The care continuum may be drawing closer together as value-based care creates new business cases for population health management, yet one segment of the healthcare delivery system has been chronically left out of the loop.
Though they provide critical preventive services that have wide-ranging impacts on clinical health, dental care providers are still relegated to the fringes of the patient-centered ecosystem.
On the consumer side, dentists have been fighting a bad rap for decades. Separate insurance protocols, which often require significant out-of-pocket expenses, along with inadequate patient education and negative perceptions about treatment options and the potential for discomfort, have contributed to cultural stereotypes of the dentist’s office as a place to fear, dread, and avoid.
Within the provider community, low participation in meaningful use, different record-keeping needs, and a unique set of health IT vendors have kept dentists technologically separate from the rest of the clinical spectrum, while limited collaboration and coordination with primary care providers has largely left dental health off the checklist for patient-centered preventive care.
But dodging or delaying dental care can have significant impacts on overall patient wellness, and may lead to more expensive, invasive, and painful procedures down the line. Dentists can act as the first line of defense for the prevention and detection of oral cancers, gum disease that results in bone loss, and difficult-to-treat infections that start in the teeth and jaws.
They can also contribute significantly to the health system’s understanding of socioeconomic patterns of chronic disease and patient activation, since poor oral health often goes hand-in-hand with lower levels of education, restricted access to care, and lower rates of health insurance coverage.
Patients with at least some college education are nearly three times more likely than those without a high school diploma to visit the dentist, according to data from Healthy People 2020, and are equally less likely to suffer from destructive periodontal disease.
Privately insured consumers access dental care more than twice as often as the uninsured, and they are 20 percent more likely to have regular contact with a dentist than those using public insurance programs, which may contribute to long-term disparities in outcomes for certain cancers.
With dental caries and periodontal disease ranking as two of the most common chronic conditions among children and adults, surpassing the national rate of diabetes, it may be time for the healthcare industry to reassess the position of dentists and other oral healthcare providers within the population health management environment in order to deliver truly comprehensive care to patients.
Examining the medical-dental health IT divide
While many dentists qualified for either the Medicare or Medicaid EHR Incentive Programs, few ended up participating in the federal push to increase health IT adoption for eligible providers and hospitals.
As of October 2016, just 272 dentists received payments within the Medicare EHR Incentive Program, complemented by much more significant participation on the Medicaid side of meaningful use, with nearly 21,000 unique providers getting paid for one or more years of successful attestation.
Compared to more than 300,000 physicians across both programs, dental adoption of certified EHR technology spurred by federal incentives has been extraordinarily modest.
That doesn’t mean that dentists are health IT luddites, but they do have habits that differ somewhat from their physician peers.
In a 2013 study from the Journal of the American Dental Association, just under three-quarters of solo dentists and 78.7 percent of group practices used computer software to manage their clinical information, while an average of 15 percent stated they were completely paperless.
Dentists tended to rely heavily on hybrid workflows, using paper to duplicate key patient data between 10 and 45 percent of the time, especially when it came to treatment plans and medical or dental histories.
Just over 30 percent of solo practitioners and nearly 60 percent of group practices stated at the time that they were likely to start using electronic dental record (EDR) systems within the next two years, and were highly likely to purchase products from one of only four major vendors – a consolidated technical landscape that might make the rest of the clinical world a little envious.
At the time, about seventy percent of solo dentists stored treatment plans and records of completed treatments in a digital format, but only about forty percent had electronic records of a patient’s diagnoses, medical histories, and progress notes.
Group practices had similar habits, although just over 50 percent had digital medical histories on their patients.
The 2013 survey predicted that if all prospective buyers followed through with their implementations plans, up to 88 percent of solo dentists and 95 percent of group practices should be reliant on EDRs by 2015.
A separate industry poll, conducted in 2016 by Software Advice, shows that prediction has more or less come true. Just 12 percent of dentists participating in the company’s poll said they were exclusively based on paper.
