Dental Home Proposal
Index
Index………………………………………………………………………….............................................1
Prologue………………………………………………………………………………………………………….……2-5
Introduction………………………………………………………………………………………………………….6-9
Proposal..……………………………………………………………………………………………………………..10-15
Clinic vs Dental Offices-cost comparison.……………………………………………………………..16
Strategic Plan (4 years).…………………………………………………………………….………………….17-19
Questions and Answers…………………………………………………………………………………….….20-22
Exhibits
A.
B.
C.
D.
E.
F.
G.
H.
I.
Prevention Fix: attracting dentists
Medicaid’s Jail
Assessing Prevention in Clinical Dentistry
General dentist’s enhanced fees compared to CareSource
ADA’s Oral Prevention Assistance
Coordinate with Schools
Decay Risk Assessment (example of patient handout)
Gaining Support of Miami County Dentists (year 2 or 3)
Contacts with Dental Medicid patients
1. Contract to participate
2. Notification that maximum utilization was reached
3. recruiting brochure
J. Need for pediatric dentists and oral surgeons
K. The Mind of the Public – Resignation to Protection
L. Prevention is the Key
23
24
25-26
27
28
28
29-31
32
33-36
37
38
39
Addendum- A Dental Home
A. Comparing my Beta site to the Current RRF System
B. Comparison of my Beta site to the new Medical Home Approach
40-42
42-47
May 2013
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Dental Home Proposal
Prologue
(Date)
Presented by Dr. Charles Smith, Owner HealthPark Dentistry
Jill Nesbitt, MBA, Administrator HealthPark Dentistry
My 40 years of experience with Medicaid
Since this proposal is very different from other attempts to solve the dental disease of the
poor in Ohio, I felt it would help you to see my involvement in working with and then attempting to
solve this problem since 1970, when I began treating the poor in my Tipp City practice. It wasn’t
until the early 1980’s that caring for the dental needs of the poor became a serious problem. Up
until this time, there were many fewer people on Medicaid, Ohio’s fees and regulations were
reasonable and at least ½ of Miami County’s dentists participated. Then each subsequent year
the fees didn’t increase and the requirements increased. Dentists began to “dropout”.
As more dentists dropped out, I began to see the Medicaid patients that they had treated.
Within a couple years, the number of poor that wanted our help outstripped my ability to
adequately serve them and still treat my fee for service patients.
I invited Rep’s Buchy (Greenville) and Netzley (Miami) to visit with me. I explained the
economics of the situation from my perspective, but following our discussion on fees and
regulations, they both left feeling that if the problem was as bad as I said, then why was I still
treating the poor? Finally, I stopped working with Medicaid in 1995. I would treat anyone in pain,
but that was all. Finally, in 2002, Jill and I met with Mr. Dan Sable (Medicaid Dental Director) to
discuss my frustrations. He had no answers.
In April of 2007, I had a series of meetings with Sen. Roberts. He visited HealthPark a couple
times and in June 2007, he brought Dr. Mark Siegel, the bureau chief of the Ohio Department of
Health, to visit. As much as we discussed the problem over a series of visits here and in Columbus,
nothing changed. In 2008, Dr. Siegel arranged for me to a meet with Teresa Wakusick, the Anthem
Grant Coordinator – again with no success.
When Sen. Roberts retired, he introduced me to Sen. Strahorn so we could continue this
discussion. After a series of meetings with Sen. Strahorn, Dr. Jackson (director of the Ohio
Department of Health) and again, Dr. Mark Siegel, at HealthPark and the Capital, it became
apparent that nothing would be done.
However, by 2010, due to the severe economic problems Ohio was dealing with, and the
swelling numbers of people on dental Medicaid the problem could no longer be ignored in favor of
a “business as usual” approach.
In discussions with Representative Richard Adams, he saw the value of my approach and,
with the added support of Senator Bill Beagle, Representative Adams hosted a series of meetings in
his office that included at various times representatives from CareSource, the Medicaid
administrator (Drs. Torbeck and Ensor), The Bureau of Policy and Health Plan Services (Chief Debbie
Saxe, Section Chief – Joe Dooden), Ohio Department of Health (Section Administrator – Carrie
Farquhar). The consensus result of their meetings was that funding for my proposal would have to
come from Federal Medicaid, so I should contact Representative Boehner’s office.
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My credentials and background
My college undergraduate focus was in Sociology and English. I have used my natural
interests and undergraduate academic training to create my organizational insights and then my
writing skills to organize my ideas into a body of work that became this proposal. I have always
been a student of dentistry with a massive effort in continuing education (over 2000 hours of
documented formal Continuing Education and uncounted hours – averaging 2-3 hours minimum
daily in a wide range of topics. I am 1 of only 50 dentists in Ohio awarded a mastership in the
Academy of General Dentistry (34,000 current general dentist members) for my efforts to improve
my dental skills for my patients.
Secondly, my family has served the Tipp City community for 3 generations – almost 100
years (grandfather - superintendent of schools, Father - Smith’s Drug Store, and in my time,
HealthPark Dentistry). I love this town and its people. As a result, my CE focused on improving the
dental health of Tipp.
Finally, 2 events came together by 1996 –
1. All the research on preventive dentistry dropped into place on how to control decay and I
built one of the largest and most professionally diverse dental practices in Ohio – focused
on improving the dental health of my patients by building strong relationships with each of
them as a real person (rather than focusing on their teeth).
2. I was exposed to the American Society of Quality’s Baldrige Award process of statistical
analysis – epitomized by Dr. Edward Demmings’ favorite quote “In God we trust. Every one
else bring their numbers”. Our early (1983) use of computers fit into this statistical
management approach. In 1996, I developed my management skills through association
with the American Society of Quality’s (ASQ) annual Baldrige award application (7 sections:
leadership, strategic planning, “customer” focus, measurement/analysis/knowledge
management, workforce focus, operations focus, and results).
In 1997, I hired Jill Nesbitt, MBA, who teamed with me to bring her extensive business
training to this project. She became a Baldrige examiner. She helped me improve how HealthPark
focused on improving the dental health of everyone in our area (not just our patients). Our
Baldrige cycle of excellence became: writing the 50 page application → submit to the ASQ’s The
Partnership for Excellence (TPE) → host 3-6 examiners from the TPE at HealthPark for 2-3 days to
thoroughly evaluate HealthPark based on their 7 systems → receive their 30-50 page report on
their observations → create our annual strategic plan to improve HealthPark based on our
experiences and their observations. Jill and I repeated this process more than 10 times since 1998,
receiving Baldrige state awards and improving HealthPark with each submission.
By 1998, Jill and I had it all, the pharmacology (fluoride, xylitol), dental research base,
(sealants) and behavioral skills (home care, sugar limitation) to solve the problem of decay, plus the
organization (HealthPark’s facility, technology, and trained staff) to implement the solution. Then I
began the political process to interest our state government in implementing (funding) my
approach.
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During this time, I have had the good fortune to be involved with a series of politicians and
bureaucrats who graciously spent a significant amount of time to help me turn my insights into a
practical plan for the people of Ohio. Here is my practical, science based approach as implemented
at HealthPark. There is no other dental office in Ohio organized around this approach. My
approach is based on several insights.
The Insights
Dentists are so focused on “fixing” the mouth that they measure “improved dental health”
in terms of the number of “fixes” they do, including dental cleanings. These are easy statistics to
gather, they are easily understandable to non-dentists, and you could base a plan of action to do
more “fixes” with no change in the current approach.
The flaw is that they have very little to do with improving the dental health of Ohioans. To
clarify, let’s discuss dental cleanings. Dentists beg/threaten their patients to return every 6 months
for another cleaning. So how long does a cleaning keep a mouth healthy?
Twenty-four hours. That’s how long it takes for plaque (food, saliva, oral bacteria) to
reorganize to create the acidic waste that eats into the teeth (decay) or infect the gums (gum
disease/bone loss).
Dentists will tell you that 24 hours is correct, but they also clean the calculus or tartar
(hardened plaque) off the teeth which also improves dental health. However, if pressed, these
dentists will admit that a person practicing good home care can have a dentally healthy mouth with
calculus around the teeth – more difficult for the patient to be healthy, but possible. (Exhibit A)
There are several factors that do reduce the potential for decay (fluoride, sealants, xylitol)
but they aren’t necessary if a person practices good home care (brush, floss) and low sugar
consumption.
So, all the current dental insurance and Medicaid approaches fail by being focused on
“fixes” that don’t solve the problem – in fact, they bleed out the limited resources that could have
been used to solve the problem. This is why the current rules/regulations/and funding approach
has not only failed for over 40 years, it actually prevents any possible solution to the problem. So
what is the answer?
First Insight:
“Everyone needs to brush/floss their teeth effectively daily and limit sugar consumption.”
Everyone already knows that! That’s the point. It is so obvious. A clean tooth won’t decay.
Now think about it. This is not a procedure that dentists do. We “fix” teeth problems, and make a
good living doing it. Insurance companies and government don’t need to pay dentists to tell people
to “brush and floss”. In fact, a key part of my proposal is to use an existing code for instructing a
patient in preventive skills that is almost never used (read: is not paid for) and actually pay $20 for
this code when submitted, so we can begin to statistically track the only result that matters –
improved dental health. That leads to my second insight.
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Second Insight:
“The goal is: Improved Dental Health!”
This is it? Well everyone knows that, but for over 40 years, dental disease is still the largest
unmet health need in Ohio. This means that almost all the money currently being spent in Ohio to
improve peoples’ dental health is being wasted. My proposal is a way to implement my insights to
actually solve the problem.
Third Insight:
“Being healthy is cheap. Being sick is expensive.”
Fourth Insight:
“You get what you pay for.”
