VALUE-BASED PAYMENT APPROACHES
We commend the authors for proposing in the March issue of
JADA (Riley W, Doherty M, Love K. Framework for Oral
Health Care Value-Based Payment Approaches. JADA.
2019;150[3]:178-185) an initial framework for value-based
payment (VBP) approaches that are applicable to oral health.
VBP strategy is purported to have an inherent potential to
reduce health care costs, improve treatment efficacy and effi-
ciency, and enhance patient experiences, in comparison with
fee-for-service payment methods.1 The concept of rewarding
value (quality) over volume (quantity) makes the most sense,
but currently there are several unanswered questions such as
how we will define value, what outcomes or metrics it
encompasses, and who will validate it? In broader terms, as
the authors pointed out, the value ranges from disease
prevention to promotion of population health, but it is
critical that we define value in oral health in such a way that
it is relevant and beneficial to all key stakeholders (patients,
health care providers, payers, and policy makers) and is
applicable to a given procedure or disease condition. In
dentistry, the time to evaluate the treatment success of dental
procedures varies broadly. Therefore, careful consideration
should be given as to when will be the appropriate time for
assessing performance and reporting for a given procedure or
a procedural bundle. In the future, it is equally important to
standardize the definition of value among different payers to
ensure consistency in maintaining the highest possible
delivery of care and its assessment for a fair, equitable, and
effective reimbursement and incentive systems.
A separate, yet related, issue in the current health care
landscape is the delay in patients receiving the appropriate
care and the innumerable appointments that a patient has to
go through before receiving the treatment. A VBP approach
that also takes into account the total treatment time for a
given care bundle will incentivize and encourage clinicians to
come up with creative approaches to improve the timeliness of
care delivery. One can expect several initial barriers unique to
dentistry during the implementation of VBP but the change is
coming and the sooner stakeholders embrace it, the sooner
we could potentially enhance clinical outcomes and institute
cost-effectiveness of procedures. I agree with authors that
actively engaging clinicians in this new system is the next
important step and that extensive research is required to
demonstrate enhanced clinical outcomes and cost-
effectiveness of VBP approaches as shown in medical care.2,3
The strong integration of evidence-based dentistry and the
scope for including patient-reported outcomes measures and
patient-centered outcomes as important metrics to evaluate
clinicians’ performance are important advantages of VBP
approaches, over currently used reimbursement methods.4 It
provides another important reason to integrate patient-
reported outcomes measures in future clinical trials and to
strongly emphasize evidence-based dentistry and critical
thinking in dental education curriculum. n
JADA 150(6) n http://jada.ada.org n June 2019
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For personal use only. No other uses without permission. Copyright ©2020. Elsevier Inc. All rights reserved.
Satheesh Elangovan, BDS, DSc, DMSc
Professor, Department of Periodontics
The University of Iowa College of Dentistry and Dental Clinics
Iowa City, IA
Veerasathpurush Allareddy, BDS, MBA, MHA, MMSc, PhD
Brodie Craniofacial Endowed Chair and Professor
Department of Orthodontics
University of Illinois at Chicago
College of Dentistry
Chicago, IL
https://doi.org/10.1016/j.adaj.2019.04.007
Copyright ª 2019 American Dental Association. All rights reserved.
1. Conrad DA. The theory of value-based payment incentives and their application to
health care. Health Serv Res. 2015;50(suppl 2):2057-2089.
2. Bao Y, McGuire TG, Chan YF, et al. Value-based payment in implementing
evidence-based care: the Mental Health Integration Program in Washington state. Am J
Manag Care. 2017;23(1):48-53.
3. Dummit LA, Kahvecioglu D, Marrufo G, et al. Association between hospital
participation in a Medicare bundled payment initiative and payments and quality
outcomes for lower extremity joint replacement episodes. JAMA. 2016;316(12):1267-
1278.
4. Squitieri L, Bozic KJ, Pusic AL. The role of patient-reported outcome measures in
value-based payment reform. Value Health. 2017;20(6):834-836.
AUTHORS’ RESPONSE
We thank Drs. Elangovan and Allareddy for their observations
and find ourselves in total agreement with these comments.
They correctly raise 3 important questions. First, how is value
defined in oral health? A common definition for value is
absolutely needed. Oral health value encompasses at least 3
dimensions of quality including professional excellence,
effective prevention efforts, and population health metrics for
enrolled patients. Second, what outcome metrics will validate
value-based payment (VBP) in a way that is relevant for all
stakeholders? The best way to validate outcome metrics for
oral health value is scientific evidence and professional stan-
dards. Third, how does VBP address treatment delays and
other barriers? Oral health VBP approaches can structure
payment mechanisms to achieve the second and third di-
mensions of quality mentioned above. Currently, only the first
dimension of quality is paid for and consistently provided in a
dental clinic.
There are indeed numerous barriers in changing a fee-for-
service payment system that has been in place for over 100
years. There are 2 classes of barriers: barriers to breaking away
from the fee-for-service model and barriers to adopting VBP
models. We propose designing VBP models in a way that
better achieves the quadruple aim to begin overcoming bar-
riers to VBP.
It is essential to start this discussion and to design models
of oral health value-based care before they are designed by
those who do not practice dentistry or understand oral health
quality. Most important, value should be defined in a way
that creates a win-win equation among all stakeholders.
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