Oral HealthValue-Based Care Training Workshop:Creating a Value-Based Oral Health Care Delivery System
The Falls Event Center - Manchester, NH
Monday, November 18, 2019 | 9:00 a.m. – 4:00 p.m.
Tuesday, November 19, 2019 | 8:00 a.m. – 4:30 p.m.
WELCOME & INTRODUCTIONS
Stephanie Pagliuca
Hillary Colcord
Danielle Apostolon
3
www.dentaquestpartnership.org
Resource libray
DENTAQUEST PARTNERSHIPFOR ORAL HEALTH ADVANCEMENT
November 22, 2019
5
Our Mission
IMPROVE THE ORAL HEALTH OF ALLDentaQuest is driven by our mission to improve the oral health of all, to achieve a nation free of dental disease.
6
Our Approach
Preventistry is our all-in approach to
revolutionizing oral health in fundamental ways
PREVENTISTRY®
CARE VALUE INNOVATION TRANSFORMATION
7
MISSION To improve the oral health of all
ORGANIZATIONBenefits Business
Increasing access to
care
Care Delivery
Scaling person-centered care
nationwide
Impact Group
Driving meaningful change,
innovation and growth
BY THE NUMBERS 27+ million members
Benefits administration in 30+ states
Care delivery practices in 5 states
Nearly 3,000 employees
Headquartered in Boston, with offices in 6 other states
Ranked “Highest in Customer Satisfaction with Dental Plans”
for 3 consecutive years by J.D. Power and Associates
DentaQuest: the Basics
8
The DentaQuest Partnership for Oral Health
Advancement is a nonprofit organization laser-focused
on transforming our broken health care system to
enable better health through oral health.
9
What We’re Focused On
10
WHY ARE WE HERE?
11
Overarching Training Objectives
• Lay the groundwork for a dental program-specific learning community to
accelerate success in VBC ecosystems.
• Discuss healthcare transformation related to integrated health systems and
patient-centered approaches to oral health.
12
• Facilitate a panel discussion on current state policy and related initiatives.
• Outline the key tenants necessary to provide value-based care to the safety net,
how the care gets delivered to at risk populations and what would it take to provide
that care.
Today’s Learning Objectives – Day One
13
Agenda
Person-Centered Care and a Changing Oral Health Landscape
Laying the Groundwork for Oral Health Value-Based Care
Table Discussion: SWOB Analysis
Panel: The Journey to Value-Based Care State by State
Exercise: Mapping Out Who are the Partners & Resources in Each Sate
Lunch
Closing/Wrap-Up
14
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 Director’s Experience in Risk-Based Oral Health Managed Care
Promising Practices from the Field
Closing/Wrap Up
15
PERSON-CENTERED CARE ANDA CHANGING ORAL HEALTH LANDSCAPECarolyn Brown, DDS, MA
November 18th, 2019
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• Consultant working with DQP, FQHCs, Primary Care Associations and Foundations advancing oral health programs
• DQP/SNS Expert Advisor
• IHI Improvement Coach
• Former Dental Director
• Research, Marketing, Finance
Carolyn Brown, DDS
Consultant, Acting Director of Value-Based Care
DentaQuest Partnership for Oral Health Advancement
• DDS, University of Maryland School of Dentistry
• BS, University of Maryland
• MEd, University of the Pacific
• Speaker, researcher, expert advisor, review panel
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Learning Objectives
• Describe the changing oral health landscape and impact on the way care is
delivered.
• Discuss patient-centered care in oral health systems.
• Review the importance of prevention and a disease management approach.
19
20
21
• $3.7 trillion
• $10,739 per
person
• 17.9% of GDP
2017 National Health Expenditures
2017 Kaiser Family Foundation
22
HCP LAN Framework
2019 HCP LAN: APM Measurement Report:; HCP LAN Framework
23HCP LAN Roadmap to Success; Executive Summary
24
MOVING FROM VOLUME TO VALUE
25
Measuring What Matters- Fragmented System of Care Today
Private Practice Office
# New patients seen
Assigned vs seen if capitated
# Treatment plans incomplete
$ produced & per provider
$ collected & monthly per provider
CDT 6000 codes completed
Recall/Hygiene maintenance
Based on this consultant's experienced
FQHC
# Unduplicated patients
# Patients seen per day
# Treatment plans complete
$ gained/lost via accounting
Broken appointment rate
# procedures
Sealant rate (annual)
26
2019 DentaQuest Research Report: Reversible Decay
Reversible Decay: Oral Health is a Public Health Problem that We Can Solve. DentaQuest
Research Report 2019
27
Oral Health Value-Based Care
https://doi.org/10.1016/j.jebdp.2019.101344
1
2 3 4
5
https://doi.org/10.1016/j.jebdp.2019.101344
28
Average Per Patient Spending on Dental in Medicaid, by Age
and Plan Type, 2017
$0.00
$100.00
$200.00
$300.00
$400.00
$500.00
$600.00
0 2 4 6 8 10 12 14 16 18 20 22 24 26 28 30 32 34 36 38 40 42 44 46 48 50 52 54 56 58 60 62 64 66 68 70
FFS - National Medicaid Average APM - National Medicaid Average
DQP analysis to be published January 2020. Analysis of the IBM Watson MarketScan Multi-State Medicaid Database, 2017
29
0%
10%
20%
30%
40%
50%
60%
70%
0 2 4 6 8 10 12 14 16 18 20 22 24 26 28 30 32 34 36 38 40 42 44 46 48 50 52 54 56 58 60 62 64 66 68 70 72 74 76 78 80 82 84 86 88
% o
f En
rolle
d A
cces
sin
g D
enta
l Ser
vice
s
FFS - National Medicaid Average APM - National Medicaid Average
Dental Service Utilization Rate, by Age and Plan Type, 2017
DQP analysis to be released January 2020. Analysis of the IBM Watson MarketScan Multi-State Medicaid Database, 2017
30Modified from Source: Agency for Health Research and Quality
…From …To
Provider Centric FOCUS Patient Centric/Consumer
Value Blind Reimbursement VALUE Value-based Reimbursement
Episodic Fragmented CarePATIENT
FLOWContinuous & Coordinated
Dental Office/OperatoryDELIVERY
SETTINGOffice + Community Setting
Individuals APPROACH Population Based
Disease and Treatment OBJECTIVE Health/Wellness & Prevention
31
INTERPROFESSIONAL PRACTICE
32
Interprofessional Practice: The Win-Win for FQHCs
Advantages
• Co-location
• Shared leadership
• Interoperability
• Shared patient population
• Improves patient outcomes
• Lowers patient financial burden
• Lower unit cost of care delivery
Source: National Network for Oral Health Access October 2019 “Integrated Models Survey Results: Embedded Dental Providers”
33
Most oral diseases and conditions
share modifiable risk factors (such as
tobacco use, alcohol consumption and
unhealthy diets high in free sugars)
common to the four leading
NCDs (cardiovascular diseases,
cancer, chronic respiratory diseases
and diabetes).