And just like their physician counterparts, dissatisfaction with electronic record systems is on the rise, with many dentists seeking replacements to eliminate performance problems (19 percent), reduce paperwork (14 percent), move to the cloud (13 percent), and improve integration with partners (10 percent).
Excessive click counts, inadequate reporting tools, and missing features are just as frustrating to dentists as they are to physicians.
Dental care professionals are also actively seeking integrated health IT systems that support claims management, patient tracking, customizable templates, and robust reporting capabilities, just like physicians. They are investing in patient-facing engagement tools, like text message reminders and patient portals.
And they are desperate to start seeing some ROI from their purchases sooner rather than later.
But despite all of the health IT experiences dentists and physicians have in common –and the potential for widely used EHRs on both sides of the dental-clinical divide to start connecting and sharing information – coordination, communication, and financial barriers are still keeping patients from receiving head-to-toe care that can impact the health of entire populations.
Recognizing oral health as a population health management imperative
The Healthy People 2020 Project, a federal initiative to chart the nation’s public health issues and develop action plans to overcome them, identifies oral health as one of the key indicators of a healthy population, pinning good dental care to reduced risk of diabetes, heart disease, stroke, premature or low birth weight, and chronic oral pain.
Oral health also has behavioral and emotional impacts, as patients with significant dental problems may feel hesitant to engage in common social situations requiring a laugh or a smile, may be more likely to turn to opioids or other substances to self-medicate painful conditions, and might suffer from increased anxiety or depression over looming debts exacerbated by delays in care.
While Healthy People asserts that many of these circumstances can be averted by regular contact with a dentist and education about proper oral hygiene at home, “the ability to access oral healthcare is associated with gender, age, education level, income, race and ethnicity, access to medical insurance, and geographic location,” the initiative says.
“Addressing these determinants is key in reducing health disparities and improving the health of all Americans. Efforts are needed to overcome barriers to access to oral healthcare caused by geographic isolation, poverty, insufficient education, and lack of communication skills.”
The accountable care organization (ACO), a favored strategy for care coordination and patient management among medical practitioners, may be one way for providers to enhance collaboration, ensure greater access to dental care, and address the whole health of vulnerable patients while decreasing overall costs.
“There is emerging evidence that improved oral health can improve broader health outcomes and even reduce healthcare spending,” said Marko Vujicic, PhD, Chief Economist and Vice President at the Health Policy Institute at the American Dental Association in a journal article for the California Dental Association.
“As medical care providers and ACOs are increasingly rewarded for health outcomes, there could be increased interest in collaborating with dentists.”
Recalibrating the care team to include dental health practitioners could have benefits for dentists and medical providers, he added. If physicians increase their referral rates to dental health homes, dentists could see around 50 new patients, bringing increased revenue to the profession.
And since approximately 9 percent of patients go to the dentist but not to a physician in a given year, dentists could play a heightened role in screening for common chronic diseases, reducing gaps in preventive care.
“Economic analysis shows that if dentists were to systematically screen for conditions such as hypertension, obesity and cholesterol, this would actually save the healthcare system money,” Vujicic said.
“The current wave of healthcare reform provides an opportunity to reconnect mouth and body,” he argued. “As medical care providers and ACOs are increasingly rewarded for health outcomes, there could be increased interest in collaborating with dentists.”
Leveraging the increasing popularity of the accountable care organization – as well the patient-centered medical home and other frameworks for engaging in value-based care – could help the healthcare industry as a whole increase the availability and usage of oral health services.
ACOs and other value-based care initiatives are well positioned to start addressing the Public Health Foundation’s four major drivers of improved oral health, which include increased patient education, broader access to preventive care, closer integration of infrastructure, and improved risk stratification to target interventions.
Accountable care arrangements and population health management programs already focus on many of the key requirements for expanding meaningful access and improving overall outcomes. Slight tweaks to a medically-centered system of education and care coordination could easily integrate oral health into existing initiatives.
