The wicked problem of the oral health care system.

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The structure of the oral health system in the United States and globally has created sustained inequities and disease burden stemming from largely preventable diseases.1 Those higher risk for oral diseases face challenges in accessing and affording care.2, 3 Social determinants of health have significant impacts on outcomes.1 Dentistry is siloed from overall healthcare, even though the oral/systemic connection is well documented.4-10 Providers are compensated based on procedures (fee-for-service) rather than outcomes,11 in spite of evidence that alternative payment models can both reduce costs and improve access.12 Workforce challenges also persist, with dentistry by and large not utilizing the same extended workforce model as medicine.11 The oral health system was not engineered with purpose, and has resulted in a patch-work landscape, which is no longer a good fit for the need.11 The system's purchasers – be it government, business, families, or individual consumers – continuously invest in this patchwork system of care. Thus, addressing the oral health system is a wicked problem.13 The overall concept of a wicked problem was articulated by Rittel and Webber in 1973.14 A wicked problem is one that has numerous and complex causes, is difficult to describe, has multiple players or stakeholders, is interconnected with other problems, and is tough to solve – and may in fact not have a right answer.15 There are several characteristics of our oral health system that are in concordance with a wicked problem.13, 15, 16 A step toward making movement in addressing this wicked problem involves rethinking the oral health system with a focus on improving oral health outcomes and acknowledging that the problem is complex, heterogeneous, and dependent on multiple influencers.13 There is not one solution to the problem,13 but there are multiple approaches that collectively can help movement in a positive direction and provide hope. One such approach involves integrating oral health care with the wider healthcare system and incentivizing optimal health outcomes.11 This approach can be described as value-based care. Value-based care is typically defined as a reimbursement model in which providers are incentivized based on patient health outcomes, with value described as improved quality at lower costs.19 However, although reimbursement presents one opportunity, this alone does not encompass the complexity needed to fully achieve a value-based approach to health care. Three areas of transformation, acting individually or synergistically, advance value-based care in support of true health systems change. Multiple initiatives are underway that involve transforming care, data/analytics, and payment. The oral health environment is at the early stages of transitioning to value-based care, and the results of this transition will strengthen health equity and reduce disparities by redistributing resources aimed at oral health care (Figure 1). Care, data/analytics, and payment transformations will collectively drive improved patient-centered, health system, and population outcomes, thereby moving toward value-based care. Deploying multifaceted solutions, involving a multitude of stakeholders, is a recommended strategy to tackle a wicked problem such as the oral care system.15 Figure 1 visualizes elements considered vital to driving evolution of a value-based oral healthcare system with equity and value at its core. This model of an oral health care system will enable redistribution and novel allocation of resources, propel innovation supporting value-based care, and will likewise impact dentistry. Reflective of these elements, contributors to this special issue of the Journal of Public Health Dentistry – which include patients, communities, providers, grant makers, advocates, policymakers, and researchers – offer evidence of their efforts to address our wicked problem. Such efforts include adapting reimbursement mechanisms, prioritizing on prevention over treatment, growing interprofessional practice, increasing data measurement, enabling interoperable Health IT, and empowering patients and communities to shape their health trajectories. Their fortitude can help – in the words of Alberti, Bonham, and Kirch – make “equity a value in value-based health care.”21