Dental Provider and Payer Perceptions of Value-Based Oral Health Care

July 2022

Scott Eric Wahlstrom, Jr., MPH Senior Project Manager, Discern Health, Part of Real Chemistry Eva Lenoir, MPH Project Manager, Discern Health, Part of Real Chemistry Brittany Perkins, MPH Project Analyst, Discern Health, Part of Real Chemistry Nina Regenold, MSc Project Analyst, Discern Health, Part of Real Chemistry Kaitlyn Esselman, MHS Director, Discern Health, Part of Real Chemistry Elizabeth Brewer, MS, MPH Head of Government Affairs, US, Haleon Kim Attanasi, Ph.D., RDH Country Medical Affairs Senior Scientist – Oral Care: North America, Haleon Karen Tracy Vice President, Strategic Alliances & Integrated Communications, The Gerontological Society of America Haleon Haleon (NYSE: HLN) is a leading global consumer health company with a portfolio of brands trusted daily by millions of people. In the United States, the organization employs more than 4,700 people who are united by Haleon’s powerful purpose to deliver better everyday health with humanity. Haleon’s products span five categories: Oral Health, Pain Relief, Respiratory Health, Digestive Health, and Wellness. Built on scientific expertise, innovation, and deep human understanding, Haleon’s brands include Abreva, Advil, Benefiber, Centrum, ChapStick®, Emergen‐C, Excedrin, Flonase, Gas‐X, Natean, Nexium, Nicorette, Parodontax, Polident, Preparation H, Pronamel, Sensodyne, Robitussin, Theraflu, TUMS, Voltaren, and more.

For more information on Haleon and its brands, please visit www.haleon.com or contact USMediaRelations@haleon.com.

The Gerontological Society of America (GSA) The GSA is the oldest and largest interdisciplinary organization devoted to research, education, and practice in the field of aging. GSA’s principal mission — and that of our 5,500 members — is to promote the study of aging and disseminate information to scientists, decision makers, and the general public.

Founded in 1945, GSA is the driving force behind advancing innovation in aging — both domestically and internationally. Our members come from more than 50 countries.

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Discern Health Discern Health, part of Real Chemistry, is a consulting firm that works with clients to improve health and health care. Our focus is enhancing the value of health care services through quality‐based payment and delivery models. These models align performance with incentives by rewarding physicians, hospitals, suppliers, and patients for working together to improve health outcomes and health care processes, while lowering total costs. Discern’s clients include a range of organizations—pharmaceutical companies, providers, payers, policymakers, purchasers, and national thought leadership organizations—that are driving the agenda for change in health care.

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Dental Provider and Payer Perceptions of Value‐Based Oral Healthcare Table of Contents Executive Summary ....................................................................................................................................... 5 Introduction .................................................................................................................................................. 6 Methods ........................................................................................................................................................ 6 Results ........................................................................................................................................................... 7 Discussion ................................................................................................................................................... 16 Conclusion ................................................................................................................................................... 18 Appendices Appendix A: Survey Questions ....................................................................................................... 19 Appendix B: Key Definitions ........................................................................................................... 25 Appendix C: Interview Discussion Guide Questions ...................................................................... 26 Appendix D: Additional Quantitative Analysis Graphs .................................................................. 30

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Executive Summary The health care system in the United States (US) is currently transitioning toward value‐based care (VBC), an approach that links payment to quality and value. Despite this trend, significant gaps and barriers remain that challenge widespread engagement in value‐based oral healthcare (VBOHC).

Notably, dental provider and payer engagement is necessary for successful implementation of VBOHC. Insight into dentist and payer perceptions and experiences related to VBOHC is necessary to understand the current state of the transition and identify barriers and opportunities to increase VBOHC participation.

To that end, Discern Health collaborated with GlaxoSmithKline (GSK) Consumer Health (now Haleon) and The Gerontological Society of America (GSA) to develop a survey and qualitative interview guide to investigate VBOHC perceptions, experiences, and challenges. This report discusses the combined results of a survey and in‐depth interviews as well as the implications for the VBOHC landscape. Findings show that while there are barriers to overcome, VBOHC is becoming more prevalent and expected to be a standard of practice. Key insights uncovered during this project include:    

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

Moving forward, collaboration among all dental health stakeholders and VBOHC education and exposure should be prioritized to advance VBOHC in the US.

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Introduction The United States (US) health care system has been steadily shifting towards paying providers based on the quality of care they provide, instead of the volume of services, through the implementation of value‐ based programs and payment models. The transition to value‐based care (VBC) supports the Centers for Medicare & Medicaid Services’ (CMS’) triple aim of providing better care for individuals, improved population health, and reduced costs.1 Despite the growing popularity of VBC in medical care, value‐based oral health care (VBOHC) trails the medical field because of factors such as lack of medical‐dental integration.2 Nevertheless, VBOHC is gaining more traction due to rising oral health care costs, enduring and profound oral health disparities, and variability in quality of oral health care.3 In particular, the high cost of dental care contributes to oral health disparities and represents a major access barrier for adults and seniors, as evidenced by the 59% increase of dental care expenditures per capita for the US geriatric population between 1996 and 2016.4 A major challenge for the transition to VBOHC is the hesitancy among the US dentist population, as dental provider buy‐in is key to successfully advance VBOHC.5 Dentists are ideally positioned to lead VBOHC initiatives because of their direct, on‐the‐ground experience, deep understanding of the field, and trust within the dental community. In addition to dentists, dental payers are central to this transition as they are responsible for developing and implementing VBC arrangements. Gathering and assessing the perceptions, experiences, and knowledge of VBOHC from these two groups is foundational to understand where we are in the journey towards VBOHC, and what is needed to achieve this goal.

These learnings can inform targeted strategies by policy leaders and other oral health stakeholders to increase dental provider and payer engagement in VBOHC and drive momentum towards VBOHC.

Methods This study employed a mixed methods approach that included a quantitative survey and qualitative interviews. Data collection for both methods was conducted concurrently.

Quantitative Survey A quantitative survey was fielded between April 22 – 26, 2022 using an online survey platform. The survey was comprised of a variety of question formats, including ranking, select‐all that apply, sliding scales, and level of agreement questions. Screener questions were used to restrict respondents to general dentists with an active license, those between the ages of 18 to 75, and those who see a minimum of five patients at their practice in a typical day, and those without affiliation to an advertising

1

CMS. Value‐based Programs. https://www.cms.gov/Medicare/Quality‐Initiatives‐Patient‐Assessment‐Instruments/Value‐ Based‐Programs/Value‐Based‐Programs. Updated March 2022.

