By Peter Milgrom, DDS, R. Mike Shirtcliff, DMD
Dentistry, a cottage industry long after changes in medical care delivery systems, is in the throes of consolidation. In the midst of this change is Oregon’s largest provider of Medicaid dental services by clients enrolled. Advantage Dental Services cares for 325,000 Oregon citizens—primarily children and adults in the rural Oregon Health Plan (Medicaid). In business since 1995, Advantage employs 300 general practitioners and specialists in more than 250 individual practices and 41 Advantage-owned clinics across 34 counties. Improving access to care and oral health for the whole community is key to our mission.
Our challenge, then, is caring for a patient population whose access to care and utilization rates have lagged behind other parts of the country. Too many clients end up at emergency departments with toothaches or in hospital operating rooms to repair the ravages of severe early childhood tooth decay.
Faced with this problem, Advantage decided to leverage its size and IT savvy to launch a delivery system and payment experiment. Could we assemble community teams of highly skilled expanded practice dental hygienists (EPDHs) and community liaisons to provide algorithm-driven risk assessment, primary and secondary preventive care, and stabilization in WIC, Head Start, schools, and other community settings so that more clients could be seen with less patient hassle and lower costs? Could we use electronic systems to link records from the field with centralized case management to help clients get needed follow-up care in dental offices and clinics? Would providers and case managers respond to benchmarks, feedback, and financial incentives to improve client access and oral health?
The PREDICT Model
Our patient-centered model is called PREDICT (Population-centered Risk- and Evidence-based Dental Inter-professional Care Team). University of Washington researchers designed and are carrying out the evaluation with the support of Finding Answers: Solving Disparities Through Payment and Delivery System Reform, a program of the Robert Wood Johnson Foundation. The target population is 83,000 clients in 14 rural counties, approximately one-quarter of our client population.
The Oregon Health Plan is capitation-based, with providers accepting full risk. Per-patient per-month payments from the plan are pooled by Advantage. The company uses this global budgeting system to direct funds toward company priorities. Providers are either salaried or are paid on a capitation or discounted-fee-for-service basis, and funds are set aside for testing new delivery system models and incentivizing provider adaptation to change.
Key to the program is that Oregon enables an expanded practice of dental hygienists, with the goal that these highly trained paraprofessionals work at the top of their license. This setting allows the hygienists and their teams greater responsibility and expanded abilities in community settings.
Under PREDICT, all clients have a dental home. Most clients are problem-free and low-risk for serious dental problems. So far, we’ve shown that a single EPDH-led community team can screen as many as 7,000 children in a single month and that basic services can be provided in field settings. The risk assessment and primary care algorithms, built into the electronic health records that are available in the field, streamline care and assure that care is evidence-based. Clients who have problems that require the attention of a dentist are promptly scheduled for needed care through the electronic case management system. The community teams regularly return to each site to reassess risk status and provide appropriate services.
Risks and Rewards
Team members receive training and quarterly feedback on access-to-care metrics in the county/counties they serve. They also receive bonuses based on performance, with metrics ratcheted up every quarter. As a result, the teams have assumed responsibility for the care of their communities beyond what is typical for employees. Satisfaction with the process for both clients and providers is high. A random sample of clients, surveyed by Advantage with the guidance of University of Washington professors, rated their care 9 out of 10, as reported at this year’s meeting of the American Association of Dental Research. Job satisfaction and measures of change commitment among staff were rated 4 out of 5.
So far, the most important lesson learned is that communication with community stakeholders is as important to the success of the program as the technical capability to deliver care. Communities who had implemented widespread preventive treatment with sealants, for example, were not accustomed to care that is risk-based, and had adopted well-intentioned practices that in our view had the potential to use up scarce resources unnecessarily, and thus limit care to other eligible Medicaid enrollees. Introducing a new approach and getting buy-in has proved both important and time-consuming.
Going forward, Advantage’s goal is to build on what we have learned and expand the new care delivery and payment model to our full book of business, and to make further gains in reducing disparities in access and oral health statewide. If successful, we plan to invest the savings from the more efficient care of children into better care for adults.
Learn more about this intervention here.
A hygienist’s perspective: http://www.solvingdisparities.org/blog/reimagining-the-dental-team