Break Down the Silos
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CREATING AND MAINTAINING INTERPROFESSIONAL CARE NETWORKS
35
Bridging the Gap….
Reversible Decay: Oral Health is a Public Health Problem that We Can Solve. DentaQuest Research Report 2019
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Evolving Interprofessional Practice in Oral Health
Adapted from Oralhealthworkforce.org
• Case Manager, Case Workers, LCSWs
37
New Staffing Models: Access and Care Coordination
CDHC’s -Community Dental Health Coordinator (ADA)
EFDAs – Enhanced Function Dental Assistants
Advanced Public Health Hygienists
Dental Therapists
Embedding RDH in Primary Care
Behavorial health embedded in Dental
Shared Clinical Support: all centers, medical records clerks, central registration
38
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Clinical:
Improvement in overall health status*
Complete Phase 1 treatment plans*
Retention in dental care*
Significantly higher*:
Treatment plan completion
Retention in specialty care
Low intensity preventive services
Care Coordination - Example of HRSA SPNS Project, NAHC
Patients:
Availability of DCM
Increase access
Knowledge
Empathy and comfort
Credited overall health improvement
to Dental Case Mngt
Reported higher quality of life*
LeMay et al (Brown),Dental case manager encounters: the association with retention in dental care and treatment plan completion. Spec Care Dentist. 2013 Mar-Apr;33(2):70-7.
*Brown C, Ponnala S, Kim J. Oral Presentation: “Maximizing Clinical and Health Outcomes: HIV+ Dental Case Management”. International Association for Dental Research, Miami, FL. 2009.
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PATIENT-CENTERED CAREEngaging and supporting patients, families and communities
41
DentaQuest’s Approach to Person-Centered Care
42
Patient Centered Approach
• Educate patients about why keeping appointments is important; scripting
can help
• Patients who feel engaged and empowered may be more likely to show for
appointments
• Important for all patients to keep appointments, but especially patients at
elevated risk of disease
• Care coordination for patients at elevated risk may be effective in removing
barriers and improving show rates
• Patients with high levels of anxiety related to dental care are at increased
risk for failed appointments
43Yara A. Halasa-Rappel, DMD, PhD; Avery R. Brow MA2; Julie Frantsve-Hawley, PhD, CAE; Eric P. Tranby, PhD. https://www.dentaquestpartnership.org/system/files/Poverty%20Report.pdf
https://www.dentaquestpartnership.org/system/files/Poverty Report.pdf
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Patient Centered Approach – Financial Impact to Patients
• Dollars out of pocket are REAL for our patients
• Waiting room time to no more than 8 minutes
• Discuss Patient $ responsibility at 3 times:
• Appointment making
• Appointment Reminder
• At appointment check in
• Front desk empathy, support and tools to discuss $ of dental visit
• Track % of visits per day with 100% collection, including nominal fee
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PREVENTION:Risk assessments and Care Pathways
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Risk Assessment and Care Pathways
Triage framework
Conditions and clinical factors
Gaps in care and quality
Likelihood of disease progression
Identify medications
Care coordination and patient navigation
Receptivity to behavior change or modification
Lifestyle influences- diet, tobacco, alcohol use, physical activity
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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
child’s caries risk
Caries Risk
Level
Recommended
Recare Interval
High Risk 1 – 3 months
Moderate Risk 3 – 6 months
Low Risk 6 – 12 months
Caries
Stabilizing
agents
Health Ed,
Nutritional
Counseling
Anti-bacterial
and Fluoride
interventions
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Disease Management Care Pathways
DentaQuest Partnership for Oral Health Advancement Disease Management Model
Caries
Stabilizing
agents
Whole
Person,
Inter-
professional
Approaches
Anti-
bacterial,
Fluoride
interventions
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Disease Management and Risk Screening Training
DentaQuest Partnership for Oral Health Advancement’s
Online Learning Center
Disease Management Series
8 modules, 4.0 CDE available
https://www.dentaquestpartnership.org/learn/online-learning-center/online-
courseware/dentaquest-disease-management-series
https://www.dentaquestpartnership.org/learn/online-learning-center/online-courseware/dentaquest-disease-management-series
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LAYING THE GROUNDWORK
FOR ORAL HEALTH VALUE-
BASED CARE Mark Koday DDS
52
Objectives
• Define value-based care in oral health and its role in
achieving the quadruple aim
• Discuss the key components that need to be in place for
a value-based care delivery system to succeed
(integration of oral health & overall health, health
information technology infrastructure, workforce,
outcome measures)
• Identify opportunities to be leaders in integrated, value-
based care delivery system
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What is VBR, Where It’s Going and why?
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What Is Value Based Reimbursement?
VBR is an alternative way to pay for health care services. It
shifts the care delivery focus from quantity to value. It applies
financial incentives to reduce costs and improve quality
outcomes.
55
Alternate Payment Models (APM)
Fee For Service (FFS) is not APM- Each health procedure is billed separately
Perspective Payment System (PPS) Payment per billable encounter determined by an average cost/ encounter formula (concentrates on quantity)
Capitation/ Global payment- Providers receive a set payment for all services specified under the contract (Per Member/ Per Month- PM/PM)
Pay For Performance- Incentive payment based on performance goals
Episode of Care/ Bundled Payments- A single payment is made for all services related to defined clinical episode of care
Shared Risk- Upside (shared savings) and Downside (shared loss)
Combinations of the above
56
THE DEVELOPMENT OF VALUE BASED REIMBURSEMENT
V
A
L
U
E
C
O
S
T
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CMS Shift to Value Based Reimbursement
Source: CMS
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Medicaid % CHIP Managed Care Final Rule
(CMS 2390-F) April 25th 2016
Supports State efforts to advance reform in the health care delivery system
Strengthens the beneficiary experience of care and provides more protections
Strengthens the program by increasing accountability and transparency
Aligns key Medicaid and CHIP managed care requirements with other health
coverage programs (i.e. dental)
59
Medical Cost Savings
60
Total Health Expenditures in the United States
2016- 3.3 Trillion
Source: Kaiser Family Foundation analysis of the National Health Expenditure (NHE data from CMMS
61
United Concordia Dental Oral Health Study
https://www.unitedconcordia.com/dental-insurance/dental-health/conditions/ucwellness-oral-health-study/results-
ucwellness-oral-health-study/
https://www.unitedconcordia.com/dental-insurance/dental-health/conditions/ucwellness-oral-health-study/results-ucwellness-oral-health-study/
62
Differences Between Medical and Dental Affecting VBR
progress
Current mix of Medicaid, private insurance and FFS paid directly by the
patients
Evidence based dentistry- not well developed
Diagnostic codes- exist but not routinely used
Outcome indicators not well defined
Lack of clear clinical markers
63
Assumptions in P4P- How do they hold up?