2 Esselman, K., et al. Using Quality Tactics to Advance Value‐Based Oral Healthcare. https://www.discernhealth.com/wp‐ content/uploads/2022/01/Oral‐Health‐Convening‐White‐Paper‐2022‐01‐10.pdf. Published January 2022.

3 Glassman P. Oral Health Quality Improvement in the Era of Accountability. Pacific Center for Special Care, University of the Pacific Arthur A. Dugoni School of Dentistry. https://dentaltherapyresourceguide.wkkf.org/resources/resource/oral‐health‐ quality‐improvement‐in‐the‐age‐of‐accountability/. Published December 2011.

4 Hung M, Lipsky MS, Moffat R, et al. Health and dental care expenditures in the United States from 1996 to 2016. PLoS One. 2020;15(6):e0234459. https://doi.org/10.1371/journal.pone.0234459.

5 See n. 2, Supra.

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agency. Outreach was conducted to 150 individuals. A total of 50 individuals were excluded due to questions posed in the screener, the final sample size was 100 respondents.

The survey included 9 demographic (e.g., gender, race and ethnicity) and background questions (e.g., practice type) and 11 content questions related to the following general content areas:   

VBOHC experiences, perceptions, and engagement Medical‐dental integration education and challenges Use of diagnostic coding and interoperability

For a full list of survey questions, please see Appendix A.

Qualitative Interviews Discern conducted one‐hour semi‐structured, in‐depth interviews with dental payers and providers using the discussion guides in Appendix C. The study employed a double blinding method to prevent biased responses and allow for open dialogue. In total, Discern completed 15 interviews with 9 dental providers and 6 payers from various US geographic regions and practice settings (Table 1).

Table 1: Qualitative Interview Participant Demographics Interviewee Type Dental Providers

Regions (N) & Settings (N) • Midwest (3), Northwest (1), Southwest (2), West Coast (2), East Coast (1)

Interviews Conducted 9

• Community health center (4), Private practice (2), Academic (2), Center for Dental Health (1) Payers

• East Coast (1), Midwest (2), West (2), National (1)

6

• Commercial medical/dental (2), Commercial dental (3), All‐payer (1) Totals

15

Results Quantitative Survey Results Table 2 provides an overview of demographics from the 100 dentists surveyed. Most respondents were male (71%), between the ages of 45‐64 years (65%), and had been practicing dentistry for 21 years or more (71%). Most respondents (72%) identified as White/ Caucasian. There was even representation across US regions. This is largely representative of the U.S. dental workforce; however female dentists

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are slightly under‐represented in survey respondents. The American Dental Association estimated that in 2020 34.5% of dentists were female while only 29% of survey respondents identified as female.6 About half (53%) of the surveyed dentists work in a solo practice operated by one dentist and serve adult patients (91%), and the majority work in suburban settings (64%).

Table 2. Survey Sample Demographics (N=100) Demographic Category

Participants (%)

Age Bracket 25‐34 years 35‐44 years 45‐54 years 55‐64 years 65‐75 years

2% 19% 29% 36% 14%

Male Female Prefer not to respond

71% 27% 2%

White/ Caucasian Black/ African American Asian/ Pacific Islander American Indian/ Alaska Native Other or Multiracial Prefer not to answer

72% 3% 13% 0% 6% 6%

Hispanic Non‐Hispanic Prefer not to respond

4% 89% 7%

Gender

Race

Ethnicity

Region South West Midwest Northeast Years Practicing Dentistry 0‐5 6‐10 11‐20 21‐30 31+ Practice Type Solo practice (operated by one dentist)

31% 24% 24% 21% 3% 9% 17% 32% 39% 53%

6

Health Policy Institute, American Dental Association. The Dentist Workforce – Key Facts. https://www.ada.org/‐ /media/project/ada‐organization/ada/ada‐ org/files/resources/research/hpi/hpigraphic_0221_1.pdf?rev=1829a4f788c14974a1ac89ff1e288c0f&hash=A27C6AD199EB6FCA B15DB069BAF0CC85. Published February 2021.

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Demographic Category Small group practice (operated by multiple dentists at one location) Large group practice (operated by multiple dentists at multiple locations) Multispecialty group practice Other (nonprofit dental center) Practice Setting Suburban Urban Rural Primary Population Served Children and/ or adolescents (ages <18) Adults (18‐64) Older adults (ages 65+) Specific Work Environments Integrated Delivery Network/ System Federally Qualified Health Center (FQHC) Patient Centered Medical Home (PCMH) Dental safety net provider Accountable care organization (ACO) None of the above

Participants (%) 28% 12% 6% 1% 64% 28% 8% 5% 91% 4% 13% 2% 4% 6% 0% 75%

Value‐based Oral Health Care The majority (91%) of respondents were not currently participating in VBC arrangements; however, among this group, about half (43%) were interested in participating in VBC arrangements in the future.

Most dentists reported that their respective dental practice understands how oral health care fits into VBC (61%) and agree that VBC has the potential to improve oral health care for their patients (60%).

Many dentists were ambivalent about VBOHC (selecting either slightly disagree or slightly agree). Most dentists (70%) did not feel that their practice was incentivized to participate in VBC, with 20% strongly disagreeing with this statement. Figures 1‐3 below show the level of agreement with these statements across respondents.

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Figure 1. Responses to “Indicate your level of agreement with the following statement: My practice understands how oral health care fits into VBC”

"My practice understands how oral health care fits into VBC" (N=100)

Percent of Dentists (%)

40 30

25%

20

16%

24%

19% 12%

10

4%

0 Strongly Disagree

Disagree

Slightly Disagree Slightly Agree

Agree

Strongly Agree

Level of Agreement

Figure 2. Responses to “Indicate your level of agreement with the following statement: VBC has the potential to improve oral health care for my patients.”

Percent of Dentists (%)

40

"VBC has the potential to improve oral health care for my patients" (N=100) 34%

30 20 10

14%

19%

17%

9%

7%

0 Strongly Disagree

Disagree

Slightly Disagree Slightly Agree

Agree

Strongly Agree

Level of Agreement

Figure 3. Responses to “Indicate your level of agreement with the following statement: My practice is incentivized to participate in VBC.”

