Early Insights on Dental Care Services in Accountable Care Organizations Authors: Taressa Fraze, Ph.D.; Carrie Colla, Ph.D.; Benjamin Harris, B.A.; Marko Vujicic, Ph.D. The Health Policy Institute (HPI) is a thought leader and trusted source for policy knowledge on critical issues affecting the U.S. dental care system. HPI strives to generate, synthesize, and disseminate innovative research for policy makers, oral health advocates, and dental care providers. Key Messages Most accountable care organization (ACO) contracts do not include dental services. However, over time, the share of commercial ACO contracts that include dental services has increased. ACOs that do include dental services are more likely to include a federally qualified health center or community health center and are much more likely to have contracts with Medicaid. Looking forward, more research is needed to understand how ACOs approach the decision to include dental services. Who We Are HPI s interdisciplinary team of health economists, statisticians, and analysts has extensive expertise in health systems policy research. HPI staff routinely collaborates with researchers in academia and policy think tanks. Contact Us Contact the Health Policy Institute for more information on products and services at hpi@ada.org or call 312.440.2928. Introduction Access to dental care is changing. Dental care use among children is the highest it has ever been, especially among low-income children. 1 Financial barriers to dental care for children also continue to fall. 2 For adults, however, the trends are generally moving in the opposite direction. Dental care use continues to decline, 1 and financial barriers to dental care remain significant. 2 One exception is that utilization of dental care by adults ages 19-25 increased by 3.3% in 2012 as a result of the Affordable Care Act. 3 At the same time, the dental care delivery model is changing. Larger dental practices are emerging, and health reform is bringing new opportunities to the dental profession. 4 Accountable care organizations (ACOs) are one of those new opportunities. 5 An ACO is a group of health care providers who are collectively and contractually responsible for a defined patient population s total cost and quality of care. 6,7,8,9,10 The ACO model has grown 2015 American Dental Association All Rights Reserved. April 2015
substantially over the past few years. Currently, there are over 600 ACOs with more than 18 million patients covered nationwide. 11 To date, there has been little comprehensive evaluation of ACOs, but initial findings show that ACOs do have potential to control costs while maintaining or improving quality. Evidence from the Medicare Physician Group Practice Demonstration, a precursor ACO-like program, showed variation in practice groups capacities to achieve savings and improve performance. 12 The Alternative Quality Contract of Massachusetts, a Blue Cross Blue Shield initiative in Massachusetts, demonstrated commercial ACOs can reduce costs and improve quality. 13,14 Further evaluation is needed to understand the variation in ACO performance. ACOs provide a platform to bring together disparate providers to create and improve their care delivery. We know that ACOs are integrating a diverse range of providers, such as federally qualified health centers 9 and behavioral health providers, 15 and that these partners are valued within the ACO. To date, few studies have examined if dental services are also being integrated into ACOs. An analysis of early ACOs found that very few included provision of dental services. 5 Medicare has the largest ACO programs, but these ACOs are not required to include dental services within ACOs. Given their more diverse patient populations, ACOs that have commercial and Medicaid contracts may be more likely to include dental services. Medicaid contracts may alter the landscape of dental care since some states require ACOs to include a diverse portfolio of services, providers, and patient populations. In Oregon, for example, all Medicaid coordinated care organizations began integrating dental care services in 2014. 16 In this research brief, we present findings from a large national survey of ACOs and analyze the integration of dental care. We highlight the extent of dental care integration within ACOs, as well as the organizational and contractual characteristics, the scope of services provided, and the geographic distribution of ACOs responsible for dental services. Data & Methods National Survey of ACOs We use data from the National Survey of ACOs (NSACO), administered by The Dartmouth Institute. This is the first national survey to comprehensively study the formation, characteristics, and implementation of ACOs. The survey asks questions on a variety of domains including organizational characteristics, contract features, health information technology, and quality improvement capabilities. The NSACO was designed based on the Dartmouth- Berkeley ACO evaluation framework, interviews with ACOs, and existing questionnaires (including the National Survey of Physician Organizations, the American Medical Group Association s ACO Readiness Assessment, and the American Hospital Association s Care Coordination Survey). The NSACO is administered online and targets executive-level decision-makers within ACOs who have a broad understanding of the ACO. The first wave of the NSACO was fielded in late 2012 through early 2013, and the second wave followed in late 2013 through early 2014. We analyze data from these two waves. Survey Population We identify likely new ACOs formed prior to the start of each wave using publicly available Medicare and Medicaid contract information, learning collaborative participants, national surveys, published case studies, and press releases on ACO contracts. A set of screening questions precede the survey to determine if the organization meets our definition of an ACO: a group of providers collectively held responsible for the 2
