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Pay-for-performance programs
THE BIG PICTURE Pay-for-performance programs Background.—Greater transparency is being requested of the healthcare system in the United States because of rising costs and uncertain quality. ‘‘Pay-for-performance’’ (P4P) programs are often founded on the concept that a quality performance involves doing the right thing at the right time in the right way for the right patient. Managed care organizations and other U.S. public programs use such incentive plans regularly in medical settings. However, unproven assumptions lurk in the foundation of P4P programs. They assume that providers will change their clinical behavior for financial rewards, that P4P indicators are indeed linked to improved quality, that payers can accurately identify as to which care components can be influenced by financial incentives, and that payers can design a payment program with more benefits than unintended consequences. Dental profession often follows the lead of medicine, hence it is possible that P4P will eventually be instituted for dentistry. Such a change should be postponed until the delivery of, and payment for, dental services can be evaluated to see whether they are appropriate for the P4P programs. The quality aspect of P4P programs was analyzed, and factors that influence the adoption of P4P principles in dentistry were investigated. Methods.—The classic quality-of-care framework proposed by Donabedian was used for the analysis. In this framework, quality was evaluated using structure, process, and outcomes parameters. Structure Factors.—Public insurance covering dental services was quite limited in the United States; only about 56% of U.S. adults have dental coverage. As a result, any payment policy initiatives by public payers will have limited effect on private dental practices in the mainstream. Insurers therefore have little power to enforce P4P programs because the costs are often borne by individuals. Instead, the private sector would have to implement such a change. Service coverage varies widely between dental plans, which would also mitigate against the institution of P4P programs. The American Dental Association has laid out 10 principles to reflect the profession’s desire to preserve decisional autonomy and noninterference by payers in the relationship between the dentist and the patient. Quality is emphasized as the goal of any financial incentive program and the right of all patients. Voluntary P4P participation is proposed, along with the proposal that any quality indicators be few, standardized, accepted, clear, measurable, and applicable to patient risk and compliance calculations. Specialist dental
associations have not yet expressed any position on valuebased purchasing programs. Sixty-five percent of dental practices, but only 24% of medical practices, are owned and operated by a solo practitioner. The provider interaction that is instrumental to quality improvement in large physician groups does not exist in most dental settings, so there are few dental quality initiatives and those that exist are limited in scope and not widely published. Peer review is preferred by dentists to the guideline-based quality initiatives of medicine. These factors will make the adoption of P4P in dentistry difficult. The urgency for quality improvement that arose in medicine is not observed among dental patients. Compared with medical costs, out-of-pocket expenses for dentistry are relatively moderate. It is unlikely that consumers will create a demand for greater scrutiny of dental services comparable with that for medical care. Process of Care Factors.—The current wide variation in dental treatment modalities makes quality control challenging. Comprehensive approaches to improving consistency across the profession should also improve quality. Among the factors leading to inconsistency are lack of timely dissemination of current scientific evidence to all dentists, clinical inertia, and changes in dental services depending on payment method. P4P programs have helped to reduce variation in medical care practices. Guidelines based on evidence or expert opinions have been developed in these cases. Dentistry, although it has a great deal of published research, lacks the strong evidence acquired through randomized controlled trials that guides medicine. Evidence-based dentistry is encouraged but little clinical guidance to achieve it has been provided (Table 1). A change in culture with respect to quality improvement similar to that accomplished in medicine is needed before P4P programs can be realistically proposed for dentistry (Table 2). Outcome Factors.—Even with high-quality structure and processes, high-quality outcomes are not guaranteed. It has been difficult to develop and measure outcome indicators. The clinical outcome indicators used in dentistry include the Decayed, Missing, Filled Surfaces, Periodontal Index, Gingival Bleeding Index, and Oral Hygiene Index. Only 9 of 352 outcomes indicators available publicly on the National Quality
Volume 55
Issue 6
2010
291
Table 1.—Stomatognathic Clinical Guidelines in the National Guideline Clearinghouse
Table 3.—Clinical Outcome Indicators for Pediatric Restorative Dentistry
Clinical guidelines directly related to the practice of dentistry
No.
Indicator
American Dental Association American Academy of Pediatric Dentistry American Cleft Palate Craniofacial Association American Academy of Pediatrics American Academy of Sleep Apnea Center for Disease Control US Preventive Services Task Force New York State Department of Health Health Partners University of Texas at Austin Non US Government Agencies
2 22 1 1 1 1 2 2 4 1 8
Percentage of deciduous teeth extracted (for pathological reasons) within 6 months following pulpotomy treatment, during the time period under study Percentage of teeth requiring re-treatment (restoration, endodontic or extraction, but not including Pit & Fissure Sealants) within 24 months of the initial fissure sealant treatment Percentage of teeth requiring repeat fissure sealant treatment within 24 months of the initial fissure sealant treatment (Courtesy of Voinea-Griffin A, Fellows JL, Rindal DB, et al: Pay for performance: Will dentistry follow? BMC Oral Health 10:9, 2010.)
