American systems of oral and systemic health—training, licensure, service delivery, and insurance—continue to operate in parallel. It is a fracture rooted in sociologic, political, and market forces rather than underlying physiology. Although the distinction may be artificial, the consequences for patients and providers are real. A growing evidence base points to the cost and quality shortfalls associated with having separate systems treat the same person.
Seeking to address these challenges, the Surgeon General recently called for more thorough integration of oral health and primary care. Roughly one in five Americans report needing dental care but lack adequate access, most often due to financial barriers. Integrating oral health services into routine primary care visits could help close this gap. Somewhat surprisingly, the converse is also true. One quarter of the 55 million Americans that do not receive outpatient medical care do see a dentist. Providing basic primary care services during dental visits could improve population health and chronic disease management.
Growing awareness of this premise has accelerated efforts to develop integrated delivery models in the primary care setting. Federally Qualified Health Centers (FQHCs) have led the way. Many FQHCs, which often serve patients whose needs and circumstances expose them to vulnerabilities and disparities in both oral and systemic health, have integrated dental services into their health centers. Notwithstanding these important advances, true integration remains elusive. Co-location is a necessary but insufficient prerequisite to fully integrated oral and systemic health care delivery. Spurring additional progress will require innovation across three principal areas: interprofessional education and cross training, financial alignment, and supportive information technology.
Interprofessional Education and Cross Training
Integration requires close collaboration between medical and dental personnel. Absent collaborative practice, co-location does little to break down existing siloes. Improving collaboration requires upstream interventions to increase interprofessional education between oral and systemic health providers. Transitioning from co-location to integration also requires seamless service delivery among dental and medical personnel. Primary care personnel should be trained to provide oral health risk assessments, anticipatory guidance, specialist referral, and to deliver basic preventive measures such as fluoride therapy. Dental providers should be trained to provide select components of annual wellness exams (e.g. screening and immunizations) and assist in chronic disease management (e.g. medication adherence, blood pressure measurement, INR monitoring). Cross training and bidirectional service provision is essential for efficient resource use and to ensure that fewer patients are lost to follow up.
In January 2016, the Harvard School of Dental Medicine (HSDM) launched a new initiative to address shortfalls in interprofessional education and cross training. Under the initiative, nurse practitioner (NP) students from Northeastern University join the Harvard Dental Center’s Teaching Practice clinics. NP and DMD students work together in the clinic, addressing patients’ oral and systemic health needs simultaneously. DMD students perform annual cleanings and other dental services while the NP students offer annual wellness exams and basic primary care, all under the supervision of experienced faculty from both schools. In addition to building collaborative, interprofessional relationships, the initiative is making early steps towards cross training medical and dental providers. NP students are learning to perform basic oral health exams and offer anticipatory guidance. DMD students are learning to provide basic primary care services and monitor chronic diseases under the supervision of primary care faculty from Harvard Medical School.
Operationalizing integrated service delivery requires financial alignment and a supportive reimbursement structure. Health care delivery organizations experimenting with oral health integration consistently cite reimbursement challenges as a principal barrier to launching, expanding, or sustaining such programs. The continued prevalence of fee-for-service reimbursement, the separation of dental and medical insurance, and uneven reimbursement policies for dental procedures all limit the sustainability and scalability of integrated clinical models. New payment arrangements are needed to catalyze and support experimentation.
CareMore Health System, a health plan and care delivery system in eight states, has elected to use Medicare Advantage financing to support oral health and primary care integration. Starting in 2017, CareMore will offer integrated oral health and chronic disease management care for patients at select southern California neighborhood care centers. Patients presenting for dental visits will be assessed by NPs to determine whether any changes are needed in the management of patient’s diabetes, congestive heart failure, depression, or other chronic diseases. Medicare Advantage financing supports this approach through capitated prepayment and benefit design. Capitated prepayment removes concerns over uncertain reimbursement, allowing CareMore to fund services—whether directed at oral or systemic health—according to clinical need. With respect to benefit design, many Medicare Advantage plans cover oral health services, shielding those patients from excessive out-of-pocket costs and promoting integration.
Opportunities for financial alignment are increasingly common among other payers. The Affordable Care Act included oral health services for children as an essential health benefit. Medicaid expansion has increased access to both oral and systemic health benefits for millions of Americans (though financial barriers persist). And some commercial insurers are experimenting with including select oral health services in health insurance plans. At the same time, more payers are shifting towards alternative payment models that move away from fee-for-service reimbursement and toward global payments. Even absent inclusion of dental services into benefit design, new payment structures may promote integration due to the potential for cost-savings and improved quality.
Supportive Information Technology
Even with other barriers removed, lack of supportive information technology can stymie integration efforts. In fact, information technology limitations have been a principal reason for the exclusion of dental services from many accountable care organizations. Developing a shared health record is challenged by differences in clinical workflow and documentation priorities between dental and medical providers, and by the lack of interoperability between prevailing medical and dental computer systems.
The Marshfield Clinic, a health care system with over 50 clinic locations in Wisconsin, has addressed this challenge by insourcing the development of an integrated electronic record that encompasses both oral and system health information. The record, which is used by dentists and primary care providers in Marshfield’s community clinics, consolidates key oral and systemic health information including appointments, diagnoses, medications, and vital signs. The record uses these data to power decision support tools that promote bidirectional service delivery. For example, given the frequent co-occurrence of diabetes and periodontal disease, primary care providers are prompted to perform oral exams on diabetic patients and make referrals to dentistry if appropriate. Relatedly, dentists are prompted to perform finger stick glucose tests on patients at risk for diabetes. Since implementing the record, Marshfield estimates it achieved $50 million in savings due to increased detection and control of diabetes.
Each of these barriers remains a substantial structural limitation to fully integrating oral and systemic health. Fortunately, the experiences of HSDM, CareMore, Marshfield, and others underscore the possibility of working within the limitations of the current system to develop innovative integrative models. Scaling these initiatives and promoting system-wide transformation will ultimately require policy changes at the national level. We are hopeful that continued experimentation and innovation will expand the evidence base and accelerate policy changes.