Financial incentives can change provider clinical behavior
A link exists between P4P and true quality improvement
Payers can determine which components of care can actually be impacted by financial incentives
P4P will reduce costs
64
Do Financial Incentives Work?
What amount of financial incentive is needed to change
provider behavior?
Are financial incentives a prime motivator for providers?-
Inconclusive *
Financial incentives may encourage cheating
Timing of payments
Buy-in of the metrics used
Upfront incentives with the potential of payback may work
better **
* Financial Incentives for Improving the Quality of Primary Care E. Salisbury-Afshar Am Fam Physician 2012 April 1;85 (7)
** “Enhancing the Efficacy of Teacher Incentives through Loss Aversion: A Field Experiment,”
National Bureau of Economics Research,
http://www.nber.org/papers/w18237
65
Does VBR Improve Health Outcomes?
Cost savings? Calculations must include all costs including
IT expenses
Incentives to providers up to $1,024 alone were not effective
in changing outcomes *
Do we have the right metrics to measure?
Do we even know how to improve health?
Social Determinants of Heath
*Effect of Financial Incentives to Physicians, Patients, or Both on Lipid Levels-
A
Ramdomized Trial JAMA. 2015;314(18):1926-1935.
doi:10.1001/jama.2015.14850
66
THE CASE FOR VALUE BASED REIMBURSEMENT
The Failure of Our Current Oral Health Delivery System
67
The Yakima Experience: A Case for Dental Value Based Reimbursement
68
Yakima County-1996
•YVFWC 3 clinics; 18 dental chairs; 5 dentists, 3 hygienists
•YNHC 5 chairs; 2 dentists
•IHS clinic: 5 chairs; 3 dentists
•Private practice: about 3 clinics seeing a large # of children
69
Yakima County- 2016
•YVFWC: 6 clinics (including two pediatric dental clinics); 56 dental chairs; 2
residency programs; 8 general dentists; 4 pediatric dentists; 6 pediatric dental
residents; 4 general dental residents
•YNHC: 2 clinics 12 dental chairs; 6 dentists
•IHS clinic: 12 chairs; 3 dentists
•Expanded Private practice access- 4 Pediatric dentists; ABCD program
70
Access Increase From 1986- 2016
•Community Health Clinics:
• Operatories: 14 to 80: 570% increase
• Dentists
• General Dentists: 8 to 17 plus 5 residents:
• Pediatric Dentists: 0-4 plus 6 residents
• 350% increase
•Private Sector: pediatric dentists- 1 to 4; ABCD program
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Child Enrollees with at Least One Dental Service, by County, FY 2014
The average commercial dental
care
utilization among children in the
United States was 58.1 percent. ADA/ Health Policy Institute Research Brief
Dental care Use Among Children Varies Widely Across States and
Between Medicaid and Commercial Plans within a State
72
We Won!!!
73
In Yakima CO- 240% Dental Medicaid Spending Increase in only 4 years
Now spending 8.8 million dollars/ year just for the 0- 5 year old population
74
Is This Sustainable?
Source: WA State HCA financial data
75
Summary of Yakima County Data
Source: WA State Smile Survey data
76
We’ve Achieved Access But Still Failed the
Populations We Serve!!!
What went wrong?
Drill and fill mind set-failure to stop the disease
Only partial medical/ dental integration
Risk assessment without risk follow-up
32% of the Medicaid eligible children did not see a dentist once in the past year
Have not even talked about the state of adult care
No real prevention
No case management
No value based measurement
77
SO HOW DOES VALUE BASED REIMBURSEMENT WORK?
78
Oral Health Delivery Models
Current siloed model– Medical and Dental separate
Current integration models: Dental overlapped with Medical
Fully Integrated model- Dental considered a specialty of medical
79
Reimbursement Models
80
Definitions
Quality Incentives
Coordinated Care Organization (CCO)
Managed Care Organization (MCO)
Dental Care Organization (DCO)
Alternative Payment Model (APM)
Outcome measures
81
Lessons for Ongoing and Future FQHC payment
Reform Efforts in California and Other States
• States should engage and partner with health center associations and managed care associations early on.
• Be clear on care delivery transformation goals before turning to the issue of payment methodology.
• Align the initiative with existing state policy goals.
• Address payment flow and administrative issues with an eye toward reducing the burden on payers and providers, creating a compelling reason for FQHC participation.
* Medicaid is Not Just for Doctor’s Visits: Innovative Early Childhood Funding Strategies
82
Lessons, Continued
Have stakeholder work groups in place to help identify and address technical
issues.
Allocate actuarial resources for data modeling and methodology testing.
Understand how health plan contracts with FQHCs are structured and may vary.
Develop a strategy for communicating the state’s vision to the Centers for
Medicare & Medicaid Services (CMS) before submitting the State Plan Amendment (SPA).
83
ADA formally comments on proposed CMS changes September 11, 2018
CMS is proposing two oral health quality measures
Quality ID-378 Percentage of children, age 0-20, who have had
tooth decay or cavities during the measurement period
Quality ID-379 Percentage of children, age 0-20, who received
a fluoride varnish application during the measurement period
84
Organizational Reporting Requirements
Dashboards: Ideally dialed down to the provider
• Metrics must be timely (data dumped from the day before)
• Metrics must be validated before data is sent to the providers
• Dashboards must be easy to understand
• Benchmarks must be established and attainable
Clinical/ Operational teams
• Analyze data
• Track and analyze clinic work flows
• Define Best Practices
• Spread Best Practices across the organization
85
PROMs and PREMs
Patient Reported Outcomes Measures (PROMs) are surveys patients complete
patients complete that give their view on their health and quality of life.
The information can be used to improve provider and patients discussions on
the best course of treatment help to improve the quality of health care provided
Patient Reported Experience Measures (PREMs) measures the experience the
patient encountered during the health care visit
86
Sample PROMs Questions
Patient-reported outcome measures and patient-reported experience measures Charlotte Kingsley, MBBS BSc FRCA Sanjiv Patel, MBBS BMedSci FRCA BJA Education, Volume 17, Issue 4, 1 April 2017
CURRENT EXAMPLES OF DENTAL VALUE BASED REIMBURSEMENT
88
OHIO: Episodes of Care
Episodes of care- Includes all the care related to a defined medical/ dental event
including the procedure, an acute exacerbation of a chronic condition), including
diagnostic tests, pre-operative visits, the care for the event itself and follow-up
care
They are built from the perspective of a “patient journey” through the health
system
89
Ohio’s Value Based Alternative to Fee for Service
90
Episode Payment Expansion Plans
91
Oregon Health Authority- Performance Metrics
Goals that produce incentive payments to CCOs from the “Quality Pool” (4.25%
of payments to CCOs)
17 CCO Incentive Metrics – two are dental metrics – Children ages 6-9 and 10-
14 who received a sealant on a permanent molar – Physical, mental, and dental
health assessments within 60 days for children in DHS custody
92
Oregon- 2017 Quality Pool Distribution
Source: Oregon Health Authority- Office of Health Analytics 2017 Final Performance
Report
93
CCO 2.0
Oregon now embarking on the next phase of managed
care:
• Improve the behavioral health system
• Increase value and pay for performance (tying 50%
of payments to APM)
• Focus on social determinants of health and health
equity
• Maintain sustainable cost growth.
