Paul Glassman DDS, MA, MBA Professor and Director of Community Oral Health University of the Pacific School of Dentistry San Francisco, CA

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1 Paul Glassman DDS, MA, MBA Professor and Director of Community Oral Health University of the Pacific School of Dentistry San Francisco, CA

2 Disclosures Direct a research center at the University of the Pacific School of Dentistry with funding for policy development and demonstration projects Member, Institute of Medicine Committee on Oral Health Access to Care Co Director, National Quality Forum Expert Panel on Oral Health Quality Measures Dental Representative, AHRQ CHIPRA Expert Panel on Pediatric Quality Measurement Member. DentaQuest Institute (DQI) Board of Directors Chair DQI Quality Committee No financial conflict of interests

3 Topics Drivers of health reform Drivers of oral health reform Quality and accountability in oral health Impact of accountability on delivery systems Opportunities for health center dental programs

4 The US Health Care System is Undergoing Profound Change

5 Zen saying Keep your head in the clouds and your feet on the ground

6 The 2011 IOM Reports on Oral Health 6

7 Themes from the 2011 IOM Reports on Oral Health Improve access to services and oral health through: Chronic disease management Delivery Systems Telehealth Payment incentives Workforce expansion Drive change and accountability through Quality measures and improvement 7

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10 What is Quality? Quality is a direct experience independent of and prior to intellectual abstractions. The place to improve the world is first in one's own heart and head and hands, and then work outward from there. Robert Pirsig. Zen and the Art of Motorcycle Maintenance: An Inquiry Into Values.

11 What is Quality the degree to which health services for individuals and populations increase the likelihood of desired health outcomes and are consistent with current professional knowledge The Institute of Medicine (IOM), Lohr, K.N. Ed Medicare: A Strategy for Quality Assurance. National Academy Press. Washington D.C.

12 Drivers of the Quality Movement in the U.S. Health Care System 1. the skyrocketing cost of health care unrelated to improvement in health outcomes, 2. increasing understanding of the harm and unwarranted variability our fragmented health care system produces, 3. evidence of the profound health disparities that still exist in the population in spite of scientific advances in care, and 4. increasing awareness of these problems in the age of consumer empowerment.

13 Drivers of the Quality Movement #1 The Cost of Health Care

14 Health Care Spending International Comparison of Spending on Health, Average spending on health per capita ($US PPP*) Total expenditures on health as percent of GDP 8,000 7,000 6,000 5,000 United States Canada Germany France Australia United Kingdom , ,000 2,000 1, United States France Germany Canada United Kingdom Australia * PPP=Purchasing Power Parity. Data: OECD Health Data 2011 (database), version 6/2011.

15 Pubic Health Care Spending vs Debt

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17 Oral Health Expenses $180 U.S. National Dental Expenditures ($ Billions) $ % $140 $ % $100 $80 150% Dental Services (DS) DS % of 2000 Level (271%) $60 100% $40 $20 50% $ % Source: CMS National Health Expenditure Projections ,

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20 Oral Health Expenses 160% Consumer Price Index (CPI) and CPI for Dental Services (% of 2000 dollars) 150% 140% 130% CPI % of 2000 Level (127%) CPI DS % of 2000 Level (154%) 120% 110% 100% Source: American Dental Association. Consumer Price Index for Dental Services, March 2011.

21 Out of Pocket Health Expenses Consumer out of pocket health care expenditures in 2008 Prescription drugs (31.0%) Medical supplies (7.6%) In patient care (8.8%) Outpatient/ emergency room care (6.4%) Physicians' services (15.9%) Out of pocket health care total $138.5 billion Other professional services (8.1%) Dental services $30.7 billion (22.2.0%) Source: Bureau of Labor Statistics. Consumner out of pocket health care expenditures in

22 Mean US Household Income 105% Mean Household Income Received by Each Fifth and Top 5 Percent in 2010 Dollars as % of 2000 Dollars 100% 95% 90% 85% Lowest fifth Second fifth Third fifth Fourth fifth Highest fifth Top 5 percent 80% 75% Source: CMS National Health Expenditure Projections

23 Payers of Oral Health Expenses 60% National Dental Expenses as % of Total National Dental Expenditures 50% 50% 51% 50% 51% 49% 50% 49% 49% 51% 51% 51% 51% 51% 51% 49% 48% 49% 49% 49% 49% 49% 44% 43% 44% 44% 44% 44% 44% 44% 44% 42% 41% 40% 40% 40% 40% 35% 34% 34% 34% 34% 34% 34% 30% 20% Out of Pocket as % of Total Private Insurance as % of Total Public Insurance as % of Total 10% 4% 5% 5% 5% 5% 5% 5% 5% 6% 7% 8% 9% 9% 9% 11% 12% 12% 12% 13% 13% 13% 0% Source: CMS National Health Expenditure Projections

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25 Drivers of the Quality Movement #2 Harm and Variability of Results

26 IOM Reports on Quality

27 Variation in Cost and Outcomes

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29 Drivers of the Quality Movement #3 Health Disparities

30 Drivers of the Quality Movement Health Disparities The IOM, in the 2003 report on Unequal Treatment: Confronting Racial and Ethnic Disparities in Health Care, clearly demonstrated that Racial and ethnic minorities tend to receive a lower quality of healthcare than nonminorities, even when access related factors, such as patients insurance status and income, are controlled. The Institute of Medicine. Unequal Treatment: Confronting Racial and Ethnic Disparities in Health Care National Academies Press. Washington D.C.