“My practice is incentivized to participate in VBC” (N=100)

40 Percent of Dentists (%)

31% 30 20%

21%

19%

20

7%

10

2% 0 Strongly Disagree

Disagree

Slightly Disagree

Slightly Agree

Agree

Strongly Agree

Level of Agreement

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Slightly less than half of respondents (45%) reported using quality measures. Among those who use quality measures (n=45), the primary use was tracking and monitoring quality improvement efforts (49%), followed by establishing and tracking progress toward performance benchmarks (36%). Only a small number of respondents reported utilizing quality measures for provider comparisons (9%) or identifying variations in care (7%). Most measures being used were developed by dental provider practices (78%), followed by measures required by the state(s) they practice in (31%), measures required by payers (20%), Dental Quality Alliance measures (9%), and other measures (7%) such as Accreditation Association for Ambulatory Health care (AAAHC) measures. Slightly more than half of respondents (55%) did not use quality measures. Within this group, 40% had some degree of interest in using quality measures in the future.

Around a third of all dentists (34%) reported no education regarding quality measures. Among the 66% with previous quality measurement education, the most common educational source was continuing dental education (67%). Some respondents noted other education during their DDS or DMD degree (41%), through a specialty/professional society or study club (24%), or another source (8%) such as dental corps training, work at a health management organization (HMO), or during residency.

Most dentists (88%) reported that their practice did not participate in alternative payment models (APMs). For the small number of dentists that reported using APMs (n= 12), the most common model type was pay‐for‐performance or pay‐for‐reporting (7% of total respondents), followed by shared savings (2%), bundled or capitated payment models (2%), and other APMs (1%). Most dentists (63%) did not have any education regarding APMs. Among dentists with education in this area (n=37), the most common sources of education mirrored the educational sources reported for quality measures: continuing dental education (46%), followed by a specialty/professional society or study club (43%), and during their DDS/ DMD degree education (24%).

Integrated Care Over half of dentists (62%) had previous education regarding medical‐dental integration. Among those with medical‐dental integration education (n=62), the most common sources of education were similar to the sources reported for quality measures and APMs, with continuing dental education (65%) leading, followed by DDS/ DMD degree education (44%), and through a specialty/professional society or study club (34%).

Participants were asked to select and rank the top 3 challenges for medical‐dental integration. Figure 4 below shows the distribution of ranked answers across the different challenges. Overall, the lack of established models or guidelines was the most selected challenge regardless of rank (47%) and 14% of respondents ranked it as the most challenging. Lack of collaboration between medical and dental practitioners was the most ranked top challenge among respondents (19%) and was the second‐most reported challenge across all respondents regardless of rank (45%).

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Figure 4. Top 3 Challenges for Providing Integrated Medical and Dental Care

Challenges

Top 3 Challenges for Providing Integrated Medical and Dental Care Lack of performance metrics

6

Variations in medical and dental payer requirements

7

12 17

Lack of established models or guidelines

14

Unclear benefits for my patients

13

Low utilization of diagnostic codes among dentists 1

12 10 15

18

8

7

Most challenging

12

Second most

9 Third most

Separation of medical and dental electronic record systems

18

Interoperability issues with medical and dental coding conventions

12

Lack of collaboration between medical and dental practitioners

12 10

5

19 0

10

9

10

16

20 30 Number of Responses

40

50

Diagnostic Coding and Interoperability Respondents were asked to select all that apply with regards to their use of diagnostic codes. Most dentists (79%) reported using diagnostic codes in their clinical practice. Figure 5 below shows respondents’ use of diagnostic codes. By far the most common use of diagnostic codes was for dental insurance claims, reported by 61% of respondents. Other uses include to record data in the electronic health record (EHR) (27%), medical insurance claims (25%), communication with external providers (14%), and quality improvement initiatives (12%). The least reported uses among dentists were for quality measure reporting (6%) and recording data in non‐electronic record systems (7%).

Figure 5. Use of Diagnostic Codes Among Dentists (*question allowed for multiple responses)

Number of Responses

Respondents' Use of Diagnostic Codes* 70 60 50 40 30 20 10 0

61

27 7

25 14

Record data in Record data in Communicate non‐electronic EHR with external systems providers

21 6

Dental insurance claims

Medical insurance claims

Quality measure reporting

12

Quality I do not use improvement diagnostic initiatives codes

Uses of Diagnostic Codes

Lastly, the survey investigated potential ways to increase utilization of diagnostic codes among dentists.

The survey asked dentists to rank the 3 most helpful options. Figure 6 below shows the different responses for each option. Education on the use and value of diagnostic codes was characterized as the

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most helpful way to increase utilization of diagnostic codes among dentists (35%), closely followed by increased dental coverage (32%). Increased dental coverage and education were the most selected across all three ranking options, being selected by 70% and 66% of respondents, respectively.

Figure 6. Top 3 Potential Ways to Increase Utilization of Diagnostic Codes Among Dentists (*question allowed for multiple responses) Ways to Increase Utilization of Diagnostic Codes

Top 3 Potential Ways to Increase Utilization of Diagnostic Codes* Financial incentives for quality patient outcomes

32

15

3

Increased dental coverage Improved information systems

11

Increased payer requirements

11

15

23

32

Most helpful Second most

19

25

Third most

Education

13

9 16

35 0

20

40

15 60

80

Number of Responses

Qualitative Interview Results The following topics emerged as the key themes from the both the dental payer and provider stakeholder interviews.

There is hesitancy from providers about the transition to VBOHC One of the most reported barriers to VBOHC identified during the interviews was provider hesitancy.

Both payer and provider participants indicated that many dentists, particularly those in private practices, are accustomed to and satisfied with their current payment system and do not feel the desire to implement value‐based payment models. Additionally, some providers expressed concerns over accountability for their patients’ behaviors, such as non‐adherence to preventative care and treatment recommendations.

Other concerns mentioned during the interviews included who would be determining quality of care and what “value” means and having payers dictate treatment for patients. There were a few participants that expressed concerns over “benign neglect” as an unintended consequence with a shift to VBOHC. Benign neglect is a concept in which the perception of limited incentives by providers may lead to certain elevated risk or vulnerable populations being deprioritized in favor of meeting quality measure benchmarks and higher reimbursement.

