Orthodontic Problem Solving WORKSHOP December 11, 2006

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Orthodontic Problem Solving WORKSHOPDecember
11, 2006
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• New contract currency
• Eligibility to treatment
• Transitional payments
• Good practice tips
• Monitoring contracts

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New Contract Currency
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New contract currency

• Under the former GDS system
• Paid on a fee for item basis
• Paid AFTER the course is completed
• Possible to claim an interim payment when
  appliance is fitted
• Delays in working being done and final payment

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New contract currency

• Units of Orthodontic Activity (UOAs)
• Gross orthodontic earning reference yr
• divided 55
• Any UDA earnings (for specialist practices)
  divided by 55 and added to UOA total
• CACVs uplifted and therefore 55 by default
  increased

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New contract currency

• New nPDS and nGDS arrangements
• Total annual sum due paid in 1/12 instalments
• Payment is for completed courses of treatment
• Number of cases started is determined by the UOAs
• No payment for completing treatments but monthly
  payment for continuing treatment

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New contract currency

• Units of orthodontic activity (UOAs)
• Assessment 1 UOA
• Case start 20 UOAs (10-17 years)
• Case start 22 UOAs (18 years or above)
• Case start 3 UOAs (under 10 years)
• New case started when first appliance is fitted

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New contract currency

• Units of Orthodontic Activity (UOAs)
• No minimum number of UOAs set out in Regulations
• No 5 activity reduction for orthodontics
• 4 below total UOA contract tolerance

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Eligibility for treatment
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Eligibility for treatment

• In the former GDS
• 96 of NHS orthodontic services provided to
  children
• No eligibility criteria, but dentists needed to
  use clinical judgement
• Prior approval rubber stamping exercise

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Eligibility for treatment

• New contract
• Case assessment
• - Patient aged under 18 for an assessment
• Case start
• Patients aged under 18 at the time of the full
  case assessment will be eligible for treatment of
  they have treatment needs assessed as
• Index of Orthodontic Treatment Need (IOTN) of 5
  or 4 and those with an IOTN Grade 3 with an
  Aesthetic Component of 6 or above

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Eligibility for treatment

• New contract
• Dentists can use their discretion where in their
  opinion treatment is suitable for those with
  lower IOTN needs
• PCTs cannot restrict eligibility but there are
  opportunities for managing referrals
• Is the new IOTN system rationing access to
  services?
• Is there a patient appeal process in place?

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Transitional payments
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Transitional payments

• GDS close down
• BSA applied the close down payments
• Based on paying the GDS fee structure (not the
  new orthodontic currency)
• Payments made in advance of treatment being
  completed
• They amount to a proportion of the fees the
  contractor would have earned under the GDS
• Separate and additional to the BSA payments being
  made in relation to the new contract value
• One-off payments
• PCTs have no discretion over the these payments

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Transitional payments

• GDS close down consisted of
• Cases in active treatment 70 of the value of
  the work
• Cases in supervised retention 50 of the value
  of the work

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Transitional payments

• GDS close down
• Those entitled to receive the payments
• Signed a new NHS contract (including disputes)
• AND
• Held a GDS contract prior to April 2006
• Former pilot PDS practices and those who
  withdrew from the NHS are not entitled to close
  down payments

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Transitional payments

• GDS close down
• Close down fees paid from the central pool
• Payments are made on requirement that patient
  treatment is completed
• Breach of contract
• Deadline for submission of forms was Sep 30 06

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Transitional payments

• STEPS TO INDENTIFYING A GROWING
• ORTHODONTIC PRACTICE

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Transitional payments

• STEP 1
• Look at the latest GDS orthodontic close down
  payment schedule and add up column 5 Total
  value of transitional claims for each contractor
• Note Need to add both the total 50 and 70
  value together

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Transitional payments

• STEP 2
• With a practice based contract, add up the total
  of all column 5s (Total value of transitional
  claims) for the dentists at the practice.

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Transitional payments

• STEP 3
• Compare the total value of the transitional
  claims v the value of the contract signed with
  the contractor as of April 2006.

