Government Dental Trends From Separation to Inclusion

What began as a simple need to acknowledge dentistry as a specialty that required a whole disparate body of knowledge has now contributed to a two-pronged healthcare system – one dental and one medical. This schism is wasting money and contributing to poorer health outcomes. How can we bridge the great medical/dental divide nearly 200 years after the fact? Here, we look at the history of medical and dental dis-integration and some solutions for bringing the two disciplines back together.

Government Dental Trends

The Midnight Ride of Dental Separatism On April 18, 1775, Paul Revere took to horseback to warn citizens that the British were coming. But one Englishman, John Baker, had been here in America since 1760, practicing as the earliest medically trained dentist. Revere fancied himself a dentist, too, buying space in a Boston paper to advertise his skills. He might also be considered the first forensic dentist, having identified a bridge he made in the mouth of a friend, Dr. Joseph Warren, who met his demise in the Battle of Breed’s Hill.1

The Baltimore College of Dental Surgery, founded by Horace Hayden and Chapin Harris in 1840, was the first dental school in the world, and it conferred upon its graduates a DDS, Doctor of Dental Surgery, degree.2 It was a defining moment in the story of oral health care and its severance from general medical care.3

“For example,” notes Lisa Simon, DMD, in her analysis of the historical separation in the AMA Journal of Ethics,

“anatomy classes for medical students do not generally include examining the teeth even when craniofacial anatomy is covered.”4

Enter medical insurance in 1929. Originally, Ray Lyman Wilbur, Secretary of the Interior in 1932, looked for public funding of healthcare services that included dental, but organized medicine opposed its inclusion of dental, simply because dentists had taken great pains to separate themselves in education and practice. Decades later, the attempt to reintroduce the dental benefit did not end well: "The concept ... arose only decades later as an appealing benefit for members of labor unions who found themselves in a position of strength following the passage of the Taft-Hartley labor law in 1947. For a set price, prepaid plans offered members comprehensive dental care for themselves and their families. From the 1950s, dental insurance structures were designed to limit the use of expensive services: a mandate required [them] to approve treatment plans before treatment commenced, and, when the cost of care exceeded subscription costs, it placed the burden of payment for non-preventive care on the subscriber."5

If the employer-paid benefits weren’t covering it, neither was the government. In 1965, Medicare and, albeit to a lesser degree Medicaid, saw resistance from the American Medical Association (AMA) and the American Dental Association (ADA) for the same reasons they argued for separatism earlier, and they won their fight.

Today, despite proof of dental health’s link to overall health—with associations to heart disease, sepsis, even dementia and Alzheimer’s disease—Medicaid coverage for dental procedures remains limited. With the exception of the pediatric dental benefit, also known as EPSDT (the Early, Periodic Screening, Diagnostic and Treatment program), dental care for adults is an optional service administered on a state-by-state basis. Slightly more than half of the states allow adult dental care for non-emergencies under Medicaid.6 And there is no mandatory dental coverage for Medicare.

The lack of integration between medical and dental is particularly acute for these government health programs because many of their enrollees, for a variety of social and economic reasons, are at higher risk for health problems. In fact, studies show that providing affordable dental care for those in these higher risk groups saves the government, and the taxpayers, an estimated $1,000 per person in overall medical costs.7

Now more than ever, with our insurance companies focusing on prevention and the government focusing on medical cost reduction, it’s time to nurture the integral relationship between Medicaid, CHIP and Medicare Advantage medical plans and dental. Doing so will emphasize oral health and coordinate comprehensive care, align payment systems that promote oral health, and help improve the overall health of the country.

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What's next? While alternative payment models (APMs) were first introduced in 2006, they have not caught on—yet. We look at the future of pay-for-performance (P4P).

Pay for Performance (P4P): A valid new model?Neither FFS nor capitation offers direct incentives to encourage inter-professional collaboration between physicians and dentists. However, alternative payment models, conceptually introduced in the United States in 2006, present creative opportunities to reward providers for collaboration across professional lines. This is where Pay for Performance comes in.

