Impacts of innovation in dental care delivery and payment in Medicaid managed care for children and adolescents.

BACKGROUND: We evaluated a 14-county quality improvement program of care delivery and payment of a dental care organization for child and adolescent managed care Medicaid beneficiaries after 2 years of implementation. METHODS: Counties were randomly assigned to either the intervention (PREDICT) or control group. Using Medicaid administrative data, difference-in-difference regression models were used to estimate PREDICT intervention effects (formally, "average marginal effects") on dental care utilization and costs to Medicaid, controlling for patient and county characteristics. RESULTS: Average marginal effects of PREDICT on expected use and expected cost of services per patient (child or adolescent) per quarter were small and insignificant for most service categories. There were statistically significant effects of PREDICT (p < .05), though still small, for certain types of service: (1) Expected number of diagnostic services per patient-quarter increased by .009 units; (2) Expected number of sealants per patient-quarter increased by .003 units, and expected cost by $0.06; (3) Total expected cost per patient-quarter for all services increased by $0.64. These consistent positive effects of PREDICT on diagnostic and certain preventive services (i.e., sealants) were not accompanied by increases in more costly service types (i.e., restorations) or extractions. CONCLUSION: The major hypothesis that primary dental care (selected preventive services and diagnostic services in general) would increase significantly over time in PREDICT counties relative to controls was supported. There were small but statistically significant, increases in differential use of diagnostic services and sealants. Total cost per beneficiary rose modestly, but restorative and dental costs did not. The findings suggest favorable developments within PREDICT counties in enhanced preventive and diagnostic procedures, while holding the line on expensive restorative and extraction procedures.

Survival of silver diamine fluoride among patients treated in community dental clinics: a naturalistic study.

BACKGROUND: Silver diamine fluoride (SDF) is a minimally-invasive preventive service used in the U.S. to avert and arrest caries since 2014. No studies document survival outcomes based in real world delivery. We analyzed 12-month survival outcomes of SDF applied independently or concurrently with other restorative procedures among a population receiving community dental care. METHODS: We analyzed data on SDF applications from de-identified dental claims on Oregon Health Plan patients served by Advantage Dental in 2016, who had been seen in 2015 (patient n = 2269; teeth n = 7787). We compared survival rates of SDF alone, SDF applied with a sedative filling, and SDF with a same-day restoration. Failure was defined as a restoration or extraction of the tooth 7 to 365 days after initial application. Survival was defined as a patient returning 180 or more days after application whose tooth did not have a restoration or extraction. Differences were assessed through Wilcoxon equality of survivor function tests and log-rank equality of survivor tests to compare failure rates, Cox Proportional Hazards models to assess factors associated with survival of SDF, and Kaplan-Meier survival estimate to calculate the probability of survival over time. RESULTS: SDF alone had an overall survival rate of 76%. SDF placed with sedative filling and with a same-day restoration had survival rates of 50% and 84% respectively, likely reflecting treatment intent. SDF alone survived exceptionally well on primary cuspids, permanent molars, and permanent bicuspids and among patients aged 10 to 20 years, with modest variation across caries risk assessment categories. A single annual application of SDF was successful in 75% of cases. Among SDF failures on permanent dentition, more than two-thirds of teeth received a minor restoration. CONCLUSION: SDF is a minimally invasive non-aerosolizing option that prevented non-cavitated lesions and arrested early decay among community dentistry patients when applied independently or concurrently with restorative procedures. Professional organizations, policy makers, providers, and payors should broaden optional SDF use by informing clinical guidelines, reimbursement policies, and treatment decisions. Future research should address clinical, social, service delivery, workforce, and economic outcomes using diverse population-based samples, and the mechanisms underlying single application success and caries prevention potential.

Care delivery and compensation system changes: a case study of organizational readiness within a large dental care practice organization in the United States.