Headlines of corporate dental practices over-treating Medicaid patients (Aspen Dental),
midlevel providers (the proposed new approach of people with 2 years’ training, post high school,
pulling/filling teeth preposed in the U.S. Senate 2013), emergency rooms ineffective in treating
people with toothaches, and general dentists turning their backs on the poor while donating a day
to provide free “fixes.” These are all wasted efforts generated by the current failed Medicaid
economic approach.
With the changes I propose, you will attract more successful dentists who have developed
their patient centered set of values to help their patients make behavioral changes. (Exhibit B)
“It is better to design systems that minimize waste than to become famous for fixing symptoms.”
David W. Chambers, PhD
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Introduction
The Current Dental Medicaid Approach is Failing
In these difficult times, it is hard being poor in Ohio. Governor Kasich was elected to work
with our state legislature to make the difficult decisions that must be made to balance our budget.
Finding a cost effective approach to improving the dental care of Ohio’s poor is part of this
solution.
Problem
1. Dental care is the #1 unmet health need of children and poor adults in Ohio. Medicaid was
30% of the state budget in 2011. In fact, dental disease is growing faster than the dental
manpower to fix it.
2. In 2013, low income children were twice as likely to have cavities as middle income
children.
3. In 2010 – 15 million Medicaid children did not see a dentist.
4. The Centers for Medicare and Medicaid Services projects total national expenditure to rise
from $62 billion in 2000 to $167.96 billion in 2020.
5. Screening for dental disease has no effect on treatment.
6. Childhood cavities increased 30% from 1994 to 2004.
7. Most low income women don’t receive dental care during their pregnancy (which
increases the risk of pre-term deliveries).
8. Ohio’s Gov. Taft reduced adult coverage in 2005, and then Gov. Strickland quickly
reinstated the original fees several years later due to the problems that developed. In
2012, Illinois dropped adult Medicaid completely.
9. Low fees keep most general dentists from participating and force some participating
dentists to “game” the system to compensate for the low fees (miscoding procedures,
overtreatment).
Dentistry for the poor in the United States since the 1950’s has been a sporadic,
unsuccessful series of isolated, well-intentioned, ineffective events. Each program focuses on one
group or one procedure, lasts for a few years, and fails. Many reasons have been given for these
failures.
 Low income people are less likely to practice preventive oral health care
 Low income people generate more need than there are funds to meet the need
 Dentists don’t treat low income patients at significantly lower fees when they can be
treating patients that will pay full fees
 Dentists worry that low income people will be late or will fail to show for appointments
or will sit next to middle class patients and scare them away
 Many with low income are elderly and have long lists of illnesses and medications that
make treatment difficult.
 Unreliable transportation plus lack of involvement leads to many broken appointments.
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



General dentists aren’t comfortable treating children younger than 3, but 8% of 2 year
olds have decay. Also, most general practitioners aren’t comfortable doing extractions
or major restorative care on children under the age of 5
Medicaid has a reputation of slow payment, impersonal bureaucracy and silly
regulations (many addressed in letter to dentists, Exhibit H) that frustrate dentists
Children can be management problems, from crying to obstinate behavior
Legislators worry that treating the poor as economically efficiently as possible to reduce
the dentists overhead will lead to the poor not receiving the same quality of services as
private pay patients paying regular fees that are three times as much. This creates a
paradox. The low fees force participating dentists to avoid low fee, time intensive
procedures (preventive) and focus on fixing as many teeth as possible (restorative). This
guarantees the worst discrimination possible – withholding preventive care.
This list could have been longer. More importantly, the benefits of providing adequate care
to the poor are very short. It is simply the right thing to do to help your fellow human beings.
The key to this proposal is to complete the circle of care. This has never been accomplished
on a sustained basis in the United States and that is why dentistry is the largest unmet health need
in Ohio.
Ohio’s Current Approach
The current system Ohio uses to help the poor is based on the outdated 20th century
concept that decay is an uncontrollable disease that requires constant fillings and extractions. In
Miami County you can see this approach in action – the Miami County Dental Clinic exists to fix/pull
teeth on as many patients as possible. The clinic was built because the county’s dentists wouldn’t
see Medicaid patients. These dentists don’t treat Medicaid patients for two reasons:
1. A fee schedule averaging approximately 42% of these dentists’ average fees.
2. Requirements both in paperwork and treatment that are time consuming and reduce
the dentists’ productivity.
This leads legislators to believe that dentists won’t treat Medicaid patients. This is not true.
The average dentist in Ohio donates $13,000 in free dental services (fixes) annually. Unfortunately,
these efforts haven’t helped reduce the problem. For example, the annual Ohio Dental
Association’s Give Kids a Smile campaign is a once per year “fix” program that, by its very nature (1
time visit), can’t build relationships, but provides a “feel good” experience for dentists and good
propaganda for organized dentistry.
A system based on continual “cheap fixes” must fail. Here is the “progression of destruction”
that results from fixing rather than preventing.
1. Cutting into a tooth to remove decay weakens its structural integrity.
2. A series of “new decay then more fillings” fixes leads to the tooth’s fracture and/or abscess.
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3. The extraction of the tooth reduces the patient’s ability to chew.
4. Extract a front tooth and the person is less employable.
5. When chewing/appearance is a problem, a partial denture is made that traps food around
the teeth and promotes more gum disease and decay.
6. When too many teeth are lost, all remaining teeth are extracted and dentures are made.
7. Dentures have 20% the chewing ability of natural teeth.
If this isn’t bad enough, the clinic based approach has drained our county’s charitable
resources (churches, service organizations, personal donations, etc.) that could have been used to
support a modern preventive, relationship-based approach. The result is a system that forces the
poor to develop a dependency on our county dental clinic as the “free” resource to fix/pull their
teeth. Since these dental treatments would be very expensive, many of the poor feel it’s better to
stay on welfare than take a low wage job that would eliminate their medical/dental (and many
other) benefits, thus forcing them to pay for it themselves. Since the county money that could
have been used to prevent dental disease has been given to the clinic to subsidize “fixing”, there is
little money available to prevent dental disease, which guarantees there will be a constant supply
of new “fixes” to keep the clinic open.
The “Fixing” Approach
1. The approach of continual “fixing” is too expensive to continue funding
2. When Ohio reduced adult Medicaid funding in 2005, it forced dental emergencies into
hospital emergency rooms. This was:
a. Very expensive
b. Unable to treat problems, only control pain for a few days ( antibiotics and pain killers
only) – and then they return to the emergency room
3. A program focused on fixing
a. Creates dependency on Medicaid, since the poor continually create more disease that
they can’t afford to pay for on their own.
b. Reduces Ohio dentists’ participation (low fees, irritating rules, red tape, etc.)
4. Probably worst of all, current programs use dental “cleanings” as their cornerstone for a
“preventive” approach. Using this as a measure of success shows how out of touch current
Medicaid programs are with the 21st century innovations that, when properly applied, stop
dental disease. Running a rubber cup over someone’s teeth and scraping off some calculus
will only reduce the dental disease process for 24 hours – and then the plaque reforms
allowing acid production to resume so that the existing dental disease continues. In fact,
dentists are taught that using the rubber cup familiarizes small children with having a
handpiece in their mouth so they won’t be frightened when the dentist drills on teeth later
while fixing their diseased teeth.
5. Cleaning out decay and placing a filling does “cure that tooth’s decay.” 24 hours later the
decay begins again on the tooth. Only now, the edge of the filling traps food and makes it
more likely decay will return.
6. Finally, without seeing the annual operating budget of the Miami County clinic, common
sense will show the impossible position a clinic is in. The clinic is charged with improving
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the dental health of the poor. That is the same goal of all dentists in the general
population. The clinic is made up of the same general equipment, supplies, staff, etc. that
all dentists use and therefore, they generate a similar overhead. However, the clinic must
cover its overhead on a fee schedule that is about 42% of an average dentist’s fees when
these “average” dentists need at least 65% of their annual production to meet their
overhead. Just by stepping back and thinking about it, the only way a Medicaid practice can
keep its doors open is by churning out as many “fixes” as possible as efficiently as possible.
In other words, since true prevention requires slowing down to build relationships with
individual poor people to help them actually learn how to effectively control their dental
disease potential and then put them into an environment that rewards them for being
responsible (show for appointments, demonstrate a healthy mouth). In February 2001, Mr.
Jim Luken, our then Miami County Health Department Director, chaired a series of meetings
to promote building a county dental clinic. I was familiar with the closure (due to poor
economics) of a similar clinic in Middletown. I attended several of these meetings offering
my opinion that low fee “fixes” would put great pressure on their proposed clinic – the
same problem that led to the closure of the Middletown clinic. My observations and
questions were not appreciated by any of those present (notes on these meetings available
on request).
7. This means a Medicaid based clinic, based on quick “fixes”, is designed to maintain the
poor’s dependency on these “fixes” and the clinic’s continued existence requires them not
to solve the problem or they won’t have enough dental disease to fix to make enough
money to stay in business.
As you think about this 40 year problem, heed the words of Daniel J. Boorstin: “The greatest
obstacle to discovery is not ignorance – it is the illusion of knowledge.”
A New Approach
HealthPark’s approach is to foster good dental health by developing trusting, respectful
relationships with the patients in order to help them be comfortable learning the modern concepts
of dental health developed since 2005. Even for private pay clients with significant dental disease,
it takes a couple years of regular care to build a commitment to the daily use of this preventive
approach that will control gum disease and decay. Once a person is healthy, the minimal cost of
maintaining good dental health fits into their budget easily.
Our new relationship-based approach helps the poor who want to be healthy by focusing
our resources on building relationships to stop their dependency on continual fixes (Exhibit C) that
requires federal money, while creating an emergency safety net for those in pain with no interest in
dental health. This will allow shifting the resources that would have been wasted on constantly
fixing into developing a 3 tiered fee schedule that incentivizes dentists to build positive
relationships with their patients and then reward those dentists who build these relationships that
reduce the need for these costly fixes. In other words, by aligning payment incentives with health
care outcomes. You can pay for value not volume.