94
Dental Sealants- Permanent Molars Ages 6-9
Source:
95
Texas Measures
Period of Measurement: 2018
Percentage of DMO Premium Dollars at Risk: 1.5%
Phased in risk share
Measures:
• Dental Quality Alliance- Oral Evaluation
• Dental Quality Alliance- Topical Fluoride
• Dental Quality Alliance- Sealants for children aged 6-9 years
• Dental Quality Alliance- Sealants for children aged 10-14 years
https://www.medicaid.gov/state-resource-center/innovation-
accelerator-program/iap-downloads/functional-areas/vbp-oral-health-
webinar.pdf
96
Redistributive Model, Focused on Improvement
If DMO performance decreases beyond a certain threshold amount overall on
the dental P4P measures, Texas will recoup from the original baseline capitation
The other DMO would only be able to earn recouped money if its performance
improves beyond a threshold amount
97
Texas VBR Results
Source:
98
Changing Service Mix Year Over Year (YOY)
99
Washington State
Managed dental care coming July 1st 2019-
Three Plans have been selected; DentaQuest, MCNA and Delta Dental
WSDA and the CHCs requesting a dental Managed Care Advisory Committee
Abruptly ended the process 2 weeks before it was scheduled to start
New report due to the Legislature this week
100
Dental Managed Care
The State reimburses the dental managed care plans
The dental Plans reimburse the CHCs on a PPS basis
CHC must chose a Plan to enroll in and then enroll their patients in that Plan(s) to receive payment
May have quality incentives (may or may not be passed down to the clinics)
101
7 CHCs seeking Risk Based Managed Care Contracts
The State reimburses the dental managed care plans
The dental Plans reimburse the CHCs on a capitated basis
Capitated revenue is reconciled with the PPS revenue
Revenue is enrollment dependent
CHC must chose a Plan to enroll in and then enroll their patients in that Plan(s) to receive payment
Case management pm/pm
The CHC shares upside and downside risk with the Plan
Quality incentives
102
NCQA and HEDIS Measures
National Committee for Quality Assurance (NCQA) develops and maintains
performance measures for multiple managed care organizations
Healthcare Effectiveness Data and Information Set (HEDIS)
NCQA Government Recognition Initiative & Projects (GRIP) oversees
HRSA contracts supporting the PCMH model in Federally Qualified Health
Centers
One oral health measure- Assesses Medicaid members 2 – 20 years of age
with dental benefits, who had at least one dental visit during the year.
103
National Quality Forum
National Quality Forum (NQF) is a non-profit membership organization that
promotes healthcare quality improvement through measurement and reporting
NQF endorses measures for organizations like the NCQA, , CMS and Physician
Consortium for Performance Improvement
Five oral health measures
104
Dental Quality Alliance
Established by the American Dental Association to develop and enhance performance measures for oral health care.
To advance the effectiveness and scientific basis of clinical performance measurement and improvement.
To foster and support professional accountability, transparency, and value in oral health care through the development, implementation and evaluation of performance measurement.
Members are major stakeholders: ADA, other dental organizations; managed care organizations, insurance companies, The Joint Commission etc.
Current measures- https://www.ada.org/en/science-research/dental-quality-alliance/dqa-measure-activities/measures-medicaid-and-dental-plan-assessments
https://www.ada.org/en/science-research/dental-quality-alliance/dqa-measure-activities/measures-medicaid-and-dental-plan-assessments
105
DQA- Medicaid Quality Improvement Learning Academy (MeQILA)
Creates a mechanism that empowers states to achieve sustainable quality
improvement in oral health through:
Creating collaborative state teams
Technical assistance
Access to national experts
Peer to Peer learning
106
PREPARING FOR THE FUTURE
107
Quality Metrics: Data is a Key to the Future
Moving the dial
Cost of developing metrics and dashboards
Balanced metric sets
NNOHA Dashboard
Dental Quality Alliance metrics
108
Innovation Needed for Value Based Reimbursement
NEW PREVENTION STRATEGIES-
TREATMENT BY RISK
TRUE MEDICAL, DENTAL AND
BEHAVIORAL HEALTH INTEGRATION
CASE MANAGEMENT
CDHC MODEL
TELE-DENTISTRY
BREAKING DOWN THE WALLS OF THE CLINIC
109
Preparing for the Future- What Can You Do Now
Understand your current financial breakdown of revenue and true costs
Improve efficiencies/ productivity and not just encounter #s
Advance your Medical/ Dental/ Behavioral Health integration- effects on
metrics
Think in terms of disease reduction : i.e. SDF
Community Dental Health Coordinators- case management
110
Preparing for the Future- What Can You Do Now
Track and understand your specialty referral needs and patterns
Explore specialty FQHC contracting
Where possible think about tele-dentistry-Expanding out the walls of
the clinic
Plan for Operational and Quality Dashboards moving to real time data
Become accustomed to moving measures
111
Preparing for the Future- What Can You Do Now
Get serious about patient satisfaction and community reputation:
Patient Centered Care
Educate and engage all staff members on changes happening in health
care
Learn about all aspects of managed care- learn about risk
Think about how to broaden your ability to offer higher-end procedures
Begin to incorporate dental diagnostic codes
112
Mark Koday DDS
(509) 949-2278
Dental Quality Consultants of WA
http://dentalqualityconsulting.com/
m
Contact Information
http://dentalqualityconsulting.com/
TABLE DISCUSSION:SWOB ANALYSIS
Danielle Apostolon
LUNCH
VALUE-BASED DENTAL CAREUTILIZING DENTAL THERAPISTS
RACHEL RIVARD, DDS
DENTAL DIRECTOR, COMMUNITY DENTAL, RUTLAND, VT
MONDAY, NOVEMBER 18, 2019
What is a Dental Therapist?
Midlevel providers, similar to PAs or NPs in medicine
Supervised by a dentist
Can perform preventative and routine restorative care, fill cavities,
pediatric care, and other duties as indicated in legislation
Adds an additional level of care and access to dental care
*Source: PEW Charitable Trust
DTs and Access to Dental Care
Study done on two dental clinics employing dental therapists, with additional insight from 5 different states that use DTs
Study focus was on boosting access to dental care for underserved populations
Study found employing a DT cost at least $50,000/year less than a dentist
From 2012-2018, DTs employed by one of the study site dental clinics provided care in over 58,000 dental visits and dispensed over $11million in dental services
In 2018 alone, DTs employed by the other study site cared for 12,000 patients
Study conclusion: use of DTs leads to increase in efficiency and profitability when properly used
*Source: PEW Charitable trust, Association of State and Territorial Dental Directors
Aging Dentist Populations
48% of Vermont dentists are 55 or older
24% are 65 or older
In Rutland County: 58% of the primary care dentists are 60 or older
(18 out of 31)
*Source: 2017 Vermont Census of Dentists
How can DTs help fill some of the holes?
