Oral Health is Essential to Achieving Population Health:

ACCESS TO CARE

A 2013 Delaware IDeA Network of Biomedical Research Excellence (INBRE) study out of the Department of Oral and Maxillofacial Surgery and Hospital Dentistry, at Christiana Care Health System, noted that in fiscal year 2012, over 3,900 patients presented to the Christiana Care Emergency Departments for non-traumatic, dental-related diseases. The total cost was $1.9 million for that year, with an average cost of $480/visit. Nationwide, similar dental visits cost the United States healthcare system at least $1.6 billion with an average cost of $749 for each of the over 2 million visits, according to the Health Policy Institute of the American Dental Association (ADA).¹

This problem stems from the fact that approximately 130 million Americans do not have dental insurance and thus access to affordable oral healthcare is problematic for many.² Moreover, in vulnerable populations such Medicaid eligible patients, there are limited dental benefits associated with coverage plans. Specifically, there are four states, one being Delaware, that have no dental benefits for adult Medicaid patients and even the states designated as having ‘extensive’ Medicaid dental benefits, typically cap expenditures at $1000 per year.³ Once the cap is met, any future costs are typically ‘out of pocket’ until the cap resets.

The result, is a disconnect between oral and systemic health which precludes the realization of optimal health and population health. Thus, as medicine moves from volume to value, the integration of oral health metrics and outcomes assessment, into at-risk contracts, will be an essential lever to drive change and improve oral healthcare for the entire population.

COORDINATED CARE

Despite the awareness that oral health can directly impact the systemic health of an individual, historically, there has been limited coordination of care between medicine and dentistry. Dentistry has operated in a silo and when attempts are taken to improve the coordination and integration of care, it is often derailed by access issues.

THINKING DIFFERENTLY

Medical and dental communities will need to think and behave fundamentally different to enhance access and truly achieve oral health integration into population health. Incremental steps are starting to emerge, however.

PRIMARY CARE IN THE ORAL HEALTHCARE SETTING

In 2016 a Nurse Practitioner-Dentist Model for Primary Care launched at Harvard Dental School, and dental school patients will have the opportunity to undergo annual wellness exams, on-site, with referral to a primary care provider, as needed.⁴ Further, a 2016 Delaware INBRE study performed by Oral and Maxillofacial Surgery at Christiana Care, looked at the viability of hyperglycemia screening in patients presenting to a high-volume, urban, academic program. Interestingly, over 40% of the patients screened did not have a primary care provider, and thus, the program was also an opportunity to connect patients to other needed healthcare resources. Tobacco cessation, screening for hypertension, and nutrition education are some additional examples of how dentists can integrate into population health.

TEAM CARE

Opportunities exist for formalized physician-dentist team care for segments of a population, such as in the optimal care of patients with diabetes, cancer and obstructive sleep apnea. The team care model brings experts together under one roof to broadly address the patient’s needs and coordinate the care. The cleft team model is an existing example of such a successful care delivery model.

TAKING CARE TO THE PATIENT

Taking care to the patient, such as placing a dental clinic in a primary care office or in a community center can ease the challenge of access. Further, embedding oral health resources in ‘hotspots’ of need, such as the emergency department, is another means of addressing access to and the quality of oral healthcare for populations of patients. The result is that these types of programs create more robust communication and coordination of care across medicine and dentistry and increase access points to care.

SOCIAL DETERMINANTS OF HEALTH

Social determinants greatly impact health. Lack of transportation, healthy food deserts, occupation limitations, inadequate social or family support, housing challenges, and lack of education are social determinants that directly impact the health, including oral health, and well-being of patients. Thus, these issues must be part of any comprehensive plan to achieve population health and improved access to care.

HEALTH INSURANCE

Lastly, dental insurance coverage must become something that is affordable and attainable by all. 40% of Americans do not have dental insurance coverage and the result is inadequate oral health for many, with little to no health maintenance and instead, attempts to access care only when an acute issue arises, such a pain and swelling. Simply, access to quality care, that includes prevention and not just acute care, is essential to changing the story around oral healthcare and keeping people healthier from an oral health standpoint will improve systemic health, which will improve the health of the entire population.

ACHIEVING CHANGE

Ultimately, to drive change and for access and quality of oral healthcare to improve, silos must be removed, outcomes must be measured, incentives must align, innovation must be fostered, and insurance must be affordable. Population health depends on it.