Value-Based Payment for Oral Health in an Accountable Care Organization
Leonard B. Goldstein, DDS, PhD; Mariam Alshukri, MS; Robert Trombly, DDS, JD; and Jack Dillenberg, DDS, MPH
Many state Medicaid programs have developed value-based payment (VBP) approaches to improve the quality and cost-effectiveness of physical health services and, more recently, behavioral health services. Accountable care organizations (ACOs) utilizing integrated, collaborative care delivery system models are being established to pursue what is referred to as the "triple aim": improving the patient experience, reducing per capita costs of care, and improving the health of populations.
VBPs and ACOs, however, typically have not accounted for oral health in their models, representing an opportunity lost. Interprofessional collaborative care models are being developed through the A.T. Still University's Arizona School of Dentistry & Oral Health's Health Resources & Services Administration (HRSA) grant and the new Dillenberg Center's Pacific Dental Services Innovation Clinic. By leveraging these models, advocates are positioned to explore how the inclusion of oral healthcare in VBPs and ACOs can improve the "triple aim" goals for patients and communities.
Discussion
US healthcare is undergoing dramatic payment innovation intended to enhance its value proposition.1 The idea that higher cost is associated with better health outcomes and greater access to care has been replaced by the "triple aim" concept,2 which emphasizes that better health outcomes are possible at lower cost with enhanced patient and population experience through efficiencies, coordination, and accountability.3
To help contain healthcare spending and improve the quality of care, practitioners, payers, and policymakers are moving away from fee-for-service toward value-based payment, which links providers' reimbursement to the value, rather than the volume, of services delivered. Calls for reform in the way healthcare providers are paid were made in the 1930s but began in earnest in the early 1970s after the implementation of the US Centers for Medicare & Medicaid Services (CMS).4 In 1983, Medicare's Hospital Inpatient Prospective Payment System led to more such calls for change.5 The inpatient prospective payment reform was followed by the resource-based Relative Payment Scale, as well as an increase in capitation-based contracting, leading to a backlash against "managed care"; hence, the experiments in pay-for-performance and shared savings.6,7
Currently, VBP models are also referred to as alternate payment models (APMs). An APM is a payment approach that offers incentives to providers to collaborate and provide high-quality and cost-effective care. The transition to value-based care is now a priority of both the private sector and federal government. For example, CMS is committed to shifting Medicare payments from volume to value. In 2015, Medicare set the goal of tying 50% of Medicare fee-for-service payments to quality or value through APMs by 2016.8
Oral-Systemic Connection
The 2019 Santa Fe Group Salon included new data on the net benefits of dental care in reducing total healthcare costs in a Medicaid population. Another study demonstrated that dental prophylaxis across an entire population also reduces total health expenses. In addition, preventive oral care reduces total healthcare costs by decreasing the need for hospitalization-not only reduced use of the emergency room for dental care, but more importantly, less hospitalizations for primary systemic diseases.9
Examples of oral diseases with potentially debilitating consequences if undetected include oral and/or pharyngeal cancers, xerostomia, and severe periodontitis, as well as temporomandibular diseases. Each of these oral manifestations may be an early indicator of systemic problems or untoward response to systemic therapies.10
Due to the high prevalence of oral disease and the known connections to many systemic conditions, there is mounting pressure for the integration of oral health into primary care. Dentistry historically has always been siloed as an independent health profession, alongside but separate from medicine. Where dentistry fits within healthcare reform relative to medical care reform has direct implications for the delivery and financing of dental care in the future.
Like many other health professions, dental education now incorporates training in interprofessional education, providing the foundation for dentists to join other healthcare providers in collaborative practice models. These models support the movement toward value-based care with goals of improving health outcomes, the patient experience, and efficient delivery of patient care. Collaboration among health professionals lowers hospital administration costs, because when multiple health individuals or organizations work together in a cohesive manner, duplication of examinations, tests, and procedures can be reduced.
This trend became apparent in a relatively recent regional collaborative improvement program implemented in Michigan. The collaboration resulted in improvements for a range of clinical conditions and reduced costs in several important areas and led to an estimated annual savings of approximately $20 million.11 Additionally, collaboration among health professionals, especially in regard to patient diagnosis, should produce more concrete diagnoses and care-plans for patients with complicated diseases, further improving outcomes and reducing costs. These developments, along with new diagnostic technologies such as salivary biomarkers, and an increased emphasis on primary care create the opportunity for dentists to incorporate general medical health screening, immunizations, and monitoring of chronic systemic conditions into their practices.12
The integration of new technology based on artificial intelligence (AI) will contribute to the improvement of patient management, health outcomes, and reduced cost as demonstrated by its use at Mount Sinai Hospital in New York, which last year partnered with AI healthcare start-up RenalytixAI to create an AI tool that identifies patients at the hospital who are at risk for advanced kidney disease. New technologies are also providing the foundation for other changes in healthcare delivery models, making value-based care possible. Personalized or precision medicine takes into account the individual variability of each patient and offers the potential to develop more accurate treatment and preventive strategies. These models allow patient-centered care, where providers have better opportunity for more personalized interactions with their patients, which in turn can increase patient confidence and compliance with planned treatment. Ultimately, this compliance improves efficiency and reduces administrative costs, as verified by Bertakis and Azari, who reiterated that patient-centered care is associated with decreased utilization of healthcare services and lower total annual charges.13 Additionally, with a patient-centered care model, physicians will likely be more inclined to implement chronic disease prevention programs to improve the overall quality of a patient's health, which also will reduce administrative costs in the long run.