BACKGROUND: Dental care delivery systems in the United States are consolidating and large practice organizations are becoming more common. At the same time, greater accountability for addressing disparities in access to care is being demanded when public funds are used to pay for care. As change occurs within these new practice structures, attempts to implement change in the delivery system may be hampered by failure to understand the organizational climate or fail to prepare employees to accommodate new goals or processes. Studies of organizational behavior within oral health care are sparse and have not addressed consolidation of current delivery systems. The objective of this case study was to assess organizational readiness for implementing change in a large dental care organization consisting of staff model clinics and affiliated dental practices and test associations of readiness with workforce characteristics and work environment. METHODS: A dental care organization implemented a multifaceted quality improvement program, called PREDICT, in which community-based mobile and clinic-based dental services were integrated and the team compensated based in part on meeting performance targets. Dental care providers and supporting staff members (N = 181) were surveyed before program implementation and organizational readiness for implementing change (ORIC) was assessed by two 5-point scales: change commitment and efficacy. RESULTS: Providers and staff demonstrated high organizational readiness for change. Median change commitment was 3.8 (Interquartile range [IQR]: 3.3-4.3) and change efficacy was 3.8 (IQR: 3.0-4.2). In the adjusted regression model, change commitment was associated with organizational climate, support for methods to arrest tooth decay and was inversely related to office chaos. Change efficacy was associated with organizational climate, support for the company's mission and was inversely related to burnout. Each unit increase in the organizational climate scale predicted 0.45 and 0.8-unit increases in change commitment and change efficacy. CONCLUSIONS: The survey identified positive readiness for change and highlighted weaknesses that are important cautions for this organization and others initiating change. Future studies will examine how organizational readiness to change, workforce characteristics and work environment influenced successful implementation within this organization.

Children's tooth decay in a public health program to encourage low-income pregnant women to utilize dental care.

BACKGROUND: A community-based public health program to provide a dental home for women covered by the Oregon Health Plan (Medicaid) in Klamath County, Oregon USA was instituted with the long-term goal to promote preventive oral care for both mothers and their new infants provided by dental managed care companies. METHODS: As part of the evaluation of the program, children in Klamath and comparable non-program counties were examined in their 2nd year of life to begin to determine if benefits accrued to the offspring of the mothers in Klamath County. RESULTS: Eighty-five and 58.9% of the children were caries free in the Klamath and comparison county samples, respectively (RR = 1.48, 95% CI 1.13, 1.93). The mean (SD) number of teeth with any decay was .75 (2.5) in the test population and 1.6 (2.5) in the comparison population (t = 2.08, p = .04). CONCLUSIONS: The assessment showed that children of mothers in the Klamath County program were about one and a half times more likely to be caries free than children in the comparison counties. Additional controlled studies are being undertaken.

System level interventions to reduce utilization of general anesthesia to treat dental caries: a practice brief.

Dental caries are the most common chronic disease of childhood. Untreated caries can result in severe pain and infection; and in some cases, difficulties in eating, speech, and education. Hospitalization and general anesthesia are often necessary for treating extensive disease in young children, which adds significant risk and expense. Interventions, such as community-based preventative care, utilization of pre-authorizations for treatment, and at-risk contracts, have been deployed as innovative strategies to reduce the incidence of caries and the cost of treatment. Value-based payment structures give payors flexibility to design a multipronged system to impact the health of consumers. This practice brief will identify interventions at a systems level that reduced the utilization of general anesthesia treating dental caries in children under the age of six. Dental claims data from the period of Q1 2011 to Q2 2020 were utilized to analyze the trends in utilization of the operating room (OR) to treat dental conditions among children under 6 years. Fixed effects analysis was utilized to identify key over time changes in the reduction of children's OR utilization. A reduction in utilization of general anesthesia and hospitalization for treating dental caries in young children was seen. The expansion of the community care team, metrics to reinforce the systems of provider education and training, and the use of incentive payments were all associated with reductions in the rate of OR utilization. Between 2012 and 2017, multiple initiatives were implemented without a systematic approach to quality improvement to evaluate.

Parents' Satisfaction with Silver Diamine Fluoride Treatment of Carious Lesions in Children.

