Rise of Managed Care in the USA: Lessons for Dentistry
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Since the 1960s, the USA has experienced rapid growth in national health care expenditures, outpacing growth in other sectors of the economy. As a result, the late 1970s experienced a rise in the use of mechanisms designed to control the cost and utilization of health care. These mechanisms have come to be known as managed care. Various models of managed care have used different approaches to contain costs and improve health care quality, including capitation payments, restricted provider networks, and, more recently, financial incentives to reduce cost and improve health outcomes. In dentistry during the past two decades, the majority of the payment system has moved from primarily fee-for-service to one model of managed care called Dental Preferred Provider Organizations (DPPOs), which now accounts for more than 80 % of the market share for commercial plans. Despite a lack of recent growth in national expenditures for dental care, dentistry will need to become increasingly involved in new types of managed care due to emphasis on reducing costs and improving health care quality in the US health care system as a whole.
KeywordsManaged care programs Managed health care insurance plans Insurance case management Health maintenance organizations Preferred provider organizations Patient care management
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Conflict of Interest
Raymond A. Kuthy, Julie C. Reynolds, Susan C. McKernan, and Peter C. Damiano declare that they have no conflict of interest.
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This article does not contain any studies with human or animal subjects performed by any of the authors.
Papers of particular interest, published recently, have been highlighted as: • Of importance •• Of major importance
- 1.Organisation for Economic Cooperation and Development. (OECD) Health statistics: how does the United States compare? Paris, France: OECD 2014. http://www.oecd.org/unitedstates/Briefing-Note-UNITED-STATES-2014.pdf. Accessed 11 Mar 2016.
- 2.••Fox PD, Kongstvedt PR. A history of managed health care and health insurance in the United States. In: Kongstvedt PR, editor. Essentials of Managed Health Care. 6th ed. Burlington: Jones & Bartlett Learning; 2013. This chapter is an excellent primer about the evolution of health insurance in the U.S.Google Scholar
- 3.Nixon R. Statement on signing the health maintenance organization act of 1973, December 29, 1973. Online by Gerhard Peters and John T. Woolley, The American Presidency Project. http://www.presidency.ucsb.edu/ws/?pid=4092. Accessed 28 Mar 2016.
- 4.•Keehan SP, Cuckler GA, Sisko AM, Madison AJ, Smith SD, Stone DA, et al. National health expenditure projections, 2014-24: spending growth faster than recent trends. Health Aff. 2015;34:1407–17. This article provides the forecast for health care spending in the USA, with emphasis on medical goods and services. Estimates for dental services are also displayed.Google Scholar
- 5.••Paradise J. Medicaid moving forward. The Kaiser Commission on Medicaid and the Uninsured. Washington, DC: The Henry J. Kaiser Family Foundation. March 9, 2015. http://kff.org/health-reform/medicaid-moving-forward Accessed 18 Mar 2016. This report, created by a private foundation that studies health care issues for traditionally underserved populations, shows major Medicaid changes at the state and national level since the passage of the Affordable Care Act.
- 6.Pearson CF. Avalere analysis: Medicaid managed care enrollment set to grow by 13.5 million. Washington, DC: Avalere Health LLC. Oct 2014. http://avalere.com/expertise/managed-care/insights/avalere-analysis-medicaid-managed-care-enrollment-set-to-grow-by-13.5-milli. Accessed 11 Mar 2016.
- 7.Mark Farrah Associates. Understanding the Medicaid market. 30 Nov 2015. http://www.markfarrah.com/healthcare-business-strategy/Understanding-the-Medicaid-Market.aspx Accessed 28 Mar 2016.
- 8.Gold J. Accountable Care Organizations, explained. Kaiser Health News. Sept 2015. http://khn.org/news/aco-accountable-care-organization-faq/ Accessed 21 Mar 2016.
- 9.Muhlestein D, Gardner P, Caughey W, de Lisle K. Projected growth of Accountable Care Organizations. Dec 2015. Leavitt Partners. http://leavittpartners.com/2015/12/projected-growth-of-accountable-care-organizations-2/ Accessed 28 Mar 2016.
