Value in healthcare is the measured improvement in patients’ health outcomes compared to the cost of achieving that improvement. All relevant parties must agree on the terms and framework for this evaluation.
Value is only created when a patient’s health outcomes improve. Cost reduction is important, but insufficient. If the only desired outcome were cost reduction, the ideal program would be a combination of supervised benign neglect and pain medication. To a large extent, that is what some dental capitation models have devolved into.
Capitation programs reduce cost of care by disincentivizing providers to deliver treatment. Providers, insurance companies, and managed care organizations (MCOs) contracted by states all benefited financially with the maximum number of patient enrollees. Providing actual services to those patients enrolled in capitation programs proves prohibitively costly. Mechanisms are utilized to discourage patients from obtaining healthcare under capitation.
A classic joke from the Soviet Union goes, “We pretend to work, and they pretend to pay.”
Nearly every Soviet citizen had enrollment in free healthcare. Unfortunately, accessing healthcare services of value was discouraged, and they often were impossible to obtain anyway. Propping up a myth of free quality healthcare was a bogus reality, paramount for socialist policymakers.
Stakeholders
A plethora of stakeholders exists in the dental care industry: patients, providers, clinics (often dental service organizations), beneficial clinic ownership (often Wall Street or private equity firms), insurers, MCOs, employee benefit providers, and policymakers. There is no commonly held definition of value. The mix of factors generating value includes quality, service, outcomes, access, and cost. Each stakeholder places its own emphasis on how it determines value.
Value has become a near-meaningless buzzword of vague and varied definition. Whatever stakeholder sets the agenda also seems to set the definition for value-based dentistry.
Too frequently, patients and providing doctors are removed from policy decisionmaking.
In December 2018, DentaQuest, a dental Medicaid MCO, and Brident Dental, a subsidiary of Western Dental (in the portfolio of private equity company New Mountain Capital), announced a joint agreement to operate 34 Texas clinics under a value-based program.
“We applaud Texas Medicaid for taking the lead to promote value-based alternative payment models as a critical step to achieving person-centered care, and we are confident the Brident Dental program will not only help control costs, but will also result in better patient care,” said Joe Vesowate, regional vice president at DentaQuest.
Specifics on delivery of care were remiss. Alternative payment models for cost-containment seemed the dominant factor announced.
“For more than two centuries, dentists have practiced in a fee-for-service (FFS) reimbursement environment. It’s a model that incentivizes high-cost, complex procedures and focuses on the volume of care that gets delivered. Put simply, the more you do, the more you get paid,” DentaQuest says on its website.
“It’s time for a new approach,” DentaQuest continues.
“Value-based care (VBC) is a care delivery model in which providers are rewarded for quality health outcomes rather than the quantity of care delivered. In this approach, providers focus on improving the health of a population of patients by offering care that is focused on prevention, best evidence, and personalization. This shift allows care teams to maximize ‘chair time’ and productivity and the industry to better integrate with the overall health care system,” the site says.
“In the value-based care model, payers reimburse providers based on the quality of care instead of the volume of care. Already, payers are starting to move away from the outdated FFS model and toward alternative value-based payment models, such as capitation or global payment, bonus and incentive payments, and shared savings models with or without shared risk,” DentaQuest says.
Obviously, capitation is not a new approach. Capitation has been a problematic failed healthcare model for several decades.
Some medical models already incentivize physicians and their employers through bonus and quota programs, not to provide more costly patient services, make referrals exclusively to pre-selected specialists, or utilize “approved” laboratories. It nearly always amounts to a disturbing form of healthcare rationing.
Some of these activities are unlawful under existing federal anti-kickback laws. Corporate healthcare lobbyists are working overtime to influence legislators to make changes in their favor.
Risks to the Disadvantaged
We fully realize that patients who are members of lower socioeconomic groups exhibit higher degrees of dental disease. This is further problematic for persons of color.
According to researchers at Harvard Medical School, value-based healthcare is mired in a tacit policy of systemic racism. African-Americans have a disturbing preponderance of preexisting co-morbidity health factors. Value-based healthcare would deprioritize their needs in favor of cost-containment measures. Those with the most pressing healthcare needs would be pushed aside.