Purpose: Current national evidence-based recommendations for treatment of carious lesions include the use of 38 percent silver diamine fluoride (SDF). The purpose of this study was to learn parents' opinions of esthetic changes to their children's teeth following treatment with SDF.
Methods: Three-hundred nineteen parents who had previously consented to SDF for caries arrest or caries prevention were asked if their child received SDF, if they noticed changes because of SDF, and how "bothered" they were by the changes.
Results: Two-hundred ten parents reported their child received SDF in the past 12 months, of whom 76 percent were confirmed by Codes on Dental Procedures and Nomenclature (CDT): 115 children received SDF for caries arrest and 45 received topical fluoride (SDF) for prevention. Of all 210 who reported SDF, 30 percent described discoloration of their child's teeth or gingiva. On a scale of zero (not bothered at all by changes due to SDF) to 10 (very bothered), parents' average rating was 1.2 ipoints; the average within the caries arrest group was 1.7.
Conclusion: Dental treatment requires a shared decision between parents and professionals, and follow-up regarding new procedures is warranted. In this study, treatment with SDF was well accepted by most parents.

Changes in Silver Diamine Fluoride Use and Dental Care Costs: A Longitudinal Study.

Purpose: This study evaluated the impact of silver diamine fluoride (SDF) by investigating coverage and reimbursement policies. Methods: We performed a population-level retrospective cohort analysis (N equals 117,599) using claims. We evaluated two policy events: (1) dental board approval permitting SDF use by expanded practice dental hygienists (EPDHs); (2) approval of SDF by Medicaid. Coincident with coverage, Advantage Dental Services instituted EPDH practice algorithms. To evaluate changes, we: estimated CDT code 1354 utilization and average quarterly costs; stratified the population into patients who initiated preventive care from an EPHD or dentist; estimated outcome differences with either policy in quarterly trends; and counted SDF use with claims by quarter and calculated utilization per 1,000 patients. Results: Average per-patient quarterly dental costs (June 2017) ranged from $384 to $423. SDF use grew associated with Medicaid policy: rates increased from $0.32 per 1,000 to $156 per 1,000 in six quarters. Care initiated by EPDHs had lower costs, with quarterly savings of $201 (P=0.011) per patient, without differences in SDF utilization. Conclusions: Policy makers can use our results to improve access and reduce costs. Clinical experts should address more clearly when SDF substitutes for or is used in conjunction with restorative treatment.

Providing a dental home for pregnant women: a community program to address dental care access--a brief communication.

OBJECTIVE: This paper describes a community-based intervention to provide a dental home for women covered by Medicaid in Klamath County, Oregon. In 2001, 8.8 percent of pregnant women served by Medicaid in Oregon received care. The long-term goal of the program is to promote preventive oral care for both mothers and their new infants. METHODS: Pregnant women received home/Women, Infant and Children visits and were assigned a dental home under a dental managed care program [Dental Care Organization (DCO)]. All initial care was provided at the Oregon Institute of Technology Dental Hygiene Clinic under the contract with the DCO. Emergency, preventive, and restorative care was provided. RESULTS: Between February 2004 and January 2006, 503 pregnant women were identified; 421 women were contactable. Of these, 339 received home visits (339/421, 80.5 percent) and 235 received care (235/339, 69.3 percent). Overall, 55.8 percent of eligible women received care (235/421). Most who did not have a visit either moved or were not the caretaker of the baby. The missed appointment rate was 9 percent. CONCLUSION: A community health partnership led to a successful and sustainable model extending care to pregnant women and is being extended to promote preventive care for both new mothers and their offspring.

Topical silver diamine fluoride for dental caries arrest in preschool children: A randomized controlled trial and microbiological analysis of caries associated microbes and resistance gene expression.

