Key points

It is safe to say that every payer in today’s health care market would prefer to be reimbursing for health outcomes over the current procedure-based payment system. The current fee-for-service system impedes models of care, such as caries management, by rewarding treatment over prevention, and proportionally rewarding more complex or intensive treatment over less invasive approaches to disease management. If one were to objectively assess this set of counterincentives you would have to ask how we got here and how we can ever break this counterproductive cycle. To make real and meaningful change we need to understand why and how we got here. We also need to understand and acknowledge the constraints of the current system and how many of these constraints will impact any type of proposed reform.

The first reality is that the current fee-for-service system is ingrained in our long history, tradition, and business model of dental care. Almost our entire delivery system is based on this model and we know and understand little else. We also know it is inherently flawed, but we have yet to put forward an acceptable and workable alternative. The flaws become even more apparent when considering the application of this system to caries management. The basis of caries management is to reduce the morbidity and progression of disease, goals that inherently reduce the future intensity of restorative services and resulting financial rewards. Our entire system is based on rewarding for doing more over doing less or doing better. Reforming this system, however, requires more than simply changing the way we reimburse providers. Our system of payment must also be acceptable and understandable to everyone that contributes toward that reimbursement. This includes patients; employers; governments; third-party payers; and all of the agents, brokers, consultants, and human resource administrators that play a role in the current payment systems. Consumers are also pushing for much greater transparency in payment systems, so any reform needs to be comprehensible, accessible, and highly transparent.

The second reality is that in any system there are only so many dollars available and health care economics are all about the allocation of those dollars. As a profession, dentistry has always valued prevention, but not to the degree that it places economic value on restoration and rehabilitation. Claims data show that more than 70% of procedures delivered in a dental office are diagnostic and preventive, yet these two categories make up less than 40% of the office revenue. The approximately 15% of procedures dedicated to restorative generates more than 30% of revenue. Applying caries management to this scenario will only further distort this misbalance of allocation as the intensity of preventive and diagnostics increases and restorative needs decrease. Reform that supports caries management will need to either change this system of economic allocation or do away with procedure-based allocation entirely.

The third consideration is resistance to change. Every industry grapples with change management and caries management is a change that impacts every stakeholder involved in the episode of care. Providers have to accept that restoration may not be the best and first option, that tooth damage and disease are not synonymous, and that the value associated with controlling this disease must be viewed through the eyes of the patient. These are difficult concepts for a profession that has been trained that caries removal is a cure, that technical excellence in a restoration defines quality, and that monitoring and managing ongoing disease could be considered professional neglect. We have been trained to fix things and not manage or limit the damage. But resistance to change goes far beyond simply providers. Employers and sponsors that pay for care are also resistant to change. They want dental benefits to be “low noise,” easy to explain, and low maintenance. They want to know their return-on-investment for any benefit reallocation or change in benefits. It is also hard to influence this perspective when dental is such a small part of their total health care spend. The same thing could be said for government programs, where dental makes up just a few percent of the total spend. Consumers also exhibit some of the same behaviors. Many payers have tested the market with innovative plan designs tailored to retirees and the individual markets, only to find that consumers desire the comfort of having a plan “just like the one I had at work.” A review of available individual dental plans reveals that they still tend to follow the same general benefit designs as employer-based plans. Another consideration related to change is the impact of the dental business model. Small independent businesses cannot afford to assume the risks associated with overhauling a payment model. An error or miscalculation in that model could put them in an unsustainable position. It is easy to see why they would resist broad-scale reform. That entrepreneurial business model, however, is also changing with larger and larger entities becoming part of the dental delivery marketplace. These larger provider organizations are testing reformed models of reimbursement, because they are better able to spread that risk across their entire business enterprise. Change is hard, but everything changes. As we try to implement a disease management approach to caries we need to keep in mind that it is not just about changing provider behavior, but rather about changing the behavior and expectations of everyone connected to delivering that model.

