Oral Health Care TransformationWilliam Riley, PhD, Director of the National Safety Net Advancement Center Mark Doherty, DMD, MPH, CCHP, Executive Director Safety Net Solutions

Objectives

• Explain Health Care Payment Reform Priorities• Critically Analyze Payment Reform Strategies• Identify Payment Reform Problems and Solutions

for Oral Health• Apply Successful Payment and Delivery Reform

Strategies for Oral Health

We have a problem in the US!

The financial crisis forcing change to the health care system

WE have to solve the problem!

Health Care Payment Reform

• Paradoxes• Severe Market Failure

Health Status: Determinants of Health and Health Care Expenditures

Access to Care

Environment

Genetics

Health Behaviors

Access to Care

Other

Health Behaviors

Influence National Health Expenditures$3 Trillion

10%20%20%

50%

88%

8%4%

Source: Centers for Disease Control and Prevention, University of California at San Francisco, Institute for the Future, http://www.cdc.gov/nchs/fastats/health-expenditures.htm

Health Status: Determinants of Health and Health Care Expenditures

Source: Centers for Disease Control and Prevention, University of California at San Francisco, Institute for the Future, http://www.cdc.gov/nchs/fastats/health-expenditures.htm

Access to Care

Environment

Genetics

Health Behaviors

Access to Care

Other

Health Behaviors

Influence National Health Expenditures$3 Trillion

10%20%20%

50%

88%

8%4%

Health Care Finance

• Prospective Payment– Pays for value

• Retrospective Payment– Pays for volume

The Value Equation

Value = QualityCost

Payment Reform Milestones• Affordable Care Act (2010)

– Access through Medicaid Expansion and Insurance Exchange

– Authorized Accountable Care Organizations– Modest Insurance reforms

• MACRA– 2015– HHS launched the LAN (on March 25, 2015) to help

advance the work being done across sectors to increase the adoption of quality-based payments and alternative payment models

DHHS Learning Action Network (LAN)

• The LAN’s mission is to help achieve better care, smarter spending, and healthier people.

• The Department of Health and Human Services (HHS) is working to transform the nation’s health system to emphasize value over volume.

• To accelerate the health care system’s transition to alternative payment models by combining the innovation, power, and reach of the private and public sectors

.To achieve the goal of better care, smarter spending, and healthier

people, the U.S. health care system must substantially reform its payment

structure to incentivize quality, health outcomes, and value over volume.

• Healthier People–Such alignment requires

the participation of the entire health care

community. The LAN is a collaborative network of

public and private stakeholders.

• Smarter Spending

–In order to achieve this, we need to shift our payment structure to pay for quality

of care over quantity of services.

• Better Care–The LAN seeks to shift our health care system from the

current fee-for-service payment model to a model

that pays providers and hospitals for quality care and

improved health.

• The Health Care Payment Learning & Action Network (LAN) was launched because of the need for:

Purpose

Better Care, Smarter Spending, Healthier People

Adoption of Alternative Payment Models (APMs)

These payment reforms are expected to demonstrate better outcomes and smarter spending for patients.

In 2018, at least 50% of U.S. health care payments are so linked.

201850%

In 2016, at least 30% of U.S. health care payments are linked to quality and value through APMs.

201630%

Goals for U.S. Health CareOur Goal

Category 1Fee for Service –

No Link to Quality & Value

Category 2Fee for Service –

Link to Quality & Value

Category 3APMs Built on

Fee-for-Service Architecture

Category 4Population-Based

Payment

A

Foundational Payments for Infrastructure &

Operations

B

Pay for Reporting

C

Rewards for Performance

D

Rewards and Penalties for Performance

A

APMs with Upside Gainsharing

B

APMs with Upside Gainsharing/Downside

Risk

A

Condition-SpecificPopulation-Based

Payment

B

Comprehensive Population-Based

Payment

Population-Based Accountability

The framework situates existing and potential APMs into a series of categories.

The Framework is a critical first step toward the goal of better care, smarter spending, and healthier people.

• Serves as the foundation for generating evidence about what works and lessons learned

• Provides a road map for payment reform capable of supporting the delivery of person-centered care

• Acts as a "gauge" for measuring progress toward adoption of alternative payment models

• Establishes a common nomenclature and a set of conventions that will facilitate discussions within and across stakeholder communities

• At-a-GlanceAPM Framework

3NRisk-based payments NOT

linked to quality

4NCapitated payments NOT

linked to quality

= example payment models will not count toward APM goal.

N = payment models in Categories 3 and 4 that do not have a link to quality and will not count toward the APM goal.

