Making Dental Care A Part Of ACOs

Editor's note: For more on this topic, stay tuned for the December issue of Health Affairs, which will feature a cluster of articles on oral health.

Dental and medical care have almost always been delivered separately and disjointedly. That division of care could now change. Provisions in the Affordable Care Act (ACA) offer new opportunities to bring medical and dental care delivery closer to one another in two ways.

First, the ACA includes pediatric oral health benefits among its list of essential health benefits, giving insurance plans the opportunity to embed pediatric dental benefits within the medical plan. Second, the ACA strives to improve quality of care while containing costs via health care delivery reform in patient-centered medical homes and accountable care organizations (ACOs).

The ACA's construct of health care places the patient at the center of care delivery of all kinds, including behavioral, mental, dental, and vision care. Early ACOs provide useful lessons about this move toward patient-centered care, but financial and practical barriers often stymie a more coordinated effort to join dental and medical care.

Dental care in hospital emergency departments (EDs) provides an excellent opening to improve, integrate, and coordinate care via ACOs or other kinds of clinically integrated networks. The majority of ED visits for dental care involve only symptomatic management, with prescriptions for antibiotics and analgesics. While timely for the patient, such care bypasses definitive treatment, fails to address the source of infection, and increases costs associated with that tooth's eventual treatment.

Most ED dental visits are financed by Medicaid or self-paying patients. In 2012 these visits accounted for nearly 2 percent of all ED visits, consumed $1.6 billion—roughly 3 percent of all ED expenditures—and averaged $749 per visit. It is estimated that 79 percent of ED dental visits could be avoided if preventive care were more routine, translating to as much as $4 million savings to a single state Medicaid program. Realizing such savings helps achieve the triple aim goals of the ACA.

ACOs as Mechanisms for Coordinating Care

An ACO or clinically integrated network assumes a degree of financial risk to care for its patient population and must deliver high-quality care that reduces associated costs to share in cost savings. Care coordination is essential to the success of ACOs, with some suggesting coordination as "the most promising path towards financial sustainability (emphasis added)."

In the ACO model, care coordination often occurs at the individual level; success, however, requires a structure of coordination even before the patient enters the system. Indeed, more health systems are recognizing the importance of working with community partners to manage chronic diseases and keep patients healthy outside an expensive hospital setting. Oral diseases should be no exception. Systems that improve coordination of dental and medical care will have the best chance of improving quality for individual patients, improving population health, and containing costs.

Data from a recent policy brief suggest 14 percent of ACOs now include dental care among the services they provide. ACOs responsible for dental services are more likely to have Medicaid contracts (25 percent) than commercial contracts (around 10 percent), as well as to include federally qualified health centers (FQHCs), vision and hearing services, and mental health and substance abuse services. Around one-third of these ACOs have co-located dental and medical care, another third offer dental care in a separate or nearby clinic, and the final third contract out their dental care to multiple dental practices.

No matter the coordination mechanism or ACO characteristics, reimbursement is an important piece of the puzzle. In many managed care contracts, medical care is paid on a capitated, or per-member-per-month basis, while dental care is often carved out and paid via a traditional fee-for-service (FFS) system.

Successful ACOs have implemented a twist on the dental carve-out in one of two ways. In the first scenario, ACOs contract with an insurance carrier on a capitated basis and pay providers FFS payments. Practitioners can receive incentive payments if they achieve certain quality measures. In the second scenario, practitioners have the opportunity to become shareholders in the ACO, allowing them to benefit from shared savings at an ownership level. Taking ownership in an ACO requires comfort with a high degree of financial risk, however, and less than half of ACOs with dental partners have practitioner ownership.

Challenges and Opportunities

Chief among the many challenges facing ACOs trying to incorporate dental care are inter-professional differences in billing and information technology, time constraints on providers, referral difficulties, and the minimal evident effect of dental care on quality measurement and improvement as those metrics are currently structured. Billing is of critical importance: dentistry, on the whole, has rarely experienced managed care or had a tradition of exploring capitation to finance care, and many medical providers report billing as a primary barrier for implementing preventive dental care and anticipatory guidance into their daily practice.

For the ACO to satisfy dental providers' reimbursement expectations and achieve its goal of containing cost, it must find creative ways to shift the paradigm from volume-based care favoring providers to value-based care favoring patients. As we have already noted, one financial mechanism pays providers FFS with the possibility for incentive payments. Incentivizing providers in addition to the FFS reimbursement causes a conflict between old and new paradigms, because FFS encourages volume while incentive payments encourage value. Models that reward volume do not create financial incentives to embrace value-based care.

Developing an electronic record that satisfies both the medical and dental providers is another significant challenge. It is difficult to craft an interface between electronic medical and electronic dental records because the needs of each provider are different. A dentist has use for tooth-specific charting, while a physician does not; a physician has use for sophisticated imaging and lab results, while most dentists do not.

Although EPIC, the medical record used in many Academic Medical Centers, has a dental module, its use in providing integrated care is still in a testing phase. With the dental profession slowly moving toward larger group practices, investments in information technology at a systems level for integrating medical and dental records become of greater importance. Integrating care delivery, as in ACOs, could both facilitate and justify such investments.

An increasing number of medical providers have been trained to provide preventive dental services and anticipatory guidance, yet few clinicians actually translate this knowledge into clinical practice. Even when physicians provide oral health counseling and identify a patient with oral health needs, they frequently report problems with the referral process. Some private offices benefit from intra-office champions to promote oral health services, but doing so at a systems level requires something greater. Because the lack of available dental providers likely plays a major role, an addition to the workforce could fulfill the role of oral health counselor in a medical practice or hospital ED, especially one with oral health training.

The American Dental Association developed the professional role of Community Dental Health Coordinator (CDHC) in 2004. An oversimplified description of this new provider might be a cross between a social worker and a dental hygienist. The CDHC's role in care coordination is still evolving, but early evidence suggests CDHC's intervention is associated with improved follow-up rates at community-based clinics.

The CDHC could be a useful member of the care coordination team in ACOs that offer dental services. Furthermore, many of the ACOs with dental partners include FQHCs as a site for dental care, and CDHCs are trained to work in community-based settings. The CDHC/ACO pairing offers an alternative vision for innovative care delivery, and the two could coevolve as medicine and dentistry continue to work toward integration.

Quality Improvement

A downstream yet robust opportunity for ACOs to include dental care is in performance measurement for quality improvement. ACOs are structured to embrace quality improvement as a disruptor of the normal volume versus value paradigm. Dentistry-specific quality improvement goals are no exception. A rigid, narrow focus on dental-specific quality measures, however, leaves little space for envisioning care integration in the short term and, instead, supports the current siloed approach to care.

In a truly integrated ACO, advancements in quality measurement and performance will arise from encompassing all aspects of oral health, including the patient experience, in existing measures. CMS Measures ACO #1 (getting timely care, appointments, and information), ACO #5 (health promotion and education), and perhaps ACO #12 (medication reconciliation) stand out as three measures where oral health could be included in overall performance measurement as dimensions of care coordination. CDHCs could accomplish all three of these tasks. Still, a committed and invested community partner or clinic is required on the distal end of the referral to provide the proper follow-up care.

An Example of Success

In 2012 Hennepin Health in Minnesota created an ACO inclusive of dental services; its leaders hoped this strategy would reduce the number of ED dental visits. The ACO combined a regional medical center, several social service organizations, an FQHC, and several contracted dentists. The financial structure included an insurance carrier that assumed financial risk to care for the state's newly expanded Medicaid population via a capitated contract. Its providers were paid FFS with incentives.

Each patient in the ACO had an assigned care coordinator to facilitate services, which resulted in a nearly 10 percent reduction in ED dental visits in the ACO's first year of operation. The FQHC was the primary site for dental care but an on-site dental clinic near the ED and several contracted dentists also were involved.

All these partners played a critical role in reducing unnecessary trips to the ED for dental care. Care coordination alone may not have had notable benefit without community partners and the appropriate providers to care for the patients' needs. A critical component of this success, then, was care coordination at both the patient and systems level to facilitate dental care for patients in the ACO. Although this case still leaves room for improvement, it sets a welcome precedent for other systems to ponder.

What Do ACOs Offer?

ACOs offer an exciting opportunity to integrate medical and dental care. The early success of a few ACOs inclusive of dentistry, states' growing recognition of the effectiveness of providing oral health benefits to their Medicaid population, and the advent of the CDHC, all evince a growing understanding that oral health providers play a significant role in the health care delivery system.

Including dental care in more medical insurance plans may provide additional incentives for organizations to establish ACOs, but this must be done carefully. The differences in cost sharing for medical plans with embedded dental plans and whether dental care should be subject to the medical deductible in such plans is being debated now. An integrated ACO could sidestep this debate with creative financial arrangements.

We must keep optimism in check. Care coordination and FFS plus incentives are not likely to be the panacea for quality improvement for all systems. Establishing an ACO requires thoughtful consideration of numerous questions beyond those discussed here, but success appears more likely when hospitals, community health partners, and dentists are engaged and invested in creating coordinated care networks and reimbursement schemes committed to improving population health.

The forces driving health care in the present moment seem to be creating a space in which dentistry and medicine need not merely co-exist. Instead, they can forge a genuine partnership.

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