2015 Na(onal Medicaid and CHIP Oral Health Symposium. Integra(ng Oral and General Healthcare. Bruce Donoff, DMD, MD. Session #

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1 MSDA Medicaid CHIP State Dental Association 2015 Na(onal Medicaid and CHIP Oral Health Symposium Session # Integra(ng Oral and General Healthcare Bruce Donoff, DMD, MD Washington Marrio4 Wardman Park Tuesday, June 2nd,

2 Disclosure and Conflict of Interest Declara4on q I declare that neither I nor any member of my family have a financial arrangement or affilia4on with any corporate organiza4on offering financial support or grant monies for this con4nuing dental educa4on program, nor do I have a financial interest in any commercial product(s) or service(s) I will discuss in the presenta4on. 2

3 Learning Objec4ve(s) Par4cipants will gain knowledge in: Ra4onale for integra4on of oral health and primary care Scien4fic evidence for oral systemic rela4onships Economic data to support integra4on 3

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5 Oral health facts $1.2 billion of hospital charges incurred by pa4ents hospitalized for a dental problem 154 million hours of work lost/51 millions lost hours of school- due to dental disease. 40% of American have no dental coverage Medicaid 16 cover only pain relief, 7 don t even cover pain and infec4ons, low reimbursement limits den4sts par4cipa4on Medicaid, Medicare and ACA require no acute coverage

6 Discomfort of thought Den4stry is the only specialty in the realm of medicine taught before the doctorate is awarded. Throughout training, the emphasis is on the perfec4on of methods rather than the a_empt to s4mulate a desire to know why the methods are necessary and what their intrinsic value is. A. Leroy Johnson, Dentistry-As I See it Today, 1955

7 Key Drivers in Dental Educa4on Ready to prac4ce upon gradua4on Licensure based upon procedural exam Interprofessional care New workforce models - DSO Globaliza4on Elderly and chronic disease Technology advances Personalized medicine Health dispari4es

8 The problem Historical separation of medicine and dentistry in education, practice and financing Oral health always the stepchild Yet #1 on best professions list (US News) Delivery system flawed-can dentistry afford to repeat its response to Medicare in 60 s Prevention needs more emphasis Address the interplay between oral disease and other health issues Shortage of primary care providers Problem of access to care

9 Key ques4ons What models exist for integra4ng oral health care into the primary care sefng? What findings on oral health care delivery in the safety net can influence the move towards the pa4ent- centered medical home or health home model? What changes in health policy and healthcare reimbursement are needed to support integrated oral health and primary care?

10 The Case for Integra4on Increase effec4veness and efficiency of both dental and medical professionals in disease preven4on, iden4fica4on of precursors IT systems key Raise pa4ent awareness of importance of oral health Improve chronic disease management and preven4on by den4sts as primary care givers Address oral health care access issues Facilitate use of interdisciplinary techniques Provide cost savings

11 Tac4cs in oral health Teleden4stry Electronic health records Teach oral health to nurses and nurse prac44oners Teach oral health to physicians Expanded duty oral health auxiliaries 11

12 Methods of Care Collabora4on or coordina4on of care when oral health and primary care providers work with one another. Pa4ents perceive that they are receiving a separate specialist service from a den4st who works with their physician. Integra4on when oral health works within primary care. Pa4ents perceive that they are receiving dental services that are a rou4ne part of their health care.

13 How to achieve Con4nue to involve dental and non- dental providers in oral health- NP, dental therapists Develop innova4ve delivery models Full integra4on Coloca4on Primary care provider focus Coopera4on and collabora4on Insurance and financing medical and dental insurance together

14 How to achieve Integrated training models oral physician program, dental residencies in dept. of primary care rather than surgery DMD new curriculum - the den4st as primary care provider DMD, MD primary care track MD curriculum - essen4als of oral health for medical students CE curriculum - den4stry and oral health for physicians, CEO s of FQHC s

15 Den4st of the future Create a collabora4ve learning and prac4ce environment - teams Permit more efficient prac4ce environment Focus on managing oral and general health rather than disease. Nutri4on. Impact of meaningful use DENTIST MANAGES THE CHRONIC DISEASE OF EXISITING PATIENTS ORTHODONTIST MANAGES OBESITY Pediatricians, pediatric den4sts and nurses do caries risk and fluoride varnish at Children s hospital in Boston

16 Barriers and problems Reimbursement low for Medicaid, not allowed for medical diagnosis Dental school /medical curriculum variances State prac4ce acts Physician response too busy Den4sts response not my job CULTURE

17 Prospec4ve health care Shins focus from disease management to disease preven4on and health management Driving force need to improve quality of care Impetus safety issues, rising costs, informa4on sharing, health homes Ra4onale to ensure the best possible pa4ent outcomes

18 Background and History Harvard Dental School history Mission Vision Dean s Advisory Board Leadership forums Harvard Primary Care Center HSDM primary care task force 18

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21 A Profession in Transition Dental benefits erode for adults Benefits increase for children Access to care not addressed Will dental benefits be part of a medical plan Oral health for aging popula4on Medicare Increase value and reduce costs Opportuni4es to raise profile of oral health Engage den4sts in primary care networks via interprofessional collabora4on

22 Tomorrow s dental practice landscape Provider consolida4on con4nues Growth in large mul4site prac4ces Interest in midlevel providers con4nues Commercial plans increase use of selec4ve networks and demand increased accountability Premium on good prac4ce management

23 Medical education/dental education Separate but equal educa4on is always separate but never equal Physicians become educated about us and oral health Bring medical model into dental educa4on New opportuni4es to change scope of prac4ce - engage den4sts in primary care networks with increased interprofessional collabora4on