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There is a need for stakeholder awareness and education to drive VBOHC Participants indicated that there was a lack of awareness about VBOHC among payers and providers.

Payers from both dental‐specific and integrated medical/dental plans7 described their efforts to implement VBOHC programs, which received varying levels of success in garnering the needed buy‐in and engagement, whether from providers or internal leadership. One participant from a dental‐specific payer organization described an initiative that incentivized dentists to utilize a performance scorecard; however, despite offering a bonus pool for being an active user, only about 20% of providers participated in the program. Barriers to program uptake included lack of knowledge on quality measurement and the relation to value‐based payment, and providers being too busy.

Participants highlighted the need for medical leaders to appreciate the importance of dental health to overall health to increase collaboration with dental stakeholders. A payer participant with prior experience at an integrated medical/dental plan mentioned the challenge they faced in garnering support from medical payer leadership to integrate dental and medical programs and consider the impact of oral health care on disease management. This participant noted that standalone dental payers do not have the same resources as large integrated medical/dental plans and may be more limited in their integration efforts, indicating a need for greater advocacy for dental collaboration with medical plans.

In contrast, a payer from an integrated medical/dental plan described a successful value‐based arrangement focused on patients with chronic conditions who could benefit from additional dental care.

As an integrated medical/dental plan, the organization was in a unique position to invest money on dental coverage and initiatives because they were able to generate a return on investment on the medical services side. Overall, this initiative helped to control dental inflammation among patients and produce better health outcomes. This participant also indicated that their VBOHC programs were well‐ received and generated engagement from the provider community.

Providers revealed that their VBOHC awareness and education primarily came from working in clinics and being involved with professional societies. FQHC and community health dentists attributed their knowledge of VBC due to their exposure working in a collaborative setting with medical providers.

The lack of educational focus on VBOHC and separation of medical and dental curriculums were acknowledged as potential barriers to driving awareness. Two providers interviewed were from academic settings and described the division in medical and dental education. One of the providers expressed that medical health care providers may not appreciate the full benefits of including dentists in overall health care. They explained that some educational initiatives exist to unite the fields but feel that these interdisciplinary programs did not fully integrate dental students. The other academic provider explained that there is a need to teach students to advocate for greater dental coverage and that VBOHC needs to be better integrated into the dental school educational curriculum.

Some participants also expressed the importance of VBOHC education for patients. Participants mentioned that dentistry is often viewed as a procedural health care service and patients could be better educated on the value and importance of oral health to their overall health. Particularly in private

7For

the purposes of this report, dental‐specific plans refer to payers that provide dental benefits only while integrated medical/dental plans that provide both medical and dental benefits.

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practices, patients are a driving force as consumers and patient literacy may help to create a demand for VBOHC that providers will need to meet.

VBOHC initiatives and progress are locally driven Some of the provider participants described their own efforts to develop quality activities such as practice‐based quality improvement systems and internal reporting metrics to collect data and analyze trends. These individual efforts were cited as a method to fill a gap in nationally required measurement and quality activities.

Priority populations of interest also varied among participants depending on the needs of their communities. Efforts on care coordination (e.g., referrals) and integrated services (e.g., co‐location) were primarily reported in FQHC or community health settings. One FQHC provider depicted how their clinic offers an obstetrics package that includes a dental visit for pregnant patients. Another provider mentioned conducting HbA1c testing for patients during dental appointments. Some integrated dental/medical payers have incentivized preventive services based on their population’s needs. For instance, one payer participant described how their integrated organization offers enhanced dental benefits for patients with diabetes, heart disease, cancer, autoimmune diseases, and during pregnancy.

Multiple participants discussed state‐based initiatives that allowed them to pursue VBOHC activities.

States in both the West and Midwestern regions were pointed to as examples where local legislative efforts are used to encourage VBOHC through practice pilot programs. One provider cited that their practice was able to implement a tele‐dentistry program from the legislative and resource support their state provided. Another provider was involved with their state’s dental collaborative program and elaborated on their success in getting their state to conduct a dental home demonstration project.

Overall, a clear theme emerged from the interviews: local level initiatives and leaders are driving VBOHC. The VBOHC initiatives described and noted in during interview discussions were isolated efforts and not scaled to a national level.

The dental data infrastructure has limitations The analytic and reporting limitations of dental EHRs were frequently mentioned as barriers to advancing VBOHC. Dental practices tend to use different health record systems than medical practices, which are not typically designed to exchange health information. The interoperability gap presents a challenge for medical/dental integration and hinders care coordination. One provider described the necessity to use a third‐party software program to pull reports and build dashboards to connect the internal dental and medical records. Another FQHC provider that utilizes the same EHR vendor as their medical colleagues described some of the benefits of having systems that are connected such as using the EHR to align scheduling for same day dental and medical appointments in priority population patients (i.e., infants, pregnant patients, diabetic patients) and eliminate the referral process, which can impact access. Overall, interview participants characterized the use of diagnostic codes by dental providers as extremely limited, making it difficult for payers to evaluate the efficacy of treatments and capture the impact of changes. As one participant stated “value‐based payment without performance measures doesn’t work.”

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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.

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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.

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.

15

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Our research has several limitations. Qualitative interviewees were selected based on their current work and association with VBOHC, which could have resulted in respondent bias. Few perspectives were included from dental providers that are not well‐versed in VBC arrangements, quality measurement, and/or medical‐dental integration. Interviewees also included more participants from FQHCs than is representative of the dental provider population. This may have created a bias in the themes that emerged from these discussions. Results from the survey were not assessed for statistical significance, limiting our ability to make definitive statements on associations. Lastly, 70% of survey respondents self‐ identified as White/Caucasian and 71% self‐identified as Male. While this is representative of the broader dental provider population, 21 it does not fully capture the experiences and perceptions of providers from racial and ethnic minority populations.

We have identified several areas for consideration for future research. Placing an emphasis on reaching a greater diversity of dental providers from minority groups (e.g., Black, Asian, women) and those who are younger and have fewer years of experience practicing dentistry for a quantitative survey is needed to better understand their experiences with VBOHC and uncover potentially unique challenges and key differences with the findings depicted within this report. This would also allow to trend knowledge and attitudes as the dental provider population evolves, with a higher proportion of female dental school graduates, among other changes.22 Variations in dental and medical coverage requirements and the impact on integration of dental and medical care is important to explore further.