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Proposal
Dental Disease is the largest unmet health need in Ohio. Our approach will solve this problem by:
A. Develop a relationship based preventively focused, dentist supported system.
B. Improving access to dental care by raising fees to increase dentist participation
C. Focusing on prevention/healing to reduce the rate of new decay, thereby reducing
program cost.
D. Develop Create a safety net to eliminate pain quickly.
E. Achieve these goals at lower cost than presently expended
Focus on Prevention/Healing, not blank check, cheap repairs
A. Risks/Rewards of instituting prevention approach into current system
1. Advantages
a. Take advantage of new concepts to remineralize (heal) small areas of decaymuch more cost effective than repair. (Exhibit B)
b. These preventive concepts, once understood by patients and incorporated into
their lifestyle habits, breaks the decay/fix cycle of dependency on expensive
dental treatments.
2. Disadvantages of instituting prevention approach into current system
a. Helping a person make a lifestyle change requires building relationships that
takes professional’s time. In the current dentist run system, time is money.
b. Dentists and their staff (including hygienists) aren’t trained in building
relationships with their clients focused on creating these lifestyle changes.
c. Today, healthcare professionals believe prevention is technique driven
(cleanings, fluoride, varnish, brush/floss techniques, sealants, fillings, etc.).
However, the real key is recognizing that these are all secondary approaches to
control decay. Primary prevention is when the patient is motivated to brush
and floss effectively at least once a day and limit sugar consumption. When the
patient accomplishes this on a daily basis, then secondary prevention is
unnecessary – except for an annual cleaning/exam
B. Prevention Based Approach (all treatment included in initial $400 evaluation/some
treatment followed by $300, each succeeding six month interval maximum.)
1. Sequence of appointments:
a. Those in pain are treated for the pain as quickly and inexpensively as possibleextraction of abscessed teeth (not root canals) or a stainless steel crown (not
custom made crowns) for a badly broken down, non-abscessed tooth. If
possible, this pain focused care will be provided the same day whenever
possible. At least the pain will be addressed and the patient will either be
seen the next day, or placed at the top of the call list. Once tooth pain is
“fixed”, no further repair is done until the person goes through a preventive
appointment. “Our 24/7 approach will be tested in the first few months since
we do not know what to expect. However this will always be our goal.
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b. Lifestyle changing appointment where the patient is motivated to accept
responsibility for improving their dental health and time is spent improving
their skills in the use of brush and floss. Finally, a complete set of x-rays and
pictures will be taken. This appointment will take significant time. This can be
done economically by using relatively inexpensive well-trained staff to provide
a 3/4 – 1 hour appointment (not a hygienist).
(Exhibit C)
c. One week later the patient returns and receives a cleaning and dentist exam.
At this time, the interest/ability of the patient to care for their teeth will be
assessed. If there is little or no food/plaque on the teeth, the patient qualifies
for up to $300 of repair dentistry. The dentist will prioritize treatment
through discussion with the patient. If the patient’s mouth is not relatively
clean, then they will not receive these repairs. However, they still will receive
emergency extractions as needed as well as an offer to be referred to other
offices that treat Medicaid patients. Six months later, they can return for
another cleaning and re-evaluation of their level of dental health to see if
their mouths are now clean enough to qualify for the $300 for repair
dentistry.
2. Dentist will diagnose/treat conservatively.
a. Old 19th century thinking (decay is a progressive disease that must be cut out
to be stopped) is replaced with 21st century healing concepts.
b. Only worst tooth/teeth would be repaired /extracted using Dentist/patient
determined priorities until the 6 month dollar maximum is reached. ($300
Medicaid fees)
3. Cost Control. A dentist won’t be able to do 8-15 surfaces of “quick fix” fillings at
one visit where even the smallest filling costs as much as a cleaning. Prevention is
cost effective, while massive “fixing” breaks the budget of the state.
4. With a rational 3 tiered incentivized fee (Exhibit D) schedule and the elimination
of unnecessary practice requirements (Exhibit A), most dentists, who (due to the
economy) have excess capacity, would see Medicaid patients.
5. County dental clinics will be recognized as expensive and ineffective.
a. Requires significant annual resource expenditures for building, supplies,
equipment, dedicated staff, dentist, and more.
b. Requires focus on “income” generation in order to make enough money to
meet the budget.
c. One location in Troy is geographically inconvenient for the poor, who often
have unreliable transportation, while private offices are spread throughout
the county.
d. Clinic drains community funds (churches, United Ways, etc.) to help keep clinic
running. These funds could be used by the Miami County Health Department
to support many preventive programs throughout the county.
e. It is much more cost effective to pay only for the services as needed in existing
county wide dentists’ offices than to create a dedicated single facility, to be
available whether services are needed or not.
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C. Cost Control
Preventive dentistry has a great return on investment while restorative dentistry is a black hole for
continual funding. All current restorative programs in Ohio fail because they assume that all decay
should be restored immediately, or it progresses requiring more extensive (expensive) treatment.
Our proposal uses an entirely different approach. Our approach will be limited to a small
geographic area to be designated as an experimental Beta site. The Federal government would,
through executive order or Federal legislation, suspend the current Rules, Regulations, and Funding
(RRF) requirements that promote cheap, quick fixes and ensure that that few dentists will provide
more than token fixes. However, I believe CareSource could develop a Funding approach in
cooperation with HealthPark if the RRF was suspended during the trial period based on the
following major points.
1. No participant should receive more than $300 in state funds each 6 months after
the initial thorough exam. This is enough for emergency care (extractions for
abscessed teeth, not root canals), preventive care, and some restorative care.
This approach recognizes that an unknown number of Medicaid recipients will
not value or want more than emergency care. This approach focuses our limited
resources on supporting those who want to be dentally healthy. Some
accommodation will need to be made for the occasional patient that presents
with severe, wide spread dental disease that must be treated immediately. A
separate contingency fund would be needed to fund these patients.
2. Medicaid patients would have a good range of preventive/restorative care
available to them, but this would not include our most expensive services
(implants, crowns, metal frame partial dentures, etc.).
3. In the future, the other Dentists in the county would participate. A three tiered
set of fee schedules incentivizing the dentist would begin at a minimally
acceptable range that improves as the dentist reduces the need for expensive
“fixes.” This would improve dentist participation while greatly reducing the per
patient cost.
4. CareSource will monitor each dentist’s success annually to determine which tier
of compensation they will receive the next year.
D. Discussion of Approach
1. Developing an incentivized preventive based approach will take time and
thought. HealthPark, with an MBA administrator, numerous state and national
awards for organizational excellence and over 25 years of experience with
computerized records, will provide the data base and expertise to provide bench
marks and then validate this approach. This approach would:
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a. Provide a safety net for all emergencies to avoid useless expensive
emergency room visits.
b. Develop a 3 tiered incentivized fee schedule rewarding each dentist based on
statistical evidence of an office’s effectiveness in helping patient’s avoid the
need for “fixes”. For example: each dentist would be tracked for:
I. Number of new Medicaid patients seen annually.
II. Percent of program dollars spent on various preventive care services.
III. Percent of total Medicaid patients seen that are in recall system.
IV. Percent of dollars spent “fixing” recall group.
2. HealthPark as a Beta site is essential to “try out” this approach since it is in a
small, relatively isolated geographic area that will not directly affect the rest of
the general dentist population funded by CareSource.
3. Essential to this project is the cooperation of HealthPark’s specialists in pediatric
dentistry and oral surgery. Their support eliminates another barrier to general
practitioner’s treatment of those on Medicaid – being forced to do complicated
cases they aren’t comfortable with.
4. The Miami County Health Department, Upper Valley Medical Center emergency
rooms, and local schools in the Troy/Tipp area will help alert those on Medicaid
to our availability. (Exhibit F)
E. Funding
1. CareSource will replace the fee schedule that Amerigroup (CareSource’s
Medicaid predecessor in Miami County) negotiated with HealthPark that raises
fees by about 20% to cover HealthPark’s overhead while we work together to
develop this concept. (Exhibit D)
2. This added cost would be offset by:
a. Limiting the amount spent per client.
b. Reducing the range of services offered.
c. Limiting “fixes” by prioritizing services based on patient needs.
d. Incentivize participating dentists to avoid overdiagnosing “fixes”.
e. Savings from eliminating hospital emergency room visits.
F. Goals
1. Improve the dental health of Ohioans on Medicaid.
2. Reduce Medicaid patient’s dependency on free dentistry to remove this barrier
from their decision to search for a job. Now they could afford to get a job and
pay for less expensive prevention themselves.
3. Statistical success based on:
a. Year after year reduction in Decayed, Missing, and Filled teeth (DMF)
b. Increased participation in preventive cleanings
c. Reduced number of emergency visits to dental offices of recall patients
d. Increase in number of Medicaid patients involved
e. Annual cost of program
i. Total
ii. Average cost/patient
D:\106762221.doc
13
4. Once statistically proven successful, widen this program to involve all dentists
and Medicaid patients in Miami County.
5. When this model is successful statistically in Miami County and then Ohio, it can
be offered as a national model in the dialogue that will be occurring before 2017.
Comparison of Approaches
Continuous “Fixing” Approach using Miami County Clinic as an example
1. Philosophical focus- blank check cheap quick fixes for Medicaid and some low income patients
in Miami County.
2. Advantages
a.
Provides dental care for those on Medicaid or with limited ability to pay (sliding fee
scale based on need)
b.