24 Dean s Advisory Board Created in 1993 Major role in research strategic plan of late 1990 s- led to new Building Serve in advisory role, development Developed Leadership forum concept with Harvard Business School Establish Ini4a4ve to Integrate Oral health and Primary Care 24

25 Why integrate care Three major factors now push the agenda for change advances in science and oral science, the demographic increase in the older popula4on, and the crisis in primary care. 25

26 List of proofs that must be fulfilled to demonstrate that periodontal bacteria are a contributing factor to atherosclerosis (i)periodontal bacteria can reach systemic vascular tissues. (ii)periodontal bacteria can be found in the affected tissues. (iii)evidence of live periodontal bacteria at the affected site. (iv)in vitro evidence of invasion of affected cell types. (v)demonstration that periodontal bacteria can promote atherosclerosis in animal models of disease. (vi)in vitro and in vivo evidence that noninvasive mutants cause significantly reduced pathology (animal model). (vii)fulfill modified Koch's postulate to demonstrate that a human atheroma isolate causes disease in animal models. 26

27 The impetus Scien4fic data len direct associa4on weak Appearance of insurance data linking oral health to general health Michael Weisner United healthcare- Jan Ideas for next Forum emerge 27

28 The Forum of October 2014 The Economic Impera4ve of good Oral health Agenda the soundness of insurance data Introduc4on of Ini4a4ve idea To foster discussion, guide as well as develop public policy and advocacy Provide interdisciplinary connec4on at Harvard Collaborate with na4onal, state and local partners on innova4ve strategies to improve oral/general health Provide scholarly review of clinical and epidemiologic data on the subject 28

29 Forum Big Ideas Things put together that should never should have been separated or things put together that should have been kept separated- dental and medical care Integra4ng oral health with overall health insurance lowers costs Fee for service like selling college courses course by course vs. tui4on What are the ac4onable strategies 29

30 Cost Savings Aetna s Dental Medical Integra4on Program Report 10/4/13 DMI members who visited the den4st have: Lowered their medical claim costs by an avg. of 17% Improved diabetes control by 45% Used 42% less major and basic dental services Required 3.5% fewer hospital admission year over year compared to 5.4 % increase for non- members

31 United Healthcare Medical Dental Integra4on Study Performed by Optum Net medical costs on average $1037 lower than medical costs for members who received other or no dental care Larger savings for diabe4c pa4ents and other chronic diseases asthma CHF, CAD COPD chronic kidney disease

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33 Promises and Pisalls in Big Data General issues Specific related to Jeffcoat paper How to reduce bias Need for clinical trials Knowledge to policy Poli4cs 33

34 Communica4on Plan New England Journal of Medicine Dec Policy ideas Inside Den4stry April 2015 Journal devoted to subject Web site 34

35 Links to educa4on Primary care task force Crimson collabora4ve Oral physician residency Teaching oral health to medical students Interprofessional educa4on and prac4ce Mass College of Pharmacy and Allied Health Sciences Northeastern Bouve College- HRSA grants 35

36 Create Ini4a4ve for Integra4on of Oral Health and Primary Care Vision to incorporate oral health as an essen4al part of overall health and wellbeing Mission create opportuni4es and advocacy to include oral care as a vital component and enabler of overall wellness by demonstra4ng the economic and health value of complete Medical/dental care integra4on, thus eleva4ng the urgency and status of dental care. 36

37 Goals Achieve integra4on of oral care into the general medical care delivery environment by 2025 Elevate the importance of professional dental care focusing on preven4on, early detec4on, managing pa4ent risk, preventa4ve self- care and dental care coverage to improve wellness and lower overall health care costs 37

38 Strategy Quan4fy opportuni4es (costs, outcomes) focus efforts on the value proposi4on for oral health Iden4fy our allies- secure support of those who can advance our cause Demonstrate total health equity new partners needed to raise awareness Focus on adults with chronic disease and/or pregnant women as basis for determining economic value proposi4on 38

39 Next Steps Enlarge/strengthen the base of core par4cipants in the ini4a4ve, as well as external to den4stry allies/partners from current 8 members Develop public affairs programming to engage leaders in poli4cs, medicine, NGOs, business communi4es Develop memorable branding/marke4ng/ communica4ons campaign material 39

40 Next Steps Develop 4melines Develop next Forum Support, disseminate and par4cipate in addi4onal research underscoring the importance of oral health on overall health, focusing in par4cular on clinical and financial outcomes. 40

41 Audience Public policy influencers Philanthropic founda4on Health care purchasers Physicians Organized den4stry and medicine Influen4al media Alternate care facili4es (CVS, Walmart, Target) 41

42 Current ini4a4ves Commonwealth Care Pilot research plan to answer ques4on does good oral are impact an elderly popula4ons general health Develop a primary care medical prac4ce within Harvard Dental Center Pa4ent Centered Health Home Develop general dental residencies at medical centers without dental school of oral health resource 42

43 Reform Agenda All health insurance policies whether provided through Medicare, Medicaid or private insurance companies could include coverage for dental care services, regardless of enrollee s age Integrate general medical and dental care in both prac4ce and workforce educa4on Ul4mate goal is care not insurance This is about building a movement- JOIN US 43

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45 References Donoff, B, JE McDonough, and CA Riedy. Integra4ng Oral and General Health Care. NEJM 371: 2247, 2014 Donoff, B. The economic Impera4ve of Oral Health. Inside Den4stry: 2, April 2015 Meyer, E. Integra4ng Oral and Medical Health Care. Inside Den4stry: 43, April

46 References Kilsdonk, GJ. Improving Health care Quality and Reducing Cost through Oral Health Access and Medical Dental Integra4on: a Case Study for Policy Considera4ons. Presented at : Returning the Mouth to the Body: Integra4ng Oral health and Primary Care; April 17, 2012; Washington, DC. 46