Report outlines 5 elements for improving oral healthcare

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Accountability, data collection, and new ways of delivering care are critical if the U.S. is going to improve the quality of its oral healthcare, according to "Oral Health Quality Improvement in the Era of Accountability," a new report funded by the W.K. Kellogg Foundation and the DentaQuest Institute.

Dental expenses are now among the highest out-of-pocket health costs to consumers, second only to expenses for drug prescriptions, according to the report.

The report, authored by Paul Glassman, DDS, MBA, a professor of dental practice and the director of the Pacific Center for Special Care at the University of the Pacific Arthur A. Dugoni School of Dentistry, lists five elements for improving oral healthcare in the U.S.:

  1. Increased use of electronic dental records and integrated health records
  2. Better measurement of oral health outcomes
  3. New payment and incentive mechanisms
  4. Expanded delivery of care by nondental professionals, as well as new types of allied dental professionals
  5. Use of telehealth technologies to reach people in remote areas

Allowing midlevel providers to treat underserved or remote populations is being discussed in many states as a way to improve access to care, but the concept remains controversial and is opposed by most dental associations, including the ADA.

“If we want to deliver more and better care, we've got to do something different.”
— Paul Glassman, DDS, MBA, University
     of the Pacific Arthur A. Dugoni School
     of Dentistry

"If we want to deliver more and better care, we've got to do something different," Dr. Glassman told "Among the possibilities are expanding the roles of existing providers or looking at ways to incur new providers, but we don't have enough evidence of experience yet to know what is the best approach."

Dental expenses are now among the highest out-of-pocket health costs for consumers, the report noted. In 2008, they accounted for $30.7 billion (22.2%) of such expenses, second only to prescription medications.

Dental costs will almost triple in the next decade, rising from $62 billion in 2000 to $168 billion in 2020, a 271% increase, according to the U.S. Centers for Medicare and Medicaid Services. The increase is significantly higher than the increase in the Consumer Price Index (CPI), according to the report.

Between 2000 and 2010, the CPI for dental care was double that for all items, even higher than the 149% rise in the CPI for all medical care.

"The focus on quality improvement for overall healthcare is an important opportunity to improve the quality of oral healthcare," Dr. Glassman said. "The biggest problem now is we are developing many measures, but they need to be connected to performance of the system."

Obstacles to improving care

The factors driving the focus on improving the quality of oral care -- and the need to align payment incentives with healthcare outcomes and value for patients -- are the same ones driving the overall healthcare quality movement:

  • The increasing cost of oral care
  • An increased understanding of the unwarranted variability produced by the oral health system
  • Evidence of profound health disparities despite scientific advances in care
  • An increasing public awareness of these problems in the age of consumer empowerment

The report lists the following obstacles to improving oral care:

  • Limited evidence of best practice for most dental procedures has led to widespread variation in clinical decisions among dentists.
  • The U.S. government only pays for about 6% of dental care nationally, and dental practices and their patients are not part of a larger provider organization that is pushing for improvements.
  • There are few incentives to implement quality improvement programs.

Increasing costs, inadequate access to care, and profound disparities are creating new pressures for the oral health delivery system to focus on value instead of volume of services, the report noted.

"It has been said that too often the dental profession has regarded quality assessment as an evaluation of the clinician, rather than of the effects of clinicians' efforts on patients' health," the report stated.

The current efforts to improve both medical and dental care call for a fundamental shift from "paying for volume" to "paying for value," the report concluded.

Although half of the U.S. public has private dental insurance, it is provided by a large number of insurers. As a result, neither dental practices nor dental patients are integrated into large provider or payor organizations that have the capacity, funds, and political will to establish meaningful quality improvement programs, the report noted.

"The rapidly increasing cost of oral healthcare, the large numbers of people who cannot or do not take advantage of the current oral health delivery system, unwarranted variability in care, and the existence of profound oral health disparities among segments of the population are attracting increasing attention," the report authors wrote.

Efforts to improve oral healthcare and oral health while also controlling escalating costs must also overcome political barriers, the report noted. To be effective, it will require coordinated efforts at the federal, state, and local levels, as well as with organized health professions, individual healthcare providers, the dental and general health benefits industry, private philanthropy, and consumer groups.

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