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32 The Surgeon General s Report Although there have been gains in oral health status for the population as a whole, they have not been evenly distributed across subpopulations. Profound health disparities exist among populations including: Racial and ethnic minorities Individuals with disabilities Elderly individuals Individuals with complicated medical and social conditions and situations

33 Drivers of the Quality Movement in the U.S. General and Oral Health Care Systems 1. the skyrocketing cost of health care unrelated to improvement in health outcomes, 2. increasing understanding of the harm and unwarranted variability our fragmented health care system produces, 3. evidence of the profound health disparities that still exist in the population in spite of scientific advances in care, and 4. increasing awareness of these problems in the age of consumer empowerment.

34 The Era of Accountability

35 The Triple Aim improving the experience of care improving the health of populations reducing per capita costs of health care

36 The Era of Accountability The Urban Institute

37 What is Value in Health Care? Value is defined as the health outcomes achieved per dollar spent over the lifecycle of a condition Process measurement and improvement are important tactics but are no substitutes for measuring outcomes and costs

38 Improving Quality Through Measurement

39

40 forum.org Measuring Quality

41 Definitions Quality Measurement (QM) collection of data about structure, process, or outcomes of health care activities Quality Assurance (QA) data to compare results from health care activities against a pre defined set of standards or quality indicators Quality Improvement (QI) cyclical set of activities designed to make continuous improvement in health care structure, process or outcomes

42 Quality Improvement Systems Plan Do Objectives, methods, measures, tasks Work the plan Study Act Gather data, analyze results Decide what to do next Incorporate the change, make a new plan

43 Six Aims for Quality Improvement Safe Effective Patient centered Timely Efficient Equitable The Institute of Medicine. Crossing the Quality Chasm: A New Health System for the 21st Century National Academies Press. Washington D.C.

44 Levels of Quality Improvement Activities

45 Quality Measurement or Improvement Activities in Sectors of the Oral Health Delivery System Federal or National Agencies and Programs The Oral Health Safety Net Large Group Dental Practices The Dental Benefits Industry Professional Dental Associations Hospital based Dental Practices Dental Practice based Research Networks

46 Healthy People 2020

47 Healthy People 2020

48

49

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52 r/oral_health/oral_health.aspx

53 NQF Oral Health Performance Measurement 2012 Report to HHS Measurement Concepts Measures of Oral Health Children and Adults Measures of Oral Health Primarily (but not exclusively) for Adults Measures of Satisfaction or Opinions about Health or Health Care Measures of Use of Services Measures of Factors that Influence Risk for Oral Disease or Disease Treatment Measures of Oral Health Infrastructure Measures of Health Disparities Measures of Healthy Communities Measures of Oral Health Expenditures Measures of Patient Safety

54

55 Other Oral Health Quality Efforts Large Group Practices Heath Partners AHRQ Guidelines, EHR feedback tobacco cessation American Dental Partners Accreditation Association for Ambulatory Health Care The American Dental Association Dental Quality Alliance The Dental Benefits Industry Claims data > Profiles DentaQuest National Quality Improvement Committee National 10 Year Roadmap to Create Oral Heath for All

56 Conclusions Lots of people are colleting lots of data The vast majority is used to inform or drive program change at large payer or plan levels. There are few examples of measurement that directly is tied to performance in a way that influences activities Movement from volume to value is not evident in oral health systems

57 Moving Oral Health Care from Volume to Value** Collect and Manage Data Meaningful Use Non Traditional Settings Non Dental Providers New Types of Allied Personnel New Roles for Existing Personnel EHRs + Other Data Sources Accountability (volume value) Delivery Systems Measurement Incentives Based on Health Outcomes Monitoring Health Home Prevention & Early Intervention Tele Health Chronic Disease Management **Value = health outcomes achieved per dollar spent over the lifecycle of a condition

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60 Records: Radiographs

61 Records: Photographs

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63

64 Radiographs

65 Radiographs

66 Photographs

67 Photographs

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69 Study on Telehealth vs In Person Decision Making

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71

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73 The CA Health Workforce Pilot Project

74 Community Prevention and Early Intervention Procedures

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82 The Virtual Dental Home Sites

83 Oral Health Systems for Underserved Populations

84 Moving Oral Health Care from Volume to Value** Collect and Manage Data Meaningful Use Non Traditional Settings Non Dental Providers New Types of Allied Personnel New Roles for Existing Personnel EHRs + Other Data Sources Accountability (volume value) Delivery Systems Measurement Incentives Based on Health Outcomes Monitoring Health Home Prevention & Early Intervention Tele Health Chronic Disease Management **Value = health outcomes achieved per dollar spent over the lifecycle of a condition

85 Impact on Health Centers The underserved population Current health center oral health capacity Opportunities for health center dental programs

86 US Population 1 People without annual GP visit 2 People not taking advantage of traditional system 3 People below poverty level 1 The Underserved Population and Health Center Capacity People below 125% poverty level 1 People served in health center dental programs 4 People served in other safety net settings million 180 million 90 million 44 million 57 million 4 million 6 million 1. US Census 2012 Statistical Abstract Vujicic M. An Analysis of Dentist s Income: JADA 2012:143: ADA. Report of the Dental Workforce Taskforce HOD Resolution Pg HRSA Primary Care Heath Center Program Bailit H, et. al. Dental Safety Net: Current Capacity and Potential for Expansion. JADA. 2006:137:

87 Opportunities for Health Centers: Practice/Learning/Advocacy Meaningful use of data Quality improvement systems Community based practice and billing Telehealth collaboration Distributed team based delivery systems Accountability for oral health outcomes of eligible population

88 Zen saying Keep your head in the clouds and your feet on the ground

89 Paul Glassman DDS, MA, MBA Professor and Director of Community Oral Health University of the Pacific School of Dentistry San Francisco, CA

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