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Transitional payments

• STEP 4
• Only where the total value of the transitional
  claims is more than 1.5 TIMES the value of the
  contract is the practice deemed to be growing

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Transitional payments

• STEP 5
• If the total value of the transitional claims is
  NOT MORE than 1.5 TIMES the value of the
  contract is the practice deemed to be steady
  state and the PCT need do nothing
• There are no missing payments UOA contract
  requirements should not be reduced

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Transitional payments

• STEP 5
• Where total value of the transitional claims is
  more than 1.5 TIMES the value of the contract
  apply the formula set out in DH fact sheets
• (Total Value of Transitional Claims) - (1.5
  times the Contract Value) x 30

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Transitional payments

• STEP 6
• (Total Value of Transitional Claims) - (1.5
  times the Contract Value) x 30
• The formula should give you a figure. This is
  the level of transitional shortfall. It is
  non-recurrent
• If the formula gives you a figure, then the
  total value of the TC is less than 1.5 times the
  CV (not a growing practice).

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Transitional payments

• STEP 7
• For growing practices only where the PCT agrees
  that there is a funding shortfall for supervised
  retention and repairs need to come to an
  agreement with contractor
• Note National average cost is approx 50 per
  case. This can be applied by uplifting the
  shortfall for the formula by 23

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Transitional payments

• STEP 7
• 1. (Total Value of Transitional Claims) - (1.5
  times the Contract Value) x 30 X
• THEN
• 2. Uplift X by 23

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Transitional payments

• STEPS TO PAYING A GROWING
• ORTHODONTIC PRACTICE FOR
• TRANSITIONAL PAYMENTS

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Transitional payments

• Growing practices outstanding fees
• Case study
• Contract value 200,000
• Total value of transitional claims 450,000
• (450,000) - (300,000) x 30 45,000
• 45,000 23 55,350 Non recurring

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Transitional payments

• Growing practices outstanding fees
• Case study 1
• Contract value 200,000
• Outstanding transitional fees 55,350
• Options
• Reduce UOA requirements on a non recurring basis
  to the value of 55,350 manageable in yr 1.
• Add a non recurring total of 55,350 to the CV
• Uplift the contract on a recurring basis to a
  level that automatically covers the shortfall.

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Transitional payments

• Growing practices outstanding fees
• Case study 2
• Orthodontic contract value 0
• Outstanding transitional fees 20,000
• Options
• Reduce UDA requirements on a non recurring basis
  to the value of 20,000 (if a contract is in
  place)
• Pay the contractor 20,000

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Good practice tips
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Good practice tips

• Assessing local needs and services
• Work collaboratively
• Getting best value from contracts

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Assessing need

• Mapping current services accessibility (inc.
  waiting times and list sizes)
• Review patient flows
• Determining local need for services /
  demographics
• Setting this within the context of overall
  service needs and priorities
• Have a clear commissioning plan agreed by
  the PEC Board

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Work collaboratively

• Joint commissioning opportunities
• Variation in orthodontic accessibility budgets
  by PCTs
• Share expertise protocols
• Sector wide protocols for referral processes
  (equity of access)
• Joint management of patient appeals re IOTN
• Clinical network groups
• Monitoring contracts
• Development of performance management framework
• Shared systems for managing poor performance or
  clinical governance systems

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Best value from contracts

• Referrals to orthodontic contractors
• Develop consistent local referral protocols
• IOTN training for referring practitioners
• Central management referral system
• Assess prioritise patients
• For primary and secondary services
• Work with contractors to
• Understanding their waiting lists
• Agree prioritisation of lists
• Agree ratio of assessments to case starts
• Opportunities beyond the guarantee period

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Best value from contracts

• Improve patients understanding of the
  eligibility criteria
• Re-commissioning
• Tender for additional/new services
• 55 is not the going rate national orthodontic
  UOA rate
• Cost per treated case?

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Monitoring contracts
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Monitoring contracts

• Contractors should inform BSA when
• Case is assessed
• Started
• Completed
• discontinued

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Monitoring contracts

• Outliers
• IOTN
• Ratio of case assessment v case starts
• Number of discontinued cases