OBJECTIVES: The Stopping Cavities Trial investigated effectiveness and safety of 38% silver diamine fluoride in arresting caries lesions. MATERIALS AND METHODS: The study was a double-blind randomized placebo-controlled superiority trial with 2 parallel groups. The sites were Oregon preschools. Sixty-six preschool children with ≥1 lesion were enrolled. Silver diamine fluoride (38%) or placebo (blue-tinted water), applied topically to the lesion. The primary endpoint was caries arrest (lesion inactivity, Nyvad criteria) 14-21days post intervention. Dental plaque was collected from all children, and microbial composition was assessed by RNA sequencing from 2 lesions and 1 unaffected surface before treatment and at follow-up for 3 children from each group. RESULTS AND CONCLUSION: Average proportion of arrested caries lesions in the silver diamine fluoride group was higher (0.72; 95% CI; 0.55, 0.84) than in the placebo group (0.05; 95% CI; 0.00, 0.16). Confirmatory analysis using generalized estimating equation log-linear regression, based on the number of arrested lesions and accounting for the number of treated surfaces and length of follow-up, indicates the risk of arrested caries was significantly higher in the treatment group (relative risk, 17.3; 95% CI: 4.3 to 69.4). No harms were observed. RNA sequencing analysis identified no consistent changes in relative abundance of caries-associated microbes, nor emergence of antibiotic or metal resistance gene expression. Topical 38% silver diamine fluoride is effective and safe in arresting cavities in preschool children. CLINICAL SIGNIFICANCE: The treatment is applicable to primary care practice and may reduce the burden of untreated tooth decay in the population.

Pay-for-performance incentive program in a large dental group practice.

BACKGROUND: Dentists increasingly are employed in large group practices that use financial incentive systems to influence provider performance. The authors describe the design and initial implementation of a pay-for-performance (P4P) incentive program for a large capitated Oregon group dental practice that cares primarily for patients receiving Medicaid. The authors do not assess the effectiveness of the incentive system on provider and staff member performance. METHODS: The data come from use of care files and integrated electronic health records, provider and staff member surveys, and interviews and community surveys from 6 counties. Quarterly individual- and team-level incentives focused on 3 performance metrics. RESULTS: The program was challenged by many complex administrative issues. The key issues included designing a P4P system for different types of providers and administrative staff members who were employed centrally and in different communities, setting realistic performance metrics, building information systems that provided timely information about performance, and educating and gaining the support of a diverse workforce. Adjustments are being made in the incentive scheme to meet these challenges. CONCLUSIONS: This is the first report of a P4P compensation system for dental care providers and supporting staff members. The complex administrative challenges will require several years to address. PRACTICAL IMPLICATIONS: Large, capitated dental practice organizations will employ more dental care providers and administrative staff members to care for patients who receive Medicaid and patients who are privately insured. It is critical to design and implement a P4P system that the workforce supports.

Everybody Brush! Consumer Satisfaction with a Tooth Decay Prevention Program.

INTRODUCTION: Twice-daily caregiver-supervised toothbrushing with fluoridated toothpaste is an effective and widely recommended strategy to prevent tooth decay in children. Qualitative research suggests that low-income caregivers know the recommendation but would benefit from toothbrushing supplies and advice about how to introduce this health behavior especially as the child becomes older and asserts autonomy to do it "myself." Our objective is to assess consumer satisfaction with the evidence-based theory-informed campaign and usefulness of materials that were home delivered. The focus of the evaluation was families with children <36 months of age because of the high incidence of disease in this population. METHODS: A dental care organization designed and implemented Everybody Brush! in three counties of Central Oregon. Participants were families of Medicaid-insured children <21 years of age. Participants were randomly assigned to one of the three study groups: test (supplies, voice/printed messages, telephone support), active (supplies), and a waitlist control. Program materials were in English and Spanish. Caregivers of children <36 months were interviewed at the beginning and end of the program. RESULTS: A total of 83,148 toothbrushing kits were mailed to 21,743 families. In addition, 93,766 printed messages and 110,367 recorded messages were sent to half of the families. Caregivers were highly satisfied. On a global rating scale from 0 to 10 (worst to best program possible), they rated the program 9.5 on average (median: 10, SD 0.9). On a scale from 0 to 10 (not at all to very useful), mean ratings for usefulness of the toothbrushing supplies was 9.5 (SD = 1.5), for the printed postcard messages was 7.2 (SD 3.6), and for the voice telephone messages was 6.5 (SD 3.9). DISCUSSION: A dental care organization carried out a complex community intervention designed to address excess tooth decay among low-income children. Caregivers were highly satisfied with the Everybody Brush! program and toothbrushing supplies were considered the most useful, followed by printed messages. Voice telephone messages were rated least useful. Further evaluation of the impact of the program on toothbrushing behavior and dental-care utilization is underway.