For example, organizations investing in new facilities that place clinical and behavioral health services in the same location could also consider recruiting a dentist to practice in the building. When developing patient-centered educational materials focusing on chronic disease management, providers could include a pamphlet or printout about the basics of oral health, the risk of comorbidities, and the importance of establishing good hygiene routines for children.
Primary care providers may also wish to include basic oral health assessments as part of a routine physical and ask about oral care habits during patient intake, and should try to include oral health as a key risk factor within the patient stratification algorithms that inform population health interventions.
Overcoming the financial challenges of expanding dental care access
Treating dental issues as just another chronic disease to be managed in an integrated, coordinated care environment will help to ensure that patients are effectively monitored and receive the necessary interventions.
However, the industry cannot ignore the financial barriers that prevent many organizations – and patients – from realizing that vision.
Medical care and dental care operate under very different systems of insurance and payment. Despite the fact that Medicaid and CHIP are required to provide dental health benefits to children, individual states can choose whether or not to offer similar coverage to adults.
Medicaid expansion under the Affordable Care Act has brought oral healthcare coverage to many, but not to enough, says Vujicic.
“Up to 8.3 million adults could be gaining some form of dental benefits via Medicaid expansion in states that provide either limited or extensive dental benefits to adults in their Medicaid programs,” he said.
However, “the dental benefits coverage expansion via health insurance marketplaces is much smaller, even for children who are subject to the individual mandate when it comes to dental benefits.”
Public programs only account for 4 percent of the $64 billion the US spends each year on oral healthcare, says HRSA. Approximately 108 million people in the country do not have dental insurance. Equally problematic, around 49 million people live in dental health professional shortage areas, which may render their insurance coverage status moot.
HRSA endorses the idea of integrating dental care more completely into the primary care setting, but despite its role in Medicaid expansion, the Affordable Care Act may be just as much of a hindrance as it is a help.
Fundamentally, the ACA still perpetuates the notion that dental and medical care exist in separate universes, explained Gayathri Subramanian, Assistant Professor in the Department of Diagnostic Science at Rutgers School of Dental Medicine.
“While the ACA mandates individual healthcare coverage for all eligible US adults, it does not recognize dental coverage as an essential health benefit for adults, perpetuating the flawed perception of overall health as exclusive and independent of oral health,” she said in an article for Health Affairs recounting the struggles of one patient to cope with simultaneous serious medical and dental health issues.
“The arguments against combining medical and dental benefits, whether valid or otherwise, are primarily financial. Secondarily, they reflect a mindset that perceives oral health as an optional milestone to strive for.”
This financial division between the two disciplines makes it extremely difficult for well-intentioned integrators to deliver truly seamless services to patients most at risk of developing long-term complications from the inability to access preventive care.
“This artificial divide is especially explicit in a hospital such as ours, which offers urgent oral healthcare services under the same roof as other healthcare services,” Subramanian added.
“Having traditional insurance allows patients access to healthcare services elsewhere in the building, but once seated in the dental chair facing a dental emergency, patients often are told that their treatment must be paid for out of pocket.”
Some private payers are attempting to bridge the gap by offering reduced dental insurance premiums to customers of their medical plans, or by offering dental insurance alongside their traditional medical insurance.
In September, Tufts Health Freedom Plan and Northeast Delta Dental announced a partnership in New Hampshire that would allow employers to benefit from lower dental insurance premiums when purchasing a medical insurance plan.
“We know that a person’s oral health is closely tied to their overall health, and we are hopeful this partnership will allow us to intercept oral disease and help those with underlying medical conditions achieve their personal best health,” said Tom Raffio, President and CEO of Northeast Delta Dental.
While the healthcare industry as a whole still has a long way to go before dental care and medical care are no longer perceived as separate institutions, the growing recognition among payers and providers that the mouth is indeed connected to the rest of the body bodes well for increased care coordination.
Adding oral healthcare to the overarching list of population health management priorities may help providers at all points of the care continuum achieve the goals of value-based care while cutting costs, improving outcomes, and delivering comprehensive care services to their most vulnerable and high-risk patients.