Column Editor: Harris Contos
To learn more about Harris, click here.
With this entry, “Open Wide” will come to an end as a regular column for the Wharton Healthcare Quarterly, to reappear with news or significant developments in oral health as warranted. I believe I have pretty much exhausted what I believe needs to be said about the dental care industry in this country and its relationship to the overall directions that health reform is taking. There is little more I have to add at this point in time.
I have been critical - very critical - of this industry for several reasons, among them its cottage industry nature, its outdated financing, its staid practice model, and its unsophisticated understanding of health policy. But at the core is my sense that the economist’s dilemma of “infinite wants vs. finite resources” takes on a moral dimension when it comes to fundamental human needs in a civilized society, which include education, housing, sustenance, and transportation, as well as healthcare. And dentistry, within the healthcare realm, is inefficient, inequitable, inaccessible, and far less effective than it should be in addressing fundamentally preventable diseases. In other words, far less than “optimal use of scarce resources” with its toll on human health and well-being. More concisely, for me, this just isn’t right. We can, should, do better, much better.
This column has allowed me to articulate for myself, and I hope for others, where dentistry stands in relation to the rest of the healthcare enterprise in this country. Without rehashing all the myriad reasons why, I believe it’s accurate to say that the way things stand now, “dentistry is too small and too distant a planet in the healthcare universe to merit much attention.” (Too small? Dentistry represents about 5% of annual national health expenditures, yet that also amounts to about $120 billion. That still sounds like a sizeable industry. Too far? The innovations and reorganization and innovation taking place as a result of health reform just aren’t being seen in dentistry, which predominantly adheres to the private, solo practice, fee-for-service model.)
So there is a policy question here - if the emphasis is on integrated, accountable, comprehensive care as stated in the Affordable Care Act (ACA), how can dentistry be brought closer to the center of the healthcare universe? Fittingly, with the New Year, the time for resolutions, I propose my own “14 Points” for policymakers, both within dentistry and without (though there should really be no distinction):
- Become familiar with the types and workings of non-fee-for-service reimbursement, such as risk-sharing, shared savings, bundled payments, and global budgeting and how they would apply to dental care.
- Become fluent in the concepts behind "value over volume" and "better care, smarter spending, healthier outcomes" and the transparency and accountability that is intrinsic to them, and see how they apply to dental care.
- Seek out examples of integration of care, and of new partnerships between organizations (e.g., retail clinics aligning with health systems) for the delivery of care, the implications for affordable care and wider access, and see how that applies to dental care.
- Become familiar with the principles behind accountable care organizations (ACOs) (e.g., their financing, their emphasis on organizing around prevention -- the "80-20 rule"-- their metrics, etc.), the different models of care (e.g., Pioneer model), and see how the same would apply to dental care.
- Examine the issues -- financial, managerial, organizational, cultural -- involved in formally integrating dental care into ACOs.
- Make the effort to have dental care included in the definition of "primary care" as used in the ACA so that conceptually and programmatically dental care is properly recognized in this fundamental tier of healthcare.
- Become familiar with term "Big Data," what it means, what its components are, what the data sources are, and how they are used in epidemiology, risk assessment, management/decision making, health service research, predictive modeling, etc.
- Related to #7, become familiar with the concepts and principles behind "population health management" and how that would apply to dental care.
- Consider the potentials of teledentistry in all settings, not just geographically remote and underserved areas.
- In line with #9, consider the delivery possibilities when the potential of teledentistry is combined with that of an expanded dental therapist workforce (e.g., the Alaska therapist experience).
- Advance the state of the art of dental care quality and accountability measures.
- Become familiar with the field of "behavioral economics" and its applications to healthcare, prevention, and improvement in health status, and how that can apply to dental care.
- Gain an understanding of how current dental "insurance" violates the principles of insurability, how the private dental insurance market works, who the major players are, and how they are responding to the changes coming about more broadly in health reform.
- Give thought to restructuring pre-doctoral dental education to reflect greater utilization of dental therapists and interaction with MDs, PAs, NPs, and pharmacists (hence emphasis on teamwork in large, integrated organizations of care), widespread use of teledentistry, quality metrics and accountability, population health management, and the economics of healthcare.
In closing, I want to say thank you for this opportunity to use my Wharton education and experience since then to shed some light on a corner of American healthcare that so far has escaped needed scrutiny as health reform gathers momentum. I have learned quite a lot; I hope the readers have too.
And, for my next WHQ gig…….I'll be morphing into a new role as "ongoing contributor," with an initial focus at least on the aphorism, "Everyone's for health reform, provided he doesn't have to change." With the competitive, consumer-oriented thrust to achieve "better care, smarter spending, healthier outcomes," implicitly there will be winners and losers in the new health reform landscape -- in other words, healthcare will no longer be open-ended, or at least a lot less open. Who will these winners and losers be among patients, providers, payers, and policymakers?
Contact Harris at: