Changes in Healthcare: It’s a good thing
Dr. Sean G. Boynes
Director of Interprofessional Practice
Disclosure: Dental Benefits for
23M People in 28 States
“Integrated” Has Many Meanings
1.
“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?
Key Attributes of Integrated Care
• Centered in primary care - PCMH
• Informed & involved patient
• Comprehensive treatment plan
for total health
Pharmacy
Social
Services
Behavioral
• Sharing data
• Coordination of care
Primary
Care
Dental
Physical
Therapy
• Effective communications
Imaging
Surgical
&
Specialty
Care
Lab
Background Information: Driving Change
Health Care Cost Crisis
Government Entitlements
Out-of- Pocket
$2,500
$2,000
P2022, 24.9%
Government 104%
Private Payers  81%
Consumers
 49%
20.0%
H2011, 16.8%
$1,750
$1,500
17.5%
15.0%
H2000, 13.4%
$1,250
H1990, 12.1%
$1,000
$750
25.0%
22.5%
12.5%
10.0%
H1970, 7.0%
H1980, 8.9%
7.5%
$500
5.0%
$250
2.5%
$0
0.0%
H1965
H1966
H1967
H1968
H1969
H1970
H1971
H1972
H1973
H1974
H1975
H1976
H1977
H1978
H1979
H1980
H1981
H1982
H1983
H1984
H1985
H1986
H1987
H1988
H1989
H1990
H1991
H1992
H1993
H1994
H1995
H1996
H1997
H1998
H1999
H2000
H2001
H2002
H2003
H2004
H2005
H2006
H2007
H2008
H2009
H2010
H2011
P2012
P2013
P2014
P2015
P2016
P2017
P2018
P2019
P2020
P2021
P2022
Expenditures (Millions)
$2,250
H = Historical
P = Projected
27.5%
National Health Expenditure Survey Historical and Projection Data
Percent of GDP
$2,750
Other Benefit Programs
Healthcare as Percent of GDP
Consumer Price Index of Goods & Services
Top 5 Most Expensive Conditions
Dental CPI growing faster than others!
Source: Medical Expenditure Panel Survey (MEPS)
Declining Dental Care Use
WHY?
Marko Vujicic, VP ADA
The Triple Aim
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/nnohacontent/uploads/2015/01/IPOHCCC-Users-GuideFinal_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 - DQI
Care 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:
Examples of Care:
Levels of Prevention
Primary
Health Promotion
• Dietary
counseling
• Behavior
modification
Specific Protection
• Fluoride varnish
• Dental sealant
• Medication
optimization
Secondary
Arrest & Reverse
• Remineralization
• Periodontal
maintenance
Tertiary
Dental Intervention
• Stabilize disease
• Restore form and
function
DQI: MORE Care Initiative
Pathway Placement
Education/Knowledge
Protocol Development
CRA/PAA
Pathway Designation
Intervention Determination
EDUCATIONAL
Anticipatory Guidance
Behavior Modification
Shared Patient Outcomes
CLINICAL
Prevention
Remineralization
Stabilization
“Prescription Power”
Dental Team Activation
Cooperative Care
Referral System Activation
Dental Professional Role Assignment
MORE Care Pathway (Pediatric)
Oral Health at Well Child Visit
1)
2)
3)
4)
5)
6)
7)
8)
9)
Review medical/dental histories
Oral Health Risk Assessment
Perform HEENOT (w/ intraoral examination)
Fluoride varnish / silver diamine fluoride
Prescriptions (PRN)
Risk based instruction
Counseling to decrease or maintain low oral
health risk (Risk Factor based)
Anticipatory guidance
Delivery of patient education documents (PRN)
Follow up and referral plan
Care Coordination
1)
2)
15 and 30 day follow up of referral to gauge
completion from patient
Repeat process at next well child visit
Dental Care Appointment
Low risk
and < 3 yr.
1)
2)
3)
4)
Dental Care
Referral
6)
7)
High risk
and > 3 yr.
8)
Review medical/dental histories
Complete Caries Risk Assessment and
assign status (Low, Mod, High)
Preventive Dental Care Appointment
Treatment Plan Creation
Disease Management
Reinforcement of counseling to decrease
or maintain low oral health risk
Provide direct support for risk
management / maintenance
Complete disease management
communication
Care Coordination
1)
2)
3)
Complete consultation letter to referring medical
provider that patient completed referral visit
Complete consultation letter that patient has
completed all necessary treatment, provide recall
schedule
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
Millions
Restorative Costs by Age and Tooth Type
ECC
$5.0
$4.5
D 2nd Molar
$4.0
Sealants
$3.5
D 1st Molar
D Canine
D Lateral Incisor
$3.0
D Central Incisor
$2.5
2nd Molars
$2.0
1st Molars
$1.5
2nd Premolars
$1.0
1st Premolars
Canines
$0.5
Lateral Incisors
$0.0
1
2
3
4
5
6
7
8 9 10 11 12 13 14 15 16 17 18 19 20
Age of Beneficiaries
Central Incisors
Ecological Plaque Hypothesis
Mom
Non-Cariogenic Plaque
•
•
•
•
•
•
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
•
Sugar
Acidic
drinks
Low-pH episodes
deeper and more
involved
Cariogenic Plaque
•
•
•
Microflora adapted to efficient use of sugar
Frequent, prolonged low-pH episodes
Acidogenic, aciduric flora
Caries Management – Science and Clinical
Practice. Hendrik Meyer-Lueckel, Sebastian
Paris, Kim R. Ekstrand. Thieme Medical
Publishers. NY 2013
Accountability – Who’s Accountable
Strep mutans is acquired at an average age of approximately 2 years
Caufield 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)
Adult Care
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
Cost Reduction
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
60000
50000
40000
30000
No Dental Care
Receiving Dental Care
20000
10000
0
United Healthcare (2013)
Integrated Model (Cost Effective)
Jeffcoat et al. (2012); United Concordia Wellness Oral Health Study (2012)
References
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Albert et al. (2006); An examination of periodontal treatment and per member per month medical costs in an insured
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Bassett, KB et al. (2014). Local anesthesia for dental professionals. Prentice Hall, 2014.
Binkley CJ, Johnson KW. Application of the precede-proceed planning model in designing an oral health strategy. J Theory
Pract Dent Public Health. 2013; 1:2-6
Borrell LN, et al. (2007) Diabetes in the dental office: using NHANES III to estimate the probability of undiagnosed
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Newsletter. Summer 2014: 5-6.
CDC (2010); National Center for Health Statistics, Oral and Dental Health. http://www.cdc.gov/nchs/fastats/dental.htm
Chan HH et al. (2012); Salivary proteins associated with periodontitis in patients with type 2 diabetes mellitus.
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Questions???