Also known as value-based payment or pay for quality (P4Q), P4P offers financial incentives for performance that leads to positive outcomes. P4P reimbursement models are designed to identify high-risk patients and offer dentists financial rewards for providing outreach, education, and preventive treatment.

Health plans and third-party payers are experimenting with P4P models in an effort to balance cost and quality with patient and provider satisfaction. In addition, the Center for Medicare & Medicaid Services State Innovation Model (SIM) recently funded pilot initiatives in 38 states to test funding models that integrate oral health with primary care.8 For example, in Washington, the Oral Health Connections Pilot Project is funding the delivery of enhanced periodontal treatment for pregnant women and/or adults with diabetes. This program is facilitating the exchange of diagnosis and treatment information between primary care physicians and dentists, training doctors from both professions to assess risk and treatment needs, and funding enhanced treatment.9

This is one example among dozens in states across the U.S., some of which are characterized as being

“challenged by many complex administrative issues.”10 Challenges included designing the plan for different staff members and provider specialists,“setting realistic performance metrics, building information systems that provided timely information about performance,”11 and getting buy-in from those in the practice. The study, involving a large Oregon Medicaid dental practice, was the first of its kind and concluded that the challenges were complex and “will require several years to address.”12

The Evolution of Financial Incentives for IntegrationDominating the dental reimbursement field are two typical models: fee for service and capitation.

Fee for service (FFS)

In the fee-for-service model, dentists are paid for services rendered. This traditional medical model is based on the concept of quantity: the more services doctors perform, the more they are paid. But for government payers—whether through state programs or health plans—this methodology offers greater financial reward to providers who overtreat and overprescribe. In other words, the FFS model is more profitable when patients have more work done.

1 Capitation

To prevent the over-treatment possible with the FFS model, in a capitation program, dentists are paid a set fee per member, per month. Keeping the patient healthy is the primary goal here, resulting in less time spent on those patients. Unfortunately, capitation can create the opposite issue: undertreatment and under-prescribing.

2

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Improved Financial Incentives in Dental Case ManagementSupporting care coordination between physicians and dentists may be as simple as implementing —and paying for—dental case management.

Dental case management is the practice of helping patients make health-affirming decisions by coordinating their pursuit of dental treatment and oral healthcare across multiple providers, provider types, specialties, healthcare settings, healthcare organizations, and payment systems.

And research supports dental case management’s effectiveness, showing that it can reduce barriers to access, particularly for children and adults with public sector health benefits.13

Dental practices can support dental case management by:

• Using motivational interviewing techniques to communicate with patients

• Assessing and accommodating a patient’s oral health literacy

• Understanding diversity in the community

• Collaborating with health plans, doctors, and other healthcare providers

• Engaging community organizations to minimize barriers to care minimize barriers to care

Code Dental Case Management

D9991 Addressing appointment compliance barriers: Individualized efforts to assist a patient to maintain scheduled appointments by solving transportation challenges or other barriers.

D9992 Care coordination: Assisting in a patient’s decisions regarding the coordination of oral health care services across multiple providers, provider types, specialty areas of treatment, healthcare settings, healthcare organizations and payment systems. This is the additional time and resources expended to provide experience or expertise beyond that possessed by the patient.

D9993 Motivational interviewing: Patient-centered, personalized counseling using methods such as Motivational Interviewing (MI) to identify and modify behaviors interfering with positive oral health outcomes. This is a separate service from traditional nutritional or tobacco counseling.

D9994 Patient education to improve oral health literacy: Individual, customized communication of information to assist the patient in making appropriate health decisions designed to improve oral health literacy, explained in a manner acknowledging economic circumstances and different cultural beliefs, values, attitudes, traditions and language preferences, and adopting information and services to these differences, which requires the expenditure of time and resources beyond that of an oral evaluation or case presentation.14

In January 2017, the ADA introduced four dental codes that may be used to reimburse dental providers for dental case management.