Reduces number of dental patients seen in hospital emergency room
3. Disadvantages
a. High total cost with poor results in improving dental health and reducing treatment
needs (my assumption: not statistically based).
b. Lack of prevention focus means that the target group will generate new dental disease
to off set the disease treated - which perpetuates the need for the clinic.
c. Hard to keep clinic dentist(my assumption), due to very low salary- you get the quality
(ability, experience, personality) you pay for (salary usually less than $90,000 or worse, a
percentage of income generated by the dentist doing the fixes.
d. Clinic high operating cost to be off-set by fees paid by patients or Medicaid- therefore,
the more you fix, the more you’re paid and the greater the chance you’ll break even or
make a profit would result in very aggressive diagnoses (more “fixes” equal more
money).
e. Prevention (defined as cleanings, sealants, fluoride) is believed by participating dentists
to be a time expense that generates slight income and reduces potential dentist
productivity that could be more productive if doing fixes, so not a priority to these
dentists.
f. Clinic staff is hired, trained, and motivated to focus on restorative care
g. Transportation is often undependable and motivation is low, leading to many broken
appointments, which increases dentist’s overhead and frustration
h. Expect clinic turnover in dentists-for example, HealthPark’s first-year dentist (no
experience) makes $120,000, I believe the dentist at the Troy Clinic earns closer to
$90,000.
HealthPark’s Preventive Approach
1. Philosophical focus- reduce the need for restorative care while providing a safety net for
emergency care (pain) and some restorative care
2. Use existing dental offices and staff scattered around the county
3. Advantages
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14
a. Provides dental care for those on Medicaid
b. Eliminates emergency dental patients from hospital
c. Each year as the preventive approach reduces the need, the restorative cost will go
down
d. Medicaid patients will learn how, and be rewarded for improved dental health. (see
examples of client handouts (Exhibit G). When they get a job and lose Medicaid, they
will have learned how to reduce the need for expensive “fix” dentistry and developed a
habit of preventive dentistry. Now, good dental health is affordable.
e. As dentists in Miami County focus on prevention, they will reduce their “fixing” income.
However, they won’t mind reducing the amount of “fixes” since they will be paid more
per service as their success at improving the health of their patients is rewarded with a
new, higher fee scale (3 tiers).
f. CareSource will focus on statistical management to monitor success, evaluate dentists
performance and select appropriate fee schedule (3 tiers) based on results
g. CareSource will monitor patients behavior: preventive accomplishments, dentist
utilization, expenses, patients only seen for emergencies, etc.
h. Very flexible, easy to modify as we “fine tune” our approach at HealthPark over the first
1-2 years.
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15
Economic Comparison Miami County Clinic vs. Dental Offices
“Fix” approach- Unable so far to get exact figures from the Miami County dental clinic. Once actual
expenses are known, then the economics of the clinic can be compared closely to HealthPark’s.
Here is my unsubstantiated estimate:
Cost
Estimate
A. First year start up
1. Space renovation (plumbing, electrical, 2-3 operatories, reception area,
business office)
2. Equipment (dental $115,000, office $20,000 – includes computer)
3. Staff salaries (1 dentist $90,000, 1 chairside assistant $22,000, 1 part-time
hygienist $25,000, 1 secretary $22,000)
4. Supplies
Total
B. Following years
1. Annual rent for space
2. Staff salaries (1 dentist $90,000, 1 chairside assistant $22,000,
1 part-time hygienist $25,000, 1 secretary $22,000)
3. Miscellaneous (inflation, staff raises, etc.)
$35,000
4. Emergency fees for dentistry at UVMC emergency room
5. Donated money from community (United Way, personal donations, etc.)
to offset expenses
Total
____?____
$135,000
$161,000
$20,000
$296,000
$12,000
$135,000
____?_____
____?_____
____?_____
Preventive Approach Cost
Expenses for pilot program is the difference between regular Medicaid fees
and the enhanced fees.
This can be completed by following the formula:
1. Enhance Medicaid payments to HealthPark
2. Minus standard Medicaid payments
Total preventive approach cost
D:\106762221.doc
__________
- __________
= __________
16
Strategic Plan
First Year
1. CareSource in partnership with HealthPark and the state of Ohio
2. Accept enhanced fee schedule (copy enclosed/Exhibit A) – include oral surgeon and pediatric
dentist
3. Accept treatment approach using a small isolated clinic (HeathPark) to evaluate the concept.
4. CareSource, State of Ohio and HealthPark develop audio/visuals
a. Explanation of preventive approach for dentists
b. Explanation of preventive approach for general population
c. Staff training in preventive approach
5. CareSource, State of Ohio and Jill develop computer software to decide what to track and how
6. Begin seeing patients
7. Miami County (Chris Cook, county health commissioner) work with us to refer patients to us
a. Schools; school nurses
b. WIC
c. Others
8. Notify emergency rooms, local physicians
9. If we max out our resources
a. Emergencies that day
b. Treatment as schedules allow
10. Begin to track Miami County’s Dental clinic on same statistical basis
11. Work out problems through regular meetings with CareSource and the Miami County Health
Department being our best resources for patient feedback.
End of First Year
1. Find out Miami County Dental Clinic’s quarterly cost and effectiveness of operation
a. Annual cost to operate
b. Sources/amount of funding
2. Find out Upper Valley Medical Center’s annual services provided for emergency dental care and
the total fees charged by codes.
3. CareSource will use their software to statistically track HealthPark’s success in treating
Medicaid patients. CareSource and the County Health Clinic can interview, a statistically
significant number of HealthPark’s Medicaid patients to determine:
a. Amount of state funds paid for each person each 6 months – not to exceed $300.
b. Statistical profile:
i. Numbers of emergency patients seen
ii. % of those emergencies that returned for a preventive care appointment
iii. % of those patients accepting a preventive care appointment who return for a
cleaning and exam. They will fall into 2 groups:
1. mouth clean (practicing good home care) – receive limited dental fixes
2. mouth not clean (not practicing good home care)– no fixes, but will treat
emergencies. We would refer them (if they choose) to another office that
accepts Medicaid.
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17
iv. The % of those who qualified for fixes that return for another cleaning and exam in 6
months. Again, 2 groups:
1. mouth clean – receive up to $300 more for remaining fixes
2. mouth not clean (not practicing good home care) – emergency treatment
only, but eligible for another cleaning/evaluation in 6 months and offer to
refer to another Medicaid office if they don’t want to wait.
v. Each of our 3 hygienist lead teams are assigned a portion of our Medicaid patients.
We will track the success of each team.
vi. Using the “Risk Assessment” form (exhibit 6) we can track the patient’s initial level
of risk as well as improvement at subsequent appointments.
4. Evaluate statistical results, compare to county clinic, decide whether to:
a. Stop project
b. Needs to develop a more extensive statistical base – 2nd year HealthPark Beta site only
c. Enlarge Beta site to entire county of dentists
When expand proposal to County
Pre-expansion
1. CareSource, with HealthPark’s and the State of Ohio’s assistance would develop:
a. 3 tier payment schedule incentivizing prevention.
b. A recruiting audio/visual presentation for general dentists and specialists explaining the
program and funding system.
c. An audio/video training presentation to train staff to present preventive care concepts to
patients. The American Dental Association has a similar program. (Exhibit E)
2. Develop support from most Miami County Dentists (Exhibit H). Currently 36% of local county
dentists participate in Medicaid.
a. Due to the present economy, all dentists in Miami County have excess capacity and may be
amenable to supporting this program making the clinic unnecessary.
b. Local dentist involvement would allow more Medicaid patients to be seen in their local
communities, which will reduce no shows as transportation becomes less of an issue.
3. CareSource expands software to track results for all dentists
After Expansion
1. Focus on developing at least one dentist to participate in each community so travel distance is
no longer a problem.
2. Create recognition system for participating Dentists (newspapers, online, etc.)
3. County Dental Clinic
a. Divert all community support funds from the clinic to the County Health Department to
fund preventive dental activities in the county.
b. Allow the clinic to operate as all other dental offices in the county who choose to treat
Medicaid patients.
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18
End of Year
1. Use CareSource statistical analysis and patient questionnaires to evaluate prevention
effectiveness and reward effective offices with 2nd or 3rd tier dental fee schedules.
Following Year
1. State of Ohio evaluate – if successful, offer to replace current system in Ohio
2. Evaluate a new system to improve dental coverage for nursing homes.
3. Evaluate a new approach to incentivizing a preventive based approach to reducing the
cost/improving the effectiveness of fee for service dental insurance.
4. Evaluate a new approach to providing dental care for the working poor who don’t qualify for
Medicaid.
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19
Questions and Answers
a. Question: Who is responsible for the statistical tracking to determine if this program is
successful?
Answer - Jill Nesbitt will consult to help with statistical management if needed, requires
significant time by CareSource with oversight by the State of Ohio.
b. Question: How will other dentists be involved past HealthPark?
Answer - Eventually will require cooperation of local dentists and partnership with
Miami County Health Department to coordinate communities’ resources to screen and
refer Medicaid people in need.
c. Question: Does this create another possibility of dentists “gaming” the system by doing
less fixing to increase their coverage tier by not treating decay?
Answer - I don’t believe this would happen to any extent. The initial series of visits to
prepare the patient to receive the limited restorative care is much more time consuming
and low fee than they could make up in the limited restorative portion.
d. Question: Is this too much of a radically different approach that dentists and dental
organizations may not feel it can work?
Answer - The answer to this is to establish HealthPark as a Beta site using Jill’s training in
statistical management to organize our statistics so we can decide after 1 or perhaps 2
years, if this approach deserves the right to be extended this trial to all dentists in Miami
County.
e. Question - Are the “working poor” included in this trial?
Answer – No, but if this approach works for Medicaid, this cost saving approach could
be extended in a “Phase 2”.
f. Question – Can I justify my “quality vs. ‘cheap fixes’” comments?
Answer – This is based on my observations of the overall dental health of the poor – and
similar observations by other dentists around the country.
g. Question – How will you keep a patient motivated between 6 month cleaning
interventions?