One example, a private practice dental clinic in MN:
In year one:
$1.3 Million in production
$834k in collections
Approximately 3000 patient encounters◼ (~1500 state insurance, 900 commercial, 600 uninsured)
Clinic composition:
Dental Therapist 4 days/week
RDH 4 days/week
DDS 1 day/Week
What Does This Mean for Dentists?
DTs offer our patients cost efficient and quality dental care
Access to care should increase
Valuable dentist time can be better utilized for more complex
procedures, time consuming, low yield procedures can be performed
by a more cost effective provider
Practices and clinics can stay open as dentists age and decrease hours
My Personal Take
DTs are a cost-effective way to reach more people and provide more
treatment to people who need it
There will be good ones and bad ones, just like dentists
When utilized well, the good ones will be an asset to your clinic
PANEL DISCUSSION:THE JOURNEY TO VALUE-BASED CARE BY STATE
Dr. Carolyn Brown
Kalie Hess
Dr. Nissa James
Dr. Sarah Finne
Katinka Hakuta
Value Based Care in MaineSystemic approaches to promoting access to quality care
Kalie Hess, MPH
11/18/2019
How are we building high-value care in Maine?
Payment incentives
Collaborative partnerships
Network development
Payment Incentives
with MaineCare
Eligibility: Ages 1 – 20; enrolled in Medicaid or a CHIP Medicaid expansion program for at least 90 continuous days and eligible for EPSDT services.
Measures: Children (ages 1-20) who received Dental Treatment: The total number of children age one to twenty years who received any dental treatment services (D2000-D9999).
Children (ages 1-20) who received Fluoride Varnish Treatment: The percentage of children ages 1-20at the end of the measurement year who received any fluoride varnish treatment (D1206).
Children (ages 1-20) who received Preventive Dental Services: The total number of children age one to twenty years who received any preventive dental services (D1000-D1999).
High-performing practices receive incentive payments.
For more information: https://www.maine.gov/dhhs/oms/provider/pccm.html
Primary Care Case Management
https://www.maine.gov/dhhs/oms/provider/pccm.html
Payment Incentives
with MaineCare Goal of accountable communities: reduce cost while improving quality
and outcomes for MaineCare members. It is similar to Medicare’s model in that groups of providers can participate in the shared savings model if they meet quality outcomes.
New measure added: Percentage of children, age 0-20 years, who received a fluoride varnish application during the measurement period.
For more info on Maine’s Accountable Communities program:https://www.maine.gov/dhhs/oms/vbp/accountable.html
For more info about this measure:https://ecqi.healthit.gov/ecqm/ep/2019/cms074v8
• Olivia Alford – Director• [email protected]
• Peter Kraut – Accountable Communities Program Manager
• [email protected]• Loretta Dutill – Operations
Manager for Health Homes and PCCM
Accountable Communities
MaineCare Value Based Purchasing Contacts
https://www.maine.gov/dhhs/oms/vbp/accountable.htmlhttps://ecqi.healthit.gov/ecqm/ep/2019/cms074v8mailto:[email protected]:[email protected]:[email protected]
Collaborative Partnerships
University of New England
University of Southern
MaineMaineHealth
Northern Light Healthcare
University of Maine at Augusta
Private practice dentists
FQHCsMaine Oral
Health Coalition
Independent practice
hygienistsSchools
National experts
National networks
MaineCareMaine Health
Data Organization
Maine Equal Justice
Maine Oral Health
Funders
HeadStartsOral Health
GranteesLegislators And more!
Initiatives that aim to promote value in care are being provided across the state in a patchwork fashion, involving many passionate partners.
Partnership results
School oral health services in more places
Enhance school oral health program at the Maine CDC
HeadStart and dentist partnerships to meet treatment plans
Dental clinic at a mid-coast hospital meeting unmet need
Legislators and partners looking to maximize EPSDT services
Data analysis in partnership with MaineCare
Building in equity through grantmaking to organizations working with at-risk populations
Legislative action to move adult dental in MaineCare forward
Community Health Workers to help access dental services
Fluoride varnish in primary care settings across the state
The problem
These successes stay localized or often fizzle out without a catalyst for expansion, replication, and identifying funding to sustain efforts that improve oral health outcomes in a meaningful, systematic, and value-driven manner.
A step forward to address this problem
The Partnership for Children’s Oral Health began 2 years ago to transform Maine into a state where we meet the oral health needs of all children and families, prioritize prevention, and address oral health as a key element of overall health and economic well-being.
Though primarily child-focused, many of these systematic efforts will improve oral health outcomes across the lifespan.
Network development
Preventive care in community and school settings
Integration of oral health into
primary and prenatal care
Innovations in managing dental
disease
Build network coordination and capacity to create lasting and system-level changes on the following strategic priorities:
Moving Maine towards high-value dental care is a wicked problem.
It requires a collaborative approach, across sectors, and requires system changes that go beyond paying for high-value care.
Partnership for Children’s Oral Health Roadmap
ConveningsCapacity Grants
Action Teams
Network Partners’
Convenings
Network-Wide
Convenings
Targeted Work Sessions
Organizational Grantees
(Engagement, Advocacy, Equity)
Regional Ambassadors/
Network Weavers
Innovation Pilots
Health Integration
School and Community
Settings
Disease Management
Oral Health Policy
Advocates Group
Structure of PCOH Network and Ways to Engage
Council• Design of Network• Monitoring health of network + metrics
for success• Relationships and connections• Shared leadership & shared learning• Capacity supports leadership/strategy• Action Team coordination and synergy
Initiative Funding Team• Process for distributing funding• Identifying initiatives to fund• Process for monitoring funded efforts
↓NETWORK SUPPORT COMES FROM↓ ↓NETWORK SUPPORT COMES FROM↓ ↓NETWORK SUPPORT COMES FROM↓ ↓NETWORK SUPPORT COMES FROM↓
“PCOH, Inc.”501c3
Backbone support functions:• Network development• Incubation leadership
• Capacity building supports• Fundraising and development• Management and administrative
Drop-In Activities
Newsletter
Policy Updates/
Action Alerts
1-on-1 Connections
Equity Consults
Data profiles & Stakeholder Conversations
Kalie Hess
Associate Director
207-805-4028
mailto:[email protected]
BEYONDTHE CLINICWALLSSocial Determinants of Health, Community Engagement, and Policy Change
Katinka HakutaNovember 18, 2019
Recap: Key components for value-based care• Health information technology
infrastructure
• Workforce
• Outcome measures
• Favorable policy environment
Components of the U.S. oral heath system
• Technology infrastructure
Data and measures
Policies, laws, regulations
Dentists and care team
Patients
Payors
Professional organizations
Healthy food access
Transportation
Education level
Income
Caregivers
Policymakers
Clinics
Teledentistry
Immigration status
Health status
Employment
Primary language
Community health workers
Access to technology
Safety
Literacy
Hunger
Stress
Discrimination
Insurance
Racism
141
A set of principles or
procedures according to
which something is done; an
organized scheme or
method
Every system is perfectly
designed to get the results
it gets.
