Our fractured medical care system might be the national headline grabber, but dental care is arguably an even bigger sore spot.
The statistics are painful: Tooth decay is the most common chronic disease among children. One in four dentists accepts Medicaid. Of those that accept it, less than half see more than one Medicaid patient per day.
Yet, with 48% of kids age 14 and younger on government assistance, access to quality care for economically disadvantaged children is a critical problem. And without prevention and treatment, cavities and gum disease can lead to life-threatening infections and are associated with medical problems including diabetes, heart disease, stroke and dementia.
With Medicaid reimbursement rates at a third to less than half of those for private insurance, more complicated billing processes and low-show rates for Medicaid patients, unfavorable economics drive dentists away from the very patients who need them most.
The bottom line: Lack of access to dental care has become a healthcare crisis. Yet it’s notably missing from our country’s conversation. And that’s bad news.
Here’s the good news: There’s a straightforward way to change Medicaid dental care delivery. In a word, alignment.
Currently, the objectives of state Medicaid officials, dental managed care organizations (MCOs) and dentists are at odds: States aim to increase access and deliver high-quality dental care to underserved children, within budgetary allocations. Meanwhile, MCOs target profitable growth. And lawmakers, oversight agencies and taxpayers demand access, cost effectiveness and positive outcomes. Finally, dentists want to grow profitably and continuously improve quality.
Ironically, while states and MCOs benefit from preventing dental problems and improving outcomes, the dentists providing the oral healthcare do not.
Here’s the beautifully simple yet comprehensive solution: Align all stakeholders’ objectives through a pay-for-performance system that rewards preventive care, cost-effective management practices and better outcomes.
Right now, 80% of dentists (compared to about 20% of physicians) are either sole or group practitioners, left to manage both their own business operations and provide clinical care. Historically, those who joined MCOs encountered some bumpy roads. There was little visibility into how money was spent on dental versus other areas of care. For example, if an MCO was losing money in other areas of its healthcare business, administrators could shift dental funds to cover losses.
Another example: Some MCOs were adept at creating the perception of patient access rather than actual access. By contracting with a statewide network of providers who saw the minimum number of Medicaid patients, they met contractual requirements without expanding access. Last and perhaps most surprisingly, there was little focus on identifying and incenting providers to increase access, while improving outcomes and lower costs.
Dental RFP and contracting best practices
State Medicaid managed care requests for proposals (RFPs) outline contract specifications they expect from an MCO. Progressive states carefully design those expectations, promote capability to align incentives across the entire system and track performance against expectations.
This alignment of incentives attracts MCOs that know how to make measurable, efficient increases in access. They allow MCOs to focus their expertise on selecting network providers skilled at increasing access and providing improved outcomes and lower costs. That superior performance is rewarded with increased incentives and/or patient dental home assignment.
Accordingly, best RFP practices are quickly emerging:
- Clearly establish RFP goals based on what the state wants to accomplish annually, against an existing service-level baseline. Include a focus on measures that have been clinically demonstrated to lead to improved outcomes and lower cost.
- Require real visibility into dollars spent on dental care and documented progress against these goals.
- Require reporting of relative performance of individual providers versus other providers in the network against the same goals.
- Establish value-based purchasing initiatives to meaningfully reward superior providers.
- Create main dental homes that facilitate patient assignment with superior providers.
By moving from fee-for-service toward fee-for-performance, states have the power to drive Medicaid dental care delivery reform. Rewarding MCOs, dentists and patients alike for prevention and better outcomes will have everybody smiling brighter.
Tom Nance is chief executive officer at Benevis, a leading practice services company for the healthcare industry. Nance has more than 35 years of experience in the healthcare, consumer products and business services industries. He joined Benevis as chief financial officer in 2005 and was named CEO in 2013. Prior to joining Benevis, Nance was CFO of Elmer’s Products Inc.