Answer – We won’t. No funds will be expended to artificially support these patients –
any more than private pay patients pay us to support them between cleanings. The
point of this approach is to break the “decay-fix” dependency cycle. Some will succeed
quickly and be rewarded with improved dental health and another $300 of fixes. Those
who return with an unhealthy mouth will get only emergency care for the next 6 months
and then they will be given the opportunity for another cleaning/exam and, if their
mouth is healthy, they will receive the $300 in fixes (if needed).
h. Question – With poor transportation resources, how will these patients be able to reach
us with only 24 hour notice?
Answer – I had not considered this. My initial thoughts would be to divert the money
CareSource allocates for transportation to the Miami County Health Department that
could coordinate volunteers in Tipp/Troy, United Ways, churches, etc. In other words,
involve our communities in helping the poor.
i. Question – Now dentists aren’t busy and they are likely to participate, but won’t they
stop when the economy improves?
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20
j.
k.
l.
m.
n.
o.
Answer 1. The average dentist provides approximately $13,000 of uncompensated care to
those in need annually (Ohio Dental Association statistic). They would continue
this support if their administrative needs are met – money isn’t everything.
2. By raising fees above 65% of a dentist’s usual fees (a dentist’s standard
overhead) this economic disincentive is removed.
3. The “fill the chair with only 24 hour notice” provision creates an economic
incentive for dentists to participate or waste productive time.
Question – Can CareSource monitor/support this pilot program?
Answer – I don’t know, but I believe this would be economically feasible. They already
track all the statistics for “fixes.”
Question – Many Medicaid patients currently work and are not available to fill in on
short notice. Would evening and Saturday pre-booked appointments be available for
them?
Answer – No – one of the major strengths in this approach is the “24 hour” feature that
creates the incentive for dentists to participate. However, we should attempt to track
the number of patients that this truly eliminates from the program. We could also, if
confirmed, put them at the top of the evening/Saturday call list. However, I do wonder
how they qualify for Medicaid and work 40 hours every week.
Thought – When new patients are added to the call list, they should include information
on days available and how many minutes it will take them to reach us.
Question – Can an assistant legally chart and receive a fee for providing this service?
Answer – No. This is illegal in Ohio. However, she can chart her observations, then the
dentist will perform the exam using these notes/observations from the conference of
the assistant with the patient to complete the exam/consultation/treatment plan and
bill to CareSource. This is the standard legal approach.
Question – How do we stop Medicaid patients from using the hospital’s emergency
room?
Answer – When the Medicaid patients visit the emergency room they will be told they
lack the trained staff necessary to help them and then they will be given HealthPark’s
contact number and we will respond.
Question – If an emergency patient goes through the preventive care process and
“drops out” or doesn’t keep his mouth clean, then he is only provided emergency
extractions – and is denied fixes. Aren’t you “rationing” dental care?
Answer – Yes. Now with limited economic resources, every Medicaid patient won’t be
given a “blank check” level of cheap fixes. With this approach, we would focus our
limited resources on those who demonstrate the interest and ability to have a healthy
mouth – while providing emergency care only to those whose dental disease is out of
control.
Question – Your approach doesn’t include root canals, porcelain/metal custom crowns,
complete and partial dentures. Why?
Answer – These are very expensive procedures that aren’t affordable for many
Americans in the lower middle class. Some special payment arrangement will be
needed to provide for complete dentures for those whose teeth can’t be saved.
D:\106762221.doc
21
p.
q.
r.
s.
t.
Fortunately, there should be fewer and fewer in this group.
Question – What happens when a patient disagrees with the treatment provided?
Answer – CareSource offers the patient a series of options (switch providers, appeal
decisions, file a grievance if quality of care is an issue, a state hearing, even a lawsuit).
However, where quality of care is not the issue, the county Health Department could be
a good resource to gather general feedback on how the patients feel about their
experience at HealthPark.
Question – I know Medicaid patients. They will never make it through their HealthPark
letter setting the ground rules for their behavior at HealthPark. What do you think?
Answer – They would be given this letter (Exhibit I) at the emergency visit where staff
would provide a brief overview. When they return for future steps at HealthPark, they
would be coached in what comes next. Remember, this program is designed to select
and help primarily those who want to improve their dental health.
Question – If this is such a commonsense approach, and you’ve been presenting it to
legislators for over 10 years, why has it never been accepted?
Answer – Dentistry is just a small part of the healthcare budget. This approach could
require exemptions from federal funding requirements, and the State had enough
money to pay for clinics and continue cheap fixes. Due to the many pressing concerns in
the State of Ohio, it was easier to ignore this problem than to spend the energy to
change the entrenched system.
Question – Why do you think this time will be different?
Answer – Government has run out of money to continue supporting the old “business as
usual” approach to healthcare. There is simply not enough money available to continue
propping up a failed system.
Question – How do you answer the question, “Why are you forcing dentists to ‘play
God’ and decide on their own whether a person on Medicaid displays ‘good enough’
oral hygiene to qualify for the $300 of fixing money?”
This is a key question that could lead to a discussion of arbitrary discrimination.
Answer – Under the existing program, the dentist has complete responsibility and
authority to decide what dentistry to do. Under our proposal this “God Power” is
reduced in 2 ways:
1) The first decision – healthy enough or not – is the dentist’s, but a set of basic
guidelines that dentists know and use daily would be used to document the dental
health of the patient.
2) The dentist would be responsible for helping patients understand their dental
problems and in discussion work out a phased (if necessary) treatment plan over an
extended period of time.
In the interim, if a dentist denies further funding due to poor dental home care, this
doesn’t mean that the patient can’t have dentistry done, it means they will have to pay
another dentist to provide the care they want that differs from the HealthPark
approach.
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22
Exhibits
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23
D:\106762221.doc
24
D:\106762221.doc
25
D:\106762221.doc
26
General Dentist Fees Comparison: Enhanced to CareSource
Exhibit D
Code
Description
D0150
Comprehensive Exam
D0120
Periodic Exam
D0140
Palliative Eval
D0330
Pano
D0210
CMS
D0220
Single PA
D0274
BWX
PC appt./Oral Hygiene Instruction
appointment fee of $20 to track
statistically
D1330.1
D1110
Adult prophy
D1120
Child Prophy
D1203
Fluoride child/adult
D1351
Sealant
D2140
1 surf silver filling perm
D2391
1 surf post comp filling perm
D2330
1 surf ant comp filling perm
D2150
2 surf silver filling perm
D2331
2 surf ant comp filling perm
D2392
2 surf post comp filling perm
D2160
3 surf silver filling perm
D3310
RCT anterior
D3320
RCT bicuspid
D3330
RCT molar
D5120.1
Complete Upper Denture
D7140
Extraction
D5211
Upper plastic partial
D5213
Metal Frame Partial Upr
GP Fee
CareSource
%
$
71.00
$
41.00
$
64.00
$
93.00
$
113.00
$
24.00
$
53.00
$
26.35
37%
$
35.00
49%
$
17.08
42%
$
21.35
52%
$
22.58
35%
$
28.23
44%
$
46.32
50%
$
60.80
65%
$
60.00
53%
$
75.00
66%
$
5.00
21%
$
10.00
42%
$
20.00
38%
$
30.00
57%
$59
$
76.00
$
59.00
$
17.00
$
47.00
$
106.00
$
134.00
$
135.00
$
135.00
$
158.00
$
186.00
$
176.00
$
666.00
$
745.00
$
889.00
$
20.00
$
34.13
45%
$
54.00
71%
$
20.00
34%
$
35.00
59%
$
15.00
88%
$
16.00
94%
$
22.00
47%
$
27.50
59%
$
40.00
38%
$
60.00
57%
$
51.21
38%
$
72.00
54%
$
51.21
38%
$
72.00
53%
$
54.00
40%
$
80.00
59%
$
63.49
40%
$
82.00
52%
$
54.00
29%
$
82.00
44%
$
65.00
37%
$
100.00
57%
$
1,294.00
$
141.00
$
401.00
$
1,320.00
37%
N/A
N/A
N/A
$
400.00
31%
$
500.00
39%
$
52.45
37%
$
70.00
50%
$
205.00
51%
256.25
64%
N/A
Average
D:\106762221.doc
Enhanced
%
41%
Average
57%
27
E. ADA’s Oral Prevention Asst.
The American Dental Association has developed training for an Oral Prevention Assistant. Some of
her duties would be:
1. Facilitate basic legal and regulatory compliance, for example, HIPPA
2. Disease prevention education and oral hygiene instruction
3. Tobacco cessation
4. Dietary counseling
5. Fluoride applications
6. Sealant applications
7. Coronal polishing for all patients
8. Scaling for periodontal Type I (gingivitis) patients
F. Coordination with Schools
Most child screening programs have led to frustration by the examiners. A significant
percent of the children examined do not receive needed dental treatment. Our approach would
be:
Following Tipp/Troy school’s dental screening, the parents of those students with dental
disease would be sent a letter making them aware of the need for their child’s dental care and a list
of dentists in the area with a star for those willing to see Medicaid children. These children would
be tracked to build a statistical base to evaluate success.
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28
Exhibit G - Decay Risk Assessment HealthPark Dentistry
Based on the newest dental research, decay is a completely controllable disease. In fact, 89% of our recall
patients are decay-free at their cleanings. This questionnaire will help you decide how frequently you need to see
us for a cleaning. We only need to see our healthiest patients once a year (x-rays every 2 years).
Name:
Risk factor
Reduced Risk
1
How many times a day do you eat sugary
foods?
2
Physical or mental disabilities
3
Have you had Chemo or Radiation
Therapy?
4
Do you take medications that cause dry
mouth? (diabetes, sjogrens, acid reflux,
etc.)