"Everybody brush!": protocol for a parallel-group randomized controlled trial of a family-focused primary prevention program with distribution of oral hygiene products and education to increase frequency of toothbrushing.

BACKGROUND: Twice daily toothbrushing with fluoridated toothpaste is the most widely advocated preventive strategy for dental caries (tooth decay) and is recommended by professional dental associations. Not all parents, children, or adolescents follow this recommendation. This protocol describes the methods for the implementation and evaluation of a quality improvement health promotion program. OBJECTIVE: The objective of the study is to show a theory-informed, evidence-based program to improve twice daily toothbrushing and oral health-related quality of life that may reduce dental caries, dental treatment need, and costs. METHODS: The design is a parallel-group, pragmatic randomized controlled trial. Families of Medicaid-insured children and adolescents within a large dental care organization in central Oregon will participate in the trial (n=21,743). Families will be assigned to one of three groups: a test intervention, an active control, or a passive control condition. The intervention aims to address barriers and support for twice-daily toothbrushing. Families in the test condition will receive toothpaste and toothbrushes by mail for all family members every three months. In addition, they will receive education and social support to encourage toothbrushing via postcards, recorded telephone messages, and an optional participant-initiated telephone helpline. Families in the active control condition will receive the kit of supplies by mail, but no additional instructional information or telephone support. Families assigned to the passive control will be on a waiting list. The primary outcomes are restorative dental care received and, only for children younger than 36 months old at baseline, the frequency of twice-daily toothbrushing. Data will be collected through dental claims records and, for children younger than 36 months old at baseline, parent interviews and clinical exams. RESULTS: Enrollment of participants and baseline interviews have been completed. Final results are expected in early summer, 2017. CONCLUSIONS: If proven effective, this simple intervention can be sustained by the dental care organization and replicated by other organizations and government. TRIAL REGISTRATION: ClinicalTrials.gov NCT02327507; http://clinicaltrials.gov/ct2/show/NCT02327507 (Archived by WebCite at http://www.webcitation.org/6YCIxJSor).

Population-centered Risk- and Evidence-based Dental Interprofessional Care Team (PREDICT): study protocol for a randomized controlled trial.

BACKGROUND: To improve the oral health of low-income children, innovations in dental delivery systems are needed, including community-based care, the use of expanded duty auxiliary dental personnel, capitation payments, and global budgets. This paper describes the protocol for PREDICT (Population-centered Risk- and Evidence-based Dental Interprofessional Care Team), an evaluation project to test the effectiveness of new delivery and payment systems for improving dental care and oral health. METHODS/DESIGN: This is a parallel-group cluster randomized controlled trial. Fourteen rural Oregon counties with a publicly insured (Medicaid) population of 82,000 children (0 to 21 years old) and pregnant women served by a managed dental care organization are randomized into test and control counties. In the test intervention (PREDICT), allied dental personnel provide screening and preventive services in community settings and case managers serve as patient navigators to arrange referrals of children who need dentist services. The delivery system intervention is paired with a compensation system for high performance (pay-for-performance) with efficient performance monitoring. PREDICT focuses on the following: 1) identifying eligible children and gaining caregiver consent for services in community settings (for example, schools); 2) providing risk-based preventive and caries stabilization services efficiently at these settings; 3) providing curative care in dental clinics; and 4) incentivizing local delivery teams to meet performance benchmarks. In the control intervention, care is delivered in dental offices without performance incentives. The primary outcome is the prevalence of untreated dental caries. Other outcomes are related to process, structure and cost. Data are collected through patient and staff surveys, clinical examinations, and the review of health and administrative records. DISCUSSION: If effective, PREDICT is expected to substantially reduce disparities in dental care and oral health. PREDICT can be disseminated to other care organizations as publicly insured clients are increasingly served by large practice organizations. TRIAL REGISTRATION: ClinicalTrials.gov NCT02312921 6 December 2014. The Robert Wood Johnson Foundation and Advantage Dental Services, LLC, are supporting the evaluation.