Value-Based Reimbursement in Dental – What is Possible?

Value-Based Reimbursement in Dental – What is Possible?

By Mike Adelberg, NADP Executive Director

April 26, 2023

Those of us who participated in passing or implementing the Affordable Care Act (ACA) will remember the giddy talk of it catalyzing a “value-based revolution” in medical care and creating a win-win-win for patients, providers, and payers. In retrospect, that talk was a little naïve. Nonetheless, the slow, steady progress of value-based reimbursement models in medical care is a trend that deserves the attention of thoughtful people in the dental community. Should we move down the same continuum?

The simple answer is “Yes, where it makes sense.” As I prepared a presentation on this topic for the annual conference of the Dental Quality Alliance, I was impressed by the pilots and initiatives underway and studies demonstrating the success of value-based dental care in particular use cases.

Pilots and Initiatives Underway

Some dental plans now offer compensation beyond fee-for-service, particularly in serving Medicaid patients. These include “dental home” capitated payments for patient education and monitoring. In addition, a dental plan serving the Medicaid population is offering bonus payments to network dentists who provide more preventive services to patients (presumably lessening the number of required major services).

Beyond Medicaid, other dental plans are piloting bonuses for dentists’ high-value care and strong practice performance. Bonuses are linked to the mix of services performed, low grievance/compliant rates, use of plan portals, and submission of electronic claims.

Dental plans are also experimenting with value-based incentives beyond network dentists. Some dental plans are also partnering with employers to design dental plans with more generous preventive benefits. For example, one dental plan has demonstrated that more generous preventive benefits can reduce dental spending by 16 percent for high-utilizing employees. Other dental plans incentivize patients to utilize preventive services with lower coinsurance and higher annual maximum benefits when patients appropriately use preventive services.

Journal Articles

There is growing evidence that value-based dental care can work. In the interest of brevity, I’ll discuss only two studies here. First, a recent JADA study looked at whether people with diabetes had lower overall healthcare costs when they received periodontal care. The authors conclude that periodontal treatment was associated with reduced overall healthcare costs of 12% for people with commercial insurance and a 14% reduction for people with Medicaid. A Penn State study of Medicaid claims concluded that advanced payment models improved the utilization of dental services over time.

Going Forward

When considering applying value-based principles to dental, we must avoid giddiness and be mindful of the fundamental differences between dental and medical. In comparison to medical, dental is inexpensive and limited in scope. The need for widely used diagnostic codes makes it hard to focus on patients with conditions with the most significant potential for value-based win-wins. As with so many other features of our work, dental cannot simply copy medical.

If my 30 years in healthcare policy have taught me anything, it is this: Revolutions in healthcare always take longer than the initial prognostications—and what improves care and saves money in one market or region will not work everywhere. For example, the ACA cheerleaders of 2010 predicted that value-based reimbursement would be near-universal by now. That didn’t happen. But, according to a recent McKinsey paper, 80-100 million Americans now receive medical care through a value-based construct, which will likely continue to creep upward.

The value-based dental pilots and initiatives summarized above, along with others not profiled, are only a small sliver of total dental care. But they are promising starts worthy of nurturing and analysis.