We have seen examples of dentists de-credentialed by MCOs because of alleged overutilization of certain fee codes. Pediatric dental specialists may treat a disproportionate number of child and special needs patients in hospital or surgical center settings with general sedation. These patients, generally through no fault of their own, frequently suffer from rampant, painful, and debilitating dental caries. These are expensive cases to treat, and they do not fit the value-based model espoused by MCOs, the insurance industry, or certain policymakers. The metrics of treating these patients does not fit the value-based model.
This demographic of patients is most often restricted to rules of a Medicaid MCO for dental care. Clinical approaches such as additional fluoride treatments, silver diamine fluoride, added annual hygiene visits, minimally invasive dentistry, use of glass ionomers, and dietary consultation definitely have benefits. Unfortunately, these treatment and preventive modalities only offer a Band-Aid approach for pediatric patients suffering severe dental disease in our most at-risk populations.
Adult dental Medicaid patients may be afforded additional preventive services under value-added dental programs. Regrettably, this population frequently exhibits multiple missing teeth, advanced caries, advanced active periodontal disease, parafunction of clenching and/or bruxing, and existing large heroic direct restorations with open margins, overhangs, recurrent decay, and fractures.
Adding complexity to these adult dental Medicaid cases may be cofactors such as medications or pathology generating xerostomia, diabetes, mental illness, drug and/or alcohol abuse, pulmonary disease, cardiac disease, limited ambulatory mobility, obesity, history of facial trauma, limited oral openings, history of sexual trauma, history of past dental abuse, transportation problems, language barriers, arthritis, limited education, illiteracy, and more.
Yes, these patients frequently require cost-saving preventive care and minimally invasive dentistry. More often, they need full-mouth rehabilitation, with all the combined specialty services of endodontics, periodontics, orthodontics, prosthodontics, and oral surgery.
Value-based dentistry is not positioned to best serve this population. In fact, an FFS model will not serve this compromised demographic, when fees are established below the cost to deliver dental services properly, to the standard of care.
Conclusion
Alternative value-based treatment models must include input from doctors and patients. I do not mean dentists retained as directors for MCOs and the insurance industry, so much as wet-gloved dentists who treat clinical patients on a daily basis. Policymaking that excludes doctors and patients is not only silly, but dangerous to our nation’s well-being.
Corporate and governmental policymakers can smear any shade of lipstick they desire on a pig called capitation. They may employ elegant terms like “value-based dentistry” or “alternative payment models.” In the final analysis, it is still capitation, which by design cuts costs by denial and rationing of services to those most in need.
Arguably, the FFS healthcare delivery model has also failed to be cost-effective. Many providers also decline participation in programs such as Medicaid because of an abysmal fee structure and excessive administrative requirements. Other providing doctors do participate, but only on a limited basis as a charity. Moreover, the dental Medicaid program has proven outrageously costly to states and the federal government.
Unlike the insurance industry, MCOs have demonstrated grossly inadequate oversight with Medicaid. A relatively few providers are out of control in cheating Medicaid, largely within elements of corporate dentistry. The US Deaprtment of Health and Human Services Office of Inspector General has been pounding on that issue for years. MCOs are disincentivized to provide oversight, and government regulatory agencies are often asleep at the wheel.
On the front end, administration of our dental Medicaid programs similar to the insurance industry would be a positive step in helping reduce fraud, waste, and abuses. On the back end, serious legal consequences both civil and especially criminal must be faced not only by deviant doctors but also by corporate management at the DSO and private equity level. Certainly, front-end prevention measures are superior to back-end “pay and chase.”
One must rationally question why value-based dentistry should be taken seriously when principal stakeholders like patients and doctors are absent at the table. Is the primary motivational factor limited to corporate greed? Do policymakers suffer from an inherent blind spot related to the history of failed socialist states and their misguided top-down policies and guidelines? Or, as others have postulated, does value-based healthcare have a foundation focused on systemic racism?
Dr. Davis practices general dentistry in Santa Fe, NM. He assists as an expert witness in dental fraud and malpractice legal cases. He currently chairs the Santa Fe District Dental Society Peer-Review Committee and serves as a state dental association member to its house of delegates. He extensively writes and lectures on related matters. He may be reached at mwdavisdds@comcast.net or smilesofsantafe.com.
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