Integrating Oral & Medical Health Care
An economic perspective on fixing the current health coverage model that separates the mouth from the rest of the body
A growing body of evidence suggests an association between oral and systemic health, particularly in terms of the impact of periodontal disease on chronic illnesses, including diabetes and cardiovascular disease, and pregnancy outcomes. Numerous studies have already demonstrated that receiving concurrent care for both oral and medical disease enhances the effectiveness of both; further, some show reduced costs mainly due to lower hospital-related expenses.
However, because dental coverage doesn’t fit neatly into the larger health insurance system, it is more difficult and expensive for patients to access and reap its benefits. Many believe the solution lies in integrating oral and medical health care. But what would be the economic impact of incorporating oral health into the larger health care system? And what will it take to make the changes needed?
R. Bruce Donoff, DMD, MD, is among those seeking answers to such questions. Donoff, who is dean of the Harvard School of Dental Medicine (HSDM), says his vision is to “transform dentistry by removing the distinction between oral and systemic health.” This, he says, will require both a public and private effort via an entity with the resources to move oral health care of out the “stepchild category” that hinders access by those who need it most.
Separate But Not Equal
How the specialty of oral health developed separately from the rest of the medical system, says Donoff, dates back to the Gies Report in 1926. Its author, William Gies, proposed making dental school part of universities, which significantly raised standards beyond its previous trade-school status. But the report stopped short of true integration, setting the stage for dentistry’s separate status and development.
While this “siloization” of the profession enabled dentists to remain relatively aloof to health care developments, including regulation, it ultimately inhibited the profession’s ability to adhere to a system equivalent to that of medical practice, with its complex interwoven hospital affiliations and reimbursement methods.
“For example, because dentistry stayed out of Medicare, we have a situation where there’s an increasing population of elderly patients who cannot receive the oral care they need,” observes Donoff. He notes further that while medicine was forced to adapt to new realities involved in serving patients covered by Medicare and Medicaid as well as employer-provided health insurance, dentists remained largely in their fee-for-service “bubble,” in which oral health care was either covered inadequately or not at all by health benefits.
DentaQuest President and Chief Executive Officer Fay Donohue, MBA, describes the challenges and differences in financing medical and dental care. Pointing out that all money for health care comes from one source—wages—she explains, “Out of our wages we pay taxes, buy insurance, or pay directly for health care services. In other words, there is only one source of money, but that source gets distributed in different ways.” According to Donohue, 86% of the overall population purchases or participates in some sort of prepayment or insurance plan for medical care services, much of it through the government, which is the largest distributer of funding for medical care through Medicare, Medicaid, FEP, the military, and other programs and plans.
Donahue says the situation is very different for dental care; expense is the number one reason cited by those who don’t receive it. “Only 50% of the population has a plan or coverage for dental care and government is a very small payer,” she explains. While coverage for children is required in Medicaid and CHIP programs, she says Medicare covers almost no dental care and most Medicaid programs either do not provide dental coverage for adults or provide a minimal benefit. As for employer-provided dental plans, although a lot of companies offer them, many, particularly small businesses, do not offer coverage, she says.
“As a result we have an oral health crisis in this country,” Donahue explains. “We have children in school with tooth pain. How are they able to learn? We have reservists unable to be sent overseas because their oral health is poor. We have people lining up at Missions of Mercy across the country hoping to get dental care because they cannot afford to get care anywhere else. We have an oral health care system that is broken for those most in need.”
Impact of the Affordable Care Act
Kathleen O’Loughlin, executive director and chief operating officer of the American Dental Association (ADA) says, “What we’re all talking about is a complex and fragmented system in the throes of change for many reasons.” Among them, and perhaps most notably, is the impact of the Affordable Care Act (ACA) on dental care.
As a result of the ACA, O’Loughlin says, she expects very significant expansion of Medicaid without needed administrative improvements in the dental Medicaid programs and concomitant expansion of the provider network. “The expansion of Medicaid has not taken into account the need to incorporate dental into the broader medical primary care system; for the most part, adults have been left behind in most states,” she explains.
O’Loughlin further maintains that many dentists don’t have relationships with primary care physicians and don’t participate in Medicaid, due to the “complexity of the dental Medicaid program.” Mainly for this reason, she says, even though ADA Health Policy Institute analysis on the adequacy of the dental workforce indicates that there is a sufficient supply of dentists, there are “dental deserts” due to maldistribution of the existing workforce, creating access to care issues in many areas. “When one combines the challenges faced by dentists participating in dental Medicaid programs with the maldistribution of dentists for many reasons—often economic—access is bound to be compromised.”
She sees the role of the ADA at this time as being the thought leader in the identification of critical trends, to assess what the health care marketplace is telling us. “At this time, there is neither the structure nor the process to support true interprofessional patient-centered collaboration between medicine and dentistry, although there are several emerging promising examples of organizations that seem to make it work,” she explains.
