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My View: Measuring dentistry

June 04, 2018

By Ryan J. Monti, Ph.D., D.D.S.

Ryan J Monti PhD DDS
Ryan J. Monti, Ph.D., D.D.S.
I am a mid-career general dentist in suburban California. I am looking with an odd mix of disgust and enthusiasm at an inflection point not only in my career but in our profession. California is joining the growing list of states where dentists are being extorted by Delta Dental. The California Dental Association sued Delta and is proudly touting that, after three and a half years of fighting, the majority of the affected dentists will get a small (almost half will get $500) monetary settlement. There will not, however, be any meaningful change to Delta’s business model here in California.

Dr. Marko Vujicic recently wrote a very interesting commentary in JADA (“Our Dental System is Stuck,” March 2018 JADA) outlining the need for major reforms needed to keep dentistry viable in the changing world of health care. I read it several times, and I can only hope that leaders in organized dentistry have done so as well. The changes he proposes are disturbing to many dentists. They are also inevitable.

For several decades all of dentistry has been sitting to the side and patting itself on the back for not getting wrapped up in the turmoil that has dogged medical insurance. As the game of musical chairs was played for health care dollars, we were proud not to be engaged in the shoving match. Now we are surprised that we don’t have a seat at the table. Dr. Vujicic has done well to identify the general steps necessary to get back in the game, but I would argue that his descriptions are too circumspect and the order is wrong. The inexorable march toward a new model of dental care cannot be stopped. Reordering Dr. Vujicic’s headings:

Define and systematically measure oral health
We must recognize that measuring success simply as the success of a procedure is meaningless to anyone except a board examiner. To say that this year I successfully treated a patient’s carious lesion in tooth 14, and last year I successfully treated tooth 3, and the year before that I successfully treated teeth 30 and 31 does not exhibit a track record of success. My treatment might be clinically perfect and aesthetically indiscernible from nature, but if I really had a patient like this then on some level I have failed them. Imagine a surgeon saying that they successfully amputated the forefoot of a diabetic patient two years ago then successfully amputated the remainder of the foot this year. Has the patient really been treated successfully? Re-care for the same procedure, rapid progression through more invasive treatment and other adverse outcomes must be measured. Obviously, there should be adjustments for characteristics unique to patient demographics, but we must be honest about our outcomes.

Reform the care delivery model
On this point there is still hope for our profession, but I can almost guarantee it will be fought to the last breath by many individuals in a short-sighted grasp to avoid real change. For dentistry to get out of its silo, we have to embrace what our colleagues in medicine call health care systems. Here in California, Kaiser Permanente is held up as the gold standard. They are expanding rapidly, and UCLA Health, Providence and others are joining them in the efficient large-scale delivery of evidence-based care. I certainly don’t think their results are perfect for every individual patient, but their success on a population basis is undeniable. In dentistry this is going to mean that the days of the stand-alone general practitioner referring to a stand-alone specialist have to end. It is a remarkably inefficient model clinically and financially. We have to integrate care and deliver the best possible care in the least possible time. We have to co-locate generalists and specialists. Unfortunately, this is frequently derided as “corporate dentistry.” Without a doubt, there are some dental service organizations that are currently doing things the wrong way. However, some will find a way to meaningfully and measurably improve the health of their patients and will grow in size and influence. Those of us that value our ethics and our ability to pay our mortgage must find a way to be the leaders of this second group

Tie reimbursement, partly, to outcomes
We need to look at ourselves and our colleagues and make an honest accounting of why some treatment works and why some fails. During the licensure reform process in California, I pushed with Dr. Arthur Dugoni, though obviously to no success, for the development a model of continuing competency assessments through repeated recertification similar to what our colleagues in medicine are required to do. Today, medical doctors are not only subject to recertification, they are increasingly subject to outcome measurements that are used to vary reimbursement rates. My friends in medicine who have embraced this change have thrived. In dentistry, as in medicine, there are factors beyond our immediate control, but we must embrace outcome measures as a proxy for quality of care.

Address the dental coverage gap
Utilization of care is absolutely tied to dental benefit coverage. I’m sure you have the same patients I do that will express their political opinion that health care reform will mean insurance companies make their health care decisions for them then tell you in the next breath that they want to put off some treatment until next year because “insurance won’t pay for it.” But, the only way we are going to achieve inclusion in broader health coverage at this point is to demonstrate that there is already a system for measuring outcomes and efficiencies in the delivery of care. Medicine is at least a decade ahead of us on this front, and insurers have come to depend on data that we cannot provide. We cannot expect to be included in the medical model of health coverage until we have integrated into the medical model of health care.

To truly serve our profession our leaders need to engage in defining its path to the future, not in priding themselves on maintaining the status quo. Dr. Vujicic cites an article from the Harvard Business Review by the economist Dr. Michael Porter. It was written about medicine five years ago, but I cannot improve on his conclusion:

“Providers that cling to today’s broken system will become dinosaurs. Reputations that are based on perception, not actual outcomes, will fade. Maintaining current cost structures and prices in the face of greater transparency and falling reimbursement levels will be untenable. Those organizations — large and small, community and academic — that can master the value agenda will be rewarded with financial viability and the only kind of reputation that should matter in health care — excellence in outcomes and pride in the value they deliver.”

Dr. Monti is a general dentist with a private practice in Santa Clarita, California.