Design Payment Transformation

The University of Washington and Advantage Dental Connecting Low-income Mothers and Children to Comprehensive Dental Care

Challenge

Low-income mothers and children in Oregon have low rates of dental care, and rates of tooth decay in young children are higher than the national average. Advantage Dental, a cooperatively owned dental care network, is changing its payment and delivery model in order to extend service to disdvantaged mothers and children in rural areas.

Partners:

University of Washington Northwest Center to Reduce Oral Health Disparities
Advantage Dental Services (owned by Advantage Community Holding Company, LLC)

Setting

In 2014, Oregon was one of two states with the lowest dental care utilization rates in the nation. Only 10% of Medicaid/CHIP-enrolled children in Oregon received the recommended dental care visit when they turned 1 year old, and only 39% of Oregon Health Plan-eligible children and 43% of eligible pregnant women received any form of preventive dental service.

Coordinated Outreach and Incentives How it Works

The University of Washington

To increase dental care utilization and decrease the incidence of oral health problems among Medicaid and CHIP-enrolled (Oregon Health Plan) mothers and children, Advantage utilized expanded-practice dental hygienists (EPDHs) to screen and treat patients individually in community settings including schools and WIC and Head Start offices. Case managers coordinated care for patients with immediate needs to make sure they were seen by a primary care dentist or clinic and ensure patients were re-assessed at appropriate intervals. Regional manager community liaisons (RMCLs) coordinated community outreach and partnerships, including community education initiatives. A per-patient global budgeting program with pay-for-performance incentives rewarded efficient and coordinated patient care.

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Patient participants

Advantage serves 82,000 pregnant women, children, and new mothers enrolled in the Oregon Health Plan across 14 rural Oregon counties; the intervention takes place in six of these counties (Deschutes, Douglas, Jackson-Josephine, Klamath, Morrow, and Wasco).

Intervention team

The intervention team for each county included all Advantage-affiliated clinics and dentists in that county; one or more EPDHs who worked in the community; and a regional manager community liaison (RMCL), who coordinated partnerships with community organizations and oversaw EPDHs. An administrative team worked across counties and included case managers who connected patients with identified needs to: services in a clinical setting, IT administrators, and other administrative staff.

Payment incentive and budgeting

Advantage employed a global budgeting capitation model, pooling the fixed payments it received per patient. It enabled funds to be directed toward innovative care models. Of the approximately $6.9 million allocated to Advantage through the Oregon Health Plan (Medicaid), the company directed a little over 2% into a bonus pool that was disbursed to the county team (EPDHs and dentists) for reaching goals of: increased screening, in-field treatment of at-risk patients, and follow-up care in target counties. Funds also were disbursed to the care coordinators and RMCLs if all counties met the targets.

Tools for success

Community-based outreach

EPDHs screened and treated patients at schools and other sites through partnerships with community organizations.

Dental home

High-risk patients identified in community settings were provided seamless access to dentists in solo practices and clinics.

Root cause analysis

Surveys of providers and patients pinpointed potential causes of low care utilization rates. Follow-up discussions with stakeholders produced action steps.

Risk-based system

All patients are screened individually, and those at risk receive silver diamine fluoride treatment, follow-up care, and, if necessary, referral to a dental home.

Silver diamine fluoride

Silver diamine flouride is a cost-effective topical medication that effectively arrests dental cavities, treating the underlying disease; it can be applied in community settings by EPDHs.

Electronic Health Record

ADIN, the EHR used by Advantage, enabled information sharing among case managers, dentists and clinics, and care teams in the field. For example, it had the capability to notify case managers when a patient was flagged for follow-up care.

Performance data

Monthly updates on patients seen and patients requiring care enabled incentive payments and allowed staff to measure their progress and understand where greater efforts were needed. Target metrics for receiving the bonus payment were adjusted upward each quarter.

Finding Answers: Solving Disparities Through Payment and Delivery System Reform was a national program funded by the Robert Wood Johnson Foundation with technical assistance and direction provided by the University of Chicago. Finding Answers was created to discover and disseminate practical ways to achieve health equity and was focused on discovering how healthcare payment and delivery systems can be redesigned to reduce and eliminate health care disparities. Its work included three pilot projects involving health systems and payers partnering to improve health equity. To read more about Finding Answers, please click here.