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Background: To improve the oral health of low-income children, innovations in dental delivery systems are needed, including community-based care, the use of expanded duty auxiliary dental personnel, capitation payments, and global budgets. This paper describes the protocol for PREDICT (Population-centered Risk- and Evidence-based Dental Interprofessional Care Team), an evaluation project to test the effectiveness of new delivery and payment systems for improving dental care and oral health., Methods/design: This is a parallel-group cluster randomized controlled trial. Fourteen rural Oregon counties with a publicly insured (Medicaid) population of 82,000 children (0 to 21 years old) and pregnant women served by a managed dental care organization are randomized into test and control counties. In the test intervention (PREDICT), allied dental personnel provide screening and preventive services in community settings and case managers serve as patient navigators to arrange referrals of children who need dentist services. The delivery system intervention is paired with a compensation system for high performance (pay-for-performance) with efficient performance monitoring. PREDICT focuses on the following: 1) identifying eligible children and gaining caregiver consent for services in community settings (for example, schools); 2) providing risk-based preventive and caries stabilization services efficiently at these settings; 3) providing curative care in dental clinics; and 4) incentivizing local delivery teams to meet performance benchmarks. In the control intervention, care is delivered in dental offices without performance incentives. The primary outcome is the prevalence of untreated dental caries. Other outcomes are related to process, structure and cost. Data are collected through patient and staff surveys, clinical examinations, and the review of health and administrative records., Discussion: If effective, PREDICT is expected to substantially reduce disparities in dental care and oral health. PREDICT can be disseminated to other care organizations as publicly insured clients are increasingly served by large practice organizations., Trial Registration: ClinicalTrials.gov NCT02312921 6 December 2014. The Robert Wood Johnson Foundation and Advantage Dental Services, LLC, are supporting the evaluation.

Utilization management (UM) is now an integral part of most public and private health plans. Hospital review, until recently the primary focus of UM, is associated with a reduction in bed days and rate of hospital cost increases. These reductions appear to have had limited impact on aggregate health care costs because of increases in unmanaged services. In the future, with electronic connectivity between payers and providers and the use of clinical guidelines and computer-based decision-support systems, the need for prospective case-level reviews will be reduced. With these changes, UM programs are likely to become more acceptable to providers and patients.

Rovin and Nash suggest that alternate dental delivery systems are more competitive and will eventually capture a large share of the dental market presently held by traditional practices. The potential advantages of alternate delivery systems, mainly advertising and capitation payment, have not received careful evaluation. It is therefore premature to conclude that alternate delivery systems are structurally more competitive. (Am J Public Health 1982; 72:662-664.)

The length of time amalgam restorations last before replacement was investigated for use as an intermediate outcome measure in utilization review and quality assurance studies. Based on record data from 37 general dental practices, a determination was made of the average percentage of two- or three-surface amalgams receiving another service at 6, 12, and 24 months from the date of insertion. After 2 years, approximately 13 per cent of the amalgams were replaced, and the estimated median life time for amalgams was between 10 and 14 years. The variation in replacement rates among practices was substantial but was not explained by the technical quality of restorations or several practice characteristics.

It has been suggested that the efficiency of claim-based utilization review systems could be improved by focusing on providers with very high utilization rates. This strategy assumes that 1) high utilizers are more likely to be overutilizers, 2) labeling claims (e.g., "high utilizer") do not bias the review, and 3) the claim review process is sufficiently reliable. These issues were studied in prospective dental utilization review system where dentists submit claims and radiographs to an insurance carrier so that they may obtain treatment authorization. A sample of dentists with very high and moderate utilization rates for amalgams, crowns, and bridges were identified and their pretreatment claims containing these services (N = 553) were collected. Half the services from high and moderate utilizer practices were labeled "high utilizer," and the other half were unlabeled. Seven dental consultants from two large insurance carriers independently assessed the appropriateness of the services (approve or deny) from radiographs. The results indicate that services submitted by dentists with high utilization rates were no more likely to be denied than those with moderate rates, labeling claims did not appear to bias the reviewers, and interconsultant agreement levels for denials seldom exceeded 50 per cent. The study suggests that further development of focused review systems requires a better understanding of the association between utilization rates and overutilization and new methods for improving the reliability of reviewers.

Methods for controlling dental care expenditures are taking on greater importance with the rapid increase in prepaid dental plans. The use of regulatory systems to monitor provider performance are necessary to prevent gross over-utilization but are unlikely to result in net savings of more than five per cent of total gross premiums. Theoretically, prepaid group dental practice (PGDP) may reduce expenditures by changing the mix of services patients receive. The modest estimated savings and the small number of PGDPs presently in operation limit the importance of this alternative for the next five to ten years. If substantial reductions in dental expenditures are to be obtained, it will be necessary to limit dental insurance plans to cover only those services which have demonstrated cost-effectiveness in improving health for the majority of people. The concept that richer benefit plans may have small marginal effects on improving oral health may not be easy for the public to accept but, until they do, expenditures for dental care will be difficult to control.

This study examines the amount and sources of variation in dental practice profiles. Three years of insurance claims data on 227 general dental practices were used to generate practice-specific utilization rates for 16 treatment service categories. The results indicated considerable heterogeneity among and within practices in the distribution of service utilization rates such that most distributions could not be described by conventional parametric probability models. Basic standardization methods were used to examine sources of variation among practices. Of the patient and insurance characteristics investigated, only patient age had a major effect on utilization rates. However, there was considerable stability in utilization rates within practices over four consecutive six-month time intervals. The implications of these findings for profile-based utilization review and quality-assurance systems are discussed.