An Economic Case for Oral Health Care Coverage
Although quantifying the benefit of integrating dental and medical care has been difficult in the past, according to Donoff, that is changing. “Burgeoning data from a whole host of insurance companies that insure both medically and dentally now indicate that there are economic as well as health benefits to be gained from including oral health care coverage in their plans,” he says. This offers a compelling cost-saving case for integration during a time of skyrocketing health care costs—especially when assessing benefits not just in dollars saved by insurance providers, but also in potential gains due to a patient’s improved ability to contribute—for example, by serving in the military, as suggested by Donohue.
This is the main reason the most recent Leadership Forum hosted by HSDM moved away from its previous emphasis on integrated professional education to a focus on integrated professional practice. “Put Your Money Where Your Mouth Is: The Economic Imperative of Oral Health” convened a group that included not just dental health care and insurance providers, but also economists and public health experts to ponder and seek solutions for the issues involved in integration.
Among them, Marjorie Jeffcoat, DMD, professor and dean emeritus, University of Pennsylvania School of Dental Medicine, says it is clear that health care dollars spent on the mouth would indeed save money, but says presenting the data effectively is crucial to supporting the case for widely accessible oral health care coverage.
“Evidence is critically important to determine where we should put our dollars in this age of limited resources for everything, including medical care,” says Jeffcoat. Her evidence-based findings on the impact of periodontal therapy on general health, which appeared in the American Journal of Preventive Medicine, was based on a study of more than 1 million patients.
She says, “We examined the evidence for answers to this question: Does treatment of periodontal disease decrease the overall medical cost for our patients—including those with diabetes, heart disease, stroke, pregnant women and outcome of pregnancy, rheumatoid arthritis?”
The study did indeed find that periodontal therapy improved general health in the population studied, which led to lower overall medical costs, Jeffcoat says. These reduced costs were due largely to a decrease in hospitalizations, particularly in patients with diabetes, cardiovascular disease, and cerebroartery disease.
The study also showed improved pregnancy outcomes in pregnant women who received periodontal treatment, which lowered cost of care for both mothers and infants. “Depending on how you define it, periodontal disease is surprisingly high—80% to 90%—among pregnant woman and simple to treat once patients are taught how to properly care for their teeth,” she says.
A longtime proponent of integrated dental and medical care, Allen L. Finkelstein, DDS, has reached the conclusion that providing definitive care for oral as well as general medical problems is good business as well as good medicine. Finkelstein, who is currently the chief executive officer of Bedford HealthCare Solutions, was formerly chief dental officer of AmeriChoice/United Health Group, insuring more than 3.5 million lives in dental government coverage. He is also a general dentist in Great Neck, New York.
He points out numerous ways health care dollars are lost to wasteful practices such as the common use of the emergency department (ED) for treatment of the painful consequence of dental neglect. “Instead of receiving the definitive care they need by a qualified oral health care practitioner, patients are generally treated mainly for the pain and infection,” he explains. “A dental problem can sometimes lead to a 1- to 2-day hospital stay, costing thousands instead of hundreds of dollars for an in-office dental procedure—eg, incision and drainage—that could be easily performed by a dentist during an office visit.”
But the greater problem, Finkelstein says, is the continuation of a behavior pattern he calls “episodic care,” stemming from the failure to establish a relationship with a dentist.
He suggests ways—some of which are being piloted—insurance companies, pediatricians, and pharmacists, as well as dentists, can work together to break the cycle of episodic care and provide effective solutions short of a total overhaul of the health care system.
Finkelstein supports incentivizing pediatricians who provide fluoride varnish—as allowed by more than 40 states for Medicaid-covered children—to refer young patients to dentists through dual reimbursement, first for the visit to the pediatrician who applies the varnish, then again when that same child presents to the dentist. He also believes placing common preventive care items—eg, toothbrushes, toothpaste, xylitol—on a prescription formulary would both provide “real time data” on utilization of preventive products and verify care by the oral health care provider prescribing them.
However, he says, as long as patients present to the ED, there should be a way to render appropriate, cost-effective dental treatment. At best, this would include a staffed dental suite connected to every ED, but at the very least there should be on-call dental staff within a certain radius of the hospital.
Making Change Happen
So, what does it take to make the needed changes and to translate public health knowledge into public health policy?
In an effort to provide a framework for thinking about how fundamental change happens structurally, John E. McDonough, DrPH, MPA, of Harvard’s department of health policy and management describes three components that feed into one another—knowledge base, social strategy, and political will.
An example of building a knowledge base that led to major changes in medical health care delivery, he says, was The Institute of Medicine’s six reports on insurance and health care. These reports, which focused on the problems of uninsurance in the United States, McDonough says, placed the spotlight on the issue “in a comprehensive, authoritative way that was blessed by a national organization with a lot of prominence.”
