Examining Dentistry’s Future
3 delivery models poised to impact dental care
Ellen Meyer, MBA
As a result of philosophical and structural changes in health care, three distinct models of oral health care delivery are gaining traction. These models are emerging from the need to address economic issues, an increased understanding of the relationship between oral and general health, and the advent of government-mandated health coverage, which includes coverage for pediatric oral health in state Medicaid programs and state exchanges.
The models include dental support organizations (DSOs), which offer an alternative to solo practice and handling the business of dentistry; the use of licensed dental therapists or other midlevel providers to help shoulder the enormous burden of delivering care—especially to children, the elderly, and those in remote areas; and medical-dental collaborative practice, which integrates dental and medical care to improve overall outcomes and potentially significantly lower cost.
A number of professionals representing different points of view recently weighed in with Inside Dentistry on the “how” and “why” of the emergence of these models, and how they can achieve the ultimate goal of expanding access to care.
Dental Support Organizations
One response to changing realities of the health care landscape has been the rise of dental support organizations (DSOs). Although some regard DSOs as a troublesome disruptor of a longstanding private practice model—that of the beloved solo practitioner treating families in a community—there is little dispute that they are here to stay.
Quinn Dufurrena, DDS, JD, is executive director of the Association of Dental Support Organizations (ADSO), whose membership includes DSOs of all sizes as well as vendors to the dental industry. He sees “a vastly altered health care environment that is dictating the emergence of DSOs.”
Heartland Dental is the largest of the DSOs, with more than 675 supported dental offices located within 31 states, including more than 1,000 dentists and 7,000 team members. As director of recruitment at Heartland Dental, Nancy Pals points to the existence of a “multitude of challenges facing modern dentists in the ever-changing dental industry,” which makes DSOs an option that resonates with many dentists at various stages of their careers. “DSO support helps dentists be dentists. It also offers an attractive alternative to private practice for many, including recent dental grads with high debt loads and fewer associate opportunities, and, at the other end of the career spectrum, dentists close to retirement who have limited transition options.”
Brad Guyton, DDS, MBA, MPH, who is dean of dentist development, Pacific Dental Services, another of the largest DSOs, brings the perspective of a clinician, educator, and business executive to the discussion. Describing that environment, he observes what he calls “a perfect storm in the dental industry,” including “a groundbreaking shift in the complexity and reimbursement mechanisms of dental insurance; rising costs of dental technology, while patients demand more of these features; rising debt of students; increased supply of dentists; demographic shifts in graduating dentists; and a slowing demand for adult dental care in the US, according to NADP statistics.”
According to Guyton, “Dentists supported by DSOs often benefit from more efficient and effective systems, economies of scale, negotiating power with third-party payers and suppliers, and access to unique platforms for professional collaboration and mentorship that allow for not only competitive advantage in the marketplace, but faster clinician ramp-up, development, and greater access to care for the dentally underserved.”
Certain advantages may also enable DSOs to provide greater access to health care among diverse populations—including those on Medicaid—than solo practitioners. Mike Plunkett, DDS, MPH, is associate director for strategy and business development at Permanente Dental Associates (PDA), which partners with Kaiser Foundation Health Plan to form the Kaiser Permanente (KP) Dental Program. He maintains that the larger and more diverse organizational structure of DSOs enables them to consider providing service to different types of populations. “Larger organizations have more access to capital, so they can develop capacity quickly and experiment with their dollars—in other words, divest and invest. They can actually create bifurcated systems with different scheduling methods and services for the different patient populations, whereas solo practitioners are challenged due to the smaller scale of their operations and associated costs.”
However, Plunkett also mentions a disadvantage of the DSO model: higher provider turnover rates—especially where dentists are employees. “When you have higher turnover of providers, you don’t get that long-term investment in a relationship with the patients, which fosters practice loyalty, consistency of treatment, and stability in the workforce.”
Help managing the business aspects of practice, the need for increased buying power in the current economy, and the potential for increased access to care are attractive advantages of the DSO model. Practitioners who still balk at the idea may find collaboration in other forms more comfortable (see sidebar “Independence Meets Buying Power”).
Medical-Collaborative Model
Plunkett states that his organization’s primary focus is supporting a medical and dental collaborative model as a prelude to the full integration of oral and medical health care delivery. This process, he adds, will be optimized by migration to a single integrated electronic health record (EHR) system (see sidebar “Managing Information”).
“Dentists have already proven to be essential partners in patient-centric collaborative models that address obstructive sleep apnea, oral/head and neck cancer, cleft palate, oral maxillofacial surgery, and other conditions,” he says. “The profession can build off these established examples of collaborative practice to create scalable models that add tremendous value by serving as extenders of primary care teams.” He says that because patients see them more frequently than other providers, “dentists are well positioned to be a critical touch point in the health care continuum by assisting in early detection of many of the chronic diseases that contribute significantly to health care costs.” It is feasible, he notes, to envision the incorporation of care professionals such as physician assistants (PAs), nurses, or RDHs with advanced training into dental practice to expand the scope of services to include enhanced screening and referral for chronic disease.
An integrated medical-dental system offering expedited access to evidence-based oral health care would come into play in a situation that is all too familiar to Plunkett. “Often the biggest barrier to timely major cardiovascular and orthopedic surgery is acquiring dental clearance due to the presence of oral infection that increases the risk of post-surgical infection. Dental clearance is also often a challenge for head and neck cancer teams preparing patients for radiation therapy,” he explains.
Yet the kind of fully operational integrated oral and medical health care Plunkett and his colleagues advocate exists to date on a large scale only in the Kaiser Permanente NW care model in Oregon and Washington, where 90% of dental members served are covered both dentally and medically by the same system. The NW is the only one of seven KP regions with a combined medical and dental delivery capability. Regions outside the NW utilize traditional dental partners such as Delta Dental to provide insurance and care.
Plunkett notes the existence of “pockets of innovation” in which inroads have been made in the direction of integration. Among them is the Virginia Oral Health Coalition (VaOHC). Sarah Holland is the executive director for this statewide advocacy organization, whose mission is to integrate oral health into all aspects of health. This work has revolved primarily around policy change related to Medicaid benefits. But in addition to the coverage provided for children through the Affordable Care Act (ACA), her organization was recently successful in “advocating for dental benefits for women enrolled in Medicaid.” She says a number of community health centers in Virginia are in the midst of creating obstetrics programs that include oral health, making sure that women who use it are getting a lot of education for themselves and their children, starting at age 1.
Midlevel Providers
Among the more controversial approaches to improving access to care is an expansion of the dental workforce at a time when many dentists are not as busy as they would like to be.
Guyton acknowledges that the topic of midlevel providers is something of a “third rail” with many clinicians, but he strongly believes they will be part of future business models of dentistry much as they have been in medicine. “Nurse practitioners (NPs) and PAs have positively impacted patient health and experiences on the general practice side of medicine, and in fact, I myself see and trust a PA for my routine medical visits.”
The emergence of midlevel providers, says Plunkett, has been historically driven almost completely by the interest in expanding access to care. “Companies may adopt the model and incorporate the providers into their respective practices if they see the opportunity to deliver care at a lower expense. If large organizations or even small practices can lower costs, they can consider expanding into population segments like Medicaid, which have traditionally had very low reimbursements.” While Plunkett observes a “mission-driven thrust” where licensed dental therapists are used now, he says, “Financial evaluation must show a reduction in cost before provider organizations will adopt the model on a larger scale in the interest of expanding access to populations that have traditionally been underserved due to limited finances.”
In Guyton’s opinion, expanded and advanced practice of dental hygienists and other “midlevel” clinicians may allow for enhanced access for dental patients, but for this model to succeed, it must offer the following: financial benefit to both dentists and patients; improved quality of care; and an appropriate level of dentist supervision and formalized training. Most of all, he says, “They should not circumvent dentists or place at risk the dentist–patient relationship; instead, they should work in conjunction with dentists to expand outreach and access.” However, he predicts, “With greater integration of oral and general health care, this new type of provider—which could be a master-level trained advanced hygienist or dental therapist, or possibly a PA or NP with dental training—may someday serve as a conduit or liaison between physician care and dentist care.”
These qualifications and concerns notwithstanding, David S. Gesko, DDS, dental director and senior vice president of HealthPartners, who has direct experience with this model, is proud that his state of Minnesota was the first to license and use dental therapists. He has no doubt they already offer economic advantages, and predicts they will someday soon be as indispensible to dentistry as PAs and NPs are now to medicine—although there was originally significant pushback from doctors, much like dentists who fear their own displacement.
“I’m a big fan of midlevel providers—dental therapists—they’re a wonderful aid to our dental team. They have done exactly what they were intended to do—become a provider in the middle, allowing dentists to focus only on things dentists can do,” Gesko explains.
As for questions about the quality of care delivered, Gesko points out that dental therapists in Minnesota are trained alongside dental students, so insufficient training is not a concern. He says, “I can’t practice without them. The three we have in our HealthPartners practice are a great addition to our team.”
Similar to Kaiser Permanente, HealthPartners includes a medical group and comprehensive medical plan and a dental group and dental plan. Gesko recently presented data supporting the economic benefits of phasing in these lower-cost providers. “The initial data that I’ve presented recently was a very high-level analysis that says that dental therapists save 25%.” This, he says, confirmed his belief that it was a viable model businesswise. “When you can get the same work performed by someone who earns significantly less, it’s kind of a no-brainer.”
HealthPartners, says Gesko, is committed to serving Medicaid populations as well as commercial. “We’re probably 75% commercial, and 25% Medicaid, but everything we do at HealthPartners—medically and dentally—is founded on the triple aim of delivering great health outcomes and great patient experiences at affordable rates.” The dental therapy model, he says, fits perfectly into that objective.
Looking Ahead
Plunkett believes all three models have some opportunity to achieve the overall objective of efficiently and cost-effectively serving the health care needs of all segments of the population, including the underserved. “By virtue of their size and access to resources, the large corporate or group practices are well positioned to experiment with nontraditional workforce and care models to deliver services in different ways to meet the unique needs of different patient populations.” It must be noted, however, that the overwhelming majority of care is still provided and will continue to be provided in small dental practices. “Consequently, for any model to provide meaningful large-scale value, it must have some level of application in that model,” Plunkett says.
Guyton expects all three dental care models presented to continue to evolve, with DSOs continuing to grow fastest. He anticipates slower growth in the medical/dental collaborative model. “Although it arguably has the greatest potential for positive impact on the systemic health of patients, its success requires fundamental changes in how we approach and pay for care,” he says. He predicts that midlevel provider models will generally progress very slowly over the next decade, but “with pockets of success in the treatment of the underserved and in providing greater efficiency for some solo and group practices.”
Getting the Payers Onboard
The required traction for widespread implementation of truly integrated models will rest on outcome-based proof that oral health care lowers medical health care costs. As Holland notes, the measure of success that matters to the main drivers—the payers—is proof that when people are healthier, costs are lower.
The process of medical integration may therefore be sped up by traditional insurance companies, which have much to gain by supporting oral health. Dufurrena notes, “The big insurance companies like United Concordia, which have both dental and medical components, are finding that patients being treated on the dental side will save money on the medical side.”
Plunkett agrees. “If we can demonstrate in our unique integrated system that dental care definitely contributes to lower overall total health care costs, then our organization and other large national health care constituents will respond. KP is both payer and provider and therefore must weigh the patients’ best interest against the economics involved in serving them. We want patients to enroll in our program and choose to stay for their lifetime because we are providing a very different value to them. Our challenge is to follow through on our commitment to improve their total health, while providing a care experience that leads to a lifetime partnership with that member.”
It seems clear that the ability to provide the proof and implement the actions that would deliver the benefit payers want—lower costs—would need to be based on large studies. Dufurrena believes that DSO-supported dentistry is well positioned to implement integrated oral and medical health care. “DSOs have the ability to aggregate information and can have better communication between larger dental groups and physicians groups. They also have the capital resources to actually make that work, while traditional solo practitioners are generally limited to developing relationships with their patients’ physicians; they don’t have the records and communication systems.”
On the other hand, he says, the combined membership of ADSO, which sees about 30 million patients in a year, can put together the information available to show what works and what doesn’t to demonstrate best practices.
HealthPartners not only has the ability to aggregate and act on data, it also has a research institute. While individual data remains confidential, aggregate results are reported back to clinic teams including dental assistants, dental hygienists, dental therapists, clinic supervisors, and regional managers.
