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transcript

Confidential and Proprietary

Learning & Informatics Summit 2018

Learning &

Informatics

Summit

Lynn Douglas Mouden, DDS, MPHVice President, Quality and Performance

Avēsis Incorporated - a GUARDIAN Company

Government

Dental Programs:

Present, and

Future

The Past

A Brief History of Dental Time

From Barbers to Stomatology

Baltimore College of Dental Surgery

Cottage Industry

Flexnor Report - Gies Report

The “Busyness” Problem

29 CFR 1910

Shortage or Maldistribution

Medical-Dental / Dental-Medical Collaboration

The Patient Protection and Affordable Care Act

Program Integrity

A Little Personal History

What Does it Take to Work in Government?

Patience, not Patients

Centers for Medicare & Medicaid Services

US Department of Health and Human Services

CMS Chief Dental Officer

CMSCenterS for Medicare & Medicaid Services

• Center for Medicare (CM)

• Center for Medicaid and CHIP Services (CMCS)

• Center for Medicare and Medicaid Innovation (CMMI)

• Center for Clinical Standards and Quality (CCSQ)

• Center for Consumer Information and Insurance Oversight (CCIIO)

• Center for Program Integrity (CPI)

67 Medical Officers

Dental Officers?

Now none !!!

“The world is moving so fast these days that when someone says ‘cannot’

you come across someone who has already ‘done’.”

Variously attributed to Elbert Hubbard,

Robert Kriegel and others

Why Government Relies on

the Private Sector

Medicaid – Federal and State Partnership

“The powers not delegated to the United States by the

Constitution, nor prohibited by it to the

States, are reserved to the States respectively, or to

the people.”

The Present

What CMCS Tracks -Ergo, what states care about

The CMS Form 416

Total number of children (enrolled for at least 90 days) receiving: (each line represents an unduplicated count of children)

• Line 12a – any dental service (by or under the supervision of a dentist)

• Line 12b – a preventive dental service

• Line 12c – a dental treatment service

• Line 12d – a sealant on a permanent molar tooth

• Line 12e – a dental diagnostic service

• Line 12f – an oral health service provided by a non-dentist (and not under the supervision of a dentist)

• Line 12g – any dental or oral health service (12a+12f)

Child Core Set

• Optional –

• but dental data is derived from the 416

• TDENT is history

• PDENT

• SEAL – requires additional data

HEDISWhat Plans Care About

Annual Dental Visit

The CDT and the Code Maintenance Committee

CDT:Risk Assesment

Since 1-1-14

• D0601 = Risk assessment – high risk

• D0602 = Risk assessment – moderate risk

• D0603 = Risk assessment – low risk

CDT does not specify the assessment tool

A proxy for diagnosis codes?

CDT:Case Management

Case management - first came up for inclusion in CDT 2016

After resubmission, since 1-1-17

• D9991 = Addressing appointment compliance barriers

• D9992 = Care coordination

• D9993 = Motivational interviewing

• D9994 = Patient education to improve oral health literacy

CDT:Silver Diamine Fluoride

(MSDA Corporate Roundtable 2014)

“Interim caries arresting medicament application” added for 2016 (per application)

For CDT 2018:• D1354, per tooth instead of per application

Quality

The Dental Quality Alliance

Lack of standardized, validated

dental quality measures

“Oral health lags significantly behind the remainder of the health care system in developing quality measures, and as a result, little is known about the quality of oral health care.”

IOM Report: Advancing Oral Health In America, Key Findings and Conclusions

“Many complex and interrelated factors contribute to poor oral health and lack of access to oral health care, including . . . a lack of quality measures by which to evaluate and improve oral health care.”

IOM Report: Improving Access to Oral Health Care for Vulnerable and Underserved Populations, Findings and Conclusions

Quality Measurement

2008 – CMS state findings…

http://www.medicaid.gov/Medicaid-CHIP-Program-Information/By-Topics/Benefits/Downloads/2008-National-Dental-Sum-Report.pdf

http://www.hhs.gov/asl/testify/2008/09/t20080923b.html

Dental Quality Alliance: CMS is interested in forming a Dental Quality Alliance (DQA)

and is currently in discussion with the American Dental Association (ADA) to begin

this process. The DQA would bring together parties from many aspects of oral

health fields including national dental organizations, Federal and State partners,

payers and consumers to begin working together on measurements that could be

used by State for purposes of improving the delivery of oral health services and the

development of quality measures. These measures could ultimately be used to

enhance reporting on the CMS form 416 or through state-based value based

purchasing initiatives. While children eligible for Medicaid will be the primary area

of concern, the DQA will also address dental services for the adult population.