• For Payment ReformAPM Goals

•P

atie

nt-c

ente

red

care

Process Engineering and System Design

• Defining a ProcessSeries of steps to produce an outcome

• Process DesignDeliberately design a process for quality, safety

and efficiency• System DesignSet of Interrelated Processes

The Goal of Highly Reliable Processes in Health Care

• Get people the care they need, no less, no more• No care based on avoidable ignorance• Respect for what matters to the individual

Value Equation:

Value = Quality/Cost

Opportunities for Alternative Payment

1. Providers focus on improving population health2. All providers practice at top of their license3. Providers get paid for what they do not do4. Fewer benefit restrictions and limitations

Opportunities for Alternative Payment

1. Providers focus on improving population health

2. All providers practice at top of their license3. Providers get paid for what they do not do4. Fewer benefit restrictions and limitations

Opportunities for Alternative Payment

1. Providers focus on improving population health

2. All providers practice at top of their license

3. Providers get paid for what they do not do4. Fewer benefit restrictions and limitations

Opportunities for Alternative Payment

1. Providers focus on improving population health2. All providers practice at top of their license

3. Providers get paid for what they do not do

4. Fewer benefit restrictions and limitations

Opportunities for Alternative Payment

1. Providers focus on improving population health2. All providers practice at top of their license3. Providers get paid for what they do not do

4. Fewer benefit restrictions and limitations

Barriers for Prospective Payment

1. If payments are actuarially unsound2. If system is complex to administer3. If population is not identified in advance4. Requires an interdisciplinary team5. Requires a care management system 6. Requires a focus on the individual and the population

Barriers for Prospective Payment

1. If payments are actuarially unsound2. If system is complex to administer3. If population is not identified in advance4. Requires an interdisciplinary team5. Requires a care management system 6. Requires a focus on the individual and the population

Barriers for Prospective Payment

1. If payments are actuarially unsound

2. If system is complex to administer3. If population is not identified in advance4. Requires an interdisciplinary team5. Requires a care management system 6. Requires a focus on the individual and the population

Barriers for Prospective Payment

1. If payments are actuarially unsound2. If system is complex to administer

3. If population is not identified in advance

4. Requires an interdisciplinary team5. Requires a care management system 6. Requires a focus on the individual and the population

Barriers for Prospective Payment

1. If payments are actuarially unsound2. If system is complex to administer3. If population is not identified in advance

4. Requires an interdisciplinary team5. Requires a care management system 6. Requires a focus on the individual and the population

Barriers for Prospective Payment

1. If payments are actuarially unsound2. If system is complex to administer3. If population is not identified in advance4. Requires an interdisciplinary team

5. Requires a care management system 6. Requires a focus on the individual and the population

Barriers for Prospective Payment

1. If payments are actuarially unsound2. If system is complex to administer3. If population is not identified in advance4. Requires an interdisciplinary team5. Requires a care management system

6. Requires a focus on the individual and the population

Oral Health And The

Dental Benefits were designed in the 1960`s

Study with Navigant

Fee-for-Service in Dental Rewards Invasive Care

Prophy Amalgam Composite CrownFee $64 $92 $152 $1,100 Cost of service $175 Net $64 $92 $152 $925 Time (hours) 0.5 0.5 0.67 1.5Gross hourly rate $128 $184 $228 $617 Overhead cost/hr $140 $120 $120 $120Net hourly Income ($12) $64 $108 $497 Profit in 8 hour day ($96) $512 $864 $3,973 Annualized Profit/Loss ($21,600) $115,200 $194,400 $894,000

Actual

Desired

What We Do

What WeKnow

Quality Care :“The degree to which health care services for individuals and populations increase the likelihood of desired health outcomes and are consistent with current professional knowledge."

Bacteria

What Causes Tooth Decay?Sugar

Tooth Time

ACID!

Caries Management – Science and Clinical Practice. Hendrik Meyer-Lueckel, Sebastian Paris, Kim R. Ekstrand. Thieme Medical Publishers. NY 2013

Fluoride Effect

Secondary Prevention - Remineralization

Winston AE, Bhaskar SN. Caries Prevention in the 21st Century. JADA, Vol. 129, Nov ’98: p1579-1587

D2150 $122D2392 $199Remineralization $0

Institute of Medicine (IOM) definition of quality of care: "the degree to which health care services for individuals and populations increase the likelihood of desired health outcomes and are consistent with current professional knowledge."