These codes, according to the American Academy of Pediatric Dentistry (AAPD), were introduced to help quantify case management efforts, particularly for those Medicaid transformation projects that include a case management component.15

The Medicaid/Medicare/CHIP Services Dental Association (MSDA) is currently testing one pilot dental case-management program in Rhode Island. It is too soon to determine the success of the program.

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Measuring Value Through Oral Health Risk Assessments For years, dentists have been performing risk assessments on patients to build custom treatment plans based on their individual needs, but there was never a code to use for that procedure. In 2014, the following caries risk assessment codes were added to the codebook:

D0601 – Low caries risk D0602 – Moderate caries risk D0603 – High caries risk

Unfortunately, the FFS mindset around the use of dental codes means providers and payers look at the codes as billable items, rather than as measures of progress. However, because the codes are used to measure relative health, most are returned as non-billable.16 Some believed these codes were to be used with services performed based on them. D0602 or D0603 could, for instance, justify the code for a dental sealant.

There is an opportunity for the dental profession and the payer community to come together to discuss how to use these codes to pay for quality. For example, a patient who presents as a D0603 in one visit might be reduced to a D0602 after complying with the dentist’s treatment plan, triggering a quality payment to the provider. Alternately, a provider who consistently performs preventive maintenance on a patient, helping to keep the patient at low caries risk, might also be rewarded for quality.

As an interim step toward the use of the codes to reward quality, payment for the risk assessment code as a treatment plan seems to have won out, at least for the moment. Currently, eight states cover the codes for Medicaid children (Connecticut, Idaho, Montana, New Jersey, Oklahoma, Oregon, South Dakota, and Texas), and two states (Montana and Pennsylvania) cover them for children covered under the CHIP program.17

Raising the States: Where Integration is Working Medical/dental integration is not merely a theoretical concept. There are states where pilots are underway to bridge the gap between the professions in an effort to reduce costs while improving health. According to Marty Dellapena, RDH MEd, Director for the MSDA Center for Medicaid-CHIP Oral Health Program Quality, Policy and Financing, every state in the U.S. has a dental plan that covers more than just dental emergencies for children. Under Federal statute, medically necessary case management for children is a required benefit under Medicaid. However, adults on Medicaid will have a harder time finding more than coverage for problem-focused oral evaluations and tooth extractions, with 40 and 41 states, respectively, providing coverage.18

For Medicare Advantage coverage, the biggest health plans and MCOs in the country (Humana, United Healthcare, BCBS, Cigna, WellCare, Kaiser Permanente, and Aetna) all cover a basic dental benefit in their markets. An estimated 20.4 million members are enrolled in Medicare Advantage across the country. In fact, 62 percent of Medicare Advantage enrollees have extra dental benefits not covered by traditional Medicare in 2018.19

But progress is not so steady in the Medicaid world. Dellapena says that “innovators are making inroads around medical-dental integration slowly.”20 These Accountable Care Organizations are neither physician- nor insurer-based; they are local. ACOs are groups of healthcare providers and hospitals delivering coordinated care to Medicaid beneficiaries, reducing duplication of services and cost.21 There is a place for dental care in these ACOs, as dental pain was identified as one of the “highest unnecessary cost drivers in the [hospital emergency department].22 According to Dellapena, ACO models in Massachusetts, Mississippi, and Oregon include oral health.23

In 2017 in Arizona, a health plan “implemented an Affiliated Practice Hygienist model…, which delivers dental services in a medical PCP setting.”24 In addition, Kaiser Permanente of California and Cigna and Aetna in their states offer what Dellapenna calls “significant chronic disease management initiatives that have oral health braided in.”25

As far as Medicaid’s integration of dental with other forms of care, Dellapenna says, “We’re not really getting that vibe yet.”26

How does one define value in oral health care? Ideally, successful dental treatment prevents or arrests the progression of disease. There is a tool for measuring this: oral health risk assessment.

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Medical/dental integration is not merely a theoretic concept.

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Back to the FutureThere is an understanding of the need to integrate dentistry and medicine in every sector of healthcare, including within the payer industries. How to get there remains a question of intellectual debate and experimentation.