There are numerous books and programs outlining how to manage change within organizations, but one thing that is central to all approaches is communication. To be successful we need to clearly communicate and educate all of the relevant stakeholders on what caries management is; why it is important; the improvement that it can make in outcomes; and how it can be integrated into the delivery systems, benefit systems, and the daily lives of consumers of care. Every stakeholder will go through similar stages of denial, resistance, exploration, and acceptance. We need to be prepared for and have the tools and information to help each stakeholder work through these stages. An insurance benefits advisor may need to know how caries management can reduce client costs, an employer may be interested in how it might impact employee absenteeism, a wellness vendor may want to see the impact on comorbidities, a provider needs to know the impact on office resources and income, and government plan administrators may focus on the impact to access. Every stakeholder in the process of delivering and paying for caries management needs to be on-board to facilitate the total system of change.

Because we currently do not have any real world examples of a value-based approach to reimbursing caries management, we can still formulate a “thought experiment,” or “Gedankenexperiment” to explore the possibilities. If we were to put together a thought experiment, or a payer’s Gedankenexperiment around a totally new approach to reimbursing caries management, what might that look like? The first and most overriding element would be the need to sell every stakeholder on the value of the program. In health care we hear a lot about cost, quality, safety, and patient experience, but rarely do we hear about value. Porter pointed out that the different stakeholders in health care often have different and often conflicting goals, but the one overarching goal common among all of them should be achieving value for patients. Value in health care can most simply be defined as outcomes relative to costs. If the goal is patient value, then everything going into the determination of value needs to be defined from the perspective of the patient. The outcomes that we measure need to be relevant to the patient and based on the perception of the patient rather than our own interpretation of intrinsic value. Such outcomes as patient comfort, speed to recovery, sustainability of health, and elimination of adverse reactions are all examples of health outcomes that directly translate to patient perceived value.

Value also needs to be measured over a full cycle or episode of care. Counting procedures and measuring processes may lead to internal process improvement, but rarely can this capture a full cycle of all the services and activities connected to comprehensive patient care. An example in caries management is that counting fluoride or silver diamine fluoride treatments might provide information that could lead to higher use of prevention, but would ignore all of the collateral services, such as nutritional counseling, home-care adjuncts, case management, and education, that are integral parts of the full cycle of caries management. Better yet, what if we measured the impact of all of these services on disease progression, normal tooth eruption, reduction in treatment needs, or reduction in lost school or work days?

Outcomes also need to be measured over longer periods. Health circumstances, such as retention of primary teeth, normal tooth eruption, and need for tooth replacement, are long-term health consequences impacted by caries management. We need to look at the outcomes from the immediate cycle of care and also the consequences of that care later on in life to establish true value. Conserving a primary dentition is a laudable goal, but has much less value if it does not lead to a healthy, functioning, permanent dentition.

If patient-centered outcomes are the numerator of value, what makes up the denominator? The cost denominator should include all of the associated costs of care for the entire care cycle. This includes not just the benefit payer’s costs, but also employer contributions and patient out-of-pocket. In an ideal setting it would also include the costs of associated comorbidities, lost work place productivity, transportation, child care, and many of the hidden costs we do not normally tie into direct health care costs.

To put our hypothetical case together, let us try to apply Porter’s three-tiered system of outcome measure hierarchy to caries management. In Porter’s hierarchy, tier 1 is the measure of health status achieved or retained over the cycle of care. The first level in that tier is survival. Fortunately, mortality from dental caries measured over any time period is low, but not zero. We all recall the tragic story of Demonte Driver and each year there are deaths tied to the treatment of caries or complications related directly to the disease. One paper describing 44 cases of child deaths reported in the general media from 1980 to 2011 found that 32 of those cases were related to restorative or tooth extraction procedures and 30 were associated with moderate sedation or general anesthesia. Although deaths related to dental treatment may be rare, it is still one outcome that can and, unfortunately, does occur.

The second level in tier 1 is degree of health recovery. This is measured when the patient is considered to be at a steady state achieved after completing an entire cycle of care. Outcomes related to the degree of recovery in dental caries management could include elimination of pain and infection, patient-rated function and aesthetics, new caries rates, and number of retained teeth. These are outcomes that impact the patient’s sense of well-being and are of importance to how a patient would value the success of the care cycle. Tools, such as dental quality-of-life assessments, can capture the patient’s perception of recovery success, whereas direct measures of biologic markers, such as tooth loss, infections, and new disease, provide objective measures of recovery. Other potential markers of recovery that could be considered are lost work/school days, emergency dental treatment, dentally related emergency department use, or hospitalizations.