Early Stage

Late Stage

Early StageReversible

Elevated Risk Late StageNon-reversible

Re-restoration Stage

At Risk Reversible Irreversible

Primary Prevention Secondary Prevention

Tertiary Prevention

Primary Care Specialty

• Dietarycounseling

• Behavior modification

• Fluoride varnish• Dental sealant

Remineralization • Restorations• Pulpotomy• Simple

endodontics• Simply

extractions

• Endodontics• Perio surgery• Complex

prosthodontics• Oral surgery• Orthodontics

• Dental Assistant$17.13

• Medical Assistant $14.80

• Nursing Assistants $12.51

• Dietetic Tech $13.74

• Dental Hygienist $34.39

• Physician Assistant$45.36

• Nurse Practitioner $45.71

• General Dentist $79.12

• Pediatric Dentist

• Oral Surgeon $105.27

• Orthodontist $94.36

• (not all specialists had income captured by BLS)

Non-Dentist Dental SurgeonGlobal Payment: Earlier Diagnosis and Prevention

Fee for Service: the more invasive and frequent, the more profitable

Increase in Prevention, Decrease in Treatment

72.6% 73.1%

22.7% 22.5%

80.2%

87.3%

16.0%9.3%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

2010 2011 2012 2013 2014 2015 2010 2011 2012 2013 2014 2015

Delta OHC

Type I BenefitsDiagnostics and Prevention

Type II BenefitsTreatment of Disease

DQ OfficeAll Providers

DQ Evidence Based Practice

DQ Office versus All Providers

$404.22 $408.12 $422.52$438.11

$415.81

$374.92 $367.13 $370.00$390.66 $396.69

$269.49 $264.97 $262.85 $267.07$250.78

$207.95

$251.42 $257.85 $243.44 $233.50

67% 65%62% 61%

60%

55%

68% 70%

62% 59%

0%

10%

20%

30%

40%

50%

60%

70%

80%

$0

$50

$100

$150

$200

$250

$300

$350

$400

$450

$500

2011 2012 2013 2014 2015 2011 2012 2013 2014 2015

All Providers DQ Office Percent

Commercial Plan Medicaid Program

DQ Evidence Based Practice

44

Risk-Based Disease Management ProtocolsINITIAL OR RECALL APPT• Medical history• Exam/X-rays• Caries Risk Assessment (CRA)• Behavioral assessment VISIT 1

• Self-management goals (diet, oral hygiene, home fluoride)• Fluoride varnish• Indicated clinical care

DISEASE MANAGEMENT VISIT• Clinical/X-ray exam• Caries Risk Assessment• Fluoride varnish• Re-define or re-emphasize self-management goals• Behavioral assessment

RESTORATIVE ITR VISIT(S)• Provide restorative care as

indicated• Provide ITR as indicated• Schedule OR time if indicated

CHILDREN AT HIGH RISK• Schedule next Disease

Management visit in 1 month

CHILDREN AT MEDIUM RISK• Schedule next Disease

Management visit in 3 months

CHILDREN AT LOW RISK• Schedule next Disease

Management visit in 6 month

44

Oregon and NASHP

• Proposed Payment Reform to FQHCs• Value – based Payment

FQHC Payment Reform

In 2011, the Oregon Primary Care Association (PCA)approached the Oregon Health Authority, the state’s Medicaid agency, with interest in developing a payment system that could support FQHC operations without regard to the frequency of face-to-face encounters while enabling FQHCs to successfully assume responsibility for a defined population. PCA leaders thought such a payment system could enable FQHCs to deliver better care, while making them more attractive places to work. This could address ongoing hiring and recruitment challenges.

Decoupling Payment from VisitsCould:

• Eliminate the incentive for FQHCs to generate more and potentially unnecessary encounters with Medicaid enrollees

• Enable FQHCs to focus efforts on high-risk/high-needs patients, keeping these individuals healthy and out of the hospital through traditionally unreimbursed activities

• Paving the way for value-based alternatives that align reimbursement with Triple Aim objectives.

Oregon: Testing a Voluntary APM

• Oregon has now proposed a voluntary APM for willing FQHCs to the Centers for Medicare & Medicaid Services (CMS). FQHCs will have the option to receive payment under this proposed system—there is no requirement to transition away from PPS. Here’s how the APM will work:

Oregon FQHCModel

1)Attributing patients: The Oregon Health Authority will identify Medicaid enrollees who have historically received care at participating FQHCs. These patients will be “passively attributed” to participating FQHCs.

2) Calculating per member per month (PMPM) rates: Actuaries will analyze information on historical utilization for the attributed patient population, as well as current PPS rates, to develop an all-inclusive monthly PMPM rate for FQHCs. The PMPMs will be set as to deliver the same level of support for FQHCs that they have historically received (assuming the number of encounters with attributed patients remains constant). Therefore, the APM will be budget neutral for the state—a key requirement given Oregon’s fiscal challenges.

Oregon FQHC Model

3) Making PMPM payments: Medicaid fee-for-service, Medicaid managed care plans, and Coordinated Care Organizations will make PMPM payments to participating FQHCs. The Oregon Health Authority will directly “wrap around” plans’ payments to FQHCs if the plans’ rates are lower than the calculated rate. (This is similar to wrap-around payments that the Oregon Health Authority currently pays under PPS.)

