Model
Caries
Stabilizing
agents
Whole
Person
Inter-
professional
Approaches
Anti-bacterial
and Fluoride
interventions
40
Disease Management and Risk Screening Training
DentaQuest Partnership for Oral Health Advancementrsquos
Online Learning Center
Disease Management Series
8 modules 40 CDE available
httpswwwdentaquestpartnershiporglearnonline-learning-centeronline-
coursewaredentaquest-disease-management-series
41
MEASUREMENT IN TEAMSSharing meaningful data with your dental clinical teams
42
rdquoDental Homerdquo = Health Home where WE can meet the patient
Oralhealthworkforceorg
43
POLL HOW OFTEN DO YOU SHARE YOUR S WITH YOUR DENTAL TEAM
A Yearly only
B Quarterly
C Monthly
D Weekly
E Daily
44
Clinical Measures ndash Dental Practice Perspective
Private Practice Office
New patients seen
Assigned vs seen if capitated
Treatment plans incomplete
$ produced amp per provider
$ collected amp monthly per provider
CDT 6000 codes completed
RecallHygiene maintenance
Based on this consultants experienced
FQHC
Unduplicated patients
patients seen per day
Treatment plans complete
$ gainedlost via accounting
Broken appointment rate
procedures
Sealant rate (annual)
45
bull HRSA Sealant Measure Compliance for FQHCs
bull Completion of phase 1 treatment plans
bull Children seen 0-5 years old
bull Children seen getting a preventive service
bull Fluoride Varnish applications
bull Pregnant women seen and treated
bull Diabetic patients with HbA1C gt 7 seen
bull Patients seen who have not been seen for 12 months
bull Patients seen getting a Risk Assessment
bull Patients with moderate or high risk who lower risk at recare
bull Sealants provided httpwwwnnohaorgnnoha-contentuploads201512Demystifying-HRSA-SEALANT-PRESENTATION_FINALpdf
Program Measures
46
HRSA Performance Measurement and Data Collection
bull FQHCs and look-alikes submit CY data to HRSA since 2008
bull UDS Uniform Data System
bull Require FTE for clinical staff patient demographics
bull Dental utilization s (UDCTPV)
bull Dental Clinical Measure dental sealants placed on 1st molars ages 6-9 yo
bull Health Center Quartile rankings (Clinical measure performance influences
HC rankings as does EHR adoption and other HC characteristics)
47
Low birth weight
Access to prenatal care
Childhood Immunization
Children (Ages 3-17) Receiving
Weight Assessment amp
Counseling
Children (Age 6-9) Receiving
Dental Sealant to First Molars
Diabetes Control
Hypertension Control
Pap Test
Depression Screening and
Follow-up (Age 12+)
Asthma Patients (Age 5-40)
Receiving Pharmacologic
Therapy
Colorectal Cancer
Screening (Ages 51-74)
HRSA UDS Clinical Measures
Adults (Age 18+) Receiving
Weight Screening amp Follow-up
Adults (Age 18+) Receiving
Tobacco Use Assessment and
Cessation Intervention
Coronary Artery Disease
Receiving Lipid Therapy (18+)
Ischemic Vascular Disease (IVD)
Receiving Aspirin Therapy (18+)
HIV Linkage to Care
48
Dashboards
Grants
Average
amp
Targets
Quality
Rev
Costs
Visits
Priority
Pop
Prevention
49
Dashboard- Provider Team Level
Patient
Compliance
Satisfaction
50
Case Study-
Incentives bonus round pools benchmark and improvement target goals risk-sharing possible later years
51
Qualitative Measurement
ldquoPatient engagement is the act of patients and providers working together
toward the end goal of improved patient wellnessrdquo
wwwpatientengagementhitcom
Access to Care
Patient Activation
Patient Satisfaction
Patient-Provider-Care Team Communication
Care Team Satisfaction
52
OHVBC Readiness
Leadership
bull Value of oral health and oral health transformation
Structure Systems and Operations
bull Operational efficiencies innovative care delivery methodologies
Care Pathways and Provider Buy-In
bull Training disease management risk-based care referrals IDC-10 coding patient engagement
Data and Analytic Technology and Personnel
bull Interoperability reporting
Financial Viability and Strength
bull Payerpatient mix billing infrastructure financial reports
httpswwwdentaquestpartnershiporglearnsafety-net-solutionsoral-health-value-based-careohvbc-readiness-
assessment
53
QUESTIONS COMMENTS
Carolyn Brown DDS
cbrownddsgmailcom
RISK BASED MANAGED CARE
Value Based Training Conference
Manchester New Hampshire
Mark Koday DDS
111919
5555
Objectives
bull Review current drivers of dental managed care
bull Understand the basics of risk-based dental managed care contracts
bull Learn the basics of managing costs in a riskndashbased contract
bull Gain an understanding in the potential advantage of risk-based contracting
56
What Is Dental Managed Care
Managed care is a health delivery system whose purpose is to manage both the
quality and cost of health care
Common types of managed care health insurance plans
bull HMOs
bull PPOs
bull POSs
bull Medicaid Managed Care
DIDNrsquoT WE ALREADY HAVE MANAGED CARE AND IT FAILED
57
What Has Happened Since the 90s
58
WHY THE FFS AND PPS DOESNrsquoT WORK FOR OUR POPULATIONS
bull Inefficient payment systems designed to produce encounters or procedures but not real health
bull No focus on population health
bull Does not incentivize innovation
bull Patients essentially on their own for accessing specialty care
59
Rule of 4
Source Kaiser Family Foundation analysis of National Health Expenditure (NHE) data from Centers for
Medicare and Medicaid Services Office of the Actuary National Health Statistics Group
60
Rule of 4
bull This helps explain why oral health has been relatively ignored so far by CMS
bull Explains why we have PCMH instead of PCHH
bull Where is the real value on a national level in preventing disease and
controlling costs
bull Beware- wersquove been found
61
Reasons Dental Managed Care is Spreading Across the States
NON-MANAGED CARE STATE DENTAL BUDGETS ARE
OPENED ENDED
STRAIN ON STATE BUDGETS
UPCOMING RECESSION WITH TRILLION DOLLAR
DEFICIT
SHIFTS FINANCIAL RISK FROM THE STATES TO THE
PLANS
6262
Types of Medicaid Managed Care
bull State Medicaid agency administrator lowest administrative
costs
bull Third Party Administrator Typically 15 administrative costs
bull Managed Care Organization Typically 15 administrative
costs
bull Carved-in
bull Carved-out
bull Risk Based Managed Care Administrative costs part of
contract negotiation
63
RISK CONTRACTS
6464
Components of a Risk-based Contract
Risk
Medical Loss Ratio
Quality withhold
Specialty withhold
Managed care payment (pmpm)
Covered services
Fee schedule Claims are paid as usual on a FFS basis
Credentialing
Quality Review process and Quality Metrics
65
Upside Risk
The possibility that the cost of
delivering dental care to an assigned
patient panel is less than the amount
of funding calculated for that care
The Plan pays the CHC additional
funds based on a predetermine
formula
Downside Risk
The possibility that the cost of
delivering dental care to an assigned
patient panel is more than the amount
of funding calculated for that care
The CHC pays the Plan additional
funds based on a predetermine
formula
Upside and Downside Risk
66
Taking On Risk 100 or Shared Risk
With 100 risk you receive 100 of the potential savings but are also at risk for
100 of the losses
Shared Risk MCO and health center share a percentage of the risk
Shared Risk leads to better cooperation since both organizations are
incentivized to save on costs
6767
Reports Needed
bull Enrollment reports lists of who is assigned on a monthly basis
bull Reconciliation reports insure appropriate payments
bull Specialty Referral reports
bull You will need your own reporting process so you donrsquot rely completely on
reports supplied by the Plan
6868
Medical Loss Ratio
Medical Loss Ratio (MLR) is proportion of premium revenues spent on clinical
services and quality improvement also known as the Medical Loss Ratio (MLR)
For CMS requires Medical Plans to spend at least 80 to 85 of the premiums
on actual medical care
69
Administrative Fees
bull Essentially the opposite of MLR
bull The State Medicaid Agency is funded by the Governorrsquos budget
bull The State Medicaid Agency will keep some of these funds for their
admin costs and give the remaining to the Managed Care Plans
bull Private Plan admin costs can be as high as 40 but most states
limit these cost for Medicaid Plans to between 15 and 20 (85-
80 MLR)
bull This may be negotiable depending on your program size of your
program
70
Quality Withhold
bull The state withholds a certain percent (typically 2-4 ) of the funds they give
to the Plans for Value Based Reimbursement
bull They choose quality metrics and set benchmarks and assign payments for
each metric based on an assigned priority for each metric
bull If a Plan meets the benchmark of every quality metric the state passes on
their full share of the quality withhold
bull The Plans may or may not withhold a percent of the funds for quality payment
to the dentists or manage care contractors
71
Quality Withhold
Either way the Plans may or may not pass the quality payments they receive to
the dentists or contractors
This should be spelled out in a risk-based contract
72
Percent of funds set aside
to cover specialty care
referrals
Typically 10-15
Goal Limit referral costs
to within or less than
Specialty set aside
Specialty Withhold
73
Per Member Per Month
bull Capitated Payment
bull Specific dollar amount paid for each enrolled member each month
bull Paid whether patient is accessed for care or not
bull States do set access benchmarks
bull In Oregon access for any dental procedure (adults and children combined)
was 267 in 2015
74
Payment Math Example
Premium per enrollee = $25
Administrative fee 15 = $375
Funds available per enrollee to the clinic = $2125
Management fee per enrollee = $175
Funds per enrollee that would undergo PPS reconciliation = $1950
For every 10000 enrollees the managed care income = $2340000
Specialty withhold (10) = $234000
YE Cost lt or gt $2340000
Upside Risk
CHC Gains $
Downside Risk
CHC Loses $
75
Covered Services and Fee Schedules
bull The state Medicaid agency spells out the minimum procedures and fees that
MCOs must cover
bull MCOs may add procedures or increase periodicity of procedures particularly
preventative services
bull MCOs may increase fees to entice rural providers and specialists to enroll in
their Plans
bull Access Rules
bull How many days it takes to access a patent
bull How many days it takes for a patent to access urgent care services
bull How many days it takes for a patent to access emergency care services
76
Credentialing
All MCOs are required to credential all Providers
All MCOs have their own credentialing process
Credentialing process is can be lengthy
Credentialing process may be negotiable
77
Quality Review Process and Quality Metrics
MCOs must have a Quality and Compliance Review Process
If you arenrsquot in compliance with both you likely wonrsquot get paid
Typical processes reviewed
bull Charting specifications
bull Incident report
bull Enrollee complaints quality rudeness and access issues
bull Medicaid compliance
78
Quality Payments
bull State Shared Incentive Withhold Typically quality metrics and benchmarks
are set by the state sets aside a certain percent (3-5) of the payments to
the Managed Care Plan (MCP)
bull If the benchmarks are achieved the MCP is then paid the a predetermine
amount
bull Benchmarks may not be the same as the states
bull Managed Care Plans do not have to pass all or any of the quality payments to
the health centers or providers
bull Managed Care contract- Metrics benchmarks should be selected and part of
the contract
7979
Achieving Quality Metric Payments
Dealing with under achievers
Process issues
Individual issues
Identifying workflows
Developing Best Practices through
PDSA process
Developing Best Practices through
PDSA process
CHC Metrics Committee
Clinicians Operations various key staff
Identify Best Practices
Spread Best Practices
80
New Team Needed Business Intelligence
Business Intelligence (BI) is critical for effective managed care business decisions
BI team inputs metrics into your EHR collects integrates analyses and displays all your managed care business and clinical information
Easy to say- hard to achieve
Build your own or outsource
Possible future role of Primary Care Associations
8181
Clinicianrsquos Dashboard
Expensive to build
Displayed on your screen when your computer is first turned on
Easy to read and understand
Data dumped from the day before
Can dialed down from Org-wide to clinic to each clinicianrsquos data
Operational and clinical metrics
bull Treatment Plan Completion
bull DQA quality measures
bull Caries at Recall
bull Re-care reports
bull Care Gap reports
82
CONTROLLING COSTS
8383
Controlling Costs- Current
bull Increasing efficiencies
bull Decreasing broken appointments
bull Controlling supplies equipment costs
bull Staff recruitment retention costs
84
Specialty Care
Training current CHC dentists in
specialty areas
Hiring general dentists with higher
specialty skill sets
Hiring in house specialists
Contract with outside specialists
Work with Managed Care Plan
specialists
Lowering Disease Rates
Community Dental Health
Coordinators case management
If your state law allows- embed
hygienists in medical and community
to provide primary and secondary
prevention procedures
In clinic Caries Classification and
Silver Diamine Fluoride
Effective recare programs
Controlling Costs- Additions in Risk-based Contracting
85
Specialty Care ndash Primary Referrals by Cost
Pediatric dentistry
Orthodontics
Oral surgery
Endodontics
86
In-clinic Pediatric Services
Encounters expected
of operatories available
State dental law and ability to have
expanded duties
General Anesthesia
GA in- house
Ability for a hospital or surgery center
to set aside regular OR time
Ability to hire or assign DAs to GA
days
Four GA cases day x PPS rate
Should You Hire a Pediatric Dentist- It Depends
8787
Solutions for Controlling Pediatric Costs
Hire a general dentist that is skilled in treating young children
Make the clinic child friendly nitrous oxide TVs in the operatory etc
Teach entire staff behavioral control techniques
Contract with a pediatric dentist for the GA care
88
Lowering Overall Disease Rates (and Costs)
You are responsible for both the patients you see in the chair and the ones
assigned to you
Breaking down the walls of the dental clinic
Community Dental Health Coordinators
Case Management
89
Cost Control Essentials
Diagnosis codes
Increased ability to identify
disease by risk
Motivational
Interviewing
Developing Polices and
Procedures design to treat
disease according to risk
ie Silver Diamine Fluoride
Treating by Risk
Effective Recare
Process
Critical to continual disease
controlPrevention education that is
meaningful and designed to
change behaviors
90
Social Determinants of Health Aunt Bertha
httpswwwauntberthacom
91
REASON TO CONSIDER RISK- BASED CONTRACTING
9292
PPS Reconciliation and Federal Code 42 CFR sect4052469(a)(2)
42 CFR sect4052469(a)(2)
ldquoAny financial incentives provided to Federally Qualified Health Centers
under their Medicare Advantage Contracts such as risk pool payments
bonuses or withholds are prohibited from being included in the
calculation of supplemental payments due to the Federally Qualified
Health Centerrdquo
9393
Why Risk Based Contract in Times of PPS Reconciliation
bull Not all Risk- based Contract funds are reconciled
bull Risk is the key word- you can come out with less money than your normal
PPS reconciliation payment
bull Can lead to better patient care
bull May improve manage care enrollment for your medical plan
bull Promotes integrated care increases health for your CHC patients
9494
Not Included in the Reconciliation
Enrollment management pmpm
Quality Payments
Upside risk payments
Downside risk losses
9595
Determinants of Financial Success in Risk-Based Contracting
bull Most critical- State pmpm payment to the Managed Care Plan
bull Reporting capabilities
bull Specialty service capabilities
bull Access numbers count
bull Ability to move metric numbers
9696
What About the Non- Medicaid Poor We Serve
bull Numbers are king in a managed care contract and the more access you have
the better contract terms you can negotiate
bull We will potentially have a steady supply of Medicaid patients
bull As managed care spreads states this may be compromising the ability of
health centers to serve the non-Medicaid poor and others lacking dental
insurance
97
Mark Koday DDS
(509) 949-2278
Dental Quality Consultants
of WA
httpdentalqualityconsultin
gcom
dentalqualityconsultantsg
mailcom
Contact Information
LUNCH
BREAKOUT EXERCISEORAL HEALTH VALUE-BASED CARE READINESS ASSESSMENT
Danielle Apostolon
PROMISING PRACTICES FROM THE FIELD STRATEGIES FOR INCREASING VALUE IN ORAL HEALTH
Dr Carolyn Brown
Dr Kelly Perry
Dr Rachel Rivard
Dr Adeloye
Commitment Compassion Community
m i d s t a t e h e a l t h o r g
Promising Practices from the
Field Strategies for Increasing
Value in Oral Health Care
Kelly Perry DMD
Better Health
Outcomes
Improved Staff
Experience
Reduced Cost
Improved Patient
Experience
Better Health
Outcomes
Improved Staff
Experience
Reduced Cost
Improved Patient
Experience
Better Health
Outcomes
Improved Staff
Experience
Reduced Cost
Improved Patient
Experience
Better Health
Outcomes
Improved Staff
Experience
Reduced Cost
Improved Patient
Experience
Commitment Compassion Community
kpe r r ymids t a tehea l t h o rg
Thank you
Completion of Disease Control Phase
Pelumi Adeloye DMD MPH
HEALTH ACCESS NETWORK (HAN) FAMILY DENTAL
Introduction
⧫1 Dentist I Hygienist 3 EFDArsquos1 Receptionist
⧫ 6 Chairs= 4 (dentist) + 2 (hygienist)
⧫ Slide ⥶80 off
⧫ Service areas Northern Penobscot Southern Aroostook Western
Washington Counties amp more
Completion of Phase I Treatment
⧫LimitedLack of Access to dental care
⧫Difficulty completing the disease control phase
Caries amp periodontal disease
⧫Attaining stable restorative state
Goal
Increase the completion of Disease Control Phase
Current practice
⧫Education
Assess level of dental literacy
Incremental strategy
⧫Increase access to dental care
Generous sliding scale (⥸$40 per visit)
Incorporate Expanded Function Dental Assistants
⧫Schedule modification
Incorporate more restorative blocks to allow
for follow-up visit and completion of restorative phase
httpswwwglasbergencomdentist-cartoons
Schedule
⧫Piggybacking technique
Increased allotted restorative blocks
⧫Sustainability of current schedule is
contingent on cooperation amp skills of HAN
Dental staff
Note
Strategies mentioned today is personalized to HAN Dental clinic
Current implemented strategies might be modified or changed in the
future as required in order to accommodate the need of our pts
THANK YOU
DAY TWOCLOSINGWRAP-UP
End of Day Two ndash Survey
Day Two Creating a Value-Based Oral Health Care Delivery
System
129
Payment Reform in Oral Health Online Learning Module
Oral Health Value-based Care Online Learning Module
Value-based Care Keys to Success Article
Readiness Assessment
Competency Development Guide
Oral Health Value-based Care Training
Dental Caries Management Practicum
Clinicians Companion Guide
Interprofessional Network Referral Process
Traditional Dental Care Vs Value-Based Care
Resources
131
wwwDentaQuestPartnershiporg
wwwfacebookcomDentaQuest
DentaQuest
wwwlinkedincomcompanyDentaQuest
Inside_DentaQuest
QUESTIONS
5
bull $37 trillion
bull $10739 per
person
bull 179 of GDP
2017 National Health Expenditures
6
Mortality Rates Decreasing
httpswwwhealthsystemtrackerorgchart-collectionquality-u-s-healthcare-system-compare-countriesitem-overall-years-
life-lost-1990-2017
7
Early Detection amp Prevention Matters
One of our providers was able to diagnose a lesion the biopsy had some cancer
cells We were trying to get that patient into an oral surgeon We contacted several
of the private practice oral surgeons in the area It was anywhere from $300 to $400
to walk into their office for an evaluation and a diagnosis That doesnt mean even
treatment
We were able to get him to The University of Maryland Its about a two-hour trip for
this patient to get there His first appointment his car broke down and he couldnt
get there The next appointment we were able to get him he traveled the two hours
and waited for four and a half hours and then wasnt seen They had a backlog and
he was sent home and told they would give him another appointment and come
back He then left our area and came back three years later in 2017 and our dentist
that does pediatrics is actually the only one in the office
8
Early Detection amp Prevention Matters
When he came as an emergency she saw him He had just came out of the
hospital His ENT just diagnosed him with stage four head and neck cancer And
if we had been able to see him got him into care with that initial diagnosis
which was a very small lesion at the time we might have been able to prevent
that
9
Evaluation survey must be completed to receive 10 CE credits
bull httpswwwsurveymonkeycomrVBCTraining1
bull httpswwwsurveymonkeycomrVBCTraining2
10
Agenda
Highlights from Day One
Group Discussion
Laying the Groundwork for Oral Health Value-Based Care Readiness
Lunch
Breakout Exercise Oral Health Value-Based Care Readiness
A Dental Directorrsquos Experience in Risk-Based Oral Health Managed Care
Promising Practices from the Field
ClosingWrap Up
11
12
bull Outline the key components to prepare for oral health value-based care
delivery system
bull Understand measurement and principles in healthcare transformation
Todayrsquos Learning Objectives ndash Day Two
LAYING THE GROUNDWORKCLINICAL OPERATIONS IN A VBR ENVIRONMENTCarolyn Brown DDS Consultant
November 19th 2019
14
INTRODUCTION
15
Todayrsquos Agenda
bull Discuss value-based health and pay-for-performance approaches to health
systems and the integral building block of data
bull Dive deep into the emerging field of value-based care measurement and
data in oral health from national and statewide perspectives
bull Present oral health and clinical measurement approaches and relate to
oversight
16
bull Consultant working with DQP FQHCs Primary Care Associations and Foundations advancing oral health programs
bull DQPSNS Expert Advisor
bull IHI Improvement Coach
bull Former Dental Director
bull Research Marketing Finance
Carolyn Brown DDS
Consultant Acting Director of Value-Based Care
DentaQuest Partnership for Oral Health Advancement
bull DDS University of Maryland School of Dentistry
bull MAEd University of the Pacific
bull BS University of Maryland
bull Speaker researcher expert advisor review panel
17
Poll What do you measure
A Dental provider productivity per day
B Treatment plan completion
C Dental new patient exams
D Combination of A-C
E No Shows
F Sealants only
18
Population
Prevention
Healthy
Minimally Invasive
Health outcomes
MDI
EHR EDR
PCC
Risk Assessment
19
VALUE-BASED CAREPushing the impact quality and quantity of measurement
20
OHVBC Readiness
Leadership
Value of oral health and oral health transformation
Structure Systems and Operations
Efficiencies innovative care delivery
Care Pathways and Provider Buy-In
Risk-based care Training patient engagement
Data and Analytic Technology and Personnel
DataReports Interoperability
Financial Viability and Strength
Payerpatient mix billing infrastructure
httpswwwdentaquestpartnershiporglearnsafety-net-solutionsoral-health-value-based-careohvbc-readiness-
assessment
21
DentaQuest Partnership OHVBC Survey
Barriers to Value-based Transformation in Oral Health ndash
Most Common Responses
bull Patient engagement
bull EHREDR
bull Tracking outcomes lack of nationally-recognized and standardized quality
metrics in dental
22
How Can FQHC Dental Programs Prepare for Value-based
Transformation in Oral Health
bull Begin or continue focusing on prevention disease management and risk-based care
bull Hygienists will be key to success ndash We need primary dental care not just surgical
interventions
bull Start measuring outcomes instead of just processutilization metrics bull of initially high-risk patients with new caries lesions
bull of initially high-risk patients with decreased risk status
bull of initially low-risk patients with risk status maintained
bull Address patient engagement in a more meaningful way and invest in case
management
bull Invest in interprofessional practice including HIT interoperability
bull Evaluate how services are being delivered and determine if its reaching the patients
who need care the most
23
Value-Based Care
Care Coordination
ldquoClosing outrdquo referrals
Diagnostic coding
Risk Screenings
Care plans based on risk
Patient Engagement
Incentive payments
Quality metrics
Clinic Response
Case Management IT
Active timely records mngt
Mapping Dx codes to CDT
Time bill CPT codes Tx plan
IPP data tofrom PC MH
Recall window important
Attention to $ related metrics
Attention to assigned metrics
Direct and Indirect Effects of VBC on Dental Systems of Care
Utilization Impact
New workforce CDT codes
New or + workforce IT
ICD-CM-10 codes
+CDT codes
Modifiers (CPT ICD10)
+ recall adherence
in incentivized procedures
in sealant POC A1C
Counseling codes SD
24
MEASUREMENT IN ORAL HEALTH
25
Poll What percentage of your adult dental patients are diabetic
or pre-diabetic
A 50-80
B 20-50
C Less than 20
D Not sure
26
27
ldquoTrue Measures of Successrdquo
1 Define your governing objective
2 Develop a theory of cause and effect to assess presumed drivers of the
objective
3 Identify the specific activities that employees can do to help achieve the
governing objective
4 Evaluate your statistics
5 Communicate the story of your measurement
Adapted from HBR ldquoThe True Measures of Successrdquo httpshbrorg201210the-true-measures-of-success
28
1 Governing objective
2 Theory of cause and effect
3 Activities of team
4 Evaluate your statistics
5 Storycraft
Sustainability
Clinic revenuegt expenses= sustainability
Patient compliance Assets Clinic Mngt
Care team Operations Pt Support Billing
Of Prod on and type Patients on time
Daily weekly monthly quarterly
ldquoTrue Measures of Successrdquo
Adapted from HBR ldquoThe True Measures of Successrdquo httpshbrorg201210the-true-measures-of-success
29
Measuring Risk and Health
November is Diabetes Awareness Month- 2019Communication Plans are as
important as cold hard numbers
Patients
Care Team
Other Health Teams
Executive Team
Funders
Data on your dental patients are medical patients of record
Data on your medical + dental patients with DM2
30
Develop Diabetic Patient
Protocols
Review evidence and rationale with dental team
Partner with primary care team
bull Protocols Care mngt Tests and Recording
Quality Goals
Protocols for newly screened and existing patients
Educate and train dental team in reading AND
charting test results and PILOT
31
External Measurement in Oral Health Programs
httpswwwadaorg~mediaADADQA2019_DiabetesOralEvaluationpdfla=en
httpswwworegongovohaHPAANALYTICSCCOMetrics2019-Oral-Evaluation-Adults-Diabetespdf
32
Baseline for 2019 271
httpswwworegongovohaHPAANALYTICSCCOMetrics2019-Oral-Evaluation-Adults-Diabetespdf
33
Diabetes burden in your panel of dental patients
Baseline Medical-Dental Integrated panel of all patients
Dental patients with DM2 MDI
Dental patients with DM2
1000 or 10
600 or 60
300010000= 30
Population Health- Clinic Level
34
1 Governing objective
2 Theory of cause and effect
3 Activities of team
4 Evaluate your statistics
5 Storycraft
Discuss at meetings (Oct + Nov) Health education training
materials NP training CQI Note in Board report Clinical
measures
Care Pathways Hygiene Resources (ScheduleAvail)
ldquoTrue Measures of Successrdquo
Adapted from HBR ldquoThe True Measures of Successrdquo httpshbrorg201210the-true-measures-of-success
Diabetes Awareness Prevention Healthier Community
Prevention Awareness Care Pathway promotes health
MDI= 10 6 out of 10 adult patients with DM2
Goal set for integrated patient panels ndash PCMH
Pre-diabetes approach for executive team
Care Pathways
Care Coordination
35
MEASURING PATIENT ORAL HEALTHRisk assessments and Care Pathways
36
37
Risk Assessment and Care Pathways
Caries Risk Assessment
Multiple tools
EDREHR modules smart notes or dot phrases
CDT Codes
Decide frequency
D0601
Low Caries Risk
D0601
Moderate Caries Risk
D0601
High Caries Risk
38
The Disease Management DifferenceDisease Management Difference
Traditional Dental Care Disease Management
Approach
All patients return in 6 months
regardless of risk status
Recare interval is based on the
childrsquos caries risk
Caries Risk
Level
Recommended
Recare Interval
High Risk 1 ndash 3 months
Moderate Risk 3 ndash 6 months
Low Risk 6 ndash 12 months
Caries
Stabilizing
agents
Health Ed
Nutritional
Counseling
Anti-bacterial
and Fluoride
interventions
39
Disease Management Care Pathways
DentaQuest Partnership for Oral Health Advancement Disease Management Model
Caries
Stabilizing
agents
Whole
Person
Inter-
professional
Approaches
Anti-bacterial
and Fluoride
interventions
40
Disease Management and Risk Screening Training
DentaQuest Partnership for Oral Health Advancementrsquos
Online Learning Center
Disease Management Series
8 modules 40 CDE available
httpswwwdentaquestpartnershiporglearnonline-learning-centeronline-
coursewaredentaquest-disease-management-series
41
MEASUREMENT IN TEAMSSharing meaningful data with your dental clinical teams
42
rdquoDental Homerdquo = Health Home where WE can meet the patient
Oralhealthworkforceorg
43
POLL HOW OFTEN DO YOU SHARE YOUR S WITH YOUR DENTAL TEAM
A Yearly only
B Quarterly
C Monthly
D Weekly
E Daily
44
Clinical Measures ndash Dental Practice Perspective
Private Practice Office
New patients seen
Assigned vs seen if capitated
Treatment plans incomplete
$ produced amp per provider
$ collected amp monthly per provider
CDT 6000 codes completed
RecallHygiene maintenance
Based on this consultants experienced
FQHC
Unduplicated patients
patients seen per day
Treatment plans complete
$ gainedlost via accounting
Broken appointment rate
procedures
Sealant rate (annual)
45
bull HRSA Sealant Measure Compliance for FQHCs
bull Completion of phase 1 treatment plans
bull Children seen 0-5 years old
bull Children seen getting a preventive service
bull Fluoride Varnish applications
bull Pregnant women seen and treated
bull Diabetic patients with HbA1C gt 7 seen
bull Patients seen who have not been seen for 12 months
bull Patients seen getting a Risk Assessment
bull Patients with moderate or high risk who lower risk at recare
bull Sealants provided httpwwwnnohaorgnnoha-contentuploads201512Demystifying-HRSA-SEALANT-PRESENTATION_FINALpdf
Program Measures
46
HRSA Performance Measurement and Data Collection
bull FQHCs and look-alikes submit CY data to HRSA since 2008
bull UDS Uniform Data System
bull Require FTE for clinical staff patient demographics
bull Dental utilization s (UDCTPV)
bull Dental Clinical Measure dental sealants placed on 1st molars ages 6-9 yo
bull Health Center Quartile rankings (Clinical measure performance influences
HC rankings as does EHR adoption and other HC characteristics)
47
Low birth weight
Access to prenatal care
Childhood Immunization
Children (Ages 3-17) Receiving
Weight Assessment amp
Counseling
Children (Age 6-9) Receiving
Dental Sealant to First Molars
Diabetes Control
Hypertension Control
Pap Test
Depression Screening and
Follow-up (Age 12+)
Asthma Patients (Age 5-40)
Receiving Pharmacologic
Therapy
Colorectal Cancer
Screening (Ages 51-74)
HRSA UDS Clinical Measures
Adults (Age 18+) Receiving
Weight Screening amp Follow-up
Adults (Age 18+) Receiving
Tobacco Use Assessment and
Cessation Intervention
Coronary Artery Disease
Receiving Lipid Therapy (18+)
Ischemic Vascular Disease (IVD)
Receiving Aspirin Therapy (18+)
HIV Linkage to Care
48
Dashboards
Grants
Average
amp
Targets
Quality
Rev
Costs
Visits
Priority
Pop
Prevention
49
Dashboard- Provider Team Level
Patient
Compliance
Satisfaction
50
Case Study-
Incentives bonus round pools benchmark and improvement target goals risk-sharing possible later years
51
Qualitative Measurement
ldquoPatient engagement is the act of patients and providers working together
toward the end goal of improved patient wellnessrdquo
wwwpatientengagementhitcom
Access to Care
Patient Activation
Patient Satisfaction
Patient-Provider-Care Team Communication
Care Team Satisfaction
52
OHVBC Readiness
Leadership
bull Value of oral health and oral health transformation
Structure Systems and Operations
bull Operational efficiencies innovative care delivery methodologies
Care Pathways and Provider Buy-In
bull Training disease management risk-based care referrals IDC-10 coding patient engagement
Data and Analytic Technology and Personnel
bull Interoperability reporting
Financial Viability and Strength
bull Payerpatient mix billing infrastructure financial reports
httpswwwdentaquestpartnershiporglearnsafety-net-solutionsoral-health-value-based-careohvbc-readiness-
assessment
53
QUESTIONS COMMENTS
Carolyn Brown DDS
cbrownddsgmailcom
RISK BASED MANAGED CARE
Value Based Training Conference
Manchester New Hampshire
Mark Koday DDS
111919
5555
Objectives
bull Review current drivers of dental managed care
bull Understand the basics of risk-based dental managed care contracts
bull Learn the basics of managing costs in a riskndashbased contract
bull Gain an understanding in the potential advantage of risk-based contracting
56
What Is Dental Managed Care
Managed care is a health delivery system whose purpose is to manage both the
quality and cost of health care
Common types of managed care health insurance plans
bull HMOs
bull PPOs
bull POSs
bull Medicaid Managed Care
DIDNrsquoT WE ALREADY HAVE MANAGED CARE AND IT FAILED
57
What Has Happened Since the 90s
58
WHY THE FFS AND PPS DOESNrsquoT WORK FOR OUR POPULATIONS
bull Inefficient payment systems designed to produce encounters or procedures but not real health
bull No focus on population health
bull Does not incentivize innovation
bull Patients essentially on their own for accessing specialty care
59
Rule of 4
Source Kaiser Family Foundation analysis of National Health Expenditure (NHE) data from Centers for
Medicare and Medicaid Services Office of the Actuary National Health Statistics Group
60
Rule of 4
bull This helps explain why oral health has been relatively ignored so far by CMS
bull Explains why we have PCMH instead of PCHH
bull Where is the real value on a national level in preventing disease and
controlling costs
bull Beware- wersquove been found
61
Reasons Dental Managed Care is Spreading Across the States
NON-MANAGED CARE STATE DENTAL BUDGETS ARE
OPENED ENDED
STRAIN ON STATE BUDGETS
UPCOMING RECESSION WITH TRILLION DOLLAR
DEFICIT
SHIFTS FINANCIAL RISK FROM THE STATES TO THE
PLANS
6262
Types of Medicaid Managed Care
bull State Medicaid agency administrator lowest administrative
costs
bull Third Party Administrator Typically 15 administrative costs
bull Managed Care Organization Typically 15 administrative
costs
bull Carved-in
bull Carved-out
bull Risk Based Managed Care Administrative costs part of
contract negotiation
63
RISK CONTRACTS
6464
Components of a Risk-based Contract
Risk
Medical Loss Ratio
Quality withhold
Specialty withhold
Managed care payment (pmpm)
Covered services
Fee schedule Claims are paid as usual on a FFS basis
Credentialing
Quality Review process and Quality Metrics
65
Upside Risk
The possibility that the cost of
delivering dental care to an assigned
patient panel is less than the amount
of funding calculated for that care
The Plan pays the CHC additional
funds based on a predetermine
formula
Downside Risk
The possibility that the cost of
delivering dental care to an assigned
patient panel is more than the amount
of funding calculated for that care
The CHC pays the Plan additional
funds based on a predetermine
formula
Upside and Downside Risk
66
Taking On Risk 100 or Shared Risk
With 100 risk you receive 100 of the potential savings but are also at risk for
100 of the losses
Shared Risk MCO and health center share a percentage of the risk
Shared Risk leads to better cooperation since both organizations are
incentivized to save on costs
6767
Reports Needed
bull Enrollment reports lists of who is assigned on a monthly basis
bull Reconciliation reports insure appropriate payments
bull Specialty Referral reports
bull You will need your own reporting process so you donrsquot rely completely on
reports supplied by the Plan
6868
Medical Loss Ratio
Medical Loss Ratio (MLR) is proportion of premium revenues spent on clinical
services and quality improvement also known as the Medical Loss Ratio (MLR)
For CMS requires Medical Plans to spend at least 80 to 85 of the premiums
on actual medical care
69
Administrative Fees
bull Essentially the opposite of MLR
bull The State Medicaid Agency is funded by the Governorrsquos budget
bull The State Medicaid Agency will keep some of these funds for their
admin costs and give the remaining to the Managed Care Plans
bull Private Plan admin costs can be as high as 40 but most states
limit these cost for Medicaid Plans to between 15 and 20 (85-
80 MLR)
bull This may be negotiable depending on your program size of your
program
70
Quality Withhold
bull The state withholds a certain percent (typically 2-4 ) of the funds they give
to the Plans for Value Based Reimbursement
bull They choose quality metrics and set benchmarks and assign payments for
each metric based on an assigned priority for each metric
bull If a Plan meets the benchmark of every quality metric the state passes on
their full share of the quality withhold
bull The Plans may or may not withhold a percent of the funds for quality payment
to the dentists or manage care contractors
71
Quality Withhold
Either way the Plans may or may not pass the quality payments they receive to
the dentists or contractors
This should be spelled out in a risk-based contract
72
Percent of funds set aside
to cover specialty care
referrals
Typically 10-15
Goal Limit referral costs
to within or less than
Specialty set aside
Specialty Withhold
73
Per Member Per Month
bull Capitated Payment
bull Specific dollar amount paid for each enrolled member each month
bull Paid whether patient is accessed for care or not
bull States do set access benchmarks
bull In Oregon access for any dental procedure (adults and children combined)
was 267 in 2015
74
Payment Math Example
Premium per enrollee = $25
Administrative fee 15 = $375
Funds available per enrollee to the clinic = $2125
Management fee per enrollee = $175
Funds per enrollee that would undergo PPS reconciliation = $1950
For every 10000 enrollees the managed care income = $2340000
Specialty withhold (10) = $234000
YE Cost lt or gt $2340000
Upside Risk
CHC Gains $
Downside Risk
CHC Loses $
75
Covered Services and Fee Schedules
bull The state Medicaid agency spells out the minimum procedures and fees that
MCOs must cover
bull MCOs may add procedures or increase periodicity of procedures particularly
preventative services
bull MCOs may increase fees to entice rural providers and specialists to enroll in
their Plans
bull Access Rules
bull How many days it takes to access a patent
bull How many days it takes for a patent to access urgent care services
bull How many days it takes for a patent to access emergency care services
76
Credentialing
All MCOs are required to credential all Providers
All MCOs have their own credentialing process
Credentialing process is can be lengthy
Credentialing process may be negotiable
77
Quality Review Process and Quality Metrics
MCOs must have a Quality and Compliance Review Process
If you arenrsquot in compliance with both you likely wonrsquot get paid
Typical processes reviewed
bull Charting specifications
bull Incident report
bull Enrollee complaints quality rudeness and access issues
bull Medicaid compliance
78
Quality Payments
bull State Shared Incentive Withhold Typically quality metrics and benchmarks
are set by the state sets aside a certain percent (3-5) of the payments to
the Managed Care Plan (MCP)
bull If the benchmarks are achieved the MCP is then paid the a predetermine
amount
bull Benchmarks may not be the same as the states
bull Managed Care Plans do not have to pass all or any of the quality payments to
the health centers or providers
bull Managed Care contract- Metrics benchmarks should be selected and part of
the contract
7979
Achieving Quality Metric Payments
Dealing with under achievers
Process issues
Individual issues
Identifying workflows
Developing Best Practices through
PDSA process
Developing Best Practices through
PDSA process
CHC Metrics Committee
Clinicians Operations various key staff
Identify Best Practices
Spread Best Practices
80
New Team Needed Business Intelligence
Business Intelligence (BI) is critical for effective managed care business decisions
BI team inputs metrics into your EHR collects integrates analyses and displays all your managed care business and clinical information
Easy to say- hard to achieve
Build your own or outsource
Possible future role of Primary Care Associations
8181
Clinicianrsquos Dashboard
Expensive to build
Displayed on your screen when your computer is first turned on
Easy to read and understand
Data dumped from the day before
Can dialed down from Org-wide to clinic to each clinicianrsquos data
Operational and clinical metrics
bull Treatment Plan Completion
bull DQA quality measures
bull Caries at Recall
bull Re-care reports
bull Care Gap reports
82
CONTROLLING COSTS
8383
Controlling Costs- Current
bull Increasing efficiencies
bull Decreasing broken appointments
bull Controlling supplies equipment costs
bull Staff recruitment retention costs
84
Specialty Care
Training current CHC dentists in
specialty areas
Hiring general dentists with higher
specialty skill sets
Hiring in house specialists
Contract with outside specialists
Work with Managed Care Plan
specialists
Lowering Disease Rates
Community Dental Health
Coordinators case management
If your state law allows- embed
hygienists in medical and community
to provide primary and secondary
prevention procedures
In clinic Caries Classification and
Silver Diamine Fluoride
Effective recare programs
Controlling Costs- Additions in Risk-based Contracting
85
Specialty Care ndash Primary Referrals by Cost
Pediatric dentistry
Orthodontics
Oral surgery
Endodontics
86
In-clinic Pediatric Services
Encounters expected
of operatories available
State dental law and ability to have
expanded duties
General Anesthesia
GA in- house
Ability for a hospital or surgery center
to set aside regular OR time
Ability to hire or assign DAs to GA
days
Four GA cases day x PPS rate
Should You Hire a Pediatric Dentist- It Depends
8787
Solutions for Controlling Pediatric Costs
Hire a general dentist that is skilled in treating young children
Make the clinic child friendly nitrous oxide TVs in the operatory etc
Teach entire staff behavioral control techniques
Contract with a pediatric dentist for the GA care
88
Lowering Overall Disease Rates (and Costs)
You are responsible for both the patients you see in the chair and the ones
assigned to you
Breaking down the walls of the dental clinic
Community Dental Health Coordinators
Case Management
89
Cost Control Essentials
Diagnosis codes
Increased ability to identify
disease by risk
Motivational
Interviewing
Developing Polices and
Procedures design to treat
disease according to risk
ie Silver Diamine Fluoride
Treating by Risk
Effective Recare
Process
Critical to continual disease
controlPrevention education that is
meaningful and designed to
change behaviors
90
Social Determinants of Health Aunt Bertha
httpswwwauntberthacom
91
REASON TO CONSIDER RISK- BASED CONTRACTING
9292
PPS Reconciliation and Federal Code 42 CFR sect4052469(a)(2)
42 CFR sect4052469(a)(2)
ldquoAny financial incentives provided to Federally Qualified Health Centers
under their Medicare Advantage Contracts such as risk pool payments
bonuses or withholds are prohibited from being included in the
calculation of supplemental payments due to the Federally Qualified
Health Centerrdquo
9393
Why Risk Based Contract in Times of PPS Reconciliation
bull Not all Risk- based Contract funds are reconciled
bull Risk is the key word- you can come out with less money than your normal
PPS reconciliation payment
bull Can lead to better patient care
bull May improve manage care enrollment for your medical plan
bull Promotes integrated care increases health for your CHC patients
9494
Not Included in the Reconciliation
Enrollment management pmpm
Quality Payments
Upside risk payments
Downside risk losses
9595
Determinants of Financial Success in Risk-Based Contracting
bull Most critical- State pmpm payment to the Managed Care Plan
bull Reporting capabilities
bull Specialty service capabilities
bull Access numbers count
bull Ability to move metric numbers
9696
What About the Non- Medicaid Poor We Serve
bull Numbers are king in a managed care contract and the more access you have
the better contract terms you can negotiate
bull We will potentially have a steady supply of Medicaid patients
bull As managed care spreads states this may be compromising the ability of
health centers to serve the non-Medicaid poor and others lacking dental
insurance
97
Mark Koday DDS
(509) 949-2278
Dental Quality Consultants
of WA
httpdentalqualityconsultin
gcom
dentalqualityconsultantsg
mailcom
Contact Information
LUNCH
BREAKOUT EXERCISEORAL HEALTH VALUE-BASED CARE READINESS ASSESSMENT
Danielle Apostolon
PROMISING PRACTICES FROM THE FIELD STRATEGIES FOR INCREASING VALUE IN ORAL HEALTH
Dr Carolyn Brown
Dr Kelly Perry
Dr Rachel Rivard
Dr Adeloye
Commitment Compassion Community
m i d s t a t e h e a l t h o r g
Promising Practices from the
Field Strategies for Increasing
Value in Oral Health Care
Kelly Perry DMD
Better Health
Outcomes
Improved Staff
Experience
Reduced Cost
Improved Patient
Experience
Better Health
Outcomes
Improved Staff
Experience
Reduced Cost
Improved Patient
Experience
Better Health
Outcomes
Improved Staff
Experience
Reduced Cost
Improved Patient
Experience
Better Health
Outcomes
Improved Staff
Experience
Reduced Cost
Improved Patient
Experience
Commitment Compassion Community
kpe r r ymids t a tehea l t h o rg
Thank you
Completion of Disease Control Phase
Pelumi Adeloye DMD MPH
HEALTH ACCESS NETWORK (HAN) FAMILY DENTAL
Introduction
⧫1 Dentist I Hygienist 3 EFDArsquos1 Receptionist
⧫ 6 Chairs= 4 (dentist) + 2 (hygienist)
⧫ Slide ⥶80 off
⧫ Service areas Northern Penobscot Southern Aroostook Western
Washington Counties amp more
Completion of Phase I Treatment
⧫LimitedLack of Access to dental care
⧫Difficulty completing the disease control phase
Caries amp periodontal disease
⧫Attaining stable restorative state
Goal
Increase the completion of Disease Control Phase
Current practice
⧫Education
Assess level of dental literacy
Incremental strategy
⧫Increase access to dental care
Generous sliding scale (⥸$40 per visit)
Incorporate Expanded Function Dental Assistants
⧫Schedule modification
Incorporate more restorative blocks to allow
for follow-up visit and completion of restorative phase
httpswwwglasbergencomdentist-cartoons
Schedule
⧫Piggybacking technique
Increased allotted restorative blocks
⧫Sustainability of current schedule is
contingent on cooperation amp skills of HAN
Dental staff
Note
Strategies mentioned today is personalized to HAN Dental clinic
Current implemented strategies might be modified or changed in the
future as required in order to accommodate the need of our pts
THANK YOU
DAY TWOCLOSINGWRAP-UP
End of Day Two ndash Survey
Day Two Creating a Value-Based Oral Health Care Delivery
System
129
Payment Reform in Oral Health Online Learning Module
Oral Health Value-based Care Online Learning Module
Value-based Care Keys to Success Article
Readiness Assessment
Competency Development Guide
Oral Health Value-based Care Training
Dental Caries Management Practicum
Clinicians Companion Guide
Interprofessional Network Referral Process
Traditional Dental Care Vs Value-Based Care
Resources
131
wwwDentaQuestPartnershiporg
wwwfacebookcomDentaQuest
DentaQuest
wwwlinkedincomcompanyDentaQuest
Inside_DentaQuest
QUESTIONS
6
Mortality Rates Decreasing
httpswwwhealthsystemtrackerorgchart-collectionquality-u-s-healthcare-system-compare-countriesitem-overall-years-
life-lost-1990-2017
7
Early Detection amp Prevention Matters
One of our providers was able to diagnose a lesion the biopsy had some cancer
cells We were trying to get that patient into an oral surgeon We contacted several
of the private practice oral surgeons in the area It was anywhere from $300 to $400
to walk into their office for an evaluation and a diagnosis That doesnt mean even
treatment
We were able to get him to The University of Maryland Its about a two-hour trip for
this patient to get there His first appointment his car broke down and he couldnt
get there The next appointment we were able to get him he traveled the two hours
and waited for four and a half hours and then wasnt seen They had a backlog and
he was sent home and told they would give him another appointment and come
back He then left our area and came back three years later in 2017 and our dentist
that does pediatrics is actually the only one in the office
8
Early Detection amp Prevention Matters
When he came as an emergency she saw him He had just came out of the
hospital His ENT just diagnosed him with stage four head and neck cancer And
if we had been able to see him got him into care with that initial diagnosis
which was a very small lesion at the time we might have been able to prevent
that
9
Evaluation survey must be completed to receive 10 CE credits
bull httpswwwsurveymonkeycomrVBCTraining1
bull httpswwwsurveymonkeycomrVBCTraining2
10
Agenda
Highlights from Day One
Group Discussion
Laying the Groundwork for Oral Health Value-Based Care Readiness
Lunch
Breakout Exercise Oral Health Value-Based Care Readiness
A Dental Directorrsquos Experience in Risk-Based Oral Health Managed Care
Promising Practices from the Field
ClosingWrap Up
11
12
bull Outline the key components to prepare for oral health value-based care
delivery system
bull Understand measurement and principles in healthcare transformation
Todayrsquos Learning Objectives ndash Day Two
LAYING THE GROUNDWORKCLINICAL OPERATIONS IN A VBR ENVIRONMENTCarolyn Brown DDS Consultant
November 19th 2019
14
INTRODUCTION
15
Todayrsquos Agenda
bull Discuss value-based health and pay-for-performance approaches to health
systems and the integral building block of data
bull Dive deep into the emerging field of value-based care measurement and
data in oral health from national and statewide perspectives
bull Present oral health and clinical measurement approaches and relate to
oversight
16
bull Consultant working with DQP FQHCs Primary Care Associations and Foundations advancing oral health programs
bull DQPSNS Expert Advisor
bull IHI Improvement Coach
bull Former Dental Director
bull Research Marketing Finance
Carolyn Brown DDS
Consultant Acting Director of Value-Based Care
DentaQuest Partnership for Oral Health Advancement
bull DDS University of Maryland School of Dentistry
bull MAEd University of the Pacific
bull BS University of Maryland
bull Speaker researcher expert advisor review panel
17
Poll What do you measure
A Dental provider productivity per day
B Treatment plan completion
C Dental new patient exams
D Combination of A-C
E No Shows
F Sealants only
18
Population
Prevention
Healthy
Minimally Invasive
Health outcomes
MDI
EHR EDR
PCC
Risk Assessment
19
VALUE-BASED CAREPushing the impact quality and quantity of measurement
20
OHVBC Readiness
Leadership
Value of oral health and oral health transformation
Structure Systems and Operations
Efficiencies innovative care delivery
Care Pathways and Provider Buy-In
Risk-based care Training patient engagement
Data and Analytic Technology and Personnel
DataReports Interoperability
Financial Viability and Strength
Payerpatient mix billing infrastructure
httpswwwdentaquestpartnershiporglearnsafety-net-solutionsoral-health-value-based-careohvbc-readiness-
assessment
21
DentaQuest Partnership OHVBC Survey
Barriers to Value-based Transformation in Oral Health ndash
Most Common Responses
bull Patient engagement
bull EHREDR
bull Tracking outcomes lack of nationally-recognized and standardized quality
metrics in dental
22
How Can FQHC Dental Programs Prepare for Value-based
Transformation in Oral Health
bull Begin or continue focusing on prevention disease management and risk-based care
bull Hygienists will be key to success ndash We need primary dental care not just surgical
interventions
bull Start measuring outcomes instead of just processutilization metrics bull of initially high-risk patients with new caries lesions
bull of initially high-risk patients with decreased risk status
bull of initially low-risk patients with risk status maintained
bull Address patient engagement in a more meaningful way and invest in case
management
bull Invest in interprofessional practice including HIT interoperability
bull Evaluate how services are being delivered and determine if its reaching the patients
who need care the most
23
Value-Based Care
Care Coordination
ldquoClosing outrdquo referrals
Diagnostic coding
Risk Screenings
Care plans based on risk
Patient Engagement
Incentive payments
Quality metrics
Clinic Response
Case Management IT
Active timely records mngt
Mapping Dx codes to CDT
Time bill CPT codes Tx plan
IPP data tofrom PC MH
Recall window important
Attention to $ related metrics
Attention to assigned metrics
Direct and Indirect Effects of VBC on Dental Systems of Care
Utilization Impact
New workforce CDT codes
New or + workforce IT
ICD-CM-10 codes
+CDT codes
Modifiers (CPT ICD10)
+ recall adherence
in incentivized procedures
in sealant POC A1C
Counseling codes SD
24
MEASUREMENT IN ORAL HEALTH
25
Poll What percentage of your adult dental patients are diabetic
or pre-diabetic
A 50-80
B 20-50
C Less than 20
D Not sure
26
27
ldquoTrue Measures of Successrdquo
1 Define your governing objective
2 Develop a theory of cause and effect to assess presumed drivers of the
objective
3 Identify the specific activities that employees can do to help achieve the
governing objective
4 Evaluate your statistics
5 Communicate the story of your measurement
Adapted from HBR ldquoThe True Measures of Successrdquo httpshbrorg201210the-true-measures-of-success
28
1 Governing objective
2 Theory of cause and effect
3 Activities of team
4 Evaluate your statistics
5 Storycraft
Sustainability
Clinic revenuegt expenses= sustainability
Patient compliance Assets Clinic Mngt
Care team Operations Pt Support Billing
Of Prod on and type Patients on time
Daily weekly monthly quarterly
ldquoTrue Measures of Successrdquo
Adapted from HBR ldquoThe True Measures of Successrdquo httpshbrorg201210the-true-measures-of-success
29
Measuring Risk and Health
November is Diabetes Awareness Month- 2019Communication Plans are as
important as cold hard numbers
Patients
Care Team
Other Health Teams
Executive Team
Funders
Data on your dental patients are medical patients of record
Data on your medical + dental patients with DM2
30
Develop Diabetic Patient
Protocols
Review evidence and rationale with dental team
Partner with primary care team
bull Protocols Care mngt Tests and Recording
Quality Goals
Protocols for newly screened and existing patients
Educate and train dental team in reading AND
charting test results and PILOT
31
External Measurement in Oral Health Programs
httpswwwadaorg~mediaADADQA2019_DiabetesOralEvaluationpdfla=en
httpswwworegongovohaHPAANALYTICSCCOMetrics2019-Oral-Evaluation-Adults-Diabetespdf
32
Baseline for 2019 271
httpswwworegongovohaHPAANALYTICSCCOMetrics2019-Oral-Evaluation-Adults-Diabetespdf
33
Diabetes burden in your panel of dental patients
Baseline Medical-Dental Integrated panel of all patients
Dental patients with DM2 MDI
Dental patients with DM2
1000 or 10
600 or 60
300010000= 30
Population Health- Clinic Level
34
1 Governing objective
2 Theory of cause and effect
3 Activities of team
4 Evaluate your statistics
5 Storycraft
Discuss at meetings (Oct + Nov) Health education training
materials NP training CQI Note in Board report Clinical
measures
Care Pathways Hygiene Resources (ScheduleAvail)
ldquoTrue Measures of Successrdquo
Adapted from HBR ldquoThe True Measures of Successrdquo httpshbrorg201210the-true-measures-of-success
Diabetes Awareness Prevention Healthier Community
Prevention Awareness Care Pathway promotes health
MDI= 10 6 out of 10 adult patients with DM2
Goal set for integrated patient panels ndash PCMH
Pre-diabetes approach for executive team
Care Pathways
Care Coordination
35
MEASURING PATIENT ORAL HEALTHRisk assessments and Care Pathways
36
37
Risk Assessment and Care Pathways
Caries Risk Assessment
Multiple tools
EDREHR modules smart notes or dot phrases
CDT Codes
Decide frequency
D0601
Low Caries Risk
D0601
Moderate Caries Risk
D0601
High Caries Risk
38
The Disease Management DifferenceDisease Management Difference
Traditional Dental Care Disease Management
Approach
All patients return in 6 months
regardless of risk status
Recare interval is based on the
childrsquos caries risk
Caries Risk
Level
Recommended
Recare Interval
High Risk 1 ndash 3 months
Moderate Risk 3 ndash 6 months
Low Risk 6 ndash 12 months
Caries
Stabilizing
agents
Health Ed
Nutritional
Counseling
Anti-bacterial
and Fluoride
interventions
39
Disease Management Care Pathways
DentaQuest Partnership for Oral Health Advancement Disease Management Model
Caries
Stabilizing
agents
Whole
Person
Inter-
professional
Approaches
Anti-bacterial
and Fluoride
interventions
40
Disease Management and Risk Screening Training
DentaQuest Partnership for Oral Health Advancementrsquos
Online Learning Center
Disease Management Series
8 modules 40 CDE available
httpswwwdentaquestpartnershiporglearnonline-learning-centeronline-
coursewaredentaquest-disease-management-series
41
MEASUREMENT IN TEAMSSharing meaningful data with your dental clinical teams
42
rdquoDental Homerdquo = Health Home where WE can meet the patient
Oralhealthworkforceorg
43
POLL HOW OFTEN DO YOU SHARE YOUR S WITH YOUR DENTAL TEAM
A Yearly only
B Quarterly
C Monthly
D Weekly
E Daily
44
Clinical Measures ndash Dental Practice Perspective
Private Practice Office
New patients seen
Assigned vs seen if capitated
Treatment plans incomplete
$ produced amp per provider
$ collected amp monthly per provider
CDT 6000 codes completed
RecallHygiene maintenance
Based on this consultants experienced
FQHC
Unduplicated patients
patients seen per day
Treatment plans complete
$ gainedlost via accounting
Broken appointment rate
procedures
Sealant rate (annual)
45
bull HRSA Sealant Measure Compliance for FQHCs
bull Completion of phase 1 treatment plans
bull Children seen 0-5 years old
bull Children seen getting a preventive service
bull Fluoride Varnish applications
bull Pregnant women seen and treated
bull Diabetic patients with HbA1C gt 7 seen
bull Patients seen who have not been seen for 12 months
bull Patients seen getting a Risk Assessment
bull Patients with moderate or high risk who lower risk at recare
bull Sealants provided httpwwwnnohaorgnnoha-contentuploads201512Demystifying-HRSA-SEALANT-PRESENTATION_FINALpdf
Program Measures
46
HRSA Performance Measurement and Data Collection
bull FQHCs and look-alikes submit CY data to HRSA since 2008
bull UDS Uniform Data System
bull Require FTE for clinical staff patient demographics
bull Dental utilization s (UDCTPV)
bull Dental Clinical Measure dental sealants placed on 1st molars ages 6-9 yo
bull Health Center Quartile rankings (Clinical measure performance influences
HC rankings as does EHR adoption and other HC characteristics)
47
Low birth weight
Access to prenatal care
Childhood Immunization
Children (Ages 3-17) Receiving
Weight Assessment amp
Counseling
Children (Age 6-9) Receiving
Dental Sealant to First Molars
Diabetes Control
Hypertension Control
Pap Test
Depression Screening and
Follow-up (Age 12+)
Asthma Patients (Age 5-40)
Receiving Pharmacologic
Therapy
Colorectal Cancer
Screening (Ages 51-74)
HRSA UDS Clinical Measures
Adults (Age 18+) Receiving
Weight Screening amp Follow-up
Adults (Age 18+) Receiving
Tobacco Use Assessment and
Cessation Intervention
Coronary Artery Disease
Receiving Lipid Therapy (18+)
Ischemic Vascular Disease (IVD)
Receiving Aspirin Therapy (18+)
HIV Linkage to Care
48
Dashboards
Grants
Average
amp
Targets
Quality
Rev
Costs
Visits
Priority
Pop
Prevention
49
Dashboard- Provider Team Level
Patient
Compliance
Satisfaction
50
Case Study-
Incentives bonus round pools benchmark and improvement target goals risk-sharing possible later years
51
Qualitative Measurement
ldquoPatient engagement is the act of patients and providers working together
toward the end goal of improved patient wellnessrdquo
wwwpatientengagementhitcom
Access to Care
Patient Activation
Patient Satisfaction
Patient-Provider-Care Team Communication
Care Team Satisfaction
52
OHVBC Readiness
Leadership
bull Value of oral health and oral health transformation
Structure Systems and Operations
bull Operational efficiencies innovative care delivery methodologies
Care Pathways and Provider Buy-In
bull Training disease management risk-based care referrals IDC-10 coding patient engagement
Data and Analytic Technology and Personnel
bull Interoperability reporting
Financial Viability and Strength
bull Payerpatient mix billing infrastructure financial reports
httpswwwdentaquestpartnershiporglearnsafety-net-solutionsoral-health-value-based-careohvbc-readiness-
assessment
53
QUESTIONS COMMENTS
Carolyn Brown DDS
cbrownddsgmailcom
RISK BASED MANAGED CARE
Value Based Training Conference
Manchester New Hampshire
Mark Koday DDS
111919
5555
Objectives
bull Review current drivers of dental managed care
bull Understand the basics of risk-based dental managed care contracts
bull Learn the basics of managing costs in a riskndashbased contract
bull Gain an understanding in the potential advantage of risk-based contracting
56
What Is Dental Managed Care
Managed care is a health delivery system whose purpose is to manage both the
quality and cost of health care
Common types of managed care health insurance plans
bull HMOs
bull PPOs
bull POSs
bull Medicaid Managed Care
DIDNrsquoT WE ALREADY HAVE MANAGED CARE AND IT FAILED
57
What Has Happened Since the 90s
58
WHY THE FFS AND PPS DOESNrsquoT WORK FOR OUR POPULATIONS
bull Inefficient payment systems designed to produce encounters or procedures but not real health
bull No focus on population health
bull Does not incentivize innovation
bull Patients essentially on their own for accessing specialty care
59
Rule of 4
Source Kaiser Family Foundation analysis of National Health Expenditure (NHE) data from Centers for
Medicare and Medicaid Services Office of the Actuary National Health Statistics Group
60
Rule of 4
bull This helps explain why oral health has been relatively ignored so far by CMS
bull Explains why we have PCMH instead of PCHH
bull Where is the real value on a national level in preventing disease and
controlling costs
bull Beware- wersquove been found
61
Reasons Dental Managed Care is Spreading Across the States
NON-MANAGED CARE STATE DENTAL BUDGETS ARE
OPENED ENDED
STRAIN ON STATE BUDGETS
UPCOMING RECESSION WITH TRILLION DOLLAR
DEFICIT
SHIFTS FINANCIAL RISK FROM THE STATES TO THE
PLANS
6262
Types of Medicaid Managed Care
bull State Medicaid agency administrator lowest administrative
costs
bull Third Party Administrator Typically 15 administrative costs
bull Managed Care Organization Typically 15 administrative
costs
bull Carved-in
bull Carved-out
bull Risk Based Managed Care Administrative costs part of
contract negotiation
63
RISK CONTRACTS
6464
Components of a Risk-based Contract
Risk
Medical Loss Ratio
Quality withhold
Specialty withhold
Managed care payment (pmpm)
Covered services
Fee schedule Claims are paid as usual on a FFS basis
Credentialing
Quality Review process and Quality Metrics
65
Upside Risk
The possibility that the cost of
delivering dental care to an assigned
patient panel is less than the amount
of funding calculated for that care
The Plan pays the CHC additional
funds based on a predetermine
formula
Downside Risk
The possibility that the cost of
delivering dental care to an assigned
patient panel is more than the amount
of funding calculated for that care
The CHC pays the Plan additional
funds based on a predetermine
formula
Upside and Downside Risk
66
Taking On Risk 100 or Shared Risk
With 100 risk you receive 100 of the potential savings but are also at risk for
100 of the losses
Shared Risk MCO and health center share a percentage of the risk
Shared Risk leads to better cooperation since both organizations are
incentivized to save on costs
6767
Reports Needed
bull Enrollment reports lists of who is assigned on a monthly basis
bull Reconciliation reports insure appropriate payments
bull Specialty Referral reports
bull You will need your own reporting process so you donrsquot rely completely on
reports supplied by the Plan
6868
Medical Loss Ratio
Medical Loss Ratio (MLR) is proportion of premium revenues spent on clinical
services and quality improvement also known as the Medical Loss Ratio (MLR)
For CMS requires Medical Plans to spend at least 80 to 85 of the premiums
on actual medical care
69
Administrative Fees
bull Essentially the opposite of MLR
bull The State Medicaid Agency is funded by the Governorrsquos budget
bull The State Medicaid Agency will keep some of these funds for their
admin costs and give the remaining to the Managed Care Plans
bull Private Plan admin costs can be as high as 40 but most states
limit these cost for Medicaid Plans to between 15 and 20 (85-
80 MLR)
bull This may be negotiable depending on your program size of your
program
70
Quality Withhold
bull The state withholds a certain percent (typically 2-4 ) of the funds they give
to the Plans for Value Based Reimbursement
bull They choose quality metrics and set benchmarks and assign payments for
each metric based on an assigned priority for each metric
bull If a Plan meets the benchmark of every quality metric the state passes on
their full share of the quality withhold
bull The Plans may or may not withhold a percent of the funds for quality payment
to the dentists or manage care contractors
71
Quality Withhold
Either way the Plans may or may not pass the quality payments they receive to
the dentists or contractors
This should be spelled out in a risk-based contract
72
Percent of funds set aside
to cover specialty care
referrals
Typically 10-15
Goal Limit referral costs
to within or less than
Specialty set aside
Specialty Withhold
73
Per Member Per Month
bull Capitated Payment
bull Specific dollar amount paid for each enrolled member each month
bull Paid whether patient is accessed for care or not
bull States do set access benchmarks
bull In Oregon access for any dental procedure (adults and children combined)
was 267 in 2015
74
Payment Math Example
Premium per enrollee = $25
Administrative fee 15 = $375
Funds available per enrollee to the clinic = $2125
Management fee per enrollee = $175
Funds per enrollee that would undergo PPS reconciliation = $1950
For every 10000 enrollees the managed care income = $2340000
Specialty withhold (10) = $234000
YE Cost lt or gt $2340000
Upside Risk
CHC Gains $
Downside Risk
CHC Loses $
75
Covered Services and Fee Schedules
bull The state Medicaid agency spells out the minimum procedures and fees that
MCOs must cover
bull MCOs may add procedures or increase periodicity of procedures particularly
preventative services
bull MCOs may increase fees to entice rural providers and specialists to enroll in
their Plans
bull Access Rules
bull How many days it takes to access a patent
bull How many days it takes for a patent to access urgent care services
bull How many days it takes for a patent to access emergency care services
76
Credentialing
All MCOs are required to credential all Providers
All MCOs have their own credentialing process
Credentialing process is can be lengthy
Credentialing process may be negotiable
77
Quality Review Process and Quality Metrics
MCOs must have a Quality and Compliance Review Process
If you arenrsquot in compliance with both you likely wonrsquot get paid
Typical processes reviewed
bull Charting specifications
bull Incident report
bull Enrollee complaints quality rudeness and access issues
bull Medicaid compliance
78
Quality Payments
bull State Shared Incentive Withhold Typically quality metrics and benchmarks
are set by the state sets aside a certain percent (3-5) of the payments to
the Managed Care Plan (MCP)
bull If the benchmarks are achieved the MCP is then paid the a predetermine
amount
bull Benchmarks may not be the same as the states
bull Managed Care Plans do not have to pass all or any of the quality payments to
the health centers or providers
bull Managed Care contract- Metrics benchmarks should be selected and part of
the contract
7979
Achieving Quality Metric Payments
Dealing with under achievers
Process issues
Individual issues
Identifying workflows
Developing Best Practices through
PDSA process
Developing Best Practices through
PDSA process
CHC Metrics Committee
Clinicians Operations various key staff
Identify Best Practices
Spread Best Practices
80
New Team Needed Business Intelligence
Business Intelligence (BI) is critical for effective managed care business decisions
BI team inputs metrics into your EHR collects integrates analyses and displays all your managed care business and clinical information
Easy to say- hard to achieve
Build your own or outsource
Possible future role of Primary Care Associations
8181
Clinicianrsquos Dashboard
Expensive to build
Displayed on your screen when your computer is first turned on
Easy to read and understand
Data dumped from the day before
Can dialed down from Org-wide to clinic to each clinicianrsquos data
Operational and clinical metrics
bull Treatment Plan Completion
bull DQA quality measures
bull Caries at Recall
bull Re-care reports
bull Care Gap reports
82
CONTROLLING COSTS
8383
Controlling Costs- Current
bull Increasing efficiencies
bull Decreasing broken appointments
bull Controlling supplies equipment costs
bull Staff recruitment retention costs
84
Specialty Care
Training current CHC dentists in
specialty areas
Hiring general dentists with higher
specialty skill sets
Hiring in house specialists
Contract with outside specialists
Work with Managed Care Plan
specialists
Lowering Disease Rates
Community Dental Health
Coordinators case management
If your state law allows- embed
hygienists in medical and community
to provide primary and secondary
prevention procedures
In clinic Caries Classification and
Silver Diamine Fluoride
Effective recare programs
Controlling Costs- Additions in Risk-based Contracting
85
Specialty Care ndash Primary Referrals by Cost
Pediatric dentistry
Orthodontics
Oral surgery
Endodontics
86
In-clinic Pediatric Services
Encounters expected
of operatories available
State dental law and ability to have
expanded duties
General Anesthesia
GA in- house
Ability for a hospital or surgery center
to set aside regular OR time
Ability to hire or assign DAs to GA
days
Four GA cases day x PPS rate
Should You Hire a Pediatric Dentist- It Depends
8787
Solutions for Controlling Pediatric Costs
Hire a general dentist that is skilled in treating young children
Make the clinic child friendly nitrous oxide TVs in the operatory etc
Teach entire staff behavioral control techniques
Contract with a pediatric dentist for the GA care
88
Lowering Overall Disease Rates (and Costs)
You are responsible for both the patients you see in the chair and the ones
assigned to you
Breaking down the walls of the dental clinic
Community Dental Health Coordinators
Case Management
89
Cost Control Essentials
Diagnosis codes
Increased ability to identify
disease by risk
Motivational
Interviewing
Developing Polices and
Procedures design to treat
disease according to risk
ie Silver Diamine Fluoride
Treating by Risk
Effective Recare
Process
Critical to continual disease
controlPrevention education that is
meaningful and designed to
change behaviors
90
Social Determinants of Health Aunt Bertha
httpswwwauntberthacom
91
REASON TO CONSIDER RISK- BASED CONTRACTING
9292
PPS Reconciliation and Federal Code 42 CFR sect4052469(a)(2)
42 CFR sect4052469(a)(2)
ldquoAny financial incentives provided to Federally Qualified Health Centers
under their Medicare Advantage Contracts such as risk pool payments
bonuses or withholds are prohibited from being included in the
calculation of supplemental payments due to the Federally Qualified
Health Centerrdquo
9393
Why Risk Based Contract in Times of PPS Reconciliation
bull Not all Risk- based Contract funds are reconciled
bull Risk is the key word- you can come out with less money than your normal
PPS reconciliation payment
bull Can lead to better patient care
bull May improve manage care enrollment for your medical plan
bull Promotes integrated care increases health for your CHC patients
9494
Not Included in the Reconciliation
Enrollment management pmpm
Quality Payments
Upside risk payments
Downside risk losses
9595
Determinants of Financial Success in Risk-Based Contracting
bull Most critical- State pmpm payment to the Managed Care Plan
bull Reporting capabilities
bull Specialty service capabilities
bull Access numbers count
bull Ability to move metric numbers
9696
What About the Non- Medicaid Poor We Serve
bull Numbers are king in a managed care contract and the more access you have
the better contract terms you can negotiate
bull We will potentially have a steady supply of Medicaid patients
bull As managed care spreads states this may be compromising the ability of
health centers to serve the non-Medicaid poor and others lacking dental
insurance
97
Mark Koday DDS
(509) 949-2278
Dental Quality Consultants
of WA
httpdentalqualityconsultin
gcom
dentalqualityconsultantsg
mailcom
Contact Information
LUNCH
BREAKOUT EXERCISEORAL HEALTH VALUE-BASED CARE READINESS ASSESSMENT
Danielle Apostolon
PROMISING PRACTICES FROM THE FIELD STRATEGIES FOR INCREASING VALUE IN ORAL HEALTH
Dr Carolyn Brown
Dr Kelly Perry
Dr Rachel Rivard
Dr Adeloye
Commitment Compassion Community
m i d s t a t e h e a l t h o r g
Promising Practices from the
Field Strategies for Increasing
Value in Oral Health Care
Kelly Perry DMD
Better Health
Outcomes
Improved Staff
Experience
Reduced Cost
Improved Patient
Experience
Better Health
Outcomes
Improved Staff
Experience
Reduced Cost
Improved Patient
Experience
Better Health
Outcomes
Improved Staff
Experience
Reduced Cost
Improved Patient
Experience
Better Health
Outcomes
Improved Staff
Experience
Reduced Cost
Improved Patient
Experience
Commitment Compassion Community
kpe r r ymids t a tehea l t h o rg
Thank you
Completion of Disease Control Phase
Pelumi Adeloye DMD MPH
HEALTH ACCESS NETWORK (HAN) FAMILY DENTAL
Introduction
⧫1 Dentist I Hygienist 3 EFDArsquos1 Receptionist
⧫ 6 Chairs= 4 (dentist) + 2 (hygienist)
⧫ Slide ⥶80 off
⧫ Service areas Northern Penobscot Southern Aroostook Western
Washington Counties amp more
Completion of Phase I Treatment
⧫LimitedLack of Access to dental care
⧫Difficulty completing the disease control phase
Caries amp periodontal disease
⧫Attaining stable restorative state
Goal
Increase the completion of Disease Control Phase
Current practice
⧫Education
Assess level of dental literacy
Incremental strategy
⧫Increase access to dental care
Generous sliding scale (⥸$40 per visit)
Incorporate Expanded Function Dental Assistants
⧫Schedule modification
Incorporate more restorative blocks to allow
for follow-up visit and completion of restorative phase
httpswwwglasbergencomdentist-cartoons
Schedule
⧫Piggybacking technique
Increased allotted restorative blocks
⧫Sustainability of current schedule is
contingent on cooperation amp skills of HAN
Dental staff
Note
Strategies mentioned today is personalized to HAN Dental clinic
Current implemented strategies might be modified or changed in the
future as required in order to accommodate the need of our pts
THANK YOU
DAY TWOCLOSINGWRAP-UP
End of Day Two ndash Survey
Day Two Creating a Value-Based Oral Health Care Delivery
System
129
Payment Reform in Oral Health Online Learning Module
Oral Health Value-based Care Online Learning Module
Value-based Care Keys to Success Article
Readiness Assessment
Competency Development Guide
Oral Health Value-based Care Training
Dental Caries Management Practicum
Clinicians Companion Guide
Interprofessional Network Referral Process
Traditional Dental Care Vs Value-Based Care
Resources
131
wwwDentaQuestPartnershiporg
wwwfacebookcomDentaQuest
DentaQuest
wwwlinkedincomcompanyDentaQuest
Inside_DentaQuest
QUESTIONS
7
Early Detection amp Prevention Matters
One of our providers was able to diagnose a lesion the biopsy had some cancer
cells We were trying to get that patient into an oral surgeon We contacted several
of the private practice oral surgeons in the area It was anywhere from $300 to $400
to walk into their office for an evaluation and a diagnosis That doesnt mean even
treatment
We were able to get him to The University of Maryland Its about a two-hour trip for
this patient to get there His first appointment his car broke down and he couldnt
get there The next appointment we were able to get him he traveled the two hours
and waited for four and a half hours and then wasnt seen They had a backlog and
he was sent home and told they would give him another appointment and come
back He then left our area and came back three years later in 2017 and our dentist
that does pediatrics is actually the only one in the office
8
Early Detection amp Prevention Matters
When he came as an emergency she saw him He had just came out of the
hospital His ENT just diagnosed him with stage four head and neck cancer And
if we had been able to see him got him into care with that initial diagnosis
which was a very small lesion at the time we might have been able to prevent
that
9
Evaluation survey must be completed to receive 10 CE credits
bull httpswwwsurveymonkeycomrVBCTraining1
bull httpswwwsurveymonkeycomrVBCTraining2
10
Agenda
Highlights from Day One
Group Discussion
Laying the Groundwork for Oral Health Value-Based Care Readiness
Lunch
Breakout Exercise Oral Health Value-Based Care Readiness
A Dental Directorrsquos Experience in Risk-Based Oral Health Managed Care
Promising Practices from the Field
ClosingWrap Up
11
12
bull Outline the key components to prepare for oral health value-based care
delivery system
bull Understand measurement and principles in healthcare transformation
Todayrsquos Learning Objectives ndash Day Two
LAYING THE GROUNDWORKCLINICAL OPERATIONS IN A VBR ENVIRONMENTCarolyn Brown DDS Consultant
November 19th 2019
14
INTRODUCTION
15
Todayrsquos Agenda
bull Discuss value-based health and pay-for-performance approaches to health
systems and the integral building block of data
bull Dive deep into the emerging field of value-based care measurement and
data in oral health from national and statewide perspectives
bull Present oral health and clinical measurement approaches and relate to
oversight
16
bull Consultant working with DQP FQHCs Primary Care Associations and Foundations advancing oral health programs
bull DQPSNS Expert Advisor
bull IHI Improvement Coach
bull Former Dental Director
bull Research Marketing Finance
Carolyn Brown DDS
Consultant Acting Director of Value-Based Care
DentaQuest Partnership for Oral Health Advancement
bull DDS University of Maryland School of Dentistry
bull MAEd University of the Pacific
bull BS University of Maryland
bull Speaker researcher expert advisor review panel
17
Poll What do you measure
A Dental provider productivity per day
B Treatment plan completion
C Dental new patient exams
D Combination of A-C
E No Shows
F Sealants only
18
Population
Prevention
Healthy
Minimally Invasive
Health outcomes
MDI
EHR EDR
PCC
Risk Assessment
19
VALUE-BASED CAREPushing the impact quality and quantity of measurement
20
OHVBC Readiness
Leadership
Value of oral health and oral health transformation
Structure Systems and Operations
Efficiencies innovative care delivery
Care Pathways and Provider Buy-In
Risk-based care Training patient engagement
Data and Analytic Technology and Personnel
DataReports Interoperability
Financial Viability and Strength
Payerpatient mix billing infrastructure
httpswwwdentaquestpartnershiporglearnsafety-net-solutionsoral-health-value-based-careohvbc-readiness-
assessment
21
DentaQuest Partnership OHVBC Survey
Barriers to Value-based Transformation in Oral Health ndash
Most Common Responses
bull Patient engagement
bull EHREDR
bull Tracking outcomes lack of nationally-recognized and standardized quality
metrics in dental
22
How Can FQHC Dental Programs Prepare for Value-based
Transformation in Oral Health
bull Begin or continue focusing on prevention disease management and risk-based care
bull Hygienists will be key to success ndash We need primary dental care not just surgical
interventions
bull Start measuring outcomes instead of just processutilization metrics bull of initially high-risk patients with new caries lesions
bull of initially high-risk patients with decreased risk status
bull of initially low-risk patients with risk status maintained
bull Address patient engagement in a more meaningful way and invest in case
management
bull Invest in interprofessional practice including HIT interoperability
bull Evaluate how services are being delivered and determine if its reaching the patients
who need care the most
23
Value-Based Care
Care Coordination
ldquoClosing outrdquo referrals
Diagnostic coding
Risk Screenings
Care plans based on risk
Patient Engagement
Incentive payments
Quality metrics
Clinic Response
Case Management IT
Active timely records mngt
Mapping Dx codes to CDT
Time bill CPT codes Tx plan
IPP data tofrom PC MH
Recall window important
Attention to $ related metrics
Attention to assigned metrics
Direct and Indirect Effects of VBC on Dental Systems of Care
Utilization Impact
New workforce CDT codes
New or + workforce IT
ICD-CM-10 codes
+CDT codes
Modifiers (CPT ICD10)
+ recall adherence
in incentivized procedures
in sealant POC A1C
Counseling codes SD
24
MEASUREMENT IN ORAL HEALTH
25
Poll What percentage of your adult dental patients are diabetic
or pre-diabetic
A 50-80
B 20-50
C Less than 20
D Not sure
26
27
ldquoTrue Measures of Successrdquo
1 Define your governing objective
2 Develop a theory of cause and effect to assess presumed drivers of the
objective
3 Identify the specific activities that employees can do to help achieve the
governing objective
4 Evaluate your statistics
5 Communicate the story of your measurement
Adapted from HBR ldquoThe True Measures of Successrdquo httpshbrorg201210the-true-measures-of-success
28
1 Governing objective
2 Theory of cause and effect
3 Activities of team
4 Evaluate your statistics
5 Storycraft
Sustainability
Clinic revenuegt expenses= sustainability
Patient compliance Assets Clinic Mngt
Care team Operations Pt Support Billing
Of Prod on and type Patients on time
Daily weekly monthly quarterly
ldquoTrue Measures of Successrdquo
Adapted from HBR ldquoThe True Measures of Successrdquo httpshbrorg201210the-true-measures-of-success
29
Measuring Risk and Health
November is Diabetes Awareness Month- 2019Communication Plans are as
important as cold hard numbers
Patients
Care Team
Other Health Teams
Executive Team
Funders
Data on your dental patients are medical patients of record
Data on your medical + dental patients with DM2
30
Develop Diabetic Patient
Protocols
Review evidence and rationale with dental team
Partner with primary care team
bull Protocols Care mngt Tests and Recording
Quality Goals
Protocols for newly screened and existing patients
Educate and train dental team in reading AND
charting test results and PILOT
31
External Measurement in Oral Health Programs
httpswwwadaorg~mediaADADQA2019_DiabetesOralEvaluationpdfla=en
httpswwworegongovohaHPAANALYTICSCCOMetrics2019-Oral-Evaluation-Adults-Diabetespdf
32
Baseline for 2019 271
httpswwworegongovohaHPAANALYTICSCCOMetrics2019-Oral-Evaluation-Adults-Diabetespdf
33
Diabetes burden in your panel of dental patients
Baseline Medical-Dental Integrated panel of all patients
Dental patients with DM2 MDI
Dental patients with DM2
1000 or 10
600 or 60
300010000= 30
Population Health- Clinic Level
34
1 Governing objective
2 Theory of cause and effect
3 Activities of team
4 Evaluate your statistics
5 Storycraft
Discuss at meetings (Oct + Nov) Health education training
materials NP training CQI Note in Board report Clinical
measures
Care Pathways Hygiene Resources (ScheduleAvail)
ldquoTrue Measures of Successrdquo
Adapted from HBR ldquoThe True Measures of Successrdquo httpshbrorg201210the-true-measures-of-success
Diabetes Awareness Prevention Healthier Community
Prevention Awareness Care Pathway promotes health
MDI= 10 6 out of 10 adult patients with DM2
Goal set for integrated patient panels ndash PCMH
Pre-diabetes approach for executive team
Care Pathways
Care Coordination
35
MEASURING PATIENT ORAL HEALTHRisk assessments and Care Pathways
36
37
Risk Assessment and Care Pathways
Caries Risk Assessment
Multiple tools
EDREHR modules smart notes or dot phrases
CDT Codes
Decide frequency
D0601
Low Caries Risk
D0601
Moderate Caries Risk
D0601
High Caries Risk
38
The Disease Management DifferenceDisease Management Difference
Traditional Dental Care Disease Management
Approach
All patients return in 6 months
regardless of risk status
Recare interval is based on the
childrsquos caries risk
Caries Risk
Level
Recommended
Recare Interval
High Risk 1 ndash 3 months
Moderate Risk 3 ndash 6 months
Low Risk 6 ndash 12 months
Caries
Stabilizing
agents
Health Ed
Nutritional
Counseling
Anti-bacterial
and Fluoride
interventions
39
Disease Management Care Pathways
DentaQuest Partnership for Oral Health Advancement Disease Management Model
Caries
Stabilizing
agents
Whole
Person
Inter-
professional
Approaches
Anti-bacterial
and Fluoride
interventions
40
Disease Management and Risk Screening Training
DentaQuest Partnership for Oral Health Advancementrsquos
Online Learning Center
Disease Management Series
8 modules 40 CDE available
httpswwwdentaquestpartnershiporglearnonline-learning-centeronline-
coursewaredentaquest-disease-management-series
41
MEASUREMENT IN TEAMSSharing meaningful data with your dental clinical teams
42
rdquoDental Homerdquo = Health Home where WE can meet the patient
Oralhealthworkforceorg
43
POLL HOW OFTEN DO YOU SHARE YOUR S WITH YOUR DENTAL TEAM
A Yearly only
B Quarterly
C Monthly
D Weekly
E Daily
44
Clinical Measures ndash Dental Practice Perspective
Private Practice Office
New patients seen
Assigned vs seen if capitated
Treatment plans incomplete
$ produced amp per provider
$ collected amp monthly per provider
CDT 6000 codes completed
RecallHygiene maintenance
Based on this consultants experienced
FQHC
Unduplicated patients
patients seen per day
Treatment plans complete
$ gainedlost via accounting
Broken appointment rate
procedures
Sealant rate (annual)
45
bull HRSA Sealant Measure Compliance for FQHCs
bull Completion of phase 1 treatment plans
bull Children seen 0-5 years old
bull Children seen getting a preventive service
bull Fluoride Varnish applications
bull Pregnant women seen and treated
bull Diabetic patients with HbA1C gt 7 seen
bull Patients seen who have not been seen for 12 months
bull Patients seen getting a Risk Assessment
bull Patients with moderate or high risk who lower risk at recare
bull Sealants provided httpwwwnnohaorgnnoha-contentuploads201512Demystifying-HRSA-SEALANT-PRESENTATION_FINALpdf
Program Measures
46
HRSA Performance Measurement and Data Collection
bull FQHCs and look-alikes submit CY data to HRSA since 2008
bull UDS Uniform Data System
bull Require FTE for clinical staff patient demographics
bull Dental utilization s (UDCTPV)
bull Dental Clinical Measure dental sealants placed on 1st molars ages 6-9 yo
bull Health Center Quartile rankings (Clinical measure performance influences
HC rankings as does EHR adoption and other HC characteristics)
47
Low birth weight
Access to prenatal care
Childhood Immunization
Children (Ages 3-17) Receiving
Weight Assessment amp
Counseling
Children (Age 6-9) Receiving
Dental Sealant to First Molars
Diabetes Control
Hypertension Control
Pap Test
Depression Screening and
Follow-up (Age 12+)
Asthma Patients (Age 5-40)
Receiving Pharmacologic
Therapy
Colorectal Cancer
Screening (Ages 51-74)
HRSA UDS Clinical Measures
Adults (Age 18+) Receiving
Weight Screening amp Follow-up
Adults (Age 18+) Receiving
Tobacco Use Assessment and
Cessation Intervention
Coronary Artery Disease
Receiving Lipid Therapy (18+)
Ischemic Vascular Disease (IVD)
Receiving Aspirin Therapy (18+)
HIV Linkage to Care
48
Dashboards
Grants
Average
amp
Targets
Quality
Rev
Costs
Visits
Priority
Pop
Prevention
49
Dashboard- Provider Team Level
Patient
Compliance
Satisfaction
50
Case Study-
Incentives bonus round pools benchmark and improvement target goals risk-sharing possible later years
51
Qualitative Measurement
ldquoPatient engagement is the act of patients and providers working together
toward the end goal of improved patient wellnessrdquo
wwwpatientengagementhitcom
Access to Care
Patient Activation
Patient Satisfaction
Patient-Provider-Care Team Communication
Care Team Satisfaction
52
OHVBC Readiness
Leadership
bull Value of oral health and oral health transformation
Structure Systems and Operations
bull Operational efficiencies innovative care delivery methodologies
Care Pathways and Provider Buy-In
bull Training disease management risk-based care referrals IDC-10 coding patient engagement
Data and Analytic Technology and Personnel
bull Interoperability reporting
Financial Viability and Strength
bull Payerpatient mix billing infrastructure financial reports
httpswwwdentaquestpartnershiporglearnsafety-net-solutionsoral-health-value-based-careohvbc-readiness-
assessment
53
QUESTIONS COMMENTS
Carolyn Brown DDS
cbrownddsgmailcom
RISK BASED MANAGED CARE
Value Based Training Conference
Manchester New Hampshire
Mark Koday DDS
111919
5555
Objectives
bull Review current drivers of dental managed care
bull Understand the basics of risk-based dental managed care contracts
bull Learn the basics of managing costs in a riskndashbased contract
bull Gain an understanding in the potential advantage of risk-based contracting
56
What Is Dental Managed Care
Managed care is a health delivery system whose purpose is to manage both the
quality and cost of health care
Common types of managed care health insurance plans
bull HMOs
bull PPOs
bull POSs
bull Medicaid Managed Care
DIDNrsquoT WE ALREADY HAVE MANAGED CARE AND IT FAILED
57
What Has Happened Since the 90s
58
WHY THE FFS AND PPS DOESNrsquoT WORK FOR OUR POPULATIONS
bull Inefficient payment systems designed to produce encounters or procedures but not real health
bull No focus on population health
bull Does not incentivize innovation
bull Patients essentially on their own for accessing specialty care
59
Rule of 4
Source Kaiser Family Foundation analysis of National Health Expenditure (NHE) data from Centers for
Medicare and Medicaid Services Office of the Actuary National Health Statistics Group
60
Rule of 4
bull This helps explain why oral health has been relatively ignored so far by CMS
bull Explains why we have PCMH instead of PCHH
bull Where is the real value on a national level in preventing disease and
controlling costs
bull Beware- wersquove been found
61
Reasons Dental Managed Care is Spreading Across the States
NON-MANAGED CARE STATE DENTAL BUDGETS ARE
OPENED ENDED
STRAIN ON STATE BUDGETS
UPCOMING RECESSION WITH TRILLION DOLLAR
DEFICIT
SHIFTS FINANCIAL RISK FROM THE STATES TO THE
PLANS
6262
Types of Medicaid Managed Care
bull State Medicaid agency administrator lowest administrative
costs
bull Third Party Administrator Typically 15 administrative costs
bull Managed Care Organization Typically 15 administrative
costs
bull Carved-in
bull Carved-out
bull Risk Based Managed Care Administrative costs part of
contract negotiation
63
RISK CONTRACTS
6464
Components of a Risk-based Contract
Risk
Medical Loss Ratio
Quality withhold
Specialty withhold
Managed care payment (pmpm)
Covered services
Fee schedule Claims are paid as usual on a FFS basis
Credentialing
Quality Review process and Quality Metrics
65
Upside Risk
The possibility that the cost of
delivering dental care to an assigned
patient panel is less than the amount
of funding calculated for that care
The Plan pays the CHC additional
funds based on a predetermine
formula
Downside Risk
The possibility that the cost of
delivering dental care to an assigned
patient panel is more than the amount
of funding calculated for that care
The CHC pays the Plan additional
funds based on a predetermine
formula
Upside and Downside Risk
66
Taking On Risk 100 or Shared Risk
With 100 risk you receive 100 of the potential savings but are also at risk for
100 of the losses
Shared Risk MCO and health center share a percentage of the risk
Shared Risk leads to better cooperation since both organizations are
incentivized to save on costs
6767
Reports Needed
bull Enrollment reports lists of who is assigned on a monthly basis
bull Reconciliation reports insure appropriate payments
bull Specialty Referral reports
bull You will need your own reporting process so you donrsquot rely completely on
reports supplied by the Plan
6868
Medical Loss Ratio
Medical Loss Ratio (MLR) is proportion of premium revenues spent on clinical
services and quality improvement also known as the Medical Loss Ratio (MLR)
For CMS requires Medical Plans to spend at least 80 to 85 of the premiums
on actual medical care
69
Administrative Fees
bull Essentially the opposite of MLR
bull The State Medicaid Agency is funded by the Governorrsquos budget
bull The State Medicaid Agency will keep some of these funds for their
admin costs and give the remaining to the Managed Care Plans
bull Private Plan admin costs can be as high as 40 but most states
limit these cost for Medicaid Plans to between 15 and 20 (85-
80 MLR)
bull This may be negotiable depending on your program size of your
program
70
Quality Withhold
bull The state withholds a certain percent (typically 2-4 ) of the funds they give
to the Plans for Value Based Reimbursement
bull They choose quality metrics and set benchmarks and assign payments for
each metric based on an assigned priority for each metric
bull If a Plan meets the benchmark of every quality metric the state passes on
their full share of the quality withhold
bull The Plans may or may not withhold a percent of the funds for quality payment
to the dentists or manage care contractors
71
Quality Withhold
Either way the Plans may or may not pass the quality payments they receive to
the dentists or contractors
This should be spelled out in a risk-based contract
72
Percent of funds set aside
to cover specialty care
referrals
Typically 10-15
Goal Limit referral costs
to within or less than
Specialty set aside
Specialty Withhold
73
Per Member Per Month
bull Capitated Payment
bull Specific dollar amount paid for each enrolled member each month
bull Paid whether patient is accessed for care or not
bull States do set access benchmarks
bull In Oregon access for any dental procedure (adults and children combined)
was 267 in 2015
74
Payment Math Example
Premium per enrollee = $25
Administrative fee 15 = $375
Funds available per enrollee to the clinic = $2125
Management fee per enrollee = $175
Funds per enrollee that would undergo PPS reconciliation = $1950
For every 10000 enrollees the managed care income = $2340000
Specialty withhold (10) = $234000
YE Cost lt or gt $2340000
Upside Risk
CHC Gains $
Downside Risk
CHC Loses $
75
Covered Services and Fee Schedules
bull The state Medicaid agency spells out the minimum procedures and fees that
MCOs must cover
bull MCOs may add procedures or increase periodicity of procedures particularly
preventative services
bull MCOs may increase fees to entice rural providers and specialists to enroll in
their Plans
bull Access Rules
bull How many days it takes to access a patent
bull How many days it takes for a patent to access urgent care services
bull How many days it takes for a patent to access emergency care services
76
Credentialing
All MCOs are required to credential all Providers
All MCOs have their own credentialing process
Credentialing process is can be lengthy
Credentialing process may be negotiable
77
Quality Review Process and Quality Metrics
MCOs must have a Quality and Compliance Review Process
If you arenrsquot in compliance with both you likely wonrsquot get paid
Typical processes reviewed
bull Charting specifications
bull Incident report
bull Enrollee complaints quality rudeness and access issues
bull Medicaid compliance
78
Quality Payments
bull State Shared Incentive Withhold Typically quality metrics and benchmarks
are set by the state sets aside a certain percent (3-5) of the payments to
the Managed Care Plan (MCP)
bull If the benchmarks are achieved the MCP is then paid the a predetermine
amount
bull Benchmarks may not be the same as the states
bull Managed Care Plans do not have to pass all or any of the quality payments to
the health centers or providers
bull Managed Care contract- Metrics benchmarks should be selected and part of
the contract
7979
Achieving Quality Metric Payments
Dealing with under achievers
Process issues
Individual issues
Identifying workflows
Developing Best Practices through
PDSA process
Developing Best Practices through
PDSA process
CHC Metrics Committee
Clinicians Operations various key staff
Identify Best Practices
Spread Best Practices
80
New Team Needed Business Intelligence
Business Intelligence (BI) is critical for effective managed care business decisions
BI team inputs metrics into your EHR collects integrates analyses and displays all your managed care business and clinical information
Easy to say- hard to achieve
Build your own or outsource
Possible future role of Primary Care Associations
8181
Clinicianrsquos Dashboard
Expensive to build
Displayed on your screen when your computer is first turned on
Easy to read and understand
Data dumped from the day before
Can dialed down from Org-wide to clinic to each clinicianrsquos data
Operational and clinical metrics
bull Treatment Plan Completion
bull DQA quality measures
bull Caries at Recall
bull Re-care reports
bull Care Gap reports
82
CONTROLLING COSTS
8383
Controlling Costs- Current
bull Increasing efficiencies
bull Decreasing broken appointments
bull Controlling supplies equipment costs
bull Staff recruitment retention costs
84
Specialty Care
Training current CHC dentists in
specialty areas
Hiring general dentists with higher
specialty skill sets
Hiring in house specialists
Contract with outside specialists
Work with Managed Care Plan
specialists
Lowering Disease Rates
Community Dental Health
Coordinators case management
If your state law allows- embed
hygienists in medical and community
to provide primary and secondary
prevention procedures
In clinic Caries Classification and
Silver Diamine Fluoride
Effective recare programs
Controlling Costs- Additions in Risk-based Contracting
85
Specialty Care ndash Primary Referrals by Cost
Pediatric dentistry
Orthodontics
Oral surgery
Endodontics
86
In-clinic Pediatric Services
Encounters expected
of operatories available
State dental law and ability to have
expanded duties
General Anesthesia
GA in- house
Ability for a hospital or surgery center
to set aside regular OR time
Ability to hire or assign DAs to GA
days
Four GA cases day x PPS rate
Should You Hire a Pediatric Dentist- It Depends
8787
Solutions for Controlling Pediatric Costs
Hire a general dentist that is skilled in treating young children
Make the clinic child friendly nitrous oxide TVs in the operatory etc
Teach entire staff behavioral control techniques
Contract with a pediatric dentist for the GA care
88
Lowering Overall Disease Rates (and Costs)
You are responsible for both the patients you see in the chair and the ones
assigned to you
Breaking down the walls of the dental clinic
Community Dental Health Coordinators
Case Management
89
Cost Control Essentials
Diagnosis codes
Increased ability to identify
disease by risk
Motivational
Interviewing
Developing Polices and
Procedures design to treat
disease according to risk
ie Silver Diamine Fluoride
Treating by Risk
Effective Recare
Process
Critical to continual disease
controlPrevention education that is
meaningful and designed to
change behaviors
90
Social Determinants of Health Aunt Bertha
httpswwwauntberthacom
91
REASON TO CONSIDER RISK- BASED CONTRACTING
9292
PPS Reconciliation and Federal Code 42 CFR sect4052469(a)(2)
42 CFR sect4052469(a)(2)
ldquoAny financial incentives provided to Federally Qualified Health Centers
under their Medicare Advantage Contracts such as risk pool payments
bonuses or withholds are prohibited from being included in the
calculation of supplemental payments due to the Federally Qualified
Health Centerrdquo
9393
Why Risk Based Contract in Times of PPS Reconciliation
bull Not all Risk- based Contract funds are reconciled
bull Risk is the key word- you can come out with less money than your normal
PPS reconciliation payment
bull Can lead to better patient care
bull May improve manage care enrollment for your medical plan
bull Promotes integrated care increases health for your CHC patients
9494
Not Included in the Reconciliation
Enrollment management pmpm
Quality Payments
Upside risk payments
Downside risk losses
9595
Determinants of Financial Success in Risk-Based Contracting
bull Most critical- State pmpm payment to the Managed Care Plan
bull Reporting capabilities
bull Specialty service capabilities
bull Access numbers count
bull Ability to move metric numbers
9696
What About the Non- Medicaid Poor We Serve
bull Numbers are king in a managed care contract and the more access you have
the better contract terms you can negotiate
bull We will potentially have a steady supply of Medicaid patients
bull As managed care spreads states this may be compromising the ability of
health centers to serve the non-Medicaid poor and others lacking dental
insurance
97
Mark Koday DDS
(509) 949-2278
Dental Quality Consultants
of WA
httpdentalqualityconsultin
gcom
dentalqualityconsultantsg
mailcom
Contact Information
LUNCH
BREAKOUT EXERCISEORAL HEALTH VALUE-BASED CARE READINESS ASSESSMENT
Danielle Apostolon
PROMISING PRACTICES FROM THE FIELD STRATEGIES FOR INCREASING VALUE IN ORAL HEALTH
Dr Carolyn Brown
Dr Kelly Perry
Dr Rachel Rivard
Dr Adeloye
Commitment Compassion Community
m i d s t a t e h e a l t h o r g
Promising Practices from the
Field Strategies for Increasing
Value in Oral Health Care
Kelly Perry DMD
Better Health
Outcomes
Improved Staff
Experience
Reduced Cost
Improved Patient
Experience
Better Health
Outcomes
Improved Staff
Experience
Reduced Cost
Improved Patient
Experience
Better Health
Outcomes
Improved Staff
Experience
Reduced Cost
Improved Patient
Experience
Better Health
Outcomes
Improved Staff
Experience
Reduced Cost
Improved Patient
Experience
Commitment Compassion Community
kpe r r ymids t a tehea l t h o rg
Thank you
Completion of Disease Control Phase
Pelumi Adeloye DMD MPH
HEALTH ACCESS NETWORK (HAN) FAMILY DENTAL
Introduction
⧫1 Dentist I Hygienist 3 EFDArsquos1 Receptionist
⧫ 6 Chairs= 4 (dentist) + 2 (hygienist)
⧫ Slide ⥶80 off
⧫ Service areas Northern Penobscot Southern Aroostook Western
Washington Counties amp more
Completion of Phase I Treatment
⧫LimitedLack of Access to dental care
⧫Difficulty completing the disease control phase
Caries amp periodontal disease
⧫Attaining stable restorative state
Goal
Increase the completion of Disease Control Phase
Current practice
⧫Education
Assess level of dental literacy
Incremental strategy
⧫Increase access to dental care
Generous sliding scale (⥸$40 per visit)
Incorporate Expanded Function Dental Assistants
⧫Schedule modification
Incorporate more restorative blocks to allow
for follow-up visit and completion of restorative phase
httpswwwglasbergencomdentist-cartoons
Schedule
⧫Piggybacking technique
Increased allotted restorative blocks
⧫Sustainability of current schedule is
contingent on cooperation amp skills of HAN
Dental staff
Note
Strategies mentioned today is personalized to HAN Dental clinic
Current implemented strategies might be modified or changed in the
future as required in order to accommodate the need of our pts
THANK YOU
DAY TWOCLOSINGWRAP-UP
End of Day Two ndash Survey
Day Two Creating a Value-Based Oral Health Care Delivery
System
129
Payment Reform in Oral Health Online Learning Module
Oral Health Value-based Care Online Learning Module
Value-based Care Keys to Success Article
Readiness Assessment
Competency Development Guide
Oral Health Value-based Care Training
Dental Caries Management Practicum
Clinicians Companion Guide
Interprofessional Network Referral Process
Traditional Dental Care Vs Value-Based Care
Resources
131
wwwDentaQuestPartnershiporg
wwwfacebookcomDentaQuest
DentaQuest
wwwlinkedincomcompanyDentaQuest
Inside_DentaQuest
QUESTIONS
8
Early Detection amp Prevention Matters
When he came as an emergency she saw him He had just came out of the
hospital His ENT just diagnosed him with stage four head and neck cancer And
if we had been able to see him got him into care with that initial diagnosis
which was a very small lesion at the time we might have been able to prevent
that
9
Evaluation survey must be completed to receive 10 CE credits
bull httpswwwsurveymonkeycomrVBCTraining1
bull httpswwwsurveymonkeycomrVBCTraining2
10
Agenda
Highlights from Day One
Group Discussion
Laying the Groundwork for Oral Health Value-Based Care Readiness
Lunch
Breakout Exercise Oral Health Value-Based Care Readiness
A Dental Directorrsquos Experience in Risk-Based Oral Health Managed Care
Promising Practices from the Field
ClosingWrap Up
11
12
bull Outline the key components to prepare for oral health value-based care
delivery system
bull Understand measurement and principles in healthcare transformation
Todayrsquos Learning Objectives ndash Day Two
LAYING THE GROUNDWORKCLINICAL OPERATIONS IN A VBR ENVIRONMENTCarolyn Brown DDS Consultant
November 19th 2019
14
INTRODUCTION
15
Todayrsquos Agenda
bull Discuss value-based health and pay-for-performance approaches to health
systems and the integral building block of data
bull Dive deep into the emerging field of value-based care measurement and
data in oral health from national and statewide perspectives
bull Present oral health and clinical measurement approaches and relate to
oversight
16
bull Consultant working with DQP FQHCs Primary Care Associations and Foundations advancing oral health programs
bull DQPSNS Expert Advisor
bull IHI Improvement Coach
bull Former Dental Director
bull Research Marketing Finance
Carolyn Brown DDS
Consultant Acting Director of Value-Based Care
DentaQuest Partnership for Oral Health Advancement
bull DDS University of Maryland School of Dentistry
bull MAEd University of the Pacific
bull BS University of Maryland
bull Speaker researcher expert advisor review panel
17
Poll What do you measure
A Dental provider productivity per day
B Treatment plan completion
C Dental new patient exams
D Combination of A-C
E No Shows
F Sealants only
18
Population
Prevention
Healthy
Minimally Invasive
Health outcomes
MDI
EHR EDR
PCC
Risk Assessment
19
VALUE-BASED CAREPushing the impact quality and quantity of measurement
20
OHVBC Readiness
Leadership
Value of oral health and oral health transformation
Structure Systems and Operations
Efficiencies innovative care delivery
Care Pathways and Provider Buy-In
Risk-based care Training patient engagement
Data and Analytic Technology and Personnel
DataReports Interoperability
Financial Viability and Strength
Payerpatient mix billing infrastructure
httpswwwdentaquestpartnershiporglearnsafety-net-solutionsoral-health-value-based-careohvbc-readiness-
assessment
21
DentaQuest Partnership OHVBC Survey
Barriers to Value-based Transformation in Oral Health ndash
Most Common Responses
bull Patient engagement
bull EHREDR
bull Tracking outcomes lack of nationally-recognized and standardized quality
metrics in dental
22
How Can FQHC Dental Programs Prepare for Value-based
Transformation in Oral Health
bull Begin or continue focusing on prevention disease management and risk-based care
bull Hygienists will be key to success ndash We need primary dental care not just surgical
interventions
bull Start measuring outcomes instead of just processutilization metrics bull of initially high-risk patients with new caries lesions
bull of initially high-risk patients with decreased risk status
bull of initially low-risk patients with risk status maintained
bull Address patient engagement in a more meaningful way and invest in case
management
bull Invest in interprofessional practice including HIT interoperability
bull Evaluate how services are being delivered and determine if its reaching the patients
who need care the most
23
Value-Based Care
Care Coordination
ldquoClosing outrdquo referrals
Diagnostic coding
Risk Screenings
Care plans based on risk
Patient Engagement
Incentive payments
Quality metrics
Clinic Response
Case Management IT
Active timely records mngt
Mapping Dx codes to CDT
Time bill CPT codes Tx plan
IPP data tofrom PC MH
Recall window important
Attention to $ related metrics
Attention to assigned metrics
Direct and Indirect Effects of VBC on Dental Systems of Care
Utilization Impact
New workforce CDT codes
New or + workforce IT
ICD-CM-10 codes
+CDT codes
Modifiers (CPT ICD10)
+ recall adherence
in incentivized procedures
in sealant POC A1C
Counseling codes SD
24
MEASUREMENT IN ORAL HEALTH
25
Poll What percentage of your adult dental patients are diabetic
or pre-diabetic
A 50-80
B 20-50
C Less than 20
D Not sure
26
27
ldquoTrue Measures of Successrdquo
1 Define your governing objective
2 Develop a theory of cause and effect to assess presumed drivers of the
objective
3 Identify the specific activities that employees can do to help achieve the
governing objective
4 Evaluate your statistics
5 Communicate the story of your measurement
Adapted from HBR ldquoThe True Measures of Successrdquo httpshbrorg201210the-true-measures-of-success
28
1 Governing objective
2 Theory of cause and effect
3 Activities of team
4 Evaluate your statistics
5 Storycraft
Sustainability
Clinic revenuegt expenses= sustainability
Patient compliance Assets Clinic Mngt
Care team Operations Pt Support Billing
Of Prod on and type Patients on time
Daily weekly monthly quarterly
ldquoTrue Measures of Successrdquo
Adapted from HBR ldquoThe True Measures of Successrdquo httpshbrorg201210the-true-measures-of-success
29
Measuring Risk and Health
November is Diabetes Awareness Month- 2019Communication Plans are as
important as cold hard numbers
Patients
Care Team
Other Health Teams
Executive Team
Funders
Data on your dental patients are medical patients of record
Data on your medical + dental patients with DM2
30
Develop Diabetic Patient
Protocols
Review evidence and rationale with dental team
Partner with primary care team
bull Protocols Care mngt Tests and Recording
Quality Goals
Protocols for newly screened and existing patients
Educate and train dental team in reading AND
charting test results and PILOT
31
External Measurement in Oral Health Programs
httpswwwadaorg~mediaADADQA2019_DiabetesOralEvaluationpdfla=en
httpswwworegongovohaHPAANALYTICSCCOMetrics2019-Oral-Evaluation-Adults-Diabetespdf
32
Baseline for 2019 271
httpswwworegongovohaHPAANALYTICSCCOMetrics2019-Oral-Evaluation-Adults-Diabetespdf
33
Diabetes burden in your panel of dental patients
Baseline Medical-Dental Integrated panel of all patients
Dental patients with DM2 MDI
Dental patients with DM2
1000 or 10
600 or 60
300010000= 30
Population Health- Clinic Level
34
1 Governing objective
2 Theory of cause and effect
3 Activities of team
4 Evaluate your statistics
5 Storycraft
Discuss at meetings (Oct + Nov) Health education training
materials NP training CQI Note in Board report Clinical
measures
Care Pathways Hygiene Resources (ScheduleAvail)
ldquoTrue Measures of Successrdquo
Adapted from HBR ldquoThe True Measures of Successrdquo httpshbrorg201210the-true-measures-of-success
Diabetes Awareness Prevention Healthier Community
Prevention Awareness Care Pathway promotes health
MDI= 10 6 out of 10 adult patients with DM2
Goal set for integrated patient panels ndash PCMH
Pre-diabetes approach for executive team
Care Pathways
Care Coordination
35
MEASURING PATIENT ORAL HEALTHRisk assessments and Care Pathways
36
37
Risk Assessment and Care Pathways
Caries Risk Assessment
Multiple tools
EDREHR modules smart notes or dot phrases
CDT Codes
Decide frequency
D0601
Low Caries Risk
D0601
Moderate Caries Risk
D0601
High Caries Risk
38
The Disease Management DifferenceDisease Management Difference
Traditional Dental Care Disease Management
Approach
All patients return in 6 months
regardless of risk status
Recare interval is based on the
childrsquos caries risk
Caries Risk
Level
Recommended
Recare Interval
High Risk 1 ndash 3 months
Moderate Risk 3 ndash 6 months
Low Risk 6 ndash 12 months
Caries
Stabilizing
agents
Health Ed
Nutritional
Counseling
Anti-bacterial
and Fluoride
interventions
39
Disease Management Care Pathways
DentaQuest Partnership for Oral Health Advancement Disease Management Model
Caries
Stabilizing
agents
Whole
Person
Inter-
professional
Approaches
Anti-bacterial
and Fluoride
interventions
40
Disease Management and Risk Screening Training
DentaQuest Partnership for Oral Health Advancementrsquos
Online Learning Center
Disease Management Series
8 modules 40 CDE available
httpswwwdentaquestpartnershiporglearnonline-learning-centeronline-
coursewaredentaquest-disease-management-series
41
MEASUREMENT IN TEAMSSharing meaningful data with your dental clinical teams
42
rdquoDental Homerdquo = Health Home where WE can meet the patient
Oralhealthworkforceorg
43
POLL HOW OFTEN DO YOU SHARE YOUR S WITH YOUR DENTAL TEAM
A Yearly only
B Quarterly
C Monthly
D Weekly
E Daily
44
Clinical Measures ndash Dental Practice Perspective
Private Practice Office
New patients seen
Assigned vs seen if capitated
Treatment plans incomplete
$ produced amp per provider
$ collected amp monthly per provider
CDT 6000 codes completed
RecallHygiene maintenance
Based on this consultants experienced
FQHC
Unduplicated patients
patients seen per day
Treatment plans complete
$ gainedlost via accounting
Broken appointment rate
procedures
Sealant rate (annual)
45
bull HRSA Sealant Measure Compliance for FQHCs
bull Completion of phase 1 treatment plans
bull Children seen 0-5 years old
bull Children seen getting a preventive service
bull Fluoride Varnish applications
bull Pregnant women seen and treated
bull Diabetic patients with HbA1C gt 7 seen
bull Patients seen who have not been seen for 12 months
bull Patients seen getting a Risk Assessment
bull Patients with moderate or high risk who lower risk at recare
bull Sealants provided httpwwwnnohaorgnnoha-contentuploads201512Demystifying-HRSA-SEALANT-PRESENTATION_FINALpdf
Program Measures
46
HRSA Performance Measurement and Data Collection
bull FQHCs and look-alikes submit CY data to HRSA since 2008
bull UDS Uniform Data System
bull Require FTE for clinical staff patient demographics
bull Dental utilization s (UDCTPV)
bull Dental Clinical Measure dental sealants placed on 1st molars ages 6-9 yo
bull Health Center Quartile rankings (Clinical measure performance influences
HC rankings as does EHR adoption and other HC characteristics)
47
Low birth weight
Access to prenatal care
Childhood Immunization
Children (Ages 3-17) Receiving
Weight Assessment amp
Counseling
Children (Age 6-9) Receiving
Dental Sealant to First Molars
Diabetes Control
Hypertension Control
Pap Test
Depression Screening and
Follow-up (Age 12+)
Asthma Patients (Age 5-40)
Receiving Pharmacologic
Therapy
Colorectal Cancer
Screening (Ages 51-74)
HRSA UDS Clinical Measures
Adults (Age 18+) Receiving
Weight Screening amp Follow-up
Adults (Age 18+) Receiving
Tobacco Use Assessment and
Cessation Intervention
Coronary Artery Disease
Receiving Lipid Therapy (18+)
Ischemic Vascular Disease (IVD)
Receiving Aspirin Therapy (18+)
HIV Linkage to Care
48
Dashboards
Grants
Average
amp
Targets
Quality
Rev
Costs
Visits
Priority
Pop
Prevention
49
Dashboard- Provider Team Level
Patient
Compliance
Satisfaction
50
Case Study-
Incentives bonus round pools benchmark and improvement target goals risk-sharing possible later years
51
Qualitative Measurement
ldquoPatient engagement is the act of patients and providers working together
toward the end goal of improved patient wellnessrdquo
wwwpatientengagementhitcom
Access to Care
Patient Activation
Patient Satisfaction
Patient-Provider-Care Team Communication
Care Team Satisfaction
52
OHVBC Readiness
Leadership
bull Value of oral health and oral health transformation
Structure Systems and Operations
bull Operational efficiencies innovative care delivery methodologies
Care Pathways and Provider Buy-In
bull Training disease management risk-based care referrals IDC-10 coding patient engagement
Data and Analytic Technology and Personnel
bull Interoperability reporting
Financial Viability and Strength
bull Payerpatient mix billing infrastructure financial reports
httpswwwdentaquestpartnershiporglearnsafety-net-solutionsoral-health-value-based-careohvbc-readiness-
assessment
53
QUESTIONS COMMENTS
Carolyn Brown DDS
cbrownddsgmailcom
RISK BASED MANAGED CARE
Value Based Training Conference
Manchester New Hampshire
Mark Koday DDS
111919
5555
Objectives
bull Review current drivers of dental managed care
bull Understand the basics of risk-based dental managed care contracts
bull Learn the basics of managing costs in a riskndashbased contract
bull Gain an understanding in the potential advantage of risk-based contracting
56
What Is Dental Managed Care
Managed care is a health delivery system whose purpose is to manage both the
quality and cost of health care
Common types of managed care health insurance plans
bull HMOs
bull PPOs
bull POSs
bull Medicaid Managed Care
DIDNrsquoT WE ALREADY HAVE MANAGED CARE AND IT FAILED
57
What Has Happened Since the 90s
58
WHY THE FFS AND PPS DOESNrsquoT WORK FOR OUR POPULATIONS
bull Inefficient payment systems designed to produce encounters or procedures but not real health
bull No focus on population health
bull Does not incentivize innovation
bull Patients essentially on their own for accessing specialty care
59
Rule of 4
Source Kaiser Family Foundation analysis of National Health Expenditure (NHE) data from Centers for
Medicare and Medicaid Services Office of the Actuary National Health Statistics Group
60
Rule of 4
bull This helps explain why oral health has been relatively ignored so far by CMS
bull Explains why we have PCMH instead of PCHH
bull Where is the real value on a national level in preventing disease and
controlling costs
bull Beware- wersquove been found
61
Reasons Dental Managed Care is Spreading Across the States
NON-MANAGED CARE STATE DENTAL BUDGETS ARE
OPENED ENDED
STRAIN ON STATE BUDGETS
UPCOMING RECESSION WITH TRILLION DOLLAR
DEFICIT
SHIFTS FINANCIAL RISK FROM THE STATES TO THE
PLANS
6262
Types of Medicaid Managed Care
bull State Medicaid agency administrator lowest administrative
costs
bull Third Party Administrator Typically 15 administrative costs
bull Managed Care Organization Typically 15 administrative
costs
bull Carved-in
bull Carved-out
bull Risk Based Managed Care Administrative costs part of
contract negotiation
63
RISK CONTRACTS
6464
Components of a Risk-based Contract
Risk
Medical Loss Ratio
Quality withhold
Specialty withhold
Managed care payment (pmpm)
Covered services
Fee schedule Claims are paid as usual on a FFS basis
Credentialing
Quality Review process and Quality Metrics
65
Upside Risk
The possibility that the cost of
delivering dental care to an assigned
patient panel is less than the amount
of funding calculated for that care
The Plan pays the CHC additional
funds based on a predetermine
formula
Downside Risk
The possibility that the cost of
delivering dental care to an assigned
patient panel is more than the amount
of funding calculated for that care
The CHC pays the Plan additional
funds based on a predetermine
formula
Upside and Downside Risk
66
Taking On Risk 100 or Shared Risk
With 100 risk you receive 100 of the potential savings but are also at risk for
100 of the losses
Shared Risk MCO and health center share a percentage of the risk
Shared Risk leads to better cooperation since both organizations are
incentivized to save on costs
6767
Reports Needed
bull Enrollment reports lists of who is assigned on a monthly basis
bull Reconciliation reports insure appropriate payments
bull Specialty Referral reports
bull You will need your own reporting process so you donrsquot rely completely on
reports supplied by the Plan
6868
Medical Loss Ratio
Medical Loss Ratio (MLR) is proportion of premium revenues spent on clinical
services and quality improvement also known as the Medical Loss Ratio (MLR)
For CMS requires Medical Plans to spend at least 80 to 85 of the premiums
on actual medical care
69
Administrative Fees
bull Essentially the opposite of MLR
bull The State Medicaid Agency is funded by the Governorrsquos budget
bull The State Medicaid Agency will keep some of these funds for their
admin costs and give the remaining to the Managed Care Plans
bull Private Plan admin costs can be as high as 40 but most states
limit these cost for Medicaid Plans to between 15 and 20 (85-
80 MLR)
bull This may be negotiable depending on your program size of your
program
70
Quality Withhold
bull The state withholds a certain percent (typically 2-4 ) of the funds they give
to the Plans for Value Based Reimbursement
bull They choose quality metrics and set benchmarks and assign payments for
each metric based on an assigned priority for each metric
bull If a Plan meets the benchmark of every quality metric the state passes on
their full share of the quality withhold
bull The Plans may or may not withhold a percent of the funds for quality payment
to the dentists or manage care contractors
71
Quality Withhold
Either way the Plans may or may not pass the quality payments they receive to
the dentists or contractors
This should be spelled out in a risk-based contract
72
Percent of funds set aside
to cover specialty care
referrals
Typically 10-15
Goal Limit referral costs
to within or less than
Specialty set aside
Specialty Withhold
73
Per Member Per Month
bull Capitated Payment
bull Specific dollar amount paid for each enrolled member each month
bull Paid whether patient is accessed for care or not
bull States do set access benchmarks
bull In Oregon access for any dental procedure (adults and children combined)
was 267 in 2015
74
Payment Math Example
Premium per enrollee = $25
Administrative fee 15 = $375
Funds available per enrollee to the clinic = $2125
Management fee per enrollee = $175
Funds per enrollee that would undergo PPS reconciliation = $1950
For every 10000 enrollees the managed care income = $2340000
Specialty withhold (10) = $234000
YE Cost lt or gt $2340000
Upside Risk
CHC Gains $
Downside Risk
CHC Loses $
75
Covered Services and Fee Schedules
bull The state Medicaid agency spells out the minimum procedures and fees that
MCOs must cover
bull MCOs may add procedures or increase periodicity of procedures particularly
preventative services
bull MCOs may increase fees to entice rural providers and specialists to enroll in
their Plans
bull Access Rules
bull How many days it takes to access a patent
bull How many days it takes for a patent to access urgent care services
bull How many days it takes for a patent to access emergency care services
76
Credentialing
All MCOs are required to credential all Providers
All MCOs have their own credentialing process
Credentialing process is can be lengthy
Credentialing process may be negotiable
77
Quality Review Process and Quality Metrics
MCOs must have a Quality and Compliance Review Process
If you arenrsquot in compliance with both you likely wonrsquot get paid
Typical processes reviewed
bull Charting specifications
bull Incident report
bull Enrollee complaints quality rudeness and access issues
bull Medicaid compliance
78
Quality Payments
bull State Shared Incentive Withhold Typically quality metrics and benchmarks
are set by the state sets aside a certain percent (3-5) of the payments to
the Managed Care Plan (MCP)
bull If the benchmarks are achieved the MCP is then paid the a predetermine
amount
bull Benchmarks may not be the same as the states
bull Managed Care Plans do not have to pass all or any of the quality payments to
the health centers or providers
bull Managed Care contract- Metrics benchmarks should be selected and part of
the contract
7979
Achieving Quality Metric Payments
Dealing with under achievers
Process issues
Individual issues
Identifying workflows
Developing Best Practices through
PDSA process
Developing Best Practices through
PDSA process
CHC Metrics Committee
Clinicians Operations various key staff
Identify Best Practices
Spread Best Practices
80
New Team Needed Business Intelligence
Business Intelligence (BI) is critical for effective managed care business decisions
BI team inputs metrics into your EHR collects integrates analyses and displays all your managed care business and clinical information
Easy to say- hard to achieve
Build your own or outsource
Possible future role of Primary Care Associations
8181
Clinicianrsquos Dashboard
Expensive to build
Displayed on your screen when your computer is first turned on
Easy to read and understand
Data dumped from the day before
Can dialed down from Org-wide to clinic to each clinicianrsquos data
Operational and clinical metrics
bull Treatment Plan Completion
bull DQA quality measures
bull Caries at Recall
bull Re-care reports
bull Care Gap reports
82
CONTROLLING COSTS
8383
Controlling Costs- Current
bull Increasing efficiencies
bull Decreasing broken appointments
bull Controlling supplies equipment costs
bull Staff recruitment retention costs
84
Specialty Care
Training current CHC dentists in
specialty areas
Hiring general dentists with higher
specialty skill sets
Hiring in house specialists
Contract with outside specialists
Work with Managed Care Plan
specialists
Lowering Disease Rates
Community Dental Health
Coordinators case management
If your state law allows- embed
hygienists in medical and community
to provide primary and secondary
prevention procedures
In clinic Caries Classification and
Silver Diamine Fluoride
Effective recare programs
Controlling Costs- Additions in Risk-based Contracting
85
Specialty Care ndash Primary Referrals by Cost
Pediatric dentistry
Orthodontics
Oral surgery
Endodontics
86
In-clinic Pediatric Services
Encounters expected
of operatories available
State dental law and ability to have
expanded duties
General Anesthesia
GA in- house
Ability for a hospital or surgery center
to set aside regular OR time
Ability to hire or assign DAs to GA
days
Four GA cases day x PPS rate
Should You Hire a Pediatric Dentist- It Depends
8787
Solutions for Controlling Pediatric Costs
Hire a general dentist that is skilled in treating young children
Make the clinic child friendly nitrous oxide TVs in the operatory etc
Teach entire staff behavioral control techniques
Contract with a pediatric dentist for the GA care
88
Lowering Overall Disease Rates (and Costs)
You are responsible for both the patients you see in the chair and the ones
assigned to you
Breaking down the walls of the dental clinic
Community Dental Health Coordinators
Case Management
89
Cost Control Essentials
Diagnosis codes
Increased ability to identify
disease by risk
Motivational
Interviewing
Developing Polices and
Procedures design to treat
disease according to risk
ie Silver Diamine Fluoride
Treating by Risk
Effective Recare
Process
Critical to continual disease
controlPrevention education that is
meaningful and designed to
change behaviors
90
Social Determinants of Health Aunt Bertha
httpswwwauntberthacom
91
REASON TO CONSIDER RISK- BASED CONTRACTING
9292
PPS Reconciliation and Federal Code 42 CFR sect4052469(a)(2)
42 CFR sect4052469(a)(2)
ldquoAny financial incentives provided to Federally Qualified Health Centers
under their Medicare Advantage Contracts such as risk pool payments
bonuses or withholds are prohibited from being included in the
calculation of supplemental payments due to the Federally Qualified
Health Centerrdquo
9393
Why Risk Based Contract in Times of PPS Reconciliation
bull Not all Risk- based Contract funds are reconciled
bull Risk is the key word- you can come out with less money than your normal
PPS reconciliation payment
bull Can lead to better patient care
bull May improve manage care enrollment for your medical plan
bull Promotes integrated care increases health for your CHC patients
9494
Not Included in the Reconciliation
Enrollment management pmpm
Quality Payments
Upside risk payments
Downside risk losses
9595
Determinants of Financial Success in Risk-Based Contracting
bull Most critical- State pmpm payment to the Managed Care Plan
bull Reporting capabilities
bull Specialty service capabilities
bull Access numbers count
bull Ability to move metric numbers
9696
What About the Non- Medicaid Poor We Serve
bull Numbers are king in a managed care contract and the more access you have
the better contract terms you can negotiate
bull We will potentially have a steady supply of Medicaid patients
bull As managed care spreads states this may be compromising the ability of
health centers to serve the non-Medicaid poor and others lacking dental
insurance
97
Mark Koday DDS
(509) 949-2278
Dental Quality Consultants
of WA
httpdentalqualityconsultin
gcom
dentalqualityconsultantsg
mailcom
Contact Information
LUNCH
BREAKOUT EXERCISEORAL HEALTH VALUE-BASED CARE READINESS ASSESSMENT
Danielle Apostolon
PROMISING PRACTICES FROM THE FIELD STRATEGIES FOR INCREASING VALUE IN ORAL HEALTH
Dr Carolyn Brown
Dr Kelly Perry
Dr Rachel Rivard
Dr Adeloye
Commitment Compassion Community
m i d s t a t e h e a l t h o r g
Promising Practices from the
Field Strategies for Increasing
Value in Oral Health Care
Kelly Perry DMD
Better Health
Outcomes
Improved Staff
Experience
Reduced Cost
Improved Patient
Experience
Better Health
Outcomes
Improved Staff
Experience
Reduced Cost
Improved Patient
Experience
Better Health
Outcomes
Improved Staff
Experience
Reduced Cost
Improved Patient
Experience
Better Health
Outcomes
Improved Staff
Experience
Reduced Cost
Improved Patient
Experience
Commitment Compassion Community
kpe r r ymids t a tehea l t h o rg
Thank you
Completion of Disease Control Phase
Pelumi Adeloye DMD MPH
HEALTH ACCESS NETWORK (HAN) FAMILY DENTAL
Introduction
⧫1 Dentist I Hygienist 3 EFDArsquos1 Receptionist
⧫ 6 Chairs= 4 (dentist) + 2 (hygienist)
⧫ Slide ⥶80 off
⧫ Service areas Northern Penobscot Southern Aroostook Western
Washington Counties amp more
Completion of Phase I Treatment
⧫LimitedLack of Access to dental care
⧫Difficulty completing the disease control phase
Caries amp periodontal disease
⧫Attaining stable restorative state
Goal
Increase the completion of Disease Control Phase
Current practice
⧫Education
Assess level of dental literacy
Incremental strategy
⧫Increase access to dental care
Generous sliding scale (⥸$40 per visit)
Incorporate Expanded Function Dental Assistants
⧫Schedule modification
Incorporate more restorative blocks to allow
for follow-up visit and completion of restorative phase
httpswwwglasbergencomdentist-cartoons
Schedule
⧫Piggybacking technique
Increased allotted restorative blocks
⧫Sustainability of current schedule is
contingent on cooperation amp skills of HAN
Dental staff
Note
Strategies mentioned today is personalized to HAN Dental clinic
Current implemented strategies might be modified or changed in the
future as required in order to accommodate the need of our pts
THANK YOU
DAY TWOCLOSINGWRAP-UP
End of Day Two ndash Survey
Day Two Creating a Value-Based Oral Health Care Delivery
System
129
Payment Reform in Oral Health Online Learning Module
Oral Health Value-based Care Online Learning Module
Value-based Care Keys to Success Article
Readiness Assessment
Competency Development Guide
Oral Health Value-based Care Training
Dental Caries Management Practicum
Clinicians Companion Guide
Interprofessional Network Referral Process
Traditional Dental Care Vs Value-Based Care
Resources
131
wwwDentaQuestPartnershiporg
wwwfacebookcomDentaQuest
DentaQuest
wwwlinkedincomcompanyDentaQuest
Inside_DentaQuest
QUESTIONS
9
Evaluation survey must be completed to receive 10 CE credits
bull httpswwwsurveymonkeycomrVBCTraining1
bull httpswwwsurveymonkeycomrVBCTraining2
10
Agenda
Highlights from Day One
Group Discussion
Laying the Groundwork for Oral Health Value-Based Care Readiness
Lunch
Breakout Exercise Oral Health Value-Based Care Readiness
A Dental Directorrsquos Experience in Risk-Based Oral Health Managed Care
Promising Practices from the Field
ClosingWrap Up
11
12
bull Outline the key components to prepare for oral health value-based care
delivery system
bull Understand measurement and principles in healthcare transformation
Todayrsquos Learning Objectives ndash Day Two
LAYING THE GROUNDWORKCLINICAL OPERATIONS IN A VBR ENVIRONMENTCarolyn Brown DDS Consultant
November 19th 2019
14
INTRODUCTION
15
Todayrsquos Agenda
bull Discuss value-based health and pay-for-performance approaches to health
systems and the integral building block of data
bull Dive deep into the emerging field of value-based care measurement and
data in oral health from national and statewide perspectives
bull Present oral health and clinical measurement approaches and relate to
oversight
16
bull Consultant working with DQP FQHCs Primary Care Associations and Foundations advancing oral health programs
bull DQPSNS Expert Advisor
bull IHI Improvement Coach
bull Former Dental Director
bull Research Marketing Finance
Carolyn Brown DDS
Consultant Acting Director of Value-Based Care
DentaQuest Partnership for Oral Health Advancement
bull DDS University of Maryland School of Dentistry
bull MAEd University of the Pacific
bull BS University of Maryland
bull Speaker researcher expert advisor review panel
17
Poll What do you measure
A Dental provider productivity per day
B Treatment plan completion
C Dental new patient exams
D Combination of A-C
E No Shows
F Sealants only
18
Population
Prevention
Healthy
Minimally Invasive
Health outcomes
MDI
EHR EDR
PCC
Risk Assessment
19
VALUE-BASED CAREPushing the impact quality and quantity of measurement
20
OHVBC Readiness
Leadership
Value of oral health and oral health transformation
Structure Systems and Operations
Efficiencies innovative care delivery
Care Pathways and Provider Buy-In
Risk-based care Training patient engagement
Data and Analytic Technology and Personnel
DataReports Interoperability
Financial Viability and Strength
Payerpatient mix billing infrastructure
httpswwwdentaquestpartnershiporglearnsafety-net-solutionsoral-health-value-based-careohvbc-readiness-
assessment
21
DentaQuest Partnership OHVBC Survey
Barriers to Value-based Transformation in Oral Health ndash
Most Common Responses
bull Patient engagement
bull EHREDR
bull Tracking outcomes lack of nationally-recognized and standardized quality
metrics in dental
22
How Can FQHC Dental Programs Prepare for Value-based
Transformation in Oral Health
bull Begin or continue focusing on prevention disease management and risk-based care
bull Hygienists will be key to success ndash We need primary dental care not just surgical
interventions
bull Start measuring outcomes instead of just processutilization metrics bull of initially high-risk patients with new caries lesions
bull of initially high-risk patients with decreased risk status
bull of initially low-risk patients with risk status maintained
bull Address patient engagement in a more meaningful way and invest in case
management
bull Invest in interprofessional practice including HIT interoperability
bull Evaluate how services are being delivered and determine if its reaching the patients
who need care the most
23
Value-Based Care
Care Coordination
ldquoClosing outrdquo referrals
Diagnostic coding
Risk Screenings
Care plans based on risk
Patient Engagement
Incentive payments
Quality metrics
Clinic Response
Case Management IT
Active timely records mngt
Mapping Dx codes to CDT
Time bill CPT codes Tx plan
IPP data tofrom PC MH
Recall window important
Attention to $ related metrics
Attention to assigned metrics
Direct and Indirect Effects of VBC on Dental Systems of Care
Utilization Impact
New workforce CDT codes
New or + workforce IT
ICD-CM-10 codes
+CDT codes
Modifiers (CPT ICD10)
+ recall adherence
in incentivized procedures
in sealant POC A1C
Counseling codes SD
24
MEASUREMENT IN ORAL HEALTH
25
Poll What percentage of your adult dental patients are diabetic
or pre-diabetic
A 50-80
B 20-50
C Less than 20
D Not sure
26
27
ldquoTrue Measures of Successrdquo
1 Define your governing objective
2 Develop a theory of cause and effect to assess presumed drivers of the
objective
3 Identify the specific activities that employees can do to help achieve the
governing objective
4 Evaluate your statistics
5 Communicate the story of your measurement
Adapted from HBR ldquoThe True Measures of Successrdquo httpshbrorg201210the-true-measures-of-success
28
1 Governing objective
2 Theory of cause and effect
3 Activities of team
4 Evaluate your statistics
5 Storycraft
Sustainability
Clinic revenuegt expenses= sustainability
Patient compliance Assets Clinic Mngt
Care team Operations Pt Support Billing
Of Prod on and type Patients on time
Daily weekly monthly quarterly
ldquoTrue Measures of Successrdquo
Adapted from HBR ldquoThe True Measures of Successrdquo httpshbrorg201210the-true-measures-of-success
29
Measuring Risk and Health
November is Diabetes Awareness Month- 2019Communication Plans are as
important as cold hard numbers
Patients
Care Team
Other Health Teams
Executive Team
Funders
Data on your dental patients are medical patients of record
Data on your medical + dental patients with DM2
30
Develop Diabetic Patient
Protocols
Review evidence and rationale with dental team
Partner with primary care team
bull Protocols Care mngt Tests and Recording
Quality Goals
Protocols for newly screened and existing patients
Educate and train dental team in reading AND
charting test results and PILOT
31
External Measurement in Oral Health Programs
httpswwwadaorg~mediaADADQA2019_DiabetesOralEvaluationpdfla=en
httpswwworegongovohaHPAANALYTICSCCOMetrics2019-Oral-Evaluation-Adults-Diabetespdf
32
Baseline for 2019 271
httpswwworegongovohaHPAANALYTICSCCOMetrics2019-Oral-Evaluation-Adults-Diabetespdf
33
Diabetes burden in your panel of dental patients
Baseline Medical-Dental Integrated panel of all patients
Dental patients with DM2 MDI
Dental patients with DM2
1000 or 10
600 or 60
300010000= 30
Population Health- Clinic Level
34
1 Governing objective
2 Theory of cause and effect
3 Activities of team
4 Evaluate your statistics
5 Storycraft
Discuss at meetings (Oct + Nov) Health education training
materials NP training CQI Note in Board report Clinical
measures
Care Pathways Hygiene Resources (ScheduleAvail)
ldquoTrue Measures of Successrdquo
Adapted from HBR ldquoThe True Measures of Successrdquo httpshbrorg201210the-true-measures-of-success
Diabetes Awareness Prevention Healthier Community
Prevention Awareness Care Pathway promotes health
MDI= 10 6 out of 10 adult patients with DM2
Goal set for integrated patient panels ndash PCMH
Pre-diabetes approach for executive team
Care Pathways
Care Coordination
35
MEASURING PATIENT ORAL HEALTHRisk assessments and Care Pathways
36
37
Risk Assessment and Care Pathways
Caries Risk Assessment
Multiple tools
EDREHR modules smart notes or dot phrases
CDT Codes
Decide frequency
D0601
Low Caries Risk
D0601
Moderate Caries Risk
D0601
High Caries Risk
38
The Disease Management DifferenceDisease Management Difference
Traditional Dental Care Disease Management
Approach
All patients return in 6 months
regardless of risk status
Recare interval is based on the
childrsquos caries risk
Caries Risk
Level
Recommended
Recare Interval
High Risk 1 ndash 3 months
Moderate Risk 3 ndash 6 months
Low Risk 6 ndash 12 months
Caries
Stabilizing
agents
Health Ed
Nutritional
Counseling
Anti-bacterial
and Fluoride
interventions
39
Disease Management Care Pathways
DentaQuest Partnership for Oral Health Advancement Disease Management Model
Caries
Stabilizing
agents
Whole
Person
Inter-
professional
Approaches
Anti-bacterial
and Fluoride
interventions
40
Disease Management and Risk Screening Training
DentaQuest Partnership for Oral Health Advancementrsquos
Online Learning Center
Disease Management Series
8 modules 40 CDE available
httpswwwdentaquestpartnershiporglearnonline-learning-centeronline-
coursewaredentaquest-disease-management-series
41
MEASUREMENT IN TEAMSSharing meaningful data with your dental clinical teams
42
rdquoDental Homerdquo = Health Home where WE can meet the patient
Oralhealthworkforceorg
43
POLL HOW OFTEN DO YOU SHARE YOUR S WITH YOUR DENTAL TEAM
A Yearly only
B Quarterly
C Monthly
D Weekly
E Daily
44
Clinical Measures ndash Dental Practice Perspective
Private Practice Office
New patients seen
Assigned vs seen if capitated
Treatment plans incomplete
$ produced amp per provider
$ collected amp monthly per provider
CDT 6000 codes completed
RecallHygiene maintenance
Based on this consultants experienced
FQHC
Unduplicated patients
patients seen per day
Treatment plans complete
$ gainedlost via accounting
Broken appointment rate
procedures
Sealant rate (annual)
45
bull HRSA Sealant Measure Compliance for FQHCs
bull Completion of phase 1 treatment plans
bull Children seen 0-5 years old
bull Children seen getting a preventive service
bull Fluoride Varnish applications
bull Pregnant women seen and treated
bull Diabetic patients with HbA1C gt 7 seen
bull Patients seen who have not been seen for 12 months
bull Patients seen getting a Risk Assessment
bull Patients with moderate or high risk who lower risk at recare
bull Sealants provided httpwwwnnohaorgnnoha-contentuploads201512Demystifying-HRSA-SEALANT-PRESENTATION_FINALpdf
Program Measures
46
HRSA Performance Measurement and Data Collection
bull FQHCs and look-alikes submit CY data to HRSA since 2008
bull UDS Uniform Data System
bull Require FTE for clinical staff patient demographics
bull Dental utilization s (UDCTPV)
bull Dental Clinical Measure dental sealants placed on 1st molars ages 6-9 yo
bull Health Center Quartile rankings (Clinical measure performance influences
HC rankings as does EHR adoption and other HC characteristics)
47
Low birth weight
Access to prenatal care
Childhood Immunization
Children (Ages 3-17) Receiving
Weight Assessment amp
Counseling
Children (Age 6-9) Receiving
Dental Sealant to First Molars
Diabetes Control
Hypertension Control
Pap Test
Depression Screening and
Follow-up (Age 12+)
Asthma Patients (Age 5-40)
Receiving Pharmacologic
Therapy
Colorectal Cancer
Screening (Ages 51-74)
HRSA UDS Clinical Measures
Adults (Age 18+) Receiving
Weight Screening amp Follow-up
Adults (Age 18+) Receiving
Tobacco Use Assessment and
Cessation Intervention
Coronary Artery Disease
Receiving Lipid Therapy (18+)
Ischemic Vascular Disease (IVD)
Receiving Aspirin Therapy (18+)
HIV Linkage to Care
48
Dashboards
Grants
Average
amp
Targets
Quality
Rev
Costs
Visits
Priority
Pop
Prevention
49
Dashboard- Provider Team Level
Patient
Compliance
Satisfaction
50
Case Study-
Incentives bonus round pools benchmark and improvement target goals risk-sharing possible later years
51
Qualitative Measurement
ldquoPatient engagement is the act of patients and providers working together
toward the end goal of improved patient wellnessrdquo
wwwpatientengagementhitcom
Access to Care
Patient Activation
Patient Satisfaction
Patient-Provider-Care Team Communication
Care Team Satisfaction
52
OHVBC Readiness
Leadership
bull Value of oral health and oral health transformation
Structure Systems and Operations
bull Operational efficiencies innovative care delivery methodologies
Care Pathways and Provider Buy-In
bull Training disease management risk-based care referrals IDC-10 coding patient engagement
Data and Analytic Technology and Personnel
bull Interoperability reporting
Financial Viability and Strength
bull Payerpatient mix billing infrastructure financial reports
httpswwwdentaquestpartnershiporglearnsafety-net-solutionsoral-health-value-based-careohvbc-readiness-
assessment
53
QUESTIONS COMMENTS
Carolyn Brown DDS
cbrownddsgmailcom
RISK BASED MANAGED CARE
Value Based Training Conference
Manchester New Hampshire
Mark Koday DDS
111919
5555
Objectives
bull Review current drivers of dental managed care
bull Understand the basics of risk-based dental managed care contracts
bull Learn the basics of managing costs in a riskndashbased contract
bull Gain an understanding in the potential advantage of risk-based contracting
56
What Is Dental Managed Care
Managed care is a health delivery system whose purpose is to manage both the
quality and cost of health care
Common types of managed care health insurance plans
bull HMOs
bull PPOs
bull POSs
bull Medicaid Managed Care
DIDNrsquoT WE ALREADY HAVE MANAGED CARE AND IT FAILED
57
What Has Happened Since the 90s
58
WHY THE FFS AND PPS DOESNrsquoT WORK FOR OUR POPULATIONS
bull Inefficient payment systems designed to produce encounters or procedures but not real health
bull No focus on population health
bull Does not incentivize innovation
bull Patients essentially on their own for accessing specialty care
59
Rule of 4
Source Kaiser Family Foundation analysis of National Health Expenditure (NHE) data from Centers for
Medicare and Medicaid Services Office of the Actuary National Health Statistics Group
60
Rule of 4
bull This helps explain why oral health has been relatively ignored so far by CMS
bull Explains why we have PCMH instead of PCHH
bull Where is the real value on a national level in preventing disease and
controlling costs
bull Beware- wersquove been found
61
Reasons Dental Managed Care is Spreading Across the States
NON-MANAGED CARE STATE DENTAL BUDGETS ARE
OPENED ENDED
STRAIN ON STATE BUDGETS
UPCOMING RECESSION WITH TRILLION DOLLAR
DEFICIT
SHIFTS FINANCIAL RISK FROM THE STATES TO THE
PLANS
6262
Types of Medicaid Managed Care
bull State Medicaid agency administrator lowest administrative
costs
bull Third Party Administrator Typically 15 administrative costs
bull Managed Care Organization Typically 15 administrative
costs
bull Carved-in
bull Carved-out
bull Risk Based Managed Care Administrative costs part of
contract negotiation
63
RISK CONTRACTS
6464
Components of a Risk-based Contract
Risk
Medical Loss Ratio
Quality withhold
Specialty withhold
Managed care payment (pmpm)
Covered services
Fee schedule Claims are paid as usual on a FFS basis
Credentialing
Quality Review process and Quality Metrics
65
Upside Risk
The possibility that the cost of
delivering dental care to an assigned
patient panel is less than the amount
of funding calculated for that care
The Plan pays the CHC additional
funds based on a predetermine
formula
Downside Risk
The possibility that the cost of
delivering dental care to an assigned
patient panel is more than the amount
of funding calculated for that care
The CHC pays the Plan additional
funds based on a predetermine
formula
Upside and Downside Risk
66
Taking On Risk 100 or Shared Risk
With 100 risk you receive 100 of the potential savings but are also at risk for
100 of the losses
Shared Risk MCO and health center share a percentage of the risk
Shared Risk leads to better cooperation since both organizations are
incentivized to save on costs
6767
Reports Needed
bull Enrollment reports lists of who is assigned on a monthly basis
bull Reconciliation reports insure appropriate payments
bull Specialty Referral reports
bull You will need your own reporting process so you donrsquot rely completely on
reports supplied by the Plan
6868
Medical Loss Ratio
Medical Loss Ratio (MLR) is proportion of premium revenues spent on clinical
services and quality improvement also known as the Medical Loss Ratio (MLR)
For CMS requires Medical Plans to spend at least 80 to 85 of the premiums
on actual medical care
69
Administrative Fees
bull Essentially the opposite of MLR
bull The State Medicaid Agency is funded by the Governorrsquos budget
bull The State Medicaid Agency will keep some of these funds for their
admin costs and give the remaining to the Managed Care Plans
bull Private Plan admin costs can be as high as 40 but most states
limit these cost for Medicaid Plans to between 15 and 20 (85-
80 MLR)
bull This may be negotiable depending on your program size of your
program
70
Quality Withhold
bull The state withholds a certain percent (typically 2-4 ) of the funds they give
to the Plans for Value Based Reimbursement
bull They choose quality metrics and set benchmarks and assign payments for
each metric based on an assigned priority for each metric
bull If a Plan meets the benchmark of every quality metric the state passes on
their full share of the quality withhold
bull The Plans may or may not withhold a percent of the funds for quality payment
to the dentists or manage care contractors
71
Quality Withhold
Either way the Plans may or may not pass the quality payments they receive to
the dentists or contractors
This should be spelled out in a risk-based contract
72
Percent of funds set aside
to cover specialty care
referrals
Typically 10-15
Goal Limit referral costs
to within or less than
Specialty set aside
Specialty Withhold
73
Per Member Per Month
bull Capitated Payment
bull Specific dollar amount paid for each enrolled member each month
bull Paid whether patient is accessed for care or not
bull States do set access benchmarks
bull In Oregon access for any dental procedure (adults and children combined)
was 267 in 2015
74
Payment Math Example
Premium per enrollee = $25
Administrative fee 15 = $375
Funds available per enrollee to the clinic = $2125
Management fee per enrollee = $175
Funds per enrollee that would undergo PPS reconciliation = $1950
For every 10000 enrollees the managed care income = $2340000
Specialty withhold (10) = $234000
YE Cost lt or gt $2340000
Upside Risk
CHC Gains $
Downside Risk
CHC Loses $
75
Covered Services and Fee Schedules
bull The state Medicaid agency spells out the minimum procedures and fees that
MCOs must cover
bull MCOs may add procedures or increase periodicity of procedures particularly
preventative services
bull MCOs may increase fees to entice rural providers and specialists to enroll in
their Plans
bull Access Rules
bull How many days it takes to access a patent
bull How many days it takes for a patent to access urgent care services
bull How many days it takes for a patent to access emergency care services
76
Credentialing
All MCOs are required to credential all Providers
All MCOs have their own credentialing process
Credentialing process is can be lengthy
Credentialing process may be negotiable
77
Quality Review Process and Quality Metrics
MCOs must have a Quality and Compliance Review Process
If you arenrsquot in compliance with both you likely wonrsquot get paid
Typical processes reviewed
bull Charting specifications
bull Incident report
bull Enrollee complaints quality rudeness and access issues
bull Medicaid compliance
78
Quality Payments
bull State Shared Incentive Withhold Typically quality metrics and benchmarks
are set by the state sets aside a certain percent (3-5) of the payments to
the Managed Care Plan (MCP)
bull If the benchmarks are achieved the MCP is then paid the a predetermine
amount
bull Benchmarks may not be the same as the states
bull Managed Care Plans do not have to pass all or any of the quality payments to
the health centers or providers
bull Managed Care contract- Metrics benchmarks should be selected and part of
the contract
7979
Achieving Quality Metric Payments
Dealing with under achievers
Process issues
Individual issues
Identifying workflows
Developing Best Practices through
PDSA process
Developing Best Practices through
PDSA process
CHC Metrics Committee
Clinicians Operations various key staff
Identify Best Practices
Spread Best Practices
80
New Team Needed Business Intelligence
Business Intelligence (BI) is critical for effective managed care business decisions
BI team inputs metrics into your EHR collects integrates analyses and displays all your managed care business and clinical information
Easy to say- hard to achieve
Build your own or outsource
Possible future role of Primary Care Associations
8181
Clinicianrsquos Dashboard
Expensive to build
Displayed on your screen when your computer is first turned on
Easy to read and understand
Data dumped from the day before
Can dialed down from Org-wide to clinic to each clinicianrsquos data
Operational and clinical metrics
bull Treatment Plan Completion
bull DQA quality measures
bull Caries at Recall
bull Re-care reports
bull Care Gap reports
82
CONTROLLING COSTS
8383
Controlling Costs- Current
bull Increasing efficiencies
bull Decreasing broken appointments
bull Controlling supplies equipment costs
bull Staff recruitment retention costs
84
Specialty Care
Training current CHC dentists in
specialty areas
Hiring general dentists with higher
specialty skill sets
Hiring in house specialists
Contract with outside specialists
Work with Managed Care Plan
specialists
Lowering Disease Rates
Community Dental Health
Coordinators case management
If your state law allows- embed
hygienists in medical and community
to provide primary and secondary
prevention procedures
In clinic Caries Classification and
Silver Diamine Fluoride
Effective recare programs
Controlling Costs- Additions in Risk-based Contracting
85
Specialty Care ndash Primary Referrals by Cost
Pediatric dentistry
Orthodontics
Oral surgery
Endodontics
86
In-clinic Pediatric Services
Encounters expected
of operatories available
State dental law and ability to have
expanded duties
General Anesthesia
GA in- house
Ability for a hospital or surgery center
to set aside regular OR time
Ability to hire or assign DAs to GA
days
Four GA cases day x PPS rate
Should You Hire a Pediatric Dentist- It Depends
8787
Solutions for Controlling Pediatric Costs
Hire a general dentist that is skilled in treating young children
Make the clinic child friendly nitrous oxide TVs in the operatory etc
Teach entire staff behavioral control techniques
Contract with a pediatric dentist for the GA care
88
Lowering Overall Disease Rates (and Costs)
You are responsible for both the patients you see in the chair and the ones
assigned to you
Breaking down the walls of the dental clinic
Community Dental Health Coordinators
Case Management
89
Cost Control Essentials
Diagnosis codes
Increased ability to identify
disease by risk
Motivational
Interviewing
Developing Polices and
Procedures design to treat
disease according to risk
ie Silver Diamine Fluoride
Treating by Risk
Effective Recare
Process
Critical to continual disease
controlPrevention education that is
meaningful and designed to
change behaviors
90
Social Determinants of Health Aunt Bertha
httpswwwauntberthacom
91
REASON TO CONSIDER RISK- BASED CONTRACTING
9292
PPS Reconciliation and Federal Code 42 CFR sect4052469(a)(2)
42 CFR sect4052469(a)(2)
ldquoAny financial incentives provided to Federally Qualified Health Centers
under their Medicare Advantage Contracts such as risk pool payments
bonuses or withholds are prohibited from being included in the
calculation of supplemental payments due to the Federally Qualified
Health Centerrdquo
9393
Why Risk Based Contract in Times of PPS Reconciliation
bull Not all Risk- based Contract funds are reconciled
bull Risk is the key word- you can come out with less money than your normal
PPS reconciliation payment
bull Can lead to better patient care
bull May improve manage care enrollment for your medical plan
bull Promotes integrated care increases health for your CHC patients
9494
Not Included in the Reconciliation
Enrollment management pmpm
Quality Payments
Upside risk payments
Downside risk losses
9595
Determinants of Financial Success in Risk-Based Contracting
bull Most critical- State pmpm payment to the Managed Care Plan
bull Reporting capabilities
bull Specialty service capabilities
bull Access numbers count
bull Ability to move metric numbers
9696
What About the Non- Medicaid Poor We Serve
bull Numbers are king in a managed care contract and the more access you have
the better contract terms you can negotiate
bull We will potentially have a steady supply of Medicaid patients
bull As managed care spreads states this may be compromising the ability of
health centers to serve the non-Medicaid poor and others lacking dental
insurance
97
Mark Koday DDS
(509) 949-2278
Dental Quality Consultants
of WA
httpdentalqualityconsultin
gcom
dentalqualityconsultantsg
mailcom
Contact Information
LUNCH
BREAKOUT EXERCISEORAL HEALTH VALUE-BASED CARE READINESS ASSESSMENT
Danielle Apostolon
PROMISING PRACTICES FROM THE FIELD STRATEGIES FOR INCREASING VALUE IN ORAL HEALTH
Dr Carolyn Brown
Dr Kelly Perry
Dr Rachel Rivard
Dr Adeloye
Commitment Compassion Community
m i d s t a t e h e a l t h o r g
Promising Practices from the
Field Strategies for Increasing
Value in Oral Health Care
Kelly Perry DMD
Better Health
Outcomes
Improved Staff
Experience
Reduced Cost
Improved Patient
Experience
Better Health
Outcomes
Improved Staff
Experience
Reduced Cost
Improved Patient
Experience
Better Health
Outcomes
Improved Staff
Experience
Reduced Cost
Improved Patient
Experience
Better Health
Outcomes
Improved Staff
Experience
Reduced Cost
Improved Patient
Experience
Commitment Compassion Community
kpe r r ymids t a tehea l t h o rg
Thank you
Completion of Disease Control Phase
Pelumi Adeloye DMD MPH
HEALTH ACCESS NETWORK (HAN) FAMILY DENTAL
Introduction
⧫1 Dentist I Hygienist 3 EFDArsquos1 Receptionist
⧫ 6 Chairs= 4 (dentist) + 2 (hygienist)
⧫ Slide ⥶80 off
⧫ Service areas Northern Penobscot Southern Aroostook Western
Washington Counties amp more
Completion of Phase I Treatment
⧫LimitedLack of Access to dental care
⧫Difficulty completing the disease control phase
Caries amp periodontal disease
⧫Attaining stable restorative state
Goal
Increase the completion of Disease Control Phase
Current practice
⧫Education
Assess level of dental literacy
Incremental strategy
⧫Increase access to dental care
Generous sliding scale (⥸$40 per visit)
Incorporate Expanded Function Dental Assistants
⧫Schedule modification
Incorporate more restorative blocks to allow
for follow-up visit and completion of restorative phase
httpswwwglasbergencomdentist-cartoons
Schedule
⧫Piggybacking technique
Increased allotted restorative blocks
⧫Sustainability of current schedule is
contingent on cooperation amp skills of HAN
Dental staff
Note
Strategies mentioned today is personalized to HAN Dental clinic
Current implemented strategies might be modified or changed in the
future as required in order to accommodate the need of our pts
THANK YOU
DAY TWOCLOSINGWRAP-UP
End of Day Two ndash Survey
Day Two Creating a Value-Based Oral Health Care Delivery
System
129
Payment Reform in Oral Health Online Learning Module
Oral Health Value-based Care Online Learning Module
Value-based Care Keys to Success Article
Readiness Assessment
Competency Development Guide
Oral Health Value-based Care Training
Dental Caries Management Practicum
Clinicians Companion Guide
Interprofessional Network Referral Process
Traditional Dental Care Vs Value-Based Care
Resources
131
wwwDentaQuestPartnershiporg
wwwfacebookcomDentaQuest
DentaQuest
wwwlinkedincomcompanyDentaQuest
Inside_DentaQuest
QUESTIONS
10
Agenda
Highlights from Day One
Group Discussion
Laying the Groundwork for Oral Health Value-Based Care Readiness
Lunch
Breakout Exercise Oral Health Value-Based Care Readiness
A Dental Directorrsquos Experience in Risk-Based Oral Health Managed Care
Promising Practices from the Field
ClosingWrap Up
11
12
bull Outline the key components to prepare for oral health value-based care
delivery system
bull Understand measurement and principles in healthcare transformation
Todayrsquos Learning Objectives ndash Day Two
LAYING THE GROUNDWORKCLINICAL OPERATIONS IN A VBR ENVIRONMENTCarolyn Brown DDS Consultant
November 19th 2019
14
INTRODUCTION
15
Todayrsquos Agenda
bull Discuss value-based health and pay-for-performance approaches to health
systems and the integral building block of data
bull Dive deep into the emerging field of value-based care measurement and
data in oral health from national and statewide perspectives
bull Present oral health and clinical measurement approaches and relate to
oversight
16
bull Consultant working with DQP FQHCs Primary Care Associations and Foundations advancing oral health programs
bull DQPSNS Expert Advisor
bull IHI Improvement Coach
bull Former Dental Director
bull Research Marketing Finance
Carolyn Brown DDS
Consultant Acting Director of Value-Based Care
DentaQuest Partnership for Oral Health Advancement
bull DDS University of Maryland School of Dentistry
bull MAEd University of the Pacific
bull BS University of Maryland
bull Speaker researcher expert advisor review panel
17
Poll What do you measure
A Dental provider productivity per day
B Treatment plan completion
C Dental new patient exams
D Combination of A-C
E No Shows
F Sealants only
18
Population
Prevention
Healthy
Minimally Invasive
Health outcomes
MDI
EHR EDR
PCC
Risk Assessment
19
VALUE-BASED CAREPushing the impact quality and quantity of measurement
20
OHVBC Readiness
Leadership
Value of oral health and oral health transformation
Structure Systems and Operations
Efficiencies innovative care delivery
Care Pathways and Provider Buy-In
Risk-based care Training patient engagement
Data and Analytic Technology and Personnel
DataReports Interoperability
Financial Viability and Strength
Payerpatient mix billing infrastructure
httpswwwdentaquestpartnershiporglearnsafety-net-solutionsoral-health-value-based-careohvbc-readiness-
assessment
21
DentaQuest Partnership OHVBC Survey
Barriers to Value-based Transformation in Oral Health ndash
Most Common Responses
bull Patient engagement
bull EHREDR
bull Tracking outcomes lack of nationally-recognized and standardized quality
metrics in dental
22
How Can FQHC Dental Programs Prepare for Value-based
Transformation in Oral Health
bull Begin or continue focusing on prevention disease management and risk-based care
bull Hygienists will be key to success ndash We need primary dental care not just surgical
interventions
bull Start measuring outcomes instead of just processutilization metrics bull of initially high-risk patients with new caries lesions
bull of initially high-risk patients with decreased risk status
bull of initially low-risk patients with risk status maintained
bull Address patient engagement in a more meaningful way and invest in case
management
bull Invest in interprofessional practice including HIT interoperability
bull Evaluate how services are being delivered and determine if its reaching the patients
who need care the most
23
Value-Based Care
Care Coordination
ldquoClosing outrdquo referrals
Diagnostic coding
Risk Screenings
Care plans based on risk
Patient Engagement
Incentive payments
Quality metrics
Clinic Response
Case Management IT
Active timely records mngt
Mapping Dx codes to CDT
Time bill CPT codes Tx plan
IPP data tofrom PC MH
Recall window important
Attention to $ related metrics
Attention to assigned metrics
Direct and Indirect Effects of VBC on Dental Systems of Care
Utilization Impact
New workforce CDT codes
New or + workforce IT
ICD-CM-10 codes
+CDT codes
Modifiers (CPT ICD10)
+ recall adherence
in incentivized procedures
in sealant POC A1C
Counseling codes SD
24
MEASUREMENT IN ORAL HEALTH
25
Poll What percentage of your adult dental patients are diabetic
or pre-diabetic
A 50-80
B 20-50
C Less than 20
D Not sure
26
27
ldquoTrue Measures of Successrdquo
1 Define your governing objective
2 Develop a theory of cause and effect to assess presumed drivers of the
objective
3 Identify the specific activities that employees can do to help achieve the
governing objective
4 Evaluate your statistics
5 Communicate the story of your measurement
Adapted from HBR ldquoThe True Measures of Successrdquo httpshbrorg201210the-true-measures-of-success
28
1 Governing objective
2 Theory of cause and effect
3 Activities of team
4 Evaluate your statistics
5 Storycraft
Sustainability
Clinic revenuegt expenses= sustainability
Patient compliance Assets Clinic Mngt
Care team Operations Pt Support Billing
Of Prod on and type Patients on time
Daily weekly monthly quarterly
ldquoTrue Measures of Successrdquo
Adapted from HBR ldquoThe True Measures of Successrdquo httpshbrorg201210the-true-measures-of-success
29
Measuring Risk and Health
November is Diabetes Awareness Month- 2019Communication Plans are as
important as cold hard numbers
Patients
Care Team
Other Health Teams
Executive Team
Funders
Data on your dental patients are medical patients of record
Data on your medical + dental patients with DM2
30
Develop Diabetic Patient
Protocols
Review evidence and rationale with dental team
Partner with primary care team
bull Protocols Care mngt Tests and Recording
Quality Goals
Protocols for newly screened and existing patients
Educate and train dental team in reading AND
charting test results and PILOT
31
External Measurement in Oral Health Programs
httpswwwadaorg~mediaADADQA2019_DiabetesOralEvaluationpdfla=en
httpswwworegongovohaHPAANALYTICSCCOMetrics2019-Oral-Evaluation-Adults-Diabetespdf
32
Baseline for 2019 271
httpswwworegongovohaHPAANALYTICSCCOMetrics2019-Oral-Evaluation-Adults-Diabetespdf
33
Diabetes burden in your panel of dental patients
Baseline Medical-Dental Integrated panel of all patients
Dental patients with DM2 MDI
Dental patients with DM2
1000 or 10
600 or 60
300010000= 30
Population Health- Clinic Level
34
1 Governing objective
2 Theory of cause and effect
3 Activities of team
4 Evaluate your statistics
5 Storycraft
Discuss at meetings (Oct + Nov) Health education training
materials NP training CQI Note in Board report Clinical
measures
Care Pathways Hygiene Resources (ScheduleAvail)
ldquoTrue Measures of Successrdquo
Adapted from HBR ldquoThe True Measures of Successrdquo httpshbrorg201210the-true-measures-of-success
Diabetes Awareness Prevention Healthier Community
Prevention Awareness Care Pathway promotes health
MDI= 10 6 out of 10 adult patients with DM2
Goal set for integrated patient panels ndash PCMH
Pre-diabetes approach for executive team
Care Pathways
Care Coordination
35
MEASURING PATIENT ORAL HEALTHRisk assessments and Care Pathways
36
37
Risk Assessment and Care Pathways
Caries Risk Assessment
Multiple tools
EDREHR modules smart notes or dot phrases
CDT Codes
Decide frequency
D0601
Low Caries Risk
D0601
Moderate Caries Risk
D0601
High Caries Risk
38
The Disease Management DifferenceDisease Management Difference
Traditional Dental Care Disease Management
Approach
All patients return in 6 months
regardless of risk status
Recare interval is based on the
childrsquos caries risk
Caries Risk
Level
Recommended
Recare Interval
High Risk 1 ndash 3 months
Moderate Risk 3 ndash 6 months
Low Risk 6 ndash 12 months
Caries
Stabilizing
agents
Health Ed
Nutritional
Counseling
Anti-bacterial
and Fluoride
interventions
39
Disease Management Care Pathways
DentaQuest Partnership for Oral Health Advancement Disease Management Model
Caries
Stabilizing
agents
Whole
Person
Inter-
professional
Approaches
Anti-bacterial
and Fluoride
interventions
40
Disease Management and Risk Screening Training
DentaQuest Partnership for Oral Health Advancementrsquos
Online Learning Center
Disease Management Series
8 modules 40 CDE available
httpswwwdentaquestpartnershiporglearnonline-learning-centeronline-
coursewaredentaquest-disease-management-series
41
MEASUREMENT IN TEAMSSharing meaningful data with your dental clinical teams
42
rdquoDental Homerdquo = Health Home where WE can meet the patient
Oralhealthworkforceorg
43
POLL HOW OFTEN DO YOU SHARE YOUR S WITH YOUR DENTAL TEAM
A Yearly only
B Quarterly
C Monthly
D Weekly
E Daily
44
Clinical Measures ndash Dental Practice Perspective
Private Practice Office
New patients seen
Assigned vs seen if capitated
Treatment plans incomplete
$ produced amp per provider
$ collected amp monthly per provider
CDT 6000 codes completed
RecallHygiene maintenance
Based on this consultants experienced
FQHC
Unduplicated patients
patients seen per day
Treatment plans complete
$ gainedlost via accounting
Broken appointment rate
procedures
Sealant rate (annual)
45
bull HRSA Sealant Measure Compliance for FQHCs
bull Completion of phase 1 treatment plans
bull Children seen 0-5 years old
bull Children seen getting a preventive service
bull Fluoride Varnish applications
bull Pregnant women seen and treated
bull Diabetic patients with HbA1C gt 7 seen
bull Patients seen who have not been seen for 12 months
bull Patients seen getting a Risk Assessment
bull Patients with moderate or high risk who lower risk at recare
bull Sealants provided httpwwwnnohaorgnnoha-contentuploads201512Demystifying-HRSA-SEALANT-PRESENTATION_FINALpdf
Program Measures
46
HRSA Performance Measurement and Data Collection
bull FQHCs and look-alikes submit CY data to HRSA since 2008
bull UDS Uniform Data System
bull Require FTE for clinical staff patient demographics
bull Dental utilization s (UDCTPV)
bull Dental Clinical Measure dental sealants placed on 1st molars ages 6-9 yo
bull Health Center Quartile rankings (Clinical measure performance influences
HC rankings as does EHR adoption and other HC characteristics)
47
Low birth weight
Access to prenatal care
Childhood Immunization
Children (Ages 3-17) Receiving
Weight Assessment amp
Counseling
Children (Age 6-9) Receiving
Dental Sealant to First Molars
Diabetes Control
Hypertension Control
Pap Test
Depression Screening and
Follow-up (Age 12+)
Asthma Patients (Age 5-40)
Receiving Pharmacologic
Therapy
Colorectal Cancer
Screening (Ages 51-74)
HRSA UDS Clinical Measures
Adults (Age 18+) Receiving
Weight Screening amp Follow-up
Adults (Age 18+) Receiving
Tobacco Use Assessment and
Cessation Intervention
Coronary Artery Disease
Receiving Lipid Therapy (18+)
Ischemic Vascular Disease (IVD)
Receiving Aspirin Therapy (18+)
HIV Linkage to Care
48
Dashboards
Grants
Average
amp
Targets
Quality
Rev
Costs
Visits
Priority
Pop
Prevention
49
Dashboard- Provider Team Level
Patient
Compliance
Satisfaction
50
Case Study-
Incentives bonus round pools benchmark and improvement target goals risk-sharing possible later years
51
Qualitative Measurement
ldquoPatient engagement is the act of patients and providers working together
toward the end goal of improved patient wellnessrdquo
wwwpatientengagementhitcom
Access to Care
Patient Activation
Patient Satisfaction
Patient-Provider-Care Team Communication
Care Team Satisfaction
52
OHVBC Readiness
Leadership
bull Value of oral health and oral health transformation
Structure Systems and Operations
bull Operational efficiencies innovative care delivery methodologies
Care Pathways and Provider Buy-In
bull Training disease management risk-based care referrals IDC-10 coding patient engagement
Data and Analytic Technology and Personnel
bull Interoperability reporting
Financial Viability and Strength
bull Payerpatient mix billing infrastructure financial reports
httpswwwdentaquestpartnershiporglearnsafety-net-solutionsoral-health-value-based-careohvbc-readiness-
assessment
53
QUESTIONS COMMENTS
Carolyn Brown DDS
cbrownddsgmailcom
RISK BASED MANAGED CARE
Value Based Training Conference
Manchester New Hampshire
Mark Koday DDS
111919
5555
Objectives
bull Review current drivers of dental managed care
bull Understand the basics of risk-based dental managed care contracts
bull Learn the basics of managing costs in a riskndashbased contract
bull Gain an understanding in the potential advantage of risk-based contracting
56
What Is Dental Managed Care
Managed care is a health delivery system whose purpose is to manage both the
quality and cost of health care
Common types of managed care health insurance plans
bull HMOs
bull PPOs
bull POSs
bull Medicaid Managed Care
DIDNrsquoT WE ALREADY HAVE MANAGED CARE AND IT FAILED
57
What Has Happened Since the 90s
58
WHY THE FFS AND PPS DOESNrsquoT WORK FOR OUR POPULATIONS
bull Inefficient payment systems designed to produce encounters or procedures but not real health
bull No focus on population health
bull Does not incentivize innovation
bull Patients essentially on their own for accessing specialty care
59
Rule of 4
Source Kaiser Family Foundation analysis of National Health Expenditure (NHE) data from Centers for
Medicare and Medicaid Services Office of the Actuary National Health Statistics Group
60
Rule of 4
bull This helps explain why oral health has been relatively ignored so far by CMS
bull Explains why we have PCMH instead of PCHH
bull Where is the real value on a national level in preventing disease and
controlling costs
bull Beware- wersquove been found
61
Reasons Dental Managed Care is Spreading Across the States
NON-MANAGED CARE STATE DENTAL BUDGETS ARE
OPENED ENDED
STRAIN ON STATE BUDGETS
UPCOMING RECESSION WITH TRILLION DOLLAR
DEFICIT
SHIFTS FINANCIAL RISK FROM THE STATES TO THE
PLANS
6262
Types of Medicaid Managed Care
bull State Medicaid agency administrator lowest administrative
costs
bull Third Party Administrator Typically 15 administrative costs
bull Managed Care Organization Typically 15 administrative
costs
bull Carved-in
bull Carved-out
bull Risk Based Managed Care Administrative costs part of
contract negotiation
63
RISK CONTRACTS
6464
Components of a Risk-based Contract
Risk
Medical Loss Ratio
Quality withhold
Specialty withhold
Managed care payment (pmpm)
Covered services
Fee schedule Claims are paid as usual on a FFS basis
Credentialing
Quality Review process and Quality Metrics
65
Upside Risk
The possibility that the cost of
delivering dental care to an assigned
patient panel is less than the amount
of funding calculated for that care
The Plan pays the CHC additional
funds based on a predetermine
formula
Downside Risk
The possibility that the cost of
delivering dental care to an assigned
patient panel is more than the amount
of funding calculated for that care
The CHC pays the Plan additional
funds based on a predetermine
formula
Upside and Downside Risk
66
Taking On Risk 100 or Shared Risk
With 100 risk you receive 100 of the potential savings but are also at risk for
100 of the losses
Shared Risk MCO and health center share a percentage of the risk
Shared Risk leads to better cooperation since both organizations are
incentivized to save on costs
6767
Reports Needed
bull Enrollment reports lists of who is assigned on a monthly basis
bull Reconciliation reports insure appropriate payments
bull Specialty Referral reports
bull You will need your own reporting process so you donrsquot rely completely on
reports supplied by the Plan
6868
Medical Loss Ratio
Medical Loss Ratio (MLR) is proportion of premium revenues spent on clinical
services and quality improvement also known as the Medical Loss Ratio (MLR)
For CMS requires Medical Plans to spend at least 80 to 85 of the premiums
on actual medical care
69
Administrative Fees
bull Essentially the opposite of MLR
bull The State Medicaid Agency is funded by the Governorrsquos budget
bull The State Medicaid Agency will keep some of these funds for their
admin costs and give the remaining to the Managed Care Plans
bull Private Plan admin costs can be as high as 40 but most states
limit these cost for Medicaid Plans to between 15 and 20 (85-
80 MLR)
bull This may be negotiable depending on your program size of your
program
70
Quality Withhold
bull The state withholds a certain percent (typically 2-4 ) of the funds they give
to the Plans for Value Based Reimbursement
bull They choose quality metrics and set benchmarks and assign payments for
each metric based on an assigned priority for each metric
bull If a Plan meets the benchmark of every quality metric the state passes on
their full share of the quality withhold
bull The Plans may or may not withhold a percent of the funds for quality payment
to the dentists or manage care contractors
71
Quality Withhold
Either way the Plans may or may not pass the quality payments they receive to
the dentists or contractors
This should be spelled out in a risk-based contract
72
Percent of funds set aside
to cover specialty care
referrals
Typically 10-15
Goal Limit referral costs
to within or less than
Specialty set aside
Specialty Withhold
73
Per Member Per Month
bull Capitated Payment
bull Specific dollar amount paid for each enrolled member each month
bull Paid whether patient is accessed for care or not
bull States do set access benchmarks
bull In Oregon access for any dental procedure (adults and children combined)
was 267 in 2015
74
Payment Math Example
Premium per enrollee = $25
Administrative fee 15 = $375
Funds available per enrollee to the clinic = $2125
Management fee per enrollee = $175
Funds per enrollee that would undergo PPS reconciliation = $1950
For every 10000 enrollees the managed care income = $2340000
Specialty withhold (10) = $234000
YE Cost lt or gt $2340000
Upside Risk
CHC Gains $
Downside Risk
CHC Loses $
75
Covered Services and Fee Schedules
bull The state Medicaid agency spells out the minimum procedures and fees that
MCOs must cover
bull MCOs may add procedures or increase periodicity of procedures particularly
preventative services
bull MCOs may increase fees to entice rural providers and specialists to enroll in
their Plans
bull Access Rules
bull How many days it takes to access a patent
bull How many days it takes for a patent to access urgent care services
bull How many days it takes for a patent to access emergency care services
76
Credentialing
All MCOs are required to credential all Providers
All MCOs have their own credentialing process
Credentialing process is can be lengthy
Credentialing process may be negotiable
77
Quality Review Process and Quality Metrics
MCOs must have a Quality and Compliance Review Process
If you arenrsquot in compliance with both you likely wonrsquot get paid
Typical processes reviewed
bull Charting specifications
bull Incident report
bull Enrollee complaints quality rudeness and access issues
bull Medicaid compliance
78
Quality Payments
bull State Shared Incentive Withhold Typically quality metrics and benchmarks
are set by the state sets aside a certain percent (3-5) of the payments to
the Managed Care Plan (MCP)
bull If the benchmarks are achieved the MCP is then paid the a predetermine
amount
bull Benchmarks may not be the same as the states
bull Managed Care Plans do not have to pass all or any of the quality payments to
the health centers or providers
bull Managed Care contract- Metrics benchmarks should be selected and part of
the contract
7979
Achieving Quality Metric Payments
Dealing with under achievers
Process issues
Individual issues
Identifying workflows
Developing Best Practices through
PDSA process
Developing Best Practices through
PDSA process
CHC Metrics Committee
Clinicians Operations various key staff
Identify Best Practices
Spread Best Practices
80
New Team Needed Business Intelligence
Business Intelligence (BI) is critical for effective managed care business decisions
BI team inputs metrics into your EHR collects integrates analyses and displays all your managed care business and clinical information
Easy to say- hard to achieve
Build your own or outsource
Possible future role of Primary Care Associations
8181
Clinicianrsquos Dashboard
Expensive to build
Displayed on your screen when your computer is first turned on
Easy to read and understand
Data dumped from the day before
Can dialed down from Org-wide to clinic to each clinicianrsquos data
Operational and clinical metrics
bull Treatment Plan Completion
bull DQA quality measures
bull Caries at Recall
bull Re-care reports
bull Care Gap reports
82
CONTROLLING COSTS
8383
Controlling Costs- Current
bull Increasing efficiencies
bull Decreasing broken appointments
bull Controlling supplies equipment costs
bull Staff recruitment retention costs
84
Specialty Care
Training current CHC dentists in
specialty areas
Hiring general dentists with higher
specialty skill sets
Hiring in house specialists
Contract with outside specialists
Work with Managed Care Plan
specialists
Lowering Disease Rates
Community Dental Health
Coordinators case management
If your state law allows- embed
hygienists in medical and community
to provide primary and secondary
prevention procedures
In clinic Caries Classification and
Silver Diamine Fluoride
Effective recare programs
Controlling Costs- Additions in Risk-based Contracting
85
Specialty Care ndash Primary Referrals by Cost
Pediatric dentistry
Orthodontics
Oral surgery
Endodontics
86
In-clinic Pediatric Services
Encounters expected
of operatories available
State dental law and ability to have
expanded duties
General Anesthesia
GA in- house
Ability for a hospital or surgery center
to set aside regular OR time
Ability to hire or assign DAs to GA
days
Four GA cases day x PPS rate
Should You Hire a Pediatric Dentist- It Depends
8787
Solutions for Controlling Pediatric Costs
Hire a general dentist that is skilled in treating young children
Make the clinic child friendly nitrous oxide TVs in the operatory etc
Teach entire staff behavioral control techniques
Contract with a pediatric dentist for the GA care
88
Lowering Overall Disease Rates (and Costs)
You are responsible for both the patients you see in the chair and the ones
assigned to you
Breaking down the walls of the dental clinic
Community Dental Health Coordinators
Case Management
89
Cost Control Essentials
Diagnosis codes
Increased ability to identify
disease by risk
Motivational
Interviewing
Developing Polices and
Procedures design to treat
disease according to risk
ie Silver Diamine Fluoride
Treating by Risk
Effective Recare
Process
Critical to continual disease
controlPrevention education that is
meaningful and designed to
change behaviors
90
Social Determinants of Health Aunt Bertha
httpswwwauntberthacom
91
REASON TO CONSIDER RISK- BASED CONTRACTING
9292
PPS Reconciliation and Federal Code 42 CFR sect4052469(a)(2)
42 CFR sect4052469(a)(2)
ldquoAny financial incentives provided to Federally Qualified Health Centers
under their Medicare Advantage Contracts such as risk pool payments
bonuses or withholds are prohibited from being included in the
calculation of supplemental payments due to the Federally Qualified
Health Centerrdquo
9393
Why Risk Based Contract in Times of PPS Reconciliation
bull Not all Risk- based Contract funds are reconciled
bull Risk is the key word- you can come out with less money than your normal
PPS reconciliation payment
bull Can lead to better patient care
bull May improve manage care enrollment for your medical plan
bull Promotes integrated care increases health for your CHC patients
9494
Not Included in the Reconciliation
Enrollment management pmpm
Quality Payments
Upside risk payments
Downside risk losses
9595
Determinants of Financial Success in Risk-Based Contracting
bull Most critical- State pmpm payment to the Managed Care Plan
bull Reporting capabilities
bull Specialty service capabilities
bull Access numbers count
bull Ability to move metric numbers
9696
What About the Non- Medicaid Poor We Serve
bull Numbers are king in a managed care contract and the more access you have
the better contract terms you can negotiate
bull We will potentially have a steady supply of Medicaid patients
bull As managed care spreads states this may be compromising the ability of
health centers to serve the non-Medicaid poor and others lacking dental
insurance
97
Mark Koday DDS
(509) 949-2278
Dental Quality Consultants
of WA
httpdentalqualityconsultin
gcom
dentalqualityconsultantsg
mailcom
Contact Information
LUNCH
BREAKOUT EXERCISEORAL HEALTH VALUE-BASED CARE READINESS ASSESSMENT
Danielle Apostolon
PROMISING PRACTICES FROM THE FIELD STRATEGIES FOR INCREASING VALUE IN ORAL HEALTH
Dr Carolyn Brown
Dr Kelly Perry
Dr Rachel Rivard
Dr Adeloye
Commitment Compassion Community
m i d s t a t e h e a l t h o r g
Promising Practices from the
Field Strategies for Increasing
Value in Oral Health Care
Kelly Perry DMD
Better Health
Outcomes
Improved Staff
Experience
Reduced Cost
Improved Patient
Experience
Better Health
Outcomes
Improved Staff
Experience
Reduced Cost
Improved Patient
Experience
Better Health
Outcomes
Improved Staff
Experience
Reduced Cost
Improved Patient
Experience
Better Health
Outcomes
Improved Staff
Experience
Reduced Cost
Improved Patient
Experience
Commitment Compassion Community
kpe r r ymids t a tehea l t h o rg
Thank you
Completion of Disease Control Phase
Pelumi Adeloye DMD MPH
HEALTH ACCESS NETWORK (HAN) FAMILY DENTAL
Introduction
⧫1 Dentist I Hygienist 3 EFDArsquos1 Receptionist
⧫ 6 Chairs= 4 (dentist) + 2 (hygienist)
⧫ Slide ⥶80 off
⧫ Service areas Northern Penobscot Southern Aroostook Western
Washington Counties amp more
Completion of Phase I Treatment
⧫LimitedLack of Access to dental care
⧫Difficulty completing the disease control phase
Caries amp periodontal disease
⧫Attaining stable restorative state
Goal
Increase the completion of Disease Control Phase
Current practice
⧫Education
Assess level of dental literacy
Incremental strategy
⧫Increase access to dental care
Generous sliding scale (⥸$40 per visit)
Incorporate Expanded Function Dental Assistants
⧫Schedule modification
Incorporate more restorative blocks to allow
for follow-up visit and completion of restorative phase
httpswwwglasbergencomdentist-cartoons
Schedule
⧫Piggybacking technique
Increased allotted restorative blocks
⧫Sustainability of current schedule is
contingent on cooperation amp skills of HAN
Dental staff
Note
Strategies mentioned today is personalized to HAN Dental clinic
Current implemented strategies might be modified or changed in the
future as required in order to accommodate the need of our pts
THANK YOU
DAY TWOCLOSINGWRAP-UP
End of Day Two ndash Survey
Day Two Creating a Value-Based Oral Health Care Delivery
System
129
Payment Reform in Oral Health Online Learning Module
Oral Health Value-based Care Online Learning Module
Value-based Care Keys to Success Article
Readiness Assessment
Competency Development Guide
Oral Health Value-based Care Training
Dental Caries Management Practicum
Clinicians Companion Guide
Interprofessional Network Referral Process
Traditional Dental Care Vs Value-Based Care
Resources
131
wwwDentaQuestPartnershiporg
wwwfacebookcomDentaQuest
DentaQuest
wwwlinkedincomcompanyDentaQuest
Inside_DentaQuest
QUESTIONS
11
12
bull Outline the key components to prepare for oral health value-based care
delivery system
bull Understand measurement and principles in healthcare transformation
Todayrsquos Learning Objectives ndash Day Two
LAYING THE GROUNDWORKCLINICAL OPERATIONS IN A VBR ENVIRONMENTCarolyn Brown DDS Consultant
November 19th 2019
14
INTRODUCTION
15
Todayrsquos Agenda
bull Discuss value-based health and pay-for-performance approaches to health
systems and the integral building block of data
bull Dive deep into the emerging field of value-based care measurement and
data in oral health from national and statewide perspectives
bull Present oral health and clinical measurement approaches and relate to
oversight
16
bull Consultant working with DQP FQHCs Primary Care Associations and Foundations advancing oral health programs
bull DQPSNS Expert Advisor
bull IHI Improvement Coach
bull Former Dental Director
bull Research Marketing Finance
Carolyn Brown DDS
Consultant Acting Director of Value-Based Care
DentaQuest Partnership for Oral Health Advancement
bull DDS University of Maryland School of Dentistry
bull MAEd University of the Pacific
bull BS University of Maryland
bull Speaker researcher expert advisor review panel
17
Poll What do you measure
A Dental provider productivity per day
B Treatment plan completion
C Dental new patient exams
D Combination of A-C
E No Shows
F Sealants only
18
Population
Prevention
Healthy
Minimally Invasive
Health outcomes
MDI
EHR EDR
PCC
Risk Assessment
19
VALUE-BASED CAREPushing the impact quality and quantity of measurement
20
OHVBC Readiness
Leadership
Value of oral health and oral health transformation
Structure Systems and Operations
Efficiencies innovative care delivery
Care Pathways and Provider Buy-In
Risk-based care Training patient engagement
Data and Analytic Technology and Personnel
DataReports Interoperability
Financial Viability and Strength
Payerpatient mix billing infrastructure
httpswwwdentaquestpartnershiporglearnsafety-net-solutionsoral-health-value-based-careohvbc-readiness-
assessment
21
DentaQuest Partnership OHVBC Survey
Barriers to Value-based Transformation in Oral Health ndash
Most Common Responses
bull Patient engagement
bull EHREDR
bull Tracking outcomes lack of nationally-recognized and standardized quality
metrics in dental
22
How Can FQHC Dental Programs Prepare for Value-based
Transformation in Oral Health
bull Begin or continue focusing on prevention disease management and risk-based care
bull Hygienists will be key to success ndash We need primary dental care not just surgical
interventions
bull Start measuring outcomes instead of just processutilization metrics bull of initially high-risk patients with new caries lesions
bull of initially high-risk patients with decreased risk status
bull of initially low-risk patients with risk status maintained
bull Address patient engagement in a more meaningful way and invest in case
management
bull Invest in interprofessional practice including HIT interoperability
bull Evaluate how services are being delivered and determine if its reaching the patients
who need care the most
23
Value-Based Care
Care Coordination
ldquoClosing outrdquo referrals
Diagnostic coding
Risk Screenings
Care plans based on risk
Patient Engagement
Incentive payments
Quality metrics
Clinic Response
Case Management IT
Active timely records mngt
Mapping Dx codes to CDT
Time bill CPT codes Tx plan
IPP data tofrom PC MH
Recall window important
Attention to $ related metrics
Attention to assigned metrics
Direct and Indirect Effects of VBC on Dental Systems of Care
Utilization Impact
New workforce CDT codes
New or + workforce IT
ICD-CM-10 codes
+CDT codes
Modifiers (CPT ICD10)
+ recall adherence
in incentivized procedures
in sealant POC A1C
Counseling codes SD
24
MEASUREMENT IN ORAL HEALTH
25
Poll What percentage of your adult dental patients are diabetic
or pre-diabetic
A 50-80
B 20-50
C Less than 20
D Not sure
26
27
ldquoTrue Measures of Successrdquo
1 Define your governing objective
2 Develop a theory of cause and effect to assess presumed drivers of the
objective
3 Identify the specific activities that employees can do to help achieve the
governing objective
4 Evaluate your statistics
5 Communicate the story of your measurement
Adapted from HBR ldquoThe True Measures of Successrdquo httpshbrorg201210the-true-measures-of-success
28
1 Governing objective
2 Theory of cause and effect
3 Activities of team
4 Evaluate your statistics
5 Storycraft
Sustainability
Clinic revenuegt expenses= sustainability
Patient compliance Assets Clinic Mngt
Care team Operations Pt Support Billing
Of Prod on and type Patients on time
Daily weekly monthly quarterly
ldquoTrue Measures of Successrdquo
Adapted from HBR ldquoThe True Measures of Successrdquo httpshbrorg201210the-true-measures-of-success
29
Measuring Risk and Health
November is Diabetes Awareness Month- 2019Communication Plans are as
important as cold hard numbers
Patients
Care Team
Other Health Teams
Executive Team
Funders
Data on your dental patients are medical patients of record
Data on your medical + dental patients with DM2
30
Develop Diabetic Patient
Protocols
Review evidence and rationale with dental team
Partner with primary care team
bull Protocols Care mngt Tests and Recording
Quality Goals
Protocols for newly screened and existing patients
Educate and train dental team in reading AND
charting test results and PILOT
31
External Measurement in Oral Health Programs
httpswwwadaorg~mediaADADQA2019_DiabetesOralEvaluationpdfla=en
httpswwworegongovohaHPAANALYTICSCCOMetrics2019-Oral-Evaluation-Adults-Diabetespdf