Providers

Specialties

Educators

Federal Agencies

Payers

Public

DQA MissionAdvance the field of performance measurement to improve oral health, patient care, and safety through a consensus building process.

DQA Membership

DQA Measures - Children

• Use of Services

• Oral Evaluation

• Topical Fluoride for Children

• Sealants in 6-9 year-olds

• Sealants in 10-14 year-olds

• Ambulatory Care (ED visit for caries-related reason)

• Follow-Up After ED Visit

• Periodontal Evaluation in Adults with Periodontitis

• Ongoing Care in Adults with Periodontitis

• Topical Fluoride for Adults at Elevated Caries Risk

DQA Measures - Adults

Dental Diagnosis Codes

•EZ Codes

•DDS

•SnoMed

•SnoDent

•SNODDS

•SNODDS GP

Dental Diagnosis CodesThe Arkansas Requirement

• ICD-10 (International Classification of Diseases)

• Z01.20 - Encounter for dental examination and cleaning without abnormal findings

• Z01.21 - Encounter for dental examination and cleaning with abnormal findings

What Policymakers See:

Media Scrutiny on

Quality in Dentistry

Program

Integrity:

Program Integrity –Dentists’ Viewpoint

• Why do we have them?

• How do they work?

• PI is more than audits!

• Should be important to all dentists

• CMS • CPI

• Payment Error Rate Measurement (PERM) Audits

• OIG (DHHS)

• FBI

(A new view from my Avesis role)

Program Integrity –Federal Viewpoint

Centers for Medicare & Medicaid Services

The seven elements of a compliance program can be summarized as:

1. Written policies

2. Designation of compliance officer/contact(s)

3. Training

4. Communication

5. Monitoring

6. Enforcing disciplinary standards

7. Responding promptly

Office of Inspector General (DHHS)

Office of Inspector General (DHHS) Reports

“Questionable Billing for Medicaid Pediatric Dental Services…”in NY, IN, LA, and CA (2014, 2015)

“Required Dental Services” (2016)

CMS CIB on periodicity schedules (2018)

The Future of Medicaid?

A Brief History of Dental Time

From Barbers to Stomatology

Baltimore College of Dental Surgery

Cottage Industry

Flexnor Report - Gies Report

The “Busyness” Problem

29 CFR 1910

Shortage or Maldistribution

Medical-Dental / Dental-Medical Collaboration

The Patient Protection and Affordable Care Act

Program Integrity

C. U. B. A.

More “Predictions”

Medicare

• 10,000 / day

• Parts A, B, C, D

• Dual-eligibles

• Will there ever be a dental benefit?

• Section 1862

• Funding

• Workforce

• Need vs. demand

• Who would run it?

In Many Ways …

Medicare often drives the

conversation

The possibilities ??

• National Coverage Determination – precedent

• CMMI

• Congress

Still possible?

A Medicare Dental Benefit

Value-Based Payment, ala Medicare

CMS adopted a framework that categorizes payment to providers

Payments are based on volume of services and

not linked to quality or efficiency

Category 1:

Fee for Service – No Link to Value

Category 2:

Fee for Service – Link to Value

At least a portion of payments vary based on the

quality and/or efficiency of health care delivery

Category 1: Fee for Service – No Link to Value

Category 2: Fee for Service – Link to Value

Category 3: Alternative Payment Models Built on

Fee for Service Architecture

Some payment is linked to effective management

of a population or episode of care

Payments still triggered by delivery of services -

opportunities for shared savings or 2-sided risk

Category 4:

Population-based Payment

Payment triggered by service delivery so volume

is not linked to payment

Responsible for the care of a beneficiary for a

long period (e.g., ≥1 year)

Category 2: Fee for Service – Link to Value

Category 3: Alternative Payment Models Built on FFS Architecture

Lynn Douglas Mouden, DDS, MPH

Vice President, Dental Director –

Quality and Performance

A National Vision, Dental and Hearing Company

The Real World

410-413-9116lmoudendds@avesis.com

Avēsis Incorporated - a GUARDIAN Company

QA vs. QI – outputs vs. outcomes

The Avesis Quality Improvement Program:

Quality Assurance and Program Improvement (QAPI)

Performance Improvement Projects (PIP)

Questions

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