Two years ago, then Secretary of Health and Human Services Sylvia Burwell put doctors and hospitals on notice that the days of traditional fee-for-service reimbursement were numbered. She announced that by 2018, the Centers for Medicare and Medicaid Services wanted 90% of all Medicare fee-for-service payments tied to objective measures of quality and value. Private insurance companies have also jumped on the value-based payment bandwagon, encouraging providers to form accountable care organizations (ACOs) and setting up various pay-for-performance quality incentives.
Although dental is not moving toward the value-based payment models with which physicians and hospitals are now contending, the trend toward paying for medical services based on the quality and value of the care provided is creating a push for better care models. This spills over into dental care because if you need to improve patient outcomes while lowering the overall cost of care, dental care is an obvious place to start.
According to the Dental Trade Alliance, if 60% of patients with diabetes received oral care, national health care savings could be $39 billion. Furthermore, if half of dental-related emergency department visits could be handled in traditional dental practices or community health centers, savings could amount to $826 million.1
These numbers are a strong argument for better access to dental care. If health systems in value-based reimbursement models respond by adding dental care to their primary care models, it could impact dental sales professionals by creating new customers. Already, dental sales distributors are seeing one such new customer type in federally qualified health centers (FQHCs).
“Community health centers have been sort of the fastest growing segments of our business for the past 3 or 4 years, and they would be the closest thing that we would have to an integrated health care home for patients,” says Charles Cohen, managing director of Benco Dental, a leading dental supply company based in Pittston, Pennsylvania. “Under the Affordable Care Act, in order to be a FQHC, the health center has to have dental, medical and mental health, all three elements,” Cohen explains. “That segment of our business was up more than 20% last year.”
HEADWINDS AND TAILWINDS
The ability to receive dental care at the same time and location as medical care makes life easier for patients, and it could improve their overall treatment outcomes while lowering the cost of such care. However, in the traditional fee-for-service world, there is little incentive for dentists and medical doctors to work together. In many ways, they are, in fact, competitors — with patients prioritizing their health care dollars on one service over the other.
Today, medical and dental care providers have different distributors, billing systems, electronic health records, diagnosis codes, payors, scheduling systems, training programs and more. Merging these siloed systems is expensive, and health care providers without a federal mandate to add dental generally pass on doing so. For them, the cost-benefit rationale is simply not there.
“Dentistry is a pretty big startup cost for a medical practice or a hospital,” Cohen says. “There are some medical operations that have made small forays into the dental world, primarily in pediatrics, and we will see that every once in awhile, but we have not yet seen it in a really big integrated way.” He adds that if it is going to happen, it will be at a large integrated health care delivery network, a major health system, or an academic medical center where the medical and dental schools collaborate.
Thomas Schwieterman, MD, vice president of clinical affairs and chief medical officer for Midmark Corporation — a health care products, equipment, and diagnostic software supplier and manufacturer — notes that the dental-medical division begins during their respective training programs, with education, for the most part, being delivered on completely separate tracks — even when the dental and medical schools are on the same university campus. But this may change as leaders in the field become more aware of the potential cost savings and patient outcome benefits of merging dental and medical care.
“It has not been forever that dentistry and medicine were siloed professions,” Schwieterman says. “Medical and dental professionals used to be taught in the same institutions. We are seeing now that institutions like the University of Pennsylvania and Harvard University are really heavily looking at whether we should bring these two health care- related professions together under one roof and reintegrate the oral cavity as part of holistic medical care.”
DENTAL IN FEDERALLY QUALIFIED HEALTH CENTERS
One of the early adopters of dental in a primary care setting was the Stephen and Sandra Sheller 11th Street Family Health Services of Drexel University in Philadelphia. The Robert Wood Johnson Foundation, the Agency of Healthcare Research and Quality, and the American Academy of Nursing have all recognized it as a national model of innovative care for its transdisciplinary approach of combining primary care, behavioral health, dental services, and health and wellness under one roof.
