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Changes in Healthcare: It’s a good thingDr. Sean G. Boynes
Director of Interprofessional Practice
Disclosure: Dental Benefits for 23M People in 28 States
“Integrated” Has Many Meanings1. “Integrated” is frequently used to refer to a package of preventive and curative
health interventions for a particular population group – often (but not always) this group is distinguished by its stage in the life cycle.
2. “Integrated health service” can refer to multi-purpose service delivery points – a range of services for a catchment population is provided at one location and under one overall manager.
3. “Integrated services” to some means achieving continuity of care over time.
4. Integration can also refer to the vertical integration of different levels of service – for example a regional hospital, health centers and private practice
5. Integration can also refer to integrated policy-making and management which is organized to bring together decisions and support functions across different parts of the health service
6. Integration can mean working across sectors.
• In countries dominated by health insurance, integration can mean that the insurance function and health care provision are provided by the same organization.
Source: World Health Organization, Technical Brief No. 1, 2008. Integrated Health Services – What and Why?
Dental
Behavioral
PharmacySocial
Services
LabSurgical
& Specialty
Care
Imaging
Physical Therapy
Primary Care
Key Attributes of Integrated Care
• Centered in primary care - PCMH
• Informed & involved patient
• Comprehensive treatment plan for total health
• Sharing data
• Coordination of care
• Effective communications
Background Information: Driving Change
Health Care Cost Crisis
H1965
H1967
H1969
H1971
H1973
H1975
H1977
H1979
H1981
H1983
H1985
H1987
H1989
H1991
H1993
H1995
H1997
H1999
H2001
H2003
H2005
H2007
H2009
H2011
P2013
P2015
P2017
P2019
P2021$0
$250
$500
$750
$1,000
$1,250
$1,500
$1,750
$2,000
$2,250
$2,500
$2,750
0.0%
2.5%
5.0%
7.5%
10.0%
12.5%
15.0%
17.5%
20.0%
22.5%
25.0%
27.5%
H1970; 7.0%H1980; 8.9%
H1990; 12.1%H2000; 13.4%
H2011; 16.8%
P2022; 24.9%
Government Entitlements Other Benefit Programs Out-of- PocketHealthcare as Percent of GDP
Expe
ndit
ures
(Mill
ions
)
Perc
ent
of G
DP
H = HistoricalP = Projected
National Health Expenditure Survey Historical and Projection Data
Government 104%Private Payers 81%Consumers 49%
Consumer Price Index of Goods & Services
Top 5 Most Expensive Conditions
Source: Medical Expenditure Panel Survey (MEPS)
Dental CPI growing faster than others!
Declining Dental Care Use
Marko Vujicic, VP ADA
WHY?
Integrating Oral Health into Primary Care“It focuses on frontline primary care health professionals, specifically nurse practitioners, nurse midwives, physicians and physician assistants. These primary care practitioners are members of the existing delivery system who could incorporate oral health core clinical competencies into their existing scope of practice.”