total cost and quality of care for a defined patient population. 6,7,8,9,10 Almost 500 organizations were identified as possible ACOs and were sent the NSACO across waves one and two. We received complete responses from 270 organizations that satisfied our requirements to be considered an ACO. Using American Association for Public Opinion Research (AAPOR) methodology, the overall response rate was 66%. 17 Measures and Analyses The survey includes items regarding the specific services, including dental care, an ACO is contractually responsible to provide to their patient population. In the first survey wave, ACOs were asked about whether they were responsible for the cost and quality of dental services for their commercial contracts only. This question was not asked of ACOs for their Medicaid nor their Medicare contracts. In the second survey wave, ACOs were asked whether they were responsible for dental services for both their Medicaid and commercial contracts. This question was not asked of ACOs for their Medicare contracts. Table 1 summarizes our survey pattern for dental services. Across the two waves, 126 ACOs responded to the item regarding inclusion of dental services. Twenty ACOs reported that they were responsible for dental services, and 106 ACOs responded that they were not responsible for dental services. Our analyses include these 126 ACOs. We examined ACO organizational characteristics (structure, leadership, staffing) stratified by whether or not an ACO was responsible for dental services. Significance was determined using two-tailed t-tests and chi-square analysis comparing ACOs that were responsible for the cost and quality of dental services and those that were not. Limitations There are limitations to our analyses. First, ACOs were asked about inclusion of dental services for their Medicaid contracts only in the second wave of the survey. Inclusion of dental services within an ACO s Medicaid contract in the first survey wave is unknown. Second, our survey population only includes ACOs with publicly available contract information. Some commercial ACO contracts may not be publicly identified. Finally, we only assess dental services if the ACO is contractually responsible for these services. ACOs that are not contractually responsible for dental services may still offer these services to their ACO patients. Results The proportion of commercial ACO contracts that are responsible for the cost and quality of dental services increased from 8.2% in the first wave of the survey (ACOs formed prior to September, 2012) to 26.4% in the second wave of the survey (ACOs formed between September, 2012 and July, 2013). Figure 1 summarizes the inclusion of dental services by contract type. Nearly one out of two (47.4%) ACOs with a Medicaid contract in the second wave of the survey are responsible for the cost and quality of dental services. In contrast, roughly one out of ten commercial (12.6%) and nearly three out of ten multipayer (28.2%) ACOs across both waves of the survey are responsible for dental services. Table 2 summarizes the organizational characteristics of ACOs by whether or not ACOs are responsible for dental services. Overall, the characteristics of ACOs responsible for dental services are similar to those that are not. There are no significant differences between the groups based on leadership models, mean number of primary care, mean number of specialty providers, 3
and provision of behavioral health, pediatric, and home health care services. However, ACOs responsible for dental services are more likely to include a federally qualified health center (FQHC) or a community health center. Table 3 summarizes ACO contract and payment characteristics for ACOs by whether or not ACOs are responsible for dental services. ACOs that are responsible for dental services are more likely to serve Medicaid populations or a mixed patient base in terms of public and private insurance compared to ACOs that serve commercially insured patients. For example, 70.0% of ACOs that are responsible for dental services had a Medicaid contract while only 30.2% of ACOs that are not responsible for dental services had a Medicaid contract. Moreover, 55.0% of ACOs that are responsible for dental services had both a Medicaid and commercial contract compared to 26.4% of ACOs that are not responsible for dental services. Conversely, ACOs responsible for dental services are significantly less likely to have a contract with a commercial payer compared to ACOs not responsible for dental services. ACOs that are responsible for dental services are also significantly more likely to receive upfront capital investments, but no differences are observed for care management payments and advanced shared savings payments. ACOs responsible for dental services and those that are not report similar patient panel sizes. Figure 2 shows the geographic distribution of ACOs by whether or not ACOs are responsible for dental services. ACOs responsible for dental services are most prevalent in the South (45.0%) and least prevalent in the Midwest (10.0%). ACOs not responsible for dental services are most prevalent in the Northeast (31.7%) and least prevalent in the South (16.8%). Table 1: Dental Services Questions within Survey Wave ACO Contract NSACO Wave 1 NSACO Wave 2 Commercial Yes Yes Medicaid No Yes Medicare No No 4
