The healthcare landscape may change dramatically over the next few years or even months. The Affordable Care Act (ACA), or Obamacare, has made some significant alternations to healthcare and health insurance, but it is certainly possible that the healthcare industry will make another giant shift in the near future.
As lawmakers consider change, they should be thinking about how those changes will affect doctors, hospitals, and clinics. They should also consider some of the often-overlooked fields of health insurance, including vision and dental.
Technically speaking, dental insurance is not a required part of the ACA. Instead, it can be an “add-on” or an upgrade option. It is frequently an entirely separate policy that companies offer independently of health insurance. However, children’s dental coverage is a required part of all ACA plans.
In addition, cost assistance offered to many lower-income Americans can be applied toward any health insurance plan that includes dental coverage. That means that even though dental insurance is not required, for some, ACA has increased access. Increased access, however, does not necessarily mean that families are taking advantage of plans with dental options.
Problems with the ACA as it relates to dental care have decreased the overall effect that the ACA has had on the dental industry. Nonetheless, this booming industry did get an additional boost from Obamacare.
The Affordable Care Act and Dental Coverage for Adults
As of 2014, the National Association of Dental Plans reported that there were 126.7 million Americans without dental coverage. This number is staggering considering it is approximately three times the number of medically uninsured for the same time period. Today, however, those lacking dental insurance is in the range of 108 million individuals by some estimates.
The ACA may not require plans to offer dental care, but many plans do. The American Dental Association conducted a study of 40 states, and it noted that 35.7 percent of medical plans now have either child or family dental benefits. This is in contrast to a rate of 26.8 percent in 2014. In 2014 alone, reports indicate that 1.1 million individuals gained stand-alone dental benefits through the health insurance marketplace. Another 6.7 million Americans gained health insurance, and many plans offered dental benefits as part of their plan package.
Child’s Dentistry and Obamacare
Although children are technically supposed to be covered by ACA-compliant plans, those in the pediatric dentistry industry see serious problems with the way the plans are purchased. Under the law as it currently stands, qualifying plans are required to offer dental insurance for those 18 or younger, but the parent or guardian is not required to actually purchase the plan. Dental plans are often sold separately, which encourages some parents or guardians to forego purchasing a dental insurance plan altogether.
This “loophole” is troubling for the dental industry and may be a major health concern. Dr. Paul Reggiardo, chair of the American Academy of Pediatric Dentistry’s Council on Dental Benefit Programs, noted, “It’s letting kids down in my mind, and it is clearly inconsistent with congressional intent. The intent was to include all children. Now it only includes some.”
A tax “glitch” also caused families in the United States to lose subsidies worth $93.6 million in 2014. Essentially, the problem was that parents could not use their tax credits for stand-alone dental plans, making the propensity to purchase a separate dental plan even lower. Reports now indicate that this problem has been addressed with a change to the tax code, however.
By some estimates created in 2013, 8.7 million children were expected to gain dental benefits by 2018 because of the ACA, reducing the number of children without dental coverage by roughly 55 percent. Of course, these estimates can change drastically with the changing political climate.
Insurance and Increased Dental Visits
Those who have dental insurance are more than two times more likely to seek out dental care compared to those who are uninsured. In addition, those who opt for private insurance are also 20 percent more likely to regularly visit the dentist compared to those who have dental insurance through a public insurance program. These statistics are not all that surprising when you consider that they generally conclude that those who sought out and independently paid for their dental insurance are more likely to have regular dental care. These individuals may be more likely to use dental care regardless.
Roughly 92 percent of those with private dental insurance obtained them through their employer or a group program. Less than one percent buy benefits as part of a medical plan, while about 7.2 will purchase individual health plans. While the 7.2 percent may seem small, it was only about two percent in 2011. This increase in purchasing plans leads to more dental visits overall, which, in turn, helps the dental industry as a whole.
Some experts are already predicting that massive job losses that will occur in the healthcare and dental industries if Obamacare is repealed. Although the dental industry may suffer, the overall impact will not be as severe as what may be in store for the medical healthcare industry.
Increased Patients and Growth in the Dental Industry
The dental industry has been experiencing significant growth for several years. In fact, U.S. News ranks a “Dentist” as #2 in the 100 Best Jobs, and part of that ranking is due to its 0.2 percent unemployment rate and estimated 18 percent growth rate of for the next three years. The low unemployment rate has a lot to do with the fact that more dentists are retiring right now compared to students graduating.
Young adults seem to have purchased the lion’s share of stand-alone dental plans in the marketplace thanks to the Affordable Care Act. This may indicate a renewed interest or understanding of the importance of dental care in overall healthcare. Perhaps the message that many leaders in the dental industry have touted for years—that dental health is an integral part of your overall health—is finally getting through to certain segments of the population.
Despite Problems, the ACA Has Still Been Helpful for the Dental Industry
Experts indicate that part of the reason the dental industry has grown so much in recent years is due, in part, to the Affordable Care Act. As those with access to dental insurance increase, those who purchase and use that insurance also increase. While the dental industry has not seen demand levels rise to the degree of the overall healthcare industry, there has still been a noticeable uptick.
If the “glitches” and problems are addressed, the impact may be even more noticeable. However, with the current political landscape and threat of repealing the ACA, the dental industry may never realize the true implications of the ACA.
Dr. Jay Fensterstock is a New York dentist who has been practicing dentistry for over 40 years. He graduated from New York University’s College of Dentistry and opened Concerned Dental Care which has now expanded to 9 locations with over 10 affiliate locations over the New York City area. When he’s not helping patients of all ages with their oral health he can be found writing informative blogs while sipping on a cup of hot chocolate (yes it’s sugar free).
Elizabeth O’Brien, “Obamacare isn’t good for your teeth,” Market Watch (Jan. 24, 2014), http://www.marketwatch.com/story/obamacare-isnt-good-for-your-teeth-2014-01-23.
Catherine Saint Louis, “A Gap in the Affordable Care Act,” The New York Times (Dec. 16, 2013), http://www.nytimes.com/2013/12/17/health/a-gap-in-the-affordable-care-act.html?_r=1.
HealthCare.gov, “Dental Coverage in the Marketplace,” accessed Jan. 5, 2017, https://www.healthcare.gov/coverage/dental-coverage/.
Kamyar Nasseh et al., “Affordable Care Act Expands Dental Benefits for Children But Does Not Address Critical Access to Dental Care Issues,” American Dental Association: Health Policy Institute (Apr. 2013), http://www.ada.org/~/media/ADA/Science%20and%20Research/HPI/Files/HPIBrief_0413_3.pdf.
Gayathri Subramanian, “Medical Insurance Often Undone by Lack of Dental Coverage,” Santa Fe New Mexican (reprinted from The Washington Post) (Jan. 1, 2017), http://www.santafenewmexican.com/news/health_and_science/medical-insurance-often-undone-by-lack-of-dental-coverage/article_6cb45137-c732-5261-bf3d-68d0e78bd0c7.html.
Jennifer Bresnick, “Dental Care is the Missing Piece of Population Health Management,” HealthITAnalystics (Dec. 28, 2016), http://healthitanalytics.com/news/dental-care-is-the-missing-piece-of-population-health-management.
National Association of Dental Plans, “Who Has Dental Benefits?,” accessed Jan. 5, 2017, http://www.nadp.org/Dental_Benefits_Basics/Dental_BB_1.aspx.
American Dental Association, “Your Guide to Finding and Paying for Dental Care,” Mouth Healthy, accessed Jan. 5, 2017, http://www.mouthhealthy.org/en/dental-care-concerns/paying-for-dental-care.
Rachel Klein, “Tax Code Fix Will Deliver Dental for Millions of Kids,” HealthInsurance.org (July 14, 2016), https://www.healthinsurance.org/blog/2016/07/14/tax-code-fix-will-deliver-dental-for-millions-of-kids/.
“Dentist: Overview,” U.S. News Careers, accessed on Jan. 5, 2017, http://money.usnews.com/careers/best-jobs/dentist.
Eric S. Solomon, “The Future of Dentistry,” Dental Economics, accessed on Jan. 5, 2017, http://www.dentaleconomics.com/articles/print/volume-94/issue-11/features/the-future-of-dentistry.html.
Apex360 Editors, “Top 2015 Dental Industry Trends and 2016 Predictions from the Apex360 Editorial Advisory Board,” DentistryIQ (Nov. 24, 2015), http://www.dentistryiq.com/articles/apex360/print/volume-2/issue-8/introducing-the-apex360-editorial-advisory-board.html.
Andrew Snyder & Keerti Kanchinadam, “A Check-Up on Dental Coverage and the ACA,” HealthAffairsBlog (Mar. 24, 2015), http://healthaffairs.org/blog/2015/03/24/a-check-up-on-dental-coverage-and-the-aca/.
Who to treat? When to treat? How to treat? How long to treat? How much to spend to treat? The list goes on and on.
Fortunately, great strides have been made in healthcare decision analysis, but not without controversy.
On the plus side, decision analysis can provide objectivity and potentially improve the quality of the final choice. On the downside, decision analysis is fraught with challenges, including methodological, process, outcomes, perspective, data sources, and how to present the data insights, to name a few.
In this blog, we’ll discuss a few of the challenges of systematic decision approaches in the context of a topic that’s been in the news of late, pharmaceutical Value Assessment Frameworks. Specifically, we will focus on a relative newcomer on the block: the Institute for Clinical and Economic Review‘s (ICER) Value Assessment Framework and explore some areas of needed improvement. While doing so, we will also compare two ways of presenting these insights: Long-form content and a visual format called PepperSlice.
What’s the beef with ICER’s Value Assessment Framework?
For more than a year, ICER has used its value assessment framework to guide its evidence reports on new drugs and other interventions. Pharma industry and patient advocacy networks have reacted strongly (and by strongly, we mean mostly negatively) to the ICER framework. One of the most common responses to ICER is that their (and other) frameworks squash pharmaceutical innovation and prevent some patients from receiving needed care.