“HRSA synthesized the following recommendations:
1. Apply oral health core clinical competencies within primary care practices to increase oral health care access for safety net populations in the United States. 2. Develop infrastructure that is interoperable, accessible across clinical settings, and enhances adoption of the oral health core clinical competencies. The defined, essential elements of the oral health core clinical competencies should be used to inform decision-making and measure health outcomes. 3. Modify payment policies to efficiently address costs of implementing oral health competencies and provide incentives to health care systems and practitioners. 4. Execute programs to develop and evaluate implementation strategies of the oral health core clinical competencies into primary care practice. “
NNOHA / IPOHCCC: Implementation of HRSA Competencies
http://www.nnoha.org/nnoha-content/uploads/2015/01/IPOHCCC-Users-Guide-Final_01-23-2015.pdf
NNOHA (2015)
NNOHA / IPOHCCC: Users Guide
• READINESS ASSESSMENT• Planning
– Establish Integration Team– Profit/Loss– Population Focus– Timeline
• Training• Health Information Systems• Clinical Care Systems
– Workflow– Methodology/Techniques– Referrals
NNOHA (2015)
Planning/Implementation: Levels of Integration
MORE CARE - DQICare Pathway Coordination of Care
• “Cross-Referral” or “Hand-off Process”• Responsibilities and Accountability
– Who is responsible for what?• Organize delivery of care options and determine pathways to
success• Primary, Secondary, and Tertiary Prevention methodology
Levels of Oral Health Care
Levels of Oral Health Care:
Levels of PreventionPrimary Secondary Tertiary
Examples of Care: Health Promotion• Dietary
counseling• Behavior
modification
Specific Protection• Fluoride varnish• Dental sealant• Medication
optimization
Arrest & Reverse• Remineralization• Periodontal
maintenance
Dental Intervention• Stabilize disease• Restore form and
function
Pathway PlacementEducation/Knowledge Protocol Development
CRA/PAAPathway Designation
DQI: MORE Care Initiative
Intervention DeterminationEDUCATIONAL
Anticipatory GuidanceBehavior Modification
Shared Patient OutcomesCLINICAL
PreventionRemineralization
Stabilization“Prescription Power”
Dental Team ActivationCooperative Care
Referral System ActivationDental Professional Role Assignment
MORE Care Pathway (Pediatric)
Oral Health at Well Child Visit
1) Review medical/dental histories2) Oral Health Risk Assessment3) Perform HEENOT (w/ intraoral examination)4) Fluoride varnish / silver diamine fluoride5) Prescriptions (PRN)
Risk based instruction6) Counseling to decrease or maintain low oral
health risk (Risk Factor based)7) Anticipatory guidance8) Delivery of patient education documents (PRN)9) Follow up and referral plan
Medical DentalLow risk and < 3 yr.
High risk and > 3 yr.
Care Coordination1) 15 and 30 day follow up of referral to gauge
completion from patient2) Repeat process at next well child visit
Dental Care Referral
Dental Care Appointment
1) Review medical/dental histories2) Complete Caries Risk Assessment and
assign status (Low, Mod, High)3) Preventive Dental Care Appointment4) Treatment Plan Creation
Disease Management6) Reinforcement of counseling to decrease
or maintain low oral health risk7) Provide direct support for risk
management / maintenance8) Complete disease management
communication
Care Coordination1) Complete consultation letter to referring medical
provider that patient completed referral visit2) Complete consultation letter that patient has
completed all necessary treatment, provide recall schedule
3) Provide communication of incomplete treatment plan completion if patient has not returned for dental care visit after initial referral visit (3 mos)
Population Health
Population Health• Population health
– Identifies target (at risk) populations• Includes outcomes, patterns of determinants, and policies and
procedures that involve the aforementioned • Opportunity for health care delivery systems, public health agencies,
community-based organizations, and many other entities to work together • Pediatric
– Majority of innovation focused on children– Dental financial system in U.S. leans toward pediatric care
• Adult– Usually organized according to systemic illness
• Primary diagnosis• Limited intervention models being evaluated• Research on systemic / oral health linkage has not resulted in
consensus
Pediatric Care
Pediatric Primary Care – Caries Disease• CDC: One in five children have untreated decay
• Pew: 29 million children enrolled in Medicaid: only 12.9 million received dental care
• Cavities are the 4th most expensive disease in the U.S.• Poor children had one half the number of dental visits
compared with higher income children– Limited access to dental: higher encounter rates with
medical• “Despite acknowledgement of this problem by dental health
providers little has changed to improve these statistics.”• Pediatricians/Family Practitioners may be able to improve
oral health outcomes.
