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value-based care

Flipping the Incentive Structure with Value-Based Care

Value-based care is coming to North Carolina. While dentistry may not be included in the first wave, oral health care providers should be prepared to make the transition sooner rather than later.

Given this reality, NCOHC will be launching a “value in dentistry” educational campaign in the coming weeks. This campaign will focus on giving both provider and consumer communities a chance to better understand how value-based care and associated payment restructuring in oral health care could work.

In 2015, the North Carolina General Assembly enacted a bill directing the Department of Health and Human Services (DHHS) to transition the state’s Medicaid program from its traditional fee-for-service model to Medicaid Managed Care.

While Medicaid Transformation — the name for the transition to Managed Care — is currently suspended due to the state’s ongoing budget stalemate, North Carolina is still on track to make the change in the coming years.

It is important to note that dentistry is not currently included in Medicaid Transformation. The federal waiver allowing Medicaid Managed Care expires in 2024, and dentistry should be prepared to be included during this time period or in subsequent rounds of transformation.

Simply stated, under Medicaid Managed Care, North Carolina will pay insurance companies a set rate per patient to provide all necessary services to those on Medicaid. This model isn’t exactly value-based care — we’ll get to that point later in this post — but it does signal a paradigm shift. Through Medicaid Transformation, the opportunity to innovate and launch value-based care and value-based payment models is ripe.

The traditional fee-for-service model of health care incentivizes more costly, invasive procedures, while Managed Care is meant to incentivize keeping patients healthy and out of the doctor’s office.

 

 

Now, before you get your feathers ruffled, we aren’t suggesting that fee-for-service payment models are some sort of conspiracy leading providers to direct patients toward more expensive treatments in the name of the almighty dollar. If you pull any medical or dental professional off the street and ask them why they chose their profession, helping people lead healthy lives is likely high up on the list. Yet, “healthy patient who needs nothing done” is not a billable procedure, even if it is the ideal outcome.

Under Managed Care, you can see clearly where the profit model incentivizes healthy outcomes. If insurance companies are paid a set rate per individual, the less work each individual needs, the larger the profit margin becomes.

Managed Care vs. Value-Based Care

Now, how is Managed Care different from — and similar to — value-based care?

First, both models focus on health outcomes rather than fees paid for services provided. While Medicaid Managed Care focuses the financial shift on health insurance companies, existing models for value-based care focus on payment reform at the provider level.

For example, “bundled payments” is one value-based care reimbursement model. Under the bundled payment model, a patient would pay a fee for an entire “episode of care,” instead of paying separate fees for every service provided along the way.

 

DentaQuest Value-Based Care Fact Sheet

 

Value-based care in oral health delivery redirects the focus from volume toward an emphasis on the overall oral health outcomes of a patient. A shift toward value in dentistry will help assist in achieving the triple aim of patient care: lowering costs, improving patient outcomes, and increasing satisfaction.

Through enhanced education and a stronger focus on preventive-centric care rather than an episodic, surgical interventionist approach, more patients may need less invasive work. This translates to more affordable care — care in which better health outcomes will be accessible to more people.

It is important to note that in order to achieve value in dentistry and incentivize the shift, payment reform must accompany this approach. We will be discussing payment barriers and further expanding upon value in dentistry in future posts, so stay tuned!

For more information, visit DentaQuest’s value-based care webpage. There you will find a plethora of resources for dental providers.

To learn more and get involved, be sure to sign up for NCOHC news.

NCOHC is a program of the Foundation for Health Leadership & Innovation. For more information and to stay up to date, subscribe to the NCOHC newsletter. If you are interested in becoming an NCOHC member, you can also fill out our membership form. It’s free!

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NCOHC’s Policy Brief: Workforce Utilization

The North Carolina Oral Health Collaborative (NCOHC) recently released its first policy brief. The document outlines changes to North Carolina’s regulatory framework that, if enacted, could significantly increase access and equity in oral health care.

Read the policy brief here.

