For Immediate Release
Date: Feb 12th, 2013
Contact: Dr. Ken Rich
A Profession in Flux
Now, more than ever in my experience, our profession is under assault by more forces that will more significantly than ever before, change what we do, who we are and how we practice. These changes are being driven mostly by economics.
Healthcare accounts for 25 percent of our national budget. This makes the U.S. government the largest payer of healthcare services in the country. This budget item continues to grow, annually. By all accounts, the U.S. has the most expensive healthcare system in the world, but that does not necessarily mean that we have the best.
Healthcare spending in the U.S. is on an unsustainable tract. As a result of this and the impact of the Accountable Care Act (ACA), our profession is sure to be affected.
Dentistry, like the rest of the healthcare delivery system, will enter the era of “accountability.”
Medicine has defined six “domains of healthcare,” which will be used to look at health care quality comprehensively.
These domains define health care that is:
- Safe — avoiding injuries to patients from care that is intended to help them
- Timely — reducing waits and sometimes harmful delays
- Effective — providing services based on scientific knowledge and refraining from services not likely to benefit
- Patient centered — providing care that is respectful or responsive to individual needs
- Efficient — avoiding waste
- Equitable — providing care that does not vary regardless of personal characteristics
It is unclear how soon or to what extent outcomes-based financing will impact dentistry, but it will happen. Once this systems change occurs, dentists will transition from being paid for doing procedures to being paid for improving oral health. In order to accomplish this, there are many wheels that must be set in motion.
Data will drive the system. At this point, data on oral health care is very closely held and the profession has very little of it. The majority of this data is held by dental insurance companies, both private and governmental. This data is mostly claims-related, which has limited use when trying to measure “health outcomes” Insurance companies consider this data to be proprietary.
Large corporate practices and not-for-profit clinics also collect data in order to increase their effectiveness and profitability and/or to document their progress, which is invaluable when applying for grants. The premise is that healthy patients have lower healthcare costs, and that data can define efficiencies in the system.
In order to measure the effect treatment has on health, a system of metrics is being developed. Medicine has had such a system for several years and it is continuing to evolve. Dentistry has just started down this path. The system will require codes for diagnosis and measuring outcomes, which will help answer the question “Did the patient’s condition improve or not and to what extent?” Presently, the ADA and a coalition of oral health stakeholders, known as the Dental Quality Alliance (DQA), are developing and testing measures that will quantify outcomes. The first set of measures is very basic. These were requested by the Centers for Medicaid and Medicare Services (CMS) for use in Medicaid. It will take several years to come up to speed with these.
This transition will also require diagnostic codes. Dentistry already has a set of diagnostic codes known as SNODENT (Systematized Nomenclature of Dentistry); these have been integrated into the ICD10 codes used by medicine.
The system will require such tools as a caries risk assessment, an electronic dental health record, additional evidence-based dentistry models of practice, a paradigm shift from disease treatment to disease management and ultimately a definition of oral health. To date, there are multiple versions of each of these tools. At some point, there will have to be a standardization of metrics used in the system. This too will take time as both the politics and the profit potential are worked out as well as the ability of the provider to be paid for such things as disease management and what is being termed “active prevention”
Yet another modality on the scene is the Accountable Care Organization (ACO). These organizations are responsible for improving the health of a population of patients and insurance companies will/do reimburse based upon the measurable effect on the health of a population.
Some of these companies claim to already have the capacity to measure the effect of oral health on total health. This is another example where the need for metrics is outpacing our ability to develop a standardized code set for measuring “outcomes.”
Most, if not all, of these changes are being driven by economic forces. Again, a healthy patient along with efficiencies in the system will decrease the cost of healthcare.
The ADA is involved with the development of many of the pieces of the new system that is being developed. The Council on Scientific Affairs is heavily involved with the development of the electronic dental health record and with evidence-based dentistry. The Council on Dental Benefit Programs involved with the creation and standardization of measures through the DQA.
Delivery systems are also changing with the growth of large practice models, many of which are owned by corporate entities. This segment of the dental delivery system is growing at a rate of 15 to 20 percent a year. These large practices enjoy an efficiency of scale and ability to negotiate with insurance companies, dental suppliers and other administrative services. They rely on data to assure their profitability and efficiency. These practice models appear to be very attractive to a large portion of dental school graduates, who are seeking opportunities beyond the traditional private practice model. Employment within a large multi-state corporate practice offers portability or the ability to move from state to state without worrying about selling a practice. New graduates have no need to borrow more money for equipment or to start their own business. In a system with limited funds, the most cost-effective delivery system will most often be the one that survives.
The demographics of the potential ADA membership pool are changing. Of the five thousand dentists graduating per year, according to the ADA 2010-2011 Survey of Dental Education*, nearly half are female, 58 percent are white with the other 42 percent being ethnically or racially diverse. The demographics of the average class show that they are much more diverse than ever before. Few people live in the same town or city all their life and few hold the same job till retirement. More are becoming employee dentists rather than business owner dentists.
The issue of changing practice models and that of diversity pose possibly the greatest challenge to the American Dental Association. Our membership is increasingly becoming less reflective of the profession or the population. The needs of the profession are also becoming more diverse. The ADA leadership is and will increasingly face the challenge of providing “member value” to a profession that will continue to become more diverse. Their efforts will be confounded by a governance model that is large, slow to respond, and also does not mirror the profession, despite the sincerity, dedication and earnestness of those who make it up.
By now, I’m sure many have asked, “Why does dentistry want to be involved in this “madness?”
To quote Dr. Marko Vujicic, health economist at the ADA, “You can never outrun the economics.”
To do nothing is an option, but to do so is to let someone else determine our future.
This data-driven system is being developed. We are a profession of oral health providers, who consider ourselves to be the authority on oral health. As such, we have a responsibility to develop a system, given the environment that will enable us to provide the highest possible quality of oral health care to our patients. To do this we must be relevant to our profession, which is our membership.
The technical expertise and resources necessary to address all of these issues are housed at 211 East Chicago, IL, home of the ADA.
The concern is whether or not we have the will to do so.