Widely recognized problems with the U.S. health care system, including rapidly increasing costs and disparities in access and outcomes also exist in oral health. If oral health systems are to meet the “Triple Aim” of improving the experience of care, improving the health of populations, and reducing per capita costs of health care, new and innovative strategies will be needed including new regulatory, delivery, and financing systems. The virtual dental home is one such system.
Widespread oral health disparities exist in the United States.1 The American Dental Association has estimated that around 30 percent of the population has difficulty accessing dental services through the current private dental care delivery system.2 A national analysis in 2010 by the Government Accountability Office (GAO) indicated that only about one-third of children enrolled in Medicaid received any dental service during the 2008 fiscal year.3 These and many other reports clearly identify significant disparities in oral health among population groups.
The situation is worse in California, where only 26 percent of enrolled beneficiaries of the Denti-Cal system received any services in 2007.4 Also in California, in 2008, 24 percent of all children, ages newborn to 11, had never seen a dentist.5 In 2011, only 22 percent of the total number of people eligible for Medi-Cal dental services received any service, a decrease of 8 percent from 2009. A decrease was expected for adults since most adults benefits were eliminated in 2009. However, there was also a decrease for children. In 2011, only 27 percent of eligible children received any dental service compared to 34 percent in 2009.6
In 2011, the Institute of Medicine (IOM) and the National Research Council of the National Academies of Science issued two reports on oral health, “Advancing Oral Health in America” and” Improving Access to Oral Health Care for Vulnerable and Underserved Populations.”7,8 Both of these reports document the significant proportion of the U.S. population that does not have access to oral health services and the disparities in oral health among population groups.
The U.S. health care system is under increasing pressure to improve performance. These changes are being driven by the widespread realization that the costs of the current fragmented system are increasing at alarming rates, and that in spite of spending close to twice the percent of our national gross domestic product (GDP) on health care compared to other developed countries we have significantly worse health outcomes in general and huge health disparities among subpopulations.9–11 These factors are driving reform of the health care system and creating pressure to form a more accountable system by moving from a system based on volume of services provided to one based on the value of those services.11–17 Donald Berwick, former administrator of the Centers for Medicare and Medicaid Services (CMS) and former president and chief executive officer of the Institute for Health Care Improvement has referred to the goals of this movement as the Triple Aim.18 The three aims are improving the experience of care, improving the health of populations, and reducing per capita costs of health care.
As described in a 2012 report, “Oral Health Quality Improvement in the Era of Accountability,” the factors that are driving reform in the general health care system all apply to the delivery of oral health care.19 Achieving the Triple Aim in oral health care will require important changes in the systems used to deliver oral health services to populations that are not adequately served by the traditional office and clinic-based oral health delivery system.
The IOM report, “Improving Access to Oral Health Care for Vulnerable and Underserved Populations,” calls for research and demonstrations of new systems to improve oral health for vulnerable and underserved populations that emphasize prevention and early intervention and use new methods and technologies such as: bringing care to where people are by delivering oral health services in nontraditional settings; engaging nondental professionals; developing expanded duties for existing oral health professionals or creating new types of dental professionals; and using technologies such as telehealth.8 The IOM report also calls for research and demonstrations of delivery systems that are based on measures of access, quality, and outcomes, and for incorporating these measures in payment and regulatory systems.
The Pacific Center for Special Care at the University of the Pacific, Arthur A. Dugoni School of Dentistry has created and is demonstrating a new oral health delivery system, the virtual dental home, which is designed to move oral health services for underserved and vulnerable populations toward the Triple Aim.