In the coming weeks, NCOHC will publish a series of deep dives into each section of the policy brief to explain the details of each proposal and how each could improve care for underserved North Carolinians.

North Carolina’s oral health workforce faces a growing imbalance that unnecessarily restricts access to care. The dental hygienist workforce is growing, and North Carolina’s dental hygiene programs remain competitive and full. Unfortunately, the population of practicing dentists is shrinking as dentists age out and retire faster than new ones graduate and enter the workforce.

This is a serious concern, as many of the access gaps in North Carolina are driven by a lack of dentists in rural and already underserved areas. In a recent post, NCOHC found that every practicing dentist in North Carolina would need to see 4,080 patients every year just to provide all residents with standard cleanings and checkups, not including follow-up appointments or visits for fillings and other advanced procedures.

Graphic comparing the 4080 annual patients dentists in NC would need to see to meet demand versus the 3,505 nationwide average annual patient load

With these trends in mind, it is important that North Carolina leaders take steps to allow the oral health workforce to provide care more efficiently. The proposals in the Workforce Utilization section of our policy brief address five policy changes* that can help:

  1. Revise the two hygienist per dentist supervision ratio
  2. Revise supervision definitions, primarily looking at revision of “direct supervision”
  3. Expand delegated duties for hygienists
  4. Eliminate restrictions on hygienists’ delivery of local anesthesia
  5. Recognize and credential Expanded Function Dental Assistants (EFDAs)

*It is important to note that these proposals do not necessarily reflect NCOHC’s current policy priorities. Rather, they are evidence-based steps that, if implemented, would increase access and equity in oral health care for North Carolinians across the state.

Supervision Requirements

North Carolina is considered one of the more restrictive states for dental hygiene scope of practice parameters. The North Carolina Dental Hygiene Act restricts dentists in private practice from employing more than two dental hygienists at the same time, and it also requires direct supervision—the most stringent form of supervision in a dental office—for most tasks that hygienists are effectively trained to perform.

Easing restrictions to these supervision requirements could significantly increase care provided, especially in community-based settings like school-based clinics and long-term care facilities, where dentists may not always be available on site.

Graphic defining the levels of supervision defined in the North Carolina General Statutes

Source: North Carolina General Statutes Chapter 16

Fortunately, easing direct supervision requirements, and expanding the number of hygienists a dentist can supervise, are not new or unique approaches to expanding access and equity in care delivery. Many states across the country have taken these steps, and often these changes were enacted several years ago.

Earlier this year, North Carolina took one important step toward a more equitable oral health landscape by allowing public health hygienists to work outside of direct supervision and rather based on a written standing order from the supervising dentist. The 16W rule change was important, but it only applies in limited settings. Allowing the rest of the dental hygiene workforce to practice in similar settings by written standing order instead of with a dentist physically present on site could significantly increase how many North Carolinians receive basic screening and preventive dental services.

Revision of Delegated Duties

North Carolina’s regulatory framework prevents hygienists from performing several clinical services in which they are required to be learn in their dental hygiene programs. With a few updates to include duties commonly delegated to hygienists in other states across the country, hygienists could significantly improve care access to the underserved, especially in settings outside the traditional dental office.

Graphic from oralhealthworkforce.org laying out allowable tasks for dental hygienists by state

Source: oralhealthworkforce.org

The NCOHC policy brief’s proposals for additional duties for hygienists includes interim therapeutic restorations (ITR), which refers to a restoration placed on a tooth to prevent the progression of a cavity. ITR’s should be done only in specific cases, when the cavity or decay in question hasn’t progressed too far. You can further read about ITR’s in the American Academy of Pediatric Dentistry’s Policy Statement on their use.

ITR is proven to reduce levels of cavity-causing bacteria and is used mostly when treating children and infants, especially when full restorative care is unavailable, unaffordable, or needs to be deferred.

Map highlighting states in the US where dental hygienists are allowed to administer interim therapeutic restorations

Source: ADHA

When restorations or other surgical procedures are necessary, dental hygienists could improve efficiency in the dental office by administering local anesthesia, which they are provided the didactic training for in their dental hygiene programs but prevented from performing under North Carolina law.