Conclusion While dental providers and payers face challenges, opportunities described in this report offer entry points to advance VBOHC initiatives. A collaborative effort among all stakeholders involved is needed to overcome underlying challenges, including the novelty of VBOHC arrangements and the chasm between dental and medical care. Local initiatives exist that depict successful, integrated models of care—these initiatives should be disseminated to increase education and understanding about VBOHC. The foundation for whole‐person centered‐care that incorporates both dental and medical care needs to be further established through interprofessional education curriculums and greater awareness and acceptance among both the dental and medical communities. While there are challenges to overcome to successfully implement VBOHC, it is a worthy cause due to its potential impact on patient care and outcomes.

21 22

See n. 6, Supra.

See n. 6, Supra.

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Appendix A: Survey Questions Background Questions 1. In which state is your primary practice located?  [INSERT DROP‐DOWN MENU FOR ALL 50 STATES + DC] 2. Which of the following categories describe your race? Select all that apply:  White / Caucasian  Black / African American  American Indian/ Alaska Native  Asian / Pacific Islander  Other; please specify: _______  Prefer not to answer 3. Ethnicity  Hispanic  Non‐Hispanic  Prefer not to respond 4. Which of the below most closely align with your gender identification?  Female  Male  Other; please specify: _________  Prefer not to respond 5. How many years of experience do you have practicing dentistry?  0‐5  6‐10  11‐20  21‐30  31+ 6. In what setting is your primary practice located?  Rural  Urban  Suburban 7. Which of the following best describes your current work environment as a dentist?  Solo practice (operated by one dentist)  Small group practice (operated by multiple dentists at one location)  Large group practice (operated by multiple dentists at multiple locations)  Multispecialty group practice  Other; please specify: _________________ Discern Health | Dental Provider and Payer Perceptions of Value‐Based Oral Healthcare | August 2022

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8. Does your dental practice fall under any of the following categories? Select all that apply:  Integrated Delivery Network/ System  Federally Qualified Health Center (FQHC)  Accountable Care Organization (ACO)  Patient Centered Medical Home (PCMH)  Dental safety net provider  Other; please specify: _________________ 9. Which of the following age groups accounts for the largest proportion of patients you serve as a dentist?  Older adults (ages 65+)  Adults (ages 18‐64)  Children and/or adolescents (ages <18) VBOHC Awareness and Acceptance

The dental profession is moving toward value‐based care (VBC), an approach to care that ties reimbursement to the quality and value of care provided (in contrast to traditional approaches to reimbursement based on the quantity of services provided). A key component of VBC is use of quality measures, which capture the quality of care provided and patient outcomes achieved. For example, the Dental Quality Alliance (DQA) has developed quality measures, including measures that evaluate preventive care processes (e.g., “Oral Evaluation”), access to care (e.g., “Usual Source of Services), and care outcomes (e.g., “Ambulatory Care Sensitive Emergency Department Visits for Dental Caries in Children”).

1. Does your dental practice utilize quality measures? Select all that apply:  Yes, to track and monitor quality improvement efforts  Yes, for public reporting purposes  Yes, for alternative payment model arrangements that tie quality of care to provider reimbursement (e.g., pay‐for‐performance)  Yes, to identify variations in care  Yes, for provider comparison purposes  Yes, to establish and track progress toward performance benchmarks  Yes, for other reasons; please specify: ______  No, my practice doesn’t utilize quality measures 2. If yes, which quality measure(s) does your practice utilize? Select all that apply:  Dental Quality Alliance (DQA) measures  Measures developed by my practice  Measures required by payers  Measures required by my state

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 

I use other quality measures; please specify: ______ My practice does not utilize quality measures

3. If you do not utilize quality measures, on a scale from 0‐10, how interested are you in using quality measures in your dental practice?

0

1

Not at all interested in using quality measures

2

3

4

5

6

7

8

Neither interested nor disinterested

9

10 Very interested and planning to use quality measures in the future

Another component of VBC is use of alternative payment models (APMs). APMs tie provider reimbursement to quality of care provided, as opposed to fee‐for‐service reimbursement based on volume of services. The following are examples of APMs that can be used by oral health providers or provider organizations: a) Shared savings: Providers receive a percentage of the total cost savings for a defined patient population b) Pay‐for‐performance (P4P): Financial rewards or penalties based on quality measure performance benchmarks c) Pay‐for‐reporting: Financial bonuses for reporting data or penalties for not reporting data d) Bundled payments: Prospective or retrospective payments based on an entire episode of care (e.g., a specific procedure, a time‐limited condition, or condition‐specific care management); Payment adjustments are based on quality measure performance e) Capitated payment models: Prospective payments to providers (per‐member and per‐ month) covering health services that are based on quality measure performance measured against quality benchmarks 4. Does your practice participate in any alternative payment models (APMs)? Select all that apply:  Shared savings  Pay‐for‐performance or Pay‐for‐reporting  Bundled or Capitated payment models  My practice does not participate in an APM  Other; please specify: ________ Another important component for value‐based oral health care is the integration of medical and dental care. Medical‐dental integration refers to an approach to care that integrates and coordinates dental medicine into primary care and behavioral health.

5. Indicate how you learned about the following; select all that apply: Discern Health | Dental Provider and Payer Perceptions of Value‐Based Oral Healthcare | August 2022

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a. I learned about quality measures…  During my education for my DDS/DMD degree  Through continuing dental education  Through a specialty/professional society/ study club  I do not have any education in this area  Other, please specify: _________ b. I learned about alternative payment models (APMs)…  During my education for my DDS/DMD degree  Through continuing dental education  Through a specialty/professional society/ study club  I do not have any education in this area  Other, please specify: _________ c. I learned about medical‐dental integration…  During my education for my DDS/DMD degree  Through continuing dental education  Through a specialty/professional society/ study club  I do not have any education in this area  Other, please specify: _________ As a reminder, value‐based care (VBC) rewards dental providers based on the quality and value of care provided. This is in contrast to the traditional model of payment in which dentists are paid based on volume of services performed.

6. Do you currently participate in a value‐based care arrangement?

Yes  No  7. If no, indicate your level of agreement with the following statement: I am interested in participating in value‐based care arrangements.

1 2 3 4 5 6 Strongly Disagree Slightly Slightly Agree Agree Strongly Agree disagree Disagree 8. Specify your level of agreement with the following statements: a. Value‐based care has the potential to improve oral health care for my patients.