“The competence of the entire team is improved with this strategy,” Gesko says. “As an example, system-wide risk assessment for caries, periodontal disease, and oral cancer (which requires the collaborative effort of both dentists and hygienists) is reported regularly. Consistently, 90% of HPDG [HealthPartners Dental Group] patients in a category of moderate or high risk for caries, periodontal disease, and/or oral cancer are provided with appropriate interventions to mitigate this risk. Monitoring of this process of assessment and intervention is conducted in an ongoing fashion and providers are kept abreast of expectations regarding this measure.”
Conclusion
Because of shifting factors such as the ACA, the widespread recognition of the “perio-systemic connection,” and socioeconomic challenges that have permanently changed dental practice, the profession is often struggling to deliver services now seen to be more important than ever. These different models have economic and humanitarian implications in terms of costs and benefits to all concerned—patients, providers, and insurers.
The ideal, says Guyton, is having dental and medical practitioners come together to rally around patient needs and wants in new, unique, and collaborative group practice settings. “These groups will have unparalleled support services, while they simultaneously enhance the quality and efficiency of care, with clinicians practicing at the top of their licensure, so that all patients win regardless of the insurance they possess.”
Given the objective of improved patient care delivered efficiently and affordably to all segments of the population, it seems clear that there is much work to be done, maximizing technology—particularly patient health records—as well as the provider workforce, and perhaps, most importantly, partnership among all those involved.
Independence Meets Buying Power
Denver, Colorado, clinician Gary M. Radz, DDS, occupies what might be seen as middle ground between a traditional private practice and a DSO-supported practice. Although he owns the cosmetic-focused dental practice he has built over nearly 2 decades, he is able to benefit from his affiliation with more than 300 colleagues who subscribe to the Texas-based dental alliance Smile Source. This nationwide network of private practice dentists, which has been evaluated and approved by the ADA CERP as an official continuing education provider, enables him to compete in the new dental economy because it gives member practitioners the bargaining power to more affordably access the equipment and resources they need to compete with the mega group practices in the new dental environment.
“SmileSource is a community of like-minded independent dentists who have dedicated themselves to working as a group to be able to compete in a changing health care market. Not only do we see the economic benefits of working together, we benefit from learning best practices from one another, can maximize marketing ideas and costs, and we have created an continuing education program to help our doctors and their teams bring the latest materials, techniques, and technology to their patients,” says Radz.
Technically a franchise, Smile Source helps independent dentists thrive in the current marketplace, according to Carvin D. Joshua, marketing manager, Smile Source. “Our goal is to provide the benefits of a DSO while the doctors remain completely independent. They retain control of all aspects of their practice while taking advantage of benefits available to them through a membership fee that gives them access to a group of executives, continuing education events, and deeply discounted products and services via ‘the leveraged buy.’”
Joshua suggests this model actually helps preserve independent dentistry, including an avenue for new grads to gain experience and a paycheck working with an independent established dentist rather than a corporate practice.
Smile Source President Trevor C. Maurer points to his company’s tagline to underscore the value of maintaining the traditional practice model despite challenges posed by the current economic environment. “‘Enriching lives by enabling independent dentists to reach their full potential’ is in the best interests of both practitioners and patients,” he says.
Managing Information
Because 90% of Kaiser Permanente (KP) NW subscribers are covered both medically and dentally, it is possible—but not yet seamless—for providers to access accurate information about the dental patient’s medical conditions and medications. “This currently involves multiple systems with the added manual process required to access separate platforms,” says Plunkett.
This process will become much easier in 2016, he says, when KP plans to launch the Wisdom Dental module within EPIC, the largest national EMR vendor. “EPIC is currently utilized by Kaiser Permanente in all other regions, so the migration will also be a key step in facilitating a possible national expansion of the unique integrated capability now found only in the NW.” Similar to KP, HealthPartners includes a medical group and comprehensive medical plan as well as a dental group and dental plan. Gesko says HealthPartners, which already has a robust electronic records system, will complete its transition to fully integrated records with the Wisdom module in 2017. “We’re very excited about the move in this direction because our medical group, which includes 1,500 physicians, is significantly larger than our interdisciplinary multi-specialty group practice, which consists of 75 dentists practicing in 24 HealthPartners dental clinics across the seven-county greater Twin Cities metropolitan area and serves more than 125,000 patients.”
