Getting the Incentives Right: Improving Oral Health Equity With Universal School-Based Caries Prevention

摘要

Despite significant financial, training, and program investments, US children’s caries experience and inequities continued to increase over the last 20 years. We posit that (1) dental insurance payment systems are not aligned with the current best evidence, exacerbating inequities, and (2) system redesign could meet health care’s triple aim and reduce children’s caries by 80%. On the basis of 2013 to 2016 Medicaid and private payment rates and the caries prevention literature, we find that effective preventive interventions are either (1) consistently compensated less than ineffective interventions or (2) not compensated at all. This economic and clinical misalignment may account for underuse of effective caries prevention and subsequent overuse of restorative care. We propose universal school-based comprehensive caries prevention to address this misalignment. Preliminary modeling suggests that universal caries prevention could eliminate 80% of children’s caries and cost less than one fifth of current Medicaid children’s oral health spending. If implemented with bundled payments based on cycle of care and measurable outcomes, there would be an alignment of incentives, best evidence, care, and outcomes. Such a program would meet the Healthy People Oral Health goals for children, as well as health care’s triple aim. We posit that current oral health insurance payment systems, although increasing access to care, are in part responsible for oral health disparities. Furthermore, to obviate insurance-driven disparities, we propose a universal school-based prekindergarten-to-grade-8 (pre-K-to-8) caries prevention program, with a bundled payment for cycle of care and health improvement. We think that such a program has the potential to virtually, and cost-effectively, eliminate children’s caries. The proposed program would increase access to care, improve children’s oral health, increase equity, and decrease system costs. In the United States, after almost 50 years of systematic reviews and federal and organizational guidelines, fewer than 50% of children have sealants, more than 50% of children without sealants have cavities, and more than 80% of low-income children without sealants have cavities. 1 Increasing insurance and access does not fully address this problem, since (1) fewer than 40% of US dentists provide sealants, 2 (2) fewer than 16% of children aged six to nine years receive sealants, 3 and (3) fewer than 15% of children who access dental care receive topical fluoride or sealants. In other words, increasing access does not translate to increased utilization of effective preventive care over less effective types of care, even if individuals have high levels of health literacy.