1 2 3 4 5 6 Strongly Disagree Slightly Slightly Agree Agree Strongly Agree disagree Disagree b. My practice understands how oral health care fits into value‐based care.

1 2 3 4 5 6 Strongly Disagree Slightly Slightly Agree Agree Strongly Agree disagree Disagree

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c. My practice is incentivized to participate in value‐based care.

1 2 3 4 5 Strongly Disagree Slightly Slightly Agree Agree disagree Disagree

6 Strongly Agree

Integrated Care, Coding, and Interoperability

9. What are the top 3 challenges that your dental practice faces in providing integrated dental and medical care?  Lack of collaboration between medical and dental practitioners  Separation of medical and dental electronic record systems  Interoperability issues stemming from different medical and dental coding conventions  Low utilization of diagnostic codes among dentists  Unclear benefits for my patients  Lack of established models or guidelines  Variations in medical and dental payer requirements  Lack of performance metrics to monitor, evaluate, and improve integration efforts  Other; please specify: ________  This question is not applicable to my dental practice 10. Indicate functions for which you use diagnostic codes (e.g., ICD‐10 codes). Select all that apply:  Record clinical data in non‐electronic record systems  Record clinical data in the electronic health record  Facilitate communication/ collaboration with external providers  Dental insurance claims  Medical insurance claims  Quality measure reporting  Quality improvement initiatives  I do not use diagnostic codes  Other; please specify: ________ 11. Which of the following would be most helpful to increase utilization of diagnostic codes in your dental practice? Select the top 3 options:  Education on the use and value of diagnostic codes  Increased payer requirements to include diagnostic codes on claim submissions  Improved information systems that capture diagnostic codes within the dentist’s workflow  Increased dental coverage

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  

Financial incentives for quality patient outcomes that are tracked using diagnostic codes N/A Other; please specify: ________

Additional Opportunities

12. Are there any additional considerations related to the transition to VBC and/ or your ability to participate in VBC arrangements that are important to mention?

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Appendix B: Key Definitions Alternative Payment Model (APM): “Payment approach that gives added incentive payments to provide high‐quality and cost‐efficient care. APMs can apply to a specific clinical condition, a care episode, or a population.”23 Interoperability: “The ability of different information systems, devices, and applications (systems) to access, exchange, integrate and cooperatively use data in a coordinated manner, within and across organizational, regional, and national boundaries, to provide timely and seamless portability of information and optimize the health of individual and populations globally.”24 Medical‐Dental Integration: “An approach to care that integrates and coordinates dental medicine into primary care and behavioral health to support individual and population health.”25 Quality: “The degree to which healthcare services for individuals and populations increase the likelihood of desired health outcomes and are consistent with current professional knowledge.”26 Quality Measure: “Tools that help us measure or quantify healthcare processes, outcomes, patient perceptions, and organizational structure and/or systems that are associated with the ability to provide high‐quality healthcare and/or that relate to one or more quality goals for healthcare. These goals include effective, safe, efficient, patient‐centered, equitable, and timely care.”27 Value‐based Care: “Care delivery model in which providers are rewarded for quality health outcomes rather than the quantity of care delivered. In this approach, providers focus on improving the health of a population of patients by offering care that is focused on prevention, best evidence, and personalization.”28

23

Centers for Medicare & Medicaid Services (CMS). “APMs Overview”. https://qpp.cms.gov/apms/overview.

Healthcare Information and Management Systems Society (HIMSS). “Interoperability in Healthcare”. https://www.himss.org/resources/interoperability‐healthcare.

25 DentaQuest. “Medical‐Dental Integration”. https://dentaquest.com/oral‐health‐resources/medical‐dental‐ integration/.

26 Agency for Healthcare Research and Quality. “Understanding Quality Measurement”. https://www.ahrq.gov/professionals/quality‐patient‐safety/quality‐ resources/tools/chtoolbx/understand/index.html.

27 CMS. “Quality Measure”. https://www.cms.gov/medicare/quality‐initiatives‐patient‐assessment‐ instruments/qualitymeasures/index.html.

28 DentaQuest. “Value‐Based Care”. https://dentaquest.com/oral‐health‐resources/value‐based‐care/.

24

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Appendix C: Interview Discussion Guide Questions Value‐based Oral Health Care: Payer Interview Guide Discussion Questions The questions below are meant to serve as general guideposts for the discussion. We may ask additional follow‐up questions throughout the interview to clarify a response or obtain more information.

Introduction 

Please describe your current roles/responsibilities as they pertain to oral health. o What is your typical beneficiary demographic (age, race/ethnicity, coverage)?

VBOHC Knowledge and Engagement  





How would you describe the trend towards value‐based care in oral health in your network? o How would you describe the current payer interest in VBOHC? How has your organization engaged in value‐based oral health? o How does your organization utilize quality measures to improve patient care, determine value for procedures/treatments?  How do you prioritize which quality measures are implemented?  What types of data points would be of most interest to your organization (e.g., structure, process, outcome, patient‐reported)?  How do current guidelines and evidence affect your prioritization or use of quality measures?  What quality‐related partnerships or collaborations has your organization engaged in? o What payment models related to oral health has your organization engaged in?  What methods do you use to incentivize dental providers to engage in value‐ based care? o What are some challenges or barriers that are preventing payers from implementing value‐based payment models related to oral health?  What support would be needed (e.g., federal, provider, patient) to overcome those barriers?  Do you have any recommendations on how to address those barriers or challenges?

How would you describe the level of interest in VBOHC among dental providers? o What percent of participating providers are engaged in VBC? How do you anticipate this trend to change over the next 5‐10 years? o Are there barriers limiting provider participation? o Do you provide any resources or education around VBOHC for dental providers?

Which population(s) are the top priority for quality improvement in oral health care at your organization? o How do you identify these priority populations? o How do you anticipate VBOHC will impact these populations? o What are potential barriers to developing or implementing VBOHC initiatives to address disparities? o What would you suggest to reduce those barriers?

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Diagnostic Coding and Interoperability 



We have heard that dental systems lag compared to medical systems in consistently collecting diagnostic codes. Can you talk about your experiences with dental diagnostic coding? o What improvements are needed to enhance the dental information technology infrastructure? o What is needed to improve coding standardization?

