Moving Towards Value-Based Care: Preventive Bundled Payments in School-Based Settings

In the United States, the fee-for-service (FFS) payment model has been the dominant dental reimbursement system for decades. Unlike medicine, where it has undergone massive payment reforms to shift the focus towards value-based care since the Affordable Care Act (ACA), there has been little of that change reflected in payment models for dentistry.

The traditional FFS model bases patient pricing on the cost of each individual service or procedure. The bill typically includes these services and their individual prices listed out for the payer and the patient. Providers are compensated for the services they provide the patient. This can lead to billing errors, service inflation, and unnecessary and preventable procedures. Additionally, this model leads to providers being rewarded for high-cost, complex, and time-consuming procedures. Since volume is rewarded in FFS, a provider who completes more high-cost invasive procedures is paid more.

Although access to oral health care has increased as a result of significant investments made since the 2000 Surgeon General Report on Oral Health in America, the prevalence of decay in children over the past few decades is still concerning. Data from the National Health and Nutrition Examination Survey reported that prevalence of total caries (untreated and treated) was 50.5% for 2015-2016 among children 6-11 years old. In the same period, the prevalence of untreated caries was 15.3% in the same population. In 2017, 84.9% of children between 2-17 years old had a dental visit in the past year.6 This leaves about 15% of the population who did not have a dental visit in the past year.

North Carolina is a largely rural state with 80 of its 100 counties designated as dental health professional shortage areas (dHPSAs). Roughly 40% of North Carolina’s communities are considered to be rural, which accounts for over 4 million people. Compared to urban counties, rural counties are more likely to have a shortage of dental health providers and be designated dHPSAs.

With many providers choosing to practice in urban areas over rural areas, the shortage is felt more acutely for children living in rural areas, where there is an additional barrier with accessing a provider for preventive services. In 2016, 2.5% of all visits to North Carolina emergency departments were related to oral health compared with 1-2% in the United States. Without sufficient providers to address the need, people may go without care until they face an emergency.

Children who live in rural areas experience higher disparities of care than their urban counterparts and are more likely to rely on Medicaid. They may also rely on others to take them to dental appointments. Children in low-income families are disproportionately at higher risk and are twice as likely to have untreated decay compared to children from higher-income neighborhoods. Additionally, there are racial and ethnic disparities in the caries prevalence. Hispanic youth had the highest prevalence of total caries, and non-Hispanic black youth had the highest prevalence of untreated caries. Native Americans have reduced access to providers, with tribal facilities often designated as HPSAs. Many HPSAs are also located in counties that are predominately African American.

The combination of an outdated FFS model, provider shortages in rural areas, and concerning prevalence rates for caries in children warrants an alternative approach to how oral health prevention is prioritized.