Do you have dry mouth for other reasons?
(tobacco, bulimia, etc.)
How many times do you eat each day?
5
6
7
Are either of your parents missing any
teeth? (except wisdom teeth)
Decay Activity
8
Extraction Due to Decay
9
10
Gums Bleed
12
Dental/Orthodontic Appliances
None
Low Risk
Age:
Date:
Moderate
High Risk
-3
None
0
No
0
Primarily at
mealtimes
+1
Mild
+1
1 Month
+1
At snacks
2-3 times a day
+3
Moderate
+3
2-3 months
+3
No
0
1-2 Times/ week
+1
3-5 times a week
+2
No
0
3 Times
0
No
0
Twice a Week
+1
4 Times
0
1-5 Teeth
+1
2-4 times a week
+3
5-6 times
-3
Upper Denture
+3
No New Decay
in last 36 mos
-3
No
0
1-2 New fillings in
last 36 mos
-1
No
No
0
None
0
0
None
0
1-2 fillings in
last 24 mos.
+2
Yes
24 Months ago
+2
Yes
1-2 Times/Week
+2
Yes
+1
Yes
-3
Yes
-2
Yes
-3
All permanent
molars
-3
After meals
and bedtime
-3
Once daily
-3
Yes
-3
None over 15
-5
Daily
-3
None
0
None
No
0
No
0
No
0
No
0
Patient Risk
At snacks
4-5 times/day
+5
Severe
+6
3 months +
+4
6+ times/week
+4
5+ times/week
+5
7 or more times
-5
Upper & Lower
Denture
+5
1-2 fillings in
last 12 months
+4
Yes
12 months ago
+4
Yes 3 or more
times a week
+3
-
Risk Reducers
Total Risk
13
14
15
16
17
Do you have fluoride in your drinking
water?
Have you had an in-office fluoride gel or
varnish in the last year?
Do you use prescription strength fluoride
toothpaste?
Do you have sealants in the grooves of
your back teeth?
How many times do you brush daily?
18
How many times do you floss daily?
19
20
Do you come in on time for regular
cleaning/exam appointments?
Diagnodent Readings (by dentist)
21
Do you use an Electric Toothbrush?
22
Do you chew gum & candy containing
Xylitol Sweetener?
Number Fillings Between Teeth (ask
dentist)
23
-3
Once and
bedtime
-2
5 times per wk.
-2
6 months late
0
None over 20
-3
Occasionally
0
3 times a day
-2
None
in last 2 years
-2
-
-
-
-
-
-
-
-
Once daily
-1
1 time a week
+1
12 months late
+2
1 or more over 30
+3
No
0
5 times a day
-5
None
in last year
-1
Less than once daily
+3
seldom
+3
18 months+ late
+3
1+ over 40
+5
2 or more
in last 2 years
+3
Total Prevention
(Next two pages are the key to determining your decay potential)
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29
How to interpret your result decay potential:
Total Decay Risk 1-12 _______
+5 or more: no risk
+1 to +4: slight risk
-1 to -3: slight risk
-4 to -6: moderate risk
-7 to -9: high risk
-10 or more: very high risk
Subtract Prevention Total Steps 13-23 ________
Decay Potential _________
1. How does drinking and snacking on sugary things between meals affect my risk?
Every time you eat or drink sugar, the bacteria in your mouth create a stronger acid, that eats into
your teeth causing decay for at least ½ hour. A strong acid (5.5pH) will cause tooth decay. See
graphs below.
Sugar Attacks for Snacker
Sugar Attacks for Non-Snacker
8
Acid Level
7
6
5
6
5
Hours Between Sugar Consumption
16
14
12
10
8
6
4
2
16
14
12
10
8
6
4
4
2
0
4
7
0
Acid Level
8
Hours Between Sugar Consumption
2. Physical or mental disabilities make it more difficult for the person to keep their teeth clean.
3. Chemo/radiation therapy reduces your supply of saliva, which lowers the ph (increases the
acidity) in your mouth.
4. Over 500 medications cause dry mouth. Saliva is needed to wash your teeth. Vitamins are not
considered a medication.
5. What does saliva do? Saliva dilutes mouth acid. Saliva also contains small particles of calcium
and phosphate that help rebuild teeth that start to decay.
6. Research in 2010 proved that all foods, not just sugar, will lower the ph of your mouth which
increases your risk of decay
7. A parent missing teeth is a good indicator of a high decay potential in the child for 2 reasons: 1)
Genetics, 2) If the parents didn’t know how to avoid severe decay, then they didn’t know how to
teach their child how to be dentally healthy.
8. Genetics is a major factor in how easy it is for you to avoid decay- the strength of your
teeth/bones, your chance of getting diseases, even the amount and quality of your saliva are
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30
partially controlled by the genes passed from your parents to you. Luckily today with modern
science, if your parents lost their teeth, you won’t have to lose yours – but you will have to work
harder to avoid your parents’ fate!
9. Decay between teeth happens when you don’t floss between your teeth daily. The more fillings
between your teeth, the harder it is for even floss to clean between your teeth.
10. Appliances trap food and bacteria around your teeth which increases the acid level and potential
for decay.
11. If you grew up with fluoride in your drinking water that was incorporated into your enamel as
your teeth were forming, you have a 50% reduced chance for decay. This fluoride protection
even helps adults – not only for decay, but in reducing osteoporosis!
12. Fluoride, applied after cleanings, can reduce a decay rate 20-25%.
13. Fluoride prescription toothpastes can reduce a decay potential 40%.
14. Sealants stop decay almost 100% – see brochure
15. It takes food and bacteria 24 hours to organize into acid forming plaque. The more frequently
you brush, the less chance this acid will form.
16. How often should I be seen for cleanings?
Back in the 1920’s the most popular radio show was “Amos and Andy”, sponsored by Ipana
toothpaste. (Exhibit K) They finished their show with “brush your teeth twice a day and see your
dentist twice a year.” 90 years ago when decay was a huge problem, most people had decay and
large numbers ended up with dentures. Dentists needed to see patients every 6 months to put in
fillings or pull teeth to keep up with the decay. Today, with good dental health, we only need to
see our healthy patients once yearly (and x-rays every 2 years).
17. Instrument that uses intense light to determine depth of decay. Decay only in the enamel does not
need a filling.
Xylitol is a naturally occurring sugar that reduces plaque acid formation. It’s found in certain candy
& gum. It’s almost as effective as fluoride and tastes great!
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H. Gaining Support of Miami County Dentists
In Miami County, the dentists are well distributed. It is much more cost effective to pay the
dentists for services rendered in their own offices that are conveniently located to all dentally
underserved residents, than to build a central clinic, as the one that opened in Miami County in
2008 and Shelby County in 2009. During the first year, only the dentists at HealthPark would
participate. Our pediatric dentist, oral surgeon, and periodontist will participate at our standard
general dentist fees rather than using their specialty (higher) fee schedule. At the end of 1 year,
HealthPark statistics on its Medicaid base can be compared to the rest of the county’s dentists to
evaluate cost effectiveness.
Based on the first year’s statistical analysis, a second year with modifications may be
needed.
By either the second or third year, we should be ready to enlarge this trial to all Miami
County dentists. In 2010, 36% of Miami County’s dentists participate in dental Medicaid, but to
what extent is unknown.
The County Health Commissioner, CareSource representative, Dr. Smith, and Dave
Herbenick would attend a dental society meeting, using the new audiovisuals to explain the
concept and enlist support. The outline of the presentation would include:
1. Dentists would be compensated only for the CareSource patients in Miami County.
2. Dentists would be allowed to limit how many Medicaid patients they are willing to see.
3. Dentists will initially be paid at the lowest of the 3 tiers of the fee schedule and this will
be reevaluated the second year.
4. A CareSource representative will make a presentation at a Western Ohio Dental Society
meeting and then visit each interested dentist to discuss participation. The advantages
to the dentist:
a. Dentist decides how many patients s/he will see
b. Patients will be scheduled only 1 day in advance to fill holes in dentists’ schedule
c. If a patient fails on appointment, the patient will be warned, placed on the bottom of
the waiting list. After a second failed appointment, they are dismissed from the
practice. (Exhibit G)
d. Dentists will be helping the less fortunate and fulfilling their civic responsibility
e. Explain the 3 tiered reimbursement system. This would significantly improve dentist
participation.
f. Specialists in oral surgery and pediatric dentistry will be available so the general
practitioner won’t be forced to provide treatment s/he doesn’t feel comfortable
providing (Exhibit K)
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Exhibit I. – Letter to Medicaid patient explaining their responsibilities when signing up
Medicaid Pilot Program
On ______________, HealthPark Dentistry, in partnership with CareSource, developed a pilot
program for those on Medicaid in Tipp City/Troy to increase participation by Miami County dentists
and stop long waits for dental appointments.
We’ll help you
Our goal is to help as many people as possible to have healthy teeth and gums. HealthPark’s
unique, health-oriented approach to dentistry has won many state awards and even national
recognition. We will help you learn the newest ways to stop decay and gum disease. Once you stop
your decay and gum disease, the cost of an annual cleaning and exam (with no need for expensive
repairs) makes the cost of dentistry so low that it will fit into your budget once you no longer have
Medicaid assistance.
You’ll help us
Since CareSource’s fee schedule (about 57% of our standard fees) doesn’t even cover a dentist’s
costs, we’ll only be able to help those that want to help themselves to be dentally healthy. Open
times in dentist’s schedules add to a dentist’s cost, so here is how you can help us to help you.
1. When you call us, your name will be added to the bottom of our “call list”. When your name
gets to the top of this list, we’ll call you for your appointment on the next day. We’ll give you
3 calls for appointments. If none of these are convenient, you’ll go to the bottom of this list
to move up again. Expect to wait several weeks for your name to reach the top of the list.
