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.

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.

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.

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.

Costs and Resource Use Among Child Patients Receiving Silver Nitrate/Fluoride Varnish Caries Arrest.

PURPOSE: The purpose of this study was to assess the impact of silver nitrate/fluoride varnish (SN/FV) on care costs. METHODS: A retrospective matched cohort study, using Oregon Medicaid claims (January 1, 2012 to December 31, 2014) for patients younger than 21 years old, compared patients treated with SN/FV to matched patients not treated with SN/FV. The number of services and costs were compared using student's t test and generalized estimating equation (GEE) regression models. RESULTS: Patients treated with SN/FV (n equals 4,612) and matched patients treated conventionally (n equals 13,498) averaged 28±7 (SD) months of continuous eligibility based on initial treatment date. The number of first-year services and total services over an average of 28 months were higher for patients treated with SN/FV (10.6 versus 6.7 in year one; 19.3 versus 8.8 overall; P<0.0001). Excluding diagnostic/preventive services, costs were higher in patients treated conventionally than patients treated with SN/FV in the first year. Overall costs were similar ($698 versus $707; P=.52). The average number of services was 58 percent higher (95 percent confidence interval [CI] 1.54 to 1.63) for patients treated with SN/FV, but costs remained similar. CONCLUSION: Patients treated with silver nitrate/fluoride varnish accrued a greater number of services and higher total costs over approximately 28 months but lower treatment costs than patients treated conventionally.

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.