- 10.National Association of Dental Plans. 2012 state of the dental benefits market. Dallas, TX: National Association of Dental Plans, Inc. Mar 2013.Google Scholar
- 11.Haider Z. Dental insurance in the U.S. industry report OD4760. New York, NY: IBISWorld. http://clients1.ibisworld.com/reports/us/industry/Default.aspx?entid=4760. Accessed 25 Mar 2016.
- 12.Center for Health Care Strategies, Inc. (CHCS) Medicaid adult dental benefits: an overview. February 2016. http://www.chcs.org/media/Adult-Oral-Health-Fact-Sheet_020816.pdf Accessed 28 Mar 2016.
- 13.United States Government Accountability Office. Dental services: information on coverage, payments, and fee variation. September 2013. GAO-13-754. Available from http://www.gao.gov/products/GAO-13-754 Accessed 10 Mar 2016.
- 14.Smith JC, Medalia C. Health insurance coverage in the United States: 2014. US Census Bureau, Current Population Reports, P60-253. Washington, DC: US Government Printing Office, 2015.Google Scholar
- 20.Wikipedia. https://en.wikipedia.org/wiki/Dental_discount_plan. Accessed 12 Apr 2016.
- 21.U.S. Department of Health and Human Services, Centers for Medicare and Medicaid Services. HealthCare.gov. https://www.healthcare.gov/glossary/exclusive-provider-organization-EPO-plan/ Accessed 12 Apr 2016.
- 22.Association of Dental Support Organizations. What is a DSO? http://theadso.org/about-adso/dso-industry/ Accessed 12 Apr 2016.
- 23.Cain K. What you know about DSOs. http://www.drbicuspid.com/index.aspx?sec=ser&sub=def&pag=dis&ItemID=318109 Accessed 12 Apr 2016.
- 24.American Dental Association. Glossary of dental clinical and administrative terms. http://www.ada.org/en/publications/cdt/glossary-of-dental-clinical-and-administrative-ter Accessed 12 Apr 2016.
- 25.The Henry J. Kaiser Family Foundation and The Health Research & Educational Trust. 2014 Employer health benefits survey. Section 8: high-deductible health plans with savings option. http://kff.org/report-section/ehbs-2014-section-eight-high-deductible-health-plans-with-savings-option/ 2014. Menlo Park, CA (Kaiser Family Foundation) and Chicago, IL (Health Research & Educational Trust. Accessed 15 Mar 2016.
- 26.U.S. Department of Health and Human Services, Centers for Medicare and Medicaid Services. HealthCare.gov. https://www.healthcare.gov/glossary/point-of-service-plan-POS-plan/ Accessed 12 Apr 2016.
- 27.National Association of Dental Plans. 2015 NADP/DDPA (Delta Dental Plans Association) benefits report: enrollment. Dallas, TX: National Association of Dental Plans, Inc. Aug 2015.Google Scholar
- 28.Ireland E. 2015-ACA reshaping dental benefits. Dallas, TX: National Association of Dental Plans. 2015. http://www.guaa.com/uploaded_files/357/files/fixed-2015-presentations/dental_workshop_6_review_of_the_affordable_care_act.pdf. Accessed 28 Mar 2016.
- 29.Smith VK, Gifford K, Ellis E, Rudowitz R, Snyder L, Hinton E. Medicaid reforms to expand coverage, control costs and improve care: results from a 50-state Medicaid budget survey for state fiscal years 2015 and 2016. Kaiser Family Foundation and National Association of Medical Directors Oct 2015. http://files.kff.org/attachment/report-medicaid-reforms-to-expand-coverage-control-costs-and-improve-care-results-from-a-50-state-medicaid-budget-survey-for-state-fiscal-years-2015-and-2016 Accessed 18 Mar 2016.
- 30.DentaQuest. State Clients. http://www.dentaquest.com/state-plans/ Accessed 16 Mar 2016.
- 31.Managed Care of North America Dental. Company overview: the premier dental plan. http://www.mcna.net/en/company-overview Accessed 16 Mar 2016.
