Discussion

Discussion

Our research illuminates the need for greater dissemination of educational information from trusted sources of authority. This will help to counter provider hesitancy and foster greater stakeholder buy‐in, which are essential to advancing VBOHC. Across survey responses and interviews, continuing dental education and conferences were the most reported sources for information on VBOHC, revealing an opportunity to increase momentum for VBOHC education through these venues. It is paramount for professional societies to prioritize and disseminate knowledge and resources on VBOHC across the dental and medical communities.

Beyond education about VBOHC, identifying and disseminating evidence‐based models and best practices is needed to demonstrate the impact of VBOHC. There is a general lack of uniformity in how to execute VBOHC initiatives and what success looks like.8 Sharing lessons learned and innovative strategies from states that are making progress (e.g., Oregon, Minnesota), outcomes‐based pilot studies, and care delivery organizations driving value in oral care helps create champions for VBOHC adoption9 and generate buy‐in from providers to modify their current care delivery practices.10 As such, dental providers and others may learn from their peer’s successes and custom fit best practices into their own workflow. Oral health stakeholder collaboration is needed to identify current successful models and develop a framework for implementation of VBOHC models.

As revealed in our quantitative survey, many dentists are not being incentivized to participate in quality measurement or other VBOHC activities. Engagement from dentists will be amplified with consistent incentives that reward providers for keeping patients healthy, preventing dental disease, and coordinating care for their patients will help to achieve value in oral health care.11 The low participation rate in VBC arrangements and APMs is not surprising considering most dentists don’t currently feel they are incentivized to engage in VBOHC. Prior research supports this sentiment, as over two‐thirds (67%) of key oral health stakeholders (including providers, payers, policy makers, and patient advocates) strongly agree that VBC reimbursement in oral health is necessary to have a successful health care system.12 Payers providing coverage for dental services should consider greater engagement in VBC models and establishing additional methods for incentivizing provider participation.

A key challenge to successfully implementing VBOHC models is the limited use and exchange of electronic data, which hinder the ability to monitor and report on quality measures and outcomes. Within the data infrastructure, limited use of diagnostic codes is a major challenge. Dentistry currently lacks a standardized vocabulary to classify and identify dental diseases13 and interviewees noted that diagnostic codes are not being used by dental providers or required by dental payers. Furthermore,

8 Jivraj A, Barrow J, Listl S. Value‐Based Oral Health Care: Implementation Lessons from Four Case Studies. J Evid Based Dent Pract. 2022 Jan;22(1S):101662. Doi: 10.1016/j.jebdp.2021.101662. Epub 2021 Nov 6. PMID: 35063180. 9 Northridge ME, Kumar A, Kaur R. Disparities in Access to Oral Health Care. Annu Rev Public Health. 2020 Apr 2;41:513‐535. Doi: 10.1146/annurev‐publhealth‐040119‐094318. Epub 2020 Jan 3. PMID: 31900100; PMCID: PMC7125002. 10 Center for Health Care Strategies. Moving Toward Value‐Based Payment in Oral Health Care. Published February 2021. https://www.chcs.org/media/Moving‐Toward‐VBP‐in‐Oral‐Health‐Care_021021.pdf. 11 DentaQuest. What is value‐based care? What does it mean for oral health care? Published March 27, 2019. https://whatsnew.dentaquest.com/what‐is‐value‐based‐care‐what‐does‐it‐mean‐for‐oral‐health‐care/. 12 Boynes S, Nelson J, Diep V, Kanan C, Pedersen DN, Brown C, et al. Understanding value in oral health: the oral health value‐based care symposium. J Public Health Dent. (2020) 80:S27–34. Doi: 10.1111/jphd.12402. 13 White JM, Kalenderian E, Stark PC, Ramoni RL, Vaderhobli R, Walji MF. Evaluating a dental diagnostic terminology in an electronic health record. J Dent Educ. 2011 May;75(5):605‐15. PMID: 21546594; PMCID: PMC3119719.

diagnostic codes are contained within the International Classification of Diseases (ICD)‐10 structure and is based on medical vocabulary which may not be comprehensive for oral health.14 Discussions of ICD‐10 coding utility in dental care across interviewees resulted in mixed views, though there was a general agreement that these were widely underutilized by dental providers. Formal and continuing education needs to be provided to dentists to standardize use of diagnostic codes and their importance to quality measurement and participation in VBOHC.

While greater emphasis is being placed on oral health care, many in the oral health community do not recognize the role and importance of VBC in achieving better oral health care. Medical and dental providers are trained separately and often practice separately.15 However, a greater focus on preventive oral health care and integration in primary care has the potential to improve patient outcomes, such as reducing emergency department visits for dental care and hospitalization for primary systemic diseases (e.g., diabetes), and reduce health care costs.16 Efforts to incorporate interventions at multiple levels can improve access to and quality of services, through implementation of multidisciplinary health care teams that provide patient‐centered care.17 This can help to narrow gaps in access to oral health and reduce health care disparities. One such example in multidisciplinary care delivery are FQHCs, which are uniquely positioned to provide integrated, patient‐centered care.18 FQHCs are required to report on dental quality measures to HRSA, encouraging some providers to develop and track their own internal metrics.19 However, integration of oral health into overall health care needs to go beyond FQHCs to see system‐level improvements in and benefits of medical‐dental integration.20

The figure below summarizes the key insights garnered from jointly assessing the results of the quantitative survey and the qualitative interviews.

Need for greater dissemination of educational information on VBOHC evidence-based models and best practices from trusted sources of authority

Consistent incentives that reward dental providers are required for widespread VBOHC engagement

Limited use of diagnostic coding and exchange of electronic data with external providers hinders collaboration with medical care delivery and quality measure reporting capabilities

Integrated medical and dental care delivery helps to improve access to oral health care, reduce disparities, and improve patient outcomes

14 Ibid. 15 See n. 12, Supra. 16 Goldstein L, Alshukri M, Trombly R, Dillenber J. Value‐based payment for oral health in an accountable care organization. Aegis Dental Network, Compendium of Continuing Education in Dentistry. Volume 40, issue 10. (2019). https://www.aegisdentalnetwork.com/cced/2019/11/value‐based‐payment‐for‐oral‐health‐in‐an‐accountable‐care‐organization. 17 See n. 9, Supra. 18 Lee, H., Chalmers, N.I., Brow, A. et al. Person‐centered care model in dentistry. BMC Oral Health 18, 198 (2018). https://doi.org/10.1186/s12903‐018‐0661‐9. 19 HRSA. Uniform Data System 2022 Manual Health Center Reporting Requirements. https://bphc.hrsa.gov/sites/default/files/bphc/data‐reporting/2022‐uds‐manual.pdf. 20 See n. 9 , Supra.