The current oral health
system created and continues
to perpetuate poor oral
health for certain underserved
communities.
What is a “system”?
Oxford English DictionaryEngaging Grassroots: Intentionally Building Community Power to Drive Oral Health Systems Change, DentaQuest Partnership, 2019.
Person/patient in the clinic
Family, job, home
Community, infrastructure, built environment
State and federal laws, programs
Racism, social power structures, historical trauma
A patient’s context
The Social Determinants of Health (SDOH)• World Health Organization:
• “The conditions in which people are born, grow, work, live, and age, and the wider set of forces and systems shaping the conditions of daily life, including economic policies and systems, development agendas, social norms, social policies, and political systems.”
https://www.who.int/social_determinants/en/ and“When Talking About Social Determinants, Precision Matters, " Health Affairs Blog, October 29, 2019. DOI: 10.1377/hblog20191025.776011
SDOH “are not something
an individual can have or
not have, and they are not
positive or negative.”
https://www.who.int/social_determinants/en/
Building an intervention:Define and locate the need
SDOH
Social Risk Factors
Social Needs
• Root causes
• Ex: Redlining
• Community level
• Ex: Food desert
• Individual or family level
• Ex: Poor oral health
Modified from:“When Talking About Social Determinants, Precision Matters, " Health Affairs Blog, October 29, 2019.DOI: 10.1377/hblog20191025.776011
Building an intervention:
Locate the levers
• Systems change
• Society and culture
• Racism
• Power structures
• Historical injustice
• Big-P policy change
• State laws
• Federal laws
• Federal regulations
• Little-p policy change
• Rules, procedures, or programs at clinic or organization level
• Local laws
• Community structures or supports
“Shifting the conditions that hold the problem in place”
Kania J, M Kramer, P Senge. The Water of Systems Change. FSG. June 2018.
Why take a policy- or systems-change approach?
• Equitable
• Effective
• Inclusive
• Long-lasting
Case Study – Systems-change grant strategy
POLICY
- Oral health is a key
component of health
policy
- Oral health policy
consistent at local,
state and federal levels
- Oral health
measurement systems
in place
- Policy to allow
expanded workforce
FINANCING
- Sufficient funding to
support care,
prevention and training
- Alignment of payment
with evidence,
prevention, disease
management and
outcomes
CARE
- Dental workforce
sufficient to meet
needs efficiently and
effectively
- Care base on
evidence, prevention,
disease management
and outcomes
- Oral health integrated
into all aspects of
health care
- Consumer focused
care delivery
COMMUNITY
- Oral health integrated
into education and
social services
- Optimal oral health
literacy
- Strong community
prevention and care
infrastructure
- Provider base
representative of
community
Improving the oral health of all
Strategies to affect policy- and systems-change
• Build networks, coalitions, and relationships
• Change power dynamics
• Engage community and consumers
• Advocate through data and
storytelling
Case Study – Networks and relationshipsNOHIIN
• WHO – National network of more than 30 primary
care associations across the country
• WHAT – Learning community, capacity building,
sharing
• GOAL – Integration of oral health and primary care
within the safety net
Case Study – Changing power dynamicsARIZONA
• WHO – Asian Pacific Community in Action,
Children’s Action Alliance, Native American
Connections
• WHAT – Reshaped and recentered the state oral
health coalition
• INFLUENCED – Passage of Dental Therapy
legislation
Case Study – Community engagementPENNSYLVANIA
• WHO – Pennsylvania Coalition for Oral Health,
ACHIEVA/Arc of Greater Pittsburgh, Berks County
Community Foundation, Put People First! PA
• INFLUENCED – Advocacy around Medicaid adult
dental benefit
Case Study – AdvocacyMARYLAND
• WHO – Maryland Dental Action Coalition
• WHAT – Emergency department utilization report
• RESULT – Medicaid pilot program for dual
eligibles
Case Study – “Little p” policy changeCALIFORNIA
• WHO – Asian-Americans Advancing Justice-LA
• WHAT – “Secret shopping” initiative to understand
potential language barriers to accessing Medicaid
services
• POTENTIAL RESULT – Process change proposals
for MediCal
155
Building cultural
competency Increased transparency and
communication
Engaging new and
nontraditional partners
Examples of policy- and systems-change tactics
Combining data and stories
Education
Consumer advocacy
• Listen• Take time• Be humble• Get uncomfortable• Understand context
(social determinants of health)
• Actively shift power
Engaging new partners – What we’ve learned
• Engaging Grassroots: Intentionally Building Community Power to Drive Oral Health Systems Change, DentaQuest Partnership, 2019. https://www.dentaquestpartnership.org/sites/default/files/BuildingCommunityPower_2020_RFP_9.21.19.pdf
• Social Determinants of Health. World Health Organization. https://www.who.int/social_determinants/en/
• “When Talking About Social Determinants, Precision Matters.” Health Affairs Blog, October 29, 2019. DOI: 10.1377/hblog20191025.776011. https://www.healthaffairs.org/do/10.1377/hblog20191025.776011/full/
• Kania J, M Kramer, P Senge. The Water of Systems Change. FSG. June 2018. https://www.fsg.org/publications/water_of_systems_change
More Information
https://www.dentaquestpartnership.org/sites/default/files/BuildingCommunityPower_2020_RFP_9.21.19.pdfhttps://www.who.int/social_determinants/en/https://www.healthaffairs.org/do/10.1377/hblog20191025.776011/full/https://www.fsg.org/publications/water_of_systems_change
The New Hampshire
Journey to Value-Based
Oral Health Care
Sarah A. Finne, DMD, MPH
New Hampshire Department of Health and Human Services
Division of Medicaid Services
Dental Director
November 18, 2019
NH Legislative Timeline
• Where did we start?
oChildren up to age 20: Fee-for-Service Medicaid/CHIP EPSDT benefit
oAdults aged 21 to 64: Emergency treatment only benefit
NH Legislative Timeline
• SB 193 Study Commission
December, 2014 to November, 2015
oCompromise
oRecommendations
NH Legislative Timeline
• HB 4 (formerly HB 692)
oRemove adult dental benefit prohibition
oManaged Care
oValue-Based Benefit
oDHHS led Working Group
Contact Information
Sarah A. Finne, DMD, MPH
NH DHHS Medicaid Dental Director
603-271-9217
https://www.dhhs.nh.gov/ombp/medicaid/
mailto:[email protected]://www.dhhs.nh.gov/ombp/medicaid/
Nissa L. James, Ph.D.