- 32.••Colla CH, Stachowski C, Kundu S, Harris B, Kennedy G, Vujicic M. Dental care within Accountable Care Organizations: Challenges and opportunities. American Dental Association. March 2016. http://www.ada.org/~/media/ADA/Science%20and%20Research/HPI/Files/HPIBrief_0316_2.pdf?la=en Accessed 28 Mar 2016. This policy brief, which was developed in partnership with the Dartmouth Institute for Health Policy & Clinical Practice, highlights perceptions by Accountable Care Organizations about either including or excluding dentistry in their health organizations to share responsibility for a specified populations’ health cost and quality of care.
- 35.American Dental Association, Health Policy Institute. Dental practice. 2014 characteristics of private dental practices. Chicago, IL: ADA. Dec 2015. http://www.ada.org/en/science-research/health-policy-institute/data-center/dental-practice Accessed 9 Mar 2016.
- 37.•Sparer M. Medicaid managed care: costs, access, and quality of care. Princeton, NJ: Robert Wood Johnson Foundation. 2012. This report summarizes research studies and other reports about the impact of Medicaid managed care on health care access and quality. One of the key findings is that “(P)eer-reviewed literature finds little savings from Medicaid managed care on the national level, but some states have been more successful than others.” Google Scholar
- 39.•Kelleher KJ, Cooper J, Deans K, Carr P, Brilli RJ, Allen S, et al. Cost saving and quality of care in a pediatric accountable care organization. Pediatrics. 2015;135(3):e582–9. This article about an Accountable Care Organization in Ohio provides an example of how it demonstrated quality improvement using both some federal and self-developed indicators yet reduced the growth of cost versus traditional statewide Medicaid fee-for-service and managed care programs.Google Scholar
- 41.Summer L, Hoadley J. The role of Medicaid managed care in health delivery system innovation. New York: Commonwealth Fund; 2014.Google Scholar
- 43.American College of Dentists. Dental managed care in the context of ethics. J Am Coll Dent. 1996;63(4):19–21.Google Scholar
- 44.Kao RT. Dentistry at the crossroads. Calif Dent Assoc J. 2014;42:91–5.Google Scholar
- 45.•Manos PA, Bramson JB. Potential future elements of dental care financing—a third-party payer’s perspective. J Calif Dent Assoc. 2013;41:887–94. This article, written by two dental directors for a national insurance company, presents some of the rationale for the change in dental care financing. Besides addressing the issue of cost, the authors also note that there is mounting pressure for accountability for the monies spent on dental care.Google Scholar
- 47.Parker MA. New practice models and trends in the practice of oral health. NC Med J. 2012;73:117–9.Google Scholar
- 49.Cole JR, Dodge WW, Findley JS, Young SK. Viewpoint 1. Large DSO-managed group practices will be the setting in which the majority of oral health care is delivered by 2025. In: will large DSO-managed group practices be the predominant setting for oral health care by 2025? Two viewpoints. J Dent Educ. 2015;79:465–71.PubMedGoogle Scholar
- 50.Horn BD, Kalkwarf KL, Martin Jr MM, Winder RL. Viewpoint 2. Increases in DSO-managed group practices will be offset by models allowing dentists to retain the independence and freedom of a traditional practice. In: will large DSO-managed group practices be the predominant setting for oral health care by 2025? Two viewpoints. J Dent Educ. 2015;79:465–71.PubMedGoogle Scholar
- 51.•Berwick DM, Nolan TW, Whittington J. The triple aim: care, health, and cost. Health Aff. 2008;27:759–69. This article was seminal for the concept of Accountable Care Organizations.Google Scholar
- 52.The Lewin Group. Medicaid managed care cost savings: a synthesis of 24 studies. Falls Church: The Lewin Group; 2009.Google Scholar
- 53.Adams R. Boom in managed care alters Medicaid’s calculations. Washington Health Policy – Week in Review. New York: Commonwealth Fund. August 11, 2014 http://www.commonwealthfund.org/publications/newsletters/washington-health-policy-in-review/2014/aug/aug-11-2014/boom-in-managed-care. Accessed 10 Mar 2016.