At your first visit, we will show you the newest ways to control decay and gum disease. At
your second appointment, we will clean your teeth and evaluate how well you are keeping
your mouth healthy. If your mouth is not clean, then we will not schedule you to fix your
teeth. You can go to another dental office. If your mouth is clean, we will set up a third
appointment for a thorough exam and a discussion with a dentist on your dental problems.
You will decide on your treatment priorities and we will provide $300 of dental care for the
next 6 months of dental care.
2. Saturday and late afternoon/evening appointments are reserved for clients that pay our full
fees. However, we will offer you these opportunities if they become available on short
notice.
3. Be on time (or 5 minutes early) for every appointment. If you miss, or are more than 5
minutes late for your appointment, we won’t be able to treat you that day. We will place
you on our call list. It may be 2-4 weeks before you will be contacted for another
appointment.
4. Due to our limited space, please do not bring more than two others to the office for your
appointment. If more than this comes, we will not be able to treat you and this will count as
a broken appointment.
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5. If you have more decay and gum disease than what your first 6 month’s budget will cover,
you can either wait 6 more months or visit the Miami County Dental Clinic (we will give you
your x-rays and a report of uncompleted treatment). In 6 months, we will call you back for
another cleaning and exam. If your mouth is not clean and healthy we will only provide
emergency extractions. If your mouth is clean, then we will provide you another $300 of
dentistry. This cycle will be repeated until all your problems are treated. Then all you will
need is regular 6 month cleanings. You may go to any other Medicaid provider who will see
you, if you want, at any time, but to be part of our study, you should only come to our
dentists at HealthPark.
Once you become dentally healthy, find a job, and lose Medicaid, you’ll be able to stay healthy and
continue to see us for continued cleanings and exams, since the cost will now be affordable.
Sincerely,
All of us at HealthPark
937-667-2417
I agree to the terms outlined in this agreement
__________________________________
Name of Authorized Legal Representative
________
Date
__________________________________
Patient Signature
________
Date
Letter to patient who has used up the $300 and still needs more treatment
Dear __________,
Healthpark has now reached your maximum dental coverage. When you return in six months for
your cleaning and exam, you will qualify for another $300 in dental care if you have kept your
mouth healthy in the meantime. If your mouth is not healthy, you won’t qualify for this $300, but
we would still see you to keep you out of pain.
You may decide to visit another office to complete any unfinished treatment. Have this office
contact us for a copy of your remaining treatment and x-rays.
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Introductory brochure to be used to recruit patients
Agreement
Then What Happens
I understand that HealthPark’s pilot
program is designed to promote and
reward those on Medicaid who will work
every day to keep their mouths clean and
healthy.
If your mouth is not clean, you will not
receive any money to have your teeth fixed,
but we will call you in 6 months for another
cleaning and exam. If your mouth is clean at
the next cleaning, you can enter our
program .
Those who successfully follow the
HealthPark home dental care approach
will receive up to $600 yearly for
services as long as this pilot program is
funded.
If your mouth is not clean/healthy at any
visit, you will not be eligible for this
program.
________________________________ ____________
Name of authorized legal representative
Date
_________________________________ ____________
Patient Signature
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From then on you will, as long as you come
in for your cleaning and have a clean mouth,
you will continue to receive up to $600
annually.
In time, you will stop your decay and gum
disease. No more painful teeth, expensive
fixes, just 2 cleanings per year. When you
get a job, now you can continue seeing a
dentist for your cleaning and exam (about
$100). Many healthy patients only need 1
cleaning appointment annually. When you
are healthy, you will not need other, more
expensive dental care!
For Our Patients
On
MEDICAID
You can stop dental pain
Have a nice smile
Have your teeth all your life
Earn up to $600 for dental care
by signing up for our special pilot
Program sponsored by the
State of Oho
Date
35
What is this Pilot
Program?
In 2012, Rep. Richard Adams and Senator
William Beagle supported Dr. Smith’s new
approach to helping improve the dental health
of those on Medicaid and reduce the cost of
providing expensive dental treatments.
Since this approach is completely different than
the current Medicaid system, all the current
rules and regulations had to be suspended in the
Tipp City/Troy area so HealthPark could
provide this new approach.
Our state government will track the results of
this experiment for several years. If this
improves the dental health of the patients
involved at a lower cost, this program may
replace the current system.
If you have any questions, complaints, or good
ideas to make our pilot program even better,
please call us at 667-2417 or the Miami County
Health Department 573-3500.
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What Does This Mean to
You?
Most people we talk to that go to
“Medicaid Dentists” complain:
1. Long waits in the reception room
2. Treated like a “number” not a
person
3. Not told why you get treatment
4. Not given a choice of treatment
5. Never shown how to stop decay
and gum disease
Now there is a better way
A Better Way
We will treat you like a real person. You will
be introduced to a team of HealthPark’s staff.
First - A caring staff member will review your
medical health history and show you the
newest ways to stop decay and gum disease.
She will give you everything you need to use to
be healthy and then take dental x-rays.
One week later - A hygienist will examine your
mouth to see if you’ve used everything you
were given at your first appointment. She will
clean your teeth and a dentist will examine
your mouth.
If you have been doing well at keeping your
mouth clean, you will qualify for up to $300 in
dental care. You and your dentist will discuss
how best to use this treatment money.
In 6 months, you can return for a dental
cleaning and check up. If your mouth is
healthy, you’ll qualify for another $300 of
dental treatment.
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Addendum
A. Comparing my Beta site to the Current RRF System
The rules, regulations, and funding (RRF) approach that has been used for the last 40 years ,
although, well meaning, is the reason that the dental health of those covered by Medicaid haven’t
improved. The current RRF is built around an open governmental checkbook that pays for cheap,
quick, unsupervised fixes that are easy for administrators to monitor. If there is money available, it’s
easier to continue a failed system than to admit the failure and search for a new solution. My proposal
is designed to promote behavioral change among the recipients and reward those (both dentists and
patients) that demonstrate improved dental health with funding over time to support the gradual,
continuous improvement of their dental health while only providing emergency, medically necessary
care to those not interested in improving their dental health (although they would be offered
alternative dental locations) The fact is that continually repairing, over and over, the same diseased
mouths of those not controlling their dental disease bleeds off a significant amount of funding that
could be used to support the behavioral change of those who are or are learning to become dentally
healthy.
From the dentist’s perspective, rewarding dentists for statistically monitored success in
improving the dental health of their Medicaid patients will change the type of dentists who participate
in Medicaid. The dentists that are geared to provide lots and lots of cheap quick fixes are not geared
to build relationships to improve the dental health of their patients and will drop out over time.
However, the significant majority of currently practicing general dentists have built their practices
around developing just this type of relationship with their patients to improve their health. They will
now have an economic incentive to participate.
Our state and federal government will save money since healthy people don’t need to be fixed,
but, more importantly, those on Medicaid that learn to effectively care for their dental health have one
less reason to remain on Medicaid. After all, being healthy is cheaper. The following chart compares
the current (RRF) approach with my dental proposal.
B. Comparison of My Beta site to the Medical Home Approach
Medicine began 2-3 years ago to reorient physicians to develop a relationship based approach with
their Medicaid patients where they assume the role of a trusted advisor who cares about the well being of the
patient and helps guide them toward a healthier life style.
Obviously, since insurance companies and hospitals have pushed medicine in the opposite direction
(see more disease, find more billable codes to report and get paid more), this will be a wrenching change.
However, medicine has one basic advantage over dentistry. The medical approach is primarily to heal
disease while, dentistry primarily cuts it out. An example is:
1. Patient visits her physician with a rash on her arm. After appropriate exam, and diagnosis,
medication(s) are prescribed to heal the rash.
2. If this same patient went to see a dentist with decay in a tooth, the dentist would cut out the diseased
portion of the tooth and patch the resulting hole.
Now reverse their roles:
1. Patient comes in to see the physician with the arm rash and the physician tells her he has a few
minutes, and, if convenient, he can cut her arm off. Would she like gold, or some of our new lifelike
composites, for her replacement arm? Ludicrous.
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2. Patient with decay visits her dentist. He tells her, after his diagnosis, that he will need to cut her tooth
down for a cap. Would she like a gold or lifelike porcelain cap? Happens everyday.
Your Medical Home approach is trying to emulate the client centered approach that dentistry began in
earnest 20 years ago – and has developed very well. Unfortunately, government and insurance companies
reward dentists for surgical procedures not for healing the disease.
What this means when I wrote up my comparison of the “Medical Home” model compared to my
“Dental Home” model is that the area that medicine will really struggle with – creating health oriented
relationships between medical staffs and their patients is how most dentists have practiced over the last 20
years. We’re good at this. It will take many years to reorient medicine into this new people centered
approach.
On the other hand, dentistry is stuck in the pre-penicillin 100 year old surgical model that medicine
evolved out of in the 1940’s. All you need to do to create a “Dental Home” is fund dentists (and track/reward
their level of success) at healing/preventing rather than amputating as many body parts as quickly as possible.
In the process, you will reduce several medical problems that dental plaque exacerbates (heart disease,
diabetes, early oral cancer detection, preterm deliveries). This tiered fee restructuring can be done much
quicker than retraining the medical profession to learn how to build relationships, and track/reward their
success in improving their patient’s health.
I believe that my proposal shows you how a working model Dental Home can be organized and placed
into operation within 1-2 years. I have included my understanding of the medical home model and how my
Dental Home model compares. The added bonus is that a healthy mouth reduces the risk of diabetes, heart
disease, preterm deliveries, etc. by eliminating a source of chronic inflammation.
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Current Policy
Effect
Proposed Policy
A. Low Fees (42% of an average
dentists usual fees) saves the
government money since they are
about 25% below an average
dentist’s total overhead expense
(65%), let alone their standard
fees.