Areas covered by other stomatognathic clinical guidelines
Preventive Services Cancer Infectious Diseases
12 3 7
TOTAL
67
(Courtesy of Voinea-Griffin A, Fellows JL, Rindal DB, et al: Pay for performance: Will dentistry follow? BMC Oral Health 10:9, 2010.)
Table 2.—Dental Care Evidence Reports and Recommendations AHRQ Evidence report
Effectiveness of Antimicrobial Adjuncts to Scaling and Root Planning Therapy for Periodontitis USPSTF Recommendations
The USPSTF recommends that primary care clinicians prescribe oral fluoride supplementation at currently recommended doses to preschool children older than 6 months of age whose primary water source, is deficient in fluoride The USPSTF concludes that the evidence is insufficient to recommend for or against routine risk assessment of preschool children by primary care clinicians for the prevention of dental disease
Level of Evidence
Insufficient
Level of Evidence
Fair
Insufficient
(Courtesy of Voinea-Griffin A, Fellows JL, Rindal DB, et al: Pay for performance: Will dentistry follow? BMC Oral Health 10:9, 2010.)
Measures Clearinghouse relate to oral and dental disease, and only 3 of these are relevant to dental practice (Table 3). Chronic dental conditions that have no established severity markers are common in dentistry. In medicine, it is possible to use markers to quantify conditions such as diabetes or hypertension. In dentistry, caries progress slowly and can be treated by several dentists over periods as long as decades. Biological and psychosocial outcomes are seldom documented, so overall it is hard to create and validate meaningful outcome indicators or increase the level of evidence in the treatment of caries and other chronic dental conditions.
292
Dental Abstracts
Third-party payers commonly use procedure codes to reimburse dental services in the United States. However, the only standardized diagnostic codes for dentistry are those developed by managed care organizations for use in their distinct networks. Dental charts therefore do not carry these designations. Thus, retrospective clinical information is difficult to retrieve, and risk adjustment and outcome assessment are greatly hampered. Dental P4P programs would likely focus on processes of care until outcome evaluation is better handled. The use of electronic dental records is not yet widespread among dental offices, with many still using paper records and collecting electronic information only to facilitate reimbursement purposes. Quality-of-care information is thus missing in many cases, making performance assessments incomplete and misleading. It will likely be many years before a Universal Electronic Medical Record designed for dentistry is adopted because for medicine it does not exist yet.
Clinical Significance.—Dentistry is not just like medicine when it comes to practice, insurance coverage, evidence-based guidelines, and performance measures. To adopt P4P programs will require significant changes in the dental profession and in health services research directions. Included in these changes would be the (1) expansion of the evidence base, (2) creation of evidence-based clinical guidelines, and (3) creation of evidence-based performance measures linked to the clinical practice guidelines already in place. It simply would not happen anytime soon.
Voinea-Griffin A, Fellows JL, Rindal DB, et al: Pay for performance: Will dentistry follow? BMC Oral Health 10:9, 2010 Reprints available from http://www.biomedcentral.com/14726831/10/9
associations have not yet expressed any position on valuebased purchasing programs. Sixty-five percent of dental practices, but only 24% of medical practices, are owned and operated by a solo practitioner. The provider interaction that is instrumental to quality improvement in large physician groups does not exist in most dental settings, so there are few dental quality initiatives and those that exist are limited in scope and not widely published. Peer review is preferred by dentists to the guideline-based quality initiatives of medicine. These factors will make the adoption of P4P in dentistry difficult. The urgency for quality improvement that arose in medicine is not observed among dental patients. Compared with medical costs, out-of-pocket expenses for dentistry are relatively moderate. It is unlikely that consumers will create a demand for greater scrutiny of dental services comparable with that for medical care. Process of Care Factors.—The current wide variation in dental treatment modalities makes quality control challenging. Comprehensive approaches to improving consistency across the profession should also improve quality. Among the factors leading to inconsistency are lack of timely dissemination of current scientific evidence to all dentists, clinical inertia, and changes in dental services depending on payment method. P4P programs have helped to reduce variation in medical care practices. Guidelines based on evidence or expert opinions have been developed in these cases. Dentistry, although it has a great deal of published research, lacks the strong evidence acquired through randomized controlled trials that guides medicine. Evidence-based dentistry is encouraged but little clinical guidance to achieve it has been provided (Table 1). A change in culture with respect to quality improvement similar to that accomplished in medicine is needed before P4P programs can be realistically proposed for dentistry (Table 2). Outcome Factors.—Even with high-quality structure and processes, high-quality outcomes are not guaranteed. It has been difficult to develop and measure outcome indicators. The clinical outcome indicators used in dentistry include the Decayed, Missing, Filled Surfaces, Periodontal Index, Gingival Bleeding Index, and Oral Hygiene Index. Only 9 of 352 outcomes indicators available publicly on the National Quality
Volume 55
Issue 6
2010
291
Table 1.—Stomatognathic Clinical Guidelines in the National Guideline Clearinghouse
Table 3.—Clinical Outcome Indicators for Pediatric Restorative Dentistry
Clinical guidelines directly related to the practice of dentistry
No.
