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Quality Measurement in the New Era of Dentistry and Healthcare
Gary Cuttrell, DDS, JD
University of New Mexico
Department of Dental Medicine
Quality Measurement: Smiles?
Quality Measurement: Smiles?
US Expenditures 2008 Diagnostic Conditions
• Oral Health $102 Billion (ADA)
• Heart Conditions $ 96 Billion (AHRQ)
• Trauma-related disorders $ 74 Billion
• Cancer $ 72 Billion
• Mental Disorders $ 72 Billion
• COPD, Asthma $ 54 Billion
• The total national expenditures for oral health care are expected to increase to $167.9B in 2020. (CMS. National Health Expenditure Projections)
The Surgeon General’s Report (2000)
• “Although there have been gains in oral health status for the population as a whole, they have not been evenly distributed across subpopulations.” Profound health disparities exist among populations including: – Racial and ethnic minorities
– Individuals with disabilities
– Elderly individuals
– Individuals with complicated medical and social conditions and situations
Dental Caries in Primary (Baby) Teeth
• Overall dental caries in the baby teeth of children 2 to 11 declined from the early 1970s until the mid 1990s. From the mid 1990s until the most recent (1999-2004) National Health and Nutrition Examination Survey, this trend has reversed: a small but significant increase in primary decay was found. This trend reversal was more severe in younger children. Tables 1 through 4 present selected caries estimates in primary teeth for children aged 2–11 years and for selected subgroups.
• Prevalence – 42% of children 2 to 11 have had dental caries in their primary teeth. – Black and Hispanic children and those living in families with lower incomes have more decay.
• Unmet Needs – 23% of children 2 to 11 have untreated dental caries. – Black and Hispanic children and those living in families with lower incomes have more
untreated decay. • Severity
– Children 2 to 11 have an average of 1.6 decayed primary teeth and 3.6 decayed primary surfaces.
– Black and Hispanic subgroups and those with lower incomes have more severe decay in primary teeth.
– Black and Hispanic subgroups and those with lower incomes have more untreated primary teeth.
• Source: National Institute of Dental and Craniofacial Research (NIDCR)National Institutes of Health
Dental Caries in Permanent (Adult) Teeth
• Dental caries in children’s permanent teeth declined from the early 1970s until the mid 1990s. Significant disparities are found in some population groups. Tables 5 through 8 present selected caries estimates in permanent teeth for children aged 2–11 years and for selected subgroups.
• Prevalence – 21% of children 6 to 11 have had dental caries in their permanent teeth. – Hispanic children and those living in families with lower incomes have more decay in their permanent teeth.
• Unmet Needs – 8% of children 6 to 11 have untreated decay. – Hispanic children and those living in families with lower incomes have more untreated decay.
• Severity – Children 6 to 11 have about 0.45 decayed permanent teeth and 0.68 decayed permanent surfaces. – Black and Hispanic subgroups and those with lower incomes have more severe decay in both permanent teeth and surfaces. – Black and Hispanic subgroups and those with lower incomes have more untreated permanent teeth and surfaces.
• Units of Measure: Dental caries is measured by a dentist examining a child’s teeth, and recording the ones with untreated decay and the ones with fillings. This provides three important numbers:
• ft (filled teeth): this is the number of decayed teeth that have been treated, which indicates access to dental care; • dt (decayed teeth): this is the number decayed teeth that have not been treated, which measures unmet need;
and • dft (decayed and filled teeth): this is the sum of ft and dt, and is the measure of person’s total lifetime tooth
decay. • In addition to counting decayed and filled teeth, this same information can be gathered at the tooth surface level.
Since every tooth has multiple surfaces, counting the decayed or filled surfaces provides a more accurate measure of the severity of decay.