1. Most general dentists (70-80%
nationally) won’t see a significant
number of Medicaid patients.
2. Most dentists that do
participate have organized their
practices to provide cheap, quick
fixes with no time allowed to build
relationships to improve the
patient’s dental health.
A. 3 Tiered Fee Schedule with the
lowest level at 50% of dentists’
usual fees (2nd tier 60%, 3rd tier
70%). The level of compensation is
based on the dentist’s success in
improving the dental health of
their patients.
B. Limited treatment of those not
practicing good home care – To
limit their treatment would be
“discrimination” and is not
allowed.
C. “Medically necessary” requires
treating all dental disease that is
diagnosed
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Effect
Although the government will now
pay 15-30% more per dental
procedure, they will save money
by:
1. Stopping the current cycle of
disease → fix → new disease → fix
→ etc. where the same patients
return for new fixes continuously.
2. There is a $300 maximum in
payment for fixes each 6 months.
3. There will be no money wasted
on patients with unhealthy mouths
that generate continual more
decay.
People with poor dental health will
B. B. Limited Care focused on:
1. Dentists will now have the time
develop new dental disease everyC. 1. Promoting improved health
to build health improvement
year with or without fixes. This D. 2. Avoid wasting money on people relationships and be statistically
adds significantly to cost with no
who are going to continue getting tracked/rewarded for their
improvement in health.
decay/gum disease.
success.
2. Those with acute (painful)
infections will still be treated
quickly.
3. those with poor home care
would be offered alternative
dentists or to return in 6 months.
Every decayed area a dentist
C. Not every spot of decay needs A healthy mouth has no active
thinks he sees should be fixed.
to be fixed. Some can be healed.
decay or gum disease.
Little effort or compensation to
What about gum disease? A
control gum disease or heal small
“cleaning” has almost no effect on
areas non-surgically.
gum disease, while good home
care and limited sugar is essential.
Small areas of decay will progress
slowly or not at all in a healthy
mouth.
Attract dentists that have
42
D. Any Dentist willing to fix cheap
is welcome
Current Policy
Promotes practices that are
organized to fix lots of teeth
cheaply and quickly.
Effect
D. Provides a “dental home”
similar to the medical modelsubstituting a 3 tier payment
system for the physicians’ monthly
stipend/payment.
organized their practices around
building relationships with their
patients to promote/support
behaviors that improve the
patients’ dental health and pay for
successful prevention that reduces
the number of fixes.
Proposed Policy
Effect
E. Save money by low fees
reduces dentist participation,
which forces Medicaid patients,
who are in pain and who can’t find
a dentist, to visit a hospital
emergency room that is required
to see these “medically necessary”
cases.
Burdens hospital emergency
E. Eliminate emergency room
rooms with Medicaid patients with coverage (no reimbursement
acute (painful) problems even
needed).
though emergency rooms have no
dentists to treat dental problems.
At an average fee of about $300
per visit. Since the problem wasn’t
solved, the patient lives with it, or
returns to the emergency room on
another day (often about 3
weeks).
All Medicaid patients when they
arrive at the emergency room will
be offered a list of dentists who
participate (initially HealthPark)
and assured we provide extended
coverage and are encouraged to
contact HealthPark. The dentist
fee (at improved Medicaid fees,
exam, x-ray, extraction) will be
about $175 less than the ER fees
and we will actually solve the
problem.
F. Treatment
Children are allowed to continue
with dental disease, being treated
continually for fixes.
Changing children’s behavior is
easier and more lasting than
changing adults behavior. The
challenge will be to get the parents
to see the value of supporting their
child’s relationship with the dentist
– which is an excellent way to
change the parents’ behavior.
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F. A preventive approach to the
dental Medicaid population must
include children.
43
Medical
A. Engaged Leadership
1. Leadership by case manager
2. GP physician is the hub and all other
medical/dental personnel are only
spokes in this wheel
B. Quality Improvement Strategy
1. Data collection to determine
opportunities for improvement.
2. Record criteria by
a. e-scribing
b. electronic medical records
c. patient use of portals
1. to schedule appointments
2. forms completion
d. e-mail communication
3. Involvement of patient, family, and
staff documented in computer file
4. Patient satisfaction surveys
5. Including staff in all aspects of data
collection, improvement planning and
implementation.
6. Maintain written policies on operational
processes.
7. Problems with implementation of
innovations tracked to
differentiate between “people” and
technical errors.
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Dental
A. Engaged Leadership
1. Hygienist manages the team
(chairside, secretary)
2. General dentists is the hub.
3. Dental speciatlists, nutritionists, etc.
are the spokes.
B. Quality Improvement Strategy
1. Data collection the same
2. Record criteria
a. e-scribing not available
b. by 2014
c. yes
1. yes
2. yes
d. yes
3. Patient involvement documented in
paper work, not organized for computer yet,
but we have an excellent tracking system.
4. Already using patient surveys part of
our strategic plan
5. Data collection is part of our Baldrige
Training
(state level awards for organizational
excellence – only practice in Ohio)
6. Dr. Smith has written over 5000 pages
describing every significant process for
HealthPark’s dentists, hygienists,
secretaries and chairside assistants.
7. Problems tracked, recorded, collated,
discussed,
and dealt with at weekly meetings.
Major problems discussed at strategic
41
planning session at 6 month intervals.
C. Empanelment
1. We plan for each hygienist (3) to be
assigned the patients. Each will have a
team of a chairside assistant and a
secretary.
C. Empanelment
1. Assigning all patients to primary care
providers or their teams.
D. Continuous Team Based Relationships
1. Emphasize that patients assigned are to
a team that establishes continuous
relationships with the patient.
D. Continuous Team Based Relationships
1. Dental offices do that with 6 month
Interval cleanings.
2. Establishing specific functions to each
team member based on skills, abilities,
and credentials.
2. Generally, already in place in our
training manuals. Any new
requirements will be assessed and
assigned using our standard approach.
3. Well defined job descriptions
3. Better than any you have ever seen in
dentistry.
E. Organized, evidence based care.
1. Meeting the needs of patients taking
into account their preferences and
concerns.
E. E. Organized, evidence based care.
1. This will be accomplished at the exam
that follows the cleaning appointment.
2. If preferences do not align with best
practices, of evidence based care?
2. We will not provide any treatment that
the patient requests that reduces the
patients level of dental health based on
evidence based standards.
3. If the patient is non-compliant?
3. Noncompliant patient:
a. 1st no show for appointment
placed on a call list, 2nd time dismissed from active care (still
cover emergencies).
b. Patient’s mouth not clean at
cleaning appointment 1 week after
preventive care appointment – no
fixes, only emergency care until
returns in 6 months for next
cleaning appointment. All this will
be tracked and documented in
patient’s chart. All emergencies will
be covered during our standard hours.
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4. Identify gaps in care.
4. documented in patient’s chart and
computer.
5. Reminding the patient to follow up for
treatment.
6. Address obstacles that caused noncompliance.
5. Part of normal dental procedure
(computerized).
6. These will be recognized, recorded,
collated, and discussed at weekly
meetings by each hygienist with her
team, all hygienists together, and by
our team lead hygienist with the other
members at the strategic planning
sessions.
F. Patient Centered Interactions
F. F. Patient Centered Interactions
1. Treating the patient as a whole, not just
1. Our initial preventive care ½ hr.
as a collection of diseases or risk factors.
appointment is designed to build a
relationship based on creating the
patient’s commitment to care for their
dental health.
2. Patient’s involvement in selfmanagement of their health care is
emphasized.
2. This is the point of my entire proposal.
3. Sufficient resources – staff training,
time, materials, follow up processes will
be invested in helping patients
comprehended the information.
3. Already in place for those speaking
English. Impaired or non-English
speaking patients will require new
approaches.
4. Have written provider – patient
agreement in the medical record which
explains anticipated benefits.
4. Included in the Proposal (exhibit I page
33).
5. Patients are required to play an active
role in their health care.
5. this is the point of my Proposal.
6. This agreement could cover what will
happen at each appointment, their
personal health care responsibilities,
and encourage them to voice concerns,
questions.
6. Most is already in our letter of
understanding. Additions/changes can
be easily made.
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G. Enhanced Access
1. 24/7 access
2. Enough slots open to meet anticipated
demand.
3. Practice measures the demand for
services in order to verify whether or
not the practice can meet the demand.
4. Training and supervision of physicians,
extended staff comply with all state
regulatory requirements.
H. Care Coordination
1. Coordinate patient care to avoid
communication breakdowns with
specialists while tracking/supporting
patients referred.
2. Develop strong ties to the local
communities.
3. Follow up after emergency room visits.
4. Establish close collaboration with other
healthcare personnel.
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G. Enhanced Access
1. Extended hours – 16 hours daily
2. Unknown – we have developed
approximately a 15% open schedule to
meet anticipated need, but we can’t
add more staff unless there is a
demonstrated need. I believe in 6
weeks I could add/train staff dedicated
to this Dental Home approach if more
coverage is required.
3. As far as I know. We currently meet all
dental board requirements.
4. Secretaries will track demand
statistically.
H. Care Coordination
1. We have specialists in orthodontics,
periodontics, a pediatric dentistry
and oral surgery.
HealthPark hopes to offer
almost 100% of dental needs for all age
groups. Also, we would hope to use the
patient’s Medical Home as the
coordinator, with our Dental Home as
only a supporting resource.
2. HealthPark has been established in the
Tipp/Troy area for over 40 years and has
a good relationship with the county
health department. Dr. Smith was Tipp
City’s man of the year in 2012.
3. Emergency room will try to avoid dental
emergencies (which they are not
equipped/staffed to serve). These
patients will be referred to us.
4. Many we already know, but Dr. Burkhart
in Troy, Ohio is developing a Medical
Home. We know each other and I
anticipate coordinating with him.
44