New Dental Care Delivery Systems: Implications for People with Disabilities

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1 New Dental Care Delivery Systems: Implications for People with Disabilities Paul Glassman DDS, MA, MBA Professor of Dental Practice, Director of Community Oral Heath University of the Pacific School of Dentistry San Francisco, CA

2 2 The Institute of Medicine Reports

3 Themes from the 2011 IOM Reports Related to Oral Health Delivery Systems Chronic disease management Composition, licensing, and deployment of the Workforce Telehealth Quality measurement and improvement Payment incentives 3

4 The 2011 Institute of Medicine Reports ACCESS RECOMMENDATION 8: Congress, the Department of Health and Human Services (HHS), federal agencies, and private foundations should fund oral health research and evaluation related to underserved and vulnerable populations, including: New methods and technologies (e.g., nontraditional settings, nondental professionals, new types of dental professionals, and telehealth); Measures of access, quality, and outcomes; and Payment and regulatory systems. 4

5 Care for Chronic Oral Diseases Acute Care/ Surgical Intervention Chronic Disease Management

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

7 The US Health Care System is Undergoing Profound Change

8 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.

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

10 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.

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12 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 ,

13 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.

14 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

15 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

16 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

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

19 IOM Reports on Quality

20 Variation in Cost and Outcomes

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22 Drivers of the Quality Movement #3 Health Disparities

23 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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25 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

26 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.

27 The Era of Accountability

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

29 The Era of Accountability The Urban Institute

30 Improving Quality Through Measurement

31 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

32 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.

33 Levels of Quality Improvement Activities

34 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

35 Conclusions Lots of people are collecting 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

36 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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39 Records: Radiographs

40 Records: Photographs

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43 Radiographs

44 Radiographs

45 Photographs

46 Photographs

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48 Study on Telehealth vs In Person Decision Making

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51 Community Prevention and Early Intervention Procedures

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63 Improving Oral Health as a Culture Change Initiative Developing an Oral Health Program In Residential Care Facilities

64 The Residential Care Demonstration Project

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66 Overcoming Obstacles Program Collaborators Pacific School of Dentistry Apple Tree Dental California Dental Association California Dental Hygiene Association American Dental Association Elder Care Committees California Association of Health Facilities American Health Care Association

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68 The CD (for use in a computer) contains: The Direct Caregiver Workbook The Daily Mouth Care planning and tracking form The Administrators and Trainers Manual Pre and Post Tests A presentation that covers the concepts in the Direct Caregiver Workbook with a presentation script The Direct Caregiver Video formatted for playback on a computer The MDS Oral Health Assessment Video for nursing staff working in health licensed facilities formatted for playback on a computer The DVD (for use in a DVD player) contains: The Direct Caregiver Video with three choices: Part I the Direct Caregiver Workbook chapters 1 6 Part II the Direct Caregiver Workbook chapters 7 13 The entire Video Direct Caregiver Workbook chapters 1 13 The MDS Oral Health Assessment Video for nursing staff

69 Components of the Program Decide to make oral health a priority Make a plan Conduct ongoing training Do follow up mentoring and coaching Perform regular monitoring and feedback Provide incentives Incorporate oral health activities into the culture of the facility

70 Making a Difference in Long Term Care

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77 The Virtual Dental Home Sites

78 Oral Health Systems for Underserved Populations

79 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

80 New Dental Care Delivery Systems: Implications for People with Disabilities Opportunities in New York

81 Recommendations Problems (opportunities) Principles Process

82 Problems (opportunities) Recommendations Data on who is being/not being served and how and why Clarify/expand scope of practice/waivers/financing (MC) Principles The Triple Aim Bring care to where people are Emphasize prevention and early intervention Foster collaboration: DDS >allied personnel >telehealth Foster collaboration: Embed oral heath in environment Process Set priorities Pilot Project

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

Paul Glassman DDS, MA, MBA Professor and Director of Community Oral Health University of the Pacific School of Dentistry San Francisco, CA Paul Glassman DDS, MA, MBA Professor and Director of Community Oral Health University of the Pacific School of Dentistry San Francisco, CA pglassman@pacific.edu Disclosures Direct a research center at

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