Table 2: Accountable Care Organizations Characteristics by Dental Services in Contracts ACO Participants ACOs including dental services (n=20) ACOs not including dental services (n=106) Contains a hospital 80.0% 74.0% Contains a medical group 80.0% 91.1% Contains a nursing facility 35.0% 22.2% Contains a specialty group 70.0% 62.6% Contains a federally qualified health center (FQHC) or community health center* Leadership Structure 52.6% 25.3% Physician-led 45.0% 44.3% Other arrangement 55.0% 55.6% Full-time Equivalent Providers (mean) Primary care providers 175.3 168.9 Specialists 210.2 259.6 Mean Number of Services Provided** 4.3 5.0 Specialty Services Provided Behavioral health 63.2% 45.7% Pediatric care 73.7% 75.7% Home health 30.0% 40.8% Note: ACOs were asked about dental services in the total cost of care in commercial contracts in both survey waves and in Medicaid contracts in the second wave. Payer categories are not mutually exclusive. An ACO may be held responsible for dental services by a commercial contract, a Medicaid contract, or both. Results presented are pooled across eligible ACOs (those with a commercial contract in either survey wave and those with a Medicaid contract in wave 2). *p<0.05. **Service options include: emergency care, routine specialty care, specialized care, skilled nursing facility care, palliative or hospice care, pediatric care, behavioral health, home health care, outpatient pharmacy, or inpatient rehabilitation care. 5
Table 3: Accountable Care Organizations Contracts and Payment Experience by Dental Services in Total Cost of Care ACO Contract ACOs including dental services (n=20) ACOs not including dental services (n=106) Have a commercial contract* 85.0% 96.2% Have a Medicaid contract**^ 70.0% 30.2% Have commercial and Medicaid contracts* 55.0% 26.4% Attributed Patients <5,000 patients 5.0% 3.8% 5,000 10,000 patients 5.0% 10.4% 10,001 20,000 patients 25.0% 15.1% 20,001 50,000 patients 30.0% 35.8% More than 50,000 patients 35.0% 34.9% Receiving Upfront Investment Care management payment 73.7% 60.8% Capital investments* 38.9% 12.9% Advanced shared savings payments 13.3% 5.9% Note: ACOs were asked about their responsibility for dental services in commercial contracts in both survey waves and in Medicaid contracts in the second wave. Payer categories are not mutually exclusive. An ACO may be held responsible for dental services by a commercial contract, a Medicaid contract, or both. Results presented are pooled across eligible ACOs (those with a commercial contract in either survey wave and those with a Medicaid contract in wave 2). *p<0.05. **p<0.001. ^For ACOs formed between September 2012 and July 2013. Figure 1: Inclusion of Dental Services in Accountable Care Organization Contracts by Contract Type 50% 40% 47.4% 30% 20% 28.2% 10% 12.6% 0% Commercial Medicaid^ Both Commercial and Medicaid Note: ACOs were asked about their responsibility for dental services in commercial contracts in both survey waves and in Medicaid contracts in the second wave. Payer categories are not mutually exclusive. An ACO may be held responsible for dental services by a commercial contract, a Medicaid contract, or both. Results presented are pooled across eligible ACOs (those with a commercial contract in either survey wave and those with a Medicaid contract in wave 2). ^For ACOs formed between September 2012 and July 2013. 6
Figure 2: Inclusion of Dental Services in Accountable Care Organization Contracts by Geographic Region* 100% 80% 20.0% 10.0% 26.7% 60% 24.8% 40% 45.0% 16.8% 20% 25.0% 31.7% 0% ACOs including dental care (n=20) ACOs not including dental care (n=105) Northeast South Midwest West Note: Note: ACOs were asked about dental services in the total cost of care in commercial contracts in both survey waves and in Medicaid contracts in the second wave. Payer categories are not mutually exclusive. An ACO may be held responsible for dental services by a commercial contract, a Medicaid contract, or both. Results presented are pooled across eligible ACOs (those with a commercial contract in either survey wave and those with a Medicaid contract in wave 2). *p<0.05. Discussion The majority of ACOs are not responsible for the cost and quality of dental services. However, the proportion of commercial ACO contracts that include responsibility for dental services has increased across our two survey waves. We do not have comparable data over time for Medicaid-focused ACOs. For most organizational, contractual, and service characteristics, ACOs that are responsible for dental services do not differ significantly from their counterparts. However, an important distinction is that ACOs responsible for dental services are more likely to have Medicaid or mixed-payer contracts and are more likely to include a federally qualified health center or community health center. We caution that these are early insights and continued research is needed to fully understand why some ACOs are including dental services while other ACOs are not. With the roll-out of key provisions of the Affordable Care Act, specifically the creation of health insurance marketplaces and the expansion of Medicaid, it will be important to monitor these trends. Our findings suggest that ACOs with a Medicaid population base are early adopters of dental service integration. As more of the U.S. population is covered by Medicaid, this could signal an early opportunity to improve the coordination of medical and dental care. For the commerciallyinsured population, there appears to be more limited inclusion of dental services. 7