The social strategy phase is about mobilization, organization, and defining the targets—for example, changing policy, passing a law, securing funding, etc. “This involves identifying the different levers of change and what it take to influence them,” McDonough says.
McDonough suggests that the best chance for achieving change in health care now lies in marshaling the forces needed through “appropriate alignment” with efforts already in progress, including those by the DentaQuest Foundation, due to its base strategy, political commitment, and current momentum.
The Role of Diagnostic Codes
Large-scale, evidence-based studies such as Jeffcoat’s are an important part of building the knowledge base and crucial to advancing the message that oral health care not only improves health, it lowers costs. However, she insists the message would likely be even more powerful if dentistry used diagnostic codes such as those used in medicine.
Diagnostic codes, Jeffcoat says, would improve researchers’ ability to conduct and interpret studies that could be the basis for “authoritative” reports such as that described by McDonough.
She says it is especially important to differentiate the various degrees of disease severity and required treatment. “We have to have clear definitions, so doctors everywhere can be on the same page,” Jeffcoat explains. “As it is now, we’re dealing with the evidence to the best of our ability, but let’s get real, and deal with definitions and codes the same way they do in medicine.”
Approaches to Solutions
Economic guru Clayton Christensen regards integration of oral and overall health care as a problem—like that of the sputtering American economy—whose solution may lie in application of the “disruptive innovation” economy theory for which he is known worldwide.
Christensen, who is the Kim B. Clark Professor of Business Administration at the Harvard Business School, says unlike “sustaining innovation,” which is now favored by business managers seeking to preserve capital, disruptive innovation spawns growth and jobs but requires the vision and patience for a long-term, possibly long-shot investment, where the big payoff may be a decade or more in the future. Disruptive innovation makes things that are complicated and expensive—as health care is now—affordable and accessible. He makes it clear this is no job for the free market or adherence to the currently predominant business “commandments,” which have discouraged truly disruptive innovation.
“The reason why health care is complicated and expensive and not accessible is because the pricing of individual services does not work,” Christensen says. “You have to put the pricing inside the system.”
Real-World Application
Mike Plunkett, DDS, is the senior director of dental care delivery at Kaiser Permanente, which is now perhaps the best known example of health care delivered “inside the system,” where the focus is keeping people out of the hospital.
The integrated managed care consortium opened for public enrollment in 1945 but got its start in the late ‘30s and ‘40s, when industrial shipping magnet Henry J. Kaiser and a young surgeon named Dr. Sidney Garfield sought to embed primary care into the worksite. “What they saw was their workers got much healthier, more productive, and did not miss as much work,” Plunkett says.
This ultimately led to the organization as it exists today, with three distinct but synergistic entities: the Kaiser Foundation Health Plan, an insurance function product; its regional operating subsidiaries, Kaiser Foundation Hospitals; and the autonomous regional Permanente Medical Groups, the medical and dental associates who contract exclusively with Kaiser Permanente.
There are now seven regional organizations covering 9.5 million subscribers in eight states and the District of Columbia. Kaiser Permanente Northwest serves more than 235,000 dental members and contracts with more than 140 dentists in the Permanente Dental Associates group practice.
Plunkett mentions that while all Kaiser Permanente regions offer both medical and dental products, the Northwest is the only region with its own Kaiser Permanente dental providers and offices. Kaiser Permanente Northwest is unique in its integrated approach to medical and dental care. Plunkett believes that this structure could serve as a model for the successful delivery of integrated preventive and clinical care on a large scale.
Donohue notes the disproportionate burden of dental disease on poor and minority populations, who, as Finkelstein lamented, are treated expensively and inappropriately in the ED. She expects solutions to the many complex issues involved will require taking a “systems approach,” including financing, care that buttresses current program focused on children with the help of pediatric nurse practitioners and physician assistants, the community, and educators.
In alignment with Christensen’s assertion that disruptive innovation—including the use of technology and people “working at the top of their license”—is needed to make health care more accessible and affordable, Donohue says, “We need to create models of care that are convenient, inexpensive, and competent, with help from nurse practitioners and physician assistants to help deliver benefits, which are currently focused on children.”
Whether change comes about via “nudges” or “massive disruption,” says O’Loughlin, will come down to the political will described by McDonough, which she says is still lacking in most states. Beyond that, she says, overcoming the fragmentation between medical and dental care requires integrating the technology that supports medical and dental practice. “We need to have just one electronic health system for dental, medical, vision, and mental health, because patients don’t walk in with their body, brain, and mouth in different places,” she asserts.
Most of all, she says, “If we’re going to make this interprofessional, patient-centered delivery system happen—and the economic data that we should is compelling—we should do it most of all because it’s in the best interest of our patients.”