However, even at an award-winning center such as this, there were challenges to fully integrating dental into the overall care model, explains Frank Torrisi, DDS, MBA — network dental director of the Family Practice and Counseling Network, which operates six locations (three with dental), including the 11th Street Family Health Services affiliated with Drexel University. For example, at 11th Street, the dental office and medical office were in the same building but in different offices, and the electronic medical record system and electronic dental record system could not share information. Patients would leave the medical office with a same-day referral to the dental office in the same building, but would still not show up. “We would find their dental referral forms in the trash,” Torrisi says.
There also was no easy way for the dental team to scan the upcoming list of medical appointments for patients that might be in particular need of dental services, and vice versa. “I realized a few years ago that what we really needed was to get into primary care,” Torrisi says. “We needed to be there so it becomes matter of fact that dental is part of your health care.”
In 2016, the Family Practice and Counseling Network received a federal grant, which was utilized to put portable dental equipment in the first-floor medical office at 11th Street Family Health Services; hire a dentist, a dental hygienist and an expanded function dental assistant; and link the dental and the medical electronic health records in order to improve care for three specific patient populations: children without a dental home, pregnant women, and patients with diabetes.
Torrisi believes that, thanks to this federal funding, he is now providing some of the best and most meaningful care of his career. For example, in the FQHC setting, it is not uncommon to see patients who have not seen a dentist in many years and are in need of extractions. However, their blood pressure is too high to safely perform the needed dental work to resolve their dental pain and infection. Dentists in this situation typically refer the patient to an oral surgeon who then refers the patient to his or her primary care physician because the high blood pressure must be treated first. Meanwhile, the patient is taking antibiotics and narcotics over a prolonged period, which is not recommended because of the risks of addiction and antibiotic resistance.
In contrast, at 11th Street Family Health Services, a nurse practitioner can see the patient right away, treat him or her with a fast-acting anti-hypertensive, and allow the dentist to perform the dental extraction that same afternoon or the next day.
“When you do that, you go home at the end of the day feeling like you are a health care provider and knowing that, to that patient, you are a hero. There isn’t a better feeling in this profession than that,” Torrisi says.
ACO: Accountable care organization. Entities established by health care providers to manage the health of a population of patients. ACOs come in many types. Some are “up-side-only” ACOs that receive a bonus from the payer if certain savings on the overall cost of care for the population of patients being managed are met. However, they will not lose money if they do not meet the savings targets. Others share more risk with the insurance company. If the patient population managed by a risk-sharing ACO costs more to care for than predicted, the loss comes out of the profits of the health care provider.
Integrated health care delivery network: A multi-specialty network of health care providers that includes both hospital and physician practice services. These networks are often big enough to offer patients their own direct insurance product. Kaiser Permanente is one example. Its insurance plan is more affordable than many traditional insurance plans, but the patient must agree to only receive health care within the network.
Fee-for-service: The traditional payment model for both medical and dental care. It pays providers pre-set fees for each service provided. A criticism of fee-for-service is that it incentivizes treating advanced health care problems, as these diseases and conditions require more services. It discourages big investments in preventive care models, as there is no payment for services not provided to a healthy patient.
DENTAL-MEDICAL INTEGRATION IN POPULATION HEALTH
In addition to FQHCs, a few ACOs have begun to look at dental. For example, according to a 2015 American Dental Association Health Policy Institute white paper, Hennepin Health — an ACO serving Medicaid expansion beneficiaries in Hennepin County, Minnesota — employs care coordinators who provide patients who present in emergency departments (ED) with acute dental situations with referrals to dentists for care.2 This has helped Hennepin Health reduce the number of costly ED visits for dental problems.
But care coordination is not quite the same as same-site care. Here, the most advanced ACO model may be Kaiser Permanente in the Pacific Northwest. Kaiser is both a health care and dental care provider with its own insurance products. This puts it fully at risk for the cost of care for its patient population and makes it among the most interested of the ACOs in realizing the potential cost savings of bringing together dental and medical care.