Director, Communications and Legislative Affairs
November 18th, 2019
Vermont’s Progress in the Journey to Value-based Care
DVHA’s mission is to improve the health and well-being of Vermonters by providing access to quality health care cost effectively.
Improving Health and Well-being 2
Act 72 of 2019
1). Evaluate current Medicaid reimbursement rates to dentists,
dental therapists, and other providers of dental services and
determine the amount of fiscally responsible increases to the
rates for specific services that would be needed to attract
additional providers to participate in the Vermont Medicaid
program;
Legislative Priorities for Oral Health and Health System Policy Change 3
https://legislature.vermont.gov/Documents/2020/Docs/ACTS/ACT072/ACT072 As Enacted.pdf
Act 72 of 2019
2) Explore opportunities to further expand access to dental
care in Vermont, including teledentistry services and
integration of dental services into the scope of services
provided through accountable care organizations;
3) Determine the feasibility of, and costs associated with,
establishing a State dental assistance program to provide
access to affordable dental services for Vermont residents
who have lower income and are enrolled in Medicare.
Legislative Priorities for Oral Health and Health System Policy Change 4
https://legislature.vermont.gov/Documents/2020/Docs/ACTS/ACT072/ACT072 As Enacted.pdf
Act 72 of 2019
Vermont Medicaid shall provide coverage for medically necessary dental services:
• Up to 2 visits per calendar year for preventive services, including prophylaxis and
fluoride treatment, with no co-payment and outside of the annual benefit limit.
• Diagnostic, restorative, and endodontic procedures up to a maximum of $1,000.00
per member per calendar year.
The Department shall develop a reimbursement structure for dental services that
encourages providers to provide preventive care.
Changes to the Adult Medicaid Dental Benefit – Planned Effective for 1/1/20
5
https://legislature.vermont.gov/Documents/2020/Docs/ACTS/ACT072/ACT072 As Enacted.pdf
• Fiscally responsible increases for Medicaid reimbursement rates for dental services;
• Access to care;
• Provider/Practice administrative burden;
• Utilization of services;
• Rural nature of Vermont.
Challenges in Meeting the Goal of Optimal Oral Health for all Vermont Residents 6
Finding:Vermont Medicaid’s reimbursement rates for the most utilized dental services are amongstthe highest when compared to other New England Medicaid programs.
Demonstrating Policy Change - Opportunities for
Improving Medicaid’s Reimbursement Rates 7
Procedure
Code
Procedure
Code
Description Vermont New Hampshire Maine Massachusettes Connecticut Rhode Island
VT rate
as a % of
NH = > 21
VT rate
as a % of
ME 21
and over = > 21
VT rate
as a % of
MA 21
and over = >21
VT rate
as a % of
CT 21
and over
VT rate
as a % of
RI
D0120 PERIODIC ORAL EVALUATION - ESTABLISHED PATIENT $ 25.00 $ 30.50 82.0% - - $ 20.00 125% $ 18.20 137% $ 10.00 250.0%
D1110 PROPHYLAXIS - ADULT $ 48.00 $ 53.00 90.6% $ 40.00 120% $ 49.00 98% $ 33.28 144% $ 30.00 160.0%
D1120 PROPHYLAXIS - CHILD $ 34.00 $ 38.00 89.5% - - $ 36.00 94% $ 23.92 142% $ 22.00 154.5%
D1206 TOPICAL APPLICATION OF FLUORIDE VARNISH $ 18.00 $ 18.00 100.0% - - $ 26.00 69% $ 15.08 119% $ 20.00 90.0%
D1351 SEALANT - PER TOOTH $ 35.00 $ 33.50 104.5% - - $ 28.00 125% - - $ 18.00 194.4%
D0274 BITEWINGS - FOUR RADIOGRAPHICIMAGES $ 30.00 $ 32.00 93.8% $ 20.00 150% $ 33.00 91% $ 24.96 120% $ 22.00 136.4%
D0140 LIMITED ORAL EVALUATION - PROBLEM FOCUSED $ 40.00 $ 45.00 88.9% $ 20.00 200% $ 39.00 103% $ 24.96 160% $ 10.00 400.0%
D2392 RESIN-BASED COMPOSITE, TWO SURFACES, POSTERIOR $ 133.00 $ 111.00 119.8% $ 90.00 148% $ 65.00 205% $ 59.28 224% $ 34.00 391.2%
D7140 EXTRACTION, ERUPTED TOOTH OR EXPOSED ROOT (ELEVATIO $ 98.00 $ 100.00 98.0% $ 91.00 108% $ 70.00 140% $ 59.80 164% $ 73.00 134.2%
D0150 COMPREHENSIVE ORAL EVALUATION - NEW OR ESTABLISHE D $ 40.00 $ 57.00 70.2% - - $ 37.00 108% $ 33.80 118% $ 20.00 200.0%
D1208 TOPICAL APPLICATION OF FLUORIDE EXCLUDING VARNISH $ 18.00 $ 18.00 100.0% - - $ 29.00 62% $ 15.08 119% $ 18.00 100.0%
D0220 INTRAORAL - PERIAPICAL FIRST RADIOGRAPHIC IMAGE $ 18.00 $ 7.00 257.1% $ 8.00 225% $ 14.00 129% $ 9.88 182% $ 10.00 180.0%
D2391 RESIN-BASED COMPOSITE, ONE SURFACE, POSTERIOR $ 90.00 $ 97.00 92.8% $ 68.00 132% $ 51.00 176% $ 49.40 182% $ 26.00 346.2%
D0272 BITEWINGS - TWO RADIOGRAPHIC IMAGES $ 24.00 $ 26.00 92.3% $ 15.00 160% $ 22.00 109% $ 16.64 144% $ 14.00 171.4%
D0330 PANORAMIC RADIOGRAPHIC IMAGE $ 60.00 $ 37.50 160.0% $ 43.00 140% $ 62.00 97% $ 45.24 133% $ 32.00 187.5%
Provider-Selected Dental Procedure Codes Compared to Northeast Delta Dental Premier 8
88% of all Vermont
dentists participate in
the Premier network;
44% participate in the
PPO network.
• Finding: The immediate oral health needs of Medicaid members influence providerselection of dental procedure codes for targeted reimbursement rate increases.
• Finding: Overall, for the 25 provider-selected dental procedure codes analyzed, VermontMedicaid reimbursement rates are at 53.5% of the rates within the Northeast Delta DentalPremier Fee Schedule (Vermont 2019).
• Finding: In addition to increasing reimbursement rates for dental services, reducing administrative burden for providers and practices is important for increasing the number of providers participating with a Medicaid program.
Demonstrating Policy Change - Opportunities for
Improving Medicaid’s Reimbursement Rates 9
• Recommendation: Establish a professional and predictable process for annually reviewing Vermont Medicaid’s reimbursement rates for dental services and evaluating progress towards achieving other recommendations detailed within this Report.