32
Baseline for 2019 271
httpswwworegongovohaHPAANALYTICSCCOMetrics2019-Oral-Evaluation-Adults-Diabetespdf
33
Diabetes burden in your panel of dental patients
Baseline Medical-Dental Integrated panel of all patients
Dental patients with DM2 MDI
Dental patients with DM2
1000 or 10
600 or 60
300010000= 30
Population Health- Clinic Level
34
1 Governing objective
2 Theory of cause and effect
3 Activities of team
4 Evaluate your statistics
5 Storycraft
Discuss at meetings (Oct + Nov) Health education training
materials NP training CQI Note in Board report Clinical
measures
Care Pathways Hygiene Resources (ScheduleAvail)
ldquoTrue Measures of Successrdquo
Adapted from HBR ldquoThe True Measures of Successrdquo httpshbrorg201210the-true-measures-of-success
Diabetes Awareness Prevention Healthier Community
Prevention Awareness Care Pathway promotes health
MDI= 10 6 out of 10 adult patients with DM2
Goal set for integrated patient panels ndash PCMH
Pre-diabetes approach for executive team
Care Pathways
Care Coordination
35
MEASURING PATIENT ORAL HEALTHRisk assessments and Care Pathways
36
37
Risk Assessment and Care Pathways
Caries Risk Assessment
Multiple tools
EDREHR modules smart notes or dot phrases
CDT Codes
Decide frequency
D0601
Low Caries Risk
D0601
Moderate Caries Risk
D0601
High Caries Risk
38
The Disease Management DifferenceDisease Management Difference
Traditional Dental Care Disease Management
Approach
All patients return in 6 months
regardless of risk status
Recare interval is based on the
childrsquos caries risk
Caries Risk
Level
Recommended
Recare Interval
High Risk 1 ndash 3 months
Moderate Risk 3 ndash 6 months
Low Risk 6 ndash 12 months
Caries
Stabilizing
agents
Health Ed
Nutritional
Counseling
Anti-bacterial
and Fluoride
interventions
39
Disease Management Care Pathways
DentaQuest Partnership for Oral Health Advancement Disease Management Model
Caries
Stabilizing
agents
Whole
Person
Inter-
professional
Approaches
Anti-bacterial
and Fluoride
interventions
40
Disease Management and Risk Screening Training
DentaQuest Partnership for Oral Health Advancementrsquos
Online Learning Center
Disease Management Series
8 modules 40 CDE available
httpswwwdentaquestpartnershiporglearnonline-learning-centeronline-
coursewaredentaquest-disease-management-series
41
MEASUREMENT IN TEAMSSharing meaningful data with your dental clinical teams
42
rdquoDental Homerdquo = Health Home where WE can meet the patient
Oralhealthworkforceorg
43
POLL HOW OFTEN DO YOU SHARE YOUR S WITH YOUR DENTAL TEAM
A Yearly only
B Quarterly
C Monthly
D Weekly
E Daily
44
Clinical Measures ndash Dental Practice Perspective
Private Practice Office
New patients seen
Assigned vs seen if capitated
Treatment plans incomplete
$ produced amp per provider
$ collected amp monthly per provider
CDT 6000 codes completed
RecallHygiene maintenance
Based on this consultants experienced
FQHC
Unduplicated patients
patients seen per day
Treatment plans complete
$ gainedlost via accounting
Broken appointment rate
procedures
Sealant rate (annual)
45
bull HRSA Sealant Measure Compliance for FQHCs
bull Completion of phase 1 treatment plans
bull Children seen 0-5 years old
bull Children seen getting a preventive service
bull Fluoride Varnish applications
bull Pregnant women seen and treated
bull Diabetic patients with HbA1C gt 7 seen
bull Patients seen who have not been seen for 12 months
bull Patients seen getting a Risk Assessment
bull Patients with moderate or high risk who lower risk at recare
bull Sealants provided httpwwwnnohaorgnnoha-contentuploads201512Demystifying-HRSA-SEALANT-PRESENTATION_FINALpdf
Program Measures
46
HRSA Performance Measurement and Data Collection
bull FQHCs and look-alikes submit CY data to HRSA since 2008
bull UDS Uniform Data System
bull Require FTE for clinical staff patient demographics
bull Dental utilization s (UDCTPV)
bull Dental Clinical Measure dental sealants placed on 1st molars ages 6-9 yo
bull Health Center Quartile rankings (Clinical measure performance influences
HC rankings as does EHR adoption and other HC characteristics)
47
Low birth weight
Access to prenatal care
Childhood Immunization
Children (Ages 3-17) Receiving
Weight Assessment amp
Counseling
Children (Age 6-9) Receiving
Dental Sealant to First Molars
Diabetes Control
Hypertension Control
Pap Test
Depression Screening and
Follow-up (Age 12+)
Asthma Patients (Age 5-40)
Receiving Pharmacologic
Therapy
Colorectal Cancer
Screening (Ages 51-74)
HRSA UDS Clinical Measures
Adults (Age 18+) Receiving
Weight Screening amp Follow-up
Adults (Age 18+) Receiving
Tobacco Use Assessment and
Cessation Intervention
Coronary Artery Disease
Receiving Lipid Therapy (18+)
Ischemic Vascular Disease (IVD)
Receiving Aspirin Therapy (18+)
HIV Linkage to Care
48
Dashboards
Grants
Average
amp
Targets
Quality
Rev
Costs
Visits
Priority
Pop
Prevention
49
Dashboard- Provider Team Level
Patient
Compliance
Satisfaction
50
Case Study-
Incentives bonus round pools benchmark and improvement target goals risk-sharing possible later years
51
Qualitative Measurement
ldquoPatient engagement is the act of patients and providers working together
toward the end goal of improved patient wellnessrdquo
wwwpatientengagementhitcom
Access to Care
Patient Activation
Patient Satisfaction
Patient-Provider-Care Team Communication
Care Team Satisfaction
52
OHVBC Readiness
Leadership
bull Value of oral health and oral health transformation
Structure Systems and Operations
bull Operational efficiencies innovative care delivery methodologies
Care Pathways and Provider Buy-In
bull Training disease management risk-based care referrals IDC-10 coding patient engagement
Data and Analytic Technology and Personnel
bull Interoperability reporting
Financial Viability and Strength
bull Payerpatient mix billing infrastructure financial reports
httpswwwdentaquestpartnershiporglearnsafety-net-solutionsoral-health-value-based-careohvbc-readiness-
assessment
53
QUESTIONS COMMENTS
Carolyn Brown DDS
cbrownddsgmailcom
RISK BASED MANAGED CARE
Value Based Training Conference
Manchester New Hampshire
Mark Koday DDS
111919
5555
Objectives
bull Review current drivers of dental managed care
bull Understand the basics of risk-based dental managed care contracts
bull Learn the basics of managing costs in a riskndashbased contract
bull Gain an understanding in the potential advantage of risk-based contracting
56
What Is Dental Managed Care
Managed care is a health delivery system whose purpose is to manage both the
quality and cost of health care
Common types of managed care health insurance plans
bull HMOs
bull PPOs
bull POSs
bull Medicaid Managed Care
DIDNrsquoT WE ALREADY HAVE MANAGED CARE AND IT FAILED
57
What Has Happened Since the 90s
58
WHY THE FFS AND PPS DOESNrsquoT WORK FOR OUR POPULATIONS
bull Inefficient payment systems designed to produce encounters or procedures but not real health
bull No focus on population health
bull Does not incentivize innovation
bull Patients essentially on their own for accessing specialty care
59
Rule of 4
Source Kaiser Family Foundation analysis of National Health Expenditure (NHE) data from Centers for
Medicare and Medicaid Services Office of the Actuary National Health Statistics Group
60
Rule of 4
bull This helps explain why oral health has been relatively ignored so far by CMS
bull Explains why we have PCMH instead of PCHH
bull Where is the real value on a national level in preventing disease and
controlling costs
bull Beware- wersquove been found
61
Reasons Dental Managed Care is Spreading Across the States
NON-MANAGED CARE STATE DENTAL BUDGETS ARE
OPENED ENDED
STRAIN ON STATE BUDGETS
UPCOMING RECESSION WITH TRILLION DOLLAR
DEFICIT
SHIFTS FINANCIAL RISK FROM THE STATES TO THE
PLANS
6262
Types of Medicaid Managed Care
bull State Medicaid agency administrator lowest administrative
costs
bull Third Party Administrator Typically 15 administrative costs
bull Managed Care Organization Typically 15 administrative
costs
bull Carved-in
bull Carved-out
bull Risk Based Managed Care Administrative costs part of
contract negotiation
63
RISK CONTRACTS
6464
Components of a Risk-based Contract
Risk
Medical Loss Ratio
Quality withhold
Specialty withhold
Managed care payment (pmpm)
Covered services
Fee schedule Claims are paid as usual on a FFS basis
Credentialing
Quality Review process and Quality Metrics
65
Upside Risk
The possibility that the cost of
delivering dental care to an assigned
patient panel is less than the amount
of funding calculated for that care
The Plan pays the CHC additional
funds based on a predetermine
formula
Downside Risk
The possibility that the cost of
delivering dental care to an assigned
patient panel is more than the amount
of funding calculated for that care
The CHC pays the Plan additional
funds based on a predetermine
formula
Upside and Downside Risk
66
Taking On Risk 100 or Shared Risk
With 100 risk you receive 100 of the potential savings but are also at risk for
100 of the losses
Shared Risk MCO and health center share a percentage of the risk
Shared Risk leads to better cooperation since both organizations are
incentivized to save on costs
6767
Reports Needed
bull Enrollment reports lists of who is assigned on a monthly basis
bull Reconciliation reports insure appropriate payments
bull Specialty Referral reports
bull You will need your own reporting process so you donrsquot rely completely on
reports supplied by the Plan
6868
Medical Loss Ratio
Medical Loss Ratio (MLR) is proportion of premium revenues spent on clinical
services and quality improvement also known as the Medical Loss Ratio (MLR)
For CMS requires Medical Plans to spend at least 80 to 85 of the premiums
on actual medical care
69
Administrative Fees
bull Essentially the opposite of MLR
bull The State Medicaid Agency is funded by the Governorrsquos budget
bull The State Medicaid Agency will keep some of these funds for their
admin costs and give the remaining to the Managed Care Plans
bull Private Plan admin costs can be as high as 40 but most states
limit these cost for Medicaid Plans to between 15 and 20 (85-
80 MLR)
bull This may be negotiable depending on your program size of your
program
70
Quality Withhold
bull The state withholds a certain percent (typically 2-4 ) of the funds they give
to the Plans for Value Based Reimbursement
bull They choose quality metrics and set benchmarks and assign payments for
each metric based on an assigned priority for each metric
bull If a Plan meets the benchmark of every quality metric the state passes on
their full share of the quality withhold
bull The Plans may or may not withhold a percent of the funds for quality payment
to the dentists or manage care contractors
71
Quality Withhold
Either way the Plans may or may not pass the quality payments they receive to
the dentists or contractors
This should be spelled out in a risk-based contract
72
Percent of funds set aside
to cover specialty care
referrals
Typically 10-15
Goal Limit referral costs
to within or less than
Specialty set aside
Specialty Withhold
73
Per Member Per Month
bull Capitated Payment
bull Specific dollar amount paid for each enrolled member each month
bull Paid whether patient is accessed for care or not
bull States do set access benchmarks
bull In Oregon access for any dental procedure (adults and children combined)
was 267 in 2015
74
Payment Math Example
Premium per enrollee = $25
Administrative fee 15 = $375
Funds available per enrollee to the clinic = $2125
Management fee per enrollee = $175
Funds per enrollee that would undergo PPS reconciliation = $1950
For every 10000 enrollees the managed care income = $2340000
Specialty withhold (10) = $234000
YE Cost lt or gt $2340000
Upside Risk
CHC Gains $
Downside Risk
CHC Loses $
75
Covered Services and Fee Schedules
bull The state Medicaid agency spells out the minimum procedures and fees that
MCOs must cover
bull MCOs may add procedures or increase periodicity of procedures particularly
preventative services
bull MCOs may increase fees to entice rural providers and specialists to enroll in
their Plans
bull Access Rules
bull How many days it takes to access a patent
bull How many days it takes for a patent to access urgent care services
bull How many days it takes for a patent to access emergency care services
76
Credentialing
All MCOs are required to credential all Providers
All MCOs have their own credentialing process
Credentialing process is can be lengthy
Credentialing process may be negotiable
77
Quality Review Process and Quality Metrics
MCOs must have a Quality and Compliance Review Process
If you arenrsquot in compliance with both you likely wonrsquot get paid
Typical processes reviewed
bull Charting specifications
bull Incident report
bull Enrollee complaints quality rudeness and access issues
bull Medicaid compliance
78
Quality Payments
bull State Shared Incentive Withhold Typically quality metrics and benchmarks
are set by the state sets aside a certain percent (3-5) of the payments to
the Managed Care Plan (MCP)
bull If the benchmarks are achieved the MCP is then paid the a predetermine
amount
bull Benchmarks may not be the same as the states
bull Managed Care Plans do not have to pass all or any of the quality payments to
the health centers or providers
bull Managed Care contract- Metrics benchmarks should be selected and part of
the contract
7979
Achieving Quality Metric Payments
Dealing with under achievers
Process issues
Individual issues
Identifying workflows
Developing Best Practices through
PDSA process
Developing Best Practices through
PDSA process
CHC Metrics Committee
Clinicians Operations various key staff
Identify Best Practices
Spread Best Practices
80
New Team Needed Business Intelligence
Business Intelligence (BI) is critical for effective managed care business decisions
BI team inputs metrics into your EHR collects integrates analyses and displays all your managed care business and clinical information
Easy to say- hard to achieve
Build your own or outsource
Possible future role of Primary Care Associations
8181
Clinicianrsquos Dashboard
Expensive to build
Displayed on your screen when your computer is first turned on
Easy to read and understand
Data dumped from the day before
Can dialed down from Org-wide to clinic to each clinicianrsquos data
Operational and clinical metrics
bull Treatment Plan Completion
bull DQA quality measures
bull Caries at Recall
bull Re-care reports
bull Care Gap reports
82
CONTROLLING COSTS
8383
Controlling Costs- Current
bull Increasing efficiencies
bull Decreasing broken appointments
bull Controlling supplies equipment costs
bull Staff recruitment retention costs
84
Specialty Care
Training current CHC dentists in
specialty areas
Hiring general dentists with higher
specialty skill sets
Hiring in house specialists
Contract with outside specialists
Work with Managed Care Plan
specialists
Lowering Disease Rates
Community Dental Health
Coordinators case management
If your state law allows- embed
hygienists in medical and community
to provide primary and secondary
prevention procedures
In clinic Caries Classification and
Silver Diamine Fluoride
Effective recare programs
Controlling Costs- Additions in Risk-based Contracting
85
Specialty Care ndash Primary Referrals by Cost
Pediatric dentistry
Orthodontics
Oral surgery
Endodontics
86
In-clinic Pediatric Services
Encounters expected
of operatories available
State dental law and ability to have
expanded duties
General Anesthesia
GA in- house
Ability for a hospital or surgery center
to set aside regular OR time
Ability to hire or assign DAs to GA
days
Four GA cases day x PPS rate
Should You Hire a Pediatric Dentist- It Depends
8787
Solutions for Controlling Pediatric Costs
Hire a general dentist that is skilled in treating young children
Make the clinic child friendly nitrous oxide TVs in the operatory etc
Teach entire staff behavioral control techniques
Contract with a pediatric dentist for the GA care
88
Lowering Overall Disease Rates (and Costs)
You are responsible for both the patients you see in the chair and the ones
assigned to you
Breaking down the walls of the dental clinic
Community Dental Health Coordinators
Case Management
89
Cost Control Essentials
Diagnosis codes
Increased ability to identify
disease by risk
Motivational
Interviewing
Developing Polices and
Procedures design to treat
disease according to risk
ie Silver Diamine Fluoride
Treating by Risk
Effective Recare
Process
Critical to continual disease
controlPrevention education that is
meaningful and designed to
change behaviors
90
Social Determinants of Health Aunt Bertha
httpswwwauntberthacom
91
REASON TO CONSIDER RISK- BASED CONTRACTING
9292
PPS Reconciliation and Federal Code 42 CFR sect4052469(a)(2)
42 CFR sect4052469(a)(2)
ldquoAny financial incentives provided to Federally Qualified Health Centers
under their Medicare Advantage Contracts such as risk pool payments
bonuses or withholds are prohibited from being included in the
calculation of supplemental payments due to the Federally Qualified
Health Centerrdquo
9393
Why Risk Based Contract in Times of PPS Reconciliation
bull Not all Risk- based Contract funds are reconciled
bull Risk is the key word- you can come out with less money than your normal
PPS reconciliation payment
bull Can lead to better patient care
bull May improve manage care enrollment for your medical plan
bull Promotes integrated care increases health for your CHC patients
9494
Not Included in the Reconciliation
Enrollment management pmpm
Quality Payments
Upside risk payments
Downside risk losses
9595
Determinants of Financial Success in Risk-Based Contracting
bull Most critical- State pmpm payment to the Managed Care Plan
bull Reporting capabilities
bull Specialty service capabilities
bull Access numbers count
bull Ability to move metric numbers
9696
What About the Non- Medicaid Poor We Serve
bull Numbers are king in a managed care contract and the more access you have
the better contract terms you can negotiate
bull We will potentially have a steady supply of Medicaid patients
bull As managed care spreads states this may be compromising the ability of
health centers to serve the non-Medicaid poor and others lacking dental
insurance
97
Mark Koday DDS
(509) 949-2278
Dental Quality Consultants
of WA
httpdentalqualityconsultin
gcom
dentalqualityconsultantsg
mailcom
Contact Information
LUNCH
BREAKOUT EXERCISEORAL HEALTH VALUE-BASED CARE READINESS ASSESSMENT
Danielle Apostolon
PROMISING PRACTICES FROM THE FIELD STRATEGIES FOR INCREASING VALUE IN ORAL HEALTH
Dr Carolyn Brown
Dr Kelly Perry
Dr Rachel Rivard
Dr Adeloye
Commitment Compassion Community
m i d s t a t e h e a l t h o r g
Promising Practices from the
Field Strategies for Increasing
Value in Oral Health Care
Kelly Perry DMD
Better Health
Outcomes
Improved Staff
Experience
Reduced Cost
Improved Patient
Experience
Better Health
Outcomes
Improved Staff
Experience
Reduced Cost
Improved Patient
Experience
Better Health
Outcomes
Improved Staff
Experience
Reduced Cost
Improved Patient
Experience
Better Health
Outcomes
Improved Staff
Experience
Reduced Cost
Improved Patient
Experience
Commitment Compassion Community
kpe r r ymids t a tehea l t h o rg
Thank you
Completion of Disease Control Phase
Pelumi Adeloye DMD MPH
HEALTH ACCESS NETWORK (HAN) FAMILY DENTAL
Introduction
⧫1 Dentist I Hygienist 3 EFDArsquos1 Receptionist
⧫ 6 Chairs= 4 (dentist) + 2 (hygienist)
⧫ Slide ⥶80 off
⧫ Service areas Northern Penobscot Southern Aroostook Western
Washington Counties amp more
Completion of Phase I Treatment
⧫LimitedLack of Access to dental care
⧫Difficulty completing the disease control phase
Caries amp periodontal disease
⧫Attaining stable restorative state
Goal
Increase the completion of Disease Control Phase
Current practice
⧫Education
Assess level of dental literacy
Incremental strategy
⧫Increase access to dental care
Generous sliding scale (⥸$40 per visit)
Incorporate Expanded Function Dental Assistants
⧫Schedule modification
Incorporate more restorative blocks to allow
for follow-up visit and completion of restorative phase
httpswwwglasbergencomdentist-cartoons
Schedule
⧫Piggybacking technique
Increased allotted restorative blocks
⧫Sustainability of current schedule is
contingent on cooperation amp skills of HAN
Dental staff
Note
Strategies mentioned today is personalized to HAN Dental clinic
Current implemented strategies might be modified or changed in the
future as required in order to accommodate the need of our pts
THANK YOU
DAY TWOCLOSINGWRAP-UP
End of Day Two ndash Survey
Day Two Creating a Value-Based Oral Health Care Delivery
System
129
Payment Reform in Oral Health Online Learning Module
Oral Health Value-based Care Online Learning Module
Value-based Care Keys to Success Article
Readiness Assessment
Competency Development Guide
Oral Health Value-based Care Training
Dental Caries Management Practicum
Clinicians Companion Guide
Interprofessional Network Referral Process
Traditional Dental Care Vs Value-Based Care
Resources
131
wwwDentaQuestPartnershiporg
wwwfacebookcomDentaQuest
DentaQuest
wwwlinkedincomcompanyDentaQuest
Inside_DentaQuest
QUESTIONS
12
bull Outline the key components to prepare for oral health value-based care
delivery system
bull Understand measurement and principles in healthcare transformation
Todayrsquos Learning Objectives ndash Day Two
LAYING THE GROUNDWORKCLINICAL OPERATIONS IN A VBR ENVIRONMENTCarolyn Brown DDS Consultant
November 19th 2019
14
INTRODUCTION
15
Todayrsquos Agenda
bull Discuss value-based health and pay-for-performance approaches to health
systems and the integral building block of data
bull Dive deep into the emerging field of value-based care measurement and
data in oral health from national and statewide perspectives
bull Present oral health and clinical measurement approaches and relate to
oversight
16
bull Consultant working with DQP FQHCs Primary Care Associations and Foundations advancing oral health programs
bull DQPSNS Expert Advisor
bull IHI Improvement Coach
bull Former Dental Director
bull Research Marketing Finance
Carolyn Brown DDS
Consultant Acting Director of Value-Based Care
DentaQuest Partnership for Oral Health Advancement
bull DDS University of Maryland School of Dentistry
bull MAEd University of the Pacific
bull BS University of Maryland
bull Speaker researcher expert advisor review panel
17
Poll What do you measure
A Dental provider productivity per day
B Treatment plan completion
C Dental new patient exams
D Combination of A-C
E No Shows
F Sealants only
18
Population
Prevention
Healthy
Minimally Invasive
Health outcomes
MDI
EHR EDR
PCC
Risk Assessment
19
VALUE-BASED CAREPushing the impact quality and quantity of measurement
20
OHVBC Readiness
Leadership
Value of oral health and oral health transformation
Structure Systems and Operations
Efficiencies innovative care delivery
Care Pathways and Provider Buy-In
Risk-based care Training patient engagement
Data and Analytic Technology and Personnel
DataReports Interoperability
Financial Viability and Strength
Payerpatient mix billing infrastructure
httpswwwdentaquestpartnershiporglearnsafety-net-solutionsoral-health-value-based-careohvbc-readiness-
assessment
21
DentaQuest Partnership OHVBC Survey
Barriers to Value-based Transformation in Oral Health ndash
Most Common Responses
bull Patient engagement
bull EHREDR
bull Tracking outcomes lack of nationally-recognized and standardized quality
metrics in dental
22
How Can FQHC Dental Programs Prepare for Value-based
Transformation in Oral Health
bull Begin or continue focusing on prevention disease management and risk-based care
bull Hygienists will be key to success ndash We need primary dental care not just surgical
interventions
bull Start measuring outcomes instead of just processutilization metrics bull of initially high-risk patients with new caries lesions
bull of initially high-risk patients with decreased risk status
bull of initially low-risk patients with risk status maintained
bull Address patient engagement in a more meaningful way and invest in case
management
bull Invest in interprofessional practice including HIT interoperability
bull Evaluate how services are being delivered and determine if its reaching the patients
who need care the most
23
Value-Based Care
Care Coordination
ldquoClosing outrdquo referrals
Diagnostic coding
Risk Screenings
Care plans based on risk
Patient Engagement
Incentive payments
Quality metrics
Clinic Response
Case Management IT
Active timely records mngt
Mapping Dx codes to CDT
Time bill CPT codes Tx plan
IPP data tofrom PC MH
Recall window important
Attention to $ related metrics
Attention to assigned metrics
Direct and Indirect Effects of VBC on Dental Systems of Care
Utilization Impact
New workforce CDT codes
New or + workforce IT
ICD-CM-10 codes
+CDT codes
Modifiers (CPT ICD10)
+ recall adherence
in incentivized procedures
in sealant POC A1C
Counseling codes SD
24
MEASUREMENT IN ORAL HEALTH
25
Poll What percentage of your adult dental patients are diabetic
or pre-diabetic
A 50-80
B 20-50
C Less than 20
D Not sure
26
27
ldquoTrue Measures of Successrdquo
1 Define your governing objective
2 Develop a theory of cause and effect to assess presumed drivers of the
objective
3 Identify the specific activities that employees can do to help achieve the
governing objective
4 Evaluate your statistics
5 Communicate the story of your measurement
Adapted from HBR ldquoThe True Measures of Successrdquo httpshbrorg201210the-true-measures-of-success
28
1 Governing objective
2 Theory of cause and effect
3 Activities of team
4 Evaluate your statistics
5 Storycraft
Sustainability
Clinic revenuegt expenses= sustainability
Patient compliance Assets Clinic Mngt
Care team Operations Pt Support Billing
Of Prod on and type Patients on time
Daily weekly monthly quarterly
ldquoTrue Measures of Successrdquo
Adapted from HBR ldquoThe True Measures of Successrdquo httpshbrorg201210the-true-measures-of-success
29
Measuring Risk and Health
November is Diabetes Awareness Month- 2019Communication Plans are as
important as cold hard numbers
Patients
Care Team
Other Health Teams
Executive Team
Funders
Data on your dental patients are medical patients of record
Data on your medical + dental patients with DM2
30
Develop Diabetic Patient
Protocols
Review evidence and rationale with dental team
Partner with primary care team
bull Protocols Care mngt Tests and Recording
Quality Goals
Protocols for newly screened and existing patients
Educate and train dental team in reading AND
charting test results and PILOT
31
External Measurement in Oral Health Programs
httpswwwadaorg~mediaADADQA2019_DiabetesOralEvaluationpdfla=en
httpswwworegongovohaHPAANALYTICSCCOMetrics2019-Oral-Evaluation-Adults-Diabetespdf
32
Baseline for 2019 271
httpswwworegongovohaHPAANALYTICSCCOMetrics2019-Oral-Evaluation-Adults-Diabetespdf
33
Diabetes burden in your panel of dental patients
Baseline Medical-Dental Integrated panel of all patients
Dental patients with DM2 MDI
Dental patients with DM2
1000 or 10
600 or 60
300010000= 30
Population Health- Clinic Level
34
1 Governing objective
2 Theory of cause and effect
3 Activities of team
4 Evaluate your statistics
5 Storycraft
Discuss at meetings (Oct + Nov) Health education training
materials NP training CQI Note in Board report Clinical
measures
Care Pathways Hygiene Resources (ScheduleAvail)
ldquoTrue Measures of Successrdquo
Adapted from HBR ldquoThe True Measures of Successrdquo httpshbrorg201210the-true-measures-of-success
Diabetes Awareness Prevention Healthier Community
Prevention Awareness Care Pathway promotes health
MDI= 10 6 out of 10 adult patients with DM2
Goal set for integrated patient panels ndash PCMH
Pre-diabetes approach for executive team
Care Pathways
Care Coordination
35
MEASURING PATIENT ORAL HEALTHRisk assessments and Care Pathways
36
37
Risk Assessment and Care Pathways
Caries Risk Assessment
Multiple tools
EDREHR modules smart notes or dot phrases
CDT Codes
Decide frequency
D0601
Low Caries Risk
D0601
Moderate Caries Risk
D0601
High Caries Risk
38
The Disease Management DifferenceDisease Management Difference
Traditional Dental Care Disease Management
Approach
All patients return in 6 months
regardless of risk status
Recare interval is based on the
childrsquos caries risk
Caries Risk
Level
Recommended
Recare Interval
High Risk 1 ndash 3 months
Moderate Risk 3 ndash 6 months
Low Risk 6 ndash 12 months
Caries
Stabilizing
agents
Health Ed
Nutritional
Counseling
Anti-bacterial
and Fluoride
interventions
39
Disease Management Care Pathways
DentaQuest Partnership for Oral Health Advancement Disease Management Model
Caries
Stabilizing
agents
Whole
Person
Inter-
professional
Approaches
Anti-bacterial
and Fluoride
interventions
40
Disease Management and Risk Screening Training
DentaQuest Partnership for Oral Health Advancementrsquos
Online Learning Center
Disease Management Series
8 modules 40 CDE available
httpswwwdentaquestpartnershiporglearnonline-learning-centeronline-
coursewaredentaquest-disease-management-series
41
MEASUREMENT IN TEAMSSharing meaningful data with your dental clinical teams
42
rdquoDental Homerdquo = Health Home where WE can meet the patient
Oralhealthworkforceorg
43
POLL HOW OFTEN DO YOU SHARE YOUR S WITH YOUR DENTAL TEAM
A Yearly only
B Quarterly
C Monthly
D Weekly
E Daily
44
Clinical Measures ndash Dental Practice Perspective
Private Practice Office
New patients seen
Assigned vs seen if capitated
Treatment plans incomplete
$ produced amp per provider
$ collected amp monthly per provider
CDT 6000 codes completed
RecallHygiene maintenance
Based on this consultants experienced
FQHC
Unduplicated patients
patients seen per day
Treatment plans complete
$ gainedlost via accounting
Broken appointment rate
procedures
Sealant rate (annual)
45
bull HRSA Sealant Measure Compliance for FQHCs
bull Completion of phase 1 treatment plans
bull Children seen 0-5 years old
bull Children seen getting a preventive service
bull Fluoride Varnish applications
bull Pregnant women seen and treated
bull Diabetic patients with HbA1C gt 7 seen
bull Patients seen who have not been seen for 12 months
bull Patients seen getting a Risk Assessment
bull Patients with moderate or high risk who lower risk at recare
bull Sealants provided httpwwwnnohaorgnnoha-contentuploads201512Demystifying-HRSA-SEALANT-PRESENTATION_FINALpdf
Program Measures
46
HRSA Performance Measurement and Data Collection
bull FQHCs and look-alikes submit CY data to HRSA since 2008
bull UDS Uniform Data System
bull Require FTE for clinical staff patient demographics
bull Dental utilization s (UDCTPV)
bull Dental Clinical Measure dental sealants placed on 1st molars ages 6-9 yo
bull Health Center Quartile rankings (Clinical measure performance influences
HC rankings as does EHR adoption and other HC characteristics)
47
Low birth weight
Access to prenatal care
Childhood Immunization
Children (Ages 3-17) Receiving
Weight Assessment amp
Counseling
Children (Age 6-9) Receiving
Dental Sealant to First Molars
Diabetes Control
Hypertension Control
Pap Test
Depression Screening and
Follow-up (Age 12+)
Asthma Patients (Age 5-40)
Receiving Pharmacologic
Therapy
Colorectal Cancer
Screening (Ages 51-74)
HRSA UDS Clinical Measures
Adults (Age 18+) Receiving
Weight Screening amp Follow-up
Adults (Age 18+) Receiving
Tobacco Use Assessment and
Cessation Intervention
Coronary Artery Disease
Receiving Lipid Therapy (18+)
Ischemic Vascular Disease (IVD)
Receiving Aspirin Therapy (18+)
HIV Linkage to Care
48
Dashboards
Grants
Average
amp
Targets
Quality
Rev
Costs
Visits
Priority
Pop
Prevention
49
Dashboard- Provider Team Level
Patient
Compliance
Satisfaction
50
Case Study-
Incentives bonus round pools benchmark and improvement target goals risk-sharing possible later years
51
Qualitative Measurement
ldquoPatient engagement is the act of patients and providers working together
toward the end goal of improved patient wellnessrdquo
wwwpatientengagementhitcom
Access to Care
Patient Activation
Patient Satisfaction
Patient-Provider-Care Team Communication
Care Team Satisfaction
52
OHVBC Readiness
Leadership
bull Value of oral health and oral health transformation
Structure Systems and Operations
bull Operational efficiencies innovative care delivery methodologies
Care Pathways and Provider Buy-In
bull Training disease management risk-based care referrals IDC-10 coding patient engagement
Data and Analytic Technology and Personnel
bull Interoperability reporting
Financial Viability and Strength
bull Payerpatient mix billing infrastructure financial reports
httpswwwdentaquestpartnershiporglearnsafety-net-solutionsoral-health-value-based-careohvbc-readiness-
assessment
53
QUESTIONS COMMENTS
Carolyn Brown DDS
cbrownddsgmailcom
RISK BASED MANAGED CARE
Value Based Training Conference
Manchester New Hampshire
Mark Koday DDS
111919
5555
Objectives
bull Review current drivers of dental managed care
bull Understand the basics of risk-based dental managed care contracts
bull Learn the basics of managing costs in a riskndashbased contract
bull Gain an understanding in the potential advantage of risk-based contracting
56
What Is Dental Managed Care
Managed care is a health delivery system whose purpose is to manage both the
quality and cost of health care
Common types of managed care health insurance plans
bull HMOs
bull PPOs
bull POSs
bull Medicaid Managed Care
DIDNrsquoT WE ALREADY HAVE MANAGED CARE AND IT FAILED
57
What Has Happened Since the 90s
58
WHY THE FFS AND PPS DOESNrsquoT WORK FOR OUR POPULATIONS
bull Inefficient payment systems designed to produce encounters or procedures but not real health
bull No focus on population health
bull Does not incentivize innovation
bull Patients essentially on their own for accessing specialty care
59
Rule of 4
Source Kaiser Family Foundation analysis of National Health Expenditure (NHE) data from Centers for
Medicare and Medicaid Services Office of the Actuary National Health Statistics Group
60
Rule of 4
bull This helps explain why oral health has been relatively ignored so far by CMS
bull Explains why we have PCMH instead of PCHH
bull Where is the real value on a national level in preventing disease and
controlling costs
bull Beware- wersquove been found
61
Reasons Dental Managed Care is Spreading Across the States
NON-MANAGED CARE STATE DENTAL BUDGETS ARE
OPENED ENDED
STRAIN ON STATE BUDGETS
UPCOMING RECESSION WITH TRILLION DOLLAR
DEFICIT
SHIFTS FINANCIAL RISK FROM THE STATES TO THE
PLANS
6262
Types of Medicaid Managed Care
bull State Medicaid agency administrator lowest administrative
costs
bull Third Party Administrator Typically 15 administrative costs
bull Managed Care Organization Typically 15 administrative
costs
bull Carved-in
bull Carved-out
bull Risk Based Managed Care Administrative costs part of
contract negotiation
63
RISK CONTRACTS
6464
Components of a Risk-based Contract
Risk
Medical Loss Ratio
Quality withhold
Specialty withhold
Managed care payment (pmpm)
Covered services
Fee schedule Claims are paid as usual on a FFS basis
Credentialing
Quality Review process and Quality Metrics
65
Upside Risk
The possibility that the cost of
delivering dental care to an assigned
patient panel is less than the amount
of funding calculated for that care
The Plan pays the CHC additional
funds based on a predetermine
formula
Downside Risk
The possibility that the cost of
delivering dental care to an assigned
patient panel is more than the amount
of funding calculated for that care
The CHC pays the Plan additional
funds based on a predetermine
formula
Upside and Downside Risk
66
Taking On Risk 100 or Shared Risk
With 100 risk you receive 100 of the potential savings but are also at risk for
100 of the losses
Shared Risk MCO and health center share a percentage of the risk
Shared Risk leads to better cooperation since both organizations are
incentivized to save on costs
6767
Reports Needed
bull Enrollment reports lists of who is assigned on a monthly basis
bull Reconciliation reports insure appropriate payments
bull Specialty Referral reports
bull You will need your own reporting process so you donrsquot rely completely on
reports supplied by the Plan
6868
Medical Loss Ratio
Medical Loss Ratio (MLR) is proportion of premium revenues spent on clinical
services and quality improvement also known as the Medical Loss Ratio (MLR)
For CMS requires Medical Plans to spend at least 80 to 85 of the premiums
on actual medical care
69
Administrative Fees
bull Essentially the opposite of MLR
bull The State Medicaid Agency is funded by the Governorrsquos budget
bull The State Medicaid Agency will keep some of these funds for their
admin costs and give the remaining to the Managed Care Plans
bull Private Plan admin costs can be as high as 40 but most states
limit these cost for Medicaid Plans to between 15 and 20 (85-
80 MLR)
bull This may be negotiable depending on your program size of your
program
70
Quality Withhold
bull The state withholds a certain percent (typically 2-4 ) of the funds they give
to the Plans for Value Based Reimbursement
bull They choose quality metrics and set benchmarks and assign payments for
each metric based on an assigned priority for each metric
bull If a Plan meets the benchmark of every quality metric the state passes on
their full share of the quality withhold
bull The Plans may or may not withhold a percent of the funds for quality payment
to the dentists or manage care contractors
71
Quality Withhold
Either way the Plans may or may not pass the quality payments they receive to
the dentists or contractors
This should be spelled out in a risk-based contract
72
Percent of funds set aside
to cover specialty care
referrals
Typically 10-15
Goal Limit referral costs
to within or less than
Specialty set aside
Specialty Withhold
73
Per Member Per Month
bull Capitated Payment
bull Specific dollar amount paid for each enrolled member each month
bull Paid whether patient is accessed for care or not
bull States do set access benchmarks
bull In Oregon access for any dental procedure (adults and children combined)
was 267 in 2015
74
Payment Math Example
Premium per enrollee = $25
Administrative fee 15 = $375
Funds available per enrollee to the clinic = $2125
Management fee per enrollee = $175
Funds per enrollee that would undergo PPS reconciliation = $1950
For every 10000 enrollees the managed care income = $2340000
Specialty withhold (10) = $234000
YE Cost lt or gt $2340000
Upside Risk
CHC Gains $
Downside Risk
CHC Loses $
75
Covered Services and Fee Schedules
bull The state Medicaid agency spells out the minimum procedures and fees that
MCOs must cover
bull MCOs may add procedures or increase periodicity of procedures particularly
preventative services
bull MCOs may increase fees to entice rural providers and specialists to enroll in
their Plans
bull Access Rules
bull How many days it takes to access a patent
bull How many days it takes for a patent to access urgent care services
bull How many days it takes for a patent to access emergency care services
76
Credentialing
All MCOs are required to credential all Providers
All MCOs have their own credentialing process
Credentialing process is can be lengthy
Credentialing process may be negotiable
77
Quality Review Process and Quality Metrics
MCOs must have a Quality and Compliance Review Process
If you arenrsquot in compliance with both you likely wonrsquot get paid
Typical processes reviewed
bull Charting specifications
bull Incident report
bull Enrollee complaints quality rudeness and access issues
bull Medicaid compliance
78
Quality Payments
bull State Shared Incentive Withhold Typically quality metrics and benchmarks
are set by the state sets aside a certain percent (3-5) of the payments to
the Managed Care Plan (MCP)
bull If the benchmarks are achieved the MCP is then paid the a predetermine
amount
bull Benchmarks may not be the same as the states
bull Managed Care Plans do not have to pass all or any of the quality payments to
the health centers or providers
bull Managed Care contract- Metrics benchmarks should be selected and part of
the contract
7979
Achieving Quality Metric Payments
Dealing with under achievers
Process issues
Individual issues
Identifying workflows
Developing Best Practices through
PDSA process
Developing Best Practices through
PDSA process
CHC Metrics Committee
Clinicians Operations various key staff
Identify Best Practices
Spread Best Practices
80
New Team Needed Business Intelligence
Business Intelligence (BI) is critical for effective managed care business decisions
BI team inputs metrics into your EHR collects integrates analyses and displays all your managed care business and clinical information
Easy to say- hard to achieve
Build your own or outsource
Possible future role of Primary Care Associations
8181
Clinicianrsquos Dashboard
Expensive to build
Displayed on your screen when your computer is first turned on
Easy to read and understand
Data dumped from the day before
Can dialed down from Org-wide to clinic to each clinicianrsquos data
Operational and clinical metrics
bull Treatment Plan Completion
bull DQA quality measures
bull Caries at Recall
bull Re-care reports
bull Care Gap reports
82
CONTROLLING COSTS
8383
Controlling Costs- Current
bull Increasing efficiencies
bull Decreasing broken appointments
bull Controlling supplies equipment costs
bull Staff recruitment retention costs
84
Specialty Care
Training current CHC dentists in
specialty areas
Hiring general dentists with higher
specialty skill sets
Hiring in house specialists
Contract with outside specialists
Work with Managed Care Plan
specialists
Lowering Disease Rates
Community Dental Health
Coordinators case management
If your state law allows- embed
hygienists in medical and community
to provide primary and secondary
prevention procedures
In clinic Caries Classification and
Silver Diamine Fluoride
Effective recare programs
Controlling Costs- Additions in Risk-based Contracting
85
Specialty Care ndash Primary Referrals by Cost
Pediatric dentistry
Orthodontics
Oral surgery
Endodontics
86
In-clinic Pediatric Services
Encounters expected
of operatories available
State dental law and ability to have
expanded duties
General Anesthesia
GA in- house
Ability for a hospital or surgery center
to set aside regular OR time
Ability to hire or assign DAs to GA
days
Four GA cases day x PPS rate
Should You Hire a Pediatric Dentist- It Depends
8787
Solutions for Controlling Pediatric Costs
Hire a general dentist that is skilled in treating young children
Make the clinic child friendly nitrous oxide TVs in the operatory etc
Teach entire staff behavioral control techniques
Contract with a pediatric dentist for the GA care
88
Lowering Overall Disease Rates (and Costs)
You are responsible for both the patients you see in the chair and the ones
assigned to you
Breaking down the walls of the dental clinic
Community Dental Health Coordinators
Case Management
89
Cost Control Essentials
Diagnosis codes
Increased ability to identify
disease by risk
Motivational
Interviewing
Developing Polices and
Procedures design to treat
disease according to risk
ie Silver Diamine Fluoride
Treating by Risk
Effective Recare
Process
Critical to continual disease
controlPrevention education that is
meaningful and designed to
change behaviors
90
Social Determinants of Health Aunt Bertha
httpswwwauntberthacom
91
REASON TO CONSIDER RISK- BASED CONTRACTING
9292
PPS Reconciliation and Federal Code 42 CFR sect4052469(a)(2)
42 CFR sect4052469(a)(2)
ldquoAny financial incentives provided to Federally Qualified Health Centers
under their Medicare Advantage Contracts such as risk pool payments
bonuses or withholds are prohibited from being included in the
calculation of supplemental payments due to the Federally Qualified
Health Centerrdquo
9393
Why Risk Based Contract in Times of PPS Reconciliation
bull Not all Risk- based Contract funds are reconciled
bull Risk is the key word- you can come out with less money than your normal
PPS reconciliation payment
bull Can lead to better patient care
bull May improve manage care enrollment for your medical plan
bull Promotes integrated care increases health for your CHC patients
9494
Not Included in the Reconciliation
Enrollment management pmpm
Quality Payments
Upside risk payments
Downside risk losses
9595
Determinants of Financial Success in Risk-Based Contracting
bull Most critical- State pmpm payment to the Managed Care Plan
bull Reporting capabilities
bull Specialty service capabilities
bull Access numbers count
bull Ability to move metric numbers
9696
What About the Non- Medicaid Poor We Serve
bull Numbers are king in a managed care contract and the more access you have
the better contract terms you can negotiate
bull We will potentially have a steady supply of Medicaid patients
bull As managed care spreads states this may be compromising the ability of
health centers to serve the non-Medicaid poor and others lacking dental
insurance
97
Mark Koday DDS
(509) 949-2278
Dental Quality Consultants
of WA
httpdentalqualityconsultin
gcom
dentalqualityconsultantsg
mailcom
Contact Information
LUNCH
BREAKOUT EXERCISEORAL HEALTH VALUE-BASED CARE READINESS ASSESSMENT
Danielle Apostolon
PROMISING PRACTICES FROM THE FIELD STRATEGIES FOR INCREASING VALUE IN ORAL HEALTH
Dr Carolyn Brown
Dr Kelly Perry
Dr Rachel Rivard
Dr Adeloye
Commitment Compassion Community
m i d s t a t e h e a l t h o r g
Promising Practices from the
Field Strategies for Increasing
Value in Oral Health Care
Kelly Perry DMD
Better Health
Outcomes
Improved Staff
Experience
Reduced Cost
Improved Patient
Experience
Better Health
Outcomes
Improved Staff
Experience
Reduced Cost
Improved Patient
Experience
Better Health
Outcomes
Improved Staff
Experience
Reduced Cost
Improved Patient
Experience
Better Health
Outcomes
Improved Staff
Experience
Reduced Cost
Improved Patient
Experience
Commitment Compassion Community
kpe r r ymids t a tehea l t h o rg
Thank you
Completion of Disease Control Phase
Pelumi Adeloye DMD MPH
HEALTH ACCESS NETWORK (HAN) FAMILY DENTAL
Introduction
⧫1 Dentist I Hygienist 3 EFDArsquos1 Receptionist
⧫ 6 Chairs= 4 (dentist) + 2 (hygienist)
⧫ Slide ⥶80 off
⧫ Service areas Northern Penobscot Southern Aroostook Western
Washington Counties amp more
Completion of Phase I Treatment
⧫LimitedLack of Access to dental care
⧫Difficulty completing the disease control phase
Caries amp periodontal disease
⧫Attaining stable restorative state
Goal
Increase the completion of Disease Control Phase
Current practice
⧫Education
Assess level of dental literacy
Incremental strategy
⧫Increase access to dental care
Generous sliding scale (⥸$40 per visit)
Incorporate Expanded Function Dental Assistants
⧫Schedule modification
Incorporate more restorative blocks to allow
for follow-up visit and completion of restorative phase
httpswwwglasbergencomdentist-cartoons
Schedule
⧫Piggybacking technique
Increased allotted restorative blocks
⧫Sustainability of current schedule is
contingent on cooperation amp skills of HAN
Dental staff
Note
Strategies mentioned today is personalized to HAN Dental clinic
Current implemented strategies might be modified or changed in the
future as required in order to accommodate the need of our pts
THANK YOU
DAY TWOCLOSINGWRAP-UP
End of Day Two ndash Survey
Day Two Creating a Value-Based Oral Health Care Delivery
System
129
Payment Reform in Oral Health Online Learning Module
Oral Health Value-based Care Online Learning Module
Value-based Care Keys to Success Article
Readiness Assessment
Competency Development Guide
Oral Health Value-based Care Training
Dental Caries Management Practicum
Clinicians Companion Guide
Interprofessional Network Referral Process
Traditional Dental Care Vs Value-Based Care
Resources
131
wwwDentaQuestPartnershiporg
wwwfacebookcomDentaQuest
DentaQuest
wwwlinkedincomcompanyDentaQuest
Inside_DentaQuest
QUESTIONS
LAYING THE GROUNDWORKCLINICAL OPERATIONS IN A VBR ENVIRONMENTCarolyn Brown DDS Consultant
November 19th 2019
14
INTRODUCTION
15
Todayrsquos Agenda
bull Discuss value-based health and pay-for-performance approaches to health
systems and the integral building block of data
bull Dive deep into the emerging field of value-based care measurement and
data in oral health from national and statewide perspectives
bull Present oral health and clinical measurement approaches and relate to
oversight
16
bull Consultant working with DQP FQHCs Primary Care Associations and Foundations advancing oral health programs
bull DQPSNS Expert Advisor
bull IHI Improvement Coach
bull Former Dental Director
bull Research Marketing Finance
Carolyn Brown DDS
Consultant Acting Director of Value-Based Care
DentaQuest Partnership for Oral Health Advancement
bull DDS University of Maryland School of Dentistry
bull MAEd University of the Pacific
bull BS University of Maryland
bull Speaker researcher expert advisor review panel
17
Poll What do you measure
A Dental provider productivity per day
B Treatment plan completion
C Dental new patient exams
D Combination of A-C
E No Shows
F Sealants only
18
Population
Prevention
Healthy
Minimally Invasive
Health outcomes
MDI
EHR EDR
PCC
Risk Assessment
19
VALUE-BASED CAREPushing the impact quality and quantity of measurement
20
OHVBC Readiness
Leadership
Value of oral health and oral health transformation
Structure Systems and Operations
Efficiencies innovative care delivery
Care Pathways and Provider Buy-In
Risk-based care Training patient engagement
Data and Analytic Technology and Personnel
DataReports Interoperability
Financial Viability and Strength
Payerpatient mix billing infrastructure
httpswwwdentaquestpartnershiporglearnsafety-net-solutionsoral-health-value-based-careohvbc-readiness-
assessment
21
DentaQuest Partnership OHVBC Survey
Barriers to Value-based Transformation in Oral Health ndash
Most Common Responses
bull Patient engagement
bull EHREDR
bull Tracking outcomes lack of nationally-recognized and standardized quality
metrics in dental
22
How Can FQHC Dental Programs Prepare for Value-based
Transformation in Oral Health
bull Begin or continue focusing on prevention disease management and risk-based care
bull Hygienists will be key to success ndash We need primary dental care not just surgical
interventions
bull Start measuring outcomes instead of just processutilization metrics bull of initially high-risk patients with new caries lesions
bull of initially high-risk patients with decreased risk status
bull of initially low-risk patients with risk status maintained
bull Address patient engagement in a more meaningful way and invest in case
management
bull Invest in interprofessional practice including HIT interoperability
bull Evaluate how services are being delivered and determine if its reaching the patients
who need care the most
23
Value-Based Care
Care Coordination
ldquoClosing outrdquo referrals
Diagnostic coding
Risk Screenings
Care plans based on risk
Patient Engagement
Incentive payments
Quality metrics
Clinic Response
Case Management IT
Active timely records mngt
Mapping Dx codes to CDT
Time bill CPT codes Tx plan
IPP data tofrom PC MH
Recall window important
Attention to $ related metrics
Attention to assigned metrics
Direct and Indirect Effects of VBC on Dental Systems of Care
Utilization Impact
New workforce CDT codes
New or + workforce IT
ICD-CM-10 codes
+CDT codes
Modifiers (CPT ICD10)
+ recall adherence
in incentivized procedures
in sealant POC A1C
Counseling codes SD
24
MEASUREMENT IN ORAL HEALTH
25
Poll What percentage of your adult dental patients are diabetic
or pre-diabetic
A 50-80
B 20-50
C Less than 20
D Not sure
26
27
ldquoTrue Measures of Successrdquo
1 Define your governing objective
2 Develop a theory of cause and effect to assess presumed drivers of the
objective
3 Identify the specific activities that employees can do to help achieve the
governing objective
4 Evaluate your statistics
5 Communicate the story of your measurement
Adapted from HBR ldquoThe True Measures of Successrdquo httpshbrorg201210the-true-measures-of-success
28
1 Governing objective
2 Theory of cause and effect
3 Activities of team
4 Evaluate your statistics
5 Storycraft
Sustainability
Clinic revenuegt expenses= sustainability
Patient compliance Assets Clinic Mngt
Care team Operations Pt Support Billing
Of Prod on and type Patients on time
Daily weekly monthly quarterly
ldquoTrue Measures of Successrdquo
Adapted from HBR ldquoThe True Measures of Successrdquo httpshbrorg201210the-true-measures-of-success
29
Measuring Risk and Health
November is Diabetes Awareness Month- 2019Communication Plans are as
important as cold hard numbers
Patients
Care Team
Other Health Teams
Executive Team
Funders
Data on your dental patients are medical patients of record
Data on your medical + dental patients with DM2
30
Develop Diabetic Patient
Protocols
Review evidence and rationale with dental team
Partner with primary care team
bull Protocols Care mngt Tests and Recording
Quality Goals
Protocols for newly screened and existing patients
Educate and train dental team in reading AND
charting test results and PILOT
31
External Measurement in Oral Health Programs
httpswwwadaorg~mediaADADQA2019_DiabetesOralEvaluationpdfla=en
httpswwworegongovohaHPAANALYTICSCCOMetrics2019-Oral-Evaluation-Adults-Diabetespdf
32
Baseline for 2019 271
httpswwworegongovohaHPAANALYTICSCCOMetrics2019-Oral-Evaluation-Adults-Diabetespdf
33
Diabetes burden in your panel of dental patients
Baseline Medical-Dental Integrated panel of all patients
Dental patients with DM2 MDI
Dental patients with DM2
1000 or 10
600 or 60
300010000= 30
Population Health- Clinic Level
34
1 Governing objective
2 Theory of cause and effect
3 Activities of team
4 Evaluate your statistics
5 Storycraft
Discuss at meetings (Oct + Nov) Health education training
materials NP training CQI Note in Board report Clinical
measures
Care Pathways Hygiene Resources (ScheduleAvail)
ldquoTrue Measures of Successrdquo
Adapted from HBR ldquoThe True Measures of Successrdquo httpshbrorg201210the-true-measures-of-success
Diabetes Awareness Prevention Healthier Community
Prevention Awareness Care Pathway promotes health
MDI= 10 6 out of 10 adult patients with DM2
Goal set for integrated patient panels ndash PCMH
Pre-diabetes approach for executive team
Care Pathways
Care Coordination
35
MEASURING PATIENT ORAL HEALTHRisk assessments and Care Pathways
36
37
Risk Assessment and Care Pathways
Caries Risk Assessment
Multiple tools
EDREHR modules smart notes or dot phrases
CDT Codes
Decide frequency
D0601
Low Caries Risk
D0601
Moderate Caries Risk
D0601
High Caries Risk
38
The Disease Management DifferenceDisease Management Difference
Traditional Dental Care Disease Management
Approach
All patients return in 6 months
regardless of risk status
Recare interval is based on the
childrsquos caries risk
Caries Risk
Level
Recommended
Recare Interval
High Risk 1 ndash 3 months
Moderate Risk 3 ndash 6 months
Low Risk 6 ndash 12 months
Caries
Stabilizing
agents
Health Ed
Nutritional
Counseling
Anti-bacterial
and Fluoride
interventions
39
Disease Management Care Pathways
DentaQuest Partnership for Oral Health Advancement Disease Management Model
Caries
Stabilizing
agents
Whole
Person
Inter-
professional
Approaches
Anti-bacterial
and Fluoride
interventions
40
Disease Management and Risk Screening Training
DentaQuest Partnership for Oral Health Advancementrsquos
Online Learning Center
Disease Management Series
8 modules 40 CDE available
httpswwwdentaquestpartnershiporglearnonline-learning-centeronline-
coursewaredentaquest-disease-management-series
41
MEASUREMENT IN TEAMSSharing meaningful data with your dental clinical teams
42
rdquoDental Homerdquo = Health Home where WE can meet the patient
Oralhealthworkforceorg
43
POLL HOW OFTEN DO YOU SHARE YOUR S WITH YOUR DENTAL TEAM
A Yearly only
B Quarterly
C Monthly
D Weekly
E Daily
44
Clinical Measures ndash Dental Practice Perspective
Private Practice Office
New patients seen
Assigned vs seen if capitated
Treatment plans incomplete
$ produced amp per provider
$ collected amp monthly per provider
CDT 6000 codes completed
RecallHygiene maintenance
Based on this consultants experienced
FQHC
Unduplicated patients
patients seen per day
Treatment plans complete
$ gainedlost via accounting
Broken appointment rate
procedures
Sealant rate (annual)
45
bull HRSA Sealant Measure Compliance for FQHCs
bull Completion of phase 1 treatment plans
bull Children seen 0-5 years old
bull Children seen getting a preventive service
bull Fluoride Varnish applications
bull Pregnant women seen and treated
bull Diabetic patients with HbA1C gt 7 seen
bull Patients seen who have not been seen for 12 months
bull Patients seen getting a Risk Assessment
bull Patients with moderate or high risk who lower risk at recare
bull Sealants provided httpwwwnnohaorgnnoha-contentuploads201512Demystifying-HRSA-SEALANT-PRESENTATION_FINALpdf
Program Measures
46
HRSA Performance Measurement and Data Collection
bull FQHCs and look-alikes submit CY data to HRSA since 2008
bull UDS Uniform Data System
bull Require FTE for clinical staff patient demographics
bull Dental utilization s (UDCTPV)
bull Dental Clinical Measure dental sealants placed on 1st molars ages 6-9 yo
bull Health Center Quartile rankings (Clinical measure performance influences
HC rankings as does EHR adoption and other HC characteristics)
47
Low birth weight
Access to prenatal care
Childhood Immunization
Children (Ages 3-17) Receiving
Weight Assessment amp
Counseling
Children (Age 6-9) Receiving
Dental Sealant to First Molars
Diabetes Control
Hypertension Control
Pap Test
Depression Screening and
Follow-up (Age 12+)
Asthma Patients (Age 5-40)
Receiving Pharmacologic
Therapy
Colorectal Cancer
Screening (Ages 51-74)
HRSA UDS Clinical Measures
Adults (Age 18+) Receiving
Weight Screening amp Follow-up
Adults (Age 18+) Receiving
Tobacco Use Assessment and
Cessation Intervention
Coronary Artery Disease
Receiving Lipid Therapy (18+)
Ischemic Vascular Disease (IVD)
Receiving Aspirin Therapy (18+)
HIV Linkage to Care
48
Dashboards
Grants
Average
amp
Targets
Quality
Rev
Costs
Visits
Priority
Pop
Prevention
49
Dashboard- Provider Team Level
Patient
Compliance
Satisfaction
50
Case Study-
Incentives bonus round pools benchmark and improvement target goals risk-sharing possible later years
51
Qualitative Measurement
ldquoPatient engagement is the act of patients and providers working together
toward the end goal of improved patient wellnessrdquo
wwwpatientengagementhitcom
Access to Care
Patient Activation
Patient Satisfaction
Patient-Provider-Care Team Communication
Care Team Satisfaction
52
OHVBC Readiness
Leadership
bull Value of oral health and oral health transformation
Structure Systems and Operations
bull Operational efficiencies innovative care delivery methodologies
Care Pathways and Provider Buy-In
bull Training disease management risk-based care referrals IDC-10 coding patient engagement
Data and Analytic Technology and Personnel
bull Interoperability reporting
Financial Viability and Strength
bull Payerpatient mix billing infrastructure financial reports
httpswwwdentaquestpartnershiporglearnsafety-net-solutionsoral-health-value-based-careohvbc-readiness-
assessment
53
QUESTIONS COMMENTS
Carolyn Brown DDS
cbrownddsgmailcom
RISK BASED MANAGED CARE
Value Based Training Conference
Manchester New Hampshire
Mark Koday DDS
111919
5555
Objectives
bull Review current drivers of dental managed care
bull Understand the basics of risk-based dental managed care contracts
bull Learn the basics of managing costs in a riskndashbased contract
bull Gain an understanding in the potential advantage of risk-based contracting
56
What Is Dental Managed Care
Managed care is a health delivery system whose purpose is to manage both the
quality and cost of health care
Common types of managed care health insurance plans
bull HMOs
bull PPOs
bull POSs
bull Medicaid Managed Care
DIDNrsquoT WE ALREADY HAVE MANAGED CARE AND IT FAILED
57
What Has Happened Since the 90s
58
WHY THE FFS AND PPS DOESNrsquoT WORK FOR OUR POPULATIONS
bull Inefficient payment systems designed to produce encounters or procedures but not real health
bull No focus on population health
bull Does not incentivize innovation
bull Patients essentially on their own for accessing specialty care
59
Rule of 4
Source Kaiser Family Foundation analysis of National Health Expenditure (NHE) data from Centers for
Medicare and Medicaid Services Office of the Actuary National Health Statistics Group
60
Rule of 4
bull This helps explain why oral health has been relatively ignored so far by CMS
bull Explains why we have PCMH instead of PCHH
bull Where is the real value on a national level in preventing disease and
controlling costs
bull Beware- wersquove been found
61
Reasons Dental Managed Care is Spreading Across the States
NON-MANAGED CARE STATE DENTAL BUDGETS ARE
OPENED ENDED
STRAIN ON STATE BUDGETS
UPCOMING RECESSION WITH TRILLION DOLLAR
DEFICIT
SHIFTS FINANCIAL RISK FROM THE STATES TO THE
PLANS
6262
Types of Medicaid Managed Care
bull State Medicaid agency administrator lowest administrative
costs
bull Third Party Administrator Typically 15 administrative costs
bull Managed Care Organization Typically 15 administrative
costs
bull Carved-in
bull Carved-out
bull Risk Based Managed Care Administrative costs part of
contract negotiation
63
RISK CONTRACTS
6464
Components of a Risk-based Contract
Risk
Medical Loss Ratio
Quality withhold
Specialty withhold
Managed care payment (pmpm)
Covered services
Fee schedule Claims are paid as usual on a FFS basis
Credentialing
Quality Review process and Quality Metrics
65
Upside Risk
The possibility that the cost of
delivering dental care to an assigned
patient panel is less than the amount
of funding calculated for that care
The Plan pays the CHC additional
funds based on a predetermine
formula
Downside Risk
The possibility that the cost of
delivering dental care to an assigned
patient panel is more than the amount
of funding calculated for that care
The CHC pays the Plan additional
funds based on a predetermine
formula
Upside and Downside Risk
66
Taking On Risk 100 or Shared Risk
With 100 risk you receive 100 of the potential savings but are also at risk for
100 of the losses
Shared Risk MCO and health center share a percentage of the risk
Shared Risk leads to better cooperation since both organizations are
incentivized to save on costs
6767
Reports Needed
bull Enrollment reports lists of who is assigned on a monthly basis
bull Reconciliation reports insure appropriate payments
bull Specialty Referral reports
bull You will need your own reporting process so you donrsquot rely completely on
reports supplied by the Plan
6868
Medical Loss Ratio
Medical Loss Ratio (MLR) is proportion of premium revenues spent on clinical
services and quality improvement also known as the Medical Loss Ratio (MLR)
For CMS requires Medical Plans to spend at least 80 to 85 of the premiums
on actual medical care
69
Administrative Fees
bull Essentially the opposite of MLR
bull The State Medicaid Agency is funded by the Governorrsquos budget
bull The State Medicaid Agency will keep some of these funds for their
admin costs and give the remaining to the Managed Care Plans
bull Private Plan admin costs can be as high as 40 but most states
limit these cost for Medicaid Plans to between 15 and 20 (85-
80 MLR)
bull This may be negotiable depending on your program size of your
program
70
Quality Withhold
bull The state withholds a certain percent (typically 2-4 ) of the funds they give
to the Plans for Value Based Reimbursement
bull They choose quality metrics and set benchmarks and assign payments for
each metric based on an assigned priority for each metric
bull If a Plan meets the benchmark of every quality metric the state passes on
their full share of the quality withhold
bull The Plans may or may not withhold a percent of the funds for quality payment
to the dentists or manage care contractors
71
Quality Withhold
Either way the Plans may or may not pass the quality payments they receive to
the dentists or contractors
This should be spelled out in a risk-based contract
72
Percent of funds set aside
to cover specialty care
referrals
Typically 10-15
Goal Limit referral costs
to within or less than
Specialty set aside
Specialty Withhold
73
Per Member Per Month
bull Capitated Payment
bull Specific dollar amount paid for each enrolled member each month
bull Paid whether patient is accessed for care or not
bull States do set access benchmarks
bull In Oregon access for any dental procedure (adults and children combined)
was 267 in 2015
74
Payment Math Example
Premium per enrollee = $25
Administrative fee 15 = $375
Funds available per enrollee to the clinic = $2125
Management fee per enrollee = $175
Funds per enrollee that would undergo PPS reconciliation = $1950
For every 10000 enrollees the managed care income = $2340000
Specialty withhold (10) = $234000
YE Cost lt or gt $2340000
Upside Risk
CHC Gains $
Downside Risk
CHC Loses $
75
Covered Services and Fee Schedules
bull The state Medicaid agency spells out the minimum procedures and fees that
MCOs must cover
bull MCOs may add procedures or increase periodicity of procedures particularly
preventative services
bull MCOs may increase fees to entice rural providers and specialists to enroll in
their Plans
bull Access Rules
bull How many days it takes to access a patent
bull How many days it takes for a patent to access urgent care services
bull How many days it takes for a patent to access emergency care services
76
Credentialing
All MCOs are required to credential all Providers
All MCOs have their own credentialing process
Credentialing process is can be lengthy
Credentialing process may be negotiable
77
Quality Review Process and Quality Metrics
MCOs must have a Quality and Compliance Review Process
If you arenrsquot in compliance with both you likely wonrsquot get paid
Typical processes reviewed
bull Charting specifications
bull Incident report
bull Enrollee complaints quality rudeness and access issues
bull Medicaid compliance
78
Quality Payments
bull State Shared Incentive Withhold Typically quality metrics and benchmarks
are set by the state sets aside a certain percent (3-5) of the payments to
the Managed Care Plan (MCP)
bull If the benchmarks are achieved the MCP is then paid the a predetermine
amount
bull Benchmarks may not be the same as the states
bull Managed Care Plans do not have to pass all or any of the quality payments to
the health centers or providers
bull Managed Care contract- Metrics benchmarks should be selected and part of
the contract
7979
Achieving Quality Metric Payments
Dealing with under achievers
Process issues
Individual issues
Identifying workflows
Developing Best Practices through
PDSA process
Developing Best Practices through
PDSA process
CHC Metrics Committee
Clinicians Operations various key staff
Identify Best Practices
Spread Best Practices
80
New Team Needed Business Intelligence
Business Intelligence (BI) is critical for effective managed care business decisions
BI team inputs metrics into your EHR collects integrates analyses and displays all your managed care business and clinical information
Easy to say- hard to achieve
Build your own or outsource
Possible future role of Primary Care Associations
8181
Clinicianrsquos Dashboard
Expensive to build
Displayed on your screen when your computer is first turned on
Easy to read and understand
Data dumped from the day before
Can dialed down from Org-wide to clinic to each clinicianrsquos data
Operational and clinical metrics
bull Treatment Plan Completion
bull DQA quality measures
bull Caries at Recall
bull Re-care reports
bull Care Gap reports
82
CONTROLLING COSTS
8383
Controlling Costs- Current
bull Increasing efficiencies
bull Decreasing broken appointments
bull Controlling supplies equipment costs
bull Staff recruitment retention costs
84
Specialty Care
Training current CHC dentists in
specialty areas
Hiring general dentists with higher
specialty skill sets
Hiring in house specialists
Contract with outside specialists
Work with Managed Care Plan
specialists
Lowering Disease Rates
Community Dental Health
Coordinators case management
If your state law allows- embed
hygienists in medical and community
to provide primary and secondary
prevention procedures
In clinic Caries Classification and
Silver Diamine Fluoride
Effective recare programs
Controlling Costs- Additions in Risk-based Contracting
85
Specialty Care ndash Primary Referrals by Cost
Pediatric dentistry
Orthodontics
Oral surgery
Endodontics
86
In-clinic Pediatric Services
Encounters expected
of operatories available
State dental law and ability to have
expanded duties
General Anesthesia
GA in- house
Ability for a hospital or surgery center
to set aside regular OR time
Ability to hire or assign DAs to GA
days
Four GA cases day x PPS rate
Should You Hire a Pediatric Dentist- It Depends
8787
Solutions for Controlling Pediatric Costs
Hire a general dentist that is skilled in treating young children
Make the clinic child friendly nitrous oxide TVs in the operatory etc
Teach entire staff behavioral control techniques
Contract with a pediatric dentist for the GA care
88
Lowering Overall Disease Rates (and Costs)
You are responsible for both the patients you see in the chair and the ones
assigned to you
Breaking down the walls of the dental clinic
Community Dental Health Coordinators
Case Management
89
Cost Control Essentials
Diagnosis codes
Increased ability to identify
disease by risk
Motivational
Interviewing
Developing Polices and
Procedures design to treat
disease according to risk
ie Silver Diamine Fluoride
Treating by Risk
Effective Recare
Process
Critical to continual disease
controlPrevention education that is
meaningful and designed to
change behaviors
90
Social Determinants of Health Aunt Bertha
httpswwwauntberthacom
91
REASON TO CONSIDER RISK- BASED CONTRACTING
9292
PPS Reconciliation and Federal Code 42 CFR sect4052469(a)(2)
42 CFR sect4052469(a)(2)
ldquoAny financial incentives provided to Federally Qualified Health Centers
under their Medicare Advantage Contracts such as risk pool payments
bonuses or withholds are prohibited from being included in the
calculation of supplemental payments due to the Federally Qualified
Health Centerrdquo
9393
Why Risk Based Contract in Times of PPS Reconciliation
bull Not all Risk- based Contract funds are reconciled
bull Risk is the key word- you can come out with less money than your normal
PPS reconciliation payment
bull Can lead to better patient care
bull May improve manage care enrollment for your medical plan
bull Promotes integrated care increases health for your CHC patients
9494
Not Included in the Reconciliation
Enrollment management pmpm
Quality Payments
Upside risk payments
Downside risk losses
9595
Determinants of Financial Success in Risk-Based Contracting
bull Most critical- State pmpm payment to the Managed Care Plan
bull Reporting capabilities
bull Specialty service capabilities
bull Access numbers count
bull Ability to move metric numbers
9696
What About the Non- Medicaid Poor We Serve
bull Numbers are king in a managed care contract and the more access you have
the better contract terms you can negotiate
bull We will potentially have a steady supply of Medicaid patients
bull As managed care spreads states this may be compromising the ability of
health centers to serve the non-Medicaid poor and others lacking dental
insurance
97
Mark Koday DDS
(509) 949-2278
Dental Quality Consultants
of WA
httpdentalqualityconsultin
gcom
dentalqualityconsultantsg
mailcom
Contact Information
LUNCH
BREAKOUT EXERCISEORAL HEALTH VALUE-BASED CARE READINESS ASSESSMENT
Danielle Apostolon
PROMISING PRACTICES FROM THE FIELD STRATEGIES FOR INCREASING VALUE IN ORAL HEALTH
Dr Carolyn Brown
Dr Kelly Perry
Dr Rachel Rivard
Dr Adeloye
Commitment Compassion Community
m i d s t a t e h e a l t h o r g
Promising Practices from the
Field Strategies for Increasing
Value in Oral Health Care
Kelly Perry DMD
Better Health
Outcomes
Improved Staff
Experience
Reduced Cost
Improved Patient
Experience
Better Health
Outcomes
Improved Staff
Experience
Reduced Cost
Improved Patient
Experience
Better Health
Outcomes
Improved Staff
Experience
Reduced Cost
Improved Patient
Experience
Better Health
Outcomes
Improved Staff
Experience
Reduced Cost
Improved Patient
Experience
Commitment Compassion Community
kpe r r ymids t a tehea l t h o rg
Thank you
Completion of Disease Control Phase
Pelumi Adeloye DMD MPH
HEALTH ACCESS NETWORK (HAN) FAMILY DENTAL
Introduction
⧫1 Dentist I Hygienist 3 EFDArsquos1 Receptionist
⧫ 6 Chairs= 4 (dentist) + 2 (hygienist)
⧫ Slide ⥶80 off
⧫ Service areas Northern Penobscot Southern Aroostook Western
Washington Counties amp more
Completion of Phase I Treatment
⧫LimitedLack of Access to dental care
⧫Difficulty completing the disease control phase
Caries amp periodontal disease
⧫Attaining stable restorative state
Goal
Increase the completion of Disease Control Phase
Current practice
⧫Education
Assess level of dental literacy
Incremental strategy
⧫Increase access to dental care
Generous sliding scale (⥸$40 per visit)
Incorporate Expanded Function Dental Assistants
⧫Schedule modification
Incorporate more restorative blocks to allow
for follow-up visit and completion of restorative phase
httpswwwglasbergencomdentist-cartoons
Schedule
⧫Piggybacking technique
Increased allotted restorative blocks
⧫Sustainability of current schedule is
contingent on cooperation amp skills of HAN
Dental staff
Note
Strategies mentioned today is personalized to HAN Dental clinic
Current implemented strategies might be modified or changed in the
future as required in order to accommodate the need of our pts
THANK YOU
DAY TWOCLOSINGWRAP-UP
End of Day Two ndash Survey
Day Two Creating a Value-Based Oral Health Care Delivery
System
129
Payment Reform in Oral Health Online Learning Module
Oral Health Value-based Care Online Learning Module
Value-based Care Keys to Success Article
Readiness Assessment
Competency Development Guide
Oral Health Value-based Care Training
Dental Caries Management Practicum
Clinicians Companion Guide
Interprofessional Network Referral Process
Traditional Dental Care Vs Value-Based Care
Resources
131
wwwDentaQuestPartnershiporg
wwwfacebookcomDentaQuest
DentaQuest
wwwlinkedincomcompanyDentaQuest
Inside_DentaQuest
QUESTIONS
14
INTRODUCTION
15
Todayrsquos Agenda
bull Discuss value-based health and pay-for-performance approaches to health
systems and the integral building block of data
bull Dive deep into the emerging field of value-based care measurement and
data in oral health from national and statewide perspectives
bull Present oral health and clinical measurement approaches and relate to
oversight
16
bull Consultant working with DQP FQHCs Primary Care Associations and Foundations advancing oral health programs
bull DQPSNS Expert Advisor
bull IHI Improvement Coach
bull Former Dental Director
bull Research Marketing Finance
Carolyn Brown DDS
Consultant Acting Director of Value-Based Care
DentaQuest Partnership for Oral Health Advancement
bull DDS University of Maryland School of Dentistry
bull MAEd University of the Pacific
bull BS University of Maryland
bull Speaker researcher expert advisor review panel
17
Poll What do you measure
A Dental provider productivity per day
B Treatment plan completion
C Dental new patient exams
D Combination of A-C
E No Shows
F Sealants only
18
Population
Prevention
Healthy
Minimally Invasive
Health outcomes
MDI
EHR EDR
PCC
Risk Assessment
19
VALUE-BASED CAREPushing the impact quality and quantity of measurement
20
OHVBC Readiness
Leadership
Value of oral health and oral health transformation
Structure Systems and Operations
Efficiencies innovative care delivery
Care Pathways and Provider Buy-In
Risk-based care Training patient engagement
Data and Analytic Technology and Personnel
DataReports Interoperability
Financial Viability and Strength
Payerpatient mix billing infrastructure
httpswwwdentaquestpartnershiporglearnsafety-net-solutionsoral-health-value-based-careohvbc-readiness-
assessment
21
DentaQuest Partnership OHVBC Survey
Barriers to Value-based Transformation in Oral Health ndash
Most Common Responses
bull Patient engagement
bull EHREDR
bull Tracking outcomes lack of nationally-recognized and standardized quality
metrics in dental
22
How Can FQHC Dental Programs Prepare for Value-based
Transformation in Oral Health
bull Begin or continue focusing on prevention disease management and risk-based care
bull Hygienists will be key to success ndash We need primary dental care not just surgical
interventions
bull Start measuring outcomes instead of just processutilization metrics bull of initially high-risk patients with new caries lesions
bull of initially high-risk patients with decreased risk status
bull of initially low-risk patients with risk status maintained
bull Address patient engagement in a more meaningful way and invest in case
management
bull Invest in interprofessional practice including HIT interoperability
bull Evaluate how services are being delivered and determine if its reaching the patients
who need care the most
23
Value-Based Care
Care Coordination
ldquoClosing outrdquo referrals
Diagnostic coding
Risk Screenings
Care plans based on risk
Patient Engagement
Incentive payments
Quality metrics
Clinic Response
Case Management IT
Active timely records mngt
Mapping Dx codes to CDT
Time bill CPT codes Tx plan
IPP data tofrom PC MH
Recall window important
Attention to $ related metrics
Attention to assigned metrics
Direct and Indirect Effects of VBC on Dental Systems of Care
Utilization Impact
New workforce CDT codes
New or + workforce IT
ICD-CM-10 codes
+CDT codes
Modifiers (CPT ICD10)
+ recall adherence
in incentivized procedures
in sealant POC A1C
Counseling codes SD
24
MEASUREMENT IN ORAL HEALTH
25
Poll What percentage of your adult dental patients are diabetic
or pre-diabetic
A 50-80
B 20-50
C Less than 20
D Not sure
26
27
ldquoTrue Measures of Successrdquo
1 Define your governing objective
2 Develop a theory of cause and effect to assess presumed drivers of the
objective
3 Identify the specific activities that employees can do to help achieve the
governing objective
4 Evaluate your statistics
5 Communicate the story of your measurement
Adapted from HBR ldquoThe True Measures of Successrdquo httpshbrorg201210the-true-measures-of-success
28
1 Governing objective
2 Theory of cause and effect
3 Activities of team
4 Evaluate your statistics
5 Storycraft
Sustainability
Clinic revenuegt expenses= sustainability
Patient compliance Assets Clinic Mngt
Care team Operations Pt Support Billing
Of Prod on and type Patients on time
Daily weekly monthly quarterly
ldquoTrue Measures of Successrdquo
Adapted from HBR ldquoThe True Measures of Successrdquo httpshbrorg201210the-true-measures-of-success
29
Measuring Risk and Health
November is Diabetes Awareness Month- 2019Communication Plans are as
important as cold hard numbers
Patients
Care Team
Other Health Teams
Executive Team
Funders
Data on your dental patients are medical patients of record
Data on your medical + dental patients with DM2
30
Develop Diabetic Patient
Protocols
Review evidence and rationale with dental team
Partner with primary care team
bull Protocols Care mngt Tests and Recording
Quality Goals
Protocols for newly screened and existing patients
Educate and train dental team in reading AND
charting test results and PILOT
31
External Measurement in Oral Health Programs
httpswwwadaorg~mediaADADQA2019_DiabetesOralEvaluationpdfla=en
httpswwworegongovohaHPAANALYTICSCCOMetrics2019-Oral-Evaluation-Adults-Diabetespdf
32
Baseline for 2019 271
httpswwworegongovohaHPAANALYTICSCCOMetrics2019-Oral-Evaluation-Adults-Diabetespdf
33
Diabetes burden in your panel of dental patients
Baseline Medical-Dental Integrated panel of all patients
Dental patients with DM2 MDI
Dental patients with DM2
1000 or 10
600 or 60
300010000= 30
Population Health- Clinic Level
34
1 Governing objective
2 Theory of cause and effect
3 Activities of team
4 Evaluate your statistics
5 Storycraft
Discuss at meetings (Oct + Nov) Health education training
materials NP training CQI Note in Board report Clinical
measures
Care Pathways Hygiene Resources (ScheduleAvail)
ldquoTrue Measures of Successrdquo
Adapted from HBR ldquoThe True Measures of Successrdquo httpshbrorg201210the-true-measures-of-success
Diabetes Awareness Prevention Healthier Community
Prevention Awareness Care Pathway promotes health
MDI= 10 6 out of 10 adult patients with DM2
Goal set for integrated patient panels ndash PCMH
Pre-diabetes approach for executive team
Care Pathways
Care Coordination
35
MEASURING PATIENT ORAL HEALTHRisk assessments and Care Pathways
36
37
Risk Assessment and Care Pathways
Caries Risk Assessment
Multiple tools
EDREHR modules smart notes or dot phrases
CDT Codes
Decide frequency
D0601
Low Caries Risk
D0601
Moderate Caries Risk
D0601
High Caries Risk
38
The Disease Management DifferenceDisease Management Difference
Traditional Dental Care Disease Management
Approach
All patients return in 6 months
regardless of risk status
Recare interval is based on the
childrsquos caries risk
Caries Risk
Level
Recommended
Recare Interval
High Risk 1 ndash 3 months
Moderate Risk 3 ndash 6 months
Low Risk 6 ndash 12 months
Caries
Stabilizing
agents
Health Ed
Nutritional
Counseling
Anti-bacterial
and Fluoride
interventions
39
Disease Management Care Pathways
DentaQuest Partnership for Oral Health Advancement Disease Management Model
Caries
Stabilizing
agents
Whole
Person
Inter-
professional
Approaches
Anti-bacterial
and Fluoride
interventions
40
Disease Management and Risk Screening Training
DentaQuest Partnership for Oral Health Advancementrsquos
Online Learning Center
Disease Management Series
8 modules 40 CDE available
httpswwwdentaquestpartnershiporglearnonline-learning-centeronline-
coursewaredentaquest-disease-management-series
41
MEASUREMENT IN TEAMSSharing meaningful data with your dental clinical teams
42
rdquoDental Homerdquo = Health Home where WE can meet the patient
Oralhealthworkforceorg
43
POLL HOW OFTEN DO YOU SHARE YOUR S WITH YOUR DENTAL TEAM
A Yearly only
B Quarterly
C Monthly
D Weekly
E Daily
44
Clinical Measures ndash Dental Practice Perspective
Private Practice Office
New patients seen
Assigned vs seen if capitated
Treatment plans incomplete
$ produced amp per provider
$ collected amp monthly per provider
CDT 6000 codes completed
RecallHygiene maintenance
Based on this consultants experienced
FQHC
Unduplicated patients
patients seen per day
Treatment plans complete
$ gainedlost via accounting
Broken appointment rate
procedures
Sealant rate (annual)
45
bull HRSA Sealant Measure Compliance for FQHCs
bull Completion of phase 1 treatment plans
bull Children seen 0-5 years old
bull Children seen getting a preventive service
bull Fluoride Varnish applications
bull Pregnant women seen and treated
bull Diabetic patients with HbA1C gt 7 seen
bull Patients seen who have not been seen for 12 months
bull Patients seen getting a Risk Assessment
bull Patients with moderate or high risk who lower risk at recare
bull Sealants provided httpwwwnnohaorgnnoha-contentuploads201512Demystifying-HRSA-SEALANT-PRESENTATION_FINALpdf
Program Measures
46
HRSA Performance Measurement and Data Collection
bull FQHCs and look-alikes submit CY data to HRSA since 2008
bull UDS Uniform Data System
bull Require FTE for clinical staff patient demographics
bull Dental utilization s (UDCTPV)
bull Dental Clinical Measure dental sealants placed on 1st molars ages 6-9 yo
bull Health Center Quartile rankings (Clinical measure performance influences
HC rankings as does EHR adoption and other HC characteristics)
47
Low birth weight
Access to prenatal care
Childhood Immunization
Children (Ages 3-17) Receiving
Weight Assessment amp
Counseling
Children (Age 6-9) Receiving
Dental Sealant to First Molars
Diabetes Control
Hypertension Control
Pap Test
Depression Screening and
Follow-up (Age 12+)
Asthma Patients (Age 5-40)
Receiving Pharmacologic
Therapy
Colorectal Cancer
Screening (Ages 51-74)
HRSA UDS Clinical Measures
Adults (Age 18+) Receiving
Weight Screening amp Follow-up
Adults (Age 18+) Receiving
Tobacco Use Assessment and
Cessation Intervention
Coronary Artery Disease
Receiving Lipid Therapy (18+)
Ischemic Vascular Disease (IVD)
Receiving Aspirin Therapy (18+)
HIV Linkage to Care
48
Dashboards
Grants
Average
amp
Targets
Quality
Rev
Costs
Visits
Priority
Pop
Prevention
49
Dashboard- Provider Team Level
Patient
Compliance
Satisfaction
50
Case Study-
Incentives bonus round pools benchmark and improvement target goals risk-sharing possible later years
51
Qualitative Measurement
ldquoPatient engagement is the act of patients and providers working together
toward the end goal of improved patient wellnessrdquo
wwwpatientengagementhitcom
Access to Care
Patient Activation
Patient Satisfaction
Patient-Provider-Care Team Communication
Care Team Satisfaction
52
OHVBC Readiness
Leadership
bull Value of oral health and oral health transformation
Structure Systems and Operations
bull Operational efficiencies innovative care delivery methodologies
Care Pathways and Provider Buy-In
bull Training disease management risk-based care referrals IDC-10 coding patient engagement
Data and Analytic Technology and Personnel
bull Interoperability reporting
Financial Viability and Strength
bull Payerpatient mix billing infrastructure financial reports
httpswwwdentaquestpartnershiporglearnsafety-net-solutionsoral-health-value-based-careohvbc-readiness-
assessment
53
QUESTIONS COMMENTS
Carolyn Brown DDS
cbrownddsgmailcom
RISK BASED MANAGED CARE
Value Based Training Conference
Manchester New Hampshire
Mark Koday DDS
111919
5555
Objectives
bull Review current drivers of dental managed care
bull Understand the basics of risk-based dental managed care contracts
bull Learn the basics of managing costs in a riskndashbased contract
bull Gain an understanding in the potential advantage of risk-based contracting
56
What Is Dental Managed Care
Managed care is a health delivery system whose purpose is to manage both the
quality and cost of health care
Common types of managed care health insurance plans
bull HMOs
bull PPOs
bull POSs
bull Medicaid Managed Care
DIDNrsquoT WE ALREADY HAVE MANAGED CARE AND IT FAILED
57
What Has Happened Since the 90s
58
WHY THE FFS AND PPS DOESNrsquoT WORK FOR OUR POPULATIONS
bull Inefficient payment systems designed to produce encounters or procedures but not real health
bull No focus on population health
bull Does not incentivize innovation
bull Patients essentially on their own for accessing specialty care
59
Rule of 4
Source Kaiser Family Foundation analysis of National Health Expenditure (NHE) data from Centers for
Medicare and Medicaid Services Office of the Actuary National Health Statistics Group
60
Rule of 4
bull This helps explain why oral health has been relatively ignored so far by CMS
bull Explains why we have PCMH instead of PCHH
bull Where is the real value on a national level in preventing disease and
controlling costs
bull Beware- wersquove been found
61
Reasons Dental Managed Care is Spreading Across the States
NON-MANAGED CARE STATE DENTAL BUDGETS ARE
OPENED ENDED
STRAIN ON STATE BUDGETS
UPCOMING RECESSION WITH TRILLION DOLLAR
DEFICIT
SHIFTS FINANCIAL RISK FROM THE STATES TO THE
PLANS
6262
Types of Medicaid Managed Care
bull State Medicaid agency administrator lowest administrative
costs
bull Third Party Administrator Typically 15 administrative costs
bull Managed Care Organization Typically 15 administrative
costs
bull Carved-in
bull Carved-out
bull Risk Based Managed Care Administrative costs part of
contract negotiation
63
RISK CONTRACTS
6464
Components of a Risk-based Contract
Risk
Medical Loss Ratio
Quality withhold
Specialty withhold
Managed care payment (pmpm)
Covered services
Fee schedule Claims are paid as usual on a FFS basis
Credentialing
Quality Review process and Quality Metrics
65
Upside Risk
The possibility that the cost of
delivering dental care to an assigned
patient panel is less than the amount
of funding calculated for that care
The Plan pays the CHC additional
funds based on a predetermine
formula
Downside Risk
The possibility that the cost of
delivering dental care to an assigned
patient panel is more than the amount
of funding calculated for that care
The CHC pays the Plan additional
funds based on a predetermine
formula
Upside and Downside Risk
66
Taking On Risk 100 or Shared Risk
With 100 risk you receive 100 of the potential savings but are also at risk for
100 of the losses
Shared Risk MCO and health center share a percentage of the risk
Shared Risk leads to better cooperation since both organizations are
incentivized to save on costs
6767
Reports Needed
bull Enrollment reports lists of who is assigned on a monthly basis
bull Reconciliation reports insure appropriate payments
bull Specialty Referral reports
bull You will need your own reporting process so you donrsquot rely completely on
reports supplied by the Plan
6868
Medical Loss Ratio
Medical Loss Ratio (MLR) is proportion of premium revenues spent on clinical
services and quality improvement also known as the Medical Loss Ratio (MLR)
For CMS requires Medical Plans to spend at least 80 to 85 of the premiums
on actual medical care
69
Administrative Fees
bull Essentially the opposite of MLR
bull The State Medicaid Agency is funded by the Governorrsquos budget
bull The State Medicaid Agency will keep some of these funds for their
admin costs and give the remaining to the Managed Care Plans
bull Private Plan admin costs can be as high as 40 but most states
limit these cost for Medicaid Plans to between 15 and 20 (85-
80 MLR)
bull This may be negotiable depending on your program size of your
program
70
Quality Withhold
bull The state withholds a certain percent (typically 2-4 ) of the funds they give
to the Plans for Value Based Reimbursement
bull They choose quality metrics and set benchmarks and assign payments for
each metric based on an assigned priority for each metric
bull If a Plan meets the benchmark of every quality metric the state passes on
their full share of the quality withhold
bull The Plans may or may not withhold a percent of the funds for quality payment
to the dentists or manage care contractors
71
Quality Withhold
Either way the Plans may or may not pass the quality payments they receive to
the dentists or contractors
This should be spelled out in a risk-based contract
72
Percent of funds set aside
to cover specialty care
referrals
Typically 10-15
Goal Limit referral costs
to within or less than
Specialty set aside
Specialty Withhold
73
Per Member Per Month
bull Capitated Payment
bull Specific dollar amount paid for each enrolled member each month
bull Paid whether patient is accessed for care or not
bull States do set access benchmarks
bull In Oregon access for any dental procedure (adults and children combined)
was 267 in 2015
74
Payment Math Example
Premium per enrollee = $25
Administrative fee 15 = $375
Funds available per enrollee to the clinic = $2125
Management fee per enrollee = $175
Funds per enrollee that would undergo PPS reconciliation = $1950
For every 10000 enrollees the managed care income = $2340000
Specialty withhold (10) = $234000
YE Cost lt or gt $2340000
Upside Risk
CHC Gains $
Downside Risk
CHC Loses $
75
Covered Services and Fee Schedules
bull The state Medicaid agency spells out the minimum procedures and fees that
MCOs must cover
bull MCOs may add procedures or increase periodicity of procedures particularly
preventative services
bull MCOs may increase fees to entice rural providers and specialists to enroll in
their Plans
bull Access Rules
bull How many days it takes to access a patent
bull How many days it takes for a patent to access urgent care services
bull How many days it takes for a patent to access emergency care services
76
Credentialing
All MCOs are required to credential all Providers
All MCOs have their own credentialing process
Credentialing process is can be lengthy
Credentialing process may be negotiable
77
Quality Review Process and Quality Metrics
MCOs must have a Quality and Compliance Review Process
If you arenrsquot in compliance with both you likely wonrsquot get paid
Typical processes reviewed
bull Charting specifications
bull Incident report
bull Enrollee complaints quality rudeness and access issues
bull Medicaid compliance
78
Quality Payments
bull State Shared Incentive Withhold Typically quality metrics and benchmarks
are set by the state sets aside a certain percent (3-5) of the payments to
the Managed Care Plan (MCP)
bull If the benchmarks are achieved the MCP is then paid the a predetermine
amount
bull Benchmarks may not be the same as the states
bull Managed Care Plans do not have to pass all or any of the quality payments to
the health centers or providers
bull Managed Care contract- Metrics benchmarks should be selected and part of
the contract
7979
Achieving Quality Metric Payments
Dealing with under achievers
Process issues
Individual issues
Identifying workflows
Developing Best Practices through
PDSA process
Developing Best Practices through
PDSA process
CHC Metrics Committee
Clinicians Operations various key staff
Identify Best Practices
Spread Best Practices
80
New Team Needed Business Intelligence
Business Intelligence (BI) is critical for effective managed care business decisions
BI team inputs metrics into your EHR collects integrates analyses and displays all your managed care business and clinical information
Easy to say- hard to achieve
Build your own or outsource
Possible future role of Primary Care Associations
8181
Clinicianrsquos Dashboard
Expensive to build
Displayed on your screen when your computer is first turned on
Easy to read and understand
Data dumped from the day before
Can dialed down from Org-wide to clinic to each clinicianrsquos data
Operational and clinical metrics
bull Treatment Plan Completion
bull DQA quality measures
bull Caries at Recall
bull Re-care reports
bull Care Gap reports
82
CONTROLLING COSTS
8383
Controlling Costs- Current
bull Increasing efficiencies
bull Decreasing broken appointments
bull Controlling supplies equipment costs
bull Staff recruitment retention costs
84
Specialty Care
Training current CHC dentists in
specialty areas
Hiring general dentists with higher
specialty skill sets
Hiring in house specialists
Contract with outside specialists
Work with Managed Care Plan
specialists
Lowering Disease Rates
Community Dental Health
Coordinators case management
If your state law allows- embed
hygienists in medical and community
to provide primary and secondary
prevention procedures
In clinic Caries Classification and
Silver Diamine Fluoride
Effective recare programs
Controlling Costs- Additions in Risk-based Contracting
85
Specialty Care ndash Primary Referrals by Cost
Pediatric dentistry
Orthodontics
Oral surgery
Endodontics
86
In-clinic Pediatric Services
Encounters expected
of operatories available
State dental law and ability to have
expanded duties
General Anesthesia
GA in- house
Ability for a hospital or surgery center
to set aside regular OR time
Ability to hire or assign DAs to GA
days
Four GA cases day x PPS rate
Should You Hire a Pediatric Dentist- It Depends
8787
Solutions for Controlling Pediatric Costs
Hire a general dentist that is skilled in treating young children
Make the clinic child friendly nitrous oxide TVs in the operatory etc
Teach entire staff behavioral control techniques
Contract with a pediatric dentist for the GA care
88
Lowering Overall Disease Rates (and Costs)
You are responsible for both the patients you see in the chair and the ones
assigned to you
Breaking down the walls of the dental clinic
Community Dental Health Coordinators
Case Management
89
Cost Control Essentials
Diagnosis codes
Increased ability to identify
disease by risk
Motivational
Interviewing
Developing Polices and
Procedures design to treat
disease according to risk
ie Silver Diamine Fluoride
Treating by Risk
Effective Recare
Process
Critical to continual disease
controlPrevention education that is
meaningful and designed to
change behaviors
90
Social Determinants of Health Aunt Bertha
httpswwwauntberthacom
91
REASON TO CONSIDER RISK- BASED CONTRACTING
9292
PPS Reconciliation and Federal Code 42 CFR sect4052469(a)(2)
42 CFR sect4052469(a)(2)
ldquoAny financial incentives provided to Federally Qualified Health Centers
under their Medicare Advantage Contracts such as risk pool payments
bonuses or withholds are prohibited from being included in the
calculation of supplemental payments due to the Federally Qualified
Health Centerrdquo
9393
Why Risk Based Contract in Times of PPS Reconciliation
bull Not all Risk- based Contract funds are reconciled
bull Risk is the key word- you can come out with less money than your normal
PPS reconciliation payment
bull Can lead to better patient care
bull May improve manage care enrollment for your medical plan
bull Promotes integrated care increases health for your CHC patients
9494
Not Included in the Reconciliation
Enrollment management pmpm
Quality Payments
Upside risk payments
Downside risk losses
9595
Determinants of Financial Success in Risk-Based Contracting
bull Most critical- State pmpm payment to the Managed Care Plan
bull Reporting capabilities
bull Specialty service capabilities
bull Access numbers count
bull Ability to move metric numbers
9696
What About the Non- Medicaid Poor We Serve
bull Numbers are king in a managed care contract and the more access you have
the better contract terms you can negotiate
bull We will potentially have a steady supply of Medicaid patients
bull As managed care spreads states this may be compromising the ability of
health centers to serve the non-Medicaid poor and others lacking dental
insurance
97
Mark Koday DDS
(509) 949-2278
Dental Quality Consultants
of WA
httpdentalqualityconsultin
gcom
dentalqualityconsultantsg
mailcom
Contact Information
LUNCH
BREAKOUT EXERCISEORAL HEALTH VALUE-BASED CARE READINESS ASSESSMENT
Danielle Apostolon
PROMISING PRACTICES FROM THE FIELD STRATEGIES FOR INCREASING VALUE IN ORAL HEALTH
Dr Carolyn Brown
Dr Kelly Perry
Dr Rachel Rivard
Dr Adeloye
Commitment Compassion Community
m i d s t a t e h e a l t h o r g
Promising Practices from the
Field Strategies for Increasing
Value in Oral Health Care
Kelly Perry DMD
Better Health
Outcomes
Improved Staff
Experience
Reduced Cost
Improved Patient
Experience
Better Health
Outcomes
Improved Staff
Experience
Reduced Cost
Improved Patient
Experience
Better Health
Outcomes
Improved Staff
Experience
Reduced Cost
Improved Patient
Experience
Better Health
Outcomes
Improved Staff
Experience
Reduced Cost
Improved Patient
Experience
Commitment Compassion Community
kpe r r ymids t a tehea l t h o rg
Thank you
Completion of Disease Control Phase
Pelumi Adeloye DMD MPH
HEALTH ACCESS NETWORK (HAN) FAMILY DENTAL
Introduction
⧫1 Dentist I Hygienist 3 EFDArsquos1 Receptionist
⧫ 6 Chairs= 4 (dentist) + 2 (hygienist)
⧫ Slide ⥶80 off
⧫ Service areas Northern Penobscot Southern Aroostook Western
Washington Counties amp more
Completion of Phase I Treatment
⧫LimitedLack of Access to dental care
⧫Difficulty completing the disease control phase
Caries amp periodontal disease
⧫Attaining stable restorative state
Goal
Increase the completion of Disease Control Phase
Current practice
⧫Education
Assess level of dental literacy
Incremental strategy
⧫Increase access to dental care
Generous sliding scale (⥸$40 per visit)
Incorporate Expanded Function Dental Assistants
⧫Schedule modification
Incorporate more restorative blocks to allow
for follow-up visit and completion of restorative phase
httpswwwglasbergencomdentist-cartoons
Schedule
⧫Piggybacking technique
Increased allotted restorative blocks
⧫Sustainability of current schedule is
contingent on cooperation amp skills of HAN
Dental staff
Note
Strategies mentioned today is personalized to HAN Dental clinic
Current implemented strategies might be modified or changed in the
future as required in order to accommodate the need of our pts
THANK YOU
DAY TWOCLOSINGWRAP-UP
End of Day Two ndash Survey
Day Two Creating a Value-Based Oral Health Care Delivery
System
129
Payment Reform in Oral Health Online Learning Module
Oral Health Value-based Care Online Learning Module
Value-based Care Keys to Success Article
Readiness Assessment
Competency Development Guide
Oral Health Value-based Care Training
Dental Caries Management Practicum
Clinicians Companion Guide
Interprofessional Network Referral Process
Traditional Dental Care Vs Value-Based Care
Resources
131
wwwDentaQuestPartnershiporg
wwwfacebookcomDentaQuest
DentaQuest
wwwlinkedincomcompanyDentaQuest
Inside_DentaQuest
QUESTIONS
15
Todayrsquos Agenda
bull Discuss value-based health and pay-for-performance approaches to health
systems and the integral building block of data
bull Dive deep into the emerging field of value-based care measurement and
data in oral health from national and statewide perspectives
bull Present oral health and clinical measurement approaches and relate to
oversight
16
bull Consultant working with DQP FQHCs Primary Care Associations and Foundations advancing oral health programs
bull DQPSNS Expert Advisor
bull IHI Improvement Coach
bull Former Dental Director
bull Research Marketing Finance
Carolyn Brown DDS
Consultant Acting Director of Value-Based Care
DentaQuest Partnership for Oral Health Advancement
bull DDS University of Maryland School of Dentistry
bull MAEd University of the Pacific
bull BS University of Maryland
bull Speaker researcher expert advisor review panel
17
Poll What do you measure
A Dental provider productivity per day
B Treatment plan completion
C Dental new patient exams
D Combination of A-C
E No Shows
F Sealants only
18
Population
Prevention
Healthy
Minimally Invasive
Health outcomes
MDI
EHR EDR
PCC
Risk Assessment
19
VALUE-BASED CAREPushing the impact quality and quantity of measurement
20
OHVBC Readiness
Leadership
Value of oral health and oral health transformation
Structure Systems and Operations
Efficiencies innovative care delivery
Care Pathways and Provider Buy-In
Risk-based care Training patient engagement
Data and Analytic Technology and Personnel
DataReports Interoperability
Financial Viability and Strength
Payerpatient mix billing infrastructure
httpswwwdentaquestpartnershiporglearnsafety-net-solutionsoral-health-value-based-careohvbc-readiness-
assessment
21
DentaQuest Partnership OHVBC Survey
Barriers to Value-based Transformation in Oral Health ndash
Most Common Responses
bull Patient engagement
bull EHREDR
bull Tracking outcomes lack of nationally-recognized and standardized quality
metrics in dental
22
How Can FQHC Dental Programs Prepare for Value-based
Transformation in Oral Health
bull Begin or continue focusing on prevention disease management and risk-based care
bull Hygienists will be key to success ndash We need primary dental care not just surgical
interventions
bull Start measuring outcomes instead of just processutilization metrics bull of initially high-risk patients with new caries lesions
bull of initially high-risk patients with decreased risk status
bull of initially low-risk patients with risk status maintained
bull Address patient engagement in a more meaningful way and invest in case
management
bull Invest in interprofessional practice including HIT interoperability
bull Evaluate how services are being delivered and determine if its reaching the patients
who need care the most
23
Value-Based Care
Care Coordination
ldquoClosing outrdquo referrals
Diagnostic coding
Risk Screenings
Care plans based on risk
Patient Engagement
Incentive payments
Quality metrics
Clinic Response
Case Management IT
Active timely records mngt
Mapping Dx codes to CDT
Time bill CPT codes Tx plan
IPP data tofrom PC MH
Recall window important
Attention to $ related metrics
Attention to assigned metrics
Direct and Indirect Effects of VBC on Dental Systems of Care
Utilization Impact
New workforce CDT codes
New or + workforce IT
ICD-CM-10 codes
+CDT codes
Modifiers (CPT ICD10)
+ recall adherence
in incentivized procedures
in sealant POC A1C
Counseling codes SD
24
MEASUREMENT IN ORAL HEALTH
25
Poll What percentage of your adult dental patients are diabetic
or pre-diabetic
A 50-80
B 20-50
C Less than 20
D Not sure
26
27
ldquoTrue Measures of Successrdquo
1 Define your governing objective
2 Develop a theory of cause and effect to assess presumed drivers of the
objective
3 Identify the specific activities that employees can do to help achieve the
governing objective
4 Evaluate your statistics
5 Communicate the story of your measurement
Adapted from HBR ldquoThe True Measures of Successrdquo httpshbrorg201210the-true-measures-of-success
28
1 Governing objective
2 Theory of cause and effect
3 Activities of team
4 Evaluate your statistics
5 Storycraft
Sustainability
Clinic revenuegt expenses= sustainability
Patient compliance Assets Clinic Mngt
Care team Operations Pt Support Billing
Of Prod on and type Patients on time
Daily weekly monthly quarterly
ldquoTrue Measures of Successrdquo
Adapted from HBR ldquoThe True Measures of Successrdquo httpshbrorg201210the-true-measures-of-success
29
Measuring Risk and Health
November is Diabetes Awareness Month- 2019Communication Plans are as
important as cold hard numbers
Patients
Care Team
Other Health Teams
Executive Team
Funders
Data on your dental patients are medical patients of record
Data on your medical + dental patients with DM2
30
Develop Diabetic Patient
Protocols
Review evidence and rationale with dental team
Partner with primary care team
bull Protocols Care mngt Tests and Recording
Quality Goals
Protocols for newly screened and existing patients
Educate and train dental team in reading AND
charting test results and PILOT
31
External Measurement in Oral Health Programs
httpswwwadaorg~mediaADADQA2019_DiabetesOralEvaluationpdfla=en
httpswwworegongovohaHPAANALYTICSCCOMetrics2019-Oral-Evaluation-Adults-Diabetespdf
32
Baseline for 2019 271
httpswwworegongovohaHPAANALYTICSCCOMetrics2019-Oral-Evaluation-Adults-Diabetespdf
33
Diabetes burden in your panel of dental patients
Baseline Medical-Dental Integrated panel of all patients
Dental patients with DM2 MDI
Dental patients with DM2
1000 or 10
600 or 60
300010000= 30
Population Health- Clinic Level
34
1 Governing objective
2 Theory of cause and effect
3 Activities of team
4 Evaluate your statistics
5 Storycraft
Discuss at meetings (Oct + Nov) Health education training
materials NP training CQI Note in Board report Clinical
measures
Care Pathways Hygiene Resources (ScheduleAvail)
ldquoTrue Measures of Successrdquo
Adapted from HBR ldquoThe True Measures of Successrdquo httpshbrorg201210the-true-measures-of-success
Diabetes Awareness Prevention Healthier Community
Prevention Awareness Care Pathway promotes health
MDI= 10 6 out of 10 adult patients with DM2
Goal set for integrated patient panels ndash PCMH
Pre-diabetes approach for executive team
Care Pathways
Care Coordination
35
MEASURING PATIENT ORAL HEALTHRisk assessments and Care Pathways
36
37
Risk Assessment and Care Pathways
Caries Risk Assessment
Multiple tools
EDREHR modules smart notes or dot phrases
CDT Codes
Decide frequency
D0601
Low Caries Risk
D0601
Moderate Caries Risk
D0601
High Caries Risk
38
The Disease Management DifferenceDisease Management Difference
Traditional Dental Care Disease Management
Approach
All patients return in 6 months
regardless of risk status
Recare interval is based on the
childrsquos caries risk
Caries Risk
Level
Recommended
Recare Interval
High Risk 1 ndash 3 months
Moderate Risk 3 ndash 6 months
Low Risk 6 ndash 12 months
Caries
Stabilizing
agents
Health Ed
Nutritional
Counseling
Anti-bacterial
and Fluoride
interventions
39
Disease Management Care Pathways
DentaQuest Partnership for Oral Health Advancement Disease Management Model
Caries
Stabilizing
agents
Whole
Person
Inter-
professional
Approaches
Anti-bacterial
and Fluoride
interventions
40
Disease Management and Risk Screening Training
DentaQuest Partnership for Oral Health Advancementrsquos
Online Learning Center
Disease Management Series
8 modules 40 CDE available
httpswwwdentaquestpartnershiporglearnonline-learning-centeronline-
coursewaredentaquest-disease-management-series
41
MEASUREMENT IN TEAMSSharing meaningful data with your dental clinical teams
42
rdquoDental Homerdquo = Health Home where WE can meet the patient
Oralhealthworkforceorg
43
POLL HOW OFTEN DO YOU SHARE YOUR S WITH YOUR DENTAL TEAM
A Yearly only
B Quarterly
C Monthly
D Weekly
E Daily
44
Clinical Measures ndash Dental Practice Perspective
Private Practice Office
New patients seen
Assigned vs seen if capitated
Treatment plans incomplete
$ produced amp per provider
$ collected amp monthly per provider
CDT 6000 codes completed
RecallHygiene maintenance
Based on this consultants experienced
FQHC
Unduplicated patients
patients seen per day
Treatment plans complete
$ gainedlost via accounting
Broken appointment rate
procedures
Sealant rate (annual)
45
bull HRSA Sealant Measure Compliance for FQHCs
bull Completion of phase 1 treatment plans
bull Children seen 0-5 years old
bull Children seen getting a preventive service
bull Fluoride Varnish applications
bull Pregnant women seen and treated
bull Diabetic patients with HbA1C gt 7 seen
bull Patients seen who have not been seen for 12 months
bull Patients seen getting a Risk Assessment
bull Patients with moderate or high risk who lower risk at recare
bull Sealants provided httpwwwnnohaorgnnoha-contentuploads201512Demystifying-HRSA-SEALANT-PRESENTATION_FINALpdf
Program Measures
46
HRSA Performance Measurement and Data Collection
bull FQHCs and look-alikes submit CY data to HRSA since 2008
bull UDS Uniform Data System
bull Require FTE for clinical staff patient demographics
bull Dental utilization s (UDCTPV)
bull Dental Clinical Measure dental sealants placed on 1st molars ages 6-9 yo
bull Health Center Quartile rankings (Clinical measure performance influences
HC rankings as does EHR adoption and other HC characteristics)
47
Low birth weight
Access to prenatal care
Childhood Immunization
Children (Ages 3-17) Receiving
Weight Assessment amp
Counseling
Children (Age 6-9) Receiving
Dental Sealant to First Molars
Diabetes Control
Hypertension Control
Pap Test
Depression Screening and
Follow-up (Age 12+)
Asthma Patients (Age 5-40)
Receiving Pharmacologic
Therapy
Colorectal Cancer
Screening (Ages 51-74)
HRSA UDS Clinical Measures
Adults (Age 18+) Receiving
Weight Screening amp Follow-up
Adults (Age 18+) Receiving
Tobacco Use Assessment and
Cessation Intervention
Coronary Artery Disease
Receiving Lipid Therapy (18+)
Ischemic Vascular Disease (IVD)
Receiving Aspirin Therapy (18+)
HIV Linkage to Care
48
Dashboards
Grants
Average
amp
Targets
Quality
Rev
Costs
Visits
Priority
Pop
Prevention
49
Dashboard- Provider Team Level
Patient
Compliance
Satisfaction
50
Case Study-
Incentives bonus round pools benchmark and improvement target goals risk-sharing possible later years
51
Qualitative Measurement
ldquoPatient engagement is the act of patients and providers working together
toward the end goal of improved patient wellnessrdquo
wwwpatientengagementhitcom
Access to Care
Patient Activation
Patient Satisfaction
Patient-Provider-Care Team Communication
Care Team Satisfaction
52
OHVBC Readiness
Leadership
bull Value of oral health and oral health transformation
Structure Systems and Operations
bull Operational efficiencies innovative care delivery methodologies
Care Pathways and Provider Buy-In
bull Training disease management risk-based care referrals IDC-10 coding patient engagement
Data and Analytic Technology and Personnel
bull Interoperability reporting
Financial Viability and Strength
bull Payerpatient mix billing infrastructure financial reports
httpswwwdentaquestpartnershiporglearnsafety-net-solutionsoral-health-value-based-careohvbc-readiness-
assessment
53
QUESTIONS COMMENTS
Carolyn Brown DDS
cbrownddsgmailcom
RISK BASED MANAGED CARE
Value Based Training Conference
Manchester New Hampshire
Mark Koday DDS
111919
5555
Objectives
bull Review current drivers of dental managed care
bull Understand the basics of risk-based dental managed care contracts
bull Learn the basics of managing costs in a riskndashbased contract
bull Gain an understanding in the potential advantage of risk-based contracting
56
What Is Dental Managed Care
Managed care is a health delivery system whose purpose is to manage both the
quality and cost of health care
Common types of managed care health insurance plans
bull HMOs
bull PPOs
bull POSs
bull Medicaid Managed Care
DIDNrsquoT WE ALREADY HAVE MANAGED CARE AND IT FAILED
57
What Has Happened Since the 90s
58
WHY THE FFS AND PPS DOESNrsquoT WORK FOR OUR POPULATIONS
bull Inefficient payment systems designed to produce encounters or procedures but not real health
bull No focus on population health
bull Does not incentivize innovation
bull Patients essentially on their own for accessing specialty care
59
Rule of 4
Source Kaiser Family Foundation analysis of National Health Expenditure (NHE) data from Centers for
Medicare and Medicaid Services Office of the Actuary National Health Statistics Group
60
Rule of 4
bull This helps explain why oral health has been relatively ignored so far by CMS
bull Explains why we have PCMH instead of PCHH
bull Where is the real value on a national level in preventing disease and
controlling costs
bull Beware- wersquove been found
61
Reasons Dental Managed Care is Spreading Across the States
NON-MANAGED CARE STATE DENTAL BUDGETS ARE
OPENED ENDED
STRAIN ON STATE BUDGETS
UPCOMING RECESSION WITH TRILLION DOLLAR
DEFICIT
SHIFTS FINANCIAL RISK FROM THE STATES TO THE
PLANS
6262
Types of Medicaid Managed Care
bull State Medicaid agency administrator lowest administrative
costs
bull Third Party Administrator Typically 15 administrative costs
bull Managed Care Organization Typically 15 administrative
costs
bull Carved-in
bull Carved-out
bull Risk Based Managed Care Administrative costs part of
contract negotiation
63
RISK CONTRACTS
6464
Components of a Risk-based Contract
Risk
Medical Loss Ratio
Quality withhold
Specialty withhold
Managed care payment (pmpm)
Covered services
Fee schedule Claims are paid as usual on a FFS basis
Credentialing
Quality Review process and Quality Metrics
65
Upside Risk
The possibility that the cost of
delivering dental care to an assigned
patient panel is less than the amount
of funding calculated for that care
The Plan pays the CHC additional
funds based on a predetermine
formula
Downside Risk
The possibility that the cost of
delivering dental care to an assigned
patient panel is more than the amount
of funding calculated for that care
The CHC pays the Plan additional
funds based on a predetermine
formula
Upside and Downside Risk
66
Taking On Risk 100 or Shared Risk
With 100 risk you receive 100 of the potential savings but are also at risk for
100 of the losses
Shared Risk MCO and health center share a percentage of the risk
Shared Risk leads to better cooperation since both organizations are
incentivized to save on costs
6767
Reports Needed
bull Enrollment reports lists of who is assigned on a monthly basis
bull Reconciliation reports insure appropriate payments
bull Specialty Referral reports
bull You will need your own reporting process so you donrsquot rely completely on
reports supplied by the Plan
6868
Medical Loss Ratio
Medical Loss Ratio (MLR) is proportion of premium revenues spent on clinical
services and quality improvement also known as the Medical Loss Ratio (MLR)
For CMS requires Medical Plans to spend at least 80 to 85 of the premiums
on actual medical care
69
Administrative Fees
bull Essentially the opposite of MLR
bull The State Medicaid Agency is funded by the Governorrsquos budget
bull The State Medicaid Agency will keep some of these funds for their
admin costs and give the remaining to the Managed Care Plans
bull Private Plan admin costs can be as high as 40 but most states
limit these cost for Medicaid Plans to between 15 and 20 (85-
80 MLR)
bull This may be negotiable depending on your program size of your
program
70
Quality Withhold
bull The state withholds a certain percent (typically 2-4 ) of the funds they give
to the Plans for Value Based Reimbursement
bull They choose quality metrics and set benchmarks and assign payments for
each metric based on an assigned priority for each metric
bull If a Plan meets the benchmark of every quality metric the state passes on
their full share of the quality withhold
bull The Plans may or may not withhold a percent of the funds for quality payment
to the dentists or manage care contractors
71
Quality Withhold
Either way the Plans may or may not pass the quality payments they receive to
the dentists or contractors
This should be spelled out in a risk-based contract
72
Percent of funds set aside
to cover specialty care
referrals
Typically 10-15
Goal Limit referral costs
to within or less than
Specialty set aside
Specialty Withhold
73
Per Member Per Month
bull Capitated Payment
bull Specific dollar amount paid for each enrolled member each month
bull Paid whether patient is accessed for care or not
bull States do set access benchmarks
bull In Oregon access for any dental procedure (adults and children combined)
was 267 in 2015
74
Payment Math Example
Premium per enrollee = $25
Administrative fee 15 = $375
Funds available per enrollee to the clinic = $2125
Management fee per enrollee = $175
Funds per enrollee that would undergo PPS reconciliation = $1950
For every 10000 enrollees the managed care income = $2340000
Specialty withhold (10) = $234000
YE Cost lt or gt $2340000
Upside Risk
CHC Gains $
Downside Risk
CHC Loses $
75
Covered Services and Fee Schedules
bull The state Medicaid agency spells out the minimum procedures and fees that
MCOs must cover
bull MCOs may add procedures or increase periodicity of procedures particularly
preventative services
bull MCOs may increase fees to entice rural providers and specialists to enroll in
their Plans
bull Access Rules
bull How many days it takes to access a patent
bull How many days it takes for a patent to access urgent care services
bull How many days it takes for a patent to access emergency care services
76
Credentialing
All MCOs are required to credential all Providers
All MCOs have their own credentialing process
Credentialing process is can be lengthy
Credentialing process may be negotiable
77
Quality Review Process and Quality Metrics
MCOs must have a Quality and Compliance Review Process
If you arenrsquot in compliance with both you likely wonrsquot get paid
Typical processes reviewed
bull Charting specifications
bull Incident report
bull Enrollee complaints quality rudeness and access issues
bull Medicaid compliance
78
Quality Payments
bull State Shared Incentive Withhold Typically quality metrics and benchmarks
are set by the state sets aside a certain percent (3-5) of the payments to
the Managed Care Plan (MCP)
bull If the benchmarks are achieved the MCP is then paid the a predetermine
amount
bull Benchmarks may not be the same as the states
bull Managed Care Plans do not have to pass all or any of the quality payments to
the health centers or providers
bull Managed Care contract- Metrics benchmarks should be selected and part of
the contract
7979
Achieving Quality Metric Payments
Dealing with under achievers
Process issues
Individual issues
Identifying workflows
Developing Best Practices through
PDSA process
Developing Best Practices through
PDSA process
CHC Metrics Committee
Clinicians Operations various key staff
Identify Best Practices
Spread Best Practices
80
New Team Needed Business Intelligence
Business Intelligence (BI) is critical for effective managed care business decisions
BI team inputs metrics into your EHR collects integrates analyses and displays all your managed care business and clinical information
Easy to say- hard to achieve
Build your own or outsource
Possible future role of Primary Care Associations
8181
Clinicianrsquos Dashboard
Expensive to build
Displayed on your screen when your computer is first turned on
Easy to read and understand
Data dumped from the day before
Can dialed down from Org-wide to clinic to each clinicianrsquos data
Operational and clinical metrics
bull Treatment Plan Completion
bull DQA quality measures
bull Caries at Recall
bull Re-care reports
bull Care Gap reports
82
CONTROLLING COSTS
8383
Controlling Costs- Current
bull Increasing efficiencies
bull Decreasing broken appointments
bull Controlling supplies equipment costs
bull Staff recruitment retention costs
84
Specialty Care
Training current CHC dentists in
specialty areas
Hiring general dentists with higher
specialty skill sets
Hiring in house specialists
Contract with outside specialists
Work with Managed Care Plan
specialists
Lowering Disease Rates
Community Dental Health
Coordinators case management
If your state law allows- embed
hygienists in medical and community
to provide primary and secondary
prevention procedures
In clinic Caries Classification and
Silver Diamine Fluoride
Effective recare programs
Controlling Costs- Additions in Risk-based Contracting
85
Specialty Care ndash Primary Referrals by Cost
Pediatric dentistry
Orthodontics
Oral surgery
Endodontics
86
In-clinic Pediatric Services
Encounters expected
of operatories available
State dental law and ability to have
expanded duties
General Anesthesia
GA in- house
Ability for a hospital or surgery center
to set aside regular OR time
Ability to hire or assign DAs to GA
days
Four GA cases day x PPS rate
Should You Hire a Pediatric Dentist- It Depends
8787
Solutions for Controlling Pediatric Costs
Hire a general dentist that is skilled in treating young children
Make the clinic child friendly nitrous oxide TVs in the operatory etc
Teach entire staff behavioral control techniques
Contract with a pediatric dentist for the GA care
88
Lowering Overall Disease Rates (and Costs)
You are responsible for both the patients you see in the chair and the ones
assigned to you
Breaking down the walls of the dental clinic
Community Dental Health Coordinators
Case Management
89
Cost Control Essentials
Diagnosis codes
Increased ability to identify
disease by risk
Motivational
Interviewing
Developing Polices and
Procedures design to treat
disease according to risk
ie Silver Diamine Fluoride
Treating by Risk
Effective Recare
Process
Critical to continual disease
controlPrevention education that is
meaningful and designed to
change behaviors
90
Social Determinants of Health Aunt Bertha
httpswwwauntberthacom
91
REASON TO CONSIDER RISK- BASED CONTRACTING
9292
PPS Reconciliation and Federal Code 42 CFR sect4052469(a)(2)
42 CFR sect4052469(a)(2)
ldquoAny financial incentives provided to Federally Qualified Health Centers
under their Medicare Advantage Contracts such as risk pool payments
bonuses or withholds are prohibited from being included in the
calculation of supplemental payments due to the Federally Qualified
Health Centerrdquo
9393
Why Risk Based Contract in Times of PPS Reconciliation
bull Not all Risk- based Contract funds are reconciled
bull Risk is the key word- you can come out with less money than your normal
PPS reconciliation payment
bull Can lead to better patient care
bull May improve manage care enrollment for your medical plan
bull Promotes integrated care increases health for your CHC patients
9494
Not Included in the Reconciliation
Enrollment management pmpm
Quality Payments
Upside risk payments
Downside risk losses
9595
Determinants of Financial Success in Risk-Based Contracting
bull Most critical- State pmpm payment to the Managed Care Plan
bull Reporting capabilities
bull Specialty service capabilities
bull Access numbers count
bull Ability to move metric numbers
9696
What About the Non- Medicaid Poor We Serve
bull Numbers are king in a managed care contract and the more access you have
the better contract terms you can negotiate
bull We will potentially have a steady supply of Medicaid patients
bull As managed care spreads states this may be compromising the ability of
health centers to serve the non-Medicaid poor and others lacking dental
insurance
97
Mark Koday DDS
(509) 949-2278
Dental Quality Consultants
of WA
httpdentalqualityconsultin
gcom
dentalqualityconsultantsg
mailcom
Contact Information
LUNCH
BREAKOUT EXERCISEORAL HEALTH VALUE-BASED CARE READINESS ASSESSMENT
Danielle Apostolon
PROMISING PRACTICES FROM THE FIELD STRATEGIES FOR INCREASING VALUE IN ORAL HEALTH
Dr Carolyn Brown
Dr Kelly Perry
Dr Rachel Rivard
Dr Adeloye
Commitment Compassion Community
m i d s t a t e h e a l t h o r g
Promising Practices from the
Field Strategies for Increasing
Value in Oral Health Care
Kelly Perry DMD
Better Health
Outcomes
Improved Staff
Experience
Reduced Cost
Improved Patient
Experience
Better Health
Outcomes
Improved Staff
Experience
Reduced Cost
Improved Patient
Experience
Better Health
Outcomes
Improved Staff
Experience
Reduced Cost
Improved Patient
Experience
Better Health
Outcomes
Improved Staff
Experience
Reduced Cost
Improved Patient
Experience
Commitment Compassion Community
kpe r r ymids t a tehea l t h o rg
Thank you
Completion of Disease Control Phase
Pelumi Adeloye DMD MPH
HEALTH ACCESS NETWORK (HAN) FAMILY DENTAL
Introduction
⧫1 Dentist I Hygienist 3 EFDArsquos1 Receptionist
⧫ 6 Chairs= 4 (dentist) + 2 (hygienist)
⧫ Slide ⥶80 off
⧫ Service areas Northern Penobscot Southern Aroostook Western
Washington Counties amp more
Completion of Phase I Treatment
⧫LimitedLack of Access to dental care
⧫Difficulty completing the disease control phase
Caries amp periodontal disease
⧫Attaining stable restorative state
Goal
Increase the completion of Disease Control Phase
Current practice
⧫Education
Assess level of dental literacy
Incremental strategy
⧫Increase access to dental care
Generous sliding scale (⥸$40 per visit)
Incorporate Expanded Function Dental Assistants
⧫Schedule modification
Incorporate more restorative blocks to allow
for follow-up visit and completion of restorative phase
httpswwwglasbergencomdentist-cartoons
Schedule
⧫Piggybacking technique
Increased allotted restorative blocks
⧫Sustainability of current schedule is
contingent on cooperation amp skills of HAN
Dental staff
Note
Strategies mentioned today is personalized to HAN Dental clinic
Current implemented strategies might be modified or changed in the
future as required in order to accommodate the need of our pts
THANK YOU
DAY TWOCLOSINGWRAP-UP
End of Day Two ndash Survey
Day Two Creating a Value-Based Oral Health Care Delivery
System
129
Payment Reform in Oral Health Online Learning Module
Oral Health Value-based Care Online Learning Module
Value-based Care Keys to Success Article
Readiness Assessment
Competency Development Guide
Oral Health Value-based Care Training
Dental Caries Management Practicum
Clinicians Companion Guide
Interprofessional Network Referral Process
Traditional Dental Care Vs Value-Based Care
Resources
131
wwwDentaQuestPartnershiporg
wwwfacebookcomDentaQuest
DentaQuest
wwwlinkedincomcompanyDentaQuest
Inside_DentaQuest
QUESTIONS
16
bull Consultant working with DQP FQHCs Primary Care Associations and Foundations advancing oral health programs
bull DQPSNS Expert Advisor
bull IHI Improvement Coach
bull Former Dental Director
bull Research Marketing Finance
Carolyn Brown DDS
Consultant Acting Director of Value-Based Care
DentaQuest Partnership for Oral Health Advancement
bull DDS University of Maryland School of Dentistry
bull MAEd University of the Pacific
bull BS University of Maryland
bull Speaker researcher expert advisor review panel
17
Poll What do you measure
A Dental provider productivity per day
B Treatment plan completion
C Dental new patient exams
D Combination of A-C
E No Shows
F Sealants only
18
Population
Prevention
Healthy
Minimally Invasive
Health outcomes
MDI
EHR EDR
PCC
Risk Assessment
19
VALUE-BASED CAREPushing the impact quality and quantity of measurement
20
OHVBC Readiness
Leadership
Value of oral health and oral health transformation
Structure Systems and Operations
Efficiencies innovative care delivery
Care Pathways and Provider Buy-In
Risk-based care Training patient engagement
Data and Analytic Technology and Personnel
DataReports Interoperability
Financial Viability and Strength
Payerpatient mix billing infrastructure
httpswwwdentaquestpartnershiporglearnsafety-net-solutionsoral-health-value-based-careohvbc-readiness-
assessment
21
DentaQuest Partnership OHVBC Survey
Barriers to Value-based Transformation in Oral Health ndash
Most Common Responses
bull Patient engagement
bull EHREDR
bull Tracking outcomes lack of nationally-recognized and standardized quality
metrics in dental
22
How Can FQHC Dental Programs Prepare for Value-based
Transformation in Oral Health
bull Begin or continue focusing on prevention disease management and risk-based care
bull Hygienists will be key to success ndash We need primary dental care not just surgical
interventions
bull Start measuring outcomes instead of just processutilization metrics bull of initially high-risk patients with new caries lesions
bull of initially high-risk patients with decreased risk status
bull of initially low-risk patients with risk status maintained
bull Address patient engagement in a more meaningful way and invest in case
management
bull Invest in interprofessional practice including HIT interoperability
bull Evaluate how services are being delivered and determine if its reaching the patients
who need care the most
23
Value-Based Care
Care Coordination
ldquoClosing outrdquo referrals
Diagnostic coding
Risk Screenings
Care plans based on risk
Patient Engagement
Incentive payments
Quality metrics
Clinic Response
Case Management IT
Active timely records mngt
Mapping Dx codes to CDT
Time bill CPT codes Tx plan
IPP data tofrom PC MH
Recall window important
Attention to $ related metrics
Attention to assigned metrics
Direct and Indirect Effects of VBC on Dental Systems of Care
Utilization Impact
New workforce CDT codes
New or + workforce IT
ICD-CM-10 codes
+CDT codes
Modifiers (CPT ICD10)
+ recall adherence
in incentivized procedures
in sealant POC A1C
Counseling codes SD
24
MEASUREMENT IN ORAL HEALTH
25
Poll What percentage of your adult dental patients are diabetic
or pre-diabetic
A 50-80
B 20-50
C Less than 20
D Not sure
26
27
ldquoTrue Measures of Successrdquo
1 Define your governing objective
2 Develop a theory of cause and effect to assess presumed drivers of the
objective
3 Identify the specific activities that employees can do to help achieve the
governing objective
4 Evaluate your statistics
5 Communicate the story of your measurement
Adapted from HBR ldquoThe True Measures of Successrdquo httpshbrorg201210the-true-measures-of-success
28
1 Governing objective
2 Theory of cause and effect
3 Activities of team
4 Evaluate your statistics
5 Storycraft
Sustainability
Clinic revenuegt expenses= sustainability
Patient compliance Assets Clinic Mngt
Care team Operations Pt Support Billing
Of Prod on and type Patients on time
Daily weekly monthly quarterly
ldquoTrue Measures of Successrdquo
Adapted from HBR ldquoThe True Measures of Successrdquo httpshbrorg201210the-true-measures-of-success
29
Measuring Risk and Health
November is Diabetes Awareness Month- 2019Communication Plans are as
important as cold hard numbers
Patients
Care Team
Other Health Teams
Executive Team
Funders
Data on your dental patients are medical patients of record
Data on your medical + dental patients with DM2
30
Develop Diabetic Patient
Protocols
Review evidence and rationale with dental team
Partner with primary care team
bull Protocols Care mngt Tests and Recording
Quality Goals
Protocols for newly screened and existing patients
Educate and train dental team in reading AND
charting test results and PILOT
31
External Measurement in Oral Health Programs
httpswwwadaorg~mediaADADQA2019_DiabetesOralEvaluationpdfla=en
httpswwworegongovohaHPAANALYTICSCCOMetrics2019-Oral-Evaluation-Adults-Diabetespdf
32
Baseline for 2019 271
httpswwworegongovohaHPAANALYTICSCCOMetrics2019-Oral-Evaluation-Adults-Diabetespdf
33
Diabetes burden in your panel of dental patients
Baseline Medical-Dental Integrated panel of all patients
Dental patients with DM2 MDI
Dental patients with DM2
1000 or 10
600 or 60
300010000= 30
Population Health- Clinic Level
34
1 Governing objective
2 Theory of cause and effect
3 Activities of team
4 Evaluate your statistics
5 Storycraft
Discuss at meetings (Oct + Nov) Health education training
materials NP training CQI Note in Board report Clinical
measures
Care Pathways Hygiene Resources (ScheduleAvail)
ldquoTrue Measures of Successrdquo
Adapted from HBR ldquoThe True Measures of Successrdquo httpshbrorg201210the-true-measures-of-success
Diabetes Awareness Prevention Healthier Community
Prevention Awareness Care Pathway promotes health
MDI= 10 6 out of 10 adult patients with DM2
Goal set for integrated patient panels ndash PCMH
Pre-diabetes approach for executive team
Care Pathways
Care Coordination
35
MEASURING PATIENT ORAL HEALTHRisk assessments and Care Pathways
36
37
Risk Assessment and Care Pathways
Caries Risk Assessment
Multiple tools
EDREHR modules smart notes or dot phrases
CDT Codes
Decide frequency
D0601
Low Caries Risk
D0601
Moderate Caries Risk
D0601
High Caries Risk
38
The Disease Management DifferenceDisease Management Difference
Traditional Dental Care Disease Management
Approach
All patients return in 6 months
regardless of risk status
Recare interval is based on the
childrsquos caries risk
Caries Risk
Level
Recommended
Recare Interval
High Risk 1 ndash 3 months
Moderate Risk 3 ndash 6 months
Low Risk 6 ndash 12 months
Caries
Stabilizing
agents
Health Ed
Nutritional
Counseling
Anti-bacterial
and Fluoride
interventions
39
Disease Management Care Pathways
DentaQuest Partnership for Oral Health Advancement Disease Management Model
Caries
Stabilizing
agents
Whole
Person
Inter-
professional
Approaches
Anti-bacterial
and Fluoride
interventions
40
Disease Management and Risk Screening Training
DentaQuest Partnership for Oral Health Advancementrsquos
Online Learning Center
Disease Management Series
8 modules 40 CDE available
httpswwwdentaquestpartnershiporglearnonline-learning-centeronline-
coursewaredentaquest-disease-management-series
41
MEASUREMENT IN TEAMSSharing meaningful data with your dental clinical teams
42
rdquoDental Homerdquo = Health Home where WE can meet the patient
Oralhealthworkforceorg
43
POLL HOW OFTEN DO YOU SHARE YOUR S WITH YOUR DENTAL TEAM
A Yearly only
B Quarterly
C Monthly
D Weekly
E Daily
44
Clinical Measures ndash Dental Practice Perspective
Private Practice Office
New patients seen
Assigned vs seen if capitated
Treatment plans incomplete
$ produced amp per provider
$ collected amp monthly per provider
CDT 6000 codes completed
RecallHygiene maintenance
Based on this consultants experienced
FQHC
Unduplicated patients
patients seen per day
Treatment plans complete
$ gainedlost via accounting
Broken appointment rate
procedures
Sealant rate (annual)
45
bull HRSA Sealant Measure Compliance for FQHCs
bull Completion of phase 1 treatment plans
bull Children seen 0-5 years old
bull Children seen getting a preventive service
bull Fluoride Varnish applications
bull Pregnant women seen and treated
bull Diabetic patients with HbA1C gt 7 seen
bull Patients seen who have not been seen for 12 months
bull Patients seen getting a Risk Assessment
bull Patients with moderate or high risk who lower risk at recare
bull Sealants provided httpwwwnnohaorgnnoha-contentuploads201512Demystifying-HRSA-SEALANT-PRESENTATION_FINALpdf
Program Measures
46
HRSA Performance Measurement and Data Collection
bull FQHCs and look-alikes submit CY data to HRSA since 2008
bull UDS Uniform Data System
bull Require FTE for clinical staff patient demographics
bull Dental utilization s (UDCTPV)
bull Dental Clinical Measure dental sealants placed on 1st molars ages 6-9 yo
bull Health Center Quartile rankings (Clinical measure performance influences
HC rankings as does EHR adoption and other HC characteristics)
47
Low birth weight
Access to prenatal care
Childhood Immunization
Children (Ages 3-17) Receiving
Weight Assessment amp
Counseling
Children (Age 6-9) Receiving
Dental Sealant to First Molars
Diabetes Control
Hypertension Control
Pap Test
Depression Screening and
Follow-up (Age 12+)
Asthma Patients (Age 5-40)
Receiving Pharmacologic
Therapy
Colorectal Cancer
Screening (Ages 51-74)
HRSA UDS Clinical Measures
Adults (Age 18+) Receiving
Weight Screening amp Follow-up
Adults (Age 18+) Receiving
Tobacco Use Assessment and
Cessation Intervention
Coronary Artery Disease
Receiving Lipid Therapy (18+)
Ischemic Vascular Disease (IVD)
Receiving Aspirin Therapy (18+)
HIV Linkage to Care
48
Dashboards
Grants
Average
amp
Targets
Quality
Rev
Costs
Visits
Priority
Pop
Prevention
49
Dashboard- Provider Team Level
Patient
Compliance
Satisfaction
50
Case Study-
Incentives bonus round pools benchmark and improvement target goals risk-sharing possible later years
51
Qualitative Measurement
ldquoPatient engagement is the act of patients and providers working together
toward the end goal of improved patient wellnessrdquo
wwwpatientengagementhitcom
Access to Care
Patient Activation
Patient Satisfaction
Patient-Provider-Care Team Communication
Care Team Satisfaction
52
OHVBC Readiness
Leadership
bull Value of oral health and oral health transformation
Structure Systems and Operations
bull Operational efficiencies innovative care delivery methodologies
Care Pathways and Provider Buy-In
bull Training disease management risk-based care referrals IDC-10 coding patient engagement
Data and Analytic Technology and Personnel
bull Interoperability reporting
Financial Viability and Strength
bull Payerpatient mix billing infrastructure financial reports
httpswwwdentaquestpartnershiporglearnsafety-net-solutionsoral-health-value-based-careohvbc-readiness-
assessment
53
QUESTIONS COMMENTS
Carolyn Brown DDS
cbrownddsgmailcom
RISK BASED MANAGED CARE
Value Based Training Conference
Manchester New Hampshire
Mark Koday DDS
111919
5555
Objectives
bull Review current drivers of dental managed care
bull Understand the basics of risk-based dental managed care contracts
bull Learn the basics of managing costs in a riskndashbased contract
bull Gain an understanding in the potential advantage of risk-based contracting
56
What Is Dental Managed Care
Managed care is a health delivery system whose purpose is to manage both the
quality and cost of health care
Common types of managed care health insurance plans
bull HMOs
bull PPOs
bull POSs
bull Medicaid Managed Care
DIDNrsquoT WE ALREADY HAVE MANAGED CARE AND IT FAILED
57
What Has Happened Since the 90s
58
WHY THE FFS AND PPS DOESNrsquoT WORK FOR OUR POPULATIONS
bull Inefficient payment systems designed to produce encounters or procedures but not real health
bull No focus on population health
bull Does not incentivize innovation
bull Patients essentially on their own for accessing specialty care
59
Rule of 4
Source Kaiser Family Foundation analysis of National Health Expenditure (NHE) data from Centers for
Medicare and Medicaid Services Office of the Actuary National Health Statistics Group
60
Rule of 4
bull This helps explain why oral health has been relatively ignored so far by CMS
bull Explains why we have PCMH instead of PCHH
bull Where is the real value on a national level in preventing disease and
controlling costs
bull Beware- wersquove been found
61
Reasons Dental Managed Care is Spreading Across the States
NON-MANAGED CARE STATE DENTAL BUDGETS ARE
OPENED ENDED
STRAIN ON STATE BUDGETS
UPCOMING RECESSION WITH TRILLION DOLLAR
DEFICIT
SHIFTS FINANCIAL RISK FROM THE STATES TO THE
PLANS
6262
Types of Medicaid Managed Care
bull State Medicaid agency administrator lowest administrative
costs
bull Third Party Administrator Typically 15 administrative costs
bull Managed Care Organization Typically 15 administrative
costs
bull Carved-in
bull Carved-out
bull Risk Based Managed Care Administrative costs part of
contract negotiation
63
RISK CONTRACTS
6464
Components of a Risk-based Contract
Risk
Medical Loss Ratio
Quality withhold
Specialty withhold
Managed care payment (pmpm)
Covered services
Fee schedule Claims are paid as usual on a FFS basis
Credentialing
Quality Review process and Quality Metrics
65
Upside Risk
The possibility that the cost of
delivering dental care to an assigned
patient panel is less than the amount
of funding calculated for that care
The Plan pays the CHC additional
funds based on a predetermine
formula
Downside Risk
The possibility that the cost of
delivering dental care to an assigned
patient panel is more than the amount
of funding calculated for that care
The CHC pays the Plan additional
funds based on a predetermine
formula
Upside and Downside Risk
66
Taking On Risk 100 or Shared Risk
With 100 risk you receive 100 of the potential savings but are also at risk for
100 of the losses
Shared Risk MCO and health center share a percentage of the risk
Shared Risk leads to better cooperation since both organizations are
incentivized to save on costs
6767
Reports Needed
bull Enrollment reports lists of who is assigned on a monthly basis
bull Reconciliation reports insure appropriate payments
bull Specialty Referral reports
bull You will need your own reporting process so you donrsquot rely completely on
reports supplied by the Plan
6868
Medical Loss Ratio
Medical Loss Ratio (MLR) is proportion of premium revenues spent on clinical
services and quality improvement also known as the Medical Loss Ratio (MLR)
For CMS requires Medical Plans to spend at least 80 to 85 of the premiums
on actual medical care
69
Administrative Fees
bull Essentially the opposite of MLR
bull The State Medicaid Agency is funded by the Governorrsquos budget
bull The State Medicaid Agency will keep some of these funds for their
admin costs and give the remaining to the Managed Care Plans
bull Private Plan admin costs can be as high as 40 but most states
limit these cost for Medicaid Plans to between 15 and 20 (85-
80 MLR)
bull This may be negotiable depending on your program size of your
program
70
Quality Withhold
bull The state withholds a certain percent (typically 2-4 ) of the funds they give
to the Plans for Value Based Reimbursement
bull They choose quality metrics and set benchmarks and assign payments for
each metric based on an assigned priority for each metric
bull If a Plan meets the benchmark of every quality metric the state passes on
their full share of the quality withhold
bull The Plans may or may not withhold a percent of the funds for quality payment
to the dentists or manage care contractors
71
Quality Withhold
Either way the Plans may or may not pass the quality payments they receive to
the dentists or contractors
This should be spelled out in a risk-based contract
72
Percent of funds set aside
to cover specialty care
referrals
Typically 10-15
Goal Limit referral costs
to within or less than
Specialty set aside
Specialty Withhold
73
Per Member Per Month
bull Capitated Payment
bull Specific dollar amount paid for each enrolled member each month
bull Paid whether patient is accessed for care or not
bull States do set access benchmarks
bull In Oregon access for any dental procedure (adults and children combined)
was 267 in 2015
74
Payment Math Example
Premium per enrollee = $25
Administrative fee 15 = $375
Funds available per enrollee to the clinic = $2125
Management fee per enrollee = $175
Funds per enrollee that would undergo PPS reconciliation = $1950
For every 10000 enrollees the managed care income = $2340000
Specialty withhold (10) = $234000
YE Cost lt or gt $2340000
Upside Risk
CHC Gains $
Downside Risk
CHC Loses $
75
Covered Services and Fee Schedules
bull The state Medicaid agency spells out the minimum procedures and fees that
MCOs must cover
bull MCOs may add procedures or increase periodicity of procedures particularly
preventative services
bull MCOs may increase fees to entice rural providers and specialists to enroll in
their Plans
bull Access Rules
bull How many days it takes to access a patent
bull How many days it takes for a patent to access urgent care services
bull How many days it takes for a patent to access emergency care services
76
Credentialing
All MCOs are required to credential all Providers
All MCOs have their own credentialing process
Credentialing process is can be lengthy
Credentialing process may be negotiable
77
Quality Review Process and Quality Metrics
MCOs must have a Quality and Compliance Review Process
If you arenrsquot in compliance with both you likely wonrsquot get paid
Typical processes reviewed
bull Charting specifications
bull Incident report
bull Enrollee complaints quality rudeness and access issues
bull Medicaid compliance
78
Quality Payments
bull State Shared Incentive Withhold Typically quality metrics and benchmarks
are set by the state sets aside a certain percent (3-5) of the payments to
the Managed Care Plan (MCP)
bull If the benchmarks are achieved the MCP is then paid the a predetermine
amount
bull Benchmarks may not be the same as the states
bull Managed Care Plans do not have to pass all or any of the quality payments to
the health centers or providers
bull Managed Care contract- Metrics benchmarks should be selected and part of
the contract
7979
Achieving Quality Metric Payments
Dealing with under achievers
Process issues
Individual issues
Identifying workflows
Developing Best Practices through
PDSA process
Developing Best Practices through
PDSA process
CHC Metrics Committee
Clinicians Operations various key staff
Identify Best Practices
Spread Best Practices
80
New Team Needed Business Intelligence
Business Intelligence (BI) is critical for effective managed care business decisions
BI team inputs metrics into your EHR collects integrates analyses and displays all your managed care business and clinical information
Easy to say- hard to achieve
Build your own or outsource
Possible future role of Primary Care Associations
8181
Clinicianrsquos Dashboard
Expensive to build
Displayed on your screen when your computer is first turned on
Easy to read and understand
Data dumped from the day before
Can dialed down from Org-wide to clinic to each clinicianrsquos data
Operational and clinical metrics
bull Treatment Plan Completion
bull DQA quality measures
bull Caries at Recall
bull Re-care reports
bull Care Gap reports
82
CONTROLLING COSTS
8383
Controlling Costs- Current
bull Increasing efficiencies
bull Decreasing broken appointments
bull Controlling supplies equipment costs
bull Staff recruitment retention costs
84
Specialty Care
Training current CHC dentists in
specialty areas
Hiring general dentists with higher
specialty skill sets
Hiring in house specialists
Contract with outside specialists
Work with Managed Care Plan
specialists
Lowering Disease Rates
Community Dental Health
Coordinators case management
If your state law allows- embed
hygienists in medical and community
to provide primary and secondary
prevention procedures
In clinic Caries Classification and
Silver Diamine Fluoride
Effective recare programs
Controlling Costs- Additions in Risk-based Contracting
85
Specialty Care ndash Primary Referrals by Cost
Pediatric dentistry
Orthodontics
Oral surgery
Endodontics
86
In-clinic Pediatric Services
Encounters expected
of operatories available
State dental law and ability to have
expanded duties
General Anesthesia
GA in- house
Ability for a hospital or surgery center
to set aside regular OR time
Ability to hire or assign DAs to GA
days
Four GA cases day x PPS rate
Should You Hire a Pediatric Dentist- It Depends
8787
Solutions for Controlling Pediatric Costs
Hire a general dentist that is skilled in treating young children
Make the clinic child friendly nitrous oxide TVs in the operatory etc
Teach entire staff behavioral control techniques
Contract with a pediatric dentist for the GA care
88
Lowering Overall Disease Rates (and Costs)
You are responsible for both the patients you see in the chair and the ones
assigned to you
Breaking down the walls of the dental clinic
Community Dental Health Coordinators
Case Management
89
Cost Control Essentials
Diagnosis codes
Increased ability to identify
disease by risk
Motivational
Interviewing
Developing Polices and
Procedures design to treat
disease according to risk
ie Silver Diamine Fluoride
Treating by Risk
Effective Recare
Process
Critical to continual disease
controlPrevention education that is
meaningful and designed to
change behaviors
90
Social Determinants of Health Aunt Bertha
httpswwwauntberthacom
91
REASON TO CONSIDER RISK- BASED CONTRACTING
9292
PPS Reconciliation and Federal Code 42 CFR sect4052469(a)(2)
42 CFR sect4052469(a)(2)
ldquoAny financial incentives provided to Federally Qualified Health Centers
under their Medicare Advantage Contracts such as risk pool payments
bonuses or withholds are prohibited from being included in the
calculation of supplemental payments due to the Federally Qualified
Health Centerrdquo
9393
Why Risk Based Contract in Times of PPS Reconciliation
bull Not all Risk- based Contract funds are reconciled
bull Risk is the key word- you can come out with less money than your normal
PPS reconciliation payment
bull Can lead to better patient care
bull May improve manage care enrollment for your medical plan
bull Promotes integrated care increases health for your CHC patients
9494
Not Included in the Reconciliation
Enrollment management pmpm
Quality Payments
Upside risk payments
Downside risk losses
9595
Determinants of Financial Success in Risk-Based Contracting
bull Most critical- State pmpm payment to the Managed Care Plan
bull Reporting capabilities
bull Specialty service capabilities
bull Access numbers count
bull Ability to move metric numbers
9696
What About the Non- Medicaid Poor We Serve
bull Numbers are king in a managed care contract and the more access you have
the better contract terms you can negotiate
bull We will potentially have a steady supply of Medicaid patients
bull As managed care spreads states this may be compromising the ability of
health centers to serve the non-Medicaid poor and others lacking dental
insurance
97
Mark Koday DDS
(509) 949-2278
Dental Quality Consultants
of WA
httpdentalqualityconsultin
gcom
dentalqualityconsultantsg
mailcom
Contact Information
LUNCH
BREAKOUT EXERCISEORAL HEALTH VALUE-BASED CARE READINESS ASSESSMENT
Danielle Apostolon
PROMISING PRACTICES FROM THE FIELD STRATEGIES FOR INCREASING VALUE IN ORAL HEALTH
Dr Carolyn Brown
Dr Kelly Perry
Dr Rachel Rivard
Dr Adeloye
Commitment Compassion Community
m i d s t a t e h e a l t h o r g
Promising Practices from the
Field Strategies for Increasing
Value in Oral Health Care
Kelly Perry DMD
Better Health
Outcomes
Improved Staff
Experience
Reduced Cost
Improved Patient
Experience
Better Health
Outcomes
Improved Staff
Experience
Reduced Cost
Improved Patient
Experience
Better Health
Outcomes
Improved Staff
Experience
Reduced Cost
Improved Patient
Experience
Better Health
Outcomes
Improved Staff
Experience
Reduced Cost
Improved Patient
Experience
Commitment Compassion Community
kpe r r ymids t a tehea l t h o rg
Thank you
Completion of Disease Control Phase
Pelumi Adeloye DMD MPH
HEALTH ACCESS NETWORK (HAN) FAMILY DENTAL
Introduction
⧫1 Dentist I Hygienist 3 EFDArsquos1 Receptionist
⧫ 6 Chairs= 4 (dentist) + 2 (hygienist)
⧫ Slide ⥶80 off
⧫ Service areas Northern Penobscot Southern Aroostook Western
Washington Counties amp more
Completion of Phase I Treatment
⧫LimitedLack of Access to dental care
⧫Difficulty completing the disease control phase
Caries amp periodontal disease
⧫Attaining stable restorative state
Goal
Increase the completion of Disease Control Phase
Current practice
⧫Education
Assess level of dental literacy
Incremental strategy
⧫Increase access to dental care
Generous sliding scale (⥸$40 per visit)
Incorporate Expanded Function Dental Assistants
⧫Schedule modification
Incorporate more restorative blocks to allow
for follow-up visit and completion of restorative phase
httpswwwglasbergencomdentist-cartoons
Schedule
⧫Piggybacking technique
Increased allotted restorative blocks
⧫Sustainability of current schedule is
contingent on cooperation amp skills of HAN
Dental staff
Note
Strategies mentioned today is personalized to HAN Dental clinic
Current implemented strategies might be modified or changed in the
future as required in order to accommodate the need of our pts
THANK YOU
DAY TWOCLOSINGWRAP-UP
End of Day Two ndash Survey
Day Two Creating a Value-Based Oral Health Care Delivery
System
129
Payment Reform in Oral Health Online Learning Module
Oral Health Value-based Care Online Learning Module
Value-based Care Keys to Success Article
Readiness Assessment
Competency Development Guide
Oral Health Value-based Care Training
Dental Caries Management Practicum
Clinicians Companion Guide
Interprofessional Network Referral Process
Traditional Dental Care Vs Value-Based Care
Resources
131
wwwDentaQuestPartnershiporg
wwwfacebookcomDentaQuest
DentaQuest
wwwlinkedincomcompanyDentaQuest
Inside_DentaQuest
QUESTIONS
17
Poll What do you measure
A Dental provider productivity per day
B Treatment plan completion
C Dental new patient exams
D Combination of A-C
E No Shows
F Sealants only
18
Population
Prevention
Healthy
Minimally Invasive
Health outcomes
MDI
EHR EDR
PCC
Risk Assessment
19
VALUE-BASED CAREPushing the impact quality and quantity of measurement
20
OHVBC Readiness
Leadership
Value of oral health and oral health transformation
Structure Systems and Operations
Efficiencies innovative care delivery
Care Pathways and Provider Buy-In
Risk-based care Training patient engagement
Data and Analytic Technology and Personnel
DataReports Interoperability
Financial Viability and Strength
Payerpatient mix billing infrastructure
httpswwwdentaquestpartnershiporglearnsafety-net-solutionsoral-health-value-based-careohvbc-readiness-
assessment
21
DentaQuest Partnership OHVBC Survey
Barriers to Value-based Transformation in Oral Health ndash
Most Common Responses
bull Patient engagement
bull EHREDR
bull Tracking outcomes lack of nationally-recognized and standardized quality
metrics in dental
22
How Can FQHC Dental Programs Prepare for Value-based
Transformation in Oral Health
bull Begin or continue focusing on prevention disease management and risk-based care
bull Hygienists will be key to success ndash We need primary dental care not just surgical
interventions
bull Start measuring outcomes instead of just processutilization metrics bull of initially high-risk patients with new caries lesions
bull of initially high-risk patients with decreased risk status
bull of initially low-risk patients with risk status maintained
bull Address patient engagement in a more meaningful way and invest in case
management
bull Invest in interprofessional practice including HIT interoperability
bull Evaluate how services are being delivered and determine if its reaching the patients
who need care the most
23
Value-Based Care
Care Coordination
ldquoClosing outrdquo referrals
Diagnostic coding
Risk Screenings
Care plans based on risk
Patient Engagement
Incentive payments
Quality metrics
Clinic Response
Case Management IT
Active timely records mngt
Mapping Dx codes to CDT
Time bill CPT codes Tx plan
IPP data tofrom PC MH
Recall window important
Attention to $ related metrics
Attention to assigned metrics
Direct and Indirect Effects of VBC on Dental Systems of Care
Utilization Impact
New workforce CDT codes
New or + workforce IT
ICD-CM-10 codes
+CDT codes
Modifiers (CPT ICD10)
+ recall adherence
in incentivized procedures
in sealant POC A1C
Counseling codes SD
24
MEASUREMENT IN ORAL HEALTH
25
Poll What percentage of your adult dental patients are diabetic
or pre-diabetic
A 50-80
B 20-50
C Less than 20
D Not sure
26
27
ldquoTrue Measures of Successrdquo
1 Define your governing objective
2 Develop a theory of cause and effect to assess presumed drivers of the
objective
3 Identify the specific activities that employees can do to help achieve the
governing objective
4 Evaluate your statistics
5 Communicate the story of your measurement
Adapted from HBR ldquoThe True Measures of Successrdquo httpshbrorg201210the-true-measures-of-success
28
1 Governing objective
2 Theory of cause and effect
3 Activities of team
4 Evaluate your statistics
5 Storycraft
Sustainability
Clinic revenuegt expenses= sustainability
Patient compliance Assets Clinic Mngt
Care team Operations Pt Support Billing
Of Prod on and type Patients on time
Daily weekly monthly quarterly
ldquoTrue Measures of Successrdquo
Adapted from HBR ldquoThe True Measures of Successrdquo httpshbrorg201210the-true-measures-of-success
29
Measuring Risk and Health
November is Diabetes Awareness Month- 2019Communication Plans are as
important as cold hard numbers
Patients
Care Team
Other Health Teams
Executive Team
Funders
Data on your dental patients are medical patients of record
Data on your medical + dental patients with DM2
30
Develop Diabetic Patient
Protocols
Review evidence and rationale with dental team
Partner with primary care team
bull Protocols Care mngt Tests and Recording
Quality Goals
Protocols for newly screened and existing patients
Educate and train dental team in reading AND
charting test results and PILOT
31
External Measurement in Oral Health Programs
httpswwwadaorg~mediaADADQA2019_DiabetesOralEvaluationpdfla=en
httpswwworegongovohaHPAANALYTICSCCOMetrics2019-Oral-Evaluation-Adults-Diabetespdf
32
Baseline for 2019 271
httpswwworegongovohaHPAANALYTICSCCOMetrics2019-Oral-Evaluation-Adults-Diabetespdf
33
Diabetes burden in your panel of dental patients
Baseline Medical-Dental Integrated panel of all patients
Dental patients with DM2 MDI
Dental patients with DM2
1000 or 10
600 or 60
300010000= 30
Population Health- Clinic Level
34
1 Governing objective
2 Theory of cause and effect
3 Activities of team
4 Evaluate your statistics
5 Storycraft
Discuss at meetings (Oct + Nov) Health education training
materials NP training CQI Note in Board report Clinical
measures
Care Pathways Hygiene Resources (ScheduleAvail)
ldquoTrue Measures of Successrdquo
Adapted from HBR ldquoThe True Measures of Successrdquo httpshbrorg201210the-true-measures-of-success
Diabetes Awareness Prevention Healthier Community
Prevention Awareness Care Pathway promotes health
MDI= 10 6 out of 10 adult patients with DM2
Goal set for integrated patient panels ndash PCMH
Pre-diabetes approach for executive team
Care Pathways
Care Coordination
35
MEASURING PATIENT ORAL HEALTHRisk assessments and Care Pathways
36
37
Risk Assessment and Care Pathways
Caries Risk Assessment
Multiple tools
EDREHR modules smart notes or dot phrases
CDT Codes
Decide frequency
D0601
Low Caries Risk
D0601
Moderate Caries Risk
D0601
High Caries Risk
38
The Disease Management DifferenceDisease Management Difference
Traditional Dental Care Disease Management
Approach
All patients return in 6 months
regardless of risk status
Recare interval is based on the
childrsquos caries risk
Caries Risk
Level
Recommended
Recare Interval
High Risk 1 ndash 3 months
Moderate Risk 3 ndash 6 months
Low Risk 6 ndash 12 months
Caries
Stabilizing
agents
Health Ed
Nutritional
Counseling
Anti-bacterial
and Fluoride
interventions
39
Disease Management Care Pathways
DentaQuest Partnership for Oral Health Advancement Disease Management Model
Caries
Stabilizing
agents
Whole
Person
Inter-
professional
Approaches
Anti-bacterial
and Fluoride
interventions
40
Disease Management and Risk Screening Training
DentaQuest Partnership for Oral Health Advancementrsquos
Online Learning Center
Disease Management Series
8 modules 40 CDE available
httpswwwdentaquestpartnershiporglearnonline-learning-centeronline-
coursewaredentaquest-disease-management-series
41
MEASUREMENT IN TEAMSSharing meaningful data with your dental clinical teams
42
rdquoDental Homerdquo = Health Home where WE can meet the patient
Oralhealthworkforceorg
43
POLL HOW OFTEN DO YOU SHARE YOUR S WITH YOUR DENTAL TEAM
A Yearly only
B Quarterly
C Monthly
D Weekly
E Daily
44
Clinical Measures ndash Dental Practice Perspective
Private Practice Office
New patients seen
Assigned vs seen if capitated
Treatment plans incomplete
$ produced amp per provider
$ collected amp monthly per provider
CDT 6000 codes completed
RecallHygiene maintenance
Based on this consultants experienced
FQHC
Unduplicated patients
patients seen per day
Treatment plans complete
$ gainedlost via accounting
Broken appointment rate
procedures
Sealant rate (annual)
45
bull HRSA Sealant Measure Compliance for FQHCs
bull Completion of phase 1 treatment plans
bull Children seen 0-5 years old
bull Children seen getting a preventive service
bull Fluoride Varnish applications
bull Pregnant women seen and treated
bull Diabetic patients with HbA1C gt 7 seen
bull Patients seen who have not been seen for 12 months
bull Patients seen getting a Risk Assessment
bull Patients with moderate or high risk who lower risk at recare
bull Sealants provided httpwwwnnohaorgnnoha-contentuploads201512Demystifying-HRSA-SEALANT-PRESENTATION_FINALpdf
Program Measures
46
HRSA Performance Measurement and Data Collection
bull FQHCs and look-alikes submit CY data to HRSA since 2008
bull UDS Uniform Data System
bull Require FTE for clinical staff patient demographics
bull Dental utilization s (UDCTPV)
bull Dental Clinical Measure dental sealants placed on 1st molars ages 6-9 yo
bull Health Center Quartile rankings (Clinical measure performance influences
HC rankings as does EHR adoption and other HC characteristics)
47
Low birth weight
Access to prenatal care
Childhood Immunization
Children (Ages 3-17) Receiving
Weight Assessment amp
Counseling
Children (Age 6-9) Receiving
Dental Sealant to First Molars
Diabetes Control
Hypertension Control
Pap Test
Depression Screening and
Follow-up (Age 12+)
Asthma Patients (Age 5-40)
Receiving Pharmacologic
Therapy
Colorectal Cancer
Screening (Ages 51-74)
HRSA UDS Clinical Measures
Adults (Age 18+) Receiving
Weight Screening amp Follow-up
Adults (Age 18+) Receiving
Tobacco Use Assessment and
Cessation Intervention
Coronary Artery Disease
Receiving Lipid Therapy (18+)
Ischemic Vascular Disease (IVD)
Receiving Aspirin Therapy (18+)
HIV Linkage to Care
48
Dashboards
Grants
Average
amp
Targets
Quality
Rev
Costs
Visits
Priority
Pop
Prevention
49
Dashboard- Provider Team Level
Patient
Compliance
Satisfaction
50
Case Study-
Incentives bonus round pools benchmark and improvement target goals risk-sharing possible later years
51
Qualitative Measurement
ldquoPatient engagement is the act of patients and providers working together
toward the end goal of improved patient wellnessrdquo
wwwpatientengagementhitcom
Access to Care
Patient Activation
Patient Satisfaction
Patient-Provider-Care Team Communication
Care Team Satisfaction
52
OHVBC Readiness
Leadership
bull Value of oral health and oral health transformation
Structure Systems and Operations
bull Operational efficiencies innovative care delivery methodologies
Care Pathways and Provider Buy-In
bull Training disease management risk-based care referrals IDC-10 coding patient engagement
Data and Analytic Technology and Personnel
bull Interoperability reporting
Financial Viability and Strength
bull Payerpatient mix billing infrastructure financial reports
httpswwwdentaquestpartnershiporglearnsafety-net-solutionsoral-health-value-based-careohvbc-readiness-
assessment
53
QUESTIONS COMMENTS
Carolyn Brown DDS
cbrownddsgmailcom
RISK BASED MANAGED CARE
Value Based Training Conference
Manchester New Hampshire
Mark Koday DDS
111919
5555
Objectives
bull Review current drivers of dental managed care
bull Understand the basics of risk-based dental managed care contracts
bull Learn the basics of managing costs in a riskndashbased contract
bull Gain an understanding in the potential advantage of risk-based contracting
56
What Is Dental Managed Care
Managed care is a health delivery system whose purpose is to manage both the
quality and cost of health care
Common types of managed care health insurance plans
bull HMOs
bull PPOs
bull POSs
bull Medicaid Managed Care
DIDNrsquoT WE ALREADY HAVE MANAGED CARE AND IT FAILED
57
What Has Happened Since the 90s
58
WHY THE FFS AND PPS DOESNrsquoT WORK FOR OUR POPULATIONS
bull Inefficient payment systems designed to produce encounters or procedures but not real health
bull No focus on population health
bull Does not incentivize innovation
bull Patients essentially on their own for accessing specialty care
59
Rule of 4
Source Kaiser Family Foundation analysis of National Health Expenditure (NHE) data from Centers for
Medicare and Medicaid Services Office of the Actuary National Health Statistics Group
60
Rule of 4
bull This helps explain why oral health has been relatively ignored so far by CMS
bull Explains why we have PCMH instead of PCHH
bull Where is the real value on a national level in preventing disease and
controlling costs
bull Beware- wersquove been found
61
Reasons Dental Managed Care is Spreading Across the States
NON-MANAGED CARE STATE DENTAL BUDGETS ARE
OPENED ENDED
STRAIN ON STATE BUDGETS
UPCOMING RECESSION WITH TRILLION DOLLAR
DEFICIT
SHIFTS FINANCIAL RISK FROM THE STATES TO THE
PLANS
6262
Types of Medicaid Managed Care
bull State Medicaid agency administrator lowest administrative
costs
bull Third Party Administrator Typically 15 administrative costs
bull Managed Care Organization Typically 15 administrative
costs
bull Carved-in
bull Carved-out
bull Risk Based Managed Care Administrative costs part of
contract negotiation
63
RISK CONTRACTS
6464
Components of a Risk-based Contract
Risk
Medical Loss Ratio
Quality withhold
Specialty withhold
Managed care payment (pmpm)
Covered services
Fee schedule Claims are paid as usual on a FFS basis
Credentialing
Quality Review process and Quality Metrics
65
Upside Risk
The possibility that the cost of
delivering dental care to an assigned
patient panel is less than the amount
of funding calculated for that care
The Plan pays the CHC additional
funds based on a predetermine
formula
Downside Risk
The possibility that the cost of
delivering dental care to an assigned
patient panel is more than the amount
of funding calculated for that care
The CHC pays the Plan additional
funds based on a predetermine
formula
Upside and Downside Risk
66
Taking On Risk 100 or Shared Risk
With 100 risk you receive 100 of the potential savings but are also at risk for
100 of the losses
Shared Risk MCO and health center share a percentage of the risk
Shared Risk leads to better cooperation since both organizations are
incentivized to save on costs
6767
Reports Needed
bull Enrollment reports lists of who is assigned on a monthly basis
bull Reconciliation reports insure appropriate payments
bull Specialty Referral reports
bull You will need your own reporting process so you donrsquot rely completely on
reports supplied by the Plan
6868
Medical Loss Ratio
Medical Loss Ratio (MLR) is proportion of premium revenues spent on clinical
services and quality improvement also known as the Medical Loss Ratio (MLR)
For CMS requires Medical Plans to spend at least 80 to 85 of the premiums
on actual medical care
69
Administrative Fees
bull Essentially the opposite of MLR
bull The State Medicaid Agency is funded by the Governorrsquos budget
bull The State Medicaid Agency will keep some of these funds for their
admin costs and give the remaining to the Managed Care Plans
bull Private Plan admin costs can be as high as 40 but most states
limit these cost for Medicaid Plans to between 15 and 20 (85-
80 MLR)
bull This may be negotiable depending on your program size of your
program
70
Quality Withhold
bull The state withholds a certain percent (typically 2-4 ) of the funds they give
to the Plans for Value Based Reimbursement
bull They choose quality metrics and set benchmarks and assign payments for
each metric based on an assigned priority for each metric
bull If a Plan meets the benchmark of every quality metric the state passes on
their full share of the quality withhold
bull The Plans may or may not withhold a percent of the funds for quality payment
to the dentists or manage care contractors
71
Quality Withhold
Either way the Plans may or may not pass the quality payments they receive to
the dentists or contractors
This should be spelled out in a risk-based contract
72
Percent of funds set aside
to cover specialty care
referrals
Typically 10-15
Goal Limit referral costs
to within or less than
Specialty set aside
Specialty Withhold
73
Per Member Per Month
bull Capitated Payment
bull Specific dollar amount paid for each enrolled member each month
bull Paid whether patient is accessed for care or not
bull States do set access benchmarks
bull In Oregon access for any dental procedure (adults and children combined)
was 267 in 2015
74
Payment Math Example
Premium per enrollee = $25
Administrative fee 15 = $375
Funds available per enrollee to the clinic = $2125
Management fee per enrollee = $175
Funds per enrollee that would undergo PPS reconciliation = $1950
For every 10000 enrollees the managed care income = $2340000
Specialty withhold (10) = $234000
YE Cost lt or gt $2340000
Upside Risk
CHC Gains $
Downside Risk
CHC Loses $
75
Covered Services and Fee Schedules
bull The state Medicaid agency spells out the minimum procedures and fees that
MCOs must cover
bull MCOs may add procedures or increase periodicity of procedures particularly
preventative services
bull MCOs may increase fees to entice rural providers and specialists to enroll in
their Plans
bull Access Rules
bull How many days it takes to access a patent
bull How many days it takes for a patent to access urgent care services
bull How many days it takes for a patent to access emergency care services
76
Credentialing
All MCOs are required to credential all Providers
All MCOs have their own credentialing process
Credentialing process is can be lengthy
Credentialing process may be negotiable
77
Quality Review Process and Quality Metrics
MCOs must have a Quality and Compliance Review Process
If you arenrsquot in compliance with both you likely wonrsquot get paid
Typical processes reviewed
bull Charting specifications
bull Incident report
bull Enrollee complaints quality rudeness and access issues
bull Medicaid compliance
78
Quality Payments
bull State Shared Incentive Withhold Typically quality metrics and benchmarks
are set by the state sets aside a certain percent (3-5) of the payments to
the Managed Care Plan (MCP)
bull If the benchmarks are achieved the MCP is then paid the a predetermine
amount
bull Benchmarks may not be the same as the states
bull Managed Care Plans do not have to pass all or any of the quality payments to
the health centers or providers
bull Managed Care contract- Metrics benchmarks should be selected and part of
the contract
7979
Achieving Quality Metric Payments
Dealing with under achievers
Process issues
Individual issues
Identifying workflows
Developing Best Practices through
PDSA process
Developing Best Practices through
PDSA process
CHC Metrics Committee
Clinicians Operations various key staff
Identify Best Practices
Spread Best Practices
80
New Team Needed Business Intelligence
Business Intelligence (BI) is critical for effective managed care business decisions
BI team inputs metrics into your EHR collects integrates analyses and displays all your managed care business and clinical information
Easy to say- hard to achieve
Build your own or outsource
Possible future role of Primary Care Associations
8181
Clinicianrsquos Dashboard
Expensive to build
Displayed on your screen when your computer is first turned on
Easy to read and understand
Data dumped from the day before
Can dialed down from Org-wide to clinic to each clinicianrsquos data
Operational and clinical metrics
bull Treatment Plan Completion
bull DQA quality measures
bull Caries at Recall
bull Re-care reports
bull Care Gap reports
82
CONTROLLING COSTS
8383
Controlling Costs- Current
bull Increasing efficiencies
bull Decreasing broken appointments
bull Controlling supplies equipment costs
bull Staff recruitment retention costs
84
Specialty Care
Training current CHC dentists in
specialty areas
Hiring general dentists with higher
specialty skill sets
Hiring in house specialists
Contract with outside specialists
Work with Managed Care Plan
specialists
Lowering Disease Rates
Community Dental Health
Coordinators case management
If your state law allows- embed
hygienists in medical and community
to provide primary and secondary
prevention procedures
In clinic Caries Classification and
Silver Diamine Fluoride
Effective recare programs
Controlling Costs- Additions in Risk-based Contracting
85
Specialty Care ndash Primary Referrals by Cost
Pediatric dentistry
Orthodontics
Oral surgery
Endodontics
86
In-clinic Pediatric Services
Encounters expected
of operatories available
State dental law and ability to have
expanded duties
General Anesthesia
GA in- house
Ability for a hospital or surgery center
to set aside regular OR time
Ability to hire or assign DAs to GA
days
Four GA cases day x PPS rate
Should You Hire a Pediatric Dentist- It Depends
8787
Solutions for Controlling Pediatric Costs
Hire a general dentist that is skilled in treating young children
Make the clinic child friendly nitrous oxide TVs in the operatory etc
Teach entire staff behavioral control techniques
Contract with a pediatric dentist for the GA care
88
Lowering Overall Disease Rates (and Costs)
You are responsible for both the patients you see in the chair and the ones
assigned to you
Breaking down the walls of the dental clinic
Community Dental Health Coordinators
Case Management
89
Cost Control Essentials
Diagnosis codes
Increased ability to identify
disease by risk
Motivational
Interviewing
Developing Polices and
Procedures design to treat
disease according to risk
ie Silver Diamine Fluoride
Treating by Risk
Effective Recare
Process
Critical to continual disease
controlPrevention education that is
meaningful and designed to
change behaviors
90
Social Determinants of Health Aunt Bertha
httpswwwauntberthacom
91
REASON TO CONSIDER RISK- BASED CONTRACTING
9292
PPS Reconciliation and Federal Code 42 CFR sect4052469(a)(2)
42 CFR sect4052469(a)(2)
ldquoAny financial incentives provided to Federally Qualified Health Centers
under their Medicare Advantage Contracts such as risk pool payments
bonuses or withholds are prohibited from being included in the
calculation of supplemental payments due to the Federally Qualified
Health Centerrdquo
9393
Why Risk Based Contract in Times of PPS Reconciliation
bull Not all Risk- based Contract funds are reconciled
bull Risk is the key word- you can come out with less money than your normal
PPS reconciliation payment
bull Can lead to better patient care
bull May improve manage care enrollment for your medical plan
bull Promotes integrated care increases health for your CHC patients
9494
Not Included in the Reconciliation
Enrollment management pmpm
Quality Payments
Upside risk payments
Downside risk losses
9595
Determinants of Financial Success in Risk-Based Contracting
bull Most critical- State pmpm payment to the Managed Care Plan
bull Reporting capabilities
bull Specialty service capabilities
bull Access numbers count
bull Ability to move metric numbers
9696
What About the Non- Medicaid Poor We Serve
bull Numbers are king in a managed care contract and the more access you have
the better contract terms you can negotiate
bull We will potentially have a steady supply of Medicaid patients
bull As managed care spreads states this may be compromising the ability of
health centers to serve the non-Medicaid poor and others lacking dental
insurance
97
Mark Koday DDS
(509) 949-2278
Dental Quality Consultants
of WA
httpdentalqualityconsultin
gcom
dentalqualityconsultantsg
mailcom
Contact Information
LUNCH
BREAKOUT EXERCISEORAL HEALTH VALUE-BASED CARE READINESS ASSESSMENT
Danielle Apostolon
PROMISING PRACTICES FROM THE FIELD STRATEGIES FOR INCREASING VALUE IN ORAL HEALTH
Dr Carolyn Brown
Dr Kelly Perry
Dr Rachel Rivard
Dr Adeloye
Commitment Compassion Community
m i d s t a t e h e a l t h o r g
Promising Practices from the
Field Strategies for Increasing
Value in Oral Health Care
Kelly Perry DMD
Better Health
Outcomes
Improved Staff
Experience
Reduced Cost
Improved Patient
Experience
Better Health
Outcomes
Improved Staff
Experience
Reduced Cost
Improved Patient
Experience
Better Health
Outcomes
Improved Staff
Experience
Reduced Cost
Improved Patient
Experience
Better Health
Outcomes
Improved Staff
Experience
Reduced Cost
Improved Patient
Experience
Commitment Compassion Community
kpe r r ymids t a tehea l t h o rg
Thank you
Completion of Disease Control Phase
Pelumi Adeloye DMD MPH
HEALTH ACCESS NETWORK (HAN) FAMILY DENTAL
Introduction
⧫1 Dentist I Hygienist 3 EFDArsquos1 Receptionist
⧫ 6 Chairs= 4 (dentist) + 2 (hygienist)
⧫ Slide ⥶80 off
⧫ Service areas Northern Penobscot Southern Aroostook Western
Washington Counties amp more
Completion of Phase I Treatment
⧫LimitedLack of Access to dental care
⧫Difficulty completing the disease control phase
Caries amp periodontal disease
⧫Attaining stable restorative state
Goal
Increase the completion of Disease Control Phase
Current practice
⧫Education
Assess level of dental literacy
Incremental strategy
⧫Increase access to dental care
Generous sliding scale (⥸$40 per visit)
Incorporate Expanded Function Dental Assistants
⧫Schedule modification
Incorporate more restorative blocks to allow
for follow-up visit and completion of restorative phase
httpswwwglasbergencomdentist-cartoons
Schedule
⧫Piggybacking technique
Increased allotted restorative blocks
⧫Sustainability of current schedule is
contingent on cooperation amp skills of HAN
Dental staff
Note
Strategies mentioned today is personalized to HAN Dental clinic
Current implemented strategies might be modified or changed in the
future as required in order to accommodate the need of our pts
THANK YOU
DAY TWOCLOSINGWRAP-UP
End of Day Two ndash Survey
Day Two Creating a Value-Based Oral Health Care Delivery
System
129
Payment Reform in Oral Health Online Learning Module
Oral Health Value-based Care Online Learning Module
Value-based Care Keys to Success Article
Readiness Assessment
Competency Development Guide
Oral Health Value-based Care Training
Dental Caries Management Practicum
Clinicians Companion Guide
Interprofessional Network Referral Process
Traditional Dental Care Vs Value-Based Care
Resources
131
wwwDentaQuestPartnershiporg
wwwfacebookcomDentaQuest
DentaQuest
wwwlinkedincomcompanyDentaQuest
Inside_DentaQuest
QUESTIONS
18
Population
Prevention
Healthy
Minimally Invasive
Health outcomes
MDI
EHR EDR
PCC
Risk Assessment
19
VALUE-BASED CAREPushing the impact quality and quantity of measurement
20
OHVBC Readiness
Leadership
Value of oral health and oral health transformation
Structure Systems and Operations
Efficiencies innovative care delivery
Care Pathways and Provider Buy-In
Risk-based care Training patient engagement
Data and Analytic Technology and Personnel
DataReports Interoperability
Financial Viability and Strength
Payerpatient mix billing infrastructure
httpswwwdentaquestpartnershiporglearnsafety-net-solutionsoral-health-value-based-careohvbc-readiness-
assessment
21
DentaQuest Partnership OHVBC Survey
Barriers to Value-based Transformation in Oral Health ndash
Most Common Responses
bull Patient engagement
bull EHREDR
bull Tracking outcomes lack of nationally-recognized and standardized quality
metrics in dental
22
How Can FQHC Dental Programs Prepare for Value-based
Transformation in Oral Health
bull Begin or continue focusing on prevention disease management and risk-based care
bull Hygienists will be key to success ndash We need primary dental care not just surgical
interventions
bull Start measuring outcomes instead of just processutilization metrics bull of initially high-risk patients with new caries lesions
bull of initially high-risk patients with decreased risk status
bull of initially low-risk patients with risk status maintained
bull Address patient engagement in a more meaningful way and invest in case
management
bull Invest in interprofessional practice including HIT interoperability
bull Evaluate how services are being delivered and determine if its reaching the patients
who need care the most
23
Value-Based Care
Care Coordination
ldquoClosing outrdquo referrals
Diagnostic coding
Risk Screenings
Care plans based on risk
Patient Engagement
Incentive payments
Quality metrics
Clinic Response
Case Management IT
Active timely records mngt
Mapping Dx codes to CDT
Time bill CPT codes Tx plan
IPP data tofrom PC MH
Recall window important
Attention to $ related metrics
Attention to assigned metrics
Direct and Indirect Effects of VBC on Dental Systems of Care
Utilization Impact
New workforce CDT codes
New or + workforce IT
ICD-CM-10 codes
+CDT codes
Modifiers (CPT ICD10)
+ recall adherence
in incentivized procedures
in sealant POC A1C
Counseling codes SD
24
MEASUREMENT IN ORAL HEALTH
25
Poll What percentage of your adult dental patients are diabetic
or pre-diabetic
A 50-80
B 20-50
C Less than 20
D Not sure
26
27
ldquoTrue Measures of Successrdquo
1 Define your governing objective
2 Develop a theory of cause and effect to assess presumed drivers of the
objective
3 Identify the specific activities that employees can do to help achieve the
governing objective
4 Evaluate your statistics
5 Communicate the story of your measurement
Adapted from HBR ldquoThe True Measures of Successrdquo httpshbrorg201210the-true-measures-of-success
28
1 Governing objective
2 Theory of cause and effect
3 Activities of team
4 Evaluate your statistics
5 Storycraft
Sustainability
Clinic revenuegt expenses= sustainability
Patient compliance Assets Clinic Mngt
Care team Operations Pt Support Billing
Of Prod on and type Patients on time
Daily weekly monthly quarterly
ldquoTrue Measures of Successrdquo
Adapted from HBR ldquoThe True Measures of Successrdquo httpshbrorg201210the-true-measures-of-success
29
Measuring Risk and Health
November is Diabetes Awareness Month- 2019Communication Plans are as
important as cold hard numbers
Patients
Care Team
Other Health Teams
Executive Team
Funders
Data on your dental patients are medical patients of record
Data on your medical + dental patients with DM2
30
Develop Diabetic Patient
Protocols
Review evidence and rationale with dental team
Partner with primary care team
bull Protocols Care mngt Tests and Recording
Quality Goals
Protocols for newly screened and existing patients
Educate and train dental team in reading AND
charting test results and PILOT
31
External Measurement in Oral Health Programs
httpswwwadaorg~mediaADADQA2019_DiabetesOralEvaluationpdfla=en
httpswwworegongovohaHPAANALYTICSCCOMetrics2019-Oral-Evaluation-Adults-Diabetespdf
32
Baseline for 2019 271
httpswwworegongovohaHPAANALYTICSCCOMetrics2019-Oral-Evaluation-Adults-Diabetespdf
33
Diabetes burden in your panel of dental patients
Baseline Medical-Dental Integrated panel of all patients
Dental patients with DM2 MDI
Dental patients with DM2
1000 or 10
600 or 60
300010000= 30
Population Health- Clinic Level
34
1 Governing objective
2 Theory of cause and effect
3 Activities of team
4 Evaluate your statistics
5 Storycraft
Discuss at meetings (Oct + Nov) Health education training
materials NP training CQI Note in Board report Clinical
measures
Care Pathways Hygiene Resources (ScheduleAvail)
ldquoTrue Measures of Successrdquo
Adapted from HBR ldquoThe True Measures of Successrdquo httpshbrorg201210the-true-measures-of-success
Diabetes Awareness Prevention Healthier Community
Prevention Awareness Care Pathway promotes health
MDI= 10 6 out of 10 adult patients with DM2
Goal set for integrated patient panels ndash PCMH
Pre-diabetes approach for executive team
Care Pathways
Care Coordination
35
MEASURING PATIENT ORAL HEALTHRisk assessments and Care Pathways
36
37
Risk Assessment and Care Pathways
Caries Risk Assessment
Multiple tools
EDREHR modules smart notes or dot phrases
CDT Codes
Decide frequency
D0601
Low Caries Risk
D0601
Moderate Caries Risk
D0601
High Caries Risk
38
The Disease Management DifferenceDisease Management Difference
Traditional Dental Care Disease Management
Approach
All patients return in 6 months
regardless of risk status
Recare interval is based on the
childrsquos caries risk
Caries Risk
Level
Recommended
Recare Interval
High Risk 1 ndash 3 months
Moderate Risk 3 ndash 6 months
Low Risk 6 ndash 12 months
Caries
Stabilizing
agents
Health Ed
Nutritional
Counseling
Anti-bacterial
and Fluoride
interventions
39
Disease Management Care Pathways
DentaQuest Partnership for Oral Health Advancement Disease Management Model
Caries
Stabilizing
agents
Whole
Person
Inter-
professional
Approaches
Anti-bacterial
and Fluoride
interventions
40
Disease Management and Risk Screening Training
DentaQuest Partnership for Oral Health Advancementrsquos
Online Learning Center
Disease Management Series
8 modules 40 CDE available
httpswwwdentaquestpartnershiporglearnonline-learning-centeronline-
coursewaredentaquest-disease-management-series
41
MEASUREMENT IN TEAMSSharing meaningful data with your dental clinical teams
42
rdquoDental Homerdquo = Health Home where WE can meet the patient
Oralhealthworkforceorg
43
POLL HOW OFTEN DO YOU SHARE YOUR S WITH YOUR DENTAL TEAM
A Yearly only
B Quarterly
C Monthly
D Weekly
E Daily
44
Clinical Measures ndash Dental Practice Perspective
Private Practice Office
New patients seen
Assigned vs seen if capitated
Treatment plans incomplete
$ produced amp per provider
$ collected amp monthly per provider
CDT 6000 codes completed
RecallHygiene maintenance
Based on this consultants experienced
FQHC
Unduplicated patients
patients seen per day
Treatment plans complete
$ gainedlost via accounting
Broken appointment rate
procedures
Sealant rate (annual)
45
bull HRSA Sealant Measure Compliance for FQHCs
bull Completion of phase 1 treatment plans
bull Children seen 0-5 years old
bull Children seen getting a preventive service
bull Fluoride Varnish applications
bull Pregnant women seen and treated
bull Diabetic patients with HbA1C gt 7 seen
bull Patients seen who have not been seen for 12 months
bull Patients seen getting a Risk Assessment
bull Patients with moderate or high risk who lower risk at recare
bull Sealants provided httpwwwnnohaorgnnoha-contentuploads201512Demystifying-HRSA-SEALANT-PRESENTATION_FINALpdf
Program Measures
46
HRSA Performance Measurement and Data Collection
bull FQHCs and look-alikes submit CY data to HRSA since 2008
bull UDS Uniform Data System
bull Require FTE for clinical staff patient demographics
bull Dental utilization s (UDCTPV)
bull Dental Clinical Measure dental sealants placed on 1st molars ages 6-9 yo
bull Health Center Quartile rankings (Clinical measure performance influences
HC rankings as does EHR adoption and other HC characteristics)
47
Low birth weight
Access to prenatal care
Childhood Immunization
Children (Ages 3-17) Receiving
Weight Assessment amp
Counseling
Children (Age 6-9) Receiving
Dental Sealant to First Molars
Diabetes Control
Hypertension Control
Pap Test
Depression Screening and
Follow-up (Age 12+)
Asthma Patients (Age 5-40)
Receiving Pharmacologic
Therapy
Colorectal Cancer
Screening (Ages 51-74)
HRSA UDS Clinical Measures
Adults (Age 18+) Receiving
Weight Screening amp Follow-up
Adults (Age 18+) Receiving
Tobacco Use Assessment and
Cessation Intervention
Coronary Artery Disease
Receiving Lipid Therapy (18+)
Ischemic Vascular Disease (IVD)
Receiving Aspirin Therapy (18+)
HIV Linkage to Care
48
Dashboards
Grants
Average
amp
Targets
Quality
Rev
Costs
Visits
Priority
Pop
Prevention
49
Dashboard- Provider Team Level
Patient
Compliance
Satisfaction
50
Case Study-
Incentives bonus round pools benchmark and improvement target goals risk-sharing possible later years
51
Qualitative Measurement
ldquoPatient engagement is the act of patients and providers working together
toward the end goal of improved patient wellnessrdquo
wwwpatientengagementhitcom
Access to Care
Patient Activation
Patient Satisfaction
Patient-Provider-Care Team Communication
Care Team Satisfaction
52
OHVBC Readiness
Leadership
bull Value of oral health and oral health transformation
Structure Systems and Operations
bull Operational efficiencies innovative care delivery methodologies
Care Pathways and Provider Buy-In
bull Training disease management risk-based care referrals IDC-10 coding patient engagement
Data and Analytic Technology and Personnel
bull Interoperability reporting
Financial Viability and Strength
bull Payerpatient mix billing infrastructure financial reports
httpswwwdentaquestpartnershiporglearnsafety-net-solutionsoral-health-value-based-careohvbc-readiness-
assessment
53
QUESTIONS COMMENTS
Carolyn Brown DDS
cbrownddsgmailcom
RISK BASED MANAGED CARE
Value Based Training Conference
Manchester New Hampshire
Mark Koday DDS
111919
5555
Objectives
bull Review current drivers of dental managed care
bull Understand the basics of risk-based dental managed care contracts
bull Learn the basics of managing costs in a riskndashbased contract
bull Gain an understanding in the potential advantage of risk-based contracting
56
What Is Dental Managed Care
Managed care is a health delivery system whose purpose is to manage both the
quality and cost of health care
Common types of managed care health insurance plans
bull HMOs
bull PPOs
bull POSs
bull Medicaid Managed Care
DIDNrsquoT WE ALREADY HAVE MANAGED CARE AND IT FAILED
57
What Has Happened Since the 90s
58
WHY THE FFS AND PPS DOESNrsquoT WORK FOR OUR POPULATIONS
bull Inefficient payment systems designed to produce encounters or procedures but not real health
bull No focus on population health
bull Does not incentivize innovation
bull Patients essentially on their own for accessing specialty care
59
Rule of 4
Source Kaiser Family Foundation analysis of National Health Expenditure (NHE) data from Centers for
Medicare and Medicaid Services Office of the Actuary National Health Statistics Group
60
Rule of 4
bull This helps explain why oral health has been relatively ignored so far by CMS
bull Explains why we have PCMH instead of PCHH
bull Where is the real value on a national level in preventing disease and
controlling costs
bull Beware- wersquove been found
61
Reasons Dental Managed Care is Spreading Across the States
NON-MANAGED CARE STATE DENTAL BUDGETS ARE
OPENED ENDED
STRAIN ON STATE BUDGETS
UPCOMING RECESSION WITH TRILLION DOLLAR
DEFICIT
SHIFTS FINANCIAL RISK FROM THE STATES TO THE
PLANS
6262
Types of Medicaid Managed Care
bull State Medicaid agency administrator lowest administrative
costs
bull Third Party Administrator Typically 15 administrative costs
bull Managed Care Organization Typically 15 administrative
costs
bull Carved-in
bull Carved-out
bull Risk Based Managed Care Administrative costs part of
contract negotiation
63
RISK CONTRACTS
6464
Components of a Risk-based Contract
Risk
Medical Loss Ratio
Quality withhold
Specialty withhold
Managed care payment (pmpm)
Covered services
Fee schedule Claims are paid as usual on a FFS basis
Credentialing
Quality Review process and Quality Metrics
65
Upside Risk
The possibility that the cost of
delivering dental care to an assigned
patient panel is less than the amount
of funding calculated for that care
The Plan pays the CHC additional
funds based on a predetermine
formula
Downside Risk
The possibility that the cost of
delivering dental care to an assigned
patient panel is more than the amount
of funding calculated for that care
The CHC pays the Plan additional
funds based on a predetermine
formula
Upside and Downside Risk
66
Taking On Risk 100 or Shared Risk
With 100 risk you receive 100 of the potential savings but are also at risk for
100 of the losses
Shared Risk MCO and health center share a percentage of the risk
Shared Risk leads to better cooperation since both organizations are
incentivized to save on costs
6767
Reports Needed
bull Enrollment reports lists of who is assigned on a monthly basis
bull Reconciliation reports insure appropriate payments
bull Specialty Referral reports
bull You will need your own reporting process so you donrsquot rely completely on
reports supplied by the Plan
6868
Medical Loss Ratio
Medical Loss Ratio (MLR) is proportion of premium revenues spent on clinical
services and quality improvement also known as the Medical Loss Ratio (MLR)
For CMS requires Medical Plans to spend at least 80 to 85 of the premiums
on actual medical care
69
Administrative Fees
bull Essentially the opposite of MLR
bull The State Medicaid Agency is funded by the Governorrsquos budget
bull The State Medicaid Agency will keep some of these funds for their
admin costs and give the remaining to the Managed Care Plans
bull Private Plan admin costs can be as high as 40 but most states
limit these cost for Medicaid Plans to between 15 and 20 (85-
80 MLR)
bull This may be negotiable depending on your program size of your
program
70
Quality Withhold
bull The state withholds a certain percent (typically 2-4 ) of the funds they give
to the Plans for Value Based Reimbursement
bull They choose quality metrics and set benchmarks and assign payments for
each metric based on an assigned priority for each metric
bull If a Plan meets the benchmark of every quality metric the state passes on
their full share of the quality withhold
bull The Plans may or may not withhold a percent of the funds for quality payment
to the dentists or manage care contractors
71
Quality Withhold
Either way the Plans may or may not pass the quality payments they receive to
the dentists or contractors
This should be spelled out in a risk-based contract
72
Percent of funds set aside
to cover specialty care
referrals
Typically 10-15
Goal Limit referral costs
to within or less than
Specialty set aside
Specialty Withhold
73
Per Member Per Month
bull Capitated Payment
bull Specific dollar amount paid for each enrolled member each month
bull Paid whether patient is accessed for care or not
bull States do set access benchmarks
bull In Oregon access for any dental procedure (adults and children combined)
was 267 in 2015
74
Payment Math Example
Premium per enrollee = $25
Administrative fee 15 = $375
Funds available per enrollee to the clinic = $2125
Management fee per enrollee = $175
Funds per enrollee that would undergo PPS reconciliation = $1950
For every 10000 enrollees the managed care income = $2340000
Specialty withhold (10) = $234000
YE Cost lt or gt $2340000
Upside Risk
CHC Gains $
Downside Risk
CHC Loses $
75
Covered Services and Fee Schedules
bull The state Medicaid agency spells out the minimum procedures and fees that
MCOs must cover
bull MCOs may add procedures or increase periodicity of procedures particularly
preventative services
bull MCOs may increase fees to entice rural providers and specialists to enroll in
their Plans
bull Access Rules
bull How many days it takes to access a patent
bull How many days it takes for a patent to access urgent care services
bull How many days it takes for a patent to access emergency care services
76
Credentialing
All MCOs are required to credential all Providers
All MCOs have their own credentialing process
Credentialing process is can be lengthy
Credentialing process may be negotiable
77
Quality Review Process and Quality Metrics
MCOs must have a Quality and Compliance Review Process
If you arenrsquot in compliance with both you likely wonrsquot get paid
Typical processes reviewed
bull Charting specifications
bull Incident report
bull Enrollee complaints quality rudeness and access issues
bull Medicaid compliance
78
Quality Payments
bull State Shared Incentive Withhold Typically quality metrics and benchmarks
are set by the state sets aside a certain percent (3-5) of the payments to
the Managed Care Plan (MCP)
bull If the benchmarks are achieved the MCP is then paid the a predetermine
amount
bull Benchmarks may not be the same as the states
bull Managed Care Plans do not have to pass all or any of the quality payments to
the health centers or providers
bull Managed Care contract- Metrics benchmarks should be selected and part of
the contract
7979
Achieving Quality Metric Payments
Dealing with under achievers
Process issues
Individual issues
Identifying workflows
Developing Best Practices through
PDSA process
Developing Best Practices through
PDSA process
CHC Metrics Committee
Clinicians Operations various key staff
Identify Best Practices
Spread Best Practices
80
New Team Needed Business Intelligence
Business Intelligence (BI) is critical for effective managed care business decisions
BI team inputs metrics into your EHR collects integrates analyses and displays all your managed care business and clinical information
Easy to say- hard to achieve
Build your own or outsource
Possible future role of Primary Care Associations
8181
Clinicianrsquos Dashboard
Expensive to build
Displayed on your screen when your computer is first turned on
Easy to read and understand
Data dumped from the day before
Can dialed down from Org-wide to clinic to each clinicianrsquos data
Operational and clinical metrics
bull Treatment Plan Completion
bull DQA quality measures
bull Caries at Recall
bull Re-care reports
bull Care Gap reports
82
CONTROLLING COSTS
8383
Controlling Costs- Current
bull Increasing efficiencies
bull Decreasing broken appointments
bull Controlling supplies equipment costs
bull Staff recruitment retention costs
84
Specialty Care
Training current CHC dentists in
specialty areas
Hiring general dentists with higher
specialty skill sets
Hiring in house specialists
Contract with outside specialists
Work with Managed Care Plan
specialists
Lowering Disease Rates
Community Dental Health
Coordinators case management
If your state law allows- embed
hygienists in medical and community
to provide primary and secondary
prevention procedures
In clinic Caries Classification and
Silver Diamine Fluoride
Effective recare programs
Controlling Costs- Additions in Risk-based Contracting
85
Specialty Care ndash Primary Referrals by Cost
Pediatric dentistry
Orthodontics
Oral surgery
Endodontics
86
In-clinic Pediatric Services
Encounters expected
of operatories available
State dental law and ability to have
expanded duties
General Anesthesia
GA in- house
Ability for a hospital or surgery center
to set aside regular OR time
Ability to hire or assign DAs to GA
days
Four GA cases day x PPS rate
Should You Hire a Pediatric Dentist- It Depends
8787
Solutions for Controlling Pediatric Costs
Hire a general dentist that is skilled in treating young children
Make the clinic child friendly nitrous oxide TVs in the operatory etc
Teach entire staff behavioral control techniques
Contract with a pediatric dentist for the GA care
88
Lowering Overall Disease Rates (and Costs)
You are responsible for both the patients you see in the chair and the ones
assigned to you
Breaking down the walls of the dental clinic
Community Dental Health Coordinators
Case Management
89
Cost Control Essentials
Diagnosis codes
Increased ability to identify
disease by risk
Motivational
Interviewing
Developing Polices and
Procedures design to treat
disease according to risk
ie Silver Diamine Fluoride
Treating by Risk
Effective Recare
Process
Critical to continual disease
controlPrevention education that is
meaningful and designed to
change behaviors
90
Social Determinants of Health Aunt Bertha
httpswwwauntberthacom
91
REASON TO CONSIDER RISK- BASED CONTRACTING
9292
PPS Reconciliation and Federal Code 42 CFR sect4052469(a)(2)
42 CFR sect4052469(a)(2)
ldquoAny financial incentives provided to Federally Qualified Health Centers
under their Medicare Advantage Contracts such as risk pool payments
bonuses or withholds are prohibited from being included in the
calculation of supplemental payments due to the Federally Qualified
Health Centerrdquo
9393
Why Risk Based Contract in Times of PPS Reconciliation
bull Not all Risk- based Contract funds are reconciled
bull Risk is the key word- you can come out with less money than your normal
PPS reconciliation payment
bull Can lead to better patient care
bull May improve manage care enrollment for your medical plan
bull Promotes integrated care increases health for your CHC patients
9494
Not Included in the Reconciliation
Enrollment management pmpm
Quality Payments
Upside risk payments
Downside risk losses
9595
Determinants of Financial Success in Risk-Based Contracting
bull Most critical- State pmpm payment to the Managed Care Plan
bull Reporting capabilities
bull Specialty service capabilities
bull Access numbers count
bull Ability to move metric numbers
9696
What About the Non- Medicaid Poor We Serve
bull Numbers are king in a managed care contract and the more access you have
the better contract terms you can negotiate
bull We will potentially have a steady supply of Medicaid patients
bull As managed care spreads states this may be compromising the ability of
health centers to serve the non-Medicaid poor and others lacking dental
insurance
97
Mark Koday DDS
(509) 949-2278
Dental Quality Consultants
of WA
httpdentalqualityconsultin
gcom
dentalqualityconsultantsg
mailcom
Contact Information
LUNCH
BREAKOUT EXERCISEORAL HEALTH VALUE-BASED CARE READINESS ASSESSMENT
Danielle Apostolon
PROMISING PRACTICES FROM THE FIELD STRATEGIES FOR INCREASING VALUE IN ORAL HEALTH
Dr Carolyn Brown
Dr Kelly Perry
Dr Rachel Rivard
Dr Adeloye
Commitment Compassion Community
m i d s t a t e h e a l t h o r g
Promising Practices from the
Field Strategies for Increasing
Value in Oral Health Care
Kelly Perry DMD
Better Health
Outcomes
Improved Staff
Experience
Reduced Cost
Improved Patient
Experience
Better Health
Outcomes
Improved Staff
Experience
Reduced Cost
Improved Patient
Experience
Better Health
Outcomes
Improved Staff
Experience
Reduced Cost
Improved Patient
Experience
Better Health
Outcomes
Improved Staff
Experience
Reduced Cost
Improved Patient
Experience
Commitment Compassion Community
kpe r r ymids t a tehea l t h o rg
Thank you
Completion of Disease Control Phase
Pelumi Adeloye DMD MPH
HEALTH ACCESS NETWORK (HAN) FAMILY DENTAL
Introduction
⧫1 Dentist I Hygienist 3 EFDArsquos1 Receptionist
⧫ 6 Chairs= 4 (dentist) + 2 (hygienist)
⧫ Slide ⥶80 off
⧫ Service areas Northern Penobscot Southern Aroostook Western
Washington Counties amp more
Completion of Phase I Treatment
⧫LimitedLack of Access to dental care
⧫Difficulty completing the disease control phase
Caries amp periodontal disease
⧫Attaining stable restorative state
Goal
Increase the completion of Disease Control Phase
Current practice
⧫Education
Assess level of dental literacy
Incremental strategy
⧫Increase access to dental care
Generous sliding scale (⥸$40 per visit)
Incorporate Expanded Function Dental Assistants
⧫Schedule modification
Incorporate more restorative blocks to allow
for follow-up visit and completion of restorative phase
httpswwwglasbergencomdentist-cartoons
Schedule
⧫Piggybacking technique
Increased allotted restorative blocks
⧫Sustainability of current schedule is
contingent on cooperation amp skills of HAN
Dental staff
Note
Strategies mentioned today is personalized to HAN Dental clinic
Current implemented strategies might be modified or changed in the
future as required in order to accommodate the need of our pts
THANK YOU
DAY TWOCLOSINGWRAP-UP
End of Day Two ndash Survey
Day Two Creating a Value-Based Oral Health Care Delivery
System
129
Payment Reform in Oral Health Online Learning Module
Oral Health Value-based Care Online Learning Module
Value-based Care Keys to Success Article
Readiness Assessment
Competency Development Guide
Oral Health Value-based Care Training
Dental Caries Management Practicum
Clinicians Companion Guide
Interprofessional Network Referral Process
Traditional Dental Care Vs Value-Based Care
Resources
131
wwwDentaQuestPartnershiporg
wwwfacebookcomDentaQuest
DentaQuest
wwwlinkedincomcompanyDentaQuest
Inside_DentaQuest
QUESTIONS
19
VALUE-BASED CAREPushing the impact quality and quantity of measurement
20
OHVBC Readiness
Leadership
Value of oral health and oral health transformation
Structure Systems and Operations
Efficiencies innovative care delivery
Care Pathways and Provider Buy-In
Risk-based care Training patient engagement
Data and Analytic Technology and Personnel
DataReports Interoperability
Financial Viability and Strength
Payerpatient mix billing infrastructure
httpswwwdentaquestpartnershiporglearnsafety-net-solutionsoral-health-value-based-careohvbc-readiness-
assessment
21
DentaQuest Partnership OHVBC Survey
Barriers to Value-based Transformation in Oral Health ndash
Most Common Responses
bull Patient engagement
bull EHREDR
bull Tracking outcomes lack of nationally-recognized and standardized quality
metrics in dental
22
How Can FQHC Dental Programs Prepare for Value-based
Transformation in Oral Health
bull Begin or continue focusing on prevention disease management and risk-based care
bull Hygienists will be key to success ndash We need primary dental care not just surgical
interventions
bull Start measuring outcomes instead of just processutilization metrics bull of initially high-risk patients with new caries lesions
bull of initially high-risk patients with decreased risk status
bull of initially low-risk patients with risk status maintained
bull Address patient engagement in a more meaningful way and invest in case
management
bull Invest in interprofessional practice including HIT interoperability
bull Evaluate how services are being delivered and determine if its reaching the patients
who need care the most
23
Value-Based Care
Care Coordination
ldquoClosing outrdquo referrals
Diagnostic coding
Risk Screenings
Care plans based on risk
Patient Engagement
Incentive payments
Quality metrics
Clinic Response
Case Management IT
Active timely records mngt
Mapping Dx codes to CDT
Time bill CPT codes Tx plan
IPP data tofrom PC MH
Recall window important
Attention to $ related metrics
Attention to assigned metrics
Direct and Indirect Effects of VBC on Dental Systems of Care
Utilization Impact
New workforce CDT codes
New or + workforce IT
ICD-CM-10 codes
+CDT codes
Modifiers (CPT ICD10)
+ recall adherence
in incentivized procedures
in sealant POC A1C
Counseling codes SD
24
MEASUREMENT IN ORAL HEALTH
25
Poll What percentage of your adult dental patients are diabetic
or pre-diabetic
A 50-80
B 20-50
C Less than 20
D Not sure
26
27
ldquoTrue Measures of Successrdquo
1 Define your governing objective
2 Develop a theory of cause and effect to assess presumed drivers of the
objective
3 Identify the specific activities that employees can do to help achieve the
governing objective
4 Evaluate your statistics
5 Communicate the story of your measurement
Adapted from HBR ldquoThe True Measures of Successrdquo httpshbrorg201210the-true-measures-of-success
28
1 Governing objective
2 Theory of cause and effect
3 Activities of team
4 Evaluate your statistics
5 Storycraft
Sustainability
Clinic revenuegt expenses= sustainability
Patient compliance Assets Clinic Mngt
Care team Operations Pt Support Billing
Of Prod on and type Patients on time
Daily weekly monthly quarterly
ldquoTrue Measures of Successrdquo
Adapted from HBR ldquoThe True Measures of Successrdquo httpshbrorg201210the-true-measures-of-success
29
Measuring Risk and Health
November is Diabetes Awareness Month- 2019Communication Plans are as
important as cold hard numbers
Patients
Care Team
Other Health Teams
Executive Team
Funders
Data on your dental patients are medical patients of record
Data on your medical + dental patients with DM2
30
Develop Diabetic Patient
Protocols
Review evidence and rationale with dental team
Partner with primary care team
bull Protocols Care mngt Tests and Recording
Quality Goals
Protocols for newly screened and existing patients
Educate and train dental team in reading AND
charting test results and PILOT
31
External Measurement in Oral Health Programs
httpswwwadaorg~mediaADADQA2019_DiabetesOralEvaluationpdfla=en
httpswwworegongovohaHPAANALYTICSCCOMetrics2019-Oral-Evaluation-Adults-Diabetespdf
32
Baseline for 2019 271
httpswwworegongovohaHPAANALYTICSCCOMetrics2019-Oral-Evaluation-Adults-Diabetespdf
33
Diabetes burden in your panel of dental patients
Baseline Medical-Dental Integrated panel of all patients
Dental patients with DM2 MDI
Dental patients with DM2
1000 or 10
600 or 60
300010000= 30
Population Health- Clinic Level
34
1 Governing objective
2 Theory of cause and effect
3 Activities of team
4 Evaluate your statistics
5 Storycraft
Discuss at meetings (Oct + Nov) Health education training
materials NP training CQI Note in Board report Clinical
measures
Care Pathways Hygiene Resources (ScheduleAvail)
ldquoTrue Measures of Successrdquo
Adapted from HBR ldquoThe True Measures of Successrdquo httpshbrorg201210the-true-measures-of-success
Diabetes Awareness Prevention Healthier Community
Prevention Awareness Care Pathway promotes health
MDI= 10 6 out of 10 adult patients with DM2
Goal set for integrated patient panels ndash PCMH
Pre-diabetes approach for executive team
Care Pathways
Care Coordination
35
MEASURING PATIENT ORAL HEALTHRisk assessments and Care Pathways
36
37
Risk Assessment and Care Pathways
Caries Risk Assessment
Multiple tools
EDREHR modules smart notes or dot phrases
CDT Codes
Decide frequency
D0601
Low Caries Risk
D0601
Moderate Caries Risk
D0601
High Caries Risk
38
The Disease Management DifferenceDisease Management Difference
Traditional Dental Care Disease Management
Approach
All patients return in 6 months
regardless of risk status
Recare interval is based on the
childrsquos caries risk
Caries Risk
Level
Recommended
Recare Interval
High Risk 1 ndash 3 months
Moderate Risk 3 ndash 6 months
Low Risk 6 ndash 12 months
Caries
Stabilizing
agents
Health Ed
Nutritional
Counseling
Anti-bacterial
and Fluoride
interventions
39
Disease Management Care Pathways
DentaQuest Partnership for Oral Health Advancement Disease Management Model
Caries
Stabilizing
agents
Whole
Person
Inter-
professional
Approaches
Anti-bacterial
and Fluoride
interventions
40
Disease Management and Risk Screening Training
DentaQuest Partnership for Oral Health Advancementrsquos
Online Learning Center
Disease Management Series
8 modules 40 CDE available
httpswwwdentaquestpartnershiporglearnonline-learning-centeronline-
coursewaredentaquest-disease-management-series
41
MEASUREMENT IN TEAMSSharing meaningful data with your dental clinical teams
42
rdquoDental Homerdquo = Health Home where WE can meet the patient
Oralhealthworkforceorg
43
POLL HOW OFTEN DO YOU SHARE YOUR S WITH YOUR DENTAL TEAM
A Yearly only
B Quarterly
C Monthly
D Weekly
E Daily
44
Clinical Measures ndash Dental Practice Perspective
Private Practice Office
New patients seen
Assigned vs seen if capitated
Treatment plans incomplete
$ produced amp per provider
$ collected amp monthly per provider
CDT 6000 codes completed
RecallHygiene maintenance
Based on this consultants experienced
FQHC
Unduplicated patients
patients seen per day
Treatment plans complete
$ gainedlost via accounting
Broken appointment rate
procedures
Sealant rate (annual)
45
bull HRSA Sealant Measure Compliance for FQHCs
bull Completion of phase 1 treatment plans
bull Children seen 0-5 years old
bull Children seen getting a preventive service
bull Fluoride Varnish applications
bull Pregnant women seen and treated
bull Diabetic patients with HbA1C gt 7 seen
bull Patients seen who have not been seen for 12 months
bull Patients seen getting a Risk Assessment
bull Patients with moderate or high risk who lower risk at recare
bull Sealants provided httpwwwnnohaorgnnoha-contentuploads201512Demystifying-HRSA-SEALANT-PRESENTATION_FINALpdf
Program Measures
46
HRSA Performance Measurement and Data Collection
bull FQHCs and look-alikes submit CY data to HRSA since 2008
bull UDS Uniform Data System
bull Require FTE for clinical staff patient demographics
bull Dental utilization s (UDCTPV)
bull Dental Clinical Measure dental sealants placed on 1st molars ages 6-9 yo
bull Health Center Quartile rankings (Clinical measure performance influences
HC rankings as does EHR adoption and other HC characteristics)
47
Low birth weight
Access to prenatal care
Childhood Immunization
Children (Ages 3-17) Receiving
Weight Assessment amp
Counseling
Children (Age 6-9) Receiving
Dental Sealant to First Molars
Diabetes Control
Hypertension Control
Pap Test
Depression Screening and
Follow-up (Age 12+)
Asthma Patients (Age 5-40)
Receiving Pharmacologic
Therapy
Colorectal Cancer
Screening (Ages 51-74)
HRSA UDS Clinical Measures
Adults (Age 18+) Receiving
Weight Screening amp Follow-up
Adults (Age 18+) Receiving
Tobacco Use Assessment and
Cessation Intervention
Coronary Artery Disease
Receiving Lipid Therapy (18+)
Ischemic Vascular Disease (IVD)
Receiving Aspirin Therapy (18+)
HIV Linkage to Care
48
Dashboards
Grants
Average
amp
Targets
Quality
Rev
Costs
Visits
Priority
Pop
Prevention
49
Dashboard- Provider Team Level
Patient
Compliance
Satisfaction
50
Case Study-
Incentives bonus round pools benchmark and improvement target goals risk-sharing possible later years
51
Qualitative Measurement
ldquoPatient engagement is the act of patients and providers working together
toward the end goal of improved patient wellnessrdquo
wwwpatientengagementhitcom
Access to Care
Patient Activation
Patient Satisfaction
Patient-Provider-Care Team Communication
Care Team Satisfaction
52
OHVBC Readiness
Leadership
bull Value of oral health and oral health transformation
Structure Systems and Operations
bull Operational efficiencies innovative care delivery methodologies
Care Pathways and Provider Buy-In
bull Training disease management risk-based care referrals IDC-10 coding patient engagement
Data and Analytic Technology and Personnel
bull Interoperability reporting
Financial Viability and Strength
bull Payerpatient mix billing infrastructure financial reports
httpswwwdentaquestpartnershiporglearnsafety-net-solutionsoral-health-value-based-careohvbc-readiness-
assessment
53
QUESTIONS COMMENTS
Carolyn Brown DDS
cbrownddsgmailcom
RISK BASED MANAGED CARE
Value Based Training Conference
Manchester New Hampshire
Mark Koday DDS
111919
5555
Objectives
bull Review current drivers of dental managed care
bull Understand the basics of risk-based dental managed care contracts
bull Learn the basics of managing costs in a riskndashbased contract
bull Gain an understanding in the potential advantage of risk-based contracting
56
What Is Dental Managed Care
Managed care is a health delivery system whose purpose is to manage both the
quality and cost of health care
Common types of managed care health insurance plans
bull HMOs
bull PPOs
bull POSs
bull Medicaid Managed Care
DIDNrsquoT WE ALREADY HAVE MANAGED CARE AND IT FAILED
57
What Has Happened Since the 90s
58
WHY THE FFS AND PPS DOESNrsquoT WORK FOR OUR POPULATIONS
bull Inefficient payment systems designed to produce encounters or procedures but not real health
bull No focus on population health
bull Does not incentivize innovation
bull Patients essentially on their own for accessing specialty care
59
Rule of 4
Source Kaiser Family Foundation analysis of National Health Expenditure (NHE) data from Centers for
Medicare and Medicaid Services Office of the Actuary National Health Statistics Group
60
Rule of 4
bull This helps explain why oral health has been relatively ignored so far by CMS
bull Explains why we have PCMH instead of PCHH
bull Where is the real value on a national level in preventing disease and
controlling costs
bull Beware- wersquove been found
61
Reasons Dental Managed Care is Spreading Across the States
NON-MANAGED CARE STATE DENTAL BUDGETS ARE
OPENED ENDED
STRAIN ON STATE BUDGETS
UPCOMING RECESSION WITH TRILLION DOLLAR
DEFICIT
SHIFTS FINANCIAL RISK FROM THE STATES TO THE
PLANS
6262
Types of Medicaid Managed Care
bull State Medicaid agency administrator lowest administrative
costs
bull Third Party Administrator Typically 15 administrative costs
bull Managed Care Organization Typically 15 administrative
costs
bull Carved-in
bull Carved-out
bull Risk Based Managed Care Administrative costs part of
contract negotiation
63
RISK CONTRACTS
6464
Components of a Risk-based Contract
Risk
Medical Loss Ratio
Quality withhold
Specialty withhold
Managed care payment (pmpm)
Covered services
Fee schedule Claims are paid as usual on a FFS basis
Credentialing
Quality Review process and Quality Metrics
65
Upside Risk
The possibility that the cost of
delivering dental care to an assigned
patient panel is less than the amount
of funding calculated for that care
The Plan pays the CHC additional
funds based on a predetermine
formula
Downside Risk
The possibility that the cost of
delivering dental care to an assigned
patient panel is more than the amount
of funding calculated for that care
The CHC pays the Plan additional
funds based on a predetermine
formula
Upside and Downside Risk
66
Taking On Risk 100 or Shared Risk
With 100 risk you receive 100 of the potential savings but are also at risk for
100 of the losses
Shared Risk MCO and health center share a percentage of the risk
Shared Risk leads to better cooperation since both organizations are
incentivized to save on costs
6767
Reports Needed
bull Enrollment reports lists of who is assigned on a monthly basis
bull Reconciliation reports insure appropriate payments
bull Specialty Referral reports
bull You will need your own reporting process so you donrsquot rely completely on
reports supplied by the Plan
6868
Medical Loss Ratio
Medical Loss Ratio (MLR) is proportion of premium revenues spent on clinical
services and quality improvement also known as the Medical Loss Ratio (MLR)
For CMS requires Medical Plans to spend at least 80 to 85 of the premiums
on actual medical care
69
Administrative Fees
bull Essentially the opposite of MLR
bull The State Medicaid Agency is funded by the Governorrsquos budget
bull The State Medicaid Agency will keep some of these funds for their
admin costs and give the remaining to the Managed Care Plans
bull Private Plan admin costs can be as high as 40 but most states
limit these cost for Medicaid Plans to between 15 and 20 (85-
80 MLR)
bull This may be negotiable depending on your program size of your
program
70
Quality Withhold
bull The state withholds a certain percent (typically 2-4 ) of the funds they give
to the Plans for Value Based Reimbursement
bull They choose quality metrics and set benchmarks and assign payments for
each metric based on an assigned priority for each metric
bull If a Plan meets the benchmark of every quality metric the state passes on
their full share of the quality withhold
bull The Plans may or may not withhold a percent of the funds for quality payment
to the dentists or manage care contractors
71
Quality Withhold
Either way the Plans may or may not pass the quality payments they receive to
the dentists or contractors
This should be spelled out in a risk-based contract
72
Percent of funds set aside
to cover specialty care
referrals
Typically 10-15
Goal Limit referral costs
to within or less than
Specialty set aside
Specialty Withhold
73
Per Member Per Month
bull Capitated Payment
bull Specific dollar amount paid for each enrolled member each month
bull Paid whether patient is accessed for care or not
bull States do set access benchmarks
bull In Oregon access for any dental procedure (adults and children combined)
was 267 in 2015
74
Payment Math Example
Premium per enrollee = $25
Administrative fee 15 = $375
Funds available per enrollee to the clinic = $2125
Management fee per enrollee = $175
Funds per enrollee that would undergo PPS reconciliation = $1950
For every 10000 enrollees the managed care income = $2340000
Specialty withhold (10) = $234000
YE Cost lt or gt $2340000
Upside Risk
CHC Gains $
Downside Risk
CHC Loses $
75
Covered Services and Fee Schedules
bull The state Medicaid agency spells out the minimum procedures and fees that
MCOs must cover
bull MCOs may add procedures or increase periodicity of procedures particularly
preventative services
bull MCOs may increase fees to entice rural providers and specialists to enroll in
their Plans
bull Access Rules
bull How many days it takes to access a patent
bull How many days it takes for a patent to access urgent care services
bull How many days it takes for a patent to access emergency care services
76
Credentialing
All MCOs are required to credential all Providers
All MCOs have their own credentialing process
Credentialing process is can be lengthy
Credentialing process may be negotiable
77
Quality Review Process and Quality Metrics
MCOs must have a Quality and Compliance Review Process
If you arenrsquot in compliance with both you likely wonrsquot get paid
Typical processes reviewed
bull Charting specifications
bull Incident report
bull Enrollee complaints quality rudeness and access issues
bull Medicaid compliance
78
Quality Payments
bull State Shared Incentive Withhold Typically quality metrics and benchmarks
are set by the state sets aside a certain percent (3-5) of the payments to
the Managed Care Plan (MCP)
bull If the benchmarks are achieved the MCP is then paid the a predetermine
amount
bull Benchmarks may not be the same as the states
bull Managed Care Plans do not have to pass all or any of the quality payments to
the health centers or providers
bull Managed Care contract- Metrics benchmarks should be selected and part of
the contract
7979
Achieving Quality Metric Payments
Dealing with under achievers
Process issues
Individual issues
Identifying workflows
Developing Best Practices through
PDSA process
Developing Best Practices through
PDSA process
CHC Metrics Committee
Clinicians Operations various key staff
Identify Best Practices
Spread Best Practices
80
New Team Needed Business Intelligence
Business Intelligence (BI) is critical for effective managed care business decisions
BI team inputs metrics into your EHR collects integrates analyses and displays all your managed care business and clinical information
Easy to say- hard to achieve
Build your own or outsource
Possible future role of Primary Care Associations
8181
Clinicianrsquos Dashboard
Expensive to build
Displayed on your screen when your computer is first turned on
Easy to read and understand
Data dumped from the day before
Can dialed down from Org-wide to clinic to each clinicianrsquos data
Operational and clinical metrics
bull Treatment Plan Completion
bull DQA quality measures
bull Caries at Recall
bull Re-care reports
bull Care Gap reports
82
CONTROLLING COSTS
8383
Controlling Costs- Current
bull Increasing efficiencies
bull Decreasing broken appointments
bull Controlling supplies equipment costs
bull Staff recruitment retention costs
84
Specialty Care
Training current CHC dentists in
specialty areas
Hiring general dentists with higher
specialty skill sets
Hiring in house specialists
Contract with outside specialists
Work with Managed Care Plan
specialists
Lowering Disease Rates
Community Dental Health
Coordinators case management
If your state law allows- embed
hygienists in medical and community
to provide primary and secondary
prevention procedures
In clinic Caries Classification and
Silver Diamine Fluoride
Effective recare programs
Controlling Costs- Additions in Risk-based Contracting
85
Specialty Care ndash Primary Referrals by Cost
Pediatric dentistry
Orthodontics
Oral surgery
Endodontics
86
In-clinic Pediatric Services
Encounters expected
of operatories available
State dental law and ability to have
expanded duties
General Anesthesia
GA in- house
Ability for a hospital or surgery center
to set aside regular OR time
Ability to hire or assign DAs to GA
days
Four GA cases day x PPS rate
Should You Hire a Pediatric Dentist- It Depends
8787
Solutions for Controlling Pediatric Costs
Hire a general dentist that is skilled in treating young children
Make the clinic child friendly nitrous oxide TVs in the operatory etc
Teach entire staff behavioral control techniques
Contract with a pediatric dentist for the GA care
88
Lowering Overall Disease Rates (and Costs)
You are responsible for both the patients you see in the chair and the ones
assigned to you
Breaking down the walls of the dental clinic
Community Dental Health Coordinators
Case Management
89
Cost Control Essentials
Diagnosis codes
Increased ability to identify
disease by risk
Motivational
Interviewing
Developing Polices and
Procedures design to treat
disease according to risk
ie Silver Diamine Fluoride
Treating by Risk
Effective Recare
Process
Critical to continual disease
controlPrevention education that is
meaningful and designed to
change behaviors
90
Social Determinants of Health Aunt Bertha
httpswwwauntberthacom
91
REASON TO CONSIDER RISK- BASED CONTRACTING
9292
PPS Reconciliation and Federal Code 42 CFR sect4052469(a)(2)
42 CFR sect4052469(a)(2)
ldquoAny financial incentives provided to Federally Qualified Health Centers
under their Medicare Advantage Contracts such as risk pool payments
bonuses or withholds are prohibited from being included in the
calculation of supplemental payments due to the Federally Qualified
Health Centerrdquo
9393
Why Risk Based Contract in Times of PPS Reconciliation
bull Not all Risk- based Contract funds are reconciled
bull Risk is the key word- you can come out with less money than your normal
PPS reconciliation payment
bull Can lead to better patient care
bull May improve manage care enrollment for your medical plan
bull Promotes integrated care increases health for your CHC patients
9494
Not Included in the Reconciliation
Enrollment management pmpm
Quality Payments
Upside risk payments
Downside risk losses
9595
Determinants of Financial Success in Risk-Based Contracting
bull Most critical- State pmpm payment to the Managed Care Plan
bull Reporting capabilities
bull Specialty service capabilities
bull Access numbers count
bull Ability to move metric numbers
9696
What About the Non- Medicaid Poor We Serve
bull Numbers are king in a managed care contract and the more access you have
the better contract terms you can negotiate
bull We will potentially have a steady supply of Medicaid patients
bull As managed care spreads states this may be compromising the ability of
health centers to serve the non-Medicaid poor and others lacking dental
insurance
97
Mark Koday DDS
(509) 949-2278
Dental Quality Consultants
of WA
httpdentalqualityconsultin
gcom
dentalqualityconsultantsg
mailcom
Contact Information
LUNCH
BREAKOUT EXERCISEORAL HEALTH VALUE-BASED CARE READINESS ASSESSMENT
Danielle Apostolon
PROMISING PRACTICES FROM THE FIELD STRATEGIES FOR INCREASING VALUE IN ORAL HEALTH
Dr Carolyn Brown
Dr Kelly Perry
Dr Rachel Rivard
Dr Adeloye
Commitment Compassion Community
m i d s t a t e h e a l t h o r g
Promising Practices from the
Field Strategies for Increasing
Value in Oral Health Care
Kelly Perry DMD
Better Health
Outcomes
Improved Staff
Experience
Reduced Cost
Improved Patient
Experience
Better Health
Outcomes
Improved Staff
Experience
Reduced Cost
Improved Patient
Experience
Better Health
Outcomes
Improved Staff
Experience
Reduced Cost
Improved Patient
Experience
Better Health
Outcomes
Improved Staff
Experience
Reduced Cost
Improved Patient
Experience
Commitment Compassion Community
kpe r r ymids t a tehea l t h o rg
Thank you
Completion of Disease Control Phase
Pelumi Adeloye DMD MPH
HEALTH ACCESS NETWORK (HAN) FAMILY DENTAL
Introduction
⧫1 Dentist I Hygienist 3 EFDArsquos1 Receptionist
⧫ 6 Chairs= 4 (dentist) + 2 (hygienist)
⧫ Slide ⥶80 off
⧫ Service areas Northern Penobscot Southern Aroostook Western
Washington Counties amp more
Completion of Phase I Treatment
⧫LimitedLack of Access to dental care
⧫Difficulty completing the disease control phase
Caries amp periodontal disease
⧫Attaining stable restorative state
Goal
Increase the completion of Disease Control Phase
Current practice
⧫Education
Assess level of dental literacy
Incremental strategy
⧫Increase access to dental care
Generous sliding scale (⥸$40 per visit)
Incorporate Expanded Function Dental Assistants
⧫Schedule modification
Incorporate more restorative blocks to allow
for follow-up visit and completion of restorative phase
httpswwwglasbergencomdentist-cartoons
Schedule
⧫Piggybacking technique
Increased allotted restorative blocks
⧫Sustainability of current schedule is
contingent on cooperation amp skills of HAN
Dental staff
Note
Strategies mentioned today is personalized to HAN Dental clinic
Current implemented strategies might be modified or changed in the
future as required in order to accommodate the need of our pts
THANK YOU
DAY TWOCLOSINGWRAP-UP
End of Day Two ndash Survey
Day Two Creating a Value-Based Oral Health Care Delivery
System
129
Payment Reform in Oral Health Online Learning Module
Oral Health Value-based Care Online Learning Module
Value-based Care Keys to Success Article
Readiness Assessment
Competency Development Guide
Oral Health Value-based Care Training
Dental Caries Management Practicum
Clinicians Companion Guide
Interprofessional Network Referral Process
Traditional Dental Care Vs Value-Based Care
Resources
131
wwwDentaQuestPartnershiporg
wwwfacebookcomDentaQuest
DentaQuest
wwwlinkedincomcompanyDentaQuest
Inside_DentaQuest
QUESTIONS
20
OHVBC Readiness
Leadership
Value of oral health and oral health transformation
Structure Systems and Operations
Efficiencies innovative care delivery
Care Pathways and Provider Buy-In
Risk-based care Training patient engagement
Data and Analytic Technology and Personnel
DataReports Interoperability
Financial Viability and Strength
Payerpatient mix billing infrastructure
httpswwwdentaquestpartnershiporglearnsafety-net-solutionsoral-health-value-based-careohvbc-readiness-
assessment
21
DentaQuest Partnership OHVBC Survey
Barriers to Value-based Transformation in Oral Health ndash
Most Common Responses
bull Patient engagement
bull EHREDR
bull Tracking outcomes lack of nationally-recognized and standardized quality
metrics in dental
22
How Can FQHC Dental Programs Prepare for Value-based
Transformation in Oral Health
bull Begin or continue focusing on prevention disease management and risk-based care
bull Hygienists will be key to success ndash We need primary dental care not just surgical
interventions
bull Start measuring outcomes instead of just processutilization metrics bull of initially high-risk patients with new caries lesions
bull of initially high-risk patients with decreased risk status
bull of initially low-risk patients with risk status maintained
bull Address patient engagement in a more meaningful way and invest in case
management
bull Invest in interprofessional practice including HIT interoperability
bull Evaluate how services are being delivered and determine if its reaching the patients
who need care the most
23
Value-Based Care
Care Coordination
ldquoClosing outrdquo referrals
Diagnostic coding
Risk Screenings
Care plans based on risk
Patient Engagement
Incentive payments
Quality metrics
Clinic Response
Case Management IT
Active timely records mngt
Mapping Dx codes to CDT
Time bill CPT codes Tx plan
IPP data tofrom PC MH
Recall window important
Attention to $ related metrics
Attention to assigned metrics
Direct and Indirect Effects of VBC on Dental Systems of Care
Utilization Impact
New workforce CDT codes
New or + workforce IT
ICD-CM-10 codes
+CDT codes
Modifiers (CPT ICD10)
+ recall adherence
in incentivized procedures
in sealant POC A1C
Counseling codes SD
24
MEASUREMENT IN ORAL HEALTH
25
Poll What percentage of your adult dental patients are diabetic
or pre-diabetic
A 50-80
B 20-50
C Less than 20
D Not sure
26
27
ldquoTrue Measures of Successrdquo
1 Define your governing objective
2 Develop a theory of cause and effect to assess presumed drivers of the
objective
3 Identify the specific activities that employees can do to help achieve the
governing objective
4 Evaluate your statistics
5 Communicate the story of your measurement
Adapted from HBR ldquoThe True Measures of Successrdquo httpshbrorg201210the-true-measures-of-success
28
1 Governing objective
2 Theory of cause and effect
3 Activities of team
4 Evaluate your statistics
5 Storycraft
Sustainability
Clinic revenuegt expenses= sustainability
Patient compliance Assets Clinic Mngt
Care team Operations Pt Support Billing
Of Prod on and type Patients on time
Daily weekly monthly quarterly
ldquoTrue Measures of Successrdquo
Adapted from HBR ldquoThe True Measures of Successrdquo httpshbrorg201210the-true-measures-of-success
29
Measuring Risk and Health
November is Diabetes Awareness Month- 2019Communication Plans are as
important as cold hard numbers
Patients
Care Team
Other Health Teams
Executive Team
Funders
Data on your dental patients are medical patients of record
Data on your medical + dental patients with DM2
30
Develop Diabetic Patient
Protocols
Review evidence and rationale with dental team
Partner with primary care team
bull Protocols Care mngt Tests and Recording
Quality Goals
Protocols for newly screened and existing patients
Educate and train dental team in reading AND
charting test results and PILOT
31
External Measurement in Oral Health Programs
httpswwwadaorg~mediaADADQA2019_DiabetesOralEvaluationpdfla=en
httpswwworegongovohaHPAANALYTICSCCOMetrics2019-Oral-Evaluation-Adults-Diabetespdf
32
Baseline for 2019 271
httpswwworegongovohaHPAANALYTICSCCOMetrics2019-Oral-Evaluation-Adults-Diabetespdf
33
Diabetes burden in your panel of dental patients
Baseline Medical-Dental Integrated panel of all patients
Dental patients with DM2 MDI
Dental patients with DM2
1000 or 10
600 or 60
300010000= 30
Population Health- Clinic Level
34
1 Governing objective
2 Theory of cause and effect
3 Activities of team
4 Evaluate your statistics
5 Storycraft
Discuss at meetings (Oct + Nov) Health education training
materials NP training CQI Note in Board report Clinical
measures
Care Pathways Hygiene Resources (ScheduleAvail)
ldquoTrue Measures of Successrdquo
Adapted from HBR ldquoThe True Measures of Successrdquo httpshbrorg201210the-true-measures-of-success
Diabetes Awareness Prevention Healthier Community
Prevention Awareness Care Pathway promotes health
MDI= 10 6 out of 10 adult patients with DM2
Goal set for integrated patient panels ndash PCMH
Pre-diabetes approach for executive team
Care Pathways
Care Coordination
35
MEASURING PATIENT ORAL HEALTHRisk assessments and Care Pathways
36
37
Risk Assessment and Care Pathways
Caries Risk Assessment
Multiple tools
EDREHR modules smart notes or dot phrases
CDT Codes
Decide frequency
D0601
Low Caries Risk
D0601
Moderate Caries Risk
D0601
High Caries Risk
38
The Disease Management DifferenceDisease Management Difference
Traditional Dental Care Disease Management
Approach
All patients return in 6 months
regardless of risk status
Recare interval is based on the
childrsquos caries risk
Caries Risk
Level
Recommended
Recare Interval
High Risk 1 ndash 3 months
Moderate Risk 3 ndash 6 months
Low Risk 6 ndash 12 months
Caries
Stabilizing
agents
Health Ed
Nutritional
Counseling
Anti-bacterial
and Fluoride
interventions
39
Disease Management Care Pathways
DentaQuest Partnership for Oral Health Advancement Disease Management Model
Caries
Stabilizing
agents
Whole
Person
Inter-
professional
Approaches
Anti-bacterial
and Fluoride
interventions
40
Disease Management and Risk Screening Training
DentaQuest Partnership for Oral Health Advancementrsquos
Online Learning Center
Disease Management Series
8 modules 40 CDE available
httpswwwdentaquestpartnershiporglearnonline-learning-centeronline-
coursewaredentaquest-disease-management-series
41
MEASUREMENT IN TEAMSSharing meaningful data with your dental clinical teams
42
rdquoDental Homerdquo = Health Home where WE can meet the patient
Oralhealthworkforceorg
43
POLL HOW OFTEN DO YOU SHARE YOUR S WITH YOUR DENTAL TEAM
A Yearly only
B Quarterly
C Monthly
D Weekly
E Daily
44
Clinical Measures ndash Dental Practice Perspective
Private Practice Office
New patients seen
Assigned vs seen if capitated
Treatment plans incomplete
$ produced amp per provider
$ collected amp monthly per provider
CDT 6000 codes completed
RecallHygiene maintenance
Based on this consultants experienced
FQHC
Unduplicated patients
patients seen per day
Treatment plans complete
$ gainedlost via accounting
Broken appointment rate
procedures
Sealant rate (annual)
45
bull HRSA Sealant Measure Compliance for FQHCs
bull Completion of phase 1 treatment plans
bull Children seen 0-5 years old
bull Children seen getting a preventive service
bull Fluoride Varnish applications
bull Pregnant women seen and treated
bull Diabetic patients with HbA1C gt 7 seen
bull Patients seen who have not been seen for 12 months
bull Patients seen getting a Risk Assessment
bull Patients with moderate or high risk who lower risk at recare
bull Sealants provided httpwwwnnohaorgnnoha-contentuploads201512Demystifying-HRSA-SEALANT-PRESENTATION_FINALpdf
Program Measures
46
HRSA Performance Measurement and Data Collection
bull FQHCs and look-alikes submit CY data to HRSA since 2008
bull UDS Uniform Data System
bull Require FTE for clinical staff patient demographics
bull Dental utilization s (UDCTPV)
bull Dental Clinical Measure dental sealants placed on 1st molars ages 6-9 yo
bull Health Center Quartile rankings (Clinical measure performance influences
HC rankings as does EHR adoption and other HC characteristics)
47
Low birth weight
Access to prenatal care
Childhood Immunization
Children (Ages 3-17) Receiving
Weight Assessment amp
Counseling
Children (Age 6-9) Receiving
Dental Sealant to First Molars
Diabetes Control
Hypertension Control
Pap Test
Depression Screening and
Follow-up (Age 12+)
Asthma Patients (Age 5-40)
Receiving Pharmacologic
Therapy
Colorectal Cancer
Screening (Ages 51-74)
HRSA UDS Clinical Measures
Adults (Age 18+) Receiving
Weight Screening amp Follow-up
Adults (Age 18+) Receiving
Tobacco Use Assessment and
Cessation Intervention
Coronary Artery Disease
Receiving Lipid Therapy (18+)
Ischemic Vascular Disease (IVD)
Receiving Aspirin Therapy (18+)
HIV Linkage to Care
48
Dashboards
Grants
Average
amp
Targets
Quality
Rev
Costs
Visits
Priority
Pop
Prevention
49
Dashboard- Provider Team Level
Patient
Compliance
Satisfaction
50
Case Study-
Incentives bonus round pools benchmark and improvement target goals risk-sharing possible later years
51
Qualitative Measurement
ldquoPatient engagement is the act of patients and providers working together
toward the end goal of improved patient wellnessrdquo
wwwpatientengagementhitcom
Access to Care
Patient Activation
Patient Satisfaction
Patient-Provider-Care Team Communication
Care Team Satisfaction
52
OHVBC Readiness
Leadership
bull Value of oral health and oral health transformation
Structure Systems and Operations
bull Operational efficiencies innovative care delivery methodologies
Care Pathways and Provider Buy-In
bull Training disease management risk-based care referrals IDC-10 coding patient engagement
Data and Analytic Technology and Personnel
bull Interoperability reporting
Financial Viability and Strength
bull Payerpatient mix billing infrastructure financial reports
httpswwwdentaquestpartnershiporglearnsafety-net-solutionsoral-health-value-based-careohvbc-readiness-
assessment
53
QUESTIONS COMMENTS
Carolyn Brown DDS
cbrownddsgmailcom
RISK BASED MANAGED CARE
Value Based Training Conference
Manchester New Hampshire
Mark Koday DDS
111919
5555
Objectives
bull Review current drivers of dental managed care
bull Understand the basics of risk-based dental managed care contracts
bull Learn the basics of managing costs in a riskndashbased contract
bull Gain an understanding in the potential advantage of risk-based contracting
56
What Is Dental Managed Care
Managed care is a health delivery system whose purpose is to manage both the
quality and cost of health care
Common types of managed care health insurance plans
bull HMOs
bull PPOs
bull POSs
bull Medicaid Managed Care
DIDNrsquoT WE ALREADY HAVE MANAGED CARE AND IT FAILED
57
What Has Happened Since the 90s
58
WHY THE FFS AND PPS DOESNrsquoT WORK FOR OUR POPULATIONS
bull Inefficient payment systems designed to produce encounters or procedures but not real health
bull No focus on population health
bull Does not incentivize innovation
bull Patients essentially on their own for accessing specialty care
59
Rule of 4
Source Kaiser Family Foundation analysis of National Health Expenditure (NHE) data from Centers for
Medicare and Medicaid Services Office of the Actuary National Health Statistics Group
60
Rule of 4
bull This helps explain why oral health has been relatively ignored so far by CMS
bull Explains why we have PCMH instead of PCHH
bull Where is the real value on a national level in preventing disease and
controlling costs
bull Beware- wersquove been found
61
Reasons Dental Managed Care is Spreading Across the States
NON-MANAGED CARE STATE DENTAL BUDGETS ARE
OPENED ENDED
STRAIN ON STATE BUDGETS
UPCOMING RECESSION WITH TRILLION DOLLAR
DEFICIT
SHIFTS FINANCIAL RISK FROM THE STATES TO THE
PLANS
6262
Types of Medicaid Managed Care
bull State Medicaid agency administrator lowest administrative
costs
bull Third Party Administrator Typically 15 administrative costs
bull Managed Care Organization Typically 15 administrative
costs
bull Carved-in
bull Carved-out
bull Risk Based Managed Care Administrative costs part of
contract negotiation
63
RISK CONTRACTS
6464
Components of a Risk-based Contract
Risk
Medical Loss Ratio
Quality withhold
Specialty withhold
Managed care payment (pmpm)
Covered services
Fee schedule Claims are paid as usual on a FFS basis
Credentialing
Quality Review process and Quality Metrics
65
Upside Risk
The possibility that the cost of
delivering dental care to an assigned
patient panel is less than the amount
of funding calculated for that care
The Plan pays the CHC additional
funds based on a predetermine
formula
Downside Risk
The possibility that the cost of
delivering dental care to an assigned
patient panel is more than the amount
of funding calculated for that care
The CHC pays the Plan additional
funds based on a predetermine
formula
Upside and Downside Risk
66
Taking On Risk 100 or Shared Risk
With 100 risk you receive 100 of the potential savings but are also at risk for
100 of the losses
Shared Risk MCO and health center share a percentage of the risk
Shared Risk leads to better cooperation since both organizations are
incentivized to save on costs
6767
Reports Needed
bull Enrollment reports lists of who is assigned on a monthly basis
bull Reconciliation reports insure appropriate payments
bull Specialty Referral reports
bull You will need your own reporting process so you donrsquot rely completely on
reports supplied by the Plan
6868
Medical Loss Ratio
Medical Loss Ratio (MLR) is proportion of premium revenues spent on clinical
services and quality improvement also known as the Medical Loss Ratio (MLR)
For CMS requires Medical Plans to spend at least 80 to 85 of the premiums
on actual medical care
69
Administrative Fees
bull Essentially the opposite of MLR
bull The State Medicaid Agency is funded by the Governorrsquos budget
bull The State Medicaid Agency will keep some of these funds for their
admin costs and give the remaining to the Managed Care Plans
bull Private Plan admin costs can be as high as 40 but most states
limit these cost for Medicaid Plans to between 15 and 20 (85-
80 MLR)
bull This may be negotiable depending on your program size of your
program
70
Quality Withhold
bull The state withholds a certain percent (typically 2-4 ) of the funds they give
to the Plans for Value Based Reimbursement
bull They choose quality metrics and set benchmarks and assign payments for
each metric based on an assigned priority for each metric
bull If a Plan meets the benchmark of every quality metric the state passes on
their full share of the quality withhold
bull The Plans may or may not withhold a percent of the funds for quality payment
to the dentists or manage care contractors
71
Quality Withhold
Either way the Plans may or may not pass the quality payments they receive to
the dentists or contractors
This should be spelled out in a risk-based contract
72
Percent of funds set aside
to cover specialty care
referrals
Typically 10-15
Goal Limit referral costs
to within or less than
Specialty set aside
Specialty Withhold
73
Per Member Per Month
bull Capitated Payment
bull Specific dollar amount paid for each enrolled member each month
bull Paid whether patient is accessed for care or not
bull States do set access benchmarks
bull In Oregon access for any dental procedure (adults and children combined)
was 267 in 2015
74
Payment Math Example
Premium per enrollee = $25
Administrative fee 15 = $375
Funds available per enrollee to the clinic = $2125
Management fee per enrollee = $175
Funds per enrollee that would undergo PPS reconciliation = $1950
For every 10000 enrollees the managed care income = $2340000
Specialty withhold (10) = $234000
YE Cost lt or gt $2340000
Upside Risk
CHC Gains $
Downside Risk
CHC Loses $
75
Covered Services and Fee Schedules
bull The state Medicaid agency spells out the minimum procedures and fees that
MCOs must cover
bull MCOs may add procedures or increase periodicity of procedures particularly
preventative services
bull MCOs may increase fees to entice rural providers and specialists to enroll in
their Plans
bull Access Rules
bull How many days it takes to access a patent
bull How many days it takes for a patent to access urgent care services
bull How many days it takes for a patent to access emergency care services
76
Credentialing
All MCOs are required to credential all Providers
All MCOs have their own credentialing process
Credentialing process is can be lengthy
Credentialing process may be negotiable
77
Quality Review Process and Quality Metrics
MCOs must have a Quality and Compliance Review Process
If you arenrsquot in compliance with both you likely wonrsquot get paid
Typical processes reviewed
bull Charting specifications
bull Incident report
bull Enrollee complaints quality rudeness and access issues
bull Medicaid compliance
78
Quality Payments
bull State Shared Incentive Withhold Typically quality metrics and benchmarks
are set by the state sets aside a certain percent (3-5) of the payments to
the Managed Care Plan (MCP)
bull If the benchmarks are achieved the MCP is then paid the a predetermine
amount
bull Benchmarks may not be the same as the states
bull Managed Care Plans do not have to pass all or any of the quality payments to
the health centers or providers
bull Managed Care contract- Metrics benchmarks should be selected and part of
the contract
7979
Achieving Quality Metric Payments
Dealing with under achievers
Process issues
Individual issues
Identifying workflows
Developing Best Practices through
PDSA process
Developing Best Practices through
PDSA process
CHC Metrics Committee
Clinicians Operations various key staff
Identify Best Practices
Spread Best Practices
80
New Team Needed Business Intelligence
Business Intelligence (BI) is critical for effective managed care business decisions
BI team inputs metrics into your EHR collects integrates analyses and displays all your managed care business and clinical information
Easy to say- hard to achieve
Build your own or outsource
Possible future role of Primary Care Associations
8181
Clinicianrsquos Dashboard
Expensive to build
Displayed on your screen when your computer is first turned on
Easy to read and understand
Data dumped from the day before
Can dialed down from Org-wide to clinic to each clinicianrsquos data
Operational and clinical metrics
bull Treatment Plan Completion
bull DQA quality measures
bull Caries at Recall
bull Re-care reports
bull Care Gap reports
82
CONTROLLING COSTS
8383
Controlling Costs- Current
bull Increasing efficiencies
bull Decreasing broken appointments
bull Controlling supplies equipment costs
bull Staff recruitment retention costs
84
Specialty Care
Training current CHC dentists in
specialty areas
Hiring general dentists with higher
specialty skill sets
Hiring in house specialists
Contract with outside specialists
Work with Managed Care Plan
specialists
Lowering Disease Rates
Community Dental Health
Coordinators case management
If your state law allows- embed
hygienists in medical and community
to provide primary and secondary
prevention procedures
In clinic Caries Classification and
Silver Diamine Fluoride
Effective recare programs
Controlling Costs- Additions in Risk-based Contracting
85
Specialty Care ndash Primary Referrals by Cost
Pediatric dentistry
Orthodontics
Oral surgery
Endodontics
86
In-clinic Pediatric Services
Encounters expected
of operatories available
State dental law and ability to have
expanded duties
General Anesthesia
GA in- house
Ability for a hospital or surgery center
to set aside regular OR time
Ability to hire or assign DAs to GA
days
Four GA cases day x PPS rate
Should You Hire a Pediatric Dentist- It Depends
8787
Solutions for Controlling Pediatric Costs
Hire a general dentist that is skilled in treating young children
Make the clinic child friendly nitrous oxide TVs in the operatory etc
Teach entire staff behavioral control techniques
Contract with a pediatric dentist for the GA care
88
Lowering Overall Disease Rates (and Costs)
You are responsible for both the patients you see in the chair and the ones
assigned to you
Breaking down the walls of the dental clinic
Community Dental Health Coordinators
Case Management
89
Cost Control Essentials
Diagnosis codes
Increased ability to identify
disease by risk
Motivational
Interviewing
Developing Polices and
Procedures design to treat
disease according to risk
ie Silver Diamine Fluoride
Treating by Risk
Effective Recare
Process
Critical to continual disease
controlPrevention education that is
meaningful and designed to
change behaviors
90
Social Determinants of Health Aunt Bertha
httpswwwauntberthacom
91
REASON TO CONSIDER RISK- BASED CONTRACTING
9292
PPS Reconciliation and Federal Code 42 CFR sect4052469(a)(2)
42 CFR sect4052469(a)(2)
ldquoAny financial incentives provided to Federally Qualified Health Centers
under their Medicare Advantage Contracts such as risk pool payments
bonuses or withholds are prohibited from being included in the
calculation of supplemental payments due to the Federally Qualified
Health Centerrdquo
9393
Why Risk Based Contract in Times of PPS Reconciliation
bull Not all Risk- based Contract funds are reconciled
bull Risk is the key word- you can come out with less money than your normal
PPS reconciliation payment
bull Can lead to better patient care
bull May improve manage care enrollment for your medical plan
bull Promotes integrated care increases health for your CHC patients
9494
Not Included in the Reconciliation
Enrollment management pmpm
Quality Payments
Upside risk payments
Downside risk losses
9595
Determinants of Financial Success in Risk-Based Contracting
bull Most critical- State pmpm payment to the Managed Care Plan
bull Reporting capabilities
bull Specialty service capabilities
bull Access numbers count
bull Ability to move metric numbers
9696
What About the Non- Medicaid Poor We Serve
bull Numbers are king in a managed care contract and the more access you have
the better contract terms you can negotiate
bull We will potentially have a steady supply of Medicaid patients
bull As managed care spreads states this may be compromising the ability of
health centers to serve the non-Medicaid poor and others lacking dental
insurance
97
Mark Koday DDS
(509) 949-2278
Dental Quality Consultants
of WA
httpdentalqualityconsultin
gcom
dentalqualityconsultantsg
mailcom
Contact Information
LUNCH
BREAKOUT EXERCISEORAL HEALTH VALUE-BASED CARE READINESS ASSESSMENT
Danielle Apostolon
PROMISING PRACTICES FROM THE FIELD STRATEGIES FOR INCREASING VALUE IN ORAL HEALTH
Dr Carolyn Brown
Dr Kelly Perry
Dr Rachel Rivard
Dr Adeloye
Commitment Compassion Community
m i d s t a t e h e a l t h o r g
Promising Practices from the
Field Strategies for Increasing
Value in Oral Health Care
Kelly Perry DMD
Better Health
Outcomes
Improved Staff
Experience
Reduced Cost
Improved Patient
Experience
Better Health
Outcomes
Improved Staff
Experience
Reduced Cost
Improved Patient
Experience
Better Health
Outcomes
Improved Staff
Experience
Reduced Cost
Improved Patient
Experience
Better Health
Outcomes
Improved Staff
Experience
Reduced Cost
Improved Patient
Experience
Commitment Compassion Community
kpe r r ymids t a tehea l t h o rg
Thank you
Completion of Disease Control Phase
Pelumi Adeloye DMD MPH
HEALTH ACCESS NETWORK (HAN) FAMILY DENTAL
Introduction
⧫1 Dentist I Hygienist 3 EFDArsquos1 Receptionist
⧫ 6 Chairs= 4 (dentist) + 2 (hygienist)
⧫ Slide ⥶80 off
⧫ Service areas Northern Penobscot Southern Aroostook Western
Washington Counties amp more
Completion of Phase I Treatment
⧫LimitedLack of Access to dental care
⧫Difficulty completing the disease control phase
Caries amp periodontal disease
⧫Attaining stable restorative state
Goal
Increase the completion of Disease Control Phase
Current practice
⧫Education
Assess level of dental literacy
Incremental strategy
⧫Increase access to dental care
Generous sliding scale (⥸$40 per visit)
Incorporate Expanded Function Dental Assistants
⧫Schedule modification
Incorporate more restorative blocks to allow
for follow-up visit and completion of restorative phase
httpswwwglasbergencomdentist-cartoons
Schedule
⧫Piggybacking technique
Increased allotted restorative blocks
⧫Sustainability of current schedule is
contingent on cooperation amp skills of HAN
Dental staff
Note
Strategies mentioned today is personalized to HAN Dental clinic
Current implemented strategies might be modified or changed in the
future as required in order to accommodate the need of our pts
THANK YOU
DAY TWOCLOSINGWRAP-UP
End of Day Two ndash Survey
Day Two Creating a Value-Based Oral Health Care Delivery
System
129
Payment Reform in Oral Health Online Learning Module
Oral Health Value-based Care Online Learning Module
Value-based Care Keys to Success Article
Readiness Assessment
Competency Development Guide
Oral Health Value-based Care Training
Dental Caries Management Practicum
Clinicians Companion Guide
Interprofessional Network Referral Process
Traditional Dental Care Vs Value-Based Care
Resources
131
wwwDentaQuestPartnershiporg
wwwfacebookcomDentaQuest
DentaQuest
wwwlinkedincomcompanyDentaQuest
Inside_DentaQuest
QUESTIONS
21
DentaQuest Partnership OHVBC Survey
Barriers to Value-based Transformation in Oral Health ndash
Most Common Responses
bull Patient engagement
bull EHREDR
bull Tracking outcomes lack of nationally-recognized and standardized quality
metrics in dental
22
How Can FQHC Dental Programs Prepare for Value-based
Transformation in Oral Health
bull Begin or continue focusing on prevention disease management and risk-based care
bull Hygienists will be key to success ndash We need primary dental care not just surgical
interventions
bull Start measuring outcomes instead of just processutilization metrics bull of initially high-risk patients with new caries lesions
bull of initially high-risk patients with decreased risk status
bull of initially low-risk patients with risk status maintained
bull Address patient engagement in a more meaningful way and invest in case
management
bull Invest in interprofessional practice including HIT interoperability
bull Evaluate how services are being delivered and determine if its reaching the patients
who need care the most
23
Value-Based Care
Care Coordination
ldquoClosing outrdquo referrals
Diagnostic coding
Risk Screenings
Care plans based on risk
Patient Engagement
Incentive payments
Quality metrics
Clinic Response
Case Management IT
Active timely records mngt
Mapping Dx codes to CDT
Time bill CPT codes Tx plan
IPP data tofrom PC MH
Recall window important
Attention to $ related metrics
Attention to assigned metrics
Direct and Indirect Effects of VBC on Dental Systems of Care
Utilization Impact
New workforce CDT codes
New or + workforce IT
ICD-CM-10 codes
+CDT codes
Modifiers (CPT ICD10)
+ recall adherence
in incentivized procedures
in sealant POC A1C
Counseling codes SD
24
MEASUREMENT IN ORAL HEALTH
25
Poll What percentage of your adult dental patients are diabetic
or pre-diabetic
A 50-80
B 20-50
C Less than 20
D Not sure
26
27
ldquoTrue Measures of Successrdquo
1 Define your governing objective
2 Develop a theory of cause and effect to assess presumed drivers of the
objective
3 Identify the specific activities that employees can do to help achieve the
governing objective
4 Evaluate your statistics
5 Communicate the story of your measurement
Adapted from HBR ldquoThe True Measures of Successrdquo httpshbrorg201210the-true-measures-of-success
28
1 Governing objective
2 Theory of cause and effect
3 Activities of team
4 Evaluate your statistics
5 Storycraft
Sustainability
Clinic revenuegt expenses= sustainability
Patient compliance Assets Clinic Mngt
Care team Operations Pt Support Billing
Of Prod on and type Patients on time
Daily weekly monthly quarterly
ldquoTrue Measures of Successrdquo
Adapted from HBR ldquoThe True Measures of Successrdquo httpshbrorg201210the-true-measures-of-success
29
Measuring Risk and Health
November is Diabetes Awareness Month- 2019Communication Plans are as
important as cold hard numbers
Patients
Care Team
Other Health Teams
Executive Team
Funders
Data on your dental patients are medical patients of record
Data on your medical + dental patients with DM2
30
Develop Diabetic Patient
Protocols
Review evidence and rationale with dental team
Partner with primary care team
bull Protocols Care mngt Tests and Recording
Quality Goals
Protocols for newly screened and existing patients
Educate and train dental team in reading AND
charting test results and PILOT
31
External Measurement in Oral Health Programs
httpswwwadaorg~mediaADADQA2019_DiabetesOralEvaluationpdfla=en
httpswwworegongovohaHPAANALYTICSCCOMetrics2019-Oral-Evaluation-Adults-Diabetespdf
32
Baseline for 2019 271
httpswwworegongovohaHPAANALYTICSCCOMetrics2019-Oral-Evaluation-Adults-Diabetespdf
33
Diabetes burden in your panel of dental patients
Baseline Medical-Dental Integrated panel of all patients
Dental patients with DM2 MDI
Dental patients with DM2
1000 or 10
600 or 60
300010000= 30
Population Health- Clinic Level
34
1 Governing objective
2 Theory of cause and effect
3 Activities of team
4 Evaluate your statistics
5 Storycraft
Discuss at meetings (Oct + Nov) Health education training
materials NP training CQI Note in Board report Clinical
measures
Care Pathways Hygiene Resources (ScheduleAvail)
ldquoTrue Measures of Successrdquo
Adapted from HBR ldquoThe True Measures of Successrdquo httpshbrorg201210the-true-measures-of-success
Diabetes Awareness Prevention Healthier Community
Prevention Awareness Care Pathway promotes health
MDI= 10 6 out of 10 adult patients with DM2
Goal set for integrated patient panels ndash PCMH
Pre-diabetes approach for executive team
Care Pathways
Care Coordination
35
MEASURING PATIENT ORAL HEALTHRisk assessments and Care Pathways
36
37
Risk Assessment and Care Pathways
Caries Risk Assessment
Multiple tools
EDREHR modules smart notes or dot phrases
CDT Codes
Decide frequency
D0601
Low Caries Risk
D0601
Moderate Caries Risk
D0601
High Caries Risk
38
The Disease Management DifferenceDisease Management Difference
Traditional Dental Care Disease Management
Approach
All patients return in 6 months
regardless of risk status
Recare interval is based on the
childrsquos caries risk
Caries Risk
Level
Recommended
Recare Interval
High Risk 1 ndash 3 months
Moderate Risk 3 ndash 6 months
Low Risk 6 ndash 12 months
Caries
Stabilizing
agents
Health Ed
Nutritional
Counseling
Anti-bacterial
and Fluoride
interventions
39
Disease Management Care Pathways
DentaQuest Partnership for Oral Health Advancement Disease Management Model
Caries
Stabilizing
agents
Whole
Person
Inter-
professional
Approaches
Anti-bacterial
and Fluoride
interventions
40
Disease Management and Risk Screening Training
DentaQuest Partnership for Oral Health Advancementrsquos
Online Learning Center
Disease Management Series
8 modules 40 CDE available
httpswwwdentaquestpartnershiporglearnonline-learning-centeronline-
coursewaredentaquest-disease-management-series
41
MEASUREMENT IN TEAMSSharing meaningful data with your dental clinical teams
42
rdquoDental Homerdquo = Health Home where WE can meet the patient
Oralhealthworkforceorg
43
POLL HOW OFTEN DO YOU SHARE YOUR S WITH YOUR DENTAL TEAM
A Yearly only
B Quarterly
C Monthly
D Weekly
E Daily
44
Clinical Measures ndash Dental Practice Perspective
Private Practice Office
New patients seen
Assigned vs seen if capitated
Treatment plans incomplete
$ produced amp per provider
$ collected amp monthly per provider
CDT 6000 codes completed
RecallHygiene maintenance
Based on this consultants experienced
FQHC
Unduplicated patients
patients seen per day
Treatment plans complete
$ gainedlost via accounting
Broken appointment rate
procedures
Sealant rate (annual)
45
bull HRSA Sealant Measure Compliance for FQHCs
bull Completion of phase 1 treatment plans
bull Children seen 0-5 years old
bull Children seen getting a preventive service
bull Fluoride Varnish applications
bull Pregnant women seen and treated
bull Diabetic patients with HbA1C gt 7 seen
bull Patients seen who have not been seen for 12 months
bull Patients seen getting a Risk Assessment
bull Patients with moderate or high risk who lower risk at recare
bull Sealants provided httpwwwnnohaorgnnoha-contentuploads201512Demystifying-HRSA-SEALANT-PRESENTATION_FINALpdf
Program Measures
46
HRSA Performance Measurement and Data Collection
bull FQHCs and look-alikes submit CY data to HRSA since 2008
bull UDS Uniform Data System
bull Require FTE for clinical staff patient demographics
bull Dental utilization s (UDCTPV)
bull Dental Clinical Measure dental sealants placed on 1st molars ages 6-9 yo
bull Health Center Quartile rankings (Clinical measure performance influences
HC rankings as does EHR adoption and other HC characteristics)
47
Low birth weight
Access to prenatal care
Childhood Immunization
Children (Ages 3-17) Receiving
Weight Assessment amp
Counseling
Children (Age 6-9) Receiving
Dental Sealant to First Molars
Diabetes Control
Hypertension Control
Pap Test
Depression Screening and
Follow-up (Age 12+)
Asthma Patients (Age 5-40)
Receiving Pharmacologic
Therapy
Colorectal Cancer
Screening (Ages 51-74)
HRSA UDS Clinical Measures
Adults (Age 18+) Receiving
Weight Screening amp Follow-up
Adults (Age 18+) Receiving
Tobacco Use Assessment and
Cessation Intervention
Coronary Artery Disease
Receiving Lipid Therapy (18+)
Ischemic Vascular Disease (IVD)
Receiving Aspirin Therapy (18+)
HIV Linkage to Care
48
Dashboards
Grants
Average
amp
Targets
Quality
Rev
Costs
Visits
Priority
Pop
Prevention
49
Dashboard- Provider Team Level
Patient
Compliance
Satisfaction
50
Case Study-
Incentives bonus round pools benchmark and improvement target goals risk-sharing possible later years
51
Qualitative Measurement
ldquoPatient engagement is the act of patients and providers working together
toward the end goal of improved patient wellnessrdquo
wwwpatientengagementhitcom
Access to Care
Patient Activation
Patient Satisfaction
Patient-Provider-Care Team Communication
Care Team Satisfaction
52
OHVBC Readiness
Leadership
bull Value of oral health and oral health transformation
Structure Systems and Operations
bull Operational efficiencies innovative care delivery methodologies
Care Pathways and Provider Buy-In
bull Training disease management risk-based care referrals IDC-10 coding patient engagement
Data and Analytic Technology and Personnel
bull Interoperability reporting
Financial Viability and Strength
bull Payerpatient mix billing infrastructure financial reports
httpswwwdentaquestpartnershiporglearnsafety-net-solutionsoral-health-value-based-careohvbc-readiness-
assessment
53
QUESTIONS COMMENTS
Carolyn Brown DDS
cbrownddsgmailcom
RISK BASED MANAGED CARE
Value Based Training Conference
Manchester New Hampshire
Mark Koday DDS
111919
5555
Objectives
bull Review current drivers of dental managed care
bull Understand the basics of risk-based dental managed care contracts
bull Learn the basics of managing costs in a riskndashbased contract
bull Gain an understanding in the potential advantage of risk-based contracting
56
What Is Dental Managed Care
Managed care is a health delivery system whose purpose is to manage both the
quality and cost of health care
Common types of managed care health insurance plans
bull HMOs
bull PPOs
bull POSs
bull Medicaid Managed Care
DIDNrsquoT WE ALREADY HAVE MANAGED CARE AND IT FAILED
57
What Has Happened Since the 90s
58
WHY THE FFS AND PPS DOESNrsquoT WORK FOR OUR POPULATIONS
bull Inefficient payment systems designed to produce encounters or procedures but not real health
bull No focus on population health
bull Does not incentivize innovation
bull Patients essentially on their own for accessing specialty care
59
Rule of 4
Source Kaiser Family Foundation analysis of National Health Expenditure (NHE) data from Centers for
Medicare and Medicaid Services Office of the Actuary National Health Statistics Group
60
Rule of 4
bull This helps explain why oral health has been relatively ignored so far by CMS
bull Explains why we have PCMH instead of PCHH
bull Where is the real value on a national level in preventing disease and
controlling costs
bull Beware- wersquove been found
61
Reasons Dental Managed Care is Spreading Across the States
NON-MANAGED CARE STATE DENTAL BUDGETS ARE
OPENED ENDED
STRAIN ON STATE BUDGETS
UPCOMING RECESSION WITH TRILLION DOLLAR
DEFICIT
SHIFTS FINANCIAL RISK FROM THE STATES TO THE
PLANS
6262
Types of Medicaid Managed Care
bull State Medicaid agency administrator lowest administrative
costs
bull Third Party Administrator Typically 15 administrative costs
bull Managed Care Organization Typically 15 administrative
costs
bull Carved-in
bull Carved-out
bull Risk Based Managed Care Administrative costs part of
contract negotiation
63
RISK CONTRACTS
6464
Components of a Risk-based Contract
Risk
Medical Loss Ratio
Quality withhold
Specialty withhold
Managed care payment (pmpm)
Covered services
Fee schedule Claims are paid as usual on a FFS basis
Credentialing
Quality Review process and Quality Metrics
65
Upside Risk
The possibility that the cost of
delivering dental care to an assigned
patient panel is less than the amount
of funding calculated for that care
The Plan pays the CHC additional
funds based on a predetermine
formula
Downside Risk
The possibility that the cost of
delivering dental care to an assigned
patient panel is more than the amount
of funding calculated for that care
The CHC pays the Plan additional
funds based on a predetermine
formula
Upside and Downside Risk
66
Taking On Risk 100 or Shared Risk
With 100 risk you receive 100 of the potential savings but are also at risk for
100 of the losses
Shared Risk MCO and health center share a percentage of the risk
Shared Risk leads to better cooperation since both organizations are
incentivized to save on costs
6767
Reports Needed
bull Enrollment reports lists of who is assigned on a monthly basis
bull Reconciliation reports insure appropriate payments
bull Specialty Referral reports
bull You will need your own reporting process so you donrsquot rely completely on
reports supplied by the Plan
6868
Medical Loss Ratio
Medical Loss Ratio (MLR) is proportion of premium revenues spent on clinical
services and quality improvement also known as the Medical Loss Ratio (MLR)
For CMS requires Medical Plans to spend at least 80 to 85 of the premiums
on actual medical care
69
Administrative Fees
bull Essentially the opposite of MLR
bull The State Medicaid Agency is funded by the Governorrsquos budget
bull The State Medicaid Agency will keep some of these funds for their
admin costs and give the remaining to the Managed Care Plans
bull Private Plan admin costs can be as high as 40 but most states
limit these cost for Medicaid Plans to between 15 and 20 (85-
80 MLR)
bull This may be negotiable depending on your program size of your
program
70
Quality Withhold
bull The state withholds a certain percent (typically 2-4 ) of the funds they give
to the Plans for Value Based Reimbursement
bull They choose quality metrics and set benchmarks and assign payments for
each metric based on an assigned priority for each metric
bull If a Plan meets the benchmark of every quality metric the state passes on
their full share of the quality withhold
bull The Plans may or may not withhold a percent of the funds for quality payment
to the dentists or manage care contractors
71
Quality Withhold
Either way the Plans may or may not pass the quality payments they receive to
the dentists or contractors
This should be spelled out in a risk-based contract
72
Percent of funds set aside
to cover specialty care
referrals
Typically 10-15
Goal Limit referral costs
to within or less than
Specialty set aside
Specialty Withhold
73
Per Member Per Month
bull Capitated Payment
bull Specific dollar amount paid for each enrolled member each month
bull Paid whether patient is accessed for care or not
bull States do set access benchmarks
bull In Oregon access for any dental procedure (adults and children combined)
was 267 in 2015
74
Payment Math Example
Premium per enrollee = $25
Administrative fee 15 = $375
Funds available per enrollee to the clinic = $2125
Management fee per enrollee = $175
Funds per enrollee that would undergo PPS reconciliation = $1950
For every 10000 enrollees the managed care income = $2340000
Specialty withhold (10) = $234000
YE Cost lt or gt $2340000
Upside Risk
CHC Gains $
Downside Risk
CHC Loses $
75
Covered Services and Fee Schedules
bull The state Medicaid agency spells out the minimum procedures and fees that
MCOs must cover
bull MCOs may add procedures or increase periodicity of procedures particularly
preventative services
bull MCOs may increase fees to entice rural providers and specialists to enroll in
their Plans
bull Access Rules
bull How many days it takes to access a patent
bull How many days it takes for a patent to access urgent care services
bull How many days it takes for a patent to access emergency care services
76
Credentialing
All MCOs are required to credential all Providers
All MCOs have their own credentialing process
Credentialing process is can be lengthy
Credentialing process may be negotiable
77
Quality Review Process and Quality Metrics
MCOs must have a Quality and Compliance Review Process
If you arenrsquot in compliance with both you likely wonrsquot get paid
Typical processes reviewed
bull Charting specifications
bull Incident report
bull Enrollee complaints quality rudeness and access issues
bull Medicaid compliance
78
Quality Payments
bull State Shared Incentive Withhold Typically quality metrics and benchmarks
are set by the state sets aside a certain percent (3-5) of the payments to
the Managed Care Plan (MCP)
bull If the benchmarks are achieved the MCP is then paid the a predetermine
amount
bull Benchmarks may not be the same as the states
bull Managed Care Plans do not have to pass all or any of the quality payments to
the health centers or providers
bull Managed Care contract- Metrics benchmarks should be selected and part of
the contract
7979
Achieving Quality Metric Payments
Dealing with under achievers
Process issues
Individual issues
Identifying workflows
Developing Best Practices through
PDSA process
Developing Best Practices through
PDSA process
CHC Metrics Committee
Clinicians Operations various key staff
Identify Best Practices
Spread Best Practices
80
New Team Needed Business Intelligence
Business Intelligence (BI) is critical for effective managed care business decisions
BI team inputs metrics into your EHR collects integrates analyses and displays all your managed care business and clinical information
Easy to say- hard to achieve
Build your own or outsource
Possible future role of Primary Care Associations
8181
Clinicianrsquos Dashboard
Expensive to build
Displayed on your screen when your computer is first turned on
Easy to read and understand
Data dumped from the day before
Can dialed down from Org-wide to clinic to each clinicianrsquos data
Operational and clinical metrics
bull Treatment Plan Completion
bull DQA quality measures
bull Caries at Recall
bull Re-care reports
bull Care Gap reports
82
CONTROLLING COSTS
8383
Controlling Costs- Current
bull Increasing efficiencies
bull Decreasing broken appointments
bull Controlling supplies equipment costs
bull Staff recruitment retention costs
84
Specialty Care
Training current CHC dentists in
specialty areas
Hiring general dentists with higher
specialty skill sets
Hiring in house specialists
Contract with outside specialists
Work with Managed Care Plan
specialists
Lowering Disease Rates
Community Dental Health
Coordinators case management
If your state law allows- embed
hygienists in medical and community
to provide primary and secondary
prevention procedures
In clinic Caries Classification and
Silver Diamine Fluoride
Effective recare programs
Controlling Costs- Additions in Risk-based Contracting
85
Specialty Care ndash Primary Referrals by Cost
Pediatric dentistry
Orthodontics
Oral surgery
Endodontics
86
In-clinic Pediatric Services
Encounters expected
of operatories available
State dental law and ability to have
expanded duties
General Anesthesia
GA in- house
Ability for a hospital or surgery center
to set aside regular OR time
Ability to hire or assign DAs to GA
days
Four GA cases day x PPS rate
Should You Hire a Pediatric Dentist- It Depends
8787
Solutions for Controlling Pediatric Costs
Hire a general dentist that is skilled in treating young children
Make the clinic child friendly nitrous oxide TVs in the operatory etc
Teach entire staff behavioral control techniques
Contract with a pediatric dentist for the GA care
88
Lowering Overall Disease Rates (and Costs)
You are responsible for both the patients you see in the chair and the ones
assigned to you
Breaking down the walls of the dental clinic
Community Dental Health Coordinators
Case Management
89
Cost Control Essentials
Diagnosis codes
Increased ability to identify
disease by risk
Motivational
Interviewing
Developing Polices and
Procedures design to treat
disease according to risk
ie Silver Diamine Fluoride
Treating by Risk
Effective Recare
Process
Critical to continual disease
controlPrevention education that is
meaningful and designed to
change behaviors
90
Social Determinants of Health Aunt Bertha
httpswwwauntberthacom
91
REASON TO CONSIDER RISK- BASED CONTRACTING
9292
PPS Reconciliation and Federal Code 42 CFR sect4052469(a)(2)
42 CFR sect4052469(a)(2)
ldquoAny financial incentives provided to Federally Qualified Health Centers
under their Medicare Advantage Contracts such as risk pool payments
bonuses or withholds are prohibited from being included in the
calculation of supplemental payments due to the Federally Qualified
Health Centerrdquo
9393
Why Risk Based Contract in Times of PPS Reconciliation
bull Not all Risk- based Contract funds are reconciled
bull Risk is the key word- you can come out with less money than your normal
PPS reconciliation payment
bull Can lead to better patient care
bull May improve manage care enrollment for your medical plan
bull Promotes integrated care increases health for your CHC patients
9494
Not Included in the Reconciliation
Enrollment management pmpm
Quality Payments
Upside risk payments
Downside risk losses
9595
Determinants of Financial Success in Risk-Based Contracting
bull Most critical- State pmpm payment to the Managed Care Plan
bull Reporting capabilities
bull Specialty service capabilities
bull Access numbers count
bull Ability to move metric numbers
9696
What About the Non- Medicaid Poor We Serve
bull Numbers are king in a managed care contract and the more access you have
the better contract terms you can negotiate
bull We will potentially have a steady supply of Medicaid patients
bull As managed care spreads states this may be compromising the ability of
health centers to serve the non-Medicaid poor and others lacking dental
insurance
97
Mark Koday DDS
(509) 949-2278
Dental Quality Consultants
of WA
httpdentalqualityconsultin
gcom
dentalqualityconsultantsg
mailcom
Contact Information
LUNCH
BREAKOUT EXERCISEORAL HEALTH VALUE-BASED CARE READINESS ASSESSMENT
Danielle Apostolon
PROMISING PRACTICES FROM THE FIELD STRATEGIES FOR INCREASING VALUE IN ORAL HEALTH
Dr Carolyn Brown
Dr Kelly Perry
Dr Rachel Rivard
Dr Adeloye
Commitment Compassion Community
m i d s t a t e h e a l t h o r g
Promising Practices from the
Field Strategies for Increasing
Value in Oral Health Care
Kelly Perry DMD
Better Health
Outcomes
Improved Staff
Experience
Reduced Cost
Improved Patient
Experience
Better Health
Outcomes
Improved Staff
Experience
Reduced Cost
Improved Patient
Experience
Better Health
Outcomes
Improved Staff
Experience
Reduced Cost
Improved Patient
Experience
Better Health
Outcomes
Improved Staff
Experience
Reduced Cost
Improved Patient
Experience
Commitment Compassion Community
kpe r r ymids t a tehea l t h o rg
Thank you
Completion of Disease Control Phase
Pelumi Adeloye DMD MPH
HEALTH ACCESS NETWORK (HAN) FAMILY DENTAL
Introduction
⧫1 Dentist I Hygienist 3 EFDArsquos1 Receptionist
⧫ 6 Chairs= 4 (dentist) + 2 (hygienist)
⧫ Slide ⥶80 off
⧫ Service areas Northern Penobscot Southern Aroostook Western
Washington Counties amp more
Completion of Phase I Treatment
⧫LimitedLack of Access to dental care
⧫Difficulty completing the disease control phase
Caries amp periodontal disease
⧫Attaining stable restorative state
Goal
Increase the completion of Disease Control Phase
Current practice
⧫Education
Assess level of dental literacy
Incremental strategy
⧫Increase access to dental care
Generous sliding scale (⥸$40 per visit)
Incorporate Expanded Function Dental Assistants
⧫Schedule modification
Incorporate more restorative blocks to allow
for follow-up visit and completion of restorative phase
httpswwwglasbergencomdentist-cartoons
Schedule
⧫Piggybacking technique
Increased allotted restorative blocks
⧫Sustainability of current schedule is
contingent on cooperation amp skills of HAN
Dental staff
Note
Strategies mentioned today is personalized to HAN Dental clinic
Current implemented strategies might be modified or changed in the
future as required in order to accommodate the need of our pts
THANK YOU
DAY TWOCLOSINGWRAP-UP
End of Day Two ndash Survey
Day Two Creating a Value-Based Oral Health Care Delivery
System
129
Payment Reform in Oral Health Online Learning Module
Oral Health Value-based Care Online Learning Module
Value-based Care Keys to Success Article
Readiness Assessment
Competency Development Guide
Oral Health Value-based Care Training
Dental Caries Management Practicum
Clinicians Companion Guide
Interprofessional Network Referral Process
Traditional Dental Care Vs Value-Based Care
Resources
131
wwwDentaQuestPartnershiporg
wwwfacebookcomDentaQuest
DentaQuest
wwwlinkedincomcompanyDentaQuest
Inside_DentaQuest
QUESTIONS
22
How Can FQHC Dental Programs Prepare for Value-based
Transformation in Oral Health
bull Begin or continue focusing on prevention disease management and risk-based care
bull Hygienists will be key to success ndash We need primary dental care not just surgical
interventions
bull Start measuring outcomes instead of just processutilization metrics bull of initially high-risk patients with new caries lesions
bull of initially high-risk patients with decreased risk status
bull of initially low-risk patients with risk status maintained
bull Address patient engagement in a more meaningful way and invest in case
management
bull Invest in interprofessional practice including HIT interoperability
bull Evaluate how services are being delivered and determine if its reaching the patients
who need care the most
23
Value-Based Care
Care Coordination
ldquoClosing outrdquo referrals
Diagnostic coding
Risk Screenings
Care plans based on risk
Patient Engagement
Incentive payments
Quality metrics
Clinic Response
Case Management IT
Active timely records mngt
Mapping Dx codes to CDT
Time bill CPT codes Tx plan
IPP data tofrom PC MH
Recall window important
Attention to $ related metrics
Attention to assigned metrics
Direct and Indirect Effects of VBC on Dental Systems of Care
Utilization Impact
New workforce CDT codes
New or + workforce IT
ICD-CM-10 codes
+CDT codes
Modifiers (CPT ICD10)
+ recall adherence
in incentivized procedures
in sealant POC A1C
Counseling codes SD
24
MEASUREMENT IN ORAL HEALTH
25
Poll What percentage of your adult dental patients are diabetic
or pre-diabetic
A 50-80
B 20-50
C Less than 20
D Not sure
26
27
ldquoTrue Measures of Successrdquo
1 Define your governing objective
2 Develop a theory of cause and effect to assess presumed drivers of the
objective
3 Identify the specific activities that employees can do to help achieve the
governing objective
4 Evaluate your statistics
5 Communicate the story of your measurement
Adapted from HBR ldquoThe True Measures of Successrdquo httpshbrorg201210the-true-measures-of-success
28
1 Governing objective
2 Theory of cause and effect
3 Activities of team
4 Evaluate your statistics
5 Storycraft
Sustainability
Clinic revenuegt expenses= sustainability
Patient compliance Assets Clinic Mngt
Care team Operations Pt Support Billing
Of Prod on and type Patients on time
Daily weekly monthly quarterly
ldquoTrue Measures of Successrdquo
Adapted from HBR ldquoThe True Measures of Successrdquo httpshbrorg201210the-true-measures-of-success
29
Measuring Risk and Health
November is Diabetes Awareness Month- 2019Communication Plans are as
important as cold hard numbers
Patients
Care Team
Other Health Teams
Executive Team
Funders
Data on your dental patients are medical patients of record
Data on your medical + dental patients with DM2
30
Develop Diabetic Patient
Protocols
Review evidence and rationale with dental team
Partner with primary care team
bull Protocols Care mngt Tests and Recording
Quality Goals
Protocols for newly screened and existing patients
Educate and train dental team in reading AND
charting test results and PILOT
31
External Measurement in Oral Health Programs
httpswwwadaorg~mediaADADQA2019_DiabetesOralEvaluationpdfla=en
httpswwworegongovohaHPAANALYTICSCCOMetrics2019-Oral-Evaluation-Adults-Diabetespdf
32
Baseline for 2019 271
httpswwworegongovohaHPAANALYTICSCCOMetrics2019-Oral-Evaluation-Adults-Diabetespdf
33
Diabetes burden in your panel of dental patients
Baseline Medical-Dental Integrated panel of all patients
Dental patients with DM2 MDI
Dental patients with DM2
1000 or 10
600 or 60
300010000= 30
Population Health- Clinic Level
34
1 Governing objective
2 Theory of cause and effect
3 Activities of team
4 Evaluate your statistics
5 Storycraft
Discuss at meetings (Oct + Nov) Health education training
materials NP training CQI Note in Board report Clinical
measures
Care Pathways Hygiene Resources (ScheduleAvail)
ldquoTrue Measures of Successrdquo
Adapted from HBR ldquoThe True Measures of Successrdquo httpshbrorg201210the-true-measures-of-success
Diabetes Awareness Prevention Healthier Community
Prevention Awareness Care Pathway promotes health
MDI= 10 6 out of 10 adult patients with DM2
Goal set for integrated patient panels ndash PCMH
Pre-diabetes approach for executive team
Care Pathways
Care Coordination
35
MEASURING PATIENT ORAL HEALTHRisk assessments and Care Pathways
36
37
Risk Assessment and Care Pathways
Caries Risk Assessment
Multiple tools
EDREHR modules smart notes or dot phrases
CDT Codes
Decide frequency
D0601
Low Caries Risk
D0601
Moderate Caries Risk
D0601
High Caries Risk
38
The Disease Management DifferenceDisease Management Difference
Traditional Dental Care Disease Management
Approach
All patients return in 6 months
regardless of risk status
Recare interval is based on the
childrsquos caries risk
Caries Risk
Level
Recommended
Recare Interval
High Risk 1 ndash 3 months
Moderate Risk 3 ndash 6 months
Low Risk 6 ndash 12 months
Caries
Stabilizing
agents
Health Ed
Nutritional
Counseling
Anti-bacterial
and Fluoride
interventions
39
Disease Management Care Pathways
DentaQuest Partnership for Oral Health Advancement Disease Management Model
Caries
Stabilizing
agents
Whole
Person
Inter-
professional
Approaches
Anti-bacterial
and Fluoride
interventions
40
Disease Management and Risk Screening Training
DentaQuest Partnership for Oral Health Advancementrsquos
Online Learning Center
Disease Management Series
8 modules 40 CDE available
httpswwwdentaquestpartnershiporglearnonline-learning-centeronline-
coursewaredentaquest-disease-management-series
41
MEASUREMENT IN TEAMSSharing meaningful data with your dental clinical teams
42
rdquoDental Homerdquo = Health Home where WE can meet the patient
Oralhealthworkforceorg
43
POLL HOW OFTEN DO YOU SHARE YOUR S WITH YOUR DENTAL TEAM
A Yearly only
B Quarterly
C Monthly
D Weekly
E Daily
44
Clinical Measures ndash Dental Practice Perspective
Private Practice Office
New patients seen
Assigned vs seen if capitated
Treatment plans incomplete
$ produced amp per provider
$ collected amp monthly per provider
CDT 6000 codes completed
RecallHygiene maintenance
Based on this consultants experienced
FQHC
Unduplicated patients
patients seen per day
Treatment plans complete
$ gainedlost via accounting
Broken appointment rate
procedures
Sealant rate (annual)
45
bull HRSA Sealant Measure Compliance for FQHCs
bull Completion of phase 1 treatment plans
bull Children seen 0-5 years old
bull Children seen getting a preventive service
bull Fluoride Varnish applications
bull Pregnant women seen and treated
bull Diabetic patients with HbA1C gt 7 seen
bull Patients seen who have not been seen for 12 months
bull Patients seen getting a Risk Assessment
bull Patients with moderate or high risk who lower risk at recare
bull Sealants provided httpwwwnnohaorgnnoha-contentuploads201512Demystifying-HRSA-SEALANT-PRESENTATION_FINALpdf
Program Measures
46
HRSA Performance Measurement and Data Collection
bull FQHCs and look-alikes submit CY data to HRSA since 2008
bull UDS Uniform Data System
bull Require FTE for clinical staff patient demographics
bull Dental utilization s (UDCTPV)
bull Dental Clinical Measure dental sealants placed on 1st molars ages 6-9 yo
bull Health Center Quartile rankings (Clinical measure performance influences
HC rankings as does EHR adoption and other HC characteristics)
47
Low birth weight
Access to prenatal care
Childhood Immunization
Children (Ages 3-17) Receiving
Weight Assessment amp
Counseling
Children (Age 6-9) Receiving
Dental Sealant to First Molars
Diabetes Control
Hypertension Control
Pap Test
Depression Screening and
Follow-up (Age 12+)
Asthma Patients (Age 5-40)
Receiving Pharmacologic
Therapy
Colorectal Cancer
Screening (Ages 51-74)
HRSA UDS Clinical Measures
Adults (Age 18+) Receiving
Weight Screening amp Follow-up
Adults (Age 18+) Receiving
Tobacco Use Assessment and
Cessation Intervention
Coronary Artery Disease
Receiving Lipid Therapy (18+)
Ischemic Vascular Disease (IVD)
Receiving Aspirin Therapy (18+)
HIV Linkage to Care
48
Dashboards
Grants
Average
amp
Targets
Quality
Rev
Costs
Visits
Priority
Pop
Prevention
49
Dashboard- Provider Team Level
Patient
Compliance
Satisfaction
50
Case Study-
Incentives bonus round pools benchmark and improvement target goals risk-sharing possible later years
51
Qualitative Measurement
ldquoPatient engagement is the act of patients and providers working together
toward the end goal of improved patient wellnessrdquo
wwwpatientengagementhitcom
Access to Care
Patient Activation
Patient Satisfaction
Patient-Provider-Care Team Communication
Care Team Satisfaction
52
OHVBC Readiness
Leadership
bull Value of oral health and oral health transformation
Structure Systems and Operations
bull Operational efficiencies innovative care delivery methodologies
Care Pathways and Provider Buy-In
bull Training disease management risk-based care referrals IDC-10 coding patient engagement
Data and Analytic Technology and Personnel
bull Interoperability reporting
Financial Viability and Strength
bull Payerpatient mix billing infrastructure financial reports
httpswwwdentaquestpartnershiporglearnsafety-net-solutionsoral-health-value-based-careohvbc-readiness-
assessment
53
QUESTIONS COMMENTS
Carolyn Brown DDS
cbrownddsgmailcom
RISK BASED MANAGED CARE
Value Based Training Conference
Manchester New Hampshire
Mark Koday DDS
111919
5555
Objectives
bull Review current drivers of dental managed care
bull Understand the basics of risk-based dental managed care contracts
bull Learn the basics of managing costs in a riskndashbased contract
bull Gain an understanding in the potential advantage of risk-based contracting
56
What Is Dental Managed Care
Managed care is a health delivery system whose purpose is to manage both the
quality and cost of health care
Common types of managed care health insurance plans
bull HMOs
bull PPOs
bull POSs
bull Medicaid Managed Care
DIDNrsquoT WE ALREADY HAVE MANAGED CARE AND IT FAILED
57
What Has Happened Since the 90s
58
WHY THE FFS AND PPS DOESNrsquoT WORK FOR OUR POPULATIONS
bull Inefficient payment systems designed to produce encounters or procedures but not real health
bull No focus on population health
bull Does not incentivize innovation
bull Patients essentially on their own for accessing specialty care
59
Rule of 4
Source Kaiser Family Foundation analysis of National Health Expenditure (NHE) data from Centers for
Medicare and Medicaid Services Office of the Actuary National Health Statistics Group
60
Rule of 4
bull This helps explain why oral health has been relatively ignored so far by CMS
bull Explains why we have PCMH instead of PCHH
bull Where is the real value on a national level in preventing disease and
controlling costs
bull Beware- wersquove been found
61
Reasons Dental Managed Care is Spreading Across the States
NON-MANAGED CARE STATE DENTAL BUDGETS ARE
OPENED ENDED
STRAIN ON STATE BUDGETS
UPCOMING RECESSION WITH TRILLION DOLLAR
DEFICIT
SHIFTS FINANCIAL RISK FROM THE STATES TO THE
PLANS
6262
Types of Medicaid Managed Care
bull State Medicaid agency administrator lowest administrative
costs
bull Third Party Administrator Typically 15 administrative costs
bull Managed Care Organization Typically 15 administrative
costs
bull Carved-in
bull Carved-out
bull Risk Based Managed Care Administrative costs part of
contract negotiation
63
RISK CONTRACTS
6464
Components of a Risk-based Contract
Risk
Medical Loss Ratio
Quality withhold
Specialty withhold
Managed care payment (pmpm)
Covered services
Fee schedule Claims are paid as usual on a FFS basis
Credentialing
Quality Review process and Quality Metrics
65
Upside Risk
The possibility that the cost of
delivering dental care to an assigned
patient panel is less than the amount
of funding calculated for that care
The Plan pays the CHC additional
funds based on a predetermine
formula
Downside Risk
The possibility that the cost of
delivering dental care to an assigned
patient panel is more than the amount
of funding calculated for that care
The CHC pays the Plan additional
funds based on a predetermine
formula
Upside and Downside Risk
66
Taking On Risk 100 or Shared Risk
With 100 risk you receive 100 of the potential savings but are also at risk for
100 of the losses
Shared Risk MCO and health center share a percentage of the risk
Shared Risk leads to better cooperation since both organizations are
incentivized to save on costs
6767
Reports Needed
bull Enrollment reports lists of who is assigned on a monthly basis
bull Reconciliation reports insure appropriate payments
bull Specialty Referral reports
bull You will need your own reporting process so you donrsquot rely completely on
reports supplied by the Plan
6868
Medical Loss Ratio
Medical Loss Ratio (MLR) is proportion of premium revenues spent on clinical
services and quality improvement also known as the Medical Loss Ratio (MLR)
For CMS requires Medical Plans to spend at least 80 to 85 of the premiums
on actual medical care
69
Administrative Fees
bull Essentially the opposite of MLR
bull The State Medicaid Agency is funded by the Governorrsquos budget
bull The State Medicaid Agency will keep some of these funds for their
admin costs and give the remaining to the Managed Care Plans
bull Private Plan admin costs can be as high as 40 but most states
limit these cost for Medicaid Plans to between 15 and 20 (85-
80 MLR)
bull This may be negotiable depending on your program size of your
program
70
Quality Withhold
bull The state withholds a certain percent (typically 2-4 ) of the funds they give
to the Plans for Value Based Reimbursement
bull They choose quality metrics and set benchmarks and assign payments for
each metric based on an assigned priority for each metric
bull If a Plan meets the benchmark of every quality metric the state passes on
their full share of the quality withhold
bull The Plans may or may not withhold a percent of the funds for quality payment
to the dentists or manage care contractors
71
Quality Withhold
Either way the Plans may or may not pass the quality payments they receive to
the dentists or contractors
This should be spelled out in a risk-based contract
72
Percent of funds set aside
to cover specialty care
referrals
Typically 10-15
Goal Limit referral costs
to within or less than
Specialty set aside
Specialty Withhold
73
Per Member Per Month
bull Capitated Payment
bull Specific dollar amount paid for each enrolled member each month
bull Paid whether patient is accessed for care or not
bull States do set access benchmarks
bull In Oregon access for any dental procedure (adults and children combined)
was 267 in 2015
74
Payment Math Example
Premium per enrollee = $25
Administrative fee 15 = $375
Funds available per enrollee to the clinic = $2125
Management fee per enrollee = $175
Funds per enrollee that would undergo PPS reconciliation = $1950
For every 10000 enrollees the managed care income = $2340000
Specialty withhold (10) = $234000
YE Cost lt or gt $2340000
Upside Risk
CHC Gains $
Downside Risk
CHC Loses $
75
Covered Services and Fee Schedules
bull The state Medicaid agency spells out the minimum procedures and fees that
MCOs must cover
bull MCOs may add procedures or increase periodicity of procedures particularly
preventative services
bull MCOs may increase fees to entice rural providers and specialists to enroll in
their Plans
bull Access Rules
bull How many days it takes to access a patent
bull How many days it takes for a patent to access urgent care services
bull How many days it takes for a patent to access emergency care services
76
Credentialing
All MCOs are required to credential all Providers
All MCOs have their own credentialing process
Credentialing process is can be lengthy
Credentialing process may be negotiable
77
Quality Review Process and Quality Metrics
MCOs must have a Quality and Compliance Review Process
If you arenrsquot in compliance with both you likely wonrsquot get paid
Typical processes reviewed
bull Charting specifications
bull Incident report
bull Enrollee complaints quality rudeness and access issues
bull Medicaid compliance
78
Quality Payments
bull State Shared Incentive Withhold Typically quality metrics and benchmarks
are set by the state sets aside a certain percent (3-5) of the payments to
the Managed Care Plan (MCP)
bull If the benchmarks are achieved the MCP is then paid the a predetermine
amount
bull Benchmarks may not be the same as the states
bull Managed Care Plans do not have to pass all or any of the quality payments to
the health centers or providers
bull Managed Care contract- Metrics benchmarks should be selected and part of
the contract
7979
Achieving Quality Metric Payments
Dealing with under achievers
Process issues
Individual issues
Identifying workflows
Developing Best Practices through
PDSA process
Developing Best Practices through
PDSA process
CHC Metrics Committee
Clinicians Operations various key staff
Identify Best Practices
Spread Best Practices
80
New Team Needed Business Intelligence
Business Intelligence (BI) is critical for effective managed care business decisions
BI team inputs metrics into your EHR collects integrates analyses and displays all your managed care business and clinical information
Easy to say- hard to achieve
Build your own or outsource
Possible future role of Primary Care Associations
8181
Clinicianrsquos Dashboard
Expensive to build
Displayed on your screen when your computer is first turned on
Easy to read and understand
Data dumped from the day before
Can dialed down from Org-wide to clinic to each clinicianrsquos data
Operational and clinical metrics
bull Treatment Plan Completion
bull DQA quality measures
bull Caries at Recall
bull Re-care reports
bull Care Gap reports
82
CONTROLLING COSTS
8383
Controlling Costs- Current
bull Increasing efficiencies
bull Decreasing broken appointments
bull Controlling supplies equipment costs
bull Staff recruitment retention costs
84
Specialty Care
Training current CHC dentists in
specialty areas
Hiring general dentists with higher
specialty skill sets
Hiring in house specialists
Contract with outside specialists
Work with Managed Care Plan
specialists
Lowering Disease Rates
Community Dental Health
Coordinators case management
If your state law allows- embed
hygienists in medical and community
to provide primary and secondary
prevention procedures
In clinic Caries Classification and
Silver Diamine Fluoride
Effective recare programs
Controlling Costs- Additions in Risk-based Contracting
85
Specialty Care ndash Primary Referrals by Cost
Pediatric dentistry
Orthodontics
Oral surgery
Endodontics
86
In-clinic Pediatric Services
Encounters expected
of operatories available
State dental law and ability to have
expanded duties
General Anesthesia
GA in- house
Ability for a hospital or surgery center
to set aside regular OR time
Ability to hire or assign DAs to GA
days
Four GA cases day x PPS rate
Should You Hire a Pediatric Dentist- It Depends
8787
Solutions for Controlling Pediatric Costs
Hire a general dentist that is skilled in treating young children
Make the clinic child friendly nitrous oxide TVs in the operatory etc
Teach entire staff behavioral control techniques
Contract with a pediatric dentist for the GA care
88
Lowering Overall Disease Rates (and Costs)
You are responsible for both the patients you see in the chair and the ones
assigned to you
Breaking down the walls of the dental clinic
Community Dental Health Coordinators
Case Management
89
Cost Control Essentials
Diagnosis codes
Increased ability to identify
disease by risk
Motivational
Interviewing
Developing Polices and
Procedures design to treat
disease according to risk
ie Silver Diamine Fluoride
Treating by Risk
Effective Recare
Process
Critical to continual disease
controlPrevention education that is
meaningful and designed to
change behaviors
90
Social Determinants of Health Aunt Bertha
httpswwwauntberthacom
91
REASON TO CONSIDER RISK- BASED CONTRACTING
9292
PPS Reconciliation and Federal Code 42 CFR sect4052469(a)(2)
42 CFR sect4052469(a)(2)
ldquoAny financial incentives provided to Federally Qualified Health Centers
under their Medicare Advantage Contracts such as risk pool payments
bonuses or withholds are prohibited from being included in the
calculation of supplemental payments due to the Federally Qualified
Health Centerrdquo
9393
Why Risk Based Contract in Times of PPS Reconciliation
bull Not all Risk- based Contract funds are reconciled
bull Risk is the key word- you can come out with less money than your normal
PPS reconciliation payment
bull Can lead to better patient care
bull May improve manage care enrollment for your medical plan
bull Promotes integrated care increases health for your CHC patients
9494
Not Included in the Reconciliation
Enrollment management pmpm
Quality Payments
Upside risk payments
Downside risk losses
9595
Determinants of Financial Success in Risk-Based Contracting
bull Most critical- State pmpm payment to the Managed Care Plan
bull Reporting capabilities
bull Specialty service capabilities
bull Access numbers count
bull Ability to move metric numbers
9696
What About the Non- Medicaid Poor We Serve
bull Numbers are king in a managed care contract and the more access you have
the better contract terms you can negotiate
bull We will potentially have a steady supply of Medicaid patients
bull As managed care spreads states this may be compromising the ability of
health centers to serve the non-Medicaid poor and others lacking dental
insurance
97
Mark Koday DDS
(509) 949-2278
Dental Quality Consultants
of WA
httpdentalqualityconsultin
gcom
dentalqualityconsultantsg
mailcom
Contact Information
LUNCH
BREAKOUT EXERCISEORAL HEALTH VALUE-BASED CARE READINESS ASSESSMENT
Danielle Apostolon
PROMISING PRACTICES FROM THE FIELD STRATEGIES FOR INCREASING VALUE IN ORAL HEALTH
Dr Carolyn Brown
Dr Kelly Perry
Dr Rachel Rivard
Dr Adeloye
Commitment Compassion Community
m i d s t a t e h e a l t h o r g
Promising Practices from the
Field Strategies for Increasing
Value in Oral Health Care
Kelly Perry DMD
Better Health
Outcomes
Improved Staff
Experience
Reduced Cost
Improved Patient
Experience
Better Health
Outcomes
Improved Staff
Experience
Reduced Cost
Improved Patient
Experience
Better Health
Outcomes
Improved Staff
Experience
Reduced Cost
Improved Patient
Experience
Better Health
Outcomes
Improved Staff
Experience
Reduced Cost
Improved Patient
Experience
Commitment Compassion Community
kpe r r ymids t a tehea l t h o rg
Thank you
Completion of Disease Control Phase
Pelumi Adeloye DMD MPH
HEALTH ACCESS NETWORK (HAN) FAMILY DENTAL
Introduction
⧫1 Dentist I Hygienist 3 EFDArsquos1 Receptionist
⧫ 6 Chairs= 4 (dentist) + 2 (hygienist)
⧫ Slide ⥶80 off
⧫ Service areas Northern Penobscot Southern Aroostook Western
Washington Counties amp more
Completion of Phase I Treatment
⧫LimitedLack of Access to dental care
⧫Difficulty completing the disease control phase
Caries amp periodontal disease
⧫Attaining stable restorative state
Goal
Increase the completion of Disease Control Phase
Current practice
⧫Education
Assess level of dental literacy
Incremental strategy
⧫Increase access to dental care
Generous sliding scale (⥸$40 per visit)
Incorporate Expanded Function Dental Assistants
⧫Schedule modification
Incorporate more restorative blocks to allow
for follow-up visit and completion of restorative phase
httpswwwglasbergencomdentist-cartoons
Schedule
⧫Piggybacking technique
Increased allotted restorative blocks
⧫Sustainability of current schedule is
contingent on cooperation amp skills of HAN
Dental staff
Note
Strategies mentioned today is personalized to HAN Dental clinic
Current implemented strategies might be modified or changed in the
future as required in order to accommodate the need of our pts
THANK YOU
DAY TWOCLOSINGWRAP-UP
End of Day Two ndash Survey
Day Two Creating a Value-Based Oral Health Care Delivery
System
129
Payment Reform in Oral Health Online Learning Module
Oral Health Value-based Care Online Learning Module
Value-based Care Keys to Success Article
Readiness Assessment
Competency Development Guide
Oral Health Value-based Care Training
Dental Caries Management Practicum
Clinicians Companion Guide
Interprofessional Network Referral Process
Traditional Dental Care Vs Value-Based Care
Resources
131
wwwDentaQuestPartnershiporg
wwwfacebookcomDentaQuest
DentaQuest
wwwlinkedincomcompanyDentaQuest
Inside_DentaQuest
QUESTIONS
23
Value-Based Care
Care Coordination
ldquoClosing outrdquo referrals
Diagnostic coding
Risk Screenings
Care plans based on risk
Patient Engagement
Incentive payments
Quality metrics
Clinic Response
Case Management IT
Active timely records mngt
Mapping Dx codes to CDT
Time bill CPT codes Tx plan
IPP data tofrom PC MH
Recall window important
Attention to $ related metrics
Attention to assigned metrics
Direct and Indirect Effects of VBC on Dental Systems of Care
Utilization Impact
New workforce CDT codes
New or + workforce IT
ICD-CM-10 codes
+CDT codes
Modifiers (CPT ICD10)
+ recall adherence
in incentivized procedures
in sealant POC A1C
Counseling codes SD
24
MEASUREMENT IN ORAL HEALTH
25
Poll What percentage of your adult dental patients are diabetic
or pre-diabetic
A 50-80
B 20-50
C Less than 20
D Not sure
26
27
ldquoTrue Measures of Successrdquo
1 Define your governing objective
2 Develop a theory of cause and effect to assess presumed drivers of the
objective
3 Identify the specific activities that employees can do to help achieve the
governing objective
4 Evaluate your statistics
5 Communicate the story of your measurement
Adapted from HBR ldquoThe True Measures of Successrdquo httpshbrorg201210the-true-measures-of-success
28
1 Governing objective
2 Theory of cause and effect
3 Activities of team
4 Evaluate your statistics
5 Storycraft
Sustainability
Clinic revenuegt expenses= sustainability
Patient compliance Assets Clinic Mngt
Care team Operations Pt Support Billing
Of Prod on and type Patients on time
Daily weekly monthly quarterly
ldquoTrue Measures of Successrdquo
Adapted from HBR ldquoThe True Measures of Successrdquo httpshbrorg201210the-true-measures-of-success
29
Measuring Risk and Health
November is Diabetes Awareness Month- 2019Communication Plans are as
important as cold hard numbers
Patients
Care Team
Other Health Teams
Executive Team
Funders
Data on your dental patients are medical patients of record
Data on your medical + dental patients with DM2
30
Develop Diabetic Patient
Protocols
Review evidence and rationale with dental team
Partner with primary care team
bull Protocols Care mngt Tests and Recording
Quality Goals
Protocols for newly screened and existing patients
Educate and train dental team in reading AND
charting test results and PILOT
31
External Measurement in Oral Health Programs
httpswwwadaorg~mediaADADQA2019_DiabetesOralEvaluationpdfla=en
httpswwworegongovohaHPAANALYTICSCCOMetrics2019-Oral-Evaluation-Adults-Diabetespdf
32
Baseline for 2019 271
httpswwworegongovohaHPAANALYTICSCCOMetrics2019-Oral-Evaluation-Adults-Diabetespdf
33
Diabetes burden in your panel of dental patients
Baseline Medical-Dental Integrated panel of all patients
Dental patients with DM2 MDI
Dental patients with DM2
1000 or 10
600 or 60
300010000= 30
Population Health- Clinic Level
34
1 Governing objective
2 Theory of cause and effect
3 Activities of team
4 Evaluate your statistics
5 Storycraft
Discuss at meetings (Oct + Nov) Health education training
materials NP training CQI Note in Board report Clinical
measures
Care Pathways Hygiene Resources (ScheduleAvail)
ldquoTrue Measures of Successrdquo
Adapted from HBR ldquoThe True Measures of Successrdquo httpshbrorg201210the-true-measures-of-success
Diabetes Awareness Prevention Healthier Community
Prevention Awareness Care Pathway promotes health
MDI= 10 6 out of 10 adult patients with DM2
Goal set for integrated patient panels ndash PCMH
Pre-diabetes approach for executive team
Care Pathways
Care Coordination
35
MEASURING PATIENT ORAL HEALTHRisk assessments and Care Pathways
36
37
Risk Assessment and Care Pathways
Caries Risk Assessment
Multiple tools
EDREHR modules smart notes or dot phrases
CDT Codes
Decide frequency
D0601
Low Caries Risk
D0601
Moderate Caries Risk
D0601
High Caries Risk
38
The Disease Management DifferenceDisease Management Difference
Traditional Dental Care Disease Management
Approach
All patients return in 6 months
regardless of risk status
Recare interval is based on the
childrsquos caries risk
Caries Risk
Level
Recommended
Recare Interval
High Risk 1 ndash 3 months
Moderate Risk 3 ndash 6 months
Low Risk 6 ndash 12 months
Caries
Stabilizing
agents
Health Ed
Nutritional
Counseling
Anti-bacterial
and Fluoride
interventions
39
Disease Management Care Pathways
DentaQuest Partnership for Oral Health Advancement Disease Management Model
Caries
Stabilizing
agents
Whole
Person
Inter-
professional
Approaches
Anti-bacterial
and Fluoride
interventions
40
Disease Management and Risk Screening Training
DentaQuest Partnership for Oral Health Advancementrsquos
Online Learning Center
Disease Management Series
8 modules 40 CDE available
httpswwwdentaquestpartnershiporglearnonline-learning-centeronline-
coursewaredentaquest-disease-management-series
41
MEASUREMENT IN TEAMSSharing meaningful data with your dental clinical teams
42
rdquoDental Homerdquo = Health Home where WE can meet the patient
Oralhealthworkforceorg
43
POLL HOW OFTEN DO YOU SHARE YOUR S WITH YOUR DENTAL TEAM
A Yearly only
B Quarterly
C Monthly
D Weekly
E Daily
44
Clinical Measures ndash Dental Practice Perspective
Private Practice Office
New patients seen
Assigned vs seen if capitated
Treatment plans incomplete
$ produced amp per provider
$ collected amp monthly per provider
CDT 6000 codes completed
RecallHygiene maintenance
Based on this consultants experienced
FQHC
Unduplicated patients
patients seen per day
Treatment plans complete
$ gainedlost via accounting
Broken appointment rate
procedures
Sealant rate (annual)
45
bull HRSA Sealant Measure Compliance for FQHCs
bull Completion of phase 1 treatment plans
bull Children seen 0-5 years old
bull Children seen getting a preventive service
bull Fluoride Varnish applications
bull Pregnant women seen and treated
bull Diabetic patients with HbA1C gt 7 seen
bull Patients seen who have not been seen for 12 months
bull Patients seen getting a Risk Assessment
bull Patients with moderate or high risk who lower risk at recare
bull Sealants provided httpwwwnnohaorgnnoha-contentuploads201512Demystifying-HRSA-SEALANT-PRESENTATION_FINALpdf
Program Measures
46
HRSA Performance Measurement and Data Collection
bull FQHCs and look-alikes submit CY data to HRSA since 2008
bull UDS Uniform Data System
bull Require FTE for clinical staff patient demographics
bull Dental utilization s (UDCTPV)
bull Dental Clinical Measure dental sealants placed on 1st molars ages 6-9 yo
bull Health Center Quartile rankings (Clinical measure performance influences
HC rankings as does EHR adoption and other HC characteristics)
47
Low birth weight
Access to prenatal care
Childhood Immunization
Children (Ages 3-17) Receiving
Weight Assessment amp
Counseling
Children (Age 6-9) Receiving
Dental Sealant to First Molars
Diabetes Control
Hypertension Control
Pap Test
Depression Screening and
Follow-up (Age 12+)
Asthma Patients (Age 5-40)
Receiving Pharmacologic
Therapy
Colorectal Cancer
Screening (Ages 51-74)
HRSA UDS Clinical Measures
Adults (Age 18+) Receiving
Weight Screening amp Follow-up
Adults (Age 18+) Receiving
Tobacco Use Assessment and
Cessation Intervention
Coronary Artery Disease
Receiving Lipid Therapy (18+)
Ischemic Vascular Disease (IVD)
Receiving Aspirin Therapy (18+)
HIV Linkage to Care
48
Dashboards
Grants
Average
amp
Targets
Quality
Rev
Costs
Visits
Priority
Pop
Prevention
49
Dashboard- Provider Team Level
Patient
Compliance
Satisfaction
50
Case Study-
Incentives bonus round pools benchmark and improvement target goals risk-sharing possible later years
51
Qualitative Measurement
ldquoPatient engagement is the act of patients and providers working together
toward the end goal of improved patient wellnessrdquo
wwwpatientengagementhitcom
Access to Care
Patient Activation
Patient Satisfaction
Patient-Provider-Care Team Communication
Care Team Satisfaction
52
OHVBC Readiness
Leadership
bull Value of oral health and oral health transformation
Structure Systems and Operations
bull Operational efficiencies innovative care delivery methodologies
Care Pathways and Provider Buy-In
bull Training disease management risk-based care referrals IDC-10 coding patient engagement
Data and Analytic Technology and Personnel
bull Interoperability reporting
Financial Viability and Strength
bull Payerpatient mix billing infrastructure financial reports
httpswwwdentaquestpartnershiporglearnsafety-net-solutionsoral-health-value-based-careohvbc-readiness-
assessment
53
QUESTIONS COMMENTS
Carolyn Brown DDS
cbrownddsgmailcom
RISK BASED MANAGED CARE
Value Based Training Conference
Manchester New Hampshire
Mark Koday DDS
111919
5555
Objectives
bull Review current drivers of dental managed care
bull Understand the basics of risk-based dental managed care contracts
bull Learn the basics of managing costs in a riskndashbased contract
bull Gain an understanding in the potential advantage of risk-based contracting
56
What Is Dental Managed Care
Managed care is a health delivery system whose purpose is to manage both the
quality and cost of health care
Common types of managed care health insurance plans
bull HMOs
bull PPOs
bull POSs
bull Medicaid Managed Care
DIDNrsquoT WE ALREADY HAVE MANAGED CARE AND IT FAILED
57
What Has Happened Since the 90s
58
WHY THE FFS AND PPS DOESNrsquoT WORK FOR OUR POPULATIONS
bull Inefficient payment systems designed to produce encounters or procedures but not real health
bull No focus on population health
bull Does not incentivize innovation
bull Patients essentially on their own for accessing specialty care
59
Rule of 4
Source Kaiser Family Foundation analysis of National Health Expenditure (NHE) data from Centers for
Medicare and Medicaid Services Office of the Actuary National Health Statistics Group
60
Rule of 4
bull This helps explain why oral health has been relatively ignored so far by CMS
bull Explains why we have PCMH instead of PCHH
bull Where is the real value on a national level in preventing disease and
controlling costs
bull Beware- wersquove been found
61
Reasons Dental Managed Care is Spreading Across the States
NON-MANAGED CARE STATE DENTAL BUDGETS ARE
OPENED ENDED
STRAIN ON STATE BUDGETS
UPCOMING RECESSION WITH TRILLION DOLLAR
DEFICIT
SHIFTS FINANCIAL RISK FROM THE STATES TO THE
PLANS
6262
Types of Medicaid Managed Care
bull State Medicaid agency administrator lowest administrative
costs
bull Third Party Administrator Typically 15 administrative costs
bull Managed Care Organization Typically 15 administrative
costs
bull Carved-in
bull Carved-out
bull Risk Based Managed Care Administrative costs part of
contract negotiation
63
RISK CONTRACTS
6464
Components of a Risk-based Contract
Risk
Medical Loss Ratio
Quality withhold
Specialty withhold
Managed care payment (pmpm)
Covered services
Fee schedule Claims are paid as usual on a FFS basis
Credentialing
Quality Review process and Quality Metrics
65
Upside Risk
The possibility that the cost of
delivering dental care to an assigned
patient panel is less than the amount
of funding calculated for that care
The Plan pays the CHC additional
funds based on a predetermine
formula
Downside Risk
The possibility that the cost of
delivering dental care to an assigned
patient panel is more than the amount
of funding calculated for that care
The CHC pays the Plan additional
funds based on a predetermine
formula
Upside and Downside Risk
66
Taking On Risk 100 or Shared Risk
With 100 risk you receive 100 of the potential savings but are also at risk for
100 of the losses
Shared Risk MCO and health center share a percentage of the risk
Shared Risk leads to better cooperation since both organizations are
incentivized to save on costs
6767
Reports Needed
bull Enrollment reports lists of who is assigned on a monthly basis
bull Reconciliation reports insure appropriate payments
bull Specialty Referral reports
bull You will need your own reporting process so you donrsquot rely completely on
reports supplied by the Plan
6868
Medical Loss Ratio
Medical Loss Ratio (MLR) is proportion of premium revenues spent on clinical
services and quality improvement also known as the Medical Loss Ratio (MLR)
For CMS requires Medical Plans to spend at least 80 to 85 of the premiums
on actual medical care
69
Administrative Fees
bull Essentially the opposite of MLR
bull The State Medicaid Agency is funded by the Governorrsquos budget
bull The State Medicaid Agency will keep some of these funds for their
admin costs and give the remaining to the Managed Care Plans
bull Private Plan admin costs can be as high as 40 but most states
limit these cost for Medicaid Plans to between 15 and 20 (85-
80 MLR)
bull This may be negotiable depending on your program size of your
program
70
Quality Withhold
bull The state withholds a certain percent (typically 2-4 ) of the funds they give
to the Plans for Value Based Reimbursement
bull They choose quality metrics and set benchmarks and assign payments for
each metric based on an assigned priority for each metric
bull If a Plan meets the benchmark of every quality metric the state passes on
their full share of the quality withhold
bull The Plans may or may not withhold a percent of the funds for quality payment
to the dentists or manage care contractors
71
Quality Withhold
Either way the Plans may or may not pass the quality payments they receive to
the dentists or contractors
This should be spelled out in a risk-based contract
72
Percent of funds set aside
to cover specialty care
referrals
Typically 10-15
Goal Limit referral costs
to within or less than
Specialty set aside
Specialty Withhold
73
Per Member Per Month
bull Capitated Payment
bull Specific dollar amount paid for each enrolled member each month
bull Paid whether patient is accessed for care or not
bull States do set access benchmarks
bull In Oregon access for any dental procedure (adults and children combined)
was 267 in 2015
74
Payment Math Example
Premium per enrollee = $25
Administrative fee 15 = $375
Funds available per enrollee to the clinic = $2125
Management fee per enrollee = $175
Funds per enrollee that would undergo PPS reconciliation = $1950
For every 10000 enrollees the managed care income = $2340000
Specialty withhold (10) = $234000
YE Cost lt or gt $2340000
Upside Risk
CHC Gains $
Downside Risk
CHC Loses $
75
Covered Services and Fee Schedules
bull The state Medicaid agency spells out the minimum procedures and fees that
MCOs must cover
bull MCOs may add procedures or increase periodicity of procedures particularly
preventative services
bull MCOs may increase fees to entice rural providers and specialists to enroll in
their Plans
bull Access Rules
bull How many days it takes to access a patent
bull How many days it takes for a patent to access urgent care services
bull How many days it takes for a patent to access emergency care services
76
Credentialing
All MCOs are required to credential all Providers
All MCOs have their own credentialing process
Credentialing process is can be lengthy
Credentialing process may be negotiable
77
Quality Review Process and Quality Metrics
MCOs must have a Quality and Compliance Review Process
If you arenrsquot in compliance with both you likely wonrsquot get paid
Typical processes reviewed
bull Charting specifications
bull Incident report
bull Enrollee complaints quality rudeness and access issues
bull Medicaid compliance
78
Quality Payments
bull State Shared Incentive Withhold Typically quality metrics and benchmarks
are set by the state sets aside a certain percent (3-5) of the payments to
the Managed Care Plan (MCP)
bull If the benchmarks are achieved the MCP is then paid the a predetermine
amount
bull Benchmarks may not be the same as the states
bull Managed Care Plans do not have to pass all or any of the quality payments to
the health centers or providers
bull Managed Care contract- Metrics benchmarks should be selected and part of
the contract
7979
Achieving Quality Metric Payments
Dealing with under achievers
Process issues
Individual issues
Identifying workflows
Developing Best Practices through
PDSA process
Developing Best Practices through
PDSA process
CHC Metrics Committee
Clinicians Operations various key staff
Identify Best Practices
Spread Best Practices
80
New Team Needed Business Intelligence
Business Intelligence (BI) is critical for effective managed care business decisions
BI team inputs metrics into your EHR collects integrates analyses and displays all your managed care business and clinical information
Easy to say- hard to achieve
Build your own or outsource
Possible future role of Primary Care Associations
8181
Clinicianrsquos Dashboard
Expensive to build
Displayed on your screen when your computer is first turned on
Easy to read and understand
Data dumped from the day before
Can dialed down from Org-wide to clinic to each clinicianrsquos data
Operational and clinical metrics
bull Treatment Plan Completion
bull DQA quality measures
bull Caries at Recall
bull Re-care reports
bull Care Gap reports
82
CONTROLLING COSTS
8383
Controlling Costs- Current
bull Increasing efficiencies
bull Decreasing broken appointments
bull Controlling supplies equipment costs
bull Staff recruitment retention costs
84
Specialty Care
Training current CHC dentists in
specialty areas
Hiring general dentists with higher
specialty skill sets
Hiring in house specialists
Contract with outside specialists
Work with Managed Care Plan
specialists
Lowering Disease Rates
Community Dental Health
Coordinators case management
If your state law allows- embed
hygienists in medical and community
to provide primary and secondary
prevention procedures
In clinic Caries Classification and
Silver Diamine Fluoride
Effective recare programs
Controlling Costs- Additions in Risk-based Contracting
85
Specialty Care ndash Primary Referrals by Cost
Pediatric dentistry
Orthodontics
Oral surgery
Endodontics
86
In-clinic Pediatric Services
Encounters expected
of operatories available
State dental law and ability to have
expanded duties
General Anesthesia
GA in- house
Ability for a hospital or surgery center
to set aside regular OR time
Ability to hire or assign DAs to GA
days
Four GA cases day x PPS rate
Should You Hire a Pediatric Dentist- It Depends
8787
Solutions for Controlling Pediatric Costs
Hire a general dentist that is skilled in treating young children
Make the clinic child friendly nitrous oxide TVs in the operatory etc
Teach entire staff behavioral control techniques
Contract with a pediatric dentist for the GA care
88
Lowering Overall Disease Rates (and Costs)
You are responsible for both the patients you see in the chair and the ones
assigned to you
Breaking down the walls of the dental clinic
Community Dental Health Coordinators
Case Management
89
Cost Control Essentials
Diagnosis codes
Increased ability to identify
disease by risk
Motivational
Interviewing
Developing Polices and
Procedures design to treat
disease according to risk
ie Silver Diamine Fluoride
Treating by Risk
Effective Recare
Process
Critical to continual disease
controlPrevention education that is
meaningful and designed to
change behaviors
90
Social Determinants of Health Aunt Bertha
httpswwwauntberthacom
91
REASON TO CONSIDER RISK- BASED CONTRACTING
9292
PPS Reconciliation and Federal Code 42 CFR sect4052469(a)(2)
42 CFR sect4052469(a)(2)
ldquoAny financial incentives provided to Federally Qualified Health Centers
under their Medicare Advantage Contracts such as risk pool payments
bonuses or withholds are prohibited from being included in the
calculation of supplemental payments due to the Federally Qualified
Health Centerrdquo
9393
Why Risk Based Contract in Times of PPS Reconciliation
bull Not all Risk- based Contract funds are reconciled
bull Risk is the key word- you can come out with less money than your normal
PPS reconciliation payment
bull Can lead to better patient care
bull May improve manage care enrollment for your medical plan
bull Promotes integrated care increases health for your CHC patients
9494
Not Included in the Reconciliation
Enrollment management pmpm
Quality Payments
Upside risk payments
Downside risk losses
9595
Determinants of Financial Success in Risk-Based Contracting
bull Most critical- State pmpm payment to the Managed Care Plan
bull Reporting capabilities
bull Specialty service capabilities
bull Access numbers count
bull Ability to move metric numbers
9696
What About the Non- Medicaid Poor We Serve
bull Numbers are king in a managed care contract and the more access you have
the better contract terms you can negotiate
bull We will potentially have a steady supply of Medicaid patients
bull As managed care spreads states this may be compromising the ability of
health centers to serve the non-Medicaid poor and others lacking dental
insurance
97
Mark Koday DDS
(509) 949-2278
Dental Quality Consultants
of WA
httpdentalqualityconsultin
gcom
dentalqualityconsultantsg
mailcom
Contact Information
LUNCH
BREAKOUT EXERCISEORAL HEALTH VALUE-BASED CARE READINESS ASSESSMENT
Danielle Apostolon
PROMISING PRACTICES FROM THE FIELD STRATEGIES FOR INCREASING VALUE IN ORAL HEALTH
Dr Carolyn Brown
Dr Kelly Perry
Dr Rachel Rivard
Dr Adeloye
Commitment Compassion Community
m i d s t a t e h e a l t h o r g
Promising Practices from the
Field Strategies for Increasing
Value in Oral Health Care
Kelly Perry DMD
Better Health
Outcomes
Improved Staff
Experience
Reduced Cost
Improved Patient
Experience
Better Health
Outcomes
Improved Staff
Experience
Reduced Cost
Improved Patient
Experience
Better Health
Outcomes
Improved Staff
Experience
Reduced Cost
Improved Patient
Experience
Better Health
Outcomes
Improved Staff
Experience
Reduced Cost
Improved Patient
Experience
Commitment Compassion Community
kpe r r ymids t a tehea l t h o rg
Thank you
Completion of Disease Control Phase
Pelumi Adeloye DMD MPH
HEALTH ACCESS NETWORK (HAN) FAMILY DENTAL
Introduction
⧫1 Dentist I Hygienist 3 EFDArsquos1 Receptionist
⧫ 6 Chairs= 4 (dentist) + 2 (hygienist)
⧫ Slide ⥶80 off
⧫ Service areas Northern Penobscot Southern Aroostook Western
Washington Counties amp more
Completion of Phase I Treatment
⧫LimitedLack of Access to dental care
⧫Difficulty completing the disease control phase
Caries amp periodontal disease
⧫Attaining stable restorative state
Goal
Increase the completion of Disease Control Phase
Current practice
⧫Education
Assess level of dental literacy
Incremental strategy
⧫Increase access to dental care
Generous sliding scale (⥸$40 per visit)
Incorporate Expanded Function Dental Assistants
⧫Schedule modification
Incorporate more restorative blocks to allow
for follow-up visit and completion of restorative phase
httpswwwglasbergencomdentist-cartoons
Schedule
⧫Piggybacking technique
Increased allotted restorative blocks
⧫Sustainability of current schedule is
contingent on cooperation amp skills of HAN
Dental staff
Note
Strategies mentioned today is personalized to HAN Dental clinic
Current implemented strategies might be modified or changed in the
future as required in order to accommodate the need of our pts
THANK YOU
DAY TWOCLOSINGWRAP-UP
End of Day Two ndash Survey
Day Two Creating a Value-Based Oral Health Care Delivery
System
129
Payment Reform in Oral Health Online Learning Module
Oral Health Value-based Care Online Learning Module
Value-based Care Keys to Success Article
Readiness Assessment
Competency Development Guide
Oral Health Value-based Care Training
Dental Caries Management Practicum
Clinicians Companion Guide
Interprofessional Network Referral Process
Traditional Dental Care Vs Value-Based Care
Resources
131
wwwDentaQuestPartnershiporg
wwwfacebookcomDentaQuest
DentaQuest
wwwlinkedincomcompanyDentaQuest
Inside_DentaQuest
QUESTIONS
24
MEASUREMENT IN ORAL HEALTH
25
Poll What percentage of your adult dental patients are diabetic
or pre-diabetic
A 50-80
B 20-50
C Less than 20
D Not sure
26
27
ldquoTrue Measures of Successrdquo
1 Define your governing objective
2 Develop a theory of cause and effect to assess presumed drivers of the
objective
3 Identify the specific activities that employees can do to help achieve the
governing objective
4 Evaluate your statistics
5 Communicate the story of your measurement
Adapted from HBR ldquoThe True Measures of Successrdquo httpshbrorg201210the-true-measures-of-success
28
1 Governing objective
2 Theory of cause and effect
3 Activities of team
4 Evaluate your statistics
5 Storycraft
Sustainability
Clinic revenuegt expenses= sustainability
Patient compliance Assets Clinic Mngt
Care team Operations Pt Support Billing
Of Prod on and type Patients on time
Daily weekly monthly quarterly
ldquoTrue Measures of Successrdquo
Adapted from HBR ldquoThe True Measures of Successrdquo httpshbrorg201210the-true-measures-of-success
29
Measuring Risk and Health
November is Diabetes Awareness Month- 2019Communication Plans are as
important as cold hard numbers
Patients
Care Team
Other Health Teams
Executive Team
Funders
Data on your dental patients are medical patients of record
Data on your medical + dental patients with DM2
30
Develop Diabetic Patient
Protocols
Review evidence and rationale with dental team
Partner with primary care team
bull Protocols Care mngt Tests and Recording
Quality Goals
Protocols for newly screened and existing patients
Educate and train dental team in reading AND
charting test results and PILOT
31
External Measurement in Oral Health Programs
httpswwwadaorg~mediaADADQA2019_DiabetesOralEvaluationpdfla=en
httpswwworegongovohaHPAANALYTICSCCOMetrics2019-Oral-Evaluation-Adults-Diabetespdf
32
Baseline for 2019 271
httpswwworegongovohaHPAANALYTICSCCOMetrics2019-Oral-Evaluation-Adults-Diabetespdf
33
Diabetes burden in your panel of dental patients
Baseline Medical-Dental Integrated panel of all patients
Dental patients with DM2 MDI
Dental patients with DM2
1000 or 10
600 or 60
300010000= 30
Population Health- Clinic Level
34
1 Governing objective
2 Theory of cause and effect
3 Activities of team
4 Evaluate your statistics
5 Storycraft
Discuss at meetings (Oct + Nov) Health education training
materials NP training CQI Note in Board report Clinical
measures
Care Pathways Hygiene Resources (ScheduleAvail)
ldquoTrue Measures of Successrdquo
Adapted from HBR ldquoThe True Measures of Successrdquo httpshbrorg201210the-true-measures-of-success
Diabetes Awareness Prevention Healthier Community
Prevention Awareness Care Pathway promotes health
MDI= 10 6 out of 10 adult patients with DM2
Goal set for integrated patient panels ndash PCMH
Pre-diabetes approach for executive team
Care Pathways
Care Coordination
35
MEASURING PATIENT ORAL HEALTHRisk assessments and Care Pathways
36
37
Risk Assessment and Care Pathways
Caries Risk Assessment
Multiple tools
EDREHR modules smart notes or dot phrases
CDT Codes
Decide frequency
D0601
Low Caries Risk
D0601
Moderate Caries Risk
D0601
High Caries Risk
38
The Disease Management DifferenceDisease Management Difference
Traditional Dental Care Disease Management
Approach
All patients return in 6 months
regardless of risk status
Recare interval is based on the
childrsquos caries risk
Caries Risk
Level
Recommended
Recare Interval
High Risk 1 ndash 3 months
Moderate Risk 3 ndash 6 months
Low Risk 6 ndash 12 months
Caries
Stabilizing
agents
Health Ed
Nutritional
Counseling
Anti-bacterial
and Fluoride
interventions
39
Disease Management Care Pathways
DentaQuest Partnership for Oral Health Advancement Disease Management Model
Caries
Stabilizing
agents
Whole
Person
Inter-
professional
Approaches
Anti-bacterial
and Fluoride
interventions
40
Disease Management and Risk Screening Training
DentaQuest Partnership for Oral Health Advancementrsquos
Online Learning Center
Disease Management Series
8 modules 40 CDE available
httpswwwdentaquestpartnershiporglearnonline-learning-centeronline-
coursewaredentaquest-disease-management-series
41
MEASUREMENT IN TEAMSSharing meaningful data with your dental clinical teams
42
rdquoDental Homerdquo = Health Home where WE can meet the patient
Oralhealthworkforceorg
43
POLL HOW OFTEN DO YOU SHARE YOUR S WITH YOUR DENTAL TEAM
A Yearly only
B Quarterly
C Monthly
D Weekly
E Daily
44
Clinical Measures ndash Dental Practice Perspective
Private Practice Office
New patients seen
Assigned vs seen if capitated
Treatment plans incomplete
$ produced amp per provider
$ collected amp monthly per provider
CDT 6000 codes completed
RecallHygiene maintenance
Based on this consultants experienced
FQHC
Unduplicated patients
patients seen per day
Treatment plans complete
$ gainedlost via accounting
Broken appointment rate
procedures
Sealant rate (annual)
45
bull HRSA Sealant Measure Compliance for FQHCs
bull Completion of phase 1 treatment plans
bull Children seen 0-5 years old
bull Children seen getting a preventive service
bull Fluoride Varnish applications
bull Pregnant women seen and treated
bull Diabetic patients with HbA1C gt 7 seen
bull Patients seen who have not been seen for 12 months
bull Patients seen getting a Risk Assessment
bull Patients with moderate or high risk who lower risk at recare
bull Sealants provided httpwwwnnohaorgnnoha-contentuploads201512Demystifying-HRSA-SEALANT-PRESENTATION_FINALpdf
Program Measures
46
HRSA Performance Measurement and Data Collection
bull FQHCs and look-alikes submit CY data to HRSA since 2008
bull UDS Uniform Data System
bull Require FTE for clinical staff patient demographics
bull Dental utilization s (UDCTPV)
bull Dental Clinical Measure dental sealants placed on 1st molars ages 6-9 yo
bull Health Center Quartile rankings (Clinical measure performance influences
HC rankings as does EHR adoption and other HC characteristics)
47
Low birth weight
Access to prenatal care
Childhood Immunization
Children (Ages 3-17) Receiving
Weight Assessment amp
Counseling
Children (Age 6-9) Receiving
Dental Sealant to First Molars
Diabetes Control
Hypertension Control
Pap Test
Depression Screening and
Follow-up (Age 12+)
Asthma Patients (Age 5-40)
Receiving Pharmacologic
Therapy
Colorectal Cancer
Screening (Ages 51-74)
HRSA UDS Clinical Measures
Adults (Age 18+) Receiving
Weight Screening amp Follow-up
Adults (Age 18+) Receiving
Tobacco Use Assessment and
Cessation Intervention
Coronary Artery Disease
Receiving Lipid Therapy (18+)
Ischemic Vascular Disease (IVD)
Receiving Aspirin Therapy (18+)
HIV Linkage to Care
48
Dashboards
Grants
Average
amp
Targets
Quality
Rev
Costs
Visits
Priority
Pop
Prevention
49
Dashboard- Provider Team Level
Patient
Compliance
Satisfaction
50
Case Study-
Incentives bonus round pools benchmark and improvement target goals risk-sharing possible later years
51
Qualitative Measurement
ldquoPatient engagement is the act of patients and providers working together
toward the end goal of improved patient wellnessrdquo
wwwpatientengagementhitcom
Access to Care
Patient Activation
Patient Satisfaction
Patient-Provider-Care Team Communication
Care Team Satisfaction
52
OHVBC Readiness
Leadership
bull Value of oral health and oral health transformation
Structure Systems and Operations
bull Operational efficiencies innovative care delivery methodologies
Care Pathways and Provider Buy-In
bull Training disease management risk-based care referrals IDC-10 coding patient engagement
Data and Analytic Technology and Personnel
bull Interoperability reporting
Financial Viability and Strength
bull Payerpatient mix billing infrastructure financial reports
httpswwwdentaquestpartnershiporglearnsafety-net-solutionsoral-health-value-based-careohvbc-readiness-
assessment
53
QUESTIONS COMMENTS
Carolyn Brown DDS
cbrownddsgmailcom
RISK BASED MANAGED CARE
Value Based Training Conference
Manchester New Hampshire
Mark Koday DDS
111919
5555
Objectives
bull Review current drivers of dental managed care
bull Understand the basics of risk-based dental managed care contracts
bull Learn the basics of managing costs in a riskndashbased contract
bull Gain an understanding in the potential advantage of risk-based contracting
56
What Is Dental Managed Care
Managed care is a health delivery system whose purpose is to manage both the
quality and cost of health care
Common types of managed care health insurance plans
bull HMOs
bull PPOs
bull POSs
bull Medicaid Managed Care
DIDNrsquoT WE ALREADY HAVE MANAGED CARE AND IT FAILED
57
What Has Happened Since the 90s
58
WHY THE FFS AND PPS DOESNrsquoT WORK FOR OUR POPULATIONS
bull Inefficient payment systems designed to produce encounters or procedures but not real health
bull No focus on population health
bull Does not incentivize innovation
bull Patients essentially on their own for accessing specialty care
59
Rule of 4
Source Kaiser Family Foundation analysis of National Health Expenditure (NHE) data from Centers for
Medicare and Medicaid Services Office of the Actuary National Health Statistics Group
60
Rule of 4
bull This helps explain why oral health has been relatively ignored so far by CMS
bull Explains why we have PCMH instead of PCHH
bull Where is the real value on a national level in preventing disease and
controlling costs
bull Beware- wersquove been found
61
Reasons Dental Managed Care is Spreading Across the States
NON-MANAGED CARE STATE DENTAL BUDGETS ARE
OPENED ENDED
STRAIN ON STATE BUDGETS
UPCOMING RECESSION WITH TRILLION DOLLAR
DEFICIT
SHIFTS FINANCIAL RISK FROM THE STATES TO THE
PLANS
6262
Types of Medicaid Managed Care
bull State Medicaid agency administrator lowest administrative
costs
bull Third Party Administrator Typically 15 administrative costs
bull Managed Care Organization Typically 15 administrative
costs
bull Carved-in
bull Carved-out
bull Risk Based Managed Care Administrative costs part of
contract negotiation
63
RISK CONTRACTS
6464
Components of a Risk-based Contract
Risk
Medical Loss Ratio
Quality withhold
Specialty withhold
Managed care payment (pmpm)
Covered services
Fee schedule Claims are paid as usual on a FFS basis
Credentialing
Quality Review process and Quality Metrics
65
Upside Risk
The possibility that the cost of
delivering dental care to an assigned
patient panel is less than the amount
of funding calculated for that care
The Plan pays the CHC additional
funds based on a predetermine
formula
Downside Risk
The possibility that the cost of
delivering dental care to an assigned
patient panel is more than the amount
of funding calculated for that care
The CHC pays the Plan additional
funds based on a predetermine
formula
Upside and Downside Risk
66
Taking On Risk 100 or Shared Risk
With 100 risk you receive 100 of the potential savings but are also at risk for
100 of the losses
Shared Risk MCO and health center share a percentage of the risk
Shared Risk leads to better cooperation since both organizations are
incentivized to save on costs
6767
Reports Needed
bull Enrollment reports lists of who is assigned on a monthly basis
bull Reconciliation reports insure appropriate payments
bull Specialty Referral reports
bull You will need your own reporting process so you donrsquot rely completely on
reports supplied by the Plan
6868
Medical Loss Ratio
Medical Loss Ratio (MLR) is proportion of premium revenues spent on clinical
services and quality improvement also known as the Medical Loss Ratio (MLR)
For CMS requires Medical Plans to spend at least 80 to 85 of the premiums
on actual medical care
69
Administrative Fees
bull Essentially the opposite of MLR
bull The State Medicaid Agency is funded by the Governorrsquos budget
bull The State Medicaid Agency will keep some of these funds for their
admin costs and give the remaining to the Managed Care Plans
bull Private Plan admin costs can be as high as 40 but most states
limit these cost for Medicaid Plans to between 15 and 20 (85-
80 MLR)
bull This may be negotiable depending on your program size of your
program
70
Quality Withhold
bull The state withholds a certain percent (typically 2-4 ) of the funds they give
to the Plans for Value Based Reimbursement
bull They choose quality metrics and set benchmarks and assign payments for
each metric based on an assigned priority for each metric
bull If a Plan meets the benchmark of every quality metric the state passes on
their full share of the quality withhold
bull The Plans may or may not withhold a percent of the funds for quality payment
to the dentists or manage care contractors
71
Quality Withhold
Either way the Plans may or may not pass the quality payments they receive to
the dentists or contractors
This should be spelled out in a risk-based contract
72
Percent of funds set aside
to cover specialty care
referrals
Typically 10-15
Goal Limit referral costs
to within or less than
Specialty set aside
Specialty Withhold
73
Per Member Per Month
bull Capitated Payment
bull Specific dollar amount paid for each enrolled member each month
bull Paid whether patient is accessed for care or not
bull States do set access benchmarks
bull In Oregon access for any dental procedure (adults and children combined)
was 267 in 2015
74
Payment Math Example
Premium per enrollee = $25
Administrative fee 15 = $375
Funds available per enrollee to the clinic = $2125
Management fee per enrollee = $175
Funds per enrollee that would undergo PPS reconciliation = $1950
For every 10000 enrollees the managed care income = $2340000
Specialty withhold (10) = $234000
YE Cost lt or gt $2340000
Upside Risk
CHC Gains $
Downside Risk
CHC Loses $
75
Covered Services and Fee Schedules
bull The state Medicaid agency spells out the minimum procedures and fees that
MCOs must cover
bull MCOs may add procedures or increase periodicity of procedures particularly
preventative services
bull MCOs may increase fees to entice rural providers and specialists to enroll in
their Plans
bull Access Rules
bull How many days it takes to access a patent
bull How many days it takes for a patent to access urgent care services
bull How many days it takes for a patent to access emergency care services
76
Credentialing
All MCOs are required to credential all Providers
All MCOs have their own credentialing process
Credentialing process is can be lengthy
Credentialing process may be negotiable
77
Quality Review Process and Quality Metrics
MCOs must have a Quality and Compliance Review Process
If you arenrsquot in compliance with both you likely wonrsquot get paid
Typical processes reviewed
bull Charting specifications
bull Incident report
bull Enrollee complaints quality rudeness and access issues
bull Medicaid compliance
78
Quality Payments
bull State Shared Incentive Withhold Typically quality metrics and benchmarks
are set by the state sets aside a certain percent (3-5) of the payments to
the Managed Care Plan (MCP)
bull If the benchmarks are achieved the MCP is then paid the a predetermine
amount
bull Benchmarks may not be the same as the states
bull Managed Care Plans do not have to pass all or any of the quality payments to
the health centers or providers
bull Managed Care contract- Metrics benchmarks should be selected and part of
the contract
7979
Achieving Quality Metric Payments
Dealing with under achievers
Process issues
Individual issues
Identifying workflows
Developing Best Practices through
PDSA process
Developing Best Practices through
PDSA process
CHC Metrics Committee
Clinicians Operations various key staff
Identify Best Practices
Spread Best Practices
80
New Team Needed Business Intelligence
Business Intelligence (BI) is critical for effective managed care business decisions
BI team inputs metrics into your EHR collects integrates analyses and displays all your managed care business and clinical information
Easy to say- hard to achieve
Build your own or outsource
Possible future role of Primary Care Associations
8181
Clinicianrsquos Dashboard
Expensive to build
Displayed on your screen when your computer is first turned on
Easy to read and understand
Data dumped from the day before
Can dialed down from Org-wide to clinic to each clinicianrsquos data
Operational and clinical metrics
bull Treatment Plan Completion
bull DQA quality measures
bull Caries at Recall
bull Re-care reports
bull Care Gap reports
82
CONTROLLING COSTS
8383
Controlling Costs- Current
bull Increasing efficiencies
bull Decreasing broken appointments
bull Controlling supplies equipment costs
bull Staff recruitment retention costs
84
Specialty Care
Training current CHC dentists in
specialty areas
Hiring general dentists with higher
specialty skill sets
Hiring in house specialists
Contract with outside specialists
Work with Managed Care Plan
specialists
Lowering Disease Rates
Community Dental Health
Coordinators case management
If your state law allows- embed
hygienists in medical and community
to provide primary and secondary
prevention procedures
In clinic Caries Classification and
Silver Diamine Fluoride
Effective recare programs
Controlling Costs- Additions in Risk-based Contracting
85
Specialty Care ndash Primary Referrals by Cost
Pediatric dentistry
Orthodontics
Oral surgery
Endodontics
86
In-clinic Pediatric Services
Encounters expected
of operatories available
State dental law and ability to have
expanded duties
General Anesthesia
GA in- house
Ability for a hospital or surgery center
to set aside regular OR time
Ability to hire or assign DAs to GA
days
Four GA cases day x PPS rate
Should You Hire a Pediatric Dentist- It Depends
8787
Solutions for Controlling Pediatric Costs
Hire a general dentist that is skilled in treating young children
Make the clinic child friendly nitrous oxide TVs in the operatory etc
Teach entire staff behavioral control techniques
Contract with a pediatric dentist for the GA care
88
Lowering Overall Disease Rates (and Costs)
You are responsible for both the patients you see in the chair and the ones
assigned to you
Breaking down the walls of the dental clinic
Community Dental Health Coordinators
Case Management
89
Cost Control Essentials
Diagnosis codes
Increased ability to identify
disease by risk
Motivational
Interviewing
Developing Polices and
Procedures design to treat
disease according to risk
ie Silver Diamine Fluoride
Treating by Risk
Effective Recare
Process
Critical to continual disease
controlPrevention education that is
meaningful and designed to
change behaviors
90
Social Determinants of Health Aunt Bertha
httpswwwauntberthacom
91
REASON TO CONSIDER RISK- BASED CONTRACTING
9292
PPS Reconciliation and Federal Code 42 CFR sect4052469(a)(2)
42 CFR sect4052469(a)(2)
ldquoAny financial incentives provided to Federally Qualified Health Centers
under their Medicare Advantage Contracts such as risk pool payments
bonuses or withholds are prohibited from being included in the
calculation of supplemental payments due to the Federally Qualified
Health Centerrdquo
9393
Why Risk Based Contract in Times of PPS Reconciliation
bull Not all Risk- based Contract funds are reconciled
bull Risk is the key word- you can come out with less money than your normal
PPS reconciliation payment
bull Can lead to better patient care
bull May improve manage care enrollment for your medical plan
bull Promotes integrated care increases health for your CHC patients
9494
Not Included in the Reconciliation
Enrollment management pmpm
Quality Payments
Upside risk payments
Downside risk losses
9595
Determinants of Financial Success in Risk-Based Contracting
bull Most critical- State pmpm payment to the Managed Care Plan
bull Reporting capabilities
bull Specialty service capabilities
bull Access numbers count
bull Ability to move metric numbers
9696
What About the Non- Medicaid Poor We Serve
bull Numbers are king in a managed care contract and the more access you have
the better contract terms you can negotiate
bull We will potentially have a steady supply of Medicaid patients
bull As managed care spreads states this may be compromising the ability of
health centers to serve the non-Medicaid poor and others lacking dental
insurance
97
Mark Koday DDS
(509) 949-2278
Dental Quality Consultants
of WA
httpdentalqualityconsultin
gcom
dentalqualityconsultantsg
mailcom
Contact Information
LUNCH
BREAKOUT EXERCISEORAL HEALTH VALUE-BASED CARE READINESS ASSESSMENT
Danielle Apostolon
PROMISING PRACTICES FROM THE FIELD STRATEGIES FOR INCREASING VALUE IN ORAL HEALTH
Dr Carolyn Brown
Dr Kelly Perry
Dr Rachel Rivard
Dr Adeloye
Commitment Compassion Community
m i d s t a t e h e a l t h o r g
Promising Practices from the
Field Strategies for Increasing
Value in Oral Health Care
Kelly Perry DMD
Better Health
Outcomes
Improved Staff
Experience
Reduced Cost
Improved Patient
Experience
Better Health
Outcomes
Improved Staff
Experience
Reduced Cost
Improved Patient
Experience
Better Health
Outcomes
Improved Staff
Experience
Reduced Cost
Improved Patient
Experience
Better Health
Outcomes
Improved Staff
Experience
Reduced Cost
Improved Patient
Experience
Commitment Compassion Community
kpe r r ymids t a tehea l t h o rg
Thank you
Completion of Disease Control Phase
Pelumi Adeloye DMD MPH
HEALTH ACCESS NETWORK (HAN) FAMILY DENTAL
Introduction
⧫1 Dentist I Hygienist 3 EFDArsquos1 Receptionist
⧫ 6 Chairs= 4 (dentist) + 2 (hygienist)
⧫ Slide ⥶80 off
⧫ Service areas Northern Penobscot Southern Aroostook Western
Washington Counties amp more
Completion of Phase I Treatment
⧫LimitedLack of Access to dental care
⧫Difficulty completing the disease control phase
Caries amp periodontal disease
⧫Attaining stable restorative state
Goal
Increase the completion of Disease Control Phase
Current practice
⧫Education
Assess level of dental literacy
Incremental strategy
⧫Increase access to dental care
Generous sliding scale (⥸$40 per visit)
Incorporate Expanded Function Dental Assistants
⧫Schedule modification
Incorporate more restorative blocks to allow
for follow-up visit and completion of restorative phase
httpswwwglasbergencomdentist-cartoons
Schedule
⧫Piggybacking technique
Increased allotted restorative blocks
⧫Sustainability of current schedule is
contingent on cooperation amp skills of HAN
Dental staff
Note
Strategies mentioned today is personalized to HAN Dental clinic
Current implemented strategies might be modified or changed in the
future as required in order to accommodate the need of our pts
THANK YOU
DAY TWOCLOSINGWRAP-UP
End of Day Two ndash Survey
Day Two Creating a Value-Based Oral Health Care Delivery
System
129
Payment Reform in Oral Health Online Learning Module
Oral Health Value-based Care Online Learning Module
Value-based Care Keys to Success Article
Readiness Assessment
Competency Development Guide
Oral Health Value-based Care Training
Dental Caries Management Practicum
Clinicians Companion Guide
Interprofessional Network Referral Process
Traditional Dental Care Vs Value-Based Care
Resources
131
wwwDentaQuestPartnershiporg
wwwfacebookcomDentaQuest
DentaQuest
wwwlinkedincomcompanyDentaQuest
Inside_DentaQuest
QUESTIONS
25
Poll What percentage of your adult dental patients are diabetic
or pre-diabetic
A 50-80
B 20-50
C Less than 20
D Not sure
26
27
ldquoTrue Measures of Successrdquo
1 Define your governing objective
2 Develop a theory of cause and effect to assess presumed drivers of the
objective
3 Identify the specific activities that employees can do to help achieve the
governing objective
4 Evaluate your statistics
5 Communicate the story of your measurement
Adapted from HBR ldquoThe True Measures of Successrdquo httpshbrorg201210the-true-measures-of-success
28
1 Governing objective
2 Theory of cause and effect
3 Activities of team
4 Evaluate your statistics
5 Storycraft
Sustainability
Clinic revenuegt expenses= sustainability
Patient compliance Assets Clinic Mngt
Care team Operations Pt Support Billing
Of Prod on and type Patients on time
Daily weekly monthly quarterly
ldquoTrue Measures of Successrdquo
Adapted from HBR ldquoThe True Measures of Successrdquo httpshbrorg201210the-true-measures-of-success
29
Measuring Risk and Health
November is Diabetes Awareness Month- 2019Communication Plans are as
important as cold hard numbers
Patients
Care Team
Other Health Teams
Executive Team
Funders
Data on your dental patients are medical patients of record
Data on your medical + dental patients with DM2
30
Develop Diabetic Patient
Protocols
Review evidence and rationale with dental team
Partner with primary care team
bull Protocols Care mngt Tests and Recording
Quality Goals
Protocols for newly screened and existing patients
Educate and train dental team in reading AND
charting test results and PILOT
31
External Measurement in Oral Health Programs
httpswwwadaorg~mediaADADQA2019_DiabetesOralEvaluationpdfla=en
httpswwworegongovohaHPAANALYTICSCCOMetrics2019-Oral-Evaluation-Adults-Diabetespdf
32
Baseline for 2019 271
httpswwworegongovohaHPAANALYTICSCCOMetrics2019-Oral-Evaluation-Adults-Diabetespdf
33
Diabetes burden in your panel of dental patients
Baseline Medical-Dental Integrated panel of all patients
Dental patients with DM2 MDI
Dental patients with DM2
1000 or 10
600 or 60
300010000= 30
Population Health- Clinic Level
34
1 Governing objective
2 Theory of cause and effect
3 Activities of team
4 Evaluate your statistics
5 Storycraft
Discuss at meetings (Oct + Nov) Health education training
materials NP training CQI Note in Board report Clinical
measures
Care Pathways Hygiene Resources (ScheduleAvail)
ldquoTrue Measures of Successrdquo
Adapted from HBR ldquoThe True Measures of Successrdquo httpshbrorg201210the-true-measures-of-success
Diabetes Awareness Prevention Healthier Community
Prevention Awareness Care Pathway promotes health
MDI= 10 6 out of 10 adult patients with DM2
Goal set for integrated patient panels ndash PCMH
Pre-diabetes approach for executive team
Care Pathways
Care Coordination
35
MEASURING PATIENT ORAL HEALTHRisk assessments and Care Pathways
36
37
Risk Assessment and Care Pathways
Caries Risk Assessment
Multiple tools
EDREHR modules smart notes or dot phrases
CDT Codes
Decide frequency
D0601
Low Caries Risk
D0601
Moderate Caries Risk
D0601
High Caries Risk
38
The Disease Management DifferenceDisease Management Difference
Traditional Dental Care Disease Management
Approach
All patients return in 6 months
regardless of risk status
Recare interval is based on the
childrsquos caries risk
Caries Risk
Level
Recommended
Recare Interval
High Risk 1 ndash 3 months
Moderate Risk 3 ndash 6 months
Low Risk 6 ndash 12 months
Caries
Stabilizing
agents
Health Ed
Nutritional
Counseling
Anti-bacterial
and Fluoride
interventions
39
Disease Management Care Pathways
DentaQuest Partnership for Oral Health Advancement Disease Management Model
Caries
Stabilizing
agents
Whole
Person
Inter-
professional
Approaches
Anti-bacterial
and Fluoride
interventions
40
Disease Management and Risk Screening Training
DentaQuest Partnership for Oral Health Advancementrsquos
Online Learning Center
Disease Management Series
8 modules 40 CDE available
httpswwwdentaquestpartnershiporglearnonline-learning-centeronline-
coursewaredentaquest-disease-management-series
41
MEASUREMENT IN TEAMSSharing meaningful data with your dental clinical teams
42
rdquoDental Homerdquo = Health Home where WE can meet the patient
Oralhealthworkforceorg
43
POLL HOW OFTEN DO YOU SHARE YOUR S WITH YOUR DENTAL TEAM
A Yearly only
B Quarterly
C Monthly
D Weekly
E Daily
44
Clinical Measures ndash Dental Practice Perspective
Private Practice Office
New patients seen
Assigned vs seen if capitated
Treatment plans incomplete
$ produced amp per provider
$ collected amp monthly per provider
CDT 6000 codes completed
RecallHygiene maintenance
Based on this consultants experienced
FQHC
Unduplicated patients
patients seen per day
Treatment plans complete
$ gainedlost via accounting
Broken appointment rate
procedures
Sealant rate (annual)
45
bull HRSA Sealant Measure Compliance for FQHCs
bull Completion of phase 1 treatment plans
bull Children seen 0-5 years old
bull Children seen getting a preventive service
bull Fluoride Varnish applications
bull Pregnant women seen and treated
bull Diabetic patients with HbA1C gt 7 seen
bull Patients seen who have not been seen for 12 months
bull Patients seen getting a Risk Assessment
bull Patients with moderate or high risk who lower risk at recare
bull Sealants provided httpwwwnnohaorgnnoha-contentuploads201512Demystifying-HRSA-SEALANT-PRESENTATION_FINALpdf
Program Measures
46
HRSA Performance Measurement and Data Collection
bull FQHCs and look-alikes submit CY data to HRSA since 2008
bull UDS Uniform Data System
bull Require FTE for clinical staff patient demographics
bull Dental utilization s (UDCTPV)
bull Dental Clinical Measure dental sealants placed on 1st molars ages 6-9 yo
bull Health Center Quartile rankings (Clinical measure performance influences
HC rankings as does EHR adoption and other HC characteristics)
47
Low birth weight
Access to prenatal care
Childhood Immunization
Children (Ages 3-17) Receiving
Weight Assessment amp
Counseling
Children (Age 6-9) Receiving
Dental Sealant to First Molars
Diabetes Control
Hypertension Control
Pap Test
Depression Screening and
Follow-up (Age 12+)
Asthma Patients (Age 5-40)
Receiving Pharmacologic
Therapy
Colorectal Cancer
Screening (Ages 51-74)
HRSA UDS Clinical Measures
Adults (Age 18+) Receiving
Weight Screening amp Follow-up
Adults (Age 18+) Receiving
Tobacco Use Assessment and
Cessation Intervention
Coronary Artery Disease
Receiving Lipid Therapy (18+)
Ischemic Vascular Disease (IVD)
Receiving Aspirin Therapy (18+)
HIV Linkage to Care
48
Dashboards
Grants
Average
amp
Targets
Quality
Rev
Costs
Visits
Priority
Pop
Prevention
49
Dashboard- Provider Team Level
Patient
Compliance
Satisfaction
50
Case Study-
Incentives bonus round pools benchmark and improvement target goals risk-sharing possible later years
51
Qualitative Measurement
ldquoPatient engagement is the act of patients and providers working together
toward the end goal of improved patient wellnessrdquo
wwwpatientengagementhitcom
Access to Care
Patient Activation
Patient Satisfaction
Patient-Provider-Care Team Communication
Care Team Satisfaction
52
OHVBC Readiness
Leadership
bull Value of oral health and oral health transformation
Structure Systems and Operations
bull Operational efficiencies innovative care delivery methodologies
Care Pathways and Provider Buy-In
bull Training disease management risk-based care referrals IDC-10 coding patient engagement
Data and Analytic Technology and Personnel
bull Interoperability reporting
Financial Viability and Strength
bull Payerpatient mix billing infrastructure financial reports
httpswwwdentaquestpartnershiporglearnsafety-net-solutionsoral-health-value-based-careohvbc-readiness-
assessment
53
QUESTIONS COMMENTS
Carolyn Brown DDS
cbrownddsgmailcom
RISK BASED MANAGED CARE
Value Based Training Conference
Manchester New Hampshire
Mark Koday DDS
111919
5555
Objectives
bull Review current drivers of dental managed care
bull Understand the basics of risk-based dental managed care contracts
bull Learn the basics of managing costs in a riskndashbased contract
bull Gain an understanding in the potential advantage of risk-based contracting
56
What Is Dental Managed Care
Managed care is a health delivery system whose purpose is to manage both the
quality and cost of health care
Common types of managed care health insurance plans
bull HMOs
bull PPOs
bull POSs
bull Medicaid Managed Care
DIDNrsquoT WE ALREADY HAVE MANAGED CARE AND IT FAILED
57
What Has Happened Since the 90s
58
WHY THE FFS AND PPS DOESNrsquoT WORK FOR OUR POPULATIONS
bull Inefficient payment systems designed to produce encounters or procedures but not real health
bull No focus on population health
bull Does not incentivize innovation
bull Patients essentially on their own for accessing specialty care
59
Rule of 4
Source Kaiser Family Foundation analysis of National Health Expenditure (NHE) data from Centers for
Medicare and Medicaid Services Office of the Actuary National Health Statistics Group
60
Rule of 4
bull This helps explain why oral health has been relatively ignored so far by CMS
bull Explains why we have PCMH instead of PCHH
bull Where is the real value on a national level in preventing disease and
controlling costs
bull Beware- wersquove been found
61
Reasons Dental Managed Care is Spreading Across the States
NON-MANAGED CARE STATE DENTAL BUDGETS ARE
OPENED ENDED
STRAIN ON STATE BUDGETS
UPCOMING RECESSION WITH TRILLION DOLLAR
DEFICIT
SHIFTS FINANCIAL RISK FROM THE STATES TO THE
PLANS
6262
Types of Medicaid Managed Care
bull State Medicaid agency administrator lowest administrative
costs
bull Third Party Administrator Typically 15 administrative costs
bull Managed Care Organization Typically 15 administrative
costs
bull Carved-in
bull Carved-out
bull Risk Based Managed Care Administrative costs part of
contract negotiation
63
RISK CONTRACTS
6464
Components of a Risk-based Contract
Risk
Medical Loss Ratio
Quality withhold
Specialty withhold
Managed care payment (pmpm)
Covered services
Fee schedule Claims are paid as usual on a FFS basis
Credentialing
Quality Review process and Quality Metrics
65
Upside Risk
The possibility that the cost of
delivering dental care to an assigned
patient panel is less than the amount
of funding calculated for that care
The Plan pays the CHC additional
funds based on a predetermine
formula
Downside Risk
The possibility that the cost of
delivering dental care to an assigned
patient panel is more than the amount
of funding calculated for that care
The CHC pays the Plan additional
funds based on a predetermine
formula
Upside and Downside Risk
66
Taking On Risk 100 or Shared Risk
With 100 risk you receive 100 of the potential savings but are also at risk for
100 of the losses
Shared Risk MCO and health center share a percentage of the risk
Shared Risk leads to better cooperation since both organizations are
incentivized to save on costs
6767
Reports Needed
bull Enrollment reports lists of who is assigned on a monthly basis
bull Reconciliation reports insure appropriate payments
bull Specialty Referral reports
bull You will need your own reporting process so you donrsquot rely completely on
reports supplied by the Plan
6868
Medical Loss Ratio
Medical Loss Ratio (MLR) is proportion of premium revenues spent on clinical
services and quality improvement also known as the Medical Loss Ratio (MLR)
For CMS requires Medical Plans to spend at least 80 to 85 of the premiums
on actual medical care
69
Administrative Fees
bull Essentially the opposite of MLR
bull The State Medicaid Agency is funded by the Governorrsquos budget
bull The State Medicaid Agency will keep some of these funds for their
admin costs and give the remaining to the Managed Care Plans
bull Private Plan admin costs can be as high as 40 but most states
limit these cost for Medicaid Plans to between 15 and 20 (85-
80 MLR)
bull This may be negotiable depending on your program size of your
program
70
Quality Withhold
bull The state withholds a certain percent (typically 2-4 ) of the funds they give
to the Plans for Value Based Reimbursement
bull They choose quality metrics and set benchmarks and assign payments for
each metric based on an assigned priority for each metric
bull If a Plan meets the benchmark of every quality metric the state passes on
their full share of the quality withhold
bull The Plans may or may not withhold a percent of the funds for quality payment
to the dentists or manage care contractors
71
Quality Withhold
Either way the Plans may or may not pass the quality payments they receive to
the dentists or contractors
This should be spelled out in a risk-based contract
72
Percent of funds set aside
to cover specialty care
referrals
Typically 10-15
Goal Limit referral costs
to within or less than
Specialty set aside
Specialty Withhold
73
Per Member Per Month
bull Capitated Payment
bull Specific dollar amount paid for each enrolled member each month
bull Paid whether patient is accessed for care or not
bull States do set access benchmarks
bull In Oregon access for any dental procedure (adults and children combined)
was 267 in 2015
74
Payment Math Example
Premium per enrollee = $25
Administrative fee 15 = $375
Funds available per enrollee to the clinic = $2125
Management fee per enrollee = $175
Funds per enrollee that would undergo PPS reconciliation = $1950
For every 10000 enrollees the managed care income = $2340000
Specialty withhold (10) = $234000
YE Cost lt or gt $2340000
Upside Risk
CHC Gains $
Downside Risk
CHC Loses $
75
Covered Services and Fee Schedules
bull The state Medicaid agency spells out the minimum procedures and fees that
MCOs must cover
bull MCOs may add procedures or increase periodicity of procedures particularly
preventative services
bull MCOs may increase fees to entice rural providers and specialists to enroll in
their Plans
bull Access Rules
bull How many days it takes to access a patent
bull How many days it takes for a patent to access urgent care services
bull How many days it takes for a patent to access emergency care services
76
Credentialing
All MCOs are required to credential all Providers
All MCOs have their own credentialing process
Credentialing process is can be lengthy
Credentialing process may be negotiable
77
Quality Review Process and Quality Metrics
MCOs must have a Quality and Compliance Review Process
If you arenrsquot in compliance with both you likely wonrsquot get paid
Typical processes reviewed
bull Charting specifications
bull Incident report
bull Enrollee complaints quality rudeness and access issues
bull Medicaid compliance
78
Quality Payments
bull State Shared Incentive Withhold Typically quality metrics and benchmarks
are set by the state sets aside a certain percent (3-5) of the payments to
the Managed Care Plan (MCP)
bull If the benchmarks are achieved the MCP is then paid the a predetermine
amount
bull Benchmarks may not be the same as the states
bull Managed Care Plans do not have to pass all or any of the quality payments to
the health centers or providers
bull Managed Care contract- Metrics benchmarks should be selected and part of
the contract
7979
Achieving Quality Metric Payments
Dealing with under achievers
Process issues
Individual issues
Identifying workflows
Developing Best Practices through
PDSA process
Developing Best Practices through
PDSA process
CHC Metrics Committee
Clinicians Operations various key staff
Identify Best Practices
Spread Best Practices
80
New Team Needed Business Intelligence
Business Intelligence (BI) is critical for effective managed care business decisions
BI team inputs metrics into your EHR collects integrates analyses and displays all your managed care business and clinical information
Easy to say- hard to achieve
Build your own or outsource
Possible future role of Primary Care Associations
8181
Clinicianrsquos Dashboard
Expensive to build
Displayed on your screen when your computer is first turned on
Easy to read and understand
Data dumped from the day before
Can dialed down from Org-wide to clinic to each clinicianrsquos data
Operational and clinical metrics
bull Treatment Plan Completion
bull DQA quality measures
bull Caries at Recall
bull Re-care reports
bull Care Gap reports
82
CONTROLLING COSTS
8383
Controlling Costs- Current
bull Increasing efficiencies
bull Decreasing broken appointments
bull Controlling supplies equipment costs
bull Staff recruitment retention costs
84
Specialty Care
Training current CHC dentists in
specialty areas
Hiring general dentists with higher
specialty skill sets
Hiring in house specialists
Contract with outside specialists
Work with Managed Care Plan
specialists
Lowering Disease Rates
Community Dental Health
Coordinators case management
If your state law allows- embed
hygienists in medical and community
to provide primary and secondary
prevention procedures
In clinic Caries Classification and
Silver Diamine Fluoride
Effective recare programs
Controlling Costs- Additions in Risk-based Contracting
85
Specialty Care ndash Primary Referrals by Cost
Pediatric dentistry
Orthodontics
Oral surgery
Endodontics
86
In-clinic Pediatric Services
Encounters expected
of operatories available
State dental law and ability to have
expanded duties
General Anesthesia
GA in- house
Ability for a hospital or surgery center
to set aside regular OR time
Ability to hire or assign DAs to GA
days
Four GA cases day x PPS rate
Should You Hire a Pediatric Dentist- It Depends
8787
Solutions for Controlling Pediatric Costs
Hire a general dentist that is skilled in treating young children
Make the clinic child friendly nitrous oxide TVs in the operatory etc
Teach entire staff behavioral control techniques
Contract with a pediatric dentist for the GA care
88
Lowering Overall Disease Rates (and Costs)
You are responsible for both the patients you see in the chair and the ones
assigned to you
Breaking down the walls of the dental clinic
Community Dental Health Coordinators
Case Management
89
Cost Control Essentials
Diagnosis codes
Increased ability to identify
disease by risk
Motivational
Interviewing
Developing Polices and
Procedures design to treat
disease according to risk
ie Silver Diamine Fluoride
Treating by Risk
Effective Recare
Process
Critical to continual disease
controlPrevention education that is
meaningful and designed to
change behaviors
90
Social Determinants of Health Aunt Bertha
httpswwwauntberthacom
91
REASON TO CONSIDER RISK- BASED CONTRACTING
9292
PPS Reconciliation and Federal Code 42 CFR sect4052469(a)(2)
42 CFR sect4052469(a)(2)
ldquoAny financial incentives provided to Federally Qualified Health Centers
under their Medicare Advantage Contracts such as risk pool payments
bonuses or withholds are prohibited from being included in the
calculation of supplemental payments due to the Federally Qualified
Health Centerrdquo
9393
Why Risk Based Contract in Times of PPS Reconciliation
bull Not all Risk- based Contract funds are reconciled
bull Risk is the key word- you can come out with less money than your normal
PPS reconciliation payment
bull Can lead to better patient care
bull May improve manage care enrollment for your medical plan
bull Promotes integrated care increases health for your CHC patients
9494
Not Included in the Reconciliation
Enrollment management pmpm
Quality Payments
Upside risk payments
Downside risk losses
9595
Determinants of Financial Success in Risk-Based Contracting
bull Most critical- State pmpm payment to the Managed Care Plan
bull Reporting capabilities
bull Specialty service capabilities
bull Access numbers count
bull Ability to move metric numbers
9696
What About the Non- Medicaid Poor We Serve
bull Numbers are king in a managed care contract and the more access you have
the better contract terms you can negotiate
bull We will potentially have a steady supply of Medicaid patients
bull As managed care spreads states this may be compromising the ability of
health centers to serve the non-Medicaid poor and others lacking dental
insurance
97
Mark Koday DDS
(509) 949-2278
Dental Quality Consultants
of WA
httpdentalqualityconsultin
gcom
dentalqualityconsultantsg
mailcom
Contact Information
LUNCH
BREAKOUT EXERCISEORAL HEALTH VALUE-BASED CARE READINESS ASSESSMENT
Danielle Apostolon
PROMISING PRACTICES FROM THE FIELD STRATEGIES FOR INCREASING VALUE IN ORAL HEALTH
Dr Carolyn Brown
Dr Kelly Perry
Dr Rachel Rivard
Dr Adeloye
Commitment Compassion Community
m i d s t a t e h e a l t h o r g
Promising Practices from the
Field Strategies for Increasing
Value in Oral Health Care
Kelly Perry DMD
Better Health
Outcomes
Improved Staff
Experience
Reduced Cost
Improved Patient
Experience
Better Health
Outcomes
Improved Staff
Experience
Reduced Cost
Improved Patient
Experience
Better Health
Outcomes
Improved Staff
Experience
Reduced Cost
Improved Patient
Experience
Better Health
Outcomes
Improved Staff
Experience
Reduced Cost
Improved Patient
Experience
Commitment Compassion Community
kpe r r ymids t a tehea l t h o rg
Thank you
Completion of Disease Control Phase
Pelumi Adeloye DMD MPH
HEALTH ACCESS NETWORK (HAN) FAMILY DENTAL
Introduction
⧫1 Dentist I Hygienist 3 EFDArsquos1 Receptionist
⧫ 6 Chairs= 4 (dentist) + 2 (hygienist)
⧫ Slide ⥶80 off
⧫ Service areas Northern Penobscot Southern Aroostook Western
Washington Counties amp more
Completion of Phase I Treatment
⧫LimitedLack of Access to dental care
⧫Difficulty completing the disease control phase
Caries amp periodontal disease
⧫Attaining stable restorative state
Goal
Increase the completion of Disease Control Phase
Current practice
⧫Education
Assess level of dental literacy
Incremental strategy
⧫Increase access to dental care
Generous sliding scale (⥸$40 per visit)
Incorporate Expanded Function Dental Assistants
⧫Schedule modification
Incorporate more restorative blocks to allow
for follow-up visit and completion of restorative phase
httpswwwglasbergencomdentist-cartoons
Schedule
⧫Piggybacking technique
Increased allotted restorative blocks
⧫Sustainability of current schedule is
contingent on cooperation amp skills of HAN
Dental staff
Note
Strategies mentioned today is personalized to HAN Dental clinic
Current implemented strategies might be modified or changed in the
future as required in order to accommodate the need of our pts
THANK YOU
DAY TWOCLOSINGWRAP-UP
End of Day Two ndash Survey
Day Two Creating a Value-Based Oral Health Care Delivery
System
129
Payment Reform in Oral Health Online Learning Module
Oral Health Value-based Care Online Learning Module
Value-based Care Keys to Success Article
Readiness Assessment
Competency Development Guide
Oral Health Value-based Care Training
Dental Caries Management Practicum
Clinicians Companion Guide
Interprofessional Network Referral Process
Traditional Dental Care Vs Value-Based Care
Resources
131
wwwDentaQuestPartnershiporg
wwwfacebookcomDentaQuest
DentaQuest
wwwlinkedincomcompanyDentaQuest
Inside_DentaQuest
QUESTIONS
26
27
ldquoTrue Measures of Successrdquo
1 Define your governing objective
2 Develop a theory of cause and effect to assess presumed drivers of the
objective
3 Identify the specific activities that employees can do to help achieve the
governing objective
4 Evaluate your statistics
5 Communicate the story of your measurement
Adapted from HBR ldquoThe True Measures of Successrdquo httpshbrorg201210the-true-measures-of-success
28
1 Governing objective
2 Theory of cause and effect
3 Activities of team
4 Evaluate your statistics
5 Storycraft
Sustainability
Clinic revenuegt expenses= sustainability
Patient compliance Assets Clinic Mngt
Care team Operations Pt Support Billing
Of Prod on and type Patients on time
Daily weekly monthly quarterly
ldquoTrue Measures of Successrdquo
Adapted from HBR ldquoThe True Measures of Successrdquo httpshbrorg201210the-true-measures-of-success
29
Measuring Risk and Health
November is Diabetes Awareness Month- 2019Communication Plans are as
important as cold hard numbers
Patients
Care Team
Other Health Teams
Executive Team
Funders
Data on your dental patients are medical patients of record
Data on your medical + dental patients with DM2
30
Develop Diabetic Patient
Protocols
Review evidence and rationale with dental team
Partner with primary care team
bull Protocols Care mngt Tests and Recording
Quality Goals
Protocols for newly screened and existing patients
Educate and train dental team in reading AND
charting test results and PILOT
31
External Measurement in Oral Health Programs
httpswwwadaorg~mediaADADQA2019_DiabetesOralEvaluationpdfla=en
httpswwworegongovohaHPAANALYTICSCCOMetrics2019-Oral-Evaluation-Adults-Diabetespdf
32
Baseline for 2019 271
httpswwworegongovohaHPAANALYTICSCCOMetrics2019-Oral-Evaluation-Adults-Diabetespdf
33
Diabetes burden in your panel of dental patients
Baseline Medical-Dental Integrated panel of all patients
Dental patients with DM2 MDI
Dental patients with DM2
1000 or 10
600 or 60
300010000= 30
Population Health- Clinic Level
34
1 Governing objective
2 Theory of cause and effect
3 Activities of team
4 Evaluate your statistics
5 Storycraft
Discuss at meetings (Oct + Nov) Health education training
materials NP training CQI Note in Board report Clinical
measures
Care Pathways Hygiene Resources (ScheduleAvail)
ldquoTrue Measures of Successrdquo
Adapted from HBR ldquoThe True Measures of Successrdquo httpshbrorg201210the-true-measures-of-success
Diabetes Awareness Prevention Healthier Community
Prevention Awareness Care Pathway promotes health
MDI= 10 6 out of 10 adult patients with DM2
Goal set for integrated patient panels ndash PCMH
Pre-diabetes approach for executive team
Care Pathways
Care Coordination
35
MEASURING PATIENT ORAL HEALTHRisk assessments and Care Pathways
36
37
Risk Assessment and Care Pathways
Caries Risk Assessment
Multiple tools
EDREHR modules smart notes or dot phrases
CDT Codes
Decide frequency
D0601
Low Caries Risk
D0601
Moderate Caries Risk
D0601
High Caries Risk
38
The Disease Management DifferenceDisease Management Difference
Traditional Dental Care Disease Management
Approach
All patients return in 6 months
regardless of risk status
Recare interval is based on the
childrsquos caries risk
Caries Risk
Level
Recommended
Recare Interval
High Risk 1 ndash 3 months
Moderate Risk 3 ndash 6 months
Low Risk 6 ndash 12 months
Caries
Stabilizing
agents
Health Ed
Nutritional
Counseling
Anti-bacterial
and Fluoride
interventions
39
Disease Management Care Pathways
DentaQuest Partnership for Oral Health Advancement Disease Management Model
Caries
Stabilizing
agents
Whole
Person
Inter-
professional
Approaches
Anti-bacterial
and Fluoride
interventions
40
Disease Management and Risk Screening Training
DentaQuest Partnership for Oral Health Advancementrsquos
Online Learning Center
Disease Management Series
8 modules 40 CDE available
httpswwwdentaquestpartnershiporglearnonline-learning-centeronline-
coursewaredentaquest-disease-management-series
41
MEASUREMENT IN TEAMSSharing meaningful data with your dental clinical teams
42
rdquoDental Homerdquo = Health Home where WE can meet the patient
Oralhealthworkforceorg
43
POLL HOW OFTEN DO YOU SHARE YOUR S WITH YOUR DENTAL TEAM
A Yearly only
B Quarterly
C Monthly
D Weekly
E Daily
44
Clinical Measures ndash Dental Practice Perspective
Private Practice Office
New patients seen
Assigned vs seen if capitated
Treatment plans incomplete
$ produced amp per provider
$ collected amp monthly per provider
CDT 6000 codes completed
RecallHygiene maintenance
Based on this consultants experienced
FQHC
Unduplicated patients
patients seen per day
Treatment plans complete
$ gainedlost via accounting
Broken appointment rate
procedures
Sealant rate (annual)
45
bull HRSA Sealant Measure Compliance for FQHCs
bull Completion of phase 1 treatment plans
bull Children seen 0-5 years old
bull Children seen getting a preventive service
bull Fluoride Varnish applications
bull Pregnant women seen and treated
bull Diabetic patients with HbA1C gt 7 seen
bull Patients seen who have not been seen for 12 months
bull Patients seen getting a Risk Assessment
bull Patients with moderate or high risk who lower risk at recare
bull Sealants provided httpwwwnnohaorgnnoha-contentuploads201512Demystifying-HRSA-SEALANT-PRESENTATION_FINALpdf
Program Measures
46
HRSA Performance Measurement and Data Collection
bull FQHCs and look-alikes submit CY data to HRSA since 2008
bull UDS Uniform Data System
bull Require FTE for clinical staff patient demographics
bull Dental utilization s (UDCTPV)
bull Dental Clinical Measure dental sealants placed on 1st molars ages 6-9 yo
bull Health Center Quartile rankings (Clinical measure performance influences
HC rankings as does EHR adoption and other HC characteristics)
47
Low birth weight
Access to prenatal care
Childhood Immunization
Children (Ages 3-17) Receiving
Weight Assessment amp
Counseling
Children (Age 6-9) Receiving
Dental Sealant to First Molars
Diabetes Control
Hypertension Control
Pap Test
Depression Screening and
Follow-up (Age 12+)
Asthma Patients (Age 5-40)
Receiving Pharmacologic
Therapy
Colorectal Cancer
Screening (Ages 51-74)
HRSA UDS Clinical Measures
Adults (Age 18+) Receiving
Weight Screening amp Follow-up
Adults (Age 18+) Receiving
Tobacco Use Assessment and
Cessation Intervention
Coronary Artery Disease
Receiving Lipid Therapy (18+)
Ischemic Vascular Disease (IVD)
Receiving Aspirin Therapy (18+)
HIV Linkage to Care
48
Dashboards
Grants
Average
amp
Targets
Quality
Rev
Costs
Visits
Priority
Pop
Prevention
49
Dashboard- Provider Team Level
Patient
Compliance
Satisfaction
50
Case Study-
Incentives bonus round pools benchmark and improvement target goals risk-sharing possible later years
51
Qualitative Measurement
ldquoPatient engagement is the act of patients and providers working together
toward the end goal of improved patient wellnessrdquo
wwwpatientengagementhitcom
Access to Care
Patient Activation
Patient Satisfaction
Patient-Provider-Care Team Communication
Care Team Satisfaction
52
OHVBC Readiness
Leadership
bull Value of oral health and oral health transformation
Structure Systems and Operations
bull Operational efficiencies innovative care delivery methodologies
Care Pathways and Provider Buy-In
bull Training disease management risk-based care referrals IDC-10 coding patient engagement
Data and Analytic Technology and Personnel
bull Interoperability reporting
Financial Viability and Strength
bull Payerpatient mix billing infrastructure financial reports
httpswwwdentaquestpartnershiporglearnsafety-net-solutionsoral-health-value-based-careohvbc-readiness-
assessment
53
QUESTIONS COMMENTS
Carolyn Brown DDS
cbrownddsgmailcom
RISK BASED MANAGED CARE
Value Based Training Conference
Manchester New Hampshire
Mark Koday DDS
111919
5555
Objectives
bull Review current drivers of dental managed care
bull Understand the basics of risk-based dental managed care contracts
bull Learn the basics of managing costs in a riskndashbased contract
bull Gain an understanding in the potential advantage of risk-based contracting
56
What Is Dental Managed Care
Managed care is a health delivery system whose purpose is to manage both the
quality and cost of health care
Common types of managed care health insurance plans
bull HMOs
bull PPOs
bull POSs
bull Medicaid Managed Care
DIDNrsquoT WE ALREADY HAVE MANAGED CARE AND IT FAILED
57
What Has Happened Since the 90s
58
WHY THE FFS AND PPS DOESNrsquoT WORK FOR OUR POPULATIONS
bull Inefficient payment systems designed to produce encounters or procedures but not real health
bull No focus on population health
bull Does not incentivize innovation
bull Patients essentially on their own for accessing specialty care
59
Rule of 4
Source Kaiser Family Foundation analysis of National Health Expenditure (NHE) data from Centers for
Medicare and Medicaid Services Office of the Actuary National Health Statistics Group
60
Rule of 4
bull This helps explain why oral health has been relatively ignored so far by CMS
bull Explains why we have PCMH instead of PCHH
bull Where is the real value on a national level in preventing disease and
controlling costs
bull Beware- wersquove been found
61
Reasons Dental Managed Care is Spreading Across the States
NON-MANAGED CARE STATE DENTAL BUDGETS ARE
OPENED ENDED
STRAIN ON STATE BUDGETS
UPCOMING RECESSION WITH TRILLION DOLLAR
DEFICIT
SHIFTS FINANCIAL RISK FROM THE STATES TO THE
PLANS
6262
Types of Medicaid Managed Care
bull State Medicaid agency administrator lowest administrative
costs
bull Third Party Administrator Typically 15 administrative costs
bull Managed Care Organization Typically 15 administrative
costs
bull Carved-in
bull Carved-out
bull Risk Based Managed Care Administrative costs part of
contract negotiation
63
RISK CONTRACTS
6464
Components of a Risk-based Contract
Risk
Medical Loss Ratio
Quality withhold
Specialty withhold
Managed care payment (pmpm)
Covered services
Fee schedule Claims are paid as usual on a FFS basis
Credentialing
Quality Review process and Quality Metrics
65
Upside Risk
The possibility that the cost of
delivering dental care to an assigned
patient panel is less than the amount
of funding calculated for that care
The Plan pays the CHC additional
funds based on a predetermine
formula
Downside Risk
The possibility that the cost of
delivering dental care to an assigned
patient panel is more than the amount
of funding calculated for that care
The CHC pays the Plan additional
funds based on a predetermine
formula
Upside and Downside Risk
66
Taking On Risk 100 or Shared Risk
With 100 risk you receive 100 of the potential savings but are also at risk for
100 of the losses
Shared Risk MCO and health center share a percentage of the risk
Shared Risk leads to better cooperation since both organizations are
incentivized to save on costs
6767
Reports Needed
bull Enrollment reports lists of who is assigned on a monthly basis
bull Reconciliation reports insure appropriate payments
bull Specialty Referral reports
bull You will need your own reporting process so you donrsquot rely completely on
reports supplied by the Plan
6868
Medical Loss Ratio
Medical Loss Ratio (MLR) is proportion of premium revenues spent on clinical
services and quality improvement also known as the Medical Loss Ratio (MLR)
For CMS requires Medical Plans to spend at least 80 to 85 of the premiums
on actual medical care
69
Administrative Fees
bull Essentially the opposite of MLR
bull The State Medicaid Agency is funded by the Governorrsquos budget
bull The State Medicaid Agency will keep some of these funds for their
admin costs and give the remaining to the Managed Care Plans
bull Private Plan admin costs can be as high as 40 but most states
limit these cost for Medicaid Plans to between 15 and 20 (85-
80 MLR)
bull This may be negotiable depending on your program size of your
program
70
Quality Withhold
bull The state withholds a certain percent (typically 2-4 ) of the funds they give
to the Plans for Value Based Reimbursement
bull They choose quality metrics and set benchmarks and assign payments for
each metric based on an assigned priority for each metric
bull If a Plan meets the benchmark of every quality metric the state passes on
their full share of the quality withhold
bull The Plans may or may not withhold a percent of the funds for quality payment
to the dentists or manage care contractors
71
Quality Withhold
Either way the Plans may or may not pass the quality payments they receive to
the dentists or contractors
This should be spelled out in a risk-based contract
72
Percent of funds set aside
to cover specialty care
referrals
Typically 10-15
Goal Limit referral costs
to within or less than
Specialty set aside
Specialty Withhold
73
Per Member Per Month
bull Capitated Payment
bull Specific dollar amount paid for each enrolled member each month
bull Paid whether patient is accessed for care or not
bull States do set access benchmarks
bull In Oregon access for any dental procedure (adults and children combined)
was 267 in 2015
74
Payment Math Example
Premium per enrollee = $25
Administrative fee 15 = $375
Funds available per enrollee to the clinic = $2125
Management fee per enrollee = $175
Funds per enrollee that would undergo PPS reconciliation = $1950
For every 10000 enrollees the managed care income = $2340000
Specialty withhold (10) = $234000
YE Cost lt or gt $2340000
Upside Risk
CHC Gains $
Downside Risk
CHC Loses $
75
Covered Services and Fee Schedules
bull The state Medicaid agency spells out the minimum procedures and fees that
MCOs must cover
bull MCOs may add procedures or increase periodicity of procedures particularly
preventative services
bull MCOs may increase fees to entice rural providers and specialists to enroll in
their Plans
bull Access Rules
bull How many days it takes to access a patent
bull How many days it takes for a patent to access urgent care services
bull How many days it takes for a patent to access emergency care services
76
Credentialing
All MCOs are required to credential all Providers
All MCOs have their own credentialing process
Credentialing process is can be lengthy
Credentialing process may be negotiable
77
Quality Review Process and Quality Metrics
MCOs must have a Quality and Compliance Review Process
If you arenrsquot in compliance with both you likely wonrsquot get paid
Typical processes reviewed
bull Charting specifications
bull Incident report
bull Enrollee complaints quality rudeness and access issues
bull Medicaid compliance
78
Quality Payments
bull State Shared Incentive Withhold Typically quality metrics and benchmarks
are set by the state sets aside a certain percent (3-5) of the payments to
the Managed Care Plan (MCP)
bull If the benchmarks are achieved the MCP is then paid the a predetermine
amount
bull Benchmarks may not be the same as the states
bull Managed Care Plans do not have to pass all or any of the quality payments to
the health centers or providers
bull Managed Care contract- Metrics benchmarks should be selected and part of
the contract
7979
Achieving Quality Metric Payments
Dealing with under achievers
Process issues
Individual issues
Identifying workflows
Developing Best Practices through
PDSA process
Developing Best Practices through
PDSA process
CHC Metrics Committee
Clinicians Operations various key staff
Identify Best Practices
Spread Best Practices
80
New Team Needed Business Intelligence
Business Intelligence (BI) is critical for effective managed care business decisions
BI team inputs metrics into your EHR collects integrates analyses and displays all your managed care business and clinical information
Easy to say- hard to achieve
Build your own or outsource
Possible future role of Primary Care Associations
8181
Clinicianrsquos Dashboard
Expensive to build
Displayed on your screen when your computer is first turned on
Easy to read and understand
Data dumped from the day before
Can dialed down from Org-wide to clinic to each clinicianrsquos data
Operational and clinical metrics
bull Treatment Plan Completion
bull DQA quality measures
bull Caries at Recall
bull Re-care reports
bull Care Gap reports
82
CONTROLLING COSTS
8383
Controlling Costs- Current
bull Increasing efficiencies
bull Decreasing broken appointments
bull Controlling supplies equipment costs
bull Staff recruitment retention costs
84
Specialty Care
Training current CHC dentists in
specialty areas
Hiring general dentists with higher
specialty skill sets
Hiring in house specialists
Contract with outside specialists
Work with Managed Care Plan
specialists
Lowering Disease Rates
Community Dental Health
Coordinators case management
If your state law allows- embed
hygienists in medical and community
to provide primary and secondary
prevention procedures
In clinic Caries Classification and
Silver Diamine Fluoride
Effective recare programs
Controlling Costs- Additions in Risk-based Contracting
85
Specialty Care ndash Primary Referrals by Cost
Pediatric dentistry
Orthodontics
Oral surgery
Endodontics
86
In-clinic Pediatric Services
Encounters expected
of operatories available
State dental law and ability to have
expanded duties
General Anesthesia
GA in- house
Ability for a hospital or surgery center
to set aside regular OR time
Ability to hire or assign DAs to GA
days
Four GA cases day x PPS rate
Should You Hire a Pediatric Dentist- It Depends
8787
Solutions for Controlling Pediatric Costs
Hire a general dentist that is skilled in treating young children
Make the clinic child friendly nitrous oxide TVs in the operatory etc
Teach entire staff behavioral control techniques
Contract with a pediatric dentist for the GA care
88
Lowering Overall Disease Rates (and Costs)
You are responsible for both the patients you see in the chair and the ones
assigned to you
Breaking down the walls of the dental clinic
Community Dental Health Coordinators
Case Management
89
Cost Control Essentials
Diagnosis codes
Increased ability to identify
disease by risk
Motivational
Interviewing
Developing Polices and
Procedures design to treat
disease according to risk
ie Silver Diamine Fluoride
Treating by Risk
Effective Recare
Process
Critical to continual disease
controlPrevention education that is
meaningful and designed to
change behaviors
90
Social Determinants of Health Aunt Bertha
httpswwwauntberthacom
91
REASON TO CONSIDER RISK- BASED CONTRACTING
9292
PPS Reconciliation and Federal Code 42 CFR sect4052469(a)(2)
42 CFR sect4052469(a)(2)
ldquoAny financial incentives provided to Federally Qualified Health Centers
under their Medicare Advantage Contracts such as risk pool payments
bonuses or withholds are prohibited from being included in the
calculation of supplemental payments due to the Federally Qualified
Health Centerrdquo
9393
Why Risk Based Contract in Times of PPS Reconciliation
bull Not all Risk- based Contract funds are reconciled
bull Risk is the key word- you can come out with less money than your normal
PPS reconciliation payment
bull Can lead to better patient care
bull May improve manage care enrollment for your medical plan
bull Promotes integrated care increases health for your CHC patients
9494
Not Included in the Reconciliation
Enrollment management pmpm
Quality Payments
Upside risk payments
Downside risk losses
9595
Determinants of Financial Success in Risk-Based Contracting
bull Most critical- State pmpm payment to the Managed Care Plan
bull Reporting capabilities
bull Specialty service capabilities
bull Access numbers count
bull Ability to move metric numbers
9696
What About the Non- Medicaid Poor We Serve
bull Numbers are king in a managed care contract and the more access you have
the better contract terms you can negotiate
bull We will potentially have a steady supply of Medicaid patients
bull As managed care spreads states this may be compromising the ability of
health centers to serve the non-Medicaid poor and others lacking dental
insurance
97
Mark Koday DDS
(509) 949-2278
Dental Quality Consultants
of WA
httpdentalqualityconsultin
gcom
dentalqualityconsultantsg
mailcom
Contact Information
LUNCH
BREAKOUT EXERCISEORAL HEALTH VALUE-BASED CARE READINESS ASSESSMENT
Danielle Apostolon
PROMISING PRACTICES FROM THE FIELD STRATEGIES FOR INCREASING VALUE IN ORAL HEALTH
Dr Carolyn Brown
Dr Kelly Perry
Dr Rachel Rivard
Dr Adeloye
Commitment Compassion Community
m i d s t a t e h e a l t h o r g
Promising Practices from the
Field Strategies for Increasing
Value in Oral Health Care
Kelly Perry DMD
Better Health
Outcomes
Improved Staff
Experience
Reduced Cost
Improved Patient
Experience
Better Health
Outcomes
Improved Staff
Experience
Reduced Cost
Improved Patient
Experience
Better Health
Outcomes
Improved Staff
Experience
Reduced Cost
Improved Patient
Experience
Better Health
Outcomes
Improved Staff
Experience
Reduced Cost
Improved Patient
Experience
Commitment Compassion Community
kpe r r ymids t a tehea l t h o rg
Thank you
Completion of Disease Control Phase
Pelumi Adeloye DMD MPH
HEALTH ACCESS NETWORK (HAN) FAMILY DENTAL
Introduction
⧫1 Dentist I Hygienist 3 EFDArsquos1 Receptionist
⧫ 6 Chairs= 4 (dentist) + 2 (hygienist)
⧫ Slide ⥶80 off
⧫ Service areas Northern Penobscot Southern Aroostook Western
Washington Counties amp more
Completion of Phase I Treatment
⧫LimitedLack of Access to dental care
⧫Difficulty completing the disease control phase
Caries amp periodontal disease
⧫Attaining stable restorative state
Goal
Increase the completion of Disease Control Phase
Current practice
⧫Education
Assess level of dental literacy
Incremental strategy
⧫Increase access to dental care
Generous sliding scale (⥸$40 per visit)
Incorporate Expanded Function Dental Assistants
⧫Schedule modification
Incorporate more restorative blocks to allow
for follow-up visit and completion of restorative phase
httpswwwglasbergencomdentist-cartoons
Schedule
⧫Piggybacking technique
Increased allotted restorative blocks
⧫Sustainability of current schedule is
contingent on cooperation amp skills of HAN
Dental staff
Note
Strategies mentioned today is personalized to HAN Dental clinic
Current implemented strategies might be modified or changed in the
future as required in order to accommodate the need of our pts
THANK YOU
DAY TWOCLOSINGWRAP-UP
End of Day Two ndash Survey
Day Two Creating a Value-Based Oral Health Care Delivery
System
129
Payment Reform in Oral Health Online Learning Module
Oral Health Value-based Care Online Learning Module
Value-based Care Keys to Success Article
Readiness Assessment
Competency Development Guide
Oral Health Value-based Care Training
Dental Caries Management Practicum
Clinicians Companion Guide
Interprofessional Network Referral Process
Traditional Dental Care Vs Value-Based Care
Resources
131
wwwDentaQuestPartnershiporg
wwwfacebookcomDentaQuest
DentaQuest
wwwlinkedincomcompanyDentaQuest
Inside_DentaQuest
QUESTIONS
27
ldquoTrue Measures of Successrdquo
1 Define your governing objective
2 Develop a theory of cause and effect to assess presumed drivers of the
objective
3 Identify the specific activities that employees can do to help achieve the
governing objective
4 Evaluate your statistics
5 Communicate the story of your measurement
Adapted from HBR ldquoThe True Measures of Successrdquo httpshbrorg201210the-true-measures-of-success
28
1 Governing objective
2 Theory of cause and effect
3 Activities of team
4 Evaluate your statistics
5 Storycraft
Sustainability
Clinic revenuegt expenses= sustainability
Patient compliance Assets Clinic Mngt
Care team Operations Pt Support Billing
Of Prod on and type Patients on time
Daily weekly monthly quarterly
ldquoTrue Measures of Successrdquo
Adapted from HBR ldquoThe True Measures of Successrdquo httpshbrorg201210the-true-measures-of-success
29
Measuring Risk and Health
November is Diabetes Awareness Month- 2019Communication Plans are as
important as cold hard numbers
Patients
Care Team
Other Health Teams
Executive Team
Funders
Data on your dental patients are medical patients of record
Data on your medical + dental patients with DM2
30
Develop Diabetic Patient
Protocols
Review evidence and rationale with dental team
Partner with primary care team
bull Protocols Care mngt Tests and Recording
Quality Goals
Protocols for newly screened and existing patients
Educate and train dental team in reading AND
charting test results and PILOT
31
External Measurement in Oral Health Programs
httpswwwadaorg~mediaADADQA2019_DiabetesOralEvaluationpdfla=en
httpswwworegongovohaHPAANALYTICSCCOMetrics2019-Oral-Evaluation-Adults-Diabetespdf
32
Baseline for 2019 271
httpswwworegongovohaHPAANALYTICSCCOMetrics2019-Oral-Evaluation-Adults-Diabetespdf
33
Diabetes burden in your panel of dental patients
Baseline Medical-Dental Integrated panel of all patients
Dental patients with DM2 MDI
Dental patients with DM2
1000 or 10
600 or 60
300010000= 30
Population Health- Clinic Level
34
1 Governing objective
2 Theory of cause and effect
3 Activities of team
4 Evaluate your statistics
5 Storycraft
Discuss at meetings (Oct + Nov) Health education training
materials NP training CQI Note in Board report Clinical
measures
Care Pathways Hygiene Resources (ScheduleAvail)
ldquoTrue Measures of Successrdquo
Adapted from HBR ldquoThe True Measures of Successrdquo httpshbrorg201210the-true-measures-of-success
Diabetes Awareness Prevention Healthier Community
Prevention Awareness Care Pathway promotes health
MDI= 10 6 out of 10 adult patients with DM2
Goal set for integrated patient panels ndash PCMH
Pre-diabetes approach for executive team
Care Pathways
Care Coordination
35
MEASURING PATIENT ORAL HEALTHRisk assessments and Care Pathways
36
37
Risk Assessment and Care Pathways
Caries Risk Assessment
Multiple tools
EDREHR modules smart notes or dot phrases
CDT Codes
Decide frequency
D0601
Low Caries Risk
D0601
Moderate Caries Risk
D0601
High Caries Risk
38
The Disease Management DifferenceDisease Management Difference
Traditional Dental Care Disease Management
Approach
All patients return in 6 months
regardless of risk status
Recare interval is based on the
childrsquos caries risk
Caries Risk
Level
Recommended
Recare Interval
High Risk 1 ndash 3 months
Moderate Risk 3 ndash 6 months
Low Risk 6 ndash 12 months
Caries
Stabilizing
agents
Health Ed
Nutritional
Counseling
Anti-bacterial
and Fluoride
interventions
39
Disease Management Care Pathways
DentaQuest Partnership for Oral Health Advancement Disease Management Model
Caries
Stabilizing
agents
Whole
Person
Inter-
professional
Approaches
Anti-bacterial
and Fluoride
interventions
40
Disease Management and Risk Screening Training
DentaQuest Partnership for Oral Health Advancementrsquos
Online Learning Center
Disease Management Series
8 modules 40 CDE available
httpswwwdentaquestpartnershiporglearnonline-learning-centeronline-
coursewaredentaquest-disease-management-series
41
MEASUREMENT IN TEAMSSharing meaningful data with your dental clinical teams
42
rdquoDental Homerdquo = Health Home where WE can meet the patient
Oralhealthworkforceorg
43
POLL HOW OFTEN DO YOU SHARE YOUR S WITH YOUR DENTAL TEAM
A Yearly only
B Quarterly
C Monthly
D Weekly
E Daily
44
Clinical Measures ndash Dental Practice Perspective
Private Practice Office
New patients seen
Assigned vs seen if capitated
Treatment plans incomplete
$ produced amp per provider
$ collected amp monthly per provider
CDT 6000 codes completed
RecallHygiene maintenance
Based on this consultants experienced
FQHC
Unduplicated patients
patients seen per day
Treatment plans complete
$ gainedlost via accounting
Broken appointment rate
procedures
Sealant rate (annual)
45
bull HRSA Sealant Measure Compliance for FQHCs
bull Completion of phase 1 treatment plans
bull Children seen 0-5 years old
bull Children seen getting a preventive service
bull Fluoride Varnish applications
bull Pregnant women seen and treated
bull Diabetic patients with HbA1C gt 7 seen
bull Patients seen who have not been seen for 12 months
bull Patients seen getting a Risk Assessment
bull Patients with moderate or high risk who lower risk at recare
bull Sealants provided httpwwwnnohaorgnnoha-contentuploads201512Demystifying-HRSA-SEALANT-PRESENTATION_FINALpdf
Program Measures
46
HRSA Performance Measurement and Data Collection
bull FQHCs and look-alikes submit CY data to HRSA since 2008
bull UDS Uniform Data System
bull Require FTE for clinical staff patient demographics
bull Dental utilization s (UDCTPV)
bull Dental Clinical Measure dental sealants placed on 1st molars ages 6-9 yo
bull Health Center Quartile rankings (Clinical measure performance influences
HC rankings as does EHR adoption and other HC characteristics)
47
Low birth weight
Access to prenatal care
Childhood Immunization
Children (Ages 3-17) Receiving
Weight Assessment amp
Counseling
Children (Age 6-9) Receiving
Dental Sealant to First Molars
Diabetes Control
Hypertension Control
Pap Test
Depression Screening and
Follow-up (Age 12+)
Asthma Patients (Age 5-40)
Receiving Pharmacologic
Therapy
Colorectal Cancer
Screening (Ages 51-74)
HRSA UDS Clinical Measures
Adults (Age 18+) Receiving
Weight Screening amp Follow-up
Adults (Age 18+) Receiving
Tobacco Use Assessment and
Cessation Intervention
Coronary Artery Disease
Receiving Lipid Therapy (18+)
Ischemic Vascular Disease (IVD)
Receiving Aspirin Therapy (18+)
HIV Linkage to Care
48
Dashboards
Grants
Average
amp
Targets
Quality
Rev
Costs
Visits
Priority
Pop
Prevention
49
Dashboard- Provider Team Level
Patient
Compliance
Satisfaction
50
Case Study-
Incentives bonus round pools benchmark and improvement target goals risk-sharing possible later years
51
Qualitative Measurement
ldquoPatient engagement is the act of patients and providers working together
toward the end goal of improved patient wellnessrdquo
wwwpatientengagementhitcom
Access to Care
Patient Activation
Patient Satisfaction
Patient-Provider-Care Team Communication
Care Team Satisfaction
52
OHVBC Readiness
Leadership
bull Value of oral health and oral health transformation
Structure Systems and Operations
bull Operational efficiencies innovative care delivery methodologies
Care Pathways and Provider Buy-In
bull Training disease management risk-based care referrals IDC-10 coding patient engagement
Data and Analytic Technology and Personnel
bull Interoperability reporting
Financial Viability and Strength
bull Payerpatient mix billing infrastructure financial reports
httpswwwdentaquestpartnershiporglearnsafety-net-solutionsoral-health-value-based-careohvbc-readiness-
assessment
53
QUESTIONS COMMENTS
Carolyn Brown DDS
cbrownddsgmailcom
RISK BASED MANAGED CARE
Value Based Training Conference
Manchester New Hampshire
Mark Koday DDS
111919
5555
Objectives
bull Review current drivers of dental managed care
bull Understand the basics of risk-based dental managed care contracts
bull Learn the basics of managing costs in a riskndashbased contract
bull Gain an understanding in the potential advantage of risk-based contracting
56
What Is Dental Managed Care
Managed care is a health delivery system whose purpose is to manage both the
quality and cost of health care
Common types of managed care health insurance plans
bull HMOs
bull PPOs
bull POSs
bull Medicaid Managed Care
DIDNrsquoT WE ALREADY HAVE MANAGED CARE AND IT FAILED
57
What Has Happened Since the 90s
58
WHY THE FFS AND PPS DOESNrsquoT WORK FOR OUR POPULATIONS
bull Inefficient payment systems designed to produce encounters or procedures but not real health
bull No focus on population health
bull Does not incentivize innovation
bull Patients essentially on their own for accessing specialty care
59
Rule of 4
Source Kaiser Family Foundation analysis of National Health Expenditure (NHE) data from Centers for
Medicare and Medicaid Services Office of the Actuary National Health Statistics Group
60
Rule of 4
bull This helps explain why oral health has been relatively ignored so far by CMS
bull Explains why we have PCMH instead of PCHH
bull Where is the real value on a national level in preventing disease and
controlling costs
bull Beware- wersquove been found
61
Reasons Dental Managed Care is Spreading Across the States
NON-MANAGED CARE STATE DENTAL BUDGETS ARE
OPENED ENDED
STRAIN ON STATE BUDGETS
UPCOMING RECESSION WITH TRILLION DOLLAR
DEFICIT
SHIFTS FINANCIAL RISK FROM THE STATES TO THE
PLANS
6262
Types of Medicaid Managed Care
bull State Medicaid agency administrator lowest administrative
costs
bull Third Party Administrator Typically 15 administrative costs
bull Managed Care Organization Typically 15 administrative
costs
bull Carved-in
bull Carved-out
bull Risk Based Managed Care Administrative costs part of
contract negotiation
63
RISK CONTRACTS
6464
Components of a Risk-based Contract
Risk
Medical Loss Ratio
Quality withhold
Specialty withhold
Managed care payment (pmpm)
Covered services
Fee schedule Claims are paid as usual on a FFS basis
Credentialing
Quality Review process and Quality Metrics
65
Upside Risk
The possibility that the cost of
delivering dental care to an assigned
patient panel is less than the amount
of funding calculated for that care
The Plan pays the CHC additional
funds based on a predetermine
formula
Downside Risk
The possibility that the cost of
delivering dental care to an assigned
patient panel is more than the amount
of funding calculated for that care
The CHC pays the Plan additional
funds based on a predetermine
formula
Upside and Downside Risk
66
Taking On Risk 100 or Shared Risk
With 100 risk you receive 100 of the potential savings but are also at risk for
100 of the losses
Shared Risk MCO and health center share a percentage of the risk
Shared Risk leads to better cooperation since both organizations are
incentivized to save on costs
6767
Reports Needed
bull Enrollment reports lists of who is assigned on a monthly basis
bull Reconciliation reports insure appropriate payments
bull Specialty Referral reports
bull You will need your own reporting process so you donrsquot rely completely on
reports supplied by the Plan
6868
Medical Loss Ratio
Medical Loss Ratio (MLR) is proportion of premium revenues spent on clinical
services and quality improvement also known as the Medical Loss Ratio (MLR)
For CMS requires Medical Plans to spend at least 80 to 85 of the premiums
on actual medical care
69
Administrative Fees
bull Essentially the opposite of MLR
bull The State Medicaid Agency is funded by the Governorrsquos budget
bull The State Medicaid Agency will keep some of these funds for their
admin costs and give the remaining to the Managed Care Plans
bull Private Plan admin costs can be as high as 40 but most states
limit these cost for Medicaid Plans to between 15 and 20 (85-
80 MLR)
bull This may be negotiable depending on your program size of your
program
70
Quality Withhold
bull The state withholds a certain percent (typically 2-4 ) of the funds they give
to the Plans for Value Based Reimbursement
bull They choose quality metrics and set benchmarks and assign payments for
each metric based on an assigned priority for each metric
bull If a Plan meets the benchmark of every quality metric the state passes on
their full share of the quality withhold
bull The Plans may or may not withhold a percent of the funds for quality payment
to the dentists or manage care contractors
71
Quality Withhold
Either way the Plans may or may not pass the quality payments they receive to
the dentists or contractors
This should be spelled out in a risk-based contract
72
Percent of funds set aside
to cover specialty care
referrals
Typically 10-15
Goal Limit referral costs
to within or less than
Specialty set aside
Specialty Withhold
73
Per Member Per Month
bull Capitated Payment
bull Specific dollar amount paid for each enrolled member each month
bull Paid whether patient is accessed for care or not
bull States do set access benchmarks
bull In Oregon access for any dental procedure (adults and children combined)
was 267 in 2015
74
Payment Math Example
Premium per enrollee = $25
Administrative fee 15 = $375
Funds available per enrollee to the clinic = $2125
Management fee per enrollee = $175
Funds per enrollee that would undergo PPS reconciliation = $1950
For every 10000 enrollees the managed care income = $2340000
Specialty withhold (10) = $234000
YE Cost lt or gt $2340000
Upside Risk
CHC Gains $
Downside Risk
CHC Loses $
75
Covered Services and Fee Schedules
bull The state Medicaid agency spells out the minimum procedures and fees that
MCOs must cover
bull MCOs may add procedures or increase periodicity of procedures particularly
preventative services
bull MCOs may increase fees to entice rural providers and specialists to enroll in
their Plans
bull Access Rules
bull How many days it takes to access a patent
bull How many days it takes for a patent to access urgent care services
bull How many days it takes for a patent to access emergency care services
76
Credentialing
All MCOs are required to credential all Providers
All MCOs have their own credentialing process
Credentialing process is can be lengthy
Credentialing process may be negotiable
77
Quality Review Process and Quality Metrics
MCOs must have a Quality and Compliance Review Process
If you arenrsquot in compliance with both you likely wonrsquot get paid
Typical processes reviewed
bull Charting specifications
bull Incident report
bull Enrollee complaints quality rudeness and access issues
bull Medicaid compliance
78
Quality Payments
bull State Shared Incentive Withhold Typically quality metrics and benchmarks
are set by the state sets aside a certain percent (3-5) of the payments to
the Managed Care Plan (MCP)
bull If the benchmarks are achieved the MCP is then paid the a predetermine
amount
bull Benchmarks may not be the same as the states
bull Managed Care Plans do not have to pass all or any of the quality payments to
the health centers or providers
bull Managed Care contract- Metrics benchmarks should be selected and part of
the contract
7979
Achieving Quality Metric Payments
Dealing with under achievers
Process issues
Individual issues
Identifying workflows
Developing Best Practices through
PDSA process
Developing Best Practices through
PDSA process
CHC Metrics Committee
Clinicians Operations various key staff
Identify Best Practices
Spread Best Practices
80
New Team Needed Business Intelligence
Business Intelligence (BI) is critical for effective managed care business decisions
BI team inputs metrics into your EHR collects integrates analyses and displays all your managed care business and clinical information
Easy to say- hard to achieve
Build your own or outsource
Possible future role of Primary Care Associations
8181
Clinicianrsquos Dashboard
Expensive to build
Displayed on your screen when your computer is first turned on
Easy to read and understand
Data dumped from the day before
Can dialed down from Org-wide to clinic to each clinicianrsquos data
Operational and clinical metrics
bull Treatment Plan Completion
bull DQA quality measures
bull Caries at Recall
bull Re-care reports
bull Care Gap reports
82
CONTROLLING COSTS
8383
Controlling Costs- Current
bull Increasing efficiencies
bull Decreasing broken appointments
bull Controlling supplies equipment costs
bull Staff recruitment retention costs
84
Specialty Care
Training current CHC dentists in
specialty areas
Hiring general dentists with higher
specialty skill sets
Hiring in house specialists
Contract with outside specialists
Work with Managed Care Plan
specialists
Lowering Disease Rates
Community Dental Health
Coordinators case management
If your state law allows- embed
hygienists in medical and community
to provide primary and secondary
prevention procedures
In clinic Caries Classification and
Silver Diamine Fluoride
Effective recare programs
Controlling Costs- Additions in Risk-based Contracting
85
Specialty Care ndash Primary Referrals by Cost
Pediatric dentistry
Orthodontics
Oral surgery
Endodontics
86
In-clinic Pediatric Services
Encounters expected
of operatories available
State dental law and ability to have
expanded duties
General Anesthesia
GA in- house
Ability for a hospital or surgery center
to set aside regular OR time
Ability to hire or assign DAs to GA
days
Four GA cases day x PPS rate
Should You Hire a Pediatric Dentist- It Depends
8787
Solutions for Controlling Pediatric Costs
Hire a general dentist that is skilled in treating young children
Make the clinic child friendly nitrous oxide TVs in the operatory etc
Teach entire staff behavioral control techniques
Contract with a pediatric dentist for the GA care
88
Lowering Overall Disease Rates (and Costs)
You are responsible for both the patients you see in the chair and the ones
assigned to you
Breaking down the walls of the dental clinic
Community Dental Health Coordinators
Case Management
89
Cost Control Essentials
Diagnosis codes
Increased ability to identify
disease by risk
Motivational
Interviewing
Developing Polices and
Procedures design to treat
disease according to risk
ie Silver Diamine Fluoride
Treating by Risk
Effective Recare
Process
Critical to continual disease
controlPrevention education that is
meaningful and designed to
change behaviors
90
Social Determinants of Health Aunt Bertha
httpswwwauntberthacom
91
REASON TO CONSIDER RISK- BASED CONTRACTING
9292
PPS Reconciliation and Federal Code 42 CFR sect4052469(a)(2)
42 CFR sect4052469(a)(2)
ldquoAny financial incentives provided to Federally Qualified Health Centers
under their Medicare Advantage Contracts such as risk pool payments
bonuses or withholds are prohibited from being included in the
calculation of supplemental payments due to the Federally Qualified
Health Centerrdquo
9393
Why Risk Based Contract in Times of PPS Reconciliation
bull Not all Risk- based Contract funds are reconciled
bull Risk is the key word- you can come out with less money than your normal
PPS reconciliation payment
bull Can lead to better patient care
bull May improve manage care enrollment for your medical plan
bull Promotes integrated care increases health for your CHC patients
9494
Not Included in the Reconciliation
Enrollment management pmpm
Quality Payments
Upside risk payments
Downside risk losses
9595
Determinants of Financial Success in Risk-Based Contracting
bull Most critical- State pmpm payment to the Managed Care Plan
bull Reporting capabilities
bull Specialty service capabilities
bull Access numbers count
bull Ability to move metric numbers
9696
What About the Non- Medicaid Poor We Serve
bull Numbers are king in a managed care contract and the more access you have
the better contract terms you can negotiate
bull We will potentially have a steady supply of Medicaid patients
bull As managed care spreads states this may be compromising the ability of
health centers to serve the non-Medicaid poor and others lacking dental
insurance
97
Mark Koday DDS
(509) 949-2278
Dental Quality Consultants
of WA
httpdentalqualityconsultin
gcom
dentalqualityconsultantsg
mailcom
Contact Information
LUNCH
BREAKOUT EXERCISEORAL HEALTH VALUE-BASED CARE READINESS ASSESSMENT
Danielle Apostolon
PROMISING PRACTICES FROM THE FIELD STRATEGIES FOR INCREASING VALUE IN ORAL HEALTH
Dr Carolyn Brown
Dr Kelly Perry
Dr Rachel Rivard
Dr Adeloye
Commitment Compassion Community
m i d s t a t e h e a l t h o r g
Promising Practices from the
Field Strategies for Increasing
Value in Oral Health Care
Kelly Perry DMD
Better Health
Outcomes
Improved Staff
Experience
Reduced Cost
Improved Patient
Experience
Better Health
Outcomes
Improved Staff
Experience
Reduced Cost
Improved Patient
Experience
Better Health
Outcomes
Improved Staff
Experience
Reduced Cost
Improved Patient
Experience
Better Health
Outcomes
Improved Staff
Experience
Reduced Cost
Improved Patient
Experience
Commitment Compassion Community
kpe r r ymids t a tehea l t h o rg
Thank you
Completion of Disease Control Phase
Pelumi Adeloye DMD MPH
HEALTH ACCESS NETWORK (HAN) FAMILY DENTAL
Introduction
⧫1 Dentist I Hygienist 3 EFDArsquos1 Receptionist
⧫ 6 Chairs= 4 (dentist) + 2 (hygienist)
⧫ Slide ⥶80 off
⧫ Service areas Northern Penobscot Southern Aroostook Western
Washington Counties amp more
Completion of Phase I Treatment
⧫LimitedLack of Access to dental care
⧫Difficulty completing the disease control phase
Caries amp periodontal disease
⧫Attaining stable restorative state
Goal
Increase the completion of Disease Control Phase
Current practice
⧫Education
Assess level of dental literacy
Incremental strategy
⧫Increase access to dental care
Generous sliding scale (⥸$40 per visit)
Incorporate Expanded Function Dental Assistants
⧫Schedule modification
Incorporate more restorative blocks to allow
for follow-up visit and completion of restorative phase
httpswwwglasbergencomdentist-cartoons
Schedule
⧫Piggybacking technique
Increased allotted restorative blocks
⧫Sustainability of current schedule is
contingent on cooperation amp skills of HAN
Dental staff
Note
Strategies mentioned today is personalized to HAN Dental clinic
Current implemented strategies might be modified or changed in the
future as required in order to accommodate the need of our pts
THANK YOU
DAY TWOCLOSINGWRAP-UP
End of Day Two ndash Survey
Day Two Creating a Value-Based Oral Health Care Delivery
System
129
Payment Reform in Oral Health Online Learning Module
Oral Health Value-based Care Online Learning Module
Value-based Care Keys to Success Article
Readiness Assessment
Competency Development Guide
Oral Health Value-based Care Training
Dental Caries Management Practicum
Clinicians Companion Guide
Interprofessional Network Referral Process
Traditional Dental Care Vs Value-Based Care
Resources
131
wwwDentaQuestPartnershiporg
wwwfacebookcomDentaQuest
DentaQuest
wwwlinkedincomcompanyDentaQuest
Inside_DentaQuest
QUESTIONS
28
1 Governing objective
2 Theory of cause and effect
3 Activities of team
4 Evaluate your statistics
5 Storycraft
Sustainability
Clinic revenuegt expenses= sustainability
Patient compliance Assets Clinic Mngt
Care team Operations Pt Support Billing
Of Prod on and type Patients on time
Daily weekly monthly quarterly
ldquoTrue Measures of Successrdquo
Adapted from HBR ldquoThe True Measures of Successrdquo httpshbrorg201210the-true-measures-of-success
29
Measuring Risk and Health
November is Diabetes Awareness Month- 2019Communication Plans are as
important as cold hard numbers
Patients
Care Team
Other Health Teams
Executive Team
Funders
Data on your dental patients are medical patients of record
Data on your medical + dental patients with DM2
30
Develop Diabetic Patient
Protocols
Review evidence and rationale with dental team
Partner with primary care team
bull Protocols Care mngt Tests and Recording
Quality Goals
Protocols for newly screened and existing patients
Educate and train dental team in reading AND
charting test results and PILOT
31
External Measurement in Oral Health Programs
httpswwwadaorg~mediaADADQA2019_DiabetesOralEvaluationpdfla=en
httpswwworegongovohaHPAANALYTICSCCOMetrics2019-Oral-Evaluation-Adults-Diabetespdf
32
Baseline for 2019 271
httpswwworegongovohaHPAANALYTICSCCOMetrics2019-Oral-Evaluation-Adults-Diabetespdf
33
Diabetes burden in your panel of dental patients
Baseline Medical-Dental Integrated panel of all patients
Dental patients with DM2 MDI
Dental patients with DM2
1000 or 10
600 or 60
300010000= 30
Population Health- Clinic Level
34
1 Governing objective
2 Theory of cause and effect
3 Activities of team
4 Evaluate your statistics
5 Storycraft
Discuss at meetings (Oct + Nov) Health education training
materials NP training CQI Note in Board report Clinical
measures
Care Pathways Hygiene Resources (ScheduleAvail)
ldquoTrue Measures of Successrdquo
Adapted from HBR ldquoThe True Measures of Successrdquo httpshbrorg201210the-true-measures-of-success
Diabetes Awareness Prevention Healthier Community
Prevention Awareness Care Pathway promotes health
MDI= 10 6 out of 10 adult patients with DM2
Goal set for integrated patient panels ndash PCMH
Pre-diabetes approach for executive team
Care Pathways
Care Coordination
35
MEASURING PATIENT ORAL HEALTHRisk assessments and Care Pathways
36
37
Risk Assessment and Care Pathways
Caries Risk Assessment
Multiple tools
EDREHR modules smart notes or dot phrases
CDT Codes
Decide frequency
D0601
Low Caries Risk
D0601
Moderate Caries Risk
D0601
High Caries Risk
38
The Disease Management DifferenceDisease Management Difference
Traditional Dental Care Disease Management
Approach
All patients return in 6 months
regardless of risk status
Recare interval is based on the
childrsquos caries risk
Caries Risk
Level
Recommended
Recare Interval
High Risk 1 ndash 3 months
Moderate Risk 3 ndash 6 months
Low Risk 6 ndash 12 months
Caries
Stabilizing
agents
Health Ed
Nutritional
Counseling
Anti-bacterial
and Fluoride
interventions
39
Disease Management Care Pathways
DentaQuest Partnership for Oral Health Advancement Disease Management Model
Caries
Stabilizing
agents
Whole
Person
Inter-
professional
Approaches
Anti-bacterial
and Fluoride
interventions
40
Disease Management and Risk Screening Training
DentaQuest Partnership for Oral Health Advancementrsquos
Online Learning Center
Disease Management Series
8 modules 40 CDE available
httpswwwdentaquestpartnershiporglearnonline-learning-centeronline-
coursewaredentaquest-disease-management-series
41
MEASUREMENT IN TEAMSSharing meaningful data with your dental clinical teams
42
rdquoDental Homerdquo = Health Home where WE can meet the patient
Oralhealthworkforceorg
43
POLL HOW OFTEN DO YOU SHARE YOUR S WITH YOUR DENTAL TEAM
A Yearly only
B Quarterly
C Monthly
D Weekly
E Daily
44
Clinical Measures ndash Dental Practice Perspective
Private Practice Office
New patients seen
Assigned vs seen if capitated
Treatment plans incomplete
$ produced amp per provider
$ collected amp monthly per provider
CDT 6000 codes completed
RecallHygiene maintenance
Based on this consultants experienced
FQHC
Unduplicated patients
patients seen per day
Treatment plans complete
$ gainedlost via accounting
Broken appointment rate
procedures
Sealant rate (annual)
45
bull HRSA Sealant Measure Compliance for FQHCs
bull Completion of phase 1 treatment plans
bull Children seen 0-5 years old
bull Children seen getting a preventive service
bull Fluoride Varnish applications
bull Pregnant women seen and treated
bull Diabetic patients with HbA1C gt 7 seen
bull Patients seen who have not been seen for 12 months
bull Patients seen getting a Risk Assessment
bull Patients with moderate or high risk who lower risk at recare
bull Sealants provided httpwwwnnohaorgnnoha-contentuploads201512Demystifying-HRSA-SEALANT-PRESENTATION_FINALpdf
Program Measures
46
HRSA Performance Measurement and Data Collection
bull FQHCs and look-alikes submit CY data to HRSA since 2008
bull UDS Uniform Data System
bull Require FTE for clinical staff patient demographics
bull Dental utilization s (UDCTPV)
bull Dental Clinical Measure dental sealants placed on 1st molars ages 6-9 yo
bull Health Center Quartile rankings (Clinical measure performance influences
HC rankings as does EHR adoption and other HC characteristics)
47
Low birth weight
Access to prenatal care
Childhood Immunization
Children (Ages 3-17) Receiving
Weight Assessment amp
Counseling
Children (Age 6-9) Receiving
Dental Sealant to First Molars
Diabetes Control
Hypertension Control
Pap Test
Depression Screening and
Follow-up (Age 12+)
Asthma Patients (Age 5-40)
Receiving Pharmacologic
Therapy
Colorectal Cancer
Screening (Ages 51-74)
HRSA UDS Clinical Measures
Adults (Age 18+) Receiving
Weight Screening amp Follow-up
Adults (Age 18+) Receiving
Tobacco Use Assessment and
Cessation Intervention
Coronary Artery Disease
Receiving Lipid Therapy (18+)
Ischemic Vascular Disease (IVD)
Receiving Aspirin Therapy (18+)
HIV Linkage to Care
48
Dashboards
Grants
Average
amp
Targets
Quality
Rev
Costs
Visits
Priority
Pop
Prevention
49
Dashboard- Provider Team Level
Patient
Compliance
Satisfaction
50
Case Study-
Incentives bonus round pools benchmark and improvement target goals risk-sharing possible later years
51
Qualitative Measurement
ldquoPatient engagement is the act of patients and providers working together
toward the end goal of improved patient wellnessrdquo
wwwpatientengagementhitcom
Access to Care
Patient Activation
Patient Satisfaction
Patient-Provider-Care Team Communication
Care Team Satisfaction
52
OHVBC Readiness
Leadership
bull Value of oral health and oral health transformation
Structure Systems and Operations
bull Operational efficiencies innovative care delivery methodologies
Care Pathways and Provider Buy-In
bull Training disease management risk-based care referrals IDC-10 coding patient engagement
Data and Analytic Technology and Personnel
bull Interoperability reporting
Financial Viability and Strength
bull Payerpatient mix billing infrastructure financial reports
httpswwwdentaquestpartnershiporglearnsafety-net-solutionsoral-health-value-based-careohvbc-readiness-
assessment
53
QUESTIONS COMMENTS
Carolyn Brown DDS
cbrownddsgmailcom
RISK BASED MANAGED CARE
Value Based Training Conference
Manchester New Hampshire
Mark Koday DDS
111919
5555
Objectives
bull Review current drivers of dental managed care
bull Understand the basics of risk-based dental managed care contracts
bull Learn the basics of managing costs in a riskndashbased contract
bull Gain an understanding in the potential advantage of risk-based contracting
56
What Is Dental Managed Care
Managed care is a health delivery system whose purpose is to manage both the
quality and cost of health care
Common types of managed care health insurance plans
bull HMOs
bull PPOs
bull POSs
bull Medicaid Managed Care
DIDNrsquoT WE ALREADY HAVE MANAGED CARE AND IT FAILED
57
What Has Happened Since the 90s
58
WHY THE FFS AND PPS DOESNrsquoT WORK FOR OUR POPULATIONS
bull Inefficient payment systems designed to produce encounters or procedures but not real health
bull No focus on population health
bull Does not incentivize innovation
bull Patients essentially on their own for accessing specialty care
59
Rule of 4
Source Kaiser Family Foundation analysis of National Health Expenditure (NHE) data from Centers for
Medicare and Medicaid Services Office of the Actuary National Health Statistics Group
60
Rule of 4
bull This helps explain why oral health has been relatively ignored so far by CMS
bull Explains why we have PCMH instead of PCHH
bull Where is the real value on a national level in preventing disease and
controlling costs
bull Beware- wersquove been found
61
Reasons Dental Managed Care is Spreading Across the States
NON-MANAGED CARE STATE DENTAL BUDGETS ARE
OPENED ENDED
STRAIN ON STATE BUDGETS
UPCOMING RECESSION WITH TRILLION DOLLAR
DEFICIT
SHIFTS FINANCIAL RISK FROM THE STATES TO THE
PLANS
6262
Types of Medicaid Managed Care
bull State Medicaid agency administrator lowest administrative
costs
bull Third Party Administrator Typically 15 administrative costs
bull Managed Care Organization Typically 15 administrative
costs
bull Carved-in
bull Carved-out
bull Risk Based Managed Care Administrative costs part of
contract negotiation
63
RISK CONTRACTS
6464
Components of a Risk-based Contract
Risk
Medical Loss Ratio
Quality withhold
Specialty withhold
Managed care payment (pmpm)
Covered services
Fee schedule Claims are paid as usual on a FFS basis
Credentialing
Quality Review process and Quality Metrics
65
Upside Risk
The possibility that the cost of
delivering dental care to an assigned
patient panel is less than the amount
of funding calculated for that care
The Plan pays the CHC additional
funds based on a predetermine
formula
Downside Risk
The possibility that the cost of
delivering dental care to an assigned
patient panel is more than the amount
of funding calculated for that care
The CHC pays the Plan additional
funds based on a predetermine
formula
Upside and Downside Risk
66
Taking On Risk 100 or Shared Risk
With 100 risk you receive 100 of the potential savings but are also at risk for
100 of the losses
Shared Risk MCO and health center share a percentage of the risk
Shared Risk leads to better cooperation since both organizations are
incentivized to save on costs
6767
Reports Needed
bull Enrollment reports lists of who is assigned on a monthly basis
bull Reconciliation reports insure appropriate payments
bull Specialty Referral reports
bull You will need your own reporting process so you donrsquot rely completely on
reports supplied by the Plan
6868
Medical Loss Ratio
Medical Loss Ratio (MLR) is proportion of premium revenues spent on clinical
services and quality improvement also known as the Medical Loss Ratio (MLR)
For CMS requires Medical Plans to spend at least 80 to 85 of the premiums
on actual medical care
69
Administrative Fees
bull Essentially the opposite of MLR
bull The State Medicaid Agency is funded by the Governorrsquos budget
bull The State Medicaid Agency will keep some of these funds for their
admin costs and give the remaining to the Managed Care Plans
bull Private Plan admin costs can be as high as 40 but most states
limit these cost for Medicaid Plans to between 15 and 20 (85-
80 MLR)
bull This may be negotiable depending on your program size of your
program
70
Quality Withhold
bull The state withholds a certain percent (typically 2-4 ) of the funds they give
to the Plans for Value Based Reimbursement
bull They choose quality metrics and set benchmarks and assign payments for
each metric based on an assigned priority for each metric
bull If a Plan meets the benchmark of every quality metric the state passes on
their full share of the quality withhold
bull The Plans may or may not withhold a percent of the funds for quality payment
to the dentists or manage care contractors
71
Quality Withhold
Either way the Plans may or may not pass the quality payments they receive to
the dentists or contractors
This should be spelled out in a risk-based contract
72
Percent of funds set aside
to cover specialty care
referrals
Typically 10-15
Goal Limit referral costs
to within or less than
Specialty set aside
Specialty Withhold
73
Per Member Per Month
bull Capitated Payment
bull Specific dollar amount paid for each enrolled member each month
bull Paid whether patient is accessed for care or not
bull States do set access benchmarks
bull In Oregon access for any dental procedure (adults and children combined)
was 267 in 2015
74
Payment Math Example
Premium per enrollee = $25
Administrative fee 15 = $375
Funds available per enrollee to the clinic = $2125
Management fee per enrollee = $175
Funds per enrollee that would undergo PPS reconciliation = $1950
For every 10000 enrollees the managed care income = $2340000
Specialty withhold (10) = $234000
YE Cost lt or gt $2340000
Upside Risk
CHC Gains $
Downside Risk
CHC Loses $
75
Covered Services and Fee Schedules
bull The state Medicaid agency spells out the minimum procedures and fees that
MCOs must cover
bull MCOs may add procedures or increase periodicity of procedures particularly
preventative services
bull MCOs may increase fees to entice rural providers and specialists to enroll in
their Plans
bull Access Rules
bull How many days it takes to access a patent
bull How many days it takes for a patent to access urgent care services
bull How many days it takes for a patent to access emergency care services
76
Credentialing
All MCOs are required to credential all Providers
All MCOs have their own credentialing process
Credentialing process is can be lengthy
Credentialing process may be negotiable
77
Quality Review Process and Quality Metrics
MCOs must have a Quality and Compliance Review Process
If you arenrsquot in compliance with both you likely wonrsquot get paid
Typical processes reviewed
bull Charting specifications
bull Incident report
bull Enrollee complaints quality rudeness and access issues
bull Medicaid compliance
78
Quality Payments
bull State Shared Incentive Withhold Typically quality metrics and benchmarks
are set by the state sets aside a certain percent (3-5) of the payments to
the Managed Care Plan (MCP)
bull If the benchmarks are achieved the MCP is then paid the a predetermine
amount
bull Benchmarks may not be the same as the states
bull Managed Care Plans do not have to pass all or any of the quality payments to
the health centers or providers
bull Managed Care contract- Metrics benchmarks should be selected and part of
the contract
7979
Achieving Quality Metric Payments
Dealing with under achievers
Process issues
Individual issues
Identifying workflows
Developing Best Practices through
PDSA process
Developing Best Practices through
PDSA process
CHC Metrics Committee
Clinicians Operations various key staff
Identify Best Practices
Spread Best Practices
80
New Team Needed Business Intelligence
Business Intelligence (BI) is critical for effective managed care business decisions
BI team inputs metrics into your EHR collects integrates analyses and displays all your managed care business and clinical information
Easy to say- hard to achieve
Build your own or outsource
Possible future role of Primary Care Associations
8181
Clinicianrsquos Dashboard
Expensive to build
Displayed on your screen when your computer is first turned on
Easy to read and understand
Data dumped from the day before
Can dialed down from Org-wide to clinic to each clinicianrsquos data
Operational and clinical metrics
bull Treatment Plan Completion
bull DQA quality measures
bull Caries at Recall
bull Re-care reports
bull Care Gap reports
82
CONTROLLING COSTS
8383
Controlling Costs- Current
bull Increasing efficiencies
bull Decreasing broken appointments
bull Controlling supplies equipment costs
bull Staff recruitment retention costs
84
Specialty Care
Training current CHC dentists in
specialty areas
Hiring general dentists with higher
specialty skill sets
Hiring in house specialists
Contract with outside specialists
Work with Managed Care Plan
specialists
Lowering Disease Rates
Community Dental Health
Coordinators case management
If your state law allows- embed
hygienists in medical and community
to provide primary and secondary
prevention procedures
In clinic Caries Classification and
Silver Diamine Fluoride
Effective recare programs
Controlling Costs- Additions in Risk-based Contracting
85
Specialty Care ndash Primary Referrals by Cost
Pediatric dentistry
Orthodontics
Oral surgery
Endodontics
86
In-clinic Pediatric Services
Encounters expected
of operatories available
State dental law and ability to have
expanded duties
General Anesthesia
GA in- house
Ability for a hospital or surgery center
to set aside regular OR time
Ability to hire or assign DAs to GA
days
Four GA cases day x PPS rate
Should You Hire a Pediatric Dentist- It Depends
8787
Solutions for Controlling Pediatric Costs
Hire a general dentist that is skilled in treating young children
Make the clinic child friendly nitrous oxide TVs in the operatory etc
Teach entire staff behavioral control techniques
Contract with a pediatric dentist for the GA care
88
Lowering Overall Disease Rates (and Costs)
You are responsible for both the patients you see in the chair and the ones
assigned to you
Breaking down the walls of the dental clinic
Community Dental Health Coordinators
Case Management
89
Cost Control Essentials
Diagnosis codes
Increased ability to identify
disease by risk
Motivational
Interviewing
Developing Polices and
Procedures design to treat
disease according to risk
ie Silver Diamine Fluoride
Treating by Risk
Effective Recare
Process
Critical to continual disease
controlPrevention education that is
meaningful and designed to
change behaviors
90
Social Determinants of Health Aunt Bertha
httpswwwauntberthacom
91
REASON TO CONSIDER RISK- BASED CONTRACTING
9292
PPS Reconciliation and Federal Code 42 CFR sect4052469(a)(2)
42 CFR sect4052469(a)(2)
ldquoAny financial incentives provided to Federally Qualified Health Centers
under their Medicare Advantage Contracts such as risk pool payments
bonuses or withholds are prohibited from being included in the
calculation of supplemental payments due to the Federally Qualified
Health Centerrdquo
9393
Why Risk Based Contract in Times of PPS Reconciliation
bull Not all Risk- based Contract funds are reconciled
bull Risk is the key word- you can come out with less money than your normal
PPS reconciliation payment
bull Can lead to better patient care
bull May improve manage care enrollment for your medical plan
bull Promotes integrated care increases health for your CHC patients
9494
Not Included in the Reconciliation
Enrollment management pmpm
Quality Payments
Upside risk payments
Downside risk losses
9595
Determinants of Financial Success in Risk-Based Contracting
bull Most critical- State pmpm payment to the Managed Care Plan
bull Reporting capabilities
bull Specialty service capabilities
bull Access numbers count
bull Ability to move metric numbers
9696
What About the Non- Medicaid Poor We Serve
bull Numbers are king in a managed care contract and the more access you have
the better contract terms you can negotiate
bull We will potentially have a steady supply of Medicaid patients
bull As managed care spreads states this may be compromising the ability of
health centers to serve the non-Medicaid poor and others lacking dental
insurance
97
Mark Koday DDS
(509) 949-2278
Dental Quality Consultants
of WA
httpdentalqualityconsultin
gcom
dentalqualityconsultantsg
mailcom
Contact Information
LUNCH
BREAKOUT EXERCISEORAL HEALTH VALUE-BASED CARE READINESS ASSESSMENT
Danielle Apostolon
PROMISING PRACTICES FROM THE FIELD STRATEGIES FOR INCREASING VALUE IN ORAL HEALTH
Dr Carolyn Brown
Dr Kelly Perry
Dr Rachel Rivard
Dr Adeloye
Commitment Compassion Community
m i d s t a t e h e a l t h o r g
Promising Practices from the
Field Strategies for Increasing
Value in Oral Health Care
Kelly Perry DMD
Better Health
Outcomes
Improved Staff
Experience
Reduced Cost
Improved Patient
Experience
Better Health
Outcomes
Improved Staff
Experience
Reduced Cost
Improved Patient
Experience
Better Health
Outcomes
Improved Staff
Experience
Reduced Cost
Improved Patient
Experience
Better Health
Outcomes
Improved Staff
Experience
Reduced Cost
Improved Patient
Experience
Commitment Compassion Community
kpe r r ymids t a tehea l t h o rg
Thank you
Completion of Disease Control Phase
Pelumi Adeloye DMD MPH
HEALTH ACCESS NETWORK (HAN) FAMILY DENTAL
Introduction
⧫1 Dentist I Hygienist 3 EFDArsquos1 Receptionist
⧫ 6 Chairs= 4 (dentist) + 2 (hygienist)
⧫ Slide ⥶80 off
⧫ Service areas Northern Penobscot Southern Aroostook Western
Washington Counties amp more
Completion of Phase I Treatment
⧫LimitedLack of Access to dental care
⧫Difficulty completing the disease control phase
Caries amp periodontal disease
⧫Attaining stable restorative state
Goal
Increase the completion of Disease Control Phase
Current practice
⧫Education
Assess level of dental literacy
Incremental strategy
⧫Increase access to dental care
Generous sliding scale (⥸$40 per visit)
Incorporate Expanded Function Dental Assistants
⧫Schedule modification
Incorporate more restorative blocks to allow
for follow-up visit and completion of restorative phase
httpswwwglasbergencomdentist-cartoons
Schedule
⧫Piggybacking technique
Increased allotted restorative blocks
⧫Sustainability of current schedule is
contingent on cooperation amp skills of HAN
Dental staff
Note
Strategies mentioned today is personalized to HAN Dental clinic
Current implemented strategies might be modified or changed in the
future as required in order to accommodate the need of our pts
THANK YOU
DAY TWOCLOSINGWRAP-UP
End of Day Two ndash Survey
Day Two Creating a Value-Based Oral Health Care Delivery
System
129
Payment Reform in Oral Health Online Learning Module
Oral Health Value-based Care Online Learning Module
Value-based Care Keys to Success Article
Readiness Assessment
Competency Development Guide
Oral Health Value-based Care Training
Dental Caries Management Practicum
Clinicians Companion Guide
Interprofessional Network Referral Process
Traditional Dental Care Vs Value-Based Care
Resources
131
wwwDentaQuestPartnershiporg
wwwfacebookcomDentaQuest
DentaQuest
wwwlinkedincomcompanyDentaQuest
Inside_DentaQuest
QUESTIONS
29
Measuring Risk and Health
November is Diabetes Awareness Month- 2019Communication Plans are as
important as cold hard numbers
Patients
Care Team
Other Health Teams
Executive Team
Funders
Data on your dental patients are medical patients of record
Data on your medical + dental patients with DM2
30
Develop Diabetic Patient
Protocols
Review evidence and rationale with dental team
Partner with primary care team
bull Protocols Care mngt Tests and Recording
Quality Goals
Protocols for newly screened and existing patients
Educate and train dental team in reading AND
charting test results and PILOT
31
External Measurement in Oral Health Programs
httpswwwadaorg~mediaADADQA2019_DiabetesOralEvaluationpdfla=en
httpswwworegongovohaHPAANALYTICSCCOMetrics2019-Oral-Evaluation-Adults-Diabetespdf
32
Baseline for 2019 271
httpswwworegongovohaHPAANALYTICSCCOMetrics2019-Oral-Evaluation-Adults-Diabetespdf
33
Diabetes burden in your panel of dental patients
Baseline Medical-Dental Integrated panel of all patients
Dental patients with DM2 MDI
Dental patients with DM2
1000 or 10
600 or 60
300010000= 30
Population Health- Clinic Level
34
1 Governing objective
2 Theory of cause and effect
3 Activities of team
4 Evaluate your statistics
5 Storycraft
Discuss at meetings (Oct + Nov) Health education training
materials NP training CQI Note in Board report Clinical
measures
Care Pathways Hygiene Resources (ScheduleAvail)
ldquoTrue Measures of Successrdquo
Adapted from HBR ldquoThe True Measures of Successrdquo httpshbrorg201210the-true-measures-of-success
Diabetes Awareness Prevention Healthier Community
Prevention Awareness Care Pathway promotes health
MDI= 10 6 out of 10 adult patients with DM2
Goal set for integrated patient panels ndash PCMH
Pre-diabetes approach for executive team
Care Pathways
Care Coordination
35
MEASURING PATIENT ORAL HEALTHRisk assessments and Care Pathways
36
37
Risk Assessment and Care Pathways
Caries Risk Assessment
Multiple tools
EDREHR modules smart notes or dot phrases
CDT Codes
Decide frequency
D0601
Low Caries Risk
D0601
Moderate Caries Risk
D0601
High Caries Risk
38
The Disease Management DifferenceDisease Management Difference
Traditional Dental Care Disease Management
Approach
All patients return in 6 months
regardless of risk status
Recare interval is based on the
childrsquos caries risk
Caries Risk
Level
Recommended
Recare Interval
High Risk 1 ndash 3 months
Moderate Risk 3 ndash 6 months
Low Risk 6 ndash 12 months
Caries
Stabilizing
agents
Health Ed
Nutritional
Counseling
Anti-bacterial
and Fluoride
interventions
39
Disease Management Care Pathways
DentaQuest Partnership for Oral Health Advancement Disease Management Model
Caries
Stabilizing
agents
Whole
Person
Inter-
professional
Approaches
Anti-bacterial
and Fluoride
interventions
40
Disease Management and Risk Screening Training
DentaQuest Partnership for Oral Health Advancementrsquos
Online Learning Center
Disease Management Series
8 modules 40 CDE available
httpswwwdentaquestpartnershiporglearnonline-learning-centeronline-
coursewaredentaquest-disease-management-series
41
MEASUREMENT IN TEAMSSharing meaningful data with your dental clinical teams
42
rdquoDental Homerdquo = Health Home where WE can meet the patient
Oralhealthworkforceorg
43
POLL HOW OFTEN DO YOU SHARE YOUR S WITH YOUR DENTAL TEAM
A Yearly only
B Quarterly
C Monthly
D Weekly
E Daily
44
Clinical Measures ndash Dental Practice Perspective
Private Practice Office
New patients seen
Assigned vs seen if capitated
Treatment plans incomplete
$ produced amp per provider
$ collected amp monthly per provider
CDT 6000 codes completed
RecallHygiene maintenance
Based on this consultants experienced
FQHC
Unduplicated patients
patients seen per day
Treatment plans complete
$ gainedlost via accounting
Broken appointment rate
procedures
Sealant rate (annual)
45
bull HRSA Sealant Measure Compliance for FQHCs
bull Completion of phase 1 treatment plans
bull Children seen 0-5 years old
bull Children seen getting a preventive service
bull Fluoride Varnish applications
bull Pregnant women seen and treated
bull Diabetic patients with HbA1C gt 7 seen
bull Patients seen who have not been seen for 12 months
bull Patients seen getting a Risk Assessment
bull Patients with moderate or high risk who lower risk at recare
bull Sealants provided httpwwwnnohaorgnnoha-contentuploads201512Demystifying-HRSA-SEALANT-PRESENTATION_FINALpdf
Program Measures
46
HRSA Performance Measurement and Data Collection
bull FQHCs and look-alikes submit CY data to HRSA since 2008
bull UDS Uniform Data System
bull Require FTE for clinical staff patient demographics
bull Dental utilization s (UDCTPV)
bull Dental Clinical Measure dental sealants placed on 1st molars ages 6-9 yo
bull Health Center Quartile rankings (Clinical measure performance influences
HC rankings as does EHR adoption and other HC characteristics)
47
Low birth weight
Access to prenatal care
Childhood Immunization
Children (Ages 3-17) Receiving
Weight Assessment amp
Counseling
Children (Age 6-9) Receiving
Dental Sealant to First Molars
Diabetes Control
Hypertension Control
Pap Test
Depression Screening and
Follow-up (Age 12+)
Asthma Patients (Age 5-40)
Receiving Pharmacologic
Therapy
Colorectal Cancer
Screening (Ages 51-74)
HRSA UDS Clinical Measures
Adults (Age 18+) Receiving
Weight Screening amp Follow-up
Adults (Age 18+) Receiving
Tobacco Use Assessment and
Cessation Intervention
Coronary Artery Disease
Receiving Lipid Therapy (18+)
Ischemic Vascular Disease (IVD)
Receiving Aspirin Therapy (18+)
HIV Linkage to Care
48
Dashboards
Grants
Average
amp
Targets
Quality
Rev
Costs
Visits
Priority
Pop
Prevention
49
Dashboard- Provider Team Level
Patient
Compliance
Satisfaction
50
Case Study-
Incentives bonus round pools benchmark and improvement target goals risk-sharing possible later years
51
Qualitative Measurement
ldquoPatient engagement is the act of patients and providers working together
toward the end goal of improved patient wellnessrdquo
wwwpatientengagementhitcom
Access to Care
Patient Activation
Patient Satisfaction
Patient-Provider-Care Team Communication
Care Team Satisfaction
52
OHVBC Readiness
Leadership
bull Value of oral health and oral health transformation
Structure Systems and Operations
bull Operational efficiencies innovative care delivery methodologies
Care Pathways and Provider Buy-In
bull Training disease management risk-based care referrals IDC-10 coding patient engagement
Data and Analytic Technology and Personnel
bull Interoperability reporting
Financial Viability and Strength
bull Payerpatient mix billing infrastructure financial reports
httpswwwdentaquestpartnershiporglearnsafety-net-solutionsoral-health-value-based-careohvbc-readiness-
assessment
53
QUESTIONS COMMENTS
Carolyn Brown DDS
cbrownddsgmailcom
RISK BASED MANAGED CARE
Value Based Training Conference
Manchester New Hampshire
Mark Koday DDS
111919
5555
Objectives
bull Review current drivers of dental managed care
bull Understand the basics of risk-based dental managed care contracts
bull Learn the basics of managing costs in a riskndashbased contract
bull Gain an understanding in the potential advantage of risk-based contracting
56
What Is Dental Managed Care
Managed care is a health delivery system whose purpose is to manage both the
quality and cost of health care
Common types of managed care health insurance plans
bull HMOs
bull PPOs
bull POSs
bull Medicaid Managed Care
DIDNrsquoT WE ALREADY HAVE MANAGED CARE AND IT FAILED
57
What Has Happened Since the 90s
58
WHY THE FFS AND PPS DOESNrsquoT WORK FOR OUR POPULATIONS
bull Inefficient payment systems designed to produce encounters or procedures but not real health
bull No focus on population health
bull Does not incentivize innovation
bull Patients essentially on their own for accessing specialty care
59
Rule of 4
Source Kaiser Family Foundation analysis of National Health Expenditure (NHE) data from Centers for
Medicare and Medicaid Services Office of the Actuary National Health Statistics Group
60
Rule of 4
bull This helps explain why oral health has been relatively ignored so far by CMS
bull Explains why we have PCMH instead of PCHH
bull Where is the real value on a national level in preventing disease and
controlling costs
bull Beware- wersquove been found
61
Reasons Dental Managed Care is Spreading Across the States
NON-MANAGED CARE STATE DENTAL BUDGETS ARE
OPENED ENDED
STRAIN ON STATE BUDGETS
UPCOMING RECESSION WITH TRILLION DOLLAR
DEFICIT
SHIFTS FINANCIAL RISK FROM THE STATES TO THE
PLANS
6262
Types of Medicaid Managed Care
bull State Medicaid agency administrator lowest administrative
costs
bull Third Party Administrator Typically 15 administrative costs
bull Managed Care Organization Typically 15 administrative
costs
bull Carved-in
bull Carved-out
bull Risk Based Managed Care Administrative costs part of
contract negotiation
63
RISK CONTRACTS
6464
Components of a Risk-based Contract
Risk
Medical Loss Ratio
Quality withhold
Specialty withhold
Managed care payment (pmpm)
Covered services
Fee schedule Claims are paid as usual on a FFS basis
Credentialing
Quality Review process and Quality Metrics
65
Upside Risk
The possibility that the cost of
delivering dental care to an assigned
patient panel is less than the amount
of funding calculated for that care
The Plan pays the CHC additional
funds based on a predetermine
formula
Downside Risk
The possibility that the cost of
delivering dental care to an assigned
patient panel is more than the amount
of funding calculated for that care
The CHC pays the Plan additional
funds based on a predetermine
formula
Upside and Downside Risk
66
Taking On Risk 100 or Shared Risk
With 100 risk you receive 100 of the potential savings but are also at risk for
100 of the losses
Shared Risk MCO and health center share a percentage of the risk
Shared Risk leads to better cooperation since both organizations are
incentivized to save on costs
6767
Reports Needed
bull Enrollment reports lists of who is assigned on a monthly basis
bull Reconciliation reports insure appropriate payments
bull Specialty Referral reports
bull You will need your own reporting process so you donrsquot rely completely on
reports supplied by the Plan
6868
Medical Loss Ratio
Medical Loss Ratio (MLR) is proportion of premium revenues spent on clinical
services and quality improvement also known as the Medical Loss Ratio (MLR)
For CMS requires Medical Plans to spend at least 80 to 85 of the premiums
on actual medical care
69
Administrative Fees
bull Essentially the opposite of MLR
bull The State Medicaid Agency is funded by the Governorrsquos budget
bull The State Medicaid Agency will keep some of these funds for their
admin costs and give the remaining to the Managed Care Plans
bull Private Plan admin costs can be as high as 40 but most states
limit these cost for Medicaid Plans to between 15 and 20 (85-
80 MLR)
bull This may be negotiable depending on your program size of your
program
70
Quality Withhold
bull The state withholds a certain percent (typically 2-4 ) of the funds they give
to the Plans for Value Based Reimbursement
bull They choose quality metrics and set benchmarks and assign payments for
each metric based on an assigned priority for each metric
bull If a Plan meets the benchmark of every quality metric the state passes on
their full share of the quality withhold
bull The Plans may or may not withhold a percent of the funds for quality payment
to the dentists or manage care contractors
71
Quality Withhold
Either way the Plans may or may not pass the quality payments they receive to
the dentists or contractors
This should be spelled out in a risk-based contract
72
Percent of funds set aside
to cover specialty care
referrals
Typically 10-15
Goal Limit referral costs
to within or less than
Specialty set aside
Specialty Withhold
73
Per Member Per Month
bull Capitated Payment
bull Specific dollar amount paid for each enrolled member each month
bull Paid whether patient is accessed for care or not
bull States do set access benchmarks
bull In Oregon access for any dental procedure (adults and children combined)
was 267 in 2015
74
Payment Math Example
Premium per enrollee = $25
Administrative fee 15 = $375
Funds available per enrollee to the clinic = $2125
Management fee per enrollee = $175
Funds per enrollee that would undergo PPS reconciliation = $1950
For every 10000 enrollees the managed care income = $2340000
Specialty withhold (10) = $234000
YE Cost lt or gt $2340000
Upside Risk
CHC Gains $
Downside Risk
CHC Loses $
75
Covered Services and Fee Schedules
bull The state Medicaid agency spells out the minimum procedures and fees that
MCOs must cover
bull MCOs may add procedures or increase periodicity of procedures particularly
preventative services
bull MCOs may increase fees to entice rural providers and specialists to enroll in
their Plans
bull Access Rules
bull How many days it takes to access a patent
bull How many days it takes for a patent to access urgent care services
bull How many days it takes for a patent to access emergency care services
76
Credentialing
All MCOs are required to credential all Providers
All MCOs have their own credentialing process
Credentialing process is can be lengthy
Credentialing process may be negotiable
77
Quality Review Process and Quality Metrics
MCOs must have a Quality and Compliance Review Process
If you arenrsquot in compliance with both you likely wonrsquot get paid
Typical processes reviewed
bull Charting specifications
bull Incident report
bull Enrollee complaints quality rudeness and access issues
bull Medicaid compliance
78
Quality Payments
bull State Shared Incentive Withhold Typically quality metrics and benchmarks
are set by the state sets aside a certain percent (3-5) of the payments to
the Managed Care Plan (MCP)
bull If the benchmarks are achieved the MCP is then paid the a predetermine
amount
bull Benchmarks may not be the same as the states
bull Managed Care Plans do not have to pass all or any of the quality payments to
the health centers or providers
bull Managed Care contract- Metrics benchmarks should be selected and part of
the contract
7979
Achieving Quality Metric Payments
Dealing with under achievers
Process issues
Individual issues
Identifying workflows
Developing Best Practices through
PDSA process
Developing Best Practices through
PDSA process
CHC Metrics Committee
Clinicians Operations various key staff
Identify Best Practices
Spread Best Practices
80
New Team Needed Business Intelligence
Business Intelligence (BI) is critical for effective managed care business decisions
BI team inputs metrics into your EHR collects integrates analyses and displays all your managed care business and clinical information
Easy to say- hard to achieve
Build your own or outsource
Possible future role of Primary Care Associations
8181
Clinicianrsquos Dashboard
Expensive to build
Displayed on your screen when your computer is first turned on
Easy to read and understand
Data dumped from the day before
Can dialed down from Org-wide to clinic to each clinicianrsquos data
Operational and clinical metrics
bull Treatment Plan Completion
bull DQA quality measures
bull Caries at Recall
bull Re-care reports
bull Care Gap reports
82
CONTROLLING COSTS
8383
Controlling Costs- Current
bull Increasing efficiencies
bull Decreasing broken appointments
bull Controlling supplies equipment costs
bull Staff recruitment retention costs
84
Specialty Care
Training current CHC dentists in
specialty areas
Hiring general dentists with higher
specialty skill sets
Hiring in house specialists
Contract with outside specialists
Work with Managed Care Plan
specialists
Lowering Disease Rates
Community Dental Health
Coordinators case management
If your state law allows- embed
hygienists in medical and community
to provide primary and secondary
prevention procedures
In clinic Caries Classification and
Silver Diamine Fluoride
Effective recare programs
Controlling Costs- Additions in Risk-based Contracting
85
Specialty Care ndash Primary Referrals by Cost
Pediatric dentistry
Orthodontics
Oral surgery
Endodontics
86
In-clinic Pediatric Services
Encounters expected
of operatories available
State dental law and ability to have
expanded duties
General Anesthesia
GA in- house
Ability for a hospital or surgery center
to set aside regular OR time
Ability to hire or assign DAs to GA
days
Four GA cases day x PPS rate
Should You Hire a Pediatric Dentist- It Depends
8787
Solutions for Controlling Pediatric Costs
Hire a general dentist that is skilled in treating young children
Make the clinic child friendly nitrous oxide TVs in the operatory etc
Teach entire staff behavioral control techniques
Contract with a pediatric dentist for the GA care
88
Lowering Overall Disease Rates (and Costs)
You are responsible for both the patients you see in the chair and the ones
assigned to you
Breaking down the walls of the dental clinic
Community Dental Health Coordinators
Case Management
89
Cost Control Essentials
Diagnosis codes
Increased ability to identify
disease by risk
Motivational
Interviewing
Developing Polices and
Procedures design to treat
disease according to risk
ie Silver Diamine Fluoride
Treating by Risk
Effective Recare
Process
Critical to continual disease
controlPrevention education that is
meaningful and designed to
change behaviors
90
Social Determinants of Health Aunt Bertha
httpswwwauntberthacom
91
REASON TO CONSIDER RISK- BASED CONTRACTING
9292
PPS Reconciliation and Federal Code 42 CFR sect4052469(a)(2)
42 CFR sect4052469(a)(2)
ldquoAny financial incentives provided to Federally Qualified Health Centers
under their Medicare Advantage Contracts such as risk pool payments
bonuses or withholds are prohibited from being included in the
calculation of supplemental payments due to the Federally Qualified
Health Centerrdquo
9393
Why Risk Based Contract in Times of PPS Reconciliation
bull Not all Risk- based Contract funds are reconciled
bull Risk is the key word- you can come out with less money than your normal
PPS reconciliation payment
bull Can lead to better patient care
bull May improve manage care enrollment for your medical plan
bull Promotes integrated care increases health for your CHC patients
9494
Not Included in the Reconciliation
Enrollment management pmpm
Quality Payments
Upside risk payments
Downside risk losses
9595
Determinants of Financial Success in Risk-Based Contracting
bull Most critical- State pmpm payment to the Managed Care Plan
bull Reporting capabilities
bull Specialty service capabilities
bull Access numbers count
bull Ability to move metric numbers
9696
What About the Non- Medicaid Poor We Serve
bull Numbers are king in a managed care contract and the more access you have
the better contract terms you can negotiate
bull We will potentially have a steady supply of Medicaid patients
bull As managed care spreads states this may be compromising the ability of
health centers to serve the non-Medicaid poor and others lacking dental
insurance
97
Mark Koday DDS
(509) 949-2278
Dental Quality Consultants
of WA
httpdentalqualityconsultin
gcom
dentalqualityconsultantsg
mailcom
Contact Information
LUNCH
BREAKOUT EXERCISEORAL HEALTH VALUE-BASED CARE READINESS ASSESSMENT
Danielle Apostolon
PROMISING PRACTICES FROM THE FIELD STRATEGIES FOR INCREASING VALUE IN ORAL HEALTH
Dr Carolyn Brown
Dr Kelly Perry
Dr Rachel Rivard
Dr Adeloye
Commitment Compassion Community
m i d s t a t e h e a l t h o r g
Promising Practices from the
Field Strategies for Increasing
Value in Oral Health Care
Kelly Perry DMD
Better Health
Outcomes
Improved Staff
Experience
Reduced Cost
Improved Patient
Experience
Better Health
Outcomes
Improved Staff
Experience
Reduced Cost
Improved Patient
Experience
Better Health
Outcomes
Improved Staff
Experience
Reduced Cost
Improved Patient
Experience
Better Health
Outcomes
Improved Staff
Experience
Reduced Cost
Improved Patient
Experience
Commitment Compassion Community
kpe r r ymids t a tehea l t h o rg
Thank you
Completion of Disease Control Phase
Pelumi Adeloye DMD MPH
HEALTH ACCESS NETWORK (HAN) FAMILY DENTAL
Introduction
⧫1 Dentist I Hygienist 3 EFDArsquos1 Receptionist
⧫ 6 Chairs= 4 (dentist) + 2 (hygienist)
⧫ Slide ⥶80 off
⧫ Service areas Northern Penobscot Southern Aroostook Western
Washington Counties amp more
Completion of Phase I Treatment
⧫LimitedLack of Access to dental care
⧫Difficulty completing the disease control phase
Caries amp periodontal disease
⧫Attaining stable restorative state
Goal
Increase the completion of Disease Control Phase
Current practice
⧫Education
Assess level of dental literacy
Incremental strategy
⧫Increase access to dental care
Generous sliding scale (⥸$40 per visit)
Incorporate Expanded Function Dental Assistants
⧫Schedule modification
Incorporate more restorative blocks to allow
for follow-up visit and completion of restorative phase
httpswwwglasbergencomdentist-cartoons
Schedule
⧫Piggybacking technique
Increased allotted restorative blocks
⧫Sustainability of current schedule is
contingent on cooperation amp skills of HAN
Dental staff
Note
Strategies mentioned today is personalized to HAN Dental clinic
Current implemented strategies might be modified or changed in the
future as required in order to accommodate the need of our pts
THANK YOU
DAY TWOCLOSINGWRAP-UP
End of Day Two ndash Survey
Day Two Creating a Value-Based Oral Health Care Delivery
System
129
Payment Reform in Oral Health Online Learning Module
Oral Health Value-based Care Online Learning Module
Value-based Care Keys to Success Article
Readiness Assessment
Competency Development Guide
Oral Health Value-based Care Training
Dental Caries Management Practicum
Clinicians Companion Guide
Interprofessional Network Referral Process
Traditional Dental Care Vs Value-Based Care
Resources
131
wwwDentaQuestPartnershiporg
wwwfacebookcomDentaQuest
DentaQuest
wwwlinkedincomcompanyDentaQuest
Inside_DentaQuest
QUESTIONS
30
Develop Diabetic Patient
Protocols
Review evidence and rationale with dental team
Partner with primary care team
bull Protocols Care mngt Tests and Recording
Quality Goals
Protocols for newly screened and existing patients
Educate and train dental team in reading AND
charting test results and PILOT
31
External Measurement in Oral Health Programs
httpswwwadaorg~mediaADADQA2019_DiabetesOralEvaluationpdfla=en
httpswwworegongovohaHPAANALYTICSCCOMetrics2019-Oral-Evaluation-Adults-Diabetespdf
32
Baseline for 2019 271
httpswwworegongovohaHPAANALYTICSCCOMetrics2019-Oral-Evaluation-Adults-Diabetespdf
33
Diabetes burden in your panel of dental patients
Baseline Medical-Dental Integrated panel of all patients
Dental patients with DM2 MDI
Dental patients with DM2
1000 or 10
600 or 60
300010000= 30
Population Health- Clinic Level
34
1 Governing objective
2 Theory of cause and effect
3 Activities of team
4 Evaluate your statistics
5 Storycraft
Discuss at meetings (Oct + Nov) Health education training
materials NP training CQI Note in Board report Clinical
measures
Care Pathways Hygiene Resources (ScheduleAvail)
ldquoTrue Measures of Successrdquo
Adapted from HBR ldquoThe True Measures of Successrdquo httpshbrorg201210the-true-measures-of-success
Diabetes Awareness Prevention Healthier Community
Prevention Awareness Care Pathway promotes health
MDI= 10 6 out of 10 adult patients with DM2
Goal set for integrated patient panels ndash PCMH
Pre-diabetes approach for executive team
Care Pathways
Care Coordination
35
MEASURING PATIENT ORAL HEALTHRisk assessments and Care Pathways
36
37
Risk Assessment and Care Pathways
Caries Risk Assessment
Multiple tools
EDREHR modules smart notes or dot phrases
CDT Codes
Decide frequency
D0601
Low Caries Risk
D0601
Moderate Caries Risk
D0601
High Caries Risk
38
The Disease Management DifferenceDisease Management Difference
Traditional Dental Care Disease Management
Approach
All patients return in 6 months
regardless of risk status
Recare interval is based on the
childrsquos caries risk
Caries Risk
Level
Recommended
Recare Interval
High Risk 1 ndash 3 months
Moderate Risk 3 ndash 6 months
Low Risk 6 ndash 12 months
Caries
Stabilizing
agents
Health Ed
Nutritional
Counseling
Anti-bacterial
and Fluoride
interventions
39
Disease Management Care Pathways
DentaQuest Partnership for Oral Health Advancement Disease Management Model
Caries
Stabilizing
agents
Whole
Person
Inter-
professional
Approaches
Anti-bacterial
and Fluoride
interventions
40
Disease Management and Risk Screening Training
DentaQuest Partnership for Oral Health Advancementrsquos
Online Learning Center
Disease Management Series
8 modules 40 CDE available
httpswwwdentaquestpartnershiporglearnonline-learning-centeronline-
coursewaredentaquest-disease-management-series
41
MEASUREMENT IN TEAMSSharing meaningful data with your dental clinical teams
42
rdquoDental Homerdquo = Health Home where WE can meet the patient
Oralhealthworkforceorg
43
POLL HOW OFTEN DO YOU SHARE YOUR S WITH YOUR DENTAL TEAM
A Yearly only
B Quarterly
C Monthly
D Weekly
E Daily
44
Clinical Measures ndash Dental Practice Perspective
Private Practice Office
New patients seen
Assigned vs seen if capitated
Treatment plans incomplete
$ produced amp per provider
$ collected amp monthly per provider
CDT 6000 codes completed
RecallHygiene maintenance
Based on this consultants experienced
FQHC
Unduplicated patients
patients seen per day
Treatment plans complete
$ gainedlost via accounting
Broken appointment rate
procedures
Sealant rate (annual)
45
bull HRSA Sealant Measure Compliance for FQHCs
bull Completion of phase 1 treatment plans
bull Children seen 0-5 years old
bull Children seen getting a preventive service
bull Fluoride Varnish applications
bull Pregnant women seen and treated
bull Diabetic patients with HbA1C gt 7 seen
bull Patients seen who have not been seen for 12 months
bull Patients seen getting a Risk Assessment
bull Patients with moderate or high risk who lower risk at recare
bull Sealants provided httpwwwnnohaorgnnoha-contentuploads201512Demystifying-HRSA-SEALANT-PRESENTATION_FINALpdf
Program Measures
46
HRSA Performance Measurement and Data Collection
bull FQHCs and look-alikes submit CY data to HRSA since 2008
bull UDS Uniform Data System
bull Require FTE for clinical staff patient demographics
bull Dental utilization s (UDCTPV)
bull Dental Clinical Measure dental sealants placed on 1st molars ages 6-9 yo
bull Health Center Quartile rankings (Clinical measure performance influences
HC rankings as does EHR adoption and other HC characteristics)
47
Low birth weight
Access to prenatal care
Childhood Immunization
Children (Ages 3-17) Receiving
Weight Assessment amp
Counseling
Children (Age 6-9) Receiving
Dental Sealant to First Molars
Diabetes Control
Hypertension Control
Pap Test
Depression Screening and
Follow-up (Age 12+)
Asthma Patients (Age 5-40)
Receiving Pharmacologic
Therapy
Colorectal Cancer
Screening (Ages 51-74)
HRSA UDS Clinical Measures
Adults (Age 18+) Receiving
Weight Screening amp Follow-up
Adults (Age 18+) Receiving
Tobacco Use Assessment and
Cessation Intervention
Coronary Artery Disease
Receiving Lipid Therapy (18+)
Ischemic Vascular Disease (IVD)
Receiving Aspirin Therapy (18+)
HIV Linkage to Care
48
Dashboards
Grants
Average
amp
Targets
Quality
Rev
Costs
Visits
Priority
Pop
Prevention
49
Dashboard- Provider Team Level
Patient
Compliance
Satisfaction
50
Case Study-
Incentives bonus round pools benchmark and improvement target goals risk-sharing possible later years
51
Qualitative Measurement
ldquoPatient engagement is the act of patients and providers working together
toward the end goal of improved patient wellnessrdquo
wwwpatientengagementhitcom
Access to Care
Patient Activation
Patient Satisfaction
Patient-Provider-Care Team Communication
Care Team Satisfaction
52
OHVBC Readiness
Leadership
bull Value of oral health and oral health transformation
Structure Systems and Operations
bull Operational efficiencies innovative care delivery methodologies
Care Pathways and Provider Buy-In
bull Training disease management risk-based care referrals IDC-10 coding patient engagement
Data and Analytic Technology and Personnel
bull Interoperability reporting
Financial Viability and Strength
bull Payerpatient mix billing infrastructure financial reports
httpswwwdentaquestpartnershiporglearnsafety-net-solutionsoral-health-value-based-careohvbc-readiness-
assessment
53
QUESTIONS COMMENTS
Carolyn Brown DDS
cbrownddsgmailcom
RISK BASED MANAGED CARE
Value Based Training Conference
Manchester New Hampshire
Mark Koday DDS
111919
5555
Objectives
bull Review current drivers of dental managed care
bull Understand the basics of risk-based dental managed care contracts
bull Learn the basics of managing costs in a riskndashbased contract
bull Gain an understanding in the potential advantage of risk-based contracting
56
What Is Dental Managed Care
Managed care is a health delivery system whose purpose is to manage both the
quality and cost of health care
Common types of managed care health insurance plans
bull HMOs
bull PPOs
bull POSs
bull Medicaid Managed Care
DIDNrsquoT WE ALREADY HAVE MANAGED CARE AND IT FAILED
57
What Has Happened Since the 90s
58
WHY THE FFS AND PPS DOESNrsquoT WORK FOR OUR POPULATIONS
bull Inefficient payment systems designed to produce encounters or procedures but not real health
bull No focus on population health
bull Does not incentivize innovation
bull Patients essentially on their own for accessing specialty care
59
Rule of 4
Source Kaiser Family Foundation analysis of National Health Expenditure (NHE) data from Centers for
Medicare and Medicaid Services Office of the Actuary National Health Statistics Group
60
Rule of 4
bull This helps explain why oral health has been relatively ignored so far by CMS
bull Explains why we have PCMH instead of PCHH
bull Where is the real value on a national level in preventing disease and
controlling costs
bull Beware- wersquove been found
61
Reasons Dental Managed Care is Spreading Across the States
NON-MANAGED CARE STATE DENTAL BUDGETS ARE
OPENED ENDED
STRAIN ON STATE BUDGETS
UPCOMING RECESSION WITH TRILLION DOLLAR
DEFICIT
SHIFTS FINANCIAL RISK FROM THE STATES TO THE
PLANS
6262
Types of Medicaid Managed Care
bull State Medicaid agency administrator lowest administrative
costs
bull Third Party Administrator Typically 15 administrative costs
bull Managed Care Organization Typically 15 administrative
costs
bull Carved-in
bull Carved-out
bull Risk Based Managed Care Administrative costs part of
contract negotiation
63
RISK CONTRACTS
6464
Components of a Risk-based Contract
Risk
Medical Loss Ratio
Quality withhold
Specialty withhold
Managed care payment (pmpm)
Covered services
Fee schedule Claims are paid as usual on a FFS basis
Credentialing
Quality Review process and Quality Metrics
65
Upside Risk
The possibility that the cost of
delivering dental care to an assigned
patient panel is less than the amount
of funding calculated for that care
The Plan pays the CHC additional
funds based on a predetermine
formula
Downside Risk
The possibility that the cost of
delivering dental care to an assigned
patient panel is more than the amount
of funding calculated for that care
The CHC pays the Plan additional
funds based on a predetermine
formula
Upside and Downside Risk
66
Taking On Risk 100 or Shared Risk
With 100 risk you receive 100 of the potential savings but are also at risk for
100 of the losses
Shared Risk MCO and health center share a percentage of the risk
Shared Risk leads to better cooperation since both organizations are
incentivized to save on costs
6767
Reports Needed
bull Enrollment reports lists of who is assigned on a monthly basis
bull Reconciliation reports insure appropriate payments
bull Specialty Referral reports
bull You will need your own reporting process so you donrsquot rely completely on
reports supplied by the Plan
6868
Medical Loss Ratio
Medical Loss Ratio (MLR) is proportion of premium revenues spent on clinical
services and quality improvement also known as the Medical Loss Ratio (MLR)
For CMS requires Medical Plans to spend at least 80 to 85 of the premiums
on actual medical care
69
Administrative Fees
bull Essentially the opposite of MLR
bull The State Medicaid Agency is funded by the Governorrsquos budget
bull The State Medicaid Agency will keep some of these funds for their
admin costs and give the remaining to the Managed Care Plans
bull Private Plan admin costs can be as high as 40 but most states
limit these cost for Medicaid Plans to between 15 and 20 (85-
80 MLR)
bull This may be negotiable depending on your program size of your
program
70
Quality Withhold
bull The state withholds a certain percent (typically 2-4 ) of the funds they give
to the Plans for Value Based Reimbursement
bull They choose quality metrics and set benchmarks and assign payments for
each metric based on an assigned priority for each metric
bull If a Plan meets the benchmark of every quality metric the state passes on
their full share of the quality withhold
bull The Plans may or may not withhold a percent of the funds for quality payment
to the dentists or manage care contractors
71
Quality Withhold
Either way the Plans may or may not pass the quality payments they receive to
the dentists or contractors
This should be spelled out in a risk-based contract
72
Percent of funds set aside
to cover specialty care
referrals
Typically 10-15
Goal Limit referral costs
to within or less than
Specialty set aside
Specialty Withhold
73
Per Member Per Month
bull Capitated Payment
bull Specific dollar amount paid for each enrolled member each month
bull Paid whether patient is accessed for care or not
bull States do set access benchmarks
bull In Oregon access for any dental procedure (adults and children combined)
was 267 in 2015
74
Payment Math Example
Premium per enrollee = $25
Administrative fee 15 = $375
Funds available per enrollee to the clinic = $2125
Management fee per enrollee = $175
Funds per enrollee that would undergo PPS reconciliation = $1950
For every 10000 enrollees the managed care income = $2340000
Specialty withhold (10) = $234000
YE Cost lt or gt $2340000
Upside Risk
CHC Gains $
Downside Risk
CHC Loses $
75
Covered Services and Fee Schedules
bull The state Medicaid agency spells out the minimum procedures and fees that
MCOs must cover
bull MCOs may add procedures or increase periodicity of procedures particularly
preventative services
bull MCOs may increase fees to entice rural providers and specialists to enroll in
their Plans
bull Access Rules
bull How many days it takes to access a patent
bull How many days it takes for a patent to access urgent care services
bull How many days it takes for a patent to access emergency care services
76
Credentialing
All MCOs are required to credential all Providers
All MCOs have their own credentialing process
Credentialing process is can be lengthy
Credentialing process may be negotiable
77
Quality Review Process and Quality Metrics
MCOs must have a Quality and Compliance Review Process
If you arenrsquot in compliance with both you likely wonrsquot get paid
Typical processes reviewed
bull Charting specifications
bull Incident report
bull Enrollee complaints quality rudeness and access issues
bull Medicaid compliance
78
Quality Payments
bull State Shared Incentive Withhold Typically quality metrics and benchmarks
are set by the state sets aside a certain percent (3-5) of the payments to
the Managed Care Plan (MCP)
bull If the benchmarks are achieved the MCP is then paid the a predetermine
amount
bull Benchmarks may not be the same as the states
bull Managed Care Plans do not have to pass all or any of the quality payments to
the health centers or providers
bull Managed Care contract- Metrics benchmarks should be selected and part of
the contract
7979
Achieving Quality Metric Payments
Dealing with under achievers
Process issues
Individual issues
Identifying workflows
Developing Best Practices through
PDSA process
Developing Best Practices through
PDSA process
CHC Metrics Committee
Clinicians Operations various key staff
Identify Best Practices
Spread Best Practices
80
New Team Needed Business Intelligence
Business Intelligence (BI) is critical for effective managed care business decisions
BI team inputs metrics into your EHR collects integrates analyses and displays all your managed care business and clinical information
Easy to say- hard to achieve
Build your own or outsource
Possible future role of Primary Care Associations
8181
Clinicianrsquos Dashboard
Expensive to build
Displayed on your screen when your computer is first turned on
Easy to read and understand
Data dumped from the day before
Can dialed down from Org-wide to clinic to each clinicianrsquos data
Operational and clinical metrics
bull Treatment Plan Completion
bull DQA quality measures
bull Caries at Recall
bull Re-care reports
bull Care Gap reports
82
CONTROLLING COSTS
8383
Controlling Costs- Current
bull Increasing efficiencies
bull Decreasing broken appointments
bull Controlling supplies equipment costs
bull Staff recruitment retention costs
84
Specialty Care
Training current CHC dentists in
specialty areas
Hiring general dentists with higher
specialty skill sets
Hiring in house specialists
Contract with outside specialists
Work with Managed Care Plan
specialists
Lowering Disease Rates
Community Dental Health
Coordinators case management
If your state law allows- embed
hygienists in medical and community
to provide primary and secondary
prevention procedures
In clinic Caries Classification and
Silver Diamine Fluoride
Effective recare programs
Controlling Costs- Additions in Risk-based Contracting
85
Specialty Care ndash Primary Referrals by Cost
Pediatric dentistry
Orthodontics
Oral surgery
Endodontics
86
In-clinic Pediatric Services
Encounters expected
of operatories available
State dental law and ability to have
expanded duties
General Anesthesia
GA in- house
Ability for a hospital or surgery center
to set aside regular OR time
Ability to hire or assign DAs to GA
days
Four GA cases day x PPS rate
Should You Hire a Pediatric Dentist- It Depends
8787
Solutions for Controlling Pediatric Costs
Hire a general dentist that is skilled in treating young children
Make the clinic child friendly nitrous oxide TVs in the operatory etc
Teach entire staff behavioral control techniques
Contract with a pediatric dentist for the GA care
88
Lowering Overall Disease Rates (and Costs)
You are responsible for both the patients you see in the chair and the ones
assigned to you
Breaking down the walls of the dental clinic
Community Dental Health Coordinators
Case Management
89
Cost Control Essentials
Diagnosis codes
Increased ability to identify
disease by risk
Motivational
Interviewing
Developing Polices and
Procedures design to treat
disease according to risk
ie Silver Diamine Fluoride
Treating by Risk
Effective Recare
Process
Critical to continual disease
controlPrevention education that is
meaningful and designed to
change behaviors
90
Social Determinants of Health Aunt Bertha
httpswwwauntberthacom
91
REASON TO CONSIDER RISK- BASED CONTRACTING
9292
PPS Reconciliation and Federal Code 42 CFR sect4052469(a)(2)
42 CFR sect4052469(a)(2)
ldquoAny financial incentives provided to Federally Qualified Health Centers
under their Medicare Advantage Contracts such as risk pool payments
bonuses or withholds are prohibited from being included in the
calculation of supplemental payments due to the Federally Qualified
Health Centerrdquo
9393
Why Risk Based Contract in Times of PPS Reconciliation
bull Not all Risk- based Contract funds are reconciled
bull Risk is the key word- you can come out with less money than your normal
PPS reconciliation payment
bull Can lead to better patient care
bull May improve manage care enrollment for your medical plan
bull Promotes integrated care increases health for your CHC patients
9494
Not Included in the Reconciliation
Enrollment management pmpm
Quality Payments
Upside risk payments
Downside risk losses
9595
Determinants of Financial Success in Risk-Based Contracting
bull Most critical- State pmpm payment to the Managed Care Plan
bull Reporting capabilities
bull Specialty service capabilities
bull Access numbers count
bull Ability to move metric numbers
9696
What About the Non- Medicaid Poor We Serve
bull Numbers are king in a managed care contract and the more access you have
the better contract terms you can negotiate
bull We will potentially have a steady supply of Medicaid patients
bull As managed care spreads states this may be compromising the ability of
health centers to serve the non-Medicaid poor and others lacking dental
insurance
97
Mark Koday DDS
(509) 949-2278
Dental Quality Consultants
of WA
httpdentalqualityconsultin
gcom
dentalqualityconsultantsg
mailcom
Contact Information
LUNCH
BREAKOUT EXERCISEORAL HEALTH VALUE-BASED CARE READINESS ASSESSMENT
Danielle Apostolon
PROMISING PRACTICES FROM THE FIELD STRATEGIES FOR INCREASING VALUE IN ORAL HEALTH
Dr Carolyn Brown
Dr Kelly Perry
Dr Rachel Rivard
Dr Adeloye
Commitment Compassion Community
m i d s t a t e h e a l t h o r g
Promising Practices from the
Field Strategies for Increasing
Value in Oral Health Care
Kelly Perry DMD
Better Health
Outcomes
Improved Staff
Experience
Reduced Cost
Improved Patient
Experience
Better Health
Outcomes
Improved Staff
Experience
Reduced Cost
Improved Patient
Experience
Better Health
Outcomes
Improved Staff
Experience
Reduced Cost
Improved Patient
Experience
Better Health
Outcomes
Improved Staff
Experience
Reduced Cost
Improved Patient
Experience
Commitment Compassion Community
kpe r r ymids t a tehea l t h o rg
Thank you
Completion of Disease Control Phase
Pelumi Adeloye DMD MPH
HEALTH ACCESS NETWORK (HAN) FAMILY DENTAL
Introduction
⧫1 Dentist I Hygienist 3 EFDArsquos1 Receptionist
⧫ 6 Chairs= 4 (dentist) + 2 (hygienist)
⧫ Slide ⥶80 off
⧫ Service areas Northern Penobscot Southern Aroostook Western
Washington Counties amp more
Completion of Phase I Treatment
⧫LimitedLack of Access to dental care
⧫Difficulty completing the disease control phase
Caries amp periodontal disease
⧫Attaining stable restorative state
Goal
Increase the completion of Disease Control Phase
Current practice
⧫Education
Assess level of dental literacy
Incremental strategy
⧫Increase access to dental care
Generous sliding scale (⥸$40 per visit)
Incorporate Expanded Function Dental Assistants
⧫Schedule modification
Incorporate more restorative blocks to allow
for follow-up visit and completion of restorative phase
httpswwwglasbergencomdentist-cartoons
Schedule
⧫Piggybacking technique
Increased allotted restorative blocks
⧫Sustainability of current schedule is
contingent on cooperation amp skills of HAN
Dental staff
Note
Strategies mentioned today is personalized to HAN Dental clinic
Current implemented strategies might be modified or changed in the
future as required in order to accommodate the need of our pts
THANK YOU
DAY TWOCLOSINGWRAP-UP
End of Day Two ndash Survey
Day Two Creating a Value-Based Oral Health Care Delivery
System
129
Payment Reform in Oral Health Online Learning Module
Oral Health Value-based Care Online Learning Module
Value-based Care Keys to Success Article
Readiness Assessment
Competency Development Guide
Oral Health Value-based Care Training
Dental Caries Management Practicum
Clinicians Companion Guide
Interprofessional Network Referral Process
Traditional Dental Care Vs Value-Based Care
Resources
131
wwwDentaQuestPartnershiporg
wwwfacebookcomDentaQuest
DentaQuest
wwwlinkedincomcompanyDentaQuest
Inside_DentaQuest
QUESTIONS
31
External Measurement in Oral Health Programs
httpswwwadaorg~mediaADADQA2019_DiabetesOralEvaluationpdfla=en
httpswwworegongovohaHPAANALYTICSCCOMetrics2019-Oral-Evaluation-Adults-Diabetespdf
32
Baseline for 2019 271
httpswwworegongovohaHPAANALYTICSCCOMetrics2019-Oral-Evaluation-Adults-Diabetespdf
33
Diabetes burden in your panel of dental patients
Baseline Medical-Dental Integrated panel of all patients
Dental patients with DM2 MDI
Dental patients with DM2
1000 or 10
600 or 60
300010000= 30
Population Health- Clinic Level
34
1 Governing objective
2 Theory of cause and effect
3 Activities of team
4 Evaluate your statistics
5 Storycraft
Discuss at meetings (Oct + Nov) Health education training
materials NP training CQI Note in Board report Clinical
measures
Care Pathways Hygiene Resources (ScheduleAvail)
ldquoTrue Measures of Successrdquo
Adapted from HBR ldquoThe True Measures of Successrdquo httpshbrorg201210the-true-measures-of-success
Diabetes Awareness Prevention Healthier Community
Prevention Awareness Care Pathway promotes health
MDI= 10 6 out of 10 adult patients with DM2
Goal set for integrated patient panels ndash PCMH
Pre-diabetes approach for executive team
Care Pathways
Care Coordination
35
MEASURING PATIENT ORAL HEALTHRisk assessments and Care Pathways
36
37
Risk Assessment and Care Pathways
Caries Risk Assessment
Multiple tools
EDREHR modules smart notes or dot phrases
CDT Codes
Decide frequency
D0601
Low Caries Risk
D0601
Moderate Caries Risk
D0601
High Caries Risk
38
The Disease Management DifferenceDisease Management Difference
Traditional Dental Care Disease Management
Approach
All patients return in 6 months
regardless of risk status
Recare interval is based on the
childrsquos caries risk
Caries Risk
Level
Recommended
Recare Interval
High Risk 1 ndash 3 months
Moderate Risk 3 ndash 6 months
Low Risk 6 ndash 12 months
Caries
Stabilizing
agents
Health Ed
Nutritional
Counseling
Anti-bacterial
and Fluoride
interventions
39
Disease Management Care Pathways
DentaQuest Partnership for Oral Health Advancement Disease Management Model
Caries
Stabilizing
agents
Whole
Person
Inter-
professional
Approaches
Anti-bacterial
and Fluoride
interventions
40
Disease Management and Risk Screening Training
DentaQuest Partnership for Oral Health Advancementrsquos
Online Learning Center
Disease Management Series
8 modules 40 CDE available
httpswwwdentaquestpartnershiporglearnonline-learning-centeronline-
coursewaredentaquest-disease-management-series
41
MEASUREMENT IN TEAMSSharing meaningful data with your dental clinical teams
42
rdquoDental Homerdquo = Health Home where WE can meet the patient
Oralhealthworkforceorg
43
POLL HOW OFTEN DO YOU SHARE YOUR S WITH YOUR DENTAL TEAM
A Yearly only
B Quarterly
C Monthly
D Weekly
E Daily
44
Clinical Measures ndash Dental Practice Perspective
Private Practice Office
New patients seen
Assigned vs seen if capitated
Treatment plans incomplete
$ produced amp per provider
$ collected amp monthly per provider
CDT 6000 codes completed
RecallHygiene maintenance
Based on this consultants experienced
FQHC
Unduplicated patients
patients seen per day
Treatment plans complete
$ gainedlost via accounting
Broken appointment rate
procedures
Sealant rate (annual)
45
bull HRSA Sealant Measure Compliance for FQHCs
bull Completion of phase 1 treatment plans
bull Children seen 0-5 years old
bull Children seen getting a preventive service
bull Fluoride Varnish applications
bull Pregnant women seen and treated
bull Diabetic patients with HbA1C gt 7 seen
bull Patients seen who have not been seen for 12 months
bull Patients seen getting a Risk Assessment
bull Patients with moderate or high risk who lower risk at recare
bull Sealants provided httpwwwnnohaorgnnoha-contentuploads201512Demystifying-HRSA-SEALANT-PRESENTATION_FINALpdf
Program Measures
46
HRSA Performance Measurement and Data Collection
bull FQHCs and look-alikes submit CY data to HRSA since 2008
bull UDS Uniform Data System
bull Require FTE for clinical staff patient demographics
bull Dental utilization s (UDCTPV)
bull Dental Clinical Measure dental sealants placed on 1st molars ages 6-9 yo
bull Health Center Quartile rankings (Clinical measure performance influences
HC rankings as does EHR adoption and other HC characteristics)
47
Low birth weight
Access to prenatal care
Childhood Immunization
Children (Ages 3-17) Receiving
Weight Assessment amp
Counseling
Children (Age 6-9) Receiving
Dental Sealant to First Molars
Diabetes Control
Hypertension Control
Pap Test
Depression Screening and
Follow-up (Age 12+)
Asthma Patients (Age 5-40)
Receiving Pharmacologic
Therapy
Colorectal Cancer
Screening (Ages 51-74)
HRSA UDS Clinical Measures
Adults (Age 18+) Receiving
Weight Screening amp Follow-up
Adults (Age 18+) Receiving
Tobacco Use Assessment and
Cessation Intervention
Coronary Artery Disease
Receiving Lipid Therapy (18+)
Ischemic Vascular Disease (IVD)
Receiving Aspirin Therapy (18+)
HIV Linkage to Care
48
Dashboards
Grants
Average
amp
Targets
Quality
Rev
Costs
Visits
Priority
Pop
Prevention
49
Dashboard- Provider Team Level
Patient
Compliance
Satisfaction
50
Case Study-
Incentives bonus round pools benchmark and improvement target goals risk-sharing possible later years
51
Qualitative Measurement
ldquoPatient engagement is the act of patients and providers working together
toward the end goal of improved patient wellnessrdquo
wwwpatientengagementhitcom
Access to Care
Patient Activation
Patient Satisfaction
Patient-Provider-Care Team Communication
Care Team Satisfaction
52
OHVBC Readiness
Leadership
bull Value of oral health and oral health transformation
Structure Systems and Operations
bull Operational efficiencies innovative care delivery methodologies
Care Pathways and Provider Buy-In
bull Training disease management risk-based care referrals IDC-10 coding patient engagement
Data and Analytic Technology and Personnel
bull Interoperability reporting
Financial Viability and Strength
bull Payerpatient mix billing infrastructure financial reports
httpswwwdentaquestpartnershiporglearnsafety-net-solutionsoral-health-value-based-careohvbc-readiness-
assessment
53
QUESTIONS COMMENTS
Carolyn Brown DDS
cbrownddsgmailcom
RISK BASED MANAGED CARE
Value Based Training Conference
Manchester New Hampshire
Mark Koday DDS
111919
5555
Objectives
bull Review current drivers of dental managed care
bull Understand the basics of risk-based dental managed care contracts
bull Learn the basics of managing costs in a riskndashbased contract
bull Gain an understanding in the potential advantage of risk-based contracting
56
What Is Dental Managed Care
Managed care is a health delivery system whose purpose is to manage both the
quality and cost of health care
Common types of managed care health insurance plans
bull HMOs
bull PPOs
bull POSs
bull Medicaid Managed Care
DIDNrsquoT WE ALREADY HAVE MANAGED CARE AND IT FAILED
57
What Has Happened Since the 90s
58
WHY THE FFS AND PPS DOESNrsquoT WORK FOR OUR POPULATIONS
bull Inefficient payment systems designed to produce encounters or procedures but not real health
bull No focus on population health
bull Does not incentivize innovation
bull Patients essentially on their own for accessing specialty care
59
Rule of 4
Source Kaiser Family Foundation analysis of National Health Expenditure (NHE) data from Centers for
Medicare and Medicaid Services Office of the Actuary National Health Statistics Group
60
Rule of 4
bull This helps explain why oral health has been relatively ignored so far by CMS
bull Explains why we have PCMH instead of PCHH
bull Where is the real value on a national level in preventing disease and
controlling costs
bull Beware- wersquove been found
61
Reasons Dental Managed Care is Spreading Across the States
NON-MANAGED CARE STATE DENTAL BUDGETS ARE
OPENED ENDED
STRAIN ON STATE BUDGETS
UPCOMING RECESSION WITH TRILLION DOLLAR
DEFICIT
SHIFTS FINANCIAL RISK FROM THE STATES TO THE
PLANS
6262
Types of Medicaid Managed Care
bull State Medicaid agency administrator lowest administrative
costs
bull Third Party Administrator Typically 15 administrative costs
bull Managed Care Organization Typically 15 administrative
costs
bull Carved-in
bull Carved-out
bull Risk Based Managed Care Administrative costs part of
contract negotiation
63
RISK CONTRACTS
6464
Components of a Risk-based Contract
Risk
Medical Loss Ratio
Quality withhold
Specialty withhold
Managed care payment (pmpm)
Covered services
Fee schedule Claims are paid as usual on a FFS basis
Credentialing
Quality Review process and Quality Metrics
65
Upside Risk
The possibility that the cost of
delivering dental care to an assigned
patient panel is less than the amount
of funding calculated for that care
The Plan pays the CHC additional
funds based on a predetermine
formula
Downside Risk
The possibility that the cost of
delivering dental care to an assigned
patient panel is more than the amount
of funding calculated for that care
The CHC pays the Plan additional
funds based on a predetermine
formula
Upside and Downside Risk
66
Taking On Risk 100 or Shared Risk
With 100 risk you receive 100 of the potential savings but are also at risk for
100 of the losses
Shared Risk MCO and health center share a percentage of the risk
Shared Risk leads to better cooperation since both organizations are
incentivized to save on costs
6767
Reports Needed
bull Enrollment reports lists of who is assigned on a monthly basis
bull Reconciliation reports insure appropriate payments
bull Specialty Referral reports
bull You will need your own reporting process so you donrsquot rely completely on
reports supplied by the Plan
6868
Medical Loss Ratio
Medical Loss Ratio (MLR) is proportion of premium revenues spent on clinical
services and quality improvement also known as the Medical Loss Ratio (MLR)
For CMS requires Medical Plans to spend at least 80 to 85 of the premiums
on actual medical care
69
Administrative Fees
bull Essentially the opposite of MLR
bull The State Medicaid Agency is funded by the Governorrsquos budget
bull The State Medicaid Agency will keep some of these funds for their
admin costs and give the remaining to the Managed Care Plans
bull Private Plan admin costs can be as high as 40 but most states
limit these cost for Medicaid Plans to between 15 and 20 (85-
80 MLR)
bull This may be negotiable depending on your program size of your
program
70
Quality Withhold
bull The state withholds a certain percent (typically 2-4 ) of the funds they give
to the Plans for Value Based Reimbursement
bull They choose quality metrics and set benchmarks and assign payments for
each metric based on an assigned priority for each metric
bull If a Plan meets the benchmark of every quality metric the state passes on
their full share of the quality withhold
bull The Plans may or may not withhold a percent of the funds for quality payment
to the dentists or manage care contractors
71
Quality Withhold
Either way the Plans may or may not pass the quality payments they receive to
the dentists or contractors
This should be spelled out in a risk-based contract
72
Percent of funds set aside
to cover specialty care
referrals
Typically 10-15
Goal Limit referral costs
to within or less than
Specialty set aside
Specialty Withhold
73
Per Member Per Month
bull Capitated Payment
bull Specific dollar amount paid for each enrolled member each month
bull Paid whether patient is accessed for care or not
bull States do set access benchmarks
bull In Oregon access for any dental procedure (adults and children combined)
was 267 in 2015
74
Payment Math Example
Premium per enrollee = $25
Administrative fee 15 = $375
Funds available per enrollee to the clinic = $2125
Management fee per enrollee = $175
Funds per enrollee that would undergo PPS reconciliation = $1950
For every 10000 enrollees the managed care income = $2340000
Specialty withhold (10) = $234000
YE Cost lt or gt $2340000
Upside Risk
CHC Gains $
Downside Risk
CHC Loses $
75
Covered Services and Fee Schedules
bull The state Medicaid agency spells out the minimum procedures and fees that
MCOs must cover
bull MCOs may add procedures or increase periodicity of procedures particularly
preventative services
bull MCOs may increase fees to entice rural providers and specialists to enroll in
their Plans
bull Access Rules
bull How many days it takes to access a patent
bull How many days it takes for a patent to access urgent care services
bull How many days it takes for a patent to access emergency care services
76
Credentialing
All MCOs are required to credential all Providers
All MCOs have their own credentialing process
Credentialing process is can be lengthy
Credentialing process may be negotiable
77
Quality Review Process and Quality Metrics
MCOs must have a Quality and Compliance Review Process
If you arenrsquot in compliance with both you likely wonrsquot get paid
Typical processes reviewed
bull Charting specifications
bull Incident report
bull Enrollee complaints quality rudeness and access issues
bull Medicaid compliance
78
Quality Payments
bull State Shared Incentive Withhold Typically quality metrics and benchmarks
are set by the state sets aside a certain percent (3-5) of the payments to
the Managed Care Plan (MCP)
bull If the benchmarks are achieved the MCP is then paid the a predetermine
amount
bull Benchmarks may not be the same as the states
bull Managed Care Plans do not have to pass all or any of the quality payments to
the health centers or providers
bull Managed Care contract- Metrics benchmarks should be selected and part of
the contract
7979
Achieving Quality Metric Payments
Dealing with under achievers
Process issues
Individual issues
Identifying workflows
Developing Best Practices through
PDSA process
Developing Best Practices through
PDSA process
CHC Metrics Committee
Clinicians Operations various key staff
Identify Best Practices
Spread Best Practices
80
New Team Needed Business Intelligence
Business Intelligence (BI) is critical for effective managed care business decisions
BI team inputs metrics into your EHR collects integrates analyses and displays all your managed care business and clinical information
Easy to say- hard to achieve
Build your own or outsource
Possible future role of Primary Care Associations
8181
Clinicianrsquos Dashboard
Expensive to build
Displayed on your screen when your computer is first turned on
Easy to read and understand
Data dumped from the day before
Can dialed down from Org-wide to clinic to each clinicianrsquos data
Operational and clinical metrics
bull Treatment Plan Completion
bull DQA quality measures
bull Caries at Recall
bull Re-care reports
bull Care Gap reports
82
CONTROLLING COSTS
8383
Controlling Costs- Current
bull Increasing efficiencies
bull Decreasing broken appointments
bull Controlling supplies equipment costs
bull Staff recruitment retention costs
84
Specialty Care
Training current CHC dentists in
specialty areas
Hiring general dentists with higher
specialty skill sets
Hiring in house specialists
Contract with outside specialists
Work with Managed Care Plan
specialists
Lowering Disease Rates
Community Dental Health
Coordinators case management
If your state law allows- embed
hygienists in medical and community
to provide primary and secondary
prevention procedures
In clinic Caries Classification and
Silver Diamine Fluoride
Effective recare programs
Controlling Costs- Additions in Risk-based Contracting
85
Specialty Care ndash Primary Referrals by Cost
Pediatric dentistry
Orthodontics
Oral surgery
Endodontics
86
In-clinic Pediatric Services
Encounters expected
of operatories available
State dental law and ability to have
expanded duties
General Anesthesia
GA in- house
Ability for a hospital or surgery center
to set aside regular OR time
Ability to hire or assign DAs to GA
days
Four GA cases day x PPS rate
Should You Hire a Pediatric Dentist- It Depends
8787
Solutions for Controlling Pediatric Costs
Hire a general dentist that is skilled in treating young children
Make the clinic child friendly nitrous oxide TVs in the operatory etc
Teach entire staff behavioral control techniques
Contract with a pediatric dentist for the GA care
88
Lowering Overall Disease Rates (and Costs)
You are responsible for both the patients you see in the chair and the ones
assigned to you
Breaking down the walls of the dental clinic
Community Dental Health Coordinators
Case Management
89
Cost Control Essentials
Diagnosis codes
Increased ability to identify
disease by risk
Motivational
Interviewing
Developing Polices and
Procedures design to treat
disease according to risk
ie Silver Diamine Fluoride
Treating by Risk
Effective Recare
Process
Critical to continual disease
controlPrevention education that is
meaningful and designed to
change behaviors
90
Social Determinants of Health Aunt Bertha
httpswwwauntberthacom
91
REASON TO CONSIDER RISK- BASED CONTRACTING
9292
PPS Reconciliation and Federal Code 42 CFR sect4052469(a)(2)
42 CFR sect4052469(a)(2)
ldquoAny financial incentives provided to Federally Qualified Health Centers
under their Medicare Advantage Contracts such as risk pool payments
bonuses or withholds are prohibited from being included in the
calculation of supplemental payments due to the Federally Qualified
Health Centerrdquo
9393
Why Risk Based Contract in Times of PPS Reconciliation
bull Not all Risk- based Contract funds are reconciled
bull Risk is the key word- you can come out with less money than your normal
PPS reconciliation payment
bull Can lead to better patient care
bull May improve manage care enrollment for your medical plan
bull Promotes integrated care increases health for your CHC patients
9494
Not Included in the Reconciliation
Enrollment management pmpm
Quality Payments
Upside risk payments
Downside risk losses
9595
Determinants of Financial Success in Risk-Based Contracting
bull Most critical- State pmpm payment to the Managed Care Plan
bull Reporting capabilities
bull Specialty service capabilities
bull Access numbers count
bull Ability to move metric numbers
9696
What About the Non- Medicaid Poor We Serve
bull Numbers are king in a managed care contract and the more access you have
the better contract terms you can negotiate
bull We will potentially have a steady supply of Medicaid patients
bull As managed care spreads states this may be compromising the ability of
health centers to serve the non-Medicaid poor and others lacking dental
insurance
97
Mark Koday DDS
(509) 949-2278
Dental Quality Consultants
of WA
httpdentalqualityconsultin
gcom
dentalqualityconsultantsg
mailcom
Contact Information
LUNCH
BREAKOUT EXERCISEORAL HEALTH VALUE-BASED CARE READINESS ASSESSMENT
Danielle Apostolon
PROMISING PRACTICES FROM THE FIELD STRATEGIES FOR INCREASING VALUE IN ORAL HEALTH
Dr Carolyn Brown
Dr Kelly Perry
Dr Rachel Rivard
Dr Adeloye
Commitment Compassion Community
m i d s t a t e h e a l t h o r g
Promising Practices from the
Field Strategies for Increasing
Value in Oral Health Care
Kelly Perry DMD
Better Health
Outcomes
Improved Staff
Experience
Reduced Cost
Improved Patient
Experience
Better Health
Outcomes
Improved Staff
Experience
Reduced Cost
Improved Patient
Experience
Better Health
Outcomes
Improved Staff
Experience
Reduced Cost
Improved Patient
Experience
Better Health
Outcomes
Improved Staff
Experience
Reduced Cost
Improved Patient
Experience
Commitment Compassion Community
kpe r r ymids t a tehea l t h o rg
Thank you
Completion of Disease Control Phase
Pelumi Adeloye DMD MPH
HEALTH ACCESS NETWORK (HAN) FAMILY DENTAL
Introduction
⧫1 Dentist I Hygienist 3 EFDArsquos1 Receptionist
⧫ 6 Chairs= 4 (dentist) + 2 (hygienist)
⧫ Slide ⥶80 off
⧫ Service areas Northern Penobscot Southern Aroostook Western
Washington Counties amp more
Completion of Phase I Treatment
⧫LimitedLack of Access to dental care
⧫Difficulty completing the disease control phase
Caries amp periodontal disease
⧫Attaining stable restorative state
Goal
Increase the completion of Disease Control Phase
Current practice
⧫Education
Assess level of dental literacy
Incremental strategy
⧫Increase access to dental care
Generous sliding scale (⥸$40 per visit)
Incorporate Expanded Function Dental Assistants
⧫Schedule modification
Incorporate more restorative blocks to allow
for follow-up visit and completion of restorative phase
httpswwwglasbergencomdentist-cartoons
Schedule
⧫Piggybacking technique
Increased allotted restorative blocks
⧫Sustainability of current schedule is
contingent on cooperation amp skills of HAN
Dental staff
Note
Strategies mentioned today is personalized to HAN Dental clinic
Current implemented strategies might be modified or changed in the
future as required in order to accommodate the need of our pts
THANK YOU
DAY TWOCLOSINGWRAP-UP
End of Day Two ndash Survey
Day Two Creating a Value-Based Oral Health Care Delivery
System
129
Payment Reform in Oral Health Online Learning Module
Oral Health Value-based Care Online Learning Module
Value-based Care Keys to Success Article
Readiness Assessment
Competency Development Guide
Oral Health Value-based Care Training
Dental Caries Management Practicum
Clinicians Companion Guide
Interprofessional Network Referral Process
Traditional Dental Care Vs Value-Based Care
Resources
131
wwwDentaQuestPartnershiporg
wwwfacebookcomDentaQuest
DentaQuest
wwwlinkedincomcompanyDentaQuest
Inside_DentaQuest
QUESTIONS
32
Baseline for 2019 271
httpswwworegongovohaHPAANALYTICSCCOMetrics2019-Oral-Evaluation-Adults-Diabetespdf
33
Diabetes burden in your panel of dental patients
Baseline Medical-Dental Integrated panel of all patients
Dental patients with DM2 MDI
Dental patients with DM2
1000 or 10
600 or 60
300010000= 30
Population Health- Clinic Level
34
1 Governing objective
2 Theory of cause and effect
3 Activities of team
4 Evaluate your statistics
5 Storycraft
Discuss at meetings (Oct + Nov) Health education training
materials NP training CQI Note in Board report Clinical
measures
Care Pathways Hygiene Resources (ScheduleAvail)
ldquoTrue Measures of Successrdquo
Adapted from HBR ldquoThe True Measures of Successrdquo httpshbrorg201210the-true-measures-of-success
Diabetes Awareness Prevention Healthier Community
Prevention Awareness Care Pathway promotes health
MDI= 10 6 out of 10 adult patients with DM2
Goal set for integrated patient panels ndash PCMH
Pre-diabetes approach for executive team
Care Pathways
Care Coordination
35
MEASURING PATIENT ORAL HEALTHRisk assessments and Care Pathways
36
37
Risk Assessment and Care Pathways
Caries Risk Assessment
Multiple tools
EDREHR modules smart notes or dot phrases
CDT Codes
Decide frequency
D0601
Low Caries Risk
D0601
Moderate Caries Risk
D0601
High Caries Risk
38
The Disease Management DifferenceDisease Management Difference
Traditional Dental Care Disease Management
Approach
All patients return in 6 months
regardless of risk status
Recare interval is based on the
childrsquos caries risk
Caries Risk
Level
Recommended
Recare Interval
High Risk 1 ndash 3 months
Moderate Risk 3 ndash 6 months
Low Risk 6 ndash 12 months
Caries
Stabilizing
agents
Health Ed
Nutritional
Counseling
Anti-bacterial
and Fluoride
interventions
39
Disease Management Care Pathways
DentaQuest Partnership for Oral Health Advancement Disease Management Model
Caries
Stabilizing
agents
Whole
Person
Inter-
professional
Approaches
Anti-bacterial
and Fluoride
interventions
40
Disease Management and Risk Screening Training
DentaQuest Partnership for Oral Health Advancementrsquos
Online Learning Center
Disease Management Series
8 modules 40 CDE available
httpswwwdentaquestpartnershiporglearnonline-learning-centeronline-
coursewaredentaquest-disease-management-series
41
MEASUREMENT IN TEAMSSharing meaningful data with your dental clinical teams
42
rdquoDental Homerdquo = Health Home where WE can meet the patient
Oralhealthworkforceorg
43
POLL HOW OFTEN DO YOU SHARE YOUR S WITH YOUR DENTAL TEAM
A Yearly only
B Quarterly
C Monthly
D Weekly
E Daily
44
Clinical Measures ndash Dental Practice Perspective
Private Practice Office
New patients seen
Assigned vs seen if capitated
Treatment plans incomplete
$ produced amp per provider
$ collected amp monthly per provider
CDT 6000 codes completed
RecallHygiene maintenance
Based on this consultants experienced
FQHC
Unduplicated patients
patients seen per day
Treatment plans complete
$ gainedlost via accounting
Broken appointment rate
procedures
Sealant rate (annual)
45
bull HRSA Sealant Measure Compliance for FQHCs
bull Completion of phase 1 treatment plans
bull Children seen 0-5 years old
bull Children seen getting a preventive service
bull Fluoride Varnish applications
bull Pregnant women seen and treated
bull Diabetic patients with HbA1C gt 7 seen
bull Patients seen who have not been seen for 12 months
bull Patients seen getting a Risk Assessment
bull Patients with moderate or high risk who lower risk at recare
bull Sealants provided httpwwwnnohaorgnnoha-contentuploads201512Demystifying-HRSA-SEALANT-PRESENTATION_FINALpdf
Program Measures
46
HRSA Performance Measurement and Data Collection
bull FQHCs and look-alikes submit CY data to HRSA since 2008
bull UDS Uniform Data System
bull Require FTE for clinical staff patient demographics
bull Dental utilization s (UDCTPV)
bull Dental Clinical Measure dental sealants placed on 1st molars ages 6-9 yo
bull Health Center Quartile rankings (Clinical measure performance influences
HC rankings as does EHR adoption and other HC characteristics)
47
Low birth weight
Access to prenatal care
Childhood Immunization
Children (Ages 3-17) Receiving
Weight Assessment amp
Counseling
Children (Age 6-9) Receiving
Dental Sealant to First Molars
Diabetes Control
Hypertension Control
Pap Test
Depression Screening and
Follow-up (Age 12+)
Asthma Patients (Age 5-40)
Receiving Pharmacologic
Therapy
Colorectal Cancer
Screening (Ages 51-74)
HRSA UDS Clinical Measures
Adults (Age 18+) Receiving
Weight Screening amp Follow-up
Adults (Age 18+) Receiving
Tobacco Use Assessment and
Cessation Intervention
Coronary Artery Disease
Receiving Lipid Therapy (18+)
Ischemic Vascular Disease (IVD)
Receiving Aspirin Therapy (18+)
HIV Linkage to Care
48
Dashboards
Grants
Average
amp
Targets
Quality
Rev
Costs
Visits
Priority
Pop
Prevention
49
Dashboard- Provider Team Level
Patient
Compliance
Satisfaction
50
Case Study-
Incentives bonus round pools benchmark and improvement target goals risk-sharing possible later years
51
Qualitative Measurement
ldquoPatient engagement is the act of patients and providers working together
toward the end goal of improved patient wellnessrdquo
wwwpatientengagementhitcom
Access to Care
Patient Activation
Patient Satisfaction
Patient-Provider-Care Team Communication
Care Team Satisfaction
52
OHVBC Readiness
Leadership
bull Value of oral health and oral health transformation
Structure Systems and Operations
bull Operational efficiencies innovative care delivery methodologies
Care Pathways and Provider Buy-In
bull Training disease management risk-based care referrals IDC-10 coding patient engagement
Data and Analytic Technology and Personnel
bull Interoperability reporting
Financial Viability and Strength
bull Payerpatient mix billing infrastructure financial reports
httpswwwdentaquestpartnershiporglearnsafety-net-solutionsoral-health-value-based-careohvbc-readiness-
assessment
53
QUESTIONS COMMENTS
Carolyn Brown DDS
cbrownddsgmailcom
RISK BASED MANAGED CARE
Value Based Training Conference
Manchester New Hampshire
Mark Koday DDS
111919
5555
Objectives
bull Review current drivers of dental managed care
bull Understand the basics of risk-based dental managed care contracts
bull Learn the basics of managing costs in a riskndashbased contract
bull Gain an understanding in the potential advantage of risk-based contracting
56
What Is Dental Managed Care
Managed care is a health delivery system whose purpose is to manage both the
quality and cost of health care
Common types of managed care health insurance plans
bull HMOs
bull PPOs
bull POSs
bull Medicaid Managed Care
DIDNrsquoT WE ALREADY HAVE MANAGED CARE AND IT FAILED
57
What Has Happened Since the 90s
58
WHY THE FFS AND PPS DOESNrsquoT WORK FOR OUR POPULATIONS
bull Inefficient payment systems designed to produce encounters or procedures but not real health
bull No focus on population health
bull Does not incentivize innovation
bull Patients essentially on their own for accessing specialty care
59
Rule of 4
Source Kaiser Family Foundation analysis of National Health Expenditure (NHE) data from Centers for
Medicare and Medicaid Services Office of the Actuary National Health Statistics Group
60
Rule of 4
bull This helps explain why oral health has been relatively ignored so far by CMS
bull Explains why we have PCMH instead of PCHH
bull Where is the real value on a national level in preventing disease and
controlling costs
bull Beware- wersquove been found
61
Reasons Dental Managed Care is Spreading Across the States
NON-MANAGED CARE STATE DENTAL BUDGETS ARE
OPENED ENDED
STRAIN ON STATE BUDGETS
UPCOMING RECESSION WITH TRILLION DOLLAR
DEFICIT
SHIFTS FINANCIAL RISK FROM THE STATES TO THE
PLANS
6262
Types of Medicaid Managed Care
bull State Medicaid agency administrator lowest administrative
costs
bull Third Party Administrator Typically 15 administrative costs
bull Managed Care Organization Typically 15 administrative
costs
bull Carved-in
bull Carved-out
bull Risk Based Managed Care Administrative costs part of
contract negotiation
63
RISK CONTRACTS
6464
Components of a Risk-based Contract
Risk
Medical Loss Ratio
Quality withhold
Specialty withhold
Managed care payment (pmpm)
Covered services
Fee schedule Claims are paid as usual on a FFS basis
Credentialing
Quality Review process and Quality Metrics
65
Upside Risk
The possibility that the cost of
delivering dental care to an assigned
patient panel is less than the amount
of funding calculated for that care
The Plan pays the CHC additional
funds based on a predetermine
formula
Downside Risk
The possibility that the cost of
delivering dental care to an assigned
patient panel is more than the amount
of funding calculated for that care
The CHC pays the Plan additional
funds based on a predetermine
formula
Upside and Downside Risk
66
Taking On Risk 100 or Shared Risk
With 100 risk you receive 100 of the potential savings but are also at risk for
100 of the losses
Shared Risk MCO and health center share a percentage of the risk
Shared Risk leads to better cooperation since both organizations are
incentivized to save on costs
6767
Reports Needed
bull Enrollment reports lists of who is assigned on a monthly basis
bull Reconciliation reports insure appropriate payments
bull Specialty Referral reports
bull You will need your own reporting process so you donrsquot rely completely on
reports supplied by the Plan
6868
Medical Loss Ratio
Medical Loss Ratio (MLR) is proportion of premium revenues spent on clinical
services and quality improvement also known as the Medical Loss Ratio (MLR)
For CMS requires Medical Plans to spend at least 80 to 85 of the premiums
on actual medical care
69
Administrative Fees
bull Essentially the opposite of MLR
bull The State Medicaid Agency is funded by the Governorrsquos budget
bull The State Medicaid Agency will keep some of these funds for their
admin costs and give the remaining to the Managed Care Plans
bull Private Plan admin costs can be as high as 40 but most states
limit these cost for Medicaid Plans to between 15 and 20 (85-
80 MLR)
bull This may be negotiable depending on your program size of your
program
70
Quality Withhold
bull The state withholds a certain percent (typically 2-4 ) of the funds they give
to the Plans for Value Based Reimbursement
bull They choose quality metrics and set benchmarks and assign payments for
each metric based on an assigned priority for each metric
bull If a Plan meets the benchmark of every quality metric the state passes on
their full share of the quality withhold
bull The Plans may or may not withhold a percent of the funds for quality payment
to the dentists or manage care contractors
71
Quality Withhold
Either way the Plans may or may not pass the quality payments they receive to
the dentists or contractors
This should be spelled out in a risk-based contract
72
Percent of funds set aside
to cover specialty care
referrals
Typically 10-15
Goal Limit referral costs
to within or less than
Specialty set aside
Specialty Withhold
73
Per Member Per Month
bull Capitated Payment
bull Specific dollar amount paid for each enrolled member each month
bull Paid whether patient is accessed for care or not
bull States do set access benchmarks
bull In Oregon access for any dental procedure (adults and children combined)
was 267 in 2015
74
Payment Math Example
Premium per enrollee = $25
Administrative fee 15 = $375
Funds available per enrollee to the clinic = $2125
Management fee per enrollee = $175
Funds per enrollee that would undergo PPS reconciliation = $1950
For every 10000 enrollees the managed care income = $2340000
Specialty withhold (10) = $234000
YE Cost lt or gt $2340000
Upside Risk
CHC Gains $
Downside Risk
CHC Loses $
75
Covered Services and Fee Schedules
bull The state Medicaid agency spells out the minimum procedures and fees that
MCOs must cover
bull MCOs may add procedures or increase periodicity of procedures particularly
preventative services
bull MCOs may increase fees to entice rural providers and specialists to enroll in
their Plans
bull Access Rules
bull How many days it takes to access a patent
bull How many days it takes for a patent to access urgent care services
bull How many days it takes for a patent to access emergency care services
76
Credentialing
All MCOs are required to credential all Providers
All MCOs have their own credentialing process
Credentialing process is can be lengthy
Credentialing process may be negotiable
77
Quality Review Process and Quality Metrics
MCOs must have a Quality and Compliance Review Process
If you arenrsquot in compliance with both you likely wonrsquot get paid
Typical processes reviewed
bull Charting specifications
bull Incident report
bull Enrollee complaints quality rudeness and access issues
bull Medicaid compliance
78
Quality Payments
bull State Shared Incentive Withhold Typically quality metrics and benchmarks
are set by the state sets aside a certain percent (3-5) of the payments to
the Managed Care Plan (MCP)
bull If the benchmarks are achieved the MCP is then paid the a predetermine
amount
bull Benchmarks may not be the same as the states
bull Managed Care Plans do not have to pass all or any of the quality payments to
the health centers or providers
bull Managed Care contract- Metrics benchmarks should be selected and part of
the contract
7979
Achieving Quality Metric Payments
Dealing with under achievers
Process issues
Individual issues
Identifying workflows
Developing Best Practices through
PDSA process
Developing Best Practices through
PDSA process
CHC Metrics Committee
Clinicians Operations various key staff
Identify Best Practices
Spread Best Practices
80
New Team Needed Business Intelligence
Business Intelligence (BI) is critical for effective managed care business decisions
BI team inputs metrics into your EHR collects integrates analyses and displays all your managed care business and clinical information
Easy to say- hard to achieve
Build your own or outsource
Possible future role of Primary Care Associations
8181
Clinicianrsquos Dashboard
Expensive to build
Displayed on your screen when your computer is first turned on
Easy to read and understand
Data dumped from the day before
Can dialed down from Org-wide to clinic to each clinicianrsquos data
Operational and clinical metrics
bull Treatment Plan Completion
bull DQA quality measures
bull Caries at Recall
bull Re-care reports
bull Care Gap reports
82
CONTROLLING COSTS
8383
Controlling Costs- Current
bull Increasing efficiencies
bull Decreasing broken appointments
bull Controlling supplies equipment costs
bull Staff recruitment retention costs
84
Specialty Care
Training current CHC dentists in
specialty areas
Hiring general dentists with higher
specialty skill sets
Hiring in house specialists
Contract with outside specialists
Work with Managed Care Plan
specialists
Lowering Disease Rates
Community Dental Health
Coordinators case management
If your state law allows- embed
hygienists in medical and community
to provide primary and secondary
prevention procedures
In clinic Caries Classification and
Silver Diamine Fluoride
Effective recare programs
Controlling Costs- Additions in Risk-based Contracting
85
Specialty Care ndash Primary Referrals by Cost
Pediatric dentistry
Orthodontics
Oral surgery
Endodontics
86
In-clinic Pediatric Services
Encounters expected
of operatories available
State dental law and ability to have
expanded duties
General Anesthesia
GA in- house
Ability for a hospital or surgery center
to set aside regular OR time
Ability to hire or assign DAs to GA
days
Four GA cases day x PPS rate
Should You Hire a Pediatric Dentist- It Depends
8787
Solutions for Controlling Pediatric Costs
Hire a general dentist that is skilled in treating young children
Make the clinic child friendly nitrous oxide TVs in the operatory etc
Teach entire staff behavioral control techniques
Contract with a pediatric dentist for the GA care
88
Lowering Overall Disease Rates (and Costs)
You are responsible for both the patients you see in the chair and the ones
assigned to you
Breaking down the walls of the dental clinic
Community Dental Health Coordinators
Case Management
89
Cost Control Essentials
Diagnosis codes
Increased ability to identify
disease by risk
Motivational
Interviewing
Developing Polices and
Procedures design to treat
disease according to risk
ie Silver Diamine Fluoride
Treating by Risk
Effective Recare
Process
Critical to continual disease
controlPrevention education that is
meaningful and designed to
change behaviors
90
Social Determinants of Health Aunt Bertha
httpswwwauntberthacom
91
REASON TO CONSIDER RISK- BASED CONTRACTING
9292
PPS Reconciliation and Federal Code 42 CFR sect4052469(a)(2)
42 CFR sect4052469(a)(2)
ldquoAny financial incentives provided to Federally Qualified Health Centers
under their Medicare Advantage Contracts such as risk pool payments
bonuses or withholds are prohibited from being included in the
calculation of supplemental payments due to the Federally Qualified
Health Centerrdquo
9393
Why Risk Based Contract in Times of PPS Reconciliation
bull Not all Risk- based Contract funds are reconciled
bull Risk is the key word- you can come out with less money than your normal
PPS reconciliation payment
bull Can lead to better patient care
bull May improve manage care enrollment for your medical plan
bull Promotes integrated care increases health for your CHC patients
9494
Not Included in the Reconciliation
Enrollment management pmpm
Quality Payments
Upside risk payments
Downside risk losses
9595
Determinants of Financial Success in Risk-Based Contracting
bull Most critical- State pmpm payment to the Managed Care Plan
bull Reporting capabilities
bull Specialty service capabilities
bull Access numbers count
bull Ability to move metric numbers
9696
What About the Non- Medicaid Poor We Serve
bull Numbers are king in a managed care contract and the more access you have
the better contract terms you can negotiate
bull We will potentially have a steady supply of Medicaid patients
bull As managed care spreads states this may be compromising the ability of
health centers to serve the non-Medicaid poor and others lacking dental
insurance
97
Mark Koday DDS
(509) 949-2278
Dental Quality Consultants
of WA
httpdentalqualityconsultin
gcom
dentalqualityconsultantsg
mailcom
Contact Information
LUNCH
BREAKOUT EXERCISEORAL HEALTH VALUE-BASED CARE READINESS ASSESSMENT
Danielle Apostolon
PROMISING PRACTICES FROM THE FIELD STRATEGIES FOR INCREASING VALUE IN ORAL HEALTH
Dr Carolyn Brown
Dr Kelly Perry
Dr Rachel Rivard
Dr Adeloye
Commitment Compassion Community
m i d s t a t e h e a l t h o r g
Promising Practices from the
Field Strategies for Increasing
Value in Oral Health Care
Kelly Perry DMD
Better Health
Outcomes
Improved Staff
Experience
Reduced Cost
Improved Patient
Experience
Better Health
Outcomes
Improved Staff
Experience
Reduced Cost
Improved Patient
Experience
Better Health
Outcomes
Improved Staff
Experience
Reduced Cost
Improved Patient
Experience
Better Health
Outcomes
Improved Staff
Experience
Reduced Cost
Improved Patient
Experience
Commitment Compassion Community
kpe r r ymids t a tehea l t h o rg
Thank you
Completion of Disease Control Phase
Pelumi Adeloye DMD MPH
HEALTH ACCESS NETWORK (HAN) FAMILY DENTAL
Introduction
⧫1 Dentist I Hygienist 3 EFDArsquos1 Receptionist
⧫ 6 Chairs= 4 (dentist) + 2 (hygienist)
⧫ Slide ⥶80 off
⧫ Service areas Northern Penobscot Southern Aroostook Western
Washington Counties amp more
Completion of Phase I Treatment
⧫LimitedLack of Access to dental care
⧫Difficulty completing the disease control phase
Caries amp periodontal disease
⧫Attaining stable restorative state
Goal
Increase the completion of Disease Control Phase
Current practice
⧫Education
Assess level of dental literacy
Incremental strategy
⧫Increase access to dental care
Generous sliding scale (⥸$40 per visit)
Incorporate Expanded Function Dental Assistants
⧫Schedule modification
Incorporate more restorative blocks to allow
for follow-up visit and completion of restorative phase
httpswwwglasbergencomdentist-cartoons
Schedule
⧫Piggybacking technique
Increased allotted restorative blocks
⧫Sustainability of current schedule is
contingent on cooperation amp skills of HAN
Dental staff
Note
Strategies mentioned today is personalized to HAN Dental clinic
Current implemented strategies might be modified or changed in the
future as required in order to accommodate the need of our pts
THANK YOU
DAY TWOCLOSINGWRAP-UP
End of Day Two ndash Survey
Day Two Creating a Value-Based Oral Health Care Delivery
System
129
Payment Reform in Oral Health Online Learning Module
Oral Health Value-based Care Online Learning Module
Value-based Care Keys to Success Article
Readiness Assessment
Competency Development Guide
Oral Health Value-based Care Training
Dental Caries Management Practicum
Clinicians Companion Guide
Interprofessional Network Referral Process
Traditional Dental Care Vs Value-Based Care
Resources
131
wwwDentaQuestPartnershiporg
wwwfacebookcomDentaQuest
DentaQuest
wwwlinkedincomcompanyDentaQuest
Inside_DentaQuest
QUESTIONS
33
Diabetes burden in your panel of dental patients
Baseline Medical-Dental Integrated panel of all patients
Dental patients with DM2 MDI
Dental patients with DM2
1000 or 10
600 or 60
300010000= 30
Population Health- Clinic Level
34
1 Governing objective
2 Theory of cause and effect
3 Activities of team
4 Evaluate your statistics
5 Storycraft
Discuss at meetings (Oct + Nov) Health education training
materials NP training CQI Note in Board report Clinical
measures
Care Pathways Hygiene Resources (ScheduleAvail)
ldquoTrue Measures of Successrdquo
Adapted from HBR ldquoThe True Measures of Successrdquo httpshbrorg201210the-true-measures-of-success
Diabetes Awareness Prevention Healthier Community
Prevention Awareness Care Pathway promotes health
MDI= 10 6 out of 10 adult patients with DM2
Goal set for integrated patient panels ndash PCMH
Pre-diabetes approach for executive team
Care Pathways
Care Coordination
35
MEASURING PATIENT ORAL HEALTHRisk assessments and Care Pathways
36
37
Risk Assessment and Care Pathways
Caries Risk Assessment
Multiple tools
EDREHR modules smart notes or dot phrases
CDT Codes
Decide frequency
D0601
Low Caries Risk
D0601
Moderate Caries Risk
D0601
High Caries Risk
38
The Disease Management DifferenceDisease Management Difference
Traditional Dental Care Disease Management
Approach
All patients return in 6 months
regardless of risk status
Recare interval is based on the
childrsquos caries risk
Caries Risk
Level
Recommended
Recare Interval
High Risk 1 ndash 3 months
Moderate Risk 3 ndash 6 months
Low Risk 6 ndash 12 months
Caries
Stabilizing
agents
Health Ed
Nutritional
Counseling
Anti-bacterial
and Fluoride
interventions
39
Disease Management Care Pathways
DentaQuest Partnership for Oral Health Advancement Disease Management Model
Caries
Stabilizing
agents
Whole
Person
Inter-
professional
Approaches
Anti-bacterial
and Fluoride
interventions
40
Disease Management and Risk Screening Training
DentaQuest Partnership for Oral Health Advancementrsquos
Online Learning Center
Disease Management Series
8 modules 40 CDE available
httpswwwdentaquestpartnershiporglearnonline-learning-centeronline-
coursewaredentaquest-disease-management-series
41
MEASUREMENT IN TEAMSSharing meaningful data with your dental clinical teams
42
rdquoDental Homerdquo = Health Home where WE can meet the patient
Oralhealthworkforceorg
43
POLL HOW OFTEN DO YOU SHARE YOUR S WITH YOUR DENTAL TEAM
A Yearly only
B Quarterly
C Monthly
D Weekly
E Daily
44
Clinical Measures ndash Dental Practice Perspective
Private Practice Office
New patients seen
Assigned vs seen if capitated
Treatment plans incomplete
$ produced amp per provider
$ collected amp monthly per provider
CDT 6000 codes completed
RecallHygiene maintenance
Based on this consultants experienced
FQHC
Unduplicated patients
patients seen per day
Treatment plans complete
$ gainedlost via accounting
Broken appointment rate
procedures
Sealant rate (annual)
45
bull HRSA Sealant Measure Compliance for FQHCs
bull Completion of phase 1 treatment plans
bull Children seen 0-5 years old
bull Children seen getting a preventive service
bull Fluoride Varnish applications
bull Pregnant women seen and treated
bull Diabetic patients with HbA1C gt 7 seen
bull Patients seen who have not been seen for 12 months
bull Patients seen getting a Risk Assessment
bull Patients with moderate or high risk who lower risk at recare
bull Sealants provided httpwwwnnohaorgnnoha-contentuploads201512Demystifying-HRSA-SEALANT-PRESENTATION_FINALpdf
Program Measures
46
HRSA Performance Measurement and Data Collection
bull FQHCs and look-alikes submit CY data to HRSA since 2008
bull UDS Uniform Data System
bull Require FTE for clinical staff patient demographics
bull Dental utilization s (UDCTPV)
bull Dental Clinical Measure dental sealants placed on 1st molars ages 6-9 yo
bull Health Center Quartile rankings (Clinical measure performance influences
HC rankings as does EHR adoption and other HC characteristics)
47
Low birth weight
Access to prenatal care
Childhood Immunization
Children (Ages 3-17) Receiving
Weight Assessment amp
Counseling
Children (Age 6-9) Receiving
Dental Sealant to First Molars
Diabetes Control
Hypertension Control
Pap Test
Depression Screening and
Follow-up (Age 12+)
Asthma Patients (Age 5-40)
Receiving Pharmacologic
Therapy
Colorectal Cancer
Screening (Ages 51-74)
HRSA UDS Clinical Measures
Adults (Age 18+) Receiving
Weight Screening amp Follow-up
Adults (Age 18+) Receiving
Tobacco Use Assessment and
Cessation Intervention
Coronary Artery Disease
Receiving Lipid Therapy (18+)
Ischemic Vascular Disease (IVD)
Receiving Aspirin Therapy (18+)
HIV Linkage to Care
48
Dashboards
Grants
Average
amp
Targets
Quality
Rev
Costs
Visits
Priority
Pop
Prevention
49
Dashboard- Provider Team Level
Patient
Compliance
Satisfaction
50
Case Study-
Incentives bonus round pools benchmark and improvement target goals risk-sharing possible later years
51
Qualitative Measurement
ldquoPatient engagement is the act of patients and providers working together
toward the end goal of improved patient wellnessrdquo
wwwpatientengagementhitcom
Access to Care
Patient Activation
Patient Satisfaction
Patient-Provider-Care Team Communication
Care Team Satisfaction
52
OHVBC Readiness
Leadership
bull Value of oral health and oral health transformation
Structure Systems and Operations
bull Operational efficiencies innovative care delivery methodologies
Care Pathways and Provider Buy-In
bull Training disease management risk-based care referrals IDC-10 coding patient engagement
Data and Analytic Technology and Personnel
bull Interoperability reporting
Financial Viability and Strength
bull Payerpatient mix billing infrastructure financial reports
httpswwwdentaquestpartnershiporglearnsafety-net-solutionsoral-health-value-based-careohvbc-readiness-
assessment
53
QUESTIONS COMMENTS
Carolyn Brown DDS
cbrownddsgmailcom
RISK BASED MANAGED CARE
Value Based Training Conference
Manchester New Hampshire
Mark Koday DDS
111919
5555
Objectives
bull Review current drivers of dental managed care
bull Understand the basics of risk-based dental managed care contracts
bull Learn the basics of managing costs in a riskndashbased contract
bull Gain an understanding in the potential advantage of risk-based contracting
56
What Is Dental Managed Care
Managed care is a health delivery system whose purpose is to manage both the
quality and cost of health care
Common types of managed care health insurance plans
bull HMOs
bull PPOs
bull POSs
bull Medicaid Managed Care
DIDNrsquoT WE ALREADY HAVE MANAGED CARE AND IT FAILED
57
What Has Happened Since the 90s
58
WHY THE FFS AND PPS DOESNrsquoT WORK FOR OUR POPULATIONS
bull Inefficient payment systems designed to produce encounters or procedures but not real health
bull No focus on population health
bull Does not incentivize innovation
bull Patients essentially on their own for accessing specialty care
59
Rule of 4
Source Kaiser Family Foundation analysis of National Health Expenditure (NHE) data from Centers for
Medicare and Medicaid Services Office of the Actuary National Health Statistics Group
60
Rule of 4
bull This helps explain why oral health has been relatively ignored so far by CMS
bull Explains why we have PCMH instead of PCHH
bull Where is the real value on a national level in preventing disease and
controlling costs
bull Beware- wersquove been found
61
Reasons Dental Managed Care is Spreading Across the States
NON-MANAGED CARE STATE DENTAL BUDGETS ARE
OPENED ENDED
STRAIN ON STATE BUDGETS
UPCOMING RECESSION WITH TRILLION DOLLAR
DEFICIT
SHIFTS FINANCIAL RISK FROM THE STATES TO THE
PLANS
6262
Types of Medicaid Managed Care
bull State Medicaid agency administrator lowest administrative
costs
bull Third Party Administrator Typically 15 administrative costs
bull Managed Care Organization Typically 15 administrative
costs
bull Carved-in
bull Carved-out
bull Risk Based Managed Care Administrative costs part of
contract negotiation
63
RISK CONTRACTS
6464
Components of a Risk-based Contract
Risk
Medical Loss Ratio
Quality withhold
Specialty withhold
Managed care payment (pmpm)
Covered services
Fee schedule Claims are paid as usual on a FFS basis
Credentialing
Quality Review process and Quality Metrics
65
Upside Risk
The possibility that the cost of
delivering dental care to an assigned
patient panel is less than the amount
of funding calculated for that care
The Plan pays the CHC additional
funds based on a predetermine
formula
Downside Risk
The possibility that the cost of
delivering dental care to an assigned
patient panel is more than the amount
of funding calculated for that care
The CHC pays the Plan additional
funds based on a predetermine
formula
Upside and Downside Risk
66
Taking On Risk 100 or Shared Risk
With 100 risk you receive 100 of the potential savings but are also at risk for
100 of the losses
Shared Risk MCO and health center share a percentage of the risk
Shared Risk leads to better cooperation since both organizations are
incentivized to save on costs
6767
Reports Needed
bull Enrollment reports lists of who is assigned on a monthly basis
bull Reconciliation reports insure appropriate payments
bull Specialty Referral reports
bull You will need your own reporting process so you donrsquot rely completely on
reports supplied by the Plan
6868
Medical Loss Ratio
Medical Loss Ratio (MLR) is proportion of premium revenues spent on clinical
services and quality improvement also known as the Medical Loss Ratio (MLR)
For CMS requires Medical Plans to spend at least 80 to 85 of the premiums
on actual medical care
69
Administrative Fees
bull Essentially the opposite of MLR
bull The State Medicaid Agency is funded by the Governorrsquos budget
bull The State Medicaid Agency will keep some of these funds for their
admin costs and give the remaining to the Managed Care Plans
bull Private Plan admin costs can be as high as 40 but most states
limit these cost for Medicaid Plans to between 15 and 20 (85-
80 MLR)
bull This may be negotiable depending on your program size of your
program
70
Quality Withhold
bull The state withholds a certain percent (typically 2-4 ) of the funds they give
to the Plans for Value Based Reimbursement
bull They choose quality metrics and set benchmarks and assign payments for
each metric based on an assigned priority for each metric
bull If a Plan meets the benchmark of every quality metric the state passes on
their full share of the quality withhold
bull The Plans may or may not withhold a percent of the funds for quality payment
to the dentists or manage care contractors
71
Quality Withhold
Either way the Plans may or may not pass the quality payments they receive to
the dentists or contractors
This should be spelled out in a risk-based contract
72
Percent of funds set aside
to cover specialty care
referrals
Typically 10-15
Goal Limit referral costs
to within or less than
Specialty set aside
Specialty Withhold
73
Per Member Per Month
bull Capitated Payment
bull Specific dollar amount paid for each enrolled member each month
bull Paid whether patient is accessed for care or not
bull States do set access benchmarks
bull In Oregon access for any dental procedure (adults and children combined)
was 267 in 2015
74
Payment Math Example
Premium per enrollee = $25
Administrative fee 15 = $375
Funds available per enrollee to the clinic = $2125
Management fee per enrollee = $175
Funds per enrollee that would undergo PPS reconciliation = $1950
For every 10000 enrollees the managed care income = $2340000
Specialty withhold (10) = $234000
YE Cost lt or gt $2340000
Upside Risk
CHC Gains $
Downside Risk
CHC Loses $
75
Covered Services and Fee Schedules
bull The state Medicaid agency spells out the minimum procedures and fees that
MCOs must cover
bull MCOs may add procedures or increase periodicity of procedures particularly
preventative services
bull MCOs may increase fees to entice rural providers and specialists to enroll in
their Plans
bull Access Rules
bull How many days it takes to access a patent
bull How many days it takes for a patent to access urgent care services
bull How many days it takes for a patent to access emergency care services
76
Credentialing
All MCOs are required to credential all Providers
All MCOs have their own credentialing process
Credentialing process is can be lengthy
Credentialing process may be negotiable
77
Quality Review Process and Quality Metrics
MCOs must have a Quality and Compliance Review Process
If you arenrsquot in compliance with both you likely wonrsquot get paid
Typical processes reviewed
bull Charting specifications
bull Incident report
bull Enrollee complaints quality rudeness and access issues
bull Medicaid compliance
78
Quality Payments
bull State Shared Incentive Withhold Typically quality metrics and benchmarks
are set by the state sets aside a certain percent (3-5) of the payments to
the Managed Care Plan (MCP)
bull If the benchmarks are achieved the MCP is then paid the a predetermine
amount
bull Benchmarks may not be the same as the states
bull Managed Care Plans do not have to pass all or any of the quality payments to
the health centers or providers
bull Managed Care contract- Metrics benchmarks should be selected and part of
the contract
7979
Achieving Quality Metric Payments
Dealing with under achievers
Process issues
Individual issues
Identifying workflows
Developing Best Practices through
PDSA process
Developing Best Practices through
PDSA process
CHC Metrics Committee
Clinicians Operations various key staff
Identify Best Practices
Spread Best Practices
80
New Team Needed Business Intelligence
Business Intelligence (BI) is critical for effective managed care business decisions
BI team inputs metrics into your EHR collects integrates analyses and displays all your managed care business and clinical information
Easy to say- hard to achieve
Build your own or outsource
Possible future role of Primary Care Associations
8181
Clinicianrsquos Dashboard
Expensive to build
Displayed on your screen when your computer is first turned on
Easy to read and understand
Data dumped from the day before
Can dialed down from Org-wide to clinic to each clinicianrsquos data
Operational and clinical metrics
bull Treatment Plan Completion
bull DQA quality measures
bull Caries at Recall
bull Re-care reports
bull Care Gap reports
82
CONTROLLING COSTS
8383
Controlling Costs- Current
bull Increasing efficiencies
bull Decreasing broken appointments
bull Controlling supplies equipment costs
bull Staff recruitment retention costs
84
Specialty Care
Training current CHC dentists in
specialty areas
Hiring general dentists with higher
specialty skill sets
Hiring in house specialists
Contract with outside specialists
Work with Managed Care Plan
specialists
Lowering Disease Rates
Community Dental Health
Coordinators case management
If your state law allows- embed
hygienists in medical and community
to provide primary and secondary
prevention procedures
In clinic Caries Classification and
Silver Diamine Fluoride
Effective recare programs
Controlling Costs- Additions in Risk-based Contracting
85
Specialty Care ndash Primary Referrals by Cost
Pediatric dentistry
Orthodontics
Oral surgery
Endodontics
86
In-clinic Pediatric Services
Encounters expected
of operatories available
State dental law and ability to have
expanded duties
General Anesthesia
GA in- house
Ability for a hospital or surgery center
to set aside regular OR time
Ability to hire or assign DAs to GA
days
Four GA cases day x PPS rate
Should You Hire a Pediatric Dentist- It Depends
8787
Solutions for Controlling Pediatric Costs
Hire a general dentist that is skilled in treating young children
Make the clinic child friendly nitrous oxide TVs in the operatory etc
Teach entire staff behavioral control techniques
Contract with a pediatric dentist for the GA care
88
Lowering Overall Disease Rates (and Costs)
You are responsible for both the patients you see in the chair and the ones
assigned to you
Breaking down the walls of the dental clinic
Community Dental Health Coordinators
Case Management
89
Cost Control Essentials
Diagnosis codes
Increased ability to identify
disease by risk
Motivational
Interviewing
Developing Polices and
Procedures design to treat
disease according to risk
ie Silver Diamine Fluoride
Treating by Risk
Effective Recare
Process
Critical to continual disease
controlPrevention education that is
meaningful and designed to
change behaviors
90
Social Determinants of Health Aunt Bertha
httpswwwauntberthacom
91
REASON TO CONSIDER RISK- BASED CONTRACTING
9292
PPS Reconciliation and Federal Code 42 CFR sect4052469(a)(2)
42 CFR sect4052469(a)(2)
ldquoAny financial incentives provided to Federally Qualified Health Centers
under their Medicare Advantage Contracts such as risk pool payments
bonuses or withholds are prohibited from being included in the
calculation of supplemental payments due to the Federally Qualified
Health Centerrdquo
9393
Why Risk Based Contract in Times of PPS Reconciliation
bull Not all Risk- based Contract funds are reconciled
bull Risk is the key word- you can come out with less money than your normal
PPS reconciliation payment
bull Can lead to better patient care
bull May improve manage care enrollment for your medical plan
bull Promotes integrated care increases health for your CHC patients
9494
Not Included in the Reconciliation
Enrollment management pmpm
Quality Payments
Upside risk payments
Downside risk losses
9595
Determinants of Financial Success in Risk-Based Contracting
bull Most critical- State pmpm payment to the Managed Care Plan
bull Reporting capabilities
bull Specialty service capabilities
bull Access numbers count
bull Ability to move metric numbers
9696
What About the Non- Medicaid Poor We Serve
bull Numbers are king in a managed care contract and the more access you have
the better contract terms you can negotiate
bull We will potentially have a steady supply of Medicaid patients
bull As managed care spreads states this may be compromising the ability of
health centers to serve the non-Medicaid poor and others lacking dental
insurance
97
Mark Koday DDS
(509) 949-2278
Dental Quality Consultants
of WA
httpdentalqualityconsultin
gcom
dentalqualityconsultantsg
mailcom
Contact Information
LUNCH
BREAKOUT EXERCISEORAL HEALTH VALUE-BASED CARE READINESS ASSESSMENT
Danielle Apostolon
PROMISING PRACTICES FROM THE FIELD STRATEGIES FOR INCREASING VALUE IN ORAL HEALTH
Dr Carolyn Brown
Dr Kelly Perry
Dr Rachel Rivard
Dr Adeloye
Commitment Compassion Community
m i d s t a t e h e a l t h o r g
Promising Practices from the
Field Strategies for Increasing
Value in Oral Health Care
Kelly Perry DMD
Better Health
Outcomes
Improved Staff
Experience
Reduced Cost
Improved Patient
Experience
Better Health
Outcomes
Improved Staff
Experience
Reduced Cost
Improved Patient
Experience
Better Health
Outcomes
Improved Staff
Experience
Reduced Cost
Improved Patient
Experience
Better Health
Outcomes
Improved Staff
Experience
Reduced Cost
Improved Patient
Experience
Commitment Compassion Community
kpe r r ymids t a tehea l t h o rg
Thank you
Completion of Disease Control Phase
Pelumi Adeloye DMD MPH
HEALTH ACCESS NETWORK (HAN) FAMILY DENTAL
Introduction
⧫1 Dentist I Hygienist 3 EFDArsquos1 Receptionist
⧫ 6 Chairs= 4 (dentist) + 2 (hygienist)
⧫ Slide ⥶80 off
⧫ Service areas Northern Penobscot Southern Aroostook Western
Washington Counties amp more
Completion of Phase I Treatment
⧫LimitedLack of Access to dental care
⧫Difficulty completing the disease control phase
Caries amp periodontal disease
⧫Attaining stable restorative state
Goal
Increase the completion of Disease Control Phase
Current practice
⧫Education
Assess level of dental literacy
Incremental strategy
⧫Increase access to dental care
Generous sliding scale (⥸$40 per visit)
Incorporate Expanded Function Dental Assistants
⧫Schedule modification
Incorporate more restorative blocks to allow
for follow-up visit and completion of restorative phase
httpswwwglasbergencomdentist-cartoons
Schedule
⧫Piggybacking technique
Increased allotted restorative blocks
⧫Sustainability of current schedule is
contingent on cooperation amp skills of HAN
Dental staff
Note
Strategies mentioned today is personalized to HAN Dental clinic
Current implemented strategies might be modified or changed in the
future as required in order to accommodate the need of our pts
THANK YOU
DAY TWOCLOSINGWRAP-UP
End of Day Two ndash Survey
Day Two Creating a Value-Based Oral Health Care Delivery
System
129
Payment Reform in Oral Health Online Learning Module
Oral Health Value-based Care Online Learning Module
Value-based Care Keys to Success Article
Readiness Assessment
Competency Development Guide
Oral Health Value-based Care Training
Dental Caries Management Practicum
Clinicians Companion Guide
Interprofessional Network Referral Process
Traditional Dental Care Vs Value-Based Care
Resources
131
wwwDentaQuestPartnershiporg
wwwfacebookcomDentaQuest
DentaQuest
wwwlinkedincomcompanyDentaQuest
Inside_DentaQuest
QUESTIONS
34
1 Governing objective
2 Theory of cause and effect
3 Activities of team
4 Evaluate your statistics
5 Storycraft
Discuss at meetings (Oct + Nov) Health education training
materials NP training CQI Note in Board report Clinical
measures
Care Pathways Hygiene Resources (ScheduleAvail)
ldquoTrue Measures of Successrdquo
Adapted from HBR ldquoThe True Measures of Successrdquo httpshbrorg201210the-true-measures-of-success
Diabetes Awareness Prevention Healthier Community
Prevention Awareness Care Pathway promotes health
MDI= 10 6 out of 10 adult patients with DM2
Goal set for integrated patient panels ndash PCMH
Pre-diabetes approach for executive team
Care Pathways
Care Coordination
35
MEASURING PATIENT ORAL HEALTHRisk assessments and Care Pathways
36
37
Risk Assessment and Care Pathways
Caries Risk Assessment
Multiple tools
EDREHR modules smart notes or dot phrases
CDT Codes
Decide frequency
D0601
Low Caries Risk
D0601
Moderate Caries Risk
D0601
High Caries Risk
38
The Disease Management DifferenceDisease Management Difference
Traditional Dental Care Disease Management
Approach
All patients return in 6 months
regardless of risk status
Recare interval is based on the
childrsquos caries risk
Caries Risk
Level
Recommended
Recare Interval
High Risk 1 ndash 3 months
Moderate Risk 3 ndash 6 months
Low Risk 6 ndash 12 months
Caries
Stabilizing
agents
Health Ed
Nutritional
Counseling
Anti-bacterial
and Fluoride
interventions
39
Disease Management Care Pathways
DentaQuest Partnership for Oral Health Advancement Disease Management Model
Caries
Stabilizing
agents
Whole
Person
Inter-
professional
Approaches
Anti-bacterial
and Fluoride
interventions
40
Disease Management and Risk Screening Training
DentaQuest Partnership for Oral Health Advancementrsquos
Online Learning Center
Disease Management Series
8 modules 40 CDE available
httpswwwdentaquestpartnershiporglearnonline-learning-centeronline-
coursewaredentaquest-disease-management-series
41
MEASUREMENT IN TEAMSSharing meaningful data with your dental clinical teams
42
rdquoDental Homerdquo = Health Home where WE can meet the patient
Oralhealthworkforceorg
43
POLL HOW OFTEN DO YOU SHARE YOUR S WITH YOUR DENTAL TEAM
A Yearly only
B Quarterly
C Monthly
D Weekly
E Daily
44
Clinical Measures ndash Dental Practice Perspective
Private Practice Office
New patients seen
Assigned vs seen if capitated
Treatment plans incomplete
$ produced amp per provider
$ collected amp monthly per provider
CDT 6000 codes completed
RecallHygiene maintenance
Based on this consultants experienced
FQHC
Unduplicated patients
patients seen per day
Treatment plans complete
$ gainedlost via accounting
Broken appointment rate
procedures
Sealant rate (annual)
45
bull HRSA Sealant Measure Compliance for FQHCs
bull Completion of phase 1 treatment plans
bull Children seen 0-5 years old
bull Children seen getting a preventive service
bull Fluoride Varnish applications
bull Pregnant women seen and treated
bull Diabetic patients with HbA1C gt 7 seen
bull Patients seen who have not been seen for 12 months
bull Patients seen getting a Risk Assessment
bull Patients with moderate or high risk who lower risk at recare
bull Sealants provided httpwwwnnohaorgnnoha-contentuploads201512Demystifying-HRSA-SEALANT-PRESENTATION_FINALpdf
Program Measures
46
HRSA Performance Measurement and Data Collection
bull FQHCs and look-alikes submit CY data to HRSA since 2008
bull UDS Uniform Data System
bull Require FTE for clinical staff patient demographics
bull Dental utilization s (UDCTPV)
bull Dental Clinical Measure dental sealants placed on 1st molars ages 6-9 yo
bull Health Center Quartile rankings (Clinical measure performance influences
HC rankings as does EHR adoption and other HC characteristics)
47
Low birth weight
Access to prenatal care
Childhood Immunization
Children (Ages 3-17) Receiving
Weight Assessment amp
Counseling
Children (Age 6-9) Receiving
Dental Sealant to First Molars
Diabetes Control
Hypertension Control
Pap Test
Depression Screening and
Follow-up (Age 12+)
Asthma Patients (Age 5-40)
Receiving Pharmacologic
Therapy
Colorectal Cancer
Screening (Ages 51-74)
HRSA UDS Clinical Measures
Adults (Age 18+) Receiving
Weight Screening amp Follow-up
Adults (Age 18+) Receiving
Tobacco Use Assessment and
Cessation Intervention
Coronary Artery Disease
Receiving Lipid Therapy (18+)
Ischemic Vascular Disease (IVD)
Receiving Aspirin Therapy (18+)
HIV Linkage to Care
48
Dashboards
Grants
Average
amp
Targets
Quality
Rev
Costs
Visits
Priority
Pop
Prevention
49
Dashboard- Provider Team Level
Patient
Compliance
Satisfaction
50
Case Study-
Incentives bonus round pools benchmark and improvement target goals risk-sharing possible later years
51
Qualitative Measurement
ldquoPatient engagement is the act of patients and providers working together
toward the end goal of improved patient wellnessrdquo
wwwpatientengagementhitcom
Access to Care
Patient Activation
Patient Satisfaction
Patient-Provider-Care Team Communication
Care Team Satisfaction
52
OHVBC Readiness
Leadership
bull Value of oral health and oral health transformation
Structure Systems and Operations
bull Operational efficiencies innovative care delivery methodologies
Care Pathways and Provider Buy-In
bull Training disease management risk-based care referrals IDC-10 coding patient engagement
Data and Analytic Technology and Personnel
bull Interoperability reporting
Financial Viability and Strength
bull Payerpatient mix billing infrastructure financial reports
httpswwwdentaquestpartnershiporglearnsafety-net-solutionsoral-health-value-based-careohvbc-readiness-
assessment
53
QUESTIONS COMMENTS
Carolyn Brown DDS
cbrownddsgmailcom
RISK BASED MANAGED CARE
Value Based Training Conference
Manchester New Hampshire
Mark Koday DDS
111919
5555
Objectives
bull Review current drivers of dental managed care
bull Understand the basics of risk-based dental managed care contracts
bull Learn the basics of managing costs in a riskndashbased contract
bull Gain an understanding in the potential advantage of risk-based contracting
56
What Is Dental Managed Care
Managed care is a health delivery system whose purpose is to manage both the
quality and cost of health care
Common types of managed care health insurance plans
bull HMOs
bull PPOs
bull POSs
bull Medicaid Managed Care
DIDNrsquoT WE ALREADY HAVE MANAGED CARE AND IT FAILED
57
What Has Happened Since the 90s
58
WHY THE FFS AND PPS DOESNrsquoT WORK FOR OUR POPULATIONS
bull Inefficient payment systems designed to produce encounters or procedures but not real health
bull No focus on population health
bull Does not incentivize innovation
bull Patients essentially on their own for accessing specialty care
59
Rule of 4
Source Kaiser Family Foundation analysis of National Health Expenditure (NHE) data from Centers for
Medicare and Medicaid Services Office of the Actuary National Health Statistics Group
60
Rule of 4
bull This helps explain why oral health has been relatively ignored so far by CMS
bull Explains why we have PCMH instead of PCHH
bull Where is the real value on a national level in preventing disease and
controlling costs
bull Beware- wersquove been found
61
Reasons Dental Managed Care is Spreading Across the States
NON-MANAGED CARE STATE DENTAL BUDGETS ARE
OPENED ENDED
STRAIN ON STATE BUDGETS
UPCOMING RECESSION WITH TRILLION DOLLAR
DEFICIT
SHIFTS FINANCIAL RISK FROM THE STATES TO THE
PLANS
6262
Types of Medicaid Managed Care
bull State Medicaid agency administrator lowest administrative
costs
bull Third Party Administrator Typically 15 administrative costs
bull Managed Care Organization Typically 15 administrative
costs
bull Carved-in
bull Carved-out
bull Risk Based Managed Care Administrative costs part of
contract negotiation
63
RISK CONTRACTS
6464
Components of a Risk-based Contract
Risk
Medical Loss Ratio
Quality withhold
Specialty withhold
Managed care payment (pmpm)
Covered services
Fee schedule Claims are paid as usual on a FFS basis
Credentialing
Quality Review process and Quality Metrics
65
Upside Risk
The possibility that the cost of
delivering dental care to an assigned
patient panel is less than the amount
of funding calculated for that care
The Plan pays the CHC additional
funds based on a predetermine
formula
Downside Risk
The possibility that the cost of
delivering dental care to an assigned
patient panel is more than the amount
of funding calculated for that care
The CHC pays the Plan additional
funds based on a predetermine
formula
Upside and Downside Risk
66
Taking On Risk 100 or Shared Risk
With 100 risk you receive 100 of the potential savings but are also at risk for
100 of the losses
Shared Risk MCO and health center share a percentage of the risk
Shared Risk leads to better cooperation since both organizations are
incentivized to save on costs
6767
Reports Needed
bull Enrollment reports lists of who is assigned on a monthly basis
bull Reconciliation reports insure appropriate payments
bull Specialty Referral reports
bull You will need your own reporting process so you donrsquot rely completely on
reports supplied by the Plan
6868
Medical Loss Ratio
Medical Loss Ratio (MLR) is proportion of premium revenues spent on clinical
services and quality improvement also known as the Medical Loss Ratio (MLR)
For CMS requires Medical Plans to spend at least 80 to 85 of the premiums
on actual medical care
69
Administrative Fees
bull Essentially the opposite of MLR
bull The State Medicaid Agency is funded by the Governorrsquos budget
bull The State Medicaid Agency will keep some of these funds for their
admin costs and give the remaining to the Managed Care Plans
bull Private Plan admin costs can be as high as 40 but most states
limit these cost for Medicaid Plans to between 15 and 20 (85-
80 MLR)
bull This may be negotiable depending on your program size of your
program
70
Quality Withhold
bull The state withholds a certain percent (typically 2-4 ) of the funds they give
to the Plans for Value Based Reimbursement
bull They choose quality metrics and set benchmarks and assign payments for
each metric based on an assigned priority for each metric
bull If a Plan meets the benchmark of every quality metric the state passes on
their full share of the quality withhold
bull The Plans may or may not withhold a percent of the funds for quality payment
to the dentists or manage care contractors
71
Quality Withhold
Either way the Plans may or may not pass the quality payments they receive to
the dentists or contractors
This should be spelled out in a risk-based contract
72
Percent of funds set aside
to cover specialty care
referrals
Typically 10-15
Goal Limit referral costs
to within or less than
Specialty set aside
Specialty Withhold
73
Per Member Per Month
bull Capitated Payment
bull Specific dollar amount paid for each enrolled member each month
bull Paid whether patient is accessed for care or not
bull States do set access benchmarks
bull In Oregon access for any dental procedure (adults and children combined)
was 267 in 2015
74
Payment Math Example
Premium per enrollee = $25
Administrative fee 15 = $375
Funds available per enrollee to the clinic = $2125
Management fee per enrollee = $175
Funds per enrollee that would undergo PPS reconciliation = $1950
For every 10000 enrollees the managed care income = $2340000
Specialty withhold (10) = $234000
YE Cost lt or gt $2340000
Upside Risk
CHC Gains $
Downside Risk
CHC Loses $
75
Covered Services and Fee Schedules
bull The state Medicaid agency spells out the minimum procedures and fees that
MCOs must cover
bull MCOs may add procedures or increase periodicity of procedures particularly
preventative services
bull MCOs may increase fees to entice rural providers and specialists to enroll in
their Plans
bull Access Rules
bull How many days it takes to access a patent
bull How many days it takes for a patent to access urgent care services
bull How many days it takes for a patent to access emergency care services
76
Credentialing
All MCOs are required to credential all Providers
All MCOs have their own credentialing process
Credentialing process is can be lengthy
Credentialing process may be negotiable
77
Quality Review Process and Quality Metrics
MCOs must have a Quality and Compliance Review Process
If you arenrsquot in compliance with both you likely wonrsquot get paid
Typical processes reviewed
bull Charting specifications
bull Incident report
bull Enrollee complaints quality rudeness and access issues
bull Medicaid compliance
78
Quality Payments
bull State Shared Incentive Withhold Typically quality metrics and benchmarks
are set by the state sets aside a certain percent (3-5) of the payments to
the Managed Care Plan (MCP)
bull If the benchmarks are achieved the MCP is then paid the a predetermine
amount
bull Benchmarks may not be the same as the states
bull Managed Care Plans do not have to pass all or any of the quality payments to
the health centers or providers
bull Managed Care contract- Metrics benchmarks should be selected and part of
the contract
7979
Achieving Quality Metric Payments
Dealing with under achievers
Process issues
Individual issues
Identifying workflows
Developing Best Practices through
PDSA process
Developing Best Practices through
PDSA process
CHC Metrics Committee
Clinicians Operations various key staff
Identify Best Practices
Spread Best Practices
80
New Team Needed Business Intelligence
Business Intelligence (BI) is critical for effective managed care business decisions
BI team inputs metrics into your EHR collects integrates analyses and displays all your managed care business and clinical information
Easy to say- hard to achieve
Build your own or outsource
Possible future role of Primary Care Associations
8181
Clinicianrsquos Dashboard
Expensive to build
Displayed on your screen when your computer is first turned on
Easy to read and understand
Data dumped from the day before
Can dialed down from Org-wide to clinic to each clinicianrsquos data
Operational and clinical metrics
bull Treatment Plan Completion
bull DQA quality measures
bull Caries at Recall
bull Re-care reports
bull Care Gap reports
82
CONTROLLING COSTS
8383
Controlling Costs- Current
bull Increasing efficiencies
bull Decreasing broken appointments
bull Controlling supplies equipment costs
bull Staff recruitment retention costs
84
Specialty Care
Training current CHC dentists in
specialty areas
Hiring general dentists with higher
specialty skill sets
Hiring in house specialists
Contract with outside specialists
Work with Managed Care Plan
specialists
Lowering Disease Rates
Community Dental Health
Coordinators case management
If your state law allows- embed
hygienists in medical and community
to provide primary and secondary
prevention procedures
In clinic Caries Classification and
Silver Diamine Fluoride
Effective recare programs
Controlling Costs- Additions in Risk-based Contracting
85
Specialty Care ndash Primary Referrals by Cost
Pediatric dentistry
Orthodontics
Oral surgery
Endodontics
86
In-clinic Pediatric Services
Encounters expected
of operatories available
State dental law and ability to have
expanded duties
General Anesthesia
GA in- house
Ability for a hospital or surgery center
to set aside regular OR time
Ability to hire or assign DAs to GA
days
Four GA cases day x PPS rate
Should You Hire a Pediatric Dentist- It Depends
8787
Solutions for Controlling Pediatric Costs
Hire a general dentist that is skilled in treating young children
Make the clinic child friendly nitrous oxide TVs in the operatory etc
Teach entire staff behavioral control techniques
Contract with a pediatric dentist for the GA care
88
Lowering Overall Disease Rates (and Costs)
You are responsible for both the patients you see in the chair and the ones
assigned to you
Breaking down the walls of the dental clinic
Community Dental Health Coordinators
Case Management
89
Cost Control Essentials
Diagnosis codes
Increased ability to identify
disease by risk
Motivational
Interviewing
Developing Polices and
Procedures design to treat
disease according to risk
ie Silver Diamine Fluoride
Treating by Risk
Effective Recare
Process
Critical to continual disease
controlPrevention education that is
meaningful and designed to
change behaviors
90
Social Determinants of Health Aunt Bertha
httpswwwauntberthacom
91
REASON TO CONSIDER RISK- BASED CONTRACTING
9292
PPS Reconciliation and Federal Code 42 CFR sect4052469(a)(2)
42 CFR sect4052469(a)(2)
ldquoAny financial incentives provided to Federally Qualified Health Centers
under their Medicare Advantage Contracts such as risk pool payments
bonuses or withholds are prohibited from being included in the
calculation of supplemental payments due to the Federally Qualified
Health Centerrdquo
9393
Why Risk Based Contract in Times of PPS Reconciliation
bull Not all Risk- based Contract funds are reconciled
bull Risk is the key word- you can come out with less money than your normal
PPS reconciliation payment
bull Can lead to better patient care
bull May improve manage care enrollment for your medical plan
bull Promotes integrated care increases health for your CHC patients
9494
Not Included in the Reconciliation
Enrollment management pmpm
Quality Payments
Upside risk payments
Downside risk losses
9595
Determinants of Financial Success in Risk-Based Contracting
bull Most critical- State pmpm payment to the Managed Care Plan
bull Reporting capabilities
bull Specialty service capabilities
bull Access numbers count
bull Ability to move metric numbers
9696
What About the Non- Medicaid Poor We Serve
bull Numbers are king in a managed care contract and the more access you have
the better contract terms you can negotiate
bull We will potentially have a steady supply of Medicaid patients
bull As managed care spreads states this may be compromising the ability of
health centers to serve the non-Medicaid poor and others lacking dental
insurance
97
Mark Koday DDS
(509) 949-2278
Dental Quality Consultants
of WA
httpdentalqualityconsultin
gcom
dentalqualityconsultantsg
mailcom
Contact Information
LUNCH
BREAKOUT EXERCISEORAL HEALTH VALUE-BASED CARE READINESS ASSESSMENT
Danielle Apostolon
PROMISING PRACTICES FROM THE FIELD STRATEGIES FOR INCREASING VALUE IN ORAL HEALTH
Dr Carolyn Brown
Dr Kelly Perry
Dr Rachel Rivard
Dr Adeloye
Commitment Compassion Community
m i d s t a t e h e a l t h o r g
Promising Practices from the
Field Strategies for Increasing
Value in Oral Health Care
Kelly Perry DMD
Better Health
Outcomes
Improved Staff
Experience
Reduced Cost
Improved Patient
Experience
Better Health
Outcomes
Improved Staff
Experience
Reduced Cost
Improved Patient
Experience
Better Health
Outcomes
Improved Staff
Experience
Reduced Cost
Improved Patient
Experience
Better Health
Outcomes
Improved Staff
Experience
Reduced Cost
Improved Patient
Experience
Commitment Compassion Community
kpe r r ymids t a tehea l t h o rg
Thank you
Completion of Disease Control Phase
Pelumi Adeloye DMD MPH
HEALTH ACCESS NETWORK (HAN) FAMILY DENTAL
Introduction
⧫1 Dentist I Hygienist 3 EFDArsquos1 Receptionist
⧫ 6 Chairs= 4 (dentist) + 2 (hygienist)
⧫ Slide ⥶80 off
⧫ Service areas Northern Penobscot Southern Aroostook Western
Washington Counties amp more
Completion of Phase I Treatment
⧫LimitedLack of Access to dental care
⧫Difficulty completing the disease control phase
Caries amp periodontal disease
⧫Attaining stable restorative state
Goal
Increase the completion of Disease Control Phase
Current practice
⧫Education
Assess level of dental literacy
Incremental strategy
⧫Increase access to dental care
Generous sliding scale (⥸$40 per visit)
Incorporate Expanded Function Dental Assistants
⧫Schedule modification
Incorporate more restorative blocks to allow
for follow-up visit and completion of restorative phase
httpswwwglasbergencomdentist-cartoons
Schedule
⧫Piggybacking technique
Increased allotted restorative blocks
⧫Sustainability of current schedule is
contingent on cooperation amp skills of HAN
Dental staff
Note
Strategies mentioned today is personalized to HAN Dental clinic
Current implemented strategies might be modified or changed in the
future as required in order to accommodate the need of our pts
THANK YOU
DAY TWOCLOSINGWRAP-UP
End of Day Two ndash Survey
Day Two Creating a Value-Based Oral Health Care Delivery
System
129
Payment Reform in Oral Health Online Learning Module
Oral Health Value-based Care Online Learning Module
Value-based Care Keys to Success Article
Readiness Assessment
Competency Development Guide
Oral Health Value-based Care Training
Dental Caries Management Practicum
Clinicians Companion Guide
Interprofessional Network Referral Process
Traditional Dental Care Vs Value-Based Care
Resources
131
wwwDentaQuestPartnershiporg
wwwfacebookcomDentaQuest
DentaQuest
wwwlinkedincomcompanyDentaQuest
Inside_DentaQuest
QUESTIONS
35
MEASURING PATIENT ORAL HEALTHRisk assessments and Care Pathways
36
37
Risk Assessment and Care Pathways
Caries Risk Assessment
Multiple tools
EDREHR modules smart notes or dot phrases
CDT Codes
Decide frequency
D0601
Low Caries Risk
D0601
Moderate Caries Risk
D0601
High Caries Risk
38
The Disease Management DifferenceDisease Management Difference
Traditional Dental Care Disease Management
Approach
All patients return in 6 months
regardless of risk status
Recare interval is based on the
childrsquos caries risk
Caries Risk
Level
Recommended
Recare Interval
High Risk 1 ndash 3 months
Moderate Risk 3 ndash 6 months
Low Risk 6 ndash 12 months
Caries
Stabilizing
agents
Health Ed
Nutritional
Counseling
Anti-bacterial
and Fluoride
interventions
39
Disease Management Care Pathways
DentaQuest Partnership for Oral Health Advancement Disease Management Model
Caries
Stabilizing
agents
Whole
Person
Inter-
professional
Approaches
Anti-bacterial
and Fluoride
interventions
40
Disease Management and Risk Screening Training
DentaQuest Partnership for Oral Health Advancementrsquos
Online Learning Center
Disease Management Series
8 modules 40 CDE available
httpswwwdentaquestpartnershiporglearnonline-learning-centeronline-
coursewaredentaquest-disease-management-series
41
MEASUREMENT IN TEAMSSharing meaningful data with your dental clinical teams
42
rdquoDental Homerdquo = Health Home where WE can meet the patient
Oralhealthworkforceorg
43
POLL HOW OFTEN DO YOU SHARE YOUR S WITH YOUR DENTAL TEAM
A Yearly only
B Quarterly
C Monthly
D Weekly
E Daily
44
Clinical Measures ndash Dental Practice Perspective
Private Practice Office
New patients seen
Assigned vs seen if capitated
Treatment plans incomplete
$ produced amp per provider
$ collected amp monthly per provider
CDT 6000 codes completed
RecallHygiene maintenance
Based on this consultants experienced
FQHC
Unduplicated patients
patients seen per day
Treatment plans complete
$ gainedlost via accounting
Broken appointment rate
procedures
Sealant rate (annual)
45
bull HRSA Sealant Measure Compliance for FQHCs
bull Completion of phase 1 treatment plans
bull Children seen 0-5 years old
bull Children seen getting a preventive service
bull Fluoride Varnish applications
bull Pregnant women seen and treated
bull Diabetic patients with HbA1C gt 7 seen
bull Patients seen who have not been seen for 12 months
bull Patients seen getting a Risk Assessment
bull Patients with moderate or high risk who lower risk at recare
bull Sealants provided httpwwwnnohaorgnnoha-contentuploads201512Demystifying-HRSA-SEALANT-PRESENTATION_FINALpdf
Program Measures
46
HRSA Performance Measurement and Data Collection
bull FQHCs and look-alikes submit CY data to HRSA since 2008
bull UDS Uniform Data System
bull Require FTE for clinical staff patient demographics
bull Dental utilization s (UDCTPV)
bull Dental Clinical Measure dental sealants placed on 1st molars ages 6-9 yo
bull Health Center Quartile rankings (Clinical measure performance influences
HC rankings as does EHR adoption and other HC characteristics)
47
Low birth weight
Access to prenatal care
Childhood Immunization
Children (Ages 3-17) Receiving
Weight Assessment amp
Counseling
Children (Age 6-9) Receiving
Dental Sealant to First Molars
Diabetes Control
Hypertension Control
Pap Test
Depression Screening and
Follow-up (Age 12+)
Asthma Patients (Age 5-40)
Receiving Pharmacologic
Therapy
Colorectal Cancer
Screening (Ages 51-74)
HRSA UDS Clinical Measures
Adults (Age 18+) Receiving
Weight Screening amp Follow-up
Adults (Age 18+) Receiving
Tobacco Use Assessment and
Cessation Intervention
Coronary Artery Disease
Receiving Lipid Therapy (18+)
Ischemic Vascular Disease (IVD)
Receiving Aspirin Therapy (18+)
HIV Linkage to Care
48
Dashboards
Grants
Average
amp
Targets
Quality
Rev
Costs
Visits
Priority
Pop
Prevention
49
Dashboard- Provider Team Level
Patient
Compliance
Satisfaction
50
Case Study-
Incentives bonus round pools benchmark and improvement target goals risk-sharing possible later years
51
Qualitative Measurement
ldquoPatient engagement is the act of patients and providers working together
toward the end goal of improved patient wellnessrdquo
wwwpatientengagementhitcom
Access to Care
Patient Activation
Patient Satisfaction
Patient-Provider-Care Team Communication
Care Team Satisfaction
52
OHVBC Readiness
Leadership
bull Value of oral health and oral health transformation
Structure Systems and Operations
bull Operational efficiencies innovative care delivery methodologies
Care Pathways and Provider Buy-In
bull Training disease management risk-based care referrals IDC-10 coding patient engagement
Data and Analytic Technology and Personnel
bull Interoperability reporting
Financial Viability and Strength
bull Payerpatient mix billing infrastructure financial reports
httpswwwdentaquestpartnershiporglearnsafety-net-solutionsoral-health-value-based-careohvbc-readiness-
assessment
53
QUESTIONS COMMENTS
Carolyn Brown DDS
cbrownddsgmailcom
RISK BASED MANAGED CARE
Value Based Training Conference
Manchester New Hampshire
Mark Koday DDS
111919
5555
Objectives
bull Review current drivers of dental managed care
bull Understand the basics of risk-based dental managed care contracts
bull Learn the basics of managing costs in a riskndashbased contract
bull Gain an understanding in the potential advantage of risk-based contracting
56
What Is Dental Managed Care
Managed care is a health delivery system whose purpose is to manage both the
quality and cost of health care
Common types of managed care health insurance plans
bull HMOs
bull PPOs
bull POSs
bull Medicaid Managed Care
DIDNrsquoT WE ALREADY HAVE MANAGED CARE AND IT FAILED
57
What Has Happened Since the 90s
58
WHY THE FFS AND PPS DOESNrsquoT WORK FOR OUR POPULATIONS
bull Inefficient payment systems designed to produce encounters or procedures but not real health
bull No focus on population health
bull Does not incentivize innovation
bull Patients essentially on their own for accessing specialty care
59
Rule of 4
Source Kaiser Family Foundation analysis of National Health Expenditure (NHE) data from Centers for
Medicare and Medicaid Services Office of the Actuary National Health Statistics Group
60
Rule of 4
bull This helps explain why oral health has been relatively ignored so far by CMS
bull Explains why we have PCMH instead of PCHH
bull Where is the real value on a national level in preventing disease and
controlling costs
bull Beware- wersquove been found
61
Reasons Dental Managed Care is Spreading Across the States
NON-MANAGED CARE STATE DENTAL BUDGETS ARE
OPENED ENDED
STRAIN ON STATE BUDGETS
UPCOMING RECESSION WITH TRILLION DOLLAR
DEFICIT
SHIFTS FINANCIAL RISK FROM THE STATES TO THE
PLANS
6262
Types of Medicaid Managed Care
bull State Medicaid agency administrator lowest administrative
costs
bull Third Party Administrator Typically 15 administrative costs
bull Managed Care Organization Typically 15 administrative
costs
bull Carved-in
bull Carved-out
bull Risk Based Managed Care Administrative costs part of
contract negotiation
63
RISK CONTRACTS
6464
Components of a Risk-based Contract
Risk
Medical Loss Ratio
Quality withhold
Specialty withhold
Managed care payment (pmpm)
Covered services
Fee schedule Claims are paid as usual on a FFS basis
Credentialing
Quality Review process and Quality Metrics
65
Upside Risk
The possibility that the cost of
delivering dental care to an assigned
patient panel is less than the amount
of funding calculated for that care
The Plan pays the CHC additional
funds based on a predetermine
formula
Downside Risk
The possibility that the cost of
delivering dental care to an assigned
patient panel is more than the amount
of funding calculated for that care
The CHC pays the Plan additional
funds based on a predetermine
formula
Upside and Downside Risk
66
Taking On Risk 100 or Shared Risk
With 100 risk you receive 100 of the potential savings but are also at risk for
100 of the losses
Shared Risk MCO and health center share a percentage of the risk
Shared Risk leads to better cooperation since both organizations are
incentivized to save on costs
6767
Reports Needed
bull Enrollment reports lists of who is assigned on a monthly basis
bull Reconciliation reports insure appropriate payments
bull Specialty Referral reports
bull You will need your own reporting process so you donrsquot rely completely on
reports supplied by the Plan
6868
Medical Loss Ratio
Medical Loss Ratio (MLR) is proportion of premium revenues spent on clinical
services and quality improvement also known as the Medical Loss Ratio (MLR)
For CMS requires Medical Plans to spend at least 80 to 85 of the premiums
on actual medical care
69
Administrative Fees
bull Essentially the opposite of MLR
bull The State Medicaid Agency is funded by the Governorrsquos budget
bull The State Medicaid Agency will keep some of these funds for their
admin costs and give the remaining to the Managed Care Plans
bull Private Plan admin costs can be as high as 40 but most states
limit these cost for Medicaid Plans to between 15 and 20 (85-
80 MLR)
bull This may be negotiable depending on your program size of your
program
70
Quality Withhold
bull The state withholds a certain percent (typically 2-4 ) of the funds they give
to the Plans for Value Based Reimbursement
bull They choose quality metrics and set benchmarks and assign payments for
each metric based on an assigned priority for each metric
bull If a Plan meets the benchmark of every quality metric the state passes on
their full share of the quality withhold
bull The Plans may or may not withhold a percent of the funds for quality payment
to the dentists or manage care contractors
71
Quality Withhold
Either way the Plans may or may not pass the quality payments they receive to
the dentists or contractors
This should be spelled out in a risk-based contract
72
Percent of funds set aside
to cover specialty care
referrals
Typically 10-15
Goal Limit referral costs
to within or less than
Specialty set aside
Specialty Withhold
73
Per Member Per Month
bull Capitated Payment
bull Specific dollar amount paid for each enrolled member each month
bull Paid whether patient is accessed for care or not
bull States do set access benchmarks
bull In Oregon access for any dental procedure (adults and children combined)
was 267 in 2015
74
Payment Math Example
Premium per enrollee = $25
Administrative fee 15 = $375
Funds available per enrollee to the clinic = $2125
Management fee per enrollee = $175
Funds per enrollee that would undergo PPS reconciliation = $1950
For every 10000 enrollees the managed care income = $2340000
Specialty withhold (10) = $234000
YE Cost lt or gt $2340000
Upside Risk
CHC Gains $
Downside Risk
CHC Loses $
75
Covered Services and Fee Schedules
bull The state Medicaid agency spells out the minimum procedures and fees that
MCOs must cover
bull MCOs may add procedures or increase periodicity of procedures particularly
preventative services
bull MCOs may increase fees to entice rural providers and specialists to enroll in
their Plans
bull Access Rules
bull How many days it takes to access a patent
bull How many days it takes for a patent to access urgent care services
bull How many days it takes for a patent to access emergency care services
76
Credentialing
All MCOs are required to credential all Providers
All MCOs have their own credentialing process
Credentialing process is can be lengthy
Credentialing process may be negotiable
77
Quality Review Process and Quality Metrics
MCOs must have a Quality and Compliance Review Process
If you arenrsquot in compliance with both you likely wonrsquot get paid
Typical processes reviewed
bull Charting specifications
bull Incident report
bull Enrollee complaints quality rudeness and access issues
bull Medicaid compliance
78
Quality Payments
bull State Shared Incentive Withhold Typically quality metrics and benchmarks
are set by the state sets aside a certain percent (3-5) of the payments to
the Managed Care Plan (MCP)
bull If the benchmarks are achieved the MCP is then paid the a predetermine
amount
bull Benchmarks may not be the same as the states
bull Managed Care Plans do not have to pass all or any of the quality payments to
the health centers or providers
bull Managed Care contract- Metrics benchmarks should be selected and part of
the contract
7979
Achieving Quality Metric Payments
Dealing with under achievers
Process issues
Individual issues
Identifying workflows
Developing Best Practices through
PDSA process
Developing Best Practices through
PDSA process
CHC Metrics Committee
Clinicians Operations various key staff
Identify Best Practices
Spread Best Practices
80
New Team Needed Business Intelligence
Business Intelligence (BI) is critical for effective managed care business decisions
BI team inputs metrics into your EHR collects integrates analyses and displays all your managed care business and clinical information
Easy to say- hard to achieve
Build your own or outsource
Possible future role of Primary Care Associations
8181
Clinicianrsquos Dashboard
Expensive to build
Displayed on your screen when your computer is first turned on
Easy to read and understand
Data dumped from the day before
Can dialed down from Org-wide to clinic to each clinicianrsquos data
Operational and clinical metrics
bull Treatment Plan Completion
bull DQA quality measures
bull Caries at Recall
bull Re-care reports
bull Care Gap reports
82
CONTROLLING COSTS
8383
Controlling Costs- Current
bull Increasing efficiencies
bull Decreasing broken appointments
bull Controlling supplies equipment costs
bull Staff recruitment retention costs
84
Specialty Care
Training current CHC dentists in
specialty areas
Hiring general dentists with higher
specialty skill sets
Hiring in house specialists
Contract with outside specialists
Work with Managed Care Plan
specialists
Lowering Disease Rates
Community Dental Health
Coordinators case management
If your state law allows- embed
hygienists in medical and community
to provide primary and secondary
prevention procedures
In clinic Caries Classification and
Silver Diamine Fluoride
Effective recare programs
Controlling Costs- Additions in Risk-based Contracting
85
Specialty Care ndash Primary Referrals by Cost
Pediatric dentistry
Orthodontics
Oral surgery
Endodontics
86
In-clinic Pediatric Services
Encounters expected
of operatories available
State dental law and ability to have
expanded duties
General Anesthesia
GA in- house
Ability for a hospital or surgery center
to set aside regular OR time
Ability to hire or assign DAs to GA
days
Four GA cases day x PPS rate
Should You Hire a Pediatric Dentist- It Depends
8787
Solutions for Controlling Pediatric Costs
Hire a general dentist that is skilled in treating young children
Make the clinic child friendly nitrous oxide TVs in the operatory etc
Teach entire staff behavioral control techniques
Contract with a pediatric dentist for the GA care
88
Lowering Overall Disease Rates (and Costs)
You are responsible for both the patients you see in the chair and the ones
assigned to you
Breaking down the walls of the dental clinic
Community Dental Health Coordinators
Case Management
89
Cost Control Essentials
Diagnosis codes
Increased ability to identify
disease by risk
Motivational
Interviewing
Developing Polices and
Procedures design to treat
disease according to risk
ie Silver Diamine Fluoride
Treating by Risk
Effective Recare
Process
Critical to continual disease
controlPrevention education that is
meaningful and designed to
change behaviors
90
Social Determinants of Health Aunt Bertha
httpswwwauntberthacom
91
REASON TO CONSIDER RISK- BASED CONTRACTING
9292
PPS Reconciliation and Federal Code 42 CFR sect4052469(a)(2)
42 CFR sect4052469(a)(2)
ldquoAny financial incentives provided to Federally Qualified Health Centers
under their Medicare Advantage Contracts such as risk pool payments
bonuses or withholds are prohibited from being included in the
calculation of supplemental payments due to the Federally Qualified
Health Centerrdquo
9393
Why Risk Based Contract in Times of PPS Reconciliation
bull Not all Risk- based Contract funds are reconciled
bull Risk is the key word- you can come out with less money than your normal
PPS reconciliation payment
bull Can lead to better patient care
bull May improve manage care enrollment for your medical plan
bull Promotes integrated care increases health for your CHC patients
9494
Not Included in the Reconciliation
Enrollment management pmpm
Quality Payments
Upside risk payments
Downside risk losses
9595
Determinants of Financial Success in Risk-Based Contracting
bull Most critical- State pmpm payment to the Managed Care Plan
bull Reporting capabilities
bull Specialty service capabilities
bull Access numbers count
bull Ability to move metric numbers
9696
What About the Non- Medicaid Poor We Serve
bull Numbers are king in a managed care contract and the more access you have
the better contract terms you can negotiate
bull We will potentially have a steady supply of Medicaid patients
bull As managed care spreads states this may be compromising the ability of
health centers to serve the non-Medicaid poor and others lacking dental
insurance
97
Mark Koday DDS
(509) 949-2278
Dental Quality Consultants
of WA
httpdentalqualityconsultin
gcom
dentalqualityconsultantsg
mailcom
Contact Information
LUNCH
BREAKOUT EXERCISEORAL HEALTH VALUE-BASED CARE READINESS ASSESSMENT
Danielle Apostolon
PROMISING PRACTICES FROM THE FIELD STRATEGIES FOR INCREASING VALUE IN ORAL HEALTH
Dr Carolyn Brown
Dr Kelly Perry
Dr Rachel Rivard
Dr Adeloye
Commitment Compassion Community
m i d s t a t e h e a l t h o r g
Promising Practices from the
Field Strategies for Increasing
Value in Oral Health Care
Kelly Perry DMD
Better Health
Outcomes
Improved Staff
Experience
Reduced Cost
Improved Patient
Experience
Better Health
Outcomes
Improved Staff
Experience
Reduced Cost
Improved Patient
Experience
Better Health
Outcomes
Improved Staff
Experience
Reduced Cost
Improved Patient
Experience
Better Health
Outcomes
Improved Staff
Experience
Reduced Cost
Improved Patient
Experience
Commitment Compassion Community
kpe r r ymids t a tehea l t h o rg
Thank you
Completion of Disease Control Phase
Pelumi Adeloye DMD MPH
HEALTH ACCESS NETWORK (HAN) FAMILY DENTAL
Introduction
⧫1 Dentist I Hygienist 3 EFDArsquos1 Receptionist
⧫ 6 Chairs= 4 (dentist) + 2 (hygienist)
⧫ Slide ⥶80 off
⧫ Service areas Northern Penobscot Southern Aroostook Western
Washington Counties amp more
Completion of Phase I Treatment
⧫LimitedLack of Access to dental care
⧫Difficulty completing the disease control phase
Caries amp periodontal disease
⧫Attaining stable restorative state
Goal
Increase the completion of Disease Control Phase
Current practice
⧫Education
Assess level of dental literacy
Incremental strategy
⧫Increase access to dental care
Generous sliding scale (⥸$40 per visit)
Incorporate Expanded Function Dental Assistants
⧫Schedule modification
Incorporate more restorative blocks to allow
for follow-up visit and completion of restorative phase
httpswwwglasbergencomdentist-cartoons
Schedule
⧫Piggybacking technique
Increased allotted restorative blocks
⧫Sustainability of current schedule is
contingent on cooperation amp skills of HAN
Dental staff
Note
Strategies mentioned today is personalized to HAN Dental clinic
Current implemented strategies might be modified or changed in the
future as required in order to accommodate the need of our pts
THANK YOU
DAY TWOCLOSINGWRAP-UP
End of Day Two ndash Survey
Day Two Creating a Value-Based Oral Health Care Delivery
System
129
Payment Reform in Oral Health Online Learning Module
Oral Health Value-based Care Online Learning Module
Value-based Care Keys to Success Article
Readiness Assessment
Competency Development Guide
Oral Health Value-based Care Training
Dental Caries Management Practicum
Clinicians Companion Guide
Interprofessional Network Referral Process
Traditional Dental Care Vs Value-Based Care
Resources
131
wwwDentaQuestPartnershiporg
wwwfacebookcomDentaQuest
DentaQuest
wwwlinkedincomcompanyDentaQuest
Inside_DentaQuest
QUESTIONS
36
37
Risk Assessment and Care Pathways
Caries Risk Assessment
Multiple tools
EDREHR modules smart notes or dot phrases
CDT Codes
Decide frequency
D0601
Low Caries Risk
D0601
Moderate Caries Risk
D0601
High Caries Risk
38
The Disease Management DifferenceDisease Management Difference
Traditional Dental Care Disease Management
Approach
All patients return in 6 months
regardless of risk status
Recare interval is based on the
childrsquos caries risk
Caries Risk
Level
Recommended
Recare Interval
High Risk 1 ndash 3 months
Moderate Risk 3 ndash 6 months
Low Risk 6 ndash 12 months
Caries
Stabilizing
agents
Health Ed
Nutritional
Counseling
Anti-bacterial
and Fluoride
interventions
39
Disease Management Care Pathways
DentaQuest Partnership for Oral Health Advancement Disease Management Model
Caries
Stabilizing
agents
Whole
Person
Inter-
professional
Approaches
Anti-bacterial
and Fluoride
interventions
40
Disease Management and Risk Screening Training
DentaQuest Partnership for Oral Health Advancementrsquos
Online Learning Center
Disease Management Series
8 modules 40 CDE available
httpswwwdentaquestpartnershiporglearnonline-learning-centeronline-
coursewaredentaquest-disease-management-series
41
MEASUREMENT IN TEAMSSharing meaningful data with your dental clinical teams
42
rdquoDental Homerdquo = Health Home where WE can meet the patient
Oralhealthworkforceorg
43
POLL HOW OFTEN DO YOU SHARE YOUR S WITH YOUR DENTAL TEAM
A Yearly only
B Quarterly
C Monthly
D Weekly
E Daily
44
Clinical Measures ndash Dental Practice Perspective
Private Practice Office
New patients seen
Assigned vs seen if capitated
Treatment plans incomplete
$ produced amp per provider
$ collected amp monthly per provider
CDT 6000 codes completed
RecallHygiene maintenance
Based on this consultants experienced
FQHC
Unduplicated patients
patients seen per day
Treatment plans complete
$ gainedlost via accounting
Broken appointment rate
procedures
Sealant rate (annual)
45
bull HRSA Sealant Measure Compliance for FQHCs
bull Completion of phase 1 treatment plans
bull Children seen 0-5 years old
bull Children seen getting a preventive service
bull Fluoride Varnish applications
bull Pregnant women seen and treated
bull Diabetic patients with HbA1C gt 7 seen
bull Patients seen who have not been seen for 12 months
bull Patients seen getting a Risk Assessment
bull Patients with moderate or high risk who lower risk at recare
bull Sealants provided httpwwwnnohaorgnnoha-contentuploads201512Demystifying-HRSA-SEALANT-PRESENTATION_FINALpdf
Program Measures
46
HRSA Performance Measurement and Data Collection
bull FQHCs and look-alikes submit CY data to HRSA since 2008
bull UDS Uniform Data System
bull Require FTE for clinical staff patient demographics
bull Dental utilization s (UDCTPV)
bull Dental Clinical Measure dental sealants placed on 1st molars ages 6-9 yo
bull Health Center Quartile rankings (Clinical measure performance influences
HC rankings as does EHR adoption and other HC characteristics)
47
Low birth weight
Access to prenatal care
Childhood Immunization
Children (Ages 3-17) Receiving
Weight Assessment amp
Counseling
Children (Age 6-9) Receiving
Dental Sealant to First Molars
Diabetes Control
Hypertension Control
Pap Test
Depression Screening and
Follow-up (Age 12+)
Asthma Patients (Age 5-40)
Receiving Pharmacologic
Therapy
Colorectal Cancer
Screening (Ages 51-74)
HRSA UDS Clinical Measures
Adults (Age 18+) Receiving
Weight Screening amp Follow-up
Adults (Age 18+) Receiving
Tobacco Use Assessment and
Cessation Intervention
Coronary Artery Disease
Receiving Lipid Therapy (18+)
Ischemic Vascular Disease (IVD)
Receiving Aspirin Therapy (18+)
HIV Linkage to Care
48
Dashboards
Grants
Average
amp
Targets
Quality
Rev
Costs
Visits
Priority
Pop
Prevention
49
Dashboard- Provider Team Level
Patient
Compliance
Satisfaction
50
Case Study-
Incentives bonus round pools benchmark and improvement target goals risk-sharing possible later years
51
Qualitative Measurement
ldquoPatient engagement is the act of patients and providers working together
toward the end goal of improved patient wellnessrdquo
wwwpatientengagementhitcom
Access to Care
Patient Activation
Patient Satisfaction
Patient-Provider-Care Team Communication
Care Team Satisfaction
52
OHVBC Readiness
Leadership
bull Value of oral health and oral health transformation
Structure Systems and Operations
bull Operational efficiencies innovative care delivery methodologies
Care Pathways and Provider Buy-In
bull Training disease management risk-based care referrals IDC-10 coding patient engagement
Data and Analytic Technology and Personnel
bull Interoperability reporting
Financial Viability and Strength
bull Payerpatient mix billing infrastructure financial reports
httpswwwdentaquestpartnershiporglearnsafety-net-solutionsoral-health-value-based-careohvbc-readiness-
assessment
53
QUESTIONS COMMENTS
Carolyn Brown DDS
cbrownddsgmailcom
RISK BASED MANAGED CARE
Value Based Training Conference
Manchester New Hampshire
Mark Koday DDS
111919
5555
Objectives
bull Review current drivers of dental managed care
bull Understand the basics of risk-based dental managed care contracts
bull Learn the basics of managing costs in a riskndashbased contract
bull Gain an understanding in the potential advantage of risk-based contracting
56
What Is Dental Managed Care
Managed care is a health delivery system whose purpose is to manage both the
quality and cost of health care
Common types of managed care health insurance plans
bull HMOs
bull PPOs
bull POSs
bull Medicaid Managed Care
DIDNrsquoT WE ALREADY HAVE MANAGED CARE AND IT FAILED
57
What Has Happened Since the 90s
58
WHY THE FFS AND PPS DOESNrsquoT WORK FOR OUR POPULATIONS
bull Inefficient payment systems designed to produce encounters or procedures but not real health
bull No focus on population health
bull Does not incentivize innovation
bull Patients essentially on their own for accessing specialty care
59
Rule of 4
Source Kaiser Family Foundation analysis of National Health Expenditure (NHE) data from Centers for
Medicare and Medicaid Services Office of the Actuary National Health Statistics Group
60
Rule of 4
bull This helps explain why oral health has been relatively ignored so far by CMS
bull Explains why we have PCMH instead of PCHH
bull Where is the real value on a national level in preventing disease and
controlling costs
bull Beware- wersquove been found
61
Reasons Dental Managed Care is Spreading Across the States
NON-MANAGED CARE STATE DENTAL BUDGETS ARE
OPENED ENDED
STRAIN ON STATE BUDGETS
UPCOMING RECESSION WITH TRILLION DOLLAR
DEFICIT
SHIFTS FINANCIAL RISK FROM THE STATES TO THE
PLANS
6262
Types of Medicaid Managed Care
bull State Medicaid agency administrator lowest administrative
costs
bull Third Party Administrator Typically 15 administrative costs
bull Managed Care Organization Typically 15 administrative
costs
bull Carved-in
bull Carved-out
bull Risk Based Managed Care Administrative costs part of
contract negotiation
63
RISK CONTRACTS
6464
Components of a Risk-based Contract
Risk
Medical Loss Ratio
Quality withhold
Specialty withhold
Managed care payment (pmpm)
Covered services
Fee schedule Claims are paid as usual on a FFS basis
Credentialing
Quality Review process and Quality Metrics
65
Upside Risk
The possibility that the cost of
delivering dental care to an assigned
patient panel is less than the amount
of funding calculated for that care
The Plan pays the CHC additional
funds based on a predetermine
formula
Downside Risk
The possibility that the cost of
delivering dental care to an assigned
patient panel is more than the amount
of funding calculated for that care
The CHC pays the Plan additional
funds based on a predetermine
formula
Upside and Downside Risk
66
Taking On Risk 100 or Shared Risk
With 100 risk you receive 100 of the potential savings but are also at risk for
100 of the losses
Shared Risk MCO and health center share a percentage of the risk
Shared Risk leads to better cooperation since both organizations are
incentivized to save on costs
6767
Reports Needed
bull Enrollment reports lists of who is assigned on a monthly basis
bull Reconciliation reports insure appropriate payments
bull Specialty Referral reports
bull You will need your own reporting process so you donrsquot rely completely on
reports supplied by the Plan
6868
Medical Loss Ratio
Medical Loss Ratio (MLR) is proportion of premium revenues spent on clinical
services and quality improvement also known as the Medical Loss Ratio (MLR)
For CMS requires Medical Plans to spend at least 80 to 85 of the premiums
on actual medical care
69
Administrative Fees
bull Essentially the opposite of MLR
bull The State Medicaid Agency is funded by the Governorrsquos budget
bull The State Medicaid Agency will keep some of these funds for their
admin costs and give the remaining to the Managed Care Plans
bull Private Plan admin costs can be as high as 40 but most states
limit these cost for Medicaid Plans to between 15 and 20 (85-
80 MLR)
bull This may be negotiable depending on your program size of your
program
70
Quality Withhold
bull The state withholds a certain percent (typically 2-4 ) of the funds they give
to the Plans for Value Based Reimbursement
bull They choose quality metrics and set benchmarks and assign payments for
each metric based on an assigned priority for each metric
bull If a Plan meets the benchmark of every quality metric the state passes on
their full share of the quality withhold
bull The Plans may or may not withhold a percent of the funds for quality payment
to the dentists or manage care contractors
71
Quality Withhold
Either way the Plans may or may not pass the quality payments they receive to
the dentists or contractors
This should be spelled out in a risk-based contract
72
Percent of funds set aside
to cover specialty care
referrals
Typically 10-15
Goal Limit referral costs
to within or less than
Specialty set aside
Specialty Withhold
73
Per Member Per Month
bull Capitated Payment
bull Specific dollar amount paid for each enrolled member each month
bull Paid whether patient is accessed for care or not
bull States do set access benchmarks
bull In Oregon access for any dental procedure (adults and children combined)
was 267 in 2015
74
Payment Math Example
Premium per enrollee = $25
Administrative fee 15 = $375
Funds available per enrollee to the clinic = $2125
Management fee per enrollee = $175
Funds per enrollee that would undergo PPS reconciliation = $1950
For every 10000 enrollees the managed care income = $2340000
Specialty withhold (10) = $234000
YE Cost lt or gt $2340000
Upside Risk
CHC Gains $
Downside Risk
CHC Loses $
75
Covered Services and Fee Schedules
bull The state Medicaid agency spells out the minimum procedures and fees that
MCOs must cover
bull MCOs may add procedures or increase periodicity of procedures particularly
preventative services
bull MCOs may increase fees to entice rural providers and specialists to enroll in
their Plans
bull Access Rules
bull How many days it takes to access a patent
bull How many days it takes for a patent to access urgent care services
bull How many days it takes for a patent to access emergency care services
76
Credentialing
All MCOs are required to credential all Providers
All MCOs have their own credentialing process
Credentialing process is can be lengthy
Credentialing process may be negotiable
77
Quality Review Process and Quality Metrics
MCOs must have a Quality and Compliance Review Process
If you arenrsquot in compliance with both you likely wonrsquot get paid
Typical processes reviewed
bull Charting specifications
bull Incident report
bull Enrollee complaints quality rudeness and access issues
bull Medicaid compliance
78
Quality Payments
bull State Shared Incentive Withhold Typically quality metrics and benchmarks
are set by the state sets aside a certain percent (3-5) of the payments to
the Managed Care Plan (MCP)
bull If the benchmarks are achieved the MCP is then paid the a predetermine
amount
bull Benchmarks may not be the same as the states
bull Managed Care Plans do not have to pass all or any of the quality payments to
the health centers or providers
bull Managed Care contract- Metrics benchmarks should be selected and part of
the contract
7979
Achieving Quality Metric Payments
Dealing with under achievers
Process issues
Individual issues
Identifying workflows
Developing Best Practices through
PDSA process
Developing Best Practices through
PDSA process
CHC Metrics Committee
Clinicians Operations various key staff
Identify Best Practices
Spread Best Practices
80
New Team Needed Business Intelligence
Business Intelligence (BI) is critical for effective managed care business decisions
BI team inputs metrics into your EHR collects integrates analyses and displays all your managed care business and clinical information
Easy to say- hard to achieve
Build your own or outsource
Possible future role of Primary Care Associations
8181
Clinicianrsquos Dashboard
Expensive to build
Displayed on your screen when your computer is first turned on
Easy to read and understand
Data dumped from the day before
Can dialed down from Org-wide to clinic to each clinicianrsquos data
Operational and clinical metrics
bull Treatment Plan Completion
bull DQA quality measures
bull Caries at Recall
bull Re-care reports
bull Care Gap reports
82
CONTROLLING COSTS
8383
Controlling Costs- Current
bull Increasing efficiencies
bull Decreasing broken appointments
bull Controlling supplies equipment costs
bull Staff recruitment retention costs
84
Specialty Care
Training current CHC dentists in
specialty areas
Hiring general dentists with higher
specialty skill sets
Hiring in house specialists
Contract with outside specialists
Work with Managed Care Plan
specialists
Lowering Disease Rates
Community Dental Health
Coordinators case management
If your state law allows- embed
hygienists in medical and community
to provide primary and secondary
prevention procedures
In clinic Caries Classification and
Silver Diamine Fluoride
Effective recare programs
Controlling Costs- Additions in Risk-based Contracting
85
Specialty Care ndash Primary Referrals by Cost
Pediatric dentistry
Orthodontics
Oral surgery
Endodontics
86
In-clinic Pediatric Services
Encounters expected
of operatories available
State dental law and ability to have
expanded duties
General Anesthesia
GA in- house
Ability for a hospital or surgery center
to set aside regular OR time
Ability to hire or assign DAs to GA
days
Four GA cases day x PPS rate
Should You Hire a Pediatric Dentist- It Depends
8787
Solutions for Controlling Pediatric Costs
Hire a general dentist that is skilled in treating young children
Make the clinic child friendly nitrous oxide TVs in the operatory etc
Teach entire staff behavioral control techniques
Contract with a pediatric dentist for the GA care
88
Lowering Overall Disease Rates (and Costs)
You are responsible for both the patients you see in the chair and the ones
assigned to you
Breaking down the walls of the dental clinic
Community Dental Health Coordinators
Case Management
89
Cost Control Essentials
Diagnosis codes
Increased ability to identify
disease by risk
Motivational
Interviewing
Developing Polices and
Procedures design to treat
disease according to risk
ie Silver Diamine Fluoride
Treating by Risk
Effective Recare
Process
Critical to continual disease
controlPrevention education that is
meaningful and designed to
change behaviors
90
Social Determinants of Health Aunt Bertha
httpswwwauntberthacom
91
REASON TO CONSIDER RISK- BASED CONTRACTING
9292
PPS Reconciliation and Federal Code 42 CFR sect4052469(a)(2)
42 CFR sect4052469(a)(2)
ldquoAny financial incentives provided to Federally Qualified Health Centers
under their Medicare Advantage Contracts such as risk pool payments
bonuses or withholds are prohibited from being included in the
calculation of supplemental payments due to the Federally Qualified
Health Centerrdquo
9393
Why Risk Based Contract in Times of PPS Reconciliation
bull Not all Risk- based Contract funds are reconciled
bull Risk is the key word- you can come out with less money than your normal
PPS reconciliation payment
bull Can lead to better patient care
bull May improve manage care enrollment for your medical plan
bull Promotes integrated care increases health for your CHC patients
9494
Not Included in the Reconciliation
Enrollment management pmpm
Quality Payments
Upside risk payments
Downside risk losses
9595
Determinants of Financial Success in Risk-Based Contracting
bull Most critical- State pmpm payment to the Managed Care Plan
bull Reporting capabilities
bull Specialty service capabilities
bull Access numbers count
bull Ability to move metric numbers
9696
What About the Non- Medicaid Poor We Serve
bull Numbers are king in a managed care contract and the more access you have
the better contract terms you can negotiate
bull We will potentially have a steady supply of Medicaid patients
bull As managed care spreads states this may be compromising the ability of
health centers to serve the non-Medicaid poor and others lacking dental
insurance
97
Mark Koday DDS
(509) 949-2278
Dental Quality Consultants
of WA
httpdentalqualityconsultin
gcom
dentalqualityconsultantsg
mailcom
Contact Information
LUNCH
BREAKOUT EXERCISEORAL HEALTH VALUE-BASED CARE READINESS ASSESSMENT
Danielle Apostolon
PROMISING PRACTICES FROM THE FIELD STRATEGIES FOR INCREASING VALUE IN ORAL HEALTH
Dr Carolyn Brown
Dr Kelly Perry
Dr Rachel Rivard
Dr Adeloye
Commitment Compassion Community
m i d s t a t e h e a l t h o r g
Promising Practices from the
Field Strategies for Increasing
Value in Oral Health Care
Kelly Perry DMD
Better Health
Outcomes
Improved Staff
Experience
Reduced Cost
Improved Patient
Experience
Better Health
Outcomes
Improved Staff
Experience
Reduced Cost
Improved Patient
Experience
Better Health
Outcomes
Improved Staff
Experience
Reduced Cost
Improved Patient
Experience
Better Health
Outcomes
Improved Staff
Experience
Reduced Cost
Improved Patient
Experience
Commitment Compassion Community
kpe r r ymids t a tehea l t h o rg
Thank you
Completion of Disease Control Phase
Pelumi Adeloye DMD MPH
HEALTH ACCESS NETWORK (HAN) FAMILY DENTAL
Introduction
⧫1 Dentist I Hygienist 3 EFDArsquos1 Receptionist
⧫ 6 Chairs= 4 (dentist) + 2 (hygienist)
⧫ Slide ⥶80 off
⧫ Service areas Northern Penobscot Southern Aroostook Western
Washington Counties amp more
Completion of Phase I Treatment
⧫LimitedLack of Access to dental care
⧫Difficulty completing the disease control phase
Caries amp periodontal disease
⧫Attaining stable restorative state
Goal
Increase the completion of Disease Control Phase
Current practice
⧫Education
Assess level of dental literacy
Incremental strategy
⧫Increase access to dental care
Generous sliding scale (⥸$40 per visit)
Incorporate Expanded Function Dental Assistants
⧫Schedule modification
Incorporate more restorative blocks to allow
for follow-up visit and completion of restorative phase
httpswwwglasbergencomdentist-cartoons
Schedule
⧫Piggybacking technique
Increased allotted restorative blocks
⧫Sustainability of current schedule is
contingent on cooperation amp skills of HAN
Dental staff
Note
Strategies mentioned today is personalized to HAN Dental clinic
Current implemented strategies might be modified or changed in the
future as required in order to accommodate the need of our pts
THANK YOU
DAY TWOCLOSINGWRAP-UP
End of Day Two ndash Survey
Day Two Creating a Value-Based Oral Health Care Delivery
System
129
Payment Reform in Oral Health Online Learning Module
Oral Health Value-based Care Online Learning Module
Value-based Care Keys to Success Article
Readiness Assessment
Competency Development Guide
Oral Health Value-based Care Training
Dental Caries Management Practicum
Clinicians Companion Guide
Interprofessional Network Referral Process
Traditional Dental Care Vs Value-Based Care
Resources
131
wwwDentaQuestPartnershiporg
wwwfacebookcomDentaQuest
DentaQuest
wwwlinkedincomcompanyDentaQuest
Inside_DentaQuest
QUESTIONS
37
Risk Assessment and Care Pathways
Caries Risk Assessment
Multiple tools
EDREHR modules smart notes or dot phrases
CDT Codes
Decide frequency
D0601
Low Caries Risk
D0601
Moderate Caries Risk
D0601
High Caries Risk
38
The Disease Management DifferenceDisease Management Difference
Traditional Dental Care Disease Management
Approach
All patients return in 6 months
regardless of risk status
Recare interval is based on the
childrsquos caries risk
Caries Risk
Level
Recommended
Recare Interval
High Risk 1 ndash 3 months
Moderate Risk 3 ndash 6 months
Low Risk 6 ndash 12 months
Caries
Stabilizing
agents
Health Ed
Nutritional
Counseling
Anti-bacterial
and Fluoride
interventions
39
Disease Management Care Pathways
DentaQuest Partnership for Oral Health Advancement Disease Management Model
Caries
Stabilizing
agents
Whole
Person
Inter-
professional
Approaches
Anti-bacterial
and Fluoride
interventions
40
Disease Management and Risk Screening Training
DentaQuest Partnership for Oral Health Advancementrsquos
Online Learning Center
Disease Management Series
8 modules 40 CDE available
httpswwwdentaquestpartnershiporglearnonline-learning-centeronline-
coursewaredentaquest-disease-management-series
41
MEASUREMENT IN TEAMSSharing meaningful data with your dental clinical teams
42
rdquoDental Homerdquo = Health Home where WE can meet the patient
Oralhealthworkforceorg
43
POLL HOW OFTEN DO YOU SHARE YOUR S WITH YOUR DENTAL TEAM
A Yearly only
B Quarterly
C Monthly
D Weekly
E Daily
44
Clinical Measures ndash Dental Practice Perspective
Private Practice Office
New patients seen
Assigned vs seen if capitated
Treatment plans incomplete
$ produced amp per provider
$ collected amp monthly per provider
CDT 6000 codes completed
RecallHygiene maintenance
Based on this consultants experienced
FQHC
Unduplicated patients
patients seen per day
Treatment plans complete
$ gainedlost via accounting
Broken appointment rate
procedures
Sealant rate (annual)
45
bull HRSA Sealant Measure Compliance for FQHCs
bull Completion of phase 1 treatment plans
bull Children seen 0-5 years old
bull Children seen getting a preventive service
bull Fluoride Varnish applications
bull Pregnant women seen and treated
bull Diabetic patients with HbA1C gt 7 seen
bull Patients seen who have not been seen for 12 months
bull Patients seen getting a Risk Assessment
bull Patients with moderate or high risk who lower risk at recare
bull Sealants provided httpwwwnnohaorgnnoha-contentuploads201512Demystifying-HRSA-SEALANT-PRESENTATION_FINALpdf
Program Measures
46
HRSA Performance Measurement and Data Collection
bull FQHCs and look-alikes submit CY data to HRSA since 2008
bull UDS Uniform Data System
bull Require FTE for clinical staff patient demographics
bull Dental utilization s (UDCTPV)
bull Dental Clinical Measure dental sealants placed on 1st molars ages 6-9 yo
bull Health Center Quartile rankings (Clinical measure performance influences
HC rankings as does EHR adoption and other HC characteristics)
47
Low birth weight
Access to prenatal care
Childhood Immunization
Children (Ages 3-17) Receiving
Weight Assessment amp
Counseling
Children (Age 6-9) Receiving
Dental Sealant to First Molars
Diabetes Control
Hypertension Control
Pap Test
Depression Screening and
Follow-up (Age 12+)
Asthma Patients (Age 5-40)
Receiving Pharmacologic
Therapy
Colorectal Cancer
Screening (Ages 51-74)
HRSA UDS Clinical Measures
Adults (Age 18+) Receiving
Weight Screening amp Follow-up
Adults (Age 18+) Receiving
Tobacco Use Assessment and
Cessation Intervention
Coronary Artery Disease
Receiving Lipid Therapy (18+)
Ischemic Vascular Disease (IVD)
Receiving Aspirin Therapy (18+)
HIV Linkage to Care
48
Dashboards
Grants
Average
amp
Targets
Quality
Rev
Costs
Visits
Priority
Pop
Prevention
49
Dashboard- Provider Team Level
Patient
Compliance
Satisfaction
50
Case Study-
Incentives bonus round pools benchmark and improvement target goals risk-sharing possible later years
51
Qualitative Measurement
ldquoPatient engagement is the act of patients and providers working together
toward the end goal of improved patient wellnessrdquo
wwwpatientengagementhitcom
Access to Care
Patient Activation
Patient Satisfaction
Patient-Provider-Care Team Communication
Care Team Satisfaction
52
OHVBC Readiness
Leadership
bull Value of oral health and oral health transformation
Structure Systems and Operations
bull Operational efficiencies innovative care delivery methodologies
Care Pathways and Provider Buy-In
bull Training disease management risk-based care referrals IDC-10 coding patient engagement
Data and Analytic Technology and Personnel
bull Interoperability reporting
Financial Viability and Strength
bull Payerpatient mix billing infrastructure financial reports
httpswwwdentaquestpartnershiporglearnsafety-net-solutionsoral-health-value-based-careohvbc-readiness-
assessment
53
QUESTIONS COMMENTS
Carolyn Brown DDS
cbrownddsgmailcom
RISK BASED MANAGED CARE
Value Based Training Conference
Manchester New Hampshire
Mark Koday DDS
111919
5555
Objectives
bull Review current drivers of dental managed care
bull Understand the basics of risk-based dental managed care contracts
bull Learn the basics of managing costs in a riskndashbased contract
bull Gain an understanding in the potential advantage of risk-based contracting
56
What Is Dental Managed Care
Managed care is a health delivery system whose purpose is to manage both the
quality and cost of health care
Common types of managed care health insurance plans
bull HMOs
bull PPOs
bull POSs
bull Medicaid Managed Care
DIDNrsquoT WE ALREADY HAVE MANAGED CARE AND IT FAILED
57
What Has Happened Since the 90s
58
WHY THE FFS AND PPS DOESNrsquoT WORK FOR OUR POPULATIONS
bull Inefficient payment systems designed to produce encounters or procedures but not real health
bull No focus on population health
bull Does not incentivize innovation
bull Patients essentially on their own for accessing specialty care
59
Rule of 4
Source Kaiser Family Foundation analysis of National Health Expenditure (NHE) data from Centers for
Medicare and Medicaid Services Office of the Actuary National Health Statistics Group
60
Rule of 4
bull This helps explain why oral health has been relatively ignored so far by CMS
bull Explains why we have PCMH instead of PCHH
bull Where is the real value on a national level in preventing disease and
controlling costs
bull Beware- wersquove been found
61
Reasons Dental Managed Care is Spreading Across the States
NON-MANAGED CARE STATE DENTAL BUDGETS ARE
OPENED ENDED
STRAIN ON STATE BUDGETS
UPCOMING RECESSION WITH TRILLION DOLLAR
DEFICIT
SHIFTS FINANCIAL RISK FROM THE STATES TO THE
PLANS
6262
Types of Medicaid Managed Care
bull State Medicaid agency administrator lowest administrative
costs
bull Third Party Administrator Typically 15 administrative costs
bull Managed Care Organization Typically 15 administrative
costs
bull Carved-in
bull Carved-out
bull Risk Based Managed Care Administrative costs part of
contract negotiation
63
RISK CONTRACTS
6464
Components of a Risk-based Contract
Risk
Medical Loss Ratio
Quality withhold
Specialty withhold
Managed care payment (pmpm)
Covered services
Fee schedule Claims are paid as usual on a FFS basis
Credentialing
Quality Review process and Quality Metrics
65
Upside Risk
The possibility that the cost of
delivering dental care to an assigned
patient panel is less than the amount
of funding calculated for that care
The Plan pays the CHC additional
funds based on a predetermine
formula
Downside Risk
The possibility that the cost of
delivering dental care to an assigned
patient panel is more than the amount
of funding calculated for that care
The CHC pays the Plan additional
funds based on a predetermine
formula
Upside and Downside Risk
66
Taking On Risk 100 or Shared Risk
With 100 risk you receive 100 of the potential savings but are also at risk for
100 of the losses
Shared Risk MCO and health center share a percentage of the risk
Shared Risk leads to better cooperation since both organizations are
incentivized to save on costs
6767
Reports Needed
bull Enrollment reports lists of who is assigned on a monthly basis
bull Reconciliation reports insure appropriate payments
bull Specialty Referral reports
bull You will need your own reporting process so you donrsquot rely completely on
reports supplied by the Plan
6868
Medical Loss Ratio
Medical Loss Ratio (MLR) is proportion of premium revenues spent on clinical
services and quality improvement also known as the Medical Loss Ratio (MLR)
For CMS requires Medical Plans to spend at least 80 to 85 of the premiums
on actual medical care
69
Administrative Fees
bull Essentially the opposite of MLR
bull The State Medicaid Agency is funded by the Governorrsquos budget
bull The State Medicaid Agency will keep some of these funds for their
admin costs and give the remaining to the Managed Care Plans
bull Private Plan admin costs can be as high as 40 but most states
limit these cost for Medicaid Plans to between 15 and 20 (85-
80 MLR)
bull This may be negotiable depending on your program size of your
program
70
Quality Withhold
bull The state withholds a certain percent (typically 2-4 ) of the funds they give
to the Plans for Value Based Reimbursement
bull They choose quality metrics and set benchmarks and assign payments for
each metric based on an assigned priority for each metric
bull If a Plan meets the benchmark of every quality metric the state passes on
their full share of the quality withhold
bull The Plans may or may not withhold a percent of the funds for quality payment
to the dentists or manage care contractors
71
Quality Withhold
Either way the Plans may or may not pass the quality payments they receive to
the dentists or contractors
This should be spelled out in a risk-based contract
72
Percent of funds set aside
to cover specialty care
referrals
Typically 10-15
Goal Limit referral costs
to within or less than
Specialty set aside
Specialty Withhold
73
Per Member Per Month
bull Capitated Payment
bull Specific dollar amount paid for each enrolled member each month
bull Paid whether patient is accessed for care or not
bull States do set access benchmarks
bull In Oregon access for any dental procedure (adults and children combined)
was 267 in 2015
74
Payment Math Example
Premium per enrollee = $25
Administrative fee 15 = $375
Funds available per enrollee to the clinic = $2125
Management fee per enrollee = $175
Funds per enrollee that would undergo PPS reconciliation = $1950
For every 10000 enrollees the managed care income = $2340000
Specialty withhold (10) = $234000
YE Cost lt or gt $2340000
Upside Risk
CHC Gains $
Downside Risk
CHC Loses $
75
Covered Services and Fee Schedules
bull The state Medicaid agency spells out the minimum procedures and fees that
MCOs must cover
bull MCOs may add procedures or increase periodicity of procedures particularly
preventative services
bull MCOs may increase fees to entice rural providers and specialists to enroll in
their Plans
bull Access Rules
bull How many days it takes to access a patent
bull How many days it takes for a patent to access urgent care services
bull How many days it takes for a patent to access emergency care services
76
Credentialing
All MCOs are required to credential all Providers
All MCOs have their own credentialing process
Credentialing process is can be lengthy
Credentialing process may be negotiable
77
Quality Review Process and Quality Metrics
MCOs must have a Quality and Compliance Review Process
If you arenrsquot in compliance with both you likely wonrsquot get paid
Typical processes reviewed
bull Charting specifications
bull Incident report
bull Enrollee complaints quality rudeness and access issues
bull Medicaid compliance
78
Quality Payments
bull State Shared Incentive Withhold Typically quality metrics and benchmarks
are set by the state sets aside a certain percent (3-5) of the payments to
the Managed Care Plan (MCP)
bull If the benchmarks are achieved the MCP is then paid the a predetermine
amount
bull Benchmarks may not be the same as the states
bull Managed Care Plans do not have to pass all or any of the quality payments to
the health centers or providers
bull Managed Care contract- Metrics benchmarks should be selected and part of
the contract
7979
Achieving Quality Metric Payments
Dealing with under achievers
Process issues
Individual issues
Identifying workflows
Developing Best Practices through
PDSA process
Developing Best Practices through
PDSA process
CHC Metrics Committee
Clinicians Operations various key staff
Identify Best Practices
Spread Best Practices
80
New Team Needed Business Intelligence
Business Intelligence (BI) is critical for effective managed care business decisions
BI team inputs metrics into your EHR collects integrates analyses and displays all your managed care business and clinical information
Easy to say- hard to achieve
Build your own or outsource
Possible future role of Primary Care Associations
8181
Clinicianrsquos Dashboard
Expensive to build
Displayed on your screen when your computer is first turned on
Easy to read and understand
Data dumped from the day before
Can dialed down from Org-wide to clinic to each clinicianrsquos data
Operational and clinical metrics
bull Treatment Plan Completion
bull DQA quality measures
bull Caries at Recall
bull Re-care reports
bull Care Gap reports
82
CONTROLLING COSTS
8383
Controlling Costs- Current
bull Increasing efficiencies
bull Decreasing broken appointments
bull Controlling supplies equipment costs
bull Staff recruitment retention costs
84
Specialty Care
Training current CHC dentists in
specialty areas
Hiring general dentists with higher
specialty skill sets
Hiring in house specialists
Contract with outside specialists
Work with Managed Care Plan
specialists
Lowering Disease Rates
Community Dental Health
Coordinators case management
If your state law allows- embed
hygienists in medical and community
to provide primary and secondary
prevention procedures
In clinic Caries Classification and
Silver Diamine Fluoride
Effective recare programs
Controlling Costs- Additions in Risk-based Contracting
85
Specialty Care ndash Primary Referrals by Cost
Pediatric dentistry
Orthodontics
Oral surgery
Endodontics
86
In-clinic Pediatric Services
Encounters expected
of operatories available
State dental law and ability to have
expanded duties
General Anesthesia
GA in- house
Ability for a hospital or surgery center
to set aside regular OR time
Ability to hire or assign DAs to GA
days
Four GA cases day x PPS rate
Should You Hire a Pediatric Dentist- It Depends
8787
Solutions for Controlling Pediatric Costs
Hire a general dentist that is skilled in treating young children
Make the clinic child friendly nitrous oxide TVs in the operatory etc
Teach entire staff behavioral control techniques
Contract with a pediatric dentist for the GA care
88
Lowering Overall Disease Rates (and Costs)
You are responsible for both the patients you see in the chair and the ones
assigned to you
Breaking down the walls of the dental clinic
Community Dental Health Coordinators
Case Management
89
Cost Control Essentials
Diagnosis codes
Increased ability to identify
disease by risk
Motivational
Interviewing
Developing Polices and
Procedures design to treat
disease according to risk
ie Silver Diamine Fluoride
Treating by Risk
Effective Recare
Process
Critical to continual disease
controlPrevention education that is
meaningful and designed to
change behaviors
90
Social Determinants of Health Aunt Bertha
httpswwwauntberthacom
91
REASON TO CONSIDER RISK- BASED CONTRACTING
9292
PPS Reconciliation and Federal Code 42 CFR sect4052469(a)(2)
42 CFR sect4052469(a)(2)
ldquoAny financial incentives provided to Federally Qualified Health Centers
under their Medicare Advantage Contracts such as risk pool payments
bonuses or withholds are prohibited from being included in the
calculation of supplemental payments due to the Federally Qualified
Health Centerrdquo
9393
Why Risk Based Contract in Times of PPS Reconciliation
bull Not all Risk- based Contract funds are reconciled
bull Risk is the key word- you can come out with less money than your normal
PPS reconciliation payment
bull Can lead to better patient care
bull May improve manage care enrollment for your medical plan
bull Promotes integrated care increases health for your CHC patients
9494
Not Included in the Reconciliation
Enrollment management pmpm
Quality Payments
Upside risk payments
Downside risk losses
9595
Determinants of Financial Success in Risk-Based Contracting
bull Most critical- State pmpm payment to the Managed Care Plan
bull Reporting capabilities
bull Specialty service capabilities
bull Access numbers count
bull Ability to move metric numbers
9696
What About the Non- Medicaid Poor We Serve
bull Numbers are king in a managed care contract and the more access you have
the better contract terms you can negotiate
bull We will potentially have a steady supply of Medicaid patients
bull As managed care spreads states this may be compromising the ability of
health centers to serve the non-Medicaid poor and others lacking dental
insurance
97
Mark Koday DDS
(509) 949-2278
Dental Quality Consultants
of WA
httpdentalqualityconsultin
gcom
dentalqualityconsultantsg
mailcom
Contact Information
LUNCH
BREAKOUT EXERCISEORAL HEALTH VALUE-BASED CARE READINESS ASSESSMENT
Danielle Apostolon
PROMISING PRACTICES FROM THE FIELD STRATEGIES FOR INCREASING VALUE IN ORAL HEALTH
Dr Carolyn Brown
Dr Kelly Perry
Dr Rachel Rivard
Dr Adeloye
Commitment Compassion Community
m i d s t a t e h e a l t h o r g
Promising Practices from the
Field Strategies for Increasing
Value in Oral Health Care
Kelly Perry DMD
Better Health
Outcomes
Improved Staff
Experience
Reduced Cost
Improved Patient
Experience
Better Health
Outcomes
Improved Staff
Experience
Reduced Cost
Improved Patient
Experience
Better Health
Outcomes
Improved Staff
Experience
Reduced Cost
Improved Patient
Experience
Better Health
Outcomes
Improved Staff
Experience
Reduced Cost
Improved Patient
Experience
Commitment Compassion Community
kpe r r ymids t a tehea l t h o rg
Thank you
Completion of Disease Control Phase
Pelumi Adeloye DMD MPH
HEALTH ACCESS NETWORK (HAN) FAMILY DENTAL
Introduction
⧫1 Dentist I Hygienist 3 EFDArsquos1 Receptionist
⧫ 6 Chairs= 4 (dentist) + 2 (hygienist)
⧫ Slide ⥶80 off
⧫ Service areas Northern Penobscot Southern Aroostook Western
Washington Counties amp more
Completion of Phase I Treatment
⧫LimitedLack of Access to dental care
⧫Difficulty completing the disease control phase
Caries amp periodontal disease
⧫Attaining stable restorative state
Goal
Increase the completion of Disease Control Phase
Current practice
⧫Education
Assess level of dental literacy
Incremental strategy
⧫Increase access to dental care
Generous sliding scale (⥸$40 per visit)
Incorporate Expanded Function Dental Assistants
⧫Schedule modification
Incorporate more restorative blocks to allow
for follow-up visit and completion of restorative phase
httpswwwglasbergencomdentist-cartoons
Schedule
⧫Piggybacking technique
Increased allotted restorative blocks
⧫Sustainability of current schedule is
contingent on cooperation amp skills of HAN
Dental staff
Note
Strategies mentioned today is personalized to HAN Dental clinic
Current implemented strategies might be modified or changed in the
future as required in order to accommodate the need of our pts
THANK YOU
DAY TWOCLOSINGWRAP-UP
End of Day Two ndash Survey
Day Two Creating a Value-Based Oral Health Care Delivery
System
129
Payment Reform in Oral Health Online Learning Module
Oral Health Value-based Care Online Learning Module
Value-based Care Keys to Success Article
Readiness Assessment
Competency Development Guide
Oral Health Value-based Care Training
Dental Caries Management Practicum
Clinicians Companion Guide
Interprofessional Network Referral Process
Traditional Dental Care Vs Value-Based Care
Resources
131
wwwDentaQuestPartnershiporg
wwwfacebookcomDentaQuest
DentaQuest
wwwlinkedincomcompanyDentaQuest
Inside_DentaQuest
QUESTIONS
38
The Disease Management DifferenceDisease Management Difference
Traditional Dental Care Disease Management
Approach
All patients return in 6 months
regardless of risk status
Recare interval is based on the
childrsquos caries risk
Caries Risk
Level
Recommended
Recare Interval
High Risk 1 ndash 3 months
Moderate Risk 3 ndash 6 months
Low Risk 6 ndash 12 months
Caries
Stabilizing
agents
Health Ed
Nutritional
Counseling
Anti-bacterial
and Fluoride
interventions
39
Disease Management Care Pathways
DentaQuest Partnership for Oral Health Advancement Disease Management Model
Caries
Stabilizing
agents
Whole
Person
Inter-
professional
Approaches
Anti-bacterial
and Fluoride
interventions
40
Disease Management and Risk Screening Training
DentaQuest Partnership for Oral Health Advancementrsquos
Online Learning Center
Disease Management Series
8 modules 40 CDE available
httpswwwdentaquestpartnershiporglearnonline-learning-centeronline-
coursewaredentaquest-disease-management-series
41
MEASUREMENT IN TEAMSSharing meaningful data with your dental clinical teams
42
rdquoDental Homerdquo = Health Home where WE can meet the patient
Oralhealthworkforceorg
43
POLL HOW OFTEN DO YOU SHARE YOUR S WITH YOUR DENTAL TEAM
A Yearly only
B Quarterly
C Monthly
D Weekly
E Daily
44
Clinical Measures ndash Dental Practice Perspective
Private Practice Office
New patients seen
Assigned vs seen if capitated
Treatment plans incomplete
$ produced amp per provider
$ collected amp monthly per provider
CDT 6000 codes completed
RecallHygiene maintenance
Based on this consultants experienced
FQHC
Unduplicated patients
patients seen per day
Treatment plans complete
$ gainedlost via accounting
Broken appointment rate
procedures
Sealant rate (annual)
45
bull HRSA Sealant Measure Compliance for FQHCs
bull Completion of phase 1 treatment plans
bull Children seen 0-5 years old
bull Children seen getting a preventive service
bull Fluoride Varnish applications
bull Pregnant women seen and treated
bull Diabetic patients with HbA1C gt 7 seen
bull Patients seen who have not been seen for 12 months
bull Patients seen getting a Risk Assessment
bull Patients with moderate or high risk who lower risk at recare
bull Sealants provided httpwwwnnohaorgnnoha-contentuploads201512Demystifying-HRSA-SEALANT-PRESENTATION_FINALpdf
Program Measures
46
HRSA Performance Measurement and Data Collection
bull FQHCs and look-alikes submit CY data to HRSA since 2008
bull UDS Uniform Data System
bull Require FTE for clinical staff patient demographics
bull Dental utilization s (UDCTPV)
bull Dental Clinical Measure dental sealants placed on 1st molars ages 6-9 yo
bull Health Center Quartile rankings (Clinical measure performance influences
HC rankings as does EHR adoption and other HC characteristics)
47
Low birth weight
Access to prenatal care
Childhood Immunization
Children (Ages 3-17) Receiving
Weight Assessment amp
Counseling
Children (Age 6-9) Receiving
Dental Sealant to First Molars
Diabetes Control
Hypertension Control
Pap Test
Depression Screening and
Follow-up (Age 12+)
Asthma Patients (Age 5-40)
Receiving Pharmacologic
Therapy
Colorectal Cancer
Screening (Ages 51-74)
HRSA UDS Clinical Measures
Adults (Age 18+) Receiving
Weight Screening amp Follow-up
Adults (Age 18+) Receiving
Tobacco Use Assessment and
Cessation Intervention
Coronary Artery Disease
Receiving Lipid Therapy (18+)
Ischemic Vascular Disease (IVD)
Receiving Aspirin Therapy (18+)
HIV Linkage to Care
48
Dashboards
Grants
Average
amp
Targets
Quality
Rev
Costs
Visits
Priority
Pop
Prevention
49
Dashboard- Provider Team Level
Patient
Compliance
Satisfaction
50
Case Study-
Incentives bonus round pools benchmark and improvement target goals risk-sharing possible later years
51
Qualitative Measurement
ldquoPatient engagement is the act of patients and providers working together
toward the end goal of improved patient wellnessrdquo
wwwpatientengagementhitcom
Access to Care
Patient Activation
Patient Satisfaction
Patient-Provider-Care Team Communication
Care Team Satisfaction
52
OHVBC Readiness
Leadership
bull Value of oral health and oral health transformation
Structure Systems and Operations
bull Operational efficiencies innovative care delivery methodologies
Care Pathways and Provider Buy-In
bull Training disease management risk-based care referrals IDC-10 coding patient engagement
Data and Analytic Technology and Personnel
bull Interoperability reporting
Financial Viability and Strength
bull Payerpatient mix billing infrastructure financial reports
httpswwwdentaquestpartnershiporglearnsafety-net-solutionsoral-health-value-based-careohvbc-readiness-
assessment
53
QUESTIONS COMMENTS
Carolyn Brown DDS
cbrownddsgmailcom
RISK BASED MANAGED CARE
Value Based Training Conference
Manchester New Hampshire
Mark Koday DDS
111919
5555
Objectives
bull Review current drivers of dental managed care
bull Understand the basics of risk-based dental managed care contracts
bull Learn the basics of managing costs in a riskndashbased contract
bull Gain an understanding in the potential advantage of risk-based contracting
56
What Is Dental Managed Care
Managed care is a health delivery system whose purpose is to manage both the
quality and cost of health care
Common types of managed care health insurance plans
bull HMOs
bull PPOs
bull POSs
bull Medicaid Managed Care
DIDNrsquoT WE ALREADY HAVE MANAGED CARE AND IT FAILED
57
What Has Happened Since the 90s
58
WHY THE FFS AND PPS DOESNrsquoT WORK FOR OUR POPULATIONS
bull Inefficient payment systems designed to produce encounters or procedures but not real health
bull No focus on population health
bull Does not incentivize innovation
bull Patients essentially on their own for accessing specialty care
59
Rule of 4
Source Kaiser Family Foundation analysis of National Health Expenditure (NHE) data from Centers for
Medicare and Medicaid Services Office of the Actuary National Health Statistics Group
60
Rule of 4
bull This helps explain why oral health has been relatively ignored so far by CMS
bull Explains why we have PCMH instead of PCHH
bull Where is the real value on a national level in preventing disease and
controlling costs
bull Beware- wersquove been found
61
Reasons Dental Managed Care is Spreading Across the States
NON-MANAGED CARE STATE DENTAL BUDGETS ARE
OPENED ENDED
STRAIN ON STATE BUDGETS
UPCOMING RECESSION WITH TRILLION DOLLAR
DEFICIT
SHIFTS FINANCIAL RISK FROM THE STATES TO THE
PLANS
6262
Types of Medicaid Managed Care
bull State Medicaid agency administrator lowest administrative
costs
bull Third Party Administrator Typically 15 administrative costs
bull Managed Care Organization Typically 15 administrative
costs
bull Carved-in
bull Carved-out
bull Risk Based Managed Care Administrative costs part of
contract negotiation
63
RISK CONTRACTS
6464
Components of a Risk-based Contract
Risk
Medical Loss Ratio
Quality withhold
Specialty withhold
Managed care payment (pmpm)
Covered services
Fee schedule Claims are paid as usual on a FFS basis
Credentialing
Quality Review process and Quality Metrics
65
Upside Risk
The possibility that the cost of
delivering dental care to an assigned
patient panel is less than the amount
of funding calculated for that care
The Plan pays the CHC additional
funds based on a predetermine
formula
Downside Risk
The possibility that the cost of
delivering dental care to an assigned
patient panel is more than the amount
of funding calculated for that care
The CHC pays the Plan additional
funds based on a predetermine
formula
Upside and Downside Risk
66
Taking On Risk 100 or Shared Risk
With 100 risk you receive 100 of the potential savings but are also at risk for
100 of the losses
Shared Risk MCO and health center share a percentage of the risk
Shared Risk leads to better cooperation since both organizations are
incentivized to save on costs
6767
Reports Needed
bull Enrollment reports lists of who is assigned on a monthly basis
bull Reconciliation reports insure appropriate payments
bull Specialty Referral reports
bull You will need your own reporting process so you donrsquot rely completely on
reports supplied by the Plan
6868
Medical Loss Ratio
Medical Loss Ratio (MLR) is proportion of premium revenues spent on clinical
services and quality improvement also known as the Medical Loss Ratio (MLR)
For CMS requires Medical Plans to spend at least 80 to 85 of the premiums
on actual medical care
69
Administrative Fees
bull Essentially the opposite of MLR
bull The State Medicaid Agency is funded by the Governorrsquos budget
bull The State Medicaid Agency will keep some of these funds for their
admin costs and give the remaining to the Managed Care Plans
bull Private Plan admin costs can be as high as 40 but most states
limit these cost for Medicaid Plans to between 15 and 20 (85-
80 MLR)
bull This may be negotiable depending on your program size of your
program
70
Quality Withhold
bull The state withholds a certain percent (typically 2-4 ) of the funds they give
to the Plans for Value Based Reimbursement
bull They choose quality metrics and set benchmarks and assign payments for
each metric based on an assigned priority for each metric
bull If a Plan meets the benchmark of every quality metric the state passes on
their full share of the quality withhold
bull The Plans may or may not withhold a percent of the funds for quality payment
to the dentists or manage care contractors
71
Quality Withhold
Either way the Plans may or may not pass the quality payments they receive to
the dentists or contractors
This should be spelled out in a risk-based contract
72
Percent of funds set aside
to cover specialty care
referrals
Typically 10-15
Goal Limit referral costs
to within or less than
Specialty set aside
Specialty Withhold
73
Per Member Per Month
bull Capitated Payment
bull Specific dollar amount paid for each enrolled member each month
bull Paid whether patient is accessed for care or not
bull States do set access benchmarks
bull In Oregon access for any dental procedure (adults and children combined)
was 267 in 2015
74
Payment Math Example
Premium per enrollee = $25
Administrative fee 15 = $375
Funds available per enrollee to the clinic = $2125
Management fee per enrollee = $175
Funds per enrollee that would undergo PPS reconciliation = $1950
For every 10000 enrollees the managed care income = $2340000
Specialty withhold (10) = $234000
YE Cost lt or gt $2340000
Upside Risk
CHC Gains $
Downside Risk
CHC Loses $
75
Covered Services and Fee Schedules
bull The state Medicaid agency spells out the minimum procedures and fees that
MCOs must cover
bull MCOs may add procedures or increase periodicity of procedures particularly
preventative services
bull MCOs may increase fees to entice rural providers and specialists to enroll in
their Plans
bull Access Rules
bull How many days it takes to access a patent
bull How many days it takes for a patent to access urgent care services
bull How many days it takes for a patent to access emergency care services
76
Credentialing
All MCOs are required to credential all Providers
All MCOs have their own credentialing process
Credentialing process is can be lengthy
Credentialing process may be negotiable
77
Quality Review Process and Quality Metrics
MCOs must have a Quality and Compliance Review Process
If you arenrsquot in compliance with both you likely wonrsquot get paid
Typical processes reviewed
bull Charting specifications
bull Incident report
bull Enrollee complaints quality rudeness and access issues
bull Medicaid compliance
78
Quality Payments
bull State Shared Incentive Withhold Typically quality metrics and benchmarks
are set by the state sets aside a certain percent (3-5) of the payments to
the Managed Care Plan (MCP)
bull If the benchmarks are achieved the MCP is then paid the a predetermine
amount
bull Benchmarks may not be the same as the states
bull Managed Care Plans do not have to pass all or any of the quality payments to
the health centers or providers
bull Managed Care contract- Metrics benchmarks should be selected and part of
the contract
7979
Achieving Quality Metric Payments
Dealing with under achievers
Process issues
Individual issues
Identifying workflows
Developing Best Practices through
PDSA process
Developing Best Practices through
PDSA process
CHC Metrics Committee
Clinicians Operations various key staff
Identify Best Practices
Spread Best Practices
80
New Team Needed Business Intelligence
Business Intelligence (BI) is critical for effective managed care business decisions
BI team inputs metrics into your EHR collects integrates analyses and displays all your managed care business and clinical information
Easy to say- hard to achieve
Build your own or outsource
Possible future role of Primary Care Associations
8181
Clinicianrsquos Dashboard
Expensive to build
Displayed on your screen when your computer is first turned on
Easy to read and understand
Data dumped from the day before
Can dialed down from Org-wide to clinic to each clinicianrsquos data
Operational and clinical metrics
bull Treatment Plan Completion
bull DQA quality measures
bull Caries at Recall
bull Re-care reports
bull Care Gap reports
82
CONTROLLING COSTS
8383
Controlling Costs- Current
bull Increasing efficiencies
bull Decreasing broken appointments
bull Controlling supplies equipment costs
bull Staff recruitment retention costs
84
Specialty Care
Training current CHC dentists in
specialty areas
Hiring general dentists with higher
specialty skill sets
Hiring in house specialists
Contract with outside specialists
Work with Managed Care Plan
specialists
Lowering Disease Rates
Community Dental Health
Coordinators case management
If your state law allows- embed
hygienists in medical and community
to provide primary and secondary
prevention procedures
In clinic Caries Classification and
Silver Diamine Fluoride
Effective recare programs
Controlling Costs- Additions in Risk-based Contracting
85
Specialty Care ndash Primary Referrals by Cost
Pediatric dentistry
Orthodontics
Oral surgery
Endodontics
86
In-clinic Pediatric Services
Encounters expected
of operatories available
State dental law and ability to have
expanded duties
General Anesthesia
GA in- house
Ability for a hospital or surgery center
to set aside regular OR time
Ability to hire or assign DAs to GA
days
Four GA cases day x PPS rate
Should You Hire a Pediatric Dentist- It Depends
8787
Solutions for Controlling Pediatric Costs
Hire a general dentist that is skilled in treating young children
Make the clinic child friendly nitrous oxide TVs in the operatory etc
Teach entire staff behavioral control techniques
Contract with a pediatric dentist for the GA care
88
Lowering Overall Disease Rates (and Costs)
You are responsible for both the patients you see in the chair and the ones
assigned to you
Breaking down the walls of the dental clinic
Community Dental Health Coordinators
Case Management
89
Cost Control Essentials
Diagnosis codes
Increased ability to identify
disease by risk
Motivational
Interviewing
Developing Polices and
Procedures design to treat
disease according to risk
ie Silver Diamine Fluoride
Treating by Risk
Effective Recare
Process
Critical to continual disease
controlPrevention education that is
meaningful and designed to
change behaviors
90
Social Determinants of Health Aunt Bertha
httpswwwauntberthacom
91
REASON TO CONSIDER RISK- BASED CONTRACTING
9292
PPS Reconciliation and Federal Code 42 CFR sect4052469(a)(2)
42 CFR sect4052469(a)(2)
ldquoAny financial incentives provided to Federally Qualified Health Centers
under their Medicare Advantage Contracts such as risk pool payments
bonuses or withholds are prohibited from being included in the
calculation of supplemental payments due to the Federally Qualified
Health Centerrdquo
9393
Why Risk Based Contract in Times of PPS Reconciliation
bull Not all Risk- based Contract funds are reconciled
bull Risk is the key word- you can come out with less money than your normal
PPS reconciliation payment
bull Can lead to better patient care
bull May improve manage care enrollment for your medical plan
bull Promotes integrated care increases health for your CHC patients
9494
Not Included in the Reconciliation
Enrollment management pmpm
Quality Payments
Upside risk payments
Downside risk losses
9595
Determinants of Financial Success in Risk-Based Contracting
bull Most critical- State pmpm payment to the Managed Care Plan
bull Reporting capabilities
bull Specialty service capabilities
bull Access numbers count
bull Ability to move metric numbers
9696
What About the Non- Medicaid Poor We Serve
bull Numbers are king in a managed care contract and the more access you have
the better contract terms you can negotiate
bull We will potentially have a steady supply of Medicaid patients
bull As managed care spreads states this may be compromising the ability of
health centers to serve the non-Medicaid poor and others lacking dental
insurance
97
Mark Koday DDS
(509) 949-2278
Dental Quality Consultants
of WA
httpdentalqualityconsultin
gcom
dentalqualityconsultantsg
mailcom
Contact Information
LUNCH
BREAKOUT EXERCISEORAL HEALTH VALUE-BASED CARE READINESS ASSESSMENT
Danielle Apostolon
PROMISING PRACTICES FROM THE FIELD STRATEGIES FOR INCREASING VALUE IN ORAL HEALTH
Dr Carolyn Brown
Dr Kelly Perry
Dr Rachel Rivard
Dr Adeloye
Commitment Compassion Community
m i d s t a t e h e a l t h o r g
Promising Practices from the
Field Strategies for Increasing
Value in Oral Health Care
Kelly Perry DMD
Better Health
Outcomes
Improved Staff
Experience
Reduced Cost
Improved Patient
Experience
Better Health
Outcomes
Improved Staff
Experience
Reduced Cost
Improved Patient
Experience
Better Health
Outcomes
Improved Staff
Experience
Reduced Cost
Improved Patient
Experience
Better Health
Outcomes
Improved Staff
Experience
Reduced Cost
Improved Patient
Experience
Commitment Compassion Community
kpe r r ymids t a tehea l t h o rg
Thank you
Completion of Disease Control Phase
Pelumi Adeloye DMD MPH
HEALTH ACCESS NETWORK (HAN) FAMILY DENTAL
Introduction
⧫1 Dentist I Hygienist 3 EFDArsquos1 Receptionist
⧫ 6 Chairs= 4 (dentist) + 2 (hygienist)
⧫ Slide ⥶80 off
⧫ Service areas Northern Penobscot Southern Aroostook Western
Washington Counties amp more
Completion of Phase I Treatment
⧫LimitedLack of Access to dental care
⧫Difficulty completing the disease control phase
Caries amp periodontal disease
⧫Attaining stable restorative state
Goal
Increase the completion of Disease Control Phase
Current practice
⧫Education
Assess level of dental literacy
Incremental strategy
⧫Increase access to dental care
Generous sliding scale (⥸$40 per visit)
Incorporate Expanded Function Dental Assistants
⧫Schedule modification
Incorporate more restorative blocks to allow
for follow-up visit and completion of restorative phase
httpswwwglasbergencomdentist-cartoons
Schedule
⧫Piggybacking technique
Increased allotted restorative blocks
⧫Sustainability of current schedule is
contingent on cooperation amp skills of HAN
Dental staff
Note
Strategies mentioned today is personalized to HAN Dental clinic
Current implemented strategies might be modified or changed in the
future as required in order to accommodate the need of our pts
THANK YOU
DAY TWOCLOSINGWRAP-UP
End of Day Two ndash Survey
Day Two Creating a Value-Based Oral Health Care Delivery
System
129
Payment Reform in Oral Health Online Learning Module
Oral Health Value-based Care Online Learning Module
Value-based Care Keys to Success Article
Readiness Assessment
Competency Development Guide
Oral Health Value-based Care Training
Dental Caries Management Practicum
Clinicians Companion Guide
Interprofessional Network Referral Process
Traditional Dental Care Vs Value-Based Care
Resources
131
wwwDentaQuestPartnershiporg
wwwfacebookcomDentaQuest
DentaQuest
wwwlinkedincomcompanyDentaQuest
Inside_DentaQuest
QUESTIONS
39
Disease Management Care Pathways
DentaQuest Partnership for Oral Health Advancement Disease Management Model
Caries
Stabilizing
agents
Whole
Person
Inter-
professional
Approaches
Anti-bacterial
and Fluoride
interventions
40
Disease Management and Risk Screening Training
DentaQuest Partnership for Oral Health Advancementrsquos
Online Learning Center
Disease Management Series
8 modules 40 CDE available
httpswwwdentaquestpartnershiporglearnonline-learning-centeronline-
coursewaredentaquest-disease-management-series
41
MEASUREMENT IN TEAMSSharing meaningful data with your dental clinical teams
42
rdquoDental Homerdquo = Health Home where WE can meet the patient
Oralhealthworkforceorg
43
POLL HOW OFTEN DO YOU SHARE YOUR S WITH YOUR DENTAL TEAM
A Yearly only
B Quarterly
C Monthly
D Weekly
E Daily
44
Clinical Measures ndash Dental Practice Perspective
Private Practice Office
New patients seen
Assigned vs seen if capitated
Treatment plans incomplete
$ produced amp per provider
$ collected amp monthly per provider
CDT 6000 codes completed
RecallHygiene maintenance
Based on this consultants experienced
FQHC
Unduplicated patients
patients seen per day
Treatment plans complete
$ gainedlost via accounting
Broken appointment rate
procedures
Sealant rate (annual)
45
bull HRSA Sealant Measure Compliance for FQHCs
bull Completion of phase 1 treatment plans
bull Children seen 0-5 years old
bull Children seen getting a preventive service
bull Fluoride Varnish applications
bull Pregnant women seen and treated
bull Diabetic patients with HbA1C gt 7 seen
bull Patients seen who have not been seen for 12 months
bull Patients seen getting a Risk Assessment
bull Patients with moderate or high risk who lower risk at recare
bull Sealants provided httpwwwnnohaorgnnoha-contentuploads201512Demystifying-HRSA-SEALANT-PRESENTATION_FINALpdf
Program Measures
46
HRSA Performance Measurement and Data Collection
bull FQHCs and look-alikes submit CY data to HRSA since 2008
bull UDS Uniform Data System
bull Require FTE for clinical staff patient demographics
bull Dental utilization s (UDCTPV)
bull Dental Clinical Measure dental sealants placed on 1st molars ages 6-9 yo
bull Health Center Quartile rankings (Clinical measure performance influences
HC rankings as does EHR adoption and other HC characteristics)
47
Low birth weight
Access to prenatal care
Childhood Immunization
Children (Ages 3-17) Receiving
Weight Assessment amp
Counseling
Children (Age 6-9) Receiving
Dental Sealant to First Molars
Diabetes Control
Hypertension Control
Pap Test
Depression Screening and
Follow-up (Age 12+)
Asthma Patients (Age 5-40)
Receiving Pharmacologic
Therapy
Colorectal Cancer
Screening (Ages 51-74)
HRSA UDS Clinical Measures
Adults (Age 18+) Receiving
Weight Screening amp Follow-up
Adults (Age 18+) Receiving
Tobacco Use Assessment and
Cessation Intervention
Coronary Artery Disease
Receiving Lipid Therapy (18+)
Ischemic Vascular Disease (IVD)
Receiving Aspirin Therapy (18+)
HIV Linkage to Care
48
Dashboards
Grants
Average
amp
Targets
Quality
Rev
Costs
Visits
Priority
Pop
Prevention
49
Dashboard- Provider Team Level
Patient
Compliance
Satisfaction
50
Case Study-
Incentives bonus round pools benchmark and improvement target goals risk-sharing possible later years
51
Qualitative Measurement
ldquoPatient engagement is the act of patients and providers working together
toward the end goal of improved patient wellnessrdquo
wwwpatientengagementhitcom
Access to Care
Patient Activation
Patient Satisfaction
Patient-Provider-Care Team Communication
Care Team Satisfaction
52
OHVBC Readiness
Leadership
bull Value of oral health and oral health transformation
Structure Systems and Operations
bull Operational efficiencies innovative care delivery methodologies
Care Pathways and Provider Buy-In
bull Training disease management risk-based care referrals IDC-10 coding patient engagement
Data and Analytic Technology and Personnel
bull Interoperability reporting
Financial Viability and Strength
bull Payerpatient mix billing infrastructure financial reports
httpswwwdentaquestpartnershiporglearnsafety-net-solutionsoral-health-value-based-careohvbc-readiness-
assessment
53
QUESTIONS COMMENTS
Carolyn Brown DDS
cbrownddsgmailcom
RISK BASED MANAGED CARE
Value Based Training Conference
Manchester New Hampshire
Mark Koday DDS
111919
5555
Objectives
bull Review current drivers of dental managed care
bull Understand the basics of risk-based dental managed care contracts
bull Learn the basics of managing costs in a riskndashbased contract
bull Gain an understanding in the potential advantage of risk-based contracting
56
What Is Dental Managed Care
Managed care is a health delivery system whose purpose is to manage both the
quality and cost of health care
Common types of managed care health insurance plans
bull HMOs
bull PPOs
bull POSs
bull Medicaid Managed Care
DIDNrsquoT WE ALREADY HAVE MANAGED CARE AND IT FAILED
57
What Has Happened Since the 90s
58
WHY THE FFS AND PPS DOESNrsquoT WORK FOR OUR POPULATIONS
bull Inefficient payment systems designed to produce encounters or procedures but not real health
bull No focus on population health
bull Does not incentivize innovation
bull Patients essentially on their own for accessing specialty care
59
Rule of 4
Source Kaiser Family Foundation analysis of National Health Expenditure (NHE) data from Centers for
Medicare and Medicaid Services Office of the Actuary National Health Statistics Group
60
Rule of 4
bull This helps explain why oral health has been relatively ignored so far by CMS
bull Explains why we have PCMH instead of PCHH
bull Where is the real value on a national level in preventing disease and
controlling costs
bull Beware- wersquove been found
61
Reasons Dental Managed Care is Spreading Across the States
NON-MANAGED CARE STATE DENTAL BUDGETS ARE
OPENED ENDED
STRAIN ON STATE BUDGETS
UPCOMING RECESSION WITH TRILLION DOLLAR
DEFICIT
SHIFTS FINANCIAL RISK FROM THE STATES TO THE
PLANS
6262
Types of Medicaid Managed Care
bull State Medicaid agency administrator lowest administrative
costs
bull Third Party Administrator Typically 15 administrative costs
bull Managed Care Organization Typically 15 administrative
costs
bull Carved-in
bull Carved-out
bull Risk Based Managed Care Administrative costs part of
contract negotiation
63
RISK CONTRACTS
6464
Components of a Risk-based Contract
Risk
Medical Loss Ratio
Quality withhold
Specialty withhold
Managed care payment (pmpm)
Covered services
Fee schedule Claims are paid as usual on a FFS basis
Credentialing
Quality Review process and Quality Metrics
65
Upside Risk
The possibility that the cost of
delivering dental care to an assigned
patient panel is less than the amount
of funding calculated for that care
The Plan pays the CHC additional
funds based on a predetermine
formula
Downside Risk
The possibility that the cost of
delivering dental care to an assigned
patient panel is more than the amount
of funding calculated for that care
The CHC pays the Plan additional
funds based on a predetermine
formula
Upside and Downside Risk
66
Taking On Risk 100 or Shared Risk
With 100 risk you receive 100 of the potential savings but are also at risk for
100 of the losses
Shared Risk MCO and health center share a percentage of the risk
Shared Risk leads to better cooperation since both organizations are
incentivized to save on costs
6767
Reports Needed
bull Enrollment reports lists of who is assigned on a monthly basis
bull Reconciliation reports insure appropriate payments
bull Specialty Referral reports
bull You will need your own reporting process so you donrsquot rely completely on
reports supplied by the Plan
6868
Medical Loss Ratio
Medical Loss Ratio (MLR) is proportion of premium revenues spent on clinical
services and quality improvement also known as the Medical Loss Ratio (MLR)
For CMS requires Medical Plans to spend at least 80 to 85 of the premiums
on actual medical care
69
Administrative Fees
bull Essentially the opposite of MLR
bull The State Medicaid Agency is funded by the Governorrsquos budget
bull The State Medicaid Agency will keep some of these funds for their
admin costs and give the remaining to the Managed Care Plans
bull Private Plan admin costs can be as high as 40 but most states
limit these cost for Medicaid Plans to between 15 and 20 (85-
80 MLR)
bull This may be negotiable depending on your program size of your
program
70
Quality Withhold
bull The state withholds a certain percent (typically 2-4 ) of the funds they give
to the Plans for Value Based Reimbursement
bull They choose quality metrics and set benchmarks and assign payments for
each metric based on an assigned priority for each metric
bull If a Plan meets the benchmark of every quality metric the state passes on
their full share of the quality withhold
bull The Plans may or may not withhold a percent of the funds for quality payment
to the dentists or manage care contractors
71
Quality Withhold
Either way the Plans may or may not pass the quality payments they receive to
the dentists or contractors
This should be spelled out in a risk-based contract
72
Percent of funds set aside
to cover specialty care
referrals
Typically 10-15
Goal Limit referral costs
to within or less than
Specialty set aside
Specialty Withhold
73
Per Member Per Month
bull Capitated Payment
bull Specific dollar amount paid for each enrolled member each month
bull Paid whether patient is accessed for care or not
bull States do set access benchmarks
bull In Oregon access for any dental procedure (adults and children combined)
was 267 in 2015
74
Payment Math Example
Premium per enrollee = $25
Administrative fee 15 = $375
Funds available per enrollee to the clinic = $2125
Management fee per enrollee = $175
Funds per enrollee that would undergo PPS reconciliation = $1950
For every 10000 enrollees the managed care income = $2340000
Specialty withhold (10) = $234000
YE Cost lt or gt $2340000
Upside Risk
CHC Gains $
Downside Risk
CHC Loses $
75
Covered Services and Fee Schedules
bull The state Medicaid agency spells out the minimum procedures and fees that
MCOs must cover
bull MCOs may add procedures or increase periodicity of procedures particularly
preventative services
bull MCOs may increase fees to entice rural providers and specialists to enroll in
their Plans
bull Access Rules
bull How many days it takes to access a patent
bull How many days it takes for a patent to access urgent care services
bull How many days it takes for a patent to access emergency care services
76
Credentialing
All MCOs are required to credential all Providers
All MCOs have their own credentialing process
Credentialing process is can be lengthy
Credentialing process may be negotiable
77
Quality Review Process and Quality Metrics
MCOs must have a Quality and Compliance Review Process
If you arenrsquot in compliance with both you likely wonrsquot get paid
Typical processes reviewed
bull Charting specifications
bull Incident report
bull Enrollee complaints quality rudeness and access issues
bull Medicaid compliance
78
Quality Payments
bull State Shared Incentive Withhold Typically quality metrics and benchmarks
are set by the state sets aside a certain percent (3-5) of the payments to
the Managed Care Plan (MCP)
bull If the benchmarks are achieved the MCP is then paid the a predetermine
amount
bull Benchmarks may not be the same as the states
bull Managed Care Plans do not have to pass all or any of the quality payments to
the health centers or providers
bull Managed Care contract- Metrics benchmarks should be selected and part of
the contract
7979
Achieving Quality Metric Payments
Dealing with under achievers
Process issues
Individual issues
Identifying workflows
Developing Best Practices through
PDSA process
Developing Best Practices through
PDSA process
CHC Metrics Committee
Clinicians Operations various key staff
Identify Best Practices
Spread Best Practices
80
New Team Needed Business Intelligence
Business Intelligence (BI) is critical for effective managed care business decisions
BI team inputs metrics into your EHR collects integrates analyses and displays all your managed care business and clinical information
Easy to say- hard to achieve
Build your own or outsource
Possible future role of Primary Care Associations
8181
Clinicianrsquos Dashboard
Expensive to build
Displayed on your screen when your computer is first turned on
Easy to read and understand
Data dumped from the day before
Can dialed down from Org-wide to clinic to each clinicianrsquos data
Operational and clinical metrics
bull Treatment Plan Completion
bull DQA quality measures
bull Caries at Recall
bull Re-care reports
bull Care Gap reports
82
CONTROLLING COSTS
8383
Controlling Costs- Current
bull Increasing efficiencies
bull Decreasing broken appointments
bull Controlling supplies equipment costs
bull Staff recruitment retention costs
84
Specialty Care
Training current CHC dentists in
specialty areas
Hiring general dentists with higher
specialty skill sets
Hiring in house specialists
Contract with outside specialists
Work with Managed Care Plan
specialists
Lowering Disease Rates
Community Dental Health
Coordinators case management
If your state law allows- embed
hygienists in medical and community
to provide primary and secondary
prevention procedures
In clinic Caries Classification and
Silver Diamine Fluoride
Effective recare programs
Controlling Costs- Additions in Risk-based Contracting
85
Specialty Care ndash Primary Referrals by Cost
Pediatric dentistry
Orthodontics
Oral surgery
Endodontics
86
In-clinic Pediatric Services
Encounters expected
of operatories available
State dental law and ability to have
expanded duties
General Anesthesia
GA in- house
Ability for a hospital or surgery center
to set aside regular OR time
Ability to hire or assign DAs to GA
days
Four GA cases day x PPS rate
Should You Hire a Pediatric Dentist- It Depends
8787
Solutions for Controlling Pediatric Costs
Hire a general dentist that is skilled in treating young children
Make the clinic child friendly nitrous oxide TVs in the operatory etc
Teach entire staff behavioral control techniques
Contract with a pediatric dentist for the GA care
88
Lowering Overall Disease Rates (and Costs)
You are responsible for both the patients you see in the chair and the ones
assigned to you
Breaking down the walls of the dental clinic
Community Dental Health Coordinators
Case Management
89
Cost Control Essentials
Diagnosis codes
Increased ability to identify
disease by risk
Motivational
Interviewing
Developing Polices and
Procedures design to treat
disease according to risk
ie Silver Diamine Fluoride
Treating by Risk
Effective Recare
Process
Critical to continual disease
controlPrevention education that is
meaningful and designed to
change behaviors
90
Social Determinants of Health Aunt Bertha
httpswwwauntberthacom
91
REASON TO CONSIDER RISK- BASED CONTRACTING
9292
PPS Reconciliation and Federal Code 42 CFR sect4052469(a)(2)
42 CFR sect4052469(a)(2)
ldquoAny financial incentives provided to Federally Qualified Health Centers
under their Medicare Advantage Contracts such as risk pool payments
bonuses or withholds are prohibited from being included in the
calculation of supplemental payments due to the Federally Qualified
Health Centerrdquo
9393
Why Risk Based Contract in Times of PPS Reconciliation
bull Not all Risk- based Contract funds are reconciled
bull Risk is the key word- you can come out with less money than your normal
PPS reconciliation payment
bull Can lead to better patient care
bull May improve manage care enrollment for your medical plan
bull Promotes integrated care increases health for your CHC patients
9494
Not Included in the Reconciliation
Enrollment management pmpm
Quality Payments
Upside risk payments
Downside risk losses
9595
Determinants of Financial Success in Risk-Based Contracting
bull Most critical- State pmpm payment to the Managed Care Plan
bull Reporting capabilities
bull Specialty service capabilities
bull Access numbers count
bull Ability to move metric numbers
9696
What About the Non- Medicaid Poor We Serve
bull Numbers are king in a managed care contract and the more access you have
the better contract terms you can negotiate
bull We will potentially have a steady supply of Medicaid patients
bull As managed care spreads states this may be compromising the ability of
health centers to serve the non-Medicaid poor and others lacking dental
insurance
97
Mark Koday DDS
(509) 949-2278
Dental Quality Consultants
of WA
httpdentalqualityconsultin
gcom
dentalqualityconsultantsg
mailcom
Contact Information
LUNCH
BREAKOUT EXERCISEORAL HEALTH VALUE-BASED CARE READINESS ASSESSMENT
Danielle Apostolon
PROMISING PRACTICES FROM THE FIELD STRATEGIES FOR INCREASING VALUE IN ORAL HEALTH
Dr Carolyn Brown
Dr Kelly Perry
Dr Rachel Rivard
Dr Adeloye
Commitment Compassion Community
m i d s t a t e h e a l t h o r g
Promising Practices from the
Field Strategies for Increasing
Value in Oral Health Care
Kelly Perry DMD
Better Health
Outcomes
Improved Staff
Experience
Reduced Cost
Improved Patient
Experience
Better Health
Outcomes
Improved Staff
Experience
Reduced Cost
Improved Patient
Experience
Better Health
Outcomes
Improved Staff
Experience
Reduced Cost
Improved Patient
Experience
Better Health
Outcomes
Improved Staff
Experience
Reduced Cost
Improved Patient
Experience
Commitment Compassion Community
kpe r r ymids t a tehea l t h o rg
Thank you
Completion of Disease Control Phase
Pelumi Adeloye DMD MPH
HEALTH ACCESS NETWORK (HAN) FAMILY DENTAL
Introduction
⧫1 Dentist I Hygienist 3 EFDArsquos1 Receptionist
⧫ 6 Chairs= 4 (dentist) + 2 (hygienist)
⧫ Slide ⥶80 off
⧫ Service areas Northern Penobscot Southern Aroostook Western
Washington Counties amp more
Completion of Phase I Treatment
⧫LimitedLack of Access to dental care
⧫Difficulty completing the disease control phase
Caries amp periodontal disease
⧫Attaining stable restorative state
Goal
Increase the completion of Disease Control Phase
Current practice
⧫Education
Assess level of dental literacy
Incremental strategy
⧫Increase access to dental care
Generous sliding scale (⥸$40 per visit)
Incorporate Expanded Function Dental Assistants
⧫Schedule modification
Incorporate more restorative blocks to allow
for follow-up visit and completion of restorative phase
httpswwwglasbergencomdentist-cartoons
Schedule
⧫Piggybacking technique
Increased allotted restorative blocks
⧫Sustainability of current schedule is
contingent on cooperation amp skills of HAN
Dental staff
Note
Strategies mentioned today is personalized to HAN Dental clinic
Current implemented strategies might be modified or changed in the
future as required in order to accommodate the need of our pts
THANK YOU
DAY TWOCLOSINGWRAP-UP
End of Day Two ndash Survey
Day Two Creating a Value-Based Oral Health Care Delivery
System
129
Payment Reform in Oral Health Online Learning Module
Oral Health Value-based Care Online Learning Module
Value-based Care Keys to Success Article
Readiness Assessment
Competency Development Guide
Oral Health Value-based Care Training
Dental Caries Management Practicum
Clinicians Companion Guide
Interprofessional Network Referral Process
Traditional Dental Care Vs Value-Based Care
Resources
131
wwwDentaQuestPartnershiporg
wwwfacebookcomDentaQuest
DentaQuest
wwwlinkedincomcompanyDentaQuest
Inside_DentaQuest
QUESTIONS
40
Disease Management and Risk Screening Training
DentaQuest Partnership for Oral Health Advancementrsquos
Online Learning Center
Disease Management Series
8 modules 40 CDE available
httpswwwdentaquestpartnershiporglearnonline-learning-centeronline-
coursewaredentaquest-disease-management-series
41
MEASUREMENT IN TEAMSSharing meaningful data with your dental clinical teams
42
rdquoDental Homerdquo = Health Home where WE can meet the patient
Oralhealthworkforceorg
43
POLL HOW OFTEN DO YOU SHARE YOUR S WITH YOUR DENTAL TEAM
A Yearly only
B Quarterly
C Monthly
D Weekly
E Daily
44
Clinical Measures ndash Dental Practice Perspective
Private Practice Office
New patients seen
Assigned vs seen if capitated
Treatment plans incomplete
$ produced amp per provider
$ collected amp monthly per provider
CDT 6000 codes completed
RecallHygiene maintenance
Based on this consultants experienced
FQHC
Unduplicated patients
patients seen per day
Treatment plans complete
$ gainedlost via accounting
Broken appointment rate
procedures
Sealant rate (annual)
45
bull HRSA Sealant Measure Compliance for FQHCs
bull Completion of phase 1 treatment plans
bull Children seen 0-5 years old
bull Children seen getting a preventive service
bull Fluoride Varnish applications
bull Pregnant women seen and treated
bull Diabetic patients with HbA1C gt 7 seen
bull Patients seen who have not been seen for 12 months
bull Patients seen getting a Risk Assessment
bull Patients with moderate or high risk who lower risk at recare
bull Sealants provided httpwwwnnohaorgnnoha-contentuploads201512Demystifying-HRSA-SEALANT-PRESENTATION_FINALpdf
Program Measures
46
HRSA Performance Measurement and Data Collection
bull FQHCs and look-alikes submit CY data to HRSA since 2008
bull UDS Uniform Data System
bull Require FTE for clinical staff patient demographics
bull Dental utilization s (UDCTPV)
bull Dental Clinical Measure dental sealants placed on 1st molars ages 6-9 yo
bull Health Center Quartile rankings (Clinical measure performance influences
HC rankings as does EHR adoption and other HC characteristics)
47
Low birth weight
Access to prenatal care
Childhood Immunization
Children (Ages 3-17) Receiving
Weight Assessment amp
Counseling
Children (Age 6-9) Receiving
Dental Sealant to First Molars
Diabetes Control
Hypertension Control
Pap Test
Depression Screening and
Follow-up (Age 12+)
Asthma Patients (Age 5-40)
Receiving Pharmacologic
Therapy
Colorectal Cancer
Screening (Ages 51-74)
HRSA UDS Clinical Measures
Adults (Age 18+) Receiving
Weight Screening amp Follow-up
Adults (Age 18+) Receiving
Tobacco Use Assessment and
Cessation Intervention
Coronary Artery Disease
Receiving Lipid Therapy (18+)
Ischemic Vascular Disease (IVD)
Receiving Aspirin Therapy (18+)
HIV Linkage to Care
48
Dashboards
Grants
Average
amp
Targets
Quality
Rev
Costs
Visits
Priority
Pop
Prevention
49
Dashboard- Provider Team Level
Patient
Compliance
Satisfaction
50
Case Study-
Incentives bonus round pools benchmark and improvement target goals risk-sharing possible later years
51
Qualitative Measurement
ldquoPatient engagement is the act of patients and providers working together
toward the end goal of improved patient wellnessrdquo
wwwpatientengagementhitcom
Access to Care
Patient Activation
Patient Satisfaction
Patient-Provider-Care Team Communication
Care Team Satisfaction
52
OHVBC Readiness
Leadership
bull Value of oral health and oral health transformation
Structure Systems and Operations
bull Operational efficiencies innovative care delivery methodologies
Care Pathways and Provider Buy-In
bull Training disease management risk-based care referrals IDC-10 coding patient engagement
Data and Analytic Technology and Personnel
bull Interoperability reporting
Financial Viability and Strength
bull Payerpatient mix billing infrastructure financial reports
httpswwwdentaquestpartnershiporglearnsafety-net-solutionsoral-health-value-based-careohvbc-readiness-
assessment
53
QUESTIONS COMMENTS
Carolyn Brown DDS
cbrownddsgmailcom
RISK BASED MANAGED CARE
Value Based Training Conference
Manchester New Hampshire
Mark Koday DDS
111919
5555
Objectives
bull Review current drivers of dental managed care
bull Understand the basics of risk-based dental managed care contracts
bull Learn the basics of managing costs in a riskndashbased contract
bull Gain an understanding in the potential advantage of risk-based contracting
56
What Is Dental Managed Care
Managed care is a health delivery system whose purpose is to manage both the
quality and cost of health care
Common types of managed care health insurance plans
bull HMOs
bull PPOs
bull POSs
bull Medicaid Managed Care
DIDNrsquoT WE ALREADY HAVE MANAGED CARE AND IT FAILED
57
What Has Happened Since the 90s
58
WHY THE FFS AND PPS DOESNrsquoT WORK FOR OUR POPULATIONS
bull Inefficient payment systems designed to produce encounters or procedures but not real health
bull No focus on population health
bull Does not incentivize innovation
bull Patients essentially on their own for accessing specialty care
59
Rule of 4
Source Kaiser Family Foundation analysis of National Health Expenditure (NHE) data from Centers for
Medicare and Medicaid Services Office of the Actuary National Health Statistics Group
60
Rule of 4
bull This helps explain why oral health has been relatively ignored so far by CMS
bull Explains why we have PCMH instead of PCHH
bull Where is the real value on a national level in preventing disease and
controlling costs
bull Beware- wersquove been found
61
Reasons Dental Managed Care is Spreading Across the States
NON-MANAGED CARE STATE DENTAL BUDGETS ARE
OPENED ENDED
STRAIN ON STATE BUDGETS
UPCOMING RECESSION WITH TRILLION DOLLAR
DEFICIT
SHIFTS FINANCIAL RISK FROM THE STATES TO THE
PLANS
6262
Types of Medicaid Managed Care
bull State Medicaid agency administrator lowest administrative
costs
bull Third Party Administrator Typically 15 administrative costs
bull Managed Care Organization Typically 15 administrative
costs
bull Carved-in
bull Carved-out
bull Risk Based Managed Care Administrative costs part of
contract negotiation
63
RISK CONTRACTS
6464
Components of a Risk-based Contract
Risk
Medical Loss Ratio
Quality withhold
Specialty withhold
Managed care payment (pmpm)
Covered services
Fee schedule Claims are paid as usual on a FFS basis
Credentialing
Quality Review process and Quality Metrics
65
Upside Risk
The possibility that the cost of
delivering dental care to an assigned
patient panel is less than the amount
of funding calculated for that care
The Plan pays the CHC additional
funds based on a predetermine
formula
Downside Risk
The possibility that the cost of
delivering dental care to an assigned
patient panel is more than the amount
of funding calculated for that care
The CHC pays the Plan additional
funds based on a predetermine
formula
Upside and Downside Risk
66
Taking On Risk 100 or Shared Risk
With 100 risk you receive 100 of the potential savings but are also at risk for
100 of the losses
Shared Risk MCO and health center share a percentage of the risk
Shared Risk leads to better cooperation since both organizations are
incentivized to save on costs
6767
Reports Needed
bull Enrollment reports lists of who is assigned on a monthly basis
bull Reconciliation reports insure appropriate payments
bull Specialty Referral reports
bull You will need your own reporting process so you donrsquot rely completely on
reports supplied by the Plan
6868
Medical Loss Ratio
Medical Loss Ratio (MLR) is proportion of premium revenues spent on clinical
services and quality improvement also known as the Medical Loss Ratio (MLR)
For CMS requires Medical Plans to spend at least 80 to 85 of the premiums
on actual medical care
69
Administrative Fees
bull Essentially the opposite of MLR
bull The State Medicaid Agency is funded by the Governorrsquos budget
bull The State Medicaid Agency will keep some of these funds for their
admin costs and give the remaining to the Managed Care Plans
bull Private Plan admin costs can be as high as 40 but most states
limit these cost for Medicaid Plans to between 15 and 20 (85-
80 MLR)
bull This may be negotiable depending on your program size of your
program
70
Quality Withhold
bull The state withholds a certain percent (typically 2-4 ) of the funds they give
to the Plans for Value Based Reimbursement
bull They choose quality metrics and set benchmarks and assign payments for
each metric based on an assigned priority for each metric
bull If a Plan meets the benchmark of every quality metric the state passes on
their full share of the quality withhold
bull The Plans may or may not withhold a percent of the funds for quality payment
to the dentists or manage care contractors
71
Quality Withhold
Either way the Plans may or may not pass the quality payments they receive to
the dentists or contractors
This should be spelled out in a risk-based contract
72
Percent of funds set aside
to cover specialty care
referrals
Typically 10-15
Goal Limit referral costs
to within or less than
Specialty set aside
Specialty Withhold
73
Per Member Per Month
bull Capitated Payment
bull Specific dollar amount paid for each enrolled member each month
bull Paid whether patient is accessed for care or not
bull States do set access benchmarks
bull In Oregon access for any dental procedure (adults and children combined)
was 267 in 2015
74
Payment Math Example
Premium per enrollee = $25
Administrative fee 15 = $375
Funds available per enrollee to the clinic = $2125
Management fee per enrollee = $175
Funds per enrollee that would undergo PPS reconciliation = $1950
For every 10000 enrollees the managed care income = $2340000
Specialty withhold (10) = $234000
YE Cost lt or gt $2340000
Upside Risk
CHC Gains $
Downside Risk
CHC Loses $
75
Covered Services and Fee Schedules
bull The state Medicaid agency spells out the minimum procedures and fees that
MCOs must cover
bull MCOs may add procedures or increase periodicity of procedures particularly
preventative services
bull MCOs may increase fees to entice rural providers and specialists to enroll in
their Plans
bull Access Rules
bull How many days it takes to access a patent
bull How many days it takes for a patent to access urgent care services
bull How many days it takes for a patent to access emergency care services
76
Credentialing
All MCOs are required to credential all Providers
All MCOs have their own credentialing process
Credentialing process is can be lengthy
Credentialing process may be negotiable
77
Quality Review Process and Quality Metrics
MCOs must have a Quality and Compliance Review Process
If you arenrsquot in compliance with both you likely wonrsquot get paid
Typical processes reviewed
bull Charting specifications
bull Incident report
bull Enrollee complaints quality rudeness and access issues
bull Medicaid compliance
78
Quality Payments
bull State Shared Incentive Withhold Typically quality metrics and benchmarks
are set by the state sets aside a certain percent (3-5) of the payments to
the Managed Care Plan (MCP)
bull If the benchmarks are achieved the MCP is then paid the a predetermine
amount
bull Benchmarks may not be the same as the states
bull Managed Care Plans do not have to pass all or any of the quality payments to
the health centers or providers
bull Managed Care contract- Metrics benchmarks should be selected and part of
the contract
7979
Achieving Quality Metric Payments
Dealing with under achievers
Process issues
Individual issues
Identifying workflows
Developing Best Practices through
PDSA process
Developing Best Practices through
PDSA process
CHC Metrics Committee
Clinicians Operations various key staff
Identify Best Practices
Spread Best Practices
80
New Team Needed Business Intelligence
Business Intelligence (BI) is critical for effective managed care business decisions
BI team inputs metrics into your EHR collects integrates analyses and displays all your managed care business and clinical information
Easy to say- hard to achieve
Build your own or outsource
Possible future role of Primary Care Associations
8181
Clinicianrsquos Dashboard
Expensive to build
Displayed on your screen when your computer is first turned on
Easy to read and understand
Data dumped from the day before
Can dialed down from Org-wide to clinic to each clinicianrsquos data
Operational and clinical metrics
bull Treatment Plan Completion
bull DQA quality measures
bull Caries at Recall
bull Re-care reports
bull Care Gap reports
82
CONTROLLING COSTS
8383
Controlling Costs- Current
bull Increasing efficiencies
bull Decreasing broken appointments
bull Controlling supplies equipment costs
bull Staff recruitment retention costs
84
Specialty Care
Training current CHC dentists in
specialty areas
Hiring general dentists with higher
specialty skill sets
Hiring in house specialists
Contract with outside specialists
Work with Managed Care Plan
specialists
Lowering Disease Rates
Community Dental Health
Coordinators case management
If your state law allows- embed
hygienists in medical and community
to provide primary and secondary
prevention procedures
In clinic Caries Classification and
Silver Diamine Fluoride
Effective recare programs
Controlling Costs- Additions in Risk-based Contracting
85
Specialty Care ndash Primary Referrals by Cost
Pediatric dentistry
Orthodontics
Oral surgery
Endodontics
86
In-clinic Pediatric Services
Encounters expected
of operatories available
State dental law and ability to have
expanded duties
General Anesthesia
GA in- house
Ability for a hospital or surgery center
to set aside regular OR time
Ability to hire or assign DAs to GA
days
Four GA cases day x PPS rate
Should You Hire a Pediatric Dentist- It Depends
8787
Solutions for Controlling Pediatric Costs
Hire a general dentist that is skilled in treating young children
Make the clinic child friendly nitrous oxide TVs in the operatory etc
Teach entire staff behavioral control techniques
Contract with a pediatric dentist for the GA care
88
Lowering Overall Disease Rates (and Costs)
You are responsible for both the patients you see in the chair and the ones
assigned to you
Breaking down the walls of the dental clinic
Community Dental Health Coordinators
Case Management
89
Cost Control Essentials
Diagnosis codes
Increased ability to identify
disease by risk
Motivational
Interviewing
Developing Polices and
Procedures design to treat
disease according to risk
ie Silver Diamine Fluoride
Treating by Risk
Effective Recare
Process
Critical to continual disease
controlPrevention education that is
meaningful and designed to
change behaviors
90
Social Determinants of Health Aunt Bertha
httpswwwauntberthacom
91
REASON TO CONSIDER RISK- BASED CONTRACTING
9292
PPS Reconciliation and Federal Code 42 CFR sect4052469(a)(2)
42 CFR sect4052469(a)(2)
ldquoAny financial incentives provided to Federally Qualified Health Centers
under their Medicare Advantage Contracts such as risk pool payments
bonuses or withholds are prohibited from being included in the
calculation of supplemental payments due to the Federally Qualified
Health Centerrdquo
9393
Why Risk Based Contract in Times of PPS Reconciliation
bull Not all Risk- based Contract funds are reconciled
bull Risk is the key word- you can come out with less money than your normal
PPS reconciliation payment
bull Can lead to better patient care
bull May improve manage care enrollment for your medical plan
bull Promotes integrated care increases health for your CHC patients
9494
Not Included in the Reconciliation
Enrollment management pmpm
Quality Payments
Upside risk payments
Downside risk losses
9595
Determinants of Financial Success in Risk-Based Contracting
bull Most critical- State pmpm payment to the Managed Care Plan
bull Reporting capabilities
bull Specialty service capabilities
bull Access numbers count
bull Ability to move metric numbers
9696
What About the Non- Medicaid Poor We Serve
bull Numbers are king in a managed care contract and the more access you have
the better contract terms you can negotiate
bull We will potentially have a steady supply of Medicaid patients
bull As managed care spreads states this may be compromising the ability of
health centers to serve the non-Medicaid poor and others lacking dental
insurance
97
Mark Koday DDS
(509) 949-2278
Dental Quality Consultants
of WA
httpdentalqualityconsultin
gcom
dentalqualityconsultantsg
mailcom
Contact Information
LUNCH
BREAKOUT EXERCISEORAL HEALTH VALUE-BASED CARE READINESS ASSESSMENT
Danielle Apostolon
PROMISING PRACTICES FROM THE FIELD STRATEGIES FOR INCREASING VALUE IN ORAL HEALTH
Dr Carolyn Brown
Dr Kelly Perry
Dr Rachel Rivard
Dr Adeloye
Commitment Compassion Community
m i d s t a t e h e a l t h o r g
Promising Practices from the
Field Strategies for Increasing
Value in Oral Health Care
Kelly Perry DMD
Better Health
Outcomes
Improved Staff
Experience
Reduced Cost
Improved Patient
Experience
Better Health
Outcomes
Improved Staff
Experience
Reduced Cost
Improved Patient
Experience
Better Health
Outcomes
Improved Staff
Experience
Reduced Cost
Improved Patient
Experience
Better Health
Outcomes
Improved Staff
Experience
Reduced Cost
Improved Patient
Experience
Commitment Compassion Community
kpe r r ymids t a tehea l t h o rg
Thank you
Completion of Disease Control Phase
Pelumi Adeloye DMD MPH
HEALTH ACCESS NETWORK (HAN) FAMILY DENTAL
Introduction
⧫1 Dentist I Hygienist 3 EFDArsquos1 Receptionist
⧫ 6 Chairs= 4 (dentist) + 2 (hygienist)
⧫ Slide ⥶80 off
⧫ Service areas Northern Penobscot Southern Aroostook Western
Washington Counties amp more
Completion of Phase I Treatment
⧫LimitedLack of Access to dental care
⧫Difficulty completing the disease control phase
Caries amp periodontal disease
⧫Attaining stable restorative state
Goal
Increase the completion of Disease Control Phase
Current practice
⧫Education
Assess level of dental literacy
Incremental strategy
⧫Increase access to dental care
Generous sliding scale (⥸$40 per visit)
Incorporate Expanded Function Dental Assistants
⧫Schedule modification
Incorporate more restorative blocks to allow
for follow-up visit and completion of restorative phase
httpswwwglasbergencomdentist-cartoons
Schedule
⧫Piggybacking technique
Increased allotted restorative blocks
⧫Sustainability of current schedule is
contingent on cooperation amp skills of HAN
Dental staff
Note
Strategies mentioned today is personalized to HAN Dental clinic
Current implemented strategies might be modified or changed in the
future as required in order to accommodate the need of our pts
THANK YOU
DAY TWOCLOSINGWRAP-UP
End of Day Two ndash Survey
Day Two Creating a Value-Based Oral Health Care Delivery
System
129
Payment Reform in Oral Health Online Learning Module
Oral Health Value-based Care Online Learning Module
Value-based Care Keys to Success Article
Readiness Assessment
Competency Development Guide
Oral Health Value-based Care Training
Dental Caries Management Practicum
Clinicians Companion Guide
Interprofessional Network Referral Process
Traditional Dental Care Vs Value-Based Care
Resources
131
wwwDentaQuestPartnershiporg
wwwfacebookcomDentaQuest
DentaQuest
wwwlinkedincomcompanyDentaQuest
Inside_DentaQuest
QUESTIONS
41
MEASUREMENT IN TEAMSSharing meaningful data with your dental clinical teams
42
rdquoDental Homerdquo = Health Home where WE can meet the patient
Oralhealthworkforceorg
43
POLL HOW OFTEN DO YOU SHARE YOUR S WITH YOUR DENTAL TEAM
A Yearly only
B Quarterly
C Monthly
D Weekly
E Daily
44
Clinical Measures ndash Dental Practice Perspective
Private Practice Office
New patients seen
Assigned vs seen if capitated
Treatment plans incomplete
$ produced amp per provider
$ collected amp monthly per provider
CDT 6000 codes completed
RecallHygiene maintenance
Based on this consultants experienced
FQHC
Unduplicated patients
patients seen per day
Treatment plans complete
$ gainedlost via accounting
Broken appointment rate
procedures
Sealant rate (annual)
45
bull HRSA Sealant Measure Compliance for FQHCs
bull Completion of phase 1 treatment plans
bull Children seen 0-5 years old
bull Children seen getting a preventive service
bull Fluoride Varnish applications
bull Pregnant women seen and treated
bull Diabetic patients with HbA1C gt 7 seen
bull Patients seen who have not been seen for 12 months
bull Patients seen getting a Risk Assessment
bull Patients with moderate or high risk who lower risk at recare
bull Sealants provided httpwwwnnohaorgnnoha-contentuploads201512Demystifying-HRSA-SEALANT-PRESENTATION_FINALpdf
Program Measures
46
HRSA Performance Measurement and Data Collection
bull FQHCs and look-alikes submit CY data to HRSA since 2008
bull UDS Uniform Data System
bull Require FTE for clinical staff patient demographics
bull Dental utilization s (UDCTPV)
bull Dental Clinical Measure dental sealants placed on 1st molars ages 6-9 yo
bull Health Center Quartile rankings (Clinical measure performance influences
HC rankings as does EHR adoption and other HC characteristics)
47
Low birth weight
Access to prenatal care
Childhood Immunization
Children (Ages 3-17) Receiving
Weight Assessment amp
Counseling
Children (Age 6-9) Receiving
Dental Sealant to First Molars
Diabetes Control
Hypertension Control
Pap Test
Depression Screening and
Follow-up (Age 12+)
Asthma Patients (Age 5-40)
Receiving Pharmacologic
Therapy
Colorectal Cancer
Screening (Ages 51-74)
HRSA UDS Clinical Measures
Adults (Age 18+) Receiving
Weight Screening amp Follow-up
Adults (Age 18+) Receiving
Tobacco Use Assessment and
Cessation Intervention
Coronary Artery Disease
Receiving Lipid Therapy (18+)
Ischemic Vascular Disease (IVD)
Receiving Aspirin Therapy (18+)
HIV Linkage to Care
48
Dashboards
Grants
Average
amp
Targets
Quality
Rev
Costs
Visits
Priority
Pop
Prevention
49
Dashboard- Provider Team Level
Patient
Compliance
Satisfaction
50
Case Study-
Incentives bonus round pools benchmark and improvement target goals risk-sharing possible later years
51
Qualitative Measurement
ldquoPatient engagement is the act of patients and providers working together
toward the end goal of improved patient wellnessrdquo
wwwpatientengagementhitcom
Access to Care
Patient Activation
Patient Satisfaction
Patient-Provider-Care Team Communication
Care Team Satisfaction
52
OHVBC Readiness
Leadership
bull Value of oral health and oral health transformation
Structure Systems and Operations
bull Operational efficiencies innovative care delivery methodologies
Care Pathways and Provider Buy-In
bull Training disease management risk-based care referrals IDC-10 coding patient engagement
Data and Analytic Technology and Personnel
bull Interoperability reporting
Financial Viability and Strength
bull Payerpatient mix billing infrastructure financial reports
httpswwwdentaquestpartnershiporglearnsafety-net-solutionsoral-health-value-based-careohvbc-readiness-
assessment
53
QUESTIONS COMMENTS
Carolyn Brown DDS
cbrownddsgmailcom
RISK BASED MANAGED CARE
Value Based Training Conference
Manchester New Hampshire
Mark Koday DDS
111919
5555
Objectives
bull Review current drivers of dental managed care
bull Understand the basics of risk-based dental managed care contracts
bull Learn the basics of managing costs in a riskndashbased contract
bull Gain an understanding in the potential advantage of risk-based contracting
56
What Is Dental Managed Care
Managed care is a health delivery system whose purpose is to manage both the
quality and cost of health care
Common types of managed care health insurance plans
bull HMOs
bull PPOs
bull POSs
bull Medicaid Managed Care
DIDNrsquoT WE ALREADY HAVE MANAGED CARE AND IT FAILED
57
What Has Happened Since the 90s
58
WHY THE FFS AND PPS DOESNrsquoT WORK FOR OUR POPULATIONS
bull Inefficient payment systems designed to produce encounters or procedures but not real health
bull No focus on population health
bull Does not incentivize innovation
bull Patients essentially on their own for accessing specialty care
59
Rule of 4
Source Kaiser Family Foundation analysis of National Health Expenditure (NHE) data from Centers for
Medicare and Medicaid Services Office of the Actuary National Health Statistics Group
60
Rule of 4
bull This helps explain why oral health has been relatively ignored so far by CMS
bull Explains why we have PCMH instead of PCHH
bull Where is the real value on a national level in preventing disease and
controlling costs
bull Beware- wersquove been found
61
Reasons Dental Managed Care is Spreading Across the States
NON-MANAGED CARE STATE DENTAL BUDGETS ARE
OPENED ENDED
STRAIN ON STATE BUDGETS
UPCOMING RECESSION WITH TRILLION DOLLAR
DEFICIT
SHIFTS FINANCIAL RISK FROM THE STATES TO THE
PLANS
6262
Types of Medicaid Managed Care
bull State Medicaid agency administrator lowest administrative
costs
bull Third Party Administrator Typically 15 administrative costs
bull Managed Care Organization Typically 15 administrative
costs
bull Carved-in
bull Carved-out
bull Risk Based Managed Care Administrative costs part of
contract negotiation
63
RISK CONTRACTS
6464
Components of a Risk-based Contract
Risk
Medical Loss Ratio
Quality withhold
Specialty withhold
Managed care payment (pmpm)
Covered services
Fee schedule Claims are paid as usual on a FFS basis
Credentialing
Quality Review process and Quality Metrics
65
Upside Risk
The possibility that the cost of
delivering dental care to an assigned
patient panel is less than the amount
of funding calculated for that care
The Plan pays the CHC additional
funds based on a predetermine
formula
Downside Risk
The possibility that the cost of
delivering dental care to an assigned
patient panel is more than the amount
of funding calculated for that care
The CHC pays the Plan additional
funds based on a predetermine
formula
Upside and Downside Risk
66
Taking On Risk 100 or Shared Risk
With 100 risk you receive 100 of the potential savings but are also at risk for
100 of the losses
Shared Risk MCO and health center share a percentage of the risk
Shared Risk leads to better cooperation since both organizations are
incentivized to save on costs
6767
Reports Needed
bull Enrollment reports lists of who is assigned on a monthly basis
bull Reconciliation reports insure appropriate payments
bull Specialty Referral reports
bull You will need your own reporting process so you donrsquot rely completely on
reports supplied by the Plan
6868
Medical Loss Ratio
Medical Loss Ratio (MLR) is proportion of premium revenues spent on clinical
services and quality improvement also known as the Medical Loss Ratio (MLR)
For CMS requires Medical Plans to spend at least 80 to 85 of the premiums
on actual medical care
69
Administrative Fees
bull Essentially the opposite of MLR
bull The State Medicaid Agency is funded by the Governorrsquos budget
bull The State Medicaid Agency will keep some of these funds for their
admin costs and give the remaining to the Managed Care Plans
bull Private Plan admin costs can be as high as 40 but most states
limit these cost for Medicaid Plans to between 15 and 20 (85-
80 MLR)
bull This may be negotiable depending on your program size of your
program
70
Quality Withhold
bull The state withholds a certain percent (typically 2-4 ) of the funds they give
to the Plans for Value Based Reimbursement
bull They choose quality metrics and set benchmarks and assign payments for
each metric based on an assigned priority for each metric
bull If a Plan meets the benchmark of every quality metric the state passes on
their full share of the quality withhold
bull The Plans may or may not withhold a percent of the funds for quality payment
to the dentists or manage care contractors
71
Quality Withhold
Either way the Plans may or may not pass the quality payments they receive to
the dentists or contractors
This should be spelled out in a risk-based contract
72
Percent of funds set aside
to cover specialty care
referrals
Typically 10-15
Goal Limit referral costs
to within or less than
Specialty set aside
Specialty Withhold
73
Per Member Per Month
bull Capitated Payment
bull Specific dollar amount paid for each enrolled member each month
bull Paid whether patient is accessed for care or not
bull States do set access benchmarks
bull In Oregon access for any dental procedure (adults and children combined)
was 267 in 2015
74
Payment Math Example
Premium per enrollee = $25
Administrative fee 15 = $375
Funds available per enrollee to the clinic = $2125
Management fee per enrollee = $175
Funds per enrollee that would undergo PPS reconciliation = $1950
For every 10000 enrollees the managed care income = $2340000
Specialty withhold (10) = $234000
YE Cost lt or gt $2340000
Upside Risk
CHC Gains $
Downside Risk
CHC Loses $
75
Covered Services and Fee Schedules
bull The state Medicaid agency spells out the minimum procedures and fees that
MCOs must cover
bull MCOs may add procedures or increase periodicity of procedures particularly
preventative services
bull MCOs may increase fees to entice rural providers and specialists to enroll in
their Plans
bull Access Rules
bull How many days it takes to access a patent
bull How many days it takes for a patent to access urgent care services
bull How many days it takes for a patent to access emergency care services
76
Credentialing
All MCOs are required to credential all Providers
All MCOs have their own credentialing process
Credentialing process is can be lengthy
Credentialing process may be negotiable
77
Quality Review Process and Quality Metrics
MCOs must have a Quality and Compliance Review Process
If you arenrsquot in compliance with both you likely wonrsquot get paid
Typical processes reviewed
bull Charting specifications
bull Incident report
bull Enrollee complaints quality rudeness and access issues
bull Medicaid compliance
78
Quality Payments
bull State Shared Incentive Withhold Typically quality metrics and benchmarks
are set by the state sets aside a certain percent (3-5) of the payments to
the Managed Care Plan (MCP)
bull If the benchmarks are achieved the MCP is then paid the a predetermine
amount
bull Benchmarks may not be the same as the states
bull Managed Care Plans do not have to pass all or any of the quality payments to
the health centers or providers
bull Managed Care contract- Metrics benchmarks should be selected and part of
the contract
7979
Achieving Quality Metric Payments
Dealing with under achievers
Process issues
Individual issues
Identifying workflows
Developing Best Practices through
PDSA process
Developing Best Practices through
PDSA process
CHC Metrics Committee
Clinicians Operations various key staff
Identify Best Practices
Spread Best Practices
80
New Team Needed Business Intelligence
Business Intelligence (BI) is critical for effective managed care business decisions
BI team inputs metrics into your EHR collects integrates analyses and displays all your managed care business and clinical information
Easy to say- hard to achieve
Build your own or outsource
Possible future role of Primary Care Associations
8181
Clinicianrsquos Dashboard
Expensive to build
Displayed on your screen when your computer is first turned on
Easy to read and understand
Data dumped from the day before
Can dialed down from Org-wide to clinic to each clinicianrsquos data
Operational and clinical metrics
bull Treatment Plan Completion
bull DQA quality measures
bull Caries at Recall
bull Re-care reports
bull Care Gap reports
82
CONTROLLING COSTS
8383
Controlling Costs- Current
bull Increasing efficiencies
bull Decreasing broken appointments
bull Controlling supplies equipment costs
bull Staff recruitment retention costs
84
Specialty Care
Training current CHC dentists in
specialty areas
Hiring general dentists with higher
specialty skill sets
Hiring in house specialists
Contract with outside specialists
Work with Managed Care Plan
specialists
Lowering Disease Rates
Community Dental Health
Coordinators case management
If your state law allows- embed
hygienists in medical and community
to provide primary and secondary
prevention procedures
In clinic Caries Classification and
Silver Diamine Fluoride
Effective recare programs
Controlling Costs- Additions in Risk-based Contracting
85
Specialty Care ndash Primary Referrals by Cost
Pediatric dentistry
Orthodontics
Oral surgery
Endodontics
86
In-clinic Pediatric Services
Encounters expected
of operatories available
State dental law and ability to have
expanded duties
General Anesthesia
GA in- house
Ability for a hospital or surgery center
to set aside regular OR time
Ability to hire or assign DAs to GA
days
Four GA cases day x PPS rate
Should You Hire a Pediatric Dentist- It Depends
8787
Solutions for Controlling Pediatric Costs
Hire a general dentist that is skilled in treating young children
Make the clinic child friendly nitrous oxide TVs in the operatory etc
Teach entire staff behavioral control techniques
Contract with a pediatric dentist for the GA care
88
Lowering Overall Disease Rates (and Costs)
You are responsible for both the patients you see in the chair and the ones
assigned to you
Breaking down the walls of the dental clinic
Community Dental Health Coordinators
Case Management
89
Cost Control Essentials
Diagnosis codes
Increased ability to identify
disease by risk
Motivational
Interviewing
Developing Polices and
Procedures design to treat
disease according to risk
ie Silver Diamine Fluoride
Treating by Risk
Effective Recare
Process
Critical to continual disease
controlPrevention education that is
meaningful and designed to
change behaviors
90
Social Determinants of Health Aunt Bertha
httpswwwauntberthacom
91
REASON TO CONSIDER RISK- BASED CONTRACTING
9292
PPS Reconciliation and Federal Code 42 CFR sect4052469(a)(2)
42 CFR sect4052469(a)(2)
ldquoAny financial incentives provided to Federally Qualified Health Centers
under their Medicare Advantage Contracts such as risk pool payments
bonuses or withholds are prohibited from being included in the
calculation of supplemental payments due to the Federally Qualified
Health Centerrdquo
9393
Why Risk Based Contract in Times of PPS Reconciliation
bull Not all Risk- based Contract funds are reconciled
bull Risk is the key word- you can come out with less money than your normal
PPS reconciliation payment
bull Can lead to better patient care
bull May improve manage care enrollment for your medical plan
bull Promotes integrated care increases health for your CHC patients
9494
Not Included in the Reconciliation
Enrollment management pmpm
Quality Payments
Upside risk payments
Downside risk losses
9595
Determinants of Financial Success in Risk-Based Contracting
bull Most critical- State pmpm payment to the Managed Care Plan
bull Reporting capabilities
bull Specialty service capabilities
bull Access numbers count
bull Ability to move metric numbers
9696
What About the Non- Medicaid Poor We Serve
bull Numbers are king in a managed care contract and the more access you have
the better contract terms you can negotiate
bull We will potentially have a steady supply of Medicaid patients
bull As managed care spreads states this may be compromising the ability of
health centers to serve the non-Medicaid poor and others lacking dental
insurance
97
Mark Koday DDS
(509) 949-2278
Dental Quality Consultants
of WA
httpdentalqualityconsultin
gcom
dentalqualityconsultantsg
mailcom
Contact Information
LUNCH
BREAKOUT EXERCISEORAL HEALTH VALUE-BASED CARE READINESS ASSESSMENT
Danielle Apostolon
PROMISING PRACTICES FROM THE FIELD STRATEGIES FOR INCREASING VALUE IN ORAL HEALTH
Dr Carolyn Brown
Dr Kelly Perry
Dr Rachel Rivard
Dr Adeloye
Commitment Compassion Community
m i d s t a t e h e a l t h o r g
Promising Practices from the
Field Strategies for Increasing
Value in Oral Health Care
Kelly Perry DMD
Better Health
Outcomes
Improved Staff
Experience
Reduced Cost
Improved Patient
Experience
Better Health
Outcomes
Improved Staff
Experience
Reduced Cost
Improved Patient
Experience
Better Health
Outcomes
Improved Staff
Experience
Reduced Cost
Improved Patient
Experience
Better Health
Outcomes
Improved Staff
Experience
Reduced Cost
Improved Patient
Experience
Commitment Compassion Community
kpe r r ymids t a tehea l t h o rg
Thank you
Completion of Disease Control Phase
Pelumi Adeloye DMD MPH
HEALTH ACCESS NETWORK (HAN) FAMILY DENTAL
Introduction
⧫1 Dentist I Hygienist 3 EFDArsquos1 Receptionist
⧫ 6 Chairs= 4 (dentist) + 2 (hygienist)
⧫ Slide ⥶80 off
⧫ Service areas Northern Penobscot Southern Aroostook Western
Washington Counties amp more
Completion of Phase I Treatment
⧫LimitedLack of Access to dental care
⧫Difficulty completing the disease control phase
Caries amp periodontal disease
⧫Attaining stable restorative state
Goal
Increase the completion of Disease Control Phase
Current practice
⧫Education
Assess level of dental literacy
Incremental strategy
⧫Increase access to dental care
Generous sliding scale (⥸$40 per visit)
Incorporate Expanded Function Dental Assistants
⧫Schedule modification
Incorporate more restorative blocks to allow
for follow-up visit and completion of restorative phase
httpswwwglasbergencomdentist-cartoons
Schedule
⧫Piggybacking technique
Increased allotted restorative blocks
⧫Sustainability of current schedule is
contingent on cooperation amp skills of HAN
Dental staff
Note
Strategies mentioned today is personalized to HAN Dental clinic
Current implemented strategies might be modified or changed in the
future as required in order to accommodate the need of our pts
THANK YOU
DAY TWOCLOSINGWRAP-UP
End of Day Two ndash Survey
Day Two Creating a Value-Based Oral Health Care Delivery
System
129
Payment Reform in Oral Health Online Learning Module
Oral Health Value-based Care Online Learning Module
Value-based Care Keys to Success Article
Readiness Assessment
Competency Development Guide
Oral Health Value-based Care Training
Dental Caries Management Practicum
Clinicians Companion Guide
Interprofessional Network Referral Process
Traditional Dental Care Vs Value-Based Care
Resources
131
wwwDentaQuestPartnershiporg
wwwfacebookcomDentaQuest
DentaQuest
wwwlinkedincomcompanyDentaQuest
Inside_DentaQuest
QUESTIONS
42
rdquoDental Homerdquo = Health Home where WE can meet the patient
Oralhealthworkforceorg
43
POLL HOW OFTEN DO YOU SHARE YOUR S WITH YOUR DENTAL TEAM
A Yearly only
B Quarterly
C Monthly
D Weekly
E Daily
44
Clinical Measures ndash Dental Practice Perspective
Private Practice Office
New patients seen
Assigned vs seen if capitated
Treatment plans incomplete
$ produced amp per provider
$ collected amp monthly per provider
CDT 6000 codes completed
RecallHygiene maintenance
Based on this consultants experienced
FQHC
Unduplicated patients
patients seen per day
Treatment plans complete
$ gainedlost via accounting
Broken appointment rate
procedures
Sealant rate (annual)
45
bull HRSA Sealant Measure Compliance for FQHCs
bull Completion of phase 1 treatment plans
bull Children seen 0-5 years old
bull Children seen getting a preventive service
bull Fluoride Varnish applications
bull Pregnant women seen and treated
bull Diabetic patients with HbA1C gt 7 seen
bull Patients seen who have not been seen for 12 months
bull Patients seen getting a Risk Assessment
bull Patients with moderate or high risk who lower risk at recare
bull Sealants provided httpwwwnnohaorgnnoha-contentuploads201512Demystifying-HRSA-SEALANT-PRESENTATION_FINALpdf
Program Measures
46
HRSA Performance Measurement and Data Collection
bull FQHCs and look-alikes submit CY data to HRSA since 2008
bull UDS Uniform Data System
bull Require FTE for clinical staff patient demographics
bull Dental utilization s (UDCTPV)
bull Dental Clinical Measure dental sealants placed on 1st molars ages 6-9 yo
bull Health Center Quartile rankings (Clinical measure performance influences
HC rankings as does EHR adoption and other HC characteristics)
47
Low birth weight
Access to prenatal care
Childhood Immunization
Children (Ages 3-17) Receiving
Weight Assessment amp
Counseling
Children (Age 6-9) Receiving
Dental Sealant to First Molars
Diabetes Control
Hypertension Control
Pap Test
Depression Screening and
Follow-up (Age 12+)
Asthma Patients (Age 5-40)
Receiving Pharmacologic
Therapy
Colorectal Cancer
Screening (Ages 51-74)
HRSA UDS Clinical Measures
Adults (Age 18+) Receiving
Weight Screening amp Follow-up
Adults (Age 18+) Receiving
Tobacco Use Assessment and
Cessation Intervention
Coronary Artery Disease
Receiving Lipid Therapy (18+)
Ischemic Vascular Disease (IVD)
Receiving Aspirin Therapy (18+)
HIV Linkage to Care
48
Dashboards
Grants
Average
amp
Targets
Quality
Rev
Costs
Visits
Priority
Pop
Prevention
49
Dashboard- Provider Team Level
Patient
Compliance
Satisfaction
50
Case Study-
Incentives bonus round pools benchmark and improvement target goals risk-sharing possible later years
51
Qualitative Measurement
ldquoPatient engagement is the act of patients and providers working together
toward the end goal of improved patient wellnessrdquo
wwwpatientengagementhitcom
Access to Care
Patient Activation
Patient Satisfaction
Patient-Provider-Care Team Communication
Care Team Satisfaction
52
OHVBC Readiness
Leadership
bull Value of oral health and oral health transformation
Structure Systems and Operations
bull Operational efficiencies innovative care delivery methodologies
Care Pathways and Provider Buy-In
bull Training disease management risk-based care referrals IDC-10 coding patient engagement
Data and Analytic Technology and Personnel
bull Interoperability reporting
Financial Viability and Strength
bull Payerpatient mix billing infrastructure financial reports
httpswwwdentaquestpartnershiporglearnsafety-net-solutionsoral-health-value-based-careohvbc-readiness-
assessment
53
QUESTIONS COMMENTS
Carolyn Brown DDS
cbrownddsgmailcom
RISK BASED MANAGED CARE
Value Based Training Conference
Manchester New Hampshire
Mark Koday DDS
111919
5555
Objectives
bull Review current drivers of dental managed care
bull Understand the basics of risk-based dental managed care contracts
bull Learn the basics of managing costs in a riskndashbased contract
bull Gain an understanding in the potential advantage of risk-based contracting
56
What Is Dental Managed Care
Managed care is a health delivery system whose purpose is to manage both the
quality and cost of health care
Common types of managed care health insurance plans
bull HMOs
bull PPOs
bull POSs
bull Medicaid Managed Care
DIDNrsquoT WE ALREADY HAVE MANAGED CARE AND IT FAILED
57
What Has Happened Since the 90s
58
WHY THE FFS AND PPS DOESNrsquoT WORK FOR OUR POPULATIONS
bull Inefficient payment systems designed to produce encounters or procedures but not real health
bull No focus on population health
bull Does not incentivize innovation
bull Patients essentially on their own for accessing specialty care
59
Rule of 4
Source Kaiser Family Foundation analysis of National Health Expenditure (NHE) data from Centers for
Medicare and Medicaid Services Office of the Actuary National Health Statistics Group
60
Rule of 4
bull This helps explain why oral health has been relatively ignored so far by CMS
bull Explains why we have PCMH instead of PCHH
bull Where is the real value on a national level in preventing disease and
controlling costs
bull Beware- wersquove been found
61
Reasons Dental Managed Care is Spreading Across the States
NON-MANAGED CARE STATE DENTAL BUDGETS ARE
OPENED ENDED
STRAIN ON STATE BUDGETS
UPCOMING RECESSION WITH TRILLION DOLLAR
DEFICIT
SHIFTS FINANCIAL RISK FROM THE STATES TO THE
PLANS
6262
Types of Medicaid Managed Care
bull State Medicaid agency administrator lowest administrative
costs
bull Third Party Administrator Typically 15 administrative costs
bull Managed Care Organization Typically 15 administrative
costs
bull Carved-in
bull Carved-out
bull Risk Based Managed Care Administrative costs part of
contract negotiation
63
RISK CONTRACTS
6464
Components of a Risk-based Contract
Risk
Medical Loss Ratio
Quality withhold
Specialty withhold
Managed care payment (pmpm)
Covered services
Fee schedule Claims are paid as usual on a FFS basis
Credentialing
Quality Review process and Quality Metrics
65
Upside Risk
The possibility that the cost of
delivering dental care to an assigned
patient panel is less than the amount
of funding calculated for that care
The Plan pays the CHC additional
funds based on a predetermine
formula
Downside Risk
The possibility that the cost of
delivering dental care to an assigned
patient panel is more than the amount
of funding calculated for that care
The CHC pays the Plan additional
funds based on a predetermine
formula
Upside and Downside Risk
66
Taking On Risk 100 or Shared Risk
With 100 risk you receive 100 of the potential savings but are also at risk for
100 of the losses
Shared Risk MCO and health center share a percentage of the risk
Shared Risk leads to better cooperation since both organizations are
incentivized to save on costs
6767
Reports Needed
bull Enrollment reports lists of who is assigned on a monthly basis
bull Reconciliation reports insure appropriate payments
bull Specialty Referral reports
bull You will need your own reporting process so you donrsquot rely completely on
reports supplied by the Plan
6868
Medical Loss Ratio
Medical Loss Ratio (MLR) is proportion of premium revenues spent on clinical
services and quality improvement also known as the Medical Loss Ratio (MLR)
For CMS requires Medical Plans to spend at least 80 to 85 of the premiums
on actual medical care
69
Administrative Fees
bull Essentially the opposite of MLR
bull The State Medicaid Agency is funded by the Governorrsquos budget
bull The State Medicaid Agency will keep some of these funds for their
admin costs and give the remaining to the Managed Care Plans
bull Private Plan admin costs can be as high as 40 but most states
limit these cost for Medicaid Plans to between 15 and 20 (85-
80 MLR)
bull This may be negotiable depending on your program size of your
program
70
Quality Withhold
bull The state withholds a certain percent (typically 2-4 ) of the funds they give
to the Plans for Value Based Reimbursement
bull They choose quality metrics and set benchmarks and assign payments for
each metric based on an assigned priority for each metric
bull If a Plan meets the benchmark of every quality metric the state passes on
their full share of the quality withhold
bull The Plans may or may not withhold a percent of the funds for quality payment
to the dentists or manage care contractors
71
Quality Withhold
Either way the Plans may or may not pass the quality payments they receive to
the dentists or contractors
This should be spelled out in a risk-based contract
72
Percent of funds set aside
to cover specialty care
referrals
Typically 10-15
Goal Limit referral costs
to within or less than
Specialty set aside
Specialty Withhold
73
Per Member Per Month
bull Capitated Payment
bull Specific dollar amount paid for each enrolled member each month
bull Paid whether patient is accessed for care or not
bull States do set access benchmarks
bull In Oregon access for any dental procedure (adults and children combined)
was 267 in 2015
74
Payment Math Example
Premium per enrollee = $25
Administrative fee 15 = $375
Funds available per enrollee to the clinic = $2125
Management fee per enrollee = $175
Funds per enrollee that would undergo PPS reconciliation = $1950
For every 10000 enrollees the managed care income = $2340000
Specialty withhold (10) = $234000
YE Cost lt or gt $2340000
Upside Risk
CHC Gains $
Downside Risk
CHC Loses $
75
Covered Services and Fee Schedules
bull The state Medicaid agency spells out the minimum procedures and fees that
MCOs must cover
bull MCOs may add procedures or increase periodicity of procedures particularly
preventative services
bull MCOs may increase fees to entice rural providers and specialists to enroll in
their Plans
bull Access Rules
bull How many days it takes to access a patent
bull How many days it takes for a patent to access urgent care services
bull How many days it takes for a patent to access emergency care services
76
Credentialing
All MCOs are required to credential all Providers
All MCOs have their own credentialing process
Credentialing process is can be lengthy
Credentialing process may be negotiable
77
Quality Review Process and Quality Metrics
MCOs must have a Quality and Compliance Review Process
If you arenrsquot in compliance with both you likely wonrsquot get paid
Typical processes reviewed
bull Charting specifications
bull Incident report
bull Enrollee complaints quality rudeness and access issues
bull Medicaid compliance
78
Quality Payments
bull State Shared Incentive Withhold Typically quality metrics and benchmarks
are set by the state sets aside a certain percent (3-5) of the payments to
the Managed Care Plan (MCP)
bull If the benchmarks are achieved the MCP is then paid the a predetermine
amount
bull Benchmarks may not be the same as the states
bull Managed Care Plans do not have to pass all or any of the quality payments to
the health centers or providers
bull Managed Care contract- Metrics benchmarks should be selected and part of
the contract
7979
Achieving Quality Metric Payments
Dealing with under achievers
Process issues
Individual issues
Identifying workflows
Developing Best Practices through
PDSA process
Developing Best Practices through
PDSA process
CHC Metrics Committee
Clinicians Operations various key staff
Identify Best Practices
Spread Best Practices
80
New Team Needed Business Intelligence
Business Intelligence (BI) is critical for effective managed care business decisions
BI team inputs metrics into your EHR collects integrates analyses and displays all your managed care business and clinical information
Easy to say- hard to achieve
Build your own or outsource
Possible future role of Primary Care Associations
8181
Clinicianrsquos Dashboard
Expensive to build
Displayed on your screen when your computer is first turned on
Easy to read and understand
Data dumped from the day before
Can dialed down from Org-wide to clinic to each clinicianrsquos data
Operational and clinical metrics
bull Treatment Plan Completion
bull DQA quality measures
bull Caries at Recall
bull Re-care reports
bull Care Gap reports
82
CONTROLLING COSTS
8383
Controlling Costs- Current
bull Increasing efficiencies
bull Decreasing broken appointments
bull Controlling supplies equipment costs
bull Staff recruitment retention costs
84
Specialty Care
Training current CHC dentists in
specialty areas
Hiring general dentists with higher
specialty skill sets
Hiring in house specialists
Contract with outside specialists
Work with Managed Care Plan
specialists
Lowering Disease Rates
Community Dental Health
Coordinators case management
If your state law allows- embed
hygienists in medical and community
to provide primary and secondary
prevention procedures
In clinic Caries Classification and
Silver Diamine Fluoride
Effective recare programs
Controlling Costs- Additions in Risk-based Contracting
85
Specialty Care ndash Primary Referrals by Cost
Pediatric dentistry
Orthodontics
Oral surgery
Endodontics
86
In-clinic Pediatric Services
Encounters expected
of operatories available
State dental law and ability to have
expanded duties
General Anesthesia
GA in- house
Ability for a hospital or surgery center
to set aside regular OR time
Ability to hire or assign DAs to GA
days
Four GA cases day x PPS rate
Should You Hire a Pediatric Dentist- It Depends
8787
Solutions for Controlling Pediatric Costs
Hire a general dentist that is skilled in treating young children
Make the clinic child friendly nitrous oxide TVs in the operatory etc
Teach entire staff behavioral control techniques
Contract with a pediatric dentist for the GA care
88
Lowering Overall Disease Rates (and Costs)
You are responsible for both the patients you see in the chair and the ones
assigned to you
Breaking down the walls of the dental clinic
Community Dental Health Coordinators
Case Management
89
Cost Control Essentials
Diagnosis codes
Increased ability to identify
disease by risk
Motivational
Interviewing
Developing Polices and
Procedures design to treat
disease according to risk
ie Silver Diamine Fluoride
Treating by Risk
Effective Recare
Process
Critical to continual disease
controlPrevention education that is
meaningful and designed to
change behaviors
90
Social Determinants of Health Aunt Bertha
httpswwwauntberthacom
91
REASON TO CONSIDER RISK- BASED CONTRACTING
9292
PPS Reconciliation and Federal Code 42 CFR sect4052469(a)(2)
42 CFR sect4052469(a)(2)
ldquoAny financial incentives provided to Federally Qualified Health Centers
under their Medicare Advantage Contracts such as risk pool payments
bonuses or withholds are prohibited from being included in the
calculation of supplemental payments due to the Federally Qualified
Health Centerrdquo
9393
Why Risk Based Contract in Times of PPS Reconciliation
bull Not all Risk- based Contract funds are reconciled
bull Risk is the key word- you can come out with less money than your normal
PPS reconciliation payment
bull Can lead to better patient care
bull May improve manage care enrollment for your medical plan
bull Promotes integrated care increases health for your CHC patients
9494
Not Included in the Reconciliation
Enrollment management pmpm
Quality Payments
Upside risk payments
Downside risk losses
9595
Determinants of Financial Success in Risk-Based Contracting
bull Most critical- State pmpm payment to the Managed Care Plan
bull Reporting capabilities
bull Specialty service capabilities
bull Access numbers count
bull Ability to move metric numbers
9696
What About the Non- Medicaid Poor We Serve
bull Numbers are king in a managed care contract and the more access you have
the better contract terms you can negotiate
bull We will potentially have a steady supply of Medicaid patients
bull As managed care spreads states this may be compromising the ability of
health centers to serve the non-Medicaid poor and others lacking dental
insurance
97
Mark Koday DDS
(509) 949-2278
Dental Quality Consultants
of WA
httpdentalqualityconsultin
gcom
dentalqualityconsultantsg
mailcom
Contact Information
LUNCH
BREAKOUT EXERCISEORAL HEALTH VALUE-BASED CARE READINESS ASSESSMENT
Danielle Apostolon
PROMISING PRACTICES FROM THE FIELD STRATEGIES FOR INCREASING VALUE IN ORAL HEALTH
Dr Carolyn Brown
Dr Kelly Perry
Dr Rachel Rivard
Dr Adeloye
Commitment Compassion Community
m i d s t a t e h e a l t h o r g
Promising Practices from the
Field Strategies for Increasing
Value in Oral Health Care
Kelly Perry DMD
Better Health
Outcomes
Improved Staff
Experience
Reduced Cost
Improved Patient
Experience
Better Health
Outcomes
Improved Staff
Experience
Reduced Cost
Improved Patient
Experience
Better Health
Outcomes
Improved Staff
Experience
Reduced Cost
Improved Patient
Experience
Better Health
Outcomes
Improved Staff
Experience
Reduced Cost
Improved Patient
Experience
Commitment Compassion Community
kpe r r ymids t a tehea l t h o rg
Thank you
Completion of Disease Control Phase
Pelumi Adeloye DMD MPH
HEALTH ACCESS NETWORK (HAN) FAMILY DENTAL
Introduction
⧫1 Dentist I Hygienist 3 EFDArsquos1 Receptionist
⧫ 6 Chairs= 4 (dentist) + 2 (hygienist)
⧫ Slide ⥶80 off
⧫ Service areas Northern Penobscot Southern Aroostook Western
Washington Counties amp more
Completion of Phase I Treatment
⧫LimitedLack of Access to dental care
⧫Difficulty completing the disease control phase
Caries amp periodontal disease
⧫Attaining stable restorative state
Goal
Increase the completion of Disease Control Phase
Current practice
⧫Education
Assess level of dental literacy
Incremental strategy
⧫Increase access to dental care
Generous sliding scale (⥸$40 per visit)
Incorporate Expanded Function Dental Assistants
⧫Schedule modification
Incorporate more restorative blocks to allow
for follow-up visit and completion of restorative phase
httpswwwglasbergencomdentist-cartoons
Schedule
⧫Piggybacking technique
Increased allotted restorative blocks
⧫Sustainability of current schedule is
contingent on cooperation amp skills of HAN
Dental staff
Note
Strategies mentioned today is personalized to HAN Dental clinic
Current implemented strategies might be modified or changed in the
future as required in order to accommodate the need of our pts
THANK YOU
DAY TWOCLOSINGWRAP-UP
End of Day Two ndash Survey
Day Two Creating a Value-Based Oral Health Care Delivery
System
129
Payment Reform in Oral Health Online Learning Module
Oral Health Value-based Care Online Learning Module
Value-based Care Keys to Success Article
Readiness Assessment
Competency Development Guide
Oral Health Value-based Care Training
Dental Caries Management Practicum
Clinicians Companion Guide
Interprofessional Network Referral Process
Traditional Dental Care Vs Value-Based Care
Resources
131
wwwDentaQuestPartnershiporg
wwwfacebookcomDentaQuest
DentaQuest
wwwlinkedincomcompanyDentaQuest
Inside_DentaQuest
QUESTIONS
43
POLL HOW OFTEN DO YOU SHARE YOUR S WITH YOUR DENTAL TEAM
A Yearly only
B Quarterly
C Monthly
D Weekly
E Daily
44
Clinical Measures ndash Dental Practice Perspective
Private Practice Office
New patients seen
Assigned vs seen if capitated
Treatment plans incomplete
$ produced amp per provider
$ collected amp monthly per provider
CDT 6000 codes completed
RecallHygiene maintenance
Based on this consultants experienced
FQHC
Unduplicated patients
patients seen per day
Treatment plans complete
$ gainedlost via accounting
Broken appointment rate
procedures
Sealant rate (annual)
45
bull HRSA Sealant Measure Compliance for FQHCs
bull Completion of phase 1 treatment plans
bull Children seen 0-5 years old
bull Children seen getting a preventive service
bull Fluoride Varnish applications
bull Pregnant women seen and treated
bull Diabetic patients with HbA1C gt 7 seen
bull Patients seen who have not been seen for 12 months
bull Patients seen getting a Risk Assessment
bull Patients with moderate or high risk who lower risk at recare
bull Sealants provided httpwwwnnohaorgnnoha-contentuploads201512Demystifying-HRSA-SEALANT-PRESENTATION_FINALpdf
Program Measures
46
HRSA Performance Measurement and Data Collection
bull FQHCs and look-alikes submit CY data to HRSA since 2008
bull UDS Uniform Data System
bull Require FTE for clinical staff patient demographics
bull Dental utilization s (UDCTPV)
bull Dental Clinical Measure dental sealants placed on 1st molars ages 6-9 yo
bull Health Center Quartile rankings (Clinical measure performance influences
HC rankings as does EHR adoption and other HC characteristics)
47
Low birth weight
Access to prenatal care
Childhood Immunization
Children (Ages 3-17) Receiving
Weight Assessment amp
Counseling
Children (Age 6-9) Receiving
Dental Sealant to First Molars
Diabetes Control
Hypertension Control
Pap Test
Depression Screening and
Follow-up (Age 12+)
Asthma Patients (Age 5-40)
Receiving Pharmacologic
Therapy
Colorectal Cancer
Screening (Ages 51-74)
HRSA UDS Clinical Measures
Adults (Age 18+) Receiving
Weight Screening amp Follow-up
Adults (Age 18+) Receiving
Tobacco Use Assessment and
Cessation Intervention
Coronary Artery Disease
Receiving Lipid Therapy (18+)
Ischemic Vascular Disease (IVD)
Receiving Aspirin Therapy (18+)
HIV Linkage to Care
48
Dashboards
Grants
Average
amp
Targets
Quality
Rev
Costs
Visits
Priority
Pop
Prevention
49
Dashboard- Provider Team Level
Patient
Compliance
Satisfaction
50
Case Study-
Incentives bonus round pools benchmark and improvement target goals risk-sharing possible later years
51
Qualitative Measurement
ldquoPatient engagement is the act of patients and providers working together
toward the end goal of improved patient wellnessrdquo
wwwpatientengagementhitcom
Access to Care
Patient Activation
Patient Satisfaction
Patient-Provider-Care Team Communication
Care Team Satisfaction
52
OHVBC Readiness
Leadership
bull Value of oral health and oral health transformation
Structure Systems and Operations
bull Operational efficiencies innovative care delivery methodologies
Care Pathways and Provider Buy-In
bull Training disease management risk-based care referrals IDC-10 coding patient engagement
Data and Analytic Technology and Personnel
bull Interoperability reporting
Financial Viability and Strength
bull Payerpatient mix billing infrastructure financial reports
httpswwwdentaquestpartnershiporglearnsafety-net-solutionsoral-health-value-based-careohvbc-readiness-
assessment
53
QUESTIONS COMMENTS
Carolyn Brown DDS
cbrownddsgmailcom
RISK BASED MANAGED CARE
Value Based Training Conference
Manchester New Hampshire
Mark Koday DDS
111919
5555
Objectives
bull Review current drivers of dental managed care
bull Understand the basics of risk-based dental managed care contracts
bull Learn the basics of managing costs in a riskndashbased contract
bull Gain an understanding in the potential advantage of risk-based contracting
56
What Is Dental Managed Care
Managed care is a health delivery system whose purpose is to manage both the
quality and cost of health care
Common types of managed care health insurance plans
bull HMOs
bull PPOs
bull POSs
bull Medicaid Managed Care
DIDNrsquoT WE ALREADY HAVE MANAGED CARE AND IT FAILED
57
What Has Happened Since the 90s
58
WHY THE FFS AND PPS DOESNrsquoT WORK FOR OUR POPULATIONS
bull Inefficient payment systems designed to produce encounters or procedures but not real health
bull No focus on population health
bull Does not incentivize innovation
bull Patients essentially on their own for accessing specialty care
59
Rule of 4
Source Kaiser Family Foundation analysis of National Health Expenditure (NHE) data from Centers for
Medicare and Medicaid Services Office of the Actuary National Health Statistics Group
60
Rule of 4
bull This helps explain why oral health has been relatively ignored so far by CMS
bull Explains why we have PCMH instead of PCHH
bull Where is the real value on a national level in preventing disease and
controlling costs
bull Beware- wersquove been found
61
Reasons Dental Managed Care is Spreading Across the States
NON-MANAGED CARE STATE DENTAL BUDGETS ARE
OPENED ENDED
STRAIN ON STATE BUDGETS
UPCOMING RECESSION WITH TRILLION DOLLAR
DEFICIT
SHIFTS FINANCIAL RISK FROM THE STATES TO THE
PLANS
6262
Types of Medicaid Managed Care
bull State Medicaid agency administrator lowest administrative
costs
bull Third Party Administrator Typically 15 administrative costs
bull Managed Care Organization Typically 15 administrative
costs
bull Carved-in
bull Carved-out
bull Risk Based Managed Care Administrative costs part of
contract negotiation
63
RISK CONTRACTS
6464
Components of a Risk-based Contract
Risk
Medical Loss Ratio
Quality withhold
Specialty withhold
Managed care payment (pmpm)
Covered services
Fee schedule Claims are paid as usual on a FFS basis
Credentialing
Quality Review process and Quality Metrics
65
Upside Risk
The possibility that the cost of
delivering dental care to an assigned
patient panel is less than the amount
of funding calculated for that care
The Plan pays the CHC additional
funds based on a predetermine
formula
Downside Risk
The possibility that the cost of
delivering dental care to an assigned
patient panel is more than the amount
of funding calculated for that care
The CHC pays the Plan additional
funds based on a predetermine
formula
Upside and Downside Risk
66
Taking On Risk 100 or Shared Risk
With 100 risk you receive 100 of the potential savings but are also at risk for
100 of the losses
Shared Risk MCO and health center share a percentage of the risk
Shared Risk leads to better cooperation since both organizations are
incentivized to save on costs
6767
Reports Needed
bull Enrollment reports lists of who is assigned on a monthly basis
bull Reconciliation reports insure appropriate payments
bull Specialty Referral reports
bull You will need your own reporting process so you donrsquot rely completely on
reports supplied by the Plan
6868
Medical Loss Ratio
Medical Loss Ratio (MLR) is proportion of premium revenues spent on clinical
services and quality improvement also known as the Medical Loss Ratio (MLR)
For CMS requires Medical Plans to spend at least 80 to 85 of the premiums
on actual medical care
69
Administrative Fees
bull Essentially the opposite of MLR
bull The State Medicaid Agency is funded by the Governorrsquos budget
bull The State Medicaid Agency will keep some of these funds for their
admin costs and give the remaining to the Managed Care Plans
bull Private Plan admin costs can be as high as 40 but most states
limit these cost for Medicaid Plans to between 15 and 20 (85-
80 MLR)
bull This may be negotiable depending on your program size of your
program
70
Quality Withhold
bull The state withholds a certain percent (typically 2-4 ) of the funds they give
to the Plans for Value Based Reimbursement
bull They choose quality metrics and set benchmarks and assign payments for
each metric based on an assigned priority for each metric
bull If a Plan meets the benchmark of every quality metric the state passes on
their full share of the quality withhold
bull The Plans may or may not withhold a percent of the funds for quality payment
to the dentists or manage care contractors
71
Quality Withhold
Either way the Plans may or may not pass the quality payments they receive to
the dentists or contractors
This should be spelled out in a risk-based contract
72
Percent of funds set aside
to cover specialty care
referrals
Typically 10-15
Goal Limit referral costs
to within or less than
Specialty set aside
Specialty Withhold
73
Per Member Per Month
bull Capitated Payment
bull Specific dollar amount paid for each enrolled member each month
bull Paid whether patient is accessed for care or not
bull States do set access benchmarks
bull In Oregon access for any dental procedure (adults and children combined)
was 267 in 2015
74
Payment Math Example
Premium per enrollee = $25
Administrative fee 15 = $375
Funds available per enrollee to the clinic = $2125
Management fee per enrollee = $175
Funds per enrollee that would undergo PPS reconciliation = $1950
For every 10000 enrollees the managed care income = $2340000
Specialty withhold (10) = $234000
YE Cost lt or gt $2340000
Upside Risk
CHC Gains $
Downside Risk
CHC Loses $
75
Covered Services and Fee Schedules
bull The state Medicaid agency spells out the minimum procedures and fees that
MCOs must cover
bull MCOs may add procedures or increase periodicity of procedures particularly
preventative services
bull MCOs may increase fees to entice rural providers and specialists to enroll in
their Plans
bull Access Rules
bull How many days it takes to access a patent
bull How many days it takes for a patent to access urgent care services
bull How many days it takes for a patent to access emergency care services
76
Credentialing
All MCOs are required to credential all Providers
All MCOs have their own credentialing process
Credentialing process is can be lengthy
Credentialing process may be negotiable
77
Quality Review Process and Quality Metrics
MCOs must have a Quality and Compliance Review Process
If you arenrsquot in compliance with both you likely wonrsquot get paid
Typical processes reviewed
bull Charting specifications
bull Incident report
bull Enrollee complaints quality rudeness and access issues
bull Medicaid compliance
78
Quality Payments
bull State Shared Incentive Withhold Typically quality metrics and benchmarks
are set by the state sets aside a certain percent (3-5) of the payments to
the Managed Care Plan (MCP)
bull If the benchmarks are achieved the MCP is then paid the a predetermine
amount
bull Benchmarks may not be the same as the states
bull Managed Care Plans do not have to pass all or any of the quality payments to
the health centers or providers
bull Managed Care contract- Metrics benchmarks should be selected and part of
the contract
7979
Achieving Quality Metric Payments
Dealing with under achievers
Process issues
Individual issues
Identifying workflows
Developing Best Practices through
PDSA process
Developing Best Practices through
PDSA process
CHC Metrics Committee
Clinicians Operations various key staff
Identify Best Practices
Spread Best Practices
80
New Team Needed Business Intelligence
Business Intelligence (BI) is critical for effective managed care business decisions
BI team inputs metrics into your EHR collects integrates analyses and displays all your managed care business and clinical information
Easy to say- hard to achieve
Build your own or outsource
Possible future role of Primary Care Associations
8181
Clinicianrsquos Dashboard
Expensive to build
Displayed on your screen when your computer is first turned on
Easy to read and understand
Data dumped from the day before
Can dialed down from Org-wide to clinic to each clinicianrsquos data
Operational and clinical metrics
bull Treatment Plan Completion
bull DQA quality measures
bull Caries at Recall
bull Re-care reports
bull Care Gap reports
82
CONTROLLING COSTS
8383
Controlling Costs- Current
bull Increasing efficiencies
bull Decreasing broken appointments
bull Controlling supplies equipment costs
bull Staff recruitment retention costs
84
Specialty Care
Training current CHC dentists in
specialty areas
Hiring general dentists with higher
specialty skill sets
Hiring in house specialists
Contract with outside specialists
Work with Managed Care Plan
specialists
Lowering Disease Rates
Community Dental Health
Coordinators case management
If your state law allows- embed
hygienists in medical and community
to provide primary and secondary
prevention procedures
In clinic Caries Classification and
Silver Diamine Fluoride
Effective recare programs
Controlling Costs- Additions in Risk-based Contracting
85
Specialty Care ndash Primary Referrals by Cost
Pediatric dentistry
Orthodontics
Oral surgery
Endodontics
86
In-clinic Pediatric Services
Encounters expected
of operatories available
State dental law and ability to have
expanded duties
General Anesthesia
GA in- house
Ability for a hospital or surgery center
to set aside regular OR time
Ability to hire or assign DAs to GA
days
Four GA cases day x PPS rate
Should You Hire a Pediatric Dentist- It Depends
8787
Solutions for Controlling Pediatric Costs
Hire a general dentist that is skilled in treating young children
Make the clinic child friendly nitrous oxide TVs in the operatory etc
Teach entire staff behavioral control techniques
Contract with a pediatric dentist for the GA care
88
Lowering Overall Disease Rates (and Costs)
You are responsible for both the patients you see in the chair and the ones
assigned to you
Breaking down the walls of the dental clinic
Community Dental Health Coordinators
Case Management
89
Cost Control Essentials
Diagnosis codes
Increased ability to identify
disease by risk
Motivational
Interviewing
Developing Polices and
Procedures design to treat
disease according to risk
ie Silver Diamine Fluoride
Treating by Risk
Effective Recare
Process
Critical to continual disease
controlPrevention education that is
meaningful and designed to
change behaviors
90
Social Determinants of Health Aunt Bertha
httpswwwauntberthacom
91
REASON TO CONSIDER RISK- BASED CONTRACTING
9292
PPS Reconciliation and Federal Code 42 CFR sect4052469(a)(2)
42 CFR sect4052469(a)(2)
ldquoAny financial incentives provided to Federally Qualified Health Centers
under their Medicare Advantage Contracts such as risk pool payments
bonuses or withholds are prohibited from being included in the
calculation of supplemental payments due to the Federally Qualified
Health Centerrdquo
9393
Why Risk Based Contract in Times of PPS Reconciliation
bull Not all Risk- based Contract funds are reconciled
bull Risk is the key word- you can come out with less money than your normal
PPS reconciliation payment
bull Can lead to better patient care
bull May improve manage care enrollment for your medical plan
bull Promotes integrated care increases health for your CHC patients
9494
Not Included in the Reconciliation
Enrollment management pmpm
Quality Payments
Upside risk payments
Downside risk losses
9595
Determinants of Financial Success in Risk-Based Contracting
bull Most critical- State pmpm payment to the Managed Care Plan
bull Reporting capabilities
bull Specialty service capabilities
bull Access numbers count
bull Ability to move metric numbers
9696
What About the Non- Medicaid Poor We Serve
bull Numbers are king in a managed care contract and the more access you have
the better contract terms you can negotiate
bull We will potentially have a steady supply of Medicaid patients
bull As managed care spreads states this may be compromising the ability of
health centers to serve the non-Medicaid poor and others lacking dental
insurance
97
Mark Koday DDS
(509) 949-2278
Dental Quality Consultants
of WA
httpdentalqualityconsultin
gcom
dentalqualityconsultantsg
mailcom
Contact Information
LUNCH
BREAKOUT EXERCISEORAL HEALTH VALUE-BASED CARE READINESS ASSESSMENT
Danielle Apostolon
PROMISING PRACTICES FROM THE FIELD STRATEGIES FOR INCREASING VALUE IN ORAL HEALTH
Dr Carolyn Brown
Dr Kelly Perry
Dr Rachel Rivard
Dr Adeloye
Commitment Compassion Community
m i d s t a t e h e a l t h o r g
Promising Practices from the
Field Strategies for Increasing
Value in Oral Health Care
Kelly Perry DMD
Better Health
Outcomes
Improved Staff
Experience
Reduced Cost
Improved Patient
Experience
Better Health
Outcomes
Improved Staff
Experience
Reduced Cost
Improved Patient
Experience
Better Health
Outcomes
Improved Staff
Experience
Reduced Cost
Improved Patient
Experience
Better Health
Outcomes
Improved Staff
Experience
Reduced Cost
Improved Patient
Experience
Commitment Compassion Community
kpe r r ymids t a tehea l t h o rg
Thank you
Completion of Disease Control Phase
Pelumi Adeloye DMD MPH
HEALTH ACCESS NETWORK (HAN) FAMILY DENTAL
Introduction
⧫1 Dentist I Hygienist 3 EFDArsquos1 Receptionist
⧫ 6 Chairs= 4 (dentist) + 2 (hygienist)
⧫ Slide ⥶80 off
⧫ Service areas Northern Penobscot Southern Aroostook Western
Washington Counties amp more
Completion of Phase I Treatment
⧫LimitedLack of Access to dental care
⧫Difficulty completing the disease control phase
Caries amp periodontal disease
⧫Attaining stable restorative state
Goal
Increase the completion of Disease Control Phase
Current practice
⧫Education
Assess level of dental literacy
Incremental strategy
⧫Increase access to dental care
Generous sliding scale (⥸$40 per visit)
Incorporate Expanded Function Dental Assistants
⧫Schedule modification
Incorporate more restorative blocks to allow
for follow-up visit and completion of restorative phase
httpswwwglasbergencomdentist-cartoons
Schedule
⧫Piggybacking technique
Increased allotted restorative blocks
⧫Sustainability of current schedule is
contingent on cooperation amp skills of HAN
Dental staff
Note
Strategies mentioned today is personalized to HAN Dental clinic
Current implemented strategies might be modified or changed in the
future as required in order to accommodate the need of our pts
THANK YOU
DAY TWOCLOSINGWRAP-UP
End of Day Two ndash Survey
Day Two Creating a Value-Based Oral Health Care Delivery
System
129
Payment Reform in Oral Health Online Learning Module
Oral Health Value-based Care Online Learning Module
Value-based Care Keys to Success Article
Readiness Assessment
Competency Development Guide
Oral Health Value-based Care Training
Dental Caries Management Practicum
Clinicians Companion Guide
Interprofessional Network Referral Process
Traditional Dental Care Vs Value-Based Care
Resources
131
wwwDentaQuestPartnershiporg
wwwfacebookcomDentaQuest
DentaQuest
wwwlinkedincomcompanyDentaQuest
Inside_DentaQuest
QUESTIONS
44
Clinical Measures ndash Dental Practice Perspective
Private Practice Office
New patients seen
Assigned vs seen if capitated
Treatment plans incomplete
$ produced amp per provider
$ collected amp monthly per provider
CDT 6000 codes completed
RecallHygiene maintenance
Based on this consultants experienced
FQHC
Unduplicated patients
patients seen per day
Treatment plans complete
$ gainedlost via accounting
Broken appointment rate
procedures
Sealant rate (annual)
45
bull HRSA Sealant Measure Compliance for FQHCs
bull Completion of phase 1 treatment plans
bull Children seen 0-5 years old
bull Children seen getting a preventive service
bull Fluoride Varnish applications
bull Pregnant women seen and treated
bull Diabetic patients with HbA1C gt 7 seen
bull Patients seen who have not been seen for 12 months
bull Patients seen getting a Risk Assessment
bull Patients with moderate or high risk who lower risk at recare
bull Sealants provided httpwwwnnohaorgnnoha-contentuploads201512Demystifying-HRSA-SEALANT-PRESENTATION_FINALpdf
Program Measures
46
HRSA Performance Measurement and Data Collection
bull FQHCs and look-alikes submit CY data to HRSA since 2008
bull UDS Uniform Data System
bull Require FTE for clinical staff patient demographics
bull Dental utilization s (UDCTPV)
bull Dental Clinical Measure dental sealants placed on 1st molars ages 6-9 yo
bull Health Center Quartile rankings (Clinical measure performance influences
HC rankings as does EHR adoption and other HC characteristics)
47
Low birth weight
Access to prenatal care
Childhood Immunization
Children (Ages 3-17) Receiving
Weight Assessment amp
Counseling
Children (Age 6-9) Receiving
Dental Sealant to First Molars
Diabetes Control
Hypertension Control
Pap Test
Depression Screening and
Follow-up (Age 12+)
Asthma Patients (Age 5-40)
Receiving Pharmacologic
Therapy
Colorectal Cancer
Screening (Ages 51-74)
HRSA UDS Clinical Measures
Adults (Age 18+) Receiving
Weight Screening amp Follow-up
Adults (Age 18+) Receiving
Tobacco Use Assessment and
Cessation Intervention
Coronary Artery Disease
Receiving Lipid Therapy (18+)
Ischemic Vascular Disease (IVD)
Receiving Aspirin Therapy (18+)
HIV Linkage to Care
48
Dashboards
Grants
Average
amp
Targets
Quality
Rev
Costs
Visits
Priority
Pop
Prevention
49
Dashboard- Provider Team Level
Patient
Compliance
Satisfaction
50
Case Study-
Incentives bonus round pools benchmark and improvement target goals risk-sharing possible later years
51
Qualitative Measurement
ldquoPatient engagement is the act of patients and providers working together
toward the end goal of improved patient wellnessrdquo
wwwpatientengagementhitcom
Access to Care
Patient Activation
Patient Satisfaction
Patient-Provider-Care Team Communication
Care Team Satisfaction
52
OHVBC Readiness
Leadership
bull Value of oral health and oral health transformation
Structure Systems and Operations
bull Operational efficiencies innovative care delivery methodologies
Care Pathways and Provider Buy-In
bull Training disease management risk-based care referrals IDC-10 coding patient engagement
Data and Analytic Technology and Personnel
bull Interoperability reporting
Financial Viability and Strength
bull Payerpatient mix billing infrastructure financial reports
httpswwwdentaquestpartnershiporglearnsafety-net-solutionsoral-health-value-based-careohvbc-readiness-
assessment
53
QUESTIONS COMMENTS
Carolyn Brown DDS
cbrownddsgmailcom
RISK BASED MANAGED CARE
Value Based Training Conference
Manchester New Hampshire
Mark Koday DDS
111919
5555
Objectives
bull Review current drivers of dental managed care
bull Understand the basics of risk-based dental managed care contracts
bull Learn the basics of managing costs in a riskndashbased contract
bull Gain an understanding in the potential advantage of risk-based contracting
56
What Is Dental Managed Care
Managed care is a health delivery system whose purpose is to manage both the
quality and cost of health care
Common types of managed care health insurance plans
bull HMOs
bull PPOs
bull POSs
bull Medicaid Managed Care
DIDNrsquoT WE ALREADY HAVE MANAGED CARE AND IT FAILED
57
What Has Happened Since the 90s
58
WHY THE FFS AND PPS DOESNrsquoT WORK FOR OUR POPULATIONS
bull Inefficient payment systems designed to produce encounters or procedures but not real health
bull No focus on population health
bull Does not incentivize innovation
bull Patients essentially on their own for accessing specialty care
59
Rule of 4
Source Kaiser Family Foundation analysis of National Health Expenditure (NHE) data from Centers for
Medicare and Medicaid Services Office of the Actuary National Health Statistics Group
60
Rule of 4
bull This helps explain why oral health has been relatively ignored so far by CMS
bull Explains why we have PCMH instead of PCHH
bull Where is the real value on a national level in preventing disease and
controlling costs
bull Beware- wersquove been found
61
Reasons Dental Managed Care is Spreading Across the States
NON-MANAGED CARE STATE DENTAL BUDGETS ARE
OPENED ENDED
STRAIN ON STATE BUDGETS
UPCOMING RECESSION WITH TRILLION DOLLAR
DEFICIT
SHIFTS FINANCIAL RISK FROM THE STATES TO THE
PLANS
6262
Types of Medicaid Managed Care
bull State Medicaid agency administrator lowest administrative
costs
bull Third Party Administrator Typically 15 administrative costs
bull Managed Care Organization Typically 15 administrative
costs
bull Carved-in
bull Carved-out
bull Risk Based Managed Care Administrative costs part of
contract negotiation
63
RISK CONTRACTS
6464
Components of a Risk-based Contract
Risk
Medical Loss Ratio
Quality withhold
Specialty withhold
Managed care payment (pmpm)
Covered services
Fee schedule Claims are paid as usual on a FFS basis
Credentialing
Quality Review process and Quality Metrics
65
Upside Risk
The possibility that the cost of
delivering dental care to an assigned
patient panel is less than the amount
of funding calculated for that care
The Plan pays the CHC additional
funds based on a predetermine
formula
Downside Risk
The possibility that the cost of
delivering dental care to an assigned
patient panel is more than the amount
of funding calculated for that care
The CHC pays the Plan additional
funds based on a predetermine
formula
Upside and Downside Risk
66
Taking On Risk 100 or Shared Risk
With 100 risk you receive 100 of the potential savings but are also at risk for
100 of the losses
Shared Risk MCO and health center share a percentage of the risk
Shared Risk leads to better cooperation since both organizations are
incentivized to save on costs
6767
Reports Needed
bull Enrollment reports lists of who is assigned on a monthly basis
bull Reconciliation reports insure appropriate payments
bull Specialty Referral reports
bull You will need your own reporting process so you donrsquot rely completely on
reports supplied by the Plan
6868
Medical Loss Ratio
Medical Loss Ratio (MLR) is proportion of premium revenues spent on clinical
services and quality improvement also known as the Medical Loss Ratio (MLR)
For CMS requires Medical Plans to spend at least 80 to 85 of the premiums
on actual medical care
69
Administrative Fees
bull Essentially the opposite of MLR
bull The State Medicaid Agency is funded by the Governorrsquos budget
bull The State Medicaid Agency will keep some of these funds for their
admin costs and give the remaining to the Managed Care Plans
bull Private Plan admin costs can be as high as 40 but most states
limit these cost for Medicaid Plans to between 15 and 20 (85-
80 MLR)
bull This may be negotiable depending on your program size of your
program
70
Quality Withhold
bull The state withholds a certain percent (typically 2-4 ) of the funds they give
to the Plans for Value Based Reimbursement
bull They choose quality metrics and set benchmarks and assign payments for
each metric based on an assigned priority for each metric
bull If a Plan meets the benchmark of every quality metric the state passes on
their full share of the quality withhold
bull The Plans may or may not withhold a percent of the funds for quality payment
to the dentists or manage care contractors
71
Quality Withhold
Either way the Plans may or may not pass the quality payments they receive to
the dentists or contractors
This should be spelled out in a risk-based contract
72
Percent of funds set aside
to cover specialty care
referrals
Typically 10-15
Goal Limit referral costs
to within or less than
Specialty set aside
Specialty Withhold
73
Per Member Per Month
bull Capitated Payment
bull Specific dollar amount paid for each enrolled member each month
bull Paid whether patient is accessed for care or not
bull States do set access benchmarks
bull In Oregon access for any dental procedure (adults and children combined)
was 267 in 2015
74
Payment Math Example
Premium per enrollee = $25
Administrative fee 15 = $375
Funds available per enrollee to the clinic = $2125
Management fee per enrollee = $175
Funds per enrollee that would undergo PPS reconciliation = $1950
For every 10000 enrollees the managed care income = $2340000
Specialty withhold (10) = $234000
YE Cost lt or gt $2340000
Upside Risk
CHC Gains $
Downside Risk
CHC Loses $
75
Covered Services and Fee Schedules
bull The state Medicaid agency spells out the minimum procedures and fees that
MCOs must cover
bull MCOs may add procedures or increase periodicity of procedures particularly
preventative services
bull MCOs may increase fees to entice rural providers and specialists to enroll in
their Plans
bull Access Rules
bull How many days it takes to access a patent
bull How many days it takes for a patent to access urgent care services
bull How many days it takes for a patent to access emergency care services
76
Credentialing
All MCOs are required to credential all Providers
All MCOs have their own credentialing process
Credentialing process is can be lengthy
Credentialing process may be negotiable
77
Quality Review Process and Quality Metrics
MCOs must have a Quality and Compliance Review Process
If you arenrsquot in compliance with both you likely wonrsquot get paid
Typical processes reviewed
bull Charting specifications
bull Incident report
bull Enrollee complaints quality rudeness and access issues
bull Medicaid compliance
78
Quality Payments
bull State Shared Incentive Withhold Typically quality metrics and benchmarks
are set by the state sets aside a certain percent (3-5) of the payments to
the Managed Care Plan (MCP)
bull If the benchmarks are achieved the MCP is then paid the a predetermine
amount
bull Benchmarks may not be the same as the states
bull Managed Care Plans do not have to pass all or any of the quality payments to
the health centers or providers
bull Managed Care contract- Metrics benchmarks should be selected and part of
the contract
7979
Achieving Quality Metric Payments
Dealing with under achievers
Process issues
Individual issues
Identifying workflows
Developing Best Practices through
PDSA process
Developing Best Practices through
PDSA process
CHC Metrics Committee
Clinicians Operations various key staff
Identify Best Practices
Spread Best Practices
80
New Team Needed Business Intelligence
Business Intelligence (BI) is critical for effective managed care business decisions
BI team inputs metrics into your EHR collects integrates analyses and displays all your managed care business and clinical information
Easy to say- hard to achieve
Build your own or outsource
Possible future role of Primary Care Associations
8181
Clinicianrsquos Dashboard
Expensive to build
Displayed on your screen when your computer is first turned on
Easy to read and understand
Data dumped from the day before
Can dialed down from Org-wide to clinic to each clinicianrsquos data
Operational and clinical metrics
bull Treatment Plan Completion
bull DQA quality measures
bull Caries at Recall
bull Re-care reports
bull Care Gap reports
82
CONTROLLING COSTS
8383
Controlling Costs- Current
bull Increasing efficiencies
bull Decreasing broken appointments
bull Controlling supplies equipment costs
bull Staff recruitment retention costs
84
Specialty Care
Training current CHC dentists in
specialty areas
Hiring general dentists with higher
specialty skill sets
Hiring in house specialists
Contract with outside specialists
Work with Managed Care Plan
specialists
Lowering Disease Rates
Community Dental Health
Coordinators case management
If your state law allows- embed
hygienists in medical and community
to provide primary and secondary
prevention procedures
In clinic Caries Classification and
Silver Diamine Fluoride
Effective recare programs
Controlling Costs- Additions in Risk-based Contracting
85
Specialty Care ndash Primary Referrals by Cost
Pediatric dentistry
Orthodontics
Oral surgery
Endodontics
86
In-clinic Pediatric Services
Encounters expected
of operatories available
State dental law and ability to have
expanded duties
General Anesthesia
GA in- house
Ability for a hospital or surgery center
to set aside regular OR time
Ability to hire or assign DAs to GA
days
Four GA cases day x PPS rate
Should You Hire a Pediatric Dentist- It Depends
8787
Solutions for Controlling Pediatric Costs
Hire a general dentist that is skilled in treating young children
Make the clinic child friendly nitrous oxide TVs in the operatory etc
Teach entire staff behavioral control techniques
Contract with a pediatric dentist for the GA care
88
Lowering Overall Disease Rates (and Costs)
You are responsible for both the patients you see in the chair and the ones
assigned to you
Breaking down the walls of the dental clinic
Community Dental Health Coordinators
Case Management
89
Cost Control Essentials
Diagnosis codes
Increased ability to identify
disease by risk
Motivational
Interviewing
Developing Polices and
Procedures design to treat
disease according to risk
ie Silver Diamine Fluoride
Treating by Risk
Effective Recare
Process
Critical to continual disease
controlPrevention education that is
meaningful and designed to
change behaviors
90
Social Determinants of Health Aunt Bertha
httpswwwauntberthacom
91
REASON TO CONSIDER RISK- BASED CONTRACTING
9292
PPS Reconciliation and Federal Code 42 CFR sect4052469(a)(2)
42 CFR sect4052469(a)(2)
ldquoAny financial incentives provided to Federally Qualified Health Centers
under their Medicare Advantage Contracts such as risk pool payments
bonuses or withholds are prohibited from being included in the
calculation of supplemental payments due to the Federally Qualified
Health Centerrdquo
9393
Why Risk Based Contract in Times of PPS Reconciliation
bull Not all Risk- based Contract funds are reconciled
bull Risk is the key word- you can come out with less money than your normal
PPS reconciliation payment
bull Can lead to better patient care
bull May improve manage care enrollment for your medical plan
bull Promotes integrated care increases health for your CHC patients
9494
Not Included in the Reconciliation
Enrollment management pmpm
Quality Payments
Upside risk payments
Downside risk losses
9595
Determinants of Financial Success in Risk-Based Contracting
bull Most critical- State pmpm payment to the Managed Care Plan
bull Reporting capabilities
bull Specialty service capabilities
bull Access numbers count
bull Ability to move metric numbers
9696
What About the Non- Medicaid Poor We Serve
bull Numbers are king in a managed care contract and the more access you have
the better contract terms you can negotiate
bull We will potentially have a steady supply of Medicaid patients
bull As managed care spreads states this may be compromising the ability of
health centers to serve the non-Medicaid poor and others lacking dental
insurance
97
Mark Koday DDS
(509) 949-2278
Dental Quality Consultants
of WA
httpdentalqualityconsultin
gcom
dentalqualityconsultantsg
mailcom
Contact Information
LUNCH
BREAKOUT EXERCISEORAL HEALTH VALUE-BASED CARE READINESS ASSESSMENT
Danielle Apostolon
PROMISING PRACTICES FROM THE FIELD STRATEGIES FOR INCREASING VALUE IN ORAL HEALTH
Dr Carolyn Brown
Dr Kelly Perry
Dr Rachel Rivard
Dr Adeloye
Commitment Compassion Community
m i d s t a t e h e a l t h o r g
Promising Practices from the
Field Strategies for Increasing
Value in Oral Health Care
Kelly Perry DMD
Better Health
Outcomes
Improved Staff
Experience
Reduced Cost
Improved Patient
Experience
Better Health
Outcomes
Improved Staff
Experience
Reduced Cost
Improved Patient
Experience
Better Health
Outcomes
Improved Staff
Experience
Reduced Cost
Improved Patient
Experience
Better Health
Outcomes
Improved Staff
Experience
Reduced Cost
Improved Patient
Experience
Commitment Compassion Community
kpe r r ymids t a tehea l t h o rg
Thank you
Completion of Disease Control Phase
Pelumi Adeloye DMD MPH
HEALTH ACCESS NETWORK (HAN) FAMILY DENTAL
Introduction
⧫1 Dentist I Hygienist 3 EFDArsquos1 Receptionist
⧫ 6 Chairs= 4 (dentist) + 2 (hygienist)
⧫ Slide ⥶80 off
⧫ Service areas Northern Penobscot Southern Aroostook Western
Washington Counties amp more
Completion of Phase I Treatment
⧫LimitedLack of Access to dental care
⧫Difficulty completing the disease control phase
Caries amp periodontal disease
⧫Attaining stable restorative state
Goal
Increase the completion of Disease Control Phase
Current practice
⧫Education
Assess level of dental literacy
Incremental strategy
⧫Increase access to dental care
Generous sliding scale (⥸$40 per visit)
Incorporate Expanded Function Dental Assistants
⧫Schedule modification
Incorporate more restorative blocks to allow
for follow-up visit and completion of restorative phase
httpswwwglasbergencomdentist-cartoons
Schedule
⧫Piggybacking technique
Increased allotted restorative blocks
⧫Sustainability of current schedule is
contingent on cooperation amp skills of HAN
Dental staff
Note
Strategies mentioned today is personalized to HAN Dental clinic
Current implemented strategies might be modified or changed in the
future as required in order to accommodate the need of our pts
THANK YOU
DAY TWOCLOSINGWRAP-UP
End of Day Two ndash Survey
Day Two Creating a Value-Based Oral Health Care Delivery
System
129
Payment Reform in Oral Health Online Learning Module
Oral Health Value-based Care Online Learning Module
Value-based Care Keys to Success Article
Readiness Assessment
Competency Development Guide
Oral Health Value-based Care Training
Dental Caries Management Practicum
Clinicians Companion Guide
Interprofessional Network Referral Process
Traditional Dental Care Vs Value-Based Care
Resources
131
wwwDentaQuestPartnershiporg
wwwfacebookcomDentaQuest
DentaQuest
wwwlinkedincomcompanyDentaQuest
Inside_DentaQuest
QUESTIONS
45
bull HRSA Sealant Measure Compliance for FQHCs
bull Completion of phase 1 treatment plans
bull Children seen 0-5 years old
bull Children seen getting a preventive service
bull Fluoride Varnish applications
bull Pregnant women seen and treated
bull Diabetic patients with HbA1C gt 7 seen
bull Patients seen who have not been seen for 12 months
bull Patients seen getting a Risk Assessment
bull Patients with moderate or high risk who lower risk at recare
bull Sealants provided httpwwwnnohaorgnnoha-contentuploads201512Demystifying-HRSA-SEALANT-PRESENTATION_FINALpdf
Program Measures
46
HRSA Performance Measurement and Data Collection
bull FQHCs and look-alikes submit CY data to HRSA since 2008
bull UDS Uniform Data System
bull Require FTE for clinical staff patient demographics
bull Dental utilization s (UDCTPV)
bull Dental Clinical Measure dental sealants placed on 1st molars ages 6-9 yo
bull Health Center Quartile rankings (Clinical measure performance influences
HC rankings as does EHR adoption and other HC characteristics)
47
Low birth weight
Access to prenatal care
Childhood Immunization
Children (Ages 3-17) Receiving
Weight Assessment amp
Counseling
Children (Age 6-9) Receiving
Dental Sealant to First Molars
Diabetes Control
Hypertension Control
Pap Test
Depression Screening and
Follow-up (Age 12+)
Asthma Patients (Age 5-40)
Receiving Pharmacologic
Therapy
Colorectal Cancer
Screening (Ages 51-74)
HRSA UDS Clinical Measures
Adults (Age 18+) Receiving
Weight Screening amp Follow-up
Adults (Age 18+) Receiving
Tobacco Use Assessment and
Cessation Intervention
Coronary Artery Disease
Receiving Lipid Therapy (18+)
Ischemic Vascular Disease (IVD)
Receiving Aspirin Therapy (18+)
HIV Linkage to Care
48
Dashboards
Grants
Average
amp
Targets
Quality
Rev
Costs
Visits
Priority
Pop
Prevention
49
Dashboard- Provider Team Level
Patient
Compliance
Satisfaction
50
Case Study-
Incentives bonus round pools benchmark and improvement target goals risk-sharing possible later years
51
Qualitative Measurement
ldquoPatient engagement is the act of patients and providers working together
toward the end goal of improved patient wellnessrdquo
wwwpatientengagementhitcom
Access to Care
Patient Activation
Patient Satisfaction
Patient-Provider-Care Team Communication
Care Team Satisfaction
52
OHVBC Readiness
Leadership
bull Value of oral health and oral health transformation
Structure Systems and Operations
bull Operational efficiencies innovative care delivery methodologies
Care Pathways and Provider Buy-In
bull Training disease management risk-based care referrals IDC-10 coding patient engagement
Data and Analytic Technology and Personnel
bull Interoperability reporting
Financial Viability and Strength
bull Payerpatient mix billing infrastructure financial reports
httpswwwdentaquestpartnershiporglearnsafety-net-solutionsoral-health-value-based-careohvbc-readiness-
assessment
53
QUESTIONS COMMENTS
Carolyn Brown DDS
cbrownddsgmailcom
RISK BASED MANAGED CARE
Value Based Training Conference
Manchester New Hampshire
Mark Koday DDS
111919
5555
Objectives
bull Review current drivers of dental managed care
bull Understand the basics of risk-based dental managed care contracts
bull Learn the basics of managing costs in a riskndashbased contract
bull Gain an understanding in the potential advantage of risk-based contracting
56
What Is Dental Managed Care
Managed care is a health delivery system whose purpose is to manage both the
quality and cost of health care
Common types of managed care health insurance plans
bull HMOs
bull PPOs
bull POSs
bull Medicaid Managed Care
DIDNrsquoT WE ALREADY HAVE MANAGED CARE AND IT FAILED
57
What Has Happened Since the 90s
58
WHY THE FFS AND PPS DOESNrsquoT WORK FOR OUR POPULATIONS
bull Inefficient payment systems designed to produce encounters or procedures but not real health
bull No focus on population health
bull Does not incentivize innovation
bull Patients essentially on their own for accessing specialty care
59
Rule of 4
Source Kaiser Family Foundation analysis of National Health Expenditure (NHE) data from Centers for
Medicare and Medicaid Services Office of the Actuary National Health Statistics Group
60
Rule of 4
bull This helps explain why oral health has been relatively ignored so far by CMS
bull Explains why we have PCMH instead of PCHH
bull Where is the real value on a national level in preventing disease and
controlling costs
bull Beware- wersquove been found
61
Reasons Dental Managed Care is Spreading Across the States
NON-MANAGED CARE STATE DENTAL BUDGETS ARE
OPENED ENDED
STRAIN ON STATE BUDGETS
UPCOMING RECESSION WITH TRILLION DOLLAR
DEFICIT
SHIFTS FINANCIAL RISK FROM THE STATES TO THE
PLANS
6262
Types of Medicaid Managed Care
bull State Medicaid agency administrator lowest administrative
costs
bull Third Party Administrator Typically 15 administrative costs
bull Managed Care Organization Typically 15 administrative
costs
bull Carved-in
bull Carved-out
bull Risk Based Managed Care Administrative costs part of
contract negotiation
63
RISK CONTRACTS
6464
Components of a Risk-based Contract
Risk
Medical Loss Ratio
Quality withhold
Specialty withhold
Managed care payment (pmpm)
Covered services
Fee schedule Claims are paid as usual on a FFS basis
Credentialing
Quality Review process and Quality Metrics
65
Upside Risk
The possibility that the cost of
delivering dental care to an assigned
patient panel is less than the amount
of funding calculated for that care
The Plan pays the CHC additional
funds based on a predetermine
formula
Downside Risk
The possibility that the cost of
delivering dental care to an assigned
patient panel is more than the amount
of funding calculated for that care
The CHC pays the Plan additional
funds based on a predetermine
formula
Upside and Downside Risk
66
Taking On Risk 100 or Shared Risk
With 100 risk you receive 100 of the potential savings but are also at risk for
100 of the losses
Shared Risk MCO and health center share a percentage of the risk
Shared Risk leads to better cooperation since both organizations are
incentivized to save on costs
6767
Reports Needed
bull Enrollment reports lists of who is assigned on a monthly basis
bull Reconciliation reports insure appropriate payments
bull Specialty Referral reports
bull You will need your own reporting process so you donrsquot rely completely on
reports supplied by the Plan
6868
Medical Loss Ratio
Medical Loss Ratio (MLR) is proportion of premium revenues spent on clinical
services and quality improvement also known as the Medical Loss Ratio (MLR)
For CMS requires Medical Plans to spend at least 80 to 85 of the premiums
on actual medical care
69
Administrative Fees
bull Essentially the opposite of MLR
bull The State Medicaid Agency is funded by the Governorrsquos budget
bull The State Medicaid Agency will keep some of these funds for their
admin costs and give the remaining to the Managed Care Plans
bull Private Plan admin costs can be as high as 40 but most states
limit these cost for Medicaid Plans to between 15 and 20 (85-
80 MLR)
bull This may be negotiable depending on your program size of your
program
70
Quality Withhold
bull The state withholds a certain percent (typically 2-4 ) of the funds they give
to the Plans for Value Based Reimbursement
bull They choose quality metrics and set benchmarks and assign payments for
each metric based on an assigned priority for each metric
bull If a Plan meets the benchmark of every quality metric the state passes on
their full share of the quality withhold
bull The Plans may or may not withhold a percent of the funds for quality payment
to the dentists or manage care contractors
71
Quality Withhold
Either way the Plans may or may not pass the quality payments they receive to
the dentists or contractors
This should be spelled out in a risk-based contract
72
Percent of funds set aside
to cover specialty care
referrals
Typically 10-15
Goal Limit referral costs
to within or less than
Specialty set aside
Specialty Withhold
73
Per Member Per Month
bull Capitated Payment
bull Specific dollar amount paid for each enrolled member each month
bull Paid whether patient is accessed for care or not
bull States do set access benchmarks
bull In Oregon access for any dental procedure (adults and children combined)
was 267 in 2015
74
Payment Math Example
Premium per enrollee = $25
Administrative fee 15 = $375
Funds available per enrollee to the clinic = $2125
Management fee per enrollee = $175
Funds per enrollee that would undergo PPS reconciliation = $1950
For every 10000 enrollees the managed care income = $2340000
Specialty withhold (10) = $234000
YE Cost lt or gt $2340000
Upside Risk
CHC Gains $
Downside Risk
CHC Loses $
75
Covered Services and Fee Schedules
bull The state Medicaid agency spells out the minimum procedures and fees that
MCOs must cover
bull MCOs may add procedures or increase periodicity of procedures particularly
preventative services
bull MCOs may increase fees to entice rural providers and specialists to enroll in
their Plans
bull Access Rules
bull How many days it takes to access a patent
bull How many days it takes for a patent to access urgent care services
bull How many days it takes for a patent to access emergency care services
76
Credentialing
All MCOs are required to credential all Providers
All MCOs have their own credentialing process
Credentialing process is can be lengthy
Credentialing process may be negotiable
77
Quality Review Process and Quality Metrics
MCOs must have a Quality and Compliance Review Process
If you arenrsquot in compliance with both you likely wonrsquot get paid
Typical processes reviewed
bull Charting specifications
bull Incident report
bull Enrollee complaints quality rudeness and access issues
bull Medicaid compliance
78
Quality Payments
bull State Shared Incentive Withhold Typically quality metrics and benchmarks
are set by the state sets aside a certain percent (3-5) of the payments to
the Managed Care Plan (MCP)
bull If the benchmarks are achieved the MCP is then paid the a predetermine
amount
bull Benchmarks may not be the same as the states
bull Managed Care Plans do not have to pass all or any of the quality payments to
the health centers or providers
bull Managed Care contract- Metrics benchmarks should be selected and part of
the contract
7979
Achieving Quality Metric Payments
Dealing with under achievers
Process issues
Individual issues
Identifying workflows
Developing Best Practices through
PDSA process
Developing Best Practices through
PDSA process
CHC Metrics Committee
Clinicians Operations various key staff
Identify Best Practices
Spread Best Practices
80
New Team Needed Business Intelligence
Business Intelligence (BI) is critical for effective managed care business decisions
BI team inputs metrics into your EHR collects integrates analyses and displays all your managed care business and clinical information
Easy to say- hard to achieve
Build your own or outsource
Possible future role of Primary Care Associations
8181
Clinicianrsquos Dashboard
Expensive to build
Displayed on your screen when your computer is first turned on
Easy to read and understand
Data dumped from the day before
Can dialed down from Org-wide to clinic to each clinicianrsquos data
Operational and clinical metrics
bull Treatment Plan Completion
bull DQA quality measures
bull Caries at Recall
bull Re-care reports
bull Care Gap reports
82
CONTROLLING COSTS
8383
Controlling Costs- Current
bull Increasing efficiencies
bull Decreasing broken appointments
bull Controlling supplies equipment costs
bull Staff recruitment retention costs
84
Specialty Care
Training current CHC dentists in
specialty areas
Hiring general dentists with higher
specialty skill sets
Hiring in house specialists
Contract with outside specialists
Work with Managed Care Plan
specialists
Lowering Disease Rates
Community Dental Health
Coordinators case management
If your state law allows- embed
hygienists in medical and community
to provide primary and secondary
prevention procedures
In clinic Caries Classification and
Silver Diamine Fluoride
Effective recare programs
Controlling Costs- Additions in Risk-based Contracting
85
Specialty Care ndash Primary Referrals by Cost
Pediatric dentistry
Orthodontics
Oral surgery
Endodontics
86
In-clinic Pediatric Services
Encounters expected
of operatories available
State dental law and ability to have
expanded duties
General Anesthesia
GA in- house
Ability for a hospital or surgery center
to set aside regular OR time
Ability to hire or assign DAs to GA
days
Four GA cases day x PPS rate
Should You Hire a Pediatric Dentist- It Depends
8787
Solutions for Controlling Pediatric Costs
Hire a general dentist that is skilled in treating young children
Make the clinic child friendly nitrous oxide TVs in the operatory etc
Teach entire staff behavioral control techniques
Contract with a pediatric dentist for the GA care
88
Lowering Overall Disease Rates (and Costs)
You are responsible for both the patients you see in the chair and the ones
assigned to you
Breaking down the walls of the dental clinic
Community Dental Health Coordinators
Case Management
89
Cost Control Essentials
Diagnosis codes
Increased ability to identify
disease by risk
Motivational
Interviewing
Developing Polices and
Procedures design to treat
disease according to risk
ie Silver Diamine Fluoride
Treating by Risk
Effective Recare
Process
Critical to continual disease
controlPrevention education that is
meaningful and designed to
change behaviors
90
Social Determinants of Health Aunt Bertha
httpswwwauntberthacom
91
REASON TO CONSIDER RISK- BASED CONTRACTING
9292
PPS Reconciliation and Federal Code 42 CFR sect4052469(a)(2)
42 CFR sect4052469(a)(2)
ldquoAny financial incentives provided to Federally Qualified Health Centers
under their Medicare Advantage Contracts such as risk pool payments
bonuses or withholds are prohibited from being included in the
calculation of supplemental payments due to the Federally Qualified
Health Centerrdquo
9393
Why Risk Based Contract in Times of PPS Reconciliation
bull Not all Risk- based Contract funds are reconciled
bull Risk is the key word- you can come out with less money than your normal
PPS reconciliation payment
bull Can lead to better patient care
bull May improve manage care enrollment for your medical plan
bull Promotes integrated care increases health for your CHC patients
9494
Not Included in the Reconciliation
Enrollment management pmpm
Quality Payments
Upside risk payments
Downside risk losses
9595
Determinants of Financial Success in Risk-Based Contracting
bull Most critical- State pmpm payment to the Managed Care Plan
bull Reporting capabilities
bull Specialty service capabilities
bull Access numbers count
bull Ability to move metric numbers
9696
What About the Non- Medicaid Poor We Serve
bull Numbers are king in a managed care contract and the more access you have
the better contract terms you can negotiate
bull We will potentially have a steady supply of Medicaid patients
bull As managed care spreads states this may be compromising the ability of
health centers to serve the non-Medicaid poor and others lacking dental
insurance
97
Mark Koday DDS
(509) 949-2278
Dental Quality Consultants
of WA
httpdentalqualityconsultin
gcom
dentalqualityconsultantsg
mailcom
Contact Information
LUNCH
BREAKOUT EXERCISEORAL HEALTH VALUE-BASED CARE READINESS ASSESSMENT
Danielle Apostolon
PROMISING PRACTICES FROM THE FIELD STRATEGIES FOR INCREASING VALUE IN ORAL HEALTH
Dr Carolyn Brown
Dr Kelly Perry
Dr Rachel Rivard
Dr Adeloye
Commitment Compassion Community
m i d s t a t e h e a l t h o r g
Promising Practices from the
Field Strategies for Increasing
Value in Oral Health Care
Kelly Perry DMD
Better Health
Outcomes
Improved Staff
Experience
Reduced Cost
Improved Patient
Experience
Better Health
Outcomes
Improved Staff
Experience
Reduced Cost
Improved Patient
Experience
Better Health
Outcomes
Improved Staff
Experience
Reduced Cost
Improved Patient
Experience
Better Health
Outcomes
Improved Staff
Experience
Reduced Cost
Improved Patient
Experience
Commitment Compassion Community
kpe r r ymids t a tehea l t h o rg
Thank you
Completion of Disease Control Phase
Pelumi Adeloye DMD MPH
HEALTH ACCESS NETWORK (HAN) FAMILY DENTAL
Introduction
⧫1 Dentist I Hygienist 3 EFDArsquos1 Receptionist
⧫ 6 Chairs= 4 (dentist) + 2 (hygienist)
⧫ Slide ⥶80 off
⧫ Service areas Northern Penobscot Southern Aroostook Western
Washington Counties amp more
Completion of Phase I Treatment
⧫LimitedLack of Access to dental care
⧫Difficulty completing the disease control phase
Caries amp periodontal disease
⧫Attaining stable restorative state
Goal
Increase the completion of Disease Control Phase
Current practice
⧫Education
Assess level of dental literacy
Incremental strategy
⧫Increase access to dental care
Generous sliding scale (⥸$40 per visit)
Incorporate Expanded Function Dental Assistants
⧫Schedule modification
Incorporate more restorative blocks to allow
for follow-up visit and completion of restorative phase
httpswwwglasbergencomdentist-cartoons
Schedule
⧫Piggybacking technique
Increased allotted restorative blocks
⧫Sustainability of current schedule is
contingent on cooperation amp skills of HAN
Dental staff
Note
Strategies mentioned today is personalized to HAN Dental clinic
Current implemented strategies might be modified or changed in the
future as required in order to accommodate the need of our pts
THANK YOU
DAY TWOCLOSINGWRAP-UP
End of Day Two ndash Survey
Day Two Creating a Value-Based Oral Health Care Delivery
System
129
Payment Reform in Oral Health Online Learning Module
Oral Health Value-based Care Online Learning Module
Value-based Care Keys to Success Article
Readiness Assessment
Competency Development Guide
Oral Health Value-based Care Training
Dental Caries Management Practicum
Clinicians Companion Guide
Interprofessional Network Referral Process
Traditional Dental Care Vs Value-Based Care
Resources
131
wwwDentaQuestPartnershiporg
wwwfacebookcomDentaQuest
DentaQuest
wwwlinkedincomcompanyDentaQuest
Inside_DentaQuest
QUESTIONS
46
HRSA Performance Measurement and Data Collection
bull FQHCs and look-alikes submit CY data to HRSA since 2008
bull UDS Uniform Data System
bull Require FTE for clinical staff patient demographics
bull Dental utilization s (UDCTPV)
bull Dental Clinical Measure dental sealants placed on 1st molars ages 6-9 yo
bull Health Center Quartile rankings (Clinical measure performance influences
HC rankings as does EHR adoption and other HC characteristics)
47
Low birth weight
Access to prenatal care
Childhood Immunization
Children (Ages 3-17) Receiving
Weight Assessment amp
Counseling
Children (Age 6-9) Receiving
Dental Sealant to First Molars
Diabetes Control
Hypertension Control
Pap Test
Depression Screening and
Follow-up (Age 12+)
Asthma Patients (Age 5-40)
Receiving Pharmacologic
Therapy
Colorectal Cancer
Screening (Ages 51-74)
HRSA UDS Clinical Measures
Adults (Age 18+) Receiving
Weight Screening amp Follow-up
Adults (Age 18+) Receiving
Tobacco Use Assessment and
Cessation Intervention
Coronary Artery Disease
Receiving Lipid Therapy (18+)
Ischemic Vascular Disease (IVD)
Receiving Aspirin Therapy (18+)
HIV Linkage to Care
48
Dashboards
Grants
Average
amp
Targets
Quality
Rev
Costs
Visits
Priority
Pop
Prevention
49
Dashboard- Provider Team Level
Patient
Compliance
Satisfaction
50
Case Study-
Incentives bonus round pools benchmark and improvement target goals risk-sharing possible later years
51
Qualitative Measurement
ldquoPatient engagement is the act of patients and providers working together
toward the end goal of improved patient wellnessrdquo
wwwpatientengagementhitcom
Access to Care
Patient Activation
Patient Satisfaction
Patient-Provider-Care Team Communication
Care Team Satisfaction
52
OHVBC Readiness
Leadership
bull Value of oral health and oral health transformation
Structure Systems and Operations
bull Operational efficiencies innovative care delivery methodologies
Care Pathways and Provider Buy-In
bull Training disease management risk-based care referrals IDC-10 coding patient engagement
Data and Analytic Technology and Personnel
bull Interoperability reporting
Financial Viability and Strength
bull Payerpatient mix billing infrastructure financial reports
httpswwwdentaquestpartnershiporglearnsafety-net-solutionsoral-health-value-based-careohvbc-readiness-
assessment
53
QUESTIONS COMMENTS
Carolyn Brown DDS
cbrownddsgmailcom
RISK BASED MANAGED CARE
Value Based Training Conference
Manchester New Hampshire
Mark Koday DDS
111919
5555
Objectives
bull Review current drivers of dental managed care
bull Understand the basics of risk-based dental managed care contracts
bull Learn the basics of managing costs in a riskndashbased contract
bull Gain an understanding in the potential advantage of risk-based contracting
56
What Is Dental Managed Care
Managed care is a health delivery system whose purpose is to manage both the
quality and cost of health care
Common types of managed care health insurance plans
bull HMOs
bull PPOs
bull POSs
bull Medicaid Managed Care
DIDNrsquoT WE ALREADY HAVE MANAGED CARE AND IT FAILED
57
What Has Happened Since the 90s
58
WHY THE FFS AND PPS DOESNrsquoT WORK FOR OUR POPULATIONS
bull Inefficient payment systems designed to produce encounters or procedures but not real health
bull No focus on population health
bull Does not incentivize innovation
bull Patients essentially on their own for accessing specialty care
59
Rule of 4
Source Kaiser Family Foundation analysis of National Health Expenditure (NHE) data from Centers for
Medicare and Medicaid Services Office of the Actuary National Health Statistics Group
60
Rule of 4
bull This helps explain why oral health has been relatively ignored so far by CMS
bull Explains why we have PCMH instead of PCHH
bull Where is the real value on a national level in preventing disease and
controlling costs
bull Beware- wersquove been found
61
Reasons Dental Managed Care is Spreading Across the States
NON-MANAGED CARE STATE DENTAL BUDGETS ARE
OPENED ENDED
STRAIN ON STATE BUDGETS
UPCOMING RECESSION WITH TRILLION DOLLAR
DEFICIT
SHIFTS FINANCIAL RISK FROM THE STATES TO THE
PLANS
6262
Types of Medicaid Managed Care
bull State Medicaid agency administrator lowest administrative
costs
bull Third Party Administrator Typically 15 administrative costs
bull Managed Care Organization Typically 15 administrative
costs
bull Carved-in
bull Carved-out
bull Risk Based Managed Care Administrative costs part of
contract negotiation
63
RISK CONTRACTS
6464
Components of a Risk-based Contract
Risk
Medical Loss Ratio
Quality withhold
Specialty withhold
Managed care payment (pmpm)
Covered services
Fee schedule Claims are paid as usual on a FFS basis
Credentialing
Quality Review process and Quality Metrics
65
Upside Risk
The possibility that the cost of
delivering dental care to an assigned
patient panel is less than the amount
of funding calculated for that care
The Plan pays the CHC additional
funds based on a predetermine
formula
Downside Risk
The possibility that the cost of
delivering dental care to an assigned
patient panel is more than the amount
of funding calculated for that care
The CHC pays the Plan additional
funds based on a predetermine
formula
Upside and Downside Risk
66
Taking On Risk 100 or Shared Risk
With 100 risk you receive 100 of the potential savings but are also at risk for
100 of the losses
Shared Risk MCO and health center share a percentage of the risk
Shared Risk leads to better cooperation since both organizations are
incentivized to save on costs
6767
Reports Needed
bull Enrollment reports lists of who is assigned on a monthly basis
bull Reconciliation reports insure appropriate payments
bull Specialty Referral reports
bull You will need your own reporting process so you donrsquot rely completely on
reports supplied by the Plan
6868
Medical Loss Ratio
Medical Loss Ratio (MLR) is proportion of premium revenues spent on clinical
services and quality improvement also known as the Medical Loss Ratio (MLR)
For CMS requires Medical Plans to spend at least 80 to 85 of the premiums
on actual medical care
69
Administrative Fees
bull Essentially the opposite of MLR
bull The State Medicaid Agency is funded by the Governorrsquos budget
bull The State Medicaid Agency will keep some of these funds for their
admin costs and give the remaining to the Managed Care Plans
bull Private Plan admin costs can be as high as 40 but most states
limit these cost for Medicaid Plans to between 15 and 20 (85-
80 MLR)
bull This may be negotiable depending on your program size of your
program
70
Quality Withhold
bull The state withholds a certain percent (typically 2-4 ) of the funds they give
to the Plans for Value Based Reimbursement
bull They choose quality metrics and set benchmarks and assign payments for
each metric based on an assigned priority for each metric
bull If a Plan meets the benchmark of every quality metric the state passes on
their full share of the quality withhold
bull The Plans may or may not withhold a percent of the funds for quality payment
to the dentists or manage care contractors
71
Quality Withhold
Either way the Plans may or may not pass the quality payments they receive to
the dentists or contractors
This should be spelled out in a risk-based contract
72
Percent of funds set aside
to cover specialty care
referrals
Typically 10-15
Goal Limit referral costs
to within or less than
Specialty set aside
Specialty Withhold
73
Per Member Per Month
bull Capitated Payment
bull Specific dollar amount paid for each enrolled member each month
bull Paid whether patient is accessed for care or not
bull States do set access benchmarks
bull In Oregon access for any dental procedure (adults and children combined)
was 267 in 2015
74
Payment Math Example
Premium per enrollee = $25
Administrative fee 15 = $375
Funds available per enrollee to the clinic = $2125
Management fee per enrollee = $175
Funds per enrollee that would undergo PPS reconciliation = $1950
For every 10000 enrollees the managed care income = $2340000
Specialty withhold (10) = $234000
YE Cost lt or gt $2340000
Upside Risk
CHC Gains $
Downside Risk
CHC Loses $
75
Covered Services and Fee Schedules
bull The state Medicaid agency spells out the minimum procedures and fees that
MCOs must cover
bull MCOs may add procedures or increase periodicity of procedures particularly
preventative services
bull MCOs may increase fees to entice rural providers and specialists to enroll in
their Plans
bull Access Rules
bull How many days it takes to access a patent
bull How many days it takes for a patent to access urgent care services
bull How many days it takes for a patent to access emergency care services
76
Credentialing
All MCOs are required to credential all Providers
All MCOs have their own credentialing process
Credentialing process is can be lengthy
Credentialing process may be negotiable
77
Quality Review Process and Quality Metrics
MCOs must have a Quality and Compliance Review Process
If you arenrsquot in compliance with both you likely wonrsquot get paid
Typical processes reviewed
bull Charting specifications
bull Incident report
bull Enrollee complaints quality rudeness and access issues
bull Medicaid compliance
78
Quality Payments
bull State Shared Incentive Withhold Typically quality metrics and benchmarks
are set by the state sets aside a certain percent (3-5) of the payments to
the Managed Care Plan (MCP)
bull If the benchmarks are achieved the MCP is then paid the a predetermine
amount
bull Benchmarks may not be the same as the states
bull Managed Care Plans do not have to pass all or any of the quality payments to
the health centers or providers
bull Managed Care contract- Metrics benchmarks should be selected and part of
the contract
7979
Achieving Quality Metric Payments
Dealing with under achievers
Process issues
Individual issues
Identifying workflows
Developing Best Practices through
PDSA process
Developing Best Practices through
PDSA process
CHC Metrics Committee
Clinicians Operations various key staff
Identify Best Practices
Spread Best Practices
80
New Team Needed Business Intelligence
Business Intelligence (BI) is critical for effective managed care business decisions
BI team inputs metrics into your EHR collects integrates analyses and displays all your managed care business and clinical information
Easy to say- hard to achieve
Build your own or outsource
Possible future role of Primary Care Associations
8181
Clinicianrsquos Dashboard
Expensive to build
Displayed on your screen when your computer is first turned on
Easy to read and understand
Data dumped from the day before
Can dialed down from Org-wide to clinic to each clinicianrsquos data
Operational and clinical metrics
bull Treatment Plan Completion
bull DQA quality measures
bull Caries at Recall
bull Re-care reports
bull Care Gap reports
82
CONTROLLING COSTS
8383
Controlling Costs- Current
bull Increasing efficiencies
bull Decreasing broken appointments
bull Controlling supplies equipment costs
bull Staff recruitment retention costs
84
Specialty Care
Training current CHC dentists in
specialty areas
Hiring general dentists with higher
specialty skill sets
Hiring in house specialists
Contract with outside specialists
Work with Managed Care Plan
specialists
Lowering Disease Rates
Community Dental Health
Coordinators case management
If your state law allows- embed
hygienists in medical and community
to provide primary and secondary
prevention procedures
In clinic Caries Classification and
Silver Diamine Fluoride
Effective recare programs
Controlling Costs- Additions in Risk-based Contracting
85
Specialty Care ndash Primary Referrals by Cost
Pediatric dentistry
Orthodontics
Oral surgery
Endodontics
86
In-clinic Pediatric Services
Encounters expected
of operatories available
State dental law and ability to have
expanded duties
General Anesthesia
GA in- house
Ability for a hospital or surgery center
to set aside regular OR time
Ability to hire or assign DAs to GA
days
Four GA cases day x PPS rate
Should You Hire a Pediatric Dentist- It Depends
8787
Solutions for Controlling Pediatric Costs
Hire a general dentist that is skilled in treating young children
Make the clinic child friendly nitrous oxide TVs in the operatory etc
Teach entire staff behavioral control techniques
Contract with a pediatric dentist for the GA care
88
Lowering Overall Disease Rates (and Costs)
You are responsible for both the patients you see in the chair and the ones
assigned to you
Breaking down the walls of the dental clinic
Community Dental Health Coordinators
Case Management
89
Cost Control Essentials
Diagnosis codes
Increased ability to identify
disease by risk
Motivational
Interviewing
Developing Polices and
Procedures design to treat
disease according to risk
ie Silver Diamine Fluoride
Treating by Risk
Effective Recare
Process
Critical to continual disease
controlPrevention education that is
meaningful and designed to
change behaviors
90
Social Determinants of Health Aunt Bertha
httpswwwauntberthacom
91
REASON TO CONSIDER RISK- BASED CONTRACTING
9292
PPS Reconciliation and Federal Code 42 CFR sect4052469(a)(2)
42 CFR sect4052469(a)(2)
ldquoAny financial incentives provided to Federally Qualified Health Centers
under their Medicare Advantage Contracts such as risk pool payments
bonuses or withholds are prohibited from being included in the
calculation of supplemental payments due to the Federally Qualified
Health Centerrdquo
9393
Why Risk Based Contract in Times of PPS Reconciliation
bull Not all Risk- based Contract funds are reconciled
bull Risk is the key word- you can come out with less money than your normal
PPS reconciliation payment
bull Can lead to better patient care
bull May improve manage care enrollment for your medical plan
bull Promotes integrated care increases health for your CHC patients
9494
Not Included in the Reconciliation
Enrollment management pmpm
Quality Payments
Upside risk payments
Downside risk losses
9595
Determinants of Financial Success in Risk-Based Contracting
bull Most critical- State pmpm payment to the Managed Care Plan
bull Reporting capabilities
bull Specialty service capabilities
bull Access numbers count
bull Ability to move metric numbers
9696
What About the Non- Medicaid Poor We Serve
bull Numbers are king in a managed care contract and the more access you have
the better contract terms you can negotiate
bull We will potentially have a steady supply of Medicaid patients
bull As managed care spreads states this may be compromising the ability of
health centers to serve the non-Medicaid poor and others lacking dental
insurance
97
Mark Koday DDS
(509) 949-2278
Dental Quality Consultants
of WA
httpdentalqualityconsultin
gcom
dentalqualityconsultantsg
mailcom
Contact Information
LUNCH
BREAKOUT EXERCISEORAL HEALTH VALUE-BASED CARE READINESS ASSESSMENT
Danielle Apostolon
PROMISING PRACTICES FROM THE FIELD STRATEGIES FOR INCREASING VALUE IN ORAL HEALTH
Dr Carolyn Brown
Dr Kelly Perry
Dr Rachel Rivard
Dr Adeloye
Commitment Compassion Community
m i d s t a t e h e a l t h o r g
Promising Practices from the
Field Strategies for Increasing
Value in Oral Health Care
Kelly Perry DMD
Better Health
Outcomes
Improved Staff
Experience
Reduced Cost
Improved Patient
Experience
Better Health
Outcomes
Improved Staff
Experience
Reduced Cost
Improved Patient
Experience
Better Health
Outcomes
Improved Staff
Experience
Reduced Cost
Improved Patient
Experience
Better Health
Outcomes
Improved Staff
Experience
Reduced Cost
Improved Patient
Experience
Commitment Compassion Community
kpe r r ymids t a tehea l t h o rg
Thank you
Completion of Disease Control Phase
Pelumi Adeloye DMD MPH
HEALTH ACCESS NETWORK (HAN) FAMILY DENTAL
Introduction
⧫1 Dentist I Hygienist 3 EFDArsquos1 Receptionist
⧫ 6 Chairs= 4 (dentist) + 2 (hygienist)
⧫ Slide ⥶80 off
⧫ Service areas Northern Penobscot Southern Aroostook Western
Washington Counties amp more
Completion of Phase I Treatment
⧫LimitedLack of Access to dental care
⧫Difficulty completing the disease control phase
Caries amp periodontal disease
⧫Attaining stable restorative state
Goal
Increase the completion of Disease Control Phase
Current practice
⧫Education
Assess level of dental literacy
Incremental strategy
⧫Increase access to dental care
Generous sliding scale (⥸$40 per visit)
Incorporate Expanded Function Dental Assistants
⧫Schedule modification
Incorporate more restorative blocks to allow
for follow-up visit and completion of restorative phase
httpswwwglasbergencomdentist-cartoons
Schedule
⧫Piggybacking technique
Increased allotted restorative blocks
⧫Sustainability of current schedule is
contingent on cooperation amp skills of HAN
Dental staff
Note
Strategies mentioned today is personalized to HAN Dental clinic
Current implemented strategies might be modified or changed in the
future as required in order to accommodate the need of our pts
THANK YOU
DAY TWOCLOSINGWRAP-UP
End of Day Two ndash Survey
Day Two Creating a Value-Based Oral Health Care Delivery
System
129
Payment Reform in Oral Health Online Learning Module
Oral Health Value-based Care Online Learning Module
Value-based Care Keys to Success Article
Readiness Assessment
Competency Development Guide
Oral Health Value-based Care Training
Dental Caries Management Practicum
Clinicians Companion Guide
Interprofessional Network Referral Process
Traditional Dental Care Vs Value-Based Care
Resources
131
wwwDentaQuestPartnershiporg
wwwfacebookcomDentaQuest
DentaQuest
wwwlinkedincomcompanyDentaQuest
Inside_DentaQuest
QUESTIONS
47
Low birth weight
Access to prenatal care
Childhood Immunization
Children (Ages 3-17) Receiving
Weight Assessment amp
Counseling
Children (Age 6-9) Receiving
Dental Sealant to First Molars
Diabetes Control
Hypertension Control
Pap Test
Depression Screening and
Follow-up (Age 12+)
Asthma Patients (Age 5-40)
Receiving Pharmacologic
Therapy
Colorectal Cancer
Screening (Ages 51-74)
HRSA UDS Clinical Measures
Adults (Age 18+) Receiving
Weight Screening amp Follow-up
Adults (Age 18+) Receiving
Tobacco Use Assessment and
Cessation Intervention
Coronary Artery Disease
Receiving Lipid Therapy (18+)
Ischemic Vascular Disease (IVD)
Receiving Aspirin Therapy (18+)
HIV Linkage to Care
48
Dashboards
Grants
Average
amp
Targets
Quality
Rev
Costs
Visits
Priority
Pop
Prevention
49
Dashboard- Provider Team Level
Patient
Compliance
Satisfaction
50
Case Study-
Incentives bonus round pools benchmark and improvement target goals risk-sharing possible later years
51
Qualitative Measurement
ldquoPatient engagement is the act of patients and providers working together
toward the end goal of improved patient wellnessrdquo
wwwpatientengagementhitcom
Access to Care
Patient Activation
Patient Satisfaction
Patient-Provider-Care Team Communication
Care Team Satisfaction
52
OHVBC Readiness
Leadership
bull Value of oral health and oral health transformation
Structure Systems and Operations
bull Operational efficiencies innovative care delivery methodologies
Care Pathways and Provider Buy-In
bull Training disease management risk-based care referrals IDC-10 coding patient engagement
Data and Analytic Technology and Personnel
bull Interoperability reporting
Financial Viability and Strength
bull Payerpatient mix billing infrastructure financial reports
httpswwwdentaquestpartnershiporglearnsafety-net-solutionsoral-health-value-based-careohvbc-readiness-
assessment
53
QUESTIONS COMMENTS
Carolyn Brown DDS
cbrownddsgmailcom
RISK BASED MANAGED CARE
Value Based Training Conference
Manchester New Hampshire
Mark Koday DDS
111919
5555
Objectives
bull Review current drivers of dental managed care
bull Understand the basics of risk-based dental managed care contracts
bull Learn the basics of managing costs in a riskndashbased contract
bull Gain an understanding in the potential advantage of risk-based contracting
56
What Is Dental Managed Care
Managed care is a health delivery system whose purpose is to manage both the
quality and cost of health care
Common types of managed care health insurance plans
bull HMOs
bull PPOs
bull POSs
bull Medicaid Managed Care
DIDNrsquoT WE ALREADY HAVE MANAGED CARE AND IT FAILED
57
What Has Happened Since the 90s
58
WHY THE FFS AND PPS DOESNrsquoT WORK FOR OUR POPULATIONS
bull Inefficient payment systems designed to produce encounters or procedures but not real health
bull No focus on population health
bull Does not incentivize innovation
bull Patients essentially on their own for accessing specialty care
59
Rule of 4
Source Kaiser Family Foundation analysis of National Health Expenditure (NHE) data from Centers for
Medicare and Medicaid Services Office of the Actuary National Health Statistics Group
60
Rule of 4
bull This helps explain why oral health has been relatively ignored so far by CMS
bull Explains why we have PCMH instead of PCHH
bull Where is the real value on a national level in preventing disease and
controlling costs
bull Beware- wersquove been found
61
Reasons Dental Managed Care is Spreading Across the States
NON-MANAGED CARE STATE DENTAL BUDGETS ARE
OPENED ENDED
STRAIN ON STATE BUDGETS
UPCOMING RECESSION WITH TRILLION DOLLAR
DEFICIT
SHIFTS FINANCIAL RISK FROM THE STATES TO THE
PLANS
6262
Types of Medicaid Managed Care
bull State Medicaid agency administrator lowest administrative
costs
bull Third Party Administrator Typically 15 administrative costs
bull Managed Care Organization Typically 15 administrative
costs
bull Carved-in
bull Carved-out
bull Risk Based Managed Care Administrative costs part of
contract negotiation
63
RISK CONTRACTS
6464
Components of a Risk-based Contract
Risk
Medical Loss Ratio
Quality withhold
Specialty withhold
Managed care payment (pmpm)
Covered services
Fee schedule Claims are paid as usual on a FFS basis
Credentialing
Quality Review process and Quality Metrics
65
Upside Risk
The possibility that the cost of
delivering dental care to an assigned
patient panel is less than the amount
of funding calculated for that care
The Plan pays the CHC additional
funds based on a predetermine
formula
Downside Risk
The possibility that the cost of
delivering dental care to an assigned
patient panel is more than the amount
of funding calculated for that care
The CHC pays the Plan additional
funds based on a predetermine
formula
Upside and Downside Risk
66
Taking On Risk 100 or Shared Risk
With 100 risk you receive 100 of the potential savings but are also at risk for
100 of the losses
Shared Risk MCO and health center share a percentage of the risk
Shared Risk leads to better cooperation since both organizations are
incentivized to save on costs
6767
Reports Needed
bull Enrollment reports lists of who is assigned on a monthly basis
bull Reconciliation reports insure appropriate payments
bull Specialty Referral reports
bull You will need your own reporting process so you donrsquot rely completely on
reports supplied by the Plan
6868
Medical Loss Ratio
Medical Loss Ratio (MLR) is proportion of premium revenues spent on clinical
services and quality improvement also known as the Medical Loss Ratio (MLR)
For CMS requires Medical Plans to spend at least 80 to 85 of the premiums
on actual medical care
69
Administrative Fees
bull Essentially the opposite of MLR
bull The State Medicaid Agency is funded by the Governorrsquos budget
bull The State Medicaid Agency will keep some of these funds for their
admin costs and give the remaining to the Managed Care Plans
bull Private Plan admin costs can be as high as 40 but most states
limit these cost for Medicaid Plans to between 15 and 20 (85-
80 MLR)
bull This may be negotiable depending on your program size of your
program
70
Quality Withhold
bull The state withholds a certain percent (typically 2-4 ) of the funds they give
to the Plans for Value Based Reimbursement
bull They choose quality metrics and set benchmarks and assign payments for
each metric based on an assigned priority for each metric
bull If a Plan meets the benchmark of every quality metric the state passes on
their full share of the quality withhold
bull The Plans may or may not withhold a percent of the funds for quality payment
to the dentists or manage care contractors
71
Quality Withhold
Either way the Plans may or may not pass the quality payments they receive to
the dentists or contractors
This should be spelled out in a risk-based contract
72
Percent of funds set aside
to cover specialty care
referrals
Typically 10-15
Goal Limit referral costs
to within or less than
Specialty set aside
Specialty Withhold
73
Per Member Per Month
bull Capitated Payment
bull Specific dollar amount paid for each enrolled member each month
bull Paid whether patient is accessed for care or not
bull States do set access benchmarks
bull In Oregon access for any dental procedure (adults and children combined)
was 267 in 2015
74
Payment Math Example
Premium per enrollee = $25
Administrative fee 15 = $375
Funds available per enrollee to the clinic = $2125
Management fee per enrollee = $175
Funds per enrollee that would undergo PPS reconciliation = $1950
For every 10000 enrollees the managed care income = $2340000
Specialty withhold (10) = $234000
YE Cost lt or gt $2340000
Upside Risk
CHC Gains $
Downside Risk
CHC Loses $
75
Covered Services and Fee Schedules
bull The state Medicaid agency spells out the minimum procedures and fees that
MCOs must cover
bull MCOs may add procedures or increase periodicity of procedures particularly
preventative services
bull MCOs may increase fees to entice rural providers and specialists to enroll in
their Plans
bull Access Rules
bull How many days it takes to access a patent
bull How many days it takes for a patent to access urgent care services
bull How many days it takes for a patent to access emergency care services
76
Credentialing
All MCOs are required to credential all Providers
All MCOs have their own credentialing process
Credentialing process is can be lengthy
Credentialing process may be negotiable
77
Quality Review Process and Quality Metrics
MCOs must have a Quality and Compliance Review Process
If you arenrsquot in compliance with both you likely wonrsquot get paid
Typical processes reviewed
bull Charting specifications
bull Incident report
bull Enrollee complaints quality rudeness and access issues
bull Medicaid compliance
78
Quality Payments
bull State Shared Incentive Withhold Typically quality metrics and benchmarks
are set by the state sets aside a certain percent (3-5) of the payments to
the Managed Care Plan (MCP)
bull If the benchmarks are achieved the MCP is then paid the a predetermine
amount
bull Benchmarks may not be the same as the states
bull Managed Care Plans do not have to pass all or any of the quality payments to
the health centers or providers
bull Managed Care contract- Metrics benchmarks should be selected and part of
the contract
7979
Achieving Quality Metric Payments
Dealing with under achievers
Process issues
Individual issues
Identifying workflows
Developing Best Practices through
PDSA process
Developing Best Practices through
PDSA process
CHC Metrics Committee
Clinicians Operations various key staff
Identify Best Practices
Spread Best Practices
80
New Team Needed Business Intelligence
Business Intelligence (BI) is critical for effective managed care business decisions
BI team inputs metrics into your EHR collects integrates analyses and displays all your managed care business and clinical information
Easy to say- hard to achieve
Build your own or outsource
Possible future role of Primary Care Associations
8181
Clinicianrsquos Dashboard
Expensive to build
Displayed on your screen when your computer is first turned on
Easy to read and understand
Data dumped from the day before
Can dialed down from Org-wide to clinic to each clinicianrsquos data
Operational and clinical metrics
bull Treatment Plan Completion
bull DQA quality measures
bull Caries at Recall
bull Re-care reports
bull Care Gap reports
82
CONTROLLING COSTS
8383
Controlling Costs- Current
bull Increasing efficiencies
bull Decreasing broken appointments
bull Controlling supplies equipment costs
bull Staff recruitment retention costs
84
Specialty Care
Training current CHC dentists in
specialty areas
Hiring general dentists with higher
specialty skill sets
Hiring in house specialists
Contract with outside specialists
Work with Managed Care Plan
specialists
Lowering Disease Rates
Community Dental Health
Coordinators case management
If your state law allows- embed
hygienists in medical and community
to provide primary and secondary
prevention procedures
In clinic Caries Classification and
Silver Diamine Fluoride
Effective recare programs
Controlling Costs- Additions in Risk-based Contracting
85
Specialty Care ndash Primary Referrals by Cost
Pediatric dentistry
Orthodontics
Oral surgery
Endodontics
86
In-clinic Pediatric Services
Encounters expected
of operatories available
State dental law and ability to have
expanded duties
General Anesthesia
GA in- house
Ability for a hospital or surgery center
to set aside regular OR time
Ability to hire or assign DAs to GA
days
Four GA cases day x PPS rate
Should You Hire a Pediatric Dentist- It Depends
8787
Solutions for Controlling Pediatric Costs
Hire a general dentist that is skilled in treating young children
Make the clinic child friendly nitrous oxide TVs in the operatory etc
Teach entire staff behavioral control techniques
Contract with a pediatric dentist for the GA care
88
Lowering Overall Disease Rates (and Costs)
You are responsible for both the patients you see in the chair and the ones
assigned to you
Breaking down the walls of the dental clinic
Community Dental Health Coordinators
Case Management
89
Cost Control Essentials
Diagnosis codes
Increased ability to identify
disease by risk
Motivational
Interviewing
Developing Polices and
Procedures design to treat
disease according to risk
ie Silver Diamine Fluoride
Treating by Risk
Effective Recare
Process
Critical to continual disease
controlPrevention education that is
meaningful and designed to
change behaviors
90
Social Determinants of Health Aunt Bertha
httpswwwauntberthacom
91
REASON TO CONSIDER RISK- BASED CONTRACTING
9292
PPS Reconciliation and Federal Code 42 CFR sect4052469(a)(2)
42 CFR sect4052469(a)(2)
ldquoAny financial incentives provided to Federally Qualified Health Centers
under their Medicare Advantage Contracts such as risk pool payments
bonuses or withholds are prohibited from being included in the
calculation of supplemental payments due to the Federally Qualified
Health Centerrdquo
9393
Why Risk Based Contract in Times of PPS Reconciliation
bull Not all Risk- based Contract funds are reconciled
bull Risk is the key word- you can come out with less money than your normal
PPS reconciliation payment
bull Can lead to better patient care
bull May improve manage care enrollment for your medical plan
bull Promotes integrated care increases health for your CHC patients
9494
Not Included in the Reconciliation
Enrollment management pmpm
Quality Payments
Upside risk payments
Downside risk losses
9595
Determinants of Financial Success in Risk-Based Contracting
bull Most critical- State pmpm payment to the Managed Care Plan
bull Reporting capabilities
bull Specialty service capabilities
bull Access numbers count
bull Ability to move metric numbers
9696
What About the Non- Medicaid Poor We Serve
bull Numbers are king in a managed care contract and the more access you have
the better contract terms you can negotiate
bull We will potentially have a steady supply of Medicaid patients
bull As managed care spreads states this may be compromising the ability of
health centers to serve the non-Medicaid poor and others lacking dental
insurance
97
Mark Koday DDS
(509) 949-2278
Dental Quality Consultants
of WA
httpdentalqualityconsultin
gcom
dentalqualityconsultantsg
mailcom
Contact Information
LUNCH
BREAKOUT EXERCISEORAL HEALTH VALUE-BASED CARE READINESS ASSESSMENT
Danielle Apostolon
PROMISING PRACTICES FROM THE FIELD STRATEGIES FOR INCREASING VALUE IN ORAL HEALTH
Dr Carolyn Brown
Dr Kelly Perry
Dr Rachel Rivard
Dr Adeloye
Commitment Compassion Community
m i d s t a t e h e a l t h o r g
Promising Practices from the
Field Strategies for Increasing
Value in Oral Health Care
Kelly Perry DMD
Better Health
Outcomes
Improved Staff
Experience
Reduced Cost
Improved Patient
Experience
Better Health
Outcomes
Improved Staff
Experience
Reduced Cost
Improved Patient
Experience
Better Health
Outcomes
Improved Staff
Experience
Reduced Cost
Improved Patient
Experience
Better Health
Outcomes
Improved Staff
Experience
Reduced Cost
Improved Patient
Experience
Commitment Compassion Community
kpe r r ymids t a tehea l t h o rg
Thank you
Completion of Disease Control Phase
Pelumi Adeloye DMD MPH
HEALTH ACCESS NETWORK (HAN) FAMILY DENTAL
Introduction
⧫1 Dentist I Hygienist 3 EFDArsquos1 Receptionist
⧫ 6 Chairs= 4 (dentist) + 2 (hygienist)
⧫ Slide ⥶80 off
⧫ Service areas Northern Penobscot Southern Aroostook Western
Washington Counties amp more
Completion of Phase I Treatment
⧫LimitedLack of Access to dental care
⧫Difficulty completing the disease control phase
Caries amp periodontal disease
⧫Attaining stable restorative state
Goal
Increase the completion of Disease Control Phase
Current practice
⧫Education
Assess level of dental literacy
Incremental strategy
⧫Increase access to dental care
Generous sliding scale (⥸$40 per visit)
Incorporate Expanded Function Dental Assistants
⧫Schedule modification
Incorporate more restorative blocks to allow
for follow-up visit and completion of restorative phase
httpswwwglasbergencomdentist-cartoons
Schedule
⧫Piggybacking technique
Increased allotted restorative blocks
⧫Sustainability of current schedule is
contingent on cooperation amp skills of HAN
Dental staff
Note
Strategies mentioned today is personalized to HAN Dental clinic
Current implemented strategies might be modified or changed in the
future as required in order to accommodate the need of our pts
THANK YOU
DAY TWOCLOSINGWRAP-UP
End of Day Two ndash Survey
Day Two Creating a Value-Based Oral Health Care Delivery
System
129
Payment Reform in Oral Health Online Learning Module
Oral Health Value-based Care Online Learning Module
Value-based Care Keys to Success Article
Readiness Assessment
Competency Development Guide
Oral Health Value-based Care Training
Dental Caries Management Practicum
Clinicians Companion Guide
Interprofessional Network Referral Process
Traditional Dental Care Vs Value-Based Care
Resources
131
wwwDentaQuestPartnershiporg
wwwfacebookcomDentaQuest
DentaQuest
wwwlinkedincomcompanyDentaQuest
Inside_DentaQuest
QUESTIONS
48
Dashboards
Grants
Average
amp
Targets
Quality
Rev
Costs
Visits
Priority
Pop
Prevention
49
Dashboard- Provider Team Level
Patient
Compliance
Satisfaction
50
Case Study-
Incentives bonus round pools benchmark and improvement target goals risk-sharing possible later years
51
Qualitative Measurement
ldquoPatient engagement is the act of patients and providers working together
toward the end goal of improved patient wellnessrdquo
wwwpatientengagementhitcom
Access to Care
Patient Activation
Patient Satisfaction
Patient-Provider-Care Team Communication
Care Team Satisfaction
52
OHVBC Readiness
Leadership
bull Value of oral health and oral health transformation
Structure Systems and Operations
bull Operational efficiencies innovative care delivery methodologies
Care Pathways and Provider Buy-In
bull Training disease management risk-based care referrals IDC-10 coding patient engagement
Data and Analytic Technology and Personnel
bull Interoperability reporting
Financial Viability and Strength
bull Payerpatient mix billing infrastructure financial reports
httpswwwdentaquestpartnershiporglearnsafety-net-solutionsoral-health-value-based-careohvbc-readiness-
assessment
53
QUESTIONS COMMENTS
Carolyn Brown DDS
cbrownddsgmailcom
RISK BASED MANAGED CARE
Value Based Training Conference
Manchester New Hampshire
Mark Koday DDS
111919
5555
Objectives
bull Review current drivers of dental managed care
bull Understand the basics of risk-based dental managed care contracts
bull Learn the basics of managing costs in a riskndashbased contract
bull Gain an understanding in the potential advantage of risk-based contracting
56
What Is Dental Managed Care
Managed care is a health delivery system whose purpose is to manage both the
quality and cost of health care
Common types of managed care health insurance plans
bull HMOs
bull PPOs
bull POSs
bull Medicaid Managed Care
DIDNrsquoT WE ALREADY HAVE MANAGED CARE AND IT FAILED
57
What Has Happened Since the 90s
58
WHY THE FFS AND PPS DOESNrsquoT WORK FOR OUR POPULATIONS
bull Inefficient payment systems designed to produce encounters or procedures but not real health
bull No focus on population health
bull Does not incentivize innovation
bull Patients essentially on their own for accessing specialty care
59
Rule of 4
Source Kaiser Family Foundation analysis of National Health Expenditure (NHE) data from Centers for
Medicare and Medicaid Services Office of the Actuary National Health Statistics Group
60
Rule of 4
bull This helps explain why oral health has been relatively ignored so far by CMS
bull Explains why we have PCMH instead of PCHH
bull Where is the real value on a national level in preventing disease and
controlling costs
bull Beware- wersquove been found
61
Reasons Dental Managed Care is Spreading Across the States
NON-MANAGED CARE STATE DENTAL BUDGETS ARE
OPENED ENDED
STRAIN ON STATE BUDGETS
UPCOMING RECESSION WITH TRILLION DOLLAR
DEFICIT
SHIFTS FINANCIAL RISK FROM THE STATES TO THE
PLANS
6262
Types of Medicaid Managed Care
bull State Medicaid agency administrator lowest administrative
costs
bull Third Party Administrator Typically 15 administrative costs
bull Managed Care Organization Typically 15 administrative
costs
bull Carved-in
bull Carved-out
bull Risk Based Managed Care Administrative costs part of
contract negotiation
63
RISK CONTRACTS
6464
Components of a Risk-based Contract
Risk
Medical Loss Ratio
Quality withhold
Specialty withhold
Managed care payment (pmpm)
Covered services
Fee schedule Claims are paid as usual on a FFS basis
Credentialing
Quality Review process and Quality Metrics
65
Upside Risk
The possibility that the cost of
delivering dental care to an assigned
patient panel is less than the amount
of funding calculated for that care
The Plan pays the CHC additional
funds based on a predetermine
formula
Downside Risk
The possibility that the cost of
delivering dental care to an assigned
patient panel is more than the amount
of funding calculated for that care
The CHC pays the Plan additional
funds based on a predetermine
formula
Upside and Downside Risk
66
Taking On Risk 100 or Shared Risk
With 100 risk you receive 100 of the potential savings but are also at risk for
100 of the losses
Shared Risk MCO and health center share a percentage of the risk
Shared Risk leads to better cooperation since both organizations are
incentivized to save on costs
6767
Reports Needed
bull Enrollment reports lists of who is assigned on a monthly basis
bull Reconciliation reports insure appropriate payments
bull Specialty Referral reports
bull You will need your own reporting process so you donrsquot rely completely on
reports supplied by the Plan
6868
Medical Loss Ratio
Medical Loss Ratio (MLR) is proportion of premium revenues spent on clinical
services and quality improvement also known as the Medical Loss Ratio (MLR)
For CMS requires Medical Plans to spend at least 80 to 85 of the premiums
on actual medical care
69
Administrative Fees
bull Essentially the opposite of MLR
bull The State Medicaid Agency is funded by the Governorrsquos budget
bull The State Medicaid Agency will keep some of these funds for their
admin costs and give the remaining to the Managed Care Plans
bull Private Plan admin costs can be as high as 40 but most states
limit these cost for Medicaid Plans to between 15 and 20 (85-
80 MLR)
bull This may be negotiable depending on your program size of your
program
70
Quality Withhold
bull The state withholds a certain percent (typically 2-4 ) of the funds they give
to the Plans for Value Based Reimbursement
bull They choose quality metrics and set benchmarks and assign payments for
each metric based on an assigned priority for each metric
bull If a Plan meets the benchmark of every quality metric the state passes on
their full share of the quality withhold
bull The Plans may or may not withhold a percent of the funds for quality payment
to the dentists or manage care contractors
71
Quality Withhold
Either way the Plans may or may not pass the quality payments they receive to
the dentists or contractors
This should be spelled out in a risk-based contract
72
Percent of funds set aside
to cover specialty care
referrals
Typically 10-15
Goal Limit referral costs
to within or less than
Specialty set aside
Specialty Withhold
73
Per Member Per Month
bull Capitated Payment
bull Specific dollar amount paid for each enrolled member each month
bull Paid whether patient is accessed for care or not
bull States do set access benchmarks
bull In Oregon access for any dental procedure (adults and children combined)
was 267 in 2015
74
Payment Math Example
Premium per enrollee = $25
Administrative fee 15 = $375
Funds available per enrollee to the clinic = $2125
Management fee per enrollee = $175
Funds per enrollee that would undergo PPS reconciliation = $1950
For every 10000 enrollees the managed care income = $2340000
Specialty withhold (10) = $234000
YE Cost lt or gt $2340000
Upside Risk
CHC Gains $
Downside Risk
CHC Loses $
75
Covered Services and Fee Schedules
bull The state Medicaid agency spells out the minimum procedures and fees that
MCOs must cover
bull MCOs may add procedures or increase periodicity of procedures particularly
preventative services
bull MCOs may increase fees to entice rural providers and specialists to enroll in
their Plans
bull Access Rules
bull How many days it takes to access a patent
bull How many days it takes for a patent to access urgent care services
bull How many days it takes for a patent to access emergency care services
76
Credentialing
All MCOs are required to credential all Providers
All MCOs have their own credentialing process
Credentialing process is can be lengthy
Credentialing process may be negotiable
77
Quality Review Process and Quality Metrics
MCOs must have a Quality and Compliance Review Process
If you arenrsquot in compliance with both you likely wonrsquot get paid
Typical processes reviewed
bull Charting specifications
bull Incident report
bull Enrollee complaints quality rudeness and access issues
bull Medicaid compliance
78
Quality Payments
bull State Shared Incentive Withhold Typically quality metrics and benchmarks
are set by the state sets aside a certain percent (3-5) of the payments to
the Managed Care Plan (MCP)
bull If the benchmarks are achieved the MCP is then paid the a predetermine
amount
bull Benchmarks may not be the same as the states
bull Managed Care Plans do not have to pass all or any of the quality payments to
the health centers or providers
bull Managed Care contract- Metrics benchmarks should be selected and part of
the contract
7979
Achieving Quality Metric Payments
Dealing with under achievers
Process issues
Individual issues
Identifying workflows
Developing Best Practices through
PDSA process
Developing Best Practices through
PDSA process
CHC Metrics Committee
Clinicians Operations various key staff
Identify Best Practices
Spread Best Practices
80
New Team Needed Business Intelligence
Business Intelligence (BI) is critical for effective managed care business decisions
BI team inputs metrics into your EHR collects integrates analyses and displays all your managed care business and clinical information
Easy to say- hard to achieve
Build your own or outsource
Possible future role of Primary Care Associations
8181
Clinicianrsquos Dashboard
Expensive to build
Displayed on your screen when your computer is first turned on
Easy to read and understand
Data dumped from the day before
Can dialed down from Org-wide to clinic to each clinicianrsquos data
Operational and clinical metrics
bull Treatment Plan Completion
bull DQA quality measures
bull Caries at Recall
bull Re-care reports
bull Care Gap reports
82
CONTROLLING COSTS
8383
Controlling Costs- Current
bull Increasing efficiencies
bull Decreasing broken appointments
bull Controlling supplies equipment costs
bull Staff recruitment retention costs
84
Specialty Care
Training current CHC dentists in
specialty areas
Hiring general dentists with higher
specialty skill sets
Hiring in house specialists
Contract with outside specialists
Work with Managed Care Plan
specialists
Lowering Disease Rates
Community Dental Health
Coordinators case management
If your state law allows- embed
hygienists in medical and community
to provide primary and secondary
prevention procedures
In clinic Caries Classification and
Silver Diamine Fluoride
Effective recare programs
Controlling Costs- Additions in Risk-based Contracting
85
Specialty Care ndash Primary Referrals by Cost
Pediatric dentistry
Orthodontics
Oral surgery
Endodontics
86
In-clinic Pediatric Services
Encounters expected
of operatories available
State dental law and ability to have
expanded duties
General Anesthesia
GA in- house
Ability for a hospital or surgery center
to set aside regular OR time
Ability to hire or assign DAs to GA
days
Four GA cases day x PPS rate
Should You Hire a Pediatric Dentist- It Depends
8787
Solutions for Controlling Pediatric Costs
Hire a general dentist that is skilled in treating young children
Make the clinic child friendly nitrous oxide TVs in the operatory etc
Teach entire staff behavioral control techniques
Contract with a pediatric dentist for the GA care
88
Lowering Overall Disease Rates (and Costs)
You are responsible for both the patients you see in the chair and the ones
assigned to you
Breaking down the walls of the dental clinic
Community Dental Health Coordinators
Case Management
89
Cost Control Essentials
Diagnosis codes
Increased ability to identify
disease by risk
Motivational
Interviewing
Developing Polices and
Procedures design to treat
disease according to risk
ie Silver Diamine Fluoride
Treating by Risk
Effective Recare
Process
Critical to continual disease
controlPrevention education that is
meaningful and designed to
change behaviors
90
Social Determinants of Health Aunt Bertha
httpswwwauntberthacom
91
REASON TO CONSIDER RISK- BASED CONTRACTING
9292
PPS Reconciliation and Federal Code 42 CFR sect4052469(a)(2)
42 CFR sect4052469(a)(2)
ldquoAny financial incentives provided to Federally Qualified Health Centers
under their Medicare Advantage Contracts such as risk pool payments
bonuses or withholds are prohibited from being included in the
calculation of supplemental payments due to the Federally Qualified
Health Centerrdquo
9393
Why Risk Based Contract in Times of PPS Reconciliation
bull Not all Risk- based Contract funds are reconciled
bull Risk is the key word- you can come out with less money than your normal
PPS reconciliation payment
bull Can lead to better patient care
bull May improve manage care enrollment for your medical plan
bull Promotes integrated care increases health for your CHC patients
9494
Not Included in the Reconciliation
Enrollment management pmpm
Quality Payments
Upside risk payments
Downside risk losses
9595
Determinants of Financial Success in Risk-Based Contracting
bull Most critical- State pmpm payment to the Managed Care Plan
bull Reporting capabilities
bull Specialty service capabilities
bull Access numbers count
bull Ability to move metric numbers
9696
What About the Non- Medicaid Poor We Serve
bull Numbers are king in a managed care contract and the more access you have
the better contract terms you can negotiate
bull We will potentially have a steady supply of Medicaid patients
bull As managed care spreads states this may be compromising the ability of
health centers to serve the non-Medicaid poor and others lacking dental
insurance
97
Mark Koday DDS
(509) 949-2278
Dental Quality Consultants
of WA
httpdentalqualityconsultin
gcom
dentalqualityconsultantsg
mailcom
Contact Information
LUNCH
BREAKOUT EXERCISEORAL HEALTH VALUE-BASED CARE READINESS ASSESSMENT
Danielle Apostolon
PROMISING PRACTICES FROM THE FIELD STRATEGIES FOR INCREASING VALUE IN ORAL HEALTH
Dr Carolyn Brown
Dr Kelly Perry
Dr Rachel Rivard
Dr Adeloye
Commitment Compassion Community
m i d s t a t e h e a l t h o r g
Promising Practices from the
Field Strategies for Increasing
Value in Oral Health Care
Kelly Perry DMD
Better Health
Outcomes
Improved Staff
Experience
Reduced Cost
Improved Patient
Experience
Better Health
Outcomes
Improved Staff
Experience
Reduced Cost
Improved Patient
Experience
Better Health
Outcomes
Improved Staff
Experience
Reduced Cost
Improved Patient
Experience
Better Health
Outcomes
Improved Staff
Experience
Reduced Cost
Improved Patient
Experience
Commitment Compassion Community
kpe r r ymids t a tehea l t h o rg
Thank you
Completion of Disease Control Phase
Pelumi Adeloye DMD MPH
HEALTH ACCESS NETWORK (HAN) FAMILY DENTAL
Introduction
⧫1 Dentist I Hygienist 3 EFDArsquos1 Receptionist
⧫ 6 Chairs= 4 (dentist) + 2 (hygienist)
⧫ Slide ⥶80 off
⧫ Service areas Northern Penobscot Southern Aroostook Western
Washington Counties amp more
Completion of Phase I Treatment
⧫LimitedLack of Access to dental care
⧫Difficulty completing the disease control phase
Caries amp periodontal disease
⧫Attaining stable restorative state
Goal
Increase the completion of Disease Control Phase
Current practice
⧫Education
Assess level of dental literacy
Incremental strategy
⧫Increase access to dental care
Generous sliding scale (⥸$40 per visit)
Incorporate Expanded Function Dental Assistants
⧫Schedule modification
Incorporate more restorative blocks to allow
for follow-up visit and completion of restorative phase
httpswwwglasbergencomdentist-cartoons
Schedule
⧫Piggybacking technique
Increased allotted restorative blocks
⧫Sustainability of current schedule is
contingent on cooperation amp skills of HAN
Dental staff
Note
Strategies mentioned today is personalized to HAN Dental clinic
Current implemented strategies might be modified or changed in the
future as required in order to accommodate the need of our pts
THANK YOU
DAY TWOCLOSINGWRAP-UP
End of Day Two ndash Survey
Day Two Creating a Value-Based Oral Health Care Delivery
System
129
Payment Reform in Oral Health Online Learning Module
Oral Health Value-based Care Online Learning Module
Value-based Care Keys to Success Article
Readiness Assessment
Competency Development Guide
Oral Health Value-based Care Training
Dental Caries Management Practicum
Clinicians Companion Guide
Interprofessional Network Referral Process
Traditional Dental Care Vs Value-Based Care
Resources
131
wwwDentaQuestPartnershiporg
wwwfacebookcomDentaQuest
DentaQuest
wwwlinkedincomcompanyDentaQuest
Inside_DentaQuest
QUESTIONS
49
Dashboard- Provider Team Level
Patient
Compliance
Satisfaction
50
Case Study-
Incentives bonus round pools benchmark and improvement target goals risk-sharing possible later years
51
Qualitative Measurement
ldquoPatient engagement is the act of patients and providers working together
toward the end goal of improved patient wellnessrdquo
wwwpatientengagementhitcom
Access to Care
Patient Activation
Patient Satisfaction
Patient-Provider-Care Team Communication
Care Team Satisfaction
52
OHVBC Readiness
Leadership
bull Value of oral health and oral health transformation
Structure Systems and Operations
bull Operational efficiencies innovative care delivery methodologies
Care Pathways and Provider Buy-In
bull Training disease management risk-based care referrals IDC-10 coding patient engagement
Data and Analytic Technology and Personnel
bull Interoperability reporting
Financial Viability and Strength
bull Payerpatient mix billing infrastructure financial reports
httpswwwdentaquestpartnershiporglearnsafety-net-solutionsoral-health-value-based-careohvbc-readiness-
assessment
53
QUESTIONS COMMENTS
Carolyn Brown DDS
cbrownddsgmailcom
RISK BASED MANAGED CARE
Value Based Training Conference
Manchester New Hampshire
Mark Koday DDS
111919
5555
Objectives
bull Review current drivers of dental managed care
bull Understand the basics of risk-based dental managed care contracts
bull Learn the basics of managing costs in a riskndashbased contract
bull Gain an understanding in the potential advantage of risk-based contracting
56
What Is Dental Managed Care
Managed care is a health delivery system whose purpose is to manage both the
quality and cost of health care
Common types of managed care health insurance plans
bull HMOs
bull PPOs
bull POSs
bull Medicaid Managed Care
DIDNrsquoT WE ALREADY HAVE MANAGED CARE AND IT FAILED
57
What Has Happened Since the 90s
58
WHY THE FFS AND PPS DOESNrsquoT WORK FOR OUR POPULATIONS
bull Inefficient payment systems designed to produce encounters or procedures but not real health
bull No focus on population health
bull Does not incentivize innovation
bull Patients essentially on their own for accessing specialty care
59
Rule of 4
Source Kaiser Family Foundation analysis of National Health Expenditure (NHE) data from Centers for
Medicare and Medicaid Services Office of the Actuary National Health Statistics Group
60
Rule of 4
bull This helps explain why oral health has been relatively ignored so far by CMS
bull Explains why we have PCMH instead of PCHH
bull Where is the real value on a national level in preventing disease and
controlling costs
bull Beware- wersquove been found
61
Reasons Dental Managed Care is Spreading Across the States
NON-MANAGED CARE STATE DENTAL BUDGETS ARE
OPENED ENDED
STRAIN ON STATE BUDGETS
UPCOMING RECESSION WITH TRILLION DOLLAR
DEFICIT
SHIFTS FINANCIAL RISK FROM THE STATES TO THE
PLANS
6262
Types of Medicaid Managed Care
bull State Medicaid agency administrator lowest administrative
costs
bull Third Party Administrator Typically 15 administrative costs
bull Managed Care Organization Typically 15 administrative
costs
bull Carved-in
bull Carved-out
bull Risk Based Managed Care Administrative costs part of
contract negotiation
63
RISK CONTRACTS
6464
Components of a Risk-based Contract
Risk
Medical Loss Ratio
Quality withhold
Specialty withhold
Managed care payment (pmpm)
Covered services
Fee schedule Claims are paid as usual on a FFS basis
Credentialing
Quality Review process and Quality Metrics
65
Upside Risk
The possibility that the cost of
delivering dental care to an assigned
patient panel is less than the amount
of funding calculated for that care
The Plan pays the CHC additional
funds based on a predetermine
formula
Downside Risk
The possibility that the cost of
delivering dental care to an assigned
patient panel is more than the amount
of funding calculated for that care
The CHC pays the Plan additional
funds based on a predetermine
formula
Upside and Downside Risk
66
Taking On Risk 100 or Shared Risk
With 100 risk you receive 100 of the potential savings but are also at risk for
100 of the losses
Shared Risk MCO and health center share a percentage of the risk
Shared Risk leads to better cooperation since both organizations are
incentivized to save on costs
6767
Reports Needed
bull Enrollment reports lists of who is assigned on a monthly basis
bull Reconciliation reports insure appropriate payments
bull Specialty Referral reports
bull You will need your own reporting process so you donrsquot rely completely on
reports supplied by the Plan
6868
Medical Loss Ratio
Medical Loss Ratio (MLR) is proportion of premium revenues spent on clinical
services and quality improvement also known as the Medical Loss Ratio (MLR)
For CMS requires Medical Plans to spend at least 80 to 85 of the premiums
on actual medical care
69
Administrative Fees
bull Essentially the opposite of MLR
bull The State Medicaid Agency is funded by the Governorrsquos budget
bull The State Medicaid Agency will keep some of these funds for their
admin costs and give the remaining to the Managed Care Plans
bull Private Plan admin costs can be as high as 40 but most states
limit these cost for Medicaid Plans to between 15 and 20 (85-
80 MLR)
bull This may be negotiable depending on your program size of your
program
70
Quality Withhold
bull The state withholds a certain percent (typically 2-4 ) of the funds they give
to the Plans for Value Based Reimbursement
bull They choose quality metrics and set benchmarks and assign payments for
each metric based on an assigned priority for each metric
bull If a Plan meets the benchmark of every quality metric the state passes on
their full share of the quality withhold
bull The Plans may or may not withhold a percent of the funds for quality payment
to the dentists or manage care contractors
71
Quality Withhold
Either way the Plans may or may not pass the quality payments they receive to
the dentists or contractors
This should be spelled out in a risk-based contract
72
Percent of funds set aside
to cover specialty care
referrals
Typically 10-15
Goal Limit referral costs
to within or less than
Specialty set aside
Specialty Withhold
73
Per Member Per Month
bull Capitated Payment
bull Specific dollar amount paid for each enrolled member each month
bull Paid whether patient is accessed for care or not
bull States do set access benchmarks
bull In Oregon access for any dental procedure (adults and children combined)
was 267 in 2015
74
Payment Math Example
Premium per enrollee = $25
Administrative fee 15 = $375
Funds available per enrollee to the clinic = $2125
Management fee per enrollee = $175
Funds per enrollee that would undergo PPS reconciliation = $1950
For every 10000 enrollees the managed care income = $2340000
Specialty withhold (10) = $234000
YE Cost lt or gt $2340000
Upside Risk
CHC Gains $
Downside Risk
CHC Loses $
75
Covered Services and Fee Schedules
bull The state Medicaid agency spells out the minimum procedures and fees that
MCOs must cover
bull MCOs may add procedures or increase periodicity of procedures particularly
preventative services
bull MCOs may increase fees to entice rural providers and specialists to enroll in
their Plans
bull Access Rules
bull How many days it takes to access a patent
bull How many days it takes for a patent to access urgent care services
bull How many days it takes for a patent to access emergency care services
76
Credentialing
All MCOs are required to credential all Providers
All MCOs have their own credentialing process
Credentialing process is can be lengthy
Credentialing process may be negotiable
77
Quality Review Process and Quality Metrics
MCOs must have a Quality and Compliance Review Process
If you arenrsquot in compliance with both you likely wonrsquot get paid
Typical processes reviewed
bull Charting specifications
bull Incident report
bull Enrollee complaints quality rudeness and access issues
bull Medicaid compliance
78
Quality Payments
bull State Shared Incentive Withhold Typically quality metrics and benchmarks
are set by the state sets aside a certain percent (3-5) of the payments to
the Managed Care Plan (MCP)
bull If the benchmarks are achieved the MCP is then paid the a predetermine
amount
bull Benchmarks may not be the same as the states
bull Managed Care Plans do not have to pass all or any of the quality payments to
the health centers or providers
bull Managed Care contract- Metrics benchmarks should be selected and part of
the contract
7979
Achieving Quality Metric Payments
Dealing with under achievers
Process issues
Individual issues
Identifying workflows
Developing Best Practices through
PDSA process
Developing Best Practices through
PDSA process
CHC Metrics Committee
Clinicians Operations various key staff
Identify Best Practices
Spread Best Practices
80
New Team Needed Business Intelligence
Business Intelligence (BI) is critical for effective managed care business decisions
BI team inputs metrics into your EHR collects integrates analyses and displays all your managed care business and clinical information
Easy to say- hard to achieve
Build your own or outsource
Possible future role of Primary Care Associations
8181
Clinicianrsquos Dashboard
Expensive to build
Displayed on your screen when your computer is first turned on
Easy to read and understand
Data dumped from the day before
Can dialed down from Org-wide to clinic to each clinicianrsquos data
Operational and clinical metrics
bull Treatment Plan Completion
bull DQA quality measures
bull Caries at Recall
bull Re-care reports
bull Care Gap reports
82
CONTROLLING COSTS
8383
Controlling Costs- Current
bull Increasing efficiencies
bull Decreasing broken appointments
bull Controlling supplies equipment costs
bull Staff recruitment retention costs
84
Specialty Care
Training current CHC dentists in
specialty areas
Hiring general dentists with higher
specialty skill sets
Hiring in house specialists
Contract with outside specialists
Work with Managed Care Plan
specialists
Lowering Disease Rates
Community Dental Health
Coordinators case management
If your state law allows- embed
hygienists in medical and community
to provide primary and secondary
prevention procedures
In clinic Caries Classification and
Silver Diamine Fluoride
Effective recare programs
Controlling Costs- Additions in Risk-based Contracting
85
Specialty Care ndash Primary Referrals by Cost
Pediatric dentistry
Orthodontics
Oral surgery
Endodontics
86
In-clinic Pediatric Services
Encounters expected
of operatories available
State dental law and ability to have
expanded duties
General Anesthesia
GA in- house
Ability for a hospital or surgery center
to set aside regular OR time
Ability to hire or assign DAs to GA
days
Four GA cases day x PPS rate
Should You Hire a Pediatric Dentist- It Depends
8787
Solutions for Controlling Pediatric Costs
Hire a general dentist that is skilled in treating young children
Make the clinic child friendly nitrous oxide TVs in the operatory etc
Teach entire staff behavioral control techniques
Contract with a pediatric dentist for the GA care
88
Lowering Overall Disease Rates (and Costs)
You are responsible for both the patients you see in the chair and the ones
assigned to you
Breaking down the walls of the dental clinic
Community Dental Health Coordinators
Case Management
89
Cost Control Essentials
Diagnosis codes
Increased ability to identify
disease by risk
Motivational
Interviewing
Developing Polices and
Procedures design to treat
disease according to risk
ie Silver Diamine Fluoride
Treating by Risk
Effective Recare
Process
Critical to continual disease
controlPrevention education that is
meaningful and designed to
change behaviors
90
Social Determinants of Health Aunt Bertha
httpswwwauntberthacom
91
REASON TO CONSIDER RISK- BASED CONTRACTING
9292
PPS Reconciliation and Federal Code 42 CFR sect4052469(a)(2)
42 CFR sect4052469(a)(2)
ldquoAny financial incentives provided to Federally Qualified Health Centers
under their Medicare Advantage Contracts such as risk pool payments
bonuses or withholds are prohibited from being included in the
calculation of supplemental payments due to the Federally Qualified
Health Centerrdquo
9393
Why Risk Based Contract in Times of PPS Reconciliation
bull Not all Risk- based Contract funds are reconciled
bull Risk is the key word- you can come out with less money than your normal
PPS reconciliation payment
bull Can lead to better patient care
bull May improve manage care enrollment for your medical plan
bull Promotes integrated care increases health for your CHC patients
9494
Not Included in the Reconciliation
Enrollment management pmpm
Quality Payments
Upside risk payments
Downside risk losses
9595
Determinants of Financial Success in Risk-Based Contracting
bull Most critical- State pmpm payment to the Managed Care Plan
bull Reporting capabilities
bull Specialty service capabilities
bull Access numbers count
bull Ability to move metric numbers
9696
What About the Non- Medicaid Poor We Serve
bull Numbers are king in a managed care contract and the more access you have
the better contract terms you can negotiate
bull We will potentially have a steady supply of Medicaid patients
bull As managed care spreads states this may be compromising the ability of
health centers to serve the non-Medicaid poor and others lacking dental
insurance
97
Mark Koday DDS
(509) 949-2278
Dental Quality Consultants
of WA
httpdentalqualityconsultin
gcom
dentalqualityconsultantsg
mailcom
Contact Information
LUNCH
BREAKOUT EXERCISEORAL HEALTH VALUE-BASED CARE READINESS ASSESSMENT
Danielle Apostolon
PROMISING PRACTICES FROM THE FIELD STRATEGIES FOR INCREASING VALUE IN ORAL HEALTH
Dr Carolyn Brown
Dr Kelly Perry
Dr Rachel Rivard
Dr Adeloye
Commitment Compassion Community
m i d s t a t e h e a l t h o r g
Promising Practices from the
Field Strategies for Increasing
Value in Oral Health Care
Kelly Perry DMD
Better Health
Outcomes
Improved Staff
Experience
Reduced Cost
Improved Patient
Experience
Better Health
Outcomes
Improved Staff
Experience
Reduced Cost
Improved Patient
Experience
Better Health
Outcomes
Improved Staff
Experience
Reduced Cost
Improved Patient
Experience
Better Health
Outcomes
Improved Staff
Experience
Reduced Cost
Improved Patient
Experience
Commitment Compassion Community
kpe r r ymids t a tehea l t h o rg
Thank you
Completion of Disease Control Phase
Pelumi Adeloye DMD MPH
HEALTH ACCESS NETWORK (HAN) FAMILY DENTAL
Introduction
⧫1 Dentist I Hygienist 3 EFDArsquos1 Receptionist
⧫ 6 Chairs= 4 (dentist) + 2 (hygienist)
⧫ Slide ⥶80 off
⧫ Service areas Northern Penobscot Southern Aroostook Western
Washington Counties amp more
Completion of Phase I Treatment
⧫LimitedLack of Access to dental care
⧫Difficulty completing the disease control phase
Caries amp periodontal disease
⧫Attaining stable restorative state
Goal
Increase the completion of Disease Control Phase
Current practice
⧫Education
Assess level of dental literacy
Incremental strategy
⧫Increase access to dental care
Generous sliding scale (⥸$40 per visit)
Incorporate Expanded Function Dental Assistants
⧫Schedule modification
Incorporate more restorative blocks to allow
for follow-up visit and completion of restorative phase
httpswwwglasbergencomdentist-cartoons
Schedule
⧫Piggybacking technique
Increased allotted restorative blocks
⧫Sustainability of current schedule is
contingent on cooperation amp skills of HAN
Dental staff
Note
Strategies mentioned today is personalized to HAN Dental clinic
Current implemented strategies might be modified or changed in the
future as required in order to accommodate the need of our pts
THANK YOU
DAY TWOCLOSINGWRAP-UP
End of Day Two ndash Survey
Day Two Creating a Value-Based Oral Health Care Delivery
System
129
Payment Reform in Oral Health Online Learning Module
Oral Health Value-based Care Online Learning Module
Value-based Care Keys to Success Article
Readiness Assessment
Competency Development Guide
Oral Health Value-based Care Training
Dental Caries Management Practicum
Clinicians Companion Guide
Interprofessional Network Referral Process
Traditional Dental Care Vs Value-Based Care
Resources
131
wwwDentaQuestPartnershiporg
wwwfacebookcomDentaQuest
DentaQuest
wwwlinkedincomcompanyDentaQuest
Inside_DentaQuest
QUESTIONS
50
Case Study-
Incentives bonus round pools benchmark and improvement target goals risk-sharing possible later years
51
Qualitative Measurement
ldquoPatient engagement is the act of patients and providers working together
toward the end goal of improved patient wellnessrdquo
wwwpatientengagementhitcom
Access to Care
Patient Activation
Patient Satisfaction
Patient-Provider-Care Team Communication
Care Team Satisfaction
52
OHVBC Readiness
Leadership
bull Value of oral health and oral health transformation
Structure Systems and Operations
bull Operational efficiencies innovative care delivery methodologies
Care Pathways and Provider Buy-In
bull Training disease management risk-based care referrals IDC-10 coding patient engagement
Data and Analytic Technology and Personnel
bull Interoperability reporting
Financial Viability and Strength
bull Payerpatient mix billing infrastructure financial reports
httpswwwdentaquestpartnershiporglearnsafety-net-solutionsoral-health-value-based-careohvbc-readiness-
assessment
53
QUESTIONS COMMENTS
Carolyn Brown DDS
cbrownddsgmailcom
RISK BASED MANAGED CARE
Value Based Training Conference
Manchester New Hampshire
Mark Koday DDS
111919
5555
Objectives
bull Review current drivers of dental managed care
bull Understand the basics of risk-based dental managed care contracts
bull Learn the basics of managing costs in a riskndashbased contract
bull Gain an understanding in the potential advantage of risk-based contracting
56
What Is Dental Managed Care
Managed care is a health delivery system whose purpose is to manage both the
quality and cost of health care
Common types of managed care health insurance plans
bull HMOs
bull PPOs
bull POSs
bull Medicaid Managed Care
DIDNrsquoT WE ALREADY HAVE MANAGED CARE AND IT FAILED
57
What Has Happened Since the 90s
58
WHY THE FFS AND PPS DOESNrsquoT WORK FOR OUR POPULATIONS
bull Inefficient payment systems designed to produce encounters or procedures but not real health
bull No focus on population health
bull Does not incentivize innovation
bull Patients essentially on their own for accessing specialty care
59
Rule of 4
Source Kaiser Family Foundation analysis of National Health Expenditure (NHE) data from Centers for
Medicare and Medicaid Services Office of the Actuary National Health Statistics Group
60
Rule of 4
bull This helps explain why oral health has been relatively ignored so far by CMS
bull Explains why we have PCMH instead of PCHH
bull Where is the real value on a national level in preventing disease and
controlling costs
bull Beware- wersquove been found
61
Reasons Dental Managed Care is Spreading Across the States
NON-MANAGED CARE STATE DENTAL BUDGETS ARE
OPENED ENDED
STRAIN ON STATE BUDGETS
UPCOMING RECESSION WITH TRILLION DOLLAR
DEFICIT
SHIFTS FINANCIAL RISK FROM THE STATES TO THE
PLANS
6262
Types of Medicaid Managed Care
bull State Medicaid agency administrator lowest administrative
costs
bull Third Party Administrator Typically 15 administrative costs
bull Managed Care Organization Typically 15 administrative
costs
bull Carved-in
bull Carved-out
bull Risk Based Managed Care Administrative costs part of
contract negotiation
63
RISK CONTRACTS
6464
Components of a Risk-based Contract
Risk
Medical Loss Ratio
Quality withhold
Specialty withhold
Managed care payment (pmpm)
Covered services
Fee schedule Claims are paid as usual on a FFS basis
Credentialing
Quality Review process and Quality Metrics
65
Upside Risk
The possibility that the cost of
delivering dental care to an assigned
patient panel is less than the amount
of funding calculated for that care
The Plan pays the CHC additional
funds based on a predetermine
formula
Downside Risk
The possibility that the cost of
delivering dental care to an assigned
patient panel is more than the amount
of funding calculated for that care
The CHC pays the Plan additional
funds based on a predetermine
formula
Upside and Downside Risk
66
Taking On Risk 100 or Shared Risk
With 100 risk you receive 100 of the potential savings but are also at risk for
100 of the losses
Shared Risk MCO and health center share a percentage of the risk
Shared Risk leads to better cooperation since both organizations are
incentivized to save on costs
6767
Reports Needed
bull Enrollment reports lists of who is assigned on a monthly basis
bull Reconciliation reports insure appropriate payments
bull Specialty Referral reports
bull You will need your own reporting process so you donrsquot rely completely on
reports supplied by the Plan
6868
Medical Loss Ratio
Medical Loss Ratio (MLR) is proportion of premium revenues spent on clinical
services and quality improvement also known as the Medical Loss Ratio (MLR)
For CMS requires Medical Plans to spend at least 80 to 85 of the premiums
on actual medical care
69
Administrative Fees
bull Essentially the opposite of MLR
bull The State Medicaid Agency is funded by the Governorrsquos budget
bull The State Medicaid Agency will keep some of these funds for their
admin costs and give the remaining to the Managed Care Plans
bull Private Plan admin costs can be as high as 40 but most states
limit these cost for Medicaid Plans to between 15 and 20 (85-
80 MLR)
bull This may be negotiable depending on your program size of your
program
70
Quality Withhold
bull The state withholds a certain percent (typically 2-4 ) of the funds they give
to the Plans for Value Based Reimbursement
bull They choose quality metrics and set benchmarks and assign payments for
each metric based on an assigned priority for each metric
bull If a Plan meets the benchmark of every quality metric the state passes on
their full share of the quality withhold
bull The Plans may or may not withhold a percent of the funds for quality payment
to the dentists or manage care contractors
71
Quality Withhold
Either way the Plans may or may not pass the quality payments they receive to
the dentists or contractors
This should be spelled out in a risk-based contract
72
Percent of funds set aside
to cover specialty care
referrals
Typically 10-15
Goal Limit referral costs
to within or less than
Specialty set aside
Specialty Withhold
73
Per Member Per Month
bull Capitated Payment
bull Specific dollar amount paid for each enrolled member each month
bull Paid whether patient is accessed for care or not
bull States do set access benchmarks
bull In Oregon access for any dental procedure (adults and children combined)
was 267 in 2015
74
Payment Math Example
Premium per enrollee = $25
Administrative fee 15 = $375
Funds available per enrollee to the clinic = $2125
Management fee per enrollee = $175
Funds per enrollee that would undergo PPS reconciliation = $1950
For every 10000 enrollees the managed care income = $2340000
Specialty withhold (10) = $234000
YE Cost lt or gt $2340000
Upside Risk
CHC Gains $
Downside Risk
CHC Loses $
75
Covered Services and Fee Schedules
bull The state Medicaid agency spells out the minimum procedures and fees that
MCOs must cover
bull MCOs may add procedures or increase periodicity of procedures particularly
preventative services
bull MCOs may increase fees to entice rural providers and specialists to enroll in
their Plans
bull Access Rules
bull How many days it takes to access a patent
bull How many days it takes for a patent to access urgent care services
bull How many days it takes for a patent to access emergency care services
76
Credentialing
All MCOs are required to credential all Providers
All MCOs have their own credentialing process
Credentialing process is can be lengthy
Credentialing process may be negotiable
77
Quality Review Process and Quality Metrics
MCOs must have a Quality and Compliance Review Process
If you arenrsquot in compliance with both you likely wonrsquot get paid
Typical processes reviewed
bull Charting specifications
bull Incident report
bull Enrollee complaints quality rudeness and access issues
bull Medicaid compliance
78
Quality Payments
bull State Shared Incentive Withhold Typically quality metrics and benchmarks
are set by the state sets aside a certain percent (3-5) of the payments to
the Managed Care Plan (MCP)
bull If the benchmarks are achieved the MCP is then paid the a predetermine
amount
bull Benchmarks may not be the same as the states
bull Managed Care Plans do not have to pass all or any of the quality payments to
the health centers or providers
bull Managed Care contract- Metrics benchmarks should be selected and part of
the contract
7979
Achieving Quality Metric Payments
Dealing with under achievers
Process issues
Individual issues
Identifying workflows
Developing Best Practices through
PDSA process
Developing Best Practices through
PDSA process
CHC Metrics Committee
Clinicians Operations various key staff
Identify Best Practices
Spread Best Practices
80
New Team Needed Business Intelligence
Business Intelligence (BI) is critical for effective managed care business decisions
BI team inputs metrics into your EHR collects integrates analyses and displays all your managed care business and clinical information
Easy to say- hard to achieve
Build your own or outsource
Possible future role of Primary Care Associations
8181
Clinicianrsquos Dashboard
Expensive to build
Displayed on your screen when your computer is first turned on
Easy to read and understand
Data dumped from the day before
Can dialed down from Org-wide to clinic to each clinicianrsquos data
Operational and clinical metrics
bull Treatment Plan Completion
bull DQA quality measures
bull Caries at Recall
bull Re-care reports
bull Care Gap reports
82
CONTROLLING COSTS
8383
Controlling Costs- Current
bull Increasing efficiencies
bull Decreasing broken appointments
bull Controlling supplies equipment costs
bull Staff recruitment retention costs
84
Specialty Care
Training current CHC dentists in
specialty areas
Hiring general dentists with higher
specialty skill sets
Hiring in house specialists
Contract with outside specialists
Work with Managed Care Plan
specialists
Lowering Disease Rates
Community Dental Health
Coordinators case management
If your state law allows- embed
hygienists in medical and community
to provide primary and secondary
prevention procedures
In clinic Caries Classification and
Silver Diamine Fluoride
Effective recare programs
Controlling Costs- Additions in Risk-based Contracting
85
Specialty Care ndash Primary Referrals by Cost
Pediatric dentistry
Orthodontics
Oral surgery
Endodontics
86
In-clinic Pediatric Services
Encounters expected
of operatories available
State dental law and ability to have
expanded duties
General Anesthesia
GA in- house
Ability for a hospital or surgery center
to set aside regular OR time
Ability to hire or assign DAs to GA
days
Four GA cases day x PPS rate
Should You Hire a Pediatric Dentist- It Depends
8787
Solutions for Controlling Pediatric Costs
Hire a general dentist that is skilled in treating young children
Make the clinic child friendly nitrous oxide TVs in the operatory etc
Teach entire staff behavioral control techniques
Contract with a pediatric dentist for the GA care
88
Lowering Overall Disease Rates (and Costs)
You are responsible for both the patients you see in the chair and the ones
assigned to you
Breaking down the walls of the dental clinic
Community Dental Health Coordinators
Case Management
89
Cost Control Essentials
Diagnosis codes
Increased ability to identify
disease by risk
Motivational
Interviewing
Developing Polices and
Procedures design to treat
disease according to risk
ie Silver Diamine Fluoride
Treating by Risk
Effective Recare
Process
Critical to continual disease
controlPrevention education that is
meaningful and designed to
change behaviors
90
Social Determinants of Health Aunt Bertha
httpswwwauntberthacom
91
REASON TO CONSIDER RISK- BASED CONTRACTING
9292
PPS Reconciliation and Federal Code 42 CFR sect4052469(a)(2)
42 CFR sect4052469(a)(2)
ldquoAny financial incentives provided to Federally Qualified Health Centers
under their Medicare Advantage Contracts such as risk pool payments
bonuses or withholds are prohibited from being included in the
calculation of supplemental payments due to the Federally Qualified
Health Centerrdquo
9393
Why Risk Based Contract in Times of PPS Reconciliation
bull Not all Risk- based Contract funds are reconciled
bull Risk is the key word- you can come out with less money than your normal
PPS reconciliation payment
bull Can lead to better patient care
bull May improve manage care enrollment for your medical plan
bull Promotes integrated care increases health for your CHC patients
9494
Not Included in the Reconciliation
Enrollment management pmpm
Quality Payments
Upside risk payments
Downside risk losses
9595
Determinants of Financial Success in Risk-Based Contracting
bull Most critical- State pmpm payment to the Managed Care Plan
bull Reporting capabilities
bull Specialty service capabilities
bull Access numbers count
bull Ability to move metric numbers
9696
What About the Non- Medicaid Poor We Serve
bull Numbers are king in a managed care contract and the more access you have
the better contract terms you can negotiate
bull We will potentially have a steady supply of Medicaid patients
bull As managed care spreads states this may be compromising the ability of
health centers to serve the non-Medicaid poor and others lacking dental
insurance
97
Mark Koday DDS
(509) 949-2278
Dental Quality Consultants
of WA
httpdentalqualityconsultin
gcom
dentalqualityconsultantsg
mailcom
Contact Information
LUNCH
BREAKOUT EXERCISEORAL HEALTH VALUE-BASED CARE READINESS ASSESSMENT
Danielle Apostolon
PROMISING PRACTICES FROM THE FIELD STRATEGIES FOR INCREASING VALUE IN ORAL HEALTH
Dr Carolyn Brown
Dr Kelly Perry
Dr Rachel Rivard
Dr Adeloye
Commitment Compassion Community
m i d s t a t e h e a l t h o r g
Promising Practices from the
Field Strategies for Increasing
Value in Oral Health Care
Kelly Perry DMD
Better Health
Outcomes
Improved Staff
Experience
Reduced Cost
Improved Patient
Experience
Better Health
Outcomes
Improved Staff
Experience
Reduced Cost
Improved Patient
Experience
Better Health
Outcomes
Improved Staff
Experience
Reduced Cost
Improved Patient
Experience
Better Health
Outcomes
Improved Staff
Experience
Reduced Cost
Improved Patient
Experience
Commitment Compassion Community
kpe r r ymids t a tehea l t h o rg
Thank you
Completion of Disease Control Phase
Pelumi Adeloye DMD MPH
HEALTH ACCESS NETWORK (HAN) FAMILY DENTAL
Introduction
⧫1 Dentist I Hygienist 3 EFDArsquos1 Receptionist
⧫ 6 Chairs= 4 (dentist) + 2 (hygienist)
⧫ Slide ⥶80 off
⧫ Service areas Northern Penobscot Southern Aroostook Western
Washington Counties amp more
Completion of Phase I Treatment
⧫LimitedLack of Access to dental care
⧫Difficulty completing the disease control phase
Caries amp periodontal disease
⧫Attaining stable restorative state
Goal
Increase the completion of Disease Control Phase
Current practice
⧫Education
Assess level of dental literacy
Incremental strategy
⧫Increase access to dental care
Generous sliding scale (⥸$40 per visit)
Incorporate Expanded Function Dental Assistants
⧫Schedule modification
Incorporate more restorative blocks to allow
for follow-up visit and completion of restorative phase
httpswwwglasbergencomdentist-cartoons
Schedule
⧫Piggybacking technique
Increased allotted restorative blocks
⧫Sustainability of current schedule is
contingent on cooperation amp skills of HAN
Dental staff
Note
Strategies mentioned today is personalized to HAN Dental clinic
Current implemented strategies might be modified or changed in the
future as required in order to accommodate the need of our pts
THANK YOU
DAY TWOCLOSINGWRAP-UP
End of Day Two ndash Survey
Day Two Creating a Value-Based Oral Health Care Delivery
System
129
Payment Reform in Oral Health Online Learning Module
Oral Health Value-based Care Online Learning Module
Value-based Care Keys to Success Article
Readiness Assessment
Competency Development Guide
Oral Health Value-based Care Training
Dental Caries Management Practicum
Clinicians Companion Guide
Interprofessional Network Referral Process
Traditional Dental Care Vs Value-Based Care
Resources
131
wwwDentaQuestPartnershiporg
wwwfacebookcomDentaQuest
DentaQuest
wwwlinkedincomcompanyDentaQuest
Inside_DentaQuest
QUESTIONS
51
Qualitative Measurement
ldquoPatient engagement is the act of patients and providers working together
toward the end goal of improved patient wellnessrdquo
wwwpatientengagementhitcom
Access to Care
Patient Activation
Patient Satisfaction
Patient-Provider-Care Team Communication
Care Team Satisfaction
52
OHVBC Readiness
Leadership
bull Value of oral health and oral health transformation
Structure Systems and Operations
bull Operational efficiencies innovative care delivery methodologies
Care Pathways and Provider Buy-In
bull Training disease management risk-based care referrals IDC-10 coding patient engagement
Data and Analytic Technology and Personnel
bull Interoperability reporting
Financial Viability and Strength
bull Payerpatient mix billing infrastructure financial reports
httpswwwdentaquestpartnershiporglearnsafety-net-solutionsoral-health-value-based-careohvbc-readiness-
assessment
53
QUESTIONS COMMENTS
Carolyn Brown DDS
cbrownddsgmailcom
RISK BASED MANAGED CARE
Value Based Training Conference
Manchester New Hampshire
Mark Koday DDS
111919
5555
Objectives
bull Review current drivers of dental managed care
bull Understand the basics of risk-based dental managed care contracts
bull Learn the basics of managing costs in a riskndashbased contract
bull Gain an understanding in the potential advantage of risk-based contracting
56
What Is Dental Managed Care
Managed care is a health delivery system whose purpose is to manage both the
quality and cost of health care
Common types of managed care health insurance plans
bull HMOs
bull PPOs
bull POSs
bull Medicaid Managed Care
DIDNrsquoT WE ALREADY HAVE MANAGED CARE AND IT FAILED
57
What Has Happened Since the 90s
58
WHY THE FFS AND PPS DOESNrsquoT WORK FOR OUR POPULATIONS
bull Inefficient payment systems designed to produce encounters or procedures but not real health
bull No focus on population health
bull Does not incentivize innovation
bull Patients essentially on their own for accessing specialty care
59
Rule of 4
Source Kaiser Family Foundation analysis of National Health Expenditure (NHE) data from Centers for
Medicare and Medicaid Services Office of the Actuary National Health Statistics Group
60
Rule of 4
bull This helps explain why oral health has been relatively ignored so far by CMS
bull Explains why we have PCMH instead of PCHH
bull Where is the real value on a national level in preventing disease and
controlling costs
bull Beware- wersquove been found
61
Reasons Dental Managed Care is Spreading Across the States
NON-MANAGED CARE STATE DENTAL BUDGETS ARE
OPENED ENDED
STRAIN ON STATE BUDGETS
UPCOMING RECESSION WITH TRILLION DOLLAR
DEFICIT
SHIFTS FINANCIAL RISK FROM THE STATES TO THE
PLANS
6262
Types of Medicaid Managed Care
bull State Medicaid agency administrator lowest administrative
costs
bull Third Party Administrator Typically 15 administrative costs
bull Managed Care Organization Typically 15 administrative
costs
bull Carved-in
bull Carved-out
bull Risk Based Managed Care Administrative costs part of
contract negotiation
63
RISK CONTRACTS
6464
Components of a Risk-based Contract
Risk
Medical Loss Ratio
Quality withhold
Specialty withhold
Managed care payment (pmpm)
Covered services
Fee schedule Claims are paid as usual on a FFS basis
Credentialing
Quality Review process and Quality Metrics
65
Upside Risk
The possibility that the cost of
delivering dental care to an assigned
patient panel is less than the amount
of funding calculated for that care
The Plan pays the CHC additional
funds based on a predetermine
formula
Downside Risk
The possibility that the cost of
delivering dental care to an assigned
patient panel is more than the amount
of funding calculated for that care
The CHC pays the Plan additional
funds based on a predetermine
formula
Upside and Downside Risk
66
Taking On Risk 100 or Shared Risk
With 100 risk you receive 100 of the potential savings but are also at risk for
100 of the losses
Shared Risk MCO and health center share a percentage of the risk
Shared Risk leads to better cooperation since both organizations are
incentivized to save on costs
6767
Reports Needed
bull Enrollment reports lists of who is assigned on a monthly basis
bull Reconciliation reports insure appropriate payments
bull Specialty Referral reports
bull You will need your own reporting process so you donrsquot rely completely on
reports supplied by the Plan
6868
Medical Loss Ratio
Medical Loss Ratio (MLR) is proportion of premium revenues spent on clinical
services and quality improvement also known as the Medical Loss Ratio (MLR)
For CMS requires Medical Plans to spend at least 80 to 85 of the premiums
on actual medical care
69
Administrative Fees
bull Essentially the opposite of MLR
bull The State Medicaid Agency is funded by the Governorrsquos budget
bull The State Medicaid Agency will keep some of these funds for their
admin costs and give the remaining to the Managed Care Plans
bull Private Plan admin costs can be as high as 40 but most states
limit these cost for Medicaid Plans to between 15 and 20 (85-
80 MLR)
bull This may be negotiable depending on your program size of your
program
70
Quality Withhold
bull The state withholds a certain percent (typically 2-4 ) of the funds they give
to the Plans for Value Based Reimbursement
bull They choose quality metrics and set benchmarks and assign payments for
each metric based on an assigned priority for each metric
bull If a Plan meets the benchmark of every quality metric the state passes on
their full share of the quality withhold
bull The Plans may or may not withhold a percent of the funds for quality payment
to the dentists or manage care contractors
71
Quality Withhold
Either way the Plans may or may not pass the quality payments they receive to
the dentists or contractors
This should be spelled out in a risk-based contract
72
Percent of funds set aside
to cover specialty care
referrals
Typically 10-15
Goal Limit referral costs
to within or less than
Specialty set aside
Specialty Withhold
73
Per Member Per Month
bull Capitated Payment
bull Specific dollar amount paid for each enrolled member each month
bull Paid whether patient is accessed for care or not
bull States do set access benchmarks
bull In Oregon access for any dental procedure (adults and children combined)
was 267 in 2015
74
Payment Math Example
Premium per enrollee = $25
Administrative fee 15 = $375
Funds available per enrollee to the clinic = $2125
Management fee per enrollee = $175
Funds per enrollee that would undergo PPS reconciliation = $1950
For every 10000 enrollees the managed care income = $2340000
Specialty withhold (10) = $234000
YE Cost lt or gt $2340000
Upside Risk
CHC Gains $
Downside Risk
CHC Loses $
75
Covered Services and Fee Schedules
bull The state Medicaid agency spells out the minimum procedures and fees that
MCOs must cover
bull MCOs may add procedures or increase periodicity of procedures particularly
preventative services
bull MCOs may increase fees to entice rural providers and specialists to enroll in
their Plans
bull Access Rules
bull How many days it takes to access a patent
bull How many days it takes for a patent to access urgent care services
bull How many days it takes for a patent to access emergency care services
76
Credentialing
All MCOs are required to credential all Providers
All MCOs have their own credentialing process
Credentialing process is can be lengthy
Credentialing process may be negotiable
77
Quality Review Process and Quality Metrics
MCOs must have a Quality and Compliance Review Process
If you arenrsquot in compliance with both you likely wonrsquot get paid
Typical processes reviewed
bull Charting specifications
bull Incident report
bull Enrollee complaints quality rudeness and access issues
bull Medicaid compliance
78
Quality Payments
bull State Shared Incentive Withhold Typically quality metrics and benchmarks
are set by the state sets aside a certain percent (3-5) of the payments to
the Managed Care Plan (MCP)
bull If the benchmarks are achieved the MCP is then paid the a predetermine
amount
bull Benchmarks may not be the same as the states
bull Managed Care Plans do not have to pass all or any of the quality payments to
the health centers or providers
bull Managed Care contract- Metrics benchmarks should be selected and part of
the contract
7979
Achieving Quality Metric Payments
Dealing with under achievers
Process issues
Individual issues
Identifying workflows
Developing Best Practices through
PDSA process
Developing Best Practices through
PDSA process
CHC Metrics Committee
Clinicians Operations various key staff
Identify Best Practices
Spread Best Practices
80
New Team Needed Business Intelligence
Business Intelligence (BI) is critical for effective managed care business decisions
BI team inputs metrics into your EHR collects integrates analyses and displays all your managed care business and clinical information
Easy to say- hard to achieve
Build your own or outsource
Possible future role of Primary Care Associations
8181
Clinicianrsquos Dashboard
Expensive to build
Displayed on your screen when your computer is first turned on
Easy to read and understand
Data dumped from the day before
Can dialed down from Org-wide to clinic to each clinicianrsquos data
Operational and clinical metrics
bull Treatment Plan Completion
bull DQA quality measures
bull Caries at Recall
bull Re-care reports
bull Care Gap reports
82
CONTROLLING COSTS
8383
Controlling Costs- Current
bull Increasing efficiencies
bull Decreasing broken appointments
bull Controlling supplies equipment costs
bull Staff recruitment retention costs
84
Specialty Care
Training current CHC dentists in
specialty areas
Hiring general dentists with higher
specialty skill sets
Hiring in house specialists
Contract with outside specialists
Work with Managed Care Plan
specialists
Lowering Disease Rates
Community Dental Health
Coordinators case management
If your state law allows- embed
hygienists in medical and community
to provide primary and secondary
prevention procedures
In clinic Caries Classification and
Silver Diamine Fluoride
Effective recare programs
Controlling Costs- Additions in Risk-based Contracting
85
Specialty Care ndash Primary Referrals by Cost
Pediatric dentistry
Orthodontics
Oral surgery
Endodontics
86
In-clinic Pediatric Services
Encounters expected
of operatories available
State dental law and ability to have
expanded duties
General Anesthesia
GA in- house
Ability for a hospital or surgery center
to set aside regular OR time
Ability to hire or assign DAs to GA
days
Four GA cases day x PPS rate
Should You Hire a Pediatric Dentist- It Depends
8787
Solutions for Controlling Pediatric Costs
Hire a general dentist that is skilled in treating young children
Make the clinic child friendly nitrous oxide TVs in the operatory etc
Teach entire staff behavioral control techniques
Contract with a pediatric dentist for the GA care
88
Lowering Overall Disease Rates (and Costs)
You are responsible for both the patients you see in the chair and the ones
assigned to you
Breaking down the walls of the dental clinic
Community Dental Health Coordinators
Case Management
89
Cost Control Essentials
Diagnosis codes
Increased ability to identify
disease by risk
Motivational
Interviewing
Developing Polices and
Procedures design to treat
disease according to risk
ie Silver Diamine Fluoride
Treating by Risk
Effective Recare
Process
Critical to continual disease
controlPrevention education that is
meaningful and designed to
change behaviors
90
Social Determinants of Health Aunt Bertha
httpswwwauntberthacom
91
REASON TO CONSIDER RISK- BASED CONTRACTING
9292
PPS Reconciliation and Federal Code 42 CFR sect4052469(a)(2)
42 CFR sect4052469(a)(2)
ldquoAny financial incentives provided to Federally Qualified Health Centers
under their Medicare Advantage Contracts such as risk pool payments
bonuses or withholds are prohibited from being included in the
calculation of supplemental payments due to the Federally Qualified
Health Centerrdquo
9393
Why Risk Based Contract in Times of PPS Reconciliation
bull Not all Risk- based Contract funds are reconciled
bull Risk is the key word- you can come out with less money than your normal
PPS reconciliation payment
bull Can lead to better patient care
bull May improve manage care enrollment for your medical plan
bull Promotes integrated care increases health for your CHC patients
9494
Not Included in the Reconciliation
Enrollment management pmpm
Quality Payments
Upside risk payments
Downside risk losses
9595
Determinants of Financial Success in Risk-Based Contracting
bull Most critical- State pmpm payment to the Managed Care Plan
bull Reporting capabilities
bull Specialty service capabilities
bull Access numbers count
bull Ability to move metric numbers
9696
What About the Non- Medicaid Poor We Serve
bull Numbers are king in a managed care contract and the more access you have
the better contract terms you can negotiate
bull We will potentially have a steady supply of Medicaid patients
bull As managed care spreads states this may be compromising the ability of
health centers to serve the non-Medicaid poor and others lacking dental
insurance
97
Mark Koday DDS
(509) 949-2278
Dental Quality Consultants
of WA
httpdentalqualityconsultin
gcom
dentalqualityconsultantsg
mailcom
Contact Information
LUNCH
BREAKOUT EXERCISEORAL HEALTH VALUE-BASED CARE READINESS ASSESSMENT
Danielle Apostolon
PROMISING PRACTICES FROM THE FIELD STRATEGIES FOR INCREASING VALUE IN ORAL HEALTH
Dr Carolyn Brown
Dr Kelly Perry
Dr Rachel Rivard
Dr Adeloye
Commitment Compassion Community
m i d s t a t e h e a l t h o r g
Promising Practices from the
Field Strategies for Increasing
Value in Oral Health Care
Kelly Perry DMD
Better Health
Outcomes
Improved Staff
Experience
Reduced Cost
Improved Patient
Experience
Better Health
Outcomes
Improved Staff
Experience
Reduced Cost
Improved Patient
Experience
Better Health
Outcomes
Improved Staff
Experience
Reduced Cost
Improved Patient
Experience
Better Health
Outcomes
Improved Staff
Experience
Reduced Cost
Improved Patient
Experience
Commitment Compassion Community
kpe r r ymids t a tehea l t h o rg
Thank you
Completion of Disease Control Phase
Pelumi Adeloye DMD MPH
HEALTH ACCESS NETWORK (HAN) FAMILY DENTAL
Introduction
⧫1 Dentist I Hygienist 3 EFDArsquos1 Receptionist
⧫ 6 Chairs= 4 (dentist) + 2 (hygienist)
⧫ Slide ⥶80 off
⧫ Service areas Northern Penobscot Southern Aroostook Western
Washington Counties amp more
Completion of Phase I Treatment
⧫LimitedLack of Access to dental care
⧫Difficulty completing the disease control phase
Caries amp periodontal disease
⧫Attaining stable restorative state
Goal
Increase the completion of Disease Control Phase
Current practice
⧫Education
Assess level of dental literacy
Incremental strategy
⧫Increase access to dental care
Generous sliding scale (⥸$40 per visit)
Incorporate Expanded Function Dental Assistants
⧫Schedule modification
Incorporate more restorative blocks to allow
for follow-up visit and completion of restorative phase
httpswwwglasbergencomdentist-cartoons
Schedule
⧫Piggybacking technique
Increased allotted restorative blocks
⧫Sustainability of current schedule is
contingent on cooperation amp skills of HAN
Dental staff
Note
Strategies mentioned today is personalized to HAN Dental clinic
Current implemented strategies might be modified or changed in the
future as required in order to accommodate the need of our pts
THANK YOU
DAY TWOCLOSINGWRAP-UP
End of Day Two ndash Survey
Day Two Creating a Value-Based Oral Health Care Delivery
System
129
Payment Reform in Oral Health Online Learning Module
Oral Health Value-based Care Online Learning Module
Value-based Care Keys to Success Article
Readiness Assessment
Competency Development Guide
Oral Health Value-based Care Training
Dental Caries Management Practicum
Clinicians Companion Guide
Interprofessional Network Referral Process
Traditional Dental Care Vs Value-Based Care
Resources
131
wwwDentaQuestPartnershiporg
wwwfacebookcomDentaQuest
DentaQuest
wwwlinkedincomcompanyDentaQuest
Inside_DentaQuest
QUESTIONS
52
OHVBC Readiness
Leadership
bull Value of oral health and oral health transformation
Structure Systems and Operations
bull Operational efficiencies innovative care delivery methodologies
Care Pathways and Provider Buy-In
bull Training disease management risk-based care referrals IDC-10 coding patient engagement
Data and Analytic Technology and Personnel
bull Interoperability reporting
Financial Viability and Strength
bull Payerpatient mix billing infrastructure financial reports
httpswwwdentaquestpartnershiporglearnsafety-net-solutionsoral-health-value-based-careohvbc-readiness-
assessment
53
QUESTIONS COMMENTS
Carolyn Brown DDS
cbrownddsgmailcom
RISK BASED MANAGED CARE
Value Based Training Conference
Manchester New Hampshire
Mark Koday DDS
111919
5555
Objectives
bull Review current drivers of dental managed care
bull Understand the basics of risk-based dental managed care contracts
bull Learn the basics of managing costs in a riskndashbased contract
bull Gain an understanding in the potential advantage of risk-based contracting
56
What Is Dental Managed Care
Managed care is a health delivery system whose purpose is to manage both the
quality and cost of health care
Common types of managed care health insurance plans
bull HMOs
bull PPOs
bull POSs
bull Medicaid Managed Care
DIDNrsquoT WE ALREADY HAVE MANAGED CARE AND IT FAILED
57
What Has Happened Since the 90s
58
WHY THE FFS AND PPS DOESNrsquoT WORK FOR OUR POPULATIONS
bull Inefficient payment systems designed to produce encounters or procedures but not real health
bull No focus on population health
bull Does not incentivize innovation
bull Patients essentially on their own for accessing specialty care
59
Rule of 4
Source Kaiser Family Foundation analysis of National Health Expenditure (NHE) data from Centers for
Medicare and Medicaid Services Office of the Actuary National Health Statistics Group
60
Rule of 4
bull This helps explain why oral health has been relatively ignored so far by CMS
bull Explains why we have PCMH instead of PCHH
bull Where is the real value on a national level in preventing disease and
controlling costs
bull Beware- wersquove been found
61
Reasons Dental Managed Care is Spreading Across the States
NON-MANAGED CARE STATE DENTAL BUDGETS ARE
OPENED ENDED
STRAIN ON STATE BUDGETS
UPCOMING RECESSION WITH TRILLION DOLLAR
DEFICIT
SHIFTS FINANCIAL RISK FROM THE STATES TO THE
PLANS
6262
Types of Medicaid Managed Care
bull State Medicaid agency administrator lowest administrative
costs
bull Third Party Administrator Typically 15 administrative costs
bull Managed Care Organization Typically 15 administrative
costs
bull Carved-in
bull Carved-out
bull Risk Based Managed Care Administrative costs part of
contract negotiation
63
RISK CONTRACTS
6464
Components of a Risk-based Contract
Risk
Medical Loss Ratio
Quality withhold
Specialty withhold
Managed care payment (pmpm)
Covered services
Fee schedule Claims are paid as usual on a FFS basis
Credentialing
Quality Review process and Quality Metrics
65
Upside Risk
The possibility that the cost of
delivering dental care to an assigned
patient panel is less than the amount
of funding calculated for that care
The Plan pays the CHC additional
funds based on a predetermine
formula
Downside Risk
The possibility that the cost of
delivering dental care to an assigned
patient panel is more than the amount
of funding calculated for that care
The CHC pays the Plan additional
funds based on a predetermine
formula
Upside and Downside Risk
66
Taking On Risk 100 or Shared Risk
With 100 risk you receive 100 of the potential savings but are also at risk for
100 of the losses
Shared Risk MCO and health center share a percentage of the risk
Shared Risk leads to better cooperation since both organizations are
incentivized to save on costs
6767
Reports Needed
bull Enrollment reports lists of who is assigned on a monthly basis
bull Reconciliation reports insure appropriate payments
bull Specialty Referral reports
bull You will need your own reporting process so you donrsquot rely completely on
reports supplied by the Plan
6868
Medical Loss Ratio
Medical Loss Ratio (MLR) is proportion of premium revenues spent on clinical
services and quality improvement also known as the Medical Loss Ratio (MLR)
For CMS requires Medical Plans to spend at least 80 to 85 of the premiums
on actual medical care
69
Administrative Fees
bull Essentially the opposite of MLR
bull The State Medicaid Agency is funded by the Governorrsquos budget
bull The State Medicaid Agency will keep some of these funds for their
admin costs and give the remaining to the Managed Care Plans
bull Private Plan admin costs can be as high as 40 but most states
limit these cost for Medicaid Plans to between 15 and 20 (85-
80 MLR)
bull This may be negotiable depending on your program size of your
program
70
Quality Withhold
bull The state withholds a certain percent (typically 2-4 ) of the funds they give
to the Plans for Value Based Reimbursement
bull They choose quality metrics and set benchmarks and assign payments for
each metric based on an assigned priority for each metric
bull If a Plan meets the benchmark of every quality metric the state passes on
their full share of the quality withhold
bull The Plans may or may not withhold a percent of the funds for quality payment
to the dentists or manage care contractors
71
Quality Withhold
Either way the Plans may or may not pass the quality payments they receive to
the dentists or contractors
This should be spelled out in a risk-based contract
72
Percent of funds set aside
to cover specialty care
referrals
Typically 10-15
Goal Limit referral costs
to within or less than
Specialty set aside
Specialty Withhold
73
Per Member Per Month
bull Capitated Payment
bull Specific dollar amount paid for each enrolled member each month
bull Paid whether patient is accessed for care or not
bull States do set access benchmarks
bull In Oregon access for any dental procedure (adults and children combined)
was 267 in 2015
74
Payment Math Example
Premium per enrollee = $25
Administrative fee 15 = $375
Funds available per enrollee to the clinic = $2125
Management fee per enrollee = $175
Funds per enrollee that would undergo PPS reconciliation = $1950
For every 10000 enrollees the managed care income = $2340000
Specialty withhold (10) = $234000
YE Cost lt or gt $2340000
Upside Risk
CHC Gains $
Downside Risk
CHC Loses $
75
Covered Services and Fee Schedules
bull The state Medicaid agency spells out the minimum procedures and fees that
MCOs must cover
bull MCOs may add procedures or increase periodicity of procedures particularly
preventative services
bull MCOs may increase fees to entice rural providers and specialists to enroll in
their Plans
bull Access Rules
bull How many days it takes to access a patent
bull How many days it takes for a patent to access urgent care services
bull How many days it takes for a patent to access emergency care services
76
Credentialing
All MCOs are required to credential all Providers
All MCOs have their own credentialing process
Credentialing process is can be lengthy
Credentialing process may be negotiable
77
Quality Review Process and Quality Metrics
MCOs must have a Quality and Compliance Review Process
If you arenrsquot in compliance with both you likely wonrsquot get paid
Typical processes reviewed
bull Charting specifications
bull Incident report
bull Enrollee complaints quality rudeness and access issues
bull Medicaid compliance
78
Quality Payments
bull State Shared Incentive Withhold Typically quality metrics and benchmarks
are set by the state sets aside a certain percent (3-5) of the payments to
the Managed Care Plan (MCP)
bull If the benchmarks are achieved the MCP is then paid the a predetermine
amount
bull Benchmarks may not be the same as the states
bull Managed Care Plans do not have to pass all or any of the quality payments to
the health centers or providers
bull Managed Care contract- Metrics benchmarks should be selected and part of
the contract
7979
Achieving Quality Metric Payments
Dealing with under achievers
Process issues
Individual issues
Identifying workflows
Developing Best Practices through
PDSA process
Developing Best Practices through
PDSA process
CHC Metrics Committee
Clinicians Operations various key staff
Identify Best Practices
Spread Best Practices
80
New Team Needed Business Intelligence
Business Intelligence (BI) is critical for effective managed care business decisions
BI team inputs metrics into your EHR collects integrates analyses and displays all your managed care business and clinical information
Easy to say- hard to achieve
Build your own or outsource
Possible future role of Primary Care Associations
8181
Clinicianrsquos Dashboard
Expensive to build
Displayed on your screen when your computer is first turned on
Easy to read and understand
Data dumped from the day before
Can dialed down from Org-wide to clinic to each clinicianrsquos data
Operational and clinical metrics
bull Treatment Plan Completion
bull DQA quality measures
bull Caries at Recall
bull Re-care reports
bull Care Gap reports
82
CONTROLLING COSTS
8383
Controlling Costs- Current
bull Increasing efficiencies
bull Decreasing broken appointments
bull Controlling supplies equipment costs
bull Staff recruitment retention costs
84
Specialty Care
Training current CHC dentists in
specialty areas
Hiring general dentists with higher
specialty skill sets
Hiring in house specialists
Contract with outside specialists
Work with Managed Care Plan
specialists
Lowering Disease Rates
Community Dental Health
Coordinators case management
If your state law allows- embed
hygienists in medical and community
to provide primary and secondary
prevention procedures
In clinic Caries Classification and
Silver Diamine Fluoride
Effective recare programs
Controlling Costs- Additions in Risk-based Contracting
85
Specialty Care ndash Primary Referrals by Cost
Pediatric dentistry
Orthodontics
Oral surgery
Endodontics
86
In-clinic Pediatric Services
Encounters expected
of operatories available
State dental law and ability to have
expanded duties
General Anesthesia
GA in- house
Ability for a hospital or surgery center
to set aside regular OR time
Ability to hire or assign DAs to GA
days
Four GA cases day x PPS rate
Should You Hire a Pediatric Dentist- It Depends
8787
Solutions for Controlling Pediatric Costs
Hire a general dentist that is skilled in treating young children
Make the clinic child friendly nitrous oxide TVs in the operatory etc
Teach entire staff behavioral control techniques
Contract with a pediatric dentist for the GA care
88
Lowering Overall Disease Rates (and Costs)
You are responsible for both the patients you see in the chair and the ones
assigned to you
Breaking down the walls of the dental clinic
Community Dental Health Coordinators
Case Management
89
Cost Control Essentials
Diagnosis codes
Increased ability to identify
disease by risk
Motivational
Interviewing
Developing Polices and
Procedures design to treat
disease according to risk
ie Silver Diamine Fluoride
Treating by Risk
Effective Recare
Process
Critical to continual disease
controlPrevention education that is
meaningful and designed to
change behaviors
90
Social Determinants of Health Aunt Bertha
httpswwwauntberthacom
91
REASON TO CONSIDER RISK- BASED CONTRACTING
9292
PPS Reconciliation and Federal Code 42 CFR sect4052469(a)(2)
42 CFR sect4052469(a)(2)
ldquoAny financial incentives provided to Federally Qualified Health Centers
under their Medicare Advantage Contracts such as risk pool payments
bonuses or withholds are prohibited from being included in the
calculation of supplemental payments due to the Federally Qualified
Health Centerrdquo
9393
Why Risk Based Contract in Times of PPS Reconciliation
bull Not all Risk- based Contract funds are reconciled
bull Risk is the key word- you can come out with less money than your normal
PPS reconciliation payment
bull Can lead to better patient care
bull May improve manage care enrollment for your medical plan
bull Promotes integrated care increases health for your CHC patients
9494
Not Included in the Reconciliation
Enrollment management pmpm
Quality Payments
Upside risk payments
Downside risk losses
9595
Determinants of Financial Success in Risk-Based Contracting
bull Most critical- State pmpm payment to the Managed Care Plan
bull Reporting capabilities
bull Specialty service capabilities
bull Access numbers count
bull Ability to move metric numbers
9696
What About the Non- Medicaid Poor We Serve
bull Numbers are king in a managed care contract and the more access you have
the better contract terms you can negotiate
bull We will potentially have a steady supply of Medicaid patients
bull As managed care spreads states this may be compromising the ability of
health centers to serve the non-Medicaid poor and others lacking dental
insurance
97
Mark Koday DDS
(509) 949-2278
Dental Quality Consultants
of WA
httpdentalqualityconsultin
gcom
dentalqualityconsultantsg
mailcom
Contact Information
LUNCH
BREAKOUT EXERCISEORAL HEALTH VALUE-BASED CARE READINESS ASSESSMENT
Danielle Apostolon
PROMISING PRACTICES FROM THE FIELD STRATEGIES FOR INCREASING VALUE IN ORAL HEALTH
Dr Carolyn Brown
Dr Kelly Perry
Dr Rachel Rivard
Dr Adeloye
Commitment Compassion Community
m i d s t a t e h e a l t h o r g
Promising Practices from the
Field Strategies for Increasing
Value in Oral Health Care
Kelly Perry DMD
Better Health
Outcomes
Improved Staff
Experience
Reduced Cost
Improved Patient
Experience
Better Health
Outcomes
Improved Staff
Experience
Reduced Cost
Improved Patient
Experience
Better Health
Outcomes
Improved Staff
Experience
Reduced Cost
Improved Patient
Experience
Better Health
Outcomes
Improved Staff
Experience
Reduced Cost
Improved Patient
Experience
Commitment Compassion Community
kpe r r ymids t a tehea l t h o rg
Thank you
Completion of Disease Control Phase
Pelumi Adeloye DMD MPH
HEALTH ACCESS NETWORK (HAN) FAMILY DENTAL
Introduction
⧫1 Dentist I Hygienist 3 EFDArsquos1 Receptionist
⧫ 6 Chairs= 4 (dentist) + 2 (hygienist)
⧫ Slide ⥶80 off
⧫ Service areas Northern Penobscot Southern Aroostook Western
Washington Counties amp more
Completion of Phase I Treatment
⧫LimitedLack of Access to dental care
⧫Difficulty completing the disease control phase
Caries amp periodontal disease
⧫Attaining stable restorative state
Goal
Increase the completion of Disease Control Phase
Current practice
⧫Education
Assess level of dental literacy
Incremental strategy
⧫Increase access to dental care
Generous sliding scale (⥸$40 per visit)
Incorporate Expanded Function Dental Assistants
⧫Schedule modification
Incorporate more restorative blocks to allow
for follow-up visit and completion of restorative phase
httpswwwglasbergencomdentist-cartoons
Schedule
⧫Piggybacking technique
Increased allotted restorative blocks
⧫Sustainability of current schedule is
contingent on cooperation amp skills of HAN
Dental staff
Note
Strategies mentioned today is personalized to HAN Dental clinic
Current implemented strategies might be modified or changed in the
future as required in order to accommodate the need of our pts
THANK YOU
DAY TWOCLOSINGWRAP-UP
End of Day Two ndash Survey
Day Two Creating a Value-Based Oral Health Care Delivery
System
129
Payment Reform in Oral Health Online Learning Module
Oral Health Value-based Care Online Learning Module
Value-based Care Keys to Success Article
Readiness Assessment
Competency Development Guide
Oral Health Value-based Care Training
Dental Caries Management Practicum
Clinicians Companion Guide
Interprofessional Network Referral Process
Traditional Dental Care Vs Value-Based Care
Resources
131
wwwDentaQuestPartnershiporg
wwwfacebookcomDentaQuest
DentaQuest
wwwlinkedincomcompanyDentaQuest
Inside_DentaQuest
QUESTIONS
53
QUESTIONS COMMENTS
Carolyn Brown DDS
cbrownddsgmailcom
RISK BASED MANAGED CARE
Value Based Training Conference
Manchester New Hampshire
Mark Koday DDS
111919
5555
Objectives
bull Review current drivers of dental managed care
bull Understand the basics of risk-based dental managed care contracts
bull Learn the basics of managing costs in a riskndashbased contract
bull Gain an understanding in the potential advantage of risk-based contracting
56
What Is Dental Managed Care
Managed care is a health delivery system whose purpose is to manage both the
quality and cost of health care
Common types of managed care health insurance plans
bull HMOs
bull PPOs
bull POSs
bull Medicaid Managed Care
DIDNrsquoT WE ALREADY HAVE MANAGED CARE AND IT FAILED
57
What Has Happened Since the 90s
58
WHY THE FFS AND PPS DOESNrsquoT WORK FOR OUR POPULATIONS
bull Inefficient payment systems designed to produce encounters or procedures but not real health
bull No focus on population health
bull Does not incentivize innovation
bull Patients essentially on their own for accessing specialty care
59
Rule of 4
Source Kaiser Family Foundation analysis of National Health Expenditure (NHE) data from Centers for
Medicare and Medicaid Services Office of the Actuary National Health Statistics Group
60
Rule of 4
bull This helps explain why oral health has been relatively ignored so far by CMS
bull Explains why we have PCMH instead of PCHH
bull Where is the real value on a national level in preventing disease and
controlling costs
bull Beware- wersquove been found
61
Reasons Dental Managed Care is Spreading Across the States
NON-MANAGED CARE STATE DENTAL BUDGETS ARE
OPENED ENDED
STRAIN ON STATE BUDGETS
UPCOMING RECESSION WITH TRILLION DOLLAR
DEFICIT
SHIFTS FINANCIAL RISK FROM THE STATES TO THE
PLANS
6262
Types of Medicaid Managed Care
bull State Medicaid agency administrator lowest administrative
costs
bull Third Party Administrator Typically 15 administrative costs
bull Managed Care Organization Typically 15 administrative
costs
bull Carved-in
bull Carved-out
bull Risk Based Managed Care Administrative costs part of
contract negotiation
63
RISK CONTRACTS
6464
Components of a Risk-based Contract
Risk
Medical Loss Ratio
Quality withhold
Specialty withhold
Managed care payment (pmpm)
Covered services
Fee schedule Claims are paid as usual on a FFS basis
Credentialing
Quality Review process and Quality Metrics
65
Upside Risk
The possibility that the cost of
delivering dental care to an assigned
patient panel is less than the amount
of funding calculated for that care
The Plan pays the CHC additional
funds based on a predetermine
formula
Downside Risk
The possibility that the cost of
delivering dental care to an assigned
patient panel is more than the amount
of funding calculated for that care
The CHC pays the Plan additional
funds based on a predetermine
formula
Upside and Downside Risk
66
Taking On Risk 100 or Shared Risk
With 100 risk you receive 100 of the potential savings but are also at risk for
100 of the losses
Shared Risk MCO and health center share a percentage of the risk
Shared Risk leads to better cooperation since both organizations are
incentivized to save on costs
6767
Reports Needed
bull Enrollment reports lists of who is assigned on a monthly basis
bull Reconciliation reports insure appropriate payments
bull Specialty Referral reports
bull You will need your own reporting process so you donrsquot rely completely on
reports supplied by the Plan
6868
Medical Loss Ratio
Medical Loss Ratio (MLR) is proportion of premium revenues spent on clinical
services and quality improvement also known as the Medical Loss Ratio (MLR)
For CMS requires Medical Plans to spend at least 80 to 85 of the premiums
on actual medical care
69
Administrative Fees
bull Essentially the opposite of MLR
bull The State Medicaid Agency is funded by the Governorrsquos budget
bull The State Medicaid Agency will keep some of these funds for their
admin costs and give the remaining to the Managed Care Plans
bull Private Plan admin costs can be as high as 40 but most states
limit these cost for Medicaid Plans to between 15 and 20 (85-
80 MLR)
bull This may be negotiable depending on your program size of your
program
70
Quality Withhold
bull The state withholds a certain percent (typically 2-4 ) of the funds they give
to the Plans for Value Based Reimbursement
bull They choose quality metrics and set benchmarks and assign payments for
each metric based on an assigned priority for each metric
bull If a Plan meets the benchmark of every quality metric the state passes on
their full share of the quality withhold
bull The Plans may or may not withhold a percent of the funds for quality payment
to the dentists or manage care contractors
71
Quality Withhold
Either way the Plans may or may not pass the quality payments they receive to
the dentists or contractors
This should be spelled out in a risk-based contract
72
Percent of funds set aside
to cover specialty care
referrals
Typically 10-15
Goal Limit referral costs
to within or less than
Specialty set aside
Specialty Withhold
73
Per Member Per Month
bull Capitated Payment
bull Specific dollar amount paid for each enrolled member each month
bull Paid whether patient is accessed for care or not
bull States do set access benchmarks
bull In Oregon access for any dental procedure (adults and children combined)
was 267 in 2015
74
Payment Math Example
Premium per enrollee = $25
Administrative fee 15 = $375
Funds available per enrollee to the clinic = $2125
Management fee per enrollee = $175
Funds per enrollee that would undergo PPS reconciliation = $1950
For every 10000 enrollees the managed care income = $2340000
Specialty withhold (10) = $234000
YE Cost lt or gt $2340000
Upside Risk
CHC Gains $
Downside Risk
CHC Loses $
75
Covered Services and Fee Schedules
bull The state Medicaid agency spells out the minimum procedures and fees that
MCOs must cover
bull MCOs may add procedures or increase periodicity of procedures particularly
preventative services
bull MCOs may increase fees to entice rural providers and specialists to enroll in
their Plans
bull Access Rules
bull How many days it takes to access a patent
bull How many days it takes for a patent to access urgent care services
bull How many days it takes for a patent to access emergency care services
76
Credentialing
All MCOs are required to credential all Providers
All MCOs have their own credentialing process
Credentialing process is can be lengthy
Credentialing process may be negotiable
77
Quality Review Process and Quality Metrics
MCOs must have a Quality and Compliance Review Process
If you arenrsquot in compliance with both you likely wonrsquot get paid
Typical processes reviewed
bull Charting specifications
bull Incident report
bull Enrollee complaints quality rudeness and access issues
bull Medicaid compliance
78
Quality Payments
bull State Shared Incentive Withhold Typically quality metrics and benchmarks
are set by the state sets aside a certain percent (3-5) of the payments to
the Managed Care Plan (MCP)
bull If the benchmarks are achieved the MCP is then paid the a predetermine
amount
bull Benchmarks may not be the same as the states
bull Managed Care Plans do not have to pass all or any of the quality payments to
the health centers or providers
bull Managed Care contract- Metrics benchmarks should be selected and part of
the contract
7979
Achieving Quality Metric Payments
Dealing with under achievers
Process issues
Individual issues
Identifying workflows
Developing Best Practices through
PDSA process
Developing Best Practices through
PDSA process
CHC Metrics Committee
Clinicians Operations various key staff
Identify Best Practices
Spread Best Practices
80
New Team Needed Business Intelligence
Business Intelligence (BI) is critical for effective managed care business decisions
BI team inputs metrics into your EHR collects integrates analyses and displays all your managed care business and clinical information
Easy to say- hard to achieve
Build your own or outsource
Possible future role of Primary Care Associations
8181
Clinicianrsquos Dashboard
Expensive to build
Displayed on your screen when your computer is first turned on
Easy to read and understand
Data dumped from the day before
Can dialed down from Org-wide to clinic to each clinicianrsquos data
Operational and clinical metrics
bull Treatment Plan Completion
bull DQA quality measures
bull Caries at Recall
bull Re-care reports
bull Care Gap reports
82
CONTROLLING COSTS
8383
Controlling Costs- Current
bull Increasing efficiencies
bull Decreasing broken appointments
bull Controlling supplies equipment costs
bull Staff recruitment retention costs
84
Specialty Care
Training current CHC dentists in
specialty areas
Hiring general dentists with higher
specialty skill sets
Hiring in house specialists
Contract with outside specialists
Work with Managed Care Plan
specialists
Lowering Disease Rates
Community Dental Health
Coordinators case management
If your state law allows- embed
hygienists in medical and community
to provide primary and secondary
prevention procedures
In clinic Caries Classification and
Silver Diamine Fluoride
Effective recare programs
Controlling Costs- Additions in Risk-based Contracting
85
Specialty Care ndash Primary Referrals by Cost
Pediatric dentistry
Orthodontics
Oral surgery
Endodontics
86
In-clinic Pediatric Services
Encounters expected
of operatories available
State dental law and ability to have
expanded duties
General Anesthesia
GA in- house
Ability for a hospital or surgery center
to set aside regular OR time
Ability to hire or assign DAs to GA
days
Four GA cases day x PPS rate
Should You Hire a Pediatric Dentist- It Depends
8787
Solutions for Controlling Pediatric Costs
Hire a general dentist that is skilled in treating young children
Make the clinic child friendly nitrous oxide TVs in the operatory etc
Teach entire staff behavioral control techniques
Contract with a pediatric dentist for the GA care
88
Lowering Overall Disease Rates (and Costs)
You are responsible for both the patients you see in the chair and the ones
assigned to you
Breaking down the walls of the dental clinic
Community Dental Health Coordinators
Case Management
89
Cost Control Essentials
Diagnosis codes
Increased ability to identify
disease by risk
Motivational
Interviewing
Developing Polices and
Procedures design to treat
disease according to risk
ie Silver Diamine Fluoride
Treating by Risk
Effective Recare
Process
Critical to continual disease
controlPrevention education that is
meaningful and designed to
change behaviors
90
Social Determinants of Health Aunt Bertha
httpswwwauntberthacom
91
REASON TO CONSIDER RISK- BASED CONTRACTING
9292
PPS Reconciliation and Federal Code 42 CFR sect4052469(a)(2)
42 CFR sect4052469(a)(2)
ldquoAny financial incentives provided to Federally Qualified Health Centers
under their Medicare Advantage Contracts such as risk pool payments
bonuses or withholds are prohibited from being included in the
calculation of supplemental payments due to the Federally Qualified
Health Centerrdquo
9393
Why Risk Based Contract in Times of PPS Reconciliation
bull Not all Risk- based Contract funds are reconciled
bull Risk is the key word- you can come out with less money than your normal
PPS reconciliation payment
bull Can lead to better patient care
bull May improve manage care enrollment for your medical plan
bull Promotes integrated care increases health for your CHC patients
9494
Not Included in the Reconciliation
Enrollment management pmpm
Quality Payments
Upside risk payments
Downside risk losses
9595
Determinants of Financial Success in Risk-Based Contracting
bull Most critical- State pmpm payment to the Managed Care Plan
bull Reporting capabilities
bull Specialty service capabilities
bull Access numbers count
bull Ability to move metric numbers
9696
What About the Non- Medicaid Poor We Serve
bull Numbers are king in a managed care contract and the more access you have
the better contract terms you can negotiate
bull We will potentially have a steady supply of Medicaid patients
bull As managed care spreads states this may be compromising the ability of
health centers to serve the non-Medicaid poor and others lacking dental
insurance
97
Mark Koday DDS
(509) 949-2278
Dental Quality Consultants
of WA
httpdentalqualityconsultin
gcom
dentalqualityconsultantsg
mailcom
Contact Information
LUNCH
BREAKOUT EXERCISEORAL HEALTH VALUE-BASED CARE READINESS ASSESSMENT
Danielle Apostolon
PROMISING PRACTICES FROM THE FIELD STRATEGIES FOR INCREASING VALUE IN ORAL HEALTH
Dr Carolyn Brown
Dr Kelly Perry
Dr Rachel Rivard
Dr Adeloye
Commitment Compassion Community
m i d s t a t e h e a l t h o r g
Promising Practices from the
Field Strategies for Increasing
Value in Oral Health Care
Kelly Perry DMD
Better Health
Outcomes
Improved Staff
Experience
Reduced Cost
Improved Patient
Experience
Better Health
Outcomes
Improved Staff
Experience
Reduced Cost
Improved Patient
Experience
Better Health
Outcomes
Improved Staff
Experience
Reduced Cost
Improved Patient
Experience
Better Health
Outcomes
Improved Staff
Experience
Reduced Cost
Improved Patient
Experience
Commitment Compassion Community
kpe r r ymids t a tehea l t h o rg
Thank you
Completion of Disease Control Phase
Pelumi Adeloye DMD MPH
HEALTH ACCESS NETWORK (HAN) FAMILY DENTAL
Introduction
⧫1 Dentist I Hygienist 3 EFDArsquos1 Receptionist
⧫ 6 Chairs= 4 (dentist) + 2 (hygienist)
⧫ Slide ⥶80 off
⧫ Service areas Northern Penobscot Southern Aroostook Western
Washington Counties amp more
Completion of Phase I Treatment
⧫LimitedLack of Access to dental care
⧫Difficulty completing the disease control phase
Caries amp periodontal disease
⧫Attaining stable restorative state
Goal
Increase the completion of Disease Control Phase
Current practice
⧫Education
Assess level of dental literacy
Incremental strategy
⧫Increase access to dental care
Generous sliding scale (⥸$40 per visit)
Incorporate Expanded Function Dental Assistants
⧫Schedule modification
Incorporate more restorative blocks to allow
for follow-up visit and completion of restorative phase
httpswwwglasbergencomdentist-cartoons
Schedule
⧫Piggybacking technique
Increased allotted restorative blocks
⧫Sustainability of current schedule is
contingent on cooperation amp skills of HAN
Dental staff
Note
Strategies mentioned today is personalized to HAN Dental clinic
Current implemented strategies might be modified or changed in the
future as required in order to accommodate the need of our pts
THANK YOU
DAY TWOCLOSINGWRAP-UP
End of Day Two ndash Survey
Day Two Creating a Value-Based Oral Health Care Delivery
System
129
Payment Reform in Oral Health Online Learning Module
Oral Health Value-based Care Online Learning Module
Value-based Care Keys to Success Article
Readiness Assessment
Competency Development Guide
Oral Health Value-based Care Training
Dental Caries Management Practicum
Clinicians Companion Guide
Interprofessional Network Referral Process
Traditional Dental Care Vs Value-Based Care
Resources
131
wwwDentaQuestPartnershiporg
wwwfacebookcomDentaQuest
DentaQuest
wwwlinkedincomcompanyDentaQuest
Inside_DentaQuest
QUESTIONS
RISK BASED MANAGED CARE
Value Based Training Conference
Manchester New Hampshire
Mark Koday DDS
111919
5555
Objectives
bull Review current drivers of dental managed care
bull Understand the basics of risk-based dental managed care contracts
bull Learn the basics of managing costs in a riskndashbased contract
bull Gain an understanding in the potential advantage of risk-based contracting
56
What Is Dental Managed Care
Managed care is a health delivery system whose purpose is to manage both the
quality and cost of health care
Common types of managed care health insurance plans
bull HMOs
bull PPOs
bull POSs
bull Medicaid Managed Care
DIDNrsquoT WE ALREADY HAVE MANAGED CARE AND IT FAILED
57
What Has Happened Since the 90s
58
WHY THE FFS AND PPS DOESNrsquoT WORK FOR OUR POPULATIONS
bull Inefficient payment systems designed to produce encounters or procedures but not real health
bull No focus on population health
bull Does not incentivize innovation
bull Patients essentially on their own for accessing specialty care
59
Rule of 4
Source Kaiser Family Foundation analysis of National Health Expenditure (NHE) data from Centers for
Medicare and Medicaid Services Office of the Actuary National Health Statistics Group
60
Rule of 4
bull This helps explain why oral health has been relatively ignored so far by CMS
bull Explains why we have PCMH instead of PCHH
bull Where is the real value on a national level in preventing disease and
controlling costs
bull Beware- wersquove been found
61
Reasons Dental Managed Care is Spreading Across the States
NON-MANAGED CARE STATE DENTAL BUDGETS ARE
OPENED ENDED
STRAIN ON STATE BUDGETS
UPCOMING RECESSION WITH TRILLION DOLLAR
DEFICIT
SHIFTS FINANCIAL RISK FROM THE STATES TO THE
PLANS
6262
Types of Medicaid Managed Care
bull State Medicaid agency administrator lowest administrative
costs
bull Third Party Administrator Typically 15 administrative costs
bull Managed Care Organization Typically 15 administrative
costs
bull Carved-in
bull Carved-out
bull Risk Based Managed Care Administrative costs part of
contract negotiation
63
RISK CONTRACTS
6464
Components of a Risk-based Contract
Risk
Medical Loss Ratio
Quality withhold
Specialty withhold
Managed care payment (pmpm)
Covered services
Fee schedule Claims are paid as usual on a FFS basis
Credentialing
Quality Review process and Quality Metrics
65
Upside Risk
The possibility that the cost of
delivering dental care to an assigned
patient panel is less than the amount
of funding calculated for that care
The Plan pays the CHC additional
funds based on a predetermine
formula
Downside Risk
The possibility that the cost of
delivering dental care to an assigned
patient panel is more than the amount
of funding calculated for that care
The CHC pays the Plan additional
funds based on a predetermine
formula
Upside and Downside Risk
66
Taking On Risk 100 or Shared Risk
With 100 risk you receive 100 of the potential savings but are also at risk for
100 of the losses
Shared Risk MCO and health center share a percentage of the risk
Shared Risk leads to better cooperation since both organizations are
incentivized to save on costs
6767
Reports Needed
bull Enrollment reports lists of who is assigned on a monthly basis
bull Reconciliation reports insure appropriate payments
bull Specialty Referral reports
bull You will need your own reporting process so you donrsquot rely completely on
reports supplied by the Plan
6868
Medical Loss Ratio
Medical Loss Ratio (MLR) is proportion of premium revenues spent on clinical
services and quality improvement also known as the Medical Loss Ratio (MLR)
For CMS requires Medical Plans to spend at least 80 to 85 of the premiums
on actual medical care
69
Administrative Fees
bull Essentially the opposite of MLR
bull The State Medicaid Agency is funded by the Governorrsquos budget
bull The State Medicaid Agency will keep some of these funds for their
admin costs and give the remaining to the Managed Care Plans
bull Private Plan admin costs can be as high as 40 but most states
limit these cost for Medicaid Plans to between 15 and 20 (85-
80 MLR)
bull This may be negotiable depending on your program size of your
program
70
Quality Withhold
bull The state withholds a certain percent (typically 2-4 ) of the funds they give
to the Plans for Value Based Reimbursement
bull They choose quality metrics and set benchmarks and assign payments for
each metric based on an assigned priority for each metric
bull If a Plan meets the benchmark of every quality metric the state passes on
their full share of the quality withhold
bull The Plans may or may not withhold a percent of the funds for quality payment
to the dentists or manage care contractors
71
Quality Withhold
Either way the Plans may or may not pass the quality payments they receive to
the dentists or contractors
This should be spelled out in a risk-based contract
72
Percent of funds set aside
to cover specialty care
referrals
Typically 10-15
Goal Limit referral costs
to within or less than
Specialty set aside
Specialty Withhold
73
Per Member Per Month
bull Capitated Payment
bull Specific dollar amount paid for each enrolled member each month
bull Paid whether patient is accessed for care or not
bull States do set access benchmarks
bull In Oregon access for any dental procedure (adults and children combined)
was 267 in 2015
74
Payment Math Example
Premium per enrollee = $25
Administrative fee 15 = $375
Funds available per enrollee to the clinic = $2125
Management fee per enrollee = $175
Funds per enrollee that would undergo PPS reconciliation = $1950
For every 10000 enrollees the managed care income = $2340000
Specialty withhold (10) = $234000
YE Cost lt or gt $2340000
Upside Risk
CHC Gains $
Downside Risk
CHC Loses $
75
Covered Services and Fee Schedules
bull The state Medicaid agency spells out the minimum procedures and fees that
MCOs must cover
bull MCOs may add procedures or increase periodicity of procedures particularly
preventative services
bull MCOs may increase fees to entice rural providers and specialists to enroll in
their Plans
bull Access Rules
bull How many days it takes to access a patent
bull How many days it takes for a patent to access urgent care services
bull How many days it takes for a patent to access emergency care services
76
Credentialing
All MCOs are required to credential all Providers
All MCOs have their own credentialing process
Credentialing process is can be lengthy
Credentialing process may be negotiable
77
Quality Review Process and Quality Metrics
MCOs must have a Quality and Compliance Review Process
If you arenrsquot in compliance with both you likely wonrsquot get paid
Typical processes reviewed
bull Charting specifications
bull Incident report
bull Enrollee complaints quality rudeness and access issues
bull Medicaid compliance
78
Quality Payments
bull State Shared Incentive Withhold Typically quality metrics and benchmarks
are set by the state sets aside a certain percent (3-5) of the payments to
the Managed Care Plan (MCP)
bull If the benchmarks are achieved the MCP is then paid the a predetermine
amount
bull Benchmarks may not be the same as the states
bull Managed Care Plans do not have to pass all or any of the quality payments to
the health centers or providers
bull Managed Care contract- Metrics benchmarks should be selected and part of
the contract
7979
Achieving Quality Metric Payments
Dealing with under achievers
Process issues
Individual issues
Identifying workflows
Developing Best Practices through
PDSA process
Developing Best Practices through
PDSA process
CHC Metrics Committee
Clinicians Operations various key staff
Identify Best Practices
Spread Best Practices
80
New Team Needed Business Intelligence
Business Intelligence (BI) is critical for effective managed care business decisions
BI team inputs metrics into your EHR collects integrates analyses and displays all your managed care business and clinical information
Easy to say- hard to achieve
Build your own or outsource
Possible future role of Primary Care Associations
8181
Clinicianrsquos Dashboard
Expensive to build
Displayed on your screen when your computer is first turned on
Easy to read and understand
Data dumped from the day before
Can dialed down from Org-wide to clinic to each clinicianrsquos data
Operational and clinical metrics
bull Treatment Plan Completion
bull DQA quality measures
bull Caries at Recall
bull Re-care reports
bull Care Gap reports
82
CONTROLLING COSTS
8383
Controlling Costs- Current
bull Increasing efficiencies
bull Decreasing broken appointments
bull Controlling supplies equipment costs
bull Staff recruitment retention costs
84
Specialty Care
Training current CHC dentists in
specialty areas
Hiring general dentists with higher
specialty skill sets
Hiring in house specialists
Contract with outside specialists
Work with Managed Care Plan
specialists
Lowering Disease Rates
Community Dental Health
Coordinators case management
If your state law allows- embed
hygienists in medical and community
to provide primary and secondary
prevention procedures
In clinic Caries Classification and
Silver Diamine Fluoride
Effective recare programs
Controlling Costs- Additions in Risk-based Contracting
85
Specialty Care ndash Primary Referrals by Cost
Pediatric dentistry
Orthodontics
Oral surgery
Endodontics
86
In-clinic Pediatric Services
Encounters expected
of operatories available
State dental law and ability to have
expanded duties
General Anesthesia
GA in- house
Ability for a hospital or surgery center
to set aside regular OR time
Ability to hire or assign DAs to GA
days
Four GA cases day x PPS rate
Should You Hire a Pediatric Dentist- It Depends
8787
Solutions for Controlling Pediatric Costs
Hire a general dentist that is skilled in treating young children
Make the clinic child friendly nitrous oxide TVs in the operatory etc
Teach entire staff behavioral control techniques
Contract with a pediatric dentist for the GA care
88
Lowering Overall Disease Rates (and Costs)
You are responsible for both the patients you see in the chair and the ones
assigned to you
Breaking down the walls of the dental clinic
Community Dental Health Coordinators
Case Management
89
Cost Control Essentials
Diagnosis codes
Increased ability to identify
disease by risk
Motivational
Interviewing
Developing Polices and
Procedures design to treat
disease according to risk
ie Silver Diamine Fluoride
Treating by Risk
Effective Recare
Process
Critical to continual disease
controlPrevention education that is
meaningful and designed to
change behaviors
90
Social Determinants of Health Aunt Bertha
httpswwwauntberthacom
91
REASON TO CONSIDER RISK- BASED CONTRACTING
9292
PPS Reconciliation and Federal Code 42 CFR sect4052469(a)(2)
42 CFR sect4052469(a)(2)
ldquoAny financial incentives provided to Federally Qualified Health Centers
under their Medicare Advantage Contracts such as risk pool payments
bonuses or withholds are prohibited from being included in the
calculation of supplemental payments due to the Federally Qualified
Health Centerrdquo
9393
Why Risk Based Contract in Times of PPS Reconciliation
bull Not all Risk- based Contract funds are reconciled
bull Risk is the key word- you can come out with less money than your normal
PPS reconciliation payment
bull Can lead to better patient care
bull May improve manage care enrollment for your medical plan
bull Promotes integrated care increases health for your CHC patients
9494
Not Included in the Reconciliation
Enrollment management pmpm
Quality Payments
Upside risk payments
Downside risk losses
9595
Determinants of Financial Success in Risk-Based Contracting
bull Most critical- State pmpm payment to the Managed Care Plan
bull Reporting capabilities
bull Specialty service capabilities
bull Access numbers count
bull Ability to move metric numbers
9696
What About the Non- Medicaid Poor We Serve
bull Numbers are king in a managed care contract and the more access you have
the better contract terms you can negotiate
bull We will potentially have a steady supply of Medicaid patients
bull As managed care spreads states this may be compromising the ability of
health centers to serve the non-Medicaid poor and others lacking dental
insurance
97
Mark Koday DDS
(509) 949-2278
Dental Quality Consultants
of WA
httpdentalqualityconsultin
gcom
dentalqualityconsultantsg
mailcom
Contact Information
LUNCH
BREAKOUT EXERCISEORAL HEALTH VALUE-BASED CARE READINESS ASSESSMENT
Danielle Apostolon
PROMISING PRACTICES FROM THE FIELD STRATEGIES FOR INCREASING VALUE IN ORAL HEALTH
Dr Carolyn Brown
Dr Kelly Perry
Dr Rachel Rivard
Dr Adeloye
Commitment Compassion Community
m i d s t a t e h e a l t h o r g
Promising Practices from the
Field Strategies for Increasing
Value in Oral Health Care
Kelly Perry DMD
Better Health
Outcomes
Improved Staff
Experience
Reduced Cost
Improved Patient
Experience
Better Health
Outcomes
Improved Staff
Experience
Reduced Cost
Improved Patient
Experience
Better Health
Outcomes
Improved Staff
Experience
Reduced Cost
Improved Patient
Experience
Better Health
Outcomes
Improved Staff
Experience
Reduced Cost
Improved Patient
Experience
Commitment Compassion Community
kpe r r ymids t a tehea l t h o rg
Thank you
Completion of Disease Control Phase
Pelumi Adeloye DMD MPH
HEALTH ACCESS NETWORK (HAN) FAMILY DENTAL
Introduction
⧫1 Dentist I Hygienist 3 EFDArsquos1 Receptionist
⧫ 6 Chairs= 4 (dentist) + 2 (hygienist)
⧫ Slide ⥶80 off
⧫ Service areas Northern Penobscot Southern Aroostook Western
Washington Counties amp more
Completion of Phase I Treatment
⧫LimitedLack of Access to dental care
⧫Difficulty completing the disease control phase
Caries amp periodontal disease
⧫Attaining stable restorative state
Goal
Increase the completion of Disease Control Phase
Current practice
⧫Education
Assess level of dental literacy
Incremental strategy
⧫Increase access to dental care
Generous sliding scale (⥸$40 per visit)
Incorporate Expanded Function Dental Assistants
⧫Schedule modification
Incorporate more restorative blocks to allow
for follow-up visit and completion of restorative phase
httpswwwglasbergencomdentist-cartoons
Schedule
⧫Piggybacking technique
Increased allotted restorative blocks
⧫Sustainability of current schedule is
contingent on cooperation amp skills of HAN
Dental staff
Note
Strategies mentioned today is personalized to HAN Dental clinic
Current implemented strategies might be modified or changed in the
future as required in order to accommodate the need of our pts
THANK YOU
DAY TWOCLOSINGWRAP-UP
End of Day Two ndash Survey
Day Two Creating a Value-Based Oral Health Care Delivery
System
129
Payment Reform in Oral Health Online Learning Module
Oral Health Value-based Care Online Learning Module
Value-based Care Keys to Success Article
Readiness Assessment
Competency Development Guide
Oral Health Value-based Care Training
Dental Caries Management Practicum
Clinicians Companion Guide
Interprofessional Network Referral Process
Traditional Dental Care Vs Value-Based Care
Resources
131
wwwDentaQuestPartnershiporg
wwwfacebookcomDentaQuest
DentaQuest
wwwlinkedincomcompanyDentaQuest
Inside_DentaQuest
QUESTIONS
5555
Objectives
bull Review current drivers of dental managed care
bull Understand the basics of risk-based dental managed care contracts
bull Learn the basics of managing costs in a riskndashbased contract
bull Gain an understanding in the potential advantage of risk-based contracting
56
What Is Dental Managed Care
Managed care is a health delivery system whose purpose is to manage both the
quality and cost of health care
Common types of managed care health insurance plans
bull HMOs
bull PPOs
bull POSs
bull Medicaid Managed Care
DIDNrsquoT WE ALREADY HAVE MANAGED CARE AND IT FAILED
57
What Has Happened Since the 90s
58
WHY THE FFS AND PPS DOESNrsquoT WORK FOR OUR POPULATIONS
bull Inefficient payment systems designed to produce encounters or procedures but not real health
bull No focus on population health
bull Does not incentivize innovation
bull Patients essentially on their own for accessing specialty care
59
Rule of 4
Source Kaiser Family Foundation analysis of National Health Expenditure (NHE) data from Centers for
Medicare and Medicaid Services Office of the Actuary National Health Statistics Group
60
Rule of 4
bull This helps explain why oral health has been relatively ignored so far by CMS
bull Explains why we have PCMH instead of PCHH
bull Where is the real value on a national level in preventing disease and
controlling costs
bull Beware- wersquove been found
61
Reasons Dental Managed Care is Spreading Across the States
NON-MANAGED CARE STATE DENTAL BUDGETS ARE
OPENED ENDED
STRAIN ON STATE BUDGETS
UPCOMING RECESSION WITH TRILLION DOLLAR
DEFICIT
SHIFTS FINANCIAL RISK FROM THE STATES TO THE
PLANS
6262
Types of Medicaid Managed Care
bull State Medicaid agency administrator lowest administrative
costs
bull Third Party Administrator Typically 15 administrative costs
bull Managed Care Organization Typically 15 administrative
costs
bull Carved-in
bull Carved-out
bull Risk Based Managed Care Administrative costs part of
contract negotiation
63
RISK CONTRACTS
6464
Components of a Risk-based Contract
Risk
Medical Loss Ratio
Quality withhold
Specialty withhold
Managed care payment (pmpm)
Covered services
Fee schedule Claims are paid as usual on a FFS basis
Credentialing
Quality Review process and Quality Metrics
65
Upside Risk
The possibility that the cost of
delivering dental care to an assigned
patient panel is less than the amount
of funding calculated for that care
The Plan pays the CHC additional
funds based on a predetermine
formula
Downside Risk
The possibility that the cost of
delivering dental care to an assigned
patient panel is more than the amount
of funding calculated for that care
The CHC pays the Plan additional
funds based on a predetermine
formula
Upside and Downside Risk
66
Taking On Risk 100 or Shared Risk
With 100 risk you receive 100 of the potential savings but are also at risk for
100 of the losses
Shared Risk MCO and health center share a percentage of the risk
Shared Risk leads to better cooperation since both organizations are
incentivized to save on costs
6767
Reports Needed
bull Enrollment reports lists of who is assigned on a monthly basis
bull Reconciliation reports insure appropriate payments
bull Specialty Referral reports
bull You will need your own reporting process so you donrsquot rely completely on
reports supplied by the Plan
6868
Medical Loss Ratio
Medical Loss Ratio (MLR) is proportion of premium revenues spent on clinical
services and quality improvement also known as the Medical Loss Ratio (MLR)
For CMS requires Medical Plans to spend at least 80 to 85 of the premiums
on actual medical care
69
Administrative Fees
bull Essentially the opposite of MLR
bull The State Medicaid Agency is funded by the Governorrsquos budget
bull The State Medicaid Agency will keep some of these funds for their
admin costs and give the remaining to the Managed Care Plans
bull Private Plan admin costs can be as high as 40 but most states
limit these cost for Medicaid Plans to between 15 and 20 (85-
80 MLR)
bull This may be negotiable depending on your program size of your
program
70
Quality Withhold
bull The state withholds a certain percent (typically 2-4 ) of the funds they give
to the Plans for Value Based Reimbursement
bull They choose quality metrics and set benchmarks and assign payments for
each metric based on an assigned priority for each metric
bull If a Plan meets the benchmark of every quality metric the state passes on
their full share of the quality withhold
bull The Plans may or may not withhold a percent of the funds for quality payment
to the dentists or manage care contractors
71
Quality Withhold
Either way the Plans may or may not pass the quality payments they receive to
the dentists or contractors
This should be spelled out in a risk-based contract
72
Percent of funds set aside
to cover specialty care
referrals
Typically 10-15
Goal Limit referral costs
to within or less than
Specialty set aside
Specialty Withhold
73
Per Member Per Month
bull Capitated Payment
bull Specific dollar amount paid for each enrolled member each month
bull Paid whether patient is accessed for care or not
bull States do set access benchmarks
bull In Oregon access for any dental procedure (adults and children combined)
was 267 in 2015
74
Payment Math Example
Premium per enrollee = $25
Administrative fee 15 = $375
Funds available per enrollee to the clinic = $2125
Management fee per enrollee = $175
Funds per enrollee that would undergo PPS reconciliation = $1950
For every 10000 enrollees the managed care income = $2340000
Specialty withhold (10) = $234000
YE Cost lt or gt $2340000
Upside Risk
CHC Gains $
Downside Risk
CHC Loses $
75
Covered Services and Fee Schedules
bull The state Medicaid agency spells out the minimum procedures and fees that
MCOs must cover
bull MCOs may add procedures or increase periodicity of procedures particularly
preventative services
bull MCOs may increase fees to entice rural providers and specialists to enroll in
their Plans
bull Access Rules
bull How many days it takes to access a patent
bull How many days it takes for a patent to access urgent care services
bull How many days it takes for a patent to access emergency care services
76
Credentialing
All MCOs are required to credential all Providers
All MCOs have their own credentialing process
Credentialing process is can be lengthy
Credentialing process may be negotiable
77
Quality Review Process and Quality Metrics
MCOs must have a Quality and Compliance Review Process
If you arenrsquot in compliance with both you likely wonrsquot get paid
Typical processes reviewed
bull Charting specifications
bull Incident report
bull Enrollee complaints quality rudeness and access issues
bull Medicaid compliance
78
Quality Payments
bull State Shared Incentive Withhold Typically quality metrics and benchmarks
are set by the state sets aside a certain percent (3-5) of the payments to
the Managed Care Plan (MCP)
bull If the benchmarks are achieved the MCP is then paid the a predetermine
amount
bull Benchmarks may not be the same as the states
bull Managed Care Plans do not have to pass all or any of the quality payments to
the health centers or providers
bull Managed Care contract- Metrics benchmarks should be selected and part of
the contract
7979
Achieving Quality Metric Payments
Dealing with under achievers
Process issues
Individual issues
Identifying workflows
Developing Best Practices through
PDSA process
Developing Best Practices through
PDSA process
CHC Metrics Committee
Clinicians Operations various key staff
Identify Best Practices
Spread Best Practices
80
New Team Needed Business Intelligence
Business Intelligence (BI) is critical for effective managed care business decisions
BI team inputs metrics into your EHR collects integrates analyses and displays all your managed care business and clinical information
Easy to say- hard to achieve
Build your own or outsource
Possible future role of Primary Care Associations
8181
Clinicianrsquos Dashboard
Expensive to build
Displayed on your screen when your computer is first turned on
Easy to read and understand
Data dumped from the day before
Can dialed down from Org-wide to clinic to each clinicianrsquos data
Operational and clinical metrics
bull Treatment Plan Completion
bull DQA quality measures
bull Caries at Recall
bull Re-care reports
bull Care Gap reports
82
CONTROLLING COSTS
8383
Controlling Costs- Current
bull Increasing efficiencies
bull Decreasing broken appointments
bull Controlling supplies equipment costs
bull Staff recruitment retention costs
84
Specialty Care
Training current CHC dentists in
specialty areas
Hiring general dentists with higher
specialty skill sets
Hiring in house specialists
Contract with outside specialists
Work with Managed Care Plan
specialists
Lowering Disease Rates
Community Dental Health
Coordinators case management
If your state law allows- embed
hygienists in medical and community
to provide primary and secondary
prevention procedures
In clinic Caries Classification and
Silver Diamine Fluoride
Effective recare programs
Controlling Costs- Additions in Risk-based Contracting
85
Specialty Care ndash Primary Referrals by Cost
Pediatric dentistry
Orthodontics
Oral surgery
Endodontics
86
In-clinic Pediatric Services
Encounters expected
of operatories available
State dental law and ability to have
expanded duties
General Anesthesia
GA in- house
Ability for a hospital or surgery center
to set aside regular OR time
Ability to hire or assign DAs to GA
days
Four GA cases day x PPS rate
Should You Hire a Pediatric Dentist- It Depends
8787
Solutions for Controlling Pediatric Costs
Hire a general dentist that is skilled in treating young children
Make the clinic child friendly nitrous oxide TVs in the operatory etc
Teach entire staff behavioral control techniques
Contract with a pediatric dentist for the GA care
88
Lowering Overall Disease Rates (and Costs)
You are responsible for both the patients you see in the chair and the ones
assigned to you
Breaking down the walls of the dental clinic
Community Dental Health Coordinators
Case Management
89
Cost Control Essentials
Diagnosis codes
Increased ability to identify
disease by risk
Motivational
Interviewing
Developing Polices and
Procedures design to treat
disease according to risk
ie Silver Diamine Fluoride
Treating by Risk
Effective Recare
Process
Critical to continual disease
controlPrevention education that is
meaningful and designed to
change behaviors
90
Social Determinants of Health Aunt Bertha
httpswwwauntberthacom
91
REASON TO CONSIDER RISK- BASED CONTRACTING
9292
PPS Reconciliation and Federal Code 42 CFR sect4052469(a)(2)
42 CFR sect4052469(a)(2)
ldquoAny financial incentives provided to Federally Qualified Health Centers
under their Medicare Advantage Contracts such as risk pool payments
bonuses or withholds are prohibited from being included in the
calculation of supplemental payments due to the Federally Qualified
Health Centerrdquo
9393
Why Risk Based Contract in Times of PPS Reconciliation
bull Not all Risk- based Contract funds are reconciled
bull Risk is the key word- you can come out with less money than your normal
PPS reconciliation payment
bull Can lead to better patient care
bull May improve manage care enrollment for your medical plan
bull Promotes integrated care increases health for your CHC patients
9494
Not Included in the Reconciliation
Enrollment management pmpm
Quality Payments
Upside risk payments
Downside risk losses
9595
Determinants of Financial Success in Risk-Based Contracting
bull Most critical- State pmpm payment to the Managed Care Plan
bull Reporting capabilities
bull Specialty service capabilities
bull Access numbers count
bull Ability to move metric numbers
9696
What About the Non- Medicaid Poor We Serve
bull Numbers are king in a managed care contract and the more access you have
the better contract terms you can negotiate
bull We will potentially have a steady supply of Medicaid patients
bull As managed care spreads states this may be compromising the ability of
health centers to serve the non-Medicaid poor and others lacking dental
insurance
97
Mark Koday DDS
(509) 949-2278
Dental Quality Consultants
of WA
httpdentalqualityconsultin
gcom
dentalqualityconsultantsg
mailcom
Contact Information
LUNCH
BREAKOUT EXERCISEORAL HEALTH VALUE-BASED CARE READINESS ASSESSMENT
Danielle Apostolon
PROMISING PRACTICES FROM THE FIELD STRATEGIES FOR INCREASING VALUE IN ORAL HEALTH
Dr Carolyn Brown
Dr Kelly Perry
Dr Rachel Rivard
Dr Adeloye
Commitment Compassion Community
m i d s t a t e h e a l t h o r g
Promising Practices from the
Field Strategies for Increasing
Value in Oral Health Care
Kelly Perry DMD
Better Health
Outcomes
Improved Staff
Experience
Reduced Cost
Improved Patient
Experience
Better Health
Outcomes
Improved Staff
Experience
Reduced Cost
Improved Patient
Experience
Better Health
Outcomes
Improved Staff
Experience
Reduced Cost
Improved Patient
Experience
Better Health
Outcomes
Improved Staff
Experience
Reduced Cost
Improved Patient
Experience
Commitment Compassion Community
kpe r r ymids t a tehea l t h o rg
Thank you
Completion of Disease Control Phase
Pelumi Adeloye DMD MPH
HEALTH ACCESS NETWORK (HAN) FAMILY DENTAL
Introduction
⧫1 Dentist I Hygienist 3 EFDArsquos1 Receptionist
⧫ 6 Chairs= 4 (dentist) + 2 (hygienist)
⧫ Slide ⥶80 off
⧫ Service areas Northern Penobscot Southern Aroostook Western
Washington Counties amp more
Completion of Phase I Treatment
⧫LimitedLack of Access to dental care
⧫Difficulty completing the disease control phase
Caries amp periodontal disease
⧫Attaining stable restorative state
Goal
Increase the completion of Disease Control Phase
Current practice
⧫Education
Assess level of dental literacy
Incremental strategy
⧫Increase access to dental care
Generous sliding scale (⥸$40 per visit)
Incorporate Expanded Function Dental Assistants
⧫Schedule modification
Incorporate more restorative blocks to allow
for follow-up visit and completion of restorative phase
httpswwwglasbergencomdentist-cartoons
Schedule
⧫Piggybacking technique
Increased allotted restorative blocks
⧫Sustainability of current schedule is
contingent on cooperation amp skills of HAN
Dental staff
Note
Strategies mentioned today is personalized to HAN Dental clinic
Current implemented strategies might be modified or changed in the
future as required in order to accommodate the need of our pts
THANK YOU
DAY TWOCLOSINGWRAP-UP
End of Day Two ndash Survey
Day Two Creating a Value-Based Oral Health Care Delivery
System
129
Payment Reform in Oral Health Online Learning Module
Oral Health Value-based Care Online Learning Module
Value-based Care Keys to Success Article
Readiness Assessment
Competency Development Guide
Oral Health Value-based Care Training
Dental Caries Management Practicum
Clinicians Companion Guide
Interprofessional Network Referral Process
Traditional Dental Care Vs Value-Based Care
Resources
131
wwwDentaQuestPartnershiporg
wwwfacebookcomDentaQuest
DentaQuest
wwwlinkedincomcompanyDentaQuest
Inside_DentaQuest
QUESTIONS
56
What Is Dental Managed Care
Managed care is a health delivery system whose purpose is to manage both the
quality and cost of health care
Common types of managed care health insurance plans
bull HMOs
bull PPOs
bull POSs
bull Medicaid Managed Care
DIDNrsquoT WE ALREADY HAVE MANAGED CARE AND IT FAILED
57
What Has Happened Since the 90s
58
WHY THE FFS AND PPS DOESNrsquoT WORK FOR OUR POPULATIONS
bull Inefficient payment systems designed to produce encounters or procedures but not real health
bull No focus on population health
bull Does not incentivize innovation
bull Patients essentially on their own for accessing specialty care
59
Rule of 4
Source Kaiser Family Foundation analysis of National Health Expenditure (NHE) data from Centers for
Medicare and Medicaid Services Office of the Actuary National Health Statistics Group
60
Rule of 4
bull This helps explain why oral health has been relatively ignored so far by CMS
bull Explains why we have PCMH instead of PCHH
bull Where is the real value on a national level in preventing disease and
controlling costs
bull Beware- wersquove been found
61
Reasons Dental Managed Care is Spreading Across the States
NON-MANAGED CARE STATE DENTAL BUDGETS ARE
OPENED ENDED
STRAIN ON STATE BUDGETS
UPCOMING RECESSION WITH TRILLION DOLLAR
DEFICIT
SHIFTS FINANCIAL RISK FROM THE STATES TO THE
PLANS
6262
Types of Medicaid Managed Care
bull State Medicaid agency administrator lowest administrative
costs
bull Third Party Administrator Typically 15 administrative costs
bull Managed Care Organization Typically 15 administrative
costs
bull Carved-in
bull Carved-out
bull Risk Based Managed Care Administrative costs part of
contract negotiation
63
RISK CONTRACTS
6464
Components of a Risk-based Contract
Risk
Medical Loss Ratio
Quality withhold
Specialty withhold
Managed care payment (pmpm)
Covered services
Fee schedule Claims are paid as usual on a FFS basis
Credentialing
Quality Review process and Quality Metrics
65
Upside Risk
The possibility that the cost of
delivering dental care to an assigned
patient panel is less than the amount
of funding calculated for that care
The Plan pays the CHC additional
funds based on a predetermine
formula
Downside Risk
The possibility that the cost of
delivering dental care to an assigned
patient panel is more than the amount
of funding calculated for that care
The CHC pays the Plan additional
funds based on a predetermine
formula
Upside and Downside Risk
66
Taking On Risk 100 or Shared Risk
With 100 risk you receive 100 of the potential savings but are also at risk for
100 of the losses
Shared Risk MCO and health center share a percentage of the risk
Shared Risk leads to better cooperation since both organizations are
incentivized to save on costs
6767
Reports Needed
bull Enrollment reports lists of who is assigned on a monthly basis
bull Reconciliation reports insure appropriate payments
bull Specialty Referral reports
bull You will need your own reporting process so you donrsquot rely completely on
reports supplied by the Plan
6868
Medical Loss Ratio
Medical Loss Ratio (MLR) is proportion of premium revenues spent on clinical
services and quality improvement also known as the Medical Loss Ratio (MLR)
For CMS requires Medical Plans to spend at least 80 to 85 of the premiums
on actual medical care
69
Administrative Fees
bull Essentially the opposite of MLR
bull The State Medicaid Agency is funded by the Governorrsquos budget
bull The State Medicaid Agency will keep some of these funds for their
admin costs and give the remaining to the Managed Care Plans
bull Private Plan admin costs can be as high as 40 but most states
limit these cost for Medicaid Plans to between 15 and 20 (85-
80 MLR)
bull This may be negotiable depending on your program size of your
program
70
Quality Withhold
bull The state withholds a certain percent (typically 2-4 ) of the funds they give
to the Plans for Value Based Reimbursement
bull They choose quality metrics and set benchmarks and assign payments for
each metric based on an assigned priority for each metric
bull If a Plan meets the benchmark of every quality metric the state passes on
their full share of the quality withhold
bull The Plans may or may not withhold a percent of the funds for quality payment
to the dentists or manage care contractors
71
Quality Withhold
Either way the Plans may or may not pass the quality payments they receive to
the dentists or contractors
This should be spelled out in a risk-based contract
72
Percent of funds set aside
to cover specialty care
referrals
Typically 10-15
Goal Limit referral costs
to within or less than
Specialty set aside
Specialty Withhold
73
Per Member Per Month
bull Capitated Payment
bull Specific dollar amount paid for each enrolled member each month
bull Paid whether patient is accessed for care or not
bull States do set access benchmarks
bull In Oregon access for any dental procedure (adults and children combined)
was 267 in 2015
74
Payment Math Example
Premium per enrollee = $25
Administrative fee 15 = $375
Funds available per enrollee to the clinic = $2125
Management fee per enrollee = $175
Funds per enrollee that would undergo PPS reconciliation = $1950
For every 10000 enrollees the managed care income = $2340000
Specialty withhold (10) = $234000
YE Cost lt or gt $2340000
Upside Risk
CHC Gains $
Downside Risk
CHC Loses $
75
Covered Services and Fee Schedules
bull The state Medicaid agency spells out the minimum procedures and fees that
MCOs must cover
bull MCOs may add procedures or increase periodicity of procedures particularly
preventative services
bull MCOs may increase fees to entice rural providers and specialists to enroll in
their Plans
bull Access Rules
bull How many days it takes to access a patent
bull How many days it takes for a patent to access urgent care services
bull How many days it takes for a patent to access emergency care services
76
Credentialing
All MCOs are required to credential all Providers
All MCOs have their own credentialing process
Credentialing process is can be lengthy
Credentialing process may be negotiable
77
Quality Review Process and Quality Metrics
MCOs must have a Quality and Compliance Review Process
If you arenrsquot in compliance with both you likely wonrsquot get paid
Typical processes reviewed
bull Charting specifications
bull Incident report
bull Enrollee complaints quality rudeness and access issues
bull Medicaid compliance
78
Quality Payments
bull State Shared Incentive Withhold Typically quality metrics and benchmarks
are set by the state sets aside a certain percent (3-5) of the payments to
the Managed Care Plan (MCP)
bull If the benchmarks are achieved the MCP is then paid the a predetermine
amount
bull Benchmarks may not be the same as the states
bull Managed Care Plans do not have to pass all or any of the quality payments to
the health centers or providers
bull Managed Care contract- Metrics benchmarks should be selected and part of
the contract
7979
Achieving Quality Metric Payments
Dealing with under achievers
Process issues
Individual issues
Identifying workflows
Developing Best Practices through
PDSA process
Developing Best Practices through
PDSA process
CHC Metrics Committee
Clinicians Operations various key staff
Identify Best Practices
Spread Best Practices
80
New Team Needed Business Intelligence
Business Intelligence (BI) is critical for effective managed care business decisions
BI team inputs metrics into your EHR collects integrates analyses and displays all your managed care business and clinical information
Easy to say- hard to achieve
Build your own or outsource
Possible future role of Primary Care Associations
8181
Clinicianrsquos Dashboard
Expensive to build
Displayed on your screen when your computer is first turned on
Easy to read and understand
Data dumped from the day before
Can dialed down from Org-wide to clinic to each clinicianrsquos data
Operational and clinical metrics
bull Treatment Plan Completion
bull DQA quality measures
bull Caries at Recall
bull Re-care reports
bull Care Gap reports
82
CONTROLLING COSTS
8383
Controlling Costs- Current
bull Increasing efficiencies
bull Decreasing broken appointments
bull Controlling supplies equipment costs
bull Staff recruitment retention costs
84
Specialty Care
Training current CHC dentists in
specialty areas
Hiring general dentists with higher
specialty skill sets
Hiring in house specialists
Contract with outside specialists
Work with Managed Care Plan
specialists
Lowering Disease Rates
Community Dental Health
Coordinators case management
If your state law allows- embed
hygienists in medical and community
to provide primary and secondary
prevention procedures
In clinic Caries Classification and
Silver Diamine Fluoride
Effective recare programs
Controlling Costs- Additions in Risk-based Contracting
85
Specialty Care ndash Primary Referrals by Cost
Pediatric dentistry
Orthodontics
Oral surgery
Endodontics
86
In-clinic Pediatric Services
Encounters expected
of operatories available
State dental law and ability to have
expanded duties
General Anesthesia
GA in- house
Ability for a hospital or surgery center
to set aside regular OR time
Ability to hire or assign DAs to GA
days
Four GA cases day x PPS rate
Should You Hire a Pediatric Dentist- It Depends
8787
Solutions for Controlling Pediatric Costs
Hire a general dentist that is skilled in treating young children
Make the clinic child friendly nitrous oxide TVs in the operatory etc
Teach entire staff behavioral control techniques
Contract with a pediatric dentist for the GA care
88
Lowering Overall Disease Rates (and Costs)
You are responsible for both the patients you see in the chair and the ones
assigned to you
Breaking down the walls of the dental clinic
Community Dental Health Coordinators
Case Management
89
Cost Control Essentials
Diagnosis codes
Increased ability to identify
disease by risk
Motivational
Interviewing
Developing Polices and
Procedures design to treat
disease according to risk
ie Silver Diamine Fluoride
Treating by Risk
Effective Recare
Process
Critical to continual disease
controlPrevention education that is
meaningful and designed to
change behaviors
90
Social Determinants of Health Aunt Bertha
httpswwwauntberthacom
91
REASON TO CONSIDER RISK- BASED CONTRACTING
9292
PPS Reconciliation and Federal Code 42 CFR sect4052469(a)(2)
42 CFR sect4052469(a)(2)
ldquoAny financial incentives provided to Federally Qualified Health Centers
under their Medicare Advantage Contracts such as risk pool payments
bonuses or withholds are prohibited from being included in the
calculation of supplemental payments due to the Federally Qualified
Health Centerrdquo
9393
Why Risk Based Contract in Times of PPS Reconciliation
bull Not all Risk- based Contract funds are reconciled
bull Risk is the key word- you can come out with less money than your normal
PPS reconciliation payment
bull Can lead to better patient care
bull May improve manage care enrollment for your medical plan
bull Promotes integrated care increases health for your CHC patients
9494
Not Included in the Reconciliation
Enrollment management pmpm
Quality Payments
Upside risk payments
Downside risk losses
9595
Determinants of Financial Success in Risk-Based Contracting
bull Most critical- State pmpm payment to the Managed Care Plan
bull Reporting capabilities
bull Specialty service capabilities
bull Access numbers count
bull Ability to move metric numbers
9696
What About the Non- Medicaid Poor We Serve
bull Numbers are king in a managed care contract and the more access you have
the better contract terms you can negotiate
bull We will potentially have a steady supply of Medicaid patients
bull As managed care spreads states this may be compromising the ability of
health centers to serve the non-Medicaid poor and others lacking dental
insurance
97
Mark Koday DDS
(509) 949-2278
Dental Quality Consultants
of WA
httpdentalqualityconsultin
gcom
dentalqualityconsultantsg
mailcom
Contact Information
LUNCH
BREAKOUT EXERCISEORAL HEALTH VALUE-BASED CARE READINESS ASSESSMENT
Danielle Apostolon
PROMISING PRACTICES FROM THE FIELD STRATEGIES FOR INCREASING VALUE IN ORAL HEALTH
Dr Carolyn Brown
Dr Kelly Perry
Dr Rachel Rivard
Dr Adeloye
Commitment Compassion Community
m i d s t a t e h e a l t h o r g
Promising Practices from the
Field Strategies for Increasing
Value in Oral Health Care
Kelly Perry DMD
Better Health
Outcomes
Improved Staff
Experience
Reduced Cost
Improved Patient
Experience
Better Health
Outcomes
Improved Staff
Experience
Reduced Cost
Improved Patient
Experience
Better Health
Outcomes
Improved Staff
Experience
Reduced Cost
Improved Patient
Experience
Better Health
Outcomes
Improved Staff
Experience
Reduced Cost
Improved Patient
Experience
Commitment Compassion Community
kpe r r ymids t a tehea l t h o rg
Thank you
Completion of Disease Control Phase
Pelumi Adeloye DMD MPH
HEALTH ACCESS NETWORK (HAN) FAMILY DENTAL
Introduction
⧫1 Dentist I Hygienist 3 EFDArsquos1 Receptionist
⧫ 6 Chairs= 4 (dentist) + 2 (hygienist)
⧫ Slide ⥶80 off
⧫ Service areas Northern Penobscot Southern Aroostook Western
Washington Counties amp more
Completion of Phase I Treatment
⧫LimitedLack of Access to dental care
⧫Difficulty completing the disease control phase
Caries amp periodontal disease
⧫Attaining stable restorative state
Goal
Increase the completion of Disease Control Phase
Current practice
⧫Education
Assess level of dental literacy
Incremental strategy
⧫Increase access to dental care
Generous sliding scale (⥸$40 per visit)
Incorporate Expanded Function Dental Assistants
⧫Schedule modification
Incorporate more restorative blocks to allow
for follow-up visit and completion of restorative phase
httpswwwglasbergencomdentist-cartoons
Schedule
⧫Piggybacking technique
Increased allotted restorative blocks
⧫Sustainability of current schedule is
contingent on cooperation amp skills of HAN
Dental staff
Note
Strategies mentioned today is personalized to HAN Dental clinic
Current implemented strategies might be modified or changed in the
future as required in order to accommodate the need of our pts
THANK YOU
DAY TWOCLOSINGWRAP-UP
End of Day Two ndash Survey
Day Two Creating a Value-Based Oral Health Care Delivery
System
129
Payment Reform in Oral Health Online Learning Module
Oral Health Value-based Care Online Learning Module
Value-based Care Keys to Success Article
Readiness Assessment
Competency Development Guide
Oral Health Value-based Care Training
Dental Caries Management Practicum
Clinicians Companion Guide
Interprofessional Network Referral Process
Traditional Dental Care Vs Value-Based Care
Resources
131
wwwDentaQuestPartnershiporg
wwwfacebookcomDentaQuest
DentaQuest
wwwlinkedincomcompanyDentaQuest
Inside_DentaQuest
QUESTIONS
57
What Has Happened Since the 90s
58
WHY THE FFS AND PPS DOESNrsquoT WORK FOR OUR POPULATIONS
bull Inefficient payment systems designed to produce encounters or procedures but not real health
bull No focus on population health
bull Does not incentivize innovation
bull Patients essentially on their own for accessing specialty care
59
Rule of 4
Source Kaiser Family Foundation analysis of National Health Expenditure (NHE) data from Centers for
Medicare and Medicaid Services Office of the Actuary National Health Statistics Group
60
Rule of 4
bull This helps explain why oral health has been relatively ignored so far by CMS
bull Explains why we have PCMH instead of PCHH
bull Where is the real value on a national level in preventing disease and
controlling costs
bull Beware- wersquove been found
61
Reasons Dental Managed Care is Spreading Across the States
NON-MANAGED CARE STATE DENTAL BUDGETS ARE
OPENED ENDED
STRAIN ON STATE BUDGETS
UPCOMING RECESSION WITH TRILLION DOLLAR
DEFICIT
SHIFTS FINANCIAL RISK FROM THE STATES TO THE
PLANS
6262
Types of Medicaid Managed Care
bull State Medicaid agency administrator lowest administrative
costs
bull Third Party Administrator Typically 15 administrative costs
bull Managed Care Organization Typically 15 administrative
costs
bull Carved-in
bull Carved-out
bull Risk Based Managed Care Administrative costs part of
contract negotiation
63
RISK CONTRACTS
6464
Components of a Risk-based Contract
Risk
Medical Loss Ratio
Quality withhold
Specialty withhold
Managed care payment (pmpm)
Covered services
Fee schedule Claims are paid as usual on a FFS basis
Credentialing
Quality Review process and Quality Metrics
65
Upside Risk
The possibility that the cost of
delivering dental care to an assigned
patient panel is less than the amount
of funding calculated for that care
The Plan pays the CHC additional
funds based on a predetermine
formula
Downside Risk
The possibility that the cost of
delivering dental care to an assigned
patient panel is more than the amount
of funding calculated for that care
The CHC pays the Plan additional
funds based on a predetermine
formula
Upside and Downside Risk
66
Taking On Risk 100 or Shared Risk
With 100 risk you receive 100 of the potential savings but are also at risk for
100 of the losses
Shared Risk MCO and health center share a percentage of the risk
Shared Risk leads to better cooperation since both organizations are
incentivized to save on costs
6767
Reports Needed
bull Enrollment reports lists of who is assigned on a monthly basis
bull Reconciliation reports insure appropriate payments
bull Specialty Referral reports
bull You will need your own reporting process so you donrsquot rely completely on
reports supplied by the Plan
6868
Medical Loss Ratio
Medical Loss Ratio (MLR) is proportion of premium revenues spent on clinical
services and quality improvement also known as the Medical Loss Ratio (MLR)
For CMS requires Medical Plans to spend at least 80 to 85 of the premiums
on actual medical care
69
Administrative Fees
bull Essentially the opposite of MLR
bull The State Medicaid Agency is funded by the Governorrsquos budget
bull The State Medicaid Agency will keep some of these funds for their
admin costs and give the remaining to the Managed Care Plans
bull Private Plan admin costs can be as high as 40 but most states
limit these cost for Medicaid Plans to between 15 and 20 (85-
80 MLR)
bull This may be negotiable depending on your program size of your
program
70
Quality Withhold
bull The state withholds a certain percent (typically 2-4 ) of the funds they give
to the Plans for Value Based Reimbursement
bull They choose quality metrics and set benchmarks and assign payments for
each metric based on an assigned priority for each metric
bull If a Plan meets the benchmark of every quality metric the state passes on
their full share of the quality withhold
bull The Plans may or may not withhold a percent of the funds for quality payment
to the dentists or manage care contractors
71
Quality Withhold
Either way the Plans may or may not pass the quality payments they receive to
the dentists or contractors
This should be spelled out in a risk-based contract
72
Percent of funds set aside
to cover specialty care
referrals
Typically 10-15
Goal Limit referral costs
to within or less than
Specialty set aside
Specialty Withhold
73
Per Member Per Month
bull Capitated Payment
bull Specific dollar amount paid for each enrolled member each month
bull Paid whether patient is accessed for care or not
bull States do set access benchmarks
bull In Oregon access for any dental procedure (adults and children combined)
was 267 in 2015
74
Payment Math Example
Premium per enrollee = $25
Administrative fee 15 = $375
Funds available per enrollee to the clinic = $2125
Management fee per enrollee = $175
Funds per enrollee that would undergo PPS reconciliation = $1950
For every 10000 enrollees the managed care income = $2340000
Specialty withhold (10) = $234000
YE Cost lt or gt $2340000
Upside Risk
CHC Gains $
Downside Risk
CHC Loses $
75
Covered Services and Fee Schedules
bull The state Medicaid agency spells out the minimum procedures and fees that
MCOs must cover
bull MCOs may add procedures or increase periodicity of procedures particularly
preventative services
bull MCOs may increase fees to entice rural providers and specialists to enroll in
their Plans
bull Access Rules
bull How many days it takes to access a patent
bull How many days it takes for a patent to access urgent care services
bull How many days it takes for a patent to access emergency care services
76
Credentialing
All MCOs are required to credential all Providers
All MCOs have their own credentialing process
Credentialing process is can be lengthy
Credentialing process may be negotiable
77
Quality Review Process and Quality Metrics
MCOs must have a Quality and Compliance Review Process
If you arenrsquot in compliance with both you likely wonrsquot get paid
Typical processes reviewed
bull Charting specifications
bull Incident report
bull Enrollee complaints quality rudeness and access issues
bull Medicaid compliance
78
Quality Payments
bull State Shared Incentive Withhold Typically quality metrics and benchmarks
are set by the state sets aside a certain percent (3-5) of the payments to
the Managed Care Plan (MCP)
bull If the benchmarks are achieved the MCP is then paid the a predetermine
amount
bull Benchmarks may not be the same as the states
bull Managed Care Plans do not have to pass all or any of the quality payments to
the health centers or providers
bull Managed Care contract- Metrics benchmarks should be selected and part of
the contract
7979
Achieving Quality Metric Payments
Dealing with under achievers
Process issues
Individual issues
Identifying workflows
Developing Best Practices through
PDSA process
Developing Best Practices through
PDSA process
CHC Metrics Committee
Clinicians Operations various key staff
Identify Best Practices
Spread Best Practices
80
New Team Needed Business Intelligence
Business Intelligence (BI) is critical for effective managed care business decisions
BI team inputs metrics into your EHR collects integrates analyses and displays all your managed care business and clinical information
Easy to say- hard to achieve
Build your own or outsource
Possible future role of Primary Care Associations
8181
Clinicianrsquos Dashboard
Expensive to build
Displayed on your screen when your computer is first turned on
Easy to read and understand
Data dumped from the day before
Can dialed down from Org-wide to clinic to each clinicianrsquos data
Operational and clinical metrics
bull Treatment Plan Completion
bull DQA quality measures
bull Caries at Recall
bull Re-care reports
bull Care Gap reports
82
CONTROLLING COSTS
8383
Controlling Costs- Current
bull Increasing efficiencies
bull Decreasing broken appointments
bull Controlling supplies equipment costs
bull Staff recruitment retention costs
84
Specialty Care
Training current CHC dentists in
specialty areas
Hiring general dentists with higher
specialty skill sets
Hiring in house specialists
Contract with outside specialists
Work with Managed Care Plan
specialists
Lowering Disease Rates
Community Dental Health
Coordinators case management
If your state law allows- embed
hygienists in medical and community
to provide primary and secondary
prevention procedures
In clinic Caries Classification and
Silver Diamine Fluoride
Effective recare programs
Controlling Costs- Additions in Risk-based Contracting
85
Specialty Care ndash Primary Referrals by Cost
Pediatric dentistry
Orthodontics
Oral surgery
Endodontics
86
In-clinic Pediatric Services
Encounters expected
of operatories available
State dental law and ability to have
expanded duties
General Anesthesia
GA in- house
Ability for a hospital or surgery center
to set aside regular OR time
Ability to hire or assign DAs to GA
days
Four GA cases day x PPS rate
Should You Hire a Pediatric Dentist- It Depends
8787
Solutions for Controlling Pediatric Costs
Hire a general dentist that is skilled in treating young children
Make the clinic child friendly nitrous oxide TVs in the operatory etc
Teach entire staff behavioral control techniques
Contract with a pediatric dentist for the GA care
88
Lowering Overall Disease Rates (and Costs)
You are responsible for both the patients you see in the chair and the ones
assigned to you
Breaking down the walls of the dental clinic
Community Dental Health Coordinators
Case Management
89
Cost Control Essentials
Diagnosis codes
Increased ability to identify
disease by risk
Motivational
Interviewing
Developing Polices and
Procedures design to treat
disease according to risk
ie Silver Diamine Fluoride
Treating by Risk
Effective Recare
Process
Critical to continual disease
controlPrevention education that is
meaningful and designed to
change behaviors
90
Social Determinants of Health Aunt Bertha
httpswwwauntberthacom
91
REASON TO CONSIDER RISK- BASED CONTRACTING
9292
PPS Reconciliation and Federal Code 42 CFR sect4052469(a)(2)
42 CFR sect4052469(a)(2)
ldquoAny financial incentives provided to Federally Qualified Health Centers
under their Medicare Advantage Contracts such as risk pool payments
bonuses or withholds are prohibited from being included in the
calculation of supplemental payments due to the Federally Qualified
Health Centerrdquo
9393
Why Risk Based Contract in Times of PPS Reconciliation
bull Not all Risk- based Contract funds are reconciled
bull Risk is the key word- you can come out with less money than your normal
PPS reconciliation payment
bull Can lead to better patient care
bull May improve manage care enrollment for your medical plan
bull Promotes integrated care increases health for your CHC patients
9494
Not Included in the Reconciliation
Enrollment management pmpm
Quality Payments
Upside risk payments
Downside risk losses
9595
Determinants of Financial Success in Risk-Based Contracting
bull Most critical- State pmpm payment to the Managed Care Plan
bull Reporting capabilities
bull Specialty service capabilities
bull Access numbers count
bull Ability to move metric numbers
9696
What About the Non- Medicaid Poor We Serve
bull Numbers are king in a managed care contract and the more access you have
the better contract terms you can negotiate
bull We will potentially have a steady supply of Medicaid patients
bull As managed care spreads states this may be compromising the ability of
health centers to serve the non-Medicaid poor and others lacking dental
insurance
97
Mark Koday DDS
(509) 949-2278
Dental Quality Consultants
of WA
httpdentalqualityconsultin
gcom
dentalqualityconsultantsg
mailcom
Contact Information
LUNCH
BREAKOUT EXERCISEORAL HEALTH VALUE-BASED CARE READINESS ASSESSMENT
Danielle Apostolon
PROMISING PRACTICES FROM THE FIELD STRATEGIES FOR INCREASING VALUE IN ORAL HEALTH
Dr Carolyn Brown
Dr Kelly Perry
Dr Rachel Rivard
Dr Adeloye
Commitment Compassion Community
m i d s t a t e h e a l t h o r g
Promising Practices from the
Field Strategies for Increasing
Value in Oral Health Care
Kelly Perry DMD
Better Health
Outcomes
Improved Staff
Experience
Reduced Cost
Improved Patient
Experience
Better Health
Outcomes
Improved Staff
Experience
Reduced Cost
Improved Patient
Experience
Better Health
Outcomes
Improved Staff
Experience
Reduced Cost
Improved Patient
Experience
Better Health
Outcomes
Improved Staff
Experience
Reduced Cost
Improved Patient
Experience
Commitment Compassion Community
kpe r r ymids t a tehea l t h o rg
Thank you
Completion of Disease Control Phase
Pelumi Adeloye DMD MPH
HEALTH ACCESS NETWORK (HAN) FAMILY DENTAL
Introduction
⧫1 Dentist I Hygienist 3 EFDArsquos1 Receptionist
⧫ 6 Chairs= 4 (dentist) + 2 (hygienist)
⧫ Slide ⥶80 off
⧫ Service areas Northern Penobscot Southern Aroostook Western
Washington Counties amp more
Completion of Phase I Treatment
⧫LimitedLack of Access to dental care
⧫Difficulty completing the disease control phase
Caries amp periodontal disease
⧫Attaining stable restorative state
Goal
Increase the completion of Disease Control Phase
Current practice
⧫Education
Assess level of dental literacy
Incremental strategy
⧫Increase access to dental care
Generous sliding scale (⥸$40 per visit)
Incorporate Expanded Function Dental Assistants
⧫Schedule modification
Incorporate more restorative blocks to allow
for follow-up visit and completion of restorative phase
httpswwwglasbergencomdentist-cartoons
Schedule
⧫Piggybacking technique
Increased allotted restorative blocks
⧫Sustainability of current schedule is
contingent on cooperation amp skills of HAN
Dental staff
Note
Strategies mentioned today is personalized to HAN Dental clinic
Current implemented strategies might be modified or changed in the
future as required in order to accommodate the need of our pts
THANK YOU
DAY TWOCLOSINGWRAP-UP
End of Day Two ndash Survey
Day Two Creating a Value-Based Oral Health Care Delivery
System
129
Payment Reform in Oral Health Online Learning Module
Oral Health Value-based Care Online Learning Module
Value-based Care Keys to Success Article
Readiness Assessment
Competency Development Guide
Oral Health Value-based Care Training
Dental Caries Management Practicum
Clinicians Companion Guide
Interprofessional Network Referral Process
Traditional Dental Care Vs Value-Based Care
Resources
131
wwwDentaQuestPartnershiporg
wwwfacebookcomDentaQuest
DentaQuest
wwwlinkedincomcompanyDentaQuest
Inside_DentaQuest
QUESTIONS
58
WHY THE FFS AND PPS DOESNrsquoT WORK FOR OUR POPULATIONS
bull Inefficient payment systems designed to produce encounters or procedures but not real health
bull No focus on population health
bull Does not incentivize innovation
bull Patients essentially on their own for accessing specialty care
59
Rule of 4
Source Kaiser Family Foundation analysis of National Health Expenditure (NHE) data from Centers for
Medicare and Medicaid Services Office of the Actuary National Health Statistics Group
60
Rule of 4
bull This helps explain why oral health has been relatively ignored so far by CMS
bull Explains why we have PCMH instead of PCHH
bull Where is the real value on a national level in preventing disease and
controlling costs
bull Beware- wersquove been found
61
Reasons Dental Managed Care is Spreading Across the States
NON-MANAGED CARE STATE DENTAL BUDGETS ARE
OPENED ENDED
STRAIN ON STATE BUDGETS
UPCOMING RECESSION WITH TRILLION DOLLAR
DEFICIT
SHIFTS FINANCIAL RISK FROM THE STATES TO THE
PLANS
6262
Types of Medicaid Managed Care
bull State Medicaid agency administrator lowest administrative
costs
bull Third Party Administrator Typically 15 administrative costs
bull Managed Care Organization Typically 15 administrative
costs
bull Carved-in
bull Carved-out
bull Risk Based Managed Care Administrative costs part of
contract negotiation
63
RISK CONTRACTS
6464
Components of a Risk-based Contract
Risk
Medical Loss Ratio
Quality withhold
Specialty withhold
Managed care payment (pmpm)
Covered services
Fee schedule Claims are paid as usual on a FFS basis
Credentialing
Quality Review process and Quality Metrics
65
Upside Risk
The possibility that the cost of
delivering dental care to an assigned
patient panel is less than the amount
of funding calculated for that care
The Plan pays the CHC additional
funds based on a predetermine
formula
Downside Risk
The possibility that the cost of
delivering dental care to an assigned
patient panel is more than the amount
of funding calculated for that care
The CHC pays the Plan additional
funds based on a predetermine
formula
Upside and Downside Risk
66
Taking On Risk 100 or Shared Risk
With 100 risk you receive 100 of the potential savings but are also at risk for
100 of the losses
Shared Risk MCO and health center share a percentage of the risk
Shared Risk leads to better cooperation since both organizations are
incentivized to save on costs
6767
Reports Needed
bull Enrollment reports lists of who is assigned on a monthly basis
bull Reconciliation reports insure appropriate payments
bull Specialty Referral reports
bull You will need your own reporting process so you donrsquot rely completely on
reports supplied by the Plan
6868
Medical Loss Ratio
Medical Loss Ratio (MLR) is proportion of premium revenues spent on clinical
services and quality improvement also known as the Medical Loss Ratio (MLR)
For CMS requires Medical Plans to spend at least 80 to 85 of the premiums
on actual medical care
69
Administrative Fees
bull Essentially the opposite of MLR
bull The State Medicaid Agency is funded by the Governorrsquos budget
bull The State Medicaid Agency will keep some of these funds for their
admin costs and give the remaining to the Managed Care Plans
bull Private Plan admin costs can be as high as 40 but most states
limit these cost for Medicaid Plans to between 15 and 20 (85-
80 MLR)
bull This may be negotiable depending on your program size of your
program
70
Quality Withhold
bull The state withholds a certain percent (typically 2-4 ) of the funds they give
to the Plans for Value Based Reimbursement
bull They choose quality metrics and set benchmarks and assign payments for
each metric based on an assigned priority for each metric
bull If a Plan meets the benchmark of every quality metric the state passes on
their full share of the quality withhold
bull The Plans may or may not withhold a percent of the funds for quality payment
to the dentists or manage care contractors
71
Quality Withhold
Either way the Plans may or may not pass the quality payments they receive to
the dentists or contractors
This should be spelled out in a risk-based contract
72
Percent of funds set aside
to cover specialty care
referrals
Typically 10-15
Goal Limit referral costs
to within or less than
Specialty set aside
Specialty Withhold
73
Per Member Per Month
bull Capitated Payment
bull Specific dollar amount paid for each enrolled member each month
bull Paid whether patient is accessed for care or not
bull States do set access benchmarks
bull In Oregon access for any dental procedure (adults and children combined)
was 267 in 2015
74
Payment Math Example
Premium per enrollee = $25
Administrative fee 15 = $375
Funds available per enrollee to the clinic = $2125
Management fee per enrollee = $175
Funds per enrollee that would undergo PPS reconciliation = $1950
For every 10000 enrollees the managed care income = $2340000
Specialty withhold (10) = $234000
YE Cost lt or gt $2340000
Upside Risk
CHC Gains $
Downside Risk
CHC Loses $
75
Covered Services and Fee Schedules
bull The state Medicaid agency spells out the minimum procedures and fees that
MCOs must cover
bull MCOs may add procedures or increase periodicity of procedures particularly
preventative services
bull MCOs may increase fees to entice rural providers and specialists to enroll in
their Plans
bull Access Rules
bull How many days it takes to access a patent
bull How many days it takes for a patent to access urgent care services
bull How many days it takes for a patent to access emergency care services
76
Credentialing
All MCOs are required to credential all Providers
All MCOs have their own credentialing process
Credentialing process is can be lengthy
Credentialing process may be negotiable
77
Quality Review Process and Quality Metrics
MCOs must have a Quality and Compliance Review Process
If you arenrsquot in compliance with both you likely wonrsquot get paid
Typical processes reviewed
bull Charting specifications
bull Incident report
bull Enrollee complaints quality rudeness and access issues
bull Medicaid compliance
78
Quality Payments
bull State Shared Incentive Withhold Typically quality metrics and benchmarks
are set by the state sets aside a certain percent (3-5) of the payments to
the Managed Care Plan (MCP)
bull If the benchmarks are achieved the MCP is then paid the a predetermine
amount
bull Benchmarks may not be the same as the states
bull Managed Care Plans do not have to pass all or any of the quality payments to
the health centers or providers
bull Managed Care contract- Metrics benchmarks should be selected and part of
the contract
7979
Achieving Quality Metric Payments
Dealing with under achievers
Process issues
Individual issues
Identifying workflows
Developing Best Practices through
PDSA process
Developing Best Practices through
PDSA process
CHC Metrics Committee
Clinicians Operations various key staff
Identify Best Practices
Spread Best Practices
80
New Team Needed Business Intelligence
Business Intelligence (BI) is critical for effective managed care business decisions
BI team inputs metrics into your EHR collects integrates analyses and displays all your managed care business and clinical information
Easy to say- hard to achieve
Build your own or outsource
Possible future role of Primary Care Associations
8181
Clinicianrsquos Dashboard
Expensive to build
Displayed on your screen when your computer is first turned on
Easy to read and understand
Data dumped from the day before
Can dialed down from Org-wide to clinic to each clinicianrsquos data
Operational and clinical metrics
bull Treatment Plan Completion
bull DQA quality measures
bull Caries at Recall
bull Re-care reports
bull Care Gap reports
82
CONTROLLING COSTS
8383
Controlling Costs- Current
bull Increasing efficiencies
bull Decreasing broken appointments
bull Controlling supplies equipment costs
bull Staff recruitment retention costs
84
Specialty Care
Training current CHC dentists in
specialty areas
Hiring general dentists with higher
specialty skill sets
Hiring in house specialists
Contract with outside specialists
Work with Managed Care Plan
specialists
Lowering Disease Rates
Community Dental Health
Coordinators case management
If your state law allows- embed
hygienists in medical and community
to provide primary and secondary
prevention procedures
In clinic Caries Classification and
Silver Diamine Fluoride
Effective recare programs
Controlling Costs- Additions in Risk-based Contracting
85
Specialty Care ndash Primary Referrals by Cost
Pediatric dentistry
Orthodontics
Oral surgery
Endodontics
86
In-clinic Pediatric Services
Encounters expected
of operatories available
State dental law and ability to have
expanded duties
General Anesthesia
GA in- house
Ability for a hospital or surgery center
to set aside regular OR time
Ability to hire or assign DAs to GA
days
Four GA cases day x PPS rate
Should You Hire a Pediatric Dentist- It Depends
8787
Solutions for Controlling Pediatric Costs
Hire a general dentist that is skilled in treating young children
Make the clinic child friendly nitrous oxide TVs in the operatory etc
Teach entire staff behavioral control techniques
Contract with a pediatric dentist for the GA care
88
Lowering Overall Disease Rates (and Costs)
You are responsible for both the patients you see in the chair and the ones
assigned to you
Breaking down the walls of the dental clinic
Community Dental Health Coordinators
Case Management
89
Cost Control Essentials
Diagnosis codes
Increased ability to identify
disease by risk
Motivational
Interviewing
Developing Polices and
Procedures design to treat
disease according to risk
ie Silver Diamine Fluoride
Treating by Risk
Effective Recare
Process
Critical to continual disease
controlPrevention education that is
meaningful and designed to
change behaviors
90
Social Determinants of Health Aunt Bertha
httpswwwauntberthacom
91
REASON TO CONSIDER RISK- BASED CONTRACTING
9292
PPS Reconciliation and Federal Code 42 CFR sect4052469(a)(2)
42 CFR sect4052469(a)(2)
ldquoAny financial incentives provided to Federally Qualified Health Centers
under their Medicare Advantage Contracts such as risk pool payments
bonuses or withholds are prohibited from being included in the
calculation of supplemental payments due to the Federally Qualified
Health Centerrdquo
9393
Why Risk Based Contract in Times of PPS Reconciliation
bull Not all Risk- based Contract funds are reconciled
bull Risk is the key word- you can come out with less money than your normal
PPS reconciliation payment
bull Can lead to better patient care
bull May improve manage care enrollment for your medical plan
bull Promotes integrated care increases health for your CHC patients
9494
Not Included in the Reconciliation
Enrollment management pmpm
Quality Payments
Upside risk payments
Downside risk losses
9595
Determinants of Financial Success in Risk-Based Contracting
bull Most critical- State pmpm payment to the Managed Care Plan
bull Reporting capabilities
bull Specialty service capabilities
bull Access numbers count
bull Ability to move metric numbers
9696
What About the Non- Medicaid Poor We Serve
bull Numbers are king in a managed care contract and the more access you have
the better contract terms you can negotiate
bull We will potentially have a steady supply of Medicaid patients
bull As managed care spreads states this may be compromising the ability of
health centers to serve the non-Medicaid poor and others lacking dental
insurance
97
Mark Koday DDS
(509) 949-2278
Dental Quality Consultants
of WA
httpdentalqualityconsultin
gcom
dentalqualityconsultantsg
mailcom
Contact Information
LUNCH
BREAKOUT EXERCISEORAL HEALTH VALUE-BASED CARE READINESS ASSESSMENT
Danielle Apostolon
PROMISING PRACTICES FROM THE FIELD STRATEGIES FOR INCREASING VALUE IN ORAL HEALTH
Dr Carolyn Brown
Dr Kelly Perry
Dr Rachel Rivard
Dr Adeloye
Commitment Compassion Community
m i d s t a t e h e a l t h o r g
Promising Practices from the
Field Strategies for Increasing
Value in Oral Health Care
Kelly Perry DMD
Better Health
Outcomes
Improved Staff
Experience
Reduced Cost
Improved Patient
Experience
Better Health
Outcomes
Improved Staff
Experience
Reduced Cost
Improved Patient
Experience
Better Health
Outcomes
Improved Staff
Experience
Reduced Cost
Improved Patient
Experience
Better Health
Outcomes
Improved Staff
Experience
Reduced Cost
Improved Patient
Experience
Commitment Compassion Community
kpe r r ymids t a tehea l t h o rg
Thank you
Completion of Disease Control Phase
Pelumi Adeloye DMD MPH
HEALTH ACCESS NETWORK (HAN) FAMILY DENTAL
Introduction
⧫1 Dentist I Hygienist 3 EFDArsquos1 Receptionist
⧫ 6 Chairs= 4 (dentist) + 2 (hygienist)
⧫ Slide ⥶80 off
⧫ Service areas Northern Penobscot Southern Aroostook Western
Washington Counties amp more
Completion of Phase I Treatment
⧫LimitedLack of Access to dental care
⧫Difficulty completing the disease control phase
Caries amp periodontal disease
⧫Attaining stable restorative state
Goal
Increase the completion of Disease Control Phase
Current practice
⧫Education
Assess level of dental literacy
Incremental strategy
⧫Increase access to dental care
Generous sliding scale (⥸$40 per visit)
Incorporate Expanded Function Dental Assistants
⧫Schedule modification
Incorporate more restorative blocks to allow
for follow-up visit and completion of restorative phase
httpswwwglasbergencomdentist-cartoons
Schedule
⧫Piggybacking technique
Increased allotted restorative blocks
⧫Sustainability of current schedule is
contingent on cooperation amp skills of HAN
Dental staff
Note
Strategies mentioned today is personalized to HAN Dental clinic
Current implemented strategies might be modified or changed in the
future as required in order to accommodate the need of our pts
THANK YOU
DAY TWOCLOSINGWRAP-UP
End of Day Two ndash Survey
Day Two Creating a Value-Based Oral Health Care Delivery
System
129
Payment Reform in Oral Health Online Learning Module
Oral Health Value-based Care Online Learning Module
Value-based Care Keys to Success Article
Readiness Assessment
Competency Development Guide
Oral Health Value-based Care Training
Dental Caries Management Practicum
Clinicians Companion Guide
Interprofessional Network Referral Process
Traditional Dental Care Vs Value-Based Care
Resources
131
wwwDentaQuestPartnershiporg
wwwfacebookcomDentaQuest
DentaQuest
wwwlinkedincomcompanyDentaQuest
Inside_DentaQuest
QUESTIONS
59
Rule of 4
Source Kaiser Family Foundation analysis of National Health Expenditure (NHE) data from Centers for
Medicare and Medicaid Services Office of the Actuary National Health Statistics Group
60
Rule of 4
bull This helps explain why oral health has been relatively ignored so far by CMS
bull Explains why we have PCMH instead of PCHH
bull Where is the real value on a national level in preventing disease and
controlling costs
bull Beware- wersquove been found
61
Reasons Dental Managed Care is Spreading Across the States
NON-MANAGED CARE STATE DENTAL BUDGETS ARE
OPENED ENDED
STRAIN ON STATE BUDGETS
UPCOMING RECESSION WITH TRILLION DOLLAR
DEFICIT
SHIFTS FINANCIAL RISK FROM THE STATES TO THE
PLANS
6262
Types of Medicaid Managed Care
bull State Medicaid agency administrator lowest administrative
costs
bull Third Party Administrator Typically 15 administrative costs
bull Managed Care Organization Typically 15 administrative
costs
bull Carved-in
bull Carved-out
bull Risk Based Managed Care Administrative costs part of
contract negotiation
63
RISK CONTRACTS
6464
Components of a Risk-based Contract
Risk
Medical Loss Ratio
Quality withhold
Specialty withhold
Managed care payment (pmpm)
Covered services
Fee schedule Claims are paid as usual on a FFS basis
Credentialing
Quality Review process and Quality Metrics
65
Upside Risk
The possibility that the cost of
delivering dental care to an assigned
patient panel is less than the amount
of funding calculated for that care
The Plan pays the CHC additional
funds based on a predetermine
formula
Downside Risk
The possibility that the cost of
delivering dental care to an assigned
patient panel is more than the amount
of funding calculated for that care
The CHC pays the Plan additional
funds based on a predetermine
formula
Upside and Downside Risk
66
Taking On Risk 100 or Shared Risk
With 100 risk you receive 100 of the potential savings but are also at risk for
100 of the losses
Shared Risk MCO and health center share a percentage of the risk
Shared Risk leads to better cooperation since both organizations are
incentivized to save on costs
6767
Reports Needed
bull Enrollment reports lists of who is assigned on a monthly basis
bull Reconciliation reports insure appropriate payments
bull Specialty Referral reports
bull You will need your own reporting process so you donrsquot rely completely on
reports supplied by the Plan
6868
Medical Loss Ratio
Medical Loss Ratio (MLR) is proportion of premium revenues spent on clinical
services and quality improvement also known as the Medical Loss Ratio (MLR)
For CMS requires Medical Plans to spend at least 80 to 85 of the premiums
on actual medical care
69
Administrative Fees
bull Essentially the opposite of MLR
bull The State Medicaid Agency is funded by the Governorrsquos budget
bull The State Medicaid Agency will keep some of these funds for their
admin costs and give the remaining to the Managed Care Plans
bull Private Plan admin costs can be as high as 40 but most states
limit these cost for Medicaid Plans to between 15 and 20 (85-
80 MLR)
bull This may be negotiable depending on your program size of your
program
70
Quality Withhold
bull The state withholds a certain percent (typically 2-4 ) of the funds they give
to the Plans for Value Based Reimbursement
bull They choose quality metrics and set benchmarks and assign payments for
each metric based on an assigned priority for each metric
bull If a Plan meets the benchmark of every quality metric the state passes on
their full share of the quality withhold
bull The Plans may or may not withhold a percent of the funds for quality payment
to the dentists or manage care contractors
71
Quality Withhold
Either way the Plans may or may not pass the quality payments they receive to
the dentists or contractors
This should be spelled out in a risk-based contract
72
Percent of funds set aside
to cover specialty care
referrals
Typically 10-15
Goal Limit referral costs
to within or less than
Specialty set aside
Specialty Withhold
73
Per Member Per Month
bull Capitated Payment
bull Specific dollar amount paid for each enrolled member each month
bull Paid whether patient is accessed for care or not
bull States do set access benchmarks
bull In Oregon access for any dental procedure (adults and children combined)
was 267 in 2015
74
Payment Math Example
Premium per enrollee = $25
Administrative fee 15 = $375
Funds available per enrollee to the clinic = $2125
Management fee per enrollee = $175
Funds per enrollee that would undergo PPS reconciliation = $1950
For every 10000 enrollees the managed care income = $2340000
Specialty withhold (10) = $234000
YE Cost lt or gt $2340000
Upside Risk
CHC Gains $
Downside Risk
CHC Loses $
75
Covered Services and Fee Schedules
bull The state Medicaid agency spells out the minimum procedures and fees that
MCOs must cover
bull MCOs may add procedures or increase periodicity of procedures particularly
preventative services
bull MCOs may increase fees to entice rural providers and specialists to enroll in
their Plans
bull Access Rules
bull How many days it takes to access a patent
bull How many days it takes for a patent to access urgent care services
bull How many days it takes for a patent to access emergency care services
76
Credentialing
All MCOs are required to credential all Providers
All MCOs have their own credentialing process
Credentialing process is can be lengthy
Credentialing process may be negotiable
77
Quality Review Process and Quality Metrics
MCOs must have a Quality and Compliance Review Process
If you arenrsquot in compliance with both you likely wonrsquot get paid
Typical processes reviewed
bull Charting specifications
bull Incident report
bull Enrollee complaints quality rudeness and access issues
bull Medicaid compliance
78
Quality Payments
bull State Shared Incentive Withhold Typically quality metrics and benchmarks
are set by the state sets aside a certain percent (3-5) of the payments to
the Managed Care Plan (MCP)
bull If the benchmarks are achieved the MCP is then paid the a predetermine
amount
bull Benchmarks may not be the same as the states
bull Managed Care Plans do not have to pass all or any of the quality payments to
the health centers or providers
bull Managed Care contract- Metrics benchmarks should be selected and part of
the contract
7979
Achieving Quality Metric Payments
Dealing with under achievers
Process issues
Individual issues
Identifying workflows
Developing Best Practices through
PDSA process
Developing Best Practices through
PDSA process
CHC Metrics Committee
Clinicians Operations various key staff
Identify Best Practices
Spread Best Practices
80
New Team Needed Business Intelligence
Business Intelligence (BI) is critical for effective managed care business decisions
BI team inputs metrics into your EHR collects integrates analyses and displays all your managed care business and clinical information
Easy to say- hard to achieve
Build your own or outsource
Possible future role of Primary Care Associations
8181
Clinicianrsquos Dashboard
Expensive to build
Displayed on your screen when your computer is first turned on
Easy to read and understand
Data dumped from the day before
Can dialed down from Org-wide to clinic to each clinicianrsquos data
Operational and clinical metrics
bull Treatment Plan Completion
bull DQA quality measures
bull Caries at Recall
bull Re-care reports
bull Care Gap reports
82
CONTROLLING COSTS
8383
Controlling Costs- Current
bull Increasing efficiencies
bull Decreasing broken appointments
bull Controlling supplies equipment costs
bull Staff recruitment retention costs
84
Specialty Care
Training current CHC dentists in
specialty areas
Hiring general dentists with higher
specialty skill sets
Hiring in house specialists
Contract with outside specialists
Work with Managed Care Plan
specialists
Lowering Disease Rates
Community Dental Health
Coordinators case management
If your state law allows- embed
hygienists in medical and community
to provide primary and secondary
prevention procedures
In clinic Caries Classification and
Silver Diamine Fluoride
Effective recare programs
Controlling Costs- Additions in Risk-based Contracting
85
Specialty Care ndash Primary Referrals by Cost
Pediatric dentistry
Orthodontics
Oral surgery
Endodontics
86
In-clinic Pediatric Services
Encounters expected
of operatories available
State dental law and ability to have
expanded duties
General Anesthesia
GA in- house
Ability for a hospital or surgery center
to set aside regular OR time
Ability to hire or assign DAs to GA
days
Four GA cases day x PPS rate
Should You Hire a Pediatric Dentist- It Depends
8787
Solutions for Controlling Pediatric Costs
Hire a general dentist that is skilled in treating young children
Make the clinic child friendly nitrous oxide TVs in the operatory etc
Teach entire staff behavioral control techniques
Contract with a pediatric dentist for the GA care
88
Lowering Overall Disease Rates (and Costs)
You are responsible for both the patients you see in the chair and the ones
assigned to you
Breaking down the walls of the dental clinic
Community Dental Health Coordinators
Case Management
89
Cost Control Essentials
Diagnosis codes
Increased ability to identify
disease by risk
Motivational
Interviewing
Developing Polices and
Procedures design to treat
disease according to risk
ie Silver Diamine Fluoride
Treating by Risk
Effective Recare
Process
Critical to continual disease
controlPrevention education that is
meaningful and designed to
change behaviors
90
Social Determinants of Health Aunt Bertha
httpswwwauntberthacom
91
REASON TO CONSIDER RISK- BASED CONTRACTING
9292
PPS Reconciliation and Federal Code 42 CFR sect4052469(a)(2)
42 CFR sect4052469(a)(2)
ldquoAny financial incentives provided to Federally Qualified Health Centers
under their Medicare Advantage Contracts such as risk pool payments
bonuses or withholds are prohibited from being included in the
calculation of supplemental payments due to the Federally Qualified
Health Centerrdquo
9393
Why Risk Based Contract in Times of PPS Reconciliation
bull Not all Risk- based Contract funds are reconciled
bull Risk is the key word- you can come out with less money than your normal
PPS reconciliation payment
bull Can lead to better patient care
bull May improve manage care enrollment for your medical plan
bull Promotes integrated care increases health for your CHC patients
9494
Not Included in the Reconciliation
Enrollment management pmpm
Quality Payments
Upside risk payments
Downside risk losses
9595
Determinants of Financial Success in Risk-Based Contracting
bull Most critical- State pmpm payment to the Managed Care Plan
bull Reporting capabilities
bull Specialty service capabilities
bull Access numbers count
bull Ability to move metric numbers
9696
What About the Non- Medicaid Poor We Serve
bull Numbers are king in a managed care contract and the more access you have
the better contract terms you can negotiate
bull We will potentially have a steady supply of Medicaid patients
bull As managed care spreads states this may be compromising the ability of
health centers to serve the non-Medicaid poor and others lacking dental
insurance
97
Mark Koday DDS
(509) 949-2278
Dental Quality Consultants
of WA
httpdentalqualityconsultin
gcom
dentalqualityconsultantsg
mailcom
Contact Information
LUNCH
BREAKOUT EXERCISEORAL HEALTH VALUE-BASED CARE READINESS ASSESSMENT
Danielle Apostolon
PROMISING PRACTICES FROM THE FIELD STRATEGIES FOR INCREASING VALUE IN ORAL HEALTH
Dr Carolyn Brown
Dr Kelly Perry
Dr Rachel Rivard
Dr Adeloye
Commitment Compassion Community
m i d s t a t e h e a l t h o r g
Promising Practices from the
Field Strategies for Increasing
Value in Oral Health Care
Kelly Perry DMD
Better Health
Outcomes
Improved Staff
Experience
Reduced Cost
Improved Patient
Experience
Better Health
Outcomes
Improved Staff
Experience
Reduced Cost
Improved Patient
Experience
Better Health
Outcomes
Improved Staff
Experience
Reduced Cost
Improved Patient
Experience
Better Health
Outcomes
Improved Staff
Experience
Reduced Cost
Improved Patient
Experience
Commitment Compassion Community
kpe r r ymids t a tehea l t h o rg
Thank you
Completion of Disease Control Phase
Pelumi Adeloye DMD MPH
HEALTH ACCESS NETWORK (HAN) FAMILY DENTAL
Introduction
⧫1 Dentist I Hygienist 3 EFDArsquos1 Receptionist
⧫ 6 Chairs= 4 (dentist) + 2 (hygienist)
⧫ Slide ⥶80 off
⧫ Service areas Northern Penobscot Southern Aroostook Western
Washington Counties amp more
Completion of Phase I Treatment
⧫LimitedLack of Access to dental care
⧫Difficulty completing the disease control phase
Caries amp periodontal disease
⧫Attaining stable restorative state
Goal
Increase the completion of Disease Control Phase
Current practice
⧫Education
Assess level of dental literacy
Incremental strategy
⧫Increase access to dental care
Generous sliding scale (⥸$40 per visit)
Incorporate Expanded Function Dental Assistants
⧫Schedule modification
Incorporate more restorative blocks to allow
for follow-up visit and completion of restorative phase
httpswwwglasbergencomdentist-cartoons
Schedule
⧫Piggybacking technique
Increased allotted restorative blocks
⧫Sustainability of current schedule is
contingent on cooperation amp skills of HAN
Dental staff
Note
Strategies mentioned today is personalized to HAN Dental clinic
Current implemented strategies might be modified or changed in the
future as required in order to accommodate the need of our pts
THANK YOU
DAY TWOCLOSINGWRAP-UP
End of Day Two ndash Survey
Day Two Creating a Value-Based Oral Health Care Delivery
System
129
Payment Reform in Oral Health Online Learning Module
Oral Health Value-based Care Online Learning Module
Value-based Care Keys to Success Article
Readiness Assessment
Competency Development Guide
Oral Health Value-based Care Training
Dental Caries Management Practicum
Clinicians Companion Guide
Interprofessional Network Referral Process
Traditional Dental Care Vs Value-Based Care
Resources
131
wwwDentaQuestPartnershiporg
wwwfacebookcomDentaQuest
DentaQuest
wwwlinkedincomcompanyDentaQuest
Inside_DentaQuest
QUESTIONS
60
Rule of 4
bull This helps explain why oral health has been relatively ignored so far by CMS
bull Explains why we have PCMH instead of PCHH
bull Where is the real value on a national level in preventing disease and
controlling costs
bull Beware- wersquove been found
61
Reasons Dental Managed Care is Spreading Across the States
NON-MANAGED CARE STATE DENTAL BUDGETS ARE
OPENED ENDED
STRAIN ON STATE BUDGETS
UPCOMING RECESSION WITH TRILLION DOLLAR
DEFICIT
SHIFTS FINANCIAL RISK FROM THE STATES TO THE
PLANS
6262
Types of Medicaid Managed Care
bull State Medicaid agency administrator lowest administrative
costs
bull Third Party Administrator Typically 15 administrative costs
bull Managed Care Organization Typically 15 administrative
costs
bull Carved-in
bull Carved-out
bull Risk Based Managed Care Administrative costs part of
contract negotiation
63
RISK CONTRACTS
6464
Components of a Risk-based Contract
Risk
Medical Loss Ratio
Quality withhold
Specialty withhold
Managed care payment (pmpm)
Covered services
Fee schedule Claims are paid as usual on a FFS basis
Credentialing
Quality Review process and Quality Metrics
65
Upside Risk
The possibility that the cost of
delivering dental care to an assigned
patient panel is less than the amount
of funding calculated for that care
The Plan pays the CHC additional
funds based on a predetermine
formula
Downside Risk
The possibility that the cost of
delivering dental care to an assigned
patient panel is more than the amount
of funding calculated for that care
The CHC pays the Plan additional
funds based on a predetermine
formula
Upside and Downside Risk
66
Taking On Risk 100 or Shared Risk
With 100 risk you receive 100 of the potential savings but are also at risk for
100 of the losses
Shared Risk MCO and health center share a percentage of the risk
Shared Risk leads to better cooperation since both organizations are
incentivized to save on costs
6767
Reports Needed
bull Enrollment reports lists of who is assigned on a monthly basis
bull Reconciliation reports insure appropriate payments
bull Specialty Referral reports
bull You will need your own reporting process so you donrsquot rely completely on
reports supplied by the Plan
6868
Medical Loss Ratio
Medical Loss Ratio (MLR) is proportion of premium revenues spent on clinical
services and quality improvement also known as the Medical Loss Ratio (MLR)
For CMS requires Medical Plans to spend at least 80 to 85 of the premiums
on actual medical care
69
Administrative Fees
bull Essentially the opposite of MLR
bull The State Medicaid Agency is funded by the Governorrsquos budget
bull The State Medicaid Agency will keep some of these funds for their
admin costs and give the remaining to the Managed Care Plans
bull Private Plan admin costs can be as high as 40 but most states
limit these cost for Medicaid Plans to between 15 and 20 (85-
80 MLR)
bull This may be negotiable depending on your program size of your
program
70
Quality Withhold
bull The state withholds a certain percent (typically 2-4 ) of the funds they give
to the Plans for Value Based Reimbursement
bull They choose quality metrics and set benchmarks and assign payments for
each metric based on an assigned priority for each metric
bull If a Plan meets the benchmark of every quality metric the state passes on
their full share of the quality withhold
bull The Plans may or may not withhold a percent of the funds for quality payment
to the dentists or manage care contractors
71
Quality Withhold
Either way the Plans may or may not pass the quality payments they receive to
the dentists or contractors
This should be spelled out in a risk-based contract
72
Percent of funds set aside
to cover specialty care
referrals
Typically 10-15
Goal Limit referral costs
to within or less than
Specialty set aside
Specialty Withhold
73
Per Member Per Month
bull Capitated Payment
bull Specific dollar amount paid for each enrolled member each month
bull Paid whether patient is accessed for care or not
bull States do set access benchmarks
bull In Oregon access for any dental procedure (adults and children combined)
was 267 in 2015
74
Payment Math Example
Premium per enrollee = $25
Administrative fee 15 = $375
Funds available per enrollee to the clinic = $2125
Management fee per enrollee = $175
Funds per enrollee that would undergo PPS reconciliation = $1950
For every 10000 enrollees the managed care income = $2340000
Specialty withhold (10) = $234000
YE Cost lt or gt $2340000
Upside Risk
CHC Gains $
Downside Risk
CHC Loses $
75
Covered Services and Fee Schedules
bull The state Medicaid agency spells out the minimum procedures and fees that
MCOs must cover
bull MCOs may add procedures or increase periodicity of procedures particularly
preventative services
bull MCOs may increase fees to entice rural providers and specialists to enroll in
their Plans
bull Access Rules
bull How many days it takes to access a patent
bull How many days it takes for a patent to access urgent care services
bull How many days it takes for a patent to access emergency care services
76
Credentialing
All MCOs are required to credential all Providers
All MCOs have their own credentialing process
Credentialing process is can be lengthy
Credentialing process may be negotiable
77
Quality Review Process and Quality Metrics
MCOs must have a Quality and Compliance Review Process
If you arenrsquot in compliance with both you likely wonrsquot get paid
Typical processes reviewed
bull Charting specifications
bull Incident report
bull Enrollee complaints quality rudeness and access issues
bull Medicaid compliance
78
Quality Payments
bull State Shared Incentive Withhold Typically quality metrics and benchmarks
are set by the state sets aside a certain percent (3-5) of the payments to
the Managed Care Plan (MCP)
bull If the benchmarks are achieved the MCP is then paid the a predetermine
amount
bull Benchmarks may not be the same as the states
bull Managed Care Plans do not have to pass all or any of the quality payments to
the health centers or providers
bull Managed Care contract- Metrics benchmarks should be selected and part of
the contract
7979
Achieving Quality Metric Payments
Dealing with under achievers
Process issues
Individual issues
Identifying workflows
Developing Best Practices through
PDSA process
Developing Best Practices through
PDSA process
CHC Metrics Committee
Clinicians Operations various key staff
Identify Best Practices
Spread Best Practices
80
New Team Needed Business Intelligence
Business Intelligence (BI) is critical for effective managed care business decisions
BI team inputs metrics into your EHR collects integrates analyses and displays all your managed care business and clinical information
Easy to say- hard to achieve
Build your own or outsource
Possible future role of Primary Care Associations
8181
Clinicianrsquos Dashboard
Expensive to build
Displayed on your screen when your computer is first turned on
Easy to read and understand
Data dumped from the day before
Can dialed down from Org-wide to clinic to each clinicianrsquos data
Operational and clinical metrics
bull Treatment Plan Completion
bull DQA quality measures
bull Caries at Recall
bull Re-care reports
bull Care Gap reports
82
CONTROLLING COSTS
8383
Controlling Costs- Current
bull Increasing efficiencies
bull Decreasing broken appointments
bull Controlling supplies equipment costs
bull Staff recruitment retention costs
84
Specialty Care
Training current CHC dentists in
specialty areas
Hiring general dentists with higher
specialty skill sets
Hiring in house specialists
Contract with outside specialists
Work with Managed Care Plan
specialists
Lowering Disease Rates
Community Dental Health
Coordinators case management
If your state law allows- embed
hygienists in medical and community
to provide primary and secondary
prevention procedures
In clinic Caries Classification and
Silver Diamine Fluoride
Effective recare programs
Controlling Costs- Additions in Risk-based Contracting
85
Specialty Care ndash Primary Referrals by Cost
Pediatric dentistry
Orthodontics
Oral surgery
Endodontics
86
In-clinic Pediatric Services
Encounters expected
of operatories available
State dental law and ability to have
expanded duties
General Anesthesia
GA in- house
Ability for a hospital or surgery center
to set aside regular OR time
Ability to hire or assign DAs to GA
days
Four GA cases day x PPS rate
Should You Hire a Pediatric Dentist- It Depends
8787
Solutions for Controlling Pediatric Costs
Hire a general dentist that is skilled in treating young children
Make the clinic child friendly nitrous oxide TVs in the operatory etc
Teach entire staff behavioral control techniques
Contract with a pediatric dentist for the GA care
88
Lowering Overall Disease Rates (and Costs)
You are responsible for both the patients you see in the chair and the ones
assigned to you
Breaking down the walls of the dental clinic
Community Dental Health Coordinators
Case Management
89
Cost Control Essentials
Diagnosis codes
Increased ability to identify
disease by risk
Motivational
Interviewing
Developing Polices and
Procedures design to treat
disease according to risk
ie Silver Diamine Fluoride
Treating by Risk
Effective Recare
Process
Critical to continual disease
controlPrevention education that is
meaningful and designed to
change behaviors
90
Social Determinants of Health Aunt Bertha
httpswwwauntberthacom
91
REASON TO CONSIDER RISK- BASED CONTRACTING
9292
PPS Reconciliation and Federal Code 42 CFR sect4052469(a)(2)
42 CFR sect4052469(a)(2)
ldquoAny financial incentives provided to Federally Qualified Health Centers
under their Medicare Advantage Contracts such as risk pool payments
bonuses or withholds are prohibited from being included in the
calculation of supplemental payments due to the Federally Qualified
Health Centerrdquo
9393
Why Risk Based Contract in Times of PPS Reconciliation
bull Not all Risk- based Contract funds are reconciled
bull Risk is the key word- you can come out with less money than your normal
PPS reconciliation payment
bull Can lead to better patient care
bull May improve manage care enrollment for your medical plan
bull Promotes integrated care increases health for your CHC patients
9494
Not Included in the Reconciliation
Enrollment management pmpm
Quality Payments
Upside risk payments
Downside risk losses
9595
Determinants of Financial Success in Risk-Based Contracting
bull Most critical- State pmpm payment to the Managed Care Plan
bull Reporting capabilities
bull Specialty service capabilities
bull Access numbers count
bull Ability to move metric numbers
9696
What About the Non- Medicaid Poor We Serve
bull Numbers are king in a managed care contract and the more access you have
the better contract terms you can negotiate
bull We will potentially have a steady supply of Medicaid patients
bull As managed care spreads states this may be compromising the ability of
health centers to serve the non-Medicaid poor and others lacking dental
insurance
97
Mark Koday DDS
(509) 949-2278
Dental Quality Consultants
of WA
httpdentalqualityconsultin
gcom
dentalqualityconsultantsg
mailcom
Contact Information
LUNCH
BREAKOUT EXERCISEORAL HEALTH VALUE-BASED CARE READINESS ASSESSMENT
Danielle Apostolon
PROMISING PRACTICES FROM THE FIELD STRATEGIES FOR INCREASING VALUE IN ORAL HEALTH
Dr Carolyn Brown
Dr Kelly Perry
Dr Rachel Rivard
Dr Adeloye
Commitment Compassion Community
m i d s t a t e h e a l t h o r g
Promising Practices from the
Field Strategies for Increasing
Value in Oral Health Care
Kelly Perry DMD
Better Health
Outcomes
Improved Staff
Experience
Reduced Cost
Improved Patient
Experience
Better Health
Outcomes
Improved Staff
Experience
Reduced Cost
Improved Patient
Experience
Better Health
Outcomes
Improved Staff
Experience
Reduced Cost
Improved Patient
Experience
Better Health
Outcomes
Improved Staff
Experience
Reduced Cost
Improved Patient
Experience
Commitment Compassion Community
kpe r r ymids t a tehea l t h o rg
Thank you
Completion of Disease Control Phase
Pelumi Adeloye DMD MPH
HEALTH ACCESS NETWORK (HAN) FAMILY DENTAL
Introduction
⧫1 Dentist I Hygienist 3 EFDArsquos1 Receptionist
⧫ 6 Chairs= 4 (dentist) + 2 (hygienist)
⧫ Slide ⥶80 off
⧫ Service areas Northern Penobscot Southern Aroostook Western
Washington Counties amp more
Completion of Phase I Treatment
⧫LimitedLack of Access to dental care
⧫Difficulty completing the disease control phase
Caries amp periodontal disease
⧫Attaining stable restorative state
Goal
Increase the completion of Disease Control Phase
Current practice
⧫Education
Assess level of dental literacy
Incremental strategy
⧫Increase access to dental care
Generous sliding scale (⥸$40 per visit)
Incorporate Expanded Function Dental Assistants
⧫Schedule modification
Incorporate more restorative blocks to allow
for follow-up visit and completion of restorative phase
httpswwwglasbergencomdentist-cartoons
Schedule
⧫Piggybacking technique
Increased allotted restorative blocks
⧫Sustainability of current schedule is
contingent on cooperation amp skills of HAN
Dental staff
Note
Strategies mentioned today is personalized to HAN Dental clinic
Current implemented strategies might be modified or changed in the
future as required in order to accommodate the need of our pts
THANK YOU
DAY TWOCLOSINGWRAP-UP
End of Day Two ndash Survey
Day Two Creating a Value-Based Oral Health Care Delivery
System
129
Payment Reform in Oral Health Online Learning Module
Oral Health Value-based Care Online Learning Module
Value-based Care Keys to Success Article
Readiness Assessment
Competency Development Guide
Oral Health Value-based Care Training
Dental Caries Management Practicum
Clinicians Companion Guide
Interprofessional Network Referral Process
Traditional Dental Care Vs Value-Based Care
Resources
131
wwwDentaQuestPartnershiporg
wwwfacebookcomDentaQuest
DentaQuest
wwwlinkedincomcompanyDentaQuest
Inside_DentaQuest
QUESTIONS
61
Reasons Dental Managed Care is Spreading Across the States
NON-MANAGED CARE STATE DENTAL BUDGETS ARE
OPENED ENDED
STRAIN ON STATE BUDGETS
UPCOMING RECESSION WITH TRILLION DOLLAR
DEFICIT
SHIFTS FINANCIAL RISK FROM THE STATES TO THE
PLANS
6262
Types of Medicaid Managed Care
bull State Medicaid agency administrator lowest administrative
costs
bull Third Party Administrator Typically 15 administrative costs
bull Managed Care Organization Typically 15 administrative
costs
bull Carved-in
bull Carved-out
bull Risk Based Managed Care Administrative costs part of
contract negotiation
63
RISK CONTRACTS
6464
Components of a Risk-based Contract
Risk
Medical Loss Ratio
Quality withhold
Specialty withhold
Managed care payment (pmpm)
Covered services
Fee schedule Claims are paid as usual on a FFS basis
Credentialing
Quality Review process and Quality Metrics
65
Upside Risk
The possibility that the cost of
delivering dental care to an assigned
patient panel is less than the amount
of funding calculated for that care
The Plan pays the CHC additional
funds based on a predetermine
formula
Downside Risk
The possibility that the cost of
delivering dental care to an assigned
patient panel is more than the amount
of funding calculated for that care
The CHC pays the Plan additional
funds based on a predetermine
formula
Upside and Downside Risk
66
Taking On Risk 100 or Shared Risk
With 100 risk you receive 100 of the potential savings but are also at risk for
100 of the losses
Shared Risk MCO and health center share a percentage of the risk
Shared Risk leads to better cooperation since both organizations are
incentivized to save on costs
6767
Reports Needed
bull Enrollment reports lists of who is assigned on a monthly basis
bull Reconciliation reports insure appropriate payments
bull Specialty Referral reports
bull You will need your own reporting process so you donrsquot rely completely on
reports supplied by the Plan
6868
Medical Loss Ratio
Medical Loss Ratio (MLR) is proportion of premium revenues spent on clinical
services and quality improvement also known as the Medical Loss Ratio (MLR)
For CMS requires Medical Plans to spend at least 80 to 85 of the premiums
on actual medical care
69
Administrative Fees
bull Essentially the opposite of MLR
bull The State Medicaid Agency is funded by the Governorrsquos budget
bull The State Medicaid Agency will keep some of these funds for their
admin costs and give the remaining to the Managed Care Plans
bull Private Plan admin costs can be as high as 40 but most states
limit these cost for Medicaid Plans to between 15 and 20 (85-
80 MLR)
bull This may be negotiable depending on your program size of your
program
70
Quality Withhold
bull The state withholds a certain percent (typically 2-4 ) of the funds they give
to the Plans for Value Based Reimbursement
bull They choose quality metrics and set benchmarks and assign payments for
each metric based on an assigned priority for each metric
bull If a Plan meets the benchmark of every quality metric the state passes on
their full share of the quality withhold
bull The Plans may or may not withhold a percent of the funds for quality payment
to the dentists or manage care contractors
71
Quality Withhold
Either way the Plans may or may not pass the quality payments they receive to
the dentists or contractors
This should be spelled out in a risk-based contract
72
Percent of funds set aside
to cover specialty care
referrals
Typically 10-15
Goal Limit referral costs
to within or less than
Specialty set aside
Specialty Withhold
73
Per Member Per Month
bull Capitated Payment
bull Specific dollar amount paid for each enrolled member each month
bull Paid whether patient is accessed for care or not
bull States do set access benchmarks
bull In Oregon access for any dental procedure (adults and children combined)
was 267 in 2015
74
Payment Math Example
Premium per enrollee = $25
Administrative fee 15 = $375
Funds available per enrollee to the clinic = $2125
Management fee per enrollee = $175
Funds per enrollee that would undergo PPS reconciliation = $1950
For every 10000 enrollees the managed care income = $2340000
Specialty withhold (10) = $234000
YE Cost lt or gt $2340000
Upside Risk
CHC Gains $
Downside Risk
CHC Loses $
75
Covered Services and Fee Schedules
bull The state Medicaid agency spells out the minimum procedures and fees that
MCOs must cover
bull MCOs may add procedures or increase periodicity of procedures particularly
preventative services
bull MCOs may increase fees to entice rural providers and specialists to enroll in
their Plans
bull Access Rules
bull How many days it takes to access a patent
bull How many days it takes for a patent to access urgent care services
bull How many days it takes for a patent to access emergency care services
76
Credentialing
All MCOs are required to credential all Providers
All MCOs have their own credentialing process
Credentialing process is can be lengthy
Credentialing process may be negotiable
77
Quality Review Process and Quality Metrics
MCOs must have a Quality and Compliance Review Process
If you arenrsquot in compliance with both you likely wonrsquot get paid
Typical processes reviewed
bull Charting specifications
bull Incident report
bull Enrollee complaints quality rudeness and access issues
bull Medicaid compliance
78
Quality Payments
bull State Shared Incentive Withhold Typically quality metrics and benchmarks
are set by the state sets aside a certain percent (3-5) of the payments to
the Managed Care Plan (MCP)
bull If the benchmarks are achieved the MCP is then paid the a predetermine
amount
bull Benchmarks may not be the same as the states
bull Managed Care Plans do not have to pass all or any of the quality payments to
the health centers or providers
bull Managed Care contract- Metrics benchmarks should be selected and part of
the contract
7979
Achieving Quality Metric Payments
Dealing with under achievers
Process issues
Individual issues
Identifying workflows
Developing Best Practices through
PDSA process
Developing Best Practices through
PDSA process
CHC Metrics Committee
Clinicians Operations various key staff
Identify Best Practices
Spread Best Practices
80
New Team Needed Business Intelligence
Business Intelligence (BI) is critical for effective managed care business decisions
BI team inputs metrics into your EHR collects integrates analyses and displays all your managed care business and clinical information
Easy to say- hard to achieve
Build your own or outsource
Possible future role of Primary Care Associations
8181
Clinicianrsquos Dashboard
Expensive to build
Displayed on your screen when your computer is first turned on
Easy to read and understand
Data dumped from the day before
Can dialed down from Org-wide to clinic to each clinicianrsquos data
Operational and clinical metrics
bull Treatment Plan Completion
bull DQA quality measures
bull Caries at Recall
bull Re-care reports
bull Care Gap reports
82
CONTROLLING COSTS
8383
Controlling Costs- Current
bull Increasing efficiencies
bull Decreasing broken appointments
bull Controlling supplies equipment costs
bull Staff recruitment retention costs
84
Specialty Care
Training current CHC dentists in
specialty areas
Hiring general dentists with higher
specialty skill sets
Hiring in house specialists
Contract with outside specialists
Work with Managed Care Plan
specialists
Lowering Disease Rates
Community Dental Health
Coordinators case management
If your state law allows- embed
hygienists in medical and community
to provide primary and secondary
prevention procedures
In clinic Caries Classification and
Silver Diamine Fluoride
Effective recare programs
Controlling Costs- Additions in Risk-based Contracting
85
Specialty Care ndash Primary Referrals by Cost
Pediatric dentistry
Orthodontics
Oral surgery
Endodontics
86
In-clinic Pediatric Services
Encounters expected
of operatories available
State dental law and ability to have
expanded duties
General Anesthesia
GA in- house
Ability for a hospital or surgery center
to set aside regular OR time
Ability to hire or assign DAs to GA
days
Four GA cases day x PPS rate
Should You Hire a Pediatric Dentist- It Depends
8787
Solutions for Controlling Pediatric Costs
Hire a general dentist that is skilled in treating young children
Make the clinic child friendly nitrous oxide TVs in the operatory etc
Teach entire staff behavioral control techniques
Contract with a pediatric dentist for the GA care
88
Lowering Overall Disease Rates (and Costs)
You are responsible for both the patients you see in the chair and the ones
assigned to you
Breaking down the walls of the dental clinic
Community Dental Health Coordinators
Case Management
89
Cost Control Essentials
Diagnosis codes
Increased ability to identify
disease by risk
Motivational
Interviewing
Developing Polices and
Procedures design to treat
disease according to risk
ie Silver Diamine Fluoride
Treating by Risk
Effective Recare
Process
Critical to continual disease
controlPrevention education that is
meaningful and designed to
change behaviors
90
Social Determinants of Health Aunt Bertha
httpswwwauntberthacom
91
REASON TO CONSIDER RISK- BASED CONTRACTING
9292
PPS Reconciliation and Federal Code 42 CFR sect4052469(a)(2)
42 CFR sect4052469(a)(2)
ldquoAny financial incentives provided to Federally Qualified Health Centers
under their Medicare Advantage Contracts such as risk pool payments
bonuses or withholds are prohibited from being included in the
calculation of supplemental payments due to the Federally Qualified
Health Centerrdquo
9393
Why Risk Based Contract in Times of PPS Reconciliation
bull Not all Risk- based Contract funds are reconciled
bull Risk is the key word- you can come out with less money than your normal
PPS reconciliation payment
bull Can lead to better patient care
bull May improve manage care enrollment for your medical plan
bull Promotes integrated care increases health for your CHC patients
9494
Not Included in the Reconciliation
Enrollment management pmpm
Quality Payments
Upside risk payments
Downside risk losses
9595
Determinants of Financial Success in Risk-Based Contracting
bull Most critical- State pmpm payment to the Managed Care Plan
bull Reporting capabilities
bull Specialty service capabilities
bull Access numbers count
bull Ability to move metric numbers
9696
What About the Non- Medicaid Poor We Serve
bull Numbers are king in a managed care contract and the more access you have
the better contract terms you can negotiate
bull We will potentially have a steady supply of Medicaid patients
bull As managed care spreads states this may be compromising the ability of
health centers to serve the non-Medicaid poor and others lacking dental
insurance
97
Mark Koday DDS
(509) 949-2278
Dental Quality Consultants
of WA
httpdentalqualityconsultin
gcom
dentalqualityconsultantsg
mailcom
Contact Information
LUNCH
BREAKOUT EXERCISEORAL HEALTH VALUE-BASED CARE READINESS ASSESSMENT
Danielle Apostolon
PROMISING PRACTICES FROM THE FIELD STRATEGIES FOR INCREASING VALUE IN ORAL HEALTH
Dr Carolyn Brown
Dr Kelly Perry
Dr Rachel Rivard
Dr Adeloye
Commitment Compassion Community
m i d s t a t e h e a l t h o r g
Promising Practices from the
Field Strategies for Increasing
Value in Oral Health Care
Kelly Perry DMD
Better Health
Outcomes
Improved Staff
Experience
Reduced Cost
Improved Patient
Experience
Better Health
Outcomes
Improved Staff
Experience
Reduced Cost
Improved Patient
Experience
Better Health
Outcomes
Improved Staff
Experience
Reduced Cost
Improved Patient
Experience
Better Health
Outcomes
Improved Staff
Experience
Reduced Cost
Improved Patient
Experience
Commitment Compassion Community
kpe r r ymids t a tehea l t h o rg
Thank you
Completion of Disease Control Phase
Pelumi Adeloye DMD MPH
HEALTH ACCESS NETWORK (HAN) FAMILY DENTAL
Introduction
⧫1 Dentist I Hygienist 3 EFDArsquos1 Receptionist
⧫ 6 Chairs= 4 (dentist) + 2 (hygienist)
⧫ Slide ⥶80 off
⧫ Service areas Northern Penobscot Southern Aroostook Western
Washington Counties amp more
Completion of Phase I Treatment
⧫LimitedLack of Access to dental care
⧫Difficulty completing the disease control phase
Caries amp periodontal disease
⧫Attaining stable restorative state
Goal
Increase the completion of Disease Control Phase
Current practice
⧫Education
Assess level of dental literacy
Incremental strategy
⧫Increase access to dental care
Generous sliding scale (⥸$40 per visit)
Incorporate Expanded Function Dental Assistants
⧫Schedule modification
Incorporate more restorative blocks to allow
for follow-up visit and completion of restorative phase
httpswwwglasbergencomdentist-cartoons
Schedule
⧫Piggybacking technique
Increased allotted restorative blocks
⧫Sustainability of current schedule is
contingent on cooperation amp skills of HAN
Dental staff
Note
Strategies mentioned today is personalized to HAN Dental clinic
Current implemented strategies might be modified or changed in the
future as required in order to accommodate the need of our pts
THANK YOU
DAY TWOCLOSINGWRAP-UP
End of Day Two ndash Survey
Day Two Creating a Value-Based Oral Health Care Delivery
System
129
Payment Reform in Oral Health Online Learning Module
Oral Health Value-based Care Online Learning Module
Value-based Care Keys to Success Article
Readiness Assessment
Competency Development Guide
Oral Health Value-based Care Training
Dental Caries Management Practicum
Clinicians Companion Guide
Interprofessional Network Referral Process
Traditional Dental Care Vs Value-Based Care
Resources
131
wwwDentaQuestPartnershiporg
wwwfacebookcomDentaQuest
DentaQuest
wwwlinkedincomcompanyDentaQuest
Inside_DentaQuest
QUESTIONS
6262
Types of Medicaid Managed Care
bull State Medicaid agency administrator lowest administrative
costs
bull Third Party Administrator Typically 15 administrative costs
bull Managed Care Organization Typically 15 administrative
costs
bull Carved-in
bull Carved-out
bull Risk Based Managed Care Administrative costs part of
contract negotiation
63
RISK CONTRACTS
6464
Components of a Risk-based Contract
Risk
Medical Loss Ratio
Quality withhold
Specialty withhold
Managed care payment (pmpm)
Covered services
Fee schedule Claims are paid as usual on a FFS basis
Credentialing
Quality Review process and Quality Metrics
65
Upside Risk
The possibility that the cost of
delivering dental care to an assigned
patient panel is less than the amount
of funding calculated for that care
The Plan pays the CHC additional
funds based on a predetermine
formula
Downside Risk
The possibility that the cost of
delivering dental care to an assigned
patient panel is more than the amount
of funding calculated for that care
The CHC pays the Plan additional
funds based on a predetermine
formula
Upside and Downside Risk
66
Taking On Risk 100 or Shared Risk
With 100 risk you receive 100 of the potential savings but are also at risk for
100 of the losses
Shared Risk MCO and health center share a percentage of the risk
Shared Risk leads to better cooperation since both organizations are
incentivized to save on costs
6767
Reports Needed
bull Enrollment reports lists of who is assigned on a monthly basis
bull Reconciliation reports insure appropriate payments
bull Specialty Referral reports
bull You will need your own reporting process so you donrsquot rely completely on
reports supplied by the Plan
6868
Medical Loss Ratio
Medical Loss Ratio (MLR) is proportion of premium revenues spent on clinical
services and quality improvement also known as the Medical Loss Ratio (MLR)
For CMS requires Medical Plans to spend at least 80 to 85 of the premiums
on actual medical care
69
Administrative Fees
bull Essentially the opposite of MLR
bull The State Medicaid Agency is funded by the Governorrsquos budget
bull The State Medicaid Agency will keep some of these funds for their
admin costs and give the remaining to the Managed Care Plans
bull Private Plan admin costs can be as high as 40 but most states
limit these cost for Medicaid Plans to between 15 and 20 (85-
80 MLR)
bull This may be negotiable depending on your program size of your
program
70
Quality Withhold
bull The state withholds a certain percent (typically 2-4 ) of the funds they give
to the Plans for Value Based Reimbursement
bull They choose quality metrics and set benchmarks and assign payments for
each metric based on an assigned priority for each metric
bull If a Plan meets the benchmark of every quality metric the state passes on
their full share of the quality withhold
bull The Plans may or may not withhold a percent of the funds for quality payment
to the dentists or manage care contractors
71
Quality Withhold
Either way the Plans may or may not pass the quality payments they receive to
the dentists or contractors
This should be spelled out in a risk-based contract
72
Percent of funds set aside
to cover specialty care
referrals
Typically 10-15
Goal Limit referral costs
to within or less than
Specialty set aside
Specialty Withhold
73
Per Member Per Month
bull Capitated Payment
bull Specific dollar amount paid for each enrolled member each month
bull Paid whether patient is accessed for care or not
bull States do set access benchmarks
bull In Oregon access for any dental procedure (adults and children combined)
was 267 in 2015
74
Payment Math Example
Premium per enrollee = $25
Administrative fee 15 = $375
Funds available per enrollee to the clinic = $2125
Management fee per enrollee = $175
Funds per enrollee that would undergo PPS reconciliation = $1950
For every 10000 enrollees the managed care income = $2340000
Specialty withhold (10) = $234000
YE Cost lt or gt $2340000
Upside Risk
CHC Gains $
Downside Risk
CHC Loses $
75
Covered Services and Fee Schedules
bull The state Medicaid agency spells out the minimum procedures and fees that
MCOs must cover
bull MCOs may add procedures or increase periodicity of procedures particularly
preventative services
bull MCOs may increase fees to entice rural providers and specialists to enroll in
their Plans
bull Access Rules
bull How many days it takes to access a patent
bull How many days it takes for a patent to access urgent care services
bull How many days it takes for a patent to access emergency care services
76
Credentialing
All MCOs are required to credential all Providers
All MCOs have their own credentialing process
Credentialing process is can be lengthy
Credentialing process may be negotiable
77
Quality Review Process and Quality Metrics
MCOs must have a Quality and Compliance Review Process
If you arenrsquot in compliance with both you likely wonrsquot get paid
Typical processes reviewed
bull Charting specifications
bull Incident report
bull Enrollee complaints quality rudeness and access issues
bull Medicaid compliance
78
Quality Payments
bull State Shared Incentive Withhold Typically quality metrics and benchmarks
are set by the state sets aside a certain percent (3-5) of the payments to
the Managed Care Plan (MCP)
bull If the benchmarks are achieved the MCP is then paid the a predetermine
amount
bull Benchmarks may not be the same as the states
bull Managed Care Plans do not have to pass all or any of the quality payments to
the health centers or providers
bull Managed Care contract- Metrics benchmarks should be selected and part of
the contract
7979
Achieving Quality Metric Payments
Dealing with under achievers
Process issues
Individual issues
Identifying workflows
Developing Best Practices through
PDSA process
Developing Best Practices through
PDSA process
CHC Metrics Committee
Clinicians Operations various key staff
Identify Best Practices
Spread Best Practices
80
New Team Needed Business Intelligence
Business Intelligence (BI) is critical for effective managed care business decisions
BI team inputs metrics into your EHR collects integrates analyses and displays all your managed care business and clinical information
Easy to say- hard to achieve
Build your own or outsource
Possible future role of Primary Care Associations
8181
Clinicianrsquos Dashboard
Expensive to build
Displayed on your screen when your computer is first turned on
Easy to read and understand
Data dumped from the day before
Can dialed down from Org-wide to clinic to each clinicianrsquos data
Operational and clinical metrics
bull Treatment Plan Completion
bull DQA quality measures
bull Caries at Recall
bull Re-care reports
bull Care Gap reports
82
CONTROLLING COSTS
8383
Controlling Costs- Current
bull Increasing efficiencies
bull Decreasing broken appointments
bull Controlling supplies equipment costs
bull Staff recruitment retention costs
84
Specialty Care
Training current CHC dentists in
specialty areas
Hiring general dentists with higher
specialty skill sets
Hiring in house specialists
Contract with outside specialists
Work with Managed Care Plan
specialists
Lowering Disease Rates
Community Dental Health
Coordinators case management
If your state law allows- embed
hygienists in medical and community
to provide primary and secondary
prevention procedures
In clinic Caries Classification and
Silver Diamine Fluoride
Effective recare programs
Controlling Costs- Additions in Risk-based Contracting
85
Specialty Care ndash Primary Referrals by Cost
Pediatric dentistry
Orthodontics
Oral surgery
Endodontics
86
In-clinic Pediatric Services
Encounters expected
of operatories available
State dental law and ability to have
expanded duties
General Anesthesia
GA in- house
Ability for a hospital or surgery center
to set aside regular OR time
Ability to hire or assign DAs to GA
days
Four GA cases day x PPS rate
Should You Hire a Pediatric Dentist- It Depends
8787
Solutions for Controlling Pediatric Costs
Hire a general dentist that is skilled in treating young children
Make the clinic child friendly nitrous oxide TVs in the operatory etc
Teach entire staff behavioral control techniques
Contract with a pediatric dentist for the GA care
88
Lowering Overall Disease Rates (and Costs)
You are responsible for both the patients you see in the chair and the ones
assigned to you
Breaking down the walls of the dental clinic
Community Dental Health Coordinators
Case Management
89
Cost Control Essentials
Diagnosis codes
Increased ability to identify
disease by risk
Motivational
Interviewing
Developing Polices and
Procedures design to treat
disease according to risk
ie Silver Diamine Fluoride
Treating by Risk
Effective Recare
Process
Critical to continual disease
controlPrevention education that is
meaningful and designed to
change behaviors
90
Social Determinants of Health Aunt Bertha
httpswwwauntberthacom
91
REASON TO CONSIDER RISK- BASED CONTRACTING
9292
PPS Reconciliation and Federal Code 42 CFR sect4052469(a)(2)
42 CFR sect4052469(a)(2)
ldquoAny financial incentives provided to Federally Qualified Health Centers
under their Medicare Advantage Contracts such as risk pool payments
bonuses or withholds are prohibited from being included in the
calculation of supplemental payments due to the Federally Qualified
Health Centerrdquo
9393
Why Risk Based Contract in Times of PPS Reconciliation
bull Not all Risk- based Contract funds are reconciled
bull Risk is the key word- you can come out with less money than your normal
PPS reconciliation payment
bull Can lead to better patient care
bull May improve manage care enrollment for your medical plan
bull Promotes integrated care increases health for your CHC patients
9494
Not Included in the Reconciliation
Enrollment management pmpm
Quality Payments
Upside risk payments
Downside risk losses
9595
Determinants of Financial Success in Risk-Based Contracting
bull Most critical- State pmpm payment to the Managed Care Plan
bull Reporting capabilities
bull Specialty service capabilities
bull Access numbers count
bull Ability to move metric numbers
9696
What About the Non- Medicaid Poor We Serve
bull Numbers are king in a managed care contract and the more access you have
the better contract terms you can negotiate
bull We will potentially have a steady supply of Medicaid patients
bull As managed care spreads states this may be compromising the ability of
health centers to serve the non-Medicaid poor and others lacking dental
insurance
97
Mark Koday DDS
(509) 949-2278
Dental Quality Consultants
of WA
httpdentalqualityconsultin
gcom
dentalqualityconsultantsg
mailcom
Contact Information
LUNCH
BREAKOUT EXERCISEORAL HEALTH VALUE-BASED CARE READINESS ASSESSMENT
Danielle Apostolon
PROMISING PRACTICES FROM THE FIELD STRATEGIES FOR INCREASING VALUE IN ORAL HEALTH
Dr Carolyn Brown
Dr Kelly Perry
Dr Rachel Rivard
Dr Adeloye
Commitment Compassion Community
m i d s t a t e h e a l t h o r g
Promising Practices from the
Field Strategies for Increasing
Value in Oral Health Care
Kelly Perry DMD
Better Health
Outcomes
Improved Staff
Experience
Reduced Cost
Improved Patient
Experience
Better Health
Outcomes
Improved Staff
Experience
Reduced Cost
Improved Patient
Experience
Better Health
Outcomes
Improved Staff
Experience
Reduced Cost
Improved Patient
Experience
Better Health
Outcomes
Improved Staff
Experience
Reduced Cost
Improved Patient
Experience
Commitment Compassion Community
kpe r r ymids t a tehea l t h o rg
Thank you
Completion of Disease Control Phase
Pelumi Adeloye DMD MPH
HEALTH ACCESS NETWORK (HAN) FAMILY DENTAL
Introduction
⧫1 Dentist I Hygienist 3 EFDArsquos1 Receptionist
⧫ 6 Chairs= 4 (dentist) + 2 (hygienist)
⧫ Slide ⥶80 off
⧫ Service areas Northern Penobscot Southern Aroostook Western
Washington Counties amp more
Completion of Phase I Treatment
⧫LimitedLack of Access to dental care
⧫Difficulty completing the disease control phase
Caries amp periodontal disease
⧫Attaining stable restorative state
Goal
Increase the completion of Disease Control Phase
Current practice
⧫Education
Assess level of dental literacy
Incremental strategy
⧫Increase access to dental care
Generous sliding scale (⥸$40 per visit)
Incorporate Expanded Function Dental Assistants
⧫Schedule modification
Incorporate more restorative blocks to allow
for follow-up visit and completion of restorative phase
httpswwwglasbergencomdentist-cartoons
Schedule
⧫Piggybacking technique
Increased allotted restorative blocks
⧫Sustainability of current schedule is
contingent on cooperation amp skills of HAN
Dental staff
Note
Strategies mentioned today is personalized to HAN Dental clinic
Current implemented strategies might be modified or changed in the
future as required in order to accommodate the need of our pts
THANK YOU
DAY TWOCLOSINGWRAP-UP
End of Day Two ndash Survey
Day Two Creating a Value-Based Oral Health Care Delivery
System
129
Payment Reform in Oral Health Online Learning Module
Oral Health Value-based Care Online Learning Module
Value-based Care Keys to Success Article
Readiness Assessment
Competency Development Guide
Oral Health Value-based Care Training
Dental Caries Management Practicum
Clinicians Companion Guide
Interprofessional Network Referral Process
Traditional Dental Care Vs Value-Based Care
Resources
131
wwwDentaQuestPartnershiporg
wwwfacebookcomDentaQuest
DentaQuest
wwwlinkedincomcompanyDentaQuest
Inside_DentaQuest
QUESTIONS
63
RISK CONTRACTS
6464
Components of a Risk-based Contract
Risk
Medical Loss Ratio
Quality withhold
Specialty withhold
Managed care payment (pmpm)
Covered services
Fee schedule Claims are paid as usual on a FFS basis
Credentialing
Quality Review process and Quality Metrics
65
Upside Risk
The possibility that the cost of
delivering dental care to an assigned
patient panel is less than the amount
of funding calculated for that care
The Plan pays the CHC additional
funds based on a predetermine
formula
Downside Risk
The possibility that the cost of
delivering dental care to an assigned
patient panel is more than the amount
of funding calculated for that care
The CHC pays the Plan additional
funds based on a predetermine
formula
Upside and Downside Risk
66
Taking On Risk 100 or Shared Risk
With 100 risk you receive 100 of the potential savings but are also at risk for
100 of the losses
Shared Risk MCO and health center share a percentage of the risk
Shared Risk leads to better cooperation since both organizations are
incentivized to save on costs
6767
Reports Needed
bull Enrollment reports lists of who is assigned on a monthly basis
bull Reconciliation reports insure appropriate payments
bull Specialty Referral reports
bull You will need your own reporting process so you donrsquot rely completely on
reports supplied by the Plan
6868
Medical Loss Ratio
Medical Loss Ratio (MLR) is proportion of premium revenues spent on clinical
services and quality improvement also known as the Medical Loss Ratio (MLR)
For CMS requires Medical Plans to spend at least 80 to 85 of the premiums
on actual medical care
69
Administrative Fees
bull Essentially the opposite of MLR
bull The State Medicaid Agency is funded by the Governorrsquos budget
bull The State Medicaid Agency will keep some of these funds for their
admin costs and give the remaining to the Managed Care Plans
bull Private Plan admin costs can be as high as 40 but most states
limit these cost for Medicaid Plans to between 15 and 20 (85-
80 MLR)
bull This may be negotiable depending on your program size of your
program
70
Quality Withhold
bull The state withholds a certain percent (typically 2-4 ) of the funds they give
to the Plans for Value Based Reimbursement
bull They choose quality metrics and set benchmarks and assign payments for
each metric based on an assigned priority for each metric
bull If a Plan meets the benchmark of every quality metric the state passes on
their full share of the quality withhold
bull The Plans may or may not withhold a percent of the funds for quality payment
to the dentists or manage care contractors
71
Quality Withhold
Either way the Plans may or may not pass the quality payments they receive to
the dentists or contractors
This should be spelled out in a risk-based contract
72
Percent of funds set aside
to cover specialty care
referrals
Typically 10-15
Goal Limit referral costs
to within or less than
Specialty set aside
Specialty Withhold
73
Per Member Per Month
bull Capitated Payment
bull Specific dollar amount paid for each enrolled member each month
bull Paid whether patient is accessed for care or not
bull States do set access benchmarks
bull In Oregon access for any dental procedure (adults and children combined)
was 267 in 2015
74
Payment Math Example
Premium per enrollee = $25
Administrative fee 15 = $375
Funds available per enrollee to the clinic = $2125
Management fee per enrollee = $175
Funds per enrollee that would undergo PPS reconciliation = $1950
For every 10000 enrollees the managed care income = $2340000
Specialty withhold (10) = $234000
YE Cost lt or gt $2340000
Upside Risk
CHC Gains $
Downside Risk
CHC Loses $
75
Covered Services and Fee Schedules
bull The state Medicaid agency spells out the minimum procedures and fees that
MCOs must cover
bull MCOs may add procedures or increase periodicity of procedures particularly
preventative services
bull MCOs may increase fees to entice rural providers and specialists to enroll in
their Plans
bull Access Rules
bull How many days it takes to access a patent
bull How many days it takes for a patent to access urgent care services
bull How many days it takes for a patent to access emergency care services
76
Credentialing
All MCOs are required to credential all Providers
All MCOs have their own credentialing process
Credentialing process is can be lengthy
Credentialing process may be negotiable
77
Quality Review Process and Quality Metrics
MCOs must have a Quality and Compliance Review Process
If you arenrsquot in compliance with both you likely wonrsquot get paid
Typical processes reviewed
bull Charting specifications
bull Incident report
bull Enrollee complaints quality rudeness and access issues
bull Medicaid compliance
78
Quality Payments
bull State Shared Incentive Withhold Typically quality metrics and benchmarks
are set by the state sets aside a certain percent (3-5) of the payments to
the Managed Care Plan (MCP)
bull If the benchmarks are achieved the MCP is then paid the a predetermine
amount
bull Benchmarks may not be the same as the states
bull Managed Care Plans do not have to pass all or any of the quality payments to
the health centers or providers
bull Managed Care contract- Metrics benchmarks should be selected and part of
the contract
7979
Achieving Quality Metric Payments
Dealing with under achievers
Process issues
Individual issues
Identifying workflows
Developing Best Practices through
PDSA process
Developing Best Practices through
PDSA process
CHC Metrics Committee
Clinicians Operations various key staff
Identify Best Practices
Spread Best Practices
80
New Team Needed Business Intelligence
Business Intelligence (BI) is critical for effective managed care business decisions
BI team inputs metrics into your EHR collects integrates analyses and displays all your managed care business and clinical information
Easy to say- hard to achieve
Build your own or outsource
Possible future role of Primary Care Associations
8181
Clinicianrsquos Dashboard
Expensive to build
Displayed on your screen when your computer is first turned on
Easy to read and understand
Data dumped from the day before
Can dialed down from Org-wide to clinic to each clinicianrsquos data
Operational and clinical metrics
bull Treatment Plan Completion
bull DQA quality measures
bull Caries at Recall
bull Re-care reports
bull Care Gap reports
82
CONTROLLING COSTS
8383
Controlling Costs- Current
bull Increasing efficiencies
bull Decreasing broken appointments
bull Controlling supplies equipment costs
bull Staff recruitment retention costs
84
Specialty Care
Training current CHC dentists in
specialty areas
Hiring general dentists with higher
specialty skill sets
Hiring in house specialists
Contract with outside specialists
Work with Managed Care Plan
specialists
Lowering Disease Rates
Community Dental Health
Coordinators case management
If your state law allows- embed
hygienists in medical and community
to provide primary and secondary
prevention procedures
In clinic Caries Classification and
Silver Diamine Fluoride
Effective recare programs
Controlling Costs- Additions in Risk-based Contracting
85
Specialty Care ndash Primary Referrals by Cost
Pediatric dentistry
Orthodontics
Oral surgery
Endodontics
86
In-clinic Pediatric Services
Encounters expected
of operatories available
State dental law and ability to have
expanded duties
General Anesthesia
GA in- house
Ability for a hospital or surgery center
to set aside regular OR time
Ability to hire or assign DAs to GA
days
Four GA cases day x PPS rate
Should You Hire a Pediatric Dentist- It Depends
8787
Solutions for Controlling Pediatric Costs
Hire a general dentist that is skilled in treating young children
Make the clinic child friendly nitrous oxide TVs in the operatory etc
Teach entire staff behavioral control techniques
Contract with a pediatric dentist for the GA care
88
Lowering Overall Disease Rates (and Costs)
You are responsible for both the patients you see in the chair and the ones
assigned to you
Breaking down the walls of the dental clinic
Community Dental Health Coordinators
Case Management
89
Cost Control Essentials
Diagnosis codes
Increased ability to identify
disease by risk
Motivational
Interviewing
Developing Polices and
Procedures design to treat
disease according to risk
ie Silver Diamine Fluoride
Treating by Risk
Effective Recare
Process
Critical to continual disease
controlPrevention education that is
meaningful and designed to
change behaviors
90
Social Determinants of Health Aunt Bertha
httpswwwauntberthacom
91
REASON TO CONSIDER RISK- BASED CONTRACTING
9292
PPS Reconciliation and Federal Code 42 CFR sect4052469(a)(2)
42 CFR sect4052469(a)(2)
ldquoAny financial incentives provided to Federally Qualified Health Centers
under their Medicare Advantage Contracts such as risk pool payments
bonuses or withholds are prohibited from being included in the
calculation of supplemental payments due to the Federally Qualified
Health Centerrdquo
9393
Why Risk Based Contract in Times of PPS Reconciliation
bull Not all Risk- based Contract funds are reconciled
bull Risk is the key word- you can come out with less money than your normal
PPS reconciliation payment
bull Can lead to better patient care
bull May improve manage care enrollment for your medical plan
bull Promotes integrated care increases health for your CHC patients
9494
Not Included in the Reconciliation
Enrollment management pmpm
Quality Payments
Upside risk payments
Downside risk losses
9595
Determinants of Financial Success in Risk-Based Contracting
bull Most critical- State pmpm payment to the Managed Care Plan
bull Reporting capabilities
bull Specialty service capabilities
bull Access numbers count
bull Ability to move metric numbers
9696
What About the Non- Medicaid Poor We Serve
bull Numbers are king in a managed care contract and the more access you have
the better contract terms you can negotiate
bull We will potentially have a steady supply of Medicaid patients
bull As managed care spreads states this may be compromising the ability of
health centers to serve the non-Medicaid poor and others lacking dental
insurance
97
Mark Koday DDS
(509) 949-2278
Dental Quality Consultants
of WA
httpdentalqualityconsultin
gcom
dentalqualityconsultantsg
mailcom
Contact Information
LUNCH
BREAKOUT EXERCISEORAL HEALTH VALUE-BASED CARE READINESS ASSESSMENT
Danielle Apostolon
PROMISING PRACTICES FROM THE FIELD STRATEGIES FOR INCREASING VALUE IN ORAL HEALTH
Dr Carolyn Brown
Dr Kelly Perry
Dr Rachel Rivard
Dr Adeloye
Commitment Compassion Community
m i d s t a t e h e a l t h o r g
Promising Practices from the
Field Strategies for Increasing
Value in Oral Health Care
Kelly Perry DMD
Better Health
Outcomes
Improved Staff
Experience
Reduced Cost
Improved Patient
Experience
Better Health
Outcomes
Improved Staff
Experience
Reduced Cost
Improved Patient
Experience
Better Health
Outcomes
Improved Staff
Experience
Reduced Cost
Improved Patient
Experience
Better Health
Outcomes
Improved Staff
Experience
Reduced Cost
Improved Patient
Experience
Commitment Compassion Community
kpe r r ymids t a tehea l t h o rg
Thank you
Completion of Disease Control Phase
Pelumi Adeloye DMD MPH
HEALTH ACCESS NETWORK (HAN) FAMILY DENTAL
Introduction
⧫1 Dentist I Hygienist 3 EFDArsquos1 Receptionist
⧫ 6 Chairs= 4 (dentist) + 2 (hygienist)
⧫ Slide ⥶80 off
⧫ Service areas Northern Penobscot Southern Aroostook Western
Washington Counties amp more
Completion of Phase I Treatment
⧫LimitedLack of Access to dental care
⧫Difficulty completing the disease control phase
Caries amp periodontal disease
⧫Attaining stable restorative state
Goal
Increase the completion of Disease Control Phase
Current practice
⧫Education
Assess level of dental literacy
Incremental strategy
⧫Increase access to dental care
Generous sliding scale (⥸$40 per visit)
Incorporate Expanded Function Dental Assistants
⧫Schedule modification
Incorporate more restorative blocks to allow
for follow-up visit and completion of restorative phase
httpswwwglasbergencomdentist-cartoons
Schedule
⧫Piggybacking technique
Increased allotted restorative blocks
⧫Sustainability of current schedule is
contingent on cooperation amp skills of HAN
Dental staff
Note
Strategies mentioned today is personalized to HAN Dental clinic
Current implemented strategies might be modified or changed in the
future as required in order to accommodate the need of our pts
THANK YOU
DAY TWOCLOSINGWRAP-UP
End of Day Two ndash Survey
Day Two Creating a Value-Based Oral Health Care Delivery
System
129
Payment Reform in Oral Health Online Learning Module
Oral Health Value-based Care Online Learning Module
Value-based Care Keys to Success Article
Readiness Assessment
Competency Development Guide
Oral Health Value-based Care Training
Dental Caries Management Practicum
Clinicians Companion Guide
Interprofessional Network Referral Process
Traditional Dental Care Vs Value-Based Care
Resources
131
wwwDentaQuestPartnershiporg
wwwfacebookcomDentaQuest
DentaQuest
wwwlinkedincomcompanyDentaQuest
Inside_DentaQuest
QUESTIONS
6464
Components of a Risk-based Contract
Risk
Medical Loss Ratio
Quality withhold
Specialty withhold
Managed care payment (pmpm)
Covered services
Fee schedule Claims are paid as usual on a FFS basis
Credentialing
Quality Review process and Quality Metrics
65
Upside Risk
The possibility that the cost of
delivering dental care to an assigned
patient panel is less than the amount
of funding calculated for that care
The Plan pays the CHC additional
funds based on a predetermine
formula
Downside Risk
The possibility that the cost of
delivering dental care to an assigned
patient panel is more than the amount
of funding calculated for that care
The CHC pays the Plan additional
funds based on a predetermine
formula
Upside and Downside Risk
66
Taking On Risk 100 or Shared Risk
With 100 risk you receive 100 of the potential savings but are also at risk for
100 of the losses
Shared Risk MCO and health center share a percentage of the risk
Shared Risk leads to better cooperation since both organizations are
incentivized to save on costs
6767
Reports Needed
bull Enrollment reports lists of who is assigned on a monthly basis
bull Reconciliation reports insure appropriate payments
bull Specialty Referral reports
bull You will need your own reporting process so you donrsquot rely completely on
reports supplied by the Plan
6868
Medical Loss Ratio
Medical Loss Ratio (MLR) is proportion of premium revenues spent on clinical
services and quality improvement also known as the Medical Loss Ratio (MLR)
For CMS requires Medical Plans to spend at least 80 to 85 of the premiums
on actual medical care
69
Administrative Fees
bull Essentially the opposite of MLR
bull The State Medicaid Agency is funded by the Governorrsquos budget
bull The State Medicaid Agency will keep some of these funds for their
admin costs and give the remaining to the Managed Care Plans
bull Private Plan admin costs can be as high as 40 but most states
limit these cost for Medicaid Plans to between 15 and 20 (85-
80 MLR)
bull This may be negotiable depending on your program size of your
program
70
Quality Withhold
bull The state withholds a certain percent (typically 2-4 ) of the funds they give
to the Plans for Value Based Reimbursement
bull They choose quality metrics and set benchmarks and assign payments for
each metric based on an assigned priority for each metric
bull If a Plan meets the benchmark of every quality metric the state passes on
their full share of the quality withhold
bull The Plans may or may not withhold a percent of the funds for quality payment
to the dentists or manage care contractors
71
Quality Withhold
Either way the Plans may or may not pass the quality payments they receive to
the dentists or contractors
This should be spelled out in a risk-based contract
72
Percent of funds set aside
to cover specialty care
referrals
Typically 10-15
Goal Limit referral costs
to within or less than
Specialty set aside
Specialty Withhold
73
Per Member Per Month
bull Capitated Payment
bull Specific dollar amount paid for each enrolled member each month
bull Paid whether patient is accessed for care or not
bull States do set access benchmarks
bull In Oregon access for any dental procedure (adults and children combined)
was 267 in 2015
74
Payment Math Example
Premium per enrollee = $25
Administrative fee 15 = $375
Funds available per enrollee to the clinic = $2125
Management fee per enrollee = $175
Funds per enrollee that would undergo PPS reconciliation = $1950
For every 10000 enrollees the managed care income = $2340000
Specialty withhold (10) = $234000
YE Cost lt or gt $2340000
Upside Risk
CHC Gains $
Downside Risk
CHC Loses $
75
Covered Services and Fee Schedules
bull The state Medicaid agency spells out the minimum procedures and fees that
MCOs must cover
bull MCOs may add procedures or increase periodicity of procedures particularly
preventative services
bull MCOs may increase fees to entice rural providers and specialists to enroll in
their Plans
bull Access Rules
bull How many days it takes to access a patent
bull How many days it takes for a patent to access urgent care services
bull How many days it takes for a patent to access emergency care services
76
Credentialing
All MCOs are required to credential all Providers
All MCOs have their own credentialing process
Credentialing process is can be lengthy
Credentialing process may be negotiable
77
Quality Review Process and Quality Metrics
MCOs must have a Quality and Compliance Review Process
If you arenrsquot in compliance with both you likely wonrsquot get paid
Typical processes reviewed
bull Charting specifications
bull Incident report
bull Enrollee complaints quality rudeness and access issues
bull Medicaid compliance
78
Quality Payments
bull State Shared Incentive Withhold Typically quality metrics and benchmarks
are set by the state sets aside a certain percent (3-5) of the payments to
the Managed Care Plan (MCP)
bull If the benchmarks are achieved the MCP is then paid the a predetermine
amount
bull Benchmarks may not be the same as the states
bull Managed Care Plans do not have to pass all or any of the quality payments to
the health centers or providers
bull Managed Care contract- Metrics benchmarks should be selected and part of
the contract
7979
Achieving Quality Metric Payments
Dealing with under achievers
Process issues
Individual issues
Identifying workflows
Developing Best Practices through
PDSA process
Developing Best Practices through
PDSA process
CHC Metrics Committee
Clinicians Operations various key staff
Identify Best Practices
Spread Best Practices
80
New Team Needed Business Intelligence
Business Intelligence (BI) is critical for effective managed care business decisions
BI team inputs metrics into your EHR collects integrates analyses and displays all your managed care business and clinical information
Easy to say- hard to achieve
Build your own or outsource
Possible future role of Primary Care Associations
8181
Clinicianrsquos Dashboard
Expensive to build
Displayed on your screen when your computer is first turned on
Easy to read and understand
Data dumped from the day before
Can dialed down from Org-wide to clinic to each clinicianrsquos data
Operational and clinical metrics
bull Treatment Plan Completion
bull DQA quality measures
bull Caries at Recall
bull Re-care reports
bull Care Gap reports
82
CONTROLLING COSTS
8383
Controlling Costs- Current
bull Increasing efficiencies
bull Decreasing broken appointments
bull Controlling supplies equipment costs
bull Staff recruitment retention costs
84
Specialty Care
Training current CHC dentists in
specialty areas
Hiring general dentists with higher
specialty skill sets
Hiring in house specialists
Contract with outside specialists
Work with Managed Care Plan
specialists
Lowering Disease Rates
Community Dental Health
Coordinators case management
If your state law allows- embed
hygienists in medical and community
to provide primary and secondary
prevention procedures
In clinic Caries Classification and
Silver Diamine Fluoride
Effective recare programs
Controlling Costs- Additions in Risk-based Contracting
85
Specialty Care ndash Primary Referrals by Cost
Pediatric dentistry
Orthodontics
Oral surgery
Endodontics
86
In-clinic Pediatric Services
Encounters expected
of operatories available
State dental law and ability to have
expanded duties
General Anesthesia
GA in- house
Ability for a hospital or surgery center
to set aside regular OR time
Ability to hire or assign DAs to GA
days
Four GA cases day x PPS rate
Should You Hire a Pediatric Dentist- It Depends
8787
Solutions for Controlling Pediatric Costs
Hire a general dentist that is skilled in treating young children
Make the clinic child friendly nitrous oxide TVs in the operatory etc
Teach entire staff behavioral control techniques
Contract with a pediatric dentist for the GA care
88
Lowering Overall Disease Rates (and Costs)
You are responsible for both the patients you see in the chair and the ones
assigned to you
Breaking down the walls of the dental clinic
Community Dental Health Coordinators
Case Management
89
Cost Control Essentials
Diagnosis codes
Increased ability to identify
disease by risk
Motivational
Interviewing
Developing Polices and
Procedures design to treat
disease according to risk
ie Silver Diamine Fluoride
Treating by Risk
Effective Recare
Process
Critical to continual disease
controlPrevention education that is
meaningful and designed to
change behaviors
90
Social Determinants of Health Aunt Bertha
httpswwwauntberthacom
91
REASON TO CONSIDER RISK- BASED CONTRACTING
9292
PPS Reconciliation and Federal Code 42 CFR sect4052469(a)(2)
42 CFR sect4052469(a)(2)
ldquoAny financial incentives provided to Federally Qualified Health Centers
under their Medicare Advantage Contracts such as risk pool payments
bonuses or withholds are prohibited from being included in the
calculation of supplemental payments due to the Federally Qualified
Health Centerrdquo
9393
Why Risk Based Contract in Times of PPS Reconciliation
bull Not all Risk- based Contract funds are reconciled
bull Risk is the key word- you can come out with less money than your normal
PPS reconciliation payment
bull Can lead to better patient care
bull May improve manage care enrollment for your medical plan
bull Promotes integrated care increases health for your CHC patients
9494
Not Included in the Reconciliation
Enrollment management pmpm
Quality Payments
Upside risk payments
Downside risk losses
9595
Determinants of Financial Success in Risk-Based Contracting
bull Most critical- State pmpm payment to the Managed Care Plan
bull Reporting capabilities
bull Specialty service capabilities
bull Access numbers count
bull Ability to move metric numbers
9696
What About the Non- Medicaid Poor We Serve
bull Numbers are king in a managed care contract and the more access you have
the better contract terms you can negotiate
bull We will potentially have a steady supply of Medicaid patients
bull As managed care spreads states this may be compromising the ability of
health centers to serve the non-Medicaid poor and others lacking dental
insurance
97
Mark Koday DDS
(509) 949-2278
Dental Quality Consultants
of WA
httpdentalqualityconsultin
gcom
dentalqualityconsultantsg
mailcom
Contact Information
LUNCH
BREAKOUT EXERCISEORAL HEALTH VALUE-BASED CARE READINESS ASSESSMENT
Danielle Apostolon
PROMISING PRACTICES FROM THE FIELD STRATEGIES FOR INCREASING VALUE IN ORAL HEALTH
Dr Carolyn Brown
Dr Kelly Perry
Dr Rachel Rivard
Dr Adeloye
Commitment Compassion Community
m i d s t a t e h e a l t h o r g
Promising Practices from the
Field Strategies for Increasing
Value in Oral Health Care
Kelly Perry DMD
Better Health
Outcomes
Improved Staff
Experience
Reduced Cost
Improved Patient
Experience
Better Health
Outcomes
Improved Staff
Experience
Reduced Cost
Improved Patient
Experience
Better Health
Outcomes
Improved Staff
Experience
Reduced Cost
Improved Patient
Experience
Better Health
Outcomes
Improved Staff
Experience
Reduced Cost
Improved Patient
Experience
Commitment Compassion Community
kpe r r ymids t a tehea l t h o rg
Thank you
Completion of Disease Control Phase
Pelumi Adeloye DMD MPH
HEALTH ACCESS NETWORK (HAN) FAMILY DENTAL
Introduction
⧫1 Dentist I Hygienist 3 EFDArsquos1 Receptionist
⧫ 6 Chairs= 4 (dentist) + 2 (hygienist)
⧫ Slide ⥶80 off
⧫ Service areas Northern Penobscot Southern Aroostook Western
Washington Counties amp more
Completion of Phase I Treatment
⧫LimitedLack of Access to dental care
⧫Difficulty completing the disease control phase
Caries amp periodontal disease
⧫Attaining stable restorative state
Goal
Increase the completion of Disease Control Phase
Current practice
⧫Education
Assess level of dental literacy
Incremental strategy
⧫Increase access to dental care
Generous sliding scale (⥸$40 per visit)
Incorporate Expanded Function Dental Assistants
⧫Schedule modification
Incorporate more restorative blocks to allow
for follow-up visit and completion of restorative phase
httpswwwglasbergencomdentist-cartoons
Schedule
⧫Piggybacking technique
Increased allotted restorative blocks
⧫Sustainability of current schedule is
contingent on cooperation amp skills of HAN
Dental staff
Note
Strategies mentioned today is personalized to HAN Dental clinic
Current implemented strategies might be modified or changed in the
future as required in order to accommodate the need of our pts
THANK YOU
DAY TWOCLOSINGWRAP-UP
End of Day Two ndash Survey
Day Two Creating a Value-Based Oral Health Care Delivery
System
129
Payment Reform in Oral Health Online Learning Module
Oral Health Value-based Care Online Learning Module
Value-based Care Keys to Success Article
Readiness Assessment
Competency Development Guide
Oral Health Value-based Care Training
Dental Caries Management Practicum
Clinicians Companion Guide
Interprofessional Network Referral Process
Traditional Dental Care Vs Value-Based Care
Resources
131
wwwDentaQuestPartnershiporg
wwwfacebookcomDentaQuest
DentaQuest
wwwlinkedincomcompanyDentaQuest
Inside_DentaQuest
QUESTIONS
65
Upside Risk
The possibility that the cost of
delivering dental care to an assigned
patient panel is less than the amount
of funding calculated for that care
The Plan pays the CHC additional
funds based on a predetermine
formula
Downside Risk
The possibility that the cost of
delivering dental care to an assigned
patient panel is more than the amount
of funding calculated for that care
The CHC pays the Plan additional
funds based on a predetermine
formula
Upside and Downside Risk
66
Taking On Risk 100 or Shared Risk
With 100 risk you receive 100 of the potential savings but are also at risk for
100 of the losses
Shared Risk MCO and health center share a percentage of the risk
Shared Risk leads to better cooperation since both organizations are
incentivized to save on costs
6767
Reports Needed
bull Enrollment reports lists of who is assigned on a monthly basis
bull Reconciliation reports insure appropriate payments
bull Specialty Referral reports
bull You will need your own reporting process so you donrsquot rely completely on
reports supplied by the Plan
6868
Medical Loss Ratio
Medical Loss Ratio (MLR) is proportion of premium revenues spent on clinical
services and quality improvement also known as the Medical Loss Ratio (MLR)
For CMS requires Medical Plans to spend at least 80 to 85 of the premiums
on actual medical care
69
Administrative Fees
bull Essentially the opposite of MLR
bull The State Medicaid Agency is funded by the Governorrsquos budget
bull The State Medicaid Agency will keep some of these funds for their
admin costs and give the remaining to the Managed Care Plans
bull Private Plan admin costs can be as high as 40 but most states
limit these cost for Medicaid Plans to between 15 and 20 (85-
80 MLR)
bull This may be negotiable depending on your program size of your
program
70
Quality Withhold
bull The state withholds a certain percent (typically 2-4 ) of the funds they give
to the Plans for Value Based Reimbursement
bull They choose quality metrics and set benchmarks and assign payments for
each metric based on an assigned priority for each metric
bull If a Plan meets the benchmark of every quality metric the state passes on
their full share of the quality withhold
bull The Plans may or may not withhold a percent of the funds for quality payment
to the dentists or manage care contractors
71
Quality Withhold
Either way the Plans may or may not pass the quality payments they receive to
the dentists or contractors
This should be spelled out in a risk-based contract
72
Percent of funds set aside
to cover specialty care
referrals
Typically 10-15
Goal Limit referral costs
to within or less than
Specialty set aside
Specialty Withhold
73
Per Member Per Month
bull Capitated Payment
bull Specific dollar amount paid for each enrolled member each month
bull Paid whether patient is accessed for care or not
bull States do set access benchmarks
bull In Oregon access for any dental procedure (adults and children combined)
was 267 in 2015
74
Payment Math Example
Premium per enrollee = $25
Administrative fee 15 = $375
Funds available per enrollee to the clinic = $2125
Management fee per enrollee = $175
Funds per enrollee that would undergo PPS reconciliation = $1950
For every 10000 enrollees the managed care income = $2340000
Specialty withhold (10) = $234000
YE Cost lt or gt $2340000
Upside Risk
CHC Gains $
Downside Risk
CHC Loses $
75
Covered Services and Fee Schedules
bull The state Medicaid agency spells out the minimum procedures and fees that
MCOs must cover
bull MCOs may add procedures or increase periodicity of procedures particularly
preventative services
bull MCOs may increase fees to entice rural providers and specialists to enroll in
their Plans
bull Access Rules
bull How many days it takes to access a patent
bull How many days it takes for a patent to access urgent care services
bull How many days it takes for a patent to access emergency care services
76
Credentialing
All MCOs are required to credential all Providers
All MCOs have their own credentialing process
Credentialing process is can be lengthy
Credentialing process may be negotiable
77
Quality Review Process and Quality Metrics
MCOs must have a Quality and Compliance Review Process
If you arenrsquot in compliance with both you likely wonrsquot get paid
Typical processes reviewed
bull Charting specifications
bull Incident report
bull Enrollee complaints quality rudeness and access issues
bull Medicaid compliance
78
Quality Payments
bull State Shared Incentive Withhold Typically quality metrics and benchmarks
are set by the state sets aside a certain percent (3-5) of the payments to
the Managed Care Plan (MCP)
bull If the benchmarks are achieved the MCP is then paid the a predetermine
amount
bull Benchmarks may not be the same as the states
bull Managed Care Plans do not have to pass all or any of the quality payments to
the health centers or providers
bull Managed Care contract- Metrics benchmarks should be selected and part of
the contract
7979
Achieving Quality Metric Payments
Dealing with under achievers
Process issues
Individual issues
Identifying workflows
Developing Best Practices through
PDSA process
Developing Best Practices through
PDSA process
CHC Metrics Committee
Clinicians Operations various key staff
Identify Best Practices
Spread Best Practices
80
New Team Needed Business Intelligence
Business Intelligence (BI) is critical for effective managed care business decisions
BI team inputs metrics into your EHR collects integrates analyses and displays all your managed care business and clinical information
Easy to say- hard to achieve
Build your own or outsource
Possible future role of Primary Care Associations
8181
Clinicianrsquos Dashboard
Expensive to build
Displayed on your screen when your computer is first turned on
Easy to read and understand
Data dumped from the day before
Can dialed down from Org-wide to clinic to each clinicianrsquos data
Operational and clinical metrics
bull Treatment Plan Completion
bull DQA quality measures
bull Caries at Recall
bull Re-care reports
bull Care Gap reports
82
CONTROLLING COSTS
8383
Controlling Costs- Current
bull Increasing efficiencies
bull Decreasing broken appointments
bull Controlling supplies equipment costs
bull Staff recruitment retention costs
84
Specialty Care
Training current CHC dentists in
specialty areas
Hiring general dentists with higher
specialty skill sets
Hiring in house specialists
Contract with outside specialists
Work with Managed Care Plan
specialists
Lowering Disease Rates
Community Dental Health
Coordinators case management
If your state law allows- embed
hygienists in medical and community
to provide primary and secondary
prevention procedures
In clinic Caries Classification and
Silver Diamine Fluoride
Effective recare programs
Controlling Costs- Additions in Risk-based Contracting
85
Specialty Care ndash Primary Referrals by Cost
Pediatric dentistry
Orthodontics
Oral surgery
Endodontics
86
In-clinic Pediatric Services
Encounters expected
of operatories available
State dental law and ability to have
expanded duties
General Anesthesia
GA in- house
Ability for a hospital or surgery center
to set aside regular OR time
Ability to hire or assign DAs to GA
days
Four GA cases day x PPS rate
Should You Hire a Pediatric Dentist- It Depends
8787
Solutions for Controlling Pediatric Costs
Hire a general dentist that is skilled in treating young children
Make the clinic child friendly nitrous oxide TVs in the operatory etc
Teach entire staff behavioral control techniques
Contract with a pediatric dentist for the GA care
88
Lowering Overall Disease Rates (and Costs)
You are responsible for both the patients you see in the chair and the ones
assigned to you
Breaking down the walls of the dental clinic
Community Dental Health Coordinators
Case Management
89
Cost Control Essentials
Diagnosis codes
Increased ability to identify
disease by risk
Motivational
Interviewing
Developing Polices and
Procedures design to treat
disease according to risk
ie Silver Diamine Fluoride
Treating by Risk
Effective Recare
Process
Critical to continual disease
controlPrevention education that is
meaningful and designed to
change behaviors
90
Social Determinants of Health Aunt Bertha
httpswwwauntberthacom
91
REASON TO CONSIDER RISK- BASED CONTRACTING
9292
PPS Reconciliation and Federal Code 42 CFR sect4052469(a)(2)
42 CFR sect4052469(a)(2)
ldquoAny financial incentives provided to Federally Qualified Health Centers
under their Medicare Advantage Contracts such as risk pool payments
bonuses or withholds are prohibited from being included in the
calculation of supplemental payments due to the Federally Qualified
Health Centerrdquo
9393
Why Risk Based Contract in Times of PPS Reconciliation
bull Not all Risk- based Contract funds are reconciled
bull Risk is the key word- you can come out with less money than your normal
PPS reconciliation payment
bull Can lead to better patient care
bull May improve manage care enrollment for your medical plan
bull Promotes integrated care increases health for your CHC patients
9494
Not Included in the Reconciliation
Enrollment management pmpm
Quality Payments
Upside risk payments
Downside risk losses
9595
Determinants of Financial Success in Risk-Based Contracting
bull Most critical- State pmpm payment to the Managed Care Plan
bull Reporting capabilities
bull Specialty service capabilities
bull Access numbers count
bull Ability to move metric numbers
9696
What About the Non- Medicaid Poor We Serve
bull Numbers are king in a managed care contract and the more access you have
the better contract terms you can negotiate
bull We will potentially have a steady supply of Medicaid patients
bull As managed care spreads states this may be compromising the ability of
health centers to serve the non-Medicaid poor and others lacking dental
insurance
97
Mark Koday DDS
(509) 949-2278
Dental Quality Consultants
of WA
httpdentalqualityconsultin
gcom
dentalqualityconsultantsg
mailcom
Contact Information
LUNCH
BREAKOUT EXERCISEORAL HEALTH VALUE-BASED CARE READINESS ASSESSMENT
Danielle Apostolon
PROMISING PRACTICES FROM THE FIELD STRATEGIES FOR INCREASING VALUE IN ORAL HEALTH
Dr Carolyn Brown
Dr Kelly Perry
Dr Rachel Rivard
Dr Adeloye
Commitment Compassion Community
m i d s t a t e h e a l t h o r g
Promising Practices from the
Field Strategies for Increasing
Value in Oral Health Care
Kelly Perry DMD
Better Health
Outcomes
Improved Staff
Experience
Reduced Cost
Improved Patient
Experience
Better Health
Outcomes
Improved Staff
Experience
Reduced Cost
Improved Patient
Experience
Better Health
Outcomes
Improved Staff
Experience
Reduced Cost
Improved Patient
Experience
Better Health
Outcomes
Improved Staff
Experience
Reduced Cost
Improved Patient
Experience
Commitment Compassion Community
kpe r r ymids t a tehea l t h o rg
Thank you
Completion of Disease Control Phase
Pelumi Adeloye DMD MPH
HEALTH ACCESS NETWORK (HAN) FAMILY DENTAL
Introduction
⧫1 Dentist I Hygienist 3 EFDArsquos1 Receptionist
⧫ 6 Chairs= 4 (dentist) + 2 (hygienist)
⧫ Slide ⥶80 off
⧫ Service areas Northern Penobscot Southern Aroostook Western
Washington Counties amp more
Completion of Phase I Treatment
⧫LimitedLack of Access to dental care
⧫Difficulty completing the disease control phase
Caries amp periodontal disease
⧫Attaining stable restorative state
Goal
Increase the completion of Disease Control Phase
Current practice
⧫Education
Assess level of dental literacy
Incremental strategy
⧫Increase access to dental care
Generous sliding scale (⥸$40 per visit)
Incorporate Expanded Function Dental Assistants
⧫Schedule modification
Incorporate more restorative blocks to allow
for follow-up visit and completion of restorative phase
httpswwwglasbergencomdentist-cartoons
Schedule
⧫Piggybacking technique
Increased allotted restorative blocks
⧫Sustainability of current schedule is
contingent on cooperation amp skills of HAN
Dental staff
Note
Strategies mentioned today is personalized to HAN Dental clinic
Current implemented strategies might be modified or changed in the
future as required in order to accommodate the need of our pts
THANK YOU
DAY TWOCLOSINGWRAP-UP
End of Day Two ndash Survey
Day Two Creating a Value-Based Oral Health Care Delivery
System
129
Payment Reform in Oral Health Online Learning Module
Oral Health Value-based Care Online Learning Module
Value-based Care Keys to Success Article
Readiness Assessment
Competency Development Guide
Oral Health Value-based Care Training
Dental Caries Management Practicum
Clinicians Companion Guide
Interprofessional Network Referral Process
Traditional Dental Care Vs Value-Based Care
Resources
131
wwwDentaQuestPartnershiporg
wwwfacebookcomDentaQuest
DentaQuest
wwwlinkedincomcompanyDentaQuest
Inside_DentaQuest
QUESTIONS
66
Taking On Risk 100 or Shared Risk
With 100 risk you receive 100 of the potential savings but are also at risk for
100 of the losses
Shared Risk MCO and health center share a percentage of the risk
Shared Risk leads to better cooperation since both organizations are
incentivized to save on costs
6767
Reports Needed
bull Enrollment reports lists of who is assigned on a monthly basis
bull Reconciliation reports insure appropriate payments
bull Specialty Referral reports
bull You will need your own reporting process so you donrsquot rely completely on
reports supplied by the Plan
6868
Medical Loss Ratio
Medical Loss Ratio (MLR) is proportion of premium revenues spent on clinical
services and quality improvement also known as the Medical Loss Ratio (MLR)
For CMS requires Medical Plans to spend at least 80 to 85 of the premiums
on actual medical care
69
Administrative Fees
bull Essentially the opposite of MLR
bull The State Medicaid Agency is funded by the Governorrsquos budget
bull The State Medicaid Agency will keep some of these funds for their
admin costs and give the remaining to the Managed Care Plans
bull Private Plan admin costs can be as high as 40 but most states
limit these cost for Medicaid Plans to between 15 and 20 (85-
80 MLR)
bull This may be negotiable depending on your program size of your
program
70
Quality Withhold
bull The state withholds a certain percent (typically 2-4 ) of the funds they give
to the Plans for Value Based Reimbursement
bull They choose quality metrics and set benchmarks and assign payments for
each metric based on an assigned priority for each metric
bull If a Plan meets the benchmark of every quality metric the state passes on
their full share of the quality withhold
bull The Plans may or may not withhold a percent of the funds for quality payment
to the dentists or manage care contractors
71
Quality Withhold
Either way the Plans may or may not pass the quality payments they receive to
the dentists or contractors
This should be spelled out in a risk-based contract
72
Percent of funds set aside
to cover specialty care
referrals
Typically 10-15
Goal Limit referral costs
to within or less than
Specialty set aside
Specialty Withhold
73
Per Member Per Month
bull Capitated Payment
bull Specific dollar amount paid for each enrolled member each month
bull Paid whether patient is accessed for care or not
bull States do set access benchmarks
bull In Oregon access for any dental procedure (adults and children combined)
was 267 in 2015
74
Payment Math Example
Premium per enrollee = $25
Administrative fee 15 = $375
Funds available per enrollee to the clinic = $2125
Management fee per enrollee = $175
Funds per enrollee that would undergo PPS reconciliation = $1950
For every 10000 enrollees the managed care income = $2340000
Specialty withhold (10) = $234000
YE Cost lt or gt $2340000
Upside Risk
CHC Gains $
Downside Risk
CHC Loses $
75
Covered Services and Fee Schedules
bull The state Medicaid agency spells out the minimum procedures and fees that
MCOs must cover
bull MCOs may add procedures or increase periodicity of procedures particularly
preventative services
bull MCOs may increase fees to entice rural providers and specialists to enroll in
their Plans
bull Access Rules
bull How many days it takes to access a patent
bull How many days it takes for a patent to access urgent care services
bull How many days it takes for a patent to access emergency care services
76
Credentialing
All MCOs are required to credential all Providers
All MCOs have their own credentialing process
Credentialing process is can be lengthy
Credentialing process may be negotiable
77
Quality Review Process and Quality Metrics
MCOs must have a Quality and Compliance Review Process
If you arenrsquot in compliance with both you likely wonrsquot get paid
Typical processes reviewed
bull Charting specifications
bull Incident report
bull Enrollee complaints quality rudeness and access issues
bull Medicaid compliance
78
Quality Payments
bull State Shared Incentive Withhold Typically quality metrics and benchmarks
are set by the state sets aside a certain percent (3-5) of the payments to
the Managed Care Plan (MCP)
bull If the benchmarks are achieved the MCP is then paid the a predetermine
amount
bull Benchmarks may not be the same as the states
bull Managed Care Plans do not have to pass all or any of the quality payments to
the health centers or providers
bull Managed Care contract- Metrics benchmarks should be selected and part of
the contract
7979
Achieving Quality Metric Payments
Dealing with under achievers
Process issues
Individual issues
Identifying workflows
Developing Best Practices through
PDSA process
Developing Best Practices through
PDSA process
CHC Metrics Committee
Clinicians Operations various key staff
Identify Best Practices
Spread Best Practices
80
New Team Needed Business Intelligence
Business Intelligence (BI) is critical for effective managed care business decisions
BI team inputs metrics into your EHR collects integrates analyses and displays all your managed care business and clinical information
Easy to say- hard to achieve
Build your own or outsource
Possible future role of Primary Care Associations
8181
Clinicianrsquos Dashboard
Expensive to build
Displayed on your screen when your computer is first turned on
Easy to read and understand
Data dumped from the day before
Can dialed down from Org-wide to clinic to each clinicianrsquos data
Operational and clinical metrics
bull Treatment Plan Completion
bull DQA quality measures
bull Caries at Recall
bull Re-care reports
bull Care Gap reports
82
CONTROLLING COSTS
8383
Controlling Costs- Current
bull Increasing efficiencies
bull Decreasing broken appointments
bull Controlling supplies equipment costs
bull Staff recruitment retention costs
84
Specialty Care
Training current CHC dentists in
specialty areas
Hiring general dentists with higher
specialty skill sets
Hiring in house specialists
Contract with outside specialists
Work with Managed Care Plan
specialists
Lowering Disease Rates
Community Dental Health
Coordinators case management
If your state law allows- embed
hygienists in medical and community
to provide primary and secondary
prevention procedures
In clinic Caries Classification and
Silver Diamine Fluoride
Effective recare programs
Controlling Costs- Additions in Risk-based Contracting
85
Specialty Care ndash Primary Referrals by Cost
Pediatric dentistry
Orthodontics
Oral surgery
Endodontics
86
In-clinic Pediatric Services
Encounters expected
of operatories available
State dental law and ability to have
expanded duties
General Anesthesia
GA in- house
Ability for a hospital or surgery center
to set aside regular OR time
Ability to hire or assign DAs to GA
days
Four GA cases day x PPS rate
Should You Hire a Pediatric Dentist- It Depends
8787
Solutions for Controlling Pediatric Costs
Hire a general dentist that is skilled in treating young children
Make the clinic child friendly nitrous oxide TVs in the operatory etc
Teach entire staff behavioral control techniques
Contract with a pediatric dentist for the GA care
88
Lowering Overall Disease Rates (and Costs)
You are responsible for both the patients you see in the chair and the ones
assigned to you
Breaking down the walls of the dental clinic
Community Dental Health Coordinators
Case Management
89
Cost Control Essentials
Diagnosis codes
Increased ability to identify
disease by risk
Motivational
Interviewing
Developing Polices and
Procedures design to treat
disease according to risk
ie Silver Diamine Fluoride
Treating by Risk
Effective Recare
Process
Critical to continual disease
controlPrevention education that is
meaningful and designed to
change behaviors
90
Social Determinants of Health Aunt Bertha
httpswwwauntberthacom
91
REASON TO CONSIDER RISK- BASED CONTRACTING
9292
PPS Reconciliation and Federal Code 42 CFR sect4052469(a)(2)
42 CFR sect4052469(a)(2)
ldquoAny financial incentives provided to Federally Qualified Health Centers
under their Medicare Advantage Contracts such as risk pool payments
bonuses or withholds are prohibited from being included in the
calculation of supplemental payments due to the Federally Qualified
Health Centerrdquo
9393
Why Risk Based Contract in Times of PPS Reconciliation
bull Not all Risk- based Contract funds are reconciled
bull Risk is the key word- you can come out with less money than your normal
PPS reconciliation payment
bull Can lead to better patient care
bull May improve manage care enrollment for your medical plan
bull Promotes integrated care increases health for your CHC patients
9494
Not Included in the Reconciliation
Enrollment management pmpm
Quality Payments
Upside risk payments
Downside risk losses
9595
Determinants of Financial Success in Risk-Based Contracting
bull Most critical- State pmpm payment to the Managed Care Plan
bull Reporting capabilities
bull Specialty service capabilities
bull Access numbers count
bull Ability to move metric numbers
9696
What About the Non- Medicaid Poor We Serve
bull Numbers are king in a managed care contract and the more access you have
the better contract terms you can negotiate
bull We will potentially have a steady supply of Medicaid patients
bull As managed care spreads states this may be compromising the ability of
health centers to serve the non-Medicaid poor and others lacking dental
insurance
97
Mark Koday DDS
(509) 949-2278
Dental Quality Consultants
of WA
httpdentalqualityconsultin
gcom
dentalqualityconsultantsg
mailcom
Contact Information
LUNCH
BREAKOUT EXERCISEORAL HEALTH VALUE-BASED CARE READINESS ASSESSMENT
Danielle Apostolon
PROMISING PRACTICES FROM THE FIELD STRATEGIES FOR INCREASING VALUE IN ORAL HEALTH
Dr Carolyn Brown
Dr Kelly Perry
Dr Rachel Rivard
Dr Adeloye
Commitment Compassion Community
m i d s t a t e h e a l t h o r g
Promising Practices from the
Field Strategies for Increasing
Value in Oral Health Care
Kelly Perry DMD
Better Health
Outcomes
Improved Staff
Experience
Reduced Cost
Improved Patient
Experience
Better Health
Outcomes
Improved Staff
Experience
Reduced Cost
Improved Patient
Experience
Better Health
Outcomes
Improved Staff
Experience
Reduced Cost
Improved Patient
Experience
Better Health
Outcomes
Improved Staff
Experience
Reduced Cost
Improved Patient
Experience
Commitment Compassion Community
kpe r r ymids t a tehea l t h o rg
Thank you
Completion of Disease Control Phase
Pelumi Adeloye DMD MPH
HEALTH ACCESS NETWORK (HAN) FAMILY DENTAL
Introduction
⧫1 Dentist I Hygienist 3 EFDArsquos1 Receptionist
⧫ 6 Chairs= 4 (dentist) + 2 (hygienist)
⧫ Slide ⥶80 off
⧫ Service areas Northern Penobscot Southern Aroostook Western
Washington Counties amp more
Completion of Phase I Treatment
⧫LimitedLack of Access to dental care
⧫Difficulty completing the disease control phase
Caries amp periodontal disease
⧫Attaining stable restorative state
Goal
Increase the completion of Disease Control Phase
Current practice
⧫Education
Assess level of dental literacy
Incremental strategy
⧫Increase access to dental care
Generous sliding scale (⥸$40 per visit)
Incorporate Expanded Function Dental Assistants
⧫Schedule modification
Incorporate more restorative blocks to allow
for follow-up visit and completion of restorative phase
httpswwwglasbergencomdentist-cartoons
Schedule
⧫Piggybacking technique
Increased allotted restorative blocks
⧫Sustainability of current schedule is
contingent on cooperation amp skills of HAN
Dental staff
Note
Strategies mentioned today is personalized to HAN Dental clinic
Current implemented strategies might be modified or changed in the
future as required in order to accommodate the need of our pts
THANK YOU
DAY TWOCLOSINGWRAP-UP
End of Day Two ndash Survey
Day Two Creating a Value-Based Oral Health Care Delivery
System
129
Payment Reform in Oral Health Online Learning Module
Oral Health Value-based Care Online Learning Module
Value-based Care Keys to Success Article
Readiness Assessment
Competency Development Guide
Oral Health Value-based Care Training
Dental Caries Management Practicum
Clinicians Companion Guide
Interprofessional Network Referral Process
Traditional Dental Care Vs Value-Based Care
Resources
131
wwwDentaQuestPartnershiporg
wwwfacebookcomDentaQuest
DentaQuest
wwwlinkedincomcompanyDentaQuest
Inside_DentaQuest
QUESTIONS
6767
Reports Needed
bull Enrollment reports lists of who is assigned on a monthly basis
bull Reconciliation reports insure appropriate payments
bull Specialty Referral reports
bull You will need your own reporting process so you donrsquot rely completely on
reports supplied by the Plan
6868
Medical Loss Ratio
Medical Loss Ratio (MLR) is proportion of premium revenues spent on clinical
services and quality improvement also known as the Medical Loss Ratio (MLR)
For CMS requires Medical Plans to spend at least 80 to 85 of the premiums
on actual medical care
69
Administrative Fees
bull Essentially the opposite of MLR
bull The State Medicaid Agency is funded by the Governorrsquos budget
bull The State Medicaid Agency will keep some of these funds for their
admin costs and give the remaining to the Managed Care Plans
bull Private Plan admin costs can be as high as 40 but most states
limit these cost for Medicaid Plans to between 15 and 20 (85-
80 MLR)
bull This may be negotiable depending on your program size of your
program
70
Quality Withhold
bull The state withholds a certain percent (typically 2-4 ) of the funds they give
to the Plans for Value Based Reimbursement
bull They choose quality metrics and set benchmarks and assign payments for
each metric based on an assigned priority for each metric
bull If a Plan meets the benchmark of every quality metric the state passes on
their full share of the quality withhold
bull The Plans may or may not withhold a percent of the funds for quality payment
to the dentists or manage care contractors
71
Quality Withhold
Either way the Plans may or may not pass the quality payments they receive to
the dentists or contractors
This should be spelled out in a risk-based contract
72
Percent of funds set aside
to cover specialty care
referrals
Typically 10-15
Goal Limit referral costs
to within or less than
Specialty set aside
Specialty Withhold
73
Per Member Per Month
bull Capitated Payment
bull Specific dollar amount paid for each enrolled member each month
bull Paid whether patient is accessed for care or not
bull States do set access benchmarks
bull In Oregon access for any dental procedure (adults and children combined)
was 267 in 2015
74
Payment Math Example
Premium per enrollee = $25
Administrative fee 15 = $375
Funds available per enrollee to the clinic = $2125
Management fee per enrollee = $175
Funds per enrollee that would undergo PPS reconciliation = $1950
For every 10000 enrollees the managed care income = $2340000
Specialty withhold (10) = $234000
YE Cost lt or gt $2340000
Upside Risk
CHC Gains $
Downside Risk
CHC Loses $
75
Covered Services and Fee Schedules
bull The state Medicaid agency spells out the minimum procedures and fees that
MCOs must cover
bull MCOs may add procedures or increase periodicity of procedures particularly
preventative services
bull MCOs may increase fees to entice rural providers and specialists to enroll in
their Plans
bull Access Rules
bull How many days it takes to access a patent
bull How many days it takes for a patent to access urgent care services
bull How many days it takes for a patent to access emergency care services
76
Credentialing
All MCOs are required to credential all Providers
All MCOs have their own credentialing process
Credentialing process is can be lengthy
Credentialing process may be negotiable
77
Quality Review Process and Quality Metrics
MCOs must have a Quality and Compliance Review Process
If you arenrsquot in compliance with both you likely wonrsquot get paid
Typical processes reviewed
bull Charting specifications
bull Incident report
bull Enrollee complaints quality rudeness and access issues
bull Medicaid compliance
78
Quality Payments
bull State Shared Incentive Withhold Typically quality metrics and benchmarks
are set by the state sets aside a certain percent (3-5) of the payments to
the Managed Care Plan (MCP)
bull If the benchmarks are achieved the MCP is then paid the a predetermine
amount
bull Benchmarks may not be the same as the states
bull Managed Care Plans do not have to pass all or any of the quality payments to
the health centers or providers
bull Managed Care contract- Metrics benchmarks should be selected and part of
the contract
7979
Achieving Quality Metric Payments
Dealing with under achievers
Process issues
Individual issues
Identifying workflows
Developing Best Practices through
PDSA process
Developing Best Practices through
PDSA process
CHC Metrics Committee
Clinicians Operations various key staff
Identify Best Practices
Spread Best Practices
80
New Team Needed Business Intelligence
Business Intelligence (BI) is critical for effective managed care business decisions
BI team inputs metrics into your EHR collects integrates analyses and displays all your managed care business and clinical information
Easy to say- hard to achieve
Build your own or outsource
Possible future role of Primary Care Associations
8181
Clinicianrsquos Dashboard
Expensive to build
Displayed on your screen when your computer is first turned on
Easy to read and understand
Data dumped from the day before
Can dialed down from Org-wide to clinic to each clinicianrsquos data
Operational and clinical metrics
bull Treatment Plan Completion
bull DQA quality measures
bull Caries at Recall
bull Re-care reports
bull Care Gap reports
82
CONTROLLING COSTS
8383
Controlling Costs- Current
bull Increasing efficiencies
bull Decreasing broken appointments
bull Controlling supplies equipment costs
bull Staff recruitment retention costs
84
Specialty Care
Training current CHC dentists in
specialty areas
Hiring general dentists with higher
specialty skill sets
Hiring in house specialists
Contract with outside specialists
Work with Managed Care Plan
specialists
Lowering Disease Rates
Community Dental Health
Coordinators case management
If your state law allows- embed
hygienists in medical and community
to provide primary and secondary
prevention procedures
In clinic Caries Classification and
Silver Diamine Fluoride
Effective recare programs
Controlling Costs- Additions in Risk-based Contracting
85
Specialty Care ndash Primary Referrals by Cost
Pediatric dentistry
Orthodontics
Oral surgery
Endodontics
86
In-clinic Pediatric Services
Encounters expected
of operatories available
State dental law and ability to have
expanded duties
General Anesthesia
GA in- house
Ability for a hospital or surgery center
to set aside regular OR time
Ability to hire or assign DAs to GA
days
Four GA cases day x PPS rate
Should You Hire a Pediatric Dentist- It Depends
8787
Solutions for Controlling Pediatric Costs
Hire a general dentist that is skilled in treating young children
Make the clinic child friendly nitrous oxide TVs in the operatory etc
Teach entire staff behavioral control techniques
Contract with a pediatric dentist for the GA care
88
Lowering Overall Disease Rates (and Costs)
You are responsible for both the patients you see in the chair and the ones
assigned to you
Breaking down the walls of the dental clinic
Community Dental Health Coordinators
Case Management
89
Cost Control Essentials
Diagnosis codes
Increased ability to identify
disease by risk
Motivational
Interviewing
Developing Polices and
Procedures design to treat
disease according to risk
ie Silver Diamine Fluoride
Treating by Risk
Effective Recare
Process
Critical to continual disease
controlPrevention education that is
meaningful and designed to
change behaviors
90
Social Determinants of Health Aunt Bertha
httpswwwauntberthacom
91
REASON TO CONSIDER RISK- BASED CONTRACTING
9292
PPS Reconciliation and Federal Code 42 CFR sect4052469(a)(2)
42 CFR sect4052469(a)(2)
ldquoAny financial incentives provided to Federally Qualified Health Centers
under their Medicare Advantage Contracts such as risk pool payments
bonuses or withholds are prohibited from being included in the
calculation of supplemental payments due to the Federally Qualified
Health Centerrdquo
9393
Why Risk Based Contract in Times of PPS Reconciliation
bull Not all Risk- based Contract funds are reconciled
bull Risk is the key word- you can come out with less money than your normal
PPS reconciliation payment
bull Can lead to better patient care
bull May improve manage care enrollment for your medical plan
bull Promotes integrated care increases health for your CHC patients
9494
Not Included in the Reconciliation
Enrollment management pmpm
Quality Payments
Upside risk payments
Downside risk losses
9595
Determinants of Financial Success in Risk-Based Contracting
bull Most critical- State pmpm payment to the Managed Care Plan
bull Reporting capabilities
bull Specialty service capabilities
bull Access numbers count
bull Ability to move metric numbers
9696
What About the Non- Medicaid Poor We Serve
bull Numbers are king in a managed care contract and the more access you have
the better contract terms you can negotiate
bull We will potentially have a steady supply of Medicaid patients
bull As managed care spreads states this may be compromising the ability of
health centers to serve the non-Medicaid poor and others lacking dental
insurance
97
Mark Koday DDS
(509) 949-2278
Dental Quality Consultants
of WA
httpdentalqualityconsultin
gcom
dentalqualityconsultantsg
mailcom
Contact Information
LUNCH
BREAKOUT EXERCISEORAL HEALTH VALUE-BASED CARE READINESS ASSESSMENT
Danielle Apostolon
PROMISING PRACTICES FROM THE FIELD STRATEGIES FOR INCREASING VALUE IN ORAL HEALTH
Dr Carolyn Brown
Dr Kelly Perry
Dr Rachel Rivard
Dr Adeloye
Commitment Compassion Community
m i d s t a t e h e a l t h o r g
Promising Practices from the
Field Strategies for Increasing
Value in Oral Health Care
Kelly Perry DMD
Better Health
Outcomes
Improved Staff
Experience
Reduced Cost
Improved Patient
Experience
Better Health
Outcomes
Improved Staff
Experience
Reduced Cost
Improved Patient
Experience
Better Health
Outcomes
Improved Staff
Experience
Reduced Cost
Improved Patient
Experience
Better Health
Outcomes
Improved Staff
Experience
Reduced Cost
Improved Patient
Experience
Commitment Compassion Community
kpe r r ymids t a tehea l t h o rg
Thank you
Completion of Disease Control Phase
Pelumi Adeloye DMD MPH
HEALTH ACCESS NETWORK (HAN) FAMILY DENTAL
Introduction
⧫1 Dentist I Hygienist 3 EFDArsquos1 Receptionist
⧫ 6 Chairs= 4 (dentist) + 2 (hygienist)
⧫ Slide ⥶80 off
⧫ Service areas Northern Penobscot Southern Aroostook Western
Washington Counties amp more
Completion of Phase I Treatment
⧫LimitedLack of Access to dental care
⧫Difficulty completing the disease control phase
Caries amp periodontal disease
⧫Attaining stable restorative state
Goal
Increase the completion of Disease Control Phase
Current practice
⧫Education
Assess level of dental literacy
Incremental strategy
⧫Increase access to dental care
Generous sliding scale (⥸$40 per visit)
Incorporate Expanded Function Dental Assistants
⧫Schedule modification
Incorporate more restorative blocks to allow
for follow-up visit and completion of restorative phase
httpswwwglasbergencomdentist-cartoons
Schedule
⧫Piggybacking technique
Increased allotted restorative blocks
⧫Sustainability of current schedule is
contingent on cooperation amp skills of HAN
Dental staff
Note
Strategies mentioned today is personalized to HAN Dental clinic
Current implemented strategies might be modified or changed in the
future as required in order to accommodate the need of our pts
THANK YOU
DAY TWOCLOSINGWRAP-UP
End of Day Two ndash Survey
Day Two Creating a Value-Based Oral Health Care Delivery
System
129
Payment Reform in Oral Health Online Learning Module
Oral Health Value-based Care Online Learning Module
Value-based Care Keys to Success Article
Readiness Assessment
Competency Development Guide
Oral Health Value-based Care Training
Dental Caries Management Practicum
Clinicians Companion Guide
Interprofessional Network Referral Process
Traditional Dental Care Vs Value-Based Care
Resources
131
wwwDentaQuestPartnershiporg
wwwfacebookcomDentaQuest
DentaQuest
wwwlinkedincomcompanyDentaQuest
Inside_DentaQuest
QUESTIONS
6868
Medical Loss Ratio
Medical Loss Ratio (MLR) is proportion of premium revenues spent on clinical
services and quality improvement also known as the Medical Loss Ratio (MLR)
For CMS requires Medical Plans to spend at least 80 to 85 of the premiums
on actual medical care
69
Administrative Fees
bull Essentially the opposite of MLR
bull The State Medicaid Agency is funded by the Governorrsquos budget
bull The State Medicaid Agency will keep some of these funds for their
admin costs and give the remaining to the Managed Care Plans
bull Private Plan admin costs can be as high as 40 but most states
limit these cost for Medicaid Plans to between 15 and 20 (85-
80 MLR)
bull This may be negotiable depending on your program size of your
program
70
Quality Withhold
bull The state withholds a certain percent (typically 2-4 ) of the funds they give
to the Plans for Value Based Reimbursement
bull They choose quality metrics and set benchmarks and assign payments for
each metric based on an assigned priority for each metric
bull If a Plan meets the benchmark of every quality metric the state passes on
their full share of the quality withhold
bull The Plans may or may not withhold a percent of the funds for quality payment
to the dentists or manage care contractors
71
Quality Withhold
Either way the Plans may or may not pass the quality payments they receive to
the dentists or contractors
This should be spelled out in a risk-based contract
72
Percent of funds set aside
to cover specialty care
referrals
Typically 10-15
Goal Limit referral costs
to within or less than
Specialty set aside
Specialty Withhold
73
Per Member Per Month
bull Capitated Payment
bull Specific dollar amount paid for each enrolled member each month
bull Paid whether patient is accessed for care or not
bull States do set access benchmarks
bull In Oregon access for any dental procedure (adults and children combined)
was 267 in 2015
74
Payment Math Example
Premium per enrollee = $25
Administrative fee 15 = $375
Funds available per enrollee to the clinic = $2125
Management fee per enrollee = $175
Funds per enrollee that would undergo PPS reconciliation = $1950
For every 10000 enrollees the managed care income = $2340000
Specialty withhold (10) = $234000
YE Cost lt or gt $2340000
Upside Risk
CHC Gains $
Downside Risk
CHC Loses $
75
Covered Services and Fee Schedules
bull The state Medicaid agency spells out the minimum procedures and fees that
MCOs must cover
bull MCOs may add procedures or increase periodicity of procedures particularly
preventative services
bull MCOs may increase fees to entice rural providers and specialists to enroll in
their Plans
bull Access Rules
bull How many days it takes to access a patent
bull How many days it takes for a patent to access urgent care services
bull How many days it takes for a patent to access emergency care services
76
Credentialing
All MCOs are required to credential all Providers
All MCOs have their own credentialing process
Credentialing process is can be lengthy
Credentialing process may be negotiable
77
Quality Review Process and Quality Metrics
MCOs must have a Quality and Compliance Review Process
If you arenrsquot in compliance with both you likely wonrsquot get paid
Typical processes reviewed
bull Charting specifications
bull Incident report
bull Enrollee complaints quality rudeness and access issues
bull Medicaid compliance
78
Quality Payments
bull State Shared Incentive Withhold Typically quality metrics and benchmarks
are set by the state sets aside a certain percent (3-5) of the payments to
the Managed Care Plan (MCP)
bull If the benchmarks are achieved the MCP is then paid the a predetermine
amount
bull Benchmarks may not be the same as the states
bull Managed Care Plans do not have to pass all or any of the quality payments to
the health centers or providers
bull Managed Care contract- Metrics benchmarks should be selected and part of
the contract
7979
Achieving Quality Metric Payments
Dealing with under achievers
Process issues
Individual issues
Identifying workflows
Developing Best Practices through
PDSA process
Developing Best Practices through
PDSA process
CHC Metrics Committee
Clinicians Operations various key staff
Identify Best Practices
Spread Best Practices
80
New Team Needed Business Intelligence
Business Intelligence (BI) is critical for effective managed care business decisions
BI team inputs metrics into your EHR collects integrates analyses and displays all your managed care business and clinical information
Easy to say- hard to achieve
Build your own or outsource
Possible future role of Primary Care Associations
8181
Clinicianrsquos Dashboard
Expensive to build
Displayed on your screen when your computer is first turned on
Easy to read and understand
Data dumped from the day before
Can dialed down from Org-wide to clinic to each clinicianrsquos data
Operational and clinical metrics
bull Treatment Plan Completion
bull DQA quality measures
bull Caries at Recall
bull Re-care reports
bull Care Gap reports
82
CONTROLLING COSTS
8383
Controlling Costs- Current
bull Increasing efficiencies
bull Decreasing broken appointments
bull Controlling supplies equipment costs
bull Staff recruitment retention costs
84
Specialty Care
Training current CHC dentists in
specialty areas
Hiring general dentists with higher
specialty skill sets
Hiring in house specialists
Contract with outside specialists
Work with Managed Care Plan
specialists
Lowering Disease Rates
Community Dental Health
Coordinators case management
If your state law allows- embed
hygienists in medical and community
to provide primary and secondary
prevention procedures
In clinic Caries Classification and
Silver Diamine Fluoride
Effective recare programs
Controlling Costs- Additions in Risk-based Contracting
85
Specialty Care ndash Primary Referrals by Cost
Pediatric dentistry
Orthodontics
Oral surgery
Endodontics
86
In-clinic Pediatric Services
Encounters expected
of operatories available
State dental law and ability to have
expanded duties
General Anesthesia
GA in- house
Ability for a hospital or surgery center
to set aside regular OR time
Ability to hire or assign DAs to GA
days
Four GA cases day x PPS rate
Should You Hire a Pediatric Dentist- It Depends
8787
Solutions for Controlling Pediatric Costs
Hire a general dentist that is skilled in treating young children
Make the clinic child friendly nitrous oxide TVs in the operatory etc
Teach entire staff behavioral control techniques
Contract with a pediatric dentist for the GA care
88
Lowering Overall Disease Rates (and Costs)
You are responsible for both the patients you see in the chair and the ones
assigned to you
Breaking down the walls of the dental clinic
Community Dental Health Coordinators
Case Management
89
Cost Control Essentials
Diagnosis codes
Increased ability to identify
disease by risk
Motivational
Interviewing
Developing Polices and
Procedures design to treat
disease according to risk
ie Silver Diamine Fluoride
Treating by Risk
Effective Recare
Process
Critical to continual disease
controlPrevention education that is
meaningful and designed to
change behaviors
90
Social Determinants of Health Aunt Bertha
httpswwwauntberthacom
91
REASON TO CONSIDER RISK- BASED CONTRACTING
9292
PPS Reconciliation and Federal Code 42 CFR sect4052469(a)(2)
42 CFR sect4052469(a)(2)
ldquoAny financial incentives provided to Federally Qualified Health Centers
under their Medicare Advantage Contracts such as risk pool payments
bonuses or withholds are prohibited from being included in the
calculation of supplemental payments due to the Federally Qualified
Health Centerrdquo
9393
Why Risk Based Contract in Times of PPS Reconciliation
bull Not all Risk- based Contract funds are reconciled
bull Risk is the key word- you can come out with less money than your normal
PPS reconciliation payment
bull Can lead to better patient care
bull May improve manage care enrollment for your medical plan
bull Promotes integrated care increases health for your CHC patients
9494
Not Included in the Reconciliation
Enrollment management pmpm
Quality Payments
Upside risk payments
Downside risk losses
9595
Determinants of Financial Success in Risk-Based Contracting
bull Most critical- State pmpm payment to the Managed Care Plan
bull Reporting capabilities
bull Specialty service capabilities
bull Access numbers count
bull Ability to move metric numbers
9696
What About the Non- Medicaid Poor We Serve
bull Numbers are king in a managed care contract and the more access you have
the better contract terms you can negotiate
bull We will potentially have a steady supply of Medicaid patients
bull As managed care spreads states this may be compromising the ability of
health centers to serve the non-Medicaid poor and others lacking dental
insurance
97
Mark Koday DDS
(509) 949-2278
Dental Quality Consultants
of WA
httpdentalqualityconsultin
gcom
dentalqualityconsultantsg
mailcom
Contact Information
LUNCH
BREAKOUT EXERCISEORAL HEALTH VALUE-BASED CARE READINESS ASSESSMENT
Danielle Apostolon
PROMISING PRACTICES FROM THE FIELD STRATEGIES FOR INCREASING VALUE IN ORAL HEALTH
Dr Carolyn Brown
Dr Kelly Perry
Dr Rachel Rivard
Dr Adeloye
Commitment Compassion Community
m i d s t a t e h e a l t h o r g
Promising Practices from the
Field Strategies for Increasing
Value in Oral Health Care
Kelly Perry DMD
Better Health
Outcomes
Improved Staff
Experience
Reduced Cost
Improved Patient
Experience
Better Health
Outcomes
Improved Staff
Experience
Reduced Cost
Improved Patient
Experience
Better Health
Outcomes
Improved Staff
Experience
Reduced Cost
Improved Patient
Experience
Better Health
Outcomes
Improved Staff
Experience
Reduced Cost
Improved Patient
Experience
Commitment Compassion Community
kpe r r ymids t a tehea l t h o rg
Thank you
Completion of Disease Control Phase
Pelumi Adeloye DMD MPH
HEALTH ACCESS NETWORK (HAN) FAMILY DENTAL
Introduction
⧫1 Dentist I Hygienist 3 EFDArsquos1 Receptionist
⧫ 6 Chairs= 4 (dentist) + 2 (hygienist)
⧫ Slide ⥶80 off
⧫ Service areas Northern Penobscot Southern Aroostook Western
Washington Counties amp more
Completion of Phase I Treatment
⧫LimitedLack of Access to dental care
⧫Difficulty completing the disease control phase
Caries amp periodontal disease
⧫Attaining stable restorative state
Goal
Increase the completion of Disease Control Phase
Current practice
⧫Education
Assess level of dental literacy
Incremental strategy
⧫Increase access to dental care
Generous sliding scale (⥸$40 per visit)
Incorporate Expanded Function Dental Assistants
⧫Schedule modification
Incorporate more restorative blocks to allow
for follow-up visit and completion of restorative phase
httpswwwglasbergencomdentist-cartoons
Schedule
⧫Piggybacking technique
Increased allotted restorative blocks
⧫Sustainability of current schedule is
contingent on cooperation amp skills of HAN
Dental staff
Note
Strategies mentioned today is personalized to HAN Dental clinic
Current implemented strategies might be modified or changed in the
future as required in order to accommodate the need of our pts
THANK YOU
DAY TWOCLOSINGWRAP-UP
End of Day Two ndash Survey
Day Two Creating a Value-Based Oral Health Care Delivery
System
129
Payment Reform in Oral Health Online Learning Module
Oral Health Value-based Care Online Learning Module
Value-based Care Keys to Success Article
Readiness Assessment
Competency Development Guide
Oral Health Value-based Care Training
Dental Caries Management Practicum
Clinicians Companion Guide
Interprofessional Network Referral Process
Traditional Dental Care Vs Value-Based Care
Resources
131
wwwDentaQuestPartnershiporg
wwwfacebookcomDentaQuest
DentaQuest
wwwlinkedincomcompanyDentaQuest
Inside_DentaQuest
QUESTIONS
69
Administrative Fees
bull Essentially the opposite of MLR
bull The State Medicaid Agency is funded by the Governorrsquos budget
bull The State Medicaid Agency will keep some of these funds for their
admin costs and give the remaining to the Managed Care Plans
bull Private Plan admin costs can be as high as 40 but most states
limit these cost for Medicaid Plans to between 15 and 20 (85-
80 MLR)
bull This may be negotiable depending on your program size of your
program
70
Quality Withhold
bull The state withholds a certain percent (typically 2-4 ) of the funds they give
to the Plans for Value Based Reimbursement
bull They choose quality metrics and set benchmarks and assign payments for
each metric based on an assigned priority for each metric
bull If a Plan meets the benchmark of every quality metric the state passes on
their full share of the quality withhold
bull The Plans may or may not withhold a percent of the funds for quality payment
to the dentists or manage care contractors
71
Quality Withhold
Either way the Plans may or may not pass the quality payments they receive to
the dentists or contractors
This should be spelled out in a risk-based contract
72
Percent of funds set aside
to cover specialty care
referrals
Typically 10-15
Goal Limit referral costs
to within or less than
Specialty set aside
Specialty Withhold
73
Per Member Per Month
bull Capitated Payment
bull Specific dollar amount paid for each enrolled member each month
bull Paid whether patient is accessed for care or not
bull States do set access benchmarks
bull In Oregon access for any dental procedure (adults and children combined)
was 267 in 2015
74
Payment Math Example
Premium per enrollee = $25
Administrative fee 15 = $375
Funds available per enrollee to the clinic = $2125
Management fee per enrollee = $175
Funds per enrollee that would undergo PPS reconciliation = $1950
For every 10000 enrollees the managed care income = $2340000
Specialty withhold (10) = $234000
YE Cost lt or gt $2340000
Upside Risk
CHC Gains $
Downside Risk
CHC Loses $
75
Covered Services and Fee Schedules
bull The state Medicaid agency spells out the minimum procedures and fees that
MCOs must cover
bull MCOs may add procedures or increase periodicity of procedures particularly
preventative services
bull MCOs may increase fees to entice rural providers and specialists to enroll in
their Plans
bull Access Rules
bull How many days it takes to access a patent
bull How many days it takes for a patent to access urgent care services
bull How many days it takes for a patent to access emergency care services
76
Credentialing
All MCOs are required to credential all Providers
All MCOs have their own credentialing process
Credentialing process is can be lengthy
Credentialing process may be negotiable
77
Quality Review Process and Quality Metrics
MCOs must have a Quality and Compliance Review Process
If you arenrsquot in compliance with both you likely wonrsquot get paid
Typical processes reviewed
bull Charting specifications
bull Incident report
bull Enrollee complaints quality rudeness and access issues
bull Medicaid compliance
78
Quality Payments
bull State Shared Incentive Withhold Typically quality metrics and benchmarks
are set by the state sets aside a certain percent (3-5) of the payments to
the Managed Care Plan (MCP)
bull If the benchmarks are achieved the MCP is then paid the a predetermine
amount
bull Benchmarks may not be the same as the states
bull Managed Care Plans do not have to pass all or any of the quality payments to
the health centers or providers
bull Managed Care contract- Metrics benchmarks should be selected and part of
the contract
7979
Achieving Quality Metric Payments
Dealing with under achievers
Process issues
Individual issues
Identifying workflows
Developing Best Practices through
PDSA process
Developing Best Practices through
PDSA process
CHC Metrics Committee
Clinicians Operations various key staff
Identify Best Practices
Spread Best Practices
80
New Team Needed Business Intelligence
Business Intelligence (BI) is critical for effective managed care business decisions
BI team inputs metrics into your EHR collects integrates analyses and displays all your managed care business and clinical information
Easy to say- hard to achieve
Build your own or outsource
Possible future role of Primary Care Associations
8181
Clinicianrsquos Dashboard
Expensive to build
Displayed on your screen when your computer is first turned on
Easy to read and understand
Data dumped from the day before
Can dialed down from Org-wide to clinic to each clinicianrsquos data
Operational and clinical metrics
bull Treatment Plan Completion
bull DQA quality measures
bull Caries at Recall
bull Re-care reports
bull Care Gap reports
82
CONTROLLING COSTS
8383
Controlling Costs- Current
bull Increasing efficiencies
bull Decreasing broken appointments
bull Controlling supplies equipment costs
bull Staff recruitment retention costs
84
Specialty Care
Training current CHC dentists in
specialty areas
Hiring general dentists with higher
specialty skill sets
Hiring in house specialists
Contract with outside specialists
Work with Managed Care Plan
specialists
Lowering Disease Rates
Community Dental Health
Coordinators case management
If your state law allows- embed
hygienists in medical and community
to provide primary and secondary
prevention procedures
In clinic Caries Classification and
Silver Diamine Fluoride
Effective recare programs
Controlling Costs- Additions in Risk-based Contracting
85
Specialty Care ndash Primary Referrals by Cost
Pediatric dentistry
Orthodontics
Oral surgery
Endodontics
86
In-clinic Pediatric Services
Encounters expected
of operatories available
State dental law and ability to have
expanded duties
General Anesthesia
GA in- house
Ability for a hospital or surgery center
to set aside regular OR time
Ability to hire or assign DAs to GA
days
Four GA cases day x PPS rate
Should You Hire a Pediatric Dentist- It Depends
8787
Solutions for Controlling Pediatric Costs
Hire a general dentist that is skilled in treating young children
Make the clinic child friendly nitrous oxide TVs in the operatory etc
Teach entire staff behavioral control techniques
Contract with a pediatric dentist for the GA care
88
Lowering Overall Disease Rates (and Costs)
You are responsible for both the patients you see in the chair and the ones
assigned to you
Breaking down the walls of the dental clinic
Community Dental Health Coordinators
Case Management
89
Cost Control Essentials
Diagnosis codes
Increased ability to identify
disease by risk
Motivational
Interviewing
Developing Polices and
Procedures design to treat
disease according to risk
ie Silver Diamine Fluoride
Treating by Risk
Effective Recare
Process
Critical to continual disease
controlPrevention education that is
meaningful and designed to
change behaviors
90
Social Determinants of Health Aunt Bertha
httpswwwauntberthacom
91
REASON TO CONSIDER RISK- BASED CONTRACTING
9292
PPS Reconciliation and Federal Code 42 CFR sect4052469(a)(2)
42 CFR sect4052469(a)(2)
ldquoAny financial incentives provided to Federally Qualified Health Centers
under their Medicare Advantage Contracts such as risk pool payments
bonuses or withholds are prohibited from being included in the
calculation of supplemental payments due to the Federally Qualified
Health Centerrdquo
9393
Why Risk Based Contract in Times of PPS Reconciliation
bull Not all Risk- based Contract funds are reconciled
bull Risk is the key word- you can come out with less money than your normal
PPS reconciliation payment
bull Can lead to better patient care
bull May improve manage care enrollment for your medical plan
bull Promotes integrated care increases health for your CHC patients
9494
Not Included in the Reconciliation
Enrollment management pmpm
Quality Payments
Upside risk payments
Downside risk losses
9595
Determinants of Financial Success in Risk-Based Contracting
bull Most critical- State pmpm payment to the Managed Care Plan
bull Reporting capabilities
bull Specialty service capabilities
bull Access numbers count
bull Ability to move metric numbers
9696
What About the Non- Medicaid Poor We Serve
bull Numbers are king in a managed care contract and the more access you have
the better contract terms you can negotiate
bull We will potentially have a steady supply of Medicaid patients
bull As managed care spreads states this may be compromising the ability of
health centers to serve the non-Medicaid poor and others lacking dental
insurance
97
Mark Koday DDS
(509) 949-2278
Dental Quality Consultants
of WA
httpdentalqualityconsultin
gcom
dentalqualityconsultantsg
mailcom
Contact Information
LUNCH
BREAKOUT EXERCISEORAL HEALTH VALUE-BASED CARE READINESS ASSESSMENT
Danielle Apostolon
PROMISING PRACTICES FROM THE FIELD STRATEGIES FOR INCREASING VALUE IN ORAL HEALTH
Dr Carolyn Brown
Dr Kelly Perry
Dr Rachel Rivard
Dr Adeloye
Commitment Compassion Community
m i d s t a t e h e a l t h o r g
Promising Practices from the
Field Strategies for Increasing
Value in Oral Health Care
Kelly Perry DMD
Better Health
Outcomes
Improved Staff
Experience
Reduced Cost
Improved Patient
Experience
Better Health
Outcomes
Improved Staff
Experience
Reduced Cost
Improved Patient
Experience
Better Health
Outcomes
Improved Staff
Experience
Reduced Cost
Improved Patient
Experience
Better Health
Outcomes
Improved Staff
Experience
Reduced Cost
Improved Patient
Experience
Commitment Compassion Community
kpe r r ymids t a tehea l t h o rg
Thank you
Completion of Disease Control Phase
Pelumi Adeloye DMD MPH
HEALTH ACCESS NETWORK (HAN) FAMILY DENTAL
Introduction
⧫1 Dentist I Hygienist 3 EFDArsquos1 Receptionist
⧫ 6 Chairs= 4 (dentist) + 2 (hygienist)
⧫ Slide ⥶80 off
⧫ Service areas Northern Penobscot Southern Aroostook Western
Washington Counties amp more
Completion of Phase I Treatment
⧫LimitedLack of Access to dental care
⧫Difficulty completing the disease control phase
Caries amp periodontal disease
⧫Attaining stable restorative state
Goal
Increase the completion of Disease Control Phase
Current practice
⧫Education
Assess level of dental literacy
Incremental strategy
⧫Increase access to dental care
Generous sliding scale (⥸$40 per visit)
Incorporate Expanded Function Dental Assistants
⧫Schedule modification
Incorporate more restorative blocks to allow
for follow-up visit and completion of restorative phase
httpswwwglasbergencomdentist-cartoons
Schedule
⧫Piggybacking technique
Increased allotted restorative blocks
⧫Sustainability of current schedule is
contingent on cooperation amp skills of HAN
Dental staff
Note
Strategies mentioned today is personalized to HAN Dental clinic
Current implemented strategies might be modified or changed in the
future as required in order to accommodate the need of our pts
THANK YOU
DAY TWOCLOSINGWRAP-UP
End of Day Two ndash Survey
Day Two Creating a Value-Based Oral Health Care Delivery
System
129
Payment Reform in Oral Health Online Learning Module
Oral Health Value-based Care Online Learning Module
Value-based Care Keys to Success Article
Readiness Assessment
Competency Development Guide
Oral Health Value-based Care Training
Dental Caries Management Practicum
Clinicians Companion Guide
Interprofessional Network Referral Process
Traditional Dental Care Vs Value-Based Care
Resources
131
wwwDentaQuestPartnershiporg
wwwfacebookcomDentaQuest
DentaQuest
wwwlinkedincomcompanyDentaQuest
Inside_DentaQuest
QUESTIONS
70
Quality Withhold
bull The state withholds a certain percent (typically 2-4 ) of the funds they give
to the Plans for Value Based Reimbursement
bull They choose quality metrics and set benchmarks and assign payments for
each metric based on an assigned priority for each metric
bull If a Plan meets the benchmark of every quality metric the state passes on
their full share of the quality withhold
bull The Plans may or may not withhold a percent of the funds for quality payment
to the dentists or manage care contractors
71
Quality Withhold
Either way the Plans may or may not pass the quality payments they receive to
the dentists or contractors
This should be spelled out in a risk-based contract
72
Percent of funds set aside
to cover specialty care
referrals
Typically 10-15
Goal Limit referral costs
to within or less than
Specialty set aside
Specialty Withhold
73
Per Member Per Month
bull Capitated Payment
bull Specific dollar amount paid for each enrolled member each month
bull Paid whether patient is accessed for care or not
bull States do set access benchmarks
bull In Oregon access for any dental procedure (adults and children combined)
was 267 in 2015
74
Payment Math Example
Premium per enrollee = $25
Administrative fee 15 = $375
Funds available per enrollee to the clinic = $2125
Management fee per enrollee = $175
Funds per enrollee that would undergo PPS reconciliation = $1950
For every 10000 enrollees the managed care income = $2340000
Specialty withhold (10) = $234000
YE Cost lt or gt $2340000
Upside Risk
CHC Gains $
Downside Risk
CHC Loses $
75
Covered Services and Fee Schedules
bull The state Medicaid agency spells out the minimum procedures and fees that
MCOs must cover
bull MCOs may add procedures or increase periodicity of procedures particularly
preventative services
bull MCOs may increase fees to entice rural providers and specialists to enroll in
their Plans
bull Access Rules
bull How many days it takes to access a patent
bull How many days it takes for a patent to access urgent care services
bull How many days it takes for a patent to access emergency care services
76
Credentialing
All MCOs are required to credential all Providers
All MCOs have their own credentialing process
Credentialing process is can be lengthy
Credentialing process may be negotiable
77
Quality Review Process and Quality Metrics
MCOs must have a Quality and Compliance Review Process
If you arenrsquot in compliance with both you likely wonrsquot get paid
Typical processes reviewed
bull Charting specifications
bull Incident report
bull Enrollee complaints quality rudeness and access issues
bull Medicaid compliance
78
Quality Payments
bull State Shared Incentive Withhold Typically quality metrics and benchmarks
are set by the state sets aside a certain percent (3-5) of the payments to
the Managed Care Plan (MCP)
bull If the benchmarks are achieved the MCP is then paid the a predetermine
amount
bull Benchmarks may not be the same as the states
bull Managed Care Plans do not have to pass all or any of the quality payments to
the health centers or providers
bull Managed Care contract- Metrics benchmarks should be selected and part of
the contract
7979
Achieving Quality Metric Payments
Dealing with under achievers
Process issues
Individual issues
Identifying workflows
Developing Best Practices through
PDSA process
Developing Best Practices through
PDSA process
CHC Metrics Committee
Clinicians Operations various key staff
Identify Best Practices
Spread Best Practices
80
New Team Needed Business Intelligence
Business Intelligence (BI) is critical for effective managed care business decisions
BI team inputs metrics into your EHR collects integrates analyses and displays all your managed care business and clinical information
Easy to say- hard to achieve
Build your own or outsource
Possible future role of Primary Care Associations
8181
Clinicianrsquos Dashboard
Expensive to build
Displayed on your screen when your computer is first turned on
Easy to read and understand
Data dumped from the day before
Can dialed down from Org-wide to clinic to each clinicianrsquos data
Operational and clinical metrics
bull Treatment Plan Completion
bull DQA quality measures
bull Caries at Recall
bull Re-care reports
bull Care Gap reports
82
CONTROLLING COSTS
8383
Controlling Costs- Current
bull Increasing efficiencies
bull Decreasing broken appointments
bull Controlling supplies equipment costs
bull Staff recruitment retention costs
84
Specialty Care
Training current CHC dentists in
specialty areas
Hiring general dentists with higher
specialty skill sets
Hiring in house specialists
Contract with outside specialists
Work with Managed Care Plan
specialists
Lowering Disease Rates
Community Dental Health
Coordinators case management
If your state law allows- embed
hygienists in medical and community
to provide primary and secondary
prevention procedures
In clinic Caries Classification and
Silver Diamine Fluoride
Effective recare programs
Controlling Costs- Additions in Risk-based Contracting
85
Specialty Care ndash Primary Referrals by Cost
Pediatric dentistry
Orthodontics
Oral surgery
Endodontics
86
In-clinic Pediatric Services
Encounters expected
of operatories available
State dental law and ability to have
expanded duties
General Anesthesia
GA in- house
Ability for a hospital or surgery center
to set aside regular OR time
Ability to hire or assign DAs to GA
days
Four GA cases day x PPS rate
Should You Hire a Pediatric Dentist- It Depends
8787
Solutions for Controlling Pediatric Costs
Hire a general dentist that is skilled in treating young children
Make the clinic child friendly nitrous oxide TVs in the operatory etc
Teach entire staff behavioral control techniques
Contract with a pediatric dentist for the GA care
88
Lowering Overall Disease Rates (and Costs)
You are responsible for both the patients you see in the chair and the ones
assigned to you
Breaking down the walls of the dental clinic
Community Dental Health Coordinators
Case Management
89
Cost Control Essentials
Diagnosis codes
Increased ability to identify
disease by risk
Motivational
Interviewing
Developing Polices and
Procedures design to treat
disease according to risk
ie Silver Diamine Fluoride
Treating by Risk
Effective Recare
Process
Critical to continual disease
controlPrevention education that is
meaningful and designed to
change behaviors
90
Social Determinants of Health Aunt Bertha
httpswwwauntberthacom
91
REASON TO CONSIDER RISK- BASED CONTRACTING
9292
PPS Reconciliation and Federal Code 42 CFR sect4052469(a)(2)
42 CFR sect4052469(a)(2)
ldquoAny financial incentives provided to Federally Qualified Health Centers
under their Medicare Advantage Contracts such as risk pool payments
bonuses or withholds are prohibited from being included in the
calculation of supplemental payments due to the Federally Qualified
Health Centerrdquo
9393
Why Risk Based Contract in Times of PPS Reconciliation
bull Not all Risk- based Contract funds are reconciled
bull Risk is the key word- you can come out with less money than your normal
PPS reconciliation payment
bull Can lead to better patient care
bull May improve manage care enrollment for your medical plan
bull Promotes integrated care increases health for your CHC patients
9494
Not Included in the Reconciliation
Enrollment management pmpm
Quality Payments
Upside risk payments
Downside risk losses
9595
Determinants of Financial Success in Risk-Based Contracting
bull Most critical- State pmpm payment to the Managed Care Plan
bull Reporting capabilities
bull Specialty service capabilities
bull Access numbers count
bull Ability to move metric numbers
9696
What About the Non- Medicaid Poor We Serve
bull Numbers are king in a managed care contract and the more access you have
the better contract terms you can negotiate
bull We will potentially have a steady supply of Medicaid patients
bull As managed care spreads states this may be compromising the ability of
health centers to serve the non-Medicaid poor and others lacking dental
insurance
97
Mark Koday DDS
(509) 949-2278
Dental Quality Consultants
of WA
httpdentalqualityconsultin
gcom
dentalqualityconsultantsg
mailcom
Contact Information
LUNCH
BREAKOUT EXERCISEORAL HEALTH VALUE-BASED CARE READINESS ASSESSMENT
Danielle Apostolon
PROMISING PRACTICES FROM THE FIELD STRATEGIES FOR INCREASING VALUE IN ORAL HEALTH
Dr Carolyn Brown
Dr Kelly Perry
Dr Rachel Rivard
Dr Adeloye
Commitment Compassion Community
m i d s t a t e h e a l t h o r g
Promising Practices from the
Field Strategies for Increasing
Value in Oral Health Care
Kelly Perry DMD
Better Health
Outcomes
Improved Staff
Experience
Reduced Cost
Improved Patient
Experience
Better Health
Outcomes
Improved Staff
Experience
Reduced Cost
Improved Patient
Experience
Better Health
Outcomes
Improved Staff
Experience
Reduced Cost
Improved Patient
Experience
Better Health
Outcomes
Improved Staff
Experience
Reduced Cost
Improved Patient
Experience
Commitment Compassion Community
kpe r r ymids t a tehea l t h o rg
Thank you
Completion of Disease Control Phase
Pelumi Adeloye DMD MPH
HEALTH ACCESS NETWORK (HAN) FAMILY DENTAL
Introduction
⧫1 Dentist I Hygienist 3 EFDArsquos1 Receptionist
⧫ 6 Chairs= 4 (dentist) + 2 (hygienist)
⧫ Slide ⥶80 off
⧫ Service areas Northern Penobscot Southern Aroostook Western
Washington Counties amp more
Completion of Phase I Treatment
⧫LimitedLack of Access to dental care
⧫Difficulty completing the disease control phase
Caries amp periodontal disease
⧫Attaining stable restorative state
Goal
Increase the completion of Disease Control Phase
Current practice
⧫Education
Assess level of dental literacy
Incremental strategy
⧫Increase access to dental care
Generous sliding scale (⥸$40 per visit)
Incorporate Expanded Function Dental Assistants
⧫Schedule modification
Incorporate more restorative blocks to allow
for follow-up visit and completion of restorative phase
httpswwwglasbergencomdentist-cartoons
Schedule
⧫Piggybacking technique
Increased allotted restorative blocks
⧫Sustainability of current schedule is
contingent on cooperation amp skills of HAN
Dental staff
Note
Strategies mentioned today is personalized to HAN Dental clinic
Current implemented strategies might be modified or changed in the
future as required in order to accommodate the need of our pts
THANK YOU
DAY TWOCLOSINGWRAP-UP
End of Day Two ndash Survey
Day Two Creating a Value-Based Oral Health Care Delivery
System
129
Payment Reform in Oral Health Online Learning Module
Oral Health Value-based Care Online Learning Module
Value-based Care Keys to Success Article
Readiness Assessment
Competency Development Guide
Oral Health Value-based Care Training
Dental Caries Management Practicum
Clinicians Companion Guide
Interprofessional Network Referral Process
Traditional Dental Care Vs Value-Based Care
Resources
131
wwwDentaQuestPartnershiporg
wwwfacebookcomDentaQuest
DentaQuest
wwwlinkedincomcompanyDentaQuest
Inside_DentaQuest
QUESTIONS
71
Quality Withhold
Either way the Plans may or may not pass the quality payments they receive to
the dentists or contractors
This should be spelled out in a risk-based contract
72
Percent of funds set aside
to cover specialty care
referrals
Typically 10-15
Goal Limit referral costs
to within or less than
Specialty set aside
Specialty Withhold
73
Per Member Per Month
bull Capitated Payment
bull Specific dollar amount paid for each enrolled member each month
bull Paid whether patient is accessed for care or not
bull States do set access benchmarks
bull In Oregon access for any dental procedure (adults and children combined)
was 267 in 2015
74
Payment Math Example
Premium per enrollee = $25
Administrative fee 15 = $375
Funds available per enrollee to the clinic = $2125
Management fee per enrollee = $175
Funds per enrollee that would undergo PPS reconciliation = $1950
For every 10000 enrollees the managed care income = $2340000
Specialty withhold (10) = $234000
YE Cost lt or gt $2340000
Upside Risk
CHC Gains $
Downside Risk
CHC Loses $
75
Covered Services and Fee Schedules
bull The state Medicaid agency spells out the minimum procedures and fees that
MCOs must cover
bull MCOs may add procedures or increase periodicity of procedures particularly
preventative services
bull MCOs may increase fees to entice rural providers and specialists to enroll in
their Plans
bull Access Rules
bull How many days it takes to access a patent
bull How many days it takes for a patent to access urgent care services
bull How many days it takes for a patent to access emergency care services
76
Credentialing
All MCOs are required to credential all Providers
All MCOs have their own credentialing process
Credentialing process is can be lengthy
Credentialing process may be negotiable
77
Quality Review Process and Quality Metrics
MCOs must have a Quality and Compliance Review Process
If you arenrsquot in compliance with both you likely wonrsquot get paid
Typical processes reviewed
bull Charting specifications
bull Incident report
bull Enrollee complaints quality rudeness and access issues
bull Medicaid compliance
78
Quality Payments
bull State Shared Incentive Withhold Typically quality metrics and benchmarks
are set by the state sets aside a certain percent (3-5) of the payments to
the Managed Care Plan (MCP)
bull If the benchmarks are achieved the MCP is then paid the a predetermine
amount
bull Benchmarks may not be the same as the states
bull Managed Care Plans do not have to pass all or any of the quality payments to
the health centers or providers
bull Managed Care contract- Metrics benchmarks should be selected and part of
the contract
7979
Achieving Quality Metric Payments
Dealing with under achievers
Process issues
Individual issues
Identifying workflows
Developing Best Practices through
PDSA process
Developing Best Practices through
PDSA process
CHC Metrics Committee
Clinicians Operations various key staff
Identify Best Practices
Spread Best Practices
80
New Team Needed Business Intelligence
Business Intelligence (BI) is critical for effective managed care business decisions
BI team inputs metrics into your EHR collects integrates analyses and displays all your managed care business and clinical information
Easy to say- hard to achieve
Build your own or outsource
Possible future role of Primary Care Associations
8181
Clinicianrsquos Dashboard
Expensive to build
Displayed on your screen when your computer is first turned on
Easy to read and understand
Data dumped from the day before
Can dialed down from Org-wide to clinic to each clinicianrsquos data
Operational and clinical metrics
bull Treatment Plan Completion
bull DQA quality measures
bull Caries at Recall
bull Re-care reports
bull Care Gap reports
82
CONTROLLING COSTS
8383
Controlling Costs- Current
bull Increasing efficiencies
bull Decreasing broken appointments
bull Controlling supplies equipment costs
bull Staff recruitment retention costs
84
Specialty Care
Training current CHC dentists in
specialty areas
Hiring general dentists with higher
specialty skill sets
Hiring in house specialists
Contract with outside specialists
Work with Managed Care Plan
specialists
Lowering Disease Rates
Community Dental Health
Coordinators case management
If your state law allows- embed
hygienists in medical and community
to provide primary and secondary
prevention procedures
In clinic Caries Classification and
Silver Diamine Fluoride
Effective recare programs
Controlling Costs- Additions in Risk-based Contracting
85
Specialty Care ndash Primary Referrals by Cost
Pediatric dentistry
Orthodontics
Oral surgery
Endodontics
86
In-clinic Pediatric Services
Encounters expected
of operatories available
State dental law and ability to have
expanded duties
General Anesthesia
GA in- house
Ability for a hospital or surgery center
to set aside regular OR time
Ability to hire or assign DAs to GA
days
Four GA cases day x PPS rate
Should You Hire a Pediatric Dentist- It Depends
8787
Solutions for Controlling Pediatric Costs
Hire a general dentist that is skilled in treating young children
Make the clinic child friendly nitrous oxide TVs in the operatory etc
Teach entire staff behavioral control techniques
Contract with a pediatric dentist for the GA care
88
Lowering Overall Disease Rates (and Costs)
You are responsible for both the patients you see in the chair and the ones
assigned to you
Breaking down the walls of the dental clinic
Community Dental Health Coordinators
Case Management
89
Cost Control Essentials
Diagnosis codes
Increased ability to identify
disease by risk
Motivational
Interviewing
Developing Polices and
Procedures design to treat
disease according to risk
ie Silver Diamine Fluoride
Treating by Risk
Effective Recare
Process
Critical to continual disease
controlPrevention education that is
meaningful and designed to
change behaviors
90
Social Determinants of Health Aunt Bertha
httpswwwauntberthacom
91
REASON TO CONSIDER RISK- BASED CONTRACTING
9292
PPS Reconciliation and Federal Code 42 CFR sect4052469(a)(2)
42 CFR sect4052469(a)(2)
ldquoAny financial incentives provided to Federally Qualified Health Centers
under their Medicare Advantage Contracts such as risk pool payments
bonuses or withholds are prohibited from being included in the
calculation of supplemental payments due to the Federally Qualified
Health Centerrdquo
9393
Why Risk Based Contract in Times of PPS Reconciliation
bull Not all Risk- based Contract funds are reconciled
bull Risk is the key word- you can come out with less money than your normal
PPS reconciliation payment
bull Can lead to better patient care
bull May improve manage care enrollment for your medical plan
bull Promotes integrated care increases health for your CHC patients
9494
Not Included in the Reconciliation
Enrollment management pmpm
Quality Payments
Upside risk payments
Downside risk losses
9595
Determinants of Financial Success in Risk-Based Contracting
bull Most critical- State pmpm payment to the Managed Care Plan
bull Reporting capabilities
bull Specialty service capabilities
bull Access numbers count
bull Ability to move metric numbers
9696
What About the Non- Medicaid Poor We Serve
bull Numbers are king in a managed care contract and the more access you have
the better contract terms you can negotiate
bull We will potentially have a steady supply of Medicaid patients
bull As managed care spreads states this may be compromising the ability of
health centers to serve the non-Medicaid poor and others lacking dental
insurance
97
Mark Koday DDS
(509) 949-2278
Dental Quality Consultants
of WA
httpdentalqualityconsultin
gcom
dentalqualityconsultantsg
mailcom
Contact Information
LUNCH
BREAKOUT EXERCISEORAL HEALTH VALUE-BASED CARE READINESS ASSESSMENT
Danielle Apostolon
PROMISING PRACTICES FROM THE FIELD STRATEGIES FOR INCREASING VALUE IN ORAL HEALTH
Dr Carolyn Brown
Dr Kelly Perry
Dr Rachel Rivard
Dr Adeloye
Commitment Compassion Community
m i d s t a t e h e a l t h o r g
Promising Practices from the
Field Strategies for Increasing
Value in Oral Health Care
Kelly Perry DMD
Better Health
Outcomes
Improved Staff
Experience
Reduced Cost
Improved Patient
Experience
Better Health
Outcomes
Improved Staff
Experience
Reduced Cost
Improved Patient
Experience
Better Health
Outcomes
Improved Staff
Experience
Reduced Cost
Improved Patient
Experience
Better Health
Outcomes
Improved Staff
Experience
Reduced Cost
Improved Patient
Experience
Commitment Compassion Community
kpe r r ymids t a tehea l t h o rg
Thank you
Completion of Disease Control Phase
Pelumi Adeloye DMD MPH
HEALTH ACCESS NETWORK (HAN) FAMILY DENTAL
Introduction
⧫1 Dentist I Hygienist 3 EFDArsquos1 Receptionist
⧫ 6 Chairs= 4 (dentist) + 2 (hygienist)
⧫ Slide ⥶80 off
⧫ Service areas Northern Penobscot Southern Aroostook Western
Washington Counties amp more
Completion of Phase I Treatment
⧫LimitedLack of Access to dental care
⧫Difficulty completing the disease control phase
Caries amp periodontal disease
⧫Attaining stable restorative state
Goal
Increase the completion of Disease Control Phase
Current practice
⧫Education
Assess level of dental literacy
Incremental strategy
⧫Increase access to dental care
Generous sliding scale (⥸$40 per visit)
Incorporate Expanded Function Dental Assistants
⧫Schedule modification
Incorporate more restorative blocks to allow
for follow-up visit and completion of restorative phase
httpswwwglasbergencomdentist-cartoons
Schedule
⧫Piggybacking technique
Increased allotted restorative blocks
⧫Sustainability of current schedule is
contingent on cooperation amp skills of HAN
Dental staff
Note
Strategies mentioned today is personalized to HAN Dental clinic
Current implemented strategies might be modified or changed in the
future as required in order to accommodate the need of our pts
THANK YOU
DAY TWOCLOSINGWRAP-UP
End of Day Two ndash Survey
Day Two Creating a Value-Based Oral Health Care Delivery
System
129
Payment Reform in Oral Health Online Learning Module
Oral Health Value-based Care Online Learning Module
Value-based Care Keys to Success Article
Readiness Assessment
Competency Development Guide
Oral Health Value-based Care Training
Dental Caries Management Practicum
Clinicians Companion Guide
Interprofessional Network Referral Process
Traditional Dental Care Vs Value-Based Care
Resources
131
wwwDentaQuestPartnershiporg
wwwfacebookcomDentaQuest
DentaQuest
wwwlinkedincomcompanyDentaQuest
Inside_DentaQuest
QUESTIONS
72
Percent of funds set aside
to cover specialty care
referrals
Typically 10-15
Goal Limit referral costs
to within or less than
Specialty set aside
Specialty Withhold
73
Per Member Per Month
bull Capitated Payment
bull Specific dollar amount paid for each enrolled member each month
bull Paid whether patient is accessed for care or not
bull States do set access benchmarks
bull In Oregon access for any dental procedure (adults and children combined)
was 267 in 2015
74
Payment Math Example
Premium per enrollee = $25
Administrative fee 15 = $375
Funds available per enrollee to the clinic = $2125
Management fee per enrollee = $175
Funds per enrollee that would undergo PPS reconciliation = $1950
For every 10000 enrollees the managed care income = $2340000
Specialty withhold (10) = $234000
YE Cost lt or gt $2340000
Upside Risk
CHC Gains $
Downside Risk
CHC Loses $
75
Covered Services and Fee Schedules
bull The state Medicaid agency spells out the minimum procedures and fees that
MCOs must cover
bull MCOs may add procedures or increase periodicity of procedures particularly
preventative services
bull MCOs may increase fees to entice rural providers and specialists to enroll in
their Plans
bull Access Rules
bull How many days it takes to access a patent
bull How many days it takes for a patent to access urgent care services
bull How many days it takes for a patent to access emergency care services
76
Credentialing
All MCOs are required to credential all Providers
All MCOs have their own credentialing process
Credentialing process is can be lengthy
Credentialing process may be negotiable
77
Quality Review Process and Quality Metrics
MCOs must have a Quality and Compliance Review Process
If you arenrsquot in compliance with both you likely wonrsquot get paid
Typical processes reviewed
bull Charting specifications
bull Incident report
bull Enrollee complaints quality rudeness and access issues
bull Medicaid compliance
78
Quality Payments
bull State Shared Incentive Withhold Typically quality metrics and benchmarks
are set by the state sets aside a certain percent (3-5) of the payments to
the Managed Care Plan (MCP)
bull If the benchmarks are achieved the MCP is then paid the a predetermine
amount
bull Benchmarks may not be the same as the states
bull Managed Care Plans do not have to pass all or any of the quality payments to
the health centers or providers
bull Managed Care contract- Metrics benchmarks should be selected and part of
the contract
7979
Achieving Quality Metric Payments
Dealing with under achievers
Process issues
Individual issues
Identifying workflows
Developing Best Practices through
PDSA process
Developing Best Practices through
PDSA process
CHC Metrics Committee
Clinicians Operations various key staff
Identify Best Practices
Spread Best Practices
80
New Team Needed Business Intelligence
Business Intelligence (BI) is critical for effective managed care business decisions
BI team inputs metrics into your EHR collects integrates analyses and displays all your managed care business and clinical information
Easy to say- hard to achieve
Build your own or outsource
Possible future role of Primary Care Associations
8181
Clinicianrsquos Dashboard
Expensive to build
Displayed on your screen when your computer is first turned on
Easy to read and understand
Data dumped from the day before
Can dialed down from Org-wide to clinic to each clinicianrsquos data
Operational and clinical metrics
bull Treatment Plan Completion
bull DQA quality measures
bull Caries at Recall
bull Re-care reports
bull Care Gap reports
82
CONTROLLING COSTS
8383
Controlling Costs- Current
bull Increasing efficiencies
bull Decreasing broken appointments
bull Controlling supplies equipment costs
bull Staff recruitment retention costs
84
Specialty Care
Training current CHC dentists in
specialty areas
Hiring general dentists with higher
specialty skill sets
Hiring in house specialists
Contract with outside specialists
Work with Managed Care Plan
specialists
Lowering Disease Rates
Community Dental Health
Coordinators case management
If your state law allows- embed
hygienists in medical and community
to provide primary and secondary
prevention procedures
In clinic Caries Classification and
Silver Diamine Fluoride
Effective recare programs
Controlling Costs- Additions in Risk-based Contracting
85
Specialty Care ndash Primary Referrals by Cost
Pediatric dentistry
Orthodontics
Oral surgery
Endodontics
86
In-clinic Pediatric Services
Encounters expected
of operatories available
State dental law and ability to have
expanded duties
General Anesthesia
GA in- house
Ability for a hospital or surgery center
to set aside regular OR time
Ability to hire or assign DAs to GA
days
Four GA cases day x PPS rate
Should You Hire a Pediatric Dentist- It Depends
8787
Solutions for Controlling Pediatric Costs
Hire a general dentist that is skilled in treating young children
Make the clinic child friendly nitrous oxide TVs in the operatory etc
Teach entire staff behavioral control techniques
Contract with a pediatric dentist for the GA care
88
Lowering Overall Disease Rates (and Costs)
You are responsible for both the patients you see in the chair and the ones
assigned to you
Breaking down the walls of the dental clinic
Community Dental Health Coordinators
Case Management
89
Cost Control Essentials
Diagnosis codes
Increased ability to identify
disease by risk
Motivational
Interviewing
Developing Polices and
Procedures design to treat
disease according to risk
ie Silver Diamine Fluoride
Treating by Risk
Effective Recare
Process
Critical to continual disease
controlPrevention education that is
meaningful and designed to
change behaviors
90
Social Determinants of Health Aunt Bertha
httpswwwauntberthacom
91
REASON TO CONSIDER RISK- BASED CONTRACTING
9292
PPS Reconciliation and Federal Code 42 CFR sect4052469(a)(2)
42 CFR sect4052469(a)(2)
ldquoAny financial incentives provided to Federally Qualified Health Centers
under their Medicare Advantage Contracts such as risk pool payments
bonuses or withholds are prohibited from being included in the
calculation of supplemental payments due to the Federally Qualified
Health Centerrdquo
9393
Why Risk Based Contract in Times of PPS Reconciliation
bull Not all Risk- based Contract funds are reconciled
bull Risk is the key word- you can come out with less money than your normal
PPS reconciliation payment
bull Can lead to better patient care
bull May improve manage care enrollment for your medical plan
bull Promotes integrated care increases health for your CHC patients
9494
Not Included in the Reconciliation
Enrollment management pmpm
Quality Payments
Upside risk payments
Downside risk losses
9595
Determinants of Financial Success in Risk-Based Contracting
bull Most critical- State pmpm payment to the Managed Care Plan
bull Reporting capabilities
bull Specialty service capabilities
bull Access numbers count
bull Ability to move metric numbers
9696
What About the Non- Medicaid Poor We Serve
bull Numbers are king in a managed care contract and the more access you have
the better contract terms you can negotiate
bull We will potentially have a steady supply of Medicaid patients
bull As managed care spreads states this may be compromising the ability of
health centers to serve the non-Medicaid poor and others lacking dental
insurance
97
Mark Koday DDS
(509) 949-2278
Dental Quality Consultants
of WA
httpdentalqualityconsultin
gcom
dentalqualityconsultantsg
mailcom
Contact Information
LUNCH
BREAKOUT EXERCISEORAL HEALTH VALUE-BASED CARE READINESS ASSESSMENT
Danielle Apostolon
PROMISING PRACTICES FROM THE FIELD STRATEGIES FOR INCREASING VALUE IN ORAL HEALTH
Dr Carolyn Brown
Dr Kelly Perry
Dr Rachel Rivard
Dr Adeloye
Commitment Compassion Community
m i d s t a t e h e a l t h o r g
Promising Practices from the
Field Strategies for Increasing
Value in Oral Health Care
Kelly Perry DMD
Better Health
Outcomes
Improved Staff
Experience
Reduced Cost
Improved Patient
Experience
Better Health
Outcomes
Improved Staff
Experience
Reduced Cost
Improved Patient
Experience
Better Health
Outcomes
Improved Staff
Experience
Reduced Cost
Improved Patient
Experience
Better Health
Outcomes
Improved Staff
Experience
Reduced Cost
Improved Patient
Experience
Commitment Compassion Community
kpe r r ymids t a tehea l t h o rg
Thank you
Completion of Disease Control Phase
Pelumi Adeloye DMD MPH
HEALTH ACCESS NETWORK (HAN) FAMILY DENTAL
Introduction
⧫1 Dentist I Hygienist 3 EFDArsquos1 Receptionist
⧫ 6 Chairs= 4 (dentist) + 2 (hygienist)
⧫ Slide ⥶80 off
⧫ Service areas Northern Penobscot Southern Aroostook Western
Washington Counties amp more
Completion of Phase I Treatment
⧫LimitedLack of Access to dental care
⧫Difficulty completing the disease control phase
Caries amp periodontal disease
⧫Attaining stable restorative state
Goal
Increase the completion of Disease Control Phase
Current practice
⧫Education
Assess level of dental literacy
Incremental strategy
⧫Increase access to dental care
Generous sliding scale (⥸$40 per visit)
Incorporate Expanded Function Dental Assistants
⧫Schedule modification
Incorporate more restorative blocks to allow
for follow-up visit and completion of restorative phase
httpswwwglasbergencomdentist-cartoons
Schedule
⧫Piggybacking technique
Increased allotted restorative blocks
⧫Sustainability of current schedule is
contingent on cooperation amp skills of HAN
Dental staff
Note
Strategies mentioned today is personalized to HAN Dental clinic
Current implemented strategies might be modified or changed in the
future as required in order to accommodate the need of our pts
THANK YOU
DAY TWOCLOSINGWRAP-UP
End of Day Two ndash Survey
Day Two Creating a Value-Based Oral Health Care Delivery
System
129
Payment Reform in Oral Health Online Learning Module
Oral Health Value-based Care Online Learning Module
Value-based Care Keys to Success Article
Readiness Assessment
Competency Development Guide
Oral Health Value-based Care Training
Dental Caries Management Practicum
Clinicians Companion Guide
Interprofessional Network Referral Process
Traditional Dental Care Vs Value-Based Care
Resources
131
wwwDentaQuestPartnershiporg
wwwfacebookcomDentaQuest
DentaQuest
wwwlinkedincomcompanyDentaQuest
Inside_DentaQuest
QUESTIONS
73
Per Member Per Month
bull Capitated Payment
bull Specific dollar amount paid for each enrolled member each month
bull Paid whether patient is accessed for care or not
bull States do set access benchmarks
bull In Oregon access for any dental procedure (adults and children combined)
was 267 in 2015
74
Payment Math Example
Premium per enrollee = $25
Administrative fee 15 = $375
Funds available per enrollee to the clinic = $2125
Management fee per enrollee = $175
Funds per enrollee that would undergo PPS reconciliation = $1950
For every 10000 enrollees the managed care income = $2340000
Specialty withhold (10) = $234000
YE Cost lt or gt $2340000
Upside Risk
CHC Gains $
Downside Risk
CHC Loses $
75
Covered Services and Fee Schedules
bull The state Medicaid agency spells out the minimum procedures and fees that
MCOs must cover
bull MCOs may add procedures or increase periodicity of procedures particularly
preventative services
bull MCOs may increase fees to entice rural providers and specialists to enroll in
their Plans
bull Access Rules
bull How many days it takes to access a patent
bull How many days it takes for a patent to access urgent care services
bull How many days it takes for a patent to access emergency care services
76
Credentialing
All MCOs are required to credential all Providers
All MCOs have their own credentialing process
Credentialing process is can be lengthy
Credentialing process may be negotiable
77
Quality Review Process and Quality Metrics
MCOs must have a Quality and Compliance Review Process
If you arenrsquot in compliance with both you likely wonrsquot get paid
Typical processes reviewed
bull Charting specifications
bull Incident report
bull Enrollee complaints quality rudeness and access issues
bull Medicaid compliance
78
Quality Payments
bull State Shared Incentive Withhold Typically quality metrics and benchmarks
are set by the state sets aside a certain percent (3-5) of the payments to
the Managed Care Plan (MCP)
bull If the benchmarks are achieved the MCP is then paid the a predetermine
amount
bull Benchmarks may not be the same as the states
bull Managed Care Plans do not have to pass all or any of the quality payments to
the health centers or providers
bull Managed Care contract- Metrics benchmarks should be selected and part of
the contract
7979
Achieving Quality Metric Payments
Dealing with under achievers
Process issues
Individual issues
Identifying workflows
Developing Best Practices through
PDSA process
Developing Best Practices through
PDSA process
CHC Metrics Committee
Clinicians Operations various key staff
Identify Best Practices
Spread Best Practices
80
New Team Needed Business Intelligence
Business Intelligence (BI) is critical for effective managed care business decisions
BI team inputs metrics into your EHR collects integrates analyses and displays all your managed care business and clinical information
Easy to say- hard to achieve
Build your own or outsource
Possible future role of Primary Care Associations
8181
Clinicianrsquos Dashboard
Expensive to build
Displayed on your screen when your computer is first turned on
Easy to read and understand
Data dumped from the day before
Can dialed down from Org-wide to clinic to each clinicianrsquos data
Operational and clinical metrics
bull Treatment Plan Completion
bull DQA quality measures
bull Caries at Recall
bull Re-care reports
bull Care Gap reports
82
CONTROLLING COSTS
8383
Controlling Costs- Current
bull Increasing efficiencies
bull Decreasing broken appointments
bull Controlling supplies equipment costs
bull Staff recruitment retention costs
84
Specialty Care
Training current CHC dentists in
specialty areas
Hiring general dentists with higher
specialty skill sets
Hiring in house specialists
Contract with outside specialists
Work with Managed Care Plan
specialists
Lowering Disease Rates
Community Dental Health
Coordinators case management
If your state law allows- embed
hygienists in medical and community
to provide primary and secondary
prevention procedures
In clinic Caries Classification and
Silver Diamine Fluoride
Effective recare programs
Controlling Costs- Additions in Risk-based Contracting
85
Specialty Care ndash Primary Referrals by Cost
Pediatric dentistry
Orthodontics
Oral surgery
Endodontics
86
In-clinic Pediatric Services
Encounters expected
of operatories available
State dental law and ability to have
expanded duties
General Anesthesia
GA in- house
Ability for a hospital or surgery center
to set aside regular OR time
Ability to hire or assign DAs to GA
days
Four GA cases day x PPS rate
Should You Hire a Pediatric Dentist- It Depends
8787
Solutions for Controlling Pediatric Costs
Hire a general dentist that is skilled in treating young children
Make the clinic child friendly nitrous oxide TVs in the operatory etc
Teach entire staff behavioral control techniques
Contract with a pediatric dentist for the GA care
88
Lowering Overall Disease Rates (and Costs)
You are responsible for both the patients you see in the chair and the ones
assigned to you
Breaking down the walls of the dental clinic
Community Dental Health Coordinators
Case Management
89
Cost Control Essentials
Diagnosis codes
Increased ability to identify
disease by risk
Motivational
Interviewing
Developing Polices and
Procedures design to treat
disease according to risk
ie Silver Diamine Fluoride
Treating by Risk
Effective Recare
Process
Critical to continual disease
controlPrevention education that is
meaningful and designed to
change behaviors
90
Social Determinants of Health Aunt Bertha
httpswwwauntberthacom
91
REASON TO CONSIDER RISK- BASED CONTRACTING
9292
PPS Reconciliation and Federal Code 42 CFR sect4052469(a)(2)
42 CFR sect4052469(a)(2)
ldquoAny financial incentives provided to Federally Qualified Health Centers
under their Medicare Advantage Contracts such as risk pool payments
bonuses or withholds are prohibited from being included in the
calculation of supplemental payments due to the Federally Qualified
Health Centerrdquo
9393
Why Risk Based Contract in Times of PPS Reconciliation
bull Not all Risk- based Contract funds are reconciled
bull Risk is the key word- you can come out with less money than your normal
PPS reconciliation payment
bull Can lead to better patient care
bull May improve manage care enrollment for your medical plan
bull Promotes integrated care increases health for your CHC patients
9494
Not Included in the Reconciliation
Enrollment management pmpm
Quality Payments
Upside risk payments
Downside risk losses
9595
Determinants of Financial Success in Risk-Based Contracting
bull Most critical- State pmpm payment to the Managed Care Plan
bull Reporting capabilities
bull Specialty service capabilities
bull Access numbers count
bull Ability to move metric numbers
9696
What About the Non- Medicaid Poor We Serve
bull Numbers are king in a managed care contract and the more access you have
the better contract terms you can negotiate
bull We will potentially have a steady supply of Medicaid patients
bull As managed care spreads states this may be compromising the ability of
health centers to serve the non-Medicaid poor and others lacking dental
insurance
97
Mark Koday DDS
(509) 949-2278
Dental Quality Consultants
of WA
httpdentalqualityconsultin
gcom
dentalqualityconsultantsg
mailcom
Contact Information
LUNCH
BREAKOUT EXERCISEORAL HEALTH VALUE-BASED CARE READINESS ASSESSMENT
Danielle Apostolon
PROMISING PRACTICES FROM THE FIELD STRATEGIES FOR INCREASING VALUE IN ORAL HEALTH
Dr Carolyn Brown
Dr Kelly Perry
Dr Rachel Rivard
Dr Adeloye
Commitment Compassion Community
m i d s t a t e h e a l t h o r g
Promising Practices from the
Field Strategies for Increasing
Value in Oral Health Care
Kelly Perry DMD
Better Health
Outcomes
Improved Staff
Experience
Reduced Cost
Improved Patient
Experience
Better Health
Outcomes
Improved Staff
Experience
Reduced Cost
Improved Patient
Experience
Better Health
Outcomes
Improved Staff
Experience
Reduced Cost
Improved Patient
Experience
Better Health
Outcomes
Improved Staff
Experience
Reduced Cost
Improved Patient
Experience
Commitment Compassion Community
kpe r r ymids t a tehea l t h o rg
Thank you
Completion of Disease Control Phase
Pelumi Adeloye DMD MPH
HEALTH ACCESS NETWORK (HAN) FAMILY DENTAL
Introduction
⧫1 Dentist I Hygienist 3 EFDArsquos1 Receptionist
⧫ 6 Chairs= 4 (dentist) + 2 (hygienist)
⧫ Slide ⥶80 off
⧫ Service areas Northern Penobscot Southern Aroostook Western
Washington Counties amp more
Completion of Phase I Treatment
⧫LimitedLack of Access to dental care
⧫Difficulty completing the disease control phase
Caries amp periodontal disease
⧫Attaining stable restorative state
Goal
Increase the completion of Disease Control Phase
Current practice
⧫Education
Assess level of dental literacy
Incremental strategy
⧫Increase access to dental care
Generous sliding scale (⥸$40 per visit)
Incorporate Expanded Function Dental Assistants
⧫Schedule modification
Incorporate more restorative blocks to allow
for follow-up visit and completion of restorative phase
httpswwwglasbergencomdentist-cartoons
Schedule
⧫Piggybacking technique
Increased allotted restorative blocks
⧫Sustainability of current schedule is
contingent on cooperation amp skills of HAN
Dental staff
Note
Strategies mentioned today is personalized to HAN Dental clinic
Current implemented strategies might be modified or changed in the
future as required in order to accommodate the need of our pts
THANK YOU
DAY TWOCLOSINGWRAP-UP
End of Day Two ndash Survey
Day Two Creating a Value-Based Oral Health Care Delivery
System
129
Payment Reform in Oral Health Online Learning Module
Oral Health Value-based Care Online Learning Module
Value-based Care Keys to Success Article
Readiness Assessment
Competency Development Guide
Oral Health Value-based Care Training
Dental Caries Management Practicum
Clinicians Companion Guide
Interprofessional Network Referral Process
Traditional Dental Care Vs Value-Based Care
Resources
131
wwwDentaQuestPartnershiporg
wwwfacebookcomDentaQuest
DentaQuest
wwwlinkedincomcompanyDentaQuest
Inside_DentaQuest
QUESTIONS
74
Payment Math Example
Premium per enrollee = $25
Administrative fee 15 = $375
Funds available per enrollee to the clinic = $2125
Management fee per enrollee = $175
Funds per enrollee that would undergo PPS reconciliation = $1950
For every 10000 enrollees the managed care income = $2340000
Specialty withhold (10) = $234000
YE Cost lt or gt $2340000
Upside Risk
CHC Gains $
Downside Risk
CHC Loses $
75
Covered Services and Fee Schedules
bull The state Medicaid agency spells out the minimum procedures and fees that
MCOs must cover
bull MCOs may add procedures or increase periodicity of procedures particularly
preventative services
bull MCOs may increase fees to entice rural providers and specialists to enroll in
their Plans
bull Access Rules
bull How many days it takes to access a patent
bull How many days it takes for a patent to access urgent care services
bull How many days it takes for a patent to access emergency care services
76
Credentialing
All MCOs are required to credential all Providers
All MCOs have their own credentialing process
Credentialing process is can be lengthy
Credentialing process may be negotiable
77
Quality Review Process and Quality Metrics
MCOs must have a Quality and Compliance Review Process
If you arenrsquot in compliance with both you likely wonrsquot get paid
Typical processes reviewed
bull Charting specifications
bull Incident report
bull Enrollee complaints quality rudeness and access issues
bull Medicaid compliance
78
Quality Payments
bull State Shared Incentive Withhold Typically quality metrics and benchmarks
are set by the state sets aside a certain percent (3-5) of the payments to
the Managed Care Plan (MCP)
bull If the benchmarks are achieved the MCP is then paid the a predetermine
amount
bull Benchmarks may not be the same as the states
bull Managed Care Plans do not have to pass all or any of the quality payments to
the health centers or providers
bull Managed Care contract- Metrics benchmarks should be selected and part of
the contract
7979
Achieving Quality Metric Payments
Dealing with under achievers
Process issues
Individual issues
Identifying workflows
Developing Best Practices through
PDSA process
Developing Best Practices through
PDSA process
CHC Metrics Committee
Clinicians Operations various key staff
Identify Best Practices
Spread Best Practices
80
New Team Needed Business Intelligence
Business Intelligence (BI) is critical for effective managed care business decisions
BI team inputs metrics into your EHR collects integrates analyses and displays all your managed care business and clinical information
Easy to say- hard to achieve
Build your own or outsource
Possible future role of Primary Care Associations
8181
Clinicianrsquos Dashboard
Expensive to build
Displayed on your screen when your computer is first turned on
Easy to read and understand
Data dumped from the day before
Can dialed down from Org-wide to clinic to each clinicianrsquos data
Operational and clinical metrics
bull Treatment Plan Completion
bull DQA quality measures
bull Caries at Recall
bull Re-care reports
bull Care Gap reports
82
CONTROLLING COSTS
8383
Controlling Costs- Current
bull Increasing efficiencies
bull Decreasing broken appointments
bull Controlling supplies equipment costs
bull Staff recruitment retention costs
84
Specialty Care
Training current CHC dentists in
specialty areas
Hiring general dentists with higher
specialty skill sets
Hiring in house specialists
Contract with outside specialists
Work with Managed Care Plan
specialists
Lowering Disease Rates
Community Dental Health
Coordinators case management
If your state law allows- embed
hygienists in medical and community
to provide primary and secondary
prevention procedures
In clinic Caries Classification and
Silver Diamine Fluoride
Effective recare programs
Controlling Costs- Additions in Risk-based Contracting
85
Specialty Care ndash Primary Referrals by Cost
Pediatric dentistry
Orthodontics
Oral surgery
Endodontics
86
In-clinic Pediatric Services
Encounters expected
of operatories available
State dental law and ability to have
expanded duties
General Anesthesia
GA in- house
Ability for a hospital or surgery center
to set aside regular OR time
Ability to hire or assign DAs to GA
days
Four GA cases day x PPS rate
Should You Hire a Pediatric Dentist- It Depends
8787
Solutions for Controlling Pediatric Costs
Hire a general dentist that is skilled in treating young children
Make the clinic child friendly nitrous oxide TVs in the operatory etc
Teach entire staff behavioral control techniques
Contract with a pediatric dentist for the GA care
88
Lowering Overall Disease Rates (and Costs)
You are responsible for both the patients you see in the chair and the ones
assigned to you
Breaking down the walls of the dental clinic
Community Dental Health Coordinators
Case Management
89
Cost Control Essentials
Diagnosis codes
Increased ability to identify
disease by risk
Motivational
Interviewing
Developing Polices and
Procedures design to treat
disease according to risk
ie Silver Diamine Fluoride
Treating by Risk
Effective Recare
Process
Critical to continual disease
controlPrevention education that is
meaningful and designed to
change behaviors
90
Social Determinants of Health Aunt Bertha
httpswwwauntberthacom
91
REASON TO CONSIDER RISK- BASED CONTRACTING
9292
PPS Reconciliation and Federal Code 42 CFR sect4052469(a)(2)
42 CFR sect4052469(a)(2)
ldquoAny financial incentives provided to Federally Qualified Health Centers
under their Medicare Advantage Contracts such as risk pool payments
bonuses or withholds are prohibited from being included in the
calculation of supplemental payments due to the Federally Qualified
Health Centerrdquo
9393
Why Risk Based Contract in Times of PPS Reconciliation
bull Not all Risk- based Contract funds are reconciled
bull Risk is the key word- you can come out with less money than your normal
PPS reconciliation payment
bull Can lead to better patient care
bull May improve manage care enrollment for your medical plan
bull Promotes integrated care increases health for your CHC patients
9494
Not Included in the Reconciliation
Enrollment management pmpm
Quality Payments
Upside risk payments
Downside risk losses
9595
Determinants of Financial Success in Risk-Based Contracting
bull Most critical- State pmpm payment to the Managed Care Plan
bull Reporting capabilities
bull Specialty service capabilities
bull Access numbers count
bull Ability to move metric numbers
9696
What About the Non- Medicaid Poor We Serve
bull Numbers are king in a managed care contract and the more access you have
the better contract terms you can negotiate
bull We will potentially have a steady supply of Medicaid patients
bull As managed care spreads states this may be compromising the ability of
health centers to serve the non-Medicaid poor and others lacking dental
insurance
97
Mark Koday DDS
(509) 949-2278
Dental Quality Consultants
of WA
httpdentalqualityconsultin
gcom
dentalqualityconsultantsg
mailcom
Contact Information
LUNCH
BREAKOUT EXERCISEORAL HEALTH VALUE-BASED CARE READINESS ASSESSMENT
Danielle Apostolon
PROMISING PRACTICES FROM THE FIELD STRATEGIES FOR INCREASING VALUE IN ORAL HEALTH
Dr Carolyn Brown
Dr Kelly Perry
Dr Rachel Rivard
Dr Adeloye
Commitment Compassion Community
m i d s t a t e h e a l t h o r g
Promising Practices from the
Field Strategies for Increasing
Value in Oral Health Care
Kelly Perry DMD
Better Health
Outcomes
Improved Staff
Experience
Reduced Cost
Improved Patient
Experience
Better Health
Outcomes
Improved Staff
Experience
Reduced Cost
Improved Patient
Experience
Better Health
Outcomes
Improved Staff
Experience
Reduced Cost
Improved Patient
Experience
Better Health
Outcomes
Improved Staff
Experience
Reduced Cost
Improved Patient
Experience
Commitment Compassion Community
kpe r r ymids t a tehea l t h o rg
Thank you
Completion of Disease Control Phase
Pelumi Adeloye DMD MPH
HEALTH ACCESS NETWORK (HAN) FAMILY DENTAL
Introduction
⧫1 Dentist I Hygienist 3 EFDArsquos1 Receptionist
⧫ 6 Chairs= 4 (dentist) + 2 (hygienist)
⧫ Slide ⥶80 off
⧫ Service areas Northern Penobscot Southern Aroostook Western
Washington Counties amp more
Completion of Phase I Treatment
⧫LimitedLack of Access to dental care
⧫Difficulty completing the disease control phase
Caries amp periodontal disease
⧫Attaining stable restorative state
Goal
Increase the completion of Disease Control Phase
Current practice
⧫Education
Assess level of dental literacy
Incremental strategy
⧫Increase access to dental care
Generous sliding scale (⥸$40 per visit)
Incorporate Expanded Function Dental Assistants
⧫Schedule modification
Incorporate more restorative blocks to allow
for follow-up visit and completion of restorative phase
httpswwwglasbergencomdentist-cartoons
Schedule
⧫Piggybacking technique
Increased allotted restorative blocks
⧫Sustainability of current schedule is
contingent on cooperation amp skills of HAN
Dental staff
Note
Strategies mentioned today is personalized to HAN Dental clinic
Current implemented strategies might be modified or changed in the
future as required in order to accommodate the need of our pts
THANK YOU
DAY TWOCLOSINGWRAP-UP
End of Day Two ndash Survey
Day Two Creating a Value-Based Oral Health Care Delivery
System
129
Payment Reform in Oral Health Online Learning Module
Oral Health Value-based Care Online Learning Module
Value-based Care Keys to Success Article
Readiness Assessment
Competency Development Guide
Oral Health Value-based Care Training
Dental Caries Management Practicum
Clinicians Companion Guide
Interprofessional Network Referral Process
Traditional Dental Care Vs Value-Based Care
Resources
131
wwwDentaQuestPartnershiporg
wwwfacebookcomDentaQuest
DentaQuest
wwwlinkedincomcompanyDentaQuest
Inside_DentaQuest
QUESTIONS
75
Covered Services and Fee Schedules
bull The state Medicaid agency spells out the minimum procedures and fees that
MCOs must cover
bull MCOs may add procedures or increase periodicity of procedures particularly
preventative services
bull MCOs may increase fees to entice rural providers and specialists to enroll in
their Plans
bull Access Rules
bull How many days it takes to access a patent
bull How many days it takes for a patent to access urgent care services
bull How many days it takes for a patent to access emergency care services
76
Credentialing
All MCOs are required to credential all Providers
All MCOs have their own credentialing process
Credentialing process is can be lengthy
Credentialing process may be negotiable
77
Quality Review Process and Quality Metrics
MCOs must have a Quality and Compliance Review Process
If you arenrsquot in compliance with both you likely wonrsquot get paid
Typical processes reviewed
bull Charting specifications
bull Incident report
bull Enrollee complaints quality rudeness and access issues
bull Medicaid compliance
78
Quality Payments
bull State Shared Incentive Withhold Typically quality metrics and benchmarks
are set by the state sets aside a certain percent (3-5) of the payments to
the Managed Care Plan (MCP)
bull If the benchmarks are achieved the MCP is then paid the a predetermine
amount
bull Benchmarks may not be the same as the states
bull Managed Care Plans do not have to pass all or any of the quality payments to
the health centers or providers
bull Managed Care contract- Metrics benchmarks should be selected and part of
the contract
7979
Achieving Quality Metric Payments
Dealing with under achievers
Process issues
Individual issues
Identifying workflows
Developing Best Practices through
PDSA process
Developing Best Practices through
PDSA process
CHC Metrics Committee
Clinicians Operations various key staff
Identify Best Practices
Spread Best Practices
80
New Team Needed Business Intelligence
Business Intelligence (BI) is critical for effective managed care business decisions
BI team inputs metrics into your EHR collects integrates analyses and displays all your managed care business and clinical information
Easy to say- hard to achieve
Build your own or outsource
Possible future role of Primary Care Associations
8181
Clinicianrsquos Dashboard
Expensive to build
Displayed on your screen when your computer is first turned on
Easy to read and understand
Data dumped from the day before
Can dialed down from Org-wide to clinic to each clinicianrsquos data
Operational and clinical metrics
bull Treatment Plan Completion
bull DQA quality measures
bull Caries at Recall
bull Re-care reports
bull Care Gap reports
82
CONTROLLING COSTS
8383
Controlling Costs- Current
bull Increasing efficiencies
bull Decreasing broken appointments
bull Controlling supplies equipment costs
bull Staff recruitment retention costs
84
Specialty Care
Training current CHC dentists in
specialty areas
Hiring general dentists with higher
specialty skill sets
Hiring in house specialists
Contract with outside specialists
Work with Managed Care Plan
specialists
Lowering Disease Rates
Community Dental Health
Coordinators case management
If your state law allows- embed
hygienists in medical and community
to provide primary and secondary
prevention procedures
In clinic Caries Classification and
Silver Diamine Fluoride
Effective recare programs
Controlling Costs- Additions in Risk-based Contracting
85
Specialty Care ndash Primary Referrals by Cost
Pediatric dentistry
Orthodontics
Oral surgery
Endodontics
86
In-clinic Pediatric Services
Encounters expected
of operatories available
State dental law and ability to have
expanded duties
General Anesthesia
GA in- house
Ability for a hospital or surgery center
to set aside regular OR time
Ability to hire or assign DAs to GA
days
Four GA cases day x PPS rate
Should You Hire a Pediatric Dentist- It Depends
8787
Solutions for Controlling Pediatric Costs
Hire a general dentist that is skilled in treating young children
Make the clinic child friendly nitrous oxide TVs in the operatory etc
Teach entire staff behavioral control techniques
Contract with a pediatric dentist for the GA care
88
Lowering Overall Disease Rates (and Costs)
You are responsible for both the patients you see in the chair and the ones
assigned to you
Breaking down the walls of the dental clinic
Community Dental Health Coordinators
Case Management
89
Cost Control Essentials
Diagnosis codes
Increased ability to identify
disease by risk
Motivational
Interviewing
Developing Polices and
Procedures design to treat
disease according to risk
ie Silver Diamine Fluoride
Treating by Risk
Effective Recare
Process
Critical to continual disease
controlPrevention education that is
meaningful and designed to
change behaviors
90
Social Determinants of Health Aunt Bertha
httpswwwauntberthacom
91
REASON TO CONSIDER RISK- BASED CONTRACTING
9292
PPS Reconciliation and Federal Code 42 CFR sect4052469(a)(2)
42 CFR sect4052469(a)(2)
ldquoAny financial incentives provided to Federally Qualified Health Centers
under their Medicare Advantage Contracts such as risk pool payments
bonuses or withholds are prohibited from being included in the
calculation of supplemental payments due to the Federally Qualified
Health Centerrdquo
9393
Why Risk Based Contract in Times of PPS Reconciliation
bull Not all Risk- based Contract funds are reconciled
bull Risk is the key word- you can come out with less money than your normal
PPS reconciliation payment
bull Can lead to better patient care
bull May improve manage care enrollment for your medical plan
bull Promotes integrated care increases health for your CHC patients
9494
Not Included in the Reconciliation
Enrollment management pmpm
Quality Payments
Upside risk payments
Downside risk losses
9595
Determinants of Financial Success in Risk-Based Contracting
bull Most critical- State pmpm payment to the Managed Care Plan
bull Reporting capabilities
bull Specialty service capabilities
bull Access numbers count
bull Ability to move metric numbers
9696
What About the Non- Medicaid Poor We Serve
bull Numbers are king in a managed care contract and the more access you have
the better contract terms you can negotiate
bull We will potentially have a steady supply of Medicaid patients
bull As managed care spreads states this may be compromising the ability of
health centers to serve the non-Medicaid poor and others lacking dental
insurance
97
Mark Koday DDS
(509) 949-2278
Dental Quality Consultants
of WA
httpdentalqualityconsultin
gcom
dentalqualityconsultantsg
mailcom
Contact Information
LUNCH
BREAKOUT EXERCISEORAL HEALTH VALUE-BASED CARE READINESS ASSESSMENT
Danielle Apostolon
PROMISING PRACTICES FROM THE FIELD STRATEGIES FOR INCREASING VALUE IN ORAL HEALTH
Dr Carolyn Brown
Dr Kelly Perry
Dr Rachel Rivard
Dr Adeloye
Commitment Compassion Community
m i d s t a t e h e a l t h o r g
Promising Practices from the
Field Strategies for Increasing
Value in Oral Health Care
Kelly Perry DMD
Better Health
Outcomes
Improved Staff
Experience
Reduced Cost
Improved Patient
Experience
Better Health
Outcomes
Improved Staff
Experience
Reduced Cost
Improved Patient
Experience
Better Health
Outcomes
Improved Staff
Experience
Reduced Cost
Improved Patient
Experience
Better Health
Outcomes
Improved Staff
Experience
Reduced Cost
Improved Patient
Experience
Commitment Compassion Community
kpe r r ymids t a tehea l t h o rg
Thank you
Completion of Disease Control Phase
Pelumi Adeloye DMD MPH
HEALTH ACCESS NETWORK (HAN) FAMILY DENTAL
Introduction
⧫1 Dentist I Hygienist 3 EFDArsquos1 Receptionist
⧫ 6 Chairs= 4 (dentist) + 2 (hygienist)
⧫ Slide ⥶80 off
⧫ Service areas Northern Penobscot Southern Aroostook Western
Washington Counties amp more
Completion of Phase I Treatment
⧫LimitedLack of Access to dental care
⧫Difficulty completing the disease control phase
Caries amp periodontal disease
⧫Attaining stable restorative state
Goal
Increase the completion of Disease Control Phase
Current practice
⧫Education
Assess level of dental literacy
Incremental strategy
⧫Increase access to dental care
Generous sliding scale (⥸$40 per visit)
Incorporate Expanded Function Dental Assistants
⧫Schedule modification
Incorporate more restorative blocks to allow
for follow-up visit and completion of restorative phase
httpswwwglasbergencomdentist-cartoons
Schedule
⧫Piggybacking technique
Increased allotted restorative blocks
⧫Sustainability of current schedule is
contingent on cooperation amp skills of HAN
Dental staff
Note
Strategies mentioned today is personalized to HAN Dental clinic
Current implemented strategies might be modified or changed in the
future as required in order to accommodate the need of our pts
THANK YOU
DAY TWOCLOSINGWRAP-UP
End of Day Two ndash Survey
Day Two Creating a Value-Based Oral Health Care Delivery
System
129
Payment Reform in Oral Health Online Learning Module
Oral Health Value-based Care Online Learning Module
Value-based Care Keys to Success Article
Readiness Assessment
Competency Development Guide
Oral Health Value-based Care Training
Dental Caries Management Practicum
Clinicians Companion Guide
Interprofessional Network Referral Process
Traditional Dental Care Vs Value-Based Care
Resources
131
wwwDentaQuestPartnershiporg
wwwfacebookcomDentaQuest
DentaQuest
wwwlinkedincomcompanyDentaQuest
Inside_DentaQuest
QUESTIONS
76
Credentialing
All MCOs are required to credential all Providers
All MCOs have their own credentialing process
Credentialing process is can be lengthy
Credentialing process may be negotiable
77
Quality Review Process and Quality Metrics
MCOs must have a Quality and Compliance Review Process
If you arenrsquot in compliance with both you likely wonrsquot get paid
Typical processes reviewed
bull Charting specifications
bull Incident report
bull Enrollee complaints quality rudeness and access issues
bull Medicaid compliance
78
Quality Payments
bull State Shared Incentive Withhold Typically quality metrics and benchmarks
are set by the state sets aside a certain percent (3-5) of the payments to
the Managed Care Plan (MCP)
bull If the benchmarks are achieved the MCP is then paid the a predetermine
amount
bull Benchmarks may not be the same as the states
bull Managed Care Plans do not have to pass all or any of the quality payments to
the health centers or providers
bull Managed Care contract- Metrics benchmarks should be selected and part of
the contract
7979
Achieving Quality Metric Payments
Dealing with under achievers
Process issues
Individual issues
Identifying workflows
Developing Best Practices through
PDSA process
Developing Best Practices through
PDSA process
CHC Metrics Committee
Clinicians Operations various key staff
Identify Best Practices
Spread Best Practices
80
New Team Needed Business Intelligence
Business Intelligence (BI) is critical for effective managed care business decisions
BI team inputs metrics into your EHR collects integrates analyses and displays all your managed care business and clinical information
Easy to say- hard to achieve
Build your own or outsource
Possible future role of Primary Care Associations
8181
Clinicianrsquos Dashboard
Expensive to build
Displayed on your screen when your computer is first turned on
Easy to read and understand
Data dumped from the day before
Can dialed down from Org-wide to clinic to each clinicianrsquos data
Operational and clinical metrics
bull Treatment Plan Completion
bull DQA quality measures
bull Caries at Recall
bull Re-care reports
bull Care Gap reports
82
CONTROLLING COSTS
8383
Controlling Costs- Current
bull Increasing efficiencies
bull Decreasing broken appointments
bull Controlling supplies equipment costs
bull Staff recruitment retention costs
84
Specialty Care
Training current CHC dentists in
specialty areas
Hiring general dentists with higher
specialty skill sets
Hiring in house specialists
Contract with outside specialists
Work with Managed Care Plan
specialists
Lowering Disease Rates
Community Dental Health
Coordinators case management
If your state law allows- embed
hygienists in medical and community
to provide primary and secondary
prevention procedures
In clinic Caries Classification and
Silver Diamine Fluoride
Effective recare programs
Controlling Costs- Additions in Risk-based Contracting
85
Specialty Care ndash Primary Referrals by Cost
Pediatric dentistry
Orthodontics
Oral surgery
Endodontics
86
In-clinic Pediatric Services
Encounters expected
of operatories available
State dental law and ability to have
expanded duties
General Anesthesia
GA in- house
Ability for a hospital or surgery center
to set aside regular OR time
Ability to hire or assign DAs to GA
days
Four GA cases day x PPS rate
Should You Hire a Pediatric Dentist- It Depends
8787
Solutions for Controlling Pediatric Costs
Hire a general dentist that is skilled in treating young children
Make the clinic child friendly nitrous oxide TVs in the operatory etc
Teach entire staff behavioral control techniques
Contract with a pediatric dentist for the GA care
88
Lowering Overall Disease Rates (and Costs)
You are responsible for both the patients you see in the chair and the ones
assigned to you
Breaking down the walls of the dental clinic
Community Dental Health Coordinators
Case Management
89
Cost Control Essentials
Diagnosis codes
Increased ability to identify
disease by risk
Motivational
Interviewing
Developing Polices and
Procedures design to treat
disease according to risk
ie Silver Diamine Fluoride
Treating by Risk
Effective Recare
Process
Critical to continual disease
controlPrevention education that is
meaningful and designed to
change behaviors
90
Social Determinants of Health Aunt Bertha
httpswwwauntberthacom
91
REASON TO CONSIDER RISK- BASED CONTRACTING
9292
PPS Reconciliation and Federal Code 42 CFR sect4052469(a)(2)
42 CFR sect4052469(a)(2)
ldquoAny financial incentives provided to Federally Qualified Health Centers
under their Medicare Advantage Contracts such as risk pool payments
bonuses or withholds are prohibited from being included in the
calculation of supplemental payments due to the Federally Qualified
Health Centerrdquo
9393
Why Risk Based Contract in Times of PPS Reconciliation
bull Not all Risk- based Contract funds are reconciled
bull Risk is the key word- you can come out with less money than your normal
PPS reconciliation payment
bull Can lead to better patient care
bull May improve manage care enrollment for your medical plan
bull Promotes integrated care increases health for your CHC patients
9494
Not Included in the Reconciliation
Enrollment management pmpm
Quality Payments
Upside risk payments
Downside risk losses
9595
Determinants of Financial Success in Risk-Based Contracting
bull Most critical- State pmpm payment to the Managed Care Plan
bull Reporting capabilities
bull Specialty service capabilities
bull Access numbers count
bull Ability to move metric numbers
9696
What About the Non- Medicaid Poor We Serve
bull Numbers are king in a managed care contract and the more access you have
the better contract terms you can negotiate
bull We will potentially have a steady supply of Medicaid patients
bull As managed care spreads states this may be compromising the ability of
health centers to serve the non-Medicaid poor and others lacking dental
insurance
97
Mark Koday DDS
(509) 949-2278
Dental Quality Consultants
of WA
httpdentalqualityconsultin
gcom
dentalqualityconsultantsg
mailcom
Contact Information
LUNCH
BREAKOUT EXERCISEORAL HEALTH VALUE-BASED CARE READINESS ASSESSMENT
Danielle Apostolon
PROMISING PRACTICES FROM THE FIELD STRATEGIES FOR INCREASING VALUE IN ORAL HEALTH
Dr Carolyn Brown
Dr Kelly Perry
Dr Rachel Rivard
Dr Adeloye
Commitment Compassion Community
m i d s t a t e h e a l t h o r g
Promising Practices from the
Field Strategies for Increasing
Value in Oral Health Care
Kelly Perry DMD
Better Health
Outcomes
Improved Staff
Experience
Reduced Cost
Improved Patient
Experience
Better Health
Outcomes
Improved Staff
Experience
Reduced Cost
Improved Patient
Experience
Better Health
Outcomes
Improved Staff
Experience
Reduced Cost
Improved Patient
Experience
Better Health
Outcomes
Improved Staff
Experience
Reduced Cost
Improved Patient
Experience
Commitment Compassion Community
kpe r r ymids t a tehea l t h o rg
Thank you
Completion of Disease Control Phase
Pelumi Adeloye DMD MPH
HEALTH ACCESS NETWORK (HAN) FAMILY DENTAL
Introduction
⧫1 Dentist I Hygienist 3 EFDArsquos1 Receptionist
⧫ 6 Chairs= 4 (dentist) + 2 (hygienist)
⧫ Slide ⥶80 off
⧫ Service areas Northern Penobscot Southern Aroostook Western
Washington Counties amp more
Completion of Phase I Treatment
⧫LimitedLack of Access to dental care
⧫Difficulty completing the disease control phase
Caries amp periodontal disease
⧫Attaining stable restorative state
Goal
Increase the completion of Disease Control Phase
Current practice
⧫Education
Assess level of dental literacy
Incremental strategy
⧫Increase access to dental care
Generous sliding scale (⥸$40 per visit)
Incorporate Expanded Function Dental Assistants
⧫Schedule modification
Incorporate more restorative blocks to allow
for follow-up visit and completion of restorative phase
httpswwwglasbergencomdentist-cartoons
Schedule
⧫Piggybacking technique
Increased allotted restorative blocks
⧫Sustainability of current schedule is
contingent on cooperation amp skills of HAN
Dental staff
Note
Strategies mentioned today is personalized to HAN Dental clinic
Current implemented strategies might be modified or changed in the
future as required in order to accommodate the need of our pts
THANK YOU
DAY TWOCLOSINGWRAP-UP
End of Day Two ndash Survey
Day Two Creating a Value-Based Oral Health Care Delivery
System
129
Payment Reform in Oral Health Online Learning Module
Oral Health Value-based Care Online Learning Module
Value-based Care Keys to Success Article
Readiness Assessment
Competency Development Guide
Oral Health Value-based Care Training
Dental Caries Management Practicum
Clinicians Companion Guide
Interprofessional Network Referral Process
Traditional Dental Care Vs Value-Based Care
Resources
131
wwwDentaQuestPartnershiporg
wwwfacebookcomDentaQuest
DentaQuest
wwwlinkedincomcompanyDentaQuest
Inside_DentaQuest
QUESTIONS
77
Quality Review Process and Quality Metrics
MCOs must have a Quality and Compliance Review Process
If you arenrsquot in compliance with both you likely wonrsquot get paid
Typical processes reviewed
bull Charting specifications
bull Incident report
bull Enrollee complaints quality rudeness and access issues
bull Medicaid compliance
78
Quality Payments
bull State Shared Incentive Withhold Typically quality metrics and benchmarks
are set by the state sets aside a certain percent (3-5) of the payments to
the Managed Care Plan (MCP)
bull If the benchmarks are achieved the MCP is then paid the a predetermine
amount
bull Benchmarks may not be the same as the states
bull Managed Care Plans do not have to pass all or any of the quality payments to
the health centers or providers
bull Managed Care contract- Metrics benchmarks should be selected and part of
the contract
7979
Achieving Quality Metric Payments
Dealing with under achievers
Process issues
Individual issues
Identifying workflows
Developing Best Practices through
PDSA process
Developing Best Practices through
PDSA process
CHC Metrics Committee
Clinicians Operations various key staff
Identify Best Practices
Spread Best Practices
80
New Team Needed Business Intelligence
Business Intelligence (BI) is critical for effective managed care business decisions
BI team inputs metrics into your EHR collects integrates analyses and displays all your managed care business and clinical information
Easy to say- hard to achieve
Build your own or outsource
Possible future role of Primary Care Associations
8181
Clinicianrsquos Dashboard
Expensive to build
Displayed on your screen when your computer is first turned on
Easy to read and understand
Data dumped from the day before
Can dialed down from Org-wide to clinic to each clinicianrsquos data
Operational and clinical metrics
bull Treatment Plan Completion
bull DQA quality measures
bull Caries at Recall
bull Re-care reports
bull Care Gap reports
82
CONTROLLING COSTS
8383
Controlling Costs- Current
bull Increasing efficiencies
bull Decreasing broken appointments
bull Controlling supplies equipment costs
bull Staff recruitment retention costs
84
Specialty Care
Training current CHC dentists in
specialty areas
Hiring general dentists with higher
specialty skill sets
Hiring in house specialists
Contract with outside specialists
Work with Managed Care Plan
specialists
Lowering Disease Rates
Community Dental Health
Coordinators case management
If your state law allows- embed
hygienists in medical and community
to provide primary and secondary
prevention procedures
In clinic Caries Classification and
Silver Diamine Fluoride
Effective recare programs
Controlling Costs- Additions in Risk-based Contracting
85
Specialty Care ndash Primary Referrals by Cost
Pediatric dentistry
Orthodontics
Oral surgery
Endodontics
86
In-clinic Pediatric Services
Encounters expected
of operatories available
State dental law and ability to have
expanded duties
General Anesthesia
GA in- house
Ability for a hospital or surgery center
to set aside regular OR time
Ability to hire or assign DAs to GA
days
Four GA cases day x PPS rate
Should You Hire a Pediatric Dentist- It Depends
8787
Solutions for Controlling Pediatric Costs
Hire a general dentist that is skilled in treating young children
Make the clinic child friendly nitrous oxide TVs in the operatory etc
Teach entire staff behavioral control techniques
Contract with a pediatric dentist for the GA care
88
Lowering Overall Disease Rates (and Costs)
You are responsible for both the patients you see in the chair and the ones
assigned to you
Breaking down the walls of the dental clinic
Community Dental Health Coordinators
Case Management
89
Cost Control Essentials
Diagnosis codes
Increased ability to identify
disease by risk
Motivational
Interviewing
Developing Polices and
Procedures design to treat
disease according to risk
ie Silver Diamine Fluoride
Treating by Risk
Effective Recare
Process
Critical to continual disease
controlPrevention education that is
meaningful and designed to
change behaviors
90
Social Determinants of Health Aunt Bertha
httpswwwauntberthacom
91
REASON TO CONSIDER RISK- BASED CONTRACTING
9292
PPS Reconciliation and Federal Code 42 CFR sect4052469(a)(2)
42 CFR sect4052469(a)(2)
ldquoAny financial incentives provided to Federally Qualified Health Centers
under their Medicare Advantage Contracts such as risk pool payments
bonuses or withholds are prohibited from being included in the
calculation of supplemental payments due to the Federally Qualified
Health Centerrdquo
9393
Why Risk Based Contract in Times of PPS Reconciliation
bull Not all Risk- based Contract funds are reconciled
bull Risk is the key word- you can come out with less money than your normal
PPS reconciliation payment
bull Can lead to better patient care
bull May improve manage care enrollment for your medical plan
bull Promotes integrated care increases health for your CHC patients
9494
Not Included in the Reconciliation
Enrollment management pmpm
Quality Payments
Upside risk payments
Downside risk losses
9595
Determinants of Financial Success in Risk-Based Contracting
bull Most critical- State pmpm payment to the Managed Care Plan
bull Reporting capabilities
bull Specialty service capabilities
bull Access numbers count
bull Ability to move metric numbers
9696
What About the Non- Medicaid Poor We Serve
bull Numbers are king in a managed care contract and the more access you have
the better contract terms you can negotiate
bull We will potentially have a steady supply of Medicaid patients
bull As managed care spreads states this may be compromising the ability of
health centers to serve the non-Medicaid poor and others lacking dental
insurance
97
Mark Koday DDS
(509) 949-2278
Dental Quality Consultants
of WA
httpdentalqualityconsultin
gcom
dentalqualityconsultantsg
mailcom
Contact Information
LUNCH
BREAKOUT EXERCISEORAL HEALTH VALUE-BASED CARE READINESS ASSESSMENT
Danielle Apostolon
PROMISING PRACTICES FROM THE FIELD STRATEGIES FOR INCREASING VALUE IN ORAL HEALTH
Dr Carolyn Brown
Dr Kelly Perry
Dr Rachel Rivard
Dr Adeloye
Commitment Compassion Community
m i d s t a t e h e a l t h o r g
Promising Practices from the
Field Strategies for Increasing
Value in Oral Health Care
Kelly Perry DMD
Better Health
Outcomes
Improved Staff
Experience
Reduced Cost
Improved Patient
Experience
Better Health
Outcomes
Improved Staff
Experience
Reduced Cost
Improved Patient
Experience
Better Health
Outcomes
Improved Staff
Experience
Reduced Cost
Improved Patient
Experience
Better Health
Outcomes
Improved Staff
Experience
Reduced Cost
Improved Patient
Experience
Commitment Compassion Community
kpe r r ymids t a tehea l t h o rg
Thank you
Completion of Disease Control Phase
Pelumi Adeloye DMD MPH
HEALTH ACCESS NETWORK (HAN) FAMILY DENTAL
Introduction
⧫1 Dentist I Hygienist 3 EFDArsquos1 Receptionist
⧫ 6 Chairs= 4 (dentist) + 2 (hygienist)
⧫ Slide ⥶80 off
⧫ Service areas Northern Penobscot Southern Aroostook Western
Washington Counties amp more
Completion of Phase I Treatment
⧫LimitedLack of Access to dental care
⧫Difficulty completing the disease control phase
Caries amp periodontal disease
⧫Attaining stable restorative state
Goal
Increase the completion of Disease Control Phase
Current practice
⧫Education
Assess level of dental literacy
Incremental strategy
⧫Increase access to dental care
Generous sliding scale (⥸$40 per visit)
Incorporate Expanded Function Dental Assistants
⧫Schedule modification
Incorporate more restorative blocks to allow
for follow-up visit and completion of restorative phase
httpswwwglasbergencomdentist-cartoons
Schedule
⧫Piggybacking technique
Increased allotted restorative blocks
⧫Sustainability of current schedule is
contingent on cooperation amp skills of HAN
Dental staff
Note
Strategies mentioned today is personalized to HAN Dental clinic
Current implemented strategies might be modified or changed in the
future as required in order to accommodate the need of our pts
THANK YOU
DAY TWOCLOSINGWRAP-UP
End of Day Two ndash Survey
Day Two Creating a Value-Based Oral Health Care Delivery
System
129
Payment Reform in Oral Health Online Learning Module
Oral Health Value-based Care Online Learning Module
Value-based Care Keys to Success Article
Readiness Assessment
Competency Development Guide
Oral Health Value-based Care Training
Dental Caries Management Practicum
Clinicians Companion Guide
Interprofessional Network Referral Process
Traditional Dental Care Vs Value-Based Care
Resources
131
wwwDentaQuestPartnershiporg
wwwfacebookcomDentaQuest
DentaQuest
wwwlinkedincomcompanyDentaQuest
Inside_DentaQuest
QUESTIONS
78
Quality Payments
bull State Shared Incentive Withhold Typically quality metrics and benchmarks
are set by the state sets aside a certain percent (3-5) of the payments to
the Managed Care Plan (MCP)
bull If the benchmarks are achieved the MCP is then paid the a predetermine
amount
bull Benchmarks may not be the same as the states
bull Managed Care Plans do not have to pass all or any of the quality payments to
the health centers or providers
bull Managed Care contract- Metrics benchmarks should be selected and part of
the contract
7979
Achieving Quality Metric Payments
Dealing with under achievers
Process issues
Individual issues
Identifying workflows
Developing Best Practices through
PDSA process
Developing Best Practices through
PDSA process
CHC Metrics Committee
Clinicians Operations various key staff
Identify Best Practices
Spread Best Practices
80
New Team Needed Business Intelligence
Business Intelligence (BI) is critical for effective managed care business decisions
BI team inputs metrics into your EHR collects integrates analyses and displays all your managed care business and clinical information
Easy to say- hard to achieve
Build your own or outsource
Possible future role of Primary Care Associations
8181
Clinicianrsquos Dashboard
Expensive to build
Displayed on your screen when your computer is first turned on
Easy to read and understand
Data dumped from the day before
Can dialed down from Org-wide to clinic to each clinicianrsquos data
Operational and clinical metrics
bull Treatment Plan Completion
bull DQA quality measures
bull Caries at Recall
bull Re-care reports
bull Care Gap reports
82
CONTROLLING COSTS
8383
Controlling Costs- Current
bull Increasing efficiencies
bull Decreasing broken appointments
bull Controlling supplies equipment costs
bull Staff recruitment retention costs
84
Specialty Care
Training current CHC dentists in
specialty areas
Hiring general dentists with higher
specialty skill sets
Hiring in house specialists
Contract with outside specialists
Work with Managed Care Plan
specialists
Lowering Disease Rates
Community Dental Health
Coordinators case management
If your state law allows- embed
hygienists in medical and community
to provide primary and secondary
prevention procedures
In clinic Caries Classification and
Silver Diamine Fluoride
Effective recare programs
Controlling Costs- Additions in Risk-based Contracting
85
Specialty Care ndash Primary Referrals by Cost
Pediatric dentistry
Orthodontics
Oral surgery
Endodontics
86
In-clinic Pediatric Services
Encounters expected
of operatories available
State dental law and ability to have
expanded duties
General Anesthesia
GA in- house
Ability for a hospital or surgery center
to set aside regular OR time
Ability to hire or assign DAs to GA
days
Four GA cases day x PPS rate
Should You Hire a Pediatric Dentist- It Depends
8787
Solutions for Controlling Pediatric Costs
Hire a general dentist that is skilled in treating young children
Make the clinic child friendly nitrous oxide TVs in the operatory etc
Teach entire staff behavioral control techniques
Contract with a pediatric dentist for the GA care
88
Lowering Overall Disease Rates (and Costs)
You are responsible for both the patients you see in the chair and the ones
assigned to you
Breaking down the walls of the dental clinic
Community Dental Health Coordinators
Case Management
89
Cost Control Essentials
Diagnosis codes
Increased ability to identify
disease by risk
Motivational
Interviewing
Developing Polices and
Procedures design to treat
disease according to risk
ie Silver Diamine Fluoride
Treating by Risk
Effective Recare
Process
Critical to continual disease
controlPrevention education that is
meaningful and designed to
change behaviors
90
Social Determinants of Health Aunt Bertha
httpswwwauntberthacom
91
REASON TO CONSIDER RISK- BASED CONTRACTING
9292
PPS Reconciliation and Federal Code 42 CFR sect4052469(a)(2)
42 CFR sect4052469(a)(2)
ldquoAny financial incentives provided to Federally Qualified Health Centers
under their Medicare Advantage Contracts such as risk pool payments
bonuses or withholds are prohibited from being included in the
calculation of supplemental payments due to the Federally Qualified
Health Centerrdquo
9393
Why Risk Based Contract in Times of PPS Reconciliation
bull Not all Risk- based Contract funds are reconciled
bull Risk is the key word- you can come out with less money than your normal
PPS reconciliation payment
bull Can lead to better patient care
bull May improve manage care enrollment for your medical plan
bull Promotes integrated care increases health for your CHC patients
9494
Not Included in the Reconciliation
Enrollment management pmpm
Quality Payments
Upside risk payments
Downside risk losses
9595
Determinants of Financial Success in Risk-Based Contracting
bull Most critical- State pmpm payment to the Managed Care Plan
bull Reporting capabilities
bull Specialty service capabilities
bull Access numbers count
bull Ability to move metric numbers
9696
What About the Non- Medicaid Poor We Serve
bull Numbers are king in a managed care contract and the more access you have
the better contract terms you can negotiate
bull We will potentially have a steady supply of Medicaid patients
bull As managed care spreads states this may be compromising the ability of
health centers to serve the non-Medicaid poor and others lacking dental
insurance
97
Mark Koday DDS
(509) 949-2278
Dental Quality Consultants
of WA
httpdentalqualityconsultin
gcom
dentalqualityconsultantsg
mailcom
Contact Information
LUNCH
BREAKOUT EXERCISEORAL HEALTH VALUE-BASED CARE READINESS ASSESSMENT
Danielle Apostolon
PROMISING PRACTICES FROM THE FIELD STRATEGIES FOR INCREASING VALUE IN ORAL HEALTH
Dr Carolyn Brown
Dr Kelly Perry
Dr Rachel Rivard
Dr Adeloye
Commitment Compassion Community
m i d s t a t e h e a l t h o r g
Promising Practices from the
Field Strategies for Increasing
Value in Oral Health Care
Kelly Perry DMD
Better Health
Outcomes
Improved Staff
Experience
Reduced Cost
Improved Patient
Experience
Better Health
Outcomes
Improved Staff
Experience
Reduced Cost
Improved Patient
Experience
Better Health
Outcomes
Improved Staff
Experience
Reduced Cost
Improved Patient
Experience
Better Health
Outcomes
Improved Staff
Experience
Reduced Cost
Improved Patient
Experience
Commitment Compassion Community
kpe r r ymids t a tehea l t h o rg
Thank you
Completion of Disease Control Phase
Pelumi Adeloye DMD MPH
HEALTH ACCESS NETWORK (HAN) FAMILY DENTAL
Introduction
⧫1 Dentist I Hygienist 3 EFDArsquos1 Receptionist
⧫ 6 Chairs= 4 (dentist) + 2 (hygienist)
⧫ Slide ⥶80 off
⧫ Service areas Northern Penobscot Southern Aroostook Western
Washington Counties amp more
Completion of Phase I Treatment
⧫LimitedLack of Access to dental care
⧫Difficulty completing the disease control phase
Caries amp periodontal disease
⧫Attaining stable restorative state
Goal
Increase the completion of Disease Control Phase
Current practice
⧫Education
Assess level of dental literacy
Incremental strategy
⧫Increase access to dental care
Generous sliding scale (⥸$40 per visit)
Incorporate Expanded Function Dental Assistants
⧫Schedule modification
Incorporate more restorative blocks to allow
for follow-up visit and completion of restorative phase
httpswwwglasbergencomdentist-cartoons
Schedule
⧫Piggybacking technique
Increased allotted restorative blocks
⧫Sustainability of current schedule is
contingent on cooperation amp skills of HAN
Dental staff
Note
Strategies mentioned today is personalized to HAN Dental clinic
Current implemented strategies might be modified or changed in the
future as required in order to accommodate the need of our pts
THANK YOU
DAY TWOCLOSINGWRAP-UP
End of Day Two ndash Survey
Day Two Creating a Value-Based Oral Health Care Delivery
System
129
Payment Reform in Oral Health Online Learning Module
Oral Health Value-based Care Online Learning Module
Value-based Care Keys to Success Article
Readiness Assessment
Competency Development Guide
Oral Health Value-based Care Training
Dental Caries Management Practicum
Clinicians Companion Guide
Interprofessional Network Referral Process
Traditional Dental Care Vs Value-Based Care
Resources
131
wwwDentaQuestPartnershiporg
wwwfacebookcomDentaQuest
DentaQuest
wwwlinkedincomcompanyDentaQuest
Inside_DentaQuest
QUESTIONS
7979
Achieving Quality Metric Payments
Dealing with under achievers
Process issues
Individual issues
Identifying workflows
Developing Best Practices through
PDSA process
Developing Best Practices through
PDSA process
CHC Metrics Committee
Clinicians Operations various key staff
Identify Best Practices
Spread Best Practices
80
New Team Needed Business Intelligence
Business Intelligence (BI) is critical for effective managed care business decisions
BI team inputs metrics into your EHR collects integrates analyses and displays all your managed care business and clinical information
Easy to say- hard to achieve
Build your own or outsource
Possible future role of Primary Care Associations
8181
Clinicianrsquos Dashboard
Expensive to build
Displayed on your screen when your computer is first turned on
Easy to read and understand
Data dumped from the day before
Can dialed down from Org-wide to clinic to each clinicianrsquos data
Operational and clinical metrics
bull Treatment Plan Completion
bull DQA quality measures
bull Caries at Recall
bull Re-care reports
bull Care Gap reports
82
CONTROLLING COSTS
8383
Controlling Costs- Current
bull Increasing efficiencies
bull Decreasing broken appointments
bull Controlling supplies equipment costs
bull Staff recruitment retention costs
84
Specialty Care
Training current CHC dentists in
specialty areas
Hiring general dentists with higher
specialty skill sets
Hiring in house specialists
Contract with outside specialists
Work with Managed Care Plan
specialists
Lowering Disease Rates
Community Dental Health
Coordinators case management
If your state law allows- embed
hygienists in medical and community
to provide primary and secondary
prevention procedures
In clinic Caries Classification and
Silver Diamine Fluoride
Effective recare programs
Controlling Costs- Additions in Risk-based Contracting
85
Specialty Care ndash Primary Referrals by Cost
Pediatric dentistry
Orthodontics
Oral surgery
Endodontics
86
In-clinic Pediatric Services
Encounters expected
of operatories available
State dental law and ability to have
expanded duties
General Anesthesia
GA in- house
Ability for a hospital or surgery center
to set aside regular OR time
Ability to hire or assign DAs to GA
days
Four GA cases day x PPS rate
Should You Hire a Pediatric Dentist- It Depends
8787
Solutions for Controlling Pediatric Costs
Hire a general dentist that is skilled in treating young children
Make the clinic child friendly nitrous oxide TVs in the operatory etc
Teach entire staff behavioral control techniques
Contract with a pediatric dentist for the GA care
88
Lowering Overall Disease Rates (and Costs)
You are responsible for both the patients you see in the chair and the ones
assigned to you
Breaking down the walls of the dental clinic
Community Dental Health Coordinators
Case Management
89
Cost Control Essentials
Diagnosis codes
Increased ability to identify
disease by risk
Motivational
Interviewing
Developing Polices and
Procedures design to treat
disease according to risk
ie Silver Diamine Fluoride
Treating by Risk
Effective Recare
Process
Critical to continual disease
controlPrevention education that is
meaningful and designed to
change behaviors
90
Social Determinants of Health Aunt Bertha
httpswwwauntberthacom
91
REASON TO CONSIDER RISK- BASED CONTRACTING
9292
PPS Reconciliation and Federal Code 42 CFR sect4052469(a)(2)
42 CFR sect4052469(a)(2)
ldquoAny financial incentives provided to Federally Qualified Health Centers
under their Medicare Advantage Contracts such as risk pool payments
bonuses or withholds are prohibited from being included in the
calculation of supplemental payments due to the Federally Qualified
Health Centerrdquo
9393
Why Risk Based Contract in Times of PPS Reconciliation
bull Not all Risk- based Contract funds are reconciled
bull Risk is the key word- you can come out with less money than your normal
PPS reconciliation payment
bull Can lead to better patient care
bull May improve manage care enrollment for your medical plan
bull Promotes integrated care increases health for your CHC patients
9494
Not Included in the Reconciliation
Enrollment management pmpm
Quality Payments
Upside risk payments
Downside risk losses
9595
Determinants of Financial Success in Risk-Based Contracting
bull Most critical- State pmpm payment to the Managed Care Plan
bull Reporting capabilities
bull Specialty service capabilities
bull Access numbers count
bull Ability to move metric numbers
9696
What About the Non- Medicaid Poor We Serve
bull Numbers are king in a managed care contract and the more access you have
the better contract terms you can negotiate
bull We will potentially have a steady supply of Medicaid patients
bull As managed care spreads states this may be compromising the ability of
health centers to serve the non-Medicaid poor and others lacking dental
insurance
97
Mark Koday DDS
(509) 949-2278
Dental Quality Consultants
of WA
httpdentalqualityconsultin
gcom
dentalqualityconsultantsg
mailcom
Contact Information
LUNCH
BREAKOUT EXERCISEORAL HEALTH VALUE-BASED CARE READINESS ASSESSMENT
Danielle Apostolon
PROMISING PRACTICES FROM THE FIELD STRATEGIES FOR INCREASING VALUE IN ORAL HEALTH
Dr Carolyn Brown
Dr Kelly Perry
Dr Rachel Rivard
Dr Adeloye
Commitment Compassion Community
m i d s t a t e h e a l t h o r g
Promising Practices from the
Field Strategies for Increasing
Value in Oral Health Care
Kelly Perry DMD
Better Health
Outcomes
Improved Staff
Experience
Reduced Cost
Improved Patient
Experience
Better Health
Outcomes
Improved Staff
Experience
Reduced Cost
Improved Patient
Experience
Better Health
Outcomes
Improved Staff
Experience
Reduced Cost
Improved Patient
Experience
Better Health
Outcomes
Improved Staff
Experience
Reduced Cost
Improved Patient
Experience
Commitment Compassion Community
kpe r r ymids t a tehea l t h o rg
Thank you
Completion of Disease Control Phase
Pelumi Adeloye DMD MPH
HEALTH ACCESS NETWORK (HAN) FAMILY DENTAL
Introduction
⧫1 Dentist I Hygienist 3 EFDArsquos1 Receptionist
⧫ 6 Chairs= 4 (dentist) + 2 (hygienist)
⧫ Slide ⥶80 off
⧫ Service areas Northern Penobscot Southern Aroostook Western
Washington Counties amp more
Completion of Phase I Treatment
⧫LimitedLack of Access to dental care
⧫Difficulty completing the disease control phase
Caries amp periodontal disease
⧫Attaining stable restorative state
Goal
Increase the completion of Disease Control Phase
Current practice
⧫Education
Assess level of dental literacy
Incremental strategy
⧫Increase access to dental care
Generous sliding scale (⥸$40 per visit)
Incorporate Expanded Function Dental Assistants
⧫Schedule modification
Incorporate more restorative blocks to allow
for follow-up visit and completion of restorative phase
httpswwwglasbergencomdentist-cartoons
Schedule
⧫Piggybacking technique
Increased allotted restorative blocks
⧫Sustainability of current schedule is
contingent on cooperation amp skills of HAN
Dental staff
Note
Strategies mentioned today is personalized to HAN Dental clinic
Current implemented strategies might be modified or changed in the
future as required in order to accommodate the need of our pts
THANK YOU
DAY TWOCLOSINGWRAP-UP
End of Day Two ndash Survey
Day Two Creating a Value-Based Oral Health Care Delivery
System
129
Payment Reform in Oral Health Online Learning Module
Oral Health Value-based Care Online Learning Module
Value-based Care Keys to Success Article
Readiness Assessment
Competency Development Guide
Oral Health Value-based Care Training
Dental Caries Management Practicum
Clinicians Companion Guide
Interprofessional Network Referral Process
Traditional Dental Care Vs Value-Based Care
Resources
131
wwwDentaQuestPartnershiporg
wwwfacebookcomDentaQuest
DentaQuest
wwwlinkedincomcompanyDentaQuest
Inside_DentaQuest
QUESTIONS
80
New Team Needed Business Intelligence
Business Intelligence (BI) is critical for effective managed care business decisions
BI team inputs metrics into your EHR collects integrates analyses and displays all your managed care business and clinical information
Easy to say- hard to achieve
Build your own or outsource
Possible future role of Primary Care Associations
8181
Clinicianrsquos Dashboard
Expensive to build
Displayed on your screen when your computer is first turned on
Easy to read and understand
Data dumped from the day before
Can dialed down from Org-wide to clinic to each clinicianrsquos data
Operational and clinical metrics
bull Treatment Plan Completion
bull DQA quality measures
bull Caries at Recall
bull Re-care reports
bull Care Gap reports
82
CONTROLLING COSTS
8383
Controlling Costs- Current
bull Increasing efficiencies
bull Decreasing broken appointments
bull Controlling supplies equipment costs
bull Staff recruitment retention costs
84
Specialty Care
Training current CHC dentists in
specialty areas
Hiring general dentists with higher
specialty skill sets
Hiring in house specialists
Contract with outside specialists
Work with Managed Care Plan
specialists
Lowering Disease Rates
Community Dental Health
Coordinators case management
If your state law allows- embed
hygienists in medical and community
to provide primary and secondary
prevention procedures
In clinic Caries Classification and
Silver Diamine Fluoride
Effective recare programs
Controlling Costs- Additions in Risk-based Contracting
85
Specialty Care ndash Primary Referrals by Cost
Pediatric dentistry
Orthodontics
Oral surgery
Endodontics
86
In-clinic Pediatric Services
Encounters expected
of operatories available
State dental law and ability to have
expanded duties
General Anesthesia
GA in- house
Ability for a hospital or surgery center
to set aside regular OR time
Ability to hire or assign DAs to GA
days
Four GA cases day x PPS rate
Should You Hire a Pediatric Dentist- It Depends
8787
Solutions for Controlling Pediatric Costs
Hire a general dentist that is skilled in treating young children
Make the clinic child friendly nitrous oxide TVs in the operatory etc
Teach entire staff behavioral control techniques
Contract with a pediatric dentist for the GA care
88
Lowering Overall Disease Rates (and Costs)
You are responsible for both the patients you see in the chair and the ones
assigned to you
Breaking down the walls of the dental clinic
Community Dental Health Coordinators
Case Management
89
Cost Control Essentials
Diagnosis codes
Increased ability to identify
disease by risk
Motivational
Interviewing
Developing Polices and
Procedures design to treat
disease according to risk
ie Silver Diamine Fluoride
Treating by Risk
Effective Recare
Process
Critical to continual disease
controlPrevention education that is
meaningful and designed to
change behaviors
90
Social Determinants of Health Aunt Bertha
httpswwwauntberthacom
91
REASON TO CONSIDER RISK- BASED CONTRACTING
9292
PPS Reconciliation and Federal Code 42 CFR sect4052469(a)(2)
42 CFR sect4052469(a)(2)
ldquoAny financial incentives provided to Federally Qualified Health Centers
under their Medicare Advantage Contracts such as risk pool payments
bonuses or withholds are prohibited from being included in the
calculation of supplemental payments due to the Federally Qualified
Health Centerrdquo
9393
Why Risk Based Contract in Times of PPS Reconciliation
bull Not all Risk- based Contract funds are reconciled
bull Risk is the key word- you can come out with less money than your normal
PPS reconciliation payment
bull Can lead to better patient care
bull May improve manage care enrollment for your medical plan
bull Promotes integrated care increases health for your CHC patients
9494
Not Included in the Reconciliation
Enrollment management pmpm
Quality Payments
Upside risk payments
Downside risk losses
9595
Determinants of Financial Success in Risk-Based Contracting
bull Most critical- State pmpm payment to the Managed Care Plan
bull Reporting capabilities
bull Specialty service capabilities
bull Access numbers count
bull Ability to move metric numbers
9696
What About the Non- Medicaid Poor We Serve
bull Numbers are king in a managed care contract and the more access you have
the better contract terms you can negotiate
bull We will potentially have a steady supply of Medicaid patients
bull As managed care spreads states this may be compromising the ability of
health centers to serve the non-Medicaid poor and others lacking dental
insurance
97
Mark Koday DDS
(509) 949-2278
Dental Quality Consultants
of WA
httpdentalqualityconsultin
gcom
dentalqualityconsultantsg
mailcom
Contact Information
LUNCH
BREAKOUT EXERCISEORAL HEALTH VALUE-BASED CARE READINESS ASSESSMENT
Danielle Apostolon
PROMISING PRACTICES FROM THE FIELD STRATEGIES FOR INCREASING VALUE IN ORAL HEALTH
Dr Carolyn Brown
Dr Kelly Perry
Dr Rachel Rivard
Dr Adeloye
Commitment Compassion Community
m i d s t a t e h e a l t h o r g
Promising Practices from the
Field Strategies for Increasing
Value in Oral Health Care
Kelly Perry DMD
Better Health
Outcomes
Improved Staff
Experience
Reduced Cost
Improved Patient
Experience
Better Health
Outcomes
Improved Staff
Experience
Reduced Cost
Improved Patient
Experience
Better Health
Outcomes
Improved Staff
Experience
Reduced Cost
Improved Patient
Experience
Better Health
Outcomes
Improved Staff
Experience
Reduced Cost
Improved Patient
Experience
Commitment Compassion Community
kpe r r ymids t a tehea l t h o rg
Thank you
Completion of Disease Control Phase
Pelumi Adeloye DMD MPH
HEALTH ACCESS NETWORK (HAN) FAMILY DENTAL
Introduction
⧫1 Dentist I Hygienist 3 EFDArsquos1 Receptionist
⧫ 6 Chairs= 4 (dentist) + 2 (hygienist)
⧫ Slide ⥶80 off
⧫ Service areas Northern Penobscot Southern Aroostook Western
Washington Counties amp more
Completion of Phase I Treatment
⧫LimitedLack of Access to dental care
⧫Difficulty completing the disease control phase
Caries amp periodontal disease
⧫Attaining stable restorative state
Goal
Increase the completion of Disease Control Phase
Current practice
⧫Education
Assess level of dental literacy
Incremental strategy
⧫Increase access to dental care
Generous sliding scale (⥸$40 per visit)
Incorporate Expanded Function Dental Assistants
⧫Schedule modification
Incorporate more restorative blocks to allow
for follow-up visit and completion of restorative phase
httpswwwglasbergencomdentist-cartoons
Schedule
⧫Piggybacking technique
Increased allotted restorative blocks
⧫Sustainability of current schedule is
contingent on cooperation amp skills of HAN
Dental staff
Note
Strategies mentioned today is personalized to HAN Dental clinic
Current implemented strategies might be modified or changed in the
future as required in order to accommodate the need of our pts
THANK YOU
DAY TWOCLOSINGWRAP-UP
End of Day Two ndash Survey
Day Two Creating a Value-Based Oral Health Care Delivery
System
129
Payment Reform in Oral Health Online Learning Module
Oral Health Value-based Care Online Learning Module
Value-based Care Keys to Success Article
Readiness Assessment
Competency Development Guide
Oral Health Value-based Care Training
Dental Caries Management Practicum
Clinicians Companion Guide
Interprofessional Network Referral Process
Traditional Dental Care Vs Value-Based Care
Resources
131
wwwDentaQuestPartnershiporg
wwwfacebookcomDentaQuest
DentaQuest
wwwlinkedincomcompanyDentaQuest
Inside_DentaQuest
QUESTIONS
8181
Clinicianrsquos Dashboard
Expensive to build
Displayed on your screen when your computer is first turned on
Easy to read and understand
Data dumped from the day before
Can dialed down from Org-wide to clinic to each clinicianrsquos data
Operational and clinical metrics
bull Treatment Plan Completion
bull DQA quality measures
bull Caries at Recall
bull Re-care reports
bull Care Gap reports
82
CONTROLLING COSTS
8383
Controlling Costs- Current
bull Increasing efficiencies
bull Decreasing broken appointments
bull Controlling supplies equipment costs
bull Staff recruitment retention costs
84
Specialty Care
Training current CHC dentists in
specialty areas
Hiring general dentists with higher
specialty skill sets
Hiring in house specialists
Contract with outside specialists
Work with Managed Care Plan
specialists
Lowering Disease Rates
Community Dental Health
Coordinators case management
If your state law allows- embed
hygienists in medical and community
to provide primary and secondary
prevention procedures
In clinic Caries Classification and
Silver Diamine Fluoride
Effective recare programs
Controlling Costs- Additions in Risk-based Contracting
85
Specialty Care ndash Primary Referrals by Cost
Pediatric dentistry
Orthodontics
Oral surgery
Endodontics
86
In-clinic Pediatric Services
Encounters expected
of operatories available
State dental law and ability to have
expanded duties
General Anesthesia
GA in- house
Ability for a hospital or surgery center
to set aside regular OR time
Ability to hire or assign DAs to GA
days
Four GA cases day x PPS rate
Should You Hire a Pediatric Dentist- It Depends
8787
Solutions for Controlling Pediatric Costs
Hire a general dentist that is skilled in treating young children
Make the clinic child friendly nitrous oxide TVs in the operatory etc
Teach entire staff behavioral control techniques
Contract with a pediatric dentist for the GA care
88
Lowering Overall Disease Rates (and Costs)
You are responsible for both the patients you see in the chair and the ones
assigned to you
Breaking down the walls of the dental clinic
Community Dental Health Coordinators
Case Management
89
Cost Control Essentials
Diagnosis codes
Increased ability to identify
disease by risk
Motivational
Interviewing
Developing Polices and
Procedures design to treat
disease according to risk
ie Silver Diamine Fluoride
Treating by Risk
Effective Recare
Process
Critical to continual disease
controlPrevention education that is
meaningful and designed to
change behaviors
90
Social Determinants of Health Aunt Bertha
httpswwwauntberthacom
91
REASON TO CONSIDER RISK- BASED CONTRACTING
9292
PPS Reconciliation and Federal Code 42 CFR sect4052469(a)(2)
42 CFR sect4052469(a)(2)
ldquoAny financial incentives provided to Federally Qualified Health Centers
under their Medicare Advantage Contracts such as risk pool payments
bonuses or withholds are prohibited from being included in the
calculation of supplemental payments due to the Federally Qualified
Health Centerrdquo
9393
Why Risk Based Contract in Times of PPS Reconciliation
bull Not all Risk- based Contract funds are reconciled
bull Risk is the key word- you can come out with less money than your normal
PPS reconciliation payment
bull Can lead to better patient care
bull May improve manage care enrollment for your medical plan
bull Promotes integrated care increases health for your CHC patients
9494
Not Included in the Reconciliation
Enrollment management pmpm
Quality Payments
Upside risk payments
Downside risk losses
9595
Determinants of Financial Success in Risk-Based Contracting
bull Most critical- State pmpm payment to the Managed Care Plan
bull Reporting capabilities
bull Specialty service capabilities
bull Access numbers count
bull Ability to move metric numbers
9696
What About the Non- Medicaid Poor We Serve
bull Numbers are king in a managed care contract and the more access you have
the better contract terms you can negotiate
bull We will potentially have a steady supply of Medicaid patients
bull As managed care spreads states this may be compromising the ability of
health centers to serve the non-Medicaid poor and others lacking dental
insurance
97
Mark Koday DDS
(509) 949-2278
Dental Quality Consultants
of WA
httpdentalqualityconsultin
gcom
dentalqualityconsultantsg
mailcom
Contact Information
LUNCH
BREAKOUT EXERCISEORAL HEALTH VALUE-BASED CARE READINESS ASSESSMENT
Danielle Apostolon
PROMISING PRACTICES FROM THE FIELD STRATEGIES FOR INCREASING VALUE IN ORAL HEALTH
Dr Carolyn Brown
Dr Kelly Perry
Dr Rachel Rivard
Dr Adeloye
Commitment Compassion Community
m i d s t a t e h e a l t h o r g
Promising Practices from the
Field Strategies for Increasing
Value in Oral Health Care
Kelly Perry DMD
Better Health
Outcomes
Improved Staff
Experience
Reduced Cost
Improved Patient
Experience
Better Health
Outcomes
Improved Staff
Experience
Reduced Cost
Improved Patient
Experience
Better Health
Outcomes
Improved Staff
Experience
Reduced Cost
Improved Patient
Experience
Better Health
Outcomes
Improved Staff
Experience
Reduced Cost
Improved Patient
Experience
Commitment Compassion Community
kpe r r ymids t a tehea l t h o rg
Thank you
Completion of Disease Control Phase
Pelumi Adeloye DMD MPH
HEALTH ACCESS NETWORK (HAN) FAMILY DENTAL
Introduction
⧫1 Dentist I Hygienist 3 EFDArsquos1 Receptionist
⧫ 6 Chairs= 4 (dentist) + 2 (hygienist)
⧫ Slide ⥶80 off
⧫ Service areas Northern Penobscot Southern Aroostook Western
Washington Counties amp more
Completion of Phase I Treatment
⧫LimitedLack of Access to dental care
⧫Difficulty completing the disease control phase
Caries amp periodontal disease
⧫Attaining stable restorative state
Goal
Increase the completion of Disease Control Phase
Current practice
⧫Education
Assess level of dental literacy
Incremental strategy
⧫Increase access to dental care
Generous sliding scale (⥸$40 per visit)
Incorporate Expanded Function Dental Assistants
⧫Schedule modification
Incorporate more restorative blocks to allow
for follow-up visit and completion of restorative phase
httpswwwglasbergencomdentist-cartoons
Schedule
⧫Piggybacking technique
Increased allotted restorative blocks
⧫Sustainability of current schedule is
contingent on cooperation amp skills of HAN
Dental staff
Note
Strategies mentioned today is personalized to HAN Dental clinic
Current implemented strategies might be modified or changed in the
future as required in order to accommodate the need of our pts
THANK YOU
DAY TWOCLOSINGWRAP-UP
End of Day Two ndash Survey
Day Two Creating a Value-Based Oral Health Care Delivery
System
129
Payment Reform in Oral Health Online Learning Module
Oral Health Value-based Care Online Learning Module
Value-based Care Keys to Success Article
Readiness Assessment
Competency Development Guide
Oral Health Value-based Care Training
Dental Caries Management Practicum
Clinicians Companion Guide
Interprofessional Network Referral Process
Traditional Dental Care Vs Value-Based Care
Resources
131
wwwDentaQuestPartnershiporg
wwwfacebookcomDentaQuest
DentaQuest
wwwlinkedincomcompanyDentaQuest
Inside_DentaQuest
QUESTIONS
82
CONTROLLING COSTS
8383
Controlling Costs- Current
bull Increasing efficiencies
bull Decreasing broken appointments
bull Controlling supplies equipment costs
bull Staff recruitment retention costs
84
Specialty Care
Training current CHC dentists in
specialty areas
Hiring general dentists with higher
specialty skill sets
Hiring in house specialists
Contract with outside specialists
Work with Managed Care Plan
specialists
Lowering Disease Rates
Community Dental Health
Coordinators case management
If your state law allows- embed
hygienists in medical and community
to provide primary and secondary
prevention procedures
In clinic Caries Classification and
Silver Diamine Fluoride
Effective recare programs
Controlling Costs- Additions in Risk-based Contracting
85
Specialty Care ndash Primary Referrals by Cost
Pediatric dentistry
Orthodontics
Oral surgery
Endodontics
86
In-clinic Pediatric Services
Encounters expected
of operatories available
State dental law and ability to have
expanded duties
General Anesthesia
GA in- house
Ability for a hospital or surgery center
to set aside regular OR time
Ability to hire or assign DAs to GA
days
Four GA cases day x PPS rate
Should You Hire a Pediatric Dentist- It Depends
8787
Solutions for Controlling Pediatric Costs
Hire a general dentist that is skilled in treating young children
Make the clinic child friendly nitrous oxide TVs in the operatory etc
Teach entire staff behavioral control techniques
Contract with a pediatric dentist for the GA care
88
Lowering Overall Disease Rates (and Costs)
You are responsible for both the patients you see in the chair and the ones
assigned to you
Breaking down the walls of the dental clinic
Community Dental Health Coordinators
Case Management
89
Cost Control Essentials
Diagnosis codes
Increased ability to identify
disease by risk
Motivational
Interviewing
Developing Polices and
Procedures design to treat
disease according to risk
ie Silver Diamine Fluoride
Treating by Risk
Effective Recare
Process
Critical to continual disease
controlPrevention education that is
meaningful and designed to
change behaviors
90
Social Determinants of Health Aunt Bertha
httpswwwauntberthacom
91
REASON TO CONSIDER RISK- BASED CONTRACTING
9292
PPS Reconciliation and Federal Code 42 CFR sect4052469(a)(2)
42 CFR sect4052469(a)(2)
ldquoAny financial incentives provided to Federally Qualified Health Centers
under their Medicare Advantage Contracts such as risk pool payments
bonuses or withholds are prohibited from being included in the
calculation of supplemental payments due to the Federally Qualified
Health Centerrdquo
9393
Why Risk Based Contract in Times of PPS Reconciliation
bull Not all Risk- based Contract funds are reconciled
bull Risk is the key word- you can come out with less money than your normal
PPS reconciliation payment
bull Can lead to better patient care
bull May improve manage care enrollment for your medical plan
bull Promotes integrated care increases health for your CHC patients
9494
Not Included in the Reconciliation
Enrollment management pmpm
Quality Payments
Upside risk payments
Downside risk losses
9595
Determinants of Financial Success in Risk-Based Contracting
bull Most critical- State pmpm payment to the Managed Care Plan
bull Reporting capabilities
bull Specialty service capabilities
bull Access numbers count
bull Ability to move metric numbers
9696
What About the Non- Medicaid Poor We Serve
bull Numbers are king in a managed care contract and the more access you have
the better contract terms you can negotiate
bull We will potentially have a steady supply of Medicaid patients
bull As managed care spreads states this may be compromising the ability of
health centers to serve the non-Medicaid poor and others lacking dental
insurance
97
Mark Koday DDS
(509) 949-2278
Dental Quality Consultants
of WA
httpdentalqualityconsultin
gcom
dentalqualityconsultantsg
mailcom
Contact Information
LUNCH
BREAKOUT EXERCISEORAL HEALTH VALUE-BASED CARE READINESS ASSESSMENT
Danielle Apostolon
PROMISING PRACTICES FROM THE FIELD STRATEGIES FOR INCREASING VALUE IN ORAL HEALTH
Dr Carolyn Brown
Dr Kelly Perry
Dr Rachel Rivard
Dr Adeloye
Commitment Compassion Community
m i d s t a t e h e a l t h o r g
Promising Practices from the
Field Strategies for Increasing
Value in Oral Health Care
Kelly Perry DMD
Better Health
Outcomes
Improved Staff
Experience
Reduced Cost
Improved Patient
Experience
Better Health
Outcomes
Improved Staff
Experience
Reduced Cost
Improved Patient
Experience
Better Health
Outcomes
Improved Staff
Experience
Reduced Cost
Improved Patient
Experience
Better Health
Outcomes
Improved Staff
Experience
Reduced Cost
Improved Patient
Experience
Commitment Compassion Community
kpe r r ymids t a tehea l t h o rg
Thank you
Completion of Disease Control Phase
Pelumi Adeloye DMD MPH
HEALTH ACCESS NETWORK (HAN) FAMILY DENTAL
Introduction
⧫1 Dentist I Hygienist 3 EFDArsquos1 Receptionist
⧫ 6 Chairs= 4 (dentist) + 2 (hygienist)
⧫ Slide ⥶80 off
⧫ Service areas Northern Penobscot Southern Aroostook Western
Washington Counties amp more
Completion of Phase I Treatment
⧫LimitedLack of Access to dental care
⧫Difficulty completing the disease control phase
Caries amp periodontal disease
⧫Attaining stable restorative state
Goal
Increase the completion of Disease Control Phase
Current practice
⧫Education
Assess level of dental literacy
Incremental strategy
⧫Increase access to dental care
Generous sliding scale (⥸$40 per visit)
Incorporate Expanded Function Dental Assistants
⧫Schedule modification
Incorporate more restorative blocks to allow
for follow-up visit and completion of restorative phase
httpswwwglasbergencomdentist-cartoons
Schedule
⧫Piggybacking technique
Increased allotted restorative blocks
⧫Sustainability of current schedule is
contingent on cooperation amp skills of HAN
Dental staff
Note
Strategies mentioned today is personalized to HAN Dental clinic
Current implemented strategies might be modified or changed in the
future as required in order to accommodate the need of our pts
THANK YOU
DAY TWOCLOSINGWRAP-UP
End of Day Two ndash Survey
Day Two Creating a Value-Based Oral Health Care Delivery
System
129
Payment Reform in Oral Health Online Learning Module
Oral Health Value-based Care Online Learning Module
Value-based Care Keys to Success Article
Readiness Assessment
Competency Development Guide
Oral Health Value-based Care Training
Dental Caries Management Practicum
Clinicians Companion Guide
Interprofessional Network Referral Process
Traditional Dental Care Vs Value-Based Care
Resources
131
wwwDentaQuestPartnershiporg
wwwfacebookcomDentaQuest
DentaQuest
wwwlinkedincomcompanyDentaQuest
Inside_DentaQuest
QUESTIONS
8383
Controlling Costs- Current
bull Increasing efficiencies
bull Decreasing broken appointments
bull Controlling supplies equipment costs
bull Staff recruitment retention costs
84
Specialty Care
Training current CHC dentists in
specialty areas
Hiring general dentists with higher
specialty skill sets
Hiring in house specialists
Contract with outside specialists
Work with Managed Care Plan
specialists
Lowering Disease Rates
Community Dental Health
Coordinators case management
If your state law allows- embed
hygienists in medical and community
to provide primary and secondary
prevention procedures
In clinic Caries Classification and
Silver Diamine Fluoride
Effective recare programs
Controlling Costs- Additions in Risk-based Contracting
85
Specialty Care ndash Primary Referrals by Cost
Pediatric dentistry
Orthodontics
Oral surgery
Endodontics
86
In-clinic Pediatric Services
Encounters expected
of operatories available
State dental law and ability to have
expanded duties
General Anesthesia
GA in- house
Ability for a hospital or surgery center
to set aside regular OR time
Ability to hire or assign DAs to GA
days
Four GA cases day x PPS rate
Should You Hire a Pediatric Dentist- It Depends
8787
Solutions for Controlling Pediatric Costs
Hire a general dentist that is skilled in treating young children
Make the clinic child friendly nitrous oxide TVs in the operatory etc
Teach entire staff behavioral control techniques
Contract with a pediatric dentist for the GA care
88
Lowering Overall Disease Rates (and Costs)
You are responsible for both the patients you see in the chair and the ones
assigned to you
Breaking down the walls of the dental clinic
Community Dental Health Coordinators
Case Management
89
Cost Control Essentials
Diagnosis codes
Increased ability to identify
disease by risk
Motivational
Interviewing
Developing Polices and
Procedures design to treat
disease according to risk
ie Silver Diamine Fluoride
Treating by Risk
Effective Recare
Process
Critical to continual disease
controlPrevention education that is
meaningful and designed to
change behaviors
90
Social Determinants of Health Aunt Bertha
httpswwwauntberthacom
91
REASON TO CONSIDER RISK- BASED CONTRACTING
9292
PPS Reconciliation and Federal Code 42 CFR sect4052469(a)(2)
42 CFR sect4052469(a)(2)
ldquoAny financial incentives provided to Federally Qualified Health Centers
under their Medicare Advantage Contracts such as risk pool payments
bonuses or withholds are prohibited from being included in the
calculation of supplemental payments due to the Federally Qualified
Health Centerrdquo
9393
Why Risk Based Contract in Times of PPS Reconciliation
bull Not all Risk- based Contract funds are reconciled
bull Risk is the key word- you can come out with less money than your normal
PPS reconciliation payment
bull Can lead to better patient care
bull May improve manage care enrollment for your medical plan
bull Promotes integrated care increases health for your CHC patients
9494
Not Included in the Reconciliation
Enrollment management pmpm
Quality Payments
Upside risk payments
Downside risk losses
9595
Determinants of Financial Success in Risk-Based Contracting
bull Most critical- State pmpm payment to the Managed Care Plan
bull Reporting capabilities
bull Specialty service capabilities
bull Access numbers count
bull Ability to move metric numbers
9696
What About the Non- Medicaid Poor We Serve
bull Numbers are king in a managed care contract and the more access you have
the better contract terms you can negotiate
bull We will potentially have a steady supply of Medicaid patients
bull As managed care spreads states this may be compromising the ability of
health centers to serve the non-Medicaid poor and others lacking dental
insurance
97
Mark Koday DDS
(509) 949-2278
Dental Quality Consultants
of WA
httpdentalqualityconsultin
gcom
dentalqualityconsultantsg
mailcom
Contact Information
LUNCH
BREAKOUT EXERCISEORAL HEALTH VALUE-BASED CARE READINESS ASSESSMENT
Danielle Apostolon
PROMISING PRACTICES FROM THE FIELD STRATEGIES FOR INCREASING VALUE IN ORAL HEALTH
Dr Carolyn Brown
Dr Kelly Perry
Dr Rachel Rivard
Dr Adeloye
Commitment Compassion Community
m i d s t a t e h e a l t h o r g
Promising Practices from the
Field Strategies for Increasing
Value in Oral Health Care
Kelly Perry DMD
Better Health
Outcomes
Improved Staff
Experience
Reduced Cost
Improved Patient
Experience
Better Health
Outcomes
Improved Staff
Experience
Reduced Cost
Improved Patient
Experience
Better Health
Outcomes
Improved Staff
Experience
Reduced Cost
Improved Patient
Experience
Better Health
Outcomes
Improved Staff
Experience
Reduced Cost
Improved Patient
Experience
Commitment Compassion Community
kpe r r ymids t a tehea l t h o rg
Thank you
Completion of Disease Control Phase
Pelumi Adeloye DMD MPH
HEALTH ACCESS NETWORK (HAN) FAMILY DENTAL
Introduction
⧫1 Dentist I Hygienist 3 EFDArsquos1 Receptionist
⧫ 6 Chairs= 4 (dentist) + 2 (hygienist)
⧫ Slide ⥶80 off
⧫ Service areas Northern Penobscot Southern Aroostook Western
Washington Counties amp more
Completion of Phase I Treatment
⧫LimitedLack of Access to dental care
⧫Difficulty completing the disease control phase
Caries amp periodontal disease
⧫Attaining stable restorative state
Goal
Increase the completion of Disease Control Phase
Current practice
⧫Education
Assess level of dental literacy
Incremental strategy
⧫Increase access to dental care
Generous sliding scale (⥸$40 per visit)
Incorporate Expanded Function Dental Assistants
⧫Schedule modification
Incorporate more restorative blocks to allow
for follow-up visit and completion of restorative phase
httpswwwglasbergencomdentist-cartoons
Schedule
⧫Piggybacking technique
Increased allotted restorative blocks
⧫Sustainability of current schedule is
contingent on cooperation amp skills of HAN
Dental staff
Note
Strategies mentioned today is personalized to HAN Dental clinic
Current implemented strategies might be modified or changed in the
future as required in order to accommodate the need of our pts
THANK YOU
DAY TWOCLOSINGWRAP-UP
End of Day Two ndash Survey
Day Two Creating a Value-Based Oral Health Care Delivery
System
129
Payment Reform in Oral Health Online Learning Module
Oral Health Value-based Care Online Learning Module
Value-based Care Keys to Success Article
Readiness Assessment
Competency Development Guide
Oral Health Value-based Care Training
Dental Caries Management Practicum
Clinicians Companion Guide
Interprofessional Network Referral Process
Traditional Dental Care Vs Value-Based Care
Resources
131
wwwDentaQuestPartnershiporg
wwwfacebookcomDentaQuest
DentaQuest
wwwlinkedincomcompanyDentaQuest
Inside_DentaQuest
QUESTIONS
84
Specialty Care
Training current CHC dentists in
specialty areas
Hiring general dentists with higher
specialty skill sets
Hiring in house specialists
Contract with outside specialists
Work with Managed Care Plan
specialists
Lowering Disease Rates
Community Dental Health
Coordinators case management
If your state law allows- embed
hygienists in medical and community
to provide primary and secondary
prevention procedures
In clinic Caries Classification and
Silver Diamine Fluoride
Effective recare programs
Controlling Costs- Additions in Risk-based Contracting
85
Specialty Care ndash Primary Referrals by Cost
Pediatric dentistry
Orthodontics
Oral surgery
Endodontics
86
In-clinic Pediatric Services
Encounters expected
of operatories available
State dental law and ability to have
expanded duties
General Anesthesia
GA in- house
Ability for a hospital or surgery center
to set aside regular OR time
Ability to hire or assign DAs to GA
days
Four GA cases day x PPS rate
Should You Hire a Pediatric Dentist- It Depends
8787
Solutions for Controlling Pediatric Costs
Hire a general dentist that is skilled in treating young children
Make the clinic child friendly nitrous oxide TVs in the operatory etc
Teach entire staff behavioral control techniques
Contract with a pediatric dentist for the GA care
88
Lowering Overall Disease Rates (and Costs)
You are responsible for both the patients you see in the chair and the ones
assigned to you
Breaking down the walls of the dental clinic
Community Dental Health Coordinators
Case Management
89
Cost Control Essentials
Diagnosis codes
Increased ability to identify
disease by risk
Motivational
Interviewing
Developing Polices and
Procedures design to treat
disease according to risk
ie Silver Diamine Fluoride
Treating by Risk
Effective Recare
Process
Critical to continual disease
controlPrevention education that is
meaningful and designed to
change behaviors
90
Social Determinants of Health Aunt Bertha
httpswwwauntberthacom
91
REASON TO CONSIDER RISK- BASED CONTRACTING
9292
PPS Reconciliation and Federal Code 42 CFR sect4052469(a)(2)
42 CFR sect4052469(a)(2)
ldquoAny financial incentives provided to Federally Qualified Health Centers
under their Medicare Advantage Contracts such as risk pool payments
bonuses or withholds are prohibited from being included in the
calculation of supplemental payments due to the Federally Qualified
Health Centerrdquo
9393
Why Risk Based Contract in Times of PPS Reconciliation
bull Not all Risk- based Contract funds are reconciled
bull Risk is the key word- you can come out with less money than your normal
PPS reconciliation payment
bull Can lead to better patient care
bull May improve manage care enrollment for your medical plan
bull Promotes integrated care increases health for your CHC patients
9494
Not Included in the Reconciliation
Enrollment management pmpm
Quality Payments
Upside risk payments
Downside risk losses
9595
Determinants of Financial Success in Risk-Based Contracting
bull Most critical- State pmpm payment to the Managed Care Plan
bull Reporting capabilities
bull Specialty service capabilities
bull Access numbers count
bull Ability to move metric numbers
9696
What About the Non- Medicaid Poor We Serve
bull Numbers are king in a managed care contract and the more access you have
the better contract terms you can negotiate
bull We will potentially have a steady supply of Medicaid patients
bull As managed care spreads states this may be compromising the ability of
health centers to serve the non-Medicaid poor and others lacking dental
insurance
97
Mark Koday DDS
(509) 949-2278
Dental Quality Consultants
of WA
httpdentalqualityconsultin
gcom
dentalqualityconsultantsg
mailcom
Contact Information
LUNCH
BREAKOUT EXERCISEORAL HEALTH VALUE-BASED CARE READINESS ASSESSMENT
Danielle Apostolon
PROMISING PRACTICES FROM THE FIELD STRATEGIES FOR INCREASING VALUE IN ORAL HEALTH
Dr Carolyn Brown
Dr Kelly Perry
Dr Rachel Rivard
Dr Adeloye
Commitment Compassion Community
m i d s t a t e h e a l t h o r g
Promising Practices from the
Field Strategies for Increasing
Value in Oral Health Care
Kelly Perry DMD
Better Health
Outcomes
Improved Staff
Experience
Reduced Cost
Improved Patient
Experience
Better Health
Outcomes
Improved Staff
Experience
Reduced Cost
Improved Patient
Experience
Better Health
Outcomes
Improved Staff
Experience
Reduced Cost
Improved Patient
Experience
Better Health
Outcomes
Improved Staff
Experience
Reduced Cost
Improved Patient
Experience
Commitment Compassion Community
kpe r r ymids t a tehea l t h o rg
Thank you
Completion of Disease Control Phase
Pelumi Adeloye DMD MPH
HEALTH ACCESS NETWORK (HAN) FAMILY DENTAL
Introduction
⧫1 Dentist I Hygienist 3 EFDArsquos1 Receptionist
⧫ 6 Chairs= 4 (dentist) + 2 (hygienist)
⧫ Slide ⥶80 off
⧫ Service areas Northern Penobscot Southern Aroostook Western
Washington Counties amp more
Completion of Phase I Treatment
⧫LimitedLack of Access to dental care
⧫Difficulty completing the disease control phase
Caries amp periodontal disease
⧫Attaining stable restorative state
Goal
Increase the completion of Disease Control Phase
Current practice
⧫Education
Assess level of dental literacy
Incremental strategy
⧫Increase access to dental care
Generous sliding scale (⥸$40 per visit)
Incorporate Expanded Function Dental Assistants
⧫Schedule modification
Incorporate more restorative blocks to allow
for follow-up visit and completion of restorative phase
httpswwwglasbergencomdentist-cartoons
Schedule
⧫Piggybacking technique
Increased allotted restorative blocks
⧫Sustainability of current schedule is
contingent on cooperation amp skills of HAN
Dental staff
Note
Strategies mentioned today is personalized to HAN Dental clinic
Current implemented strategies might be modified or changed in the
future as required in order to accommodate the need of our pts
THANK YOU
DAY TWOCLOSINGWRAP-UP
End of Day Two ndash Survey
Day Two Creating a Value-Based Oral Health Care Delivery
System
129
Payment Reform in Oral Health Online Learning Module
Oral Health Value-based Care Online Learning Module
Value-based Care Keys to Success Article
Readiness Assessment
Competency Development Guide
Oral Health Value-based Care Training
Dental Caries Management Practicum
Clinicians Companion Guide
Interprofessional Network Referral Process
Traditional Dental Care Vs Value-Based Care
Resources
131
wwwDentaQuestPartnershiporg
wwwfacebookcomDentaQuest
DentaQuest
wwwlinkedincomcompanyDentaQuest
Inside_DentaQuest
QUESTIONS
85
Specialty Care ndash Primary Referrals by Cost
Pediatric dentistry
Orthodontics
Oral surgery
Endodontics
86
In-clinic Pediatric Services
Encounters expected
of operatories available
State dental law and ability to have
expanded duties
General Anesthesia
GA in- house
Ability for a hospital or surgery center
to set aside regular OR time
Ability to hire or assign DAs to GA
days
Four GA cases day x PPS rate
Should You Hire a Pediatric Dentist- It Depends
8787
Solutions for Controlling Pediatric Costs
Hire a general dentist that is skilled in treating young children
Make the clinic child friendly nitrous oxide TVs in the operatory etc
Teach entire staff behavioral control techniques
Contract with a pediatric dentist for the GA care
88
Lowering Overall Disease Rates (and Costs)
You are responsible for both the patients you see in the chair and the ones
assigned to you
Breaking down the walls of the dental clinic
Community Dental Health Coordinators
Case Management
89
Cost Control Essentials
Diagnosis codes
Increased ability to identify
disease by risk
Motivational
Interviewing
Developing Polices and
Procedures design to treat
disease according to risk
ie Silver Diamine Fluoride
Treating by Risk
Effective Recare
Process
Critical to continual disease
controlPrevention education that is
meaningful and designed to
change behaviors
90
Social Determinants of Health Aunt Bertha
httpswwwauntberthacom
91
REASON TO CONSIDER RISK- BASED CONTRACTING
9292
PPS Reconciliation and Federal Code 42 CFR sect4052469(a)(2)
42 CFR sect4052469(a)(2)
ldquoAny financial incentives provided to Federally Qualified Health Centers
under their Medicare Advantage Contracts such as risk pool payments
bonuses or withholds are prohibited from being included in the
calculation of supplemental payments due to the Federally Qualified
Health Centerrdquo
9393
Why Risk Based Contract in Times of PPS Reconciliation
bull Not all Risk- based Contract funds are reconciled
bull Risk is the key word- you can come out with less money than your normal
PPS reconciliation payment
bull Can lead to better patient care
bull May improve manage care enrollment for your medical plan
bull Promotes integrated care increases health for your CHC patients
9494
Not Included in the Reconciliation
Enrollment management pmpm
Quality Payments
Upside risk payments
Downside risk losses
9595
Determinants of Financial Success in Risk-Based Contracting
bull Most critical- State pmpm payment to the Managed Care Plan
bull Reporting capabilities
bull Specialty service capabilities
bull Access numbers count
bull Ability to move metric numbers
9696
What About the Non- Medicaid Poor We Serve
bull Numbers are king in a managed care contract and the more access you have
the better contract terms you can negotiate
bull We will potentially have a steady supply of Medicaid patients
bull As managed care spreads states this may be compromising the ability of
health centers to serve the non-Medicaid poor and others lacking dental
insurance
97
Mark Koday DDS
(509) 949-2278
Dental Quality Consultants
of WA
httpdentalqualityconsultin
gcom
dentalqualityconsultantsg
mailcom
Contact Information
LUNCH
BREAKOUT EXERCISEORAL HEALTH VALUE-BASED CARE READINESS ASSESSMENT
Danielle Apostolon
PROMISING PRACTICES FROM THE FIELD STRATEGIES FOR INCREASING VALUE IN ORAL HEALTH
Dr Carolyn Brown
Dr Kelly Perry
Dr Rachel Rivard
Dr Adeloye
Commitment Compassion Community
m i d s t a t e h e a l t h o r g
Promising Practices from the
Field Strategies for Increasing
Value in Oral Health Care
Kelly Perry DMD
Better Health
Outcomes
Improved Staff
Experience
Reduced Cost
Improved Patient
Experience
Better Health
Outcomes
Improved Staff
Experience
Reduced Cost
Improved Patient
Experience
Better Health
Outcomes
Improved Staff
Experience
Reduced Cost
Improved Patient
Experience
Better Health
Outcomes
Improved Staff
Experience
Reduced Cost
Improved Patient
Experience
Commitment Compassion Community
kpe r r ymids t a tehea l t h o rg
Thank you
Completion of Disease Control Phase
Pelumi Adeloye DMD MPH
HEALTH ACCESS NETWORK (HAN) FAMILY DENTAL
Introduction
⧫1 Dentist I Hygienist 3 EFDArsquos1 Receptionist
⧫ 6 Chairs= 4 (dentist) + 2 (hygienist)
⧫ Slide ⥶80 off
⧫ Service areas Northern Penobscot Southern Aroostook Western
Washington Counties amp more
Completion of Phase I Treatment
⧫LimitedLack of Access to dental care
⧫Difficulty completing the disease control phase
Caries amp periodontal disease
⧫Attaining stable restorative state
Goal
Increase the completion of Disease Control Phase
Current practice
⧫Education
Assess level of dental literacy
Incremental strategy
⧫Increase access to dental care
Generous sliding scale (⥸$40 per visit)
Incorporate Expanded Function Dental Assistants
⧫Schedule modification
Incorporate more restorative blocks to allow
for follow-up visit and completion of restorative phase
httpswwwglasbergencomdentist-cartoons
Schedule
⧫Piggybacking technique
Increased allotted restorative blocks
⧫Sustainability of current schedule is
contingent on cooperation amp skills of HAN
Dental staff
Note
Strategies mentioned today is personalized to HAN Dental clinic
Current implemented strategies might be modified or changed in the
future as required in order to accommodate the need of our pts
THANK YOU
DAY TWOCLOSINGWRAP-UP
End of Day Two ndash Survey
Day Two Creating a Value-Based Oral Health Care Delivery
System
129
Payment Reform in Oral Health Online Learning Module
Oral Health Value-based Care Online Learning Module
Value-based Care Keys to Success Article
Readiness Assessment
Competency Development Guide
Oral Health Value-based Care Training
Dental Caries Management Practicum
Clinicians Companion Guide
Interprofessional Network Referral Process
Traditional Dental Care Vs Value-Based Care
Resources
131
wwwDentaQuestPartnershiporg
wwwfacebookcomDentaQuest
DentaQuest
wwwlinkedincomcompanyDentaQuest
Inside_DentaQuest
QUESTIONS
86
In-clinic Pediatric Services
Encounters expected
of operatories available
State dental law and ability to have
expanded duties
General Anesthesia
GA in- house
Ability for a hospital or surgery center
to set aside regular OR time
Ability to hire or assign DAs to GA
days
Four GA cases day x PPS rate
Should You Hire a Pediatric Dentist- It Depends
8787
Solutions for Controlling Pediatric Costs
Hire a general dentist that is skilled in treating young children
Make the clinic child friendly nitrous oxide TVs in the operatory etc
Teach entire staff behavioral control techniques
Contract with a pediatric dentist for the GA care
88
Lowering Overall Disease Rates (and Costs)
You are responsible for both the patients you see in the chair and the ones
assigned to you
Breaking down the walls of the dental clinic
Community Dental Health Coordinators
Case Management
89
Cost Control Essentials
Diagnosis codes
Increased ability to identify
disease by risk
Motivational
Interviewing
Developing Polices and
Procedures design to treat
disease according to risk
ie Silver Diamine Fluoride
Treating by Risk
Effective Recare
Process
Critical to continual disease
controlPrevention education that is
meaningful and designed to
change behaviors
90
Social Determinants of Health Aunt Bertha
httpswwwauntberthacom
91
REASON TO CONSIDER RISK- BASED CONTRACTING
9292
PPS Reconciliation and Federal Code 42 CFR sect4052469(a)(2)
42 CFR sect4052469(a)(2)
ldquoAny financial incentives provided to Federally Qualified Health Centers
under their Medicare Advantage Contracts such as risk pool payments
bonuses or withholds are prohibited from being included in the
calculation of supplemental payments due to the Federally Qualified
Health Centerrdquo
9393
Why Risk Based Contract in Times of PPS Reconciliation
bull Not all Risk- based Contract funds are reconciled
bull Risk is the key word- you can come out with less money than your normal
PPS reconciliation payment
bull Can lead to better patient care
bull May improve manage care enrollment for your medical plan
bull Promotes integrated care increases health for your CHC patients
9494
Not Included in the Reconciliation
Enrollment management pmpm
Quality Payments
Upside risk payments
Downside risk losses
9595
Determinants of Financial Success in Risk-Based Contracting
bull Most critical- State pmpm payment to the Managed Care Plan
bull Reporting capabilities
bull Specialty service capabilities
bull Access numbers count
bull Ability to move metric numbers
9696
What About the Non- Medicaid Poor We Serve
bull Numbers are king in a managed care contract and the more access you have
the better contract terms you can negotiate
bull We will potentially have a steady supply of Medicaid patients
bull As managed care spreads states this may be compromising the ability of
health centers to serve the non-Medicaid poor and others lacking dental
insurance
97
Mark Koday DDS
(509) 949-2278
Dental Quality Consultants
of WA
httpdentalqualityconsultin
gcom
dentalqualityconsultantsg
mailcom
Contact Information
LUNCH
BREAKOUT EXERCISEORAL HEALTH VALUE-BASED CARE READINESS ASSESSMENT
Danielle Apostolon
PROMISING PRACTICES FROM THE FIELD STRATEGIES FOR INCREASING VALUE IN ORAL HEALTH
Dr Carolyn Brown
Dr Kelly Perry
Dr Rachel Rivard
Dr Adeloye
Commitment Compassion Community
m i d s t a t e h e a l t h o r g
Promising Practices from the
Field Strategies for Increasing
Value in Oral Health Care
Kelly Perry DMD
Better Health
Outcomes
Improved Staff
Experience
Reduced Cost
Improved Patient
Experience
Better Health
Outcomes
Improved Staff
Experience
Reduced Cost
Improved Patient
Experience
Better Health
Outcomes
Improved Staff
Experience
Reduced Cost
Improved Patient
Experience
Better Health
Outcomes
Improved Staff
Experience
Reduced Cost
Improved Patient
Experience
Commitment Compassion Community
kpe r r ymids t a tehea l t h o rg
Thank you
Completion of Disease Control Phase
Pelumi Adeloye DMD MPH
HEALTH ACCESS NETWORK (HAN) FAMILY DENTAL
Introduction
⧫1 Dentist I Hygienist 3 EFDArsquos1 Receptionist
⧫ 6 Chairs= 4 (dentist) + 2 (hygienist)
⧫ Slide ⥶80 off
⧫ Service areas Northern Penobscot Southern Aroostook Western
Washington Counties amp more
Completion of Phase I Treatment
⧫LimitedLack of Access to dental care
⧫Difficulty completing the disease control phase
Caries amp periodontal disease
⧫Attaining stable restorative state
Goal
Increase the completion of Disease Control Phase
Current practice
⧫Education
Assess level of dental literacy
Incremental strategy
⧫Increase access to dental care
Generous sliding scale (⥸$40 per visit)
Incorporate Expanded Function Dental Assistants
⧫Schedule modification
Incorporate more restorative blocks to allow
for follow-up visit and completion of restorative phase
httpswwwglasbergencomdentist-cartoons
Schedule
⧫Piggybacking technique
Increased allotted restorative blocks
⧫Sustainability of current schedule is
contingent on cooperation amp skills of HAN
Dental staff
Note
Strategies mentioned today is personalized to HAN Dental clinic
Current implemented strategies might be modified or changed in the
future as required in order to accommodate the need of our pts
THANK YOU
DAY TWOCLOSINGWRAP-UP
End of Day Two ndash Survey
Day Two Creating a Value-Based Oral Health Care Delivery
System
129
Payment Reform in Oral Health Online Learning Module
Oral Health Value-based Care Online Learning Module
Value-based Care Keys to Success Article
Readiness Assessment
Competency Development Guide
Oral Health Value-based Care Training
Dental Caries Management Practicum
Clinicians Companion Guide
Interprofessional Network Referral Process
Traditional Dental Care Vs Value-Based Care
Resources
131
wwwDentaQuestPartnershiporg
wwwfacebookcomDentaQuest
DentaQuest
wwwlinkedincomcompanyDentaQuest
Inside_DentaQuest
QUESTIONS
8787
Solutions for Controlling Pediatric Costs
Hire a general dentist that is skilled in treating young children
Make the clinic child friendly nitrous oxide TVs in the operatory etc
Teach entire staff behavioral control techniques
Contract with a pediatric dentist for the GA care
88
Lowering Overall Disease Rates (and Costs)
You are responsible for both the patients you see in the chair and the ones
assigned to you
Breaking down the walls of the dental clinic
Community Dental Health Coordinators
Case Management
89
Cost Control Essentials
Diagnosis codes
Increased ability to identify
disease by risk
Motivational
Interviewing
Developing Polices and
Procedures design to treat
disease according to risk
ie Silver Diamine Fluoride
Treating by Risk
Effective Recare
Process
Critical to continual disease
controlPrevention education that is
meaningful and designed to
change behaviors
90
Social Determinants of Health Aunt Bertha
httpswwwauntberthacom
91
REASON TO CONSIDER RISK- BASED CONTRACTING
9292
PPS Reconciliation and Federal Code 42 CFR sect4052469(a)(2)
42 CFR sect4052469(a)(2)
ldquoAny financial incentives provided to Federally Qualified Health Centers
under their Medicare Advantage Contracts such as risk pool payments
bonuses or withholds are prohibited from being included in the
calculation of supplemental payments due to the Federally Qualified
Health Centerrdquo
9393
Why Risk Based Contract in Times of PPS Reconciliation
bull Not all Risk- based Contract funds are reconciled
bull Risk is the key word- you can come out with less money than your normal
PPS reconciliation payment
bull Can lead to better patient care
bull May improve manage care enrollment for your medical plan
bull Promotes integrated care increases health for your CHC patients
9494
Not Included in the Reconciliation
Enrollment management pmpm
Quality Payments
Upside risk payments
Downside risk losses
9595
Determinants of Financial Success in Risk-Based Contracting
bull Most critical- State pmpm payment to the Managed Care Plan
bull Reporting capabilities
bull Specialty service capabilities
bull Access numbers count
bull Ability to move metric numbers
9696
What About the Non- Medicaid Poor We Serve
bull Numbers are king in a managed care contract and the more access you have
the better contract terms you can negotiate
bull We will potentially have a steady supply of Medicaid patients
bull As managed care spreads states this may be compromising the ability of
health centers to serve the non-Medicaid poor and others lacking dental
insurance
97
Mark Koday DDS
(509) 949-2278
Dental Quality Consultants
of WA
httpdentalqualityconsultin
gcom
dentalqualityconsultantsg
mailcom
Contact Information
LUNCH
BREAKOUT EXERCISEORAL HEALTH VALUE-BASED CARE READINESS ASSESSMENT
Danielle Apostolon
PROMISING PRACTICES FROM THE FIELD STRATEGIES FOR INCREASING VALUE IN ORAL HEALTH
Dr Carolyn Brown
Dr Kelly Perry
Dr Rachel Rivard
Dr Adeloye
Commitment Compassion Community
m i d s t a t e h e a l t h o r g
Promising Practices from the
Field Strategies for Increasing
Value in Oral Health Care
Kelly Perry DMD
Better Health
Outcomes
Improved Staff
Experience
Reduced Cost
Improved Patient
Experience
Better Health
Outcomes
Improved Staff
Experience
Reduced Cost
Improved Patient
Experience
Better Health
Outcomes
Improved Staff
Experience
Reduced Cost
Improved Patient
Experience
Better Health
Outcomes
Improved Staff
Experience
Reduced Cost
Improved Patient
Experience
Commitment Compassion Community
kpe r r ymids t a tehea l t h o rg
Thank you
Completion of Disease Control Phase
Pelumi Adeloye DMD MPH
HEALTH ACCESS NETWORK (HAN) FAMILY DENTAL
Introduction
⧫1 Dentist I Hygienist 3 EFDArsquos1 Receptionist
⧫ 6 Chairs= 4 (dentist) + 2 (hygienist)
⧫ Slide ⥶80 off
⧫ Service areas Northern Penobscot Southern Aroostook Western
Washington Counties amp more
Completion of Phase I Treatment
⧫LimitedLack of Access to dental care
⧫Difficulty completing the disease control phase
Caries amp periodontal disease
⧫Attaining stable restorative state
Goal
Increase the completion of Disease Control Phase
Current practice
⧫Education
Assess level of dental literacy
Incremental strategy
⧫Increase access to dental care
Generous sliding scale (⥸$40 per visit)
Incorporate Expanded Function Dental Assistants
⧫Schedule modification
Incorporate more restorative blocks to allow
for follow-up visit and completion of restorative phase
httpswwwglasbergencomdentist-cartoons
Schedule
⧫Piggybacking technique
Increased allotted restorative blocks
⧫Sustainability of current schedule is
contingent on cooperation amp skills of HAN
Dental staff
Note
Strategies mentioned today is personalized to HAN Dental clinic
Current implemented strategies might be modified or changed in the
future as required in order to accommodate the need of our pts
THANK YOU
DAY TWOCLOSINGWRAP-UP
End of Day Two ndash Survey
Day Two Creating a Value-Based Oral Health Care Delivery
System
129
Payment Reform in Oral Health Online Learning Module
Oral Health Value-based Care Online Learning Module
Value-based Care Keys to Success Article
Readiness Assessment
Competency Development Guide
Oral Health Value-based Care Training
Dental Caries Management Practicum
Clinicians Companion Guide
Interprofessional Network Referral Process
Traditional Dental Care Vs Value-Based Care
Resources
131
wwwDentaQuestPartnershiporg
wwwfacebookcomDentaQuest
DentaQuest
wwwlinkedincomcompanyDentaQuest
Inside_DentaQuest
QUESTIONS
88
Lowering Overall Disease Rates (and Costs)
You are responsible for both the patients you see in the chair and the ones
assigned to you
Breaking down the walls of the dental clinic
Community Dental Health Coordinators
Case Management
89
Cost Control Essentials
Diagnosis codes
Increased ability to identify
disease by risk
Motivational
Interviewing
Developing Polices and
Procedures design to treat
disease according to risk
ie Silver Diamine Fluoride
Treating by Risk
Effective Recare
Process
Critical to continual disease
controlPrevention education that is
meaningful and designed to
change behaviors
90
Social Determinants of Health Aunt Bertha
httpswwwauntberthacom
91
REASON TO CONSIDER RISK- BASED CONTRACTING
9292
PPS Reconciliation and Federal Code 42 CFR sect4052469(a)(2)
42 CFR sect4052469(a)(2)
ldquoAny financial incentives provided to Federally Qualified Health Centers
under their Medicare Advantage Contracts such as risk pool payments
bonuses or withholds are prohibited from being included in the
calculation of supplemental payments due to the Federally Qualified
Health Centerrdquo
9393
Why Risk Based Contract in Times of PPS Reconciliation
bull Not all Risk- based Contract funds are reconciled
bull Risk is the key word- you can come out with less money than your normal
PPS reconciliation payment
bull Can lead to better patient care
bull May improve manage care enrollment for your medical plan
bull Promotes integrated care increases health for your CHC patients
9494
Not Included in the Reconciliation
Enrollment management pmpm
Quality Payments
Upside risk payments
Downside risk losses
9595
Determinants of Financial Success in Risk-Based Contracting
bull Most critical- State pmpm payment to the Managed Care Plan
bull Reporting capabilities
bull Specialty service capabilities
bull Access numbers count
bull Ability to move metric numbers
9696
What About the Non- Medicaid Poor We Serve
bull Numbers are king in a managed care contract and the more access you have
the better contract terms you can negotiate
bull We will potentially have a steady supply of Medicaid patients
bull As managed care spreads states this may be compromising the ability of
health centers to serve the non-Medicaid poor and others lacking dental
insurance
97
Mark Koday DDS
(509) 949-2278
Dental Quality Consultants
of WA
httpdentalqualityconsultin
gcom
dentalqualityconsultantsg
mailcom
Contact Information
LUNCH
BREAKOUT EXERCISEORAL HEALTH VALUE-BASED CARE READINESS ASSESSMENT
Danielle Apostolon
PROMISING PRACTICES FROM THE FIELD STRATEGIES FOR INCREASING VALUE IN ORAL HEALTH
Dr Carolyn Brown
Dr Kelly Perry
Dr Rachel Rivard
Dr Adeloye
Commitment Compassion Community
m i d s t a t e h e a l t h o r g
Promising Practices from the
Field Strategies for Increasing
Value in Oral Health Care
Kelly Perry DMD
Better Health
Outcomes
Improved Staff
Experience
Reduced Cost
Improved Patient
Experience
Better Health
Outcomes
Improved Staff
Experience
Reduced Cost
Improved Patient
Experience
Better Health
Outcomes
Improved Staff
Experience
Reduced Cost
Improved Patient
Experience
Better Health
Outcomes
Improved Staff
Experience
Reduced Cost
Improved Patient
Experience
Commitment Compassion Community
kpe r r ymids t a tehea l t h o rg
Thank you
Completion of Disease Control Phase
Pelumi Adeloye DMD MPH
HEALTH ACCESS NETWORK (HAN) FAMILY DENTAL
Introduction
⧫1 Dentist I Hygienist 3 EFDArsquos1 Receptionist
⧫ 6 Chairs= 4 (dentist) + 2 (hygienist)
⧫ Slide ⥶80 off
⧫ Service areas Northern Penobscot Southern Aroostook Western
Washington Counties amp more
Completion of Phase I Treatment
⧫LimitedLack of Access to dental care
⧫Difficulty completing the disease control phase
Caries amp periodontal disease
⧫Attaining stable restorative state
Goal
Increase the completion of Disease Control Phase
Current practice
⧫Education
Assess level of dental literacy
Incremental strategy
⧫Increase access to dental care
Generous sliding scale (⥸$40 per visit)
Incorporate Expanded Function Dental Assistants
⧫Schedule modification
Incorporate more restorative blocks to allow
for follow-up visit and completion of restorative phase
httpswwwglasbergencomdentist-cartoons
Schedule
⧫Piggybacking technique
Increased allotted restorative blocks
⧫Sustainability of current schedule is
contingent on cooperation amp skills of HAN
Dental staff
Note
Strategies mentioned today is personalized to HAN Dental clinic
Current implemented strategies might be modified or changed in the
future as required in order to accommodate the need of our pts
THANK YOU
DAY TWOCLOSINGWRAP-UP
End of Day Two ndash Survey
Day Two Creating a Value-Based Oral Health Care Delivery
System
129
Payment Reform in Oral Health Online Learning Module
Oral Health Value-based Care Online Learning Module
Value-based Care Keys to Success Article
Readiness Assessment
Competency Development Guide
Oral Health Value-based Care Training
Dental Caries Management Practicum
Clinicians Companion Guide
Interprofessional Network Referral Process
Traditional Dental Care Vs Value-Based Care
Resources
131
wwwDentaQuestPartnershiporg
wwwfacebookcomDentaQuest
DentaQuest
wwwlinkedincomcompanyDentaQuest
Inside_DentaQuest
QUESTIONS
89
Cost Control Essentials
Diagnosis codes
Increased ability to identify
disease by risk
Motivational
Interviewing
Developing Polices and
Procedures design to treat
disease according to risk
ie Silver Diamine Fluoride
Treating by Risk
Effective Recare
Process
Critical to continual disease
controlPrevention education that is
meaningful and designed to
change behaviors
90
Social Determinants of Health Aunt Bertha
httpswwwauntberthacom
91
REASON TO CONSIDER RISK- BASED CONTRACTING
9292
PPS Reconciliation and Federal Code 42 CFR sect4052469(a)(2)
42 CFR sect4052469(a)(2)
ldquoAny financial incentives provided to Federally Qualified Health Centers
under their Medicare Advantage Contracts such as risk pool payments
bonuses or withholds are prohibited from being included in the
calculation of supplemental payments due to the Federally Qualified
Health Centerrdquo
9393
Why Risk Based Contract in Times of PPS Reconciliation
bull Not all Risk- based Contract funds are reconciled
bull Risk is the key word- you can come out with less money than your normal
PPS reconciliation payment
bull Can lead to better patient care
bull May improve manage care enrollment for your medical plan
bull Promotes integrated care increases health for your CHC patients
9494
Not Included in the Reconciliation
Enrollment management pmpm
Quality Payments
Upside risk payments
Downside risk losses
9595
Determinants of Financial Success in Risk-Based Contracting
bull Most critical- State pmpm payment to the Managed Care Plan
bull Reporting capabilities
bull Specialty service capabilities
bull Access numbers count
bull Ability to move metric numbers
9696
What About the Non- Medicaid Poor We Serve
bull Numbers are king in a managed care contract and the more access you have
the better contract terms you can negotiate
bull We will potentially have a steady supply of Medicaid patients
bull As managed care spreads states this may be compromising the ability of
health centers to serve the non-Medicaid poor and others lacking dental
insurance
97
Mark Koday DDS
(509) 949-2278
Dental Quality Consultants
of WA
httpdentalqualityconsultin
gcom
dentalqualityconsultantsg
mailcom
Contact Information
LUNCH
BREAKOUT EXERCISEORAL HEALTH VALUE-BASED CARE READINESS ASSESSMENT
Danielle Apostolon
PROMISING PRACTICES FROM THE FIELD STRATEGIES FOR INCREASING VALUE IN ORAL HEALTH
Dr Carolyn Brown
Dr Kelly Perry
Dr Rachel Rivard
Dr Adeloye
Commitment Compassion Community
m i d s t a t e h e a l t h o r g
Promising Practices from the
Field Strategies for Increasing
Value in Oral Health Care
Kelly Perry DMD
Better Health
Outcomes
Improved Staff
Experience
Reduced Cost
Improved Patient
Experience
Better Health
Outcomes
Improved Staff
Experience
Reduced Cost
Improved Patient
Experience
Better Health
Outcomes
Improved Staff
Experience
Reduced Cost
Improved Patient
Experience
Better Health
Outcomes
Improved Staff
Experience
Reduced Cost
Improved Patient
Experience
Commitment Compassion Community
kpe r r ymids t a tehea l t h o rg
Thank you
Completion of Disease Control Phase
Pelumi Adeloye DMD MPH
HEALTH ACCESS NETWORK (HAN) FAMILY DENTAL
Introduction
⧫1 Dentist I Hygienist 3 EFDArsquos1 Receptionist
⧫ 6 Chairs= 4 (dentist) + 2 (hygienist)
⧫ Slide ⥶80 off
⧫ Service areas Northern Penobscot Southern Aroostook Western
Washington Counties amp more
Completion of Phase I Treatment
⧫LimitedLack of Access to dental care
⧫Difficulty completing the disease control phase
Caries amp periodontal disease
⧫Attaining stable restorative state
Goal
Increase the completion of Disease Control Phase
Current practice
⧫Education
Assess level of dental literacy
Incremental strategy
⧫Increase access to dental care
Generous sliding scale (⥸$40 per visit)
Incorporate Expanded Function Dental Assistants
⧫Schedule modification
Incorporate more restorative blocks to allow
for follow-up visit and completion of restorative phase
httpswwwglasbergencomdentist-cartoons
Schedule
⧫Piggybacking technique
Increased allotted restorative blocks
⧫Sustainability of current schedule is
contingent on cooperation amp skills of HAN
Dental staff
Note
Strategies mentioned today is personalized to HAN Dental clinic
Current implemented strategies might be modified or changed in the
future as required in order to accommodate the need of our pts
THANK YOU
DAY TWOCLOSINGWRAP-UP
End of Day Two ndash Survey
Day Two Creating a Value-Based Oral Health Care Delivery
System
129
Payment Reform in Oral Health Online Learning Module
Oral Health Value-based Care Online Learning Module
Value-based Care Keys to Success Article
Readiness Assessment
Competency Development Guide
Oral Health Value-based Care Training
Dental Caries Management Practicum
Clinicians Companion Guide
Interprofessional Network Referral Process
Traditional Dental Care Vs Value-Based Care
Resources
131
wwwDentaQuestPartnershiporg
wwwfacebookcomDentaQuest
DentaQuest
wwwlinkedincomcompanyDentaQuest
Inside_DentaQuest
QUESTIONS
90
Social Determinants of Health Aunt Bertha
httpswwwauntberthacom
91
REASON TO CONSIDER RISK- BASED CONTRACTING
9292
PPS Reconciliation and Federal Code 42 CFR sect4052469(a)(2)
42 CFR sect4052469(a)(2)
ldquoAny financial incentives provided to Federally Qualified Health Centers
under their Medicare Advantage Contracts such as risk pool payments
bonuses or withholds are prohibited from being included in the
calculation of supplemental payments due to the Federally Qualified
Health Centerrdquo
9393
Why Risk Based Contract in Times of PPS Reconciliation
bull Not all Risk- based Contract funds are reconciled
bull Risk is the key word- you can come out with less money than your normal
PPS reconciliation payment
bull Can lead to better patient care
bull May improve manage care enrollment for your medical plan
bull Promotes integrated care increases health for your CHC patients
9494
Not Included in the Reconciliation
Enrollment management pmpm
Quality Payments
Upside risk payments
Downside risk losses
9595
Determinants of Financial Success in Risk-Based Contracting
bull Most critical- State pmpm payment to the Managed Care Plan
bull Reporting capabilities
bull Specialty service capabilities
bull Access numbers count
bull Ability to move metric numbers
9696
What About the Non- Medicaid Poor We Serve
bull Numbers are king in a managed care contract and the more access you have
the better contract terms you can negotiate
bull We will potentially have a steady supply of Medicaid patients
bull As managed care spreads states this may be compromising the ability of
health centers to serve the non-Medicaid poor and others lacking dental
insurance
97
Mark Koday DDS
(509) 949-2278
Dental Quality Consultants
of WA
httpdentalqualityconsultin
gcom
dentalqualityconsultantsg
mailcom
Contact Information
LUNCH
BREAKOUT EXERCISEORAL HEALTH VALUE-BASED CARE READINESS ASSESSMENT
Danielle Apostolon
PROMISING PRACTICES FROM THE FIELD STRATEGIES FOR INCREASING VALUE IN ORAL HEALTH
Dr Carolyn Brown
Dr Kelly Perry
Dr Rachel Rivard
Dr Adeloye
Commitment Compassion Community
m i d s t a t e h e a l t h o r g
Promising Practices from the
Field Strategies for Increasing
Value in Oral Health Care
Kelly Perry DMD
Better Health
Outcomes
Improved Staff
Experience
Reduced Cost
Improved Patient
Experience
Better Health
Outcomes
Improved Staff
Experience
Reduced Cost
Improved Patient
Experience
Better Health
Outcomes
Improved Staff
Experience
Reduced Cost
Improved Patient
Experience
Better Health
Outcomes
Improved Staff
Experience
Reduced Cost
Improved Patient
Experience
Commitment Compassion Community
kpe r r ymids t a tehea l t h o rg
Thank you
Completion of Disease Control Phase
Pelumi Adeloye DMD MPH
HEALTH ACCESS NETWORK (HAN) FAMILY DENTAL
Introduction
⧫1 Dentist I Hygienist 3 EFDArsquos1 Receptionist
⧫ 6 Chairs= 4 (dentist) + 2 (hygienist)
⧫ Slide ⥶80 off
⧫ Service areas Northern Penobscot Southern Aroostook Western
Washington Counties amp more
Completion of Phase I Treatment
⧫LimitedLack of Access to dental care
⧫Difficulty completing the disease control phase
Caries amp periodontal disease
⧫Attaining stable restorative state
Goal
Increase the completion of Disease Control Phase
Current practice
⧫Education
Assess level of dental literacy
Incremental strategy
⧫Increase access to dental care
Generous sliding scale (⥸$40 per visit)
Incorporate Expanded Function Dental Assistants
⧫Schedule modification
Incorporate more restorative blocks to allow
for follow-up visit and completion of restorative phase
httpswwwglasbergencomdentist-cartoons
Schedule
⧫Piggybacking technique
Increased allotted restorative blocks
⧫Sustainability of current schedule is
contingent on cooperation amp skills of HAN
Dental staff
Note
Strategies mentioned today is personalized to HAN Dental clinic
Current implemented strategies might be modified or changed in the
future as required in order to accommodate the need of our pts
THANK YOU
DAY TWOCLOSINGWRAP-UP
End of Day Two ndash Survey
Day Two Creating a Value-Based Oral Health Care Delivery
System
129
Payment Reform in Oral Health Online Learning Module
Oral Health Value-based Care Online Learning Module
Value-based Care Keys to Success Article
Readiness Assessment
Competency Development Guide
Oral Health Value-based Care Training
Dental Caries Management Practicum
Clinicians Companion Guide
Interprofessional Network Referral Process
Traditional Dental Care Vs Value-Based Care
Resources
131
wwwDentaQuestPartnershiporg
wwwfacebookcomDentaQuest
DentaQuest
wwwlinkedincomcompanyDentaQuest
Inside_DentaQuest
QUESTIONS
91
REASON TO CONSIDER RISK- BASED CONTRACTING
9292
PPS Reconciliation and Federal Code 42 CFR sect4052469(a)(2)
42 CFR sect4052469(a)(2)
ldquoAny financial incentives provided to Federally Qualified Health Centers
under their Medicare Advantage Contracts such as risk pool payments
bonuses or withholds are prohibited from being included in the
calculation of supplemental payments due to the Federally Qualified
Health Centerrdquo
9393
Why Risk Based Contract in Times of PPS Reconciliation
bull Not all Risk- based Contract funds are reconciled
bull Risk is the key word- you can come out with less money than your normal
PPS reconciliation payment
bull Can lead to better patient care
bull May improve manage care enrollment for your medical plan
bull Promotes integrated care increases health for your CHC patients
9494
Not Included in the Reconciliation
Enrollment management pmpm
Quality Payments
Upside risk payments
Downside risk losses
9595
Determinants of Financial Success in Risk-Based Contracting
bull Most critical- State pmpm payment to the Managed Care Plan
bull Reporting capabilities
bull Specialty service capabilities
bull Access numbers count
bull Ability to move metric numbers
9696
What About the Non- Medicaid Poor We Serve
bull Numbers are king in a managed care contract and the more access you have
the better contract terms you can negotiate
bull We will potentially have a steady supply of Medicaid patients
bull As managed care spreads states this may be compromising the ability of
health centers to serve the non-Medicaid poor and others lacking dental
insurance
97
Mark Koday DDS
(509) 949-2278
Dental Quality Consultants
of WA
httpdentalqualityconsultin
gcom
dentalqualityconsultantsg
mailcom
Contact Information
LUNCH
BREAKOUT EXERCISEORAL HEALTH VALUE-BASED CARE READINESS ASSESSMENT
Danielle Apostolon
PROMISING PRACTICES FROM THE FIELD STRATEGIES FOR INCREASING VALUE IN ORAL HEALTH
Dr Carolyn Brown
Dr Kelly Perry
Dr Rachel Rivard
Dr Adeloye
Commitment Compassion Community
m i d s t a t e h e a l t h o r g
Promising Practices from the
Field Strategies for Increasing
Value in Oral Health Care
Kelly Perry DMD
Better Health
Outcomes
Improved Staff
Experience
Reduced Cost
Improved Patient
Experience
Better Health
Outcomes
Improved Staff
Experience
Reduced Cost
Improved Patient
Experience
Better Health
Outcomes
Improved Staff
Experience
Reduced Cost
Improved Patient
Experience
Better Health
Outcomes
Improved Staff
Experience
Reduced Cost
Improved Patient
Experience
Commitment Compassion Community
kpe r r ymids t a tehea l t h o rg
Thank you
Completion of Disease Control Phase
Pelumi Adeloye DMD MPH
HEALTH ACCESS NETWORK (HAN) FAMILY DENTAL
Introduction
⧫1 Dentist I Hygienist 3 EFDArsquos1 Receptionist
⧫ 6 Chairs= 4 (dentist) + 2 (hygienist)
⧫ Slide ⥶80 off
⧫ Service areas Northern Penobscot Southern Aroostook Western
Washington Counties amp more
Completion of Phase I Treatment
⧫LimitedLack of Access to dental care
⧫Difficulty completing the disease control phase
Caries amp periodontal disease
⧫Attaining stable restorative state
Goal
Increase the completion of Disease Control Phase
Current practice
⧫Education
Assess level of dental literacy
Incremental strategy
⧫Increase access to dental care
Generous sliding scale (⥸$40 per visit)
Incorporate Expanded Function Dental Assistants
⧫Schedule modification
Incorporate more restorative blocks to allow
for follow-up visit and completion of restorative phase
httpswwwglasbergencomdentist-cartoons
Schedule
⧫Piggybacking technique
Increased allotted restorative blocks
⧫Sustainability of current schedule is
contingent on cooperation amp skills of HAN
Dental staff
Note
Strategies mentioned today is personalized to HAN Dental clinic
Current implemented strategies might be modified or changed in the
future as required in order to accommodate the need of our pts
THANK YOU
DAY TWOCLOSINGWRAP-UP
End of Day Two ndash Survey
Day Two Creating a Value-Based Oral Health Care Delivery
System
129
Payment Reform in Oral Health Online Learning Module
Oral Health Value-based Care Online Learning Module
Value-based Care Keys to Success Article
Readiness Assessment
Competency Development Guide
Oral Health Value-based Care Training
Dental Caries Management Practicum
Clinicians Companion Guide
Interprofessional Network Referral Process
Traditional Dental Care Vs Value-Based Care
Resources
131
wwwDentaQuestPartnershiporg
wwwfacebookcomDentaQuest
DentaQuest
wwwlinkedincomcompanyDentaQuest
Inside_DentaQuest
QUESTIONS
9292
PPS Reconciliation and Federal Code 42 CFR sect4052469(a)(2)
42 CFR sect4052469(a)(2)
ldquoAny financial incentives provided to Federally Qualified Health Centers
under their Medicare Advantage Contracts such as risk pool payments
bonuses or withholds are prohibited from being included in the
calculation of supplemental payments due to the Federally Qualified
Health Centerrdquo
9393
Why Risk Based Contract in Times of PPS Reconciliation
bull Not all Risk- based Contract funds are reconciled
bull Risk is the key word- you can come out with less money than your normal
PPS reconciliation payment
bull Can lead to better patient care
bull May improve manage care enrollment for your medical plan
bull Promotes integrated care increases health for your CHC patients
9494
Not Included in the Reconciliation
Enrollment management pmpm
Quality Payments
Upside risk payments
Downside risk losses
9595
Determinants of Financial Success in Risk-Based Contracting
bull Most critical- State pmpm payment to the Managed Care Plan
bull Reporting capabilities
bull Specialty service capabilities
bull Access numbers count
bull Ability to move metric numbers
9696
What About the Non- Medicaid Poor We Serve
bull Numbers are king in a managed care contract and the more access you have
the better contract terms you can negotiate
bull We will potentially have a steady supply of Medicaid patients
bull As managed care spreads states this may be compromising the ability of
health centers to serve the non-Medicaid poor and others lacking dental
insurance
97
Mark Koday DDS
(509) 949-2278
Dental Quality Consultants
of WA
httpdentalqualityconsultin
gcom
dentalqualityconsultantsg
mailcom
Contact Information
LUNCH
BREAKOUT EXERCISEORAL HEALTH VALUE-BASED CARE READINESS ASSESSMENT
Danielle Apostolon
PROMISING PRACTICES FROM THE FIELD STRATEGIES FOR INCREASING VALUE IN ORAL HEALTH
Dr Carolyn Brown
Dr Kelly Perry
Dr Rachel Rivard
Dr Adeloye
Commitment Compassion Community
m i d s t a t e h e a l t h o r g
Promising Practices from the
Field Strategies for Increasing
Value in Oral Health Care
Kelly Perry DMD
Better Health
Outcomes
Improved Staff
Experience
Reduced Cost
Improved Patient
Experience
Better Health
Outcomes
Improved Staff
Experience
Reduced Cost
Improved Patient
Experience
Better Health
Outcomes
Improved Staff
Experience
Reduced Cost
Improved Patient
Experience
Better Health
Outcomes
Improved Staff
Experience
Reduced Cost
Improved Patient
Experience
Commitment Compassion Community
kpe r r ymids t a tehea l t h o rg
Thank you
Completion of Disease Control Phase
Pelumi Adeloye DMD MPH
HEALTH ACCESS NETWORK (HAN) FAMILY DENTAL
Introduction
⧫1 Dentist I Hygienist 3 EFDArsquos1 Receptionist
⧫ 6 Chairs= 4 (dentist) + 2 (hygienist)
⧫ Slide ⥶80 off
⧫ Service areas Northern Penobscot Southern Aroostook Western
Washington Counties amp more
Completion of Phase I Treatment
⧫LimitedLack of Access to dental care
⧫Difficulty completing the disease control phase
Caries amp periodontal disease
⧫Attaining stable restorative state
Goal
Increase the completion of Disease Control Phase
Current practice
⧫Education
Assess level of dental literacy
Incremental strategy
⧫Increase access to dental care
Generous sliding scale (⥸$40 per visit)
Incorporate Expanded Function Dental Assistants
⧫Schedule modification
Incorporate more restorative blocks to allow
for follow-up visit and completion of restorative phase
httpswwwglasbergencomdentist-cartoons
Schedule
⧫Piggybacking technique
Increased allotted restorative blocks
⧫Sustainability of current schedule is
contingent on cooperation amp skills of HAN
Dental staff
Note
Strategies mentioned today is personalized to HAN Dental clinic
Current implemented strategies might be modified or changed in the
future as required in order to accommodate the need of our pts
THANK YOU
DAY TWOCLOSINGWRAP-UP
End of Day Two ndash Survey
Day Two Creating a Value-Based Oral Health Care Delivery
System
129
Payment Reform in Oral Health Online Learning Module
Oral Health Value-based Care Online Learning Module
Value-based Care Keys to Success Article
Readiness Assessment
Competency Development Guide
Oral Health Value-based Care Training
Dental Caries Management Practicum
Clinicians Companion Guide
Interprofessional Network Referral Process
Traditional Dental Care Vs Value-Based Care
Resources
131
wwwDentaQuestPartnershiporg
wwwfacebookcomDentaQuest
DentaQuest
wwwlinkedincomcompanyDentaQuest
Inside_DentaQuest
QUESTIONS
9393
Why Risk Based Contract in Times of PPS Reconciliation
bull Not all Risk- based Contract funds are reconciled
bull Risk is the key word- you can come out with less money than your normal
PPS reconciliation payment
bull Can lead to better patient care
bull May improve manage care enrollment for your medical plan
bull Promotes integrated care increases health for your CHC patients
9494
Not Included in the Reconciliation
Enrollment management pmpm
Quality Payments
Upside risk payments
Downside risk losses
9595
Determinants of Financial Success in Risk-Based Contracting
bull Most critical- State pmpm payment to the Managed Care Plan
bull Reporting capabilities
bull Specialty service capabilities
bull Access numbers count
bull Ability to move metric numbers
9696
What About the Non- Medicaid Poor We Serve
bull Numbers are king in a managed care contract and the more access you have
the better contract terms you can negotiate
bull We will potentially have a steady supply of Medicaid patients
bull As managed care spreads states this may be compromising the ability of
health centers to serve the non-Medicaid poor and others lacking dental
insurance
97
Mark Koday DDS
(509) 949-2278
Dental Quality Consultants
of WA
httpdentalqualityconsultin
gcom
dentalqualityconsultantsg
mailcom
Contact Information
LUNCH
BREAKOUT EXERCISEORAL HEALTH VALUE-BASED CARE READINESS ASSESSMENT
Danielle Apostolon
PROMISING PRACTICES FROM THE FIELD STRATEGIES FOR INCREASING VALUE IN ORAL HEALTH
Dr Carolyn Brown
Dr Kelly Perry
Dr Rachel Rivard
Dr Adeloye
Commitment Compassion Community
m i d s t a t e h e a l t h o r g
Promising Practices from the
Field Strategies for Increasing
Value in Oral Health Care
Kelly Perry DMD
Better Health
Outcomes
Improved Staff
Experience
Reduced Cost
Improved Patient
Experience
Better Health
Outcomes
Improved Staff
Experience
Reduced Cost
Improved Patient
Experience
Better Health
Outcomes
Improved Staff
Experience
Reduced Cost
Improved Patient
Experience
Better Health
Outcomes
Improved Staff
Experience
Reduced Cost
Improved Patient
Experience
Commitment Compassion Community
kpe r r ymids t a tehea l t h o rg
Thank you
Completion of Disease Control Phase
Pelumi Adeloye DMD MPH
HEALTH ACCESS NETWORK (HAN) FAMILY DENTAL
Introduction
⧫1 Dentist I Hygienist 3 EFDArsquos1 Receptionist
⧫ 6 Chairs= 4 (dentist) + 2 (hygienist)
⧫ Slide ⥶80 off
⧫ Service areas Northern Penobscot Southern Aroostook Western
Washington Counties amp more
Completion of Phase I Treatment
⧫LimitedLack of Access to dental care
⧫Difficulty completing the disease control phase
Caries amp periodontal disease
⧫Attaining stable restorative state
Goal
Increase the completion of Disease Control Phase
Current practice
⧫Education
Assess level of dental literacy
Incremental strategy
⧫Increase access to dental care
Generous sliding scale (⥸$40 per visit)
Incorporate Expanded Function Dental Assistants
⧫Schedule modification
Incorporate more restorative blocks to allow
for follow-up visit and completion of restorative phase
httpswwwglasbergencomdentist-cartoons
Schedule
⧫Piggybacking technique
Increased allotted restorative blocks
⧫Sustainability of current schedule is
contingent on cooperation amp skills of HAN
Dental staff
Note
Strategies mentioned today is personalized to HAN Dental clinic
Current implemented strategies might be modified or changed in the
future as required in order to accommodate the need of our pts
THANK YOU
DAY TWOCLOSINGWRAP-UP
End of Day Two ndash Survey
Day Two Creating a Value-Based Oral Health Care Delivery
System
129
Payment Reform in Oral Health Online Learning Module
Oral Health Value-based Care Online Learning Module
Value-based Care Keys to Success Article
Readiness Assessment
Competency Development Guide
Oral Health Value-based Care Training
Dental Caries Management Practicum
Clinicians Companion Guide
Interprofessional Network Referral Process
Traditional Dental Care Vs Value-Based Care
Resources
131
wwwDentaQuestPartnershiporg
wwwfacebookcomDentaQuest
DentaQuest
wwwlinkedincomcompanyDentaQuest
Inside_DentaQuest
QUESTIONS
9494
Not Included in the Reconciliation
Enrollment management pmpm
Quality Payments
Upside risk payments
Downside risk losses
9595
Determinants of Financial Success in Risk-Based Contracting
bull Most critical- State pmpm payment to the Managed Care Plan
bull Reporting capabilities
bull Specialty service capabilities
bull Access numbers count
bull Ability to move metric numbers
9696
What About the Non- Medicaid Poor We Serve
bull Numbers are king in a managed care contract and the more access you have
the better contract terms you can negotiate
bull We will potentially have a steady supply of Medicaid patients
bull As managed care spreads states this may be compromising the ability of
health centers to serve the non-Medicaid poor and others lacking dental
insurance
97
Mark Koday DDS
(509) 949-2278
Dental Quality Consultants
of WA
httpdentalqualityconsultin
gcom
dentalqualityconsultantsg
mailcom
Contact Information
LUNCH
BREAKOUT EXERCISEORAL HEALTH VALUE-BASED CARE READINESS ASSESSMENT
Danielle Apostolon
PROMISING PRACTICES FROM THE FIELD STRATEGIES FOR INCREASING VALUE IN ORAL HEALTH
Dr Carolyn Brown
Dr Kelly Perry
Dr Rachel Rivard
Dr Adeloye
Commitment Compassion Community
m i d s t a t e h e a l t h o r g
Promising Practices from the
Field Strategies for Increasing
Value in Oral Health Care
Kelly Perry DMD
Better Health
Outcomes
Improved Staff
Experience
Reduced Cost
Improved Patient
Experience
Better Health
Outcomes
Improved Staff
Experience
Reduced Cost
Improved Patient
Experience
Better Health
Outcomes
Improved Staff
Experience
Reduced Cost
Improved Patient
Experience
Better Health
Outcomes
Improved Staff
Experience
Reduced Cost
Improved Patient
Experience
Commitment Compassion Community
kpe r r ymids t a tehea l t h o rg
Thank you
Completion of Disease Control Phase
Pelumi Adeloye DMD MPH
HEALTH ACCESS NETWORK (HAN) FAMILY DENTAL
Introduction
⧫1 Dentist I Hygienist 3 EFDArsquos1 Receptionist
⧫ 6 Chairs= 4 (dentist) + 2 (hygienist)
⧫ Slide ⥶80 off
⧫ Service areas Northern Penobscot Southern Aroostook Western
Washington Counties amp more
Completion of Phase I Treatment
⧫LimitedLack of Access to dental care
⧫Difficulty completing the disease control phase
Caries amp periodontal disease
⧫Attaining stable restorative state
Goal
Increase the completion of Disease Control Phase
Current practice
⧫Education
Assess level of dental literacy
Incremental strategy
⧫Increase access to dental care
Generous sliding scale (⥸$40 per visit)
Incorporate Expanded Function Dental Assistants
⧫Schedule modification
Incorporate more restorative blocks to allow
for follow-up visit and completion of restorative phase
httpswwwglasbergencomdentist-cartoons
Schedule
⧫Piggybacking technique
Increased allotted restorative blocks
⧫Sustainability of current schedule is
contingent on cooperation amp skills of HAN
Dental staff
Note
Strategies mentioned today is personalized to HAN Dental clinic
Current implemented strategies might be modified or changed in the
future as required in order to accommodate the need of our pts
THANK YOU
DAY TWOCLOSINGWRAP-UP
End of Day Two ndash Survey
Day Two Creating a Value-Based Oral Health Care Delivery
System
129
Payment Reform in Oral Health Online Learning Module
Oral Health Value-based Care Online Learning Module
Value-based Care Keys to Success Article
Readiness Assessment
Competency Development Guide
Oral Health Value-based Care Training
Dental Caries Management Practicum
Clinicians Companion Guide
Interprofessional Network Referral Process
Traditional Dental Care Vs Value-Based Care
Resources
131
wwwDentaQuestPartnershiporg
wwwfacebookcomDentaQuest
DentaQuest
wwwlinkedincomcompanyDentaQuest
Inside_DentaQuest
QUESTIONS
9595
Determinants of Financial Success in Risk-Based Contracting
bull Most critical- State pmpm payment to the Managed Care Plan
bull Reporting capabilities
bull Specialty service capabilities
bull Access numbers count
bull Ability to move metric numbers
9696
What About the Non- Medicaid Poor We Serve
bull Numbers are king in a managed care contract and the more access you have
the better contract terms you can negotiate
bull We will potentially have a steady supply of Medicaid patients
bull As managed care spreads states this may be compromising the ability of
health centers to serve the non-Medicaid poor and others lacking dental
insurance
97
Mark Koday DDS
(509) 949-2278
Dental Quality Consultants
of WA
httpdentalqualityconsultin
gcom
dentalqualityconsultantsg
mailcom
Contact Information
LUNCH
BREAKOUT EXERCISEORAL HEALTH VALUE-BASED CARE READINESS ASSESSMENT
Danielle Apostolon
PROMISING PRACTICES FROM THE FIELD STRATEGIES FOR INCREASING VALUE IN ORAL HEALTH
Dr Carolyn Brown
Dr Kelly Perry
Dr Rachel Rivard
Dr Adeloye
Commitment Compassion Community
m i d s t a t e h e a l t h o r g
Promising Practices from the
Field Strategies for Increasing
Value in Oral Health Care
Kelly Perry DMD
Better Health
Outcomes
Improved Staff
Experience
Reduced Cost
Improved Patient
Experience
Better Health
Outcomes
Improved Staff
Experience
Reduced Cost
Improved Patient
Experience
Better Health
Outcomes
Improved Staff
Experience
Reduced Cost
Improved Patient
Experience
Better Health
Outcomes
Improved Staff
Experience
Reduced Cost
Improved Patient
Experience
Commitment Compassion Community
kpe r r ymids t a tehea l t h o rg
Thank you
Completion of Disease Control Phase
Pelumi Adeloye DMD MPH
HEALTH ACCESS NETWORK (HAN) FAMILY DENTAL
Introduction
⧫1 Dentist I Hygienist 3 EFDArsquos1 Receptionist
⧫ 6 Chairs= 4 (dentist) + 2 (hygienist)
⧫ Slide ⥶80 off
⧫ Service areas Northern Penobscot Southern Aroostook Western
Washington Counties amp more
Completion of Phase I Treatment
⧫LimitedLack of Access to dental care
⧫Difficulty completing the disease control phase
Caries amp periodontal disease
⧫Attaining stable restorative state
Goal
Increase the completion of Disease Control Phase
Current practice
⧫Education
Assess level of dental literacy
Incremental strategy
⧫Increase access to dental care
Generous sliding scale (⥸$40 per visit)
Incorporate Expanded Function Dental Assistants
⧫Schedule modification
Incorporate more restorative blocks to allow
for follow-up visit and completion of restorative phase
httpswwwglasbergencomdentist-cartoons
Schedule
⧫Piggybacking technique
Increased allotted restorative blocks
⧫Sustainability of current schedule is
contingent on cooperation amp skills of HAN
Dental staff
Note
Strategies mentioned today is personalized to HAN Dental clinic
Current implemented strategies might be modified or changed in the
future as required in order to accommodate the need of our pts
THANK YOU
DAY TWOCLOSINGWRAP-UP
End of Day Two ndash Survey
Day Two Creating a Value-Based Oral Health Care Delivery
System
129
Payment Reform in Oral Health Online Learning Module
Oral Health Value-based Care Online Learning Module
Value-based Care Keys to Success Article
Readiness Assessment
Competency Development Guide
Oral Health Value-based Care Training
Dental Caries Management Practicum
Clinicians Companion Guide
Interprofessional Network Referral Process
Traditional Dental Care Vs Value-Based Care
Resources
131
wwwDentaQuestPartnershiporg
wwwfacebookcomDentaQuest
DentaQuest
wwwlinkedincomcompanyDentaQuest
Inside_DentaQuest
QUESTIONS
9696
What About the Non- Medicaid Poor We Serve
bull Numbers are king in a managed care contract and the more access you have
the better contract terms you can negotiate
bull We will potentially have a steady supply of Medicaid patients
bull As managed care spreads states this may be compromising the ability of
health centers to serve the non-Medicaid poor and others lacking dental
insurance
97
Mark Koday DDS
(509) 949-2278
Dental Quality Consultants
of WA
httpdentalqualityconsultin
gcom
dentalqualityconsultantsg
mailcom
Contact Information
LUNCH
BREAKOUT EXERCISEORAL HEALTH VALUE-BASED CARE READINESS ASSESSMENT
Danielle Apostolon
PROMISING PRACTICES FROM THE FIELD STRATEGIES FOR INCREASING VALUE IN ORAL HEALTH
Dr Carolyn Brown
Dr Kelly Perry
Dr Rachel Rivard
Dr Adeloye
Commitment Compassion Community
m i d s t a t e h e a l t h o r g
Promising Practices from the
Field Strategies for Increasing
Value in Oral Health Care
Kelly Perry DMD
Better Health
Outcomes
Improved Staff
Experience
Reduced Cost
Improved Patient
Experience
Better Health
Outcomes
Improved Staff
Experience
Reduced Cost
Improved Patient
Experience
Better Health
Outcomes
Improved Staff
Experience
Reduced Cost
Improved Patient
Experience
Better Health
Outcomes
Improved Staff
Experience
Reduced Cost
Improved Patient
Experience
Commitment Compassion Community
kpe r r ymids t a tehea l t h o rg
Thank you
Completion of Disease Control Phase
Pelumi Adeloye DMD MPH
HEALTH ACCESS NETWORK (HAN) FAMILY DENTAL
Introduction
⧫1 Dentist I Hygienist 3 EFDArsquos1 Receptionist
⧫ 6 Chairs= 4 (dentist) + 2 (hygienist)
⧫ Slide ⥶80 off
⧫ Service areas Northern Penobscot Southern Aroostook Western
Washington Counties amp more
Completion of Phase I Treatment
⧫LimitedLack of Access to dental care
⧫Difficulty completing the disease control phase
Caries amp periodontal disease
⧫Attaining stable restorative state
Goal
Increase the completion of Disease Control Phase
Current practice
⧫Education
Assess level of dental literacy
Incremental strategy
⧫Increase access to dental care
Generous sliding scale (⥸$40 per visit)
Incorporate Expanded Function Dental Assistants
⧫Schedule modification
Incorporate more restorative blocks to allow
for follow-up visit and completion of restorative phase
httpswwwglasbergencomdentist-cartoons
Schedule
⧫Piggybacking technique
Increased allotted restorative blocks
⧫Sustainability of current schedule is
contingent on cooperation amp skills of HAN
Dental staff
Note
Strategies mentioned today is personalized to HAN Dental clinic
Current implemented strategies might be modified or changed in the
future as required in order to accommodate the need of our pts
THANK YOU
DAY TWOCLOSINGWRAP-UP
End of Day Two ndash Survey
Day Two Creating a Value-Based Oral Health Care Delivery
System
129
Payment Reform in Oral Health Online Learning Module
Oral Health Value-based Care Online Learning Module
Value-based Care Keys to Success Article
Readiness Assessment
Competency Development Guide
Oral Health Value-based Care Training
Dental Caries Management Practicum
Clinicians Companion Guide
Interprofessional Network Referral Process
Traditional Dental Care Vs Value-Based Care
Resources
131
wwwDentaQuestPartnershiporg
wwwfacebookcomDentaQuest
DentaQuest
wwwlinkedincomcompanyDentaQuest
Inside_DentaQuest
QUESTIONS
97
Mark Koday DDS
(509) 949-2278
Dental Quality Consultants
of WA
httpdentalqualityconsultin
gcom
dentalqualityconsultantsg
mailcom
Contact Information
LUNCH
BREAKOUT EXERCISEORAL HEALTH VALUE-BASED CARE READINESS ASSESSMENT
Danielle Apostolon
PROMISING PRACTICES FROM THE FIELD STRATEGIES FOR INCREASING VALUE IN ORAL HEALTH
Dr Carolyn Brown
Dr Kelly Perry
Dr Rachel Rivard
Dr Adeloye
Commitment Compassion Community
m i d s t a t e h e a l t h o r g
Promising Practices from the
Field Strategies for Increasing
Value in Oral Health Care
Kelly Perry DMD
Better Health
Outcomes
Improved Staff
Experience
Reduced Cost
Improved Patient
Experience
Better Health
Outcomes
Improved Staff
Experience
Reduced Cost
Improved Patient
Experience
Better Health
Outcomes
Improved Staff
Experience
Reduced Cost
Improved Patient
Experience
Better Health
Outcomes
Improved Staff
Experience
Reduced Cost
Improved Patient
Experience
Commitment Compassion Community
kpe r r ymids t a tehea l t h o rg
Thank you
Completion of Disease Control Phase
Pelumi Adeloye DMD MPH
HEALTH ACCESS NETWORK (HAN) FAMILY DENTAL
Introduction
⧫1 Dentist I Hygienist 3 EFDArsquos1 Receptionist
⧫ 6 Chairs= 4 (dentist) + 2 (hygienist)
⧫ Slide ⥶80 off
⧫ Service areas Northern Penobscot Southern Aroostook Western
Washington Counties amp more
Completion of Phase I Treatment
⧫LimitedLack of Access to dental care
⧫Difficulty completing the disease control phase
Caries amp periodontal disease
⧫Attaining stable restorative state
Goal
Increase the completion of Disease Control Phase
Current practice
⧫Education
Assess level of dental literacy
Incremental strategy
⧫Increase access to dental care
Generous sliding scale (⥸$40 per visit)
Incorporate Expanded Function Dental Assistants
⧫Schedule modification
Incorporate more restorative blocks to allow
for follow-up visit and completion of restorative phase
httpswwwglasbergencomdentist-cartoons
Schedule
⧫Piggybacking technique
Increased allotted restorative blocks
⧫Sustainability of current schedule is
contingent on cooperation amp skills of HAN
Dental staff
Note
Strategies mentioned today is personalized to HAN Dental clinic
Current implemented strategies might be modified or changed in the
future as required in order to accommodate the need of our pts
THANK YOU
DAY TWOCLOSINGWRAP-UP
End of Day Two ndash Survey
Day Two Creating a Value-Based Oral Health Care Delivery
System
129
Payment Reform in Oral Health Online Learning Module
Oral Health Value-based Care Online Learning Module
Value-based Care Keys to Success Article
Readiness Assessment
Competency Development Guide
Oral Health Value-based Care Training
Dental Caries Management Practicum
Clinicians Companion Guide
Interprofessional Network Referral Process
Traditional Dental Care Vs Value-Based Care
Resources
131
wwwDentaQuestPartnershiporg
wwwfacebookcomDentaQuest
DentaQuest
wwwlinkedincomcompanyDentaQuest
Inside_DentaQuest
QUESTIONS
LUNCH
BREAKOUT EXERCISEORAL HEALTH VALUE-BASED CARE READINESS ASSESSMENT
Danielle Apostolon
PROMISING PRACTICES FROM THE FIELD STRATEGIES FOR INCREASING VALUE IN ORAL HEALTH
Dr Carolyn Brown
Dr Kelly Perry
Dr Rachel Rivard
Dr Adeloye
Commitment Compassion Community
m i d s t a t e h e a l t h o r g
Promising Practices from the
Field Strategies for Increasing
Value in Oral Health Care
Kelly Perry DMD
Better Health
Outcomes
Improved Staff
Experience
Reduced Cost
Improved Patient
Experience
Better Health
Outcomes
Improved Staff
Experience
Reduced Cost
Improved Patient
Experience
Better Health
Outcomes
Improved Staff
Experience
Reduced Cost
Improved Patient
Experience
Better Health
Outcomes
Improved Staff
Experience
Reduced Cost
Improved Patient
Experience
Commitment Compassion Community
kpe r r ymids t a tehea l t h o rg
Thank you
Completion of Disease Control Phase
Pelumi Adeloye DMD MPH
HEALTH ACCESS NETWORK (HAN) FAMILY DENTAL
Introduction
⧫1 Dentist I Hygienist 3 EFDArsquos1 Receptionist
⧫ 6 Chairs= 4 (dentist) + 2 (hygienist)
⧫ Slide ⥶80 off
⧫ Service areas Northern Penobscot Southern Aroostook Western
Washington Counties amp more
Completion of Phase I Treatment
⧫LimitedLack of Access to dental care
⧫Difficulty completing the disease control phase
Caries amp periodontal disease
⧫Attaining stable restorative state
Goal
Increase the completion of Disease Control Phase
Current practice
⧫Education
Assess level of dental literacy
Incremental strategy
⧫Increase access to dental care
Generous sliding scale (⥸$40 per visit)
Incorporate Expanded Function Dental Assistants
⧫Schedule modification
Incorporate more restorative blocks to allow
for follow-up visit and completion of restorative phase
httpswwwglasbergencomdentist-cartoons
Schedule
⧫Piggybacking technique
Increased allotted restorative blocks
⧫Sustainability of current schedule is
contingent on cooperation amp skills of HAN
Dental staff
Note
Strategies mentioned today is personalized to HAN Dental clinic
Current implemented strategies might be modified or changed in the
future as required in order to accommodate the need of our pts
THANK YOU
DAY TWOCLOSINGWRAP-UP
End of Day Two ndash Survey
Day Two Creating a Value-Based Oral Health Care Delivery
System
129
Payment Reform in Oral Health Online Learning Module
Oral Health Value-based Care Online Learning Module
Value-based Care Keys to Success Article
Readiness Assessment
Competency Development Guide
Oral Health Value-based Care Training
Dental Caries Management Practicum
Clinicians Companion Guide
Interprofessional Network Referral Process
Traditional Dental Care Vs Value-Based Care
Resources
131
wwwDentaQuestPartnershiporg
wwwfacebookcomDentaQuest
DentaQuest
wwwlinkedincomcompanyDentaQuest
Inside_DentaQuest
QUESTIONS
BREAKOUT EXERCISEORAL HEALTH VALUE-BASED CARE READINESS ASSESSMENT
Danielle Apostolon
PROMISING PRACTICES FROM THE FIELD STRATEGIES FOR INCREASING VALUE IN ORAL HEALTH
Dr Carolyn Brown
Dr Kelly Perry
Dr Rachel Rivard
Dr Adeloye
Commitment Compassion Community
m i d s t a t e h e a l t h o r g
Promising Practices from the
Field Strategies for Increasing
Value in Oral Health Care
Kelly Perry DMD
Better Health
Outcomes
Improved Staff
Experience
Reduced Cost
Improved Patient
Experience
Better Health
Outcomes
Improved Staff
Experience
Reduced Cost
Improved Patient
Experience
Better Health
Outcomes
Improved Staff
Experience
Reduced Cost
Improved Patient
Experience
Better Health
Outcomes
Improved Staff
Experience
Reduced Cost
Improved Patient
Experience
Commitment Compassion Community
kpe r r ymids t a tehea l t h o rg
Thank you
Completion of Disease Control Phase
Pelumi Adeloye DMD MPH
HEALTH ACCESS NETWORK (HAN) FAMILY DENTAL
Introduction
⧫1 Dentist I Hygienist 3 EFDArsquos1 Receptionist
⧫ 6 Chairs= 4 (dentist) + 2 (hygienist)
⧫ Slide ⥶80 off
⧫ Service areas Northern Penobscot Southern Aroostook Western
Washington Counties amp more
Completion of Phase I Treatment
⧫LimitedLack of Access to dental care
⧫Difficulty completing the disease control phase
Caries amp periodontal disease
⧫Attaining stable restorative state
Goal
Increase the completion of Disease Control Phase
Current practice
⧫Education
Assess level of dental literacy
Incremental strategy
⧫Increase access to dental care
Generous sliding scale (⥸$40 per visit)
Incorporate Expanded Function Dental Assistants
⧫Schedule modification
Incorporate more restorative blocks to allow
for follow-up visit and completion of restorative phase
httpswwwglasbergencomdentist-cartoons
Schedule
⧫Piggybacking technique
Increased allotted restorative blocks
⧫Sustainability of current schedule is
contingent on cooperation amp skills of HAN
Dental staff
Note
Strategies mentioned today is personalized to HAN Dental clinic
Current implemented strategies might be modified or changed in the
future as required in order to accommodate the need of our pts
THANK YOU
DAY TWOCLOSINGWRAP-UP
End of Day Two ndash Survey
Day Two Creating a Value-Based Oral Health Care Delivery
System
129
Payment Reform in Oral Health Online Learning Module
Oral Health Value-based Care Online Learning Module
Value-based Care Keys to Success Article
Readiness Assessment
Competency Development Guide
Oral Health Value-based Care Training
Dental Caries Management Practicum
Clinicians Companion Guide
Interprofessional Network Referral Process
Traditional Dental Care Vs Value-Based Care
Resources
131
wwwDentaQuestPartnershiporg
wwwfacebookcomDentaQuest
DentaQuest
wwwlinkedincomcompanyDentaQuest
Inside_DentaQuest
QUESTIONS
PROMISING PRACTICES FROM THE FIELD STRATEGIES FOR INCREASING VALUE IN ORAL HEALTH
Dr Carolyn Brown
Dr Kelly Perry
Dr Rachel Rivard
Dr Adeloye
Commitment Compassion Community
m i d s t a t e h e a l t h o r g
Promising Practices from the
Field Strategies for Increasing
Value in Oral Health Care
Kelly Perry DMD
Better Health
Outcomes
Improved Staff
Experience
Reduced Cost
Improved Patient
Experience
Better Health
Outcomes
Improved Staff
Experience
Reduced Cost
Improved Patient
Experience
Better Health
Outcomes
Improved Staff
Experience
Reduced Cost
Improved Patient
Experience
Better Health
Outcomes
Improved Staff
Experience
Reduced Cost
Improved Patient
Experience
Commitment Compassion Community
kpe r r ymids t a tehea l t h o rg
Thank you
Completion of Disease Control Phase
Pelumi Adeloye DMD MPH
HEALTH ACCESS NETWORK (HAN) FAMILY DENTAL
Introduction
⧫1 Dentist I Hygienist 3 EFDArsquos1 Receptionist
⧫ 6 Chairs= 4 (dentist) + 2 (hygienist)
⧫ Slide ⥶80 off
⧫ Service areas Northern Penobscot Southern Aroostook Western
Washington Counties amp more
Completion of Phase I Treatment
⧫LimitedLack of Access to dental care
⧫Difficulty completing the disease control phase
Caries amp periodontal disease
⧫Attaining stable restorative state
Goal
Increase the completion of Disease Control Phase
Current practice
⧫Education
Assess level of dental literacy
Incremental strategy
⧫Increase access to dental care
Generous sliding scale (⥸$40 per visit)
Incorporate Expanded Function Dental Assistants
⧫Schedule modification
Incorporate more restorative blocks to allow
for follow-up visit and completion of restorative phase
httpswwwglasbergencomdentist-cartoons
Schedule
⧫Piggybacking technique
Increased allotted restorative blocks
⧫Sustainability of current schedule is
contingent on cooperation amp skills of HAN
Dental staff
Note
Strategies mentioned today is personalized to HAN Dental clinic
Current implemented strategies might be modified or changed in the
future as required in order to accommodate the need of our pts
THANK YOU
DAY TWOCLOSINGWRAP-UP
End of Day Two ndash Survey
Day Two Creating a Value-Based Oral Health Care Delivery
System
129
Payment Reform in Oral Health Online Learning Module
Oral Health Value-based Care Online Learning Module
Value-based Care Keys to Success Article
Readiness Assessment
Competency Development Guide
Oral Health Value-based Care Training
Dental Caries Management Practicum
Clinicians Companion Guide
Interprofessional Network Referral Process
Traditional Dental Care Vs Value-Based Care
Resources
131
wwwDentaQuestPartnershiporg
wwwfacebookcomDentaQuest
DentaQuest
wwwlinkedincomcompanyDentaQuest
Inside_DentaQuest
QUESTIONS
Commitment Compassion Community
m i d s t a t e h e a l t h o r g
Promising Practices from the
Field Strategies for Increasing
Value in Oral Health Care
Kelly Perry DMD
Better Health
Outcomes
Improved Staff
Experience
Reduced Cost
Improved Patient
Experience
Better Health
Outcomes
Improved Staff
Experience
Reduced Cost
Improved Patient
Experience
Better Health
Outcomes
Improved Staff
Experience
Reduced Cost
Improved Patient
Experience
Better Health
Outcomes
Improved Staff
Experience
Reduced Cost
Improved Patient
Experience
Commitment Compassion Community
kpe r r ymids t a tehea l t h o rg
Thank you
Completion of Disease Control Phase
Pelumi Adeloye DMD MPH
HEALTH ACCESS NETWORK (HAN) FAMILY DENTAL
Introduction
⧫1 Dentist I Hygienist 3 EFDArsquos1 Receptionist
⧫ 6 Chairs= 4 (dentist) + 2 (hygienist)
⧫ Slide ⥶80 off
⧫ Service areas Northern Penobscot Southern Aroostook Western
Washington Counties amp more
Completion of Phase I Treatment
⧫LimitedLack of Access to dental care
⧫Difficulty completing the disease control phase
Caries amp periodontal disease
⧫Attaining stable restorative state
Goal
Increase the completion of Disease Control Phase
Current practice
⧫Education
Assess level of dental literacy
Incremental strategy
⧫Increase access to dental care
Generous sliding scale (⥸$40 per visit)
Incorporate Expanded Function Dental Assistants
⧫Schedule modification
Incorporate more restorative blocks to allow
for follow-up visit and completion of restorative phase
httpswwwglasbergencomdentist-cartoons
Schedule
⧫Piggybacking technique
Increased allotted restorative blocks
⧫Sustainability of current schedule is
contingent on cooperation amp skills of HAN
Dental staff
Note
Strategies mentioned today is personalized to HAN Dental clinic
Current implemented strategies might be modified or changed in the
future as required in order to accommodate the need of our pts
THANK YOU
DAY TWOCLOSINGWRAP-UP
End of Day Two ndash Survey
Day Two Creating a Value-Based Oral Health Care Delivery
System
129
Payment Reform in Oral Health Online Learning Module
Oral Health Value-based Care Online Learning Module
Value-based Care Keys to Success Article
Readiness Assessment
Competency Development Guide
Oral Health Value-based Care Training
Dental Caries Management Practicum
Clinicians Companion Guide
Interprofessional Network Referral Process
Traditional Dental Care Vs Value-Based Care
Resources
131
wwwDentaQuestPartnershiporg
wwwfacebookcomDentaQuest
DentaQuest
wwwlinkedincomcompanyDentaQuest
Inside_DentaQuest
QUESTIONS
Better Health
Outcomes
Improved Staff
Experience
Reduced Cost
Improved Patient
Experience
Better Health
Outcomes
Improved Staff
Experience
Reduced Cost
Improved Patient
Experience
Better Health
Outcomes
Improved Staff
Experience
Reduced Cost
Improved Patient
Experience
Better Health
Outcomes
Improved Staff
Experience
Reduced Cost
Improved Patient
Experience
Commitment Compassion Community
kpe r r ymids t a tehea l t h o rg
Thank you
Completion of Disease Control Phase
Pelumi Adeloye DMD MPH
HEALTH ACCESS NETWORK (HAN) FAMILY DENTAL
Introduction
⧫1 Dentist I Hygienist 3 EFDArsquos1 Receptionist
⧫ 6 Chairs= 4 (dentist) + 2 (hygienist)
⧫ Slide ⥶80 off
⧫ Service areas Northern Penobscot Southern Aroostook Western
Washington Counties amp more
Completion of Phase I Treatment
⧫LimitedLack of Access to dental care
⧫Difficulty completing the disease control phase
Caries amp periodontal disease
⧫Attaining stable restorative state
Goal
Increase the completion of Disease Control Phase
Current practice
⧫Education
Assess level of dental literacy
Incremental strategy
⧫Increase access to dental care
Generous sliding scale (⥸$40 per visit)
Incorporate Expanded Function Dental Assistants
⧫Schedule modification
Incorporate more restorative blocks to allow
for follow-up visit and completion of restorative phase
httpswwwglasbergencomdentist-cartoons
Schedule
⧫Piggybacking technique
Increased allotted restorative blocks
⧫Sustainability of current schedule is
contingent on cooperation amp skills of HAN
Dental staff
Note
Strategies mentioned today is personalized to HAN Dental clinic
Current implemented strategies might be modified or changed in the
future as required in order to accommodate the need of our pts
THANK YOU
DAY TWOCLOSINGWRAP-UP
End of Day Two ndash Survey
Day Two Creating a Value-Based Oral Health Care Delivery
System
129
Payment Reform in Oral Health Online Learning Module
Oral Health Value-based Care Online Learning Module
Value-based Care Keys to Success Article
Readiness Assessment
Competency Development Guide
Oral Health Value-based Care Training
Dental Caries Management Practicum
Clinicians Companion Guide
Interprofessional Network Referral Process
Traditional Dental Care Vs Value-Based Care
Resources
131
wwwDentaQuestPartnershiporg
wwwfacebookcomDentaQuest
DentaQuest
wwwlinkedincomcompanyDentaQuest
Inside_DentaQuest
QUESTIONS
Better Health
Outcomes
Improved Staff
Experience
Reduced Cost
Improved Patient
Experience
Better Health
Outcomes
Improved Staff
Experience
Reduced Cost
Improved Patient
Experience
Better Health
Outcomes
Improved Staff
Experience
Reduced Cost
Improved Patient
Experience
Commitment Compassion Community
kpe r r ymids t a tehea l t h o rg
Thank you
Completion of Disease Control Phase
Pelumi Adeloye DMD MPH
HEALTH ACCESS NETWORK (HAN) FAMILY DENTAL
Introduction
⧫1 Dentist I Hygienist 3 EFDArsquos1 Receptionist
⧫ 6 Chairs= 4 (dentist) + 2 (hygienist)
⧫ Slide ⥶80 off
⧫ Service areas Northern Penobscot Southern Aroostook Western
Washington Counties amp more
Completion of Phase I Treatment
⧫LimitedLack of Access to dental care
⧫Difficulty completing the disease control phase
Caries amp periodontal disease
⧫Attaining stable restorative state
Goal
Increase the completion of Disease Control Phase
Current practice
⧫Education
Assess level of dental literacy
Incremental strategy
⧫Increase access to dental care
Generous sliding scale (⥸$40 per visit)
Incorporate Expanded Function Dental Assistants
⧫Schedule modification
Incorporate more restorative blocks to allow
for follow-up visit and completion of restorative phase
httpswwwglasbergencomdentist-cartoons
Schedule
⧫Piggybacking technique
Increased allotted restorative blocks
⧫Sustainability of current schedule is
contingent on cooperation amp skills of HAN
Dental staff
Note
Strategies mentioned today is personalized to HAN Dental clinic
Current implemented strategies might be modified or changed in the
future as required in order to accommodate the need of our pts
THANK YOU
DAY TWOCLOSINGWRAP-UP
End of Day Two ndash Survey
Day Two Creating a Value-Based Oral Health Care Delivery
System
129
Payment Reform in Oral Health Online Learning Module
Oral Health Value-based Care Online Learning Module
Value-based Care Keys to Success Article
Readiness Assessment
Competency Development Guide
Oral Health Value-based Care Training
Dental Caries Management Practicum
Clinicians Companion Guide
Interprofessional Network Referral Process
Traditional Dental Care Vs Value-Based Care
Resources
131
wwwDentaQuestPartnershiporg
wwwfacebookcomDentaQuest
DentaQuest
wwwlinkedincomcompanyDentaQuest
Inside_DentaQuest
QUESTIONS
Better Health
Outcomes
Improved Staff
Experience
Reduced Cost
Improved Patient
Experience
Better Health
Outcomes
Improved Staff
Experience
Reduced Cost
Improved Patient
Experience
Commitment Compassion Community
kpe r r ymids t a tehea l t h o rg
Thank you
Completion of Disease Control Phase
Pelumi Adeloye DMD MPH
HEALTH ACCESS NETWORK (HAN) FAMILY DENTAL
Introduction
⧫1 Dentist I Hygienist 3 EFDArsquos1 Receptionist
⧫ 6 Chairs= 4 (dentist) + 2 (hygienist)
⧫ Slide ⥶80 off
⧫ Service areas Northern Penobscot Southern Aroostook Western
Washington Counties amp more
Completion of Phase I Treatment
⧫LimitedLack of Access to dental care
⧫Difficulty completing the disease control phase
Caries amp periodontal disease
⧫Attaining stable restorative state
Goal
Increase the completion of Disease Control Phase
Current practice
⧫Education
Assess level of dental literacy
Incremental strategy
⧫Increase access to dental care
Generous sliding scale (⥸$40 per visit)
Incorporate Expanded Function Dental Assistants
⧫Schedule modification
Incorporate more restorative blocks to allow
for follow-up visit and completion of restorative phase
httpswwwglasbergencomdentist-cartoons
Schedule
⧫Piggybacking technique
Increased allotted restorative blocks
⧫Sustainability of current schedule is
contingent on cooperation amp skills of HAN
Dental staff
Note
Strategies mentioned today is personalized to HAN Dental clinic
Current implemented strategies might be modified or changed in the
future as required in order to accommodate the need of our pts
THANK YOU
DAY TWOCLOSINGWRAP-UP
End of Day Two ndash Survey
Day Two Creating a Value-Based Oral Health Care Delivery
System
129
Payment Reform in Oral Health Online Learning Module
Oral Health Value-based Care Online Learning Module
Value-based Care Keys to Success Article
Readiness Assessment
Competency Development Guide
Oral Health Value-based Care Training
Dental Caries Management Practicum
Clinicians Companion Guide
Interprofessional Network Referral Process
Traditional Dental Care Vs Value-Based Care
Resources
131
wwwDentaQuestPartnershiporg
wwwfacebookcomDentaQuest
DentaQuest
wwwlinkedincomcompanyDentaQuest
Inside_DentaQuest
QUESTIONS
Better Health
Outcomes
Improved Staff
Experience
Reduced Cost
Improved Patient
Experience
Commitment Compassion Community
kpe r r ymids t a tehea l t h o rg
Thank you
Completion of Disease Control Phase
Pelumi Adeloye DMD MPH
HEALTH ACCESS NETWORK (HAN) FAMILY DENTAL
Introduction
⧫1 Dentist I Hygienist 3 EFDArsquos1 Receptionist
⧫ 6 Chairs= 4 (dentist) + 2 (hygienist)
⧫ Slide ⥶80 off
⧫ Service areas Northern Penobscot Southern Aroostook Western
Washington Counties amp more
Completion of Phase I Treatment
⧫LimitedLack of Access to dental care
⧫Difficulty completing the disease control phase
Caries amp periodontal disease
⧫Attaining stable restorative state
Goal
Increase the completion of Disease Control Phase
Current practice
⧫Education
Assess level of dental literacy
Incremental strategy
⧫Increase access to dental care
Generous sliding scale (⥸$40 per visit)
Incorporate Expanded Function Dental Assistants
⧫Schedule modification
Incorporate more restorative blocks to allow
for follow-up visit and completion of restorative phase
httpswwwglasbergencomdentist-cartoons
Schedule
⧫Piggybacking technique
Increased allotted restorative blocks
⧫Sustainability of current schedule is
contingent on cooperation amp skills of HAN
Dental staff
Note
Strategies mentioned today is personalized to HAN Dental clinic
Current implemented strategies might be modified or changed in the
future as required in order to accommodate the need of our pts
THANK YOU
DAY TWOCLOSINGWRAP-UP
End of Day Two ndash Survey
Day Two Creating a Value-Based Oral Health Care Delivery
System
129
Payment Reform in Oral Health Online Learning Module
Oral Health Value-based Care Online Learning Module
Value-based Care Keys to Success Article
Readiness Assessment
Competency Development Guide
Oral Health Value-based Care Training
Dental Caries Management Practicum
Clinicians Companion Guide
Interprofessional Network Referral Process
Traditional Dental Care Vs Value-Based Care
Resources
131
wwwDentaQuestPartnershiporg
wwwfacebookcomDentaQuest
DentaQuest
wwwlinkedincomcompanyDentaQuest
Inside_DentaQuest
QUESTIONS
Commitment Compassion Community
kpe r r ymids t a tehea l t h o rg
Thank you
Completion of Disease Control Phase
Pelumi Adeloye DMD MPH
HEALTH ACCESS NETWORK (HAN) FAMILY DENTAL
Introduction
⧫1 Dentist I Hygienist 3 EFDArsquos1 Receptionist
⧫ 6 Chairs= 4 (dentist) + 2 (hygienist)
⧫ Slide ⥶80 off
⧫ Service areas Northern Penobscot Southern Aroostook Western
Washington Counties amp more
Completion of Phase I Treatment
⧫LimitedLack of Access to dental care
⧫Difficulty completing the disease control phase
Caries amp periodontal disease
⧫Attaining stable restorative state
Goal
Increase the completion of Disease Control Phase
Current practice
⧫Education
Assess level of dental literacy
Incremental strategy
⧫Increase access to dental care
Generous sliding scale (⥸$40 per visit)
Incorporate Expanded Function Dental Assistants
⧫Schedule modification
Incorporate more restorative blocks to allow
for follow-up visit and completion of restorative phase
httpswwwglasbergencomdentist-cartoons
Schedule
⧫Piggybacking technique
Increased allotted restorative blocks
⧫Sustainability of current schedule is
contingent on cooperation amp skills of HAN
Dental staff
Note
Strategies mentioned today is personalized to HAN Dental clinic
Current implemented strategies might be modified or changed in the
future as required in order to accommodate the need of our pts
THANK YOU
DAY TWOCLOSINGWRAP-UP
End of Day Two ndash Survey
Day Two Creating a Value-Based Oral Health Care Delivery
System
129
Payment Reform in Oral Health Online Learning Module
Oral Health Value-based Care Online Learning Module
Value-based Care Keys to Success Article
Readiness Assessment
Competency Development Guide
Oral Health Value-based Care Training
Dental Caries Management Practicum
Clinicians Companion Guide
Interprofessional Network Referral Process
Traditional Dental Care Vs Value-Based Care
Resources
131
wwwDentaQuestPartnershiporg
wwwfacebookcomDentaQuest
DentaQuest
wwwlinkedincomcompanyDentaQuest
Inside_DentaQuest
QUESTIONS
Completion of Disease Control Phase
Pelumi Adeloye DMD MPH
HEALTH ACCESS NETWORK (HAN) FAMILY DENTAL
Introduction
⧫1 Dentist I Hygienist 3 EFDArsquos1 Receptionist
⧫ 6 Chairs= 4 (dentist) + 2 (hygienist)
⧫ Slide ⥶80 off
⧫ Service areas Northern Penobscot Southern Aroostook Western
Washington Counties amp more
Completion of Phase I Treatment
⧫LimitedLack of Access to dental care
⧫Difficulty completing the disease control phase
Caries amp periodontal disease
⧫Attaining stable restorative state
Goal
Increase the completion of Disease Control Phase
Current practice
⧫Education
Assess level of dental literacy
Incremental strategy
⧫Increase access to dental care
Generous sliding scale (⥸$40 per visit)
Incorporate Expanded Function Dental Assistants
⧫Schedule modification
Incorporate more restorative blocks to allow
for follow-up visit and completion of restorative phase
httpswwwglasbergencomdentist-cartoons
Schedule
⧫Piggybacking technique
Increased allotted restorative blocks
⧫Sustainability of current schedule is
contingent on cooperation amp skills of HAN
Dental staff
Note
Strategies mentioned today is personalized to HAN Dental clinic
Current implemented strategies might be modified or changed in the
future as required in order to accommodate the need of our pts
THANK YOU
DAY TWOCLOSINGWRAP-UP
End of Day Two ndash Survey
Day Two Creating a Value-Based Oral Health Care Delivery
System
129
Payment Reform in Oral Health Online Learning Module
Oral Health Value-based Care Online Learning Module
Value-based Care Keys to Success Article
Readiness Assessment
Competency Development Guide
Oral Health Value-based Care Training
Dental Caries Management Practicum
Clinicians Companion Guide
Interprofessional Network Referral Process
Traditional Dental Care Vs Value-Based Care
Resources
131
wwwDentaQuestPartnershiporg
wwwfacebookcomDentaQuest
DentaQuest
wwwlinkedincomcompanyDentaQuest
Inside_DentaQuest
QUESTIONS
Introduction
⧫1 Dentist I Hygienist 3 EFDArsquos1 Receptionist
⧫ 6 Chairs= 4 (dentist) + 2 (hygienist)
⧫ Slide ⥶80 off
⧫ Service areas Northern Penobscot Southern Aroostook Western
Washington Counties amp more
Completion of Phase I Treatment
⧫LimitedLack of Access to dental care
⧫Difficulty completing the disease control phase
Caries amp periodontal disease
⧫Attaining stable restorative state
Goal
Increase the completion of Disease Control Phase
Current practice
⧫Education
Assess level of dental literacy
Incremental strategy
⧫Increase access to dental care
Generous sliding scale (⥸$40 per visit)
Incorporate Expanded Function Dental Assistants
⧫Schedule modification
Incorporate more restorative blocks to allow
for follow-up visit and completion of restorative phase
httpswwwglasbergencomdentist-cartoons
Schedule
⧫Piggybacking technique
Increased allotted restorative blocks
⧫Sustainability of current schedule is
contingent on cooperation amp skills of HAN
Dental staff
Note
Strategies mentioned today is personalized to HAN Dental clinic
Current implemented strategies might be modified or changed in the
future as required in order to accommodate the need of our pts
THANK YOU
DAY TWOCLOSINGWRAP-UP
End of Day Two ndash Survey
Day Two Creating a Value-Based Oral Health Care Delivery
System
129
Payment Reform in Oral Health Online Learning Module
Oral Health Value-based Care Online Learning Module
Value-based Care Keys to Success Article
Readiness Assessment
Competency Development Guide
Oral Health Value-based Care Training
Dental Caries Management Practicum
Clinicians Companion Guide
Interprofessional Network Referral Process
Traditional Dental Care Vs Value-Based Care
Resources
131
wwwDentaQuestPartnershiporg
wwwfacebookcomDentaQuest
DentaQuest
wwwlinkedincomcompanyDentaQuest
Inside_DentaQuest
QUESTIONS
Completion of Phase I Treatment
⧫LimitedLack of Access to dental care
⧫Difficulty completing the disease control phase
Caries amp periodontal disease
⧫Attaining stable restorative state
Goal
Increase the completion of Disease Control Phase
Current practice
⧫Education
Assess level of dental literacy
Incremental strategy
⧫Increase access to dental care
Generous sliding scale (⥸$40 per visit)
Incorporate Expanded Function Dental Assistants
⧫Schedule modification
Incorporate more restorative blocks to allow
for follow-up visit and completion of restorative phase
httpswwwglasbergencomdentist-cartoons
Schedule
⧫Piggybacking technique
Increased allotted restorative blocks
⧫Sustainability of current schedule is
contingent on cooperation amp skills of HAN
Dental staff
Note
Strategies mentioned today is personalized to HAN Dental clinic
Current implemented strategies might be modified or changed in the
future as required in order to accommodate the need of our pts
THANK YOU
DAY TWOCLOSINGWRAP-UP
End of Day Two ndash Survey
Day Two Creating a Value-Based Oral Health Care Delivery
System
129
Payment Reform in Oral Health Online Learning Module
Oral Health Value-based Care Online Learning Module
Value-based Care Keys to Success Article
Readiness Assessment
Competency Development Guide
Oral Health Value-based Care Training
Dental Caries Management Practicum
Clinicians Companion Guide
Interprofessional Network Referral Process
Traditional Dental Care Vs Value-Based Care
Resources
131
wwwDentaQuestPartnershiporg
wwwfacebookcomDentaQuest
DentaQuest
wwwlinkedincomcompanyDentaQuest
Inside_DentaQuest
QUESTIONS
Goal
Increase the completion of Disease Control Phase
Current practice
⧫Education
Assess level of dental literacy
Incremental strategy
⧫Increase access to dental care
Generous sliding scale (⥸$40 per visit)
Incorporate Expanded Function Dental Assistants
⧫Schedule modification
Incorporate more restorative blocks to allow
for follow-up visit and completion of restorative phase
httpswwwglasbergencomdentist-cartoons
Schedule
⧫Piggybacking technique
Increased allotted restorative blocks
⧫Sustainability of current schedule is
contingent on cooperation amp skills of HAN
Dental staff
Note
Strategies mentioned today is personalized to HAN Dental clinic
Current implemented strategies might be modified or changed in the
future as required in order to accommodate the need of our pts
THANK YOU
DAY TWOCLOSINGWRAP-UP
End of Day Two ndash Survey
Day Two Creating a Value-Based Oral Health Care Delivery
System
129
Payment Reform in Oral Health Online Learning Module
Oral Health Value-based Care Online Learning Module
Value-based Care Keys to Success Article
Readiness Assessment
Competency Development Guide
Oral Health Value-based Care Training
Dental Caries Management Practicum
Clinicians Companion Guide
Interprofessional Network Referral Process
Traditional Dental Care Vs Value-Based Care
Resources
131
wwwDentaQuestPartnershiporg
wwwfacebookcomDentaQuest
DentaQuest
wwwlinkedincomcompanyDentaQuest
Inside_DentaQuest
QUESTIONS
Current practice
⧫Education
Assess level of dental literacy
Incremental strategy
⧫Increase access to dental care
Generous sliding scale (⥸$40 per visit)
Incorporate Expanded Function Dental Assistants
⧫Schedule modification
Incorporate more restorative blocks to allow
for follow-up visit and completion of restorative phase
httpswwwglasbergencomdentist-cartoons
Schedule
⧫Piggybacking technique
Increased allotted restorative blocks
⧫Sustainability of current schedule is
contingent on cooperation amp skills of HAN
Dental staff
Note
Strategies mentioned today is personalized to HAN Dental clinic
Current implemented strategies might be modified or changed in the
future as required in order to accommodate the need of our pts
THANK YOU
DAY TWOCLOSINGWRAP-UP
End of Day Two ndash Survey
Day Two Creating a Value-Based Oral Health Care Delivery
System
129
Payment Reform in Oral Health Online Learning Module
Oral Health Value-based Care Online Learning Module
Value-based Care Keys to Success Article
Readiness Assessment
Competency Development Guide
Oral Health Value-based Care Training
Dental Caries Management Practicum
Clinicians Companion Guide
Interprofessional Network Referral Process
Traditional Dental Care Vs Value-Based Care
Resources
131
wwwDentaQuestPartnershiporg
wwwfacebookcomDentaQuest
DentaQuest
wwwlinkedincomcompanyDentaQuest
Inside_DentaQuest
QUESTIONS
Schedule
⧫Piggybacking technique
Increased allotted restorative blocks
⧫Sustainability of current schedule is
contingent on cooperation amp skills of HAN
Dental staff
Note
Strategies mentioned today is personalized to HAN Dental clinic
Current implemented strategies might be modified or changed in the
future as required in order to accommodate the need of our pts
THANK YOU
DAY TWOCLOSINGWRAP-UP
End of Day Two ndash Survey
Day Two Creating a Value-Based Oral Health Care Delivery
System
129
Payment Reform in Oral Health Online Learning Module
Oral Health Value-based Care Online Learning Module
Value-based Care Keys to Success Article
Readiness Assessment
Competency Development Guide
Oral Health Value-based Care Training
Dental Caries Management Practicum
Clinicians Companion Guide
Interprofessional Network Referral Process
Traditional Dental Care Vs Value-Based Care
Resources
131
wwwDentaQuestPartnershiporg
wwwfacebookcomDentaQuest
DentaQuest
wwwlinkedincomcompanyDentaQuest
Inside_DentaQuest
QUESTIONS
Note
Strategies mentioned today is personalized to HAN Dental clinic
Current implemented strategies might be modified or changed in the
future as required in order to accommodate the need of our pts
THANK YOU
DAY TWOCLOSINGWRAP-UP
End of Day Two ndash Survey
Day Two Creating a Value-Based Oral Health Care Delivery
System
129
Payment Reform in Oral Health Online Learning Module
Oral Health Value-based Care Online Learning Module
Value-based Care Keys to Success Article
Readiness Assessment
Competency Development Guide
Oral Health Value-based Care Training
Dental Caries Management Practicum
Clinicians Companion Guide
Interprofessional Network Referral Process
Traditional Dental Care Vs Value-Based Care
Resources
131
wwwDentaQuestPartnershiporg
wwwfacebookcomDentaQuest
DentaQuest
wwwlinkedincomcompanyDentaQuest
Inside_DentaQuest
QUESTIONS
THANK YOU
DAY TWOCLOSINGWRAP-UP
End of Day Two ndash Survey
Day Two Creating a Value-Based Oral Health Care Delivery
System
129
Payment Reform in Oral Health Online Learning Module
Oral Health Value-based Care Online Learning Module
Value-based Care Keys to Success Article
Readiness Assessment
Competency Development Guide
Oral Health Value-based Care Training
Dental Caries Management Practicum
Clinicians Companion Guide
Interprofessional Network Referral Process
Traditional Dental Care Vs Value-Based Care
Resources
131
wwwDentaQuestPartnershiporg
wwwfacebookcomDentaQuest
DentaQuest
wwwlinkedincomcompanyDentaQuest
Inside_DentaQuest
QUESTIONS
DAY TWOCLOSINGWRAP-UP
End of Day Two ndash Survey
Day Two Creating a Value-Based Oral Health Care Delivery
System
129
Payment Reform in Oral Health Online Learning Module
Oral Health Value-based Care Online Learning Module
Value-based Care Keys to Success Article
Readiness Assessment
Competency Development Guide
Oral Health Value-based Care Training
Dental Caries Management Practicum
Clinicians Companion Guide
Interprofessional Network Referral Process
Traditional Dental Care Vs Value-Based Care
Resources
131
wwwDentaQuestPartnershiporg
wwwfacebookcomDentaQuest
DentaQuest
wwwlinkedincomcompanyDentaQuest
Inside_DentaQuest
QUESTIONS
129
Payment Reform in Oral Health Online Learning Module
Oral Health Value-based Care Online Learning Module
Value-based Care Keys to Success Article
Readiness Assessment
Competency Development Guide
Oral Health Value-based Care Training
Dental Caries Management Practicum
Clinicians Companion Guide
Interprofessional Network Referral Process
Traditional Dental Care Vs Value-Based Care
Resources
131
wwwDentaQuestPartnershiporg
wwwfacebookcomDentaQuest
DentaQuest
wwwlinkedincomcompanyDentaQuest
Inside_DentaQuest
QUESTIONS
131
wwwDentaQuestPartnershiporg
wwwfacebookcomDentaQuest
DentaQuest
wwwlinkedincomcompanyDentaQuest
Inside_DentaQuest
QUESTIONS
QUESTIONS