Cyrus Lee, DMD, is the lead dentist at Kaiser Permanente’s newly opened Cedar Hills Dental and Medical Office in Beaverton, Oregon, that is a pilot testing site for co-located medical and dental care with a single electronic health record and a unified scheduling workflow. The same schedulers book appointments for both dental and medical services. And, when patients come in, the practice nurses can look ahead in their full medical records to see if they are due for various preventive services. If a patient needs a vaccination or is due for a blood draw for lab work, it can be done in the dental chair prior to or after Dr. Lee sees the patient, or during any wait time in the middle of the visit, such as while a localized dental anesthetic is taking effect.
“At the end of last year, the dental department migrated to the same electronic health record that every other department in Kaiser uses, which is Epic Health Connect, and that really facilitated the sharing of information needed to do this dental-medical integration,” Dr. Lee says. “This is an innovation site, where we are piloting new ways to combine medical and dental care that maximizes convenience for our members and also ensures their visits address their total health,” he shares. For example, “The licensed practical nurses will look at our schedules 72 hours ahead to see what kind of care gaps a patient may have. If tomorrow I have a 9 a.m. dental patient coming in for a filling and that patient is due for a vaccine, the nurses will have that vaccine ready to go. And when that patient is in the dental chair, I can talk to him or her about the opportunity to get that vaccination during the dental appointment.”
The hope is that delivering more care in the dental setting could help Kaiser lower overall care costs while improving outcomes for patients who have both its dental and medical plans. According to an American Dental Association Health Policy Resources Center study, simply having dentists screen for common chronic medical diseases like undiagnosed hypertension, diabetes or high cholesterol could save the American health care system as much as $102.6 million annually.3
“Kaiser is integrated. So, anything that dental does to help increase a person’s overall health not only benefits that person, but it also benefits Kaiser Permanente because this model can lower the overall cost of care,” Dr. Lee explains to Mentor. “We have studies showing that our members who have both medical and dental coverage weigh less, smoke less, and visit the hospital and ED less than our members who have just medical coverage.”
IMPACT ON SALES
What this means for dental sales professionals is that someday soon, they could be serving a new medical-dental hybrid office. And so could their counterparts in medical supply sales.
Cohen says that with the possible exception of Henry Schein — a worldwide distributor of medical, dental and veterinary products — most dental distributors are specialized in this market. However, they are always watching for new companies that may want to enter the dental market and looking for new sales opportunities.
“The distribution and manufacturing side have proven very resilient to figuring out how to serve emerging segments of dentistry in a way that provides a high level of value and is profitable for the industry,” Cohen says. “Whether it is Benco Dental, Henry Schein, Patterson Dental or smaller distributors, I think we would all tell you we have different segments that need to be handled in different ways.”
Benco Dental has representatives helping FQHCs and is not at all adverse to serving these new markets, because dentists in an integrated primary care setting are very much advancing access to dental care — an issue Benco also puts a high priority on.
“Not only do we like to serve those customers because they buy stuff that we sell, but we like to serve them because they fit the mission of figuring out how to provide more access points for dental care for the American population,” Cohen says. “We are a for-profit business, but at the same time, we feel we have a mission to serve dentists who care for all segments of the American patient base. As such, Benco really likes FQHCs because they are bringing dental care to a segment of the population that otherwise might not get easy access to it. We are very enthusiastic about that segment from a business and a community service standpoint.”
Featured photo by VIZERSKAYA/VETTA/GETTY IMAGES PLUS
- Dental Trade Alliance. The business case for oral health. Available at: dentaltradealliance.org/oral-health. Accessed May 7, 2017.
- Leavitt Partners. Dental Care in Accountable Care Organizations: Insights from 5 Case Studies. Available at: ada.org/~/media/ADA/Science%20and%20Research-/HPI/Files/HPIBrief_0615_1.pdf?la=en. Accessed May 10, 2017.
- Nasseh K, Greenberg B, Vujicic M, Glick M. The effect of chairside chronic disease screenings by oral health professionals on health care costs. Am J Public Health. 2014;104:744–750.
From MENTOR. June 2017;8(6):12-16.