Second highest out-of-pocket cost: Dental

The report contends that quality improvement in oral health lags behind similar efforts for overall health, but efforts are intensifying. Titled "Oral Health Quality Improvement in the Era of Accountability," the report provides an overview of current efforts and cites elements that are critical for advancing this agenda: increased use of electronic dental records and integrated health records; better measurement of oral health outcomes; new payment and incentive mechanisms; and expanded delivery of care by non-dental professionals, as well as new types of allied professionals.

The report — the latest in a growing number of analyses of the oral health-care system — was released in February at a national meeting of oral health professionals, government leaders, consumer advocates and others convened by the Kellogg Foundation and DentaQuest Institute. The meeting was intended to launch a national dialogue on quality improvement and increased access to dental care. The Institute of Medicine and U.S. Government Accounting Office released reports on dental access and quality in 2011.

“The focus on quality improvement for overall health care is an important opportunity to improve the quality of oral health care,” said study author Paul Glassman, DDS, MA, MBA, director of the Pacific Center for Special Care at University of the Pacific Arthur A. Dugoni School of Dentistry. “The biggest problem now is we are developing many measures, but they need to be connected to performance of the system. This report provides an opportunity for a new dialogue on how best to collect and use data to improve quality and increase access to affordable dental care.”

Glassman said the factors driving the focus on quality improvement in oral health care — and the need to align payment incentives with health-care outcomes and value for patients — are the same ones driving the overall health-care quality movement:

• Rising costs of oral health care;
• An increasing understanding of the unwarranted variability produced by the oral health system;
• Evidence of profound health disparities in spite of scientific advances in care; and
• Increasing awareness of these problems in the age of consumer empowerment.

The report also outlines the systemic barriers that have slowed change:

• Limited evidence of best practice for most dental procedures has led to widespread variation in clinical decisions by dentists;
• Government pays for only about 6 percent of dental care nationally, and dental practices and their patients are not part of a larger provider organization pushing for improvements; and
• Incentives to implement quality improvement programs are few.

However, 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.

“With the current focus on quality improvement in health care, we need to make sure that oral health isn’t left behind,” said Alice Warner, program officer at the W.K. Kellogg Foundation. “Right now, 37 percent of African American children and 41 percent of Hispanic children have untreated tooth decay, compared with 25 percent of white children. We need to do better by all our children and this report provides ideas that can help lead the way.”

Oral health costs making dental services unaffordable for many

Dental expenses are now among the highest out-of-pocket health expenditures for consumers. In 2008, they accounted for $30.7 billion or 22.2 percent of total out-of-pocket health expenditures, second only to prescription medications, according to the Bureau of Labor Statistics.

The keys to better access and quality are better measurement of oral health-care outcomes and promoting innovation at the systems level, said Glassman, who suggests 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 on oral health outcomes of populations;
• Innovation in payment, monitoring and incentive mechanisms tied to the oral health of the population served;
• Improvements in oral health delivery that include using chronic disease management strategies, delivering care in nontraditional settings, developing new types of allied dental professionals and engaging non-dental professionals in delivering services; and
• Use of telehealth technologies to reach people in geographically remote areas.

“The DentaQuest Institute is working closely with clinical partners to implement quality improvement strategies that emphasize prevention and disease management in dental care,” said Dr. Mark Doherty, executive director of the DentaQuest Institute. “We have begun to see success applying a disease management model to the care of chronic disease.”

(Sources: W.K. Kellogg Foundation and DentaQuest Institute)