Tough Questions for the Future of Dental Care

In this month’s letter, Dr. Rick Valachovic considers how the movements toward health care integration and paying for value might affect dentistry.

Those who attended the 2017 ADEA Annual Session & Exhibition in March likely heard the buzz generated by a Chair of the Board Symposium on health care transformation. The speaker, Nirav Shah, M.D., M.P.H., Senior Vice President and Chief Operating Officer for Clinical Operations at Kaiser Permanente in Southern California, posed several provocative and urgent questions:

• How can we minimize the variation in the delivery of dental care?
• How can we provide patient-centered rather than dentist-centered care?
• How will we prepare to shift from a procedure-based to an outcome-based profession?
• What areas of dental care are ripe for bundled and other forms of value-based payment?
• How will we help thousands of solo practitioners adapt to greater delivery system integration?
• How might dental hygienists and dental therapists help solve the need for unmet care?

The primary goal, said Dr. Shah, is to evolve an ecosystem of health care providers working for the greater good; in his view, the key to reaching that goal is standardization. He used the automotive industry to illustrate his point. From Henry Ford’s introduction of the assembly line to Toyota’s development of lean manufacturing, automobile makers have transformed their industry and produced products that are affordable, reliable and widely accessible—three fundamental goals of health care delivery that today remain elusive.

“In complicated systems, standardization is innovation,” Dr. Shah says. He and his colleagues have applied this principle at Kaiser Permanente with some truly remarkable results.

Take, for example, the way Kaiser Permanente handles hip-replacement surgery. For more than half of its patients, hip replacement has become an outpatient procedure. How? To begin with, the patient goes into the surgery fully informed about and prepared for the recovery process. A nurse has already visited the patient’s home to make sure there is a bed on the ground floor and that handrails are installed in the bathroom. Walkers and canes have been delivered, and a pharmacist has visited to explain how the patient’s medication will change. Family members who will be providing care in the home are educated about their roles as well.

On the provider side, evidence-based care rules the day. Anesthesiologists are taught to use an anterior block, which allows the patient to walk off the operating table without pain, and every patient receives that block. Orthopedic surgeons are told which devices to use, and everyone on the team is thoroughly acquainted with the ins and outs of how these work. Patients are sent home the same day, minimizing the risk of hospital-acquired infections, and a physical therapist comes to the home the next morning. The result? According to Dr. Shah, Kaiser Permanente achieves “better care, higher quality, lower costs and better safety.”

The advent of bundled payments that reimburse providers for all of the services associated with an episode of care has been key to incentivizing these types of innovations. The Centers for Medicare & Medicaid Services reimburses Kaiser Permanente and other providers a fixed amount per joint replacement, unless, of course, something goes wrong.

Under the current fee-for-service reimbursement model, hospitals take in more revenue when patients develop infections during their stays or are readmitted to the hospital following discharge. Under the bundled-payment model, providers are docked a percentage of their reimbursement when these adverse events occur, so investing up front in better patient care is financially wise as well as good practice.

The success of the hip-replacement bundle and other value-based payment experiments suggests that we’ll be seeing a continued shift away from fee-for-service medicine toward greater care integration. How this shift will impact dentistry is less clear, but no one doubts that we will also be swept up in the coming change. During his talk, Dr. Shah asked where bundled payments might work well for dental care, and ADEA members had lots of ideas—dental hygiene care for diabetes patients, dental implants for full mouth rehabilitation, and orthodontic care, among other services.

Dr. Shah described similarly impressive protocols Kaiser Permanente has put in place for averting diabetes-related blindness and for easing kidney-failure patients into a home dialysis regimen that allows them far greater control over their symptoms. He told us that in each case, treatments have become less expensive, safer and more patient-centered, and the quality of patient health has improved in tandem.

These achievements rest on several strategies:

• Moving care out of the hospital or clinic and into the home.
• Reducing the amount of care in the hands of specialists and empowering the whole team.
• Requiring that providers follow evidence-based protocols.
• Practicing transparency to improve quality.

How might we in dentistry adopt, and perhaps adapt, some of these practices to serve our own goals of increasing access, lowering costs, and improving care quality and the patient experience?

In Dr. Shah’s view, we need to begin by reducing our traditional isolation. He is firmly convinced that quality care emanates from teams, not from individuals. When it comes to one- and two-person primary care practices, Dr. Shah insists that the data show these practices provide substandard care. What does that mean for the legions of dentists in private practice? Dr. Shah challenged us to create an “off-ramp” to lead existing solo dental care providers into large integrated systems of medical and dental care that can “deliver reliably on quality.” Kaiser Permanente has already blazed a path, integrating dental- and medical-care delivery in its Oregon facilities. Dr. Shah called the arrangement a “spectacular success,” and said the company plans to replicate the model in other regions where it provides care.

Dr. Shah also had some concrete proposals for adapting our educational model to better prepare students for the integrated, person-centered care environments of the future. Among his suggestions:

• Spend less time teaching students about surgery and more time teaching them about prevention.
• Educate them to work in teams.
• Foster their creativity, perhaps by having them work on some of the “wicked” problems that continue to burden health care.
• Help them develop leadership and performance-improvement skills.
• Acquaint them with systems engineering and encourage them to co-design care models and workflows in collaboration with their patients.

Medical education is adopting these approaches, Dr. Shah told us, but he also expressed frustration at the slow pace of change. It currently takes about three years, he said, for new hires to unlearn the habits (such as ordering too many tests) that Kaiser Permanente wants physicians to break. To address this concern, Kaiser Permanente is creating its own medical school in Pasadena, CA, to prepare physicians who are ready to deliver “Permanente medicine” upon graduation. The curriculum will emphasize leadership skills, quality improvement and systems engineering, positioning graduates to lead change wherever they go.

Kaiser Permanente’s foray into medical education represents a “deliberate decision to start over” rather than reform an educational system that has been focused on the basic sciences and research since the release of the Flexner Report on medical education in 1910. Kaiser Permanente’s departure from the educational status quo—like many of the other ideas Dr. Shah espoused—will be controversial. In dental education, for instance, we have striven to embrace innovation while still retaining and expanding our research enterprise. Likewise, not all dentists would be comfortable with the flattened hierarchy that characterizes Kaiser Permanente teams, and many of us would question the use of evidence-based protocols that obviate provider decision-making or undervalue the provider’s clinical experience in determining the best course of care.

Nevertheless, Dr. Shah’s provocative ideas demand the consideration of anyone with a stake in shaping the future of dental care delivery. If we choose to embrace integrated delivery models, expanded care teams and increased standardization, what might we gain?

Dr. Shah argues that standardizing care delivery will ultimately free health care providers from the time-consuming activities that currently prevent them from getting to know their patients, engaging with them in care planning and customizing care to better meet their individual needs. If Dr. Shah’s experience is any guide, he and others at Kaiser Permanente are onto something big, and our community would do well to consider the thought-provoking questions he posed. Coming to a consensus on the answers won’t be easy, but we must try—for the sake of our professions and our patients’ health.