Moving forward, it will be critical to monitor how the inclusion of dental services in ACOs affects and addresses long-documented barriers to dental care. 18 As ACOs develop and advance, we intend to investigate in more detail their motivations for including dental services and how exactly those services are paid for and delivered. About the Authors Dr. Fraze is a research project director at The Dartmouth Institute for Health Policy and Clinical Practice. Dr. Colla is an assistant professor at The Dartmouth Institute for Health Policy and Clinical Practice. Mr. Harris is a health policy fellow at The Dartmouth Institute for Health Policy and Clinical Practice. Dr. Vujicic is the chief economist and vicepresident of the American Dental Association s Health Policy Institute. The Dartmouth Institute was commissioned by the Health Policy Institute to carry out a comprehensive analysis of dental care delivery and financing within ACOs. This Research Brief was published by the American Dental Association s Health Policy Institute. 211 E. Chicago Avenue Chicago, Illinois 60611 312.440.2928 hpi@ada.org For more information on products and services, please visit our website, www.ada.org/hpi. 8
References 1 Nasseh K, Vujicic M. Dental care utilization rate highest ever among children, continues to decline among working-age adults. Health Policy Resources Center Research Brief American Dental Association. 2014. 2 Wall T, Nasseh K, Vujicic M. Most important barriers to dental care are financial, not supply related. Health Policy Resources Center Research Brief American Dental Association. 2014. 3 Vujicic M, Yarbrough C, Nasseh K. The Effect of the Affordable Care Act s Expanded Coverage Policy on Access to Dental Care. Medical care. 2014;52(8):715-9. 4 Guay AH, Wall TP, Petersen BC, Lazar VF. Evolving trends in size and structure of group dental practices in the United States. Journal of dental education. 2012;76(8):1036-44. 5 Vujicic M, Nasseh K. Accountable Care Organizations Present Key Opportunities for the Dental Profession. Health Policy Resources Center Research Brief American Dental Association. 2013. 6 Fisher ES, McClellan MB, Bertko J, Lieberman SM, Lee JJ, Lewis JL, et al. Fostering accountable health care: moving forward in Medicare. Health Affairs. 2009;28(2):w219-w31. 7 Colla CH, Lewis VA, Shortell SM, Fisher ES. First National Survey Of ACOs Finds That Physicians Are Playing Strong Leadership And Ownership Roles. Health Affairs. 2014;33(6):964-71. 8 Lewis VA, Colla CH, Carluzzo KL, Kler SE, Fisher ES. Accountable care organizations in the United States: market and demographic factors associated with formation. Health services research. 2013;48(6pt1):1840-58. 9 Lewis VA, Colla CH, Schoenherr KE, Shortell SM, Fisher ES. Innovation in the Safety Net: Integrating Community Health Centers Through Accountable Care. Journal of general internal medicine. 2014;29(11):1484-90. 10 McClellan M, McKethan AN, Lewis JL, Roski J, Fisher ES. A national strategy to put accountable care into practice. Health Affairs. 2010;29(5):982-90. 11 Muhlestein D. Accountable care growth in 2014 - a look ahead. Health Affairs. 2014. [cited 2014]. Available from: http://healthaffairs.org/blog/2014/01/29/accountable-care-growth-in-2014-a-look-ahead/. 12 Colla CH, Wennberg DE, Meara E, Skinner JS, Gottlieb D, Lewis VA, et al. Spending differences associated with the Medicare physician group practice demonstration. JAMA. 2012;308(10):1015-23. 13 Song Z, Safran DG, Landon BE, He Y, Ellis RP, Mechanic RE, et al. Health care spending and quality in year 1 of the alternative quality contract. New England Journal of Medicine. 2011;365(10):909-18. 14 Song Z, Safran DG, Landon BE, Landrum MB, He Y, Mechanic RE, et al. The Alternative Quality Contract, based on a global budget, lowered medical spending and improved quality. Health Affairs. 2012;31(8):1885-94. 15 Lewis VA, Colla CH, Tierney K, Van Citters AD, Fisher ES, Meara E. Few ACOs Pursue Innovative Models That Integrate Care For Mental Illness And Substance Abuse With Primary Care. Health Affairs. 2014;33(10):1808-16. 16 Bill 3650: Health System Transformation, Oregon House of Representatives, 76 Sess. (2011). 17 The American Association for Public Opinion Research. Standard Definitions: Final Dispositions of Case Codes and Outcome Rates for Surveys. Lenexa, Kansas: 2008. 18 Yarbrough C, Vujicic M, Nasseh K. Health Insurance Marketplaces Offer a Variety of Dental Benefit Options, but Information Availability is an Issue. Health Policy Resources Center Research Brief American Dental Association. 2014. Suggested Citation Fraze T, Colla C, Harris B, Vujicic M. Early insights on dental care services in accountable care organizations. Health Policy Institute Research Brief. American Dental Association. April 2015. Available from: http://www.ada.org/~/media/ada/science%20and%20research/hpi/files/hpibrief_0415_1.ashx. 9