Does your organization require diagnostic codes on claims submissions? o What codes are required? o For what purposes are codes required (e.g., service authorization)? o What are the benefits of dental providers submitting ICD‐10 codes? o Are there any gaps in diagnostic codes? o What opportunities would increase use of diagnostic codes by dental providers? o For organizations that don’t require diagnostic codes on claims submissions:  Has your organization considered implementing diagnostic code requirements in the near future? Why or why not?

Closing 



 

As we discussed in our introduction, the US health care system is increasingly beginning to adopt value‐based oral health care through tactics such as medical‐dental integration, alternative payment models with oral health incentives, etc. How do you view this change with regards to how it will impact your organization?

How will value‐based oral health care affect population health overall/in your beneficiary population? o How will this shift towards value‐based care impact health equity?  What might be potential unintended consequences on vulnerable populations (e.g., realignment of resources)?

What are your concerns about transitioning to value‐based oral health care?

What is needed for value‐based oral health care to be widely and successfully implemented?

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Value‐based Oral Health care: Provider Interview Guide Discussion Questions The questions below are meant to serve as general guideposts for the discussion. We may ask additional follow‐up questions throughout the interview to clarify a response or obtain more information.

Introduction 

Please describe your current roles/responsibilities. o What type of setting do you work in?  General dentist and chief dental officer o What is your typical patient demographic (age, race/ethnicity, coverage)?

VBOHC Knowledge and Engagement 



How would you describe your level of knowledge regarding value‐based oral health care? o What would you say was the most significant source of your knowledge and experience in value‐based oral health care (e.g., DDS/DMD education, continuing dental education, specialty/professional society resource, study club, etc.)?  How much would you say your education prepared you for value‐based care in the clinical setting?  What recommendations do you have for how your education or other dental schools could improve their efforts to prepare students?  What resources, materials, or specific issues and topics did you find the most helpful?

How does your practice engage in value‐based care? o How do you track oral health quality measures?  What quality measures or data points are most important for you in providing care for your patients?  If not, what might incentivize you to use measures?  What support or resources would you need to start collecting data on quality measures (i.e., technology support)?  How might using measures be useful to you and your practice? o Do you participate in any value‐based care arrangements?  How are you incentivized by payers to engage in value‐based care? o What are some challenges or barriers that have prevented or limited your engagement? o Conversely, are there any resources or external factors that have helped your practice’s participation in value‐based oral health care?

Integrated and Team‐based Care 

How would you describe the relationship between medical and dental health delivery? o Do you work directly with primary care or other health care providers as part of an integrated team?  What kind of health care providers do you collaborate with? Can you briefly describe the workflow?  What partnerships or collaborations would you suggest to increase team‐based care? (e.g., data‐sharing, payment models) o What are the challenges to medical‐dental integration?

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o

What recommendations do you have for how medical and dental professionals can work collaboratively to improve patient oral health?

Closing 



 

As we discussed in our introduction, the US health care system is increasingly beginning to adopt value‐based oral health care through tactics such as medical‐dental integration, alternative payment models with oral health incentives, etc. How do you view this change with regards to how it will impact your practice and how you deliver care to your patients?

How will it affect population health overall/in your patient population? o How will this shift towards value‐based care impact health equity?  What might be potential unintended consequences on vulnerable populations (e.g., uneven allocation of resources, lack of focus on outcomes important to patients, increasing health disparities)?

What are your concerns about transitioning to value‐based oral health care?

What is needed for value‐based oral health care to be widely and successfully implemented?

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Appendix D: Additional Quantitative Analysis Graphs Figure D1. Responses to “Indicate your level of agreement with the following statement: I am interested in participating in VBC arrangements.”

“I am interested in participating in VBC arrangements” (n=91)

40

36% Percent of Dentists (%)

30 22% 20

15%

15% 11%

10 1% 0 Strongly Disagree

Disagree

Slightly Disagree

Slightly Agree

Agree

Strongly Agree

Level of Agreement

Figure D2. Utilization of Quality Measures Among Dentists

Does your dental practice utilize quality measures?

(N=100) Uses of Measures

Yes, to identify variations in care

3%

Yes, for provider comparison purposes

4%

Yes, to establish and track progress toward performance benchmarks

16%

Yes, to track and monitor quality improvement efforts

22%

No, my practice doesn't utilize quality measures

55% 0

20 40 Percent of Dentists (%)

60

Figure D3. Utilization of Quality Measures by Measure Type (*question allowed for multiple responses)

Which quality measures do you use? (n=45)*

Measure Type

DQA measures

4

Measures developed by my practice

35

Measures required by payers

9

Measures required by my state

14

Other measures

3 0

10

20 30 40 Number of Responses

50

60

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Figure D4. Interest in Using Quality Measures among Dentists not Currently Using Measures

Interest in Using Quality Measures (n=55)

Percentage of Dentists

60 50

40%

40 30 20 10

15% 9% 2%

4%

2%

4%

1

2

3

4

9%

9%

4%

2%

9

10

0 0

5

6

7

8

Level of Interest

Key: 0 = Not at all interested, 5 = Neither interested nor disinterested, 10 = Very interested and planning to participate in the future Figure D5. Sources of Education Regarding Quality Measures, Medical‐Dental Integration, and APMs (*question allowed for multiple responses)

I learned about quality measures, medical‐dental integration, and APMs through…*

Education Source

DDS/ DMD degree

27

Continuing dental education

27

9

44

Specialty/ professional society/ study club

16

Other

5 32

No education

21

40 16

34 0

20

17

38 40

63 60

80

100

120

140

160

Number of Responses Quality Measures

Medical‐Dental Integration

APMs

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Figure D6. Participation in Alternative Payment Models (APMs)

Percent of Dentists (%)

APM Participation (N=100) 88%

100 80 60 40 20 0

7%

2% Shared savings

2%

1%

Pay‐for‐performance Bundled or capitated or pay‐for‐reporting payment models

Other APM

My practice does NOT participate in APMs

APM Type

Stratifications by Practice Type Figure D7. Responses to “Indicate your level of agreement with the following statement: My practice understands how oral health care fits into VBC,” Stratified by Practice Type

“My practice understands how oral health care fits into VBC," By Practice Type (N=100) 15

16

Number of Responses

14

12

12

10

10

9

8 6 4 2

2

3

3 3 1

4 2 2

1 1

5

1

10

6 4 2

3 1

0 Large group practice Multispecialty group Small group practice Solo practice (n=53) (n=12) practice (n=6) (n=28) Practice Type Strongly Disagree

