What Is the Potential for Value-Based Care in Dentistry?

Caitlin Walsdorf, a partner at HealthScape Advisors, a Chartis company, recently spoke with Healthcare Innovation about a new survey-based report that explores value-based care (VBC) implementation in dentistry.  The survey was a collaboration between HealthScape, the CareQuest Institute of Oral Health and the National Association of Dental Plans. 

Walsdorf co-leads  HealthScape’s Ancillary Center of Excellence focusing on areas such as dental, vision, and hearing. She is also an active member of the Medicare and Transaction Advisory  Centers of Excellence

Healthcare Innovation: We write a lot about value-based care in the medical space, especially in primary care, but we haven't written about it much in the dental space. Is value-based care in dentistry in its very early stages? 

Walsdorf: Typically, when people hear value-based care in the context of dental, they think about the Medicaid market, where it might be a capitated payment made to providers for members that are assigned to that provider in a dental home model, similar to how you think about a medical home model on the medical side. But not as many people think about dental value-based care in the context of the commercial markets. 

Commercial dental is typically associated with fee-for-service payments and large, broad networks. That said, I think value-based care is much broader than capitated payments. There are value-based incentives that could work in the commercial line of business that both payers and providers find favorable, at least according to our survey results. These could be things like member steerage opportunities, so things like preferred provider locator placement or a quality designator on a locator. Also, quality bonus payments are incentives that both payers and providers ranked pretty favorably in the survey.

HCI: Is it the Medicaid managed care organizations that we typically write about for medical care that are also involved in the dental plans or is it usually a separate dental plan?

Walsdorf: It's a mix. Medicaid dental, depending on the state, can look one of two ways. It can either be embedded within the medical Medicaid contract administered by an MCO, or it can be a state that has a separate, carved-out Medicaid dental contract that is administered directly by a dental care organization. When it's the former, when it is a state that has dental embedded within medical, that can also have two different flavors. So that can either be that the MCO maintains a dental network and manages the dental cost of care directly themselves, or that they partner with a managed dental care organization in order to administer that business.

HCI: In cases where the MCO keeps that responsibility in-house, is that where we're most likely to see the value-based care moving into the dental realm?

Walsdorf: In our survey, we did find that health plans — plans that had both medical and dental — were more likely both to have experience with value-based care in the past as well as more likely to implement value-based care in the future.

HCI: Is one of the limiting factors of making this more widespread the EHR and data infrastructure required? Smaller dentist's office may not have that.

Walsdorf: The survey focused on DSOs or dental support organizations. These are larger organizations that typically have somewhere between 20 and 100 practices. Those types of organizations tend to have broader tech infrastructure and easier data transfer than maybe some of the smaller practices do.

HCI: What about the plans themselves? Do they have technology issues as well? 

Walsdorf: Technology is certainly a barrier we saw in the survey results. Folks report to us both the infrastructure to receive additional data elements from providers as well as processes and technology to report back out, to produce, say, a provider scorecard as an example.

HCI: Are the types of quality measures that value-based care plans in dentistry would focus on fairly well established and aligned across these payers, or do they vary quite a bit?

Walsdorf: There's still work to do yet on quality measures. I really think that the dental industry has an opportunity to define value-based care for themselves and design some programs that work for both payers and providers. I think that providers should take an active role in the program design so that they don't feel like they are simply accepting the terms of a value-based program that has been defined by a payer. I also think that both payers and providers should work together to design mutually beneficial programs and align around quality measures before regulators put forth programs with which the industry must comply. 

HCI: The description of the survey results said that payers and providers distrust each other's motivations for value-based care, but that they actually do have common goals. What are some of the sources of that distrust and what are some ways to overcome it?

Walsdorf: At the onset of the survey, we hypothesized that organizations might define value-based care a bit differently. And in the survey, we asked respondents to provide three or four phrases to describe what value-based care means to them, and the results of that is what we put into the word cloud that appears in the paper. At first glance, you see many of the same phrases, like quality and improved outcomes and prevention. We think that this might indicate some level of definitional alignment. But when you start to take a closer look, you can identify some differences in sentiment. Providers start to say things like “strings attached,” or “less money” or “more work,” and you see payers acknowledge that value-based care is sometimes not well received by providers. 

We think that what what we're picking up on here could potentially be this idea of value-based care fatigue in the industry. We've been talking about this concept for a really long time, but outside of certain applications within the Medicaid market, we really don't have much to show for it. So we think that fatigue could be a potential driver.

HCI: If Congress were to enable Medicare to start covering dental care, what kind of impact would that have on the idea of value-based care in dentistry?

Walsdorf: I think that if that type of legislation were to be passed, and dental care were covered in the senior markets, it would certainly be interesting. I think senior care is a logical place for this type of program to take place. So I certainly think it could be a difference maker. 

HCI: Is there anything else from the results of the survey that stood out to you that I haven't asked about yet?

Walsdorf: I might just double down on this idea that the survey certainly showed that parties don't trust each other. You know, payers and providers each think the other is primarily motivated by financial gain, and if we're going to move forward, we certainly need to overcome that deficit. But you know, despite not trusting each other today, payers and providers are more aligned in their commitment to improving patient outcomes and improving care than they appreciate. I really think that commonality can be used as a launching point for more productive industry conversations on all things value-based care. Entities can start small and design pilot programs that align with their broader strategic goals. They just have to pick a starting dance partner, if you will. So a provider can pick one or two payer partners that have meaningful scale in their local market and bring forth ideas for a program that could be mutually beneficial, just as a payer could select a handful of providers and work together to design a program.