Title: Dental Value-Based Models and a Proposed Revision of Metrics for New York State's Quality Assurance of Preventive Dental Care
Description: The 2000 Surgeon General report declared dental caries (tooth decay) a "silent epidemic" [1]. Dental caries is preventable, yet it is the most common chronic disease among children and adolescents in the US [2]–[6]. US dental care systems have fallen short of preventing avoidable oral diseases and their consequences, despite enormous dental expenditures. Self-care through oral hygiene, a key health behavior for caries risk reduction, is not practiced nearly as consistently or accurately as dentists and health organizations would like [7],[8]. Evidence-based and cost-effective preventive dental treatments exist but are underutilized. Value-based care (VBC) is an effort to strengthen the quality of dental care, decrease unnecessary expenditure and increase cost-effectiveness through an emphasis on prevention. This paper has three aims. Aim #1 is to understand the current dental VBC landscape through a narrative review. It synthesizes the available literature on dental value-based models and their challenges.

Aim #2 discusses the need for quality metrics to help meet VBC goals. It evaluates New York State’s (NYS) quality assurance of dental care among NYS’s Medicaid recipients 0-20 years of age through their Quality Assurance Reporting Requirement (QARR). Aim #3 proposes a revision of metrics and identifies the needed indicators for NYS’s quality assurance of preventive dental care for Medicaid recipients 0-20 years of age. Under Aim #1 Sixty-nine abstracts were reviewed. Forty-six articles met the inclusion criterion and were classified according to four prominent themes: dental metrics, interprofessional collaboration, information technology, and care/case management. Common challenges were identified in dental VBC, including but not limited to, the requirement for interdisciplinary, interoperability; too much involvement of stakeholders; variations in dental treatment modalities and coverage; and challenges in developing appropriate metrics. While initiatives in the peer-reviewed articles leveraged value metrics for the assessment of their programs, no studies among the 46 articles evaluated statewide governmental quality measures’ effectiveness for VBC.

Gray literature was therefore utilized for Aim #2. The second aim discusses the need for quality metrics to help meet VBC goals and identifies tested and scalable dental metrics. Healthcare Effectiveness Data Information Set and Dental Quality Alliance were found to be the leading dental metric developers. NYS’s Quality Assurance Reporting Requirement (QARR) indicators were identified as the lead metric set used to evaluate NYS’s Medicaid Managed Care plans and Managed Care Organizations. Several limitations were identified in NYS’s QARR dental metric. It is limited to one dental indicator, it does not measure the quality of dental services and has unintended consequences. Under AIM #3, ten recommended steps are provided for the NYS Department of Health Office of Health Insurance Program (NYS DOH OHIP) to strengthen their quality assurance of preventive dental care among Medicaid recipients 0-20 years of age. The ten steps NYS DOH OHIP can take to develop a dental metric set aimed to assess and improve the utilization of preventive dental services are as follows, 1.

Define value from the perspective of the patient 2. Select tested, specific, and measurable metrics 3. Metrics need to be attainable, relevant and anchored within a time frame 4. Metrics need to be appropriate proxies 5. Account for patient characteristics, when feasible 6. Strive for standardized data collection and harmonization 7. Build appropriate information technology infrastructure 8. Reimburse dental providers through alternative payment models 9. Strengthen Provider Accountability by Improving QARR’s Use of Dental Metrics 10. Amend QARR to strengthen quality assurance of preventive dental services A final set of recommendations proposes revisions to NYS’s assessment of preventive dental services through QARR. The recommendations provide technical details on the needed amendments and additions for a more robust metric set to improve NYS’s quality assurance of preventive dental care among NY’s youngest Medicaid recipients. The final set of recommendations which will make system-level changes in dental care delivery and shift NYS towards dental VBC are as follows,  Revise QARR’s oral health indicator to measure the percentage of all enrolled children under age 21 who received dental services within the reporting year  Replace QARR’s dental screening encounter code (D0190) with comprehensive (D0150) or periodic (D0120) oral examination codes  Create a metric for the application of sealants in the erupted, unrestored adult molar teeth of children.  Create a metric for the application of topical fluoride at least once every six months on all teeth of children and adolescents under the age of 21  Utilize existing tested and validated preventive dental metrics  Raise statewide QARR benchmark metrics annually to encourage higher utilization and success of services  Tie performance metrics’ achievement to reimbursement (P4P)  Evaluate implemented metrics for their effectiveness in reducing the need for restorative services to help achieve VBC goals among NYS Medicaid recipients 0-20 years of age  Release an open comment period to seek stakeholders’ perception.