Barriers & Facilitators to Transforming to Primary and Secondary Prevention for ECC

1. Barriers & Facilitators to Transforming to Primary and Secondary Prevention for ECC Robert Compton, DDS President, DentaQuest Institute

2. Disclosure: Benefits for 22M People in 28 States Delta Dental of MA

3. Traditional Barriers & Facilitators Fontana M and Wolf M. Translating the Caries Management Paradigm into Practice: Challenges and Opportunities. CDA Journal. Vol. 39 No 10. Oct 2011 In an era of evidence-based care, the question of how much evidence is needed to implement changes into practice becomes central to dentistry’s recognition that dental caries management must change to a focus on risk-based, patient-centered disease management rather than just restorative care. We need: A caries classification system A validated risk assessment tool Need diagnostic codes Need clinical training and calibration Need to be reimbursed for disease management, remineralization, etc. Need to change public’s expectations

4. Systems Approach to Change

5. Business Perspective Primary and Secondary Prevention are Disruptive Innovations “It is almost always new business models that adopt disruptive innovations” * Current dental care system not likely to change much New Models of Policy and Financing will happen Accountable Care Organizations such as Patient-Centered Medical Homes will grow Interprofessional initiatives to integrate oral health into primary care ACOs will grow Innovative reimbursement models have already started * Clayton Christensen. Innovator’s Prescription: A Disruptive Solution for Health Care

6. Value Proposition Determines Business Model Value Proposition Resources Processes Business Model Profit Formula Processes Value Proposition Resources Profit Formula A product or service that provides a customer with something they need People, equipment, facilities, etc. needed to provide the value proposition Work that uses the resources to deliver the service to the customer The price necessary to cover the cost of resources, processes and profit margins needed to deliver the service Clayton Christensen. Innovator’s Prescription: A Disruptive Solution for Health Care

7. Business Model Determines Value Proposition • Eventually the only value propositions that the organization can take to market are those that fit the existing resources, processes and profit formula The starting point in the creation of a business model is the value proposition However, the business model that emerges begins to determine the value propositions that can and cannot be delivered Clayton Christensen. Innovator’s Prescription: A Disruptive Solution for Health Care

8. Facilitative Networks – Dental Benefit Design

9. Disruptive Innovation Disruptive innovation theory explains the process by which complicated, expensive products and services are transformed into simple, affordable ones. It also shows why it is so difficult for the existing companies or institutions in an industry to succeed at disruption. Historically, it is always new companies or totally independent business units of existing firms that succeed in disrupting an industry Disruptive technologies ANDbusiness model innovations are both necessary conditions for disruption of an industry to occur. Clayton Christensen. Innovator’s Prescription: A Disruptive Solution for Health Care

10. Example of Disruptive Innovation Adoption Mainframe computer manufacturers Control Data Corporation (CDC) Digital Equipment Corporation (DEC) International Business Machine (IBM) Margin on a minicomputer = $125,000 Margin on a mainframe computer = $800,000 Margin on a personal computer = $800 All had microprocessor technology IBM set up a separate business unit in Florida for PC Clayton Christensen. Innovator’s Prescription: A Disruptive Solution for Health Care

11. Sealants – Disruptive Innovation

12. Sealants – Disruptive Innovation Cochran Review Sealants introduce 1960 40% decay rate – reduces decay by 84.4% in a 2 year period 70% decay rate – reduces decay by 73% in a 2 year period Healthy People Sealant Goals 2010 – 50% of 8 year olds 2020 – 28% of 6-9 year olds 25% of children have 80% of disease – low income, minority Medicaid/CHIP populations

13. Provider Performance in State Medicaid Program

14. Early Childhood Caries Treatment Costs

15. Risk Assessment Ng MW, et al. Disease Management of early childhood caries: results of a pilot quality improvement project. Journal of Health Care for the Poor and Underserved 23 (2012): 193-209 The ECC disease management approach is based on the premise that a patient’s caries risk status is not static, but can be managed and improved over time.

16. Disruptive Secondary Prevention D2150 $112 D2392 $185

17. Disruptive Innovation: Healing Teeth

18. Healthy • Low Risk • Healthy • Elevated Risk • Disease Reversible • Disease Irreversible Disruption – Simpler, More Affordable Allied Health Professional Can be done anywhere Dental Surgeon Dental Office Earlier Diagnosis & Prevention Risk Reduction Oral Evaluation Risk Assessment Behavior modification Remineralization

19. Interim Therapeutic Restorations for ECC Complete Phase I Treatment Stops progression of disease Reduces pain Reduces need for OR

20. Improved Outcomes and Patient Experience (Percent reduction in each outcome measure) 20

21. Financial Analysis from Boston Children’s Hospital $810,000 vs. $505,200 400 Patients X $762 = $304,800 reduction in cost Reduced per capita costs by 37%

22. Can We Get Policy & Payment to Change? Motivational interviewing, behavior modification, self-management goal setting Remineralization – cover fluoride treatments based on needs of patient Covered interim therapeutic restorations

23. Health Care Cost Crisis 2012 National Health Expenditures Actuals and Projections CBO Projections on GDP, February 2014

24. Per Capita Cost for Insurance & Out-of-Pocket 2012 National Health Expenditures Actuals and Projections

25. Percent of Expenditure by Source of Payment Insurance includes Government, Commercial and other third party payers 2012 National Health Expenditures Actuals and Projections

26. New Models: ACOs and PCHH Accountable Care Organizations (ACOs) are groups of doctors, hospitals, and other health care providers, who come together voluntarily to give coordinated high quality care to their Medicare patients. Patient-Centered Medical Home: A primary care practice that gives patients the individualized care and support they need to stay healthy…the patient, the primary care physician and a medical team work together to develop and implement a plan of care for the patient that details the patient’s optimal medication use, diet,exercise, behavioral health treatments, etc. to get and keep the patient healthy. Interested in ECC model – outcomes and savings

27. Oral - Systemic Connection & Inflammation United Concordia Columbia/Aetna Diabetic • 6 years • 1.5 million patients • Lowered medical claims costs 17% • Mean annual cost saving $1,814 • Improved diabetes control 45% • Hospital admissions: • Perio Treated  3.5% • Not Treated  5.4% BCBSMA:Diabetes Coronary Artery Disease Medical Costs =  67 PMPM  487 PMPM

28. ECC Program at BCH $300,000 savings 25% to ACO $75,000 Shared $30,000 Disease Management $45,000 Reward for Outcomes $225,000 to Medicaid Accountable Care Organization – Shared Savings

29. ACO – Bundled, Episode-based or Global Payment ECC Program at BCH $300,000 savings $300,000 to ACO Bundled Payment $2000  $1400

30. Suggested Reading

31. Barriers & Facilitators to Transforming to Primary and Secondary Prevention for ECC Robert Compton, DDS President, DentaQuest Institute