Quality in Medicine
• The kick starters in Medicine. “To Err is Human: Building a Safer Healthcare System” 1(1999) and “Crossing the Quality Chasm: A New Health System for the 21st Century” 2 (2001) both by the Institute of Medicine (IOM)
• These reports described problems in patient safety, the high cost of medical errors
• Inefficient use of resources
• Need to redesign fragmented health care delivery
Continual Improvement Process
• A continual improvement process, also often called a continuous improvement process (abbreviated as CIP or CI), is an ongoing effort to improve products, services, or processes. These efforts can seek "incremental" improvement over time or "breakthrough" improvement all at once. Delivery (customer valued) processes are constantly evaluated and improved in the light of their efficiency, effectiveness and flexibility. (W. Edwards Deming, a pioneer of the field)
• Some see CIPs as a meta-process for most management systems.
Quality of life
• In general, quality of life (QoL or QOL) is the perceived quality of an individual's daily life, that is, an assessment of their well-being or lack thereof. This includes all emotional, social, and physical aspects of the individual's life. In health care, health-related quality of life (HRQoL) is an assessment of how the individual's well-being may be affected over time by a disease, disability, or disorder.[1] – Source: http://www.cdc.gov/hrqol/concept.htm
Organizations in Quality
• Organizations which work to set standards and measures for health care quality include:
• Government agencies – HRSA, CMS, CDC . . .
• Accreditation programs such as those for hospital accreditation, health associations, or those who wish to establish international healthcare accreditation
• Philanthropic foundations • Health research institutions
– These organizations seek to define the concept of quality in healthcare, measure that quality, and then encourage the regular measurement of quality so as to provide evidence that health interventions are effective.
Institute of Medicine
• IOM called for a national strategy to transform our healthcare system into one that is safe, effective, patient-centered, timely, efficient and equitable (1999-2001)
• IOM states quality improvement is urgent due to system’s increasing complexity and ever-escalating costs (1999-2001)
• IOM (2012): Opportunities due to vast and affordable computational capabilities to improve reliability and efficiency of care processes, and recognition that effective care must be delivered by collaborations between teams of clinicians and patients.
Affordable Care Act
• ACA: U.S. Department of Health and Human Services (HHS) produced: National Strategy for Quality Improvement in Health Care (2011)
• Strategy includes the “triple aim” – Better health care – A healthier population and community – Lower per capita care cost
• HHS: improve health care quality and patient safety, in part by implementing payment reforms that reward quality care and quality improvement efforts
Michael Glick, DMD & Daniel M Meyer, DDS Defining oral health: JADA 145(6) June 2014
• Traditional measures of dental disease may not be appropriate any longer and new and improved measures may be needed.
• Oral health researchers often rely on clinical measures (which can be visualized) for oral disease.
• Better markers of oral health and disease will need to evolve to match needed changes in clinical measures
British Dental Journal
• Statement: Quality needs to be defined and understood before it can be measured
• Quality improvement requires indicators of quality, measurement and targets
• Quality improvement strategies for medicine do not apply readily to dentistry because the professions differ in significant ways that influence how stakeholders view quality.
ACA & CMS
• The Patient Protection and Affordable Care Act (ACA) mandates that the Centers for Medicare and Medicaid Services (CMS) collect and analyze health services data prior to developing and implementing the new payment system.
• This requires that the appropriate revenue code and Healthcare Common Procedure Coding System (HCPCS) code is listed with each service provided. (HHS)
GOVERNMENT
• CMS expanding it role beyond a payer of claims
• An agency actively promoting the quality of care for its beneficiaries.
• CMS is collaborating with HHS Agency for Healthcare Research and Quality to develop new dental measures by contracting with multiple organizations outside of dentistry
Why Dentistry is not covered by Medicare
• 1980 by Dr. H. BARRY WALDMAN, DDS, PHD, MPH, entitled “The Reaction of the Dental Profession to Changes in the 1970s.” In the article, Dr. Waldman notes:
“In the mid-1960s, during the Congressional review of the then pending Medicare and Medicaid legislation, the ADA opposed dental care for the aged under the Medicare bill, while lobbying for the inclusion of dentistry as a benefit under the proposed extension to the Kerr-Mills legislation for services to the poor (Medicaid).”
State Medicaid Programs
• Texas: Pay-for-performance by holding providers accountable for selected quality measures
• Florida: Major study on quality measures through DQA about to be released. (CMS & DQA Project)
• Oregon: Manages the oral health care through coordinated care organizations and dental care organizations that must delineate appropriated performance and quality measures
– These activities lead by governmental agencies
Commercial Dental Plans Quality Improvements in Industry
• Historically, dental benefits paid for services deemed to improve oral health
• No university accepted standards for dental necessity for every procedure – Payers concerned with overutilization attempt to
improve quality by not paying for services they deem not to be appropriate
• The evidence, narratives and diagnostic images is measured against the payer’s criteria to determine payment
Commercial Dental Plans Quality Improvements in Industry
• Dental benefit companies traditionally measure the use of services as a measure of quality – Utilization for access to care – Use of diagnostic and preventive services based on
concept that early detection leads to early treatment and less disease
• These measures are traditionally derived from claims data which only identify the procedures an individual received – Unfortunately, there are not diagnostic measures in
common use to determine the oral health status of the individual at the time of treatment
Commercial Dental Plans Quality Improvements in Industry
• Without diagnostic codes, there are widespread unexplained variations in clinical decisions among dentists
• This will need to change if a fundamental shift from “paying for volume” to “paying for value” occurs
• As most dental care has been provided in private dental offices, data has not been available
Practice Models in Dentistry Changing
• Fewer dentists will own their practices complicated by the large debt many carry once graduating dental school
• More dentistry is being done each year in corporate practices large and small
• With EDR becoming the norm, data will be available
• Payers may well require data be furnished for payment agreements
Who will lead dental’s quality movement
• Quality measurement has been slow coming to dentistry. – Slowed by the historic “cottage industry” practice model
and the slower use full electronic dental records.
• The ADA is attempting to represent dentistry through its development of the Dental Quality Alliance. (2008) – How will dentistry partner with commercial payers? – Will the ACA eventually mandate for oral health care
coverage? – Will there be funding to help? – How will the value and quality measurement shape the
practice of dentistry?
Dental Quality Alliance “Improving Oral Health Through Measurement”
• The Dental Quality Alliance (DQA) was established by the American Dental Association to develop performance measures for oral health care. The DQA is an organization of major stakeholders in oral health care delivery that will use a collaborative approach to develop oral health care measures.
• Mission – The mission of the Dental Quality Alliance is to advance performance
measurement as a means to improve oral health, patient care and safety through a consensus-building process.
• Objectives
– 1. To identify and develop evidence-based oral health care performance measures and measurement resources.
– 2. To advance the effectiveness and scientific basis of clinical performance measurement and improvement.
– 3. To foster and support professional accountability, transparency, and value in oral health care through the development, implementation and evaluation of performance measurement.
DQA: Organizational Members
• Academy of General Dentistry • American Academy of Oral & Maxillofacial
Pathology • American Academy of Oral & Maxillofacial
Radiology • American Academy of Pediatric Dentistry • American Academy of Periodontology • American Association of Endodontists • American Association of Oral and
Maxillofacial Surgeons • American Association of Orthodontists • American Association of Public Health
Dentistry • American Board of Pediatric Dentistry • American College of Prosthodontists • American Dental Association’s Board of
Trustees • American Dental Education Association
• American Dental Hygienists' Association • American Medical Association • America's Health Insurance Plans • Council on Access, Prevention and
Interprofessional Relations (ADA) • Council on Dental Benefit Programs (ADA) • Council on Dental Practice (ADA) • Council on Government Affairs (ADA) • Delta Dental Plans Association • DentaQuest • Managed Care of North America Dental • Medicaid-CHIP State Dental Association • National Association of Dental Plans • National Network for Oral Health Access • The Joint Commission
DQA: Technical Advisors
• Agency for Healthcare Research and Quality
• Centers for Disease Control and Prevention
• Centers for Medicare and Medicaid Services
• Health Resources and Services Administration
• Public Member
Dental Quality Alliance “Improving Oral Health Through Measurement”
• The lack of use of diagnostic codes in dentistry currently limits outcome measurements, but evidence-based and outcome-based process measures can serve as a useful basis for program improvement.
