Arizona, through its Arizona Health Care Cost Containment System (AHCCCS). the state’s Medicaid agency, has instituted a value-based healthcare initiative with its Differential Adjusted Payment (DAP) program, which has been running for several years.
Value-based healthcare initiative
Value-based healthcare focuses on rewarding healthcare providers for the quality, efficiency, and effectiveness of the care they deliver rather than simply the quantity of services. The Arizona DAP program aligns with these principles by providing additional payments to providers, including dentists, who meet specific criteria that improve patient care experience, enhance patient health outcomes, and reduce healthcare costs. These performance-based incentives are central to value-based healthcare models, aiming to improve healthcare delivery and patient outcomes while controlling costs.
DAP add 3% to fees
As far as dentistry is concerned, there are three specific performance measures and criteria that qualify providers for a 1.0% DAP fee increase for each performance measure met.
These are:
- Dental Sealants for Children Performance Measure (1%): Providers who increased the number of AHCCCS child members aged 5 to 15 years receiving dental sealants meet this measure.
- Provision of Dental Services on Weekends (1%): Providers qualify for this if 2.0% or more of their services are provided on weekends.
- Bundled Services (1%): Providers who increased their bundled services (defined as billing for an exam and cleaning, plus fluoride or sealants) by 5.0% are eligible for this DAP increase.
So, Medicaid dental providers in Arizona can increase their reimbursements by up to 3% by performing these services.
While the DAP program is reported to be successful and plays a role in improving access to healthcare in Arizona, it would be nice to be able to report specific data on dental care outcomes, such as improvements in oral health, patient satisfaction, or cost efficiencies as evidence of the effectiveness of this program. Such would be useful because it would be an excellent program for Texas Medicaid, too.
Lack of fee increase in Texas
There is consternation in Texas about the lack of a fee increase for dental providers. This kind of program gives providers an opportunity to increase their reimbursement and increase the benefits to their patients.
In Texas, Medicaid and the Children’s Health Insurance Program (CHIP) have implemented several value-based care (VBC) initiatives including:
- Annual Reporting and Alternative Payment Models Targets: Since 2012, each MCO and DMO is required to submit an annual report on its APM contracts with providers. From calendar year 2017, Texas Health and Human Services Commission (HHSC) introduced APM targets into managed care contracts. By 2021, 25% of the MCO’s and DMO’s payments to providers must be through APMs, increasing to 50% by 2021. This includes a portion of these APMs involving downside financial risk for providers.
- Contractual Requirements for MCOs and DMOs: HHSC has incorporated requirements for MCOs and DMOs to support their VBP activities. This includes establishing data-sharing processes with providers, developing Provider Performance Reports, and dedicating resources to evaluate the impact of APMs on utilization, quality, and cost.
- Dental Pay-for-Quality (P4Q) Programs: In Texas, 1.5% of each dental plan’s capitation is at risk based on performance measures in Medicaid and CHIP. Plans that do not improve or decline beyond a set threshold can retain all of their capitation. Those whose performance declines beyond the threshold may have up to 1.5% of their capitation recouped. Conversely, if a plan’s performance improves beyond the threshold, it can earn incentive payments.
Providers should be rewarded for healthcare improvements
However, there is no direct provider program such as the Arizona DAP. Providers should be rewarded for their treatment protocols, not just DMOs.
By bringing this DAP alternative to light, it would be good to see this implemented in Texas.
