Background
Dental caries (tooth decay) predominantly afflict low-income children [
1] who also receive fewer dental services [
2]. Approximately 45 % of children 3 to 5 years old and fewer than 10 % of children younger than 2 years old received dental services in 2008 in the United States [
2]. Many children have their first dental visit in the Emergency Department, and surgical in-hospital treatment of dental caries is becoming more common and costly. Indeed, preventable dental conditions were the primary reason for 830,590 ED visits by Americans in 2009, a 16 % increase from 2006 [
3].
Medicaid is the public health insurance program for low-income children in the United States. It is funded by the federal government and states and administered by states. Most Medicaid dental programs operate on a fee-for-service model. These programs largely fail to reduce access disparities because they provide services for those who access care independent of need and because fees are often very low. Where there are managed care systems, they often graft the same limited model with low capitated payments that incentivize less care. In addition, both approaches focus on open-ended budgets versus global payments and office-based versus community-based care. The United States government Centers for Medicaid and Medicare Services expects to move away from the traditional “fee-for-service” system to one based on global budgets, capitation payments, and pay for performance [
4]. A recent Cochrane review identified only two studies, both European, on the effects of financial incentives on the delivery of primary dental care [
5]. Neither study examined risk-based capitation programs or community-based care systems. Conrad and Perry reviewed the effect of financial incentives on physician behavior and reported that comprehensive financial incentives (for example, balancing rewards and penalties; blending structure, process, and outcome measures; emphasizing continuous, absolute performance standards) offer the prospect of significantly enhancing quality beyond the modest impacts of prevailing pay-for-performance programs [
6]. From these reviews, it is also clear that no one has tried to incentivize the entire dental team. Community-based auxiliaries, outreach personnel, case managers, and other practice staff are essential to identify children at risk and to ensure they receive intensive and appropriate management.
Aims and objectives
To improve the oral health of Medicaid-enrolled children, dental delivery systems innovations are needed, including community-based care, the use of expanded duty auxiliary dental personnel [
7,
8], capitation payments, and global budgets [
6,
9]. The project aim is to implement and evaluate the PREDICT (
Population-centered Risk- and Evidence-based Dental Interprofessional Care Team) dental care system. The primary objective is to determine the effectiveness of the new model on decreasing dental caries in Medicaid-enrolled children, pregnant women and new mothers. The secondary objectives are to determine the impact of PREDICT on access, quality, equity and cost.
Discussion
In most states, children enrolled in the Medicaid program have low utilization of dental care and a high prevalence of untreated decayed teeth. Barriers to care and per patient treatment costs can be substantially reduced by a population-based approach to dental care and the provision of basic services outside of traditional clinics. Total expenses increase because more children and mothers receive care. This alternative model does not depend on caregivers taking children to dental offices during work time and can achieve substantial savings in capital costs associated with facilities and equipment and personnel. Children at high risk can be identified and intensive evidence-based effective preventive and curative services provided.
To our knowledge, this intervention will be the first large scale, “real world” test of an alternative delivery and payment model that has the potential to reduce dental care and oral health disparities nationally. This delivery model is replicable in the 47 states where dental hygienists are legally able to provide services to low-income children in community settings under indirect dentist supervision (for example, dentist is not physically present but is on call).
The major challenges for PREDICT are obtaining the permission of community organizations and schools to implement the new dental care system, gaining the cooperation of community leaders, educators, principals and teachers, and getting parents to sign-up for the program. Another challenge is providing the screening, risk assessment and risk-based services to children at community settings cost-effectively. Finally, children with dental diseases or other oral health needs that require treatment in dental offices need to receive it in a timely fashion through well-organized pathways.
Both the evaluation and effective management of this intervention depend on the availability of operational data. First, staff members have to complete annual environmental scans of test and control counties. These scans address differences among counties in availability of dentists, community prevention programs, population income and ethnicity, etc. Second, data are needed on community settings and schools for planning the intervention and evaluation. Third, data are needed on the characteristics and oral health of the children who do/do not consent for the program. Finally, the costs and services provided in test and control dental delivery systems need to be assessed. Determining the categories of cost that are incremental to evaluation versus care delivery (for example, analysis costs and any space, time, and supply costs unique to the evaluation) will also be important. This requires a clear understanding and measurement of all costs, so costs specific to the evaluation can be identified. Realistically, the final cost assignment is best done retrospectively. This is because some evaluation costs may cover business or clinical processes that turn out to be critical for the effective management of the program. As such, they should be considered care delivery costs.
The key to this intervention is effective management and HIT support. Managers and staff members need monthly management reports so they can adjust to problems that arise. ADS has substantial public relations and financial risk, so it is incentivized to make an all-out implementation effort. This “real’ world” operational environment increases the chances for success and the generalizability of the results. Indeed, if the intervention is cost-effective, ADS plans to make it the primary delivery model for Medicaid children and mothers.
The role of financial incentives in the proposed intervention has special importance. Most incentive plans try to influence the behaviors of the dominant providers, in this case, shareholder and employed dentists. However, a careful assessment of the actual intervention indicates that the EPPDHs and administrative staff are the main drivers of program success. This is because only 25 to 30 % of assigned patients will need to be seen by dentists for curative care in the first few years of the program. Moreover, this proportion will decline as the backlog of disease is treated, and new disease is prevented. Developing sensible incentive plans for the nonprofessional staff is not easy, and this will be one of the first studies to address this issue on a large scale in dentistry or medicine. The incentive plan has to take into account the culture of the organization, the interests of the staff in the intervention program, and other factors. For this reason, incentives are mainly positive rather than negative. That is, high performance is rewarded financially, but average or poor performance does not result in substantial reductions to base pay. In the case of below-average performance, emphasis instead is on performance feedback and development of a specific improvement plan.
In summary, we have presented the trial protocol for the PREDICT quality improvement project and discussed the challenges in implementing and evaluating this new dental care delivery and payment systems in a large dental care organization serving Oregon rural counties.
Trial status
The quality improvement project started in October 2014, and counties have been identified and randomly allocated. Delivery system and payment system changes will be deployed in August 2015 and January 2015, respectively. Data collection for the parent/caregiver/child and staff surveys will be conducted in July and August 2015 and in September and October 2017. The study is not yet recruiting participants.
Competing interests
RSM, SL, MM, JD and GA are employees of the Sponsor. The other authors declare that they have no competing interests.
Authors’ contributions
JCC is the primary author of the protocol on which the paper is based and wrote the final version of this manuscript. PM contributed to the conception and design of the study and the protocol and wrote the initial version of this manuscript. RMS contributed to the conception and design of the study and the protocol and to authorship of the manuscript. HLB drafted the discussion of the manuscript and contributed to the conception and design of the study and the protocol and to authorship of the manuscript. CEH contributed to the conception and design of the study and the protocol and to authorship of the manuscript. DC wrote the economics section of the protocol and contributed to conception and design of the study and the protocol and to authorship of the manuscript. SL contributed to the conception and design of the study and the protocol and to authorship of the manuscript. MM contributed to the conception and design of the study and the protocol and to authorship of the manuscript. JD contributed to the conception and design of the study and the protocol and to authorship of the manuscript. GA contributed to the conception and design of the study and the protocol and to authorship of the manuscript. JAS and LM wrote the statistical section of the protocol and contributed to the conception and design of the study and the protocol and to authorship of the manuscript. All authors read and approved the final manuscript.