Conclusion
No matter how well any type of health care is priced or made available, it can only be effective—from both a human health and monetary standpoint—if it is accessed. This point was sadly apparent in the widely publicized case of Deamonte Driver, a Maryland child who died from infection from an abscessed tooth. Although Driver was in fact covered by insurance, it was not accessed on his behalf.
Plunkett asserts that claims data—ie, proof of accessed care—“demonstrates a strong association between dental utilization and reduction in total cost of care.” Access to care, and its economic and patient care benefits, would be assisted by Donoff’s call for a shift from interprofessional education to interprofessional practice.
“Placing a spotlight on the economic imperative of good oral health indicates that the focus should be less on interprofessional education and more on interprofessional practice. But the main thing for me is less talk and more action,” maintains Donoff. In keeping with that position, Donoff, who calls himself “a great believer in experiments,” says Harvard Dental School plans to implement a primary care medical practice in its dental center so physicians, dentists, medical students, dental students, and nurses can all see patients together.
This, he says, is just one of the many first steps needed to achieve the goal of removing the distinction between oral and systemic health. “We’re working on a roadmap to integrate oral health into primary care,” he concludes. “This transformation is going to take people who are committed to change without the certainty of knowing where it will lead, people who look at the bigger picture, not just the lesions on teeth.”
How Dentistry Can Close Care Gaps
While Mike Plunkett, DDS, says the benefits of dual care and coverage are dramatically demonstrated in the Northwest Kaiser Permanente region, it is not the dental care alone, per se, that is most important.
“What is truly unique in this system is not so much that care and coverage come together when most dental care is separated,” he says. “Sure, we deliver comprehensive dental care and that is important, but the profound opportunity to lower costs and improve quality of life for our patients lies in the fact that we are among the top access points for health care in our system; patients come to the dental office more than nearly any other clinical department.”
This, he says, means dental care teams are in a unique position to close care gaps; for example, they can note and follow-up on evidence-based treatments and preventive services such as mammography and colorectal screenings.
Kaiser Permanente is moving toward an integrated medical and dental electronic health record system. “In this integrated record system, dental won’t be separate as it is now,” Plunkett says, “Dental providers will be able to more easily coordinate patients’ total health needs like any other specialty.”
This integrated health record, will offer an improved ability to leverage dental providers’ immense opportunity to serve as extenders of the entire health care system. Patients will be able to schedule medical appointments or even receive needed services during dental visits, which not only typically occur more frequently but also last longer than medical visits.
“Even if the dental and medical providers continue to be somewhat separated, if we can demonstrate that we can contribute significantly to reducing breast cancer, colon cancer, unchecked diabetes, and more by closing the care gap, there’s a significant value proposition that goes well beyond dental.”
Japan Takes Aim at Improving Oral Health
Makoto Nakao, chairman of CG Corporation, describes the oral health initiatives taken by the Japanese government in its campaign to improve the overall health of its citizens. This included Healthy Japan 21, a nationwide program formulated by Japanese Ministry of Health, Labor, and Welfare that set targets for lifestyle and quality-of-life improvements in nine key areas.
“In the area of dental/oral health, 16 target figures were set for 13 items, and their overall achievement ratio reached nearly 92%, the highest among all the nine areas,” says Nakao.
Another initiative, the Japan Dental Association’s (JDA’s) 8020 national campaign for oral health promotion, targets what Nakao calls Japan’s “super-aging society.” Based on findings that link the number of functioning teeth to improved health and longevity, it focuses on tooth retention, setting retaining at least 20 teeth at age 80 as its goal. This, says Nakao, involves continuously sending messages to the Japanese public in an easy-to-understand way. “Each one of the JDA members has taken a concrete action for every one of their patients to realize the 8020 goal of retaining at least 20 teeth at the age of 80.”
Nakao observes that caring for this segment of its population in particular—the proportion of the people aged 65 and older reached 24.1% in 2012—calls for “close collaboration among clinicians, academia, and dental businesses.” Because the number of beds at long-term care facilities is limited, “measures for increasing inpatients at long-term care facilities” and “enhancement of in-house long-term care” are urgently needed.
To accommodate the increasing need for home-visiting treatment by oral health care specialists in the meantime, Nakao says, his company is among those striving to develop equipment and treatment systems for more efficient in-house treatment, which are more portable, more energy-efficient, and need shorter chair time.
Nakao noted that the importance of raising awareness and participating in activities promoting oral health was a central issue at the World Congress 2015 held in March in Tokyo, saying, “The key to the success of the Congress is how much we can raise the awareness of the world dental professional/practitioners about the role and the increasing importance of dental medicine.”
Editor's Note
Inside Dentistry will continue to follow HSDM's Leadership Forum initiative. Look to InsideDentistry.net and future issues of Inside Dentistry and Compendium for upcoming white papers, webinars, and other related events on the economic imperative of oral health.