As one of the largest payer of healthcare benefits in the U.S., the Centers for Medicare & Medicaid Services (CMS) has collaborated with states, health plans, professional associations, and third-party payers. It is only through continued effort in exploring and testing new modalities that these patients will truly receive the benefits of knowing that the mouth, treated by dental professionals, plays an important role in the well-being of their whole body.

Notes

1. “History of Dentistry Timeline,” American Dental Association, accessed February 2019, https://www.ada.org/en/about-the-ada/ada-history-and-presidents-of-the-ada/ada-history-of-dentistry-timeline.

2. Ibid.

3. Lisa Simon, DMD, AMA Journal of Ethics, “Overcoming Historical Separation between Oral and General Health Care: Interprofessional Collaboration for Promoting Health Equity, September 2016, https://journalofethics.ama-assn.org/article/overcoming-historical-separation-between-oral-and-general-health-care-interprofessional/2016-09.

4. Ibid.

5. Ibid.

6. Ibid.

7. Ibid.

8. Stacey Chazin and Maria Crawford. “Oral Health Integration in Statewide Delivery System and Payment Reform.” May 2016. Center for Health Care Strategies. https://www.chcs.org/media/Oral-Health-Integration-Opportunities-Brief-052516-FINAL.pdf.

9. “Oral Health Connections Pilot Project: Enhanced Periodontal Services for women experience pregnancy and clients with diabetes,” Report to the Legislature, Washington State Health Care Authority, December 1, 2017, https://app.leg.wa.gov/ReportsToTheLegislature/Home/GetPDF?fileName=HCA%20Report%20-%20Oral%20Health%20Connections%20Pilot%20Project_c859f54d-7f47-4ad0-b030-27053624afc8.pdf.

10. Douglas A. Conrad, et al., Journal of the American Dental Association, “Pay-for-performance incentive program in a large dental group

practice,” November 18, 2017, https://jada.ada.org/article/S0002-8177(17)31069-3/fulltext.

11. Ibid.

12. Ibid.

13. “The Use of Case Management to Improve Dental Health in High Risk Populations,” Pediatric Oral Health Research & Policy Center, Accessed June 2019, http://www.aapd.org/assets/1/7/Case_Management.pdf.

14. “Coding Corner – CDT 2017 New Codes for Pediatric Dentistry include Four new Case Management Codes, Pediatric Dentistry Today, Coding & Insurance Manual 2017, Pediatric Dentistry Today, Coding & Insurance Manual 2017, p. 36, May 2017, http://www.pediatricdentistrytoday.org/assets/3/23/Coding_Corner1.pdf.

15. Ibid.

16. Theresa Duncan, MS, FADIA, FAADOM, “Coach’s Corner for Dental Coding: Caries risk assessment codes,” Dentistry IQ, Accessed July 2019, https://www.dentistryiq.com/articles/2014/08/coach-s-corner-for-dental-coding.html.

17. “2017 National: Benefits,” MSDA Medicaid | Medicare | CHIP Services Dental Association, April 2019, https://www.msdanationalprofile.com/profiles/2017/national/all/benefits/dental-codes/8?chip=1.

18. Gretchen Jacobson, et al., “A Dozen Facts About Medicare Advantage,” KFF Henry J Kaiser Family Foundation, November 13, 2018, https://www.kff.org/medicare/issue-brief/a-dozen-facts-about-medicare-advantage.

19. “2017 National: Benefits.”

20. Marty Dellapenna, email interview by Leslie F. Miller, April 15, 2019.

21. “Is there a place for dental care in ACOs?” First Impressions, Accessed June 2019, http://www.firstimpressionsmag.com/ is-there-a-place-for-dental-care-in-acos.html.

22. Ibid.

23. Dellapenna, interview.

24. Ibid.

25. Ibid.

26. Ibid.

Material discussed is meant for general informational purposes only and is not to be construed as medical advice. Although the information has been gathered from sources believed to be reliable, please note that individual situations can vary. You should always consult a licensed professional when making decisions concerning dental care.

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