Demonstration of payer readiness for value‐based care in a fee‐for‐service environment: Measuring provider performance on sealant delivery

Abstract

Objectives: Previously published sealant measures are not useful when applied to Medicaid claims data in states where dental services are carved out of managed care. A novel sealant measure was developed to assess the degree to which dental providers seal eligible teeth during preventive dental visits (PDVs) in an effort to ascertain if such a measure can be used to valuate provider performance, as condition of potential value-based care model implementation. Methods: A single-county feasibility study was conducted using Medicaid claims. A study cohort included children aged 8 years and enrolled 12 months during 2018. Prospective analysis was used to determine whether dental sealants were applied by the same dentists during PDVs or up to 9 months thereafter. Eligible teeth included first permanent molars. Teeth previously restored, sealed or missing were excluded. PDV was defined as any encounter with prophylaxis, fluoride treatment, or EPSDT. Claims were compared to public health surveillance for measurement validation. Results: Single-county results showed 11 percent of eligible teeth were sealed. Only 9 percent of dentists applied sealants to at least 40 percent of eligible teeth. Face validation of sealant rate was 23 percent Medicaid versus 36 percent Public Health. The former measures incidence and the latter prevalence with greater heterogeneity that included partially retained sealants. Conclusions: A sealant measure that assesses provider adherence to sealant standards of care was produced. It has potential application for assessing performance of pediatric preventive services and informing value-based performance expectations.

Annual review of selected scientific literature: A report of the Committee on Scientific Investigation of the American Academy of Restorative Dentistry

“…The first article describes a Medicaid-based feasibility study of a revised methodology where the measure numerator eliminated teeth previously restored, sealed, or missing, and the denominator was a sealant applied by the same dentists within 9 months of an initial preventive visit. 306 The previously used method did not eliminate unsealable teeth from the numerator. Singlecounty results showed that overall, 11% of all eligible teeth were sealed, and only 9% of dentists applied sealants within the 9-month period to 40% of the eligible teeth.…”

Health Equity Needs Teeth

“…45,46 Equitable health care can only occur in an integrated system of value-based care that supports transformations in prevention, treatment, payment models, and data and analytics to deliver patient-centered care and improve population outcomes. 47,48 Public and private insurance programs can be restructured to bundle payments, incentivize prevention and health promotion, and create flexible payment options for health services delivered outside of the clinic via telehealth and home-based care. Payment transformation that occurs through alternative models that incentivize prevention and optimal health lends itself to improved health systems outcomes, especially if the health system works to focus not on disease interventions but on the upstream, localized, and systemic causes of disease.…”