Along with hygienists, dental assistants play important roles in the dental office, and they, too, could increase dental office efficiency if allowed to perform expanded functions. Many states credential Expanded Function Dental Assistants (EFDAs). This workforce receives additional training to perform certain restorative procedures, such as the direct placement and modification of restorative filling material.

Map highlighting states in the US where dental assistants can be credentialed for expanded restorative functions

Source: AAPD

Stay tuned as we break down the rest of NCOHC’s policy brief. To receive updates in your inbox, sign up for NCOHC news today!

NCOHC is a program of the Foundation for Health Leadership & Innovation. For more information and to stay up to date, subscribe to the NCOHC newsletter. If you are interested in becoming an NCOHC member, you can also fill out our membership form. It’s free!

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Healthy Oral Care at Home

As some states reopen, others pause reopening, and more consider shutting down again, figuring out what is and isn’t safe to do can feel like a nationwide game of “red light, green light.” In a recent Kaiser Family Foundation poll, 52 percent of adults reported that they or a family member had skipped a medical appointment because of COVID-19. Sadly, the most common appointment skipped was for dental care.

In North Carolina, many dental offices are still closed, and others are only open for emergency services or are limiting services as they reopen. If your dental office is open for full services, you still might choose to stay home if a family member is immunocompromised, or if you are concerned about North Carolina’s rising case count, which is regularly topping 1,000 new confirmed cases daily.

Regardless of the reason, if you or a loved one are staying home and have missed an appointment—or even if you have seen a dentist or will see one soon—here are some steps we all can take for better oral care at home.

Use Fluoride Toothpaste AND Mouth Rinse

While brushing your teeth alone is important, fluoride actually strengthens your enamel and in some cases can reverse early signs of tooth decay. Fluoride toothpaste can be used at all ages, but it is important to use the right amount.

Mind Your Peas and Q’s

Fluoride toothpaste can be used as soon as a child’s primary teeth have started erupting from the gums. Before age three, just use a smear of toothpaste, no more than the size of a grain o rice. Start using a “pea at three”—a pea-sized amount of fluoride toothpaste for children and adults ages 3 and up.

Figure displaying a smear of toothpaste for children under 3 and a pea sized amount for children and adults 3 and up

Source: American Dental Association

Remember that less is more. You really don’t need the long squirt of toothpaste covering the entire brush you may see on commercials.

Know the Basics of Good Brushing

The saying doesn’t go “close only counts in horseshoes and brushing your teeth.” Brush for two minutes to ensure that you hit every single tooth, even those back molars. Two minutes may feel like a long time, but it is necessary to properly brush all sides of all your teeth.

While brushing, makes you are you are using circular motions. Brushing with a sawing motion can actually harm your teeth by increasing abrasive removal of your enamel and potentially damaging your gums. You should only apply mild pressure to your brush, about the same amount of pressure you would use to write with a pencil. It might feel like you aren’t cleaning hard enough if you use less pressure, but that’s just another reason why the full two minutes is so important!

Last, but not least, don’t forget about your tongue. Bacteria and other germs can build up on your tongue and can contribute to tooth decay, gum disease, and bad breath. Brushing your tongue is an important part of maintaining good oral health.

Change your Brush Regularly

A picture of a frayed toothbrush, with bristles flattened and sticking out in different directions

When your brush becomes frayed, its time to replace it.

Most dentists recommend changing your brush every three months or when the bristles become worn down.

Floss Daily

Brushing thoroughly can clean three sides of your teeth, but brushing alone can’t remove plaque or bacteria in between your teeth. Adding floss to your routine is an extra layer of protection from cavities, tooth decay, and gum disease.

Check your Mouth Regularly for Signs of Oral Cancer

Oropharyngeal cancers kill one person every hour in the U.S. Fortunately, early detection significantly increases survivability. Self-exams for oral cancer warning signs are quick and easy, and they are an important component of a healthy oral routine.

