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One Year In:
A conversation with three grantees working to reduce health disparities through payment and delivery system reform:

The University of Washington

“We’re employing risk assessment and formal dental care algorithms to use resources wisely. And we’re doing it with highly trained people incentivized to do it right.” — Peter Milgrom, DDS, Professor of Oral Health Sciences and Pediatric Dentistry, The University of Washington

The University of Washington partners with Advantage Dental Services to target disparities in access to care and good oral health outcomes for low-income pregnant women and children in several counties of rural Oregon. They are using pay-for-performance incentives and restructuring the care team to rely more on expanded-practice dental hygienists in community-based settings.

At one year in, Scott Cook, PhD, Deputy Director of Finding Answers, asked Principal Investigator Peter Milgrom, DDS, Professor of Oral Health Sciences and Pediatric Dentistry in the School of Dentistry and adjunct Professor of Health Services in the School of Public Health at the University of Washington, to take stock of the group’s progress and offer some early observations and lessons learned.

Dr. Cook:  I have to assume that you were extremely busy before taking on the challenge of designing and implementing a new payment and delivery system to address health disparities. What drove you to take it on? 

Dr. Milgrom: I had been working with the principals at Advantage Dental for more than a decade. The president and CEO, Dr. Mike Shirtcliff, had heard me give a talk as part of another project I was doing in southern Oregon, where he was chair of a dentist/patient navigator program for low-income pregnant women. He liked what I said. We started talking about strategies to lower the burden of disease for the low-income population in Oregon and things his company might do – they’re the largest provider for managed dental care in the state. I gave him ideas, we struck up a relationship, and ideas were shaped to meet the mission of his company to serve everyone in the community. He was implementing these ideas, and it was natural as his business grew to continue to find ways to work together.

Dr. Cook: What are your specific goals? How will you measure success?

Dr. Milgrom: Our overall goal is to increase dental care use and decrease dental caries incidence among children and pregnant women who are Medicaid and CHIP program recipients in 14 rural counties. Because Advantage uses global budgeting, improvements in health among children and pregnant women will free up resources to provide care to underserved adults that are now eligible for dental services with the Medicaid expansion.

We also have a number of specific goals for this population that have to do with increasing screening, counseling and services. For instance, we have a goal to increase by 30 percentage points the proportion of children, and by 20 percent, the proportion of pregnant women, who receive at least one dental service per year. Another goal is to provide dental care to 80 percent of all continuously enrolled children and pregnant women with cavities, pain, or infection and to decrease the proportion of children receiving dental care in hospitals or emergency departments by 10 percent. If successful, the intervention can be implemented across the other 36 counties served by Advantage in Oregon.

Dr. Cook: So how’s it going? What lessons have you learned from getting the project off the ground?

Dr. Milgrom: The project is going well. It offers a continuing commitment to the population. Everybody gets a risk assessment based on their need, and they don’t have to go to a clinic for things that are possible to do in the field. It’s inefficient and expensive, for example, to do fluoride treatment at a clinic and a burden for parents to get there. At the same time, if a patient’s need exceeds what can be done in the school or community setting, there are seamless electronic connections to facilitate care in an Advantage clinic. We’re employing risk assessment and formal dental care algorithms to use resources wisely. And we’re doing it with highly trained people incentivized to do it right.

We’re also using paraprofessionals at the top of their license, encouraging and supervising them. In one month, a dental hygienist can risk-assess 3,000 kids—7,000 in six weeks. It blows your mind. If it’s pay for performance, people perform. In a normal setting, you might expect to see pushback from dentists because paraprofessionals are doing the work. But there’s no pushback here because, everybody at Advantage profits from the work that’s going on. That’s pretty cool—you get the efficiencies of business and the capital to invest on a scale much larger than in a system still conceptually driven by individual dentists or clinics.

During the process, we learned a lot about making community partnerships work. We had randomly chosen which counties to test the model in.  As expected, things went more smoothly in the counties where there was more experience, where they already had dental hygienists doing outreach work, and there were already affiliations with the schools and WIC.  In some counties, a nonprofit intermediary was doing fissure sealants and the Advantage model was new and different for them. Through Oregon health departments and community foundations, programs were focused on sealants rather than comprehensive care. This new larger focus unsettled some folks.  We have learned that we need to do a better job of communicating the changes.

Dr. Cook: What would be your advice to other providers and payers who want to try an integrated payment and delivery system reform program to reduce health disparities?

Dr. Milgrom:  If you organize yourself to reduce disparities in a more efficient, cost effective way, you can do it, but you have to have the right data systems in place in order to understand the impact. Advantage, with our technical assistance, has developed county scorecards that give regular feedback to staff members about progress toward the project goals and this progress can be shared with communities as rates of care go up.