Indicator
American Dental Association American Academy of Pediatric Dentistry American Cleft Palate Craniofacial Association American Academy of Pediatrics American Academy of Sleep Apnea Center for Disease Control US Preventive Services Task Force New York State Department of Health Health Partners University of Texas at Austin Non US Government Agencies
2 22 1 1 1 1 2 2 4 1 8
Percentage of deciduous teeth extracted (for pathological reasons) within 6 months following pulpotomy treatment, during the time period under study Percentage of teeth requiring re-treatment (restoration, endodontic or extraction, but not including Pit & Fissure Sealants) within 24 months of the initial fissure sealant treatment Percentage of teeth requiring repeat fissure sealant treatment within 24 months of the initial fissure sealant treatment (Courtesy of Voinea-Griffin A, Fellows JL, Rindal DB, et al: Pay for performance: Will dentistry follow? BMC Oral Health 10:9, 2010.)
Areas covered by other stomatognathic clinical guidelines
Preventive Services Cancer Infectious Diseases
12 3 7
TOTAL
67
(Courtesy of Voinea-Griffin A, Fellows JL, Rindal DB, et al: Pay for performance: Will dentistry follow? BMC Oral Health 10:9, 2010.)
Table 2.—Dental Care Evidence Reports and Recommendations AHRQ Evidence report
Effectiveness of Antimicrobial Adjuncts to Scaling and Root Planning Therapy for Periodontitis USPSTF Recommendations
The USPSTF recommends that primary care clinicians prescribe oral fluoride supplementation at currently recommended doses to preschool children older than 6 months of age whose primary water source, is deficient in fluoride The USPSTF concludes that the evidence is insufficient to recommend for or against routine risk assessment of preschool children by primary care clinicians for the prevention of dental disease
Level of Evidence
Insufficient
Level of Evidence
Fair
Insufficient
(Courtesy of Voinea-Griffin A, Fellows JL, Rindal DB, et al: Pay for performance: Will dentistry follow? BMC Oral Health 10:9, 2010.)
Measures Clearinghouse relate to oral and dental disease, and only 3 of these are relevant to dental practice (Table 3). Chronic dental conditions that have no established severity markers are common in dentistry. In medicine, it is possible to use markers to quantify conditions such as diabetes or hypertension. In dentistry, caries progress slowly and can be treated by several dentists over periods as long as decades. Biological and psychosocial outcomes are seldom documented, so overall it is hard to create and validate meaningful outcome indicators or increase the level of evidence in the treatment of caries and other chronic dental conditions.
292
Dental Abstracts
Third-party payers commonly use procedure codes to reimburse dental services in the United States. However, the only standardized diagnostic codes for dentistry are those developed by managed care organizations for use in their distinct networks. Dental charts therefore do not carry these designations. Thus, retrospective clinical information is difficult to retrieve, and risk adjustment and outcome assessment are greatly hampered. Dental P4P programs would likely focus on processes of care until outcome evaluation is better handled. The use of electronic dental records is not yet widespread among dental offices, with many still using paper records and collecting electronic information only to facilitate reimbursement purposes. Quality-of-care information is thus missing in many cases, making performance assessments incomplete and misleading. It will likely be many years before a Universal Electronic Medical Record designed for dentistry is adopted because for medicine it does not exist yet.
Clinical Significance.—Dentistry is not just like medicine when it comes to practice, insurance coverage, evidence-based guidelines, and performance measures. To adopt P4P programs will require significant changes in the dental profession and in health services research directions. Included in these changes would be the (1) expansion of the evidence base, (2) creation of evidence-based clinical guidelines, and (3) creation of evidence-based performance measures linked to the clinical practice guidelines already in place. It simply would not happen anytime soon.
Voinea-Griffin A, Fellows JL, Rindal DB, et al: Pay for performance: Will dentistry follow? BMC Oral Health 10:9, 2010 Reprints available from http://www.biomedcentral.com/14726831/10/9