Check out our recent graphic about oral cancer and HPV for self-exam guidelines.

A fact sheet with information about oral cancer and HPV

Click here for a full PDF to access any hyperlinks above.

Know How Your Food Affects Your Teeth

What we eat can seriously impact our oral health, even with good brushing habits.

A graphic of unhealthy food for your teeth: fast food, cereal, sodas and sugary drinks, candies, beer (especially when mixed with tobacco) and starches

A graphic of healthy food for your teeth: leafy greens, fish and lean meats, beans, nuts, seeds, milk and dairy, eggs, and tofu

To learn more and get involved, be sure to sign up for NCOHC news.

NCOHC is a program of the Foundation for Health Leadership & Innovation. For more information and to stay up to date, subscribe to the NCOHC newsletter. If you are interested in becoming an NCOHC member, you can also fill out our membership form. It’s free!

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Social Determinants of Health: How the World Around Us Impacts our Mouths

Graphic depicting five social determinants of health: physical environment, structural & governmental influences, education, food, and economic stability

Where you live can have significant impacts on your oral health.

NCOHC recently dove deep into the first of a series of factors that impact health, known as “social determinants of health.” You can catch up and learn how government structures impact our oral health here.

A US National Resource Council and US Institute of Medicine report highlights three important physical environmental factors that impact health: proximity to toxic substances, like air pollution; access to resources, like grocery stores and health care practices; and community design, or the built environment.

All of these factors can have negative oral health consequences, from cavities and gum disease to tooth loss and oral cancer.

Can Pollution Really Impact Oral Health?

A study in the Journal of Clinical Pediatric Dentistry found that hard dental tissue could be an environmental indicator—your teeth can say a lot about the world around you, no pun intended. Children in this study living in high-pollution areas had higher cavity rates and even had significant levels of toxic compounds in their tooth tissues.

Similarly, a study in the British Medical Journal found an association between air pollution and mouth cancer.

These studies were conducted in the Eastern European country of Georgia and Taiwan, respectively. Georgia and other USSR countries endured significant environmental degradation during the Soviet era, and Taiwan is known to have particularly significant periods of air pollution.

While more research is necessary to explore links between pollution and oral health, one thing can be said for North Carolinians: if you live in a high-pollution area—such as in the vicinity of one of the 3,300 hog waste lagoons in the state—you are more likely to be Black and poor, two well-documented determinants of oral health.

Access to Resources and the Built Environment

In North Carolina, where you live can significantly impact your access to resources necessary to live a healthy life. For example, rural North Carolinians are more likely to live in food deserts. Poor nutrition and high intake of fast food and other high-sugar, high-carb foods significantly increases the risk of tooth decay and gum disease.

Additionally, 75 of North Carolina’s 100 counties are designated dental health provider shortage areas (dHPSAs). So, rural North Carolinians are more likely to face long drives—and in turn, longer periods of time off from work, childcare costs, and transportation costs—just to get to see a dentist.

To compound the effects of limited resources in rural areas, especially for low-income residents, other aspects of our built environment such as public transportation can further limit access to oral health care. In a city, you’re more likely to be able to hop on a bus if you need to see a dentist and don’t own a car. For much of rural North Carolina, however, that is simply not an option.

This isn’t to say that the only shortages in optimal oral health care occur in rural areas. There are plenty of urban food deserts, and oral health disparities between affluent and low-income individuals exist everywhere.

As we navigate oral health care systems and work to build an equitable future, where all North Carolinians have access to quality care, we have to think outside of the dental office. Join NCOHC in its work toward structural changes that expand oral health care access for underserved populations across our state.

To learn more and get involved, be sure to sign up for NCOHC news.

NCOHC is a program of the Foundation for Health Leadership & Innovation. For more information and to stay up to date, subscribe to the NCOHC newsletter. If you are interested in becoming an NCOHC member, you can also fill out our membership form. It’s free!