In addition, major industry groups have challenged the readiness of the ICER framework, questioning its appropriateness in several areas. To their credit, ICER has requested stakeholder comments in preparation for a 2017 revision of the framework.
The NPC (National Pharmaceutical Council), PhRMA (biopharma trade group), and AMCP (the Academy of Managed Care Pharmacy) have significant concerns about ICER’s methodology. In particular, they take issue with the following areas:
NPC says “ICER [should] have a clear process for managing the evolution of evidence, especially in the case of emerging therapies…. [T]hese reviews will continue to be relied upon by other stakeholders even after additional data (e.g., real-world evidence) emerge.”
And AMCP suggests real-world evidence and patient-reported outcomes should be “re-examined to further enhance the utility and relevance of the value assessment framework.”
ICER should not confuse budget impact with value. “Budget impact assessments — which are measures of resource use, not of value — should remain completely separate from value assessments,” says NPC.
And this from PhRMA: ICER should suspend “the use of budget impact estimates until more sound methods are developed and validated.”
Economic model transparency.
The information provided is “not sufficient to enable reviewers to reproduce the results and provide meaningful, real-time input. Full transparency — down to the equation level — is needed to enable reproducible results and support fully informed stakeholder collaboration.” NPC asks that ICER release the model to all stakeholders.
PhRMA asks for “Adjustment of the cost-effectiveness component of the framework to reflect the inherent and widely recognized limitations in traditional quality adjusted life years-based cost-effectiveness analysis (CEA), including capturing a wider range of benefits in CEA and presenting a range of care value estimates based on sound assumptions and varied approaches.”
Other responses to the ICER Value Assessment Framework include:
NPC: To guide future development, NPC published a set of Guiding Practices for Patient-Centered Value Assessment. Dan Leonard recently recapped NPC’s viewpoint on how frameworks should be developed.
PhRMA: Four specific recommendations are offered, intended to move ICER in a more “methodologically rigorous, patient-centered direction”. They request significantly more transparency into how it works with stakeholders. And they offer specific advice on How to Get Value Assessment Frameworks Right.
AMCP: The managed care and specialty pharmacists’ group expresses concern that the current framework “lacks a process for incorporating real-world evidence (RWE) and patient reported outcomes (PROs) into the catalog of evidence that informs the underlying economic models. [Doing so would] better represent the patient experience.”
ICER Value Framework Version 2.0.
In October, ICER convened a broad group of stakeholders to inform its planned update. Invitees included people from pharma, academia, payers, patient advocates, and trade groups. A revised framework will be posted for additional comments next month; ICER’s 2.0 version will likely become final in early 2017.
What’s next for value frameworks?
ICER is only one of several frameworks gaining traction in healthcare. Stakeholders are weighing in. To help establish best practices going forward, the International Society for Pharmacoeconomics and Outcomes Research (ISPOR) has launched an initiative on US value assessment frameworks; more than 250 people attended the kickoff stakeholder conference. A task force is preparing a policy white paper on the appropriate definition and use of value assessment frameworks, expected Q1 2017. ISPOR is the sole funder of the effort.
Moving From Data Output to Data Insights.
Much of the data derived from decision analysis is challenging to present to decision-makers. As an industry, we all need to get better at communicating complex evidence – simply. One tool, called PepperSlice, may help. PepperSlice is designed to deliver insights and Evidence Graphs by structuring analytics and evidence in a simple way.
Capturing insights with PepperSlice.
Let’s look at how we can visually present the concerns with ICER’s Value Assessment Framework using PepperSlice insights and data visualization.
The images below depict the issues around RWE and the ICER framework, in easy-to-consume graphics that are transparent, show the relationship between the data inputs, and the data source behind the images.
The first “board” (Image 1 ) explains the issue, graphically on this topic: “ICER’s value assessment framework is not ready for widespread adoption by stakeholders”.
Below each board are “slices” (Image 2), designed as cards, and each of these slices offers an insight. In the PepperSlice platform, these slices can be pinned to a single board or multiple boards, can be saved, and are searchable and reusable.
A database provides the underlying structure to the insight slices (Image 3 below), and provides the relationship (reduces, lacks, improves, etc.) between the two inputs, the result, the analyst name (i.e., the “slicer”), and the evidence collection method.
Through this method of PepperSlicing, one can present insights with a click of a button, build and manage the inventory of evidence-based insights, use them for one or multiple analyses, and see how an insight was derived (What are the supporting data? How was the evidence analyzed? Who did the work?). In just a few images, one can see inputs, outputs, and relationships.
In this blog, we’ve given you an overview of the ICER Value Assessment Framework and the major concerns of the decision framework according to key stakeholders. We’ve also showed you, by example, how insights can be captured about this issue – or any decision/choice – using a new methodology called PepperSlice.
What do you think are the major concerns with Value Assessment Frameworks in general and the ICER framework, in particular? Let us know what you think about the two presentations of the data: long-form vs short-form visual presentation using PepperSlice?
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