Tier 2 in Porter’s hierarchy is made up of measures that reflect the process of recovery. The first level in this tier is the time required to achieve recovery or return to normal function. Again, from a patient’s perspective the shortest time to complete a treatment plan, the time to eliminate discomfort or regain complete function, and the number of visits necessary to complete the cycle of care would all be valid measures within this level. Level two in this tier is comprised of measures that reflect the disutility of the care or treatment process. This could include measures of patient discomfort during and after treatment; retreatment needs; failed treatments resulting in tooth loss or pulpal therapy; post-treatment complications, such as extraction site infections; and short-term restoration replacements. These are all measures of added morbidity that are associated with the treatment delivered, and not necessarily the disease state driving the additional treatment needs. These types of measures could play a large role in affirming the greater value of caries management, where more invasive treatment options could carry a higher risk for complications and adverse outcomes.

Tier 3 is comprised of measures reflecting the sustainability of health recovery. From the patient perspective the value of achieving a successful outcome matters most if that outcome can be maintained over time. The first level in this tier relates to recurrence of disease or longer-term complications of the disease. Recurrent or new caries would be one measure. Normal retention and exfoliation of primary teeth for children and retention of functional teeth in adults would be others. Longer-term retreatment needs or the needs for more complex or invasive treatment, such as root canals and crowns, fall into this level. Quality of life assessments can also provide a patient perspective of how they rate the success of their care. The second level in the health recovery tier includes the long-term consequences of care. Every intervention has long-term consequences and this level attempts to define some measure of those consequences. For caries management that may be orthodontic needs stemming from early tooth loss, tooth replacement needs for permanent tooth loss, persistent or recurrent pain, or temporomandibular joint problems associated with occlusal disharmony.

Einstein was able to translate his theory of general relativity via his Gendankenexperiment, so how do we translate this thought model of value-based reimbursement to caries management? First, we need to communicate the value of caries management clearly and concisely to all the parties involved in this cycle of care. Focusing on providers, patients, and even policy makers is not enough. The value must be understood by everyone participating in the benefit decision process, and everyone contributing to the delivery of and payment for care. Next we need to develop measures based on outcomes rather than processes. There are no shortage of potential measures, but we need to put our own value systems aside and look at outcomes purely from the perspective of patients. We could start with just a few examples from Porter’s three tiers of hierarchy. One could envision a system with a base capitation rate and an allocation earned via the outcome measures. Capitation would need to be risk and disease stratified to account for the large variation in initial disease state among individuals and populations. The disease burden, management needs, and challenges in care are much different for children versus older adults, and much different for subsets within those populations. Payment systems need to reflect these differences in the capitation and earned value payments. In a successful caries management world the stratification should decline over time as patient populations benefit from the longer cycle of care. The value-based payment would need to also reward this population improvement in disease and risk stratification. This system would reward the outcomes earned from effective caries prevention and management rather than cost-shift payment to restorations.

No existing delivery or payment system can afford to take the risk of making sweeping, system-wide changes to an economic model. Change will likely come in smaller pilot programs, where risk is managed by the larger system and where greater agility is applied to modifying and improving approaches. Caries management may provide an excellent opportunity to test these pilot programs. We have well-defined populations of need in high-risk children and older adult populations. The tools for prevention and management are well tested and available, and there has been good progress in developing the risk and disease assessment methods to stratify or risk-adjust those populations. What we lack most are the outcomes measures to administer the effective allocation of value-based payments. There are some early models currently being tested, but they rely primarily on process measures and not true outcomes.

Thought experiments are intriguing, but only have value when translated into reality. To build a value-based payment system around caries management we need to concentrate a great deal of our efforts into two areas: communication and outcomes measurement. The dental community needs to effectively communicate the patient-centered value of caries management in a way that appeals to all the players involved in benefit decisions, care delivery, and payment. At the same time, payers and providers need to build a hierarchical model of outcome-based measures that allocates payment based on providing and measuring greater value through caries management. From a payer’s perspective caries management would provide an excellent model to test value-based payment. With the current emphasis on changing how we reimburse health care in medicine, this is certain to occur for dental. Caries management may be the best opportunity to begin reshaping our future.