• Recommendation: After the end of the last quarter in state fiscal year 2020, reviewutilization and reimbursement rates for preventive dental care services.
• Recommendation: Implement fiscally responsible increases to rates for 25 provider-selected dental services effective for January 1st, 2021. The estimated annual fiscal impact of increasing those 25 dental procedure codes to 60% of the Northeast Delta Dental Premier Fee Schedule is $973,252 (gross) based on calendar year 2018 utilization information.
Demonstrating Policy Change - Opportunities for
Improving Medicaid’s Reimbursement Rates 10
• Recommendation: The Vermont State Dental Society (VSDS) is committed to helping dentists to report usual and customary fees to the Department of Vermont Health Access and will commit to improving access to dental services for Medicaid members if Vermont Medicaid reimbursement rates are increased to 60 percent of the usual and customary rates in accordance with VSDS-referenced literature regarding the relationship between reimbursement rates and dentist participation in Medicaid programs.
• Recommendation: Eliminate co-payment requirements for Medicaid members receiving covered dental services to remove substantial administrative burden on dental practices and financial burden for members. The estimated annual fiscal impact of removing co-payments for all dental services was $159,694.
Demonstrating Policy Change - Opportunities for
Improving Medicaid’s Reimbursement Rates 11
Finding:
For telehealth, store and forward technology is currently only covered for teledermatology and teleophthalmology. Telemedicine is a covered service under Vermont Medicaid.
Recommendation:
Vermont Medicaid shall further study and report on the national use of and estimated fiscal impact for expansion of coverage for store and forward technology for dental services that are appropriate through this method and medically necessary. The Department shall provide its recommendations as part of its state fiscal year 2021 budget presentation.
Demonstrating Policy Change - Opportunities for Expanding Access to Dental Services 12
Finding:
Integration of dental services within the scope of services provided by accountable care organizations is possible; feasibility for integration requires additional exploration to evaluate the most appropriate pathway to pursue in future years.
Recommendation:
In recognition that oral health is part of overall health, the feasibility for future integration of dental services within an Accountable Care Organization model shall be further explored and evaluated.
Demonstrating Policy Change - Opportunities for Expanding Access to Dental Services 13
• VPharm is supplemental coverage to Medicaid Part D coverage that provides the same pharmaceutical coverage for Medicare-enrolled individuals (participating in Medicare Part D and who are up to 225 percent of the federal poverty guidelines) that is provided to Medicaid members by Vermont Medicaid.
• ‘VDent’ would have to be a new benefit that would exist outside of the existingMedicare Benefit; Medicare provides a very limited dental benefit that does notinclude any preventive or restorative treatments.
• To pursue this, DVHA would have to seek CMS approval though waiver authority to create an entirely new program for Medicare eligible beneficiaries up to 225% FPL. Any expansion in waiver services, including the creation of VDent, would exacerbate the already significant pressure Vermont is facing under the waiver’s budget neutrality cap.
Feasibility of a Dental Assistance Program -Findings 14
https://legislature.vermont.gov/Documents/2020/WorkGroups/House General/Bills/S.23/Written Testimony/S.23~Sarah Clark~Bottom Line- 1115 Waivers and Budget Neutrality~4-25-2019.pdf
Recommendation:In order to preserve the State’s ability to enhance payment and services for the Vermont Medicaid population in response to emerging needs, establishment of a state dental assistance program for Medicare beneficiaries should not occur in the current budget neutrality environment.
Feasibility of a Dental Assistance Program 15
Finding:Evolving delivery system and payment models for providing dental care may be essential to achieve the Triple Aim (improving the patient experience of care, improving the health of populations, and reducing the per capita cost of health care).
Recommendation:Explore employment of strategic partnerships and evolving payment models to expand upon the successful strategies of the Brattleboro and Bennington communities, Federally Qualified Health Center model for integrated care, and not-for-profit dental offices for improving access to dental services statewide.
Next Steps in Vermont’s Journey to Value-based Care for Oral Health 16
MAPPING OUT PARTNERS & RESOURCES IN EACH STATE
Carolyn Brown
180
Value-Based Care Drivers
Oral Health +
Health Advocates
Health Systems
Community Engagement
Care Coordination
Policy + Payers
Stakeholders
181
Instructions- Part 1
1. Gather by State
2. Assign a Recorder and a Leader
3. Discuss Drivers or Issues in your state or from your perspective
4. Use existing drivers or name your own in the blank
5. Fill in stakeholders- be specific if possible
6. Draw connecting lines from drivers to the stakeholders named
182
Instructions- Part 2
Regard the Stakeholders collectively
Assign – if stakeholder non-active in OHVBC
Assign + if stakeholder IS active in OHVBC
Leave blank if unknown
Count number of connecting lines to each stakeholder
Resources (Persons, Places, Things, Events) aligning Stakeholders into Partners
Brainstorm on ideas aligning resources as oral health landscape evolves
Report out and turn in your state’s worksheet for Overview Day 2
183
Value-Based Care Drivers
Oral Health +
Health Advocates
Health Systems
Community Engagement
Care Coordination
Policy + Payers
Stakeholders
Hospitals ME Hospital Association (-) 2
Schools School-based Health of ME (+) 1
ME Patient Alliance (+) 2
Senior Programs
Resources
Maine Primary Care AssociationMaine Health PartnershipChildren’s Dental Health Month
DAY ONE:CLOSING/WRAP-UP
End of Day One – Survey
Day One: Creating a Value-Based Oral Health Care Delivery
System
https://www.surveymonkey.com/r/VBCTraining1
185
Evaluation survey must be completed to receive 10 CE credits
• https://www.surveymonkey.com/r/VBCTraining1
• https://www.surveymonkey.com/r/VBCTraining2
186
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
https://www.dentaquestpartnership.org/learn/online-learning-center/online-courseware/dentaquest-special-topics-serieshttps://www.dentaquestpartnership.org/learn/online-learning-center/online-courseware/dentaquest-special-topics-serieshttps://www.dentaquestinstitute.org/about/keys-to-success/value-based-carehttp://www.dentaquestinstitute.org/learn/safety-net-solutions/oral-health-value-based-care/ohvbc-readiness-assessmenthttp://www.dentaquestinstitute.org/learn/safety-net-solutions/oral-health-value-based-care/ohvbc-readiness-assessmenthttps://www.dentaquestpartnership.org/sites/default/files/OHVBC_Training Program_5.3.19_0.pdfhttps://www.dentaquestpartnership.org/learn/dental-caries-management-practicumhttp://companion.dentaquestinstitute.org/publication/?i=481476#{"issue_id":481476,"page":0}https://www.dentaquestpartnership.org/sites/default/files/InterprofessionalNetworkReferralProcess_FINAL.pdfhttps://www.dentaquestpartnership.org/sites/default/files/OHVBC_5.2.19.pdf
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