Overcoming Hurdles
A number of hurdles may slow progress toward VBP systems. A major issue the healthcare field faces today is that despite a trend toward increased electronic medical record (EMR) implementation, a wide variety of formats and implementations still are used by various organizations. An important step in reducing administrative costs and improving the quality of provided healthcare is to encourage the adoption of a single EMR format on at least a local scale. This implementation will be essential because incomplete electronic record transfer among incompatible EMR systems can lead to costly duplicate testing.14
Another key area for standardization is the billing and transaction systems used by healthcare organizations, including primary providers, hospitals, and insurance companies. Having a varied collection of systems wastes time and resources through recurring compatibility and miscommunication issues. To incentivize organizations to change, they should be made aware of the financial gains that are possible through implementing a more standardized billing and transaction system and new patient management technology.
The "triple aim" framework, first articulated in 2007, can be summarized relatively simply: improve the patient experience and the health of populations while reducing per capita cost. This concept at the time was considered to be radical, and movement in the direction of "triple aim" over the past dozen years has proven to be elusive and challenging in our fragmented healthcare system. Providers, payers, and policymakers all must act collaboratively to unearth multiple innovative strategies to move the healthcare profession toward better health outcomes for patients. Advances in technology, including those associated with precision medicine, AI, and application of "big data," will continue to make a positive impact in the long term.
The integration of oral health into VBP approaches is one relatively simple short-term strategy that will help move the healthcare system in the direction of "triple aim." The foundation for this integration has been established over the past several years as new healthcare providers have been trained through interprofessional education models. This continued integration should encourage the development of alternative collaborative care delivery models to further enhance the patient experience. Most significantly, the integration of oral health into VBP should improve patients' oral and overall health and the population health of communities in a more cost-effective manner.
Leonard B. Goldstein, DDS, PhD
Assistant Vice President for Clinical Education Development, Arizona School of Dentistry & Oral Health, A.T. Still University, Mesa, Arizona; The ATSU Center for the Future of the Health Professions
Mariam Alshukri, MS
OMS-II Curriculum Coordinator, School of Osteopathic Medicine in Arizona, A.T. Still University,
Mesa, Arizona
Robert Trombly, DDS, JD
Dean, Arizona School of Dentistry & Oral Health, A.T. Still University, Mesa, Arizona
Jack Dillenberg, DDS, MPH
Dean Emeritus, Arizona School of Dentistry & Oral Health, A.T. Still University, Mesa, Arizona; The ATSU Center for the Future of the Health Professions
References
1. de Brantes F, Rosenthal MB, Painter M. Building a bridge from fragmentation to accountability-the Prometheus Payment model. N Engl J Med. 2009;361(11):1033-1036.
2. Kissick WL. Medicine's Dilemmas: Infinite Needs Versus Finite Resources. New Haven, CT: Yale University Press; 1994.
3. Berwick DM, Nolan TW, Whittington J. The triple aim: care, health, and costs. Health Aff (Millwood). 2008;27(3):759-769.
4. Feldstein MS. The rising price of physicians' services. Rev Econ Stat. 1970;52(2):121-133.
5. Hodgkin D, McGuire TG. Payment levels and hospital response to prospective payment. J Health Econ. 1994;13(1):1-29.
6. Van Herck P, DeSmedt D, Annemans L, et al.Systematic review: effects, design choices, and context of pay-for-performance in health care. BMC Health Serv Res. 2010;10:247.
7. Conrad DA, Perry L. Quality-based financial incentives in health care: can we improve quality by paying for it? Annu Rev Public Health. 2009;30:357-371.
8. Better care. Smarter spending. Healthier people: paying providers for value, not volume. Fact Sheet. Washington, DC: Centers for Medicare & Medicaid Services; January 26, 2015. https://www.cms.gov/newsroom/fact-sheets/better-care-smarter-spending-healthier-people-paying-providers-value-not-volume. Accessed October 8, 2019.
9. Alfano MC. Teeth in Medicare movement gains momentum-let's challenge the system! Inside Dentistry. 2019;15(6):12.
10. Lee JS, Somerman MJ. The importance of oral health in comprehensive health care. JAMA. 2018;320(4):339-340.
11. Share DA, Campbell DA, Birkmeyer N, et al. How a regional collaborative of hospitals and physicians in Michigan cut costs and improved the quality of care. Health Aff (Millwood). 2011;30(4):636-645.
12. Hummel J, Phillips KE, Holt B, Hayes C. Oral health: an essential component of primary care. June 2015. https://www.safetynetmedicalhome.org/sites/default/files/White-Paper-Oral-Health-Primary-Care.pdf. Accessed October 8, 2019.
13. Bertakis KD, Azari R. Patient-centered care is associated with decreased health care utilization. J Am Board Fam Med. 2011;24(3):229-239.
14. Stewart BA, Fernandes S, Rodriguez-Huertas E, Landzberg M. A preliminary look at duplicate testing associated with lack of electronic health record interoperability for transferred patients. J Am Med Inform Assoc. 2010;17(3):341-344.
