The Truven Health Blog

The latest healthcare topics from a trusted, proven, and unbiased source.

Dental Care Access vs. Coverage

By Katie Fingar/Wednesday, August 26, 2015
Katie Fingar
Mark Smith
A recent Washington Post article, Dental care for Medicaid patients is expanding, but a study says that won’t reduce ER visits, highlights the results of a study published in Health Affairs, which was conducted by researchers at the Agency for Healthcare Research and Quality, Truven Health Analytics, Stanford University, and the University of California, San Francisco. The study found that in urban areas, where over 90 percent of dental ED visits occur, rates of dental ED visits by patients with Medicaid remained high even in states that covered preventive and restorative dental services through Medicaid and in counties with an adequate number of dentists. What are the implications of this?


We know that dental insurance coverage is increasing via the expansion of Medicaid under the Affordable Care Act (ACA). Both the expansion of Medicaid and the provision of preventive and restorative dental care (e.g., fillings, dentures) beyond emergency services (e.g., extractions of diseased teeth) are left to each state’s discretion. As of 2012, fewer than half of all states provided non-emergency dental coverage to non-pregnant and non-disabled adult Medicaid enrollees. At the same time, as of July 2015, 30 states and the District of Columbia have opted to expand Medicaid to adults with incomes up to 138% of the Federal Poverty Level. In those states that both expanded Medicaid and cover non-emergency dental services, millions of Americans now have dental coverage.

What is less clear is whether these gains in coverage will lead to increased access to care. The study published in Health Affairs also found that the supply of dentists was not correlated with reduced ED use for dental conditions by patients with Medicaid, possibly because many dentists do not accept Medicaid. The percentage of dentists who accept Medicaid has been reported to be as low as 11% in Missouri, 15% in Florida, and 20% in New York. Therefore, while coverage is important, without access to dentists who accept Medicaid, it is likely that people will continue to use the ED for dental conditions.

More research is needed to examine whether the coverage expansion under the ACA has indeed resulted in greater access to dental care and a reduction in ED use for dental conditions.

Katie Fingar, PhD, MPH
Research Leader

Mark Smith, PhD
Director, Behavioral Health & Quality Research


Sharing Quality Insights With Providers

By Michael L. Taylor/Tuesday, August 18, 2015

BlueCross/Blue Shield of Illinois (BCBSIL) recently announced a new data sharing arrangement with the DuPage Medical Group, a large independently owned physician medical group in the Chicago area.  This arrangement calls for BCBSIL to share its medical claims and (unnamed) quality data with physicians of the DuPage Medical Group. These data will help the physicians better understand the healthcare services their patients are receiving outside the DuPage clinic walls, including the quantity and quality of care their patients are receiving from non-DuPage physicians.

This information is becoming more important to physicians as their reimbursement for services provided is increasingly tied to patient outcomes. The Blues organization also announced their goal of having 75% of their Illinois market to be paid on the basis of improved quality and lower costs within the next 5 years. This trend has been driven by the Center for Medicare and Medicaid Services (CMS), with HHS Secretary Burwell announcing the 2018 CMS target of 50% of payments based on value, and 95% of fee for service payments having a quality component as part of the payment.

We are likely to see many other arrangements similar to the BCBSI deal in the commercial market over the coming months and years. The country is gradually realizing that fee for service payment arrangements become an incentive to provide more care, while value based payment models incent higher quality care.

Rewarding higher quality care and penalizing poorer quality care is a step in the right direction, and for certain elements of care, quality can be readily measured. For example, for most common surgical procedures, standards have been developed to measure complications, length of stay, hospital-induced infections, mortality and other discrete endpoints. It may not be as straightforward to measure quality of care in the primary care settings, but quality can be measured.

An interesting article published in 2012 in The New England Journal of Medicine offered a framework for measuring system-related quality of care. The authors suggested 6 domains of quality that could be measured:

  1. Patient safety
  2. Patient and caregiver-centered experiences and outcomes
  3. Care coordination
  4. Clinical care
  5. Population and community health
  6. Efficiency and cost reduction

This framework may be well suited to measure the effectiveness and quality of care being delivered in the primary care setting, and these efforts need to be supported. Hopefully this BCBSIL and DuPage Medical Group partnership will spur other large carriers to try similar arrangements with hospitals and physicians. Combining cost metrics with quality metrics can deliver the type of transparency that is lacking in today’s fee for service world. The payer community has been asking for this type of transparency, and consumers are now asking for the same information.