Mattheus and Mattheus (2014); CDC (2010); Truman et al. (2002); USDHHS (2000); PEW (2011)
Restorative Costs - Typical Medicaid Program
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20$0.0
$500,000.0
$1,000,000.0
$1,500,000.0
$2,000,000.0
$2,500,000.0
$3,000,000.0
$3,500,000.0
$4,000,000.0
$4,500,000.0
$5,000,000.0
Restorative Costs by Age and Tooth Type
D 2nd MolarD 1st MolarD CanineD Lateral IncisorD Central Incisor2nd Molars1st Molars2nd Premolars1st PremolarsCaninesLateral IncisorsCentral Incisors
Age of Beneficiaries
ECC
Sealants
Ecological Plaque Hypothesis
• Microflora adapted to low-sugar diet• Infrequent low-pH episodes• Non-aciduric/non-acidogenic flora
• Selection against non-aciduric bacteria• Aciduric bacteria gain competitive
advantage• Growth of aciduric-acidogenic bacteria
• Low-pH episodes deeper and more involved
• Microflora adapted to efficient use of sugar• Frequent, prolonged low-pH episodes• Acidogenic, aciduric flora
SugarAcidic drinks
Caries Management – Science and Clinical Practice. Hendrik Meyer-Lueckel, Sebastian Paris, Kim R. Ekstrand. Thieme Medical Publishers. NY 2013
Non-Cariogenic Plaque
Cariogenic Plaque
Mom
Accountability – Who’s Accountable
Strep mutans is acquired at an average age of approximately 2 yearsCaufield PW, Cutter GR, Dasanayake AP. Initial acquisition of Mutans streptococci by infants: evidence for a discrete window of infectivity. J Dent Res. 1993;72:37–45
Fluoride application in Primary Care• Holve’s Well Visit Study: Children with 4 or more treatments
had 15.5 dmfs (95%CI 10.8–20.4) versus children with no fluoride varnish treatments who had 23.6 dmfs (95%CI 19.5–25.8) for a 35% decrease in overall caries.
• COCHRANE LIBRARY REVIEW: – The 13 trials that looked at children and adolescents with
permanent teeth the review found that the young people treated with fluoride varnish experienced on average a 43% reduction in decayed, missing and filled tooth surfaces.
– In the 10 trials looking at the effect of fluoride varnish on first or baby teeth the evidence suggests a 37% reduction in decayed, missing and filled tooth surfaces.
Holve, S. (2008); Marinho [Cochrane Library] (2014)
Proposed Mechanisms of Oral Health’s Systemic Impact• Inflammation
– Chronic oral infection contributes to systemic inflammation and increases in the plasma concentration of acute-phase proteins, inflammatory cytokines and coagulation factors which increase the potential for cardiovascular disease (persists long after tooth extraction)
• Infection– Bacterial end products enter the blood stream and result in
transient bacteremia • Diet and Nutrition
– Based on the dysfunctional masticatory system and on the ability to obtain proper nutrition from the diet
Oral Health Systemic Connection
Oral Health Systemic Connection
Aetna’s Data Warehouse Analysis - 2006
• Periodontitis treatment groups had a lower retrospective risk for their chronic condition than patients without periodontitis treatment.
• Recommend examination of the oral cavity for patients with diabetes, coronary artery disease, and cerebrovascular disease.
• Found a need for periodic dental visits for patients with diabetes and cardiovascular disease
• Patients with periodontitis had a higher cost per member per month than patients with gingivitis, other dental diagnosis or no dental diagnosis
Albert et al. (2006)
United Healthcare: Medical Dental Integration Study - 2013
• Study compares the medical and pharmacy costs of individuals with six chronic medical conditions with the dental treatment they receive to determine if there is a difference in total health care costs associated with dental treatments.– Diabetes– Asthma– Congestive Heart Failure– Coronary Artery Disease– Chronic Obstructive Pulmonary Disease– Chronic Kidney/Renal Failure
United Healthcare (2013)
United Healthcare: Medical Dental Integration Study - 2013
• Utilized 3 years of dental claims experience with 2 years of United Healthcare Evidence Based Medicine and episode treatment group claims analysis.
• Summary– Net medical costs (including pharmacy costs) for members who
received dental care was on average $1,037 lower per individual than medical costs for members not receiving care, after adjusting for extra expense of dental care.
– The largest medical savings ($1,849) were for members who were not medically compliant with their disease management program.
– Biggest impact related to members who received frequent cleanings and/or periodontal maintenance.
United Healthcare (2013)
United Healthcare: [Non-Med Compliant] Medical Dental Integration Study - 2013
United Healthcare (2013)
Dia-betes
Asthma CAD CHF COPD Renal Dx
0
10000
20000
30000
40000
50000
60000
No Dental CareReceiving Dental Care
Integrated Model (Cost Effective)
Jeffcoat et al. (2012); United Concordia Wellness Oral Health Study (2012)
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