• DQA statement: What Gets Measured Can be Changed – Data Driven Policies
HRSA’s National Health Initiative (2010-11)
• Because quality assessment and improvement efforts lag significantly behind those in the rest of healthcare, HHS can promote the development of oral health measures of quality
• Despite the breadth of these efforts, it is often assumed that HHS has a fairly minor role in and very little leverage to influence the day-to-day functioning of the oral health care system in America. Data indicate that only 9 (2013-6%) percent of dental expenditures come from public insurance (com-pared with 34 percent for physician and clinical services and 34 percent for prescription drugs).
HRSA’s National Health Initiative (2010-11)
• The committee concluded that (1) distinct segments of the U.S. population have challenges with accessing care in typical settings of care; (2) lack of dental coverage contributes to access problems; (3) newer financing mechanisms might help contain costs and improve health outcomes; and (4)new delivery models need to be explored to improve efficiency.
HRSA’s National Health Initiative (2010-11): RECOMMENDATION 6:
• HHS should place a high priority on efforts to improve open, actionable, and timely information to advance science and improve oral health through research by Leveraging resources for research to promote a more robust evidence base specific to oral health care,
• Including, but not limited to, oral health disparities, and to best practices in oral health care and oral health behavior change;
• Working across HHS agencies—in collaboration with other federal departments (e.g., Department of Defense, Veterans Administration) involved in the collection of oral health data—to integrate, standardize, and promote public availability of relevant databases;
• Promoting the creation and implementation of new, useful, and appropriate measures of quality oral health care practices, cost and efficiency, and oral health outcomes.
HRSA’s National Health Initiative (2010-11)
• Finally, the committee concluded that an effective NOHI needs an on-going process for maintaining accountability and for measuring progress toward achieving specific goals of improved oral health
Quotation
• Can you imagine a time when we fully incorporate mental and dental health into our thinking about health? What is it about problems above the neck that seems to exclude them so often from policy about health care?
– Harvey V. Fineberg, President, Institute of Medicine Institute of Medicine Annual Meeting, October 12, 2009
Observations
• Little has changed since the 2000 General Surgeon’s report on oral health.
• Policymakers have not matched known need with funding necessary as oral health care is still not “valued” by their funding decisions.
• Oral Health funding does not reflect a national value of providing oral health care
• Health Homes need to include dental homes for comprehensive care
• Government and third party payers do not elicit great trust. – Often seen as controlling costs at expense of providers
Observations
• Dentistry will be required to demonstrate “value” based on someone’s measurement data based on outcomes
• Value = health outcomes achieved per dollar spent over the lifecycle of a condition
• Lots of organizations are attempting to set the standards used for outcome measurement
• Personal clinical experience emerged as the determining factor in dentists’ treatment decisions. This will be changed by value movement
The Era of Accountability Report by Paul Glassman DDS
• Keys to better access and quality are better measurement of oral health care outcomes and promoting innovation at the systems level.
• The pathway to better measurement will involve increased use of electronic health records to make collection and analysis of data easier;
• development and use of measures of oral health outcomes; • development and use of diagnostic coding systems to better track oral
health outcomes across large populations; • innovation in payment; • monitoring and incentive mechanisms tied to the oral health of the
population served; • delivery of care in nontraditional settings; • developing new types of allied dental professionals; • and use of telehealth technologies to reach people in geographically
remote areas.
Care for Chronic Oral Diseases
• Acute Care/Surgical Intervention • Provider‐centric model • Care delivered in fixed offices • and clinics • “Treatment” based on discrete
procedure‐based episodes of care • Payment based on discrete
procedure‐based episodes of care
• Emphasis on surgical interventions
• Chronic Disease Management • Patient‐centric model • Care delivered where people • are to the extent possible • “Management” based on
maintaining health across the life‐cycle of a condition
• Payment based on value of health improvement across life‐cycle of a condition
• Emphasis on risk assessment, prevention, and early
• intervention, using biological, medical, behavioral, and social tools
Quotation
• Not everything that can be counted counts, and not everything that counts can be counted.
– Albert Einstein, (attributed) US (German-born) physicist (1879 – 1955