I’m hopeful the metrics agreed upon will be shared publicly.  It will be interesting to follow this new arrangement over time to see if the quality metrics are robust, and if patient care actually improves.

Michael L. Taylor, MD, FACP
Chief Medical Officer


No Organization Likes Surprises – Especially When it Comes to PBM Contracts

By Marie Bowker/Monday, August 10, 2015

CVS Health Corp., the second largest pharmacy chain in the country, is the latest company involved in a class-action lawsuit for allegedly overcharging patients for generic prescription drugs.

Though CVS has yet to make a public statement about the claim because they haven’t been officially served with the lawsuit, company spokesman Michael DeAngelis did state that co-pays are determined by a patient's prescription coverage plan, not by the pharmacy, and that a similar lawsuit in Massachusetts was dismissed.

Plan sponsors don’t always prevail in these kinds of complaints, but situations like this are exactly why you don’t want to use a pharmacy benefit manager’s (PBM’s) standard contact language.

The details around factors such as discount programs and “usual and customary” pricing can make all the difference in how much you and your plan members pay for prescription drugs.

For example, your PBM contract should include language that the PBM will charge you for the lowest of the following pharmacy network claims (less member copayments or deductibles):

  • Participating pharmacies’ usual & customary (U&C) price
  • AWP discount (ingredient cost) plus the guaranteed dispensing fee, if applicable, or
  • Maximum allowable cost (MAC) plus the guaranteed dispensing fee, if applicable

Ensure your PBM contract protects your interests.

Health Plans, download these best practices for contracting with your PBM, visit our website or contact us here

Employers, download these best practices for contracting with your PBM, visit our website or contact us here

Marie Bowker
Senior Director, Payment Integrity

Data-Driven Healthcare Decisions

Two Minutes With Jen Huyck, Vice President Analytics and Consulting, Truven Health Analytics

By Jennifer Huyck/Friday, August 7, 2015


Healthcare payers are turning to data and analytics for a variety of reasons, but the most prominent is the impact of healthcare reform. The evolving healthcare landscape has put a lot of pressure on employers, health plans, and providers alike. And with that, from an employer perspective, the C-suite is putting a lot of pressure on their health benefits group, who in turn is putting more pressure on their health plans to understand the ROI or VOI for every dollar spent. 

Payers Have Different Needs From Data Analytics and Reporting 

When payers are thinking about data analytics and reporting, they have a variety of needs:

  • They’re looking for benchmarking information to help show how they compare to others and where opportunities are. 
  • They’re looking for flexibility when it comes to reporting. Different audiences have different needs. How you report information back to the C-suite might be very different from how you report to a case manager or to someone in the health benefits department. Having the ability to show data and information in different ways is essential. 

Experience is important both from a data management as well as a consultative perspective. When you think of data management, you want to make sure your partner understands the importance of data accuracy and takes it seriously in order to ensure the data you put in is as accurate as the data you get out. 

How Do Payers Use Advantage Suite from Truven Health? 

Advantage Suite is our flagship product. It allows users to take disparate data sources and integrate them together. 

When using Advantage Suite, users are able to take a variety of data sources, such as medical, prescription drug, and eligibility information, as well as data sources that include health risk assessment information, disease management, and care management and integrate it together so that they really can look at cost and quality as well as provider information to make decisions. The power of the Advantage Suite data warehouse is that you have the ability to get down to claim level analysis, as well as summary level analysis, executive reporting, and dashboard information. 

As you look at data, it’s most important to understand what that data means. If you can get the right data to answer the good and bad news as well as the so and now what, then you will make the right decisions for your company and for your employees. 

Learn how to put your data to work with Advantage Suite®. 

Health Plans, please visit our website here or contact us here

Employers, please visit our website here or contact us here.