Achieving the Triple Aim

In 2013, the American Dental Association published a research brief describing the advent of accountable care organizations (ACOs) within the context of a changing health care landscape.¹ One key takeaway was that “ACOs could help bridge the gap between oral and general health care, improve coordination of care, and help reduce overall health care costs. They also provide an opportunity to re-examine the role of oral care providers within the health care team.”

At the time, the idea was that dental care would be delivered as part of a medical ACO, linking dental care to whole health care. The reality is that there were and continues to be independent dental health care organizations that operate as ACOs. These organizations have been adapting their clinical practices to meet the goal of fulfilling the “triple aim,” set forth in the Patient Protection and Affordable Care Act (Table 1).²

An ACO in the dental world is fundamentally no different than a traditional medical ACO, meaning that it is fully accountable for high-quality care and total per capita costs across the continuum of its members. Rather than a third-party payer reimbursement model, the dental ACO is both insurer and provider, responsible for the entirety of patients’ dental health care. In this model of care delivery, the staff is employed by the group dental practice, and its individual clinics are carefully aligned and supported to ensure provider teams are delivering consistent and excellent patient care. Culturally, the staff rally around the core organizational beliefs of the practice, and systems are designed, trained, implemented, and supported to bolster these values.

As opposed to traditional fee-for-service dentistry, a dental ACO’s business model is truly aligned with the concepts emphasized in modern medicine’s triple aim. Developed by the Institute for Healthcare Improvement, the framework is designed to simultaneously improve the health of the patient, increase the population’s access to health care, and reduce cost.² When the dental practice is both the insurer and caregiver, the business benefits, but, more importantly, the patient benefits from the successful achievement of the triple aim. Dental providers, at all levels of patient care, appreciate the focus on providing excellent health care as the only measure that matters, instead of focusing on concepts such as procedures, profit, and production.

FOCUS ON PATIENTS

As the provider of a true dental health care plan, the dental ACO can provide clinically excellent dentistry that focuses on patients. Patients will respond to the ACO’s model, noting how the oral health professionals are motivated, how the business operates, how the entire clinical staff works together, and how the focus is on improving dental health. The ACO’s dental health care plan—because of specific benefits, such as no yearly maximums, no waiting periods for major restorative work, low office visit fees, reasonable co-pays, and full coverage of diagnostic and preventive procedures—is superior to the traditional fee-for-service dental plan that may be offered as a dual-choice option. ACOs have the opportunity to see their patient base grow year after year due to these benefits. The triple aim can be boiled down into the simple connection between patients and their caregivers. The unique model of the dental ACO allows for an emphasis on shared success. The healthier the patient is, the healthier the organization is, as well.

EXPANDING SCOPE OF PRACTICE

A dental ACO’s model of care and core organizational beliefs of innovation and health are reinforced by the support and early adoption of changes in legislation—specifically those that expand the scope of practice for dental hygienists. ACOs should be active supporters of new and ongoing legislative efforts and rulemaking processes that can improve oral health in high-risk and underserved populations. By supporting these efforts to develop innovative practices in the oral health care delivery system, the organization focuses on providing care to populations that studies show have the highest disease rates and the least access to dental care.

A key focus of the dental ACO is delivering coordinated care through the use of all members of the dental team to their highest ability and full extent of licensure. Clinicians are supported in their efforts to continue their education and training so they may hold the highest licensure allowed in their states. This includes supporting the continuing education of dental hygienists and the hiring of highly skilled clinicians with restorative capabilities. These providers should be encouraged to use their skills to support their dental team in nontraditional roles. In high-needs areas, these dental hygienists should utilize this endorsement in a full-time capacity.

THERAPEUTIC ALLIANCE

The dental ACO model recognizes that one method of building a strong relationship that can be leveraged to improve the health of patients is through a therapeutic alliance, or a partnership between patients and clinicians, including support staff. This philosophy can blur the lines of traditional structure within the clinical staff, empowering providers at every level—dentists, dental hygienists, dental assistants, and front-office staff—to create this new, patient-centered clinical team in order to deliver the best care possible. When they strategize about how to improve patient health, they realize that it is this partnership between clinicians and patients that will achieve the desired results. Even though dentists have traditionally been “captains of the ship,” this team-based model of patient-centered care offers every clinician the opportunity and responsibility to positively impact the patient. At every stage of a patient’s experience—from the initial phone call to the recare reminder—the focus remains on the patient’s health literacy and engagement in the process. This is critical to the success of the ACO model.

SYSTEMS SUPPORT

The offices must also be supported by technology and systems, with an attempt to standardize the patient experience as much as is practical. If the goal is the triple aim, the tools, training, support, and measures must help providers achieve it. Additionally, if the dental ACO removes the financial incentive from the equation, in as much as the providers are not reimbursed for procedures, the organization must develop new metrics to incentivize clinicians. This allows for creative processes that will emphasize the core values of the organization and importance of the triple aim. If the intent is to deliver truly exceptional patient care—which can be challenging in the context of what can be, for some people, a traditionally unpleasant experience—the dental ACO must prioritize patient satisfaction. This is measured by a third party survey distributed to patients following their visits. The organization can additionally place high value on the concept of open access to providers, with expectations that patients are able to be seen at a clinic within a few days.

Most important, however, is that the clinical teams are aware of the global impact their efforts can have on patients. A dental ACO must further differentiate itself from traditional dentistry by measuring the quality of care provided and outcomes of that care. This lofty goal can only be accomplished with a robust electronic record, standardized risk assessment tools, evidence-based clinical guidelines, universal adoption of diagnostic codes, enhanced patient education and engagement, and strategies to ensure that patients return for follow-up. It is only through this commitment to delivering truly exceptional oral health care that a dental ACO can meet the triple aim. The simple truth is that this approach benefits both the business and patients, which is what guides ACOs in their mission to be the providers of choice in a rapidly evolving health care environment.

From Perspectives on the Midlevel Practitioner, a supplement to Dimensions of Dental Hygiene. October 2016;3(10):35-37.