Disagree

Slightly Disagree

Slightly Agree

Agree

Other (n=1)

Strongly Agree

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Figure D8. Utilization of Quality Measures, Stratified by Practice Type

Utilization of Quality Measures, By Practice Type (N=100)

40

36

Number of Responses

35 30

Yes, for any reason

25 20

17 14

15

No, my practice doesn't utilize quality measures

14

10

10 5

4

2

2

0

1

0 Large group Multispecialty Small group practice (n=12) group practice practice (n=28) (n=6) Practice Type

Solo practice (n=53)

Other (n=1)

Figure D9. Different Uses of Quality Measures Among Dentists, Stratified by Practice Type (*question allowed for multiple responses)

Utilization of Quality Measures, By Practice Type (n=45)* 10 Number of Responses

9

9

Track and monitor quality improvement efforts

8

8 7

Identify variations in care

6

6

6

5

5 4 2

Establish and track progress toward performance benchmarks

3

3

2 1 1

1

1

1

1

1

Provider comparison purposes

0 Large group Multispecialty Small group practice (n=12) group practice practice (n=28) (n=6) Practice Type

Solo practice (n=53)

Other (n=1)

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Figure D10. Interest in Using Quality Measures Among Dentists Not Currently Using Measures, Stratified

by Practice Type Note: 0 = Not at all interested, 5 = Neither interested nor disinterested, 10 = Very interested and planning to participate in the future

Interest in Using Quality Measures, By Practice Type (n=55) 17

18

Number of Responses

16

Large group practice (n=2)

14 12

Multispecialty group practice (n=2) Small group practice (n=14)

10 8 5

6

5

4

2

1

2

1

11

3

4

11

2

4 2

1 11

3

1

Solo practice (n=36)

2

11

1

0

Other (n=1) 0

1

2

5

6

7

8

9

10

Level of Interest

Number of Responses

Figure D11. Responses to “Indicate your level of agreement with the following statement: My practice is incentivized to participate in VBC,” Stratified by Practice Type

20 18 16 14 12 10 8 6 4 2 0

“My practice is incentivized to participate in VBC,” By Practice Type (N=100) 18

9

10

7 7 3

5

4 2

1

2

2

9

10 6

1 1

1

Large group practice Multispecialty group Small group practice Solo practice (n=53) (n=12) practice (n=6) (n=28) Strongly Disagree

Disagree

Practice Type Slightly Disagree Slightly Agree

Agree

Other (n=1)

Strongly Agree

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Figure D12. Utilization of Diagnostic Codes, Stratified by Practice Type (*question allowed for multiple responses)

Utilization of Diagnostic Codes, By Practice Type (n=79)* 30

Record clinical data in non‐ electronic record systems

28

Record clinical data in EHR

Number of Responses

25 20 20 15

13 8

2

7

6

5 2

1

2

4

4

3 1

2

1

3

22

Dental insurance claims

11

10 10 5

Facilitate communication/ collaboration with external providers

6

2

11

1

Medical insurance claims 1

11 Quality measure reporting

0 Large group Multispecialty Small group practice (n=8) group practice practice (n=25) (n=5)

Solo practice (n=40)

Other (n=1) Quality improvement initiatives

Practice Type

Stratifications by Years Practicing Dentistry Figure D13. Responses to “Indicate your level of agreement with the following statement: My practice understands how oral health care fits into VBC,” Stratified by Years Practicing Dentistry

“My practice understands how oral health care fits into VBC,” By Years Practicing Dentistry (N=100) 12

11 10

Number of Responses

10 8 8

7

7

6 6

5 4

4

5

5

5

4

4

4 2 2 2

1 1

2

1

1

2 1

1

1

0 0‐5 years (n=3)

6‐10 years (n=9)

11‐20 years (n=17)

21‐30 years (n=32)

31+ years (n=39)

Years Practicing Strongly Disagree

Disagree

Slightly Disagree

Slightly Agree

Agree

Strongly Agree

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Figure D14. Responses to “Indicate your level of agreement with the following statement: VBC has the potential to improve oral health care for my patients,” Stratified by Years Practicing Dentistry

“VBC has the potential to improve oral health care for my patients,” By Years Practicing Dentistry (N=100) 14 12 Number of Responses

12

11

10 8 8

8

6

5

5 4

4

3 1

1 1

4 3

3 3

2 2

8

7

2 1 1

1 1

2 1

1 1

0 0‐5 years (n=3)

6‐10 years (n=9)

11‐20 years (n=17)

21‐30 years (n=32)

31+ years (n=39)

Years Practicing Strongly Disagree

Disagree

Slightly Disagree

Slightly Agree

Agree

Strongly Agree

Stratifications by Geographic Region Figure D15. Utilization of Quality Measures, Stratified by Geographic Region

Utilization of Quality Measures, By Geographic Region (N=100) Number of Responses

20

17 15

15 10

16 14

12 10

9 7

5 0 Midwest (n=24)

Northeast (n=21)

South (n=31)

West (n=24)

Geographic Region Yes, for any reason

No, my practice doesn't utilize quality measures

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Figure D16. Responses to “Indicate your level of agreement with the following statement: My practice understands how oral health fits into value‐based care,” Stratified by Geographic Region

"My practice understands how oral health fits into value‐based care," By Geographic Region (N=100) Number of Responses

10

9

8

7

7 6

6

5

9

6

5

5

5

5

5

4

4

4

4

3

3

3

2 2

1

1

1

0 Midwest (n=24)

Northeast (n=21)

South (n=31)

West (n=24)

Geographic Region Strongly Disagree

Disagree

Slightly Disagree

Slightly Agree

Agree

Strongly Agree

Figure D17. Responses to “Indicate your level of agreement with the following statement: My practice is incentivized to participate in value‐based care,” Stratified by Geographic Region

"My practice is incentivized to participate in value‐based care," By Geographic Region (N=100) Number of Responses

10

9

8

7

7 6

6

5

9

6

5

5

5

5

5

4

4

4

4

3

3

3

2 2

1

1

1

0 Midwest (n=24)

Northeast (n=21)

South (n=31)

West (n=24)

Geographic Region Strongly Disagree

Disagree

Slightly Disagree

Slightly Agree

Agree

Strongly Agree

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