Oregon FQHC Model

4) Reconciling (if needed): At the end of the year, the state will examine encounter data to determine what each participating FQHC would have been paid under PPS for the preceding year. If the amount of the aggregated PMPM payments is less than this figure for any given FQHC, the state will make a supplementary payment. Oregon expects that participating FQHCs will bill fewer encounters than they have historically—so reconciliation payments will not be necessary. However, a provision for reconciliation is required by federal law, which specifies that APMs must pay no less than PPS.

Oregon FQHC Model

5) Monitoring: The state will monitor a set of quality and access measures to ensure that FQHC performance improves or holds steady. These selected metrics will align with existing measures that many FQHCs are already reporting.

Oregon: Initial FQHC Pilot

• Three large FQHCs volunteered to pilot the APM once CMS granted approval.

• In the future, Oregon hopes to expand the pilot program to additional FQHCs.

• The state is also interested in eventually including mental health and dental services in the all-inclusive PMPM rates.

• Adolescent well-care visits (NCQA)

• Alcohol or other substance misuse (SBIRT)

• Ambulatory Care: Emergency Department utilization

• CAHPS composite: access to care

• CAHPS composite: satisfaction with care

• Childhood immunization status (NQF 0038)

• Cigarette smoking prevalence

• Colorectal cancer screening (HEDIS)

• Controlling high blood pressure (NQF 0018)

• Dental sealants on permanent molars

2016 Oregon Health Authority CCO Incentive Measures

• Depression screening and follow up plan (NQF 0418)

• Developmental screening in the first 36 months of life (NQF 1448)

• Diabetes: HbA1c Poor Control (NQF 0059)

• Effective contraceptive use among women at risk of unintended pregnancy

• Electronic health record (EHR) adoption

• Follow-up after hospitalization for mental illness (NQF 0576)

• Mental, physical, and dental health assessments within 60 days for children in DHS custody

• Patient-Centered Primary Care Home Enrollment •

• Prenatal and postpartum care: Timeliness of Prenatal Care (NQF 1517)

2016 Oregon Health Authority CCO Incentive Measures cont.

Sealants Significantly Reduce Decay!

Decayed Teeth, 1,000

Decayed Teeth, 400

Decayed Teeth, 63

Decayed Teeth, 700

Decayed Teeth, 189

Saved Teeth, 338

Saved Teeth, 511

0

100

200

300

400

500

600

700

800

900

1000

Total Teeth No Sealant 40% w/ Seal No Sealant 70% w/Seal

Decay Rate for 1000 Teeth With & Without Sealants

In a population with a 40% decay rate, 338 out of 400

teeth that would have gotten decay will be saved

In a population with a 70% decay rate 511 out of 700 teeth that would

have gotten decay will be saved

15.6% of 6-9 Year Olds in Medicaid Received a Sealant in 2014

84%

73%

1. Percentage of children who receive a risk assessment with each initial or periodic oral evaluation

2. Percentage of children whose risk assessment moved towards higher risk from the previous risk assessment

3. Percentage of children whose risk assessment was lower than the previous risk assessment.

4. Percentage of elevated risk children who receive a topical fluoride at least every six months during measurement period.

5. Average number of fluoride treatments during the six month period for the population of elevated risk children

Oral Health Quality Process Metrics for Children

Oral Health Quality Process Metrics for Children

6. Percentage of elevated risk children age 6 thru 9 who receive a dental sealant on a first permanent molar during the measurement period7. Average number of sealants placed per child on permanent first molars for children at elevated risk ages 6 thru 9.8. Percentage of elevated risk children age 10 thru 14 who receive a dental sealant of a first permanent molar during the measurement period.9. Percentage of elevated risk children age 3 to 5 that received a sealant on a primary molar10. Average number of sealants placed per child on a primary molar for children at elevated risk ages 3 to 5.11. Percentage of patients of record (had at least one oral evaluation in year prior to measurement year and no record of transfer) that had an oral evaluation in measurement period.

Oral Health and Pay for Performance

1. What is Oral Health`s Value Proposition?

2. Who should we be watching and learning from?

3. Which areas of “waste” should we be focusing on?

4. What are the priorities?

5. If the Medical Model is better, why won’t dentists simply change?

6. What changes do we need in the other systems to enable us to change the Care System?

7. How can we work with Health Benefit Stakeholders?

550 N 3rd St, Phoenix, AZ 85004Tel: 602.803.4228 Safetnet.asu.edu

Advancing the Health Safety Net

Partnering to Strengthen and Preserve the Oral Health Safety Net

A PROGRAM OF THE2400 Computer Drive, Westborough, MA 01581 Tel: 508.329